What is Infertility, Principles, Diagnosis and Treatment

There are important steps in our body to become pregnant. The brain produces reproductive hormones, the egg matures and is released through ovulation. The fallopian tubes catch the egg, the male partner’s sperm cells travel and a sperm cell must fertilize the egg. The fertilized egg implants in the uterus, marking the beginning of pregnancy. Disruptions in this complex process may cause pregnancy not to occur. However, not every unsuccessful experience is considered infertility. Now let’s examine what infertility is.

What is Infertility?

Infertility is a medical condition in which one cannot become pregnant despite regular and unprotected sexual intercourse for at least one year. In individuals over the age of 35, failure to become pregnant for more than 6 months is considered infertility. Infertility can occur due to health problems in you or your partner or a combination of factors that prevent pregnancy. However, many safe and effective treatment options can increase the chances of pregnancy.
​​Types of infertility are defined according to different scenarios and experiences. First, the type called primary infertility involves people who have never had children before. This type of infertility occurs when a person or couple cannot achieve pregnancy for one year (or six months if over 35) after regular, unprotected sexual intercourse. Another type is secondary infertility. This refers to the inability to get pregnant again after having at least one successful pregnancy. If a previous pregnancy has occurred but there is now difficulty in achieving pregnancy again, this is called secondary infertility.

Infertility is a fairly common condition that affects men and women equally. While one-fifth of women ages 15 to 49 in the United States struggle with primary infertility, approximately one in 20 women also faces secondary infertility. While approximately 48 million couples around the world are living with infertility, in Turkey, according to the Ministry of Health data, it is known that 2 million couples have problems in having children.

Risk Factors for Infertility

While the factors that cause infertility sometimes affect only one partner, in some cases they can affect both partners. Risk factors for infertility include:

• advanced age
• Eating disorders such as anorexia nervosa and bulimia
• Exposure to environmental toxins such as chemicals, lead, and pesticides
• excessive exercise
• Radiation therapy and chemotherapy
• sexually transmitted infections
• Smoking and using tobacco products (These behaviors play a role in approximately 13% to 15% of infertility cases.)
• substance use
• Obesity or being underweight
• Abnormalities of the hormone-producing centers of the brain, the hypothalamus or pituitary
• Chronic health problems and diseases

These factors increase the risk of infertility and negatively affect reproductive ability.

Infertility Causes and Symptoms

Factors contributing to infertility in women are quite diverse. Endometriosis (also known as chocolate cyst), a chronic disease characterized by the presence of endometrial tissue lining the lining of the uterus in the ovaries, fallopian tubes or in areas outside the uterus such as the abdominal cavity, structural abnormalities of the vagina, uterus or fallopian tubes, autoimmune diseases such as celiac disease or lupus, kidney diseases, pelvic inflammatory disease (PID), hypothalamus and pituitary gland disorders, polycystic ovary syndrome (PCOS), primary ovarian failure or poor egg quality, sickle cell anemia, uterine fibroids or uterine polyps, thyroid diseases, fallopian tube disease located between the ovaries and the uterus. These factors include tubal ligation, in which the egg, which is the female reproductive cell, is prevented from descending to the uterus by surgically tying the tubes, or salpingectomy procedures in which the fallopian tubes are removed, genetic or chromosomal disorders, sexual dysfunctions, surgical or congenital deficiency of the ovaries, infrequent menstrual periods or absence of menstrual periods. These factors reflect the complexity and diversity of infertility problems in women.

The most common cause of infertility in men is problems with sperm shape, movement (motility) or quantity (low sperm count). However, varicocele is the enlargement of the veins surrounding your testicles in your scrotum; genetic disorders such as cystic fibrosis; chromosomal disorders such as Klinefelter syndrome; High temperature exposure to your testicles, such as wearing tight clothing, frequently using hot tubs and saunas, or keeping computers or heating pads close to your testicles; Injuries to your scrotum or testicles; Low testosterone levels (hypogonadism); Misuse of anabolic steroids; Sexual dysfunctions, for example, erectile dysfunction, anejaculation, premature ejaculation or retrograde ejaculation; Undescended testicles; Previous chemotherapy or radiotherapy treatments; Surgical or congenital testicular deficiency; Previous surgical sterilization (vasectomy) is among the causes of infertility. The origins of male infertility are also complex and may require intervention from a specialist.

