How is infertility investigated
In cases of infertility it is important that both partners are investigated because either of them could be responsible. Infertility needs to be investigated if the couple has failed to conceive after one year of unprotected sex, there is a concern about the patient’s fertility or if the female patient is over the age of 35. The first step of the investigation involves taking a medical, sexual and social history of the couple and it is extremely important to find out if either partner has ever acquired a sexually transmitted infection. Information such as menstrual history, previous pregnancies and the use of contraceptive medication should also be obtained.
From the male, it is important to ask if they have ever acquired infections such as mumps or tuberculosis or if they smoke or abuse any substances. Physical examination may need to be undertaken on the female to look for signs of fibroids, genital abnormalities such as a rigid hymen or vaginismus. Male examination results which may increase risk of infertility include small testicular size or presence of lumps or abnormal penis structure.
Causes of subfertility in women
There are a number of male and female factors which can both contribute to subfertility. If neither of the partners have conceived before or have fathered a child it is considered to be primary subfertility. However, if either partner has been involved in a successful conception previously then they are considered to have secondary subfertility. Approximately 50% of infertility cases are caused by female problems, 25% due to male problems and in 25% of cases are due to unknown reasons.
Female causes of infertility include defects in ovulation, womb, fallopian tube and use of certain types of drugs and of course age. Ovulation disorders can arise due premature ovarian failure, polycystic ovarian syndrome(PCOS), thyroid problems and Cushing’s syndrome. These conditions can cause the failure of the development of an ovum and its release into the fallopian tube. Surgical procedures in the pelvis and cervix can damage and cause scarring of the fallopian tube. The fallopian tube is where fertilisation of the ovum occurs and the cilia are involved in the movement of the fertilised egg down into the womb.
The presence of benign tumours such as fibroids in the womb can cause the failure of the fertilised ovum to implant itself into the womb. Medical treatment such as chemotherapy, neuroleptic drugs and spirnolactone can also cause infertility. Age is also important because fertility reduces with increasing age.
Causes of subfertility in Men
The most common cause of infertility in male which account for 75% of cases of infertility is due to the production of abnormal sperm. This maybe as a result of decreased number of sperm, decrease number of mobile sperm or the production of abnormal sperm which cannot fertilise the ovum. Male causes of infertility can acquired for example cyrptorchism, where they have undescended tests, Klinefelter’s where there is androgen deficiency or cystic fibrosis where there is an absence of the vas deferens. Male infertility can also be acquired by contracting sexual transmitted diseases such as chlamydia and gonorrhoea or mumps which leads to orchitis which involves the inflammation of the epididyis and then testicular atrophy. Other factors which can increase the risk factor for male infertility include drinking, smoking, medical drugs such as cimetidine, sulfasalazine, chemotherapy and non recreational drugs such as marijuana and cocaine.
Azoospermia is the total absence of spermatozoa in the male ejaculate. Azoospermia can be categorised into non obstructive and obstructive. This condition can be determined by a semen analysis where a sperm count and morphology is performed as well as the percentage of active sperm. If the first sample of sperm is abnormal then another sperm analysis must be carried out to ensure the sperm sample was viable and was not affected by external factors such as not high teste temperature, large consumption of alcohol or smoking. In non obstructive cases the testes fail to produce the spermatozoa in the first place and in obstructive cases, there is a defective transport system where the sperm fails to be transported into the ejaculate but normal sperm production can occur. The reasons why patients develop non obstructive azoospermia include testes of small size and of softer consistency, dietary deficiencies and exposure to certain chemical toxins such as cadmium and insecticides. In these patients the testosterone and LH levels are often within the normal range but levels of FSH maybe elevated. Patients who have obstructive azoospermia often have testes which are of normal size and consistency and are able to produce spermatozoa but have congenital disorders like cystic fibrosis which cause an absent vas deferens or secondary infections such as gonorrhoea or tuberculosis which has causes ejaculatory duct obstruction and therefore this highlights the importance of taking a history about medical conditions and previous infections.
Treatment options for infertility
The three main fertility treatment available include medication to assist fertility, surgery and assisted conception and they are based on the type of fertility problem the couple have Fertility medications such as clomifene, gonadotrophins, gonadotrophin releasing hormones to encourage ovulation . Surgical procedure can be carried out to correct fallopian tubes blockage, removal of fibroids or epididymal blockage. There are number of methods available with assisted conception. Intrauterine insemination involves selecting the best quality sperm and placing it directly into the womb when it will coincide with ovulation. In-vitro fertilisation involves the fertilisation of the ovum and sperm outside the body. Fertility medication is used to stimulate the ovaries to produce more eggs than normal so they can be removed and fertilised with sperm. Once the ovum has been fertilised it is planted in the females womb. Intracytoplasmic sperm injection involves a single spermatozoa being picked up by a micropipette and inserted into the cytoplasm of the ovum outside the body. This can be particularly useful if the sperm is unable to penetrate through the zona pellucida of the ovum. If the assisted conception method fails the patients may need to opt for use of donor sperm or eggs, or may need to use a surrogate mother for the pregnancy or they may need to adopt in order to fulfil the needs of parenting.