Female Infertility

Female infertility is a common contributor to difficulties in producing children. At least half of all couples consulting for infertility will involve a female partner with a “problem”. In the old days, the female partner used to bear the brunt of blame and only about 5% of couples seeking help with having a baby were thought to be due to a male infertility, but today we know better! There are many categories of female infertility.

The normal female cycle

As most ladies know, their cycles are about 28 days long. Every 28 days, a bleed lasting about 5 days will occur. Four hormones control this cycle and they are controlled mainly by the hypothalamus, which is an area in the brain. It acts on the pituitary gland to release FSH and LH, the sex hormones that stimulate the ovary and produce ovulation. Under the influence of FSH and LH, the ovary makes oestrogen. The oestrogen has a strong effect on the uterus, causing the lining of the womb to grow during the first 14 days of the cycle. After ovulation, progesterone becomes the important hormone. Its main action is to maintain the endometrium so that the fertilized egg may implant. If it does, pregnancy results, if not the bleed will occur.

Immature Egg	Mature Egg

Anovulation

No cycle. No bleeds. No ovulation. No baby. A common cause of infertility in women. It is sometimes caused by low levels of LH and FSH (sex hormones) which results in low oestrogen and progesterone levels. In some women anovulation is manifested by high FSH levels indicating primary ovarian failure. Often the women may be Turner`s (XO) syndrome. Anovulation may also be caused by hyperprolactinaemia (excessive production of prolactin-how contraception is achieved in nursing mothers). This hormone normally induces the breasts to produce milk. Prolactin is also able to suppress ovulation. Ovulation can sometimes be variable - oligomenorrhoea. This may sometimes be due to the above-mentioned reasons, but more commonly is caused by PCO (Polycystic ovaries). This is a condition revealed by abnormal LH levels in the blood. Another feature is high androgen levels (male hormones). In serious cases of PCO anovulation/amenorrhoea may also happen. A common test of ovulation is a day 21 progesterone.

Tubal blockage

One of the most common causes of tubal blockage is pelvic inflammatory disease. Other mechanisms may also cause blockage, but the key to this condition is that the egg almost never reaches the womb, since its passage is blocked. This is a fairly common cause of infertility.

Non tubal related infertility:

Unexplained

Despite routine investigations, no obvious reason can be determined. This is, after anovulation, one of the most common diagnoses of infertility.

Endometriosis

Here, uterine tissue is found in the abdomen. On the outside of the uterus or on the ovaries. Endometriosis does not always cause infertility. Yet it is commonly associated with involuntary childlessness.

Morphological

Abnormal pelvic anatomy may contribute greatly to infertility. Fibroids in the womb, severe retroversion or torsion of the ovaries or tubes due to pelvic adhesions, etc, etc, may all contribute to difficulties.

Diagnostics

Physical examination is the first port of call, as well as an ultrasound scan to ensure that the gross anatomy is as it should be. Following a detailed history, an arrangement for a “day 21” blood test will be made. In the case of anovulation, a blood sample may be taken at any time and an arrangement made for follicular. Hormone levels to be tested will be FSH, LH, Progesterone, Prolactin and sometimes, testosterone. These tests will reveal reasons for anovulation or provide information on the endocrinal state of the female patient. Further tests will follow at different times depending on the age, duration of infertility and the urgency of the couple.

Tubal patency should be proven as a matter of priority. There is some controversy, though, as to the timing of such tests. An early test avoiding surgery is the use of X ray. This test is called hysterosalpingography. Dye is passed into the womb and its passage is monitored by X ray. A new method of this is being developed. Instead of X ray, ultrasound is used instead. Laparoscopy reveals more information, since a visual inspection of the anatomy of the pelvis is also carried out at the same time as the tubal patency test (dye spill). At least two blood tests should be carried out initially (three month gap). Thereafter, after initial diagnosis and treatment, blood and tubal patency tests should be carried out every 12-24 months.

