Dr. C P Agarwal

Introduction

When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.

What is needed for pregnancy?

In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.

In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.

It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.

Thus, to summarise, pregnancy requires

1.Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes

2.Transport of these sperms through the sperm conducting ducts from testes to penis

3.Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina

4.Transport of these sperms from vagina through cervix to the uterus and the tubes

5.Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries

6.Pick up of the eggs by the tubes

7.Approximation of eggs and the sperms to form the embryo

8.Transport of embryo from the tubes into the uterus

9.Acceptance of the embryo by the uterus and its growth

What is Infertility?

Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.

It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.

The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.

What causes Infertility?

Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.

Thus the common causes may be

1.Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.

2.Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examles include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.

3.Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out.

Treatment of Infertility

To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.

In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.

Semen Analysis

Semen analysis is an indispensable part of evaluation of an infertile couple. It is accepted that if semen analysis report is normal, male factor is usually said to be normal. However, a single abnormal semen analysis does not always mean that there is any abnormality in the man. This is, because, semen consists of 2 parts- the sperms and the fluid ("seminal plasma"). In a man, sperm production requires 3 months and it needs cool temperature than rest of the body. This is why, men have their testes hanging outside the body in the scrotum.Thus, today's semen analysis reflects a man's health 3 months before. If, for any reason (for example, high fever, tight underwear, hot tub bath etc), man's health was abnormal 3 months ago, the semen analysis may become abnormal. Again, the results can vary from one laboratory to another.

How semen collection and analysis is done?

The easiest and the most commonly used method is masturbation. But remember, you have to do it in awkward environment, where privacy will be maintained, but the mental pressure, that you have to give semen, may be harmful. So, stay relaxed. It's preferable to collect semen in the laboratory. But if its not possible, you can collect it at home, carry it in the pocket of your trousers and must reach the laboratory within 30 minutes of collection. Please inform the laboratory about the timing of collection.

Please maintain abstinence for 3 to 5 days (not more than 5, not less than 5). That means you should avoid intercourse and masturbation for 3-5 days prior to the test. It's important to collect all the semen in the collection pot and not to spill a portion outside.

Then it's tested in the laboratory for certain parameters like- volume (amount of semen), liquefaction (time needed for semen to become liquid), total sperm count, motility (ability of the sperms to move), morphology (the appearance of the sperms), vitality (whether sperms are living or not) etc. Please make sure that your laboratory is following WHO 2010 criteria for semen analysis (not the older criteria like 1992). Sometimes, some special tests may be done on the semen depending on your scenario.

What happens if a man cannot collect semen?

Collection of semen in unfamiliar environment is understandably a matter of discomfort and seems awkward. Proper counseling and maintenance of privacy can help. Stress-free approach is needed. If it fails, do not hesitate to inform your doctor, especially if you are not accustomed to masturbation or had difficulty earlier.. Some medicines can help. But in those, who are unable to masturbate, there are some instruments, like vibro-ejaculator, can help to solve this problem. This is a small device applied on the front part of the penis ("Glans Penis") to stimulate the organ to discharge the semen. The other options include rubbing the penis against a special Non-Toxic Condom (Not ordinary condom) or intercourse with that condom. Some men feel comfortable to practise coitus interruptus.

In few men, when no semen comes out, the problem may be retrograde ejaculation (Semen going into bladder instead of moving forward). In that case, sperms can be collected from the urine immediately after masturbation. If it fails, options include some medicines, electroejaculation (Putting current in prostate gland by a small probe inserted through the anus under general anaesthesia), prostatic message and sometimes collecting sperms from testes with a small fine needle.

What happens if the report is abnormal?

If a single report is abnormal, as mentioned above, it may not be conclusive. So, we usually advise repeating the test after few days, preferably from a second laboratory. At the same time, its important to diagnose the cause of this abnormality. To find out the cause, you may need physical examination of your genital organs. Your doctor may ask you some questions and with your permission, may check your body areas (hair growth, breast development), penis, scrotum, testicular size etc. Doctor can advise you some tests like ultrasound of your testes, or sometimes of your prostate gland. I severe cases, doctor can advise you some hormonal tests (blood tests- LH, FSH, Testosterone etc) and in some occasions, karyotyping (chromosomal analysis)

So, whenever we find abnormality, we have to detect the cause. Treatment without detecting thee cause is more likely to fail. So, first thing is- whether sperms are produced or not.

One important thing is to remember, sperm production has nothing to do with manliness. You may feel absolutely normal with normal sex life but sperm production may be defective. So, first thing is not to feel depressed when the report comes abnormal.

What treatment can be done?

Every attempt is made to find out the cause and treat the cause so that you can father your baby using your own sperm by natural means. Treatment includes some life-style advice, some medicines (antioxidants etc). But if the problem is severe, medicines may not act. The only conditions, where medicines act very well, is when the sperms are not produced because of hormonal problems in the pituitary gland.

What lifestyle changes are advised?

Remember, life style changes can improve your sperm count to some extent. You should avoid smoking, alcohol, taking drugs like anabolic steroids etc. You should try avoiding heat exposure to your scrotum. This can be done by avoiding tight underwear, avoiding prolonged sitting, avoiding prolonged driving, avoiding hot bath tub etc. Try keeping laptop and mobile phone away from your lap or thighs.

What is the next action?

If the sperm count improves, then natural conception is possible. In other cases, we may not be able to improve the sperm count, but pregnancy is possible. If the problem is mild, intrauterine insemination (IUI) can be done, with the success rate 20-25% per cycle. This means, every 100 women undergoing IUI, 25 can conceive in the 1st cycle. In other cases, up to 3-4 cycles of IUI can be done. If IUI fails, then the option remains IVF with success rate 40%. Remember, in all these cases, your sperms will be used.

