1. What is infertility?
Infertility, whether male or female, can be defined as 'the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse'.

2. What is the incidence of infertility worldwide?
The World Health Organization (WHO) estimates that approximately 8-10% of couples experience some form of infertility problems. On a worldwide scale, this means that 50-80 million people suffer from infertility. However, the incidence of infertility may vary from region to region.

3. Is infertility exclusively a female problem?
No. The incidence of infertility in men and women is almost identical. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 30-40% of the cases. Problems common to both partners are diagnosed in 10-15% of infertile couples. After thorough medical investigations, the causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%). This is called unexplained infertility.

4. What are the most common causes of infertility?
The most common causes of female infertility are ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes. Less frequent causes include, for example, endometriosis and hyperprolactinemia, thyroid gland related problems.

In developing countries like India , infections of the womb such as gonorrhoea, chlamydia and tuberculosis significantly, contribute to infertility.

Causes of male infertility can be divided into three main categories:
Sperm production disorders affecting the quality and/or the quantity of sperm;
Anatomical obstructions;
Other factors such immunological disorders.
Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.

5. PCOS
Polycystic ovary syndrome or shortly PCOS, is an ovulation disorder which affects 4-6% of all women. Several factors contribute to the disease. At this moment researchers think that the cause of the disease is genetic.

The major features of this syndrome are irregular or no menstruation, Hirsutism and acne due to high levels of male hormones, obesity (40-50%), high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound.

Women with PCOS usually present at fertility clinics for counseling. To increase fecundity the treatment possibilities are mostly focused on regulation of the menstrual cycle. For this, several drugs are used (Clomiphene Citrate, Bromocriptine, Gonadotrophins) and weight loss is strongly advised.

In many cases the cycle will be ovulatory and regulated by these treatments. Newer oral anti diabetic drugs such as Metformin are being more frequently used to treat PCOS, with very good outcome. Alternately, one can Electrocoagulate the ovarian surface using a laparoscope, especially in those women with highly elevated levels of LH hormone.

If these women fail to become pregnant, they may be subjected to Gonadotropin injections, to stimulate ovulation. This may be combined with an Intrauterine insemination procedure (IUI) . Resistant cases may be treated by performing ART procedures such as IVF or ICSI.

6. What are the causes of damaged fallopian tubes?
In the beginning In Vitro Fertilisation (IVF) was developed for patients facing infertility due to damaged fallopian tubes. Later on the indications to perform IVF was broadened with for example unexplained infertility and male infertility.

Nowadays tubal damage still accounts for a large number of all IVF treatments. The main cause is abdominal infection. In developing countries such as India , the biggest culprit is Genital Tuberculosis, in which the womb of the patient is infected by the tuberculosis germ. For the tubes this is mostly due to sexually transmitted diseases (for example Chlamydia or Gonorrhea) but complicated appendicitis or Pelvic Inflammatory Disease (PID) can also cause damaged tubes.

Other causes are abdominal operations (gynecological operations, cesarean section, sterilization or other) and internal diseases like Crohn's disease. Affected patients can have fertility problems and are at risk for having a pregnancy located in the tubes (ectopic or tubal pregnancy).

7. What does Laparoscopy involve?
The laparoscope allows visual inspection of the pelvic organs through a very tiny incision. Abnormalities that lead to infertility can be treated surgically through additional small incisions to remove scar tissue, laser, coagulate, or excise endometriosis, and repair tubes blocked at the fimbrial end. Many types of female reproductive surgery can be performed Laparoscopically, in the outpatient setting.

8. What is Endometriosis?
Histologically identical to endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well.

Endometriosis is one of the most common problems that gynecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories, we still do not have a clear understanding of the cause or of its relationship to infertility.

Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow. Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all. It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow.

By the same token, endometriosis may not be the cause of infertility, but the result of it. Further technological developments may be necessary in order for us to fully understand this problem.

Endometriosis is generally diagnosed at the time of Laparoscopy. Nowadays one can treat it by performing advanced Laparoscpic surgery using Lasers, electric current and scissors. In fact, with the advent of operative Laparoscopy, very few patients need to undergo the traditional method of opening the abdomen. Endometriosis can also be controlled (if not totally cured) by using various drugs such as Danazol, GnRh analogues or progesterones. The above mentioned treatments help many patients to become pregnant. The remaining patients may have to resort to IVF or ICSI. In our unit, we have found that ICSI gives better results than IVF.

9. Infertility after 40
It is generally accepted that fertility decreases with age. A woman in her twenties and thirties has a 20-25% chance of a naturally occurring pregnancy, but for a woman in her early forties this possibility decreases to 5%. In IVF therapy women over the age of 35 are seen twice as frequently compared with younger women. In fact, age is the most important factor in IVF success rates. Research has recently revealed that fertility decreases with age because of the declining quality of the woman's eggs.

