Published in Panorama
Making Strides in Infertility Treatment
Diagnosis and treatment of infertility have made rapid strides as we step into the new millennium. A vast gamut of therapeutic options are available to infertile couples, particularly in the industrialised world, thanks to the technological advancements and sound infrastructure in these countries.
Infertility, on account of Polycystic Ovaries Syndrome and Endometriosis in women, account for 60% of all female infertility, says Prof.Dr.R.Rajan, Consultant Gynaecologist and Specialist in Infertility, Reproductive Endocrinology and Operative Laparoscopy, Zulekha Hospital, Sharjah. And the good news is, “Both these conditions are more easily corrected and treated than any other cause of infertility!”
Infertility is believed to affect both genders almost equally and in roughly one third of cases, they may be infertile for no explainable reasons. A woman is most fertile during her early 20s. Fertility rates in females, says Dr.Rajan, slowly declines past the age of 30, slowing still further after the age of 35. “One of the major causes of infertility in women is Polycystic Ovarian Disease (PCOD) and inability to ovulate which results in irregular monthly cycles. This is largely related to an excess of the male hormone, testosterone in her. Many of these women have a family history of diabetes which in turn causes a tendency for them to have a high male hormone.”
Endometriosis is the other major cause of female infertility, opines Dr.Rajan. “In this case, the lining inside the uterus which comes out during the monthly cycles, grows outside the uterus, on the surface of the fallopian tubes, the ovary, abdominal cavity or the pelvis, consequent to which it can produce some scarring, affecting tubal motility. Further, the ovaries will develop cyst formation containing blood, called chocolate cyst.”
Other factors leading to female infertility include congenital defects involving the structure of the uterus, uterine tumors or fibroids, blocked or damaged fallopian tubes resulting from surgery or pelvic infections, according to Dr.Rajan. “These infections may arise on account of tuberculosis, venereal diseases, miscarriage or abortion, infection following delivery and use of intra-uterine contraceptives.”
The most common factors leading to infertility in males, explains Dr.Rajan “are azoospermia (no sperm production) and oligospermia (production of few sperms). Very rarely, infertility in men is caused by a genetic disease such as cystic fibrosis or a chromosomal abnormality. Cigarette smoking and excessive alcohol is most hazardous for male fertility,” emphasizes Dr.Rajan.
Varicocele is another major cause of male infertility says Dr.Rajan. “It occurs when a vein that carries blood out of the scrotum dilates, much like a varicose vein in another location. This results in a pool of blood around the testicles, raising the temperature of the scrotum, resulting in decreased production and motility of sperms.”
“Mumps, developed in a male child after the onset of puberty, can cause irreversible problem to the testicles and result in infertility,” reveals Dr.Rajan.
How is Infertility Diagnosed and treated? Says Dr.Rajan, “If a woman under 30 fails to get a pregnancy after one year under normal circumstances, we may have to test for infertility, and after 6 months in the case of women above 30 years.”
“On half of the infertility management”, opines Dr.Rajan, “rests with proper counseling and routine investigations. While history and semen analysis is done for the males, history is the mainstay in the females because it will make it evident whether she has a problem or not.”
Vaginal ultrasound has totally revolutionized the management of infertility, according to Dr.Rajan. “We use it to make a precise evaluation of the pelvic organs like the cross sections of the uterus and ovaries. Tubal problems, however, need to be diagnosed using laparoscopy, explains Dr.Rajan. “Alternatively, we may also use Hysterosalpinograph, a process in which a radioactive dye is injected into the uterus and fallopian tubes. The pelvic region is then scanned by a special x-ray machine which reveals fibroid tumors, scar tissue, abnormal uterus or blockages in the fallopian tubes.”
“If the woman is not ovulating, we basically treat her medically with gonadotrophin injections and drugs to tackle diabetes to suppress the level of insulin. With this alone, many women become pregnant,” says Dr.Rajan.
