Infertility

What is Infertility?

Infertility is an inability to have a child. It is called primary infertility when the woman has never been pregnant and secondary infertility, when the woman has previously been pregnant.

Between 10 and 20% of couples will at some point in their lives experience a period of infertility, in the sense that they have tried to get pregnant for more than 1-2 years. As women today are waiting longer to have children, the frequency may be somewhat higher today.

You talked earlier only about infertility, when a couple had tried to get pregnant for 2 years, but in the latest WHO criteria defined infertility as lack of pregnancy for more than one year at a pair of regular intercourse.

Today commence evaluation and treatment often after one year trial – but it depends on the couple’s age, and whether there are obvious reasons for their infertility.

In young, healthy couple, the likelihood of becoming pregnant during a menstrual period from 20 to 25%, and during one year will be 80-90% of those who want it, pregnant. If a couple can not become pregnant in the course of a year, the chance of getting pregnant the following year almost 50%. As the years pass, reduced woman’s ability to become pregnant, and the risk of miscarriage increases. Women mid-30s have half as much chance of pregnancy per month as when they were in their 20s.

After 35 years of age, the proportion of successfully treated infertility significantly. ‘

After the age of 40, fertility declines rapidly, and it’s only every third woman who actually have the ability to become pregnant, and she becomes pregnant, the risk of a miscarriage about 50%.

What causes infertility?

The cause of infertility can be found both the woman and the man. In some cases, a cause of both, and in other cases, one can not point to an obvious cause. Among 10-15% of couples who are treated for infertility, can not find a cause, and in these cases we are talking about unexplained infertility.

At the couples where one finds a reason because approximately 1/3 male factor, 1/3 female factors and in third is the factors of both, which is the cause.

The main causes of infertility are:

Infertility in women

Lack of ovulation. The woman often have even a suspicion because of disturbances in menstruation. An irregular menstrual cycle of more than 35 days (counting from the first day of bleeding for the next first day of bleeding) indicates that there is no normal ovulation. For some there may be single ovulations, but the time is not predictable. Others have only a few periods a year, and some have none at all.

There can be various reasons for the lack of ovulation. The most common cause is the condition called polycystic ovary syndrome (PCOS), seen in 80-90% of women with anovulation.

Poor passing through the fallopian tubes . May be due to previous abdominal surgery, which formed adhesions and following pelvic inflammatory disease, such as chlamydia. The risk is especially great if there have been several cases of pelvic inflammatory disease, and if the infection has been accompanied by fever. Pelvic infections can destroy the fallopian tubes, forming scar tissue and lead to the fallopian tubes closed off, so eggs and sperm can not reach each other, and the fertilized egg can not be fed from the fallopian tube into the uterus.

The condition often causes no symptoms, but can be detected by, for example, the contrast study in the context of an ultrasound scan or an X-ray. Earlier ectopic pregnancy is a sign of bad passage through one or both fallopian tubes.

Other reasons . It may be endometriosis , which is a relatively common condition in which there are endometrium outside the uterine cavity.

It can also be about fibroids in the uterus.

Finally, some women even if they are only in their thirties, have a reduced number of active eggs left in the ovaries.

Infertility in men

Decreased sperm count in men is one of the major causes of infertility. Sometimes there is a suspicion in advance, for example, if the testicles were not in place in the scrotum at birth (cryptorchidism). Most often, however, it as a surprise for the man.

Apparently sperm quality general decline in our part of the world, but it is unclear why this is. Several factors have been mentioned include pollution, and the influence of the so-called endocrine disrupters.

The risk of reduced sperm quality is increased if previously had been diseases of the testicles or scrotum, such as mumps or inflammation of the epididymis associated with chlamydia infection. Testicles that was not in place in the scrotum at birth, and small testes (as a pea or almond) suggests reduced sperm count or even abolished sperm production.

Rarer causes are chromosomal abnormalities, ejaculation of the urinary bladder, lack of formation of sperm cells, antibodies to the sperm cells, etc. Anabolic steroids and hasrygning gives poor sperm quality.

Remember: There is usually a reason for your infertility, but in 10-15% can not identify the cause. It is extremely rare for your “own fault”, and although lifestyle and environmental factors (obesity, smoking, excessive exercise, occupational and environmental factors) may play a role, it is, after all, rarely the direct cause.

How is it diagnosed?

Clearing infertility will depend on how the problem is perceived by the individual couple. It makes sense to start this report around 1- 2 years of normal sex life without having achieved pregnancy. It is important that the study gets underway before the age of 35, as the possibility of having children is reduced considerably with increasing age of the woman. Is there an obvious cause of infertility, for example. the woman does not have menstrual periods or have few periods a year, or if for instance, she had an ectopic pregnancy, there is no reason to wait that long.

