Infertility

Posted On April 6, 2018 by Dr.Shobhana Mohandas

Q:When should a couple worry about infertility?

A:Ordinarily, if a couple stays together for 6 months without using contraceptive methods unable to conceive, it may be time to investigate for infertility. If the woman has grossly abnormal menstrual periods, investigations may be started much earlier.

Q:What is the normal physiology of fertilization?

A: Normally, a woman produces ova from her ovary. The ova are extruded out every month at about the 14^th to 16^th day of the cycle. This process is called ovulation. These ova are picked up by finger like tubular organs attached to the womb (uterus) called fallopian tubes. The ovum travels through the fallopian tube to reach the uterus. The sperm from the man enters the woman’s vagina , uterus and from there, goes into the fallopian tube to meet the ovum to form a zygote, which is the smallest form of the beginning of human life. This zygote then enters the uterus and lodges there to develop into a foetus and gradually grows there till the woman delivers the baby.

Q:Why does conception not occur in the first cycle after marriage in all couples?

A: All couples who cohabitate together do not conceive immediately after marriage even if they have not been using contraception for the following reasons:

A woman may not ovulate in all cycles.

The sperm may not meet the ova in spite of being near it.

The zygote may not lodge properly in the uterus.

This fact is important to remember in patients with infertility. When a couple starts infertility treatment, they should not be disappointed unduly in case they do not get positive results in the first or second cycle of trying for a conception.

Q: What are the causes of infertility?

A: The main causes of infertility are:

Poor quality of the husband’s sperms. Normally there are 20million sperms per ml of semen. Decrease or absence in count, motility etc of sperms may result in infertility.

2.Anovulation, meaning lack of regular ovulation occurring from the woman’s ovary.

Usually such women have irregular periods.

Block in the fallopian tubes due to birth defects or infections.
Abnormalities in the cervix which is the mouth of the uterus.
Some immulogical problem, by which the man or the woman may produce antibodies against the sperms or ova which render them ineffective.

Q: What are the social causes of infertility?

A: 1.Poor quality of sperms can be worsened by smoking and alcoholism.

2.Excessive heat can be a deterrent for the production of sperms.

3.Excessive weight gain as well as excessive weight loss in the female can lead to hormonal disturbances which can lead to anovulation or oligoovulation. Overweight women would do well to cut down on sweets and fatty foods and to

exercise regularly . These simple and cheap measures could go a long way in regularizing ovulation.

4.Infertility causes a lot of mental tension. Mental tension can affect the hypothalamus, an organ in the brain which controls the production of all female reproductive hormones necessary for proper ovulation and conception. This is the reason why a lot

of women conceive spontaneously when they are not on any treatment and are not planning actively for conception. The tension release in these months probably removes any hypothalamic block that may be posing a problem for conception.

5.Long working hours prevent couples from cohabitating normally, thus causing apparent infertility. Similarly, couples,

where the husband is staying abroad, or in another part of the country also suffer from apparent infertility. The couple

start trying for conception in the 2 or 3 months that the husband is in station, which may prove inadequate for normal

conception. This leads to over treatment for infertility as fertility has to be artificially enhanced in the months that the

husband is in station.

Q:What are the basic evaluations a couple will have to undergo in case of infertility?

A: The basic evaluations in a case of infertility are

Clinical history and examination
Blood tests
Semen Analysis.

Specialised investigations.

Clinical history and examination Male:Since 50% of infertility is caused due to poor quality of semen, a semen analysis is mandatory in all cases of infertility. If there are abnormalities in the semen, the man should by evaluated by way of history and physical examination. History might reveal noxious factors like smoking, alcoholism, working in an overheated environment,erectile dysfunction, etc, which could be remedied. Physical examination may reveal enlarged veins near the scrotum which is called varicocoel. The presence of significant varicocoel may mandate surgical correction.
Female: The main points in clinical history of a female are menstruation, coital history and history of abnormal vaginal discharge.
Menstruation: Irregularities in menstruation could be an indication of hormonal imbalance. Hormonal imbalance results in anovulation, where the ovum required for fertilisation is not released by the ovary.
Regular coital history: Infrequent coitus may lead to infertility if the couple co-habitate in the nonfertile periods of the cycle. This is particulary important in couples with different working hours or couples who stay separately and meet only occasionally. Care should be taken to see that the couple are together in the fertile period of the cycle.

