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Specialities

Infertility

Parenthood is the dream of every couple. The urge to procreate is genetically motivated and is one of the greatest sources of enduring joy for couples.
Yet, given increasing levels of infertility in today's generation, there are millions of couples who pine for the joy of having a baby.

Most people will have a strong desire to conceive a child at some point during their lifetime. Most couples (approximately 85%) will achieve pregnancy within one year of trying, with the greatest likelihood of conception occurring during the earlier months. Only an additional 7% of couples will conceive in the second year. As a result, infertility has come to be defined as the inability to conceive within 12 months.

Various conditions where one may be advised to seek help earlier:

  • Infrequent menstrual periods
  • Female age of 35 years or older
  • A history of pelvic infections or sexually transmitted diseases
  • Known uterine fibroids or endometrial polyps
  • Known malefactor semen abnormalities
Infertility Tests
  • History and physical examination - First and foremost, your fertility physician will take a very thorough medical and fertility history. In addition to a careful history, a physical evaluation may also, be performed.
  • Transvaginal ultrasound - Ultrasound is an important tool in evaluating the structure of the uterus, tubes, and ovaries. Ultrasound can detect uterine abnormalities such as fibroids and polyps, distal fallopian tube occlusion, and ovarian abnormalities including ovarian cysts. Additionally, transvaginal ultrasound affords the opportunity for your physician to assess the relative number of available eggs. This measurement is called the antral follicle count and may correlate with fertility potential.
  • Laboratory testing - The most common of these tests include measurements of blood levels of certain hormones such as estradiol and FSH, which are related to ovarian function and overall egg numbers; TSH, which assesses thyroid function; and prolactin, a hormone that can affect menstrual function if elevated.
  • Hysterosalpingogram (HSG) - This test is essential for evaluating fallopian tubal patency, uterine filling defects such as fibroids and polyps, and scarring of the uterine cavity (Asherman syndrome). Many uterine and tubal abnormalities detected by the HSG can be surgically corrected.
  • Semen Analysis - The semen analysis is the main test to evaluate the male partner. There are four parameters analyzed:
    • Semen volume - Should be at least 1.5 to 2ml. A smaller amount may suggest a structural or hormonal problem leading to deficient semen production
    • Sperm concentration - Normal concentration should be at least 20 million sperm per 1 ml of semen. A lower concentration may lead to a lower chance for conception without treatment
    • Sperm motility or movement - normal motility should be at least 50%. Less than 50% motility may significantly affect the ability for sperm to fertilize the egg without therapy
    • Morphology, or shape - there are three parts of the sperm that are analyzed for morphology: the head, midpiece, and tail. Abnormality in any of these any cause infertility.
Common Causes of Infertility -
  • Advancing Maternal Age - In our modern era, women are delaying childbirth until their thirties and forties, which has lead to the discovery of the adverse effect of advanced maternal age on egg function. In fact, female age-related infertility is the most common cause of infertility today, for unknown reasons, as women age, egg numbers decrease at a rapid rate. And as ageing occurs, egg quality, or the likelihood of an egg is being genetically normal decreases as well. Hence the ability to conceive a normal pregnancy decreases from when a woman is in her early 30s into her 40s.
  • Ovulation Disorders - Normal and regular ovulation, or release of a mature egg, is essential for women to conceive naturally. Ovulation often can be detected by keeping a menstrual calendar or using an ovulation predictor kit. There are many disorders that may impact the ability for a woman to ovulate normally. The most common disorders impacting ovulation include polycystic ovary syndrome (PCOS), hypogonadotropic hypogonadism (from signaling problems in the brain), and ovarian insufficiency (from problems of the ovary).
  • Tubal occlusion (blockage) - As discussed previously, a history of sexually transmitted infections including chlamydia, gonorrhoea or pelvic inflammatory disease can predispose a woman to have blocked fallopian tubes. Tubal occlusion is a cause of infertility because of an ovulated egg is unable to be fertilized by sperm or to reach the endometrial cavity. If both tubes are blocked, then in vitro fertilization (IVF) is required. If a tube is blocked and filled with fluid (called a hydrosalpinx), then minimally invasive surgery (laparoscopy or hysteroscopy) to either remove the tube or block/separate it from the uterus prior to any fertility treatments is recommended.
  • Uterine Fibroids - Fibroids are very common (approximately 40% of women may have them) and the mere presence alone does not necessarily cause infertility. There are three types of fibroids
    • Subserosal, or fibroids that extend more than 50% outside of the uterus
    • Intramural, where the majority of the fibroid is within the muscle of the uterus without any indentation of the uterine cavity;
    • Submucosal, or fibroids the project into the uterine cavity. Submucosal fibroids are the type if fibroid that has clearly been demonstrated to reduce pregnancy rate, roughly by 50% and removal of which will double pregnancy rate. In some cases, simply removing the submucosal fibroid solves infertility.
  • Endometrial Polyps - Endometrial polyps are finger-like growths in the uterine cavity arising from the lining of the uterus called the endometrium. Polyps are can decrease fertility by up to 50% according to some studies. Removal of polyps by hysteroscopy is associated with a doubling of pregnancy rate.
  • Male factors affecting sperm function - Male factor infertility has been associated as a contributing factor causing infertility in 40-50% of cases, and as the sole cause for infertility in 15-20% of cases. If a semen analysis is found to be abnormal, generally it is first repeated to confirm the abnormality. Once confirmed, the male partner is referred to a reproductive urologist, especially if the abnormality is severe. In some cases, the reproductive urologist can improve semen function by recommending certain lifestyle changes, by hormonal treatments, or by surgery. In most cases, however, sperm function may not improve and therefore any attempts at pregnancy may require additional treatments or procedures.
  • Endometriosis - Endometriosis is a condition whereby cells very similar to the ones lining the uterine cavity, or endometrium, are found outside the uterine cavity. Endometriosis causes infertility by producing inflammation and scarring, which can result in not only pain but also potentially detrimental effects on the egg, sperm or embryo. Endomettriosis can only be confirmed by surgery, usually laparoscopy. If endometriosis is found, it can be surgically removed by various methods, and its removal may lead to a decrease in pain as well as improvement in the ability to conceive naturally.
  • Unexplained / Other - Sometimes a full evaluation does not reveal the cause of infertility. This occurs approximately 15% of the time. Thankfully, even when the cause of infertility is not known, various fertility treatments can overcome the unknown roadblock that was preventing pregnancy and eventually lead to the delivery of a healthy baby.

