INFERTILITY

INTRODUCTION
When talking about infertility in marriage, a common misconception is that infertility is only
a woman problem. Whereas almost 50% of infertile couples have the causes related to the
male partner, either alone or in addition to a female factor.
Worldwide 8 – 12% of couples experience fertility problems. Between 45 and 50% of cases
are thought to stem from factors affect man.
Infertility means not being able to become pregnant within certain parameters. Infertility is a
common problem of about 10% of women aged 15 – 44 years. About 33% of infertility cases
can be due to the woman’s factors, while 33% can be due to man’s factors and approximately
33% by both sexes or due to unknown problems.
When a couple has fertility concern, it is recommended that both the male and female have
full work-ups in order to determine the most effective treatment approach. It is a common
issue with more than 100,000 cases per year in Nigeria.

Definition: Infertility can be defined as the inability to conceive or achieve pregnancy within
12 months of regular and unprotected sexual intercourse or inability to carry a pregnancy to
term.

TYPES
Infertility can be classified into primary or secondary.
- Primary infertility: This is when a couple has not conceived after trying for at least 12
months without using any contraceptive method.
- Secondary infertility: This happens is when couples have previously conceived but are no
longer able to.
CAUSES IN FEMALES
There are several factors that can impair conception in females.
1) AGE: Ability to conceive falls with the advancement in age. Before twentieth century
women were conceiving in their teens and twenties when age related abnormalities
with the ovaries (eggs) were not common or evident. But nowadays in these modern
days, women are delaying child birth until their thirties and forties which has led to
diagnosis of adverse effect of advanced maternal age on egg functions. In fact female
egg related fertility is the most common cause of infertility today.
2) OVULATION DISORDERS: For a woman to conceive naturally a normal and
matured egg is essential. To detect an ovulation a menstrual calendar can be kept or
Ovulation predictor kit can be used.
Ovulation disorders appear to be the most common cause of infertility in women. Ovulation
is the monthly release of an egg. The eggs may never be released or they may only be
released in some cycles. Ovulation disorders can be due to:
a) Premature ovarian failure: The ovaries stop working before the age of 40 years.
b) Polycystic ovary syndrome (PCOS): The ovaries function abnormally and ovulation
may not occur.

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c) Hyperprolactinemia: If prolactin levels are high, and the woman is not pregnant or
breastfeeding, it may affect ovulation and fertility.
d) Hypogonadotropic Hypogonadism: this can cause anovula menses. It is responsible for
about 15 – 20% of cases.

e) Poor egg quality: Eggs that are damaged or develop genetic abnormalities cannot sustain
a pregnancy. The older a woman is, the higher the risk.
f) Thyroid problems: An overactive or underactive thyroid gland can lead to a hormonal
imbalance which may affect ovulation.
g) Chronic conditions: These include AIDS or cancer.
3) INTRAUTERINE AND TUBAL ABNORMALITIES: Abnormality to the shape of
the uterus can impact fertility. Problems in the uterus or fallopian tubes can prevent
migration of eggs from the ovary to the uterus. If the egg does not travel it can be
harder to conceive naturally.
Causes responsible for these include:
a) Surgery: Pelvic surgery can sometimes cause scarring or damage to the fallopian
tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix.
b) Uterine Fibroid: Fibroids are very common; approximately 40% of women may
have it. There are three types of fibroids:
i) Subserosal fibroids: These are fibroid outside of the uterus. It extends more than 50%
outside of uterus.
ii) Intramural fibroid: In this the majority of the fibroid is within the muscle of the uterus
without any indentation of the uterine cavity.
iii) Sub mucosal fibroid: these projects into uterine cavity. This is the type of fibroid that
reduce pregnancy rate roughly by 50% and its removal will double pregnancy rate.
Sub mucosal fibroid can interfere with implantation or block fallopian tubes, prevent
sperm from fertilizing the egg. Larger ones may make uterine cavity bigger increasing
the distance the sperm has to travel. Often but not always, sub mucosal fibroid can
cause menorrhagia. In some cases simple removal of sub mucosal fibroid saves
infertility.
c) Endometriosis: This is a condition whereby cells very similar to the ones lining
the uterine cavity are found outside the uterine cavity. It is found in approximately
10 -50% of reproductive aged women and can be associated with infertility as
well as pain during intercourse and/ or menstrual periods. Endometriosis causes
infertility by producing inflammation and scaring which can result in not only
pain but also detrimental effect on eggs, sperm or embryo. Endometriosis can only
be confirmed by surgery, usually laparoscopy.
d) Endometrial polyps: These are finger like growths in the uterine cavity arising
from the endometrial lining of the uterus. Polys can decrease infertility by up to
50% according to some studies. Removal by simple hysteroscopy is associated
with doubling of pregnancy rate.
e) Tubal occlusion (blockage): This can occur as a result of STIs e.g. Chlamydia,
gonorrhea, or pelvic inflammatory disease can predispose to a woman to having
tubal blockage. Tubal occlusion is a cause of infertility; an ovulated egg is unable
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 to be fertilized by sperm or to reach the endometrial cavity. If both tubes are
blocked then in vitro fertilization (IVF) is required. If tubes is blocked and filled
with fluid (hydrosalpix) then minimal invasive surgery (Laparoscopy or
hysteroscopy) can be performed to either remove the tubes or separate it from the
uterus prior to any fertility treatment is recommended.
f) Previous sterilization treatment: In some women, who have chosen to have tubal
ligation, the process can be reversed but the chances of becoming fertile again are
very low.