Abnormal vaginal discharge: At the time of first visit, gynaecologist are generally very diligent and look for abnormal vaginal discharge and ask for presence of itching or copious vaginal discharge. The clear watery discharge coming about 15 days before menstruation is normal and is helpful for sperms to reach the uterus.. However, if there is foul smelling discharge, or itching in the private parts, it is indicative of infection in the vagina or cervix. This may be harmful for the sperms entering the vagina and will contribute to infertility. This is usually taken care of by many gynaecologists by routinely prescribing a course of antibiotics, antifungal and antitrichomonal agents, which are tablets which kill organisms causing vaginal infection

InvestigationsAny factor that affects the motility or patency of the fallopian tube can cause infertility. Tubal disease has been implicatedin 15-20% of couples presenting with infertility. The tubal ends are some times closed because of agglutinations. These can be released through laparoscopic instruments. Releasing adhesions between the tube, ovary, and the uterus can improve the motility of the tube
Ovarian cysts: Resection and vaporization of endoetriosis is the most common indication for laparoscopy in infertility. Laparoscopic treatment of endometriosis yields a pregnancy rate of upto 60%.

Sometimes in a condition called the polycystic ovarian disease, medical treatment might fail. In such cases making tiny holes in the ovary might help enhance fertility. Picture shows multiple punctures made into the ovary of a woman with this problem.
Endometriosis:
After a good clinical examination, investigations will have to be done on the husband and wife to detect abnormalities which need attention.  The following investigations will need to be done in the male and the female.Semen Analysis
Male infertility affects almost 50% of infertile couples. A simple semen analysis would rule out male factor straight away.
Semen should be collected in a clean, dry, wide mouthed container after 2 days of abstinence. The specimen is collected after masturbation in the laboratory. Some men prefer to collect it at home and in that case, the specimen should be handed over to the labarotary within half an hour noting the time of collection.                                                             Female factors

Ovulation studies:
Various tests can be done to find out if a woman is ovulating or not.
BBT: Basal body temperature:A woman is asked to record her temperature first thing in the morning, before getting up or having any beverages. The temperature varies mildly over the days. If the temperature rises and falls twice in the month, around midcycle, the temperature chart is said to be biphasic and indicative of ovulation. However, this is a retrospective test and can only tell that ovulation has occurred/not occurred. It cannot predict when ovulation will occur and thus it is not helpful in planning intercourse.

Ultrasonography:
A woman is asked to undergo ultrasonography every two days ,starting from the 10th day onwards till ovulation is confirmed. The ultrasonogram documents the growth of the follicle in the ovaries. The follicle gradually grows from a size of 8 mm till it reaches 18mm and in a couple of days is seen no more. This is indicative of ovulation. . Doctors use this modality of testing quite frequently to know whether a patient is ovulating , so that intercourse can be timed appropriately and also sometimes to find out if medications given for inducing ovulation are working properly or not.

LH kits: Urine is tested on alternate days and a special paper is inserted into it. The change in colour in the dipstick is used to indicate ovulation. This can be done by the patient at home itself and avoids the necessity of visiting the doctor every 2 days. But the overall cost of testing per cycle would be higher than that of serial ultrasonography done by most sonology centers.

Tubal studies:
As mentioned before, the uterus is connected by two tubes which communicate with the abdominal cavity. These tubes are responsible for the transport of the ovum , the sperm and in case of successful fertilization, the transport of the embryo into the uterus. It is done rather invasively by vaious modalities.

Tube testing: It is the local language used for testing the tubal patency by injecting air into the uterus. The gush of air in the abdomen in the case of patent tubes can be heard through the stethoscope. It is a very crude form of investigation . It is hardly ever performed in full-fledged institutions.
Hysterosalpingogram: In this test, a radio-opaque dye is injected into the uterus. The path of the dye is recorded on an X-ray film. The dye normally passes through the uterus into the tubes and finally into the abdomen proving that the tube is open. This test can be done on a day care basis, but if there is block in one of the tubes, it can be quite painful.

Sonosalpingogram: Any plain fluid is pushed into the uterus and the ejection of the fluid into the abdomen is recorded on sonography. Unless very high resolution ultrasonograhy machines are used, it may not be as accurate as the hysterosalpingogram.

Laparoscopy: Generally in current practice, laparoscopy is not used as a routine investigation to test the patency of the tube. But if a patient does not conceive after a reasonable period of time inspite of treatment, a laparoscopy is done. A fluid with or without dye is injected into the uterus and the flow of dye through the tubes is observed through the laparoscope. Any abnormalities in the abdomen can be corrected at the same sitting.