IUI can be successful if sperm count is minimum more than 5 million per ml and there is reasonably good morphology and motility. If not, IVF or ICSI would be the better option. But IUI can serve as trial also. That means before putting the semen, the prepared sperms can be examined and it can be predicted what is the success rate of IUI in this particular case and whether IVF or ICSI would be needed. In rare occasions, where sperm count is extremely low but the couple do not wish for IVF or ICSI, pooled semen IUI can help- where the semen is collected in number of occasions and is preserved and the final pool is used for insemination, to give a reasonable success rate.

What is insemination?

Insemination literally means putting semen in a particular place. Various forms of insemination exist in fertility treatment. First one is “Intravaginal Insemination (IVI)”, where the raw semen, collected by the husband can be put inside the vagina, taking precautions (to prevent infection) by the husband himself or by the wife. Rarely, it needs medical assistance from a doctor. It’s usually advised to couples having sexual disorders where full penetrative intercourse is not possible (erectile dysfunction of the husband or very painful intercourse experienced by the wife) or where ejaculation cannot happen during intercourse (a very unusual problem). Thus, the success rate of IVI is no better than natural intercourse (success rate 15% per cycle), for those couples who can manage successful intercourse.

“Intrauterine Insemination (IUI)” is the treatment where “prepared” semen is put inside the cavity of the uterus, near the Fallopian tubes. Thus, IUI bypasses some hurdles that can cause problems during natural intercourse. The vagina, cervix and the whole length of the uterus are bypassed, putting the sperms near the eggs. Thus it increases the success rate compared to natural intercourse or IVI.

However, to achieve pregnancy after IUI, the female partner must have open tubes, adequate number of eggs produced by ovaries, eggs must be released by the ovaries and sperms must meet the eggs. And, thus nature plays important role, as in natural intercourse.

Please note, we used the word “prepared” semen. In natural intercourse, as mentioned earlier, the dead sperms and bacteria cannot enter the uterus, because cervix prevents their entry. If they are put artificially by IUI inside the uterus, severe reaction can happen. So, after collection, the husband’s semen is processed in the laboratory to remove all those impurities and to select only the best number of healthy and movable sperms and it definitely increases success rates of IUI

What can be done if there is no or very few sperms?

In such cases, we have to find out the exact problem. If the problem is due to adequate sperm production but blockage in the sperm conducting duct, some surgery can be done. However, such surgery is not widely available and may fail. So, most of the men usually opt for special type of IVF (In Vitro Fertilization) using the technique called ICSI (Intracytoplasmic sperm injection). Here sperms are collected from semen (is some sperms are there), or urine (in retrograde ejaculation) or by putting needle inside your scrotum (usually under anaesthesia). In case of block, the cahn=ance that we can collect your sperm from your body is 80-100%. That means, out of 100 such men, in more than 80 cases, sperms can be obtained from his testes. The procedures include TESA (Testicular Sperm Aspiration), TESE (Testicular Sperm Extraction), MESE (Microsyurgical Epididymal Sperm Extraction) and PESA (Percutaneous Epididymal Sperm Aspiration).

If it appears that the sperms are not produced well, still sometimes some sperms can be seen inside the testis. However, the chance of getting your sperms is 50%. So, if you agree, we can try collecting the sperms from your testes using TESA or TESE. Before that, we need to be sure that there is adequate chance of getting sperms from your body and so, you may need further investigations.

What is ICSI?

ICSI is a type of IVF. In standard IVF, your wife will be given some injections to mature her eggs, which will be collected under anaesthesia through the vagina using ultrasound. These eggs are then mixed with the sperms in the laboratory and the embryos, thus produced, are either directly put inside your wife's uterus or some may be frozen and kept for future use, if the 1st cycle fails.

In ICSI, the best single sperm is chosen and is inserted directly inside the egg to produce the embryo.

When donor sperm is used and how?

If a man does not have any sperms or too few sperms to do IUI, IVF or ICSI is not affordable, donor IUI is an alternative. But it is not done without consent from both husband and wife. The donor is not known to the couple or the doctor and no identity of the donor is revealed. No relative or friend can serve as donor. Donor semen is frozen semen, collected 6 months ago and the donor is tested for diseases like STD, HIV, Hepatitis B or C. Usual attempt is taken to chose donor having blood group and skin colour similar to those of the husband. But remember, it’s only given after discussion and written consent by the couple.

How Abnormal Sperm Count is Treated at clinics of Dr Sujoy Dasgupta?

We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.

We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.

We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.

We advise only those investigations that are needed and then find out the cause, if possible. We give the ouples all the options like medicines, IUI, ICSI, surgery, donor sperms etc and given them adequate time to consider their decision, Once, they decide, we respect their decision and proceed according to their wishes. The privacy and confidentiality are maintained strictly throughout

Conclusion

Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Often we find that patients planning for treatment and in the mean time, they conceive naturally. That means even without treatment, there is some chance of pregnancy. Of course, it’s stressful situation for both the partners. Stress affects conjugal relationships and lead to many couples avoiding conjugal life. Indeed stress can affect the hormone levels in females and affects sexual performances in males. It’s easier for us to advise you to stay stress-free but is difficult to practice. Nevertheless, try relaxation as much as possible. Think that majority of the couples ultimately conceive by some form of treatment. Have faith in yourself and have faith in your doctor.