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What is Infertility?
Infertility can be defined as the inability to become pregnant. This does not mean that the couple is unable to have children, but assistance might be needed in the process. The term ‘infertility’ is used in the following cases: where couples have not conceived after twelve months of attempting to conceive; the female partner is over the age of 35 and the couple has not been able to conceive within six months of attempting.
QUICK STATS on INFERTILITY
What causes infertility?
Infertility may result from fertility issues with you or your partner and can also be a combination of factors from both partners. Secondary infertility is also prevalent, where a woman is unable to fall pregnant or unable to carry a pregnancy to full term, after previously carrying a pregnancy to live birth. This could also include spontaneous miscarriages. Fortunately, assisted reproductive technologies (ART) have improved significantly and many safe and effective therapies are available to improve your changes of falling pregnant.
Female infertility

Female infertility is often caused by ovulatory complications. Ovulation is when an egg is released from the ovaries to be fertilized by the sperm. If ovulation does not take place, there is no egg available to be fertilized. Anovulation (when an egg is not released) can be due to several causes and each of these causes can be treated by your fertility specialist using a few possible treatment plans.

Signs & symptoms of female infertility

There are no obvious symptoms indicating infertility. The main indication of infertility is struggling to fall pregnant after having unprotected intercourse for 12 months. Women who might have ovulation problems, could have irregular or absent menstrual cycles. It is recommended to seek assistance from a reproductive specialist if pregnancy is not achieved within 12 months and earlier if the below scenarios are valid: Infrequent menstrual periods, females of 35 years and older,  history of pelvic infections or sexually transmitted diseases, known uterine fibroids or endometrial polyps, known male factor semen abnormalities.

Medical conditions and causes

There are several causes for fertility problems in females. These can include the following:

Polycystic ovarian syndrome (PCOS)
PCOS is a hormone imbalance problem which can interfere with normal ovulation. PCOS is a common cause of female infertility.

Uterine abnormalities
These include uterine fibroids and/or polyps, which are clumps of tissue and muscle in the uterus, prohibiting the fertilized egg from implanting.

Fallopian tube damage or blockage
Fallopian tube abnormalities can be caused by inflammation from sexually transmitted diseases, endometriosis, adhesions or surgery due to an ectopic pregnancy. This may lead to the inability of the fallopian tube to catch the ovulated egg and guide the egg to the uterus.

Endometriosis
This is another common cause, which occurs when endometrial tissue grows on the outside of the uterine cavity, affecting the function of the ovaries, uterus as well as the fallopian tubes.

Primary Ovarian Insufficiency
This is better known as early menopause. Here the ovaries stop functioning and menstruation ceases before the age of 40 years.

Cancer patients
Cancer treatment is known to affect our gametes when undergoing both radiation and chemotherapy. Particularly cancers that target the reproductive organs. Patients are advised to freeze their gametes prior to having therapy and might require IVF treatment after they have undergone cancer treatment.

Egg and Sperm donors
In some instances, patients require egg or sperm donors. Donor eggs are needed for patients who either cannot produce eggs or who have a genetic disease. This is also applicable to social infertility, such as same-sex couples, or single parents. Our clinic offers our own in-house egg and donor bank, ready to assist our patients throughout the process. Please visit (please link to donor pages) egg and donor bank section for more information on this option.

Surrogacy
This option is available to patients who are not medically fit to carry a baby due to having no uterus, serious health problems or same-sex male couples. The couple will use their own or donor gametes (or a combination thereof) to create the embryo, which is transferred into the surrogate’s uterus. This involves a willing surrogate who carries the baby to full term for the couple, without being genetically related to the child. This process is regulated by strict legal and ethical policies.

Testing for female infertility

Women will have a general gynaecological examination, which includes an ultrasound scan and a pap smear. The doctor will also take a full medical history and a few standard tests will be performed, which include blood tests and a semen analysis (if applicable to a male partner). Depending on the outcome of the evaluation by the doctor, he or she will request specific tests. These include hormonal tests such as Estradiol (E2), FSH, TSH, prolactin and AMH to determine whether a woman is ovulating and what her egg reserve status is. All patients will need to go for sexual transmitted disease (STD) screening before starting their fertility treatment.

