1. What is infertility?
Ans. Infertility is defined as the inability to conceive after at least two years of intercourse while not using any contraceptive method. A normal fertile having regular sex and wishing to have a baby has a 50% chance of conceiving in 5 months, 75 % in 12 months and 88 to 90% at the end of 24 months.
2. When should a couple start worrying about not being able to conceive?
Ans. It takes two years for 88-90% of couples to conceive. However, any period is adequate for starting investigations in a couple of advanced age or with history of menstrual problems, medical problems or related surgical problems in either partner.
3. Who is at fault?
Ans. The female partner is responsible for infertility in 40 to 45 % of cases and the male in another 30 to 40%. In a few cases both are at fault. However in 15% to 20% of cases no fault in either partner can be found.
4. Who should a couple go for counseling regarding conception?
Ans. There are tertiary centers for reproductive medicine with facilities for in vitro fertilisation also. These centers have dedicated gynecologists who generally look after problem of infertility only. Such centers are best suited for counseling regarding infertility.
5. What are the causes of infertility in women?
Ans. The ovaries may not be able to produce fully-grown eggs. The fallopian tubes that transfer the egg from the ovary to the uterus may be blocked or non-functional. This may happen in cases of infections like tuberculosis, endometriosis, or previous surgery of tubes or ovaries.The mouth of the uterus known as the cervix opens into the vagina and normally produces a thin watery mucous discharge at the time of ovulation. If this mucous is thick or contains substances that kill the sperms, then this may prevent the sperms from swimming through it into the uterine cavity into the tubes to reach the egg.
Distorted or partially blocked cavity of the uterus such as with fibroids or adhesions may not let the embryo implant and grow within it.
6. What are the causes of infertility in males?
Ans. A semen sample which shows number of sperms less than 15 million per ml or active forward motility of less than 32% of sperms or less than 4% of structurally normal sperms may adversely affect fertility.
*Men who are not able to reach or deposit semen into the female genital tract satisfactorily may also have difficulty in conception.
*Sperms may be completely absent in the semen either due to no production by testis or blockage in the tube which carries the sperms from the testis to the ejaculate.
7. When does ovulation occur?
Ans. In women who have regular 28 days cycle, ovulation occurs between 13th to 16th day of menstruation. In-patients with longer cycle’s ovulation may occur later or may not occur at all.
8. What are the signs, which can tell the women when she has ovulated?
Ans. Just before ovulation mucus discharge from the vagina increases and becomes copious. In addition there could be lower abdominal discomfort or pain ranging from half an hour- to 24 hours. Urinary LH kits are also available, which are similar to urine pregnancy kits. A drop of urine on the plate of the kit may show a colour change-indicating surge of LH hormone, which is associated with ovulation.
9. What tests are done in females to see if all is well or not?
Ans. The doctor first takes a detailed clinical history to ascertain the possible cause of infertility. If the problem lies in faulty sexual practice, this can be mostly counselled but rarely corrected. Structural abnormalities in the sex organs are looked for, and sometimes an ultrasound scan may need to be done to ensure normal internal organs. Ultrasound is also useful to help in determining the exact time of ovulation. Blood and urine are tested to assess hormonal status and general health of the couple. Performing a hysterosalpingography or HSG can test the patency of fallopian tubes. In this a dye is injected into the uterus and x-rays are taken which show the filling up of open tubes. No anesthesia is required for this test and there is only minimal discomfort. A laparoscopy can also be performed for diagnosis in which a telescope is inserted into the abdomen under general anesthesia to visualize the internal organs including the uterus ovaries and tubes as well as their patency.
10. If a patient does not ovulate what needs to be done?
Ans. In such cases help of medicines, which can develop eggs in the ovary, is taken. The most commonly used drug is clomiphene citrate, which is available over the counter in our Indian market. Due to its low price and easy availability this drug is being used empirically and injudiciously by most of the general practitioners. It is advisable not to use this drug for more than 12 cycles in ones life time as it may marginally increase the risk of ovarian epithelial cancers still a controversial statement. Apart from this, the drug has its own side effects along with risk of over stimulation of the ovaries and multiple pregnancy. Therefore, caution is required regarding the use of this drug unnecessarily or without proper monitoring. All other drugs are injectable gonadotropins and should be used by a person experienced and specialized in their use with proper monitoring of ovulation by ultrasonography and hormonal assay.
11. Can a woman, who has never menstruated, conceive?
Ans. If the woman has a uterus and a patent passage into the vagina and vulva she should be able to conceive. This can be achieved either with the use of medicines such as gonadotropins to stimulate ovulation in cases of hypogonadotropic hypogonasim or by the help IVF and donor eggs in cases of ovarian failure.
12. What options does a woman with blocked tubes have?
Ans. If the blockage involves a small part of the tube then tube can be surgically recanalised. This can be either done, by open microsurgery or keyhole surgery, which involves the use of hysteroscopy and laparoscopy. If her tubes are damaged beyond repair or repair has failed she can be helped by IVF. Such patients should go to a center where facilities for tubal microsurgery and IVF both are available so that, she is treated without a bias towards any of the above technique.
13. What tests are done for men?
Ans. Men are advised to undergo analysis of their semen. For this their semen is collected by masturbation. The must have abstained from sexual intercourse preferably for 3 to 5 days before giving the semen sample for testing. In semen analysis the sperm count is noted along with the motility and structure of sperms. If there is any doubt about the functional status of the sperms specialised tests known as sperm function tests can be done to ensure sperm DNA integrity.
14. What is the normal sperm count?
Ans. WHO has recommended that a sperm count of 15 million, progressive motility of 32% and 4% of sperms with normal structure is required to produce successful conception.
15. Are there any physical signs in a male, which indicate his role in infertility?
Ans. Inability to perform normally such as failure of erection, premature ejaculation, retrograde ejaculation, problems in size and structure of penis (Hypospadias, epispadias) are indicators towards his role in failure towards conception.
16. Do men with no or low sperm counts have any physical characteristics indicating this problem?
Ans. Person may be able to perform perfectly normally and yet may have sperm count ranging from zero to normal.
17. What should one do for low semen count?
Ans. The man should consult a urologist/andrologist and undertake either medical or surgical treatment. Minor problems will respond and the results of the treatment should be evaluated for six months to one year. If the treatment appears to fail then intrauterine insemination (IUI) can be tried. However if the problem is not corrected by the above measures then assisted conception by IVF with ICSI (intra cytoplasmic sperm injection) can be offered with considerable success.