Detailed Study on Infertility its Causes and

Treatment

Published on Oct 05, 2018

Introduction
Infertility is the inability of a person, animal or plant to reproduce by natural means. It is usually not
the natural state of a healthy adult organism, except notably among certain eusocial species (mostly
haplo diploid insects).
In humans, infertility may describe a woman who is unable to conceive as well as being unable to
carry a pregnancy to full term. There are many biological and other causes of infertility, including
some that medical intervention can treat. Infertility rates have increased by 4% since the 1980s,
mostly from problems with fecundity due to an increase in age. About 40% of the issues involved
with infertility are due to the man, another 40% due to the woman, and 20% result from
complications with both partners.
Women who are fertile experience a natural period of fertility before and during ovulation, and they
are naturally infertile during the rest of the menstrual cycle. Fertility awareness methods are used to
discern when these changes occur by tracking changes incervical mucus or basal body temperature
Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical
pregnancy after 12 months or more of regular unprotected sexual intercourse (and there is no other
reason, such as breastfeeding or postpartum amenorrhea). Primary infertility is infertility in a couple
who have never had a child. Secondary infertility is failure to conceive following a previous
pregnancy. Infertility may be caused by infection in the man or woman, but often there is no obvious
underlying cause.
One definition of infertility that is frequently used in the United States by doctors who specialize in
infertility, to consider a couple eligible for treatment is:
• a woman under 35 has not conceived after 12 months of contraceptive-free intercourse. Twelve
months is the lower reference limit for Time to Pregnancy (TTP) by the World Health Organization.
• a woman over 35 has not conceived after 6 months of contraceptive-free sexual intercourse

Theory
Researchers commonly base demographic studies on infertility prevalence on a five-year period.
Practical measurement problems, however, exist for any definition, because it is difficult to measure
continuous exposure to the risk of pregnancy over a period of years.
Types of Infertility
Primary vs. secondary infertility
Primary infertility is defined as the absence of a live birth for women who desire a child and have
been in a union for at least five years, during which they have not used any contraceptives. The
World Health Organization also adds that 'women whose pregnancy spontaneously miscarries, or
whose pregnancy results in a still born child, without ever having had a live birth would present with
primarily infertility
Secondary infertility is defined as the absence of a live birth for women who desire a child and have
been in a union for at least five years since their last live birth, during which they did not use any
contraceptives.
Thus the distinguishing feature is whether or not the couple have ever had a pregnancy which led to
a live birth.

Effects
Psychological impact
The consequences of infertility are manifold and can include societal repercussions and personal
suffering. Advances in assisted reproductive technologies, such as IVF, can offer hope to many
couples where treatment is available, although barriers exist in terms of medical coverage and
affordability. The medicalization of infertility has unwittingly led to a disregard for the emotional
responses that couples experience, which include distress, loss of control, stigmatization, and a
disruption in the developmental trajectory of adulthood.
Infertility may have profound psychological effects. Partners may become more anxious to conceive,
increasing sexual dysfunction Marital discord often develops in infertile couples, especially when
they are under pressure to make medical decisions. Women trying to conceive often have clinical
depression rates similar to women who have heart disease or cancer. Even couples undertaking IVF
face considerable stress.
The emotional losses created by infertility include the denial of motherhood as a rite of passage; the
loss of one’s anticipated and imagined life; feeling a loss of control over one’s life; doubting one’s
womanhood; changed and sometimes lost friendships; and, for many, the loss of one’s religious
environment as a support system.
Emotional stress and marital difficulties are greater in couples where the infertility lies with the man.

Social impact
In many cultures, inability to conceive bears a stigma. In closed social groups, a degree of rejection
(or a sense of being rejected by the couple) may cause considerable anxiety and disappointment.
Some respond by actively avoiding the issue altogether; middle-class men are the most likely to
respond in this way.
In an effort to end the shame and secrecy of infertility, Redbook in October 2011 launched a video
campaign, The Truth About Trying, to start an open conversation about infertility, which strikes one
in eight women in the United States. In a survey of couples having difficulty conceiving, conducted
by the pharmaceutical company Merck, 61 percent of respondents hid their infertility from family and
friends. Nearly half didn't even tell their mothers. The message of those speaking out: It's not always
easy to get pregnant, and there's no shame in that.
There are legal ramifications as well. Infertility has begun to gain more exposure to legal domains.
An estimated 4 million workers in the U.S. used the Family and Medical Leave Act (FMLA) in 2004 to
care for a child, parent or spouse, or because of their own personal illness. Many treatments for
infertility, including diagnostic tests, surgery and therapy for depression, can qualify one for FMLA
leave. It has been suggested that infertility be classified as a form of disability.

