Updated on 31.10.2016.
Unbiased Evidence Based Information
*Infertility is defined as failure to conceive after regular unprotected vaginal sexual intercourse for one year (NICE 2013).
*Infertility is an extremely common medical problem with significant psychological, social and financial impact.
*One in seven couples (15%) has fertility problems.
*Male factors are responsible in 30%, female factors in 40% and the rest 30% are associated with combined male and female factors, and unexplained infertility.
*The prevalence of infertility is likely to increase
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1. A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner. (The National Institute for Health and Care Excellence, UK, 2013).
2. Infertility is an extremely common medical problem with significant psychological, social and financial impact.
3. One in seven couples (15%) have fertility problems.
4. Male factors are responsible in 30%, female factors in 45%, and the rest 25% are associated with unexplained infertility and combined male and female factors.
5. The prevalence of infertility is likely to increase due to delayed childbearing, and increasing obesity and pelvic infection.
6. Women over 35 years of age have increased risks of early and late pregnancy, and neonatal (newborn related) complications.
7. The optimal age for childbearing, for the health of the mother and baby, is between 20-35 years (preferably 20-30 years).
8. Biologically, the only aim of life of all living beings is to pass the genes to the next generation.
9. Simple measures like using condom and prompt treatment of pelvic infection would have a significant impact in reducing the incidence of tubal damage and pelvic adhesions, and consequent infertility and pelvic pain.
10. Women should be particularly careful while having abortion, and should ensure that it is done in an appropriate environment.
11. Pelvic infection may result in chronic pelvic pain due to adhesions that increases the risk of having a hysterectomy (removal of the womb) by 10-fold.
12. Of 100 couples trying to conceive naturally
► 85 would conceive within 12 months
► 95 would conceive within two years
13. The highest rate of natural conception (20%, 1 in 5) is found in the first month since the couple commenced to try for pregnancy. The rate falls to about 12% (1 in 8, approx.) per month between 2nd-6th months, about 8% (1 in 12, approx.) per month between 7th-12th months and about 6% (1 in 17, approx.) per month between 13th-24th months.
14. Natural conception rate in the female gradually declines from the age of 30 years and the decline is more marked after 34.
15. The prevalence of infertility is directly proportional to the woman’s age.
16. The risk of being childless would be about 60% if the woman starts to try for pregnancy after the age of 39 years.
17. The success rates of all treatment for infertility are inversely proportional to the woman’s age.
18. The chance of having a baby following IVF (test tube baby) halves from 20.3% per treatment for women aged 35-39 years (about 5 IVF treatment would be required to achieve a pregnancy) to 10% per treatment for women aged 40-42 years (about 10 IVF treatment would be required to achieve a pregnancy).
19. It would be prudent to commence investigations and treatment of women with infertility close to 30 years or earlier, if possible, rather than 35 years as the natural conception rate and success rates of any treatment would be substantially lower at 35 years and beyond.
20. People should be aware of the relationship between advanced female age and infertility.
21. The couple with fertility problem should be investigated and treated as early as possible to maximise their chances.
22. “The Five Pillars of Natural Conception” include 1. Ovulation, 2. Normal Fallopian tubes (reproductive channels), 3. Functionally normal uterus and endometrium (womb-lining), 4. Production of good quality sperm in adequate numbers and 5. Regular unprotected sexual intercourse without any sexual dysfunction.
23. The causes of Infertility (Seven colours) include 1. Male problems (30%) 2. Anovulation (no egg is produced, 25%), 2. Unexplained infertility (when no cause could be found, 25%), 4. Tubal problems (20%), 5. Endometriosis, 6. Sexual dysfunction and 7. Cervical mucus hostility.
24. Causes of male infertility include abnormal semen test, impotence, ejaculatory failure etc.
25. In the majority (66%) of men with abnormal semen test, however, no cause is found.
26. Oligozoospermia (low sperm count) and azoospermia (no sperm in the semen) are associated with abnormal Karyotype (chromosomal composition) and Yq (Y chromosome) microdeletions in substantial number of cases.
27. Sperm concentration > 15 million/ml is normal as per the latest WHO criteria (2010).
28. The commonest (85%) cause of anovulation is polycystic ovarian syndrome (PCOS).
29. PCOS is associated with obesity (40%, 2 in 5), no periods (20%, 1 in 5) or infrequent periods (50%, 1 in 2), no ovulation, infertility, excessive facial and body hair growth, acanthosis nigricans (grey-brown velvety, sometimes verrucous, discolouration of the skin in the axilla, groin, neck and under the breasts, in 5-50%) etc.
30. PCOS is also associated with increased risks of miscarriage, diabetes in pregnancy, non-insulin dependent diabetes, high blood pressure, heart attacks, cancer of the womb and possibly breast cancer at a relatively younger age.
31. The commonest cause of tubal factor infertility is pelvic infection.
32. There is about 10% (1 in 10) chance of contracting pelvic infection during termination of pregnancy (abortion).
33. Symptoms of endometriosis include pain just before and during periods (progressive dysmenorrhoea), painful sexual intercourse (dyspareunia) and pelvic pain, infertility etc (Triad of endometriosis).
34. Endometriosis is found in 15-25% (1 in 4-7) of the infertile women.
35. The incidence of infertility in women with endometriosis is 20-65% (2 in 3-10).
36. Mere presence of uterine fibroid is not a cause of infertility.
37. Removal of uterine fibroid (myomectomy) does not necessarily improve fertility except in selective cases.
38. It is possible to have a biological child even in the absence of the womb through IVF (test-tube baby) and surrogacy.
