Inability to conceive can be a stressful situation for a couple. There can be many reasons for infertility. Infertility in males can be due to genetic factors which have adversely affected a man’s sexual organs, habits such as excessive consumption of alcohol or a lower sperm count. Among women, it may have something to do with ovulation, age, conditions such as endometriosis, etc. Common approaches to treat infertility include intra-uterine insemination (IUI), in vitro fertilisation (IVF), administration of superovulation medications, etc. Each of these approaches is employed based on the factors influencing your infertility as well as various other conditions such as pelvic or related disorders.

It remains a desire of almost all couples to have a baby of their own. Couples try their best to give birth to a baby through regular sexual intercourses. With the passing of every month, the fears of their inability to give birth to a baby may start mounting. It is a fact that one in 6 women in this world is currently experiencing an infertility related problem. In some communities, inability of a woman to conceive is treated as a curse. Even otherwise, a couple may go through stressful and often depressing times if their attempts do not result in pregnancy.

Infertility among women

More than 50% of infertility is due to a medical condition of women. If you are having regular and unprotected sex for more than 6 months and if you are unable to get pregnant, it is termed as infertility. Period of observation can be extended upto 12 months if the couple do not belong to a younger age group. A distinct sign of infertility is the inability to get pregnant; it remains as a key symptom that defines this medical condition. However, your body may exhibit a few other signs such as – periods becoming more difficult to predict and hence are irregular, excessive or lighter bleeding during periods, etc. A few related symptoms are stoppage of periods, presence of acute pain in your abdomen, pelvic or lower back regions. In some instances, infertility in women may also be due to hormonal conditions. You may witness the following signs in case of hormonal imbalances – inexplicable increase in body weight, changes in libido or sexual urge, acne or other skin conditions, hair loss, etc. Infertility among women can be of various types. It may be a primary level of infertility, a secondary condition, psychological reasons for infertility, sterility and inexplicable infertility.

Primary level of infertility occurs due to disorders in your reproductive system or your genetic disposition. This primary condition is usually noted well ahead of your attempts to get pregnant for the very first time.

Infertility among women at the secondary level: This occurs when your first pregnancy triggers a few conditions that can present problems to your getting pregnant again. A most common sign is the formation of scars in your uterine region – as part of a surgery done on your womb. A secondary level of infertility may also occur when your baby’s blood group does not match with yours. This condition occurs when an Rh-positive baby is born to an Rh-negative mother. Antibodies in the mother’s body will ensure terminating her fetus (second pregnancy) at a preliminary stage itself. If you are conscious of this, you will start needful precautions to stay fertile. In case you have no awareness of this condition, it is likely to trigger secondary level of infertility in you.

Sterility is a condition – often having genetic origins – wherein your reproductive organ is impaired in an irreversible manner. It may show up as organs that are not capable of producing a baby. Though a few treatment options do exist, such options require another woman’s body i.e., through surrogacy or a surrogate mother.

Asexuality or psychological reasons for infertility among women – This is a condition whereby a woman assumes an asexual role. This shows up when you do not think you are a woman. Moreover, by being asexual, you also tend to think that making a baby is not a thing for you. In such conditions, miscarriages are a common occurrence. It is considered as a psychological condition as your mind is simply not in tune with your body.

Not stopping with the above, you may also have a few problems (often, minor conditions) which may collectively make you infertile. The causes for such a condition are very difficult to diagnose. This condition is termed as unexplained or inexplicable infertility.

When to consult your doctor or a mental health professional?

If you experience a few signs; especially – extremely irregular periods, unpredictable levels of bleeding in times of periods – bleeding levels can either be very light or excessive, but never normal; some women may see a sudden cessation of their periods or may experience sharp, severe pains in pelvic, back and abdominal areas. The most glaring sign above all is a miscarriage. It is time to consult a qualified medical practitioner if you experience any of these signs.

Apart from a medical professional, you may also need help through counselling from a mental healthcare professional. This is because of the risks of (1) domestic violence, (2) divorce, (3) mood shifts – especially depression, are relatively high. In many communities all over the world – even when the male partner is infertile, blame often falls onto the woman for not making a baby.

