INFERTILITY Infertility is defined as the inability of a couple to achieve conception after a year of unprotected intercourse, 6 months if the woman is over 35, or the inability to carry a pregnancy to a live birth. Today couples plan their life and take decisions about having a baby very carefully and wait until the time is just right to expand their family. Most couples assume that once they stop using birth control pills, pregnancy will happen right away. Although this is somewhat true and occurs without too much difficulty for the majority of couples, but for some conceiving becomes difficult. At least 15% of couples will experience some degree of infertility. Many couples who do not conceive easily have specific problems causing their infertility. These problems can be quite involved and may be related to the woman, the man or both partners. Traditionally, infertility has largely been attributed to the female and it has been the common belief that women are the culprits. However, in reality, it affects men and women almost equally. In 40% of cases, the problem is attributable to the male; in 40%, the problem is traced to the female. In about 10% of cases, fertility problems are linked to both partners. The remaining 10% of infertility is unexplained, even after exhaustive testing. Therefore, it is important for both partners to be aware of the problems and discuss the problems together with the doctor. Possible causes Precautions Treatment a) Possible Causes Listed below are the most common causes for infertility. Male infertility Female infertility Egg quality Can the egg and sperm unite? Age factor Sequence of events 1. Male Infertility: Male infertility may be caused by a number of factors, including problems with sperm production, obstruction of the sperm delivery system, problems relating to hormone production, antibodies against sperm, injury to the testicle, anatomical problems or the presence of a varicose vein around the testicle. All these factor may affect sperm quality and quantity. Testicular injury that results in damage to sperm producing structures may cause infertility. Hormonal imbalances can also result in infertility. Occasionally, the presence of other diseases, such as diabetes mellitus, central nervous system problems and pituitary tumors, can affect fertility. Past illnesses, infections, various diseases and medications can also cause infertility in men. 2. Female infertility: Female infertility can be caused by a number of factor most common being Endometriosis. This condition results when tissue that normally lines the inside of the uterus travels back through the fallopian tubes into the pelvic cavity and adheres to the outside of the uterus and/or ovaries causing infertility in women. Because endometriosis has had more time to develop, it can be more severe and damaging in women over age 35. Another cause is luteal phase deficiency, which causes when the ovaries release an egg each month but do not produce enough of the hormone progesterone. Progesterone is responsible for maintaining the lining of the uterus. If progesterone production is insufficient, a fertilized egg will be unable to implant in the uterine wall. Yet another cause of infertility is when egg production and ovulation is not regular. Usually, if a woman is menstruating regularly, she is also ovulating; but this isn't always true. A woman can have irregular ovulation or have no ovulation and still have periods. However, her periods are generally either irregular (oligomenorrhea) or absent altogether (amenorrhea). As a result, women may require a number of tests to determine ovulatory status. 3. Egg Quality: As a woman ages, the quality of her eggs also deteriorates. Eggs from older women do not fertilize as well as those of younger women and are less likely to survive when they do fertilize. Also, because eggs are one of the longest living cells in the body {surviving from birth to the start of menopause), there is an increased risk of abnormal eggs later in life. 4. Can the egg and sperm unite? Infertility is sometimes caused by factors in either the man or the woman that make it difficult for the sperm and egg to come together. When such circumstances exist it becomes difficult to conceive. This is also caused when sex happens less frequently in marital life. This reduces the likelihood of sperm contact with the egg at the optimal point in a woman's menstrual cycle. Blocked or damaged fallopian tubes may impact fertility by interfering with the egg and sperm uniting or with proper embryo development and implantation in the uterus thereby causing infertility. 5. Age factor: Age is not an absolute barrier to pregnancy. However, the ability of a woman conceive, does decrease with age. This decline in reproductive function is basically due to a decline in the number of eggs remaining in a woman's ovaries or a woman's capacity to reproduce eggs. Ovulation contributes to the decrease in the eggs, but the body ultimately absorbs the majority of eggs. By the fifth or sixth decade of life, women will have depleted the egg supply they were born with. This is referred to as ovarian failure. Ovarian failure is the absence of follicles and eggs. It is also the cessation of the production of the female sex hormones, estrogen and progesterone, which are necessary for menstruation and maintaining pregnancy. In some women, there is an acceleration of this process, with egg depletion occurring before age 40. This is called premature menopause or premature ovarian failure. Maximum fertility for women occurs between the ages of 15 and 24. Many women delay starting a family until they are in their 30's or 40's. About one third of women who defer pregnancy until their mid 30's will have a problem becoming pregnant, and at least half of women over age 40 will have problems conceiving. Because fertility levels decrease and the likelihood of conceiving declines, women over age 35 should wait no more than 6 months before seeking help if a fertility problem is suspected. Age also affects a man's reproductive potential The major factors contributing to an age-related decline in fertility are the quality of the ejaculate and the frequency of intercourse. For some men, advancing age is associated with declining testosterone levels, decreased sexual interest and reduced sexual activity. The decreasing frequency of ejaculation adversely affects the ease of conception. Sperm production and sperm motility can also decline with age. However, men produce such a large number of sperm that the decline in fertility in men isn't as pronounced as it is in women, who usually produce only a single egg each month while a man produces millions of sperm each day and millions are normally present in each ejaculation. 