4) MEDICATION, TREATMENTS AND DRUGS: Some drugs can affect fertility in a

woman which include the following
- Non- steroidal anti- inflammatory drugs (NSAIDs): Long tern use of aspirin or
ibuprofen may make it harder to conceive
- Chemotherapy: Some chemotherapy drugs can result in ovarian failure. In some
cases, this may be permanent. Medications, treatments, and some drugs can affect
fertility in a woman.
- Illegal drugs: Some women who use marijuana or cocaine may have fertility
problems.
- Radiation therapy: If this is aimed near the reproductive organs, it can increase the
risk of fertility problems.
- Cholesterol: One study has found that high cholesterol levels may have an impact
on fertility in women.

5) CERVICAL FACTOR: e.g. poor mucus quality, cervical stenosis and sperm
antibodies. Also cervical abnormalities can affect fertility. One of the most common
causes is the prior surgery on the cervix such as a cone surgery, or laser therapy to treat
cervical cancer. Treatment for this includes insemination or IVF.
6) CONGENITAL ABNORMALITY: Birth defect that affect the reproductive tract,
clotting disorder, hormonal imbalance, chromosomal disorder, turner syndrome.

RISK FACTORS (IN FEMALES)

These are factors that increase a woman’s vulnerability to suffer infertility or that makes her
prone to infertility, they include:
Smoking: Smoking significantly increases your risk of infertility in both men and women; it
may undermine the effect of fertility treatment. Smoking during pregnancy increases the
chance of pregnancy loss. Passive smoking has also been linked to lower fertility.
Age: The ability to conceive starts to fall around the age of 32 years.
Alcohol: Any amount of alcohol consumption can affect the chances of conceiving.
Obesity or overweight: This can increase the risk of infertility in women as well as men.
Eating disorders: If an eating disorder leads to serious weight loss, fertility problems may
arise.
Diet: A lack of folic acid, iron, zinc, and vitamin B-12 can affect fertility. Women, who are at
risk, including those on a vegan diet.