Additional test may be requested, depending on the evaluation by the fertility specialist and their recommendations.

Hysterosalpingography
This is a test to determine whether the fallopian tubes are open and functioning properly. Fluid is injected into the woman’s uterus and X-rays are taken to determine whether the fluid travels properly out of the uterus and through the fallopian tubes.

Laparoscopy
A thin, flexible tube with a camera at the end of it is inserted into the abdomen and pelvis, allowing a doctor to look at the fallopian tubes, uterus, and ovaries. This can reveal signs of endometriosis, scarring, blockages, and some irregularities of the uterus and fallopian tubes.

Hysteroscopy
Hysteroscopy is the evaluation of the uterine cavity by endoscopy (using a camera) with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention.

FAQ


Q Is infertility just a woman’s problem?
No, infertility is not only due to female factors. Both women and men can have problems that cause infertility. About one-third of infertility cases are caused by female factors. Another one third of infertility problems are due to male factors. The other cases are caused by a combination of male and female factors or by unexplained problems.

Q What factors increase a woman’s risk of infertility?

  • Female age – we know that after the age of 35, the chances of falling pregnant naturally start to decline exponentially and egg quality decreases substantially. Smoking and excessive alcohol use can have a negative impact by damaging the egg quality.
  • Lifestyle factors such as stress, poor diet and excessive athletic training can increase the chances of infertility.
  • Being overweight or underweight, as this will affect ovulation.

Q How does age affect a woman’s ability to have children?
Due to many women waiting until their 30s and 40s to have children today, we are seeing an increased number of patients who require assistance to fall pregnant. Science has well established that aging decreases a woman’s chances of having a baby due to the following reasons:

  • Egg quality decreases with age (at age 40, 3 in every 4 eggs will be abnormal, despite regularovulation).
  • Egg reserve gets less with age.
  • Miscarriages are more likely due to increased DNA damage, leading to abnormal eggs.
Male infertility

Male infertility is due to low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. Illnesses, injuries, chronic health problems, lifestyle choices and other factors can play a role in causing male infertility.

Male factor infertility makes up approximately 40% of South African couples struggling to conceive. Fortunately, most cases can be relatively easily rectified by the use of assisted reproductive technologies (ART). Moreover, most male infertility cases present rather as sub-fertile. This means that with most male infertility cases, there are one or more sub-optimal semen parameters causing the lowered chances of natural conception.

Few cases are due to there being no sperm present at all, however, this can also be ‘rectified’ by making use of donor sperm

Signs & symptoms of male infertility

As with female infertility, the same applies to the male. There are no obvious symptoms indicating infertility. The main symptom of infertility is struggling to fall pregnant after having unprotected intercourse for 12 months. With that said, however, there are some indirect symptoms that may be indicative of, or elude to, male infertility.

These symptoms include:

  • Pain or swelling in the groin, penis or testes
  • Physical trauma to the testes
  • Sexual dysfunction
  • Severe decrease in libido
  • Any signs of chromosomal or hormonal abnormalities (these include factors such as decreased body hair and/or secondary sexual characteristic development)
  • Abnormal growth on the testes
  • Genital or testicular surgery as a child (e.g. undescended testis as a child)
Medical conditions and causes

There are several causes for fertility problems in males. These can include the following:

Semen analysis diagnoses: (WHO manual, 2010)