Infertility among men

A wide range of factors can influence infertility in men. Most of them are physical in nature and a few may pertain to the count or quality of sperm. The possibility of infertility can arise due to congenital disorders, ejaculation-related problems, genetic disposition, incidence of sexually transmitted conditions, hormonal imbalances, autoimmune conditions, enlargement of blood vessels (in the scrotal area) and other sexual conditions such as ejaculating in a premature stage or impotency among males.

Congenital conditions can lead to infertility in men when there are blocks in men’s scrotal bags or testes. Such blocks may stand in the way of sperm and prevent them from getting blended with semen. Surgical interventions are known to correct such congenital problems. Ejaculating in a retrograde manner may cause prostatic secretions such as semen to move back, and not forward. In short, semen does not get ejaculated from the male sex organ. This is not a congenital condition; this may be triggered by a few pre-existing medical conditions or surgeries performed in the prostatic region. At times, ejaculation may get reversed due to the intake of a few types of drugs.

Male-infertility may also be due to a genetic condition. Men with chromosomal dysfunction or a few extremely uncommon conditions like fibrosis or cysts can get afflicted by infertility. In some instances, sexually transmitted conditions such as gonorrhea (manifests as a swelling of the balls) or chlamydia (a bacterial infection and a common condition in US; it shows up as itchiness in and around the penis).

Defective glands – especially, thyroid or pituitary – can often lead to infertility in men. Such conditions can be set right with needful drugs. An autoimmune condition can also lead to infertility.

This occurs when the immune system treats cells in the sperm as foreign bodies. An attack is launched on such cells. In the process, it can leave the reproductive cells in the sperm damaged and thus rendering infertility to men.

Enlargement of veins in the scrotal bags can block flow of blood. More than 1/3rd of all men with infertility are observed to have such swollen veins near their reproductive organs. Surgical options to correct this condition are currently explored with active interest.

The highly visible causes for male infertility are premature ejaculation and erectile dysfunction. These can occur upon taking an excessive dose of medications to treat mood swings such as depression. Prolonged intake of such drugs can often lead to impotence. Also, male impotence can be due to psychological conditions such as lower self-respect, shame or excessive levels of anxiety.

Other causes for infertility among males include low count of sperm, absence of sperm in semen, immobility of sperm as well as irregular shape of sperm. When sperm count is at a lower than normal level, the treating doctor may suggest having sexual intercourses less often. This is mainly to build a larger count of sperm cells.

When to consult your doctor?

Women do have a conspicuous sign – i.e., irregular or erratic periods – to give a possible indication about their infertility. This of course is not the case with men. So, if you are trying to get your partner pregnant for 9 months or more, it is a right time to meet a doctor. Some men may also experience a marked reduction in their sexual desire or libido; a few men may also show hormonal health conditions showing up as sexual problems or abnormal growth of hair.

Other factors such as excessive smoking or drinking and intake of a few drugs may also trigger infertility in men. If you have the aforesaid lifestyle habits or if you are part of a treatment plan, you may need to consult a qualified medical professional.

Treatment of infertility

Your doctor will aim to understand your medical history, current medication plans – if any, frequency of sexual intercourse, lifestyle habits, etc. For males, a physical examination as well as an assessment of the condition of their sperm is done.
For women, the doctor will perform a pelvic examination as well as understand your medical history in detail. Not stopping with these, health of ovaries to release eggs as well as hormonal health is assessed. Health of your hormones can be inferred by prescribing a few blood tests. Radiological scans are taken to understand the functioning of your fallopian tubes and uterus; this is done with x-rays. Ultrasound scan of your uterus and ovaries can also help assess their present condition.

Medical studies indicate that as high as 75% (or, even more) of the instances, infertility is triggered by a blocked fallopian tube, a sperm condition or an inability to release eggs (i.e., ovulation). In some 10% of infertile partners, the real reasons for their inability to conceive remain largely unknown.

Treatment offered to women

Infertility among women may be treated with hormones or drugs as well as surgery. Commonly prescribed drugs are clomid, antagon, parlodel and dostinex. For some women though, it can be corrected with a surgical intervention.