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Exercise: Both too much and too little exercise can lead to fertility problems.
Sexually transmitted infections (STIs): Chlamydia can damage the fallopian tubes in a
woman and cause inflammation in a man’s scrotum. Some other STIs may also cause
infertility.
Exposure to some chemicals: Some pesticides, herbicides, metals, such as lead, and solvents
have been linked to fertility problems in both men and women. A mouse study has suggested
that ingredients in some household detergents may reduce fertility.
Mental stress: This may affect female ovulation and male sperm production and can lead to
reduced sexual activity.
Medical conditions: Some medical conditions can affect fertility.
CAUSES IN MEN
Several factors may be attributed to infertility in men some of which may include the
following:
1) SEMEN AND SPERM FACTORS: Semen is the fluid that a man releases during
ejaculation and consists of fluid from the prostate gland, seminal vesicle and spermatozoa.
After ejaculation the seminal fluid helps transport the sperm towards the eggs. Sometimes the
sperm cannot travel effectively to meet the egg; inability of sperm to travel down may be due
to the following problems:
a) Low sperm count: When there is a low number of sperm, a sperm count fewer than 15
million is considered low. Low sperm count account for one third of infertility cases in males.
b) Low sperm mobility (motility): This is when sperm cannot “swim” as well as they should
to reach the egg.
c) Abnormal sperm: The sperm may have an unusual shape, making it harder to move and
fertilize an egg. If the sperm do not have the right shape, or they cannot travel rapidly and
accurately towards the egg, conception may be difficult. Up to 2 percent of men are thought
to have suboptimal sperm. Abnormal semen too may not be able to carry the sperm
effectively. This can result from:
- A medical condition: This could be a testicular infection, cancer, or surgery.
- Overheated testicles: Causes include an undescended testicle, a varicocele, or varicose vein
in the scrotum, the use of saunas or hot tubs, wearing tight clothes, and working in hot
environments.
2) EJACULATION DISORDERS: Occurs in ejaculatory duct blockage, semen may be
ejaculated into the bladder as in retrograde ejaculation (when semen goes through the wrong
way into the bladder).
3) HORMONAL IMBALANCE: Hypogonadism, for example, can lead to a testosterone
deficiency.
4) GENETIC FACTORS: A man is supposed to have an X and Y chromosome, if he has
two X chromosomes and one Y chromosome, as in Klinefelter’s syndrome, the testicles will
develop abnormally and there will be low testosterone and a low sperm count or no sperm
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(oligospermia or azoospermia). Azoospermia occurs in about 1% of all men and 15% of
infertile men.
5) HYPOSPADIAS: In this, the urethral opening is under the penis, instead of its tip. This
abnormality is usually surgically corrected in infancy. If the correction is not done, it may be
harder for the sperm to get to the female’s cervix. Hypospadias affects about 1 in every 500
newborn boys.
6) CYSTIC FIBROSIS: This is a chronic disease that results in the creation of sticky mucus.
This mucus mainly affects the lungs, but males may also have a missing or obstructed vas
deferens. Most men with cystic fibrosis (97-98%) are infertile because of the blockage or
absence of sperm canal known as congenital bilateral absence of the vas deferens (CBAVD).
The sperm never make it into the semen, making it impossible to reach and fertilize an egg
through intercourse.
RISK FACTOR IN MALES
i) Radiation therapy: This can impair sperm production. The severity usually depends on
how near to the testicles the radiation was aimed.
ii) Smoking and excessive alcohol consumption: this may lower male fertility Moderate
alcohol consumption has not been shown to lower fertility in most men but may affect those
who already have lower sperm count.
iii) Age: Male fertility start to decline after 40 years.
iv) Disease condition: Those that are sometimes linked to lower fertility are anemia,
Cushing’s syndrome, diabetes.

v) Medication: Some diseases conditions that are sometimes linked to lower fertility in
males are anemia, Cushing’s syndrome, diabetes, and thyroid disease. Some drugs increase
the risk of fertility problems in men. They include:
a) Sulfasalazine - This anti-inflammatory drug can significantly lower a man’s sperm count.
It is often prescribed for Crohn’s disease or rheumatoid arthritis. Sperm count often returns to
normal after stopping the medication.
b) Anabolic steroids - Popular with bodybuilders and athletes, long-term use can seriously
reduce sperm count and mobility.
c) Acetaminophen - Lab studies have shown that long term use of this drug may affect
fertility in males by lowering testosterone production and may affect pregnancy in females.
Chemotherapy: Some medications increase the risk of fertility problems in men. Some types
may significantly reduce sperm count.
vi) Illegal drugs: Consumption of marijuana and cocaine can lower the sperm count.
vii) Mumps: If this occurs after puberty, inflammation of the testicles may affect sperm
production.
viii) Exposure to chemicals: Pesticides, for example, may increase the risk.
Other risk factors include:
- Smoking substance/ drug abuse

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- Chronic medical condition e.g. liver cirrhosis, diabetes
- Overweight or obesity
- Mental stress - Stress can be a factor, especially if it leads to reduced sexual activity.
Causes involving male and female
- Infrequent sexual intercourse
- Wrong timing of coitus
- Immunological causes e.g. autoimmune disorders such as anti- phospholipids syndrome
(APS).

