Modern methods of treatment for infertility problems
Dr.
Jeyarani Kamaraj
Bio-Data
Name : Dr. K.S. Jeyarani Kamaraj
Graduation : M.B.B.S., Madurai Medical College,
Post Graduation : M.D., Tanjore Medical College,
Specialisation : D.G.O, Madras Medical College,
Government : Omandur Public Health Centre,
Marakkanam Public Health Centre
Asst. Professor : Madras Medical College-Hospital
Director : Aakash Institute of Infertility and Research, Chennai
Indian Institute of Sexual Medicine, Chennai
Asst. Director : Stem Cell Research Unit, Aakash Institute of Fertility and Research,
Chennai - 26
Publisher : New World Publications, Chennai – 26
Gold medal during DGO
Dr. Vadamalaiyan Endowment Prize,
Rajamani Janakiraman Prize in Gynecology and Obstetrics
Dr. Ananthachari Prize for being University first in Medicine
Indian Medical Association
Federation of Obstetrician and Gynecologist
Association of Human Reproduction
v Importing the most modern laser device ‘Saturn Active’ for the first time in India and serving the public.
v Giving free consultation on infertility and sexual problems through Internet and SMS.
v Conducting for the first time in India, exhibitions on fertilization and sexual problems for seven consecutive years.
v Placental circulation – Conference of Anatomy
v Azygous venus systems – Conference of Anatomy
v Infertility causing sexual problems and sexual problems causing infertility – First International Conference on Sexology, Chennai
Articles
and columns published in:
English
dailies:
The Hindu, Indian Express
Tamil
dailies:
Dinathanthi, Dinakaran, Dinamalar, Dinamani, Eenadu, Dinaboomi, Tamilmurasu, Malai Murasu, Makkal Kural and Malai Malar.
Weeklies in
English and Tamil:
Kumudam, Kungumam, Ananda Vikatan, Rani, Devi, Kalki, Mangaiyar Malar, Vasantham, Health and Beauty, Health Time, Health and Fashion, Arogya etc.
Other
services:
v Aakash Institute of Fertility – Research on treatment for infertility problems and stem cell research
v Indian Institute of Sexual Medicine – Research on finding cure for sexual deficiencies and drug discoveries
v Indian Association for Sexology – Active member of the association that includes eminent members from all walks of life and strives to impart awareness on AIDS
v New World Publications – Publishing quality books
v Hormone Points – Distribution of medicines that would benefit issueless couples
*********
Sex and procreation are two important factors that have been responsible for the existence of life on earth; without them the world would have ceased to exist.
Sex has been the major driving force that had driven all forms of life into coitus leading to procreation. Infact, barring a few living species, most forms of life exist only till coitus and die instantly once their job is over. Only humans and a few others stay beyond their reproductive years.
Many claim to procreate in order to establish their dynasty, but in reality most feel they attain eternity by their successive generations or progeny. Science also does not deny this.
Progeny have remained the only evidences of existence for any form of life.
Wealth that was someone else’s yesterday could be yours today and someone else’s tomorrow. But your children are not like that. Your genes have come from your forefathers. Similarly, your genes are going to be with your successors.
But unfortunately, sometimes, some people are not able to transmit their genes to their next generation for certain reasons. That is some people are not able to bear children. This is called infertility or inability to produce offsprings.
It is estimated that both men and women are equally responsible for 80% of infertility problems and the remaining 20% due to other factors.
Why and how do these problems arise? How can we alter these problems to be able to have children? How does Science achieve what Nature has failed?
This book is going to tell us all about these things. This is going to bring new hope to couples languishing without children.
We are presenting here all facts about child birth from beginning to end based on scientific knowledge and the experience we gained by adopting different methods in our hospital, for ensuring fertility among hundreds of issueless couples.
We have in our hospital, facilities that can ensure a baby if there is a capacity to produce even one ovum in the female and one single sperm in the male. We also have facilities to evaluate the fetus when the fertilized embryo is in the16 cell stage itself and see if the baby is likely to have deformities.