If that also has been infertility in a previous relationship, there is no reason to wait that long. If the man has had a lack of descent of one or both testicles (cryptorchidism) is a good idea to examine sperm quality.

The studies start with a visit to your doctor. The first step is a consultation with the doctor, with emphasis on areas such as sexual life, sexual function, use of contraception, psychosocial conditions and use of alcohol, tobacco and drugs and narcotics as well as diet and exercise habits. The doctor identifies previous infections in the abdomen, symptoms that may indicate a disturbance in the normal menstrual cycle and course of any previous pregnancies.

Your own doctor’s role is to talk with you about the problem and to carry out the first studies to find the cause and refer you on. In South Africa perish the further evaluation and treatment for infertility by gynecologists in specialist practice and in fertility clinics in public or private.

Semen sample . The sample is delivered to a sædprøvelaboratorium, and the result is sent to your own doctor. If the sample is normal, is made no further. If it shows a reduced sperm quality, it should always be repeated after three months, as the results can vary a lot from one sample to another. Your doctor will tell you what the test shows. It will often be only a very rough estimate, unless the sample is really nice, or it is very small.

If sædcelletallet is severely impaired man will be referred for further investigation of male infertility.

Passage through the fallopian tubes . Examination of the woman’s fallopian tubes can be made in two ways, either using. X-ray (salpingo-hystero chromatography – HSG) or by means of ultrasound (hystero salpingo-chromatography with ultrasound – HSU). In both HSG and HSU sprayed, by a gynecological examination little contrast fluid into the uterus, and by either X-ray or ultrasound contrast sees on the liquid passes out through the fallopian tubes. HSG is typically performed at a private radiology clinic or local hospital while HSU performed by a gynecological specialist. Both studies have proven to be equally good.

Hormone Study . At irregular or absent menstrual periods may be suspected problems with ovulation, and it will be enough to refer you directly to a gynecologist.

There may also be blood test to measure hormone progesterone. The sample taken one week before the expected menstruation. A value above 25 indicates that the woman has ovulated. A lower value may indicate problems with ovulation. The amount of the broad hormones follicle stimulating hormone (FSH) and luteinizing hormone (LH) can be measured on the 2nd-5th cycle. Is hormone FSH very high, it may indicate that there are not many eggs left in the ovaries. In a disease such as PCOS, the ratio of LH and FSH often be elevated.

Where the problem of lack of ovulation and increased hairiness measured the male hormones as well. Anti-mullerian hormone (AMH) cooked in small æganlæg in the woman’s ovaries and is a good measure of the number of eggs a woman has left in the ovaries. AMH is low, if the woman has few eggs left.

There must also be metabolism test (TSH) at the woman as too low or too high metabolism can cause menstrual disorders. It is also important for the fetus normal development that the woman’s metabolism is normal in pregnancy. If elevated TSH is made, an additional antibody sample (TPO antibodies). Both low and high metabolism can be treated with medication also in pregnancy, it’s just important that the treatment gets started before pregnancy.

The compulsory tests (infection tests) . South African legislation also requires that, should I be treated with assisted fertilization, both the man as the woman having a blood test to rule out infection with diseases that can be transmitted sexually – that is, HIV and hepatitis (Hepatitis B and C). These tests are only valid if they are taken to an approved laboratory. The laboratory must be approved according to the EU vævstypedirektiv. Many clinics also tests for chlamydia.

Fertility Clinic will also often require that you have been taking a normal cell sample from the cervix in the last three years. It’s a good idea to find out whether the woman has previously had rubella when an infection during pregnancy can cause birth defects.

When there are answers to the surveys, the doctor often a good idea of ​​what the cause may be, and it’s time to be referred to a gynecologist or directly to a fertility clinic. There will be made an internal ultrasound of the woman and possibly. be given additional blood samples for hormone analysis, if there is bleeding disorders. If the man has very poor sperm quality, he should be further explored with hormone analysis, ultrasound of the testicles and possibly a chromosome analysis. In certain cases, this examination of the man at the fertility clinic, but the other takes it in a specialized facility for male infertility.

What treatment is there?

There may be more options for treatment, depending on the cause of infertility. Fertility treatment can be complicated, but all departments and clinics dealing with infertility, have their own websites and patient information that explains the different treatment options.

Correction of anatomy

If there are conditions that can be corrected by using larger or smaller operations, this can increase the chance of achieving pregnancy. It may be, for example removal of fibroids  (fibroids), or polyps in the uterus and surgery for tubal blockage. In men, varicose veins in the scrotum sometimes treatable, but most often will wait this operation until after the completed fertility treatments.