Although it is not possible to improve the quality of the eggs, women in their forties (and fifties and sixties) can become pregnant using techniques which can improve IVF outcome. For example, increasing the doses of drugs used to induce ovulation will increase the number of eggs that develop in a given month, thereby increasing the chance that at least one egg will be fertilized and develop into a viable pregnancy.

The most consistently successful method to increase the chance of pregnancy in women with age-related infertility is egg donation from a relative or anonymous donor. To predict a woman's fertility two blood tests - FSH (Follicle Stimulating Hormone) and E-2 (Oestradiol) - can be carried out on the third day of the menstrual cycle. These assess a woman's "ovarian reserve", in other words whether she is still producing eggs and whether these are able to produce a pregnancy.

The higher the FSH, the less capable a woman's eggs are of producing a pregnancy. As a woman ages, her FSH levels increase, but younger women with poor quality eggs can also have high FSH levels.

Male Infertility
Production of Sperms | Transport of Sperms

Retrograde Ejaculation
This is a condition where the semen is released into the bladder during ejaculation. You could have this condition since birth or you could have developed it due to diabetes, multiple sclerosis, prostrate surgery or some medications.

Duct system obstruction
This condition accounts for 6% of the male fertility problems. There may be some obstruction in the passage of the sperm en route from the testis to the penis. This maybe in the vas, the epididymis duct. If the blockage is on both sides there will be no sperm.

Hypospadias
This is a condition one is born with, the opening of the urethra is on the underside of the penis instead and thus the semen does not reach the penis.

Female Infertility
Endometriosis | Ovulatory Disorders

So, your medical diagnosis says that you are infertile. We understand it is devastating. But it is not the end of the road.

Most likely, your cause is due to endometriosis , ovulatory disorders , fallopian tube damage, cervical factor or even age. Sometimes, infertility is a result of unexplained factors. It is important to know and understand your fertilization cycle and its implications on conception, so that you feel secure and at ease at the time of treatment.

Fallopian Tube Damage:
The damage to the tubes can occur due to infections, endometriosis or adhesions. These block the fallopian tubes thereby inhibiting the egg to travel towards the sperm and vice versa.

Cervical Factors:
The cervix produces a substance (mucous) that becomes thin at the time of ovulation, so that the sperm can easily pass through to meet the egg. Abnormality in the cervix results in poor quality of the mucous, usually a poor viscous mass that prevents the sperm journey through the cervix.

WHEN WILL FERTILIZATION TAKE PLACE?
The menstrual cycle of a woman represents the fertilization phenomenon. The various stages that your body goes through every month, are the essential processes that determine fertility or infertility. Any flaw or malfunction of the organs can disrupt the cycle and can result in infertility.

You have a pair of ovaries, one of which produces an egg every twenty-eight days to thirty-six days. Each of these twenty-eight days represents the menstrual cycle. The female reproductive system must undergo the following processes for fertilization to take place.

:: The ovary houses many follicles, each of which produces a single egg
:: The follicles must mature satisfactorily under the influence of the FSH (Follicle Stimulating Hormone) and LH (Luteinzing     Hormone) produced by the pituitary gland.
:: While maturing, the follicles must produce another hormone called estrogen , which prepares the uterus lining (womb) for     receiving the fertilized egg. (implantation)
:: The most mature and dominant follicle should release an egg in the middle of the cycle. In other words, you must ovulate     without any disorders.
:: The mature egg must travel through the fallopian tube where it might get fertilized with a sperm.
:: The sperm must pass through the cervical mucus to fertilize the egg
:: The fertilized egg must get implanted into the uterus.

Female Infertility
Endometriosis | Ovulatory Disorders
What is Endometriosis?
Endometriosis is a curable abnormality of the endometrial tissue that lines your uterus. Endometriosis can be treated medically and surgically.

In endometriosis, microscopic bits of the tissue escape the uterus, instead of getting washed out during your menstrual cycle and get deposited onto other organs like the ovaries, inner walls of the uterus, the ligaments that support the uterus and the space between the uterus and the rectum.

The tissue reacts to estrogen and progesterone , to thicken and bleed. The blood does not have any escape and effects the surrounding organs to develop what are referred as cysts, scars, lesions, nodules, growths and adhesions.

You could be diagnosed as having minimal, mild, moderate or severe endometriosis. But, the presence of endometrioisis demands immediate attention and cure or else it can cause infertility.

Female Infertility
Endometriosis | Ovulatory Disorders

These occur when the FSH, LH and estrogen hormones are not produced at the right time, in the right order and in the right amount. An imbalance in any of these prevents the mature egg from being released from the ovary, thereby causing infertility. The three types of ovulation disorders are:

Anovulation
This is a condition when a woman does not ovulate at all.

Luteal Phase defect
is a condition where there is a mature egg, but it does not attach itself to the uterus, thus preventing pregnancy. This is due to a deficiency in the production of a hormone (progesterone which is needed to build the uterine lining for implantation)