To understand what infertility means and what type of treatments are available at our unit, let us
first understand how normal conception happens and then go on to the more complicated matters.
Please study the following pages in the order to understand the infertility.

  • Normal Coneption
    To understand what infertility means and what type of treatments are available at our unit, let us first understand how normal conception happens and then go on to the more complicated matters.

    Many couples believe that it is easy to have a child and are often surprised when the woman does not fall pregnant as soon as they start trying for a baby.
    The chance of getting pregnant in each menstrual cycle (each month) is calculated to be one in four for an average fertile couple. However, it may take a long time to conceive, even if everything is normal.
    It is common for couples to seek help and advice if there is difficulty conceiving. Overall, around 15 per cent (one in six) of all couples will seek help. The point at which they may want to seek help will depend on various factors.

    What happens during normal conception?

    THE WOMAN

    Ovulation is the end of a complicated series of events leading to the release of an egg from the ovary. If that egg is fertilized by a sperm and implants in the lining of the womb (endometrium), a pregnancy has started.
    All of a woman's eggs will already be present when she is born. From the early years of childhood, she starts to lose eggs.

    A woman's cycle begins with a hormonal signal from the pituitary gland at the base of the brain. It releases a follicle stimulating hormone (FSH), which stimulates the ovaries. FSH stimulates a group of about 20 follicles on the surface of the ovary to grow.
    Within the follicles are the developing eggs.

    Another hormone, oestrogen, is produced by the ovary and in response to increasing oestrogen levels, the largest follicle continues to develop. This is why most pregnancies result in only a single baby.

    Another hormone, luteinizing hormone (LH), also produced by the pituitary gland, causes the follicle in the ovary to release the egg. This release of the egg (or ovum) is called ovulation.

    After ovulation, the empty follicle forms a structure called the corpus luteum which produces a hormone called progesterone. Levels of progesterone rise after ovulation and prepare the womb to receive a fertilized egg (embryo). Fertilization by a sperm, if this occurs, takes place in the Fallopian tube, which then moves the early embryo along towards the womb itself. If the egg is not fertilized, or the embryo does not implant in the womb, the progesterone levels fall and a period starts. The whole cycle then begins again.

    THE MAN
    The man's role in conception is the production and ejaculation of sperm cells. To fertilise an egg, a man must be capable of producing adequate numbers of swimming (motile) sperm. Only a few of these sperm cells will in the end reach the egg, and only one will actually enter and fertilise it.
    During puberty, the testes become active and start to produce sperm. From his teens until about the age of 70, a man will typically produce 5,000 sperm cells every minute. Ejaculation produces semen, which is a mixture of two per cent sperm cells and 98 per cent liquid produced by the glands in the testes.
    Production of sperm is under the control of FSH and LH, the same hormones that control the woman's fertility.

    The chances of fertilization and conception
    Fertilization only happens if intercourse takes place almost around the time of ovulation. Ovulation only takes place once in every menstrual cycle, which means that there are only a few days each month when a woman can fall pregnant. However, intercourse and ovulation don't need to be at exactly the same time as healthy sperm can survive for about 48 to 72 hours inside a woman's body and a woman's egg lives for about 12 to 24 hours after ovulation.

    Fertility is therefore a result of sperm and egg meeting each other almost immediately after ovulation. Ovulation occurs 14 days before the onset of a period. This is reasonably predictable if the cycle is regular, but may be very unpredictable if the cycle is irregular.

    The hormone balance must be correct to ensure an egg develops and ovulates normally. Intercourse must take place during the fertile part of the cycle. There must be an adequate number of motile sperm and no mechanical barrier such as blocked Fallopian tubes, which may prevent sperm reaching the egg.
  • What is infertility?
    We have seen how normal conception happens and so now the question arises as to what is infertility and what it means to be an infertile couple? If a couple is infertile, this means that they have been unable to conceive a child after 12 months of regular sexual intercourse without birth control. Primary infertility means they have never had a child.
    Secondary infertility means that the infertile person has had one or more children in the past, but a medical problem is impairing fertility. About one in seven couples are infertile. Age, lifestyle and physical problems can all contribute to infertility. The four factors responsible for conception are- Eggs, sperms, uterus and tubes. If either one or many has/have a problem then conception could be difficult. And there may be the need to seek help from an expert.

    Female Infertility

    Infertility in a woman may stem from many causes, such as hormonal deficiencies, problems in the reproductive organs, and some illnesses. Complications from surgery and certain medications may also impair fertility.

