/ العقم عند النساء Infertility

Infertility
Infertility primarily refers to the biological inability of a man or a woman to contribute to conception. Infertility may
also refer to the state of a woman who is unable to carry a pregnancy to full term. There are many biological causes of infertility, some which may be bypassed with medical intervention. [1]
Women who are fertile experience a natural period of fertility before and during ovulation, and they are naturally infertile during the rest of the menstrual cycle. Fertility awareness methods are used to discern when these changes occur by tracking changes in cervical mucus or basal body temperature.
Definition
There are strict definitions of infertility used by many doctors. However, there are also similar terms, e.g. subfertility for a more benign condition and fecundity for the natural improbability to conceive. Infertility in a couple can be due to either the woman or the man, not necessarily both.
Infertility
Reproductive endocrinologists, the doctors specializing in infertility, consider a couple to be infertile if:
• the couple has not conceived after 12 months of contraceptive-free intercourse if the female is under the age of 34
• the couple has not conceived after 6 months of contraceptive-free intercourse if the female is over the age of 35 (declining egg quality of females over the age of 35 account for the age-based discrepancy as when to seek medical intervention)
• the female is incapable of carrying a pregnancy to term.
Subfertility
A couple that has tried unsuccessfully to have a child for a year or more is said to be subfertile meaning less fertile than a typical couple. The couple's fecundability rate is approximately 3-5%. Many of its causes are the same as those of infertility. Such causes could be endometriosis, or polycystic ovarian syndrome.
Primary vs. secondary infertility
Couples with primary infertility have never been able to conceive,[2] while, on the other hand, secondary infertility is difficulty conceiving after already having conceived and carried a normal pregnancy. Technically, secondary infertility is not present if there has been a change of partners.
Some women are infertile because their ovaries do not mature and release eggs. In this case synthetic FSH by injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate follicles to mature in the ovaries.
Prevalence
• Generally, worldwide it is estimated that one in seven couples have problems conceiving, with the incidence similar in most countries independent of the level of the country's development.
• Fertility problems affect one in seven couples in the UK. Most couples (about 84 out of every 100) who have regular sexual intercourse (that is, every 2 to 3 days) and who do not use contraception will get pregnant within a year. About 92 out of 100 couples who are trying to get pregnant do so within 2 years. [3]
• Women become less fertile as they get older. For women aged 35, about 94 out of every 100 who have regular unprotected sexual intercourse will get pregnant after 3 years of trying. For women aged 38, however, only 77 out of every 100 will do so. The effect of age upon men’s fertility is less clear. [3]
• In people going forward for IVF in the UK, roughly half of fertility problems with a diagnosed cause are due to problems with the man, and about half due to problems with the woman. However, about one in five cases of infertility have no clear diagnosed cause [4]
• In Britain, male factor infertility accounts for 25% of infertile couples, whilst 25% remain unexplained. 50% are female causes with 25% being due to anovulation and 25% tubal problems/other [5]
• In Sweden, approximately 10% of couples are infertile.[6] In approximately one third of these cases the man is the factor, in one third the woman is the factor and in the remaining third the infertility is a product of factors on both parts.
Causes
Virus
a virus called Adeno-associated virus might have a role in male infertility
Causes in either sex
For a woman to conceive, certain things have to happen: intercourse must take place around the time when an egg is released from her ovary; the systems that produce eggs and sperm have to be working at optimum levels; and her hormones must be balanced.[9]
There are several possible reasons why it may not be happening naturally. In a third of cases, it can be because of male problems such as low sperm count.
Problems affecting women include endometriosis or damage to the fallopian tubes (which may have been caused by infections such as chlamydia).
Other factors that can affect a woman's chances of conceiving include being over- or underweight or her age - female fertility declines sharply after the age of 35. Sometimes it can be a combination of factors, and sometimes a clear cause is never established.
Factors that can cause male as well as female infertility are:
• Genetic Factors
o A Robertsonian translocation in either partner may cause recurrent spontaneous abortions or complete infertility.
• General factors
o Diabetes mellitus, thyroid disorders, adrenal disease
• Hypothalamic-pituitary factors
o Kallmann syndrome
o Hyperprolactinemia
o Hypopituitarism
• Environmental Factors
o Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts, and pesticides.
What causes infertility in women?
Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.
Less common causes of fertility problems in women include:
• blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy
• physical problems with the uterus
• uterine fibroids
What things increase a woman's risk of infertility?
Many things can affect a woman's ability to have a baby. These include:

• age
• stress
• poor diet
• athletic training
• being overweight or underweight
• tobacco smoking
• alcohol

• sexually transmitted diseases (STDs)
• health problems that cause hormonal changes
How does age affect a woman's ability to have children?
More and more women are waiting until their 30s and 40s to have children. Actually, about 20 percent of women in the United States now have their first child after age 35. So age is an increasingly common cause of fertility problems. About one third of couples in which the woman is over 35 have fertility problems.
Aging decreases a woman's chances of having a baby in the following ways:
• The ability of a woman's ovaries to release eggs ready for fertilization declines with age.
• The health of a woman's eggs declines with age.
• As a woman ages she is more likely to have health problems that can interfere with fertility.
• As a women ages, her risk of having a miscarriage increases.
Combined infertility
In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility arises from the combination of these conditions. In other cases, the cause is suspected to be immunological or genetic; it may be that each partner is independently fertile but the couple cannot conceive together without assistance.
Unexplained infertility
In about 15% of cases the infertility investigation will show no abnormalities. In these cases abnormalities are likely to be present but not detected by current methods. Possible problems could be that the egg is not released at the optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization.
Assessment
If both partners are both young and healthy, and have been trying for a baby for 12 months to two years without success, a visit to the family doctor could help to highlight potential medical problems earlier rather than later. He or she may also be able to suggest lifestyle changes you can make to increase your chances of conceiving. [12]
Women over the age of 35 should see their family doctor after six months as fertility tests can take some time to complete, and your age may affect the treatment options that are open in that case.
A family doctor will take a medical history and give you a physical examination. They can also carry out some basic tests on both partners to see if there is an identifiable reason for not having achieved a pregnancy yet. If necessary, they can refer you to a fertility clinic or your local hospital for more specialist tests. The results of these tests will help determine which is the best fertility treatment for you and your partner.
Treatment
Treatment methods for infertility may be grouped as medical or complementary and alternative treatments. Some methods may be used in concert with other methods.
Take-home baby assessment
Prior to undergoing expensive fertility procedures, many women and couples will turn to online sources to determine their estimate chances of success. A take-home baby assessment can provide a best guess estimate compared with on women who have succeeded with in vitro fertilization, based on variables such as maternal age, duration of infertility and number of prior pregnancies.[13]

Medical treatments
Medical treatment of infertility generally involves the use of medication, surgery, or both. If the sperm are of good quality, and the mechanics of the woman’s reproductive structures are good (patent fallopian tubes, no adhesions or scarring) physicians may start by prescribing a course of ovarian stimulating medication. The physician may also suggest intrauterine insemination (IUI), in which the doctor introduces sperm into the uterus during ovulation, via a catheter. In these methods, fertilization occurs inside the body.
If conservative medical treatments fail to achieve a full term pregnancy, the physician may suggest the patient undergo in vitro fertilization (IVF). IVF and related techniques (ICSI, ZIFT, GIFT) are called assisted reproductive technology (ART) techniques.
ART techniques generally start with stimulating the ovaries to increase egg production. After stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman’s reproductive tract, in a procedure called embryo transfer.
Other medical techniques are e.g. tuboplasty, assisted hatching and PGD.
Intrauterine insemination (IUI) is another type of treatment for infertility. IUI is known by most people as artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.
IUI is often used to treat:
• mild male factor infertility
• women who have problems with their cervical mucus
• couples with unexplained infertility
What medicines are used to treat infertility in women?
Some common medicines used to treat infertility in women include:
• Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have Polycystic Ovarian Syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
• Human menopausal gonadotropin or hMG (Repronex, Pergonal): This medicine is often used for women who don't ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
• Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
• Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
• Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or Polycystic Ovarian Syndrome (PCOS). This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
• Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production.
Psychological impact
Infertility may have profound psychological effects. Partners may become more anxious to conceive, ironically increasing sexual dysfunction.[23] Marital discord often develops in infertile couples, especially when they are under pressure to make medical decisions. Women trying to conceive often have clinical depression rates similar to women who have heart disease or cancer. Even couples undertaking IVF face considerable stress.
Emotional stress and marital difficulties are greater in couples where the infertility lies with the man.
Social impact
In many cultures, inability to conceive bears a stigma. In closed social groups, a degree of rejection (or a sense of being rejected by the couple) may cause considerable anxiety and disappointment. Some respond by actively avoiding the issue altogether; middle-class men are the most likely to respond in this way

Dr Rachid ALAN Adnan

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