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Fertility

Fertilisation is the joining of the egg and the sperm in the outer third of the Fallopian tube closest to the ovary. It can occur only when an egg, released by the ovary, meets sperm which have swum up through the cervix and uterus into the Fallopian tube. Fertilisation normally occurs within 36 hours of the release of the egg. Only one sperm is needed to successfully fertilise the egg. Once fertilised, the egg moves down the Fallopian tube towards the uterus. It grows rapidly as it does so, and by the time it reaches the uterus 2-3 days later, it is called an embryo. The embryo then comes to lie within one of the folds of the lining of the uterus. By this time the embryo is composed of two distinct cell types – one which forms the placenta, and the other which forms the baby. The embryo then embeds itself into the wall of the uterus and pregnancy is achieved. This occurs about 7 days after fertilisation.

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The Female Genital Tract

The female genital tract includes the ovaries, Fallopian tubes, uterus (womb), cervix, vagina and vulva. The ovaries produce eggs, one of which is released each month, and then 'collected' by the fallopian tube. The egg is then passed through to the uterus; the organ in which a baby will develop. The inner lining of the uterus (endometrium) thickens in preparation to receive a fertilised egg, however is shed each month as a menstrual period if no egg has been fertilised. The neck of the womb is called the cervix, which lies at the top of the vagina. The vulva are the fleshy folds that surround the entrance to the vagina.

The Male Genital Tract

The male genital tract includes the testes (testicles), the epididymis, the vas, the prostate and the urethra. The testes lie within the scrotum and produce sperm, and also the male hormone testosterone. The epididymis lies next to the testis. The newly formed sperm pass through and are stored in the epididymis, and here they continue their development into mature sperm. The tube which carries the sperm from the epididymis to the urethra is called the vas. Sitting around the urethra is a small gland called the prostate, which as well as the seminal vesicles (situated on either side of the prostate), produces fluid which forms part of the ejaculated semen. The urethra is a tube in through which semen and urine pass out of the penis. The sperm enter the urethra at the time of ejaculation.

What is Infertility?

Infertility can result from problems that interfere with any of the above fertilisation and implantation steps.With regular unprotected intercourse, a couple has approximately a 50% chance of conception within the first 6 months, 80% by the first year, and 90% within 2 years. Most experts define infertility as not being able to get pregnant after at least one year of trying.

Causes Of Infertility

There are many varying causes for infertility. These include:

  • Blockages in Fallopian Tubes (May be the result of infection, endometriosis, and sterilisation.)

  • Abnormalities within the uterus, such as polyps, a septum (a piece of tissue diving the uterus), and fibroids (tissue in the wall of the uterus).

  • Adhesions – Scar tissue which can form between internal organs causing them to adhere to each other, reducing their mobility. These can be a result of previous surgery, infection or endometriosis.

  • Previous sterilisation.

  • Polycystic Ovary Syndrome (PCOS). This is when the ovaries contain many cysts, causing some or all of the following; fertility problems, irregular menstrual cycles, excessive body hair, acne and obesity.

  • Failure of ovulation (May be related to PCOS or premature menopause).

  • Hostile Cervical Mucous

  • Abnormal Hormone levels

  • Varicocele. This is when the veins in the scrotum become swollen. They form a varicocele which may slow the blood flow away from the scrotum, causing the testes temperature to rise. This can reduce the quality, motility and number of sperm produced.

  • Vasectomy. This is when a man has had both vas cut in order to prevent sperm from entering the semen.

  • Obstructions within the vas or at the junction of the vas and epididymis.

  • Low Sperm Count

  • High numbers of abnormal Sperm

  • Antisperm antibodies

Diagnosis and Treatment

There are many different diagnostic tools used during the investigation of infertility. These may include:

  • Ultrasound – used to examine the pelvic organs using sound waves. It may be used to detect abnormalities within the uterus, Fallopian tubes and ovaries.