Clomid contains an active ingredient called clomiphene citrate; it is prescribed to correct issues related to ovulation (release of eggs). It belongs to a class of drugs called as estrogen blockers. The drug plays a key role in stimulating your pituitary gland to secrete hormones to facilitate your ovaries to make eggs. Doctors use this drug along with several assisted techniques to help couples to reproduce. Once you begin ovulating, you may need to stop taking clomid. If you are getting pregnant over the next few months, your medical team may recommend another variant of the same or other drugs. Common side effects of taking this drug include nausea, flatulence, blurring of eyesight, etc.

Hormonal injections such as follicle stimulating hormone – FSH, human menopausal gonadotropin – hMG, human chorionic gonadotprin – hCG, gonadotropin releasing hormone antagonist – GnRHa, gonadotropin releasing hormone – GnRH, etc. are prescribed to help you start releasing eggs.

Most of these hormones are injected into your muscles while some are administered underneath your skin. These hormonal injections do have a higher success rate in triggering the release of eggs. Side effects of these injections include inflammation, blisters and formation of bruises on your skin.

In some specific instances, your doctor may recommend a surgical intervention. The medical team either surgically opens blockages in fallopian tube or takes out obstructing tissues, as needed.

Treatment offered to men

Men’s fertility problems are managed through a range of treatment options. This range includes hormonal supplements or injections – this approach focuses on setting right the hormonal balance in men. At times, men’s bodies may make a high or low level of sex hormones. Hormonal balance is established by either enhancing or reducing the levels of such hormones. The treatment range also includes antibiotic medicines; prescribed to treat infections in sexual organs of males.

Your doctor may also suggest a surgical option if the veins of your scrotal bags have widened or enlarged due to a varicose condition. At times, the passage of sperm or semen may get blocked due to a few internal blockages. Such blocks can be removed with the help of needful surgeries. Last but not least, if fertility problems are due to earlier ejaculation or inability to have and sustain an erection, needful erectile dysfunction medications or counselling are administered.

Assisted reproduction technologies

Technologies used for the treatment of infertility are increasingly becoming popular among couples. These technologies deal with eggs as well as embryos. The general outlook of these technologies is to remove eggs from the ovaries of a woman and combine it with a sperm. Once combined, it is brought into the body of a woman. The woman into whose body the combination (egg and sperm) is placed can also be another person. In short, reproduction is enabled without a conventional mode of sexual intercourse. Assisted reproduction techniques are chosen when all other forms of treating infertility have failed to yield results. These techniques also present a unique advantage of being able to have a baby without an opposite-sex partner.

(1) Intra-Uterine Insemination (IUI)

This approach takes a non-invasive route to help you get pregnant. It is often taken when you have issues with your cervix or with your partner’s sperm. So, how is intra-uterine insemination done? The easiest way to answer this is – IUI is a procedure wherein the male partner’s sperm is placed inside the female partner’s uterus. Such placement helps sperm to get nearer to an egg, as it emerges out of the ovary. In other words, this technique gives the sperm its best possible chance to fertilise an egg.

Lack of adequate movement of sperm cells, premature ejaculation or a lesser count of sperm are some of the reasons for infertility among men. If men have any of these conditions, sperm cells run the risk of never reaching the uterus of their female partner. It occurs because sperm may quickly need to be separated away from semen. This biological separation of sperm occurs because seminal liquid may cramp your uterine region. This process is essential to allow only the sperm to enter a woman’s cervix. In other words, the liquid in which sperm swims is never let to enter the cervix. Once deprived of a medium to swim (read: semen), sperm cells which are more mobile are likely to gain further entry into the uterine passage.

The uterine region can be ruthlessly hostile for sperm cells. Hence, it is only the healthiest and most mobile sperm cell that gets to reach its partner-egg. It is one way to ensure access to the best of a man’s sperm cells to fertilise a well-developed egg, once released from the fallopian tube. IUI technique can help sperm cells successfully face the many challenges your female-partner’s uterine region throws at them. On top of all these hurdles, the cervix may present further challenges for the sperm to meet its egg. There is also the scar tissue challenge which also obstructs a possible union of the sperm with an egg. In all these aspects, IUI helps the sperm to score high; it is a procedure wherein the sperm gets to be strategically well-placed to get an egg to impregnate.