    The most likely causes for female infertility are:
    •  Pelvic Inflammatory Disease (PID)
    •  Polycystic ovary syndrome (PCO)
    •  Endometriosis
    •  Other sexually transmitted diseases such as genital herpes can decrease fertility
    •  Ovary Problems
    •  Hormonal Problems
    •  Immune System Problems
    •  Luteal Phase Defect
    •  Fibroids
    •  Other Uterine Problems
    •  Surgical Complications
    •  Uterine muscle problems
    •  Poor quality cervical mucous
    •  Illness
    •  Medications
    •  Premature Menopause
    •  Other causes: some other contributors to infertility include excessive exercise, stress or anorexia
    Male Inferility
    • a. Vas Deferens- the tubes that conduct sperm and testicular fluid from the epididymis into the ejaculatory ducts.

    • b. Penis- the male organ of intercourse c. Urethra- the tube through which urine from the bladder is expelled.

    • d. Epididymis- the tightly coiled, thin-walled tube that conducts sperm from the testicles to the vas deferens.

    • e.Testicle (testis)- the male gonad; it produces sperm and male sex hormones.

    • f.Prostate- the male gland encircling the urethra that produces one third of the fluid in the ejaculate.
    The most common causes for male infertility are:
    •  Problem with the sperm - either low sperm count or sperm with poor quality
    •  Under-developed testes-usually arising after a mumps infection, a hernia surgery, an injury or birth defect.
    •  Swollen veins in the scrotum.
    •  Undescended testes-a problem often present from birth in which the testes remain in the body cavity. Normally they descend into the scrotum before birth.
    •  Infections, such as gonorrhea or tuberculosis, that block the ducts through which the sperm travel.
    •  Exposure to metals such as leads, or chemicals such as pesticides.
    •  Certain medications
    •  Injury to the testicles
    •  Chronic prostate infections
    •  Autoimmunity, in which antibodies or cells of the man's immune system attack sperm cells, mistaking them for toxic invaders.
    •  Retrograde ejaculation
    •  Drugs such as tranquilizers or high blood pressure medicines.
    •  Diseases such as diabetes or multiple sclerosis.
    •  Neck, bladder or prostate surgery.
    •  Spinal cord injury.
    •  Small percentage of cases, male infertility is caused by sexual difficulties such as impotence, premature ejaculation, or painful intercourse. Genetic defects or structural problems. Defects in the Y chromosome or in certain genes may also play a part in infertility. Rarely, a hormonal difficulty that decreases or stops the man's production of sperm. Hormonal problems may be present from birth or can develop from brain or pituitary gland tumors or radiation treatment. Sometimes, hormonal difficulties are induced by excessive exercise, malnutrition or other illnesses.
  • Disgnostic Tests
    There are various methods to diagnose and reach a conclusion for the best treatment for a particular infertile couple. A complete medical history and/or a physical examination are the first steps in diagnosing a fertility problem. The husband and wife need to be evaluated. The couple may also need blood tests, semen specimens from the husband, and ultrasound exams or exploratory surgery for the wife. In your first visit to the hospital you should remember to bring along any previous records and reports if any. That may help the Doctor understand your problem and the avoid any repetition of tests. Your Doctor will need information about the couple's sexual and medical history.

