Female Infertility – Causes and Investigation

There are a number of problems that can contribute to infertility in women. Main factors that cause female infertility can be listed as the following:

Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods. In order to make an assessment, the patient is asked to undergo hormone testing and a pelvic scan. More advanced testing might be necessary for certain patient groups. Patients entering menopause or patients with premature ovarian failure belong in this category. Patients who have received chemotherapy or radiation therapy are also likely to face problems with their ovarian reserves.

Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy can also cause infertility. In these cases, there is ovulation, and the patient may have a sufficient reserve of oocytes, but one of the main component of the reproductive system does not allow the eggs to be released for fertilization to occur.

Physical problems with the uterus. Shape or size of the uterus can be a problem, or there might be polyps, fibroids or free fluids in the uterus that might interfere with implantation or maintaining a successful pregnancy.

How does age affect a woman’s ability to have children?

More and more women are waiting until their 30s and 40s to have children. Actually, about 20 percent of women in the United States now have their first child after age 35. So age is an increasingly common cause of fertility problems. About one third of couples in which the woman is over 35 have fertility problems. Aging decreases a woman’s chances of having a baby in the following ways:

The quality and quantity of the eggs remaining in the ovarian reserves decline with age.  Each woman is born with a finite number of eggs and starting at puberty, the number of eggs declines through menstruation. One indication of this is high FSH and a low AMH level.

The genetic health of a woman’s eggs declines with age. Just like any other cell in our bodies, the egg cells also age. Given that ovaries do not produce any new egg cells over the course of female life, the ones that you are born with tend to age over time. This also increases the likelihood of miscarriages in advanced age brackets.

As a woman ages she is more likely to have health problems that can interfere with fertility. This can include diabetes, coronory and vascular problems and many others.

Graphic to the right depicts the amount of ovarian reserves at different age brackets. Every woman is born with a limited number of ovarian reserves and this number declines with age. While a newborn will have approximately about one million follicles in her ovaries, this number declines to about 100,000 by the time she reaches 30 years of age. This means, she will have lost 90% of her ovarian reserves by the age of 30 and this decline becomes even sharper in later years. While in menopause there seems to be some reserves remaining, these are no longer viable for pregnancy.

How long should women try to get pregnant before calling their doctors?

Most healthy women under the age of 30 shouldn’t worry about infertility unless they’ve been trying to get pregnant for at least a year. At this point, women should talk to their doctors about a fertility evaluation. Men should also seek attention if they have been trying to conceive but have been unable to do so. In some cases, the couple should not wait a year before seeking attention. For instance, if the female patient has irregular menstrual periods or has experienced recurrent miscarriages, further investigation will be needed.

Some health issues also increase the risk of fertility problems. So women with the following issues should speak to their doctors as soon as possible:
irregular periods or no menstrual periods
very painful periods
pelvic inflammatory disease
more than one miscarriage

No matter how old you are, it’s always a good idea to talk to a doctor before you start trying to get pregnant. Doctors can help you prepare your body for a healthy baby. They can also answer questions on fertility and give tips on conceiving. At hospitals with IVF centres affiliated with our group, we make sure that each and every patient is assessed individually based on their own unique history of infertility. This helps us achieve higher success rates with our patients. Please see the Infertility section for more information on infertility testing.

Male Infertility: Causes and Investigation

The hospitals with IVF centres affiliated with our group specialize in infertility investigation as much as the treatments. Even though there is a common misconception that majority of fertility problems are female oriented, in quite a few cases, infertility arises from a male factor. It has been estimated in 2014 that 30% of all infertility cases are male related while female related infertility is also estimated to be 30%. Both male and female factor infertility is also categorized as 30% while the remaining 10% is unexplained infertility. This tells us that around one-third of all infertility cases are solely male factor related, which makes male infertility investigation an important part of fertility/infertility assessment.

