Since the birth of Louise Brown in 1978 with the help of in vitro fertilization, the outlook for infertile couples has drastically changed. The advanced IVF techniques, Intra cytoplasmic sperm injection (ICSI), potent pro fertility medicines, high resolution ultrasound, safe and effective key hole surgery (laparoscopy and hysteroscopy) have helped millions of couples worldwide to conceive even in the presence of seemingly impossible situations. Acceptance of procreation with the help of donor sperms, eggs and uterus by the infertile couples, the society and the law of the country have widened the treatment options for even those couples in whom damage is beyond repair. Today, an infertile couple can look towards an 80-90% chance of conception. While the developments in the field are very exciting there are many pertinent questions which have arisen: Why is the incidence of infertility increasing? Is it real or apparent? What are the common reasons for infertility? How can we diagnose and prevent infertility? We shall try to answer some of these questions here.
Before we go in to the causes of infertility, we have to understand the normal process of conception. We can take the simple analogy of the development of a plant. The uterus is like the mother earth. The hormones which support and nourish the pregnancy are like water and fertilizers. The seeds i.e. sperm and ova (eggs) come from father and mother respectively. The two seeds combine to form an embryo or the sapling. Pituitary gland situated in the brain acts like the farmer – guiding, regulating and helping the whole process. Fecundity rate per month for any individual couple is only about 15-20 percent. Infertility is defined only if a conception fails to occur despite unprotected intercourse for more than 12 months. Conception may occur even in the presence of apparent milder problems. Therefore, investigations and treatment before one year are generally counter-productive. At the same time, the duration of infertility of more than three years has a negative impact. In older couples, investigations and treatment should be started early.
Infertility occurs commonly due to the present day life style factors, many of which are not conducive to pregnancy. The incidence of infertility is rising due to the causes that include delayed childbearing, obesity per se and the related disorders, increased sexual promiscuity and sexually transmitted diseases. In the males, there is a trend towards decreasing sperm counts. Obesity, sedentary life style, smoking, mental stress, air and chemical pollutants and use of electronic devices (etc.) have been also implicated. Of all of these issues, obesity is one factor which has a serious and direct bearing on fertility. In addition to infertility, obesity is an important contributory cause of poor success of treatment, abortions, malformations in baby and adverse pregnancy outcome. Many of these problems can be reversed by losing weight.
In conclusion, the first step to treat infertility is the elucidation of all the contributory causes in both the partners. It takes two to make one baby. There may be one or multiple causes in one partner or both the partners. Treatment has to be tailored according to the age, cause and duration of infertility. Too much, too little, too early and too late are all counter-productive in management of infertility. If a treatment modality fails for 3-4 treatment cycles – the same is unlikely to succeed. Spontaneous pregnancies are still possible. Unnecessary and futile treatment especially surgical intervention is more harmful than no treatment. It is better to opt for IVF or adoption in such cases.
15 to 20 percent of people within reproductive age have some level of infertility. It is considered that the causes of infertility can be attributed to either the male or female partner each 50% of the time. There is a large subset of nearly 20% of infertile couples where no cause can be detected in both partners despite extensive workup. Here, the defect lies at the functional or biochemical level which is neither possible to diagnose with current workup techniques nor required. The treatment remains IVF in the most of these couples. IVF is indicated after 3-5 years of unexplained infertility in young couples also.