DO YOU KNOW YOU CAN PERFORM A COMPLETE AND COMPREHENSIVE EVALUATION OF YOUR FERTILITY ?

CAUSES OF INFERTILITY IN FEMALES

• Ovulation disturbances - which include hormonal imbalance.
• Tubal problems- PID, Tubal blockade, Pelvic adhesions.
• Uterine and endometrial factors- Fibroids, malformations
• Cervical factors-Stenosis.
• Nutritional deficiencies.
• Genetic factors.
• Aging of the reproductive system.
• Immunologic factors


Both tubal and cervical factors are common in secondary infertility as exemplified by non sterile, and traumatic D&C, performed by unskilled providers, with subsequent pelvic infection, cervical stenosis or cervical incompetence – a condition that causes recurrent miscarriages at varying gestational ages, especially in the second trimester of pregnancy.

In some cases, following thorough investigations, no apparent causes for the infertility are found in the male or female. This condition is called unexplained infertility as both husband and wife appear normal following exhaustive evaluation by all currently known methods of investigation.

CAUSES OF INFERTILITY IN MALES

PATHOLOGICAL CAUSES OF INFERTILITY

Fibroids can be found in 20-50% of all women over the age of 30 years. They occur with a greater frequency as the woman advances in age. Fibroid conditions are found in all races.

What are fibroids?

Fibroids are benign tumors that originate mostly from the muscles of the womb. On very rare occasions, it can become cancer especially when its growth is rapid in women who have reached menopause. Fibroids can grow as a single lump or in clusters. Their sizes vary greatly from tiny ones like palm kernel nuts to others that can be as large as soccer ball.

Most fibroids grow slowly over years. Each fibroid starts its growth by transformation of a single muscle cell of the uterus. Most fibroids grow within the wall of the uterus. These types are called intra-mural fibroids. Others occur less frequently on the inside cavity of the uterus called endometrium, and can cause serious problems and infertility for the woman. These are called sub-mucous fibroids. Others also occur on the surface of the womb and are more harmless. They are called sub-serous fibroids.

It is , therefore, very important that your infertility specialist must evaluate you thoroughly to determine if you have fibroids and where they are located. Most specialists will tell you if you have fibroids or not by performing a single pelvic examination in the office. They can further confirm the uterine location by trans-vaginal ultrasound.

The question most women ask is what causes fibroids? Simply answered: we don’t know. We do know that fibroids occur in some races more frequently than others. African women of child bearing age have a higher incidence of fibroids than their caucasian women. We also know that fibroids can run in families. If your mother has it, there is an increased chance that you may develop it later in life. We think that fibroids form as a result of many factors among which may include but not limited to genetic, hormonal, environmental and other things interracting together.

The fibroid can cause infertility by presenting as a space occupying lesion; by contiguous enlargement and subsequent blockade of the tubes, by formation of adhesions, by exhibiting heavy menstrual flow causing symptomatic anemia and causing irregularities of menstruation and hormonal imbalance, and by causing discomfort and pain during intercourse. Frequent urination can be as a result of the pressure exerted on the urinary bladder by a huge fibroid. Lower back pain and sciatica can be as a result of some large fibroids sitting in the pelvic cavity over many years.

Management of fibroids depend on the expertise of the consultant and the patient's presenting complaints. Small fibroids found without symptoms should be left alone.

Many pregnancies have occurred in women with fibroids. The pregnancies will co-exist with the pathology. Even large fibroids can co-exist with viable and successful pregnancies if they are located* on the surface of the uterus, but not within the muscle or the endometrium.

Fibroid treatment can be harmful or helpful depending where you go for consultation. Many women have sought help and treatments from places like massage clinics, prayer houses, herbalists, with hopes that their fibroids will dissolve or simply go away. Such women soon discover that their fibroids have even grown larger because of unnecessary delays.

A good specialist will consider a lot of issues before recommending any form of treatment for fibroid to the afflicted woman. He will consider
-the woman’s age
-fertility desires
-how serious are her fibroid symptoms
-how big and the locations of her fibroids.