For anovulation or oligomenorrhoea, treatment is simple and usually effective. Injections with sex hormones LH and FSH are routinely in use. This therapy is effective for 70-90% of patients. Patients with PCO will benefit from FSH only injections. Success with PCO patients is about 55-70% of all treated cases.

Failure with treatment means progression to IVF. IVF is the first port of call for patients with tubal disease, if they are unsuitable for tubal surgery or choose not to consider it. It may also be suitable for some of the other categories of female infertility, after prolonged treatment with less stressful and invasive options.

Male Infertility

Male infertility is a common contributor to difficulties in producing children. At least half of all couples consulting for infertility will involve a male partner with a “problem”. The first test to be done in order to assess male infertility is the traditional semen analysis, commonly known as the sperm count. This consists of estimating count, motility, progression and the rate of abnormality. Although this is not adequate on its own, it is a good place to start. Low count <20 million per ml does not indicate sub fertility per se, but the probability of subfertility is increased.  It is important to obtain at least 3 samples, since semen samples can vary a great deal from sample to sample.

Some general information 

Before a sample is obtained up to 48 hours abstinence is ideal. More than 5 days is no good. Samples are usually produced by masturbation. Samples produced by COITUS INTERRUPTUS are not suitable, because...the first portion of the sample (the most important part) is usually lost when using this method.  Cell and bacterial contamination will also occur.  After ejaculation, room temperature (20-30 C) is ideal for transport and storage of semen. 

Once the sperm count has been done, if it is okay, no further action is required. If the sperm count is poor, the next step is a physical examination and a blood test. In most cases no abnormality is detectable in the man’s “plumbing”. This is usually checked by a physical examination, followed by an x-ray test using radio-opaque dye (vasogram. When the vasogram reveals a blockage, the problems are just the same as in blocked tubes in the female. The treatment is also similar; either surgery to repair the block, or IVF where the sperm used for ICSI have to be surgically retrieved as the eggs are, when the female partner has blocked tubes. If no blockage is detected, there is no surgical intervention which will be of value.  

In situations where the physical examination reveals abnormal anatomy, eg Cryptorchidism-undescended testes, congenital absence of vas-no tubes or small testes; there is little evidence to suggest that much may be done. In conditions such as epididymal cysts, blockage of vas and varicocoele, surgical intervention may be considered, but even here success rates vary from 0-25%.  

Diagnosis is not complete until testicular function has been tested. The best non-surgical method is to take a sample of the male partners blood and to measure the LH (luteinising hormone or interstitial cell stimulating hormone-this acts on the Leydig cells in the testes, which make testosterone), FSH (follicle stimulating hormone-acts on Sertoli cells of the testes which have an intimate relationship with sperm) and testosterone (promotes sperm development) levels.  Low LH or FSH levels indicates hypogonadic function, which is sometimes associated with a low sperm count. This condition might respond to tamoxifen, hCG or FSH therapy. High FSH levels are usually an indication of testicular failure and is almost always associated with a low sperm count and sometimes no sperm (called azoospermia). High testosterone may be an indication of testicular cancer and should be followed up by  an urologist. If the endocrinology (blood test results) needs confirmation a testicular biopsy can be performed by an urologist.  

So at the end of the day, if all the tests indicate absence of abnormality  (endocrinal or mechanical) and surgical intervention is either not required or has been completed, provided the male partner is not azoospermic, we have to deal with what we`ve got! 

What is a normal sperm count? 

Guidelines from the WHO suggest that normal count is about 50-150 million per ml.  Motility 50-80%. Progression is a subjective parameter, which is scored 0-3. Normal is scored 2 or better, which indicates that the motile sperm move with vigour. Feeble moving motile sperms would be scored 0 or 1. Generally only donor samples score progression of 3. The WHO fertile abnormality rate would be 25-40%. The WHO suggests that the following values indicate infertility. Count less than 20 million per ml, motility less than 40%, progression less than 2, abnormality rate in excess of 40%.