DIAGNOSTIC INVESTIGATIONS FOR INFERTILITY

a) Medical history and investigation
Couples with infertility problem should ideally be seen together from the outset and full
medical history taken from both partners.
For the Male partner:
Medical Examination and History Taking: The first and foremost test is thorough medical
examination and history taking.
- History taking and physical examination e.g. of previous sexual partners, any ulceration or
urethral discharge to identify STIs.
- General examination to exclude metabolic, endocrine, cardiovascular, respiratory,
gastrointestinal and neurological problems.
- Measurement of height, weight and blood pressure to highlight systemic disease. Gross
overweight is associated or suggestive of spermatogenesis impairment.
- Test to exclude Klinefelter syndrome (males born with low testosterone and reduced muscle
mass, facial hair and body hair, most of them produce little or no sperm) disproportionate
long limbs, length in relation to the trunk length.
- Check for signs of hypoandrogenism (Androgen deficiency characterized by reduced
androgenic activity in the body) e.g. Poor expression of secondary sex characteristics and
gynecomastia (Swelling of male breast tissue due to reduced male hormone or increased
female hormones).
- Examine, inspect and palpate the penis to detect hypospadias, surgical or truncate scars,
induration or plagues due to presence of disease which may cause difficulty in the erection of
penis with consequent hindrances of vagina intercourse. Check for scar from previous
surgery to rule out urethral stricture which may cause ejaculatory blockage. Inspect if the
semen is delivered outside of the vagina.
- Examine the testes for abnormalities e.g.
- Site of testes: This is best determined with the man standing. The testes should both be
palpable suspended low in the scrotum.
- Estimate testicular volume and consistency by gentle pressure. Sperm count less than
normal volume is indicative of damage.
- Examine the scrotum for swelling, check for presence of hydrocele and varicose which may
indicate testicular tumor, check inguinal scars.
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- Semen sample is taken for screening.
- Urine analysis.