Causes
Sexually transmitted disease
Infections with the following sexually transmitted pathogens have a negative effect on fertility:
Chlamydia trachomatis, Neisseria gonorrhoeae, and Syphilis. There is a consistent association of
Mycoplasma genitalium infection and female reproductive tract syndromes. M. genitalium infection is
associated with increased risk of infertility.

Genetic
A Robertsonian translocation in either partner may cause recurrent spontaneous abortions or
complete infertility.

Other causes
Factors that can cause male as well as female infertility are:

• DNA damage
• DNA damage reduces fertility in female oocytes, as caused by smoking, other xenobiotic DNA
damaging agents (such as radiation or chemotherapy)or accumulation of the oxidative DNA damage
8-hydroxy-deoxyguanosine
• DNA damage reduces fertility in male sperm, as caused by oxidative DNA damage, smoking, other
xenobiotic DNA damaging agents (such as drugs or chemotherapy)or other DNA damaging agents
including reactive oxygen species, fever or high testicular temperature

• General factors
• Diabetes mellitus, thyroid disorders, undiagnosed and untreated coeliac disease adrenal disease
• Hypothalamic-pituitary factors
• Hyperprolactinemia
• Hypopituitarism
• The presence of anti-thyroid antibodies is associated with an increased risk of unexplained
subfertility with an odds ratio of 1.5 and 95% confidence interval of 1.1–2.0
• Environmental factors
• Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts, and
pesticides Tobacco smokers are 60% more likely to be infertile than non-smokers.
German scientists have reported that a virus called Adeno-associated virus might have a role in
male infertility, though it is otherwise not harmful. Other diseases such aschlamydia, and gonorrhea
can also cause infertility, due to internal scarring (fallopian tube obstruction).
 The causes of Infertility in Females
The following causes of infertility may only be found in females. For a woman to conceive, certain
things have to happen: intercourse must take place around the time when an egg is released from
her ovary; the system that produces eggs has to be working at optimum levels; and her hormones
must be balanced.
For women, problems with fertilisation arise mainly from either structural problems in the Fallopian
tube or uterus or problems releasing eggs. Infertility may be caused by blockage of the Fallopian
tube due to malformations, infections such as Chlamydia and/or scar tissue. For example,
endometriosis can cause infertility with the growth of endometrial tissue in the Fallopian tubes and/or
around the ovaries. Endometriosis is usually more common in women in their mid-twenties and
older, especially when postponed childbirth has taken place.
Another major cause of infertility in women may be the inability to ovulate. Malformation of the eggs
themselves may complicate conception. For example, polycystic ovarian syndrome is when the eggs
only partially developed within the ovary and there is an excess of male hormones. Some women
are infertile because their ovaries do not mature and release eggs. In this case synthetic FSH by
injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate follicles to mature in the
ovaries.
Other factors that can affect a woman's chances of conceiving include being overweight or
underweight, or her age as female fertility declines after the age of 30.
Sometimes it can be a combination of factors, and sometimes a clear cause is never established.
Common causes of infertility of females include:
• Ovulation problems (e.g. polycystic ovarian syndrome, PCOS, the leading reason why women
present to fertility clinics due to an ovulatory infertility)
• tubal blockage
• pelvic inflammatory disease caused by infections like tuberculosis
• age-related factors
• uterine problems
• previous tubal ligation
• endometriosis
• advanced maternal age

The causes of Infertility in Males

The main cause of male infertility is low semen quality. In men who have the necessary reproductive
organs to procreate, infertility can be caused by low sperm count due to endocrine problems, drugs,
radiation, or infection. There may be testicular malformations, hormone imbalance, or blockage of
the man's duct system. Although many of these can be treated through surgery or hormonal
substitutions, some may be indefinite. Infertility associated with viable, but immotile sperm may be
caused by primary ciliary dyskinesia

Combined infertility
In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility
arises from the combination of these conditions. In other cases, the cause is suspected to be
immunological or genetic; it may be that each partner is independently fertile but the couple cannot
conceive together without assistance.

Unexplained infertility
In the US, up to 20% of infertile couples have unexplained infertility. In these cases abnormalities
are likely to be present but not detected by current methods. Possible problems could be that the
egg is not released at the optimum time for fertilization, which it may not enter the fallopian tube,
sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may
be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical
importance and women of advanced maternal age have eggs of reduced capacity for normal and
successful fertilization. Also, polymorphisms in foliate pathway genes could be one reason for
fertility complications in some women with unexplained infertility.

