Infertility means not being able to become pregnant after a year of trying. If a woman can get pregnant but keeps having miscarriages or stillbirths, that’s also called infertility.
Infertility is fairly common. After one year of having unprotected sex, about 15% of couples are unable to get pregnant. About a third of the time, infertility can be traced to the woman. In another third of cases, it is because of the man. The rest of the time, it is because of both partners or no cause can be found.

There are treatments that are specifically for men or for women. Some involve both partners. Drugs, assisted reproductive technology, and surgery are common treatments. Happily, many couples treated for infertility go on to have babies.

GENERAL INFORMATION AND INTERNATIONAL PERSPECTIVE

The birth of Louise Brown (the world’s first IVF baby) in 1978 ushered in a new revolution in the treatment of infertility.

IVF and its derivatives in preimplantation diagnosis, stem cells and the ethics of assisted reproduction continue to attract immense attention scientifically and socially. All these topics were introduced by 1970 but yet hardly a day passes without some public recognition of events related to IVF, and clinics spread even further worldwide. Now we must be approaching 2 million IVF births, it is time to celebrate what has been achieved by so many investigators, clinical, scientific and ethical.

IVF primarily dealt with female related infertility for patients with blocked tubes, endometriosis, PCOS and unexplained Infertility. Little could be done for sever male related infertility until the advent of Intra Cytoplasmic Sperm Injection (ICSI), about 20 years ago wherein scientists could actually inject a single sperm into the egg of the wife and produce a baby even with the lowest of sperm counts and worst of sperm motility. It is now possible to extract sperm from the testicles (TESA) in cases of azoospermia (zero sperm counts) and use these for ICSI and help the couple have their own biological child (without the need for sperm donors). Also, for men with blocked vas deferens (the tube that transports sperms from the testicles to the outside) can avail of Percutaneousepididymal sperm aspiration (PESA) with ICSI for the same successful outcome as TESA-ICSI.

The third biggest advance since the introduction of IVF & ICSI has been vitrification (cryo-freezing) of gametes and embryos. Over the past two years there has been a shift towards performing more frozen embryo transfers with better preparation of the uterus resulting in higher take home baby rates. Most clinics with a good vitrification program can now deliver success rates of 50% per IVF cycle as compared to about 35-40% with conventional fresh embryo transfer.

More and more women are opting for higher education and pursuit of their career ambitions. In the bargain, marriage and child bearing are being deferred to a later age. Often, after the age of 37 the egg quality is not the best and many of them have to resort to egg donation, thereby sacrificing their genetic component in the child. These young and dynamic women now have the option of freezing their eggs (saving their fertility “in time”) at a young age for use at a later date thereby making their lives complete both on the career as well as personal front.

A simpler technique called Intrauterine insemination (IUI) has been in existence for a long time and is beneficial for young couples with minor problems or those experiencing sexual dysfunction.

Recently, Preimplantation genetic diagnosis (PGD) has further helped to enhance success rates especially in women over the age of 35 or those with history of miscarriages or abnormal offspring. In this technique, the embryos are biopsied and evaluated in a special genetic laboratory to ensure that only genetically normal embryos are transferred back into the woman.

Most modern clinics also offer time-lapse imaging using video monitoring of embryo growth which helps select the best embryo for transfer and further improve on the success rates There is another very important aspect of ART practice and that is third party reproduction which is extremely successful but governed by religious, ethical and legal issues. In India, most of the clinics are compliant with the ART guidelines laid down by the Indian Council of Medical Research for the practice of these techniques. There is sperm donation for men who have total testicular failure and zero sperm counts or for those who cannot afford ICSI. There is egg donation for women who are menopausal or have had multiple IVF failures owing to poor egg quality. And finally, there is gestational surrogacy for women who have had failed multiple cycles of IVF because of problems in the uterus.

On the horizon, we have stem cell treatment for augmenting oocyte and endometrial quality (in women with poor quality eggs or uterus). Also, a fast developing field of epigenetics (DNA contribution from the mother even if there is a donor egg involved) offers renewed hope to many patients who have to opt for a donor egg. Three-parent IVF holds great promise for couples as it would ensure that the genetic component is the mother’s even if she has to take a donor egg for some help with the pregnancy.

Causes & Symptoms

The main symptom of infertility is not getting pregnant. There may be no other obvious symptoms. Sometimes, women with infertility may have irregular or absent menstrual periods. In some cases, men with infertility may have some signs of hormonal problems, such as changes in hair growth or sexual function.

Most couples will eventually conceive, with or without treatment.

When to see a doctor

You probably don’t need to see your health care provider about infertility unless you have been trying regularly to get pregnant for at least one year. Women should talk with a care provider earlier, however, if they:

  • Are age 35 or older and have been trying to conceive for six months or longer
  • Are over age 40
  • Have irregular or absent periods
  • Have very painful periods
  • Have known fertility problems
  • Have been diagnosed with endometriosis or pelvic inflammatory disease
  • Have had multiple miscarriages
  • Have undergone treatment for cancer

Men should talk to a health care provider if they have:

  • A low sperm count or other problems with sperm
  • A history of testicular, prostate or sexual problems
  • Undergone treatment for cancer
  • Small testicles or swelling in the scrotum
  • Others in your family with infertility problems

Causes

All of the steps during ovulation and fertilization need to happen correctly in order to get pregnant. Sometimes the issues that cause infertility in couples are present at birth, and sometimes they develop later in life.