How is IUI done?

IUI is not as invasive as IVF and hence costs lesser. Medical experts suggest IUI as the best way to commence your treatment for infertility. It is done by inserting a catheter through your vagina. Proper positioning of the catheter is done with the support of an ultrasound scan. Sperm is injected at the point where your fallopian tube with an optimally grown egg is identified. The injection process consumes only less than a minute. It is recommended to remain in a sitting posture for a few minutes soon after the injection. As sperm gets injected higher up the uterine pathway – closer to the fallopian tubes, the chances of it leaking through your vagina are less.

IUI is safer for women as it is not invasive in nature. However, some women may experience a few side effects – such as, a sensation of being full, cramps (minor episodes only), etc. You need not be worried of these aftereffects; these are not considered as adverse and they do not persist for long.

Types of IUI procedures

There are two broad ways to perform the intra-uterine insemination procedure. One is the natural approach to IUI and the second is IUI done with fertility-boosting drugs.

Natural approach to IUI – This approach employs the natural ovulation cycle and insemination is done at the apt time. Your medical team primarily monitors the quantum of luteinizing hormone (secreted by cells in the anterior part of your pituitary gland, which helps eggs to mature) in the woman’s body. Levels of hormonal secretion in the woman’s body can be detected with a panel of tests including blood samples as well as ultrasound scan. Medical teams know that the release of eggs starts within 1 day (24 hours) to 1.5 days (36 hours) after they witness a spike in luteinizing hormone level.

IUI performed with drugs to boost fertility – As the name suggests, this procedure is done by administering drugs that can aid release of eggs i.e., ovulation. Such drugs give your medical team a better way to understand the timing of ovulation. For example, you may start ovulating in nearly 1.5 days (36 hours) from the time of administering an hCG hormone.

Importance of timing the IUI procedure well

Your medical team fully knows the value of timing while performing IUI procedures. In fact, the success of IUI procedure rests solely on timing. Your egg only has a few hours of active life. For some women, it can be as low as 12 hours and for some it may last upto 18 hours. But, the maximum time available for an egg never exceeds more than 24 hours. Beyond 24 hours (the outer limit), an egg loses its ability to get fertilised by a sperm. This slim time-window makes IUI a timing-sensitive procedure. When the egg is released and is active on the fertility front, sperm cells from your partner needs to be closer to it. In fact, your male-partner’s sperm has to be there – at the right time and at the right place – to grab the chance to fertilise your egg. You may know that a male’s sperm can live upto, say 4 to 5 days. It hence is possible to make sperm cells to wait and be ready to choose an egg once it emerges.

Likely rate of success – IUI

The average rate of success stands at 9 to 10% in an ovulation cycle. This rate is possible when you have taken a medicine to enable the release of egg and if your age is less than 35 years. As mentioned, medicine like clomid can assist in this. On the other hand, if you are inseminated in your natural ovulation cycle, the rate of success gets lower. Success can elude further if your reserve of eggs (in ovaries) is not high and if you are more than 35 years old. However, if you are less than 35 years of age and are injected with FSH drugs, your rate of success can be as high as 15% in each cycle.

Your medical team may administer IUI for as much as 3 ovulation cycles. You need to stay aware that the odds of your getting pregnant can reduce significantly. It is when your treating doctor may advice you to try an IVF procedure.

In general, IUI is a good way to start treating infertility. It is the closest you will ever get to a natural way of getting pregnant. A key merit of it is your body is primed with hormones or other drugs to make your pregnant. In fact, there is no need of medications soon after injecting your partner’s sperm into your uterus. In simple terms, IUI is an activity of bringing sperm to come closer to your matured egg, and thus letting the natural forces to take their own course.