Treatment
Treatment depends on the cause of infertility, but may include counseling, fertility treatments, which
include in vitro fertilization. According to ESHRE recommendations, couples with an estimated live
birth rate of 40% or higher per year are encouraged to continue aiming for a spontaneous
pregnancy. Treatment methods for infertility may be grouped as medical or complementary and
alternative treatments. Some methods may be used in concert with other methods. Drugs used for
both women and men include clomiphene citrate, human menopausal gonadotropin (hMG), follicle-
stimulating hormone (FSH), human chorionic gonadotropin (hCG), gonadotropin-releasing hormone
(GnRH) analogues, aromatase inhibitors, and metformin

Medical treatments
Medical treatment of infertility generally involves the use of fertility medication, medical device,
surgery, or a combination of the following. If the sperm are of good quality and the mechanics of the
woman's reproductive structures are good (patent fallopian tubes, no adhesions or scarring), a
course of ovarian stimulating medication maybe used. The physician or WHNP may also suggest
using a conception cap cervical cap, which the patient uses at home by placing the sperm inside the
cap and putting the conception device on the cervix, or intrauterine insemination (IUI), in which the
doctor or WHNP introduces sperm into the uterus during ovulation, via a catheter. In these methods,
fertilization occurs inside the body.
If conservative medical treatments fail to achieve a full term pregnancy, the physician or WHNP may
suggest the patient undergo in vitro fertilization (IVF). IVF and related techniques (ICSI, ZIFT, and
GIFT) are called assisted reproductive technology (ART) techniques.
ART techniques generally start with stimulating the ovaries to increase egg production. After
stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with
sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes
place outside the body, and the fertilized egg is reinserted into the woman's reproductive tract, in a
procedure called embryo transfer
Other medical techniques are e.g. tuboplasty, assisted hatching, and Preimplantation genetic
diagnosis.

Effects on the Population

Perhaps except for infertility in science fiction, films and other fiction depicting emotional struggles of
assisted reproductive technology have had an upswing first in the latter part of the 2000s decade,
although the techniques have been available for decades. Yet, the number of people that can relate
to it by personal experience in one way or another is ever growing, and the variety of trials and
struggles is huge.
Pixar's Up contains a depiction of infertility in an extended life montage that lasts the first few
minutes of the film.
There are several ethical issues associated with infertility and its treatment.
• High-cost treatments are out of financial reach for some couples.
• Debate over whether health insurance companies (e.g. in the US) should be required to cover
infertility treatment.
• Allocation of medical resources that could be used elsewhere
• The legal status of embryos fertilized in vitro and not transferred in vivo. (See also Beginning of
pregnancy controversy).
• Pro-life opposition to the destruction of embryos not transferred in vivo.
• IVF and other fertility treatments have resulted in an increase in multiple births, provoking ethical
analysis because of the link between multiple pregnancies, premature birth, and a host of health
problems.
• Religious leaders' opinions on fertility treatments; for example, the Roman Catholic Church views
infertility as a calling to adopt or to use natural treatments (medication, surgery, and/or cycle
charting) and members must reject assisted reproductive technologies.
• Infertility caused by DNA defects on the Y chromosome is passed on from father to son. If natural
selection is the primary error correction mechanism that prevents random mutations on the Y
chromosome, then fertility treatments for men with abnormal sperm (in particular ICSI) only defer the
underlying problem to the next male generation.
Many countries have special frameworks for dealing with the ethical and social issues around fertility
treatment.
• One of the best known is the HFEA – The UK's regulator for fertility treatment and embryo
research. This was set up on 1 August 1991 following a detailed commission of enquiry led by Mary
Warnock in the 1980s
• A similar model to the HFEA has been adopted by the rest of the countries in the European Union.
Each country has its own body or bodies responsible for the inspection and licencing of fertility
treatment under the EU Tissues and Cells directive
• Regulatory bodies are also found in Canada and in the state of Victoria in Australia

