What is the difference between sterility and infertility?

Infertility should not be confused with sterility which is a harsh word because it denotes a state of absolute inability to conceive in any manner. With today’s state of the art techniques of Assisted Reproductive Technology (ART), having a baby is not impossible.

Theoretically speaking, infertility denotes a relative state of sub fertility. About 85% of ‘normal’ married couples will get pregnant within a span of 12 months of active married life. Out of the remaining 15%, another 75% will also conceive on their own without any medical help during some period of their married life.
Since this implies an indefinite period of waiting, most people will seek medical assistance after one year of unsuccessful sexual exposure. Family pressures, peer pressure and disharmony between the partners can contribute to reduced quality of married life.

Psychosomatic problems increase due to an infertility complex and may turn into a serious illness.

What is the contribution of each partner to infertility?

 

The cause of infertility is usually multifarious; it is difficult to put a finger on any one person unless it is a case of hopelessly damaged tubes or an irreversible loss of spermatogenic apparatus.
On a broad platform, the partner has a 40% is contributed by the female partner and in the remaining 20% they are both responsible.
In 10% of cases, when none of the investigations point out a person for infertility, such cases referred to as unexplained infertility cases.

Is an impotent man also sterile?

 

It must be emphasized that virility are two entirely different conditions. An impotent man may have very good sperm quality with a good population of normal looking and normal moving spermatozoa and he can impregnate his wife by artificially introducing neat semen into the depth of his wife’s vagina by the use of simple gadgets like a long plastic or glass syringe..
Likewise, a virile man who can boast of daily sexual activity may not have any sperm in his semen at all. He may have a total block in the channel that carries the spermatozoa from the testis to the urethra.

What does the seminal fluid contain if there are no spermatozoa?

 

The normal quantity of semen is usually about 2.5-5 ml, out of which only 0.5 ml is produced from the testicular gland and this contains all the spermatozoa.
The rest of the semen consists of seminal plasma produced by a structure called a ‘seminal vesicle’ and other accessory glands along the base of the prostrate gland.
So a man who has an obstructed duct (van deference) can still produce 2.5 ml- 3 ml of semen without any spermatozoa in it.

Does pain during menstrual periods amount to infertility?

The normal quantity of semen is usually about 2.5-5 ml, out of which only 0.5 ml is produced from the testicular gland and this contains all the spermatozoa.
The rest of the semen consists of seminal plasma produced by a structure called a ‘seminal vesicle’ and other accessory glands along the base of the prostrate gland.
So a man who has an obstructed duct (van deference) can still produce 2.5 ml- 3 ml of semen without any spermatozoa in it.

Is it unnatural if semen flows out of the vagina after a sexual act?

Semen overflowing from the vagina is not an abnormal phenomenon. If the quantity of semen is less than 1ml, viscous in nature and if the vagina is deep there may be no overflow of seminal fluid after sexual activity.
In reverse situations, there will be an overflow, which results in wetting of bedclothes, etc. Since this happens to a majority of women, this has never been responsible for infertility, but one can practice the habit of keeping a pillow beneath the buttocks during intercourse to prevent the overflow.

When is the best time to have intercourse in a menstrual cycle for improving of fertility?

This should of course be targeted at the ovulation, but the couple should not be obsessed by a ‘calendar’ requirement.
Most couple who have intercourse 3-4 times a week will be able to catch the time of ovulation and establish pregnancy; but timing of intercourse is important for couples who live away from each other.

How does one recognize the event of ovulation ?

Roughly, a woman who is menstruating every 28 days ovulates on the 14th day. The day of ovulation is unfortunately related to the next ensuring menses, i.e., ovulation normally seems to occur 14 days before the next expected period. For example, if a woman has a 35- day cycle, her ovulation is likely to occur on the 21st day of the cycle. There are certain signs that occur during ovulation. Sudden appearance of thin translucent wiry mucus is indicative of impending ovulation and the change of mucus to a thick, rubbery type means that the ovulation is over and the lower end of the cervix has plugged its opening in order to cause a barrier against entry of spermatozoa, from then on the ovary also starts producing a new type of hormone which results in fullness of breasts and some amount of weight gain. The woman’s body temperature rises in the morning, as is seen if she keeps a record of body temperature taken daily before getting out of bed.
This will definitely show what is called “Biphasic Curve”. The Post-ovulatory temperature will be about 0.7 – 0.8 degrees F more than the preovulatory temperature.

What is tubal block? How does it occur and how does one avoid it?

Tubal blocks are usually acquired by disease. Only occasionally is it congenital in nature. The block may occur either due to infection that enters the genital canal from the upper end of the vagina or it may occur from general peritoneal disease. For e.g. an acute appendicitis, which bursts causing general peritonitis. The former is much more common than the latter.
The organisms that produce tubal block are frequently transmitted sexually. So it is very important that both men and women practice some kind of discipline in their sexual habits. Multiple partners includ
ing in sexual activity without the use of condoms can inflict trouble on each other. As of today, the most important cause of tubal block is due to Chlamydia infection. There are many other conditions which cause inflammation inside the pelvis, knitting the pelvic organs together. These are not necessarily caused by bacteria or viruses. These have to be identified by your doctor and the only clue you will get is severe pain during periods, sexual intercourse and defecation.

