Evaluation of Couple

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Infertility

Inability to have a child naturally has been a source of sadness and despair since the earliest times, with stories of the emotional and social struggles of being unable to reproduce even appearing in Historical aspect.
Our body working against our will can be a painful realization. Expectations to make difficult decisions about the future can add to the agony.
A multitude of questions surges through the minds of a couple going through the pain of waiting for a dream to come true… Some find it difficult to accept the fact, to deal with the reality, to take a decision about this problem, some are scared due to lack of information and guidance.
Counseling plays an important role in the management of Infertility.
Explaining the couple that like any other disease it is a medical condition.
Not social and emotional stigma.
Giving them scientific information helps to understand the nature, magnitude of the problem and gives strength to follow their dream,
Before dealing with abnormal, we need to know what is Normal

Normal Anatomy-Physiology of Female Reproductive Tractatus is divided into Body of uterus, Cervix which opens into a passage called Vagina and Two Fallopian Tubes.
Ovaries are in close proximity to Fallopian Tubes. Normally, every month one of the ovaries release Egg (Ovulation).
Fallopian tube catches the Egg which travels to the ampullary region of the tube. If the intercourse takes place during this period, the motile sperms travel from the vagina into the uterus and then to the fallopian tube to meet Egg (Fertilization) and Embryo is formed.
This embryo travels from tube to uterine cavity to get attached (Implantation).

For Natural conception following things should be in order:

Normal anatomy of uterus and vagina with good endometrium.
Patent and functional fallopian tubes.
Regular ovulation.
Normal sperm count in a male partner.

Abnormality in any of the above can result in INFERTILITY.

What is Infertility?

Infertility means

not being able to get pregnant after one year of trying OR
six months, if a woman is 35 or older.

Some woman can get pregnant but are unable to remain pregnant.

Primary: No history of achieving pregnancy.

Secondary: Failure to achieve a pregnancy after the previous history of getting pregnant.

What are the causes of Infertility?

Infertility is a common problem with 10% incidence in the reproductive age group.
Unlike the common belief that infertility is the female origin, male and female factors are equally responsible.

About one-third of infertility cases are caused by women’s problems. Another one-third of fertility problems are due to the man.
The other cases are caused by a mixture of male and female problems or by unknown problems.

Female factor Infertility:

Anovulation (No / Abnormal release of Egg):

Most cases of female infertility are caused by problems with ovulation.
Without ovulation, there are no eggs to be fertilized.
A woman might present with the history of absent menses or irregular menses.
Ovulation problems are often caused by Polycystic ovarian syndrome (PCOS).
PCOS is a hormone imbalance problem which can interfere with normal ovulation. PCOS is the most common cause of female infertility

Another less common reason is:

Primary or Premature Ovarian Insufficiency: occurs when ovarian reserve is diminished before she is 40.
Anatomical obstruction to reproductive tract preventing sperms reaching ovum

Blocked Fallopian Tubes:

Can occur due to:

✓ Infection (pelvic inflammatory disease) causing swelling of tubesHydrosalpinx.

✓ Tuberculosis.

✓ Endometriosis.

✓ Surgery on tubes (for previous ectopic pregnancy) or adnexa (Ovarian cyst,to rsion).

Abnormalities of Uterus:

1. Endometriosis:

Presence of endometrial tissue outside endometrial cavity which can cause accumulation of blood during menstruation.
Commonest affected are ovaries producing chocolate cysts.
This reduces egg giving capacity of ovaries.

2. ENDOCRINE FACTOR

Malfunctioning of any of endocrine gland like Thyroid, Pituitary, Adrenal can cause defects in ovulation.

3. IMMUNOLOGICAL FACTOR

Presence of antibodies directed to endometrium or embryo formed can cause defects in implantation resulting in infertility or recurrent pregnancy loss.

4. SUDDEN WEIGHT CHANGES

Results in hormonal imbalances.

Advanced Maternal Age:

Aging decreases a woman’s chances of having a baby in the following ways:

She has lesser number of eggs reduced ovarian reserve- Low
Quantity.
Her eggs are not as healthy: Poor quality of eggs.
She is more likely to have health conditions that can cause.
fertility problems: thyroid abnormality, Diabetes.
She is more likely to have a miscarriage: due to increased genetic abnormalities attributed to advancing age.

It is suggested that woman can wait for one year of marriage to get pregnant before seeking medical help however Women 35 or older should see their doctors after six months of trying.
A woman’s chances of having a baby decrease rapidly every year after the age of 35.

Male factor Infertility:

Less Sperm production low count (Oligospermia)

Slow sperms reduced motility (Asthenospermia)

Abnormal shapes and sizes of sperms abnormal morphology (Teratospermia)

Absent sperms in semen sample (Azoospermia) Needs to be checked at least from 3 samples taken at different intervals

Blockage to the passage of sperms (Obstructive).
Defective sperm formation process with no Blockage to the passage of sperms (Non-Obstructive).