CONCLUSIONS
Infertility is often not seen (by the West) as being an issue outside industrialized countries. This is
because of assumptions about overpopulation problems and hyper fertility in developing countries,
and a perceived need for them to decrease their populations and birth rates. The lack of health care
and high rates of life-threatening illness (such as HIV/AIDS) in developing countries, such as those
in Africa, are supporting reasons for the inadequate supply of fertility treatment options. Fertility
treatments, even simple ones such as treatment for STIs that cause infertility, are therefore not
usually made available to individuals in these countries.
Despite this, infertility has profound effects on individuals in developing countries, as the production
of children is often highly socially valued and is vital for social security and health networks as well
as for family income generation. Infertility in these societies often leads to social stigmatization and
abandonment by spouses. Infertility is, in fact, common in sub-Saharan Africa. Unlike in the West,
secondary infertility is more common than primary infertility, being most often the result of untreated
STIs or complications from pregnancy/birth.
Due to the assumptions surrounding issues of hyper-fertility in developing countries, ethical
controversy surrounds the idea of whether or not access to assisted reproductive technologies
should comprise a critical aspect of reproductive health or at least, whether or not the distribution
and access of such technologies should be subject to greater equity. However, as highlighted by
Inhorn the overarching conceptualisation of infertility, to a great extent, disguises important
distinctions that can be made within a local context, both demographically and epidemiological and
moreover, that these factors are highly significant in the ethics of reproduction.
An important factor, argues Inhorn, is the positioning of men within the paradigm of reproductive
health, whereby because rates of general infertility mask differences between male and female
infertility, men remain a largely invisible facet within the theorisation and d0iscourse surrounding
infertility, as well as the related treatments and biotechnologies. This is particularly significant given
that male infertility accounts for more than half of all cases of infertility and moreover, it is evident
that the attitudes and behaviours of men have profound implications for the reproductive health of
both individuals and couples. For example, Inhorn notes that when couples in Egypt are faced with
seemingly intractable infertility problems - due to a range of family and societal pressures that centre
around the place of children in constituting the gender identity of men and women - it is often the
women who is forced to seek continued treatment; this continues to occur, even in known instances
of male infertility and that the constant seeking of treatment frequently becomes iatrogenic for the
women.
Inhorn states that infertility often leads to “marital demise, physical violence, emotional abuse, social
exclusion, community exile, ineffective and iatrogenic therapies, poverty, old age insecurity,
increased risk of HIV/AIDS, and death”Significantly, Inhorn demonstrates that this phenomenon
cannot simply be explained by a lack of knowledge, rather it occurs in a complex interaction between
the centrality of children in the male gender identity as a symbol of maturity and the relative lack of
power of women in Egyptian society, whereby they effectively become scapegoats for a culturally
accepted narrative as a site of blame for the lack of childlessness. It should be emphasised that this
is not simply an issue of “women oppressed by men” but rather, that men and women both share the
burden of this narrative, but in different, unequal and highly complex ways.
Therefore, while the notion that reproductive health is a ‘women’s issue’, may have powerful social
currency, especially within popular discourse and indigenous systems of meaning, the reality of
infertility suggests that medical and health paradigms have a significant part to play in challenging
the validity of this entrenched belief . Moreover, the effectiveness of any therapeutic intervention,
medical or otherwise will be contingent on such outcomes and has an important part to play in the
alleviation of gendered suffering, especially the burden imposed on women, who continue to suffer
disproportionately from the effects of infertility.
High costs may also be a factor and research by the Genk Institute for Fertility Technology, in
Belgium, claimed a much lower cost methodology (about 90% reduction) with similar efficacy, which
may be suitable for some fertility treatment. At the 1994 United Nations International Conference on
Population and Development (ICPD) in Cairo, the prevention and treatment of infertility was
accepted into the program of action for reproductive healthcare. Infertility has shown to have a
greater affect on developing nations than on birth rates or population control, but also on a social
level as well.
Reproduction is a large aspect of life for many cultures within developing nations, and infertility can
lead to social and familial problems such as rejection or abandonment as well as personal
psychological issues. Currently, fertility treatment options and programs are only available through
private health sectors in developing nations and little-to-no treatment is available through public
health sectors. The fertility treatment options offered through the private sectors are often costly or
not easily accessible. Additionally, counseling is considered an essential aspect of fertility treatment,
and due to lack of education and resources such forms of therapy remain scarce as well. While
quality fertility care is not readily available in developing nations (such as sub-Saharan African
countries), a standard procedure of care could be easily implemented for a low cost as a basic
intervention. The lack of fertility treatment is problematic, and high birth and population rates are
every reason to implement treatment options rather than reject them.

Reference
 Biological Science: Third Edition By, N. P. O. Green (Author), G. W. Stout (Author), D. J. Taylor
(Author), R. Soper (Editor)
 Exploring Biology By, Ella Thea Smith
 NCERT Text Book
 Tell Me Why
 Encyclopaedia Britannica

Case Study 1.

Case study: Couple triumphs over infertility through

IVF
December 9, 2016, 6:41 PM IST Dr Rita Bakshi in Your fertility friend | Lifestyle, Science | TOI

Long ago, Riya and her husband Sumeil were trying to have a baby. A few months later,
she was diagnosed with Endometriosis (blocked fallopian tubes), where the tissue from
uterine lining extends outside towards the fallopian tubes and neighbouring organs. It is
not a severe condition but causes great pain and many side effects. It is also a common
factor of infertility in women.

