Medical Matters

Common Causes
and Treatment of

Infertility

What Are The Causes Of Infertility?

Fertility problems may arise due to problems in the female or the male reproductive system.

Female infertility reasons can broadly be divided into
1. ovulation disorders e.g. caused by polycystic ovaries,
2. endometriosis where the lining of the uterus occurs outside its normal position e.g. at the back of the uterus and around the ovaries, and
3. tubal disease.

If a woman managed to conceive previously but has problems conceiving again, she is said to have ‘secondary infertility’. In such cases, it is possible that a patient had an underlying health problem when she conceived before, but was fortunately not affected then.

Age is also an important contributing factor to infertility. Although the evidence is less strong compared to women, men may also become less fertile as they get older. In men, the quantity and quality of sperm may deteriorate with time making it difficult for them to reach and fertilise an egg. This can occur as a result of poor diet or lifestyle habits as well as chronic illnesses such as diabetes and raised blood pressure.

In women, fertility steadily declines with age. Women are born with a fixed number of eggs. With increasing age, there is a fall in ovarian reserve – i.e. the number of functioning follicles or eggs left in the ovaries. In cases of early menopause, the eggs run out much sooner than usual. In general, the likelihood of conceiving falls from 20% a month in a woman’s late 20s to 8% in the late 30s. Even the success rate of artificial reproductive treatment is not spared and pregnancy rates fall with increasing age from 40% in women < 35 years to just 10% in women over 40 years.

With increasing age, our general health also tends to decline. Existing conditions may worsen or new illnesses may develop, which can have an impact on fertility too. In addition, there is also a decline in quality of eggs with an increased risk of genetic abnormalities. This in turn results in an increased risk of miscarriage. Women under the age of 35 yrs have about a 15% chance of miscarriage while those 35-45 yrs old have a 20-35% chance of miscarriage.

What Advice Should Be Given To Couples Trying To Conceive?

For Couples:

• Try to start planning for a family as early as possible
• Maintain a normal weight, exercise and eat a diet rich in fruits, vegetables and antioxidants
• Stop smoking – smoking impairs sperm quality and female smokers are 1.6 times more likely to be infertile
• Limit alcohol intake to two drinks per day

For Women:

• Limit coffee intake to one cup a day; high levels of caffeine are associated with decreased fertility and an increased risk of miscarriage
• Take folic acid to prevent certain birth defects For men:
• Wear loose-fitting undergarments
• Avoid extremely hot temperatures, such as hot tubs or saunas
• Use lubricants which are suitable for conceiving


When Should A Patient See A Fertility Specialist?

Early diagnosis and treatment of infertility is crucial in the successful management of a couple seeking infertility treatment. Infertility is defined as the inability to conceive after 1 year of unprotected sexual intercourse. Ideally, the frequency of intercourse should be 2-3 times a week. Up to 90% of couples should have conceived by the end of the 1st year of trying. At this point, if they still have not conceived, further investigations are warranted.

However, older couples should be referred to a specialist earlier, particularly in the case of women over the age of 35. Such couples should be referred to a fertility specialist after six months of trying to get pregnant.

In other cases where the likelihood of a gynaecological disorder may be high, she should also seek specialist advice sooner rather than later. For example, an early referral is indicated if she has a history of amenorrhoea (no periods), oligomenorrhoea (infrequent periods), dysmenorrhoea (painful periods), pelvic inf lammatory disease (PID), or previous surgery. A history of menstrual irregularity could

indicate an ovulation problem which would benefit from ovulation induction medication. Painful periods may indicate the presence of endometriosis, ovarian cysts or fibroids which may benefit from surgery to improve her fertility status. A history of PID or previous pelvic surgery may cause tubal disease which would then require tubal surgery to unblock the tubes, or in-vitro- fertilization to bypass the tubal blockage.


How Can Infertility Be Treated?