  • Hysterosalpingography (HSG) – used to detect a blockage in the Fallopian tubes, and possibly abnormalities in the uterus. A special dye is injected through a tube which has been passed through the cervix. X-rays are then taken to see if the dye completely fills the uterus and passes through the Fallopian tubes.

  • Ultrasound with HyCoSe – This procedure is very similar to the HSG, however a special sugar-based dye is used, and instead of x-rays, an ultrasound probe is inserted into the vagina to trace the path of the dye.

  • Hysteroscopy – Used to examine the uterus. A small fibre-optic 'telescope' is passed through the vagina and cervix into the uterus. The uterus can then clearly be seen. Polyps, fibroids and septums can be treated during hysteroscopy.

  • Falloposcopy – This is similar to hysteroscopy, however the telescope is passed into each Fallopian tube in turn. Used to examine the internal lining of the Fallopian tubes for any abnormalities.

  • Laparoscopy – Used to examine the reproductive organs lying within the abdomen. Carbon dioxide gas is pumped into the abdomen to separate the organs, and a fibre-optic telescope (laparoscope) is inserted via a small incision. Another incision may be made to allow a second probe to manipulate the organs. If an abnormality is found, 'keyhole' surgery may be performed. This avoids the need for a repeat procedure.

As there are many causes of infertility, there are also many treatment options. These can include:

  • Adhesiolysis – Removal of adhesions using specially designed instruments. Can be done using either 'keyhole' surgery, or if necessary, via a larger incision in the abdomen.

  • Salpingostomy – Used to treat a blockage at the end of the Fallopian tube. It can be done as 'keyhole' surgery or an abdominal incision. Any scar tissue covering the end of the Fallopian tube is removed, and the tube is then opened and turned back on itself so it will remain open.

  • Reversal of Sterilisation – either via 'keyhole' surgery or an abdominal incision.

  • Ovarian Diathermy – this is used to treat polycystic ovaries. Via 'keyhole' surgery, the ovaries are examined and then the cysts are destroyed by either diathermy or laser.

  • Drug treatment – Aims to restore the natural balance of hormones in the body.

  • Assisted contraception techniques – Such as IVF (in vitro fertilisation) and IUI (intra uterine insemination). IVF is the uniting of egg and sperm in vitro (in the lab). The embryos are transferred into the uterus through the cervix. The process is done in conjunction with ovulation induction through drugs, monitoring of hormone levels and follicle scans with ultrasound. IUI involves sperm being collected from the male, washed using special solutions, and then injected directly into the uterus using a special catheter.

  • Ovulation Induction - Ovulation induction medications, often referred to as fertility drugs, are used to stimulate the follicles in your ovaries resulting in the production of multiple eggs in one cycle. The medications also control the time that you release the eggs, or ovulate, so sexual intercourse, intrauterine inseminations, and in vitro fertilisation procedures can be scheduled at the most likely time to achieve pregnancy.

Treatments for men include:

  • Varicocele ligation – An operation to remove the varicocele. Carried out under a general anaesthetic.

  • Reversal of Vasectomy – Involves rejoining both vas (the tubes that carry semen from the testis to the urethra). It is performed under a general anaesthetic and a small incision is made in the scrotum. The ends of the vas are located and carefully rejoined on both sides.

  • Vasovasostomy – used to treat a blockage within the vas or at the junction of the vas and epididymis. The site of the obstruction is located using a special dye and x-ray, and the damaged section is then removed and the two healthy sections joined together. Done either via a small incision in the scrotum or a low abdominal incision.

  • Epididymovasostomy – used if a vasovasostomy is not possible. A cut is made in the vas on either side of the obstruction. The two cut sections are then stitched together, bypassing the obstruction.

  • Sperm retrieval – Collection of immature sperm from the vas, epididymis or testis. The sperm are then directly injected into the woman's egg to achieve fertilisation.

This is not a complete list of all of the causes, diagnosis and treatments for infertility, just a broad overview. Each individual is different and diagnostic and treatment options will vary from person to person. These will be discussed fully with the treating physician.