What Causes Infertility

The causes of  infertility may either belong to the man or the woman. However, no problems can be identified in 15% of the couples presenting for an evaluation. This is a condition called unexplained infertility, in which assisted reproductive techniques help achieve pregnancy. Also, there may be only one factor causing infertility or there may be more than one. The causes of  infertility can be listed under two categories: male and female factors of infertility. The causes of infertility are distributed equally between the two genders at a rate of 40% in men and 40% in women in general. In the remaining 15-20% of couples, pregnancy cannot be achieved although no causes can be detected.

A general outline of the factors required to achieve conception includes patent uterine tubes and regular ovulation, and there should be no factors like a membrane (septum), polyp , myoma etc. within the uterine cavity hindering the embryo's implantation.

Causes of infertility in women:

• Polycystic Ovary Syndrome (PCOS): Being essentially a metabolic disorder caused by a defect in insulin binding to its respective receptors, PCOS prevents the couples to achieve pregnancy because of the increased androgen (male hormone) levels, impairing ovulation.
• AGE : Unfortunately, the reproductive potential of women declines by advancing age. The eggs in women begin to die even during the fetal period in the uterus.

• Women are born with an ovarian reserve of about 2 million eggs (oocytes), of which they will lose some of them each month until the end of their lifespans. There will be approximately 450,000 eggs left when they have their first menstrual bleeding. Approximately 1000 eggs will be dead each month before the woman is 35 years old, and about 1500 eggs will die every month after the woman becomes older than 35 years of age. How about doing a simple calculation? If we start by assuming that 1000 out of 450,000 eggs die  each month, we can argue that you are likely to have 450 menstrual periods and you can get pregnant 450 times until menopause. In other words, a girl who begins to have her periods at the age of 12, will have menopause after 450 months (37 years) or at the age of 49 years, which is a reasonable age for menopause. With advancing age, the quality and fertilizability of the eggs decline, along with the reduction of their likelihood to adhere to the inner membrane of the uterus. In this respect, women over the age of 35 years and who have not got pregnant for 6 months should undergo a gynecologic evaluation as soon as possible. In men, the effect of age on fertility is not as distinct as in women.
• Irregular menstrual cycles
• Diminished ovarian reserve (low ovarian reserve)
• Blocked fallopian tubes or adhesions inside the tubes
• History of previous infections or intra-abdominal interventions
• Endometriosis: It is described as the migration of the endometrium, which is the inner layer of the uterus and which is poured out with each menstrual bleeding every month, to another location in the body, impairing the functioning of the ovaries, uterus or the fallopian tubes.
• High prolactin levels
• Early menopause
• Fibroids (myomas): Fibroids are benign tumors in the uterus. They hamper conception based on their location and size. When they are located especially inside the uterus, they can hinder implantation. When they locate out of the uterus, they can divert the tubes or they can cause blockage in the tubes by compressing them.
• Intra-abdominal Adhesions: This term describes tissue adhesions inside the abdominal cavity following pelvic infections, appendicitis or abdominal or pelvic surgery.
• Thyroid Problems: Too much or too little synthesis of the thyroid hormones by the thyroid gland may disrupt ovulation and cause infertility.
• Cancer history and cancer treatment: In particular, cancers in the female reproductive system can lead to infertility. Radiotherapy and chemotherapy also have an act on the reproductive ability of women.
• Other medical conditions: Disorders such as late puberty, amenorrhea (no menstrual periods), liver diseases or diabetes can cause female infertility.
• Excessive caffeine consumption.
• Being overweight
• Smoking and alcohol use

Several diagnostic tests are carried out in couples presenting for the evaluation of infertility . The tests may reveal no underlying factors as it occurs in unexplained infertility or they may reveal more than one underlying factor.

What is early reduction of ovarian reserve? (premature ovarian failure)

Early depletion of the ovarian reserve It defines diminished ovarian functions before the age of 40. Anti-Müllerien hormone (AMH) is synthesized in the existing eggs in the ovaries and the levels of this hormone are used for making the diagnosis. AMH levels of <1><!--1-->

Especially patients with a history of ovarian surgery have a great risk of early reduction of ovarian reserve.  Individuals need to be consulted with an IVF specialist for reserve control if they have history of undergoing ovarian surgery due to a chocolate cyst (endometrioma), torsion, hemorrhagic cysts or cyst ruptures etc., and if they have not conceived for 6 months although they are under 35 years of age.

