Infertility

Description

The broad term infertility combines both the inability to procreate and to conceive: male sterility and female infertility. The causes of infertility in couples can, medically speaking, lie in either the man or the woman, or be due to a combination of different factors (idiopathic infertility). Aside from physical causes, stress and psychological pressure can negatively affect fertility. It is not always possible to determine the cause of infertility.

Symptoms

Infertility is a not infrequent problem in family planning, but is not always easy to recognize as such. It is called primary infertility (also: primary sterility) when the patient wants a child but after one year there is still no pregnancy (despite regular intercourse and no use of contraceptives), and the woman has never before conceived nor the man fathered a child. Secondary infertility is when pregnancy does not occur after trying to conceive for one year, but the patient had been pregnant or fathered a child at least once before.

Causes and Risks

The causes of infertility are very diverse. In addition to psychological factors such as chronic stress, fertility in both partners can be affected by alcohol, nicotine and drug abuse. In women, eating disorders and being overweight or underweight may cause menstrual disorders, which can also encourage and promote infertility. Physical causes (fallopian tube blockage, adhesions in the uterus) and diseases such as endometriosis, uterine myomatosis, hormonal cycle disorders (polymenorrhoea,  oligomenorrhoea, amenorrhoea) and sexually transmitted diseases may also be relevant. In women generally, advancing age often leads to disturbances in ovum maturation, which is an additional burden on reproductive ability.

In the male partner, reduced sperm quality and production, hormonal dysfunction, testicular malfunction (e.g. after parotitis), blockage of the seminal ducts (e.g. from chlamydia infection or after a hernia) or inflammation can lead to sterility.

Examination and Diagnosis

The basic diagnostic procedure includes a medical interview with both partners in which the couple's previous history is recorded, including questions about previous illnesses, miscarriages and the frequency of intercourse. Afterward, the woman receives a gynecological examination to evaluate any physical causes, and in addition an ultrasound is performed. Ovulation can be tracked by means of the basal temperature curve or by cycle monitoring. A hysteroscopy or laparoscopy may be necessary for further diagnosis.

During examination of the male partner a spermiogram is prepared to evaluate decreased semen quality. Testicular abnormalities or inflammation can be detected via palpation of the genitals. In case of a very contricted spermiogram, a testicular biopsy can be performed for further diagnosis.

Treatment

The treatment of sterile couples depends on the specific conditions and is based on the cause of the dysfunction. To this end, different methods can be used including hormonal stimulation, insemination, in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), to name a few.

Ovarian stimulation is achieved via hormonal medication to encourage egg maturation, and can be administered in the form of tablets or an injection. There can be a number of side effects including hyperstimulation, hot flashes, headaches or depressive moods.

With insemination, the specially prepared male seed is placed in the uterus about 36 hours before ovulation, thus allowing the sperm to reach the ovum at the optimum time. In women with fertility problems, this method is used in combination with hormonal stimulation.

In vitro fertilization (IVF) is an extracorporeal artificial insemination which lasts for several weeks and requires extensive preparation. After a hormone treatment induced hyperovulation, several mature cells are taken from the patient via a transvaginal follicle puncture, then extracorporeally (in vitro) fertilized and reinserted into the uterus (embryo transfer).

In ICSI, a sperm cell is injected with a needle directly into the egg of the woman.

Course and Prognosis

The chance of successful treatment with in vitro fertilization (IVF and ICSI) is between 25-60% depending on the number of transferred ova. In the Department of Obstetrics and Gynecology at the the Medical Center - University of Freiburg, the rate is as high as 50%.

Transferring multiple embryos may lead to a multiple pregnancy, which carries the risk of premature birth and miscarriage as well as pregnancy complications or developmental disorders of the embryos.