  • Aspermia: no semen (no or retrograde ejaculation)
  • Asthenozoospermia: percentage of progressively motile (PR) spermatozoa below the lower reference limit
  • Asthenoteratozoospermia: percentages of both progressively motile (PR) and morphologically normal spermatozoa below the lower reference limits
  • Azoospermia: no spermatozoa in the ejaculate
  • Cryptozoospermia: spermatozoa absent from fresh preparations but observed in a centrifuged pellet
  • Haemospermia (haematospermia): presence of red blood cells in the ejaculate
  • Leukospermia (leukocytospermia, pyospermia):presence of white blood cells in the ejaculate above the threshold value
  • Necrozoospermia: low percentage of live, and high percentage of immotile, spermatozoa in the ejaculate
  • Normozoospermia: total number spermatozoa, and percentages of progressively motile (PR) and morphologically normal spermatozoa, equal to or above the lower reference limits
  • Oligoasthenozoospermia: total number of spermatozoa, and percentage of progressively motile (PR) spermatozoa, below the lower reference limits
  • Oligoasthenoteratozoospermia: total number of spermatozoa, and percentages of both progressively motile (PR) and morphologically normal spermatozoa, below the lower reference limits
  • Oligoteratozoospermia: total number of spermatozoa, and percentage of morphologically normal spermatozoa, below the lower reference limits
  • Oligozoospermia: total number of spermatozoa below the lower reference limit
  • Teratozoospermia: percentage of morphologically normal spermatozoa below the lower reference limit

Obstructive Azoospermia
This is a condition where no sperm is present within the ejaculate, however sperm are found upon dissection of a testis biopsy sample. This concludes that the primary reason for there being no sperm within the ejaculate is that there is a blockage whereby the sperm fail to be released in the ejaculate. Testis biopsy sperm can only be used in an in vitro setting, only with ICSI (intra cytoplasmic sperm injection) (please link to ICSI page).

Non-obstructive azoospermia
This is a condition where no sperm are found in the ejaculate as well as upon dissection of a testis biopsy sample. This type of azoospermia usually eludes to an underlying condition that could have caused the failure of ones testes to produce (make) sperm. For these cases, making use of donor sperm is the only option.

Anejaculation
A condition whereby one is unable to ejaculate and therefore unable to release semen. This can be caused by a plethora of reasons such as: spinal cord injuries, diabetes, multiple sclerosis, abnormalities present at birth and other mental, emotional or unknown problems. Medication is usually the first prompt to resolving this problem. Other treatment options include rectal probe electroejaculation (RPE) (done under anaesthetic) and/or penile vibratory stimulation (less severe cases and non-invasive), or testis biopsy (done under anaesthetic).

Congenital disorders (condition present from birth)

  • Congenital Adrenal Hyperplasia (CAH): CAH is a rare condition that involves the abnormal production of certain hormones and be treated with hormone replacement therapies.
  • Klinefelter’s syndrome (KS): KS is one of the main causes of azoospermia, however, having azoospermia does not equal having KS. KS individuals present with an extra X-chromosome (47,XXY) and infertility is one of the main features of this disorder.
  • Cryptorchidism: a condition in which one or both of the testes fail to descend from the abdomen into the scrotum. This disorder may have a negative effect on sperm production in men. A testis biopsy is recommended for these cases when there is no sperm in the ejaculate.
  • Anorchia: a condition where a male is born without testicles.
  • Sertoli cell-only syndrome (SCO): These patients are typically normal on physical examination as this condition presents with infertility without sexual abnormality. SCO is usually diagnosed by testis biopsy findings. Individuals with SCO can still achieve a pregnancy, however will need fertility treatment.
  • Congenital bilateral absence of the vas deferens (CBAVD): occurs in males when the tubes that carry sperm out of the testes (vas deferens) fail to develop properly. Although the testes usually develop and function normally, sperm cannot be transported through the vas deferens to become part of semen. A testis biopsy may be used to harvest sperm from CBAVD affect individuals. Notably, CBAVD mostly occur in men that present with cystic fibrosis.

Hyperprolactinemia
This condition includes the overproduction of the hormone prolactin. This condition is often linked to erectile dysfunctions in men. Treatment of this depends on what the cause of the condition is. Certain medication can cause the onset of this condition, so in these cases ceasing the causative medication is strongly recommended. Another cause of this condition could be due to a growth in the pituitary gland, which can be removed via surgical interventions.

