Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO-ICMART glossary*). There are two kinds of infertility - primary and secondary:
Primary infertility means that the couple has never conceived. Secondary infertility means that the couple has experienced a pregnancy before and failed to conceive later. Globally, most infertile couples suffer from primary infertility.
Sexually transmitted infections (STIs) are the leading preventable cause of infertility by causing 70% of pelvic inflammatory diseases responsible for tubal damage. Low fertility is becoming more common worldwide, particularly in many urban settings where women are planning their first babies at older ages.
Infertility affects up to 15% of reproductive-aged couples worldwide. According to World Health Organization estimate the overall prevalence of primary infertility in India is between 3.9 to 16.8%. In Indian states prevalence of infertility varies from state to state such as 3.7 per cent in Uttar Pradesh, Himachal Pradesh and Maharashtra, to 5 per cent in Andhra Pradesh, and 15 per cent in Kashmir and prevalence varies in same region across tribes and caste.
The inability to have children affects couples and causes emotional and psychological distress in both men and women. Despite the various social, psychological, economic and physical implications, infertility prevention and care often remain neglected public health issues, or at least they rank low on the priority list, especially for low-income countries that are already under population pressure. But in recent years there is increased awareness to integrate infertility prevention, care and treatment into the basic health care services.
For a woman, infertility (or a state of subfertility) can manifest itself as either (WHO):
Infertility can be caused by both men and women factors. About a third of infertility problems are due to female infertility and another third are due to male infertility. In remaining cases infertility may be due to problems in both partners or the cause is unclear.
Female infertility can be caused by a number of factors:
(a)Damage to fallopian tubes: Damage to the fallopian tubes (carry the eggs from the ovaries to the uterus) can prevent contact between the egg and sperm. Pelvic inflammatory diseases (PID) caused by various infections, endometriosis, pelvic surgery may lead to damage to fallopian tubes. Sexually transmitted infections (STIs) are the common cause of PIDs.
(b)Disturb ovarian function/hormonal causes: Synchronized hormonal changes occur during the menstrual cycle leading to the release of an egg from the ovary (ovulation) and the thickening of the endometrium (inner lining of the uterus) in preparation for the fertilized egg (embryo) to implant inside the uterus. Difficulty in ovulation is seen in following conditions-
(c)Uterine causes: Abnormal anatomy of the uterus; the presence of polyps and fibroids may lead to infertility.
(d)Cervical causes: A small group of women may have a cervical condition in which the sperm cannot pass through the cervical canal due to abnormal mucus production or a prior cervical surgical procedure.
Male factors causing infertility-
More than 90% of male infertility cases are due to low sperm counts, poor sperm quality, or both. The remaining cases of male infertility can be caused by number of factors including anatomical problems, hormonal imbalances, and genetic defects. Sperm abnormalities include:
Different factors including congenital birth defects, diseases (such as mumps), chemical exposure, and life style habits can cause sperm abnormalities.
Factors that affect the fertility of both sexes include the following:
Both male and female factors can contribute to infertility. A detailed medical history, physical examination and investigations are needed to assess the cause of infertility.
Evaluation of infertility includes following steps:
(a) History taking: Couples with infertility problem are interviewed separately as well as together to know about important facts with full history taking. Full history includes: present history; menstrual and obstetric history (in female partner); contraceptive and sexual history; family and past history.
(b)Clinical examination: Full clinical examination of both partners is required for detection of any physical problem. It includes general examination along with examination of chest, breast, abdomen, and genitalia. It helps to health care professional to make a provisional diagnosis. Investigations are advised to prove the clinical diagnosis and to exclude other close possible causes.
(c) Investigations: Infertile couples are usually advised to start their investigations after 12 months of trying to conceive or after six months if the female partner is more than 35 years old or immediately if there is an obvious cause for their infertility or subfertility.
As the major causes of infertility are sperm abnormalities, ovulation dysfunction, and fallopian tube obstruction, the preliminary investigations for the infertile couple should be focused on:
Semen analysis: It should be done after 72 hours of sexual abstinence and two analysis should be advised with 3 months apart at the same lab.(Results may be interpreted for its volume, sperm count, motility, and morphology according to the WHO reference values*).
Management of infertility ranges from counseling and advice to medications and surgery.
Counseling of both partners is an important aspect in the management of infertility with medical and psychological support to the couple. Counseling is provided for the healthy life style measures such as:
Specific treatment of disease that causes infertility- Whatever cause is detected during investigations relating to female or male partner, treatment is given accordingly. Management of STIs and PCOS can be viewed on www.nhp.gov.in.
When initial treatments don't work, couple may decide for assisted reproduction technology.
Assisted reproduction techniques (ART):
IUI is of two types
Surrogate and gestational carriers-If a woman is unable to carry a pregnancy to term, the couple may choose a surrogate or gestational carrier.
Adopting a healthier life style through simple lifestyle changes may help to reduce the chances of infertility.
Life style changes include:
(a)Weight management is important in preventing and treating infertility. Women who are overweight or underweight ovulate less regularly compared to women of a healthy weight. Similarly overweight men are likely to have reduced fertility. Therefore maintain a healthy weight with healthy diet and exercise.
(b)Eat a balanced diet which should include whole grains, pulses, fresh fruits and vegetables, low fat milk products. Limiting consumption of sugar, alcohol, caffeine, no smoking including passive smoking can have a beneficial impact on a couple’s ability to conceive.
(c)Participating in moderate exercise can help improve menstrual regularities and overall health, whereas sometimes excessive exercise can disturb menstrual cycle as seen in competitive athletes practicing intense training sessions.
(d)Making time for leisure and enjoyment is a healthy step to lower stress levels and improves physical and emotional health.
(e) Illegal drugs such as marijuana or cocaine should be avoided as can affect fertility.
(f) Practice safe sex-Sexually transmitted infections (STIs), such as chlamydia and gonorrhea, are leading causes of infertility. STIs can lead to blockage of fallopian tubes, prostatitis and other problems that reduce fertility.
(g)Age and fertility- The decision to have a baby and determining the right time to start a family is a highly personal choice. However, women need to understand, that the biological clock is a real issue, older the female partner, the more difficulty a couple can face when trying to get pregnant.