InfertilityInfertility is a condition that is hardly understood by people who do not face it. Most people consider having children a natural thing. Those who cannot make this dream come true may feel they have failed and that they don’t meet their partner’s and society’s expectations. This causes an increasing tension, which cannot be easily controlled. Moreover, they often try to hide the problem. The consequence of this typical attitude is that the desire to have children becomes unbearable; sex life loses its spontaneous character. This faces the partners with a new force test, and they realize they can’t solve their problem without help. This is usually the moment when they call the doctor.
This can have a beneficial effect in itself, because they feel they are no longer alone in overcoming their problem. This explains why many women become pregnant even before starting any treatment. However, if during the first discussion it becomes evident that the partners don’t have or have very little chances of having children naturally, then artificial insemination methods must be taken into account. The same comes into question also when the pregnancy does not occur after a longer traditional treatment. It is extremely important our patients to be thoroughly informed before starting the treatment and to build up their trust in the doctor and the clinical staff.
Before talking about the factors that trigger and influence infertility, let’s analyze the concept of „normal” fertility, ie. what is the probability for a woman to become pregnant during the menstruation cycle, under normal conditions. This chance is not higher than 20-25%. So, out of 100 healthy couples, who don’t use any contraceptive method and who have a regular sex life, 20-25% of women become pregnant after the first attempt.
Definition of infertilityWe can speak about infertility when a pregnancy does not occur within a year after having regular sex and not using any contraceptive method. In the case of a regular sex life, without contraception, the probability of a pregnancy during the menstruation cycle is of approximately 25-30%, thus, throughout a year, about 85% of the couples can have a child. Of course, it doesn’t necessarily mean that they all have to wait for a year to ask the physician’s help, because fertility drops as the years pass. Thus, for example, after the age of 35 infertile couples can go to a fertility clinic even after a half year of failure to conceive.
Frequency of infertilityNowadays, infertility affects almost 10-15% of the reproductive population worldwide. It seems that the frequency of infertility has obviously shown an increasing trend during the past centuries: while in the second part of the 1600’s the proportion of childless couples was of 2%, in the 1970’s it increased to almost 12%. Infertility has dramatically grown especially in men.
Causes of infertilityThe absence of conception can have several causes. Generally, we can say that 30-40% of the cases deal with female factors and approximately the same percentage with male factors. Fertility issues present both in men and women make up 20-25% of the cases, and in 10-15% of the cases the cause of infertility cannot be established. The above mentioned aspects obviously indicate that our examinations performed in order establish the etiology of infertility must be initiated in both partners. In many cases, infertility does not appear as an independent disease, but as a main symptom of several physical and psychological conditions. Of course, in order to conceive a child, both members of the couple must fulfill several conditions. Women need to have an adequate hormonal environment to produce a mature egg, and the uterine mucus has to become suitable for the attachment and growth of the fertilized egg. The genital tract (including vagina, the uterine cavity, the fallopian tube) must be permeable and also free of infections to allow the fertilization process. In men, for conception to take place, several conditions must be met, including the production of adequate semen volume with high sperm concentration and appropriate viability and mobility; the genital canal must be permeable and free of infections (vas deferens and seminal vesicles, sperm cord and ureter) as well good a mating ability. If any of these functions is altered, conception might not occur. The examination and the treatment of infertility is aimed to ensure the criteria mentioned above.
No doubt that stress related to environment and personality affects fertility significantly. Newer research has demonstrated that one of the most important factors which, paradoxically, reduce fertility, is the emphatic desire to have children. Those women who permanently wait with excitement the absence of the next menstruation, and its occurrence is experienced like a failure, often become depressed. While waiting in vain to conceive, love and harmony between partners can diminish.
The cause of infertility is often an anomaly which can be effectively treated with medicines or surgical interventions.
As is known, in the background of female infertility in 25-30% of cases lie the anomalies of ovulation, out of which the most important is the polycystic ovarian syndrome (PCOS), but the differences in lifestyle, excessive sports, excessive diets, stress, obesity can also cause menstruation cycle disorders and, as a consequence, sterility.