This is why, Riya opted for surgery to cure endometriosis. In 2010, she and her
husband had begun trying for a baby. For four years, they failed to start their family. At
last, feeling frustrated, losing all hope and out of options, Riya made an appointment at
our clinic International Fertility Centre (IFC) located in New Delhi. At her first few visits,
she learnt about the fertility issues she was facing.

Riya says, “When I first spoke to Dr Rita Bakshi, she was very patient and
understanding. She confirmed that endometriosis was likely the main reason behind my
inability to conceive, despite the surgery. She also explained me in detail, why the odds
of becoming pregnant through natural means were less for me. She had a well-defined
treatment plan for me.”
 From that point, Riya’s full one-year treatment began at IFC. We advised her to undergo
In-vitro fertilization.

“It was a very pleasant experience. They didn’t make me feel uncomfortable in any way
and I felt like they were truly there to help me. Dr Rita Bakshi is the best doctor for me
as she was very supportive, compassionate, understanding and motivating, Riya said.”

IVF treatment for endometriosis

The team at IFC decided Riya’s best chance for pregnancy was In-vitro Fertilization. It is
a simple procedure that involves fusing of male parent’s sperm and female parent’s
eggs in a laboratory dish outside the human body and then transferring into the female
parent’s uterus.

Riya added that “Dr Rita Bakshi was helpful and she wished me good luck. It was the
little things that the doctors, nurses and other staff did at the clinic that made my journey
at IFC unforgettable.”

Patience, determination and success

A few months later, Riya and Sumeil had a successful pregnancy.

“It was fortunate that we had a successful IVF in 2nd cycle itself. I feel that the only Dr
Rita Bakshi could have helped us win over endometriosis and thus, helped us
conceive,” said Riya.

Riya and Sumeil gave birth to a baby girl in June 2015.

Closing Thoughts

My biggest piece of advice is to just relax. You should have faith and you have to make
your own future. I would advise couples to try for pregnancy in the early childbearing
age before it’s too late.

Case Study 2.

SpectraCell Blog

Case Study: 25 Year Old Female with History of Infertility

Posted by SpectraCell Laboratories, Inc. on Tue, Jun 12, 2012 @ 10:16 AM


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 Previously treated for ogilomenorrhea, acne, menorrhaggia,
cold intolerance, obesity with gradual weight gain and Polycystic Ovarian Syndrome

In September 2003, the patient was very interested in becoming pregnant. She was counseled in
and utilized Basal Body Temperature charting with adjunctive use of the LH ovulation kit. She and
her husband were counseled on focused sex for five days before and three days after ovulation.
After more than a year and a half of unsuccessful attempts at pregnancy, the physician performed
Spectra Cell’s micronutrient testing in June 2005. Her results returned gross deficiencies of vitamins
B1 (Thiamin), B6 (Pyridoxine) and E (alpha-tocopherol). She was also grossly deficient in Zinc,
Serine, Glutamine and Coenzyme Q10 in addition to revealing a Glucose-Insulin interaction
consistent with insulin resistence frequently found in PCOS. Her Antioxidant Function was
remarkably low at 38.1% demonstrating increased potential for oxidative damage. All of the
abnormalities were present despite the patient taking excellent prenatal vitamins, fish oil, chromium
and NAC. Based upon her deficiencies found with SpectraCell’s micronutrient testing, she was
placed on adequate replacement for each of the gross and even the marginal deficiencies in June
2005.

Clinical Outcome:
She and her husband subsequently became pregnant very quickly within a month and she attended
her first obstetrics appointment on August 2005. She delivered a 8lb. 7oz. viable baby boy at 38 and
a half weeks by vaginal delivery after being induced for mild preeclampsia.

Conclusion:
As a result of performing Spectra Cell’s micronutrient testing, her physician was able to identify key
nutritional deficiencies in this patient which occurred despite the patient following a good diet and
taking good prenatal vitamins and other nutritional supplements. Her physician safely supplemented
her during her pregnancy knowing that the patient and thus the baby did in fact need these nutrients.
This helped allay fears of over supplementation and facilitated optimal growth and development of

what proved to become an extremely healthy and happy young male child.

Approximately 85% of women will become pregnant within one year of trying. This young lady had
been unsuccessful for 21 months before her nutritional deficiencies were identified and
supplemented and then became pregnant shortly thereafter. She would have probably had to
undergo fertility treatment as do many women with PCOS. The 27 year old white female with PCOS
and infertility is forever grateful for the existence and utilization of Spectra Cell’s micronutrient
testing.