How is Infertility Diagnosed?

Assessing reproductive ability for women involves regular maturation and fertilization of healthy eggs. This process requires your brain to send the hormonal signals necessary to release an egg. The egg must start from the ovary and make its way to the fallopian tube and the inner layer of the uterus. Reproductive tests are performed to detect whether there are any problems in these complex processes. These tests can also be used to identify or rule out potential problems:

• Pelvic exam: It is usually performed as part of routine check-ups and is used to detect signs of ovarian cysts, sexually transmitted infections, uterine fibroids, structural disorders or early-stage cancer.
• Blood test: A blood test to check hormone levels can be used to see if there are hormonal imbalances or regular ovulation.
• Transvaginal ultrasound: An ultrasound probe inserted into the vagina is used to observe potential problems in the reproductive system.
• Hysteroscopy: A thin lighted tube (hysteroscope) is inserted into the vagina and the inside of the uterus is examined.
• Saline sonohysterogram (SIS): The uterus is filled with sterilized saline and examined by transvaginal ultrasound.
• Sono hysterosalpingography (HSG): During the SIS procedure, the fallopian tubes are filled with saline and air bubbles to check for tube blockages.
• X-ray hysterosalpingography (HSG): X-rays track dye injected into the fallopian tubes and are used to diagnose blockages.
• Laparoscopy: A tube (laparoscope) inserted into the abdomen with a thin camera is used to identify problems such as endometriosis, uterine fibroids, and tissue scars.

To diagnose infertility in men, it aims to determine whether the person can ejaculate healthy sperm. Most fertility tests look for problems with sperm.

These tests are:

Semen analysis: This test checks for low sperm count and low sperm motility. Some people may need to have a needle biopsy, in which sperm is removed from their testicles for testing.

Blood test: A blood test can check thyroid and other hormone levels. Genetic blood tests look for chromosomal abnormalities.

Scrotal ultrasound: An ultrasound of your scrotum identifies varicocele or other testicular problems.

Infertility Treatment

Infertility treatment varies depending on the cause of infertility, how long it has been going on, your age, and the age of your partner. Some causes of infertility may not be correctable. If pregnancy does not occur for a year after unprotected sex, couples may still have a chance at pregnancy with infertility treatments often called assisted reproductive technologies (ART).

Infertility treatment for men may include the following in case of general sexual problems or lack of healthy sperm:

• Lifestyle changes: Lifestyle changes such as having sexual intercourse more frequently, having intercourse closer to the time of ovulation, exercising regularly, and stopping medications that may affect infertility without a doctor’s advice.
• Medications: Medications to increase sperm count and increase the chances of a successful pregnancy.
• Surgical intervention: Surgical procedures such as repair of a large varicocele with the possibility of opening the sperm pathway or restoring infertility.
• Sperm collection procedures: Sperm collection procedures may be used if you are unable to ejaculate or if there is no sperm in your semen. It can also be used when assisted reproductive techniques are planned and sperm counts are low or irregular.

Infertility treatment for women due to ovulation problems may include the following treatments:

• Fertility medications: If ovulation is irregular or does not occur at all, these medications can stimulate the ovaries to release more eggs.
• Intrauterine insemination (IUI): Healthy sperm is placed directly into the uterus around the time the ovary releases one or more eggs.
• Surgical procedures to restore fertility: Some conditions related to the uterus can be treated with hysteroscopy.
• Assisted reproductive technologies (ART) include all fertility treatments in which the egg and sperm cell are processed by healthcare professionals. In vitro fertilization (IVF) is the most common ART method. Fertility drugs in IVF help the ovaries produce more eggs. Mature eggs are removed. Eggs are fertilized with sperm in a laboratory environment. Fertilized eggs (embryos) are placed in the uterus. Sometimes other techniques such as intracytoplasmic sperm injection (ICSI) or assisted insemination may be used in the IVF cycle. There are also treatment options such as donor egg or sperm, gestational carrier, or genetic testing.

Infertility is a very common and challenging experience for couples. However, there are many effective treatment options available. Treatment can be successful when couples cooperate with healthcare professionals and treatment processes include a personalized approach. Individuals who have not achieved the desired pregnancy despite regular and unprotected sexual intercourse for more than a year should consult a specialist physician.