6. Following is a sequence of events necessary for conception 1. The man has to have a sufficient sperm count. 2. Intercourse must occur two to three days before or at the time the woman ovulates. 3. The woman has to develop and expel an egg (ovum) from one of her ovaries. 4. The ovum has to travel through the fallopian tubes and go into the oviduct. 5. Millions of sperm must swim by wriggling and twisting through the secretions of the cervix into the uterus. 6. Hundreds of sperm have to survive the trip through the uterine cavity. 7. Tens of sperm have to get into the oviduct opening and, against the current, swim along it. 8. A single sperm has to get through the ovum's 'shell' and the head of the sperm has to fuse with the nucleus in the ovum. 9. The new fertilized cell has to form properly, dividing repeatedly in the five days it needs to reach the uterine cavity. 10. The egg has to implant itself in the uterine lining and grow. b) Precautions to be taken for healthy pregnancy In order to have a healthy pregnancy you need to have a healthy lifestyle. Your overall health can have a significant impact on your fertility. That is why you need to take special care of yourself even before you start trying to conceive. Several things can impact the ability to conceive which are as follows. Behavioral Factors Behavioral factor include certain habits and lifestyle that cause an adverse effect on your health as well as your capacity to conceive. These are as under. 1. Smoking: Cigarette smoking may increase the risk of miscarriage; premature birth and low-birth-weight babies in women. In men, it may affect the sperm count. 2. Alcohol: Alcohol intake can impact sperm counts in men. In women, it may contribute to an increased risk of babies born with birth defects. 3. Caffeine: Caffeine may impact a woman's fertility and may increase the risk of miscarriage. However, there is no clear understanding of what amount affects fertility. 4. Drugs: Cocaine or other drugs use in pregnant women may increase the risk of kidney problems in the baby. While in men the quality of sperm may deteriorate. 5. Diet and Exercise: Proper diet and exercise are important for optimal reproductive functioning. Women who are significantly overweight or underweight may have difficulty conceiving. 6. Lubricants: A number of products used for lubrication during intercourse, such as petroleum jelly or vaginal creams, have been shown to affect sperm quality and therefore it is advisable to avoid its use if you are trying to conceive. Environmental Factors Environmental and occupational exposure to chemicals or toxins may impact the ability to conceive. Exposure and use of the following chemicals and medicines should be avoided. 1. Ethylene Oxide: Exposure to ethylene oxide, a chemical used in the sterilization of surgical instruments and in the manufacturing of certain pesticides, may cause birth defects in early pregnancy. It also has the potential to cause early miscarriage. 2. Medical Treatment: Repeated exposure to sources of radiation, such as x-rays and cancer treatments (e.g., chemotherapy), has been shown to affect sperm production and contribute to ovarian problems. 3. Lead: Exposure to lead has been shown to impact fertility in humans. Individuals working with paints/varnishes and auto manufacturing may be at risk. Biological Factors Following are the biological factors, which affect the fertility rate in women and men. 1. Blocked Fallopian Tubes: Blocked or damaged fallopian tubes may impact fertility by interfering with the egg and sperm uniting or with proper embryo development and implantation in the uterus. 2. Endometriosis: This is a disease in which tissue from the uterus implants on the ovaries and other pelvic organs and may cause infertility. 3. Abnormal Ovulation: About 40% of women who are infertile will suffer from ovulatory problems. Abnormal ovulation may be indicated by irregular or absent menstrual periods, which can be the result of a hormonal imbalance. 4. Age: Age is an important factor in the fertility of a couple. Levels decrease with age, especially in women. 5. Male infertility: Problems may be related to inadequate sperm count or abnormalities relating to size, shape and movement of sperm. About 30% to 50% of male infertility relates to the presence of a varicocele, or varicose veins within the scrotum, which affect sperm quality and quantity. c) Infertility Treatment Great strides are being made in the diagnosis and treatment of infertility. About 65% of the couples who seek medical help eventually succeed in having children. Depending on the underlying cause, many relatively simple and affordable procedures are available to treat infertility. If you and your partner are having trouble conceiving, the best opportunity for evaluation and treatment is from a physician with a special interest and expertise in the area of infertility. Refer an obstetrician/gynecologist or an urologist for treatment. You may also choose to see a reproductive endocrinologist, a "fertility specialist," who deals particularly with male infertility and sexual dysfunction. The treatment for your infertility will depend on the diagnosis and possible cause of infertility. Any treatment suggested to you or you choose will however largely depend on your age factor, your health and most important factor that is to be considered is the probability that the treatment undertaken will result in pregnancy within a reasonable time frame. Given the decline in fertility after the age of 35, it is not logical to choose a treatment with a relatively low probability for success or one that requires a prolonged treatment period. However your doctor will the able to guide you best as to what treatment you ought to take.