Let’s examine closer the role of the two factors, age and body weight.
Age related fertilityIn many cases, the aging of follicles, and, as a result, the aging of eggs (oocytes), is characterized by well-defined clinical symptoms: diminished fertility, increased number of abortions and higher frequency of pregnancies with chromosomal anomalies. The results of the recent investigations let us better understand the aging process of the ovary.
It has long been known that the fertility of women who have a regular menstrual cycle decreases with age. This fact is very well documented by the observations according to which the pregnancy rate of women over 35, inseminated with donor sperm is far lower than that of women under 25, inseminated by intra-uterine insemination. In female fetus, the oocytes reach their maximum number after approximately 20 weeks, after which their production stops in a certain phase and it will continue only in the moment of ovulation and fertilization. The number of oocytes continually drops after birth. At birth, ovaries contain approximately 1 million ovules, during the first menstrual cycle in the ovaries there are approximately 300 thousand oocytes. After the age of 37, this process accelerates, while at menopause (the last menstrual cycle, which in our country occurs at about the age of 51) the ovaries contain only about 1000 follicles.
As the number of eggs decreases, the number of pathological pregnancies increases, which carry anomalies related to the number of chromosomes. According to experience, 60-70% of the older ovaries contain chromosome above or below the normal number. So, it is no coincidence that chromosomal anomalies are responsible for 50% of the abortions occurred at older ages, but there are statistical data indicating even higher incidence (80-90%).
Clinically, the first warning sign may be the shortening of menstrual cycles, involving mainly the shortening of the first part of the cycle. At the same time, with age the level of the follicle stimulating hormone (FSH) increases, measured in the second or the third day of the cycle. All these processes may also appear at younger ages and during these periods fertility could be diminished temporarily. Elevated FSH levels adversely affect the quality of zona pellucida, the glycoprotein membrane surrounding the ovule. Due to the pathological high level of the hormone, a rougher surrounding area is formed, thus the fixation of the fertilized ovule to the uterine mucosa will face serious difficulties. During the aging of the cycle, the level of the progesterone (the hormone secreted by the corpus luteum) also rises which decreases even more the survival chances of the created embryo.
Why do we have to address the issue of age? Partly, because the processes described above are present in many cycles aged over 35 years, but they can appear at younger ages as well. This is why it is important that before performing assisted reproduction interventions (insemination, in vitro fertilization etc.) to make sure the patient meets the criteria of an optimal regular cycle, using the so-called cycle selection methods. On the other hand, age is important for the gynecologist, because even in our country increases the number of women suffering from primary or secondary infertility, due to the changed birth habits. This means that in the past the population was characterized by the oriental births: women gave birth to their first child at the age of 22-24. Nowadays, with an accelerated lifestyle aimed to gain even more education and performance, women have embraced a western birth habits – having their first child at the age of 26-28 years or even later – due to the desire to enhance their professional careers. Thus, it is no wonder that at the moment of the planning the second child, we can already experience age related fertility problems. Perhaps a healthy social vision should determine women to give birth to their children when the biological circumstances are most favorable.
Nowadays, during the in vitro fertilization procedure, the routinely applied technique involves opening the glycoprotein membrane which surrounds the fertilized ovule, before transferring the embryos. The procedure called assisted hatching facilitates the exit of the embryo, increasing the fixation rate. Aged ovules and embryos are characterized by the fact that the surrounding membrane becomes thicker, rougher. Using the mechanical hatching, with acid or laser applied on the glycoprotein membrane generates a hole of 15 microns which can increase the success rate of the fertilization procedure.
Ongoing investigations performed in several medical areas aim to solve the age related fertility issues. However, we must understand that up to a certain phase everything is programmed. Even the reproduction time has an optimum duration: according to some authors, this period extents to the age of 35, according to others to 37 years old, after which every other two years the chances of getting pregnant decrease by 50% and parallel to this the frequency of the spontaneous abortions increases. If we dedicate the earlier stages of our life to other activities – whether they have a noble purpose or represent a hobby – we will face certain disadvantages in other areas.