    They should be prepared for these questions:
    •  What medical conditions have you had?
    •  What medications do you take?
    •  Have you had any past surgeries?
    •  How often do you have intercourse?
    •  When do you have intercourse?
    •  Do you use a lubricant?
    •  Is there any discomfort during intercourse?
    •  Do you feel anxious or depressed about being unable to conceive?
    •  For the woman:When did your periods begin? How regularly do your periods occur, and how long do they last?
    •  For the man:Do you experience any erection or other sexual problems during intercourse?
    Further diagnostic tests for the wife may involve-
    •  Blood tests/ urine tests
    •  An endometrial biopsy
    •  An ultrasound to look for fibroids and cysts in the uterus and ovaries.
    A laparoscopy- If the doctor suspects ovarian or fallopian tube scarring or endometriosis, a woman may undergo a laparoscopy. The doctor makes two small incisions at the pubic bone and navel, and carbon dioxide gas is injected into the stomach to enlarge it.
    Then the doctor inserts a laparoscope, a long tube with lenses and a fiberoptic light, into one incision and a long probe through the other opening in the skin. With the probe, the doctor can view the ovaries, fallopian tubes and uterus to check for scar tissue. In some cases, he may cut away scar tissue discovered during this operation. A hysterosalpingogram (HSG): This test checks the condition of the woman's fallopian tubes.
    The doctor clamps the cervix and injects a needle filled with dye into the woman's uterus. An X-ray is taken to determine whether the dye passes through the open ends of the fallopian tubes. If the dye emerges from the end of the tubes, they are not blocked. The test may also reveal other fertility problems, such as fibroid tumors, structural abnormalities and endometrial polyps. In some cases, the dye actually clears away blockages in the fallopian tubes, and restores the woman's fertility. The dye is harmless and is absorbed by the woman's body after going through her tubes. The test may be uncomfortable, but is rarely painful. A Hysteroscopy: It is the visualisation of the inside of your womb (uterus) to establish that it is structurally normal and that there are no abnormal findings within the cavity of the uterus, such as fibroids, polyps or adhesions.The investigation will usually allow the doctor to see the openings to the Fallopian tubes at the top of the uterine cavity on each side (i.e. the tubal ostia).A solution of saline is used to distend the cavity to give a clear picture.The findings are normally recorded on videotape, which can be viewed afterwards at your follow-up consultation. Further diagnostic tests for the husband may involve- After a medical history and an examination, the man's sperm are tested. He'll be asked to ejaculate into a cup, and this specimen will be evaluated. The man should not ejaculate for several days before he takes the test, because each ejaculation may reduce the sperm count.
    •  Several factors checked in the semen- sperm count , movement, maturity and shape of the sperm (which reveal its quality), the amount of sperm produced (one teaspoon is sufficient), acidity (the semen should be slightly acidic)
    •  Hormonal blood tests.
    •  Imaging tests that check for swollen veins or reproductive system blockages.
    •  A testicular biopsy- The doctor takes bits of tissue from the testes, and this tissue is examined to see whether the cells that produce the sperm are working properly.
    •  Anti-sperm antibody tests, which check whether the woman's mucous rejects the man's sperm. These tests also show whether the man produces antibodies to reject his own sperm.
  • Fertility Treatment
    After the doctor has determined possible causes of the infertility, a course of treatment can then be planned. Sometimes simple instructions, like knowing when having sex is most likely to produce a pregnancy, are all that is needed. In many cases, medications are indicated, while in other cases, the woman may require surgery or other forms of treatment. If medications are unhelpful or surgery is not appropriate, other specialized techniques will be offered.

    Medications can help solve hormonal problems and ease infections in women with fertility problems. Surgery to repair reproductive organs may also resolve a woman's infertility.

    A number of drugs can be prescribed to ease male fertility problems, but their effectiveness varies widely. If investigations suggest that surgery may help with male infertility, then depending on the cause, surgery may be used to deal with: Varicose (or swollen) veins in the man's scrotum, helping to restore proper sperm movement, An obstruction in the man's reproductive organs, including the epididymis, vas deferens and ejaculatory duct. These blockages can halt the sperm's passage or prevent it from mixing with semen.

    The course of treatment planned for a couple will vary in individual cases. It could start from a simple medication or ovulation induction leading to a more complex procedure like IVF/ ICSI. To go through the details of each treatment click on the links :

  • Pregnancy/Birth
    15 -17 days after your treatment is the most crucial day- the pregnancy test!! If the test is -ve then it is roller coster ride for all involved in the process. And a plan about what to do next needs to be decided along with a lot of couselling. But if the test is +ve then this pregnancy following IUI,IVF or ICSI brings its own special joys and concerns. This is a time of lots of hopes, fears, doubts and delights.


    Anxiety is the most comon feeling during this time-
    When you finally reach your goal in becoming pregnant, you will probably feel many conflicting emotions. The first trimester is usually the hardest because the pregnancy is not obvious to you or others yet. Many women have trouble believing that they are pregnant after trying for so long. Pregnancy symptoms can be a source of comfort, however symptoms can fluctuate from day to day and not all women have them. It is important to realize that many women that have gone through infertility feel the same emotions that you do. It is perfectly normal to feel a bit worried about your pregnancy, even women who haven't gone through infertility do. Try sharing your feelings with women in a similar situation and you will soon find that you are not alone.


    Milestones of Pregnancy
    6 weeks: A fetal heartbeat may be detected on an ultrasound.
    11 weeks: The development of the embryo's organs is now underway and it enters the fetal period
    12 weeks: A doppler device can sometimes detect an audible heartbeat.
    13 weeks: The second trimester officially begins and the miscarriage rate decreases for most pregnancies.
    16-20 weeks: The mother may be able to feel the first fluttering movements of the baby.
    23 weeks: A baby born now can sometimes survive outside the womb with assisted neonatal intensive care.
    24 weeks: A baby born now has more than a 50% survival chance, but at this early stage complications are still common. As each week goes by the baby has a better chance of survival outside the womb.
    28 weeks: The third trimester officially begins.
    37-40 weeks: A baby born now is considered full-term.