39. Drinking alcohol could be harmful to the developing baby.
40. Smoking is likely to reduce fertility in the female.
41. Increased body weight (in both female and male) is associated with reduced fertility. In the female, it is also associated with an increased risk of miscarriage.
42. Women should avoid taking vitamin A and D when they are trying for pregnancy and in the first three months of pregnancy as these might have adverse effects on the baby. Check that multivitamins and “Health” drinks do not contain vitamin A and D.
43. The effectiveness of complementary (non-Allopathic) therapies for fertility problems is questionable.
44. A number of prescriptions, over-the-counter and recreational drugs interfere with male and female fertility.
45. All women should take 0.4 mg folic acid per day while trying for pregnancy and continue up to 12 weeks’ pregnancy.
46. All women who are trying for pregnancy should have Rubella IgG (blood test) checked.
47. Women who are trying for baby should be offered Chicken pox susceptibility screening (Varicella Zoster IgG, a blood test) if they are not sure whether they had Chicken pox.
48. To avoid delay in fertility treatment the women should be up-to-date with cervical (Pap) smears.
49. All infertile couples should be appropriately counselled in relation to the causes, investigations, and the nature, success rates, side effects and costs of potential treatment options.
50. The infertile couple should consult an Infertility Specialist at the appropriate time depending on the age of the woman, how long they have been trying for and whether any reproductive pathology is present or not.
51. The usual initial investigations include BMI, blood tests, USG, HSG/laparoscopy, swabs, husband’s semen analysis etc.
52. The initial investigations check for ovulation, tubal patency and husband’s semen quality.
53. The type of hormone tests in the female depends on the nature of her menstrual periods.
54. Transvaginal ultrasound scan (TVS) or internal scan is better than transabdominal ultrasound scan. TVS should be the default method of gynaecological ultrasonography unless there is a large abdominal mass.
55. Laparoscopy & dye test is superior to HSG as a test for tubal patency and detection of pelvic diseases.
56. Hysteroscopy should not be performed as a routine as part of the initial investigations unless it is clinically indicated.
57. Only one semen analysis from the husband/male partner is required initially (repeated in 3 months only if the first test is abnormal).
58. In developing countries like India women should be given adequate courses of Tetanus vaccination.
59. Women who are susceptible to rubella should be offered rubella vaccination and advised not to become pregnant for at least 1 month following vaccination.
60. Women who are susceptible to Chicken pox should be offered Chicken pox vaccination and advised not to become pregnant for at least 3 months following vaccination.
61. There is no place for routine multivitamins, progesterone or any other supplementation.
62. Offering treatment without proper investigations and diagnosis is not a good practice.
63. Treatment for infertility is less effective if the female partner’s BMI is more than 29. Reduction in the BMI should be advised first rather than other treatment.
64. In women with PCOS and a BMI of >25, losing weight to achieve a BMI of <25 by exercise and dieting is the cornerstone of management.
65. Ovulation induction alone should not be used in presence of other factors associated with infertility. It is inappropriate to prescribe ovulation inducing drugs such as Clomifene to any woman whoever comes with infertility as “fertility drug” without investigating the possible cause of infertility.
66. Misuse of ovulation inducing agents such as Clomifene (and others) indiscriminately in absence of anovulation or prior to proper investigations being done is widespread practice.
67. Ovulation induction requires ultrasound monitoring (folliculometry) by a trained Infertility Specialist to have a better success rate and to reduce serious complications.
68. Use of ovulation inducing agents beyond 12 months has been linked with an increased risk of ovarian cancer, and is not recommended.
69. Women having ovulation induction should inform their Doctor immediately if they develop significant tummy pain/swelling and/or breathing difficulty.
70. Tubal surgery is a cost effective alternative to IVF.
71. IUI is a cost effective alternative to IVF.
72. In women with endometriosis, laparoscopic surgery is the best option to improve the chance of having a baby.
73. In women with endometriosis, medical treatment is not useful to improve the chance of having a baby.
74. The usual treatment options for male problems are two – IUI and IVF.
75. The role of hormones in male infertility is very limited and is indicated in some specific cases only. The use of Clomifene, vitamins and anti-oxidants is not recommended.
76. Over three million IVF babies were born around the world between 1978 and 2006.
77. The oldest mothers, who gave birth to their babies in 2008 at the age of 70 years following IVF, are both Indians.
78. IVF pregnancies are at an increased risk of perinatal mortality and other adverse perinatal outcomes such as preterm delivery (delivery before 37 weeks), low birth weight (<2500 g), admission to neonatal intensive care unit and congenital anomalies.
79. IVF pregnancies have higher rates of adverse maternal outcomes such as Caesarean section delivery, pregnancy-induced hypertension (high blood pressure in pregnancy), pre-eclampsia (high blood pressure and protein in the urine in pregnancy) and gestational diabetes (diabetes in pregnancy).
80. Chromosomal defects causing male infertility such as Yq deletions (affecting the long arm of the Y chromosome) could be passed to the male offspring through ICSI.
81. Treatment for infertility is not covered by the majority of medical insurance companies.
82. For the Indian couples, a helpful tip is to save about Rs 7000.00 per month when the couple starts to try for a baby. If they do not have a baby by 2 years of trying, they would have Rs 168000.00+ to spend on treatment, and could afford 2 treatment of Test-tube baby (IVF) if that is required. If pregnancy occurs naturally within 2 years, they could use the money saved till then for the care in pregnancy, delivery and for the baby.
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© Dr Sudipta Paul, themedideas.com, 2013