You will see how effectively this treatment has brought down the number of couples who take religious trips to various temples or go around the Banyan tree or spend thousands of rupees for getting commonly available herbs in search of a solution for their problems.
We offer her a new dawn for those who are languishing with humiliation and anxiety over their misfortune. We have the latest in laser technology namely the Saturn Active in our Aakash Institute of Infertility and Research. This facility has been brought in to help out the rich, the middle and the poor like one.
What should I do to get treated by this machine?
We would like to say a few words to those who ask me the same question.
“Read this book first. Only when you are satisfied that this instrument could really help you, come to us”. This would prove what the contemporary Tamil poet Vairamuthu wrote as,
“Now a days, issueless couples
Do not go around the Peepul Tree;
They only go around the Aakash Infertility Centre”.
Now let’s begin our journey into each chapter.
Regards,
Prof. T. Kamaraj
Dr. Jeyarani Kamaraj
Index
Authors note
1. Are you ready to be a mother?
2. Reproductive organs
3. First meeting
4. Recognizing signs of pregnancy
5. What happens after fertilization?
6. Changes in the pregnant woman
7. Female infertility
8. Male infertility
9. Methods of diagnosis
10. Different treatment methods
11. Test-tube babies
12.
Total infertility and charity
13. Motherhood in old age
14. Hereditary disorders and modern treatment for them
15. Dr. Kamaraj- BIO-DATA
CHAPTER
1. ARE YOU READY TO BE A MOTHER
Everyone is eager to become a parent soon after marriage as a matter of duty. When parenthood is delayed they start investigating who is responsible for it; then they spend their time and money and energy on trying to solve it.
But, there are certain basic facts that everyone should know about pregnancy and childbirth; unfortunately neither the female who is to become the mother nor the male who makes a mother is bothered to learn about them.
This is because generally people tend to take pregnancy and childbirth very lightly as matter of routine.
Please remember that the physically handicapped, mentally handicapped and those born with congenital disorders in this world are languishing because their parents ignored these facts.
Instead of bearing a child who is born with congenital defects and regretting through a lifetime by looking at the child’s sufferings, would it not be better to plan well before the child is born?
There may be a few who may laugh at such a suggestion. For them copulation between a male and a female is more than enough to bear a child. For them planning a family may sound ridiculous. But the number of people who throng the hospitals and infertility clinics in the hope of their dream coming true someday is evidence to prove that copulation alone will not ensure a child.
Waiting for a child is important; but so is planning a family and being ready for the arrival of the new life. One should plan as to how to raise the child, responsibilities of the mother, the father, how to behave with the child, how to react to the child’s needs, how to protect, how to provide a healthy body and mind etc.
Many parents are not even aware that their physical and mental health could affect the growing fetus. Diseases, drugs and medicines, habits like smoking and liquor, occupational hazards of the patients could all affect the fetus and may cause congenital disorders.
The beginning period of pregnancy is a very crucial stage. By the twelfth week of pregnancy, the vital organs of the fetus like, brain, nervous system and heart would have begun to form. Many women are not even aware that they are pregnant during this period. During this period, any undesirable events or factors or illnesses could affect the fetus.
So, it is very essential to plan well before becoming a parent. When you know exactly when you are likely to become pregnant, you could start being very careful about adopting all necessary steps to ensure that the baby is hale and healthy.
We are going to talk about what all you should know before you become a mother.
Before motherhood check the following..
§ Are you old enough to be a mother or have you already crossed that age?
§ Have you got vaccinated for pox infections/
§ Is your blood group compatible with your husband’s?
§ When is it ideal to get rid of contraceptives?
§ Do you have habits like smoking or alcohol?
§ Are you exposed to any occupational hazards?
§ Is there likelihood of any hereditary problems?
§ When would it be possible to be fertilized?
§ How can we know when or whether the ovum has matured?
§ How long does it take for fertilization to occur?
§ Is it right to investigate the sex of the fetus?