Immunologic Infertility
Immunologically caused infertility refers to the presence of anti-sperm antibodies (ASAB). This immunological obstacle, however, can be bypassed via the use of sperm preparation methods used in fertility treatments.

Reactive Oxygen Species (ROS)
It is normal for semen to contain levels of ROS to aid the fertilization of a sperm and egg, however, too many ROS can have detrimental effects on sperm parameters. ROS can be reduced by the administration of antioxidant supplements, however the recovery is not guaranteed.

Retrograde Ejaculation
Whereby the semen flows backwards into the bladder, instead of outwards forming the ejaculate. This is caused by many different factors and be relatively easily rectified by means of sperm preparation methods that assist in harvesting the sperm out of the urine.

Genital tract infections
I
nfections are not a common cause for male infertility, however it does occur. A genital tract infection is picked up during a semen analysis whereby the amount of white blood cells usually exceed the normal reference limit. Having a white blood cell count that exceeds the reference limit, does not however, always indicate an infection. Indicative cases are usually sent off for separate culture tests that are done on the same sample used during the semen analysis. Large amounts of white blood cells in a semen sample cause higher levels of reactive oxidative stress (ROS) within the sample, which could negatively affect semen parameters by possibly lowering chances of fertilization (DNA damage), causing possible blockage, and causing possible testicular shrinkage.  Infections can usually be treated by prescribing the appropriate antibiotics.

Varicocele
Varicoceles refer to the physical swelling and entangling of veins within the scrotum. Varicoceles can have a negative effect on sperm count and quality. Varicoceles can be surgically removed, however, the improvement of sperm parameters post-surgery do not always improve.

Lifestyle factors
Although most types of infertility aren’t preventable in men, these strategies may help:

  • Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
  • Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
  • Avoid exposure to industrial or environmental toxins, which can affect sperm production.
  • Limit medications that may impact fertility, both prescription and non-prescription drugs.
  • Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy.
Testing for male infertility

To determine a male’s fertility status is relatively easy and inexpensive. A semen analysis (sperm test) is a test that is performed on a male’s ejaculate. This test concludes a fertility-related diagnosis that relates to parameters of the semen sample.

A minimum of two sperate semen analysis is recommended, with a preferred time frame of 4 weeks between tests, in order to get the most accurate results.

A more comprehensive work-up, along with the semen analysis results, includes a physical examination as well as an extensive medical history with or without blood-hormone tests done by a fertility specialist.

An important factor to remember when using a semen analysis for fertility treatment is that a semen analysis doesn’t measure fertilization potential of sperm, but it does measure and gives insight into the possible underlying aetiologies of male-related fertility. Once a semen analysis is abnormal, it is advised that the test be repeated at a fertility unit. These repeat tests will then be evaluated by an embryologist and a fertility specialist, who can then propose the appropriate treatment to achieve a pregnancy.

FAQ

Q Is infertility just a man’s problem?
No, in short, it is not. Couples struggling to fall pregnant may experience female factor-, male factor- and combination factor- infertility complications. Notably, male factor infertility makes up approximately 40% of South African couples struggling to conceive.

Q How can I get my sperm tested?
Sperm testing is quick, easily and relatively inexpensive. One can simply book an appointment for a semen analysis, arrive at the decided time and date, pass a sample and receive the results up to 3 working days later. Make a booking here. (please add link)

Q Can I take any medication to improve my sperm?
There is a multivitamin available that has shown to have a positive effect on sperm parameters. With that said, improvements are not guaranteed. This supplement is inexpensive and available over the counter at most pharmacies. There are products available (e.g. Sperm-i-Prove).

Q Can I do anything to improve my sperm?
Sperm is heavily affected by various lifestyle factors. Factors to avoid include:

  • Excessive alcohol consumption
  • Smoking
  • Marijuana
  • Hot baths
  • Tight underwear for prolonged periods of time
  • Excessive or no exercise
  • Excessive consumption of caffeine
Still have questions?
Should you require any additional information, please contact the clinic directly and one of our friendly staff members will happily assist you.
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