If a woman shows no symptoms of her fibroid and the fibroid is not inside her endometrium and she is desiring pregnancy, the couple will be counseled on conservative management of her fibroid condition. She may not need any treatments.

When a woman has problems with her fibroids, she may be offered medical or surgical therapy.

Medical therapy may include
-reduction of the size of the fibroids through the use of hormones gonadotropin releasing hormone agonists GnRHa. The main disadvantages of this medication are its serious side effects and that the tumor regrows after you stop the medication.
- pain medications

If a woman has symptomatic fibroids, surgery may be the best form of treatment.

Any fibroids found to be a real cause of infertility should be removed by experienced gynecologists. Delaying the surgery complicates the situation because with time, the fibroids can undergo degeneration, calcification and sometimes, may even progress to cancer. Sometimes the fibroid can form bulky irregular uterine masses pressing on the urinary bladder and causing urinary frequency and urinary retention. So it is dangerous to delay removal of bad fibroids. Fibroids found within the endometrium (submucus fibroids) can interfere with implantation or may cause cornual occlusion, and as such must be removed preferably by hysteroscopy.

Trans-Vaginal Sonography (TVS) with high frequency transducer has become a very important tool for management of female infertility. It is used throughout the woman’s cycle to monitor ovarian follicular activity and development, follicular rupture and timing of inseminations. It is used to follow all stimulated cycles and timing of Human Chorionic Gonadotropin (hcG) administration and retrieval of eggs 34 to 36 hours after the injection.

SONOHYSTEROGRAPHY (SHG)

Sonohysterography is a new procedure that helps the infertility specialist to engage in a detailed study of the endometrium. This is the cavity that houses the embryo. It cancontain fibroids or polyps or adhesions from previous D&C.

IN WOMEN OLDER THAN 35 YEARS

ASSISTED CONCEPTION TECHNOLOGY

Assisted Reproductive Technologies (ART) have become a major tool in treatment of infertility. Historically, Louise Brown was the first baby born by ART in 1978 (July 25). Since then there has been an explosion of this technology leading to the birth of thousands of babies to many childless couples all over the world. The first developed method is the In Vitro Fertilization and Embryo Transfer and later, other methods were developed. The most recent advance in this technology is waiting till the blastocyst stage prior to transplantation. This has many advantages, including but not limited to decreased number of embryo transferred into the uterine cavity and avoiding multiple pregnancies; increased success rate with each procedure and better pregnancy outcome. ART requires accurate timing of ovulation for egg retrieval.

INDICATIONS FOR IN VITRO FERTILIZATIOIN

The major indications for the use of IVF-ET in the infertile couple include but not limited to the following conditions:

1. Irreparable Tubal disease and bilateral tubal blockade.
2. Male factor infertility.
3. Cervical Factors.
4. Immunologic factors.
5. Idiopathic factors.
6. Ovarian disorders.
7. Genetic disorders.
8. Uterine disease or its absence.
9. Endometriosis.

In the absence of the uterus, a surrogate mother can be used to accomplish the desired pregnancy if the patient has normal and functioning ovaries that can make good follicles.

ART (Assisted Reproductive Technology) involve high technology, careful monitoring, and counseling. It is extremely expensive and the pregnancy rate is at best 35%. As stated before, increased pregnancy rates up to 40-50% can be obtained by waiting until the blastocyst stage before intra uterine transfer. Through this technology, women in their late forties and fifties have successfully carried pregnancies when carefully monitored by infertility endocrinologists. It is however, the last resort in infertility treatment. The alternative option is adoption.

For those women in their forties and fifties who are seeking to conceive through ART, it is recommended that they use DONOR oocytes from young females because they often yield better results with fewer anomalies and/or miscarriages.

The future holds great promise for the infertile couple as new technologies are being developed everyday to help overcome the problems that prevent natural conception. My vision is that one day, every woman seeking to conceive will be able to do so with minimal difficulty and at a considerably reduced expense.

Most women seeking Assisted Reproductive technology must have failed to realize pregnancy through conventional methods available. A great length of time must have been spent going through one treatment protocol or another, or carrying one test or another. By the time the woman and her husband present for ART, the woman is somewhat advanced in age, thereby making fecundity even more unlikely.