• In the case of cysts, fibroids and blocked fallopian tubes: laparoscopic or key-hole surgery may help to improve chances.
• For problems related to abnormal ovulation: fertility drugs or injections may help to enable ovulation to occur in a more predictable manner.
• For poor sperm count and quality: intra- uterine insemination, or assisted reproductive techniques (ART) may be needed.


ART refers to the use of laboratory techniques to bring the egg and sperm together outside of the woman's body. ART may also be referred to as In-Vitro Fertilisation (IVF). ART generally involves several treatment stages. Firstly, in order to increase the number of eggs produced by her ovaries, the woman has to undergo hormonal injections. Secondly, ultrasound scans and blood tests are needed to assess the growth and maturity of the eggs. Once the eggs are ready, they are retrieved with the help of a vaginal ultrasound while the woman is under anaesthesia. The eggs are then fertilized with the sperm in the laboratory to form embryos before they are transferred back into the woman’s womb several days later.


Is There Hope For Fertility In Cancer Patients?

Treatments for cancer - such as chemotherapy and radiotherapy – may damage fertility. In such cases, sperm and eggs can be frozen before treatment starts in order to prolong fertility.

Recent advances in cancer therapy have resulted in an increased number of long-term cancer survivors. Quality of life is an important issue for cancer survivors and fertility after cancer treatment is often a concern. With the recent success and advances made in fertility preservation for cancer patients, international guidelines now recommend that these options should be discussed with the patient. If a young patient is diagnosed with cancer, it is important to let them know early about such possibilities.

The strategies to preserve fertility in women with cancer include frozen storage of embryos, storage of oocytes for future in- vitro fertililization, and storage of ovarian tissues.


Cryopreservation Of Embryos

Cryopreservation of embryos is the most established

technique but requires ovarian stimulation, oocyte retrieval and in- vitro fertilization, which takes about 2 to 5 weeks. This may not be practical for many cancer patients. It is also not an option for pre- pubertal girls and to women who do not have a partner and do not want to use donor sperm to fertilize their eggs. However, if embryos are frozen, the pregnancy success rate per thaw cycle for non- cancer cases is well- documented at around 20%.


Cryopreservation Of Oocytes

Cryopreservation of mature oocytes or eggs requires ovarian stimulation and will also delay cancer therapy. Without ovarian stimulation, a reasonable number of immature oocytes may be retrieved. The current trend is to retrieve these immature oocytes and mature them in- vitro before freezing them by vitrification. Vitrification refers to a method of ‘rapid freezing’ to prevent ice crystal formation in the eggs which tends to destroy the egg cells.


Ovarian Tissue Cryopreservation And Transplantation

In recent years, there have been an increasing number of reports of successful restoration of fertility after autotransplantation. For such cases, before cancer treatment is commenced, ovarian tissue is surgically removed and frozen. Following treatment of the cancer if the patient is diagnosed to have premature menopause and is keen to get pregnant, the frozen ovarian tissue is thawed and transplanted back into the patient.


Fertility Preservation For Males

For males, semen cryopreservation is an established technique for adult males, but it is difficult in adolescents. For adolescents as well as pre- pubertal boys, testicular tissue may be harvested before gonadotoxic cancer therapy and cryopreserved. Testicular tissue banking may therefore be promising for fertility preservation in prepubertal boys undergoing oncological treatment, although this is still in experimental stages.

A survey conducted on the attitudes of our local Singaporean patient population published in the Journal of Reproductive Medicine in 2010, indicated that there is an interest in fertility preservation, and that the medical information received may inf luence the attitudes of our patients. Greater emphasis should therefore be placed on informing patients on the issues of fertility preservation during the treatment planning process. To preserve the full range of options, fertility preservation approaches should be considered as early as possible during the treatment planning process.

Dr Kelly Loi
BMBCh, BA, MA, MRCOG, DFFP, FAMS
Obstetrician & Gynaecologist
Fertility & IVF Specialist
Health & Fertility Centre for Women