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Infertility Basics

What is infertility and what are the causes?

Infertility is failure to conceive after two years of unprotected intercourse. The incidence of infertility in general population is 5-10%. About 80% of couples conceive in the first year of active intercourse and another 10-15% conceive in the second year.

In majority of cases females are blamed for infertility. But it is important to know that in 20-25% of cases of infertility, male is solely responsible for the problem and in another 20-25%, male is partially responsible for infertility. Therefore it is very important to find out the cause of infertility, before treating it. A systematic approach to investigate an infertile couple is therefore to first understand the causes of infertility.

How does conception occur?

Intercourse causes deposition of sperms in the vagina. These sperms gradually pass through the cervix to enter the uterus. Cervix acts as a barrier to seminal plasma, debris, etc. Sperms traverse through the cornu of the uterus to fallopian tubes. When ovum matures in the ovary, the ovarian end of the fallopian tube, which has fimbriae(finger like processes) extends towards the ovary. The fimbriae cover the ovary like a ball in the fist. There are tiny hair like processes in the tubes, known as cilia. Movements of these cilia cause a 1mm of Hg negative pressure in the tube, that sucks the ova from the ovary. The ova moves in the tube towards the uterus. It comes in contact with the sperms. One sperm becomes successful in penetrating the ovum and fertilizes it. This fertilized ovum starts dividing into 2-4-6 cells and is now known as embryo. In the mean time it comes into the endometrial cavity and implants. The female misses the next period and it is known as conception.

Therefore for a normal pregnancy to occur, the following factors should be normal and should be assessed for:

  1. Sperm count, motility and morphology
  2. Cervical factor
  3. Endometrial cavity
  4. Tubal patency and tuboovarian relationship
  5. Ovulation

1. Sperm count, motility and morphology:

meaning the male factor. Normal sperm count required for natural conception is 15 million/ml and not 60 million as is being mentioned in several laboratory reports. Even when only 30% of these sperms are motile, it is considered and normal and only 14% sperms with normal morphology are sufficient for natural conception to occur. These males require no treatment. But it should be remembered that abstinence of more than 3-4 days should not be allowed before semen examination.

Males with 10-15 million count, 4-14% normal sperm morphology and 20-30% motility may be able to father a child with intrauterine insemination. Even when the sperm count is 5-10 million, these males must be given medical therapy to increase the sperm count and that gives excellent results, so much so that may even result in natural conception.

2. Cervical factor:

Around ovulation there is copious secretion in the cervix, this helps the sperms to remain alive and traverse into the uterus. It also acts as a lubricant. It is because of this secretion that cervix acts as a reservoir for sperms in periovulatory period. Sperms remain alive in the cervix from 72 hours to 7 days and keep on traversing into the uterus from time to time. This can be confirmed by examining the cervical mucous under microscope, 12 hours after intercourse. This test is called a post coital test (PCT). Post coital test is called positive when 7-10 motile sperms are seen in the cervical mucous under the microscope in a single high power field. This means that if intercourse is done once in 2-3 days during 10-20th day of 28 days cycle, chances of conception are very good. If the positive post coital test is shown to the couple, their confidence boosts up and helps them to conceive.

Positive post coital test confirms that the sperm count is normal and the cervical factor is not the cause of infertility.

3. Endometrial cavity or the uterine factor:

A normal endometrial cavity is an absolute necessity for implantation to occur. Uterine cavity can be best assessed by 3D ultrasonography. This helps not only to rule out congenital uterine abnormalities distorting the shape of the endometrial cavity like unicornuate, bicornuate or septate uterus, but also diagnoses acquired uterine abnormalities like fibroids, polyps, adhesions, etc. Uterine cavity can also be assessed by hysteroscopy. But endometrial biopsy with curettage do not have any role except when endometrial tuberculosis is suspected. Curretting does more harm than advantage.

4. Tubal patency and tubo-ovarian relationship:

Patent tubes are very vital for fertility. These should not only be patent but also be functionally normal and tubo-ovarian relationship should also be normal, as we have understood during the explanation of how conception occurs. This means that the tests done to assess the tubal patency alone, like Rubin’s test(RT) or hysterosalpingography(HSG- x ray assessment of tubal patency) are not sufficient also. More over HSG is very painful and injurious also due to x-ray exposure and iodinated dye that is used in it. Sonosalpingography, in which saline is injected into the uterus and its passage is seen through the fimbrial end of the tube under ultrasound. HyCoSy is an investigation in which ultrasound contrast is used instead of saline These procedures when clubbed with Doppler and 3D -4D ultrasound, it gives the same or even more information than HSG and are not painful. But as far as assessment of tubal factor is concerned, laparoscopy is a gold standard and must be done in each patient of long term infertility before starting treatment.

5. Ovulation:

Ovulation consists of a complete process of development of ovum, maturation of ovum and release of ovum. Though all these processes occur naturally in a natural cycle. But when IUI or IVF is planned, ovaries are stimulated to produce more and better quality ova. What drugs and how much dose is to be used can be decided by ultrasound with Doppler and 3D ultrasound on baseline scan that is done on 2nd-3rd day of the cycle. Drugs used for the purpose are tablets- clomiphene citrate(CC), or injections, gonadotrophins. We shall discuss more about the injections when we discuss about IUI. But it must be remembered that CC should not be taken if ovulation is not monitored by ultrasound and CC should not be taken for more than 6 months at a stretch and more than 12 months in life time.

Ultrasound is used to assess the maturity of the follicle. Using Doppler and 3D ultrasound increases the accuracy of assessment to ultimately improve the results of infertility treatment. This assessment is done to decide the time of hCG( injection to rupture the follicle) and to decide the time of IUI. But it is important to remember that ultrasound must never be done before IUI to check the ruptured follicle. Moreover, if hCG is not to be given for rupture, there is no point in doing serial scans just to confirm that ovulation has occurred. This can be known by a single blood test- S. Progesterone done on day 22 of the cycle.

You must at least know this:

  1. No matter for how long the birth control pills are taken, you can have pregnancy from the very month that you have stopped it.
  2. Less menstrual flow leads to weight gain is a false belief, actually because of weight gain the periods become irregular & menstrual flow becomes scanty.
  3. It is believed that there is lower abdominal pain at the time of follicle rupture & ovum release but actually this pain is 24 hours before this process.
  4. It is not necessary to have intercourse when the ovum releases because the sperms remain live in the cervix(mouth of the uterus) till 3-7 days after intercourse and at any time during this period if the ovum releases it can be fertilized. Therefore if periods are regular, the chances of pregnancy are very good if the couple performs intercourse nd rdat least every 2 or 3 day between 10-20 days of the cycle.
  5. Curetting (D & C) does not help to conceive (keep pregnancy). Actually it damages the inner wall of the uterus, which makes conception difficult.
  6. Ayurvedic, Homeopathic and other commercial preparations available in market for increasing sperm count have not yet proved their worth.
  7. Jaggery is a good source of iron and must be included in diet during pregnancy. It does no harm to the pregnancy. Groundnut Chana & jaggery makes a good mid day snacks for pregnant females as it supplies protein & iron in sufficient amount. Similarly lots of vegetables, fruits & milk must be taken during pregnancy & 6 months after delivery also. Fats are actually not required.
  8. Sonography is not X-radiation it is only sound waves & has no ill effects on the baby in the womb and can be done for any number of times during pregnancy.
  9. Two Sonographies are essential during whole pregnancy.
    1. At three months, to rule out chromosomal abnormalities which is known as “genetic scan’.
    2. A detailed scan done at 5 months of pregnancy to rule out any structural abnormalities including fetal echocardiography & fetal neurosonogram