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Infertility Issue Faced By The Couple

Written and reviewed by
MBBS, MD - Obstetrics & Gynaecology
IVF Specialist, Mumbai  •  40 years experience
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Hello good evening!

Today we will talk of fertility issues in couples. I am Dr. Sudha Tandon. Now if we see a hundred couples who wish to get pregnant, about 75-80% of the couples will get pregnant in the in one year without using contraception whereas there is 15 to 20% will have problems in getting pregnant. Now, what are the important things that are required for a couple to get pregnant without any problem? By and large, if the woman is young, they get her periods regularly at regular intervals that means she is ovulating regularly, the frequency of intercourse should be normal that means at least every alternate day and especially during the ovulatory period which is roughly between the 10th to the 18 days in every menstrual cycle. The semen analysis of the husband, the husband should have the good number of sperms in the semen, frequency of intercourse should be normal and her fallopian tubes all the pelvic organs uterus and fallopian tubes should be normal. So, if these criteria are met about 75 to 85% of the couples will get pregnant in the one in one year when they try. Now, what happens if, or what is it that if they don't get pregnant what are the issues or what is the options that we have for these couples. If it's a young couple let’s say the woman is about just 20 or 25 years old, she could wait for you know 2 years but if the couple is especially the woman if the woman is more than 30 or 35 years of age and she doesn't get pregnant, she should not wait for more than 1 year of trying naturally. Now suppose they do not get pregnant, they have tried for 1 year, they meet all the criteria of a natural conception but she does not get pregnant naturally what are the problems and what are the options that are available. It is important that these couples go to a fertility specialist to seek advice because the getting the right advice at the right time is most important.

Now first is for the history that if they have regular intercourse and the periods are regular, she is young, then this couple should not have any problem in getting pregnant but if let's say the husband's semen count is below normal, so what is the normal sperm count? Normal sperm count is in in a semen sample, the sample should be at least 1ml or more, should have 15 million sperms per ml and about 40% should be actively motile and about 4% of the sperms should be normal of normal morphology. Now if the couple of them or if the husband has got a low sperm count to let's say less than 2 million or 3 million the probability of natural conception is very less. So these patients would require help, would require assistance in the form of a test tube baby treatment where the fertilization of the egg and the sperm happens in the laboratory which will help them to get pregnant or if the women have got blocked fallopian tubes, now if the blockage in the fallopian tubes could be either in one tube, it could be in both the tube, it could be because of past infection or if there is a history of abortion or if there is a pregnancy in the fallopian tubes in the past and both the tubes have to be removed or the other problem could be if she is not ovulating regularly especially the women is obese or even very thin PCOS or obese PCOS, now these are the woman who will not ovulate. What do you mean by ovulation is that the egg which does not get released at regular intervals and these the cycles are anovulatory, so these women also will not get pregnant naturally.

So, these are basically the main or the main focus of the of which women require some form of treatment from fertility specialist. Unexplained infertility, now unexplained infertility is where everything is normal but still, the couple is not getting pregnant. So, all these once we counsel a couple, we get the history, we may find out as to what the cause is and how do you evaluate. First is of course getting the complete history of the of the couple, next is we will do some basic test to find out if everything is in place, like we do a semen analysis of the male partner, after that we'll do a sonography of the female and see if there is being major issues like growing cyst or uterine fibroid or any problem with the uterus. Second is finding out whether fallopian tubes are open. Now that can be found out by doing a very simple test which is an X-ray which is called histosalpingography to know if the fallopian tubes are open. Now suppose there is a big fibroid or there is a cyst in the ovary or the fallopian tubes are blocked; now these patients definitely require an operative treatment to correct this pathology now this and this can be very very done in today's world by doing what is keyhole surgery or surgery through very very small incisions or just punctures of the abdomen through the laproscope or suppose if there is some problem in the uterus like there is a polyp, there is a growth in the uterus or the uterus the fallopian tubes where it enters the uterus is blocked that that can be opened up hysteroscopically.

A septum in the uterus can be corrected hysteroscopically; so hysteroscopy is a surgery where the uterine cavity is evaluated, it's actually seen from inside the uterine cavity and any pathology which is present is corrected at the same time whereas laparoscopy is where a small puncture is made through abdomen, the telescope is inserted and two other secondary ports very small incisions are made and the instruments are passed. You see on the monitor, the cameras attached to the telescope and the picture you get you to see on the monitor and the instruments are used for correcting the surgery and that surgery is video recorded, can be discussed with the patient and their relatives; so this is a very advanced form of surgery and very helpful from patient's point of view. They recover very fast, the pain factor is very less and they can go home within a few hours of the surgery. So, this is and nowadays whether you have to do fibroid surgery or an ovarian cyst surgery, everything all surgeries can be done laproscopically. So, laparoscopy is an excellent modality to diagnose as well as correct any form, any problem in the pelvis. Next is to know whether she is ovulating regularly. Now if she gets regular periods that means probably there is no anovulation, regular periods in the sense whether she gets a period at the 28th to 30th days, so she would be ovulating regularly and we can also find out by doing some blood test or there are some kits which are available in the market where you can do the LH surge, it’s a hormone.