Hormone stimulation to induce ovulation

If the cause of infertility due to failure of ovulation, hormone therapy is topical. The woman gets when medicine in the form of hormones that promote ovulation, thereby increasing the chance of fertilization and pregnancy. Hormone therapy can be given as tablets or as daily injections.

The treatment is often complemented with insemination treatment. If the woman has a lack of ovulation offered six treatments with hormonal stimulation and insemination.

In hormone disorders in men, treatment of male sex hormones in some cases be beneficial.

Insemination with the husband’s sperm

You treat mild to moderate renal sperm count and unexplained infertility insemination. Usually offered three treatments with insemination with husband’s sperm before the couple offered IVF treatment.

Insemination involves purified sperm are placed in the woman’s uterus with a thin plastic catheter to improve the chance of fertilization. The woman is treated simultaneously with hormones for the development of 2 to 3 eggs, which increases the chance of pregnancy. Is performed about 10,000 of these treatments in South Africa a year.

Insemination with donor sperm

Insemination with sperm from anonymous or non-anonymous donor offered to couples where the man has no sperm (azoospermia) or in couples where ICSI (ICSI) has failed. Single women or lesbians can also receive treatment with sperm from anonymous or not anonymous sperm donor. This occurs most often in her own cycle without the use of hormone stimulation.

Overall carried just under 10,000 treatments with donor insemination each year in South Africa, which carried about 4,600 of South African women, while just as many treatments are performed on women from abroad.

In vitro fertilization (IVF or IVF and ICSI (ICSI))

In vitro fertilization (IVF treatment) means that the eggs are removed from the ovaries and fertilized outside the woman’s body to be subsequently put back into the womb again in 2-5 days. At ordinary IVF fertilization treatment takes place in that the eggs are put in the respective small bowl and then add about 80-100000 sperm to each dish. After which a sperm find their way into the egg. In ICSI (ISCI) injected a single sperm directly into the egg cell. IVF or ICSI is used today by almost all forms of infertility unless simpler treatment in the form of insemination is not possible or is carried in vain.

There are obtained about 25 births per 100 treatment trials – it is quite similar to what fertile thus not infertile couples achieve, namely a 25% chance per month.

The use of IVF has increased significantly over the past 10-20 years. 10-15 years ago it was quite common to put two eggs left with a greater chance of pregnancy and childbirth, but also a greater risk of twin pregnancy.

Twin Pregnancy is associated with a 7-10 fold increased risk of giving birth prematurely and thus for low birth weight in the infant with a higher risk of disease in children.

Since 2000, twin rates of IVF fallen from almost 30% to 10%, because we are now the majority of the couples only put one egg back and freeze the surplus embryos. These frozen embryos can be used later.

What can you do yourself?

The realization that you may not achieve pregnancy can be very stressful for both the individual and the relationship. Some talk with family, friends and colleagues about the issue, while others keep it for themselves. It is often the woman who first recognizes the problem openly.

The chance of achieving pregnancy is greatest in the days before ovulation. Ovulation occurs 14 days before the first day of menstruation in the next cycle. If women have a completely regular cycle, you can therefore count time out – it’s more difficult if the cycle is irregular.

You can buy ovulation tests (LH test) (sticks), for example pharmacy. Morning urine specimen tested daily at about the time of ovulation is expected (starting day 11-12 after the first day of bleeding in the cycle). When ovulation test is positive, you should have intercourse that day and the following one or two days after the test is positive. The best thing you can do as a couple is to have intercourse 2-3 times a week regardless of what the tests show.

As a “pair” it is important to live healthy, avoid too much alcohol and stop smoking. Obesity can reduce the chance of becoming pregnant and many fertility clinics do not treat women with body mass index (BMI)> 35 woman’s BMI is calculated as weight in kg divided by the height in meters of the other.

When the woman is 40 years falling birth chances to 15-20% per attempt and after 40 years of age to under 10%.

Overall, two out of three couples where the woman is under 35, obtain a child for the total public treatment.

The total treatment services in the public are three IVF treatments each with hormone stimulation, egg retrieval and ægtilbagelægning. A little more than half of all couples undergoing IVF treatment, the eggs that can freeze. These additional treatments with frozen embryos do not count in the total accounts. So treatments with frozen and thawed eggs is all in addition to the three IVF attempts.

How is long-term prospects?

For many couples have infertility a temporary problem, and a small part of those who seek fertility treatment become pregnant without help. Of the couples who undergo the public treatment achieves about one out of three couples not having a child. Some of these couples will continue in private treatment, while others choose to adopt or continue life without children.

Some people also choose to stop before they complete three treatments. There can be many reasons, but a significant reason is that it is physically and mentally stressful for the couple.