Reproductive Organ Abnormalities

Varicocele: Engorgement of blood vessels surrounding
spermatic cord
Hydrocele – accumulation of fluid around testes
Hernia – the presence of abdominal organs like bowel,
omentum in inguinal canal and scrotum.
Systemic diseases like Diabetes can cause all defects in sperms mentioned above
Genetic disorders: Sometimes a man is born with genetic problems that affect his sperm.
Systemic illness in childhood leading to permanent end-organ damage like Mumps.

Lifestyle-related: Addictions like smoking, Tobacco, Gutkha chewing, Heavy alcohol use, Drugs damage sperms and genetic material.
Environmental toxins, including pesticides and lead
Age
Stress, pollution
Chemotherapy or radiation treatment for cancers
Genetic disorders of a Y chromosome, abnormal set of chromosomes, Klinefelter syndrome
Trauma
Idiopathic: unexplained sperm deficiencies account for 30% of male infertility.

Investigating Infertility:

Investigation of each couple facing Infertility problem requires meticulous access by specialists in the field of Assisted Reproductive Technologies.
Detailed History of the couple gives clues to possible reasons behind it.

History of Female Partner

Detailed menstrual history, the regularity of menses, Amount of flow, pain during cycles, previous diseases, medical-surgical history, previous treatment for infertility, Ability to have coitus, pain during the act, frequency of sexual intercourse, Difficulty in coitus, time period of conceiving efforts.

History of Male Partner

History of difficulty during intercourse can point to a diagnosis of conditions like ejaculatory dysfunction, premature ejaculation, retrograde ejaculation.
History of childhood illnesses like mumps can explain oligo or azoospermia
History of addictions warrant need for lifestyle changes.
History is followed by a general and gynaecological examination.

Diagnostic Investigation of Male Partner

The main test in a male investigation is the assessment of Sperm ( Semen Analysis).
It is recommended to be performed after 3-4 days of abstinence from the sex, while its collection by means of masturbation to be performed preferably in Laboratory (If collection is done at home then the sample is to be kept warm and brought to laboratory within 30 mins of the collection)

The Semen analysis gives information on Volume, Acidity of sample Liquification time, Number, Motility, and Morphology of Spermatozoa, also on the presence of inflammatory cells and on its glucose and other substance content.
On suspicion of infection, the semen culture can be done for infection and antibiotic sensitivity. In suspicion of anti spermantibodies, a series of specific detection examinations may follow.
It is possible to determine by means of specialized tests the functional capability of spermatozoa to penetrate oocyte in order to fertilize it. On suspicion of Varicocele, Colour Doppler sonography can be done to visualize dilated veins.
Hormonal Tests can be performed- Sr.Testosterone, FSH, LH, Prolactin, Inhibin B, advanced test DNA fragmentation, Y chromosome microdeletion teat are reserved in a minor proportion of cases.
In cases of severe Oligospermia and Azoospermia chromosomal analysis (Karyotype) and genetic analysis for Cystic Fibrosis can be done.

Diagnostic Investigation of Female Partner

The Ultrasound scan is an indispensable diagnostic examination.
Baseline sonography is done for visualization of pelvic organs- Uterus: Size, dimensions, endometrial thickness, the presence of malformations or growths.

Hysterosalpingography:

This radiological test includes the injection of a contrast dye through the cervix, while continuous x-ray pictures are taken at subsequent stages in order to detect the passage of dye through tubes in pelvic cavity indicating patency of tubes.

In this way, we can detect any abnormalities found into the uterine cavity such as septa, sub-mucous fibroids or adhesions, cervical pathologies, and tubal abnormalities such as lumen dilation or obstruction of the fallopian tube.
Similar results can be obtained by Sonosalpingography which involves confirmation of spill of normal saline from tubes visualized by Color Doppler sonography. This procedure gives additional information regarding pelvic organs along with tubal patency.

Endocrinological investigation

Basic hormonal evaluation is done to rule out thyroid gland dysfunction, hypersecretion of prolactin.
In the case of clinical evidence of increased male hormones as increased facial hair growth or acne, androgen evaluation can be done.
In case of polycystic ovarian pathology baseline menstrual day 2 or 3 levels of FSH and LH hormones along with AMH can be done for predicting ovarian response to hormones and to decide the dose.

Hystero Laparoscopy:

In cases of doubt or detection of pathology after performing a hysterosalpingogram or ultrasonogram, there may need to proceed to the performance of hysteroscopy and/or laparoscopy as parts of the diagnostic investigation

Hysteroscopy:

Hysteroscopy This Involves visualization of the uterine cavity by 4mm scope under anaesthesia by distension of cavity by Normal saline.

Laparoscopy This procedure involves distension of abdomen with CO2 gas and visualization of pelvic and abdominal organs by 10mm laparoscope.
Abnormal lesions of the uterine cavity or pelvic organs can be dealt at the same sitting.