The test can be done in the urine and see whether she is ovulating. A follicular sonography kit can be done to see whether she is whether the follicles, follicles are where which contain the egg with, whether the follicles are maturing, whether they are getting released; so, she can time her intercourse according to the follicular sonography. Now follicular sonography can be done in a natural cycle or it can be done in the treatment cycle, whether we are doing intrauterine insemination or IVF or ICSE. So you will be seeing right from day 6th or 7th or day 8 depending on what treatment you are on every alternate day and when you are giving when you are given injections the fertility enhancement in injections are given and the growth of the follicles will be seen whether the follicles are growing or not. So, this is a very standard form of treatment. Now if you would need some sort of assistance for getting pregnant now suppose, you do the intrauterine insemination or what is commonly called as IUI. Now for IUI, what is IUI is basically where the women is given some fertility enhancing to increase her fertility in the form of tablets or injections would be given to the women and the follicular sonography at times to see how she is responding, how many eggs are maturing and when the eggs become of the mature or the mature size the last injection is given for the final maturity. Then the after 36-40 hours after that last injection, an IUI is performed where the husband’s semen is taken and it is processed in the lab where the good quality sperms are separated from the entire semen. The process it takes about 45 minutes to 1 hour and so 2ml let's say of semen is then converted to 0.7 or 0.6 ml of good quality sperms in a concentrated semen sample is injected into the uterine cavity with a very fine catheter. Now for this, the patient doesn't have to get admitted, there is no anaesthesia required, it's an OPD procedure. Now suppose this how does this increase fertility?

This increases fertility by about 15% over a natural conception. It is not 100% definitely. The women who do not get pregnant by using IUI by doing IUI, you do about 3-4 cycles or maximum 6 cycles of IUI in a woman provided everything is normal, provided the fallopian tubes are normal, the semen count is good, so these are the woman who is ideal candidates or unexplained infertility, so these are the candidates for whom IUI of help and if it's a case of early endometriosis. Now suppose there is a woman who's got both her tubes are blocked or the male has got a very low sperm count; now these cases are the case where they should not be wasting their time for natural conception or for an IUI. Now, these are the cases which would definitely go for an early IVF and that would really be of very helpful. In IVF as the name suggests its vitro fertilization where the fertilization of the egg and the sperm is done in the laboratory, it is done outside the body whereas in natural conception and IUI it happens in the women's body itself. So, we require the eggs from the woman and the sperms from the husband and these the sperms are then injected in very under a microscope with micro-manipulators called as intra cytoplasmic sperm injection where the sperm is injected into the egg all this is under the microscope and then the embryos put into the uterine cavity. So there are actual clear indications where an IVF or ICSE should not be delayed so one as I have told you about blocked fallopian tubes, repeated IUI failures, very low sperm count, an elderly woman let's say a 40-year-old or 42 years old woman who wants to get pregnant and she doesn't have eggs, she requires somebody else's eggs, donor eggs, these are also the indications for doing IVF.

Now if the woman doesn't have a uterus, has an absent uterus then the woman's eggs and the husband's sperms, the embryos can be put into the surrogate; so, this is also an absolute indication for doing ICSE or in vitro fertilization. So, there are very clear indications where the women should not be wasting her time and taking a quick decision for doing an IVF or ICSE or test tube baby treatment. I think that is all in a nutshell that I would like to explain very broad about what is natural fertility, which patients require IUI, which patients which couples would require IVF or ICSE and its important that one understands the procedure and understands what is the indication and does not delay her treatment because there is definitely a lot of psychological impacts, there is lot of financial involvement on the couple's part and hence if you start early the success rate is always better. Also, the important point is that when we do IVF, we get extra eggs and extra embryos, now these embryos can be frozen and these frozen embryos can be then transferred in subsequent cycles. So, these are very good advantages to doing IVF. Then there are there are some women who would like to postpone their fertility or postpone motherhood, postpone getting pregnant; now this niche of woman who does not have the right partner, who has not decided on the life partner they can freeze their eggs so with the same injections hormone injections are given to the women and the eggs are retrieved in the final mature stage and the eggs can be frozen. Now, these frozen eggs can then be used later on once she finds a partner. Also, there are some women who undergo cancer treatment, so before they undergo the cancer treatment before they undergo chemotherapy their eggs can be stored. And also, there are men who before vasectomy can store their sperms, before going in for chemotherapy for cancer treatment they can store their sperms and they these can be used later on for fertility. So, this is in a nutshell which I have told you very broadly about fertility, endoscopy, IUI, IVF and freezing of the gametes, freezing of eggs, freezing of sperms and freezing of embryos. If there is any query you can you get in touch with me through Lybrate.

Thanks!

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