Factors Affecting Sperm Parameters and Male Fertility

There are a number of factors that may affect sperm quality and therefore cause male infertility. These range from genetic problems to pathophysiology and lifestyle and environmental factors. Some things that may reduce sperm viability and its ability to fertilize eggs can include:

  • Congenital birth defects or genetic disorders can affect spermatogenesis at various stages.
  • Excessive alcohol consumption is known to negatively affect many sperm parameters.
  • Recreational drugs or some prescription drugs can possibly interfere with spermatogenesis and sperm quality. Anabolic steroids have also been shown to dramatically reduce sperm count.
  • Environmental toxins, including pesticides used during farming and exposure to lead can impact sperm viability.
  • Smoking cigarettes or other tobacco products have been shown to reduce sperm quality.
  • Health problems associated with bodily infections and fever can severely reduce sperm count. If you had sperm testing following an infection, the sperm parameters may have been affected. We recommend a retest after three months to double check.
  • Some medication have been shown to reduce certain sperm parameters. Some antidepressants are also under scrutiny in terms of their impact on sperm DNA fragmentation.
  • Chemotherapy and radiation therapy affect cells that divide quickly. Germ cells are also such cells and they are targeted by these therapies.  Age is also an important factor in terms of decline in male fertility.

How to Interpret a Sperm Analysis?

The World Health Organization (WHO) has established standardized minimum sperm parameters required for natural conception via intercourse. The following values are the WHO established minimum acceptable sperm parameters:

Volume: > 2.0 ml

Concentration: >20 million/ml

Motility: > 50%

Morphology: >30% with normal morphology

White Blood Cells (Round Cells): < 1 million/ml

pH: 7.2-7.8

However, given that these values are established for natural conception, it is possible to achieve pregnancy with values lower values during IVF treatments, especially when ICSI is used.

The following classification system is used depending on how the values on your sperm analysis report relate to the reference values established by WHO: Oligozoospermia refers to sperm samples with count lower than 20 million/ml. Astenozoospermia refers to the sample of sperm whose motility has been found to be lower than 50%.Teratospermia (teratozoospermia) refers to a high level of sperm cells in the ejaculate that are considered to be morphologically “abnormal”. Azoospermia is a condition characterized by the total absence of sperm cells in the sperm. Azoospermia is further dividen into two sub-categories: Obstructive azoospermia where sperm production occurs but the duct system carrying sperm outside has an obstruction. Non-obstructive azoospermia refers to problems (either genetic or pathophysiological) where sperm production is absent.

If your sperm analysis indicates a problem  with any one or more than one of the sperm parameters, further evaluation will be in order. Problems with sperm parameters may indicate other underlying medical conditions which can only be elucidated via proper medical history taking. Effective history taking will allow us to review possible medical issues such as recent fevers, infectious diseases, past history of cancer, problems that might be associated with previous surgeries including retroperitoneal, pelvic, bladder or prostate surgeries as well as family history of cryptorchidism or hypogonadism. Certain medications are known to interfere with spermatogenesis and sperm maturation, therefore, prescription and non-prescription medication, sports supplements or any other drugs must be evaluated in terms of their possible impact. For an effective assessment, you must be forthcoming about all the relevant information because failure to do so can affect the level and quality of your care.

Obstructive Azoospermia versus Non-Obstructive Azoospermia

If you have been diagnosed with azoospermia (total absence of sperm cells in the ejaculate), it will be important to be able to precisely identify the type of azoospermia present. As mentioned above, exposure to certain environmental factors as well as previous diseases or medication can possibly affect your sperm parameters. If a thorough investigation has been made and no direct effector has been identified, a second diagnosis will be in order. This will be to classify the type of azoospermia present.

Obstructive azoospermia refers to a condition where spermatogenesis (sperm production and possibly sperm maturation) is present, however, the channels which carry the sperm outside via ejaculate may be blocked or damaged. In such cases, surgical sperm retrieval / extraction methods are used to aspire or extract sperm cells. Depending on the type or location of obstruction, sperm aspiration, extraction or other biopsy methods can be used.

Non-obstructive azoospermia refers to problems with production and/or maturation of sperm cells. The problem with non-obstructive azoospermia is more severe compared to obstructive azoospermia since surgical sperm extraction methods are not likely to produce desired results. In such cases, using donor sperm usually becomes the next best alternative. At hospitals with IVF centres affiliated with our group, we are currently offering stem cell therapy on a clinical trial basis for patients with non-obstructive azoospermia