Treatment for Infertility

  • Education - We strongly believe that educating our patients about the normal process of fertility, problems that affect fertility, and treatment options will empower our patients to make the best choices. Understanding the normal reproductive process is essential in knowing when to seek help. Helping our patients develop a deep understanding of their fertility options will make the process smoother. Our goal is to have each and every patient feel like part of our team, a team that is focused on helping them have a healthy baby.
  • Medication to induce egg development and ovulation -
    Fertility drugs might be prescribed to regulate or induce ovulation.

    They include:

    • Clomifene (Clomid, Serophene) : This encourages ovulation in those who ovulate either irregularly or not at all, because of PCOS or another disorder. It makes the pituitary gland release more follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
    • Metformin (Glucophage) : If Clomifene is not effective, metformin may help women with PCOS, especially then linked to insulin resistance.
    • Human menopausal gonadotropin, or hMG (Repronex): This contains both FSH and LH. Patients who do not ovulate because of a fault in the pituitary gland may receive this drug as an injection.
    • Follicle-stimulating hormone (Gonal-F, Bravelle): This hormone is produced by the pituitary gland that controls estrogen production by the ovaries. It stimulated the ovaries to mature egg follicles.
    • Human chorionic gonadotropin (Ovidrel, Pregnyl): Used together with clomiphene, hMG, and FSH, this can stimulate the follicle to ovulate.
    • Gonadotropin - releasing hormone (Gn-RH) analogues: These can help women who ovulate too early - before the lead follicle is mature - during HMG treatment. It delivers a constant supply of Gn-RH to the pituitary gland, which alters the production of the hormone, allowing the doctor to induce follicle growth with FSH.
    • Bromocriptine (Parlodel) : This drug inhibits prolactin production. Prolactin stimulates milk production during breastfeeding. Outside pregnancy and lactation, women with high levels of prolactin may have irregular ovulation cycles and fertility problems.
  • Insemination - Intrauterine insemination, also known as IUI, is a process by which sperm is washed and prepared for placement into the uterine cavity, therefore bypassing the cervix and bringing a higher concentration of motile sperm closer to the tubes and ovulated egg. In order to accomplish this, the semen is washed with a solution safe to sperm and eggs and then centrifuged to separate motile sperm from immotile sperm and other cells. Those motile and viable sperms are then placed in a very small amount of solution, and then very gently and painlessly injected into the uterine cavity using a very thin, soft, and flexible catheter.
  • In Vitro Fertilization (IVF) - In vitro means "outside the body." IVF is a process whereby eggs are collected and then fertilized by sperm outside the body, in an embryology laboratory. IVF was a major breakthrough because it allowed for successful pregnancies in women that were previously deemed permanently infertile, such as when the fallopian tubes are both markedly damaged. IVF involves removal of eggs directly from the ovary, fertilization with sperm in the laboratory, followed by transfer of the embryos directly into the uterus, thereby bypassing the tubes. Although the tubal disease was the original indication for IVF, many more indications have developed over the years. These include advancing maternal age, severe male factor infertility (whereby ICSI can be used to fertilize the egg), and endometriosis, amongst many others.
  • Surgery - After a thorough history, physical examination, and ultrasound are performed, your doctor may recommend surgery to correct and abnormality. In reproductive medicine, the most common surgical procedures are laparoscopy, hysteroscopy, and abdominal myomectomy (removal of uterine fibroids).

Fertility Treatments for Men

Treatment will depend on the underlying cause of infertility.
  • Erectile Dysfunction or Premature Ejaculation: Medication, behavioural approaches, or both may help improve fertility.
  • Varicocele: Surgically removing a varicose vein in the scrotum may help.
  • Blockage of the ejaculatory duct: Sperm can be extracted directly from the testicles and injected into an egg in the laboratory.
  • Retrograde Ejaculation: Sperm can be taken directly from the bladder and injected into an egg in the laboratory.
  • Surgery for Epididymal Blockage: A blocked epididymis can be surgically repaired. The epididymis is a coil-like structure in the testicles which helps store and transport sperm. It the epididymis is blocked, sperm may not be ejaculated properly.