Gynaecology Departments

Infertility Treatment

What is infertility?

Infertility, whether male or female, can be defined as 'the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse.

What is the incidence of infertility worldwide?

The World Health Organization (WHO) estimates that approximately 8-10% of couples experience some form of infertility problems. On a worldwide scale, this means that 50-80 million people suffer from infertility. However, the incidence of infertility may vary from region to region.

Is infertility exclusively a female problem?

No. The incidence of infertility in men and women is almost identical. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 30-40% of the cases. Problems common to both partners are diagnosed in 10-15% of infertile couples. After thorough medical investigations, the causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%). This is called unexplained infertility.

What are the most common causes of infertility?

The most common causes of female infertility are ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes. Less frequent causes include, for example, endometriosis and hyperprolactinemia, thyroid gland related problems.
In developing countries like India, infections of the womb such as gonorrhoea, chlamydia and tuberculosis significantly, contribute to infertility.

Causes of male infertility can be divided into three main categories:

Sperm production disorders affecting the quality and/or the quantity of sperm;
Anatomical obstructions;
Other factors such immunological disorders.
Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.

Ectopic Pregnancy

When a pregnancy is not located in the uterus it is called an Extra Uterine Pregnancy (EUG) or ectopic pregnancy.
The most common place for an EUG is the fallopian tube but sometimes the ectopic pregnancy is located elsewhere, such as in the cervix, the ovary or in the abdomen. EUG is a rare disease and occurs in 1% of all pregnancies. With IVF treatment the risk can increase. Risk factors for EUG are a history of infection of the tubes (Salpingitis), Chlamydia infection, Pelvic Inflammatory Disease (PID), genital tuberculosis, former EUG, operation on the tubes or in the lower abdomen, endometrioses and appendicitis.
The symptoms of ectopic pregnancy are often similar to those of a normal miscarriage and may include a positive pregnancy test together with or without vaginal bleeding and abdominal pain. Although it is not common, the possibility of EUG has to be considered in patients with the symptoms and one (or more) of the risk factors for EUG. Diagnoses is made by questioning the patient on the risk factors, physical examination, vaginal ultrasound and laboratory findings, especially the serum BHCG levels.
Depending on the size and the location of the EUG, different treatments can be given. Nowadays, most of the ectopic pregnancies can be removed surgically by Laparoscope, without opening the abdomen. But occasionally medical treatment in the form of Methotrexate injection or expectant treatment is offered when the pregnancy is very small and thorough control of the patient is possible. Alternatively, one can directly inject drugs into the ectopic pregnancy, making use of a thin needle, under the guidance of Tranvaginal Sonography.

(PCOS) Polycystic Ovarian Disease (PCOD) – The new epidemic?

One out of every four girls suffers from it. It causes all the problems that she most detests - weight gain, acne, facial hair growth and irregular periods. Not only young girls but even middle aged women may be affected by the problem of PCOD.
This is a problem that often runs in families and the mother and daughters may both be affected as there is a strong genetic component in its inheritance. One of the main problems in PCOD or Polycystic Ovarian Syndrome (PCOS) as it is now called – is resistance to insulin.
As the person usually has high insulin levels – she has a tendency to gain weight and to develop diabetes as she grows older. Also, as there is a problem of anovulation the ovary does not produce eggs every month, hence the girl suffers from irregular periods (usually delayed) scanty or heavy flow and often has difficulty in conceiving. Due to the excess of male hormone in the system, there is acne and excess facial hair growth. Some girls with PCOS may be thin and not show acne etc but sonography will show ovaries with multiple small water filed cysts thus establishing the diagnosis. Also a hormone check will show high levels of male hormone and also high levels of insulin. As a result of abnormal hormones and irregular periods for many years, these women have a higher chance of developing cancer of the womb.
The treatment of PCOS depends a lot on the symptoms the patient has. The most important thing in the obese patients is weight loss as it significantly improves the entire picture. Lifestyle change is necessary which includes improvement in diet, increase in exercise and keeping weight in control.
For a young lady who has lot of pimples and facial hair and has irregular periods the best treatment is combined hormonal pill. Some of these drugs contain medicines which reduce facial hair growth and within a few months the patient has significant improvement. The existing facial hair can be treated cosmetically, and new growth will reduce. Also pimples will clear out and menses will become absolutely regular with regular hormone treatment.
The other group of women in whom conceiving is the major problem the treatment is totally different. They require medicines such as clomiphene or gonadotrophin injections to induce ovulation. Sonography is done to check if the egg is coming out every month or not (ovulation). Many of these patients have a very erratic response to drugs, either no effect or an excessive number of eggs growing in response to normal dose of medicines. Hence great care has to be taken when these women are treated for infertility. Many of these women become pregnant either with simple treatment or with test tube baby treatment (IVF) but there is also a high miscarriage rate in women with PCOS.
A good drug in these women with high insulin levels is metformin, an antidiabetic drug but which has been proven to improve the metabolism and help weight loss in obese PCOS patents even when their sugar levels are normal. Another treatment for patients with many cysts in their ovaries is laparoscopic burning of the cysts with a thin needle through which a current is passed (laparoscopic ovarian drilling). This is a simple short procedure and requires 2 – 3 small (1 cm) cuts on the belly through which the laparoscope (telescope) and camera are passed. As the cysts are burned, the male hormone levels fall and the patient may begin to ovulate spontaneously.
This is a good technique especially in infertile patients where the tubes also have to be checked to see if they are open or not, as the procedures can be combined.
The problem of polycystic ovaries is massive; the important point is to have a healthy lifestyle with a good diet and exercise which will help to control this epidemic.