Around 15-20% of the adult population experience infertility. This is due in part to the trend to delay starting a family (with increased age, fertility declines), but is also due to adverse conditions in lifestyle and the environment (e.g. stress and pollution).
In couples experiencing infertility, male and female infertility account for around 30% each, with a further 30% due to combined male/female causes, and the remaining 10% unexplained.
Approximately 20% of female infertility cases are due to blockage of the fallopian tubes. The fallopian tubes are small and delicate organs that capture the egg released during ovulation and transport it towards the uterus where it is fertilized to become an embryo that is then implanted in the lining of the uterus. Blockage of the fallopian tubes often results from scarring due to surgery and/or infections such as Pelvic Inflammatory Disease or chlamydia.
The remaining 80% of female infertility cases are caused by a variety of factors that may include:
Male infertility is an increasing problem around the world, often resulting from lifestyle and environmental factors. Other causes of male infertility include varicocele (abnormal enlargement of veins in the scrotum), infection, and unsuccessful reversal of vasectomy. In men, hormonal deficiencies are quite rare but can cause reduced or absent production of sperm.
Measuring Fertility Potential
Empirical data show that female fertility declines significantly after the age of 35 years. Although individual differences permit some women in their 40s to conceive, generally egg production continues to decline.
There are tests that measure the potential of the ovaries to produce eggs and these consist mainly of an Antral Follicle Count (AFC) of the ovaries by transvaginal ultrasound and a blood test for the Anti-Müllerian Hormone (AMH), allowing us to create a fertility profile.
Before conducting these investigations, a thorough understanding of the medical history of the woman and her male partner is required to exclude other factors that may inhibit fertility and this includes infertility investigations.
Couples seeking assistance to have a child should expect to undergo the following investigations, some mandatory and others appropriate to individual circumstances:
Assisted Reproduction Techniques (ART)
From simple cycle monitoring and ovarian stimulation, to intrauterine insemination (IUI) and in vitro fertilization (IVF) procedures, the most up-to-date techniques are available through Dr Naumann’s practice.
Cycle Monitoring is done by a combination of ultrasound scanning and hormone assays from blood samples. This allows the development and maturation of eggs to be monitored.
Ovarian Stimulation is achieved by the administration of hormones in combination with cycle monitoring and can be used in both IUI and IVF treatment.
Oocyte (egg) Collection is performed via the vagina under anesthesia, for use in conventional IVF or ICSI.
Conventional IVF is the combining of eggs and sperm in a test tube to allow spontaneous fertilization and the early development of an embryo.
ICSI is the injection of a single sperm into an egg to achieve fertilization. This technique can be used to overcome most forms of male infertility.
PESA/TESA are procedures to obtain sperm either from the testicle itself or from the epididymus (storage organ for sperm). These procedures can be used to locate sperm where none is found in the ejaculate.
Embryo Transfer is performed 36 to 48 hours after the fertilized eggs have become embryos. The embryos are transferred into the uterus with a smooth catheter. This procedure is not usually painful and does not require anesthesia. A pregnancy test should be performed two weeks after embryo transfer.
Embryo Implantation is when the embryo is implanted into the lining of the uterus, thus creating a pregnancy. This process is performed by Nature with the aid of administered progesterone and is not influenced by physical activity. However, we do advise that the woman adopts a positive attitude and avoids unnecessary stress.
Assisted Hatching is a technique that facilitates the development of the embryo and improves the process of implantation. In some cases the protective shell (zona pellucida) covering the early embryo fails to dissolve and the embryo cannot ‘hatch’ and develop to a stage where it is capable of implanting in the lining of the uterus. In assisted hatching, the dissolution of the zona pellucida is assisted by the application of a special solution or laser.
Cryopreservation & Storage Embryos that are not used for transfer are cryopreserved (frozen) and stored for use in future treatment, thus avoiding repeated ovarian stimulation treatments. Sperm samples can also be cryopreserved and stored for future use. In the case of medical treatment that can diminish or destroy fertility cryopreservation of ovarian and testicular tissue is also an option.
Oocyte Freezing for Non-Medical Reasons or ” social freezing ” Postponing pregnancy for non-medical reasons of personal preference can bring with it concerns about diminishing or lost fertility with increasing age, especially for women aged from 35 onwards. Freezing oocytes can facilitate the conservation of a woman’s fertility for future attempts at pregnancy.
Pre-Implantation Diagnosis (PGD) is a diagnostic procedure performed on the early embryo to determine genetic abnormalities such as Down syndrome or cystic fibrosis. A single cell is removed to be analyzed by florescence in situ hybridization (FISH) or specific genes by polymerase chain reaction (PCR). PGD is recommended when at least five embryos are available.
Oocyte Donation is the only ART option for women who are not able to produce their own eggs due to diminished ovarian function or the onset of early menopause can be treated using donated oocytes. The donor undergoes ovarian stimulation to produce oocytes that can be collected and used in IVF with the sperm of the male of the recipient couple. Only women under the age of 35 who have already had children are suitable to donate eggs resulting in a conception rate of slightly over 50 %. Donors are comprehensively screened and matched with a recipient couple, for things such as physical characteristics. Usually egg donation is anonymous, but in some cases a female relative may elect to be the egg donor. It is recommended that donors and recipients undergo counseling.
Although in some cases counseling is mandatory, counseling and emotional support is available to everybody undergoing ART. We collaborate with counselors of German, English, French and Italian origin.
Recurrent Miscarriage and Repeated IVF Failure
Recurrent miscarriage in the first trimester can have many different causes, including chromosomal disorders of the embryo itself, undiscovered genetic abnormalities in the parents, and infections of the cervix and vagina, especially Clamydia which may reduce fertility and cause loss of pregnancy. More rarely, uterine abnormalities and systemic illnesses may contribute to miscarriage.
Women who experience recurrent miscarriage or repeated
IVF failure often suffer from immunological or haematological disorders that affect early embryo implantation, because the immune system rejects the embryo; thyroiditis and lupus erytomatosus are common causes of immunological disorders. Also, abnormalities of the clotting system negatively affect the development and functioning of the early placenta.
Laboratory investigations are able to pick up irregularities that benefit from pharmaceutical therapy. The most common therapies involve high-dose vitamins, heparin and cortisone. Sometimes additional treatment with immunoglobulins is necessary to help reduce the immunological reaction and thus the rejection of the early embryo.
Achieving a pregnancy is influenced by multiple factors that include maternal age, individual problems and pathologies, as well as the Assisted Reproductive Therapy chosen. For women aged 20-35 years undergoing IVF with a transfer of three embryos, the pregnancy success rate is around 40%.
Embryos that reach the blastocyst stage have a higher implant percentage that reaches 60%.
Diagnosing prior to implantation
On the fifth day after fertilisation the embryo becomes a blastocyst. At this stage a biopsy allows to investigate on its chromosomes or genes.
The former is known as Pre-implantation Genetic Screening ( PGS ) and allows to find out about trisomy or lacking chromosomes.
PGD stands for Pre-Implantation Genetic Diagnosis and analyses single genes like the one responsable for cystic fibrosis.
The techniques are aimed at avoiding transfer of pathological embryos and avoid tests during a later pregnancy like NIPT and amniocentesis.