INFERTILITY

1. Definition.
Infertility refers to an inability to conceive after having regular unprotected sex. Infertility can also refer to the biological inability of an individual to contribute to conception, or to a female who cannot carry a pregnancy to full term. In many countries infertility refers to a couple that has failed to conceive after 12 months of regular sexual intercourse without the use of contraception. Studies indicate that slightly over half of all cases of infertility are a result of female conditions, while the rest are caused by either sperm disorders or unidentified factors. According to The Mayo Clinic, USA:
• About 20% of cases of infertility are due to a problem in the man.
• About 40% to 50% of cases of infertility are due to a problem in the woman.
• About 30% to 40% of cases of infertility are due to problems in both the man and the woman.
According to the Department of Health and Human Services, USA, approximately 10% to 15% of couples in the USA are infertile – meaning they have not conceived after at least one year of regular, unprotected sex.
Many cases of apparent infertility are treatable. Infertility may have a single cause in one of the partners, or it could be the result of a combination of factors.
There are two types of infertility:
• Primary infertility, where someone who has never conceived a child.
• Secondary infertility, where a person has had one or more babies in the past, but is having difficulty conceiving again.

2. Infertility in women
Ovulation is vital to pregnancy, and without the monthly release of an egg there will be nothing for the male sperm to combine with. Failure to ovulate for whatever reason, is one of the most common causes of infertility and can occur as a result of a number of conditions:
• Polycystic ovary syndrome (PCOS)
This is a condition that often inhibits the ovaries from producing an egg.
• Early menopause
A women’s ovaries stop working before she reaches the age of 40.
• Thyroid problems
An underactive or overactive thyroid gland can prevent the occurrence of ovulation.
• Chronic long term illness
Some women who suffer from long term chronic illnesses such as diabetes, cancer or kidney failure may not ovulate.
• Cushing’s syndrome
A hormonal disease that can stop the ovaries from releasing an egg.
• Endometriosis
Endometriosis is a condition in which minute pieces of the womb lining begin to grow in other places.
• Problems with the womb or fallopian tubes
The fallopian tubes are essentially the pathway from the ovary to the womb, along which the egg travels whilst being fertilised along the way.

3. Male infertility
For men, the most common cause of infertility is abnormal semen, accounting for 75% of all male infertility cases.
There are a number of explanations for abnormal male semen, some of which can be found listed below:
• Low sperm count
Some men have a very low number of sperm, or in some cases they have none at all.
• Low sperm mobility
This is where the sperm has difficulty making its way to the egg.
• Abnormal sperm
In some cases, sperm may be an abnormal shape which makes it difficult for them to swim to the egg and fertilize it.
Other causes of male infertility include:
• Testicles
The primary role of the testicles is to produce and store sperm, meaning that if they are damaged this can heavily impact the quality of semen. Damage can occur through infection, congenital defect, testicular cancer, injury, surgery, a lump in the testicles.
• Ejaculation disorders
When a man ejaculates or ‘comes’ during sex, the sperm then travels up the cervix to gain access to the main part of the uterus and into the fallopian tubes. However, problems with ejaculation often means that the sperm is unable to do this.
– Retrograde ejaculation is where the semen is ejaculated into the bladder, preventing it from taking the path it needs to in order to fertilize the egg.
– Premature ejaculation is when ejaculation happens too fast. This is a relatively common condition which in many cases may not be so premature as to prevent conception. However, in cases where a man ejaculates before enough semen is deposited into the vagina, the migration of sperm to the fallopian tubes may be difficult.

