Infertility

Male Infertility: The causes

Generally, the male ejaculates 4 to 6ml of semen during sexual intercourse. The sperm count or the quantity of sperm in a sample of semen plays an important role in determining infertility. Approximately 15-150 million sperms per ml is regarded normal. A sperm count, which is below 15 million per ml, suggests a low sperm count and could lead to infertility.

Normally, a sperm moves or swims in a forward direction and have a unique shape with a head, neck and tail.

Male infertility is usually evaluated using the following:

Medical History

To identify if there are any conditions which might negatively impact fertility of the male, a comprehensive study of the patient’s medical history is done. This will, in turn, help to ascertain any specific conditions such as:

• Endocrine disorders (Diabetes)
• Trauma from previous surgery
• Infectious diseases
• Genetic conditions
• Medications that could affect reproductive function
• Consumption of alcohol, nicotine, drugs etc.
• Excessive psychological stress
• Work environment (Exposure to chemical industry, contact with X-rays, excess heat etc.)
• Difficulty in sexual intercourse

Clinical Examination

The patient’s medical history is supported by a clinical examination of his external genital organs namely; the testes, the penis, the scrotum, the epididymis, the vas deference, the presence of varicoceles and tight foreskin (phimosis). It is the urologist who reviews the medical history and conducts the clinical examination.

Semen Analysis

A semen sample is produced by various methods such as masturbation, coitus interruptus, condom collection, epididymal extraction etc. The semen sample is analysed for:

• The quantity of sperms
• Their mobility
• Their physical appearance
• Morphology of Sperms

Additional Investigations

The following additional investigations are sometimes required if the medical history, clinical examination or semen analysis indicates any issues. The tests may include:

• Biochemical examination of semen
• Bacteriological testing
• Hormone analysis
• Chromosomal analysis

Female Infertility: The causes

There are several factors that are responsible for female infertility. This includes:

1. Ovulation disorders

Ovulation disorders are a prominent cause of infertility in couples. Ovulation disorders could mean either infrequent ovulation or no ovulation at all. These could be caused by improper regulation of reproductive hormones by the hypothalamus or the pituitary gland, or by disorders in the ovary itself.

Polycystic Ovary Syndrome:

In Polycystic Ovary Syndrome (PCOS), certain complex changes take place in the hypothalamus, pituitary gland and ovaries, causing hormone imbalance, which further tends to affect ovulation. One of the most common causes of female infertility, PCOS is often linked with insulin resistance, obesity, abnormal growth of hair on the face or body, and acne.

Around 30-40% of women who suffer from infertility problems do not produce eggs. This condition is called Anovulation. Anovulation may be caused due to complete failure or imbalance in the production of hormones by the pituitary gland, which further prevents the stimulation of follicles and release of eggs.

2. Tubal infertility

When there is a block or damage in the fallopian tubes, it prevents the sperm from reaching the egg or interrupts the passage of the fertilized egg into the uterus. The blockage of fallopian tube could be due to various reasons such as sexually transmitted diseases, previous surgery in the abdomen or pelvis, infections after abortions, endometriosis or the abnormal shape of the fallopian tube itself.

3. Endometriosis

Endometriosis is a condition that happens when tissue that generally grows in the uterus, implants and develops in other locations. The surgical removal of this extra tissue growth could result in scarring, which may block the fallopian tube and prevents the egg and sperm from uniting. It could also severely affect the lining of the uterus, disrupt the process of implantation of the fertilized egg or even damage the sperm or egg.

4. Uterine or Cervical causes

Normally, the sperms move up from the vagina through the cervix to the uterus and finally to the fallopian tube to meet the egg. The cervical canal is extremely narrow and is contains mucus through which the sperms have to pass. If there are any problems in the structure of the cervix or the type and texture of the mucus, it can disrupt the movement of sperms to the uterus. Uterine or cervical problems are mostly caused by the growth of benign polyps or tumours in the uterus, endometriosis, uterine abnormalities or Cervical stenosis.