Laparoscopy in infertility:
Laparoscopy is an important modality of investigation in the investigation and treatment of infertility. Laparoscopy is used to diagnose any subtle causes for infertility.
Tubal disease:

A good clinical examination by the infertiliy specialist can detect many abnormalities, which may then be corroborated with findings of investigations. Some factors that doctors detect through clinical examination are as follows:
Improper intercourse: Surprisingly, some couples who come for infertility treatment are found to not even have undergone normal coitus. This happens sometimes because, they are either unaware of how intercourse should be done or sometimes because the man has difficulty in attaining erection. Embarassment prevents them from disclosing this to their doctors and in this era where many doctors rely more and more on investigations and less and less on clinical examination, this deficit remains undiagnosed, specially when some glaring deficits like low sperm count or very irregular periods is present. When gross abnormalities are present, the onus of investigations shift to correct these abnormalities and sometimes the lack of intercourse remains undetected!!!
Polyps: Simple growths like polyps near the mouth of the uterus could be revealed by a proper clinical examination.
Galactorrhoea:Expression of milk or a watery discharge from the breasts (Galactorrhoea) could be an indication of increased levels of a hormone called prolactin , which could cause infertility.
Hirsuitism: Presence of hair on the upper lip, or a male distribution of hair on the abdomen, could be an indication of abnormal hormone levels in the body. However, it must be remembered that not all women with hair on the upper lip have abnormal hormone levels. Some could be having just familial hirsuitism.
Body weight: Both excessive weight gain, as well as excessive weight loss are deterrants for normal ovulation .

However, when the couple have been infertile for a long time, this aspect tends to get forgotten. This may be a reason why when some major factors contributing to infertility have been treated, the couple continues to remain childless, as this minor factor is forgotten. Thus it is important for the infertile couple to report to the gynaecologist any change in her vaginal secretions, at any point during the treatment for infertiliy.
Stress: Stress can cause anovulation and a couple desiring pregnancy should learn to cope up with the stress inherent in the investigation of infertility. It is easier said than done, as there is a lot of pressure from social and family circles when the couple do not concieve for a long time. This coupled with the tedious investigations and frequent visits to the gynaecologist can be stressful. However, it is important for the couple to find some ways to let out their emotions and remain stressfree, so that they get better results out of their infertility treatment.

Laparoscopic puncture of ovaries can cure some cases of Polycystic ovaries, one of the causes of infertility.

Hysteroscopy: Usually at the time of laparoscopy itself, a scope is passed into the uterus to make sure there are no abnormalities inside the uterine cavity. In case of blocks in the tubal opening into the uterus, a cannula is passed into the opening to remove the block.Sometimes there are polyps or fingerlike growths in the uterus, which prevent normal conception.

Presence of adhesions or small flimsy bands in the uterus can also be picked up using hysteroscopy. Correction of these abnormalities could lead to fertility.

Hysteroscopy is also useful in patients who get pregnant, but continously have abortions. One of the reasons could be presence of congenital walls dividing the cavity, called uterine septum. This can be cut using hysteroscope. Infections can also cause the walls of the uterus to stick together and this can be cut using the hysteroscope.

Q: What are polycystic ovaries: what are the options available for treatment

Normally, women develop many follicle, about 8-9mm in her ovaries. One of them become dominant and ovulate. In women with polycystic ovaries, none of the follicle are able to attain a size capable of ovulating.

These women also have excess of oestrogen in them. Most of them are associated with obesity. The androgen level is quite often high in these women and they have excess hair on their upper lip and hair may grow in a slightly male pattern. there may be light pigmentation on the back, called acanthosis nigricans. Many of them have cells which are resistant to the hormone insulin, which normally digests glucose in cells. as a result some of them have excess glucose in their blood.

Treatment options; 1.drugs like Clomiphene citrate can be given for 3- 6 months. giving it for more than 6 months may be harmful .

Hormone injections can be given

3.Drugs like metformin and Pioglitazone can reduce insulin levels

In patients who cannot concieve on clomiphene, laparoscopic puncture of the ovaries is an option. multiple punctures are made into the ovary using unipolar cautery. This is an alternative to hormone therapy as hormone therapy is expensive.

Dietary advice in Polycystic ovarian disease:

Polycystic ovarian syndrome is a condition were the body is resistant to the hormone insulin. Excess of insulin acts on the ovary to produce more male hormones

This leads to irregular periods and signs like excessive hair growth and lack of ovulation, which may lead to infertility.

The following diet guidelines are useful to practice in women suffering from PCOS:

Limiting milk and diary products;
Limiting carbohydrates and foods containing carbohydrates, as they need insulin to digest them. Foods containing carbohydrates include white rice, sugar, sweets and fleshy root vegetables like potato, beetroot, sweet potato, yam,etc, because they have a high glycemic index, meaning they get converted to glucose quickly, increasing the need for insulin to digest them. Since the body is resistant to this action, there would be increased production of insulin, which will again act on the ovaries to produce more androgens, or male hormones.
Use unpolished rice, if at all
Avoid Rava/Sooji and maida. In kerala, avoid the kerala paratha as it is made of maida. Avoid Upma with sooji.
Carbohydrates in the form of fresh fruits, vegetables, whole grains such as wheat, barley, oats, may be preferred.
Use whole wheat chapattis.
Smaller, more frequent meals (every 3-4 hours) to help control blood glucose levels.
Proteins should form about 25-30% of your total calories. Good quality protein such as fish, egg whites, lean chicken, soy products etc may be preferred. Also, pulses and legumes such as cowpea, moth, lentils, green and red gram provide good amount of protein. They also provide essential fiber when consumed with the skin. Fish also provides the omega-3 fatty acids that are beneficial for women with PCOS.
Use lemon juice, mustard, vinegar, pepper, herbs and spices instead of table salt to season foods. Limit salt intake (aim for less than 2400 milligrams of salt per day),
Avoid excess coffee and tea. Coffee increases urinary secretion of important minerals such as magnesium, potassium and sodium and uses up a fair amount of vitamin B1.
Coconut oil has a large amount of medium chain fatty acids. For the hypothyroid sufferer the MCFAs in coconut oil speed up the body’s sluggish metabolism and promotes weight loss as well. MCFAs in coconut oil are digested and absorbed quickly and with minimal effort. Because of this there is less strain on the pancreas, liver and the digestive system.
Sesame oil, almond oil, olive oil and saffflower oil can be used in patients with PCOS . Avoid sunflower oil. Oils can be used only 4 or less tablespoons per day.
Monounsaturated fat containing food choices include: avocado, canola, olive and peanut oils; olives, nuts such as almonds, cashews, peanuts and pecans; peanut butter, nut butters, sesame oil, seeds and paste.
Omega-3 fatty acid (specifically EPA and DHA) containing food choices include: cold water fish .salmon, (KORA,KAALA).Mackerel (Aikoora),Tuna (Choora),sardines(Mathi, chaala),

Two to three servings of fatty fish/week will provide the 220 mg each of EPA and DHA that is recommended.

Women with PCOS should consume at least 3-4 serving of fruits per day. Fruits such as apple, raspberry, kiwi, pineapple, papaya, melons, blackberry, cherry, guava, apricot, orange, sweetlime, lemon, mandarin, nectarin, pomegranate, plum, peach etc. may be included in your diet. Restrict the use of banana, mango, custard apple, grapes and sapota..
Vegetables are the best source of fiber. Fiber is essential for cutting down fats and reducing the blood cholesterol. They form a bulk in stomach and give an early feeling of satiety. A variety of green leafy vegetables such as Spinach, fenugreek, celery, parsley, cabbage, cauliflower greens, cowpea leaves, mustard leaves may be included. Other vegetables such as eggplant, bottle gourd, pumpkin, bitter gourd, okra, capsicum, radish, broccoli, carrot nourish you with plenty of vitamins and minerals.
Fenugreek(Methi,Uluva, Trigonella foenum–graecum) promotes excellent glucose metabolism in the body. It improves glucose-tolerance and insulin-sensitivity, thereby promoting weight loss and moderation of androgen levels in blood. It also lowers LDL and increases HDL and supports healthy functioning of the heart. Fenugreek can be used in the treatment of PCOS in the forms of seeds, fresh leaves and dried leaves. 1 tsp. of soaked seeds thrice a day would be a good option, if possible.However, it is very bitter. The seeds should be soaked for at least 6-8 hours to make them soft and chewable. In the form of leaves, 1 cup of cooked fresh leaves once a week would be a good option. It gives a special flavor to chapattis. Dried leaves may be used as a seasoning in soups/salads. PCOS patients could include 10-15 grams of dried leaves everyday in their diet.
Cinnamon: Researchers at Columbia University’s Department of Medicine found that women with PCOS who took 1,500 mg of a cinnamon supplement every day for six months began to have more regular menstrual cycles than women receiving a placebo. ½ to 2 teaspoons of cinnamon powder along with honey could be a good option. Cinnamon is an anti oxidant, antimicrobial and can reduce cholesterol.
Sesame seeds are loaded with nutrients that are known to be particularly beneficial for women with PCOS. These little seeds area great source of vitamin B6, with half a cup providing more than a quarter of the recommended daily intake for this vitamin. Furthermore, they are an excellent source of plant-based calcium, magnesium and certain healthful fatty acids. On top of that, they provide a very good source of zinc.
Source: http://www.healwithfood.org/pcos/foods2.php#ixzz2qg3khpbM.
Liquorice: Glycyrrhizin in licorice root has been shown to significantly reduce plasma testosterone, 120 mg of glycyrrhizin daily for two menstrual cycles was found to reduce testosterone levels. frequent consumption of large quantities of licorice may cause high blood pressure, edema, depletion of potassium, headache, heart problems, and other health complications.
Poppy seeds / khus khus can be useful in pcos. Sprinkling poppy seeds on top of a dish can provide calcium , magnesium, calcium, B vitamins and zinc.
Pumpkin seeds and sunflower seeds are good for PCOS,

Infertility

Infertility

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