One of the worst and avoidable causes of tubal disease is acquired by abortions procured through unconventional methods, by non-medical attendants.

Are abortions allowed legally?

The Medical Termination of Pregnancy (MTP) act was passed by the Government of India on two occasions: first implemented in the year 1972 and later revised in 1975. The gist of the act is that abortions can be legally done by certified medical persons provide the reason for seeking abortion is given. The act is so broad that almost any couple can qualify for it. Any couple who claims that pregnancy has occurred due to failed contraception is entitled to get an abortion.
There is no need to show any proof for it. One could have used barrier contraception like a common or a contraceptive cream or coitus interrupts, even a failed rhythm method will be accepted as a reason for conducting an abortion.
A couple who declares that their socioeconomic environment is unsuitable for raising a baby is also eligible for legal abortion. The law does not discriminate between a married and unmarried man. So there is no excuse for anyone to go in for illegal abortions and acquire complications thereof.

When the tubes are blocked due to disease can you reverse the condition?

Tubal blocks caused by infection can never be satisfactorily reversed. The blocks are frequently seen in multiple segments. The inflammatory reaction would have caused scarring and immobilization of tubes even though there is anatomical patency. The tubal disease is usually bilateral.
If there is a small segment of tubal block, the affected segments can be exercised, the ‘normal’ segments can be rejoined. Unfortunately, such people have a high chance of getting a tubal pregnancy even after a successful repair.

What treatment can you offer for tubal blocks due to disease?

One must make sure that there is no active infection going on and tubal disease is cured, although it has left the tubes blocked.
These patients can be taken up for In Vitro Fertilization (IVF) outside the body and can be returned to the uterine cavity for implantation and further growth.

What are indications for infertility apart from tubal disease?

Although the original reason for inventing the IVF programme was to bypass the nonfunctioning tubes, it later got extended to many other conditions like generalized pelvic disease causing immobilization of ovaries and uterus, situations where there is borderline deficiency of sperm count in the male, etc. There are many other conditions where ovulatory phenomenon is infrequent and ovulation has to be induced artificially by injections. In such situations, the ovaries can produce too many ova threatening to produce a high order of multiple pregnancies.
Such pregnancies are harmful both to the unborn babies. In such situations, it is wiser to take out these eggs, fertilize them artificially outside the body and freeze the extra embryos leaving only 2 or 3 good embryos for transfer in that cycle.
The frozen embryos can be thawed and transferred during any other cycle or after any number of years.

What is the status of a woman who is getting irregular periods? Will she become fertile if her menses are regulated?

Women who are menstruating irregularly may be producing eggs in each cycle. They are not necessarily infertile. But irregularity of cycle associated with obesity and increased facial hair is a condition where in the ovulations are infrequent and even if they do ovulate, the ovum may not be healthy. Such people require special investigation and treatment.

There are some women who do not get periods for several months or years. Does it mean that they have attained menopause?

A woman who has attained menopause does not have any eggs in her ovary. It is a state of its depot of ova or egg bearing follicles.
These women have a low level of ovarian hormones associated with high level of pituitary gland function. Such women can be treated with pituitary hormone. Such ova get fertilized either by the sexual act or by IUI or IVF.

What does ovum donation entail?

Patients with ovarian failure can be counseled regarding ovum donation. Usually the patients themselves bring the donors and these women are either close relatives or friends who volunteer out of altruistic reasons. Commercial donors may also be available if the country’s law allows. The donor is stimulated in order to produce eggs, at the same time the recipient is stimulated to produce the kind of endomentrium (lining of the uterus) that is required for implantation. The donor’s eggs are then aspirated and fertilized by the recipient’s sperm. The embryo so formed can be transferred after 2-3 days into the recipient’s uterus. The recipient has to be under hormone therapy until the pregnancy has occurred and has continued until 12-13 weeks: after this period the products of conception will manage itself without outside support.
Some women develop antibodies against their ovarian tissues and this is one of the various features of autoimmune reaction when the body system produces antibodies against its own cells. This can be identified by looking for anti-ovarian antibody. An ovarian biopsy might also show some evidence of inflammatory reaction generated by autoimmune disease. Such patients occasionally have periods of remission during which an occasional ovulation might occur, even producing pregnancy. But one cannot wait endlessly for an unknown result. Ovum donation is the answer for this situation.

What is the lowest seminal count that can be accepted for IVF ?