b) Laboratory investigations
1) Semen analysis: A sample may be taken to test for sperm concentration, motility,
color, quality, any infections and whether any blood is present. Sperm count can
fluctuate, so several samples may be necessary.
2) Hormone test: This is a blood test to determine the level of testosterone and other
male hormones
3) Genetic test: Genetic test are done to determine whether there is a genetic defect
causing fertility.
4) Chlamydia test (and other STIs): Chlamydia can affect fertility. But antibiotic can
treat it.
c) Testicular biopsy: This is done in selected cases, a testicular biopsy may be
performed to identify abnormalities contributing to infertility and to retrieve sperm to
use with assisted reproductive technique such as IVF.
d) Imagin: In certain situations, imagin studies such as a brain MRI, bone mineral
density scan, Trans rectal or scrotal ultrasound, or a test of the vas deference
(vasograpy) may be performed.
e) Ultrasound: This may reveal issues such as ejaculatory duct obstruction or retrograde
ejaculation.
Other Special Tests: In rare cases there other tests to evaluate the quality of the sperm
may be performed, such as evaluating a semen specimen for DNA abnormalities.
Infertility tests for women
Physical Examination: The woman will undergo a general physical examination, and the
health personnel will ask about her medical history, medications, menstruation cycle, and
sexual habits.
Gynecological examination
The woman will also undergo a gynecologic examination and a number of tests which
includes:
a) Laparoscopy: involves inserting a thin tube with a camera on to investigate and possibly
remove unwanted tissue.
b) Blood test: This can assess hormone levels and whether a woman is ovulating.
c) Hysterosalpingography: A dye is injected into the woman’s uterus and X-rays are taken to
determine if a blockage is present, surgery may be necessary.
d) Laparoscopy: A thin, flexible tube with a camera at the end is inserted into the abdomen
and pelvis, allowing the doctor to view the fallopian tubes, uterus, and ovaries. This can
reveal signs of endometriosis, scarring, blockages, and some irregularities of the uterus and
fallopian tubes.
Other tests include:
i) Ovarian reserve testing, to find out how effective the eggs are after ovulation
ii) Genetic testing, to see if a genetic abnormality is interfering with fertility
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iii) Pelvic ultrasound, to produce an image of the uterus, fallopian tubes, and ovaries
iv) Chlamydia test, which may indicate the need for antibiotic treatment
v) Thyroid function test, as this may affect the hormonal balance
TREATMENT
Treatment will depend on many factors, including the age of the person who wishes to
conceive, how long the infertility has lasted, personal preferences, and their general state of
health.
Frequency of intercourse
The couple may be advised to have sexual intercourse more often around the time of
ovulation as sperm can survive inside the female for up to 5 days, while an egg can be
fertilized for up to 1 day after ovulation.
However, some researchers suggested that the 3 days most likely to offer a fertile window are
the 2 days before ovulation plus the 1 day of ovulation.
Some suggest that the number of times a couple has intercourse should be reduced to increase
sperm supply, but this is unlikely to make a difference.
Fertility treatments for men
Treatment will depend on the underlying cause of the infertility.
1) Erectile dysfunction or premature ejaculation: Medication, behavioral approaches, or
both may help improve fertility.
2) Varicocele: Surgically removing a varicose vein in the scrotum may help.
3) Blockage of the ejaculatory duct: Sperm can be extracted directly from the testicles and
injected into an egg in the laboratory.
4) Retrograde ejaculation: Sperm can be taken directly from the bladder and injected into
an egg in the laboratory.
5) Surgery for epididymal blockage: A blocked epididymis can be surgically repaired. The
epididymis is a coil-like structure in the testicles which helps store and transport sperm. If the
epididymis is blocked, sperm may not be ejaculated properly.
Fertility treatments for women
A) Medical management or Chemotherapy: Fertility drugs might be prescribed to regulate
or induce ovulation.
They include:
a) Clomifene (Clomid, Serophene): This encourages ovulation in those who ovulate either
irregularly or not at all, because of PCOS or another disorder. It makes the pituitary gland
release more follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

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b) Metformin (Glucophage): If Clomifene is not effective, metformin may help women with
PCOS, especially when linked to insulin resistance.
c) Human menopausal gonadotropin or hMG (Repronex): This contains both FSH and LH.
Patients who do not ovulate because of a fault in the pituitary gland may receive this drug as
an injection.
d) Follicle-stimulating hormone (Gonal-F, Bravelle): This hormone is produced by the
pituitary gland that controls estrogen production by the ovaries. It stimulates the ovaries to
mature egg follicles.
e) Human chorionic gonadotropin (Ovidrel, Pregnyl): Used together with clomiphene, hMG,
and FSH, this can stimulate the follicle to ovulate.
f) Gonadotropin-releasing hormone (Gn-RH) analogs: These can help women who ovulate
too early—before the lead follicle are mature—during hmG treatment. It delivers a constant
supply of Gn-RH to the pituitary gland, which alters the production of hormone, allowing the
doctor to induce follicle growth with FSH.
g) Bromocriptine (Parlodel): This drug inhibits prolactin production. Prolactin stimulates
milk production during breastfeeding. Outside pregnancy and lactation, women with high
levels of prolactin may have irregular ovulation cycles and fertility problems.
Reducing the risk of multiple pregnancies
Injectable fertility drugs can sometimes result in multiple births, for example, twins or
triplets. The chance of a multiple birth is lower with an oral fertility drug.
Careful monitoring during treatment and pregnancy can help reduce the risk of
complications. The more fetuses there are, the higher the risk of premature labor.
If too many embryos develop, one or more can be removed. Couples will have to consider the
ethical and emotional aspects of this procedure.

