Chapter 14 Infertility and diagnosis of foetal health

• unfortunately, sometimes there are

  difficulties in establishing pregnancy
• understanding process has

  increased immensely

  allowed development of more effective methods of testing, establishing and sustaining pregnancy

  various factors and regulations that must be considered in regard to these tech
• infertility

  unable to achieve pregnancy despite frequent unprotected sex over the period of at least a year

  in Aus. infertility affects approx. 1/6 couples
• causes of infertility

  40% of infertility is due to problems with sperm

  40% is due to problems in female reproductive system

  20% is due to combination of male and female factors
• for sperm to be able to fertilise an egg 


  produced in sufficient quantities

  able to move in forward direction

  able to penetrate the corona radiate and zone pellucida
• means that there are needs to be

  high number of sperm produced with a correct structure

  problems with any of these qualities will greatly reduce chance of a pregnancy
• several factors that may result in sperm being unable to fertilise egg

  semen

  males immune system

  blockages

  hormonal imbalances
• semen

  and sperm it contains, may flow into the bladder, rather than out the urethra
• males immune system

  may develop antibodies for their own sperm, altering them and reducing their effectiveness
• blockages

  may occur in males reproductive tract, especially in the vas deferens, which may stop the sperm leaving the testes
• hormonal imbalances

  can affect sex driven the production of sperm
• as females get older

  number of healthy eggs remaining decreases

  reduces chance of pregnancy, especially after 36
• polycystic ovarian syndrome (PCOS)

  affects fertility in females

  hormonal condition where the ovaries contain many partially formed follicles that fail to mature

  means that egg is not released, and therefore cannot be fertilised
• hyperprolactinemia

  high levels of hormone prolactin may occur in people with pituitary tumours, hypothyroidism and PCOS

  high levels of prolactin results in intermittent or lack of ovulation
• once female has gone through menopause

  she will no longer be ovulating
• early menopause or primary ovarian insufficiency

  some females experience menopause before 40 and will be unable to get pregnant from this time

  cancer treatment may also cause this, and hence infertility

  women younger than 30, it may be temporary, and they may become fertile again after treatment

  older the woman is, the less likely her fertility will return
• endometriosis 


  affects 10% of women

  painful condition where cells of endometrium grow outside uterus

  resulting scar tissue or distortion of uterine tubes can affect fertility by blocking egg's release or pathway through to uterus
• fibroids

  presence may also affect fertility

  benign growths in muscular part of uterus

  very common, they only affect fertility if their location distorts uterine cavity or blocks the uterine tubes
• blockages of uterine tube

  will stop egg from passing to uterus

  occur from infections such as gonorrhoea or chlamydia, or damage e.g. due to ectopic pregnancies
• problems with menstrual cycle

  also affect fertility as it influences implantation of the blastocyst

  hormonal imbalances can reduce the development of endometrium and its maintenance
• method of treating infertility

  depend on reason for issue

  possible to correct problem so that couple can conceive naturally

  other times not possible, and so techniques are used to assist fertilisation and the maintenance of pregnancy
• surgery

  microsurgery can be used to solve problems of infertility

  blocked uterine tubes and sperm ducts can be opened, and fibroids or endometriosis can be removed
• possible to identify time when

  female is most fertile through a series of blood tests

  surge in luteinising hormone prior to ovulation

  level of the hormone can be monitored through blood tests so that couple knows when they are most likely to conceive
• sperm remain viable for

  two to three days in uterine tubes, while the egg inly survives for 24 hours

  highest chance of conception occurs by insemination prior to ovulation

  if couple tracks ovulation over number of cycles, possible to identify most effective time to have sexual intercourse
• problems with ovulation 


  infertility due to low levels of hormones

  solved by medications used to correct problem

  two types of drugs used, both using follicle-stimulating hormone to induce development of follicles
• drugs used to solve infertility from low hormones

  clomiphene stimulates body to make more FSH

  hormone injections of FSH increase blood levels of hormone

  human chronic gonadotrophin may also be used to trigger ovulation once follicle has matured
• females affected by hyperprolactinemia

  will need to lower their prolactin levels so that ovulation can occur

  correction of underlying cause is important consideration

  oral medication is available to restore normal levels of prolactins and, hence, ovulation
• artificial insemination (intrauterine insemination IUI)


  sperm is released into uterus by catheter being inserted through cervix

  sperm sample is injected though catheter

  from uterus, sperm are able to move more naturally through uterine tubes where they may fertilise an egg

  increases chance of pregnancy by increasing number of sperm that reach uterine tubes
• IUI has advantage of

  allowing control over sperm being inseminated

  sperm used may be male partner or donor male
• in IUI sperm is

  collected, analysed, processed and concentrated

  ensures only high quality sperm used

  possible for sperm to be collected at earlier time and frozen for storage

  sperm is then thawed under controlled conditions prior to insemination
• circumstances that would benefit from IUI

  low sperm count or decreased mobility

  ejaculation dysfunctions

  sperm stored and frozen due to male's absence or needing to undergo treatment (chemotherapy)

  cervical scarring

  hostile cervical mucus

  same sex couples

  single females
• success rate of IUI

  approx. 10-20% per cycle

  over three to six cycles, average 80% chance of getting pregnant

  couple with no fertility issue has 96% if under 25, if 37 the rate is 78%

  success rate is high
• not always possible for

  couple to use their own egg and sperm, or for the female to carry the child
• donor gametes or embryos

  use eggs, sperm or embryos from donors to achieve pregnancy

  donor may be known to couple, or anonymous

  strict regulations, including counselling for both donors, recipients, cooling-off periods and health screening
• if female unable to conceive or carry baby 


  surrogacy is option

  another woman carries child for duration of pregnancy and then gives child to couple to raise as their own
• strict laws regarding surrogacy

  not legal for surrogate to be paid beyond expenses arising from pregnancy

  agreement between birth mother and parents is not legally binding

  means birth mother has right to change her mind and keep child
• traditional surrogacy

  achieved by artificial insemination of fathers sperm

  surrogate mother is genetically related to child
• gestational surrogacy

  IVF is used to produce embryo that is then inserted into surrogate

  more common in Aus.
• infertility treatments that allow unassisted fertilisation

  surgery

  ovulation tracking

  ovulation induction

  artificial insemination
• assisted fertilisation

  gamete intrafallopian transfer (GIFT)

  in vitro fertilisation (IVF)

  intracytoplasmic sperm injection (ICIS)

  surgical sperm retrieval