INFERTILITY TYPES
Infertility types are classified according to the presence or absence of the elements listed below.
Infertility can be caused by a variety of factors in the female reproductive system, including:
Tubal Factor: The woman’s Fallopian tubes are either blocked or adhered to the tissue around it. This makes it impossible for the sperm to fertilise the egg or for the fertilised egg to migrate to the uterus. Pregnancy rarely occurs, and if it does, chances of having an ectopic pregnancy are high.
Endometriosis: A condition where the tissue that should be found only in the uterus is found in other areas such as the abdomen, the ovaries’ surface, and sometimes even adhered to the intestines. By causing severe adhesions in the Fallopian tubes, the ovaries or the uterus, or in some cases, immunological problems.
Male infertility accounts for 15% of infertility cases. Also, male infertility may contribute to 30-40% of all infertility instances. Because of this, couples who cannot get pregnant should apply to the clinic together. Couples who cannot get pregnant after one year of unprotected, timed intercourse are regarded as infertile. When one partner is over 35, they can consider being evaluated for infertility sooner than one year.
Male infertility may be due to the following reasons:
When evaluating for infertility, semen analysis is the first test that must be done. In order to standardise the results, 2-4 days of sexual abstinence is recommended.
If the results of the semen analysis are sub-normal, the test must be repeated one month later. If the second test also shows subnormal results, a physical exam and blood tests will be required.
The doctor will examine the penis, opening of the urethra, testes, epididymis, and prostate. The patient’s body type, hair growth, genitalia will be discussed in detail. Sexual functions, erection – ejaculation and other habits that might result in infertility will also be evaluated.
The doctor can discern the congenital absence of vas deference (CAVD) during the physical exam. Vas deference is the sperm carrying tube that moves sperm from the testes to the urethra. The possibility of a genetic disease called Cystic Fibrosis must be investigated in patients when CAVD is observed.
Kleinfelter’s syndrome is a genetic condition whose genetic composition is 47, XXY, characterised by small tests. These patients do not have sperm in their ejaculate, but tissue biopsied from the testes can contain sperm. If testes are smaller than normal, then genetic diseases may be the cause. When there are abnormalities in secondary sexual characteristics such as body hair, sexual dysfunction, hormonal problems such as hypogonadotropic hypogonadism should be investigated.
Cryptorchidism (undescended testes): testes descend into the scrotum at birth or one year after the birth at the latest. The condition where one or both testes have not fallen into the scrotum is called Cryptorchidism. Testes that remain in the abdomen are exposed to prolonged heat, which breaks down sperm production. Bilateral Cryptorchidism only causes infertility.
Varicocoele: Caused by incompetent valves in the blood vessels around the testes and like varicose veins in the legs, the veins in the testes expand. Sperm production is negatively affected by the reduced blood circulation and increased heat in the testes. Some people may need surgery to correct the condition.
Hormone tests are required if semen analysis is subnormal or if the patient has other endocrinological disorders such as diabetes. FSH and Testosterone are the most commonly tested hormones. More detailed tests will be done if necessary. FSH may appear to be normal in some patients with abnormal spermatogenesis. But an increased level of FSH in the serum is a sign of abnormal spermatogenesis. Some patients may have their urine checked for the presence of sperm right after ejaculation. Ultrasonography, the anti-sperm antibody test, cervical mucous interaction test is some of the more detailed tests that may be done on semen and sperm. When looking at semen under a microscope, leukocytes and immature germ cells are difficult to tell apart.
These cells are labelled round cells. Many laboratories evaluate all the round cells like leukocytes and report them as such. In such cases, doctors will assess the genital tract for infection. Immunological tests also need to determine whether the round cells observed are immature germ cells or leukocytes.
Azoospermia:
Azoospermia is the condition describing a complete lack of sperm cells in the ejaculate. There is a 1% incidence in all men and 10-15% incidence in infertile men. Azoospermia is divided into three categories: pre-testicular, testicular and post testicular.
Pre testicular azoospermia usually has endocrinological causes which affect spermatogenesis. Hypogonadotropic hypogonadism can cause Azoospermia but can be treated with hormone replacement therapy.
Primary testicular failure applies to problems relating to the testes specifically.
Post testicular problems usually relate to ejaculation dysfunction or obstruction in the ducts. Incidences of this nature are found in 40% of the cases.
Pre and post testicular abnormalities are treatable. Testicular failure is irreversible. Varicocoele is excluded from this group, however.
Another way of categorising Azoospermia is by dividing up groups based on whether or not the ducts are blocked
TESA: Testicular Sperm Aspiration is a procedure used to retrieve sperm for IVF/ICSI purposes. A needle is inserted into the testicle, and tissue/sperm are aspirated from a man with obstructive Azoospermia (s/p vasectomy).
TESE: Testicular Sperm Extraction is a surgical procedure that involves removing a small portion of testicular tissue and extracting any viable sperm cells for use in subsequent procedures, the most common of which is intracytoplasmic sperm injection (ICSI) as part of in vitro fertilisation (IVF).
PESA: Percutaneous Epididymal Sperm Aspiration is a surgical method that extracts sperm from the epididymis of men with Azoospermia or a low sperm count.
MESA: Microsurgical Epididymal Sperm Aspiration is a sperm collection procedure that includes opening the tiny tubes within the epididymis with a surgical microscope to look for sperm. This method is effective in situations where sperm are produced in sufficient numbers but cannot move from the testicle to the ejaculate.
Normal semen analysis values
Varicocele and Infertility:
The veins surrounding the testes expand and result in an increased temperature which is believed to affect sperm production negatively. Surgery may be required to correct the condition. Men who have varicocele are not infertile but 1/3 of infertile men have varicocele. Usually, varicocele is seen in 15% of the general population, whereas 40% of infertile men have varicocele. The doctor will examine the patient both in an upright position and while the patient is lying down. Palpation done when the patient is standing will feel like a sack of worms, but this feeling will decrease or disappear when lying down. Varicocele can only be treated surgically.
Surgical Techniques:
There are a variety of procedures for varicocele treatment. Retroperitoneal, inguinal (an incision is made in the groin area), microsurgical, making sub inguinal cut near the scrotum, laparoscopic ligation or blocking the veins with radiation (embolisation) via radiologic occlusion of the blood vessel (embolisation) are some of the methods. The ultimate goal is to perform the treatment that best fits varicocele type and has the slightest chance of recurrence. Ligating veins near the scrotum with the aid of a microscope (microsurgical varicocelectomy) appears to be the most successful treatment. This method also has less post-operative pain.
Varicocoele and Azoospermia:
Some studies suggest that azoospermic men with clinical type varicocele might benefit from varicocele surgery. According to research results, 50% of patients show spermatogenesis resumption, and 20% report spontaneous pregnancy. A testicular biopsy done before or during surgery will give the doctors an idea of the procedure’s success. Men who have immature sperm cells may start sperm production, but previously, patients who had no spermatogenesis do not start producing sperm after varicocele treatment. Consequently, azoospermia patients with varicocele who have begun infertility treatment, and have sperm cells found in the testicular biopsy, should be treated for varicocele even if they get pregnant through IVF.