Certain fundamental workup will enhance a woman's chance of a successful ART.

A thorough personal and family histories need to be obtained. If there is a family hostory of diabetes (first relative), it might be beneficial to screen these patients and those with anovulatory cycles as determined by BBT for isulin resistance by performing fasting blood sugar and insulin ratio following 12 hours of fasting. If that ratio is less than 4.5, consideration should be given to the treatment of the patient with metformin or glucophage 500mg tid and follow this up with subsequent lab. Within a month or two, the patient's insulin resistance may be normal and this increases her chances of conception and carrying that pregnancy to live birth. Stop the metformin once the woman becomes pregnant.

Again, basic laboratory investigations should be done including but not limited to Prolactin, TSH, sexually transmitted diseases such as gonorrhea, chlaydia, syphilis, hepatitis, and HIV.

The older women - especially those beyond the age of 35, should undergo secreening for ovarian reserve. It has been well decumented that the diminished ovarian reserve is the principal reasons for the decline in fertility with age. Diminished Ovarian reserve is characterized by early follicular phase elevation of FSH or Estradiol; elevated FSH after clomiphine challenge test; shortened cycle interval and irregular cycles; and finally a low inhibin B in the early follicular phase.

Clomiphine Challenge Test for assessing ovarian reserve is performed on days 1 thru 4 by checking FSH, estrodiol, and inhibin B levels. Then give clomiphine citrate 50mg daily from day 5 thru 9 and rechecking FSH, Estradiol and inhinbin B on day 10 or 11. Elevated FSH (greater than 15 mIU/ml) after a clomiphine challenge is uniformly associated with poor pregnancy outcome. It is important that you use the same lab to maintain the same threshold values. When there is a documented Diminished ovarian reserve, the physician should counsel the woman and recommend ART with Donor oocyte which increases her chances of pregnancy substantially.

I think that the woman's environment, psycho-social life-style, nutritional status and body weight impact on her chances of successful pregnancy. Therefore, she should eat right, include vitamins especially folic acid in her daily diet and exercise to maintain ideal body weight and reduce stress. She should stop smoking, use of alcohol and hard drugs.

ASSISTED CONCEPTION IN SUMMARY

This may involve simple and inexpensive procedures like
a. Counselling and guiding the couple on correct timing of intercourse during ovulation to enhance conception.
b. preparing washed sperm for intra uterine insemination.

c. Stimulation of the woman’s cycle with medications such as clomid, or more expensive human menopausal gonadotrophins or most expensive recombinant FSH such as Gonal-F or Puregon and proceed to IVF or ICSI. ICSI (intra Cytoplasmic Sperm Injection) has become the procedure of choice for many infertile couples where the male has the problem.

The steps involved in IVF/ICSI are:

a. The woman’s ovaries are stimulated to produce many follicles by administering hormonal injections for several days.

b. Another hormone called hCG is then administered to further mature the follicles when they reach a critical diameter as monitored by transvaginal sonogram. This hormone also makes it easier for the specialist to retrieve the eggs from the follicles during aspiration.

c. The eggs are aspirated from the follicles about 34 to 36 hours after the hCG injection and immeditely transfered to the embryologist for isolation in special media.

d. The eggs are incubated for about four hours and then prepared for injection (ICSI) with single sperm or conventional IVF (cIVF) where thousands of washed sperm are used to inseminate a single egg.

e. Only matured eggs (Metaphase II) are injected.

f. The injected eggs are then incubated under strict conditions for about 18 to 20 hours and then examined for evidence of fertilization.

Fertilization is assumed if there are two PRONUCLEI.

h. These embryos can then be loaded in special transfer catheters on DAY 3, 5 or 6 and transfered into the prepared endometrium (womb) of the woman.

i. The growth of the embryo in the womb is supported by hormones until pregnancy test is obtained some two weeks later ( counting from the day of egg retrieval). If the woman is pregnant, Trans-vaginal sonogram is performed one to three weeks later and the hormonal support will continue for about ten weeks when the baby,s placenta can support the growing fetus.