Early ovarian failure (premature ovarian failure) may result from several genetic diseases. Especially patients with a family history of early menopause should have their ovarian reserves followed up regularly and they are advised to plan conception accordingly.

Early depletion of ovarian reserve may also develop in smokers, in individuals receiving cancer treatment (radiotherapy-chemotherapy), and in several medical conditions including obesity, vitamin D deficiency, insufficient intake of some antioxidants, or after exposure to various toxins.

After the diagnosis, treatment for infertility (IVF) should start immediately.

Early ovarian failure (premature ovarian failure) does not DEFINITELY mean EARLY MENOPAUSE . Just because you have regular periods, it does not mean that your ovarian reserve is good. Patients often think that their reserves are sufficient because they have their periods regularly. However, periods are often not irregular in poor ovarian reserve. Depletion of the ovarian reserve enough to disrupt the menstrual cycles indicates a considerable reduction in the likelihood of getting pregnant with IVF. Therefore, it will be prudent if women having the abovementioned risks immediately contact with an IVF specialist to have their ovarian reserve checked.

 

How can poor ovarian reserve be detected?

Every healthy female infant is born having an average of one and a half million eggs. At the time of menarche , adolescent girls have 400,000 to 500,000 eggs. Of these eggs, 1000 are lost every month, and in fact, a woman ovulates 400 - 500 times on the average during the reproductive period. Regarding the ovarian reserve and reproductive age, it is known that diminished ovarian reserve resulting in menopause occurs in one out of every 100 women before the age of 40 and in one out of every 10 women around the age of 45. Therefore, diagnostic tests to check and determine the ovarian reserve become primarily important.

The most effective method to measure the ovarian reserve is to test the Anti-Müllerian Hormone (AMH) levels and the second one on the rank is to count the number of follicles in the ovary (antral follicle count).

• Transvaginal ultrasonography

The antral follicles count measured with ultrasound on the 3rd day of the menstrual period provides very reliable information to estimate the egg reserves. Presence of at least 6-7 potentially growing follicles   (antral follicles) in the ovaries indicate a good ovarian reserve. However; if the number of follicles is less than 6-5, this will indicate a diminishing ovarian reserve. However, this finding should be evaluated in combination with other diagnostic tests, rather than to be used as a stand-alone method.

• Measurement of the FSH (Follicle Stimulant Hormone) levels

Blood levels of FSH is tested on the 3rd day of the woman's menstruation. The test results provide information on the ovarian reserve. Synthesized by the pituitary gland in the brain, FSH stimulates the maturation of eggs in the ovaries. The main task of FSH is to stimulate the growth of the eggs and to induce estrogen hormone release. The better the woman's ovaries respond to this hormone, the less FSH will be secreted. After a decline in the number of eggs, consequently leading to lower levels of  estrogen, FSH levels will be elevated again.  If the FSH test on the 3rd day of menstruation reveals low levels, these levels will indicate good ovarian reserve.  Higher levels will indicate diminished ovarian reserve.  In this context, patients with FSH values of over 10 are at risk for having dinminished ovarian reserve.

• AMH (Anti Müllerian Hormone)

When ovarian reserve is reduced, AMH levels will decline. The AMH test is a very reliable method for determining ovarian reserve. This test can be performed any day. Although the hormones FSH and LH act on the ovarian functions, they are the indirect markers to determine ovarian reserve. Because AMH is produced directly in the ovaries, it clearly indicates the ovarian reserve and ovarian functions.

Causes of Infertility in Men:

Unlike women, the causes of infertility in men are not many. In general, they include abnormalities in the count, shape, and the motility of the sperms.

• Reduction in sperm count and motility
• Structural abnormalities in sperms
• No sperm cells in the semen (azoospermia)
• Ejaculatory duct obstruction
• Retrograde ejaculation (ejaculating into the bladder)
• Hormonal causes
• Undescended testicle at birth or after the birth
• Feverish illnesses in childhood, diseases such as mumps in adolescence
• Genetic diseases
• Varicocele (dilation of vessels supplying and draining testis)
• Giseases such as syphilis and gonorrhea
• Sexual dysfunction (such as erectile disorders and premature ejaculation)
• Diabetes
• Previous cancer treatment
• Infections
• Testosterone deficiency
• Smoking or alcohol use
• Stress

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