Newsletter October 2007
Basic Medical Consideration (Causes, Diagnosis & Investigations)
Dr. Pawan S. Chandak
Definition: Infertility primarily refers to the biological inability of a man or a woman to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term.
There are strict definitions of infertility used by many doctors. However, there are also similar terms, e.g. subfertility for a more benign condition and fecundity for the natural improbability to conceive.
Reproductive endocrinologists, the doctors specializing in infertility, consider a couple to be infertile if:
the couple has not conceived after 12 months of contraceptive-free intercourse if the female is under the age of 35
the couple has not conceived after 6 months of contraceptive-free intercourse if the female is over the age of 35 (declining egg quality of females over the age of 35 account for the age-based discrepancy as when to seek medical intervention)
the female is incapable of carrying a pregnancy to term.
Healthy couples in their mid-20s having regular sex have a one-in-four chance of getting pregnant in any given month. This is called "Fecundity".
A couple that has tried unsuccessfully to have a child for a year or more is said to be subfertile. The couple's fecundability rate is approximately 3-5%. Many of its causes are the same as those of infertility. Such causes could be endometriosis, or polycystic ovarian syndrome.
(1)Infertility affects approximately 10% of people of reproductive age and 15% of couples.
(2) Roughly 40% of cases involve a male contribution or factor, 40% involve a female factor, and the remainder involve both sexes.
This section deals with unintentional causes of sterility. For more information about surgical techniques for preventing procreation, see sterilization.
Primary vs. secondary
Couples with primary infertility have never been able to conceive while, on the other hand,
secondary infertility is difficulty conceiving after already having conceived and carried a normal pregnancy. Technically, secondary infertility is not present if there has been a change of partners.
Some women are infertile because their ovaries do not mature and release eggs. In this case synthetic FSH by injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate follicles to mature in the ovaries.
Causes in either sex
Factors that can cause male as well as female infertility are:
A Robertsonian translocation in either partner may cause recurrent abortions or complete infertility.
Diabetes mellitus, thyroid disorders, adrenal disease
Factors relating only to female infertility are:
Significant liver, kidney disease
Polycystic ovarian syndrome
Diminished ovarian reserve, also see Poor Ovarian Reserve
Gonadal dysgenesis (Turner syndrome)
Pelvic inflammatory disease (PID, usually due to chlamydia)
Uterine fibroids (leiomyoma)
Insufficient cervical mucus (for the travel and survival of sperm)
Various intersexed conditions, such as androgen insensitivity syndrome
Factors relating only to male infertility include:
Hypogonadism due to various causes
Drugs, alcohol, smoking
Strenuous riding [Bicycle, Horseback]
Bad semen quality
Abnormal sperm morphology
Azoospermia (complete lack of sperm in semen, can be due to scar tissue in testicle)
Genetic defects on the Y chromosome
Y chromosome microdeletions
Abnormal set of chromosomes
Neoplasm, e.g. seminoma
Testicular dysgenesis syndrome
Vas deferens obstruction
Lack of Vas deferens, often related to genetic markers for Cystic Fibrosis
Infection, e.g. prostatitis
Acrosomal defect/egg penetration defect
In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility arises from the combination of these conditions. In other cases, the cause is suspected to be immunological or genetic; it may be that each partner is independently fertile but the couple cannot conceive together without assistance.
In about 15% of cases the infertility investigation will show no abnormalities. In these cases abnormalities are likely to be present but not detected by current methods. Possible problems could be that the egg is not released at the optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization.
The diagnosis of infertility begins with a medical history and physical exam by a urologist, preferably one with experience or who specializes in male infertility. The provider may order blood tests to look for hormone imbalances or disease. A semen sample will be needed. Blood tests may indicate genetic causes.
In the majority of cases of male infertility and low sperm quality, no clear cause can be identified with current diagnostic methods.
The cornerstone of the male partner evaluation is the history. It should note the duration of infertility, earlier pregnancies with present or past partners, and whether there was previous difficulty with conception.
The history should include prior testicular (penis) insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors (excessive heat, radiation, chemotherapy), medications (anabolic steroids, cimetidine, and spironolactone may affect spermatogenesis; phenytoin may lower FSH; sulfasalazine and nitrofurantoin affect sperm motility), and drug use (alcohol, smoking, marijuana).
Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility experiences are important. Loss of libido and headaches or visual disturbances may indicate a pituitary tumor.
The past medical or surgical history may reveal thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply).
A complete examination of the infertile male is important to identify general health issues associated with infertility. For example, the patient should be adequately virilized; signs of decreased body hair or gynecomastia may suggest androgen deficiency.
The scrotal contents should be carefully palpated with the patient standing.
As it is often psychologically uncomfortable for men to be examined, one helpful hint is to make the examination as efficient and as matter of fact as possible.
The peritesticular area should also be examined. Irregularities of the epididymis, located posterior-lateral to the testis, include induration, tenderness, or cysts.
Main article: semen quality
The volume of the semen is measured, as well as the number of sperm in the sample. How well the sperm move is also assessed. This is the most common type of fertility testing.
A blood sample can reveal genetic causes of infertility, e.g. a Y chromosome microdeletion, cystic fibrosis.
Diagnosis of infertility begins with a medical history and physical exam. The healthcare provider may order tests, including the following:
an endometrial biopsy, to verify ovulation and inspect the lining of the uterus
hormone testing, to measure levels of female hormones at certain times during a menstrual cycle
day 2 or 3 measure of FSH and estrogen, to assess ovarian reserve
measurements of thyroid function (a thyroid stimulating hormone(TSH) level of between 1 and 2 is considered optimal for conception)
laparoscopy, which allows the provider to inspect the pelvic organs
measurement of progesterone in the second half of the cycle to help confirm ovulation
Pap smear, to check for signs of infection
pelvic exam, to look for abnormalities or infection
a postcoital test, which is done soon after intercourse to check for problems with sperm surviving in cervical mucous (not commonly used now because of test unreliability)
special X-ray tests
Diagnosis and treatment of infertility should be made by physicians who are fellowship trained as reproductive endocrinologists.
Reproductive Endocrinologists are usually Obstetrician-Gynecologists with advanced training in Reproductive Endocrinology & Infertility (in North America). These highly educated professionals and qualified physicians treat Reproductive Disorders affecting not only women but also men, children, and teens.
Prospective patients should note that reproductive endocrinology & infertility medical practices do not see women for general maternity care. The practice is primarily focused on helping their patients to conceive and to correct any issues related to recurring pregnancy loss.
“Frequently Asked Questions About Infertility” (2006). American Society for Reproductive Medicine.
^ Male Infertility. Infertility. Armenian Medical Network (2006).
^ American Society for Reproductive Medicine (FAQ)
^ Rowe PJ, Comhaire FH, Hargreave TB, Mahmoud AMA. WHO Manual for the Standardized Investigation, Diagnosis and Management of the Infertile Male. Cambridge University Press, 2000. ISBN 0-521-77474-8.
^ Fertility Testing
^ Domar AD, Zuttermeister PC, Friedman R. The psychological impact of infertility: a comparison with patients with other medical conditions. J Psychosom Obstet Gynaecol. 1993;14 Suppl:45-52. PMID 8142988.
^ Beutel M, Kupfer J, Kirchmeyer P, Kehde S, Kohn FM, Schroeder-Printzen I, Gips H, Herrero HJG, Weidner W. Treatment-related stresses and depression in couples undergoing assisted reproductive treatment by IVF or ICSI. Andrologia. 31 (1999): 27-35.
^ Schmidt et al. "The Social Epidemiology of Coping with Infertility." Human Reproduction. 20 (2005): 1044-1052.
Brugh VM 3rd et al: Male factor infertility: evaluation and management. Med Clin North Am 2004;88:367.PMID: 15049583
Hirsh A: Male subfertility. BMJ 2003;327:669.PMID: 14500443
Makar RS et al: The evaluation of infertility. Am J Clin Pathol 2002;117(Suppl):S95.PMID: 14569805
McGuckin I: Pink for a Girl: Wanting a baby and not conceiving - my personal story
Shepperson Mills D, Vernon M: Endometriosis a key to healing and fertility through nutrition. ISBN 0-00-713310-3
Article Presented by
Dr. Pawan S. Chandak
‘Shradha’ Vishnu nagar,
Basmat Road, Parbhani 431401