Infertility causes can affect one or both partners. Sometimes, no cause can be found.

Causes of male infertility

These may include:

  • Abnormal sperm production or function due to undescended testicles, genetic defects, health problems such as diabetes, or infections such as chlamydia, gonorrhea, mumps or HIV. Enlarged veins in the testes (varicocele) also can affect the quality of sperm.
  • Problems with the delivery of sperm due to sexual problems, such as premature ejaculation; certain genetic diseases, such as cystic fibrosis; structural problems, such as a blockage in the testicle; or damage or injury to the reproductive organs.
  • Overexposure to certain environmental factors, such as pesticides and other chemicals, and radiation. Cigarette smoking, alcohol, marijuana, anabolic steroids, and taking medications to treat bacterial infections, high blood pressure and depression also can affect fertility. Frequent exposure to heat, such as in saunas or hot tubs, can raise body temperature and may affect sperm production.
  • Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely.

Causes of female infertility

Causes of female infertility may include:

  • Ovulation disorders, which affect the release of eggs from the ovaries. These include hormonal disorders such as polycystic ovary syndrome. Hyperprolactinemia, a condition in which you have too much prolactin — the hormone that stimulates breast milk production — also may interfere with ovulation. Either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism) can affect the menstrual cycle or cause infertility. Other underlying causes may include too much exercise, eating disorders or tumors.
  • Uterine or cervical abnormalities, including abnormalities with the cervix, polyps in the uterus or the shape of the uterus. Noncancerous (benign) tumors in the uterine wall (uterine fibroids) may cause infertility by blocking the fallopian tubes or stopping a fertilized egg from implanting in the uterus.
  • Fallopian tube damage or blockage, often caused by inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, which is usually caused by a sexually transmitted infection, endometriosis or adhesions.
  • Endometriosis, which occurs when endometrial tissue grows outside of the uterus, may affect the function of the ovaries, uterus and fallopian tubes.
  • Primary ovarian insufficiency (early menopause), when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain factors are associated with early menopause, including immune system diseases, certain genetic conditions such as Turner syndrome or carriers of Fragile X syndrome, and radiation or chemotherapy treatment.
  • Pelvic adhesions, bands of scar tissue that bind organs that can form after pelvic infection, appendicitis, endometriosis or abdominal or pelvic surgery.
  • Cancer and its treatment. Certain cancers — particularly reproductive cancers — often impair female fertility. Both radiation and chemotherapy may affect fertility.

Risk factors

Many of the risk factors for both male and female infertility are the same. They include:

  • Age. Women’s fertility gradually declines with age, especially in the mid-30s, and it drops rapidly after age 37. Infertility in older women is likely due to the lower number and quality of eggs, and can also be due to health problems that affect fertility. Men over age 40 may be less fertile than younger men.
  • Tobacco use. Smoking tobacco or marijuana by either partner may reduce the likelihood of pregnancy. Smoking also reduces the possible effectiveness of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can increase the risk of erectile dysfunction and a low sperm count in men.
  • Alcohol use. For women, there’s no safe level of alcohol use during conception or pregnancy. Alcohol use may contribute to infertility. For men, heavy alcohol use can decrease sperm count and motility.
  • Being overweight. Among American women, an inactive lifestyle and being overweight may increase the risk of infertility. For men, sperm count also may be affected by being overweight.
  • Being underweight. Women at risk of fertility problems include those with eating disorders, such as anorexia or bulimia, and those who follow a very low-calorie or restrictive diet.
  • Exercise issues. A lack of exercise contributes to obesity, which increases the risk of infertility. Less often, ovulation problems may be associated with frequent strenuous, intense exercise in women who are not overweight.
Prevention

Some types of infertility aren’t preventable. But several strategies may increase your chances of pregnancy. Have regular intercourse several times around the time of ovulation for the highest pregnancy rate. Intercourse beginning at least five days before and until a day after ovulation improves your chances of getting pregnant. Ovulation usually occurs in the middle of the cycle — halfway between menstrual periods — for most women with menstrual cycles about 28 days apart.

Men

Although most types of infertility aren’t preventable in men, these strategies may help:

  • Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
  • Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
  • Avoid exposure to industrial or environmental toxins, which can affect sperm production.
  • Limit medications that may impact fertility, both prescription and nonprescription drugs. Talk with your doctor about any medications you take regularly, but don’t stop taking prescription medications without medical advice.
  • Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy.
Women

For women, a number of strategies may increase the chances of becoming pregnant:

  • Quit smoking. Tobacco has many negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
  • Avoid alcohol and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don’t drink alcohol or use recreational drugs, such as marijuana, if you’re trying to get pregnant.
  • Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for guidance on the safe use of caffeine.
  • Exercise moderately. Regular exercise is important, but exercising so intensely that your periods are infrequent or absent can affect fertility.
  • Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.