Obesity and infertilityObesity is a worldwide serious health problem. Approximately 20-25% of women of reproductive age are struggling with numerous side effects of obesity, while approximately 55-65% of the adult population is obese. It has been known for several decades that there is an inverse proportional relation between the extra pounds and the possibility of becoming pregnant, and also between overweight and the success of fertility treatments. The difficulty is increased by the fact that after the desired pregnancy has occurred, during the nine months various complications may arise, that do not occur in women with a normal weight or occur with low frequency.
Obesity is nothing but excess accumulation of body fat. It is worth mentioning that obesity increases the risk of cardiovascular diseases, diabetes, lipometabolic disorders, tumoral pathologies and premature mortality, and as a cosmetic problem, it may be associated with pronounced hair growth. Its occurrence is facilitated by genetic factors (unfortunately we have little knowledge about them) and by the environment, lack of exercise and sedentary lifestyle, and last but not least, excessive consumption of calories. We must know that in 90-95% of cases obesity involves a simple weight gain and it has mainly lifestyle related causes, including poor physical exercise and unhealthy eating habits.
Body fat can be measured in several ways, out of which the most commonly used method is the measuring of the body weight/height proportion. This ratio can be calculated by dividing the weight to the square of the height expressed in meters. Hus we get the body mass index (BMI), well known in the clinical practice, which equals body weight/height2 (kg/m2). The normal BMI varies between 20 and 25; values between 25-30 indicate pre-obesity, between 30-35 obesity, and over 35 it reflects serious obesity. If the BMI ranges between 18-20 we deal with an underweight person and below 18 we face with a case of malnutrition. In case of obesity, we must first consider the ovulating disorders. The cycles become more rare, they have a shorter length. During cycle monitoring it can be determined if the ovulation of the follicles containing eggs occurs or not. All these cycle disorders are characteristics the so-called metabolic syndrome which occurs due to obesity. It is not adventitious that by eating less calories a very good result can be obtained: after reducing the body mass index by 5-8% the ovule production can be recovered, and besides regular ovulations, the fertilization can occur more quickly. Perhaps less well known is that in obese men the testicle reacts to the extra weight with a reduced function, the sperm can differ from the physiological values both in concentration and mobility – of course, in a negative direction.
In obese female patients, another problem is that the fertilization rate of the ovules created with ovarian stimulation drug therapies is much lower than in healthy women, also fixing of the eggs in the uterine cavity is more difficult and the abortion rate is higher. The polycystic ovarian syndrome can be diagnosed in a significant number of overweight patients.
Maternal obesity can be a risk factor for developmental anomalies of the fetus. It obviously increases the frequency of the neural tube closing disorders (e.g. open vertebral spine), as well as that of heart development disorders, the cleft lip, wolf mouth. Several specialists explain this by the fact that in the obese patients the absorption of the folic acid is poor and thus its beneficial effects diminish, failing to prevent different closure defects. During the first trimester of pregnancy there is an increased risk of fetus mortality, obesity being a pathological factor in the case of repeated abortions as well. The number of induced premature births increases (this was noticed especially in women at their first birth): due to the pathological states that appear during the last stage of the pregnancy, inducing preterm birth is more common.
What definitive conclusions can be drawn? First, we are responsible for our obesity and solving this problem depends primarily on us. Besides the reduced consumption of calories, it is also important to change our lifestyle, to do regular exercise (1 hour walk is equivalent to the loss of 300 kcal, 2-3 km of running, 3-10 km of bike riding and 100 m of swimming). We must avoid unhealthy foods and beverages, as well as to stop the bad habit of snacking. For decades a wide range of pills for weight loss has been available. This abundance of products often indicates the fact that there is no ideal medicine. Let us not forget: besides the supplementary medicine treatment, we must never give up on diet and regular physical activity. To sum up all of these: changing our lifestyle.