4. Infertility testing
Tests for males
• General physical exam – the doctor will ask the man about his medical history, medications, and sexual habits. The physician will also carry out an examination of his genitals. The testicles will be checked for lumps or deformities, while the shape and structure of the penis will be examined for any abnormalities.
• Semen analysis – the doctor may ask for some specimens of semen. They will be analyzed in a laboratory for sperm concentration, motility, color, quality, infections and whether any blood is present. As sperm counts can fluctuate, the man may have to produce more samples.
• Blood test – the lab will test for several things, including the man’s level of testosterone and other male hormones.
• Ultrasound test – the doctor will determine whether there is any ejaculatory duct obstruction, retrograde ejaculation, or other abnormality.
• Chlamydia test – if the man is found to have Chlamydia, which can affect fertility, he will be prescribed antibiotics to treat it.
Tests for females
• General physical exam – the doctor will ask the woman about her medical history, medications, menstruation cycle, and sexual habits. She will also undergo a gynecological examination.
• Blood test – several things will be checked, for example, whether hormone levels are correct and whether the woman is ovulating (progesterone test).
• Hysterosalpingography – fluid is injected into the woman’s uterus which shows up in X-ray pictures. X-rays are taken to determine whether the fluid travels properly out of the uterus and into the fallopian tubes. If the doctor identifies any problems, such as a blockage, surgery may need to be performed.
• Laparoscopy – a thin, flexible tube with a camera at the end (laparoscope) is inserted into the abdomen and pelvis to look at the fallopian tubes, uterus and ovaries. A small incision is made below the belly button and a needle is inserted into the abdominal cavity; carbon dioxide is injected to create a space for the laparoscope. The doctor will be able to detect endometriosis, scarring, blockages, and some irregularities of the uterus and fallopian tubes.
• Ovarian reserve testing – this is done to find out how effective the eggs are after ovulation.
• Genetic testing – this is to find out whether a genetic abnormality is interfering with the woman’s fertility.
• Pelvic ultrasound – high frequency sound waves create an image of an organ in the body, which in this case is the woman’s uterus, fallopian tubes, and ovaries.
• Chlamydia test – if the woman is found to have Chlamydia, which can affect fertility, she will be prescribed antibiotics to treat it.
• Thyroid function test – according to the National Health Service (UK) between 1.3% and 5.1% of infertile women have an abnormal thyroid

5. Treatment
Fertility treatment for men
• Erectile dysfunction or premature ejaculation – medication and/or behavioral approaches can help men with general sexual problems, resulting in possibly improved fertility.
• Varicocele – if there is a varicose vein in the scrotum, it can be surgically removed.
• Blockage of the ejaculatory duct – sperm can be extracted directly from the testicles and injected into an egg in the laboratory.
• Retrograde ejaculation – sperm can be taken directly from the bladder and injected into an egg in the laboratory.
• Surgery for epididymal blockage – if the epididymis is blocked it can be surgically repaired. The epididymis is a coil-like structure in the testicles which helps store and transport sperm. If the epididymis is blocked sperm may not be ejaculated properly.
Fertility treatment for women
• Ovulation disorders – if the woman has an ovulation disorder she will probably be prescribed fertility drugs which regulate or induce ovulation. These include:
• Clomifene (Clomid, Serophene) – this medication helps encourage ovulation in females who do not ovulate regularly, or who do not ovulate at all, because of polycystic ovary syndrome (PCOS) or some other disorder. It makes the pituitary gland release more FSH (follicle-stimulating hormone) and LH (luteinizing hormone).
• Metformin (Glucophage) – women who have not responded to Clomifene may have to take this medication. It is especially effective for women with PCOS, especially when linked to insulin resistance.
• Human menopausal gonadotropin, or hMG, (Repronex) – this medication contains both FSH and LH. It is an injection and is used for patients who don’t ovulate on their own because of a fault in their pituitary gland.
• Follicle-stimulating hormone (Gonal-F, Bravelle) – this is a hormone produced by the pituitary gland that controls estrogen production by the ovaries. It stimulates the ovaries to mature egg follicles.
• Human chorionic gonadotropin (Ovidrel, Pregnyl) – this medication is used together with clomiphene, hMG and FSH. It stimulates the follicle to ovulate.
• Gn-RH (gonadotropin-releasing hormone) analogs – for women who ovulate prematurely, before the lead follicle is mature enough during hmG treatment. This medication delivers a constant supply of Gn-RH to the pituitary gland, which alters the production of hormone, allowing the doctor to induce follicle growth with FSH.
• Bromocriptine (Parlodel) – this drug inhibits prolactin production. Prolactin stimulates milk production in breast feeding mothers. If non-pregnant, non-breast feeding women have high levels of prolactin they may have irregular ovulation cycles and have fertility problems.

BIBLIOGRAPHY
2015. http://www.counselling-directory.org.uk/infertility.html
Christian Nordqvist. (2014). http://www.medicalnewstoday.com/articles/165748.php
2015.www.innerbody.com/image/refov.html
2015.www.innerbody.com/image/repmov.html