Infertility is defined as the inability to conceive after 1 year of unprotected intercourse, or after 6 months in woman older than 35 years.
It affects 1 in 6 couples (15%). It affects their emotional and psychological well-being. Unfortunately there is still a stigma associated with infertility, resulting in couples delaying seeking help. Woman are also delaying child bearing due to financial reasons, to complete their studies or to pursue their careers. This causes an added burden to fertility, as conception rates drop dramatically after the age of 35 years.
These can be divided into male factor (40%), female (45%) and unexplained (15%).
The diagnosis of male factor infertility is based on the semen analysis.
Normal semen analysis
Volume: 1 - 5 mls
Count: >15 million/ml
Motility: > 50%
Morphology: > 4%
The commonest causes of an abnormal semen analysis are due to:
Accounts for 40% of infertility
Tubal damage is diagnosed by Laparoscopy or by an x-ray procedure called a hysterosalpingogram.
Endometriosis is a condition where the cells that make up the lining of the womb (the endometrium) is found outside the womb. The commonest sites are around the ligament that support the womb, in the ovary, on the bladder and on the membrane (peritoneum) covering the pelvic organs. During menstruation these endometriotic cells bleed, resulting in pelvic pain and scarring. Endometriosis also causes a hormonal change that can affect the environment inside the tube and the lining of the womb, affecting fertilisation and implantation.
The commonest symptoms of endometriosis are lower abdominal pain, pelvic pain, painful periods and painful intercourse. Endometriosis is diagnosed by Laparoscopy.,
Fibroids are also known as myomas. They are very common, about 20% of woman over the age of 35 have asymptomatic fibroids. They are benign growths. The exact causes of fibroids are not known but they are hormone dependent. It is more common in the African population. There could be one or many fibroids, ranging in size from 1cm to 10cm. Fibroids can cause heavy menstrual bleeding, severe period pain, abdominal discomfort, backache and pressure symptoms on the bladder. Fibroids can cause infertility, especially if it is situated in the lining of the womb or if it distorts the shape of the lining of the womb, interfering with implantation.
Large fibroids may also cause complications during pregnancy (e.g.) abdominal pain, miscarriage, preterm labour and abnormal foetal presentation.
Fibroids are surgically removed either by Laparoscopy or Laparotomy.
The operation is called a myomectomy.
Unfortunately fibroids tend to regrow.
Some patients may need a repeat operation.
Age is important in determining a woman’s fertility. It’s also used in determining the success rate of fertility treatment. A woman is born with a finite number of eggs in the ovary. The older the woman gets, her chances of conceiving diminishes.Therefore older woman take longer to conceive and the rates of miscarriage and abnormalities are higher.
Today we can accurately determine a woman’s fertility and biological clock by doing a blood test for anti-mullerian hormone. The ovarian reserve can also be determined by ultrasound by counting the number of eggs in the ovary.
This affects 12-15 % of couples. All the tests done on the male and female partner is normal. These are tests for ovulation, tubal patency, pelvic ultrasound and semen analysis.
IVF is used as a last resort for woman with PCO that fail to ovulate on Clomid or Letrozole. These women are at high risk of developing ovarian hyper stimulation syndrome (OHSS) during the IVF stimulation. This risk has been greatly reduced as a result of the GnRH antagonist protocol and using Lucrin as a trigger in preparation for egg retrieval. In some cases the embryos are frozen to avoid OHSS.
Woman that do not ovulate, tend to skip their periods or have very short cycles. Polycystic ovarian syndrome is the commonest reason for not ovulating. Other reasons are the contraceptive injection, thyroid abnormalities, high prolactin levels, strenuous physical exercise and excessive weight gain and weight loss.