5. Anti-sperm secretions

If there is infection in the cervix, or antibodies are present in the mucus secreted, it results in the destruction of the sperms, thus causing infertility.

6. Disorders of the endocrine system

Certain disorders of the endocrine system such as diabetes, thyroid etc can cause infertility.

7. Emotional & psychological stress

Modern life style and habits often causes emotional and psychological stress in couples which have negative implications in the functioning of the reproductive systems of the couple. This could in turn result in infertility.

8. Unexplained infertility

In certain cases, even after extensive investigations, the disorder with either the wife or husband cannot be identified. This condition is called unexplained infertility. However, there is a possibility that the wife may become pregnant after sometime. It is to be noted that after two years, the chances for the couple to conceive may decrease significantly.

Infertility – Myths & Facts

✗ Proper diet and exercise will help in preserving your fertility.
✓ The quality of a woman’s eggs tends to decline as her age progresses, irrespective of how healthy she is.
✗ Consuming birth control pills will make it difficult to get pregnant.
✓ Birth control pills don’t affect your fertility. Research indicates that once you stop taking the pills, the
process of ovulation will start normally within three months and possibly even sooner.

✗ In order to get pregnant quickly, you should have sex daily.
✓ Sperm is alive for a period of 38 to 72 hours in your reproductive tract. As a result, there’s no reason to overload
it. Moreover, having sexual intercourse more than once a day, and repeatedly for a few days, might reduce
the sperm count.

✗ Age doesn’t influence fertility.
✓ Age is, perhaps, the foremost factor that affects fertility.

✗ Poor nutrition level doesn’t influence fertility.
✓ An individual’s nutrition level does have an effect on fertility. Being extremely thin or too obese can reduce fertility. Women who do not consume sufficient calories and fats may not be able to ovulate normally. This could, in turn, reduce their chances of
becoming pregnant. On the contrary, being overweight or obese can also have negative implications on the ability of a person to conceive, as obesity can disrupt the normal functioning of hormones and fertility.

✗ Smoking doesn’t have any effect on fertility.
✓ Smoking cigarettes does reduce fertility. This holds true for both assisted (IVF) and non-assisted reproduction.

✗ The type of food that you consume has an impact on fertility.
✓ This is not true. Some studies have indicated that consuming more (or sometimes less) soya affects fertility as it contains Phytoestrogens. However, until now, there isn’t enough scientific evidence to prove that certain foods have an impact on fertility.

✗ Caffeine has an adverse impact on fertility.
✓ This is quite unlikely. Consumption of Caffeine might not enhance infertility.

✗ Stress does not reduce fertility.
✓ A reasonable amount of stress may not cause infertility. However, excessive stress does have a negative impact on our physical and mental health. A recent study indicates that women who undergo stress reduction courses have considerably greater success with IVF. Hence, it’s obvious that extreme stress could affect the reproductive cycle too.

Gynecology and Infertility

Dr Santhamma Mathew MD, DGO
Chief Consultant and Infertility Specialist

Dr A Santha Devi MD, DGO
Senior Consultant

Dr Sunitha R DGO, DNB
Consultant

Dr Bindhu P.S DGO
Consultant

Minimally Invasive Surgery

Dr Bimal John MS, Dip AES (France), Dip End. Surg. (Germany)
Senior Laparoscopic Surgeon

Embryology

Lakshmi S Udayan MSc (Biotechnology), Ph.D Scholar
Consultant Embryologist

Prasanth C P MSc (Biotechnology), Ph.D
Consultant Embryologist

Urology

Dr Arun P MS, MCh
Senior Consultant

In Vitro Fertilisation – IVF

In Vitro Fertilisation (IVF) refers to the process by which fertilization of the egg by sperm occurs outside the body. IVF is a prominent treatment for infertility and is recommended when other techniques of assisted reproductive technology have failed to produce the desired results. The process involves various steps that include comprehensive monitoring of a woman’s ovulatory cycle, removal of ovum or ova (egg or eggs) from the ovaries and allowing the sperm to fertilise them in a fluid medium in a lab.