(2) In Vitro fertilization (IVF)

IUI helps place your male partner’s sperm in your uterus and thus can enhance the odds of pregnancy. In case of In Vitro Fertilization (IVF), this coming together of the sperm and your egg happens inside the laboratory i.e., not inside your body. The action returns to your body once an embryo takes shape; this embryo is placed inside your uterus. All these intricate as well as complex processes make IVF as an expensive process.

How is IVF done?

It starts with administering hormones so that you release many matured eggs and not a single egg. Before your eggs get ready to be retrieved, drugs are administered to help eggs to get matured and also to get all the matured eggs released. The success of this process depends a lot on timing. Success rates are high when eggs are taken when they freshly come out of your fallopian tube. Your doctor knows that if eggs are taken out earlier or later they may not fetch the desired results. So, how do doctors ensure taking the eggs at the right point in time? For this, they use ultrasound scan or a panel of blood tests to ensure eggs are their matured stage while being taken out.

Eggs are retrieved through a needle (with a hollow space within it); your ovaries are scanned by an ultrasound equipment to help identify the fallopian tube. Painkilling drugs are administered or at times a sedating medication is injected. Retrieval of eggs may consume 20 minutes to 60 minutes depending on the timing of ovulation. On the very same day while your eggs are being taken, sperm from your male partner is also collected. As soon as your eggs are retrieved, doctors mix them with sperm. Thereafter, eggs that have turned fertile are closely monitored. It may at times take upto say 4 to 5 days for the embryos to develop before they can be transferred back into your uterus. Your medical team will inform you to return to the IVF center for transferring such developed embryos into your body.

The process of transferring embryos into your uterus is a relatively simpler procedure – i.e., when compared with retrieving of eggs from ovaries. For placing the embryos, your doctor will use a catheter (flexible and hollow) to transfer the embryos inside your uterus. It is a widely followed practice to place more than one embryo; often, your doctor may deposit upto three embryos. This practice though is done to minimize the odds of failure, may result in your getting pregnant with multiple babies. You are advised to take good rest soon after placement of embryos. After say, six or seven hours, you may be asked to leave the IVF center. You will be asked to return to the center within 10 to 15 days to test for pregnancy.

Limited sperm mobility and an additional IVF procedure

Movement of sperm is an essential prerequisite to fertilise eggs. But some men’s sperm may have limited mobility (called as motility). If your male partner’s sperm has such a limitation, your medical team may perform another procedure to solve this condition. An additional procedure known as intracytoplasmic injection of sperm is performed. This is done by taking sperm cells from your male partner’s semen. The harvested sperm cells are directly injected into your eggs. The rest of the IVF procedure is continued from here; i.e., developed embryos are placed inside your womb.

Common infertility conditions for which IVF can be an apt treatment option
IVF can serve as an approach to treat a wide range of conditions leading to infertility. Of these, the most common ones are – (1) lesser count of sperm cells in your partner’s semen. (2) uterine problems or issues with your ovarian health, (3) linings of the inside walls of your uterus start growing outside – a condition called endometriosis, (4) autoimmune conditions – wherein your body attacks your own eggs (this can also happen among men – their body may start harming the sperm cells), (5) bad quality of eggs, (6) genetic disorders, etc.

Prior to even starting an IVF procedure, you may need to understand if it will suit you. How to know this? You may seek inputs from the IVF center on – (1) the average age of couples who became parents after an IVF procedure at the center, (2) the chosen center’s success rate of pregnancy, (3) number of couples who have had multiple pregnancies – such as, twins or triplets, (4) total cost of the IVF procedure at their center – inclusive of cost of hormonal injections, treatments, etc.

Cost of IVF procedure

Your cost can depend upon the percentage your insurer offers. Apart from this, cost of an IVF procedure will also depend on how many cycles you aim to attempt, kind of hormonal back-up treatment you will need, motility / speed of movement of sperm of your male partner, your age as well as the city in which your IVF center is located. You can refer the average pricing guidelines for an IVF treatment issued by the Society of Reproductive Med in the US.

