Infertility means not being able to get pregnant after one year of trying (or six months if a woman is 35 or older). Women who can get pregnant but are unable to stay pregnant may also be referred to as infertile.

Pregnancy is the result of a process that involves various steps. To get pregnant:

• A woman's body must release an egg from one of her ovaries (ovulation)
• The egg must go through a fallopian tube toward the uterus (womb)
• A man's sperm must join with (fertilize) the egg along the way
• The fertilized egg must attach to the inside of the uterus (implantation)

Infertility can happen if there are problems:

Childless couples lack the public support. Loss of fertility is the loss of women’s hope for the future. Most of the time pressure to conceive is directed towards women.

The term secondary infertility means women who have had at least one successful pregnancy in the past but are not able to conceive now. We will focus on female infertility on this article

   ACOG (American College of Obstetricians and Gynecologists) make following recommendations –

1)   Infertility evaluation offered to any patient who by definition has infertility or is at high risk for infertility

2)   Women older than 35 years of age should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to pregnant or earlier if clinically indicated

3)   If women is older than 40 years immediate evaluation and treatment is required

Women should consult a gynaecologist. Pre-Pregnancy counselling and evaluation is important

What does it include?

-         It includes detailed medical history, physical examination, blood tests, and other investigations.

-         How long couple is suffering from infertility

-         Menstrual history like age at menarche, cycle interval, length

-         Ovulation signs like positive ovulation tests, cervical mucus changes

-         Biphasic basal body temperature

-         Pregnancy history

-         Previous methods of contraception

-         Coital frequency, timing

-         Sexual dysfunction, Sexual history

-         Any abdominal, pelvic surgery

-         Any history of PID,STI (sexually transmitted Infections),endometriosis, leiomyoma

-         H/O thyroid disease, hirsutism, galactorrhoea, pain during coitus

-         Occupational hazards

-         Any addictions

Physical examination includes –

BMI, thyroid evaluation, breast examination, Skin examination, abdominal,vaginal, cervical anatomy, pelvic masses.

Causes of Infertility –

Most cases of female infertility are caused by problems with ovulation. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.

Ovulation problems are often caused by polycystic ovarian syndrome (PCOS). PCOS is the most common cause of female infertility. Primary ovarian insufficiency (POI) is another cause of ovulation problems. POI occurs when a woman's ovaries stop working normally before she is 40. POI is not the same as early menopause.

Less common causes of fertility problems in women include:

• Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy
• Physical problems with the uterus
• Uterine fibroids which are non-cancerous clumps of tissue and muscle on the walls of the uterus.

·         Hypothalamic amenorrhoea  - occurs in eating disorders, excessive exercise, associated weight loss

How to detect PCOS –

Clinical signs like hirsutism (excessive hairs on body),acne, alopecia, dark velvety patches over body folds and polycystic ovaries on ultrasonography.

Risk factors –

Many things can change a woman's ability to have a baby. These include:

• Age
• Smoking
• Excess alcohol use
• Stress
• Poor diet
• Athletic training
• Being overweight or underweight
• Sexually transmitted infections (STIs)
• Health problems that cause hormonal changes, such as polycystic ovarian syndrome and primary ovarian insufficiency

In women, the first step is to find out if she is ovulating each month. There are a few ways to do this. A woman can track her ovulation at home by:

• Writing down changes in her morning body temperature for several months
• Writing down how her cervical mucus looks for several months
• Using a home ovulation test kit

How does age affect a woman's ability to have children?

Many women are waiting until their 30s and 40s to have children. So age is a growing cause of fertility problems. About one-third of couples in which the woman is over 35 have fertility problems.

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

• Her ovaries become less able to release eggs
• She has a smaller number of eggs left
• Her eggs are not as healthy
• She is more likely to have health conditions that can cause fertility problems
• She is more likely to have a miscarriage

How to evaluate infertility –

1)   For Male – Semen analysis, Serum Testosterone, Physical examination

2)   For Females – Serum FSH, LH, Prolactin, estradiol, AMH (indicates ovarian reserve),tubal patency is evaluated by laparoscopy which also detects pelvic adhesions, endometriosis,

Hysterosalpingography is more commonly used as less invasive technique

Preventive factors –

-         Lifestyle changes like healthy diet, avoid junk food

-         Late marriages should be discouraged as fertility declines with age and chances of birth defects, hypertension, diabetes increases

Treatment –

-         Couple counselling by infertility specialist

-         Fertility drugs (clomiphene citrate or FSH and LH hormone injections) are the primary treatment for women with ovulation disorders

-         Intrauterine insemination IUI

-         Fibroid, polyp removal by operative hysteroscopy

-         IVF (In vitro Fertilization)  means fertilization outside of the body. It is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.

Surrogacy

Women with no eggs or unhealthy eggs might also want to consider surrogacy. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child will be genetically related to the surrogate and the male partner. After birth, the surrogate will give up the baby for adoption by the parents

Among women with recognised infertility, only one-third had sought advice and used hormonal/IVF treatment by the time they were aged 28-33 years. Women with an identi?able cause for their infertility, i.e. PCOS and endometriosis were the most proactive in seeking advice and using ART. There is a strong need to raise awareness of infertility issues and treatment options among the general population and medical professionals from whom advice is sought in the ?rst instance.  Raised awareness is particularly important  for  partnered  women  aged  ~30  years  to  encourage trying  to  become  pregnant  during  their  prime  reproductive years  and  reduce  the  risk  of  infertility. For women who seek advice for their recognised infertility, prompt referral for further investigations maximises their chance of pregnancy before the age of 35 years.

Dr PriyaMakodeTonape

MBBS, DGO,

Consultant Gynaecologist

Pune