Most couples are able to achieve conception without much strain or effort. But information about all the above basic facts, provides an insight into factors like, which is the right time for conception, what is the safe period, how to avoid congenital disorders etc.
The present generation is very particular about establishing themselves well in their profession before settling in life. In order to achieve this, they resort to all sorts of contraceptives.
They presume that getting rid of the contraceptive would automatically make them ready for conceptions. This is the first decision they take together as a couple. But ironically, this is not true though logically it is correct. If you have this impression, please try to change it. This is the advice of doctors like us. You may take about ten years to get yourself established in your career. By then, you would be in the early thirties.
You may ask me, “Why? What’s wrong with it?”!
Unlike the other organs, the female reproductive organs tend to mature very fast. Sometimes, menopause occurs even in middle age, thrashing all hopes of child bearing.
The chances of fertilization start diminishing from the age of thirty itself and become almost impossible after reaching forty.
The ova are also affected depending on the age of the female. An aged uterus reduces the chances of successful conception and pregnancy drastically.
On many occasions, late pregnancies created by artificial means do not remain stable. Complications arise and problems associated with ovulation seem to take the main position among them.
Other complications like improper ovulation, inability of the ovum to fuse with the defective sperm produced by an aging male and the subsequent destruction of the ovum could all follow one after the other.
When compared with this, conception during a younger age seems to be much simpler and easier. It is even possible to implant the ovum from a young female in to the uterus of an elderly female. But women generally do not consider this option.
So the ideal age for planning child bearing and for enjoying every moment associated with it is between 20 and 30.
Conception beyond this age always is associated with some sort of complications. Chances of conception between thirty and thirty years of age are almost half of the chances during the twenties.
Several researches have been conducted to find out the right combination of the woman’s age and successful conception and the ultimate result was that highest rates of conception occurred between the ages of 19 and 25.
These were as far as the woman is concerned. In case of the man, several factors like habits, life style, occupational hazards and tensions reduce the capacity to produce sperms. So the sperms lose their virulence to impregnate the woman or are highly defective. So, planning the family early in life would be better than regretting later.
Vaccination
against pox infections:
It is very unfortunate to be affected by German Measles during pregnancy. When the mother is inflicted with this ailment during pregnancy, it affects the fetus in many ways.
Affliction of the mother during the first trimester can damage the development of the heart and nervous system resulting in congenital disorders connected with the heart or mental status.
Disabilities and impairment could be anything like, deafness, blindness or premature birth or stillbirth.
Now, don’t you think that the mother should have got herself immunized against this infection with a vaccination?
You should check whether you’ve had yourself immunized. If not, then you should insist with your doctor for getting yourself a vaccinated. This is a commonly available injection. Remember you should avoid conceiving for the next three months.
If you have conceived without being vaccinated and there is chance that you might have contracted the infection from someone during pregnancy, you should inform your doctor immediately and get your blood examined.
You should know if you are infected or whether you have enough resistance power to tackle the infection etc.
Two blood tests spanning a fortnight would be enough to confirm if you are infected. If so, the best thing would be to medically terminate the pregnancy.
Blood
compatibility or Rh compatibility between the couples:
The husband and the wife may have their blood Rh as positive or negative. If the husband has Rh +ve type and the wife has Rh-ve type then there are chances that the child may be affected. Mostly, the first child is not affected, but the subsequent child may be even fatally affected. Early detection of this compatibility would eliminate this possibility.
If you are on contraceptive pills then it is better to plan conception three months after stopping the pills. Till then pregnancy can be postponed with the use of other contraceptives like spermicidal jellies etc. In these three months, the hormone balance would be restored in your body.
When the menstruation cycle is restored to normalcy, you may get ready for conception and stop using the contraceptives.
Getting rid
of habits:
Hazards to the fetus by smoking are many. The growing fetus may develop with deformities or may be still born. Mostly, babies born to smoking mother weigh less than normal children by at least 200gms.
Nicotine from the cigarettes you smoke is transmitted to the growing fetus. The carbon monoxide formed when gets in to the child’s circulating system becomes deprived of oxygen