On insurance coverage for IVF treatment, not all states in the US have implemented laws and guidelines to govern the costs to be covered by an insurer. However, some of the states in the US do have laws and policies on the cost items to be covered by insurers for IVF treatment. In general, not all insurers will cover the entire costs. They are selective in their coverage – for example, some many cover the cost of drugs while a few others may include monitoring costs. A majority of the insurers may not cover the cost of the IVF procedure or cost of other allied technologies falling under the domain of artificial / assisted reproduction.

Success rate of IVF procedures

Among the many factors influencing the success of IVF procedures, woman’s age is a paramount factor. The other critical factors are your center’s capabilities to enable pregnancies / live births, the reasons why a couple is unable to conceive, etc. IVF remains the most commonly done procedure among several other alternatives – such as zygote intra-fallopian transfer (popularly referred as ZIFT), gamete intra-fallopian transfer (known as GIFT), etc. IVF in fact has the lion’s share among all other approaches available to treat infertility. Based on secondary data sources, IVF enjoys a share of more than 97% among all options available to treat infertile couples. Couples successfully witnessed pregnancies in nearly 27% of the cycles and in more than 21% of cycles a live birth was witnessed. The rate of success however heavily depends on your age.

Embryos which are not placed back in your fallopian tube can be frozen. Such frozen embryos may be used at a later stage if first placement does not make you pregnant. On the other hand, if you have conceived successfully, you may ask the IVF center to either destroy the remaining embryos or can offer them as a donation to help other couples with infertility issues.

Variations in IVF procedure

Zygote intra-fallopian transfer (ZIFT) is a varied approach of IVF treatment. This follows the same process of retrieval of eggs, making it “mate” with sperm and placing the developed embryos into your uterus. The only difference is the zygotes – fertile eggs – are placed inside your body in less than a day (i.e., over a timeline shorter than 24 hours). In case of gamete intra-follicular transfer (GIFT), the coming together of your eggs and your male partner’s sperm is done just before getting placed inside your fallopian tube.
These modified treatment approaches can help a wide range of infertility conditions. They can be helpful in a few instances of male infertility (of the milder kind). However, both ZIFT and GIFT may not be able to assist reproduction if your ovaries are damaged or if you have anomalies due to genetic as well as congenital reasons.

IUI Vs. IVF

The approach to treat infertility is your personal choice. However, a few factors may influence the choice of treatment such as-

– Costs: IUI costs only a fraction of IVF’s pricing. If your fertility issues lend well to be treated with IUI, it has the least cost per birth ratio when compared with IVF. But, after the third cycle, every incremental IUI cycle may become very expensive.

– Risks of miscarriages: Genetic tests on embryos are possible with the IVF procedure and not with IUI. Hence, the chances of a miscarriage are more with IUI.

– Success rates: IVF presents a higher success rate – especially if you are young.
Caveat- If your male partner’s infertility level is acute IUI may not be the right choice.

Apart from this, if there are blockages in your fallopian tube or if your ovaries have a limited reserve of eggs, IUI may not be a right approach to treat infertility owing to such limitations.

In sum, infertility in men can be due to congenital disorders, ejaculation-related problems, hormonal imbalances, enlargement of blood vessels and other conditions such as premature ejaculation or erectile dysfunction. Infertility in women can be a primary level of infertility, a secondary condition, psychological reasons for infertility, sterility or inexplicable infertility.

Assisted reproduction technologies are used when other forms of treatment have failed to fetch desired results. Intra-Uterine Insemination (IUI) is a procedure in which your male partner’s sperm is placed inside your uterus. This process helps the sperm to come nearer to your egg. IUI gives a sperm the best possible chance to fertilise the egg. In Vitro Fertilization (IVF) is a procedure wherein the sperm and your egg come together inside a laboratory. Soon after initial development – within a few days – the embryo is placed back inside your uterus.

Selection of an approach to treat infertility is a very personal decision. But, you may need to consider a few other factors like costs (IUI costs only a fraction of IVF and IUI’s cost per birth ratio is quite low; but after the 3rd cycle, cost per IUI cycle is very expensive), success rates (IVF offers a better success rate), etc. You are advised to talk to a qualified medical practitioner and obtain needful inputs to decide as well as start a plan to treat infertility.

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