The lowest normal count that can produce a baby by natural insemination would be approximately 25 mill/ml of ejaculated with a motility of 40% and a normal morphology of 20%. But as the quality goes on dropping, one has to change the motility of treatment; one will take recourse to intrauterine insemination of chosen and processed spermatozoa, even if the count is marginally substandard.
For IVF one would ask for a count of at least 10 ml with about 30% motility and 8-10% normal looking spermatozoa. One has to use at least 50,000-100,000 motile spermatozoa/egg in a petridish in order to get fertilization in the laboratory.

What is the need for so many spermatozoa for fertilization of one egg ?

The egg has a very large protective globular network of tissue around it. The egg looks like the center of a sunflower. The rest of it is all a network of cells with minute canals running in between. There are tiny microscopic gaps in between cells. Between the network and the naked egg there is also a shell. When the spermatozoa attack the egg, they find a huge barrier produced by the globular matrix of tissue. They make their way through them using the enzymes, which they release from their head end. This enzyme known as Acrosin dissolves the matrix and the shell of the egg and eventually one spermatozoa penetrates the shell and gets into the cytoplasm. As soon as this happens, the egg release certain granules to from a fort at its periphery and these are known as cortical granules, which from a barrier to further sperm entry.
In natural fertilization, about 100-200 sperm only reach the site of the tube where the ovum is accessed, although the number of sperm deposited in the vagina during an act of sexual intercourse contains more than 150 million. There is a selection process that operates from end of the genital canal and all the way until the sperm reaches the last one third of the segment of the tube where the ovum is waiting. It is in this context that IVF can enforce better chances of fertilization in the laboratory. The selection is made in the laboratory and a concentration of 50,000 sperm is placed in the vicinity of a mature cycle. Temperature, humidity, osmolality and pH are all controlled within the nutrient media kept in the incubator specially built for this purpose. So IVF can be used as a treatment for unexplained infertility by forcing excess number of sperm to assist the fertilization of the ovum.

What is the difference between IVF and ICSI ?

IntraCytoplasmic Sperm Injection(ICSI) is different from In vitro fertilization (IVF) in the sense that ICSI requires the same number of good quality spermatozoa as the number of eggs, which are required to be fertilized. For instance, when one has produced a cohort (batch) of 10 eggs during an IVF procedure, fertilization in the laboratory would require at least half a million good spermatozoa in order to get all the oocytes fertilized.
When one does an ICSI procedure, one requires only 10 normal spermatozoa. In the ICSI procedure, a good quality ovum that has been aspirated is stripped off its outer covering of cellular matrix and held naked under the microscope with the help of a glass suction pipette. The egg is injected mechanically with a normal looking spermatozoan and the egg cytoplasm is given a small joit.
This starts off the process of fertilization, which involves the release of chromosome material from the sperm and fusion from 2 sets of gene material from the male and female gametes to form a pre-embryo or zygote. ICSI is more or less the ultimate treatment as of today for assisting fertilization outside the body.

What is the cause of male infertility ? Can we not improve male infertility by medicines ?

The causes of male sub fertility are not well understood. Many organisms can cause sub clinical infection of the testes, the epididymis and the male accessory glands like the seminal vesicle and the prostate. Infected secretions from the glands cause sperm dysfunction. This can cause injury to the various parts of spermatozoa causing immobilization or insult to precious genetic material contained in the head of the sperm. The testicular glands itself can get inflamed as part of a systematic disease. Many childhood virus infections can cause testicular atrophy totally or in patches- mumps and small pox are notorious for this complication. Since small pox is eradicated globally, it is sensible to talk of mumps only. All children are nowadays being immunized against measles, mumps and rubella in one injection. So children are systematically vaccinated, testicular disease due to mumps will also be a matter of historical importance. Some children are born with testes that retract frequently into a higher place onto the abdominal wall.
Sometimes, the testis remains inside the abdomen and scrotum appears empty. Such children have to be shown to a pediatric surgeon; operative intervention is required as soon as possible to bring them down to the scrotal sac. Tubercular infection of the testis or Epididymis is another common problem in our country. Although Antituberculus Treatme (ATT) can eradicate the infection, whether it start in the testis and descends along the canal or starts from the urethra and ascends towards the test, the end point result in multiple blocks along the semen transmitting channel. There are also other conditions where the body produces antibodies against the sperm. The is also part of testicular infection or injury.

Does absence of sperm in the semen amount to absolute sterility ?

When obstruction of vas deferens is the cause of absence of spermatozoa in the ejaculate, it can be overcome by withdrawing the spermatozoa from the somniferous tubules situated within the testis itself. The procedure is known as Testicular Aspiration (TESA) or Testicular Extraction (TESE).
Sometimes, you can get spermatozoa in large numbers in a cluster of tubules, stilting on top of the testis known as epididymis. A blown up epididymis with collection of spermatozoa can be felt as a swelling and by putting a needle into the region one can aspirate a fairly large number of spermatozoa which can be used for IUI.