Highlighting the advantages of Laparoscopy , Dr.Rajan states, “Firstly it diagnoses the condition precisely and secondly, it allows us to simultaneously operate to correct the underlying problem responsible for the infertility. Many of these women are benefited just by puncturing their ovaries, followed by medication. This enhances chance of ovulation because the ovary-produced androgen levels (the male hormones) are decreasing temporarily, for at least a period of six months. Within this period the woman is expected to become pregnant.”
For infertility caused by a tumor in the uterus, clarifies Dr.Rajan, “ or for endometriosis, again laparascopically we reset all the pelvic organs to normal. Also, if there is any tubal distortion, cysts or adhesions in the ovary, we correct them.”
On the efficacy of these measures, Dr.Rajan is certain: “If we do 100 laparoscopies at random for infertile women, at least 40% of them will surely become pregnant within 6 months and 60% of them will get pregnant within the year, irrespective of the cause, if they are below 30 years of age. For the 30 plus women, we have to subtract 10-15% from the above percentage. Still, upto the age of 35, there is an average fertility improvement by 30%.
“Should these treatments fail, the next step,” delineates Dr.Rajan, “is intra-uterine insemination. The process involves collecting the sperms, washing them in a nutrient solution and aspirating them. These are then placed in the wife’s uterus. If the tubes are normal and the woman is otherwise normal, this enhances pregnancy chance by another 10-15%.”
Under what situations does one go in for ART or Assisted Reproductive Technology? “Yes, if even the intra-uterine insemination fails, this is the next stage. Here we have two techniques, the In Vitro Fertilisation and Embryo Transfer (IVFET) or Intra Cytoplasmic Sperm Injection (ICSI). In infertile couples where women have blocked or absent fallopian tubes, or where men have low sperm counts, in vitro fertilization (IVF) offers a chance at parenthood,” says Dr.Rajan.
In IVFET, explains Dr.Rajan, “We collect the sperms, wash them and we get multiple ova by superovulating the woman and aspirating the follicle. The sperm and the ova are kept together for incubation, to get fertilized. Once fertilization occurs after a couple of days, the fertilized embryo is placed in the woman’s uterine cavity. However, this method can also lead to multiple pregnancies because more than one fertilized egg is usually placed into the uterine cavity to make sure that at least one of them will grow. The risk involved here is that, occasionally, it may result in a tubal pregnancy.”
ICSI, says Dr.Rajan, is one step above the IVFET. “A micro-manipulator which has a pippet is used to get a single good sperm. The ovum is then penetrated with the pippet and the sperm is deliberately put inside it. This method is particularly helpful for couples where the men have a severely reduced sperm count, because what we need for this procedure is only one good sperm. Alternatively, those who fail in IVFET, may go in for ICSI, especially in cases of elderly women in whom the cause of infertility is unexplained.”
What about success rate associated with these procedures and is it possible to do these procedures repeatedly, should the attempts fail? The success rate on an average is 20% achieving pregnancy and a carry-home-baby rate at 10-15%, says Dr.Rajan. “The ICSI procedure is cycle-dependent, that is, the treatment given is only for that cycle. Whereas, if I do a laparoscopy and correct a problem, you have to wait for at least 6 months to a year to observe the result; it is applicable for a few cycles to come. Either procedures can be repeated.”
What are the risks involved in these procedures? Dr.Rajan explains, “We are using hormone injections to stimulate the ovaries. Sometimes, they may hyper-stimulate the ovary and cause enlargement of the follicle but that will regress once the injections are stopped since these are used only for a short period of time – for 10-12 days. Majority of the side effects associated with these techniques relate to levels of depression or may be headache in some instances which are due to the psychological state fearing failure of the treatment and consequent anxiety therefrom.”
Any precautions to be taken while on medication or treatment? Dr.Rajan emphasizes a 50% vegetable diet, suitable exercise to reduce their weight and most importantly, couples involved, need to divert their attention from the problem of infertility and keep their minds relaxed, concentrating on routine work.