Expectations for a fertile tomorrow - Dr. Nalin Abeysinghe

Expectations for a fertile tomorrow - Dr. Nalin Abeysinghe writes to eDoctor eDoctor lk 4:02 AM Fertility is the natural capability to produce offspring. It explains the whole process from gamete production, fertilization and carrying a pregnancy to term. Simply it explains the complete process of producing a live offspring. On the other hand fecundity means the potential for reproduction or the ability to get pregnant. Fertile couples are invariably fecund and the reverse is not possible always. Lack of fertility is referred as infertility and lack of fecundity (the basic ability in the process of producing a live offspring) is called sterility. World Health Organization defines infertility as a DISEASE (certain insurance companies do not accept claims though) of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Infertility generates disability. Infertility in women was ranked the 5th highest serious global disability. Worldwide one out of every seven couples is infertile. In Sri Lanka 10% of the couples are infertile. In 50% of these cases male is the factor while in one third woman is the factor. The reasons for infertility are described under five categories (See the Table) Causes for Infertility Primary (%) Secondary (%) Anovulation (Failure to produce mature eggs) 20 15 Male factors 25 20 Fallopian tube problems 15 40 Endometriosis 10 5 Unexplained 30 20 Although single category may be the only reason for a given couple’s infertility, some of these categories may coexist in the same couple (i.e. anovulation and male factor). Generally likelihood of a spontaneous live birth in an infertile couple is strongly influenced by the age of the female, duration of infertility, previous pregnancies, and cause of infertility. Unexplained infertility has the best outcome. Anovulation or failure to release mature eggs is one of the commonest causes of infertility. Among conditions causing anovulation, Polycystic Ovarian Syndrome (PCOS) would be the commonest. It is characterized by irregular menstrual cycles, androgen (male hormone) excess and Ultrasound evidence of polycystic ovaries. PCOS is commonly seen among young women in a prevalence of 5% – 7%. It manifests commonly as irregular menstrual cycles. Not only PCOS possess gynecological implications, but also those related to other systems too. They are obese and tend to get metabolic syndrome and diabetes. They are good candidates for deranged lipid metabolism. Figure 1 Abnormal Hair Growth in the Face Seen in a Woman with PCOS Endometriosis by far one of the commonest problems among females. It also found in younger females. The key feature is presence of endometrial tissue (the inner lining of the womb that sheds during menses) outside the uterine cavity. This ectopic tissue too undergoes cyclical bleeding due to hormonal changes and find no way to be drained out hence get collected. These internal menstrual collections adhere the surrounding structures together. This causes an intense pain during cycles – sometimes outlasting the duration of menses. Endometriosis associates with infertility in various ways by interfering egg maturation, ovulation, gamete (eggs and sperms) transfer and implantation (‘seeding’ of the fertilized egg in the womb). Fallopian tubes are important transporters contributing to fertility. They involved in transfer of gametes (eggs and sperms towards each other) and transportation of fertilized egg in to womb. In fertility treatment tubal disease exerts a great challenge. Although infertility has been defined with one year, a couple has to be investigated earlier if they have any pre-existing disease or the female is over 35 years. Extensive clinical assessment of the couple has to be carried out. Baseline investigations will be a Seminal Fluid Analysis (SFA) and Trans Vaginal Ultrasound (TVS) Scan of the female. SFA though a baseline investigation provides a big picture about the male partner; several parameters related to the quality of sperms will be assessed according to a standard criteria issued by the WHO. Figure 2 Normal Hysterosalphyngogram Hysterosalphyngogram (HSG) and Diagnostic Laparoscopy and Dye Test (Laparoscopy + DT) will be used depending on each situation to assess the patency of Fallopian tubes while latter provides a comprehensive image (under direct vision) about the female reproductive system. Various hormonal assays are available to investigate the problems with internal signaling pathways related in reproduction and menstrual cycle. Blood tests as well as urinary dipstick tests are available to correctly find out the time of ovulation. As a habit all females seeking treatment for infertility are asked to maintain a menstrual diary where they have to document the details of each day of their cycle. As a standard first day of the period (first day of bleeding) will be taken as Day 1 of the cycle and following days numbered accordingly. Ovarian reserve is one of the major concerns when managing couples with infertility. Unlike men women are destined to have a limited period of fertility. They are provided with limited number of eggs, few of which are disposed in each cycle. Therefore ovarian reserve – in other words the number of retrievable eggs for fertilization has major implications on the success rate of infertility treatment. The main factor determining ovarian reserve is the age of the female. Figure 1- Laparoscopic Diagnostic Test Showing Free Spill of the Dye All infertility treatment is focused on utilizing this ovarian reserve effectively in order to provide couple with a healthy pregnancy. Treatment options are enormous. First of all identified underlying diseases contributing to the condition has to be treated. Obese females are encouraged to reduce their weight which will invariably return their regular cycles hence fertility. Few tablets are available in a basic treatment called ovulation induction where doctors stimulate ovaries to produce good quality eggs as required. Seminal fluid (the liquid containing sperms) is processed in laboratory setup so the quality of the sperms is improved, will be used to be deposited inside the womb (Intra Uterine Insemination – IUI). When a male partner cannot produce a sample with adequate amount of sperms donor samples can be used orIUI. Figure 4 ICSI One of the IVF technologies in which a selected sperm is directly injected into an ovum (egg) Invitro Fertilization (IVF) has shown some light to many of bereft couples. This technique involves the artificial combination (in a laboratory setup) of sperms and eggs and implanting the embryos formed thereafter inside the female’s womb. Various methods are available under this category. Women are advised to take folic acid throughout and have Rubella vaccination (if it has not been given when schooling) six months prior to the initiation of treatment. To read the article in our website click here... Key Facts · Infertility/Subfertility is a Disease · Both Males and Females equally contribute for its causation · Female’s age is the most important factor in determining the success rate of treatment · Most couples will benefit from simple treatment option Dr Nalin Abeysinghe MBBS (Sri Jayewardenepura), Medical Officer in Obstetrics and Gynaecology, Sri Jayewardenepura General Hospital, Nugegoda.

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