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Introduction to subfertility
Having babies is a right and wish of all the couples after marriage, but an intact hormonal system, psychological stability, and emotional composure are the merits for achieving due to maturation of the sperm and ovum leading to the fertilization followed by the birth of a healthy being. Fertility refers to the ability to conceive and bear offsprings, while fecundity expresses the prospect of women to reproduce on a monthly basis. The incompetence of a couple to conceive after more than 12 months of unprotected intercourse is called “infertility.” According to the World Health Organization, “infertility is the inability to conceive a child.” Inability of a woman to become pregnant after 1 year of regular intercourse for what so ever the cause may be labels the couple as infertile.
Infertility is consistent with all cultures and societies and affects an estimated 10%–15% of couples of reproductive age worldwide. Every one in six couples is affected by this debarment. Infertility is prevalent in all societies of the world, including 50% of West African societies, 12% of Western European families, and 23% of couples in Pakistan. This universal burden is growing at a tremendous rate with topographical variations and affecting the quality of life of not only the married couples but also families at large. It is undoubtedly a key threat to a married female and demands financial stability for its investigation and choice of treatment plans eventually.
Prevalence
Infertility is taken as a problem in every culture and society and is considered to affect approximately 10%–15% of couples of reproductive ages. Lately, the graph of treatment-seeking couples for infertility has gone high due to many factors including delayed marriages, belated childbearing in women, and knowledge of the development of successful new techniques for infertility treatment.
Infertility can be classified as “primary infertility,” a condition where the female is deprived of conceiving at all or has been unable to carry on pregnancy fruitfully to a live birth, and “secondary infertility,” where the female is incapable of conceiving a new pregnancy for 1 year following a previous pregnancy. Primary infertility contributes 5% of the 23% infertile couples while secondary type of infertility is approximately three times more.
According to WHO-DHS Comparative Report, 2004, approximately 186 million women of the developing countries (excluding China) are suffering from any type of infertility. This number represents that in every four ever-married women, more than one woman is subfertile during their reproductive age. The prevalence of infertility in Pakistan is approximately 23%, where primary infertility contributes to 3.5%–3.9% and secondary infertility is 18.0%–18.4%.
Determinants of male subfertility
Men and women are equally (40%) responsible for infertility while the remaining 20% couples have no identified cause for conception (unexplained infertility). Apart from physiological variations, three types of factors can act by themselves or interact in complex pathways, which are environmental, genetic, and physiological. The causes are summarized in Fig. 5.1 .
Known etiology of male factor subfertility is around 10% and repeated specimen analysis of semen can reduce this rate to 2%. The normal values of semen characteristics are given in the previous chapter.
Male infertility contributes to 40% of the total cases of subfertility. Abnormal semen characteristics have no reason (idiopathic) in around 26% of infertile men. Oligoasthenoteratozoospermia is characterized by dysfunctional spermatozoa, whereby some percentage of sperms is incapable of fertilization. Antisperm antibodies are a probable cause of this condition.
Hypothalamic pituitary failure may lead to azoospermia. Its two types are nonobstructive azoospermia causing primary testicular failure and obstructive azoospermia causing the obstruction of the genital tract.
Less than 1% of the infertile men problems are due to hypothalamic or pituitary dysfunctions. In this case, luteinizing hormone and follicular-stimulating hormone are less than normal, which affects the normal spermatogenesis and testosterone production and secretion.
Causes of female subfertility
In general, the causes or factors of female infertility can be classified based on whether they are acquired or genetic, or strictly on the basis of location. Causes of infertility in the Pakistani population can broadly be categorized into male factors (23%), female (44%) or unexplained infertility (28%), and coital factors (5%).
A number of dietary, infectious, environmental, endocrine as well as hormonal imbalances can be the contributing factors. Hence, female infertility turns out to be a pressing global burden, especially in South Asian countries. It is a well-known fact that the scale of infertility spreads from the reproductive disorders leading to detrimental psychological as well as social implications ( Fig. 5.2 ).
Delayed conception
The known causes of infertility are mostly related to defects in fallopian tubes, uterus, or hormonal balance. The increase in age at the time of marriage due to the attainment of higher education is another contributing factor. Increased age (> 35 years) affects the efficiency of ovaries and has been documented to be reciprocal with reproductive capacity. Additionally, females being work-oriented and pursuing professional growth tend to spend hours at a job, and later, being tired has also decreased the frequency of sexual intercourse and increased the chromosomal abnormalities and rate of abortions.
Lifestyle
Apart from physiological aspects, the occupation of the couple is another point of concern. Long working hours or shift duties may affect the frequency and correct timings of sexual intercourse. Exposure to radiations, harmful substances, and heat is likely to reduce sperm parameters in males. Living in a joint family system with the burden of household chores makes workingwomen too tired to be available to male partners. Monitoring the body basal temperature or maintaining a monthly chart of the menstrual cycle could be helpful in achieving conception by coinciding with ovulation.
The consumption of alcohol has not been effectively found to be associated with female infertility, but excessive alcohol intake has reversible detrimental effects on sperm quality. However, smoking has a strong association with delayed conception, reducing infertility in females and with derangement of sperm parameters in males. There is no consistent evidence to demonstrate an association between caffeinated drinks and fertility difficulties.
Obesity
Obesity stands as a well-known independent risk factor for not only cardiovascular diseases and diabetes mellitus but also reproductive malfunction in both males and females and has been associated with lower success rates following assisted reproduction. Integral differences of oocytes in these obese patients increase with the duration of stimulation, decrease number of oocytes, and affect oocyte maturity, implantation, and clinical pregnancy rates. Obesity impacts females starting from menstrual irregularities to delayed conception and spontaneous abortions in females; obesity has a negative association with erectile function and normal amount motile sperms.
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