Primary and secondary infertility
Infertility or more often, subfertility is defined as failure to conceive within a reasonable time period. Twelve months is considered reasonable for those females under 35 years of age and six months if over 35 years before seeking medical advice. Further, it is divided into primary and secondary, depending on whether there has been a pregnancy or not in the past. Interestingly, the most frequent causes of both primary and secondary infertility are the same. In other words, evaluating fertility in those that struggle the second time around does not significantly differ.
We are always considering three areas of interest, egg, sperm and womb or uterus. The population under observation matters since the contributing causes occur at varying rates in different socioeconomic groups. However, the main factors are ovulation disorders, ageing of the eggs or oocyte quality issues as well as quantity, uterine or pelvic diseases including fibroids, tubal disease, endometriosis, adenomyosis and male factor or sperm disorders. Sperm disorders generally involve numbers and quality, often seen in combinations together. Couples may commonly present where one has been sterilised after having had children in the past.
Diagnosing the cause
The required information to form a management opinion is easily and rapidly gathered through consultation with a fertility specialist, history taking, physical examination, ultrasonography, x-ray, blood tests and a sperm analysis. The quickest and most efficient route to a solution is by completing all of these, as opposed to looking at the female or male in isolation or in a staggered fashion.
Around 50% of couples presenting have mixed pathology and few have absolute causes. Occasionally operative procedures are necessary, such as laparoscopy, to diagnose and manage endometriosis, hysteroscopy for uterine cavity problems, sperm retrieval, etc. Since there are only three ways to conceive a baby, it is simple to decide on a treatment plan when viewing a complete picture. Your choices are natural conception with or without ovulatory assistance, artificial insemination (AI) and in vitro fertilisation (IVF).
Natural conception with or without ovulatory assistance
The importance of a thorough assessment is to treat and manage any accessible factors, including lifestyle and mental, since often this alone will result in natural conception success. Examples include dietary advice, cessation of smoking, weight management, exercise review, sleep review, stress management, nutritional supplement advice, along with correcting any hormonal or medical disorders. These optimisations will also impact the success rates of AI and IVF. It takes 90 days to realise a change in sperm quality or quantity following the introduction of a medication, supplement or lifestyle alteration. The cells that support oocytes similarly take time for some intervention improvements to be fully realised.
If natural conception fails to occur despite corrections expected to achieve it, generally over a period of three to six months, depending again on age primarily, it is time to move on.
Artificial insemination is effective in younger women under the age of 35 years, where there is little uterine pathology and the sperm is normal. Success rates at the very best reflect a return to the expected natural conception rate of the female age being treated, 15% to 20% in young women per attempt. If there are sperm abnormalities, then the rates fall away dramatically.
IVF is the other option and often the treatment option of choice in older women, since the success rates are higher and time to pregnancy is reduced. IVF generally involves three processes. The first is egg retrieval after stimulating the ovaries with biologically identical hormones administered through subcutaneous injections for a number of days. These eggs are then fertilised either naturally by dropping prepared sperm on them or by injecting them with a single sperm through a process known as intracytoplasmic sperm injection (ICSI). ICSI is specifically for sperm issues and not egg issues. Embryos that form after five days, known as blastocysts, can then be transferred into the uterus. One embryo at a time is strongly recommended for younger women to avoid multiple pregnancy. Safe freezing for future transfer or storage would take care of the extras.
IVF pregnancies after some initial support in the first three months are like any other and the babies born are just the same. There is no difference in approach for those women that have children over those that don’t.
By Dr Nicholas Clark
MB BS (London) FCOG (SA) FRANZCOG (Australia)
Reproductive Medicine Specialist / Gynaecologist