In Natural cycle IVF, a woman’s ovulatory cycle is continuously monitored to collect a naturally selected ovum (egg) for the process of fertilisation. Then, the fertilised egg (zygote) is transferred to the uterus of the patient to achieve a successful pregnancy

Intrauterine Insemination – IUI

Intrauterine Insemination (IUI) is the process by which semen is deliberately introduced into the vagina or oviduct of a female for the purpose of fertilisation by certain methods other than ejaculation. IUI is a widely recommended medical alternative to sexual intercourse, or natural insemination.

Intracytoplasmic Sperm Injection – ICSI

Intracytoplasmic Sperm Injection (ICSI) refers to an In Vitro Fertilization procedure in which a single sperm is directly injected into an egg. This process is commonly used to combat male infertility problems. However, this procedure may also be used in certain cases where the sperm cannot easily penetrate the eggs, and sometimes, in addition to sperm donation.

Embryo Freezing

Embryo freezing is the process by which an embryo is preserved at sub-zero temperatures, ideally at an embryogenesis stage that corresponds to pre-implantation, that is, from the phase of fertilisation to the blastocyst stage. Embryo freezing is suitable for leftover embryos after a cycle of In Vitro Fertilisation. This is because patients who have failed to conceive have greater chances of becoming pregnant using such embryos without having to go through a complete IVF cycle. Or, in case, the pregnancy has already occurred, they could later opt for another pregnancy using such embryos.

Assisted Hatching

Before an embryo attaches itself to the wall of the womb, it has to break out or, in other words, ‘hatch’ from its outer layer known as the ‘Zona pellucida.’ Creating a hole in the outer layer or thinning it may allow embryos to ‘hatch’, thus enhancing the chances of the woman to become pregnant in certain cases. However, it is to be noted that assisted hatching does not augment the quality of embryos.

Oocyte Donation

Oocyte donation refers to the process by which a woman provides either one or several (generally 10-15) eggs (Oocytes) for the purpose of assisted reproduction or biomedical research. Egg donation, for assisted reproduction, essentially involves the process of In Vitro Fertilisation or fertilization of eggs in the laboratory. Egg donation plays an integral role in the process of third party reproduction as part of Assisted Reproductive Technology (ART).

Surrogacy

Surrogacy refers to an arrangement or a practice in which a woman carries and delivers a child for an individual or another couple. This woman, often referred to as the surrogate mother, may be the child’s genetic mother (known as Traditional surrogacy), or she may be genetically unrelated to the child (known as Gestational surrogacy).

Sperm & Egg Freezing

Sperm & Egg Freezing involves the process of preserving both sperm and egg at sub-zero temperatures for the purpose of assisted reproduction.

As fertility is known to decrease with age, freezing your eggs at an early reproductive age will ensure greater chances for a future pregnancy. Frozen eggs are generally stored at -196 degrees, Hence, the quality of the egg do not deteriorate with time. As chemotherapy/radiotherapy may cause infertility problems, Egg freezing is an appropriate option for women who suffer from potentially curable cancer. The egg freezing process essentially involves administering various injections in order to stimulate the ovaries for a period of 12 to 14 days. The eggs are then collected under sedation. The process of egg collection is a relatively non-invasive, and carries a reduced risk of bleeding.

• Well-equipped operation theatre
• State-of-the-art ART laboratory
• Sperm freezing and embryo freezing
• Clinical and Andrology laboratory
• 18 bed level 3 neonatal intensive care unit
• 24 hour specialists for labor and delivery

• First baby conceived and delivered through Testicular Sperm Aspiration (TESA) combined with Intra- Cytoplasmic Sperm Injection (ICSI) technique in South Kerala in a 42-year-old lady
• First baby in South Kerala born using Frozen Embryo