B) Surgical treatment for women

- If the fallopian tubes are blocked or scarred, surgical repair may make it easier for eggs to
pass through.
- Endometriosis may be treated through laparoscopic surgery with a small incision made in
the abdomen, and a thin, flexible microscope with a light at the end, called a laparoscope
inserted through it. The surgeon can remove implants and scar tissue, and this may reduce
pain and aid fertility.
C) Assisted conception
The following methods are currently available for assisted conception.
1) Intrauterine insemination (IUI): This is done at the time of ovulation, with a fine
catheter inserted through the cervix into the uterus to place a sperm sample directly into the

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uterus. The sperm is washed in a fluid and the best specimens are selected. The woman may
be given a low dose of ovary stimulating hormones.
IUI is more commonly done when the man has a low sperm count, decreased sperm motility,
or when infertility does not have an identifiable cause. It can also help if a man has severe
erectile dysfunction.
2) In-vitro fertilization (IVF): This involves placing of sperm with unfertilized eggs in a
petri dish, where fertilization can take place. The embryo is then placed in the uterus to begin
a pregnancy. Sometimes the embryo is frozen for future use.
3) Intra-cytoplasmic sperm injection (ICSI): This involves injection of a single sperm into
an egg to achieve fertilization during an IVF procedure. The likelihood of fertilization
improves significantly for men with low sperm concentrations.
4) Sperm or egg donation: If necessary, sperm or eggs can be received from a donor.
Fertility treatment with donor eggs is usually done using IVF.
5) Assisted hatching: This is done when an embryologist opens a small hole in the outer
membrane of the embryo, known as the zona pellucid. The opening improves the ability of
the embryo to implant into the uterine lining. This improves the chances that the embryo will
implant at, or attach to, the wall of the uterus.
This may be used if IVF has not been effective, if there has been poor embryo growth rate,
and if the woman is older. In some women, and especially with age, the membrane becomes
harder. This can make it difficult for the embryo to implant.
6) Electric or vibratory stimulation to achieve ejaculation: Ejaculation is achieved with
electric or vibratory stimulation. This can help a man who cannot ejaculate normally, for
example, because of a spinal cord injury.
7) Surgical sperm aspiration: The sperm is removed from part of the male reproductive
tract, such as the vas deferens, testicle, or epididymis.
Complications
Some complications can result from infertility and its treatment.
1) Stress and depression: If conception does not occur after many months or years of trying, it
can lead to stress and possibly depression.
2) Some physical effects may also result from treatment.
3) Ovarian hyperstimulation syndrome: Ovarian hyperstimulation syndrome (OHSS) usually
results from taking medications to stimulate the ovaries, such as clomifene and
gonadotrophins. It can also develop after IVF.
4) The ovaries can swell, leak excess fluid into the body, and produce too many follicles, the
small fluid sacs in which an egg develops.
Symptoms include:
Bloating, constipation, dark urine, diarrhea, nausea, abdominal pain, vomiting.

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They are usually mild and easy to treat.

Ectopic pregnancy
This is when a fertilized egg implants outside the womb, usually in a fallopian tube. If it stays
in there, complications can develop, such as the rupture of the fallopian tube. This pregnancy
has no chance of continuing.
Immediate surgery is needed and, sadly, the tube on that side will be lost. However, future
pregnancy is possible with the other ovary and tube.
Women receiving fertility treatment have a slightly higher risk of an ectopic pregnancy. An
ultrasound scan can detect an ectopic pregnancy.
Coping mentally
It is impossible to know how long treatment will go on for and how successful it will be.
Coping and persevering can be stressful. The emotional toll on both partners can affect their
relationship.
Some people find that joining a support group helps, as it offers the chance to talk to others in
a similar situation.
It is important to tell a doctor if excessive mental and emotional stress develops. They can
often recommend a counselor and others who can offer appropriate support. Online support
from organizations such as Resolve can be helpful.
Prognosis
For couples who experience fertility problems and those who wish to have children at an
older age, there are more options available than ever before.
In 1978, the first baby was born as a result of IVF. By 2014, over 5 million people had been
born after being conceived through IVF.
As new technology becomes available, fertility treatment is now accessible to more people,
and success rates and safety are improving all the time. Financing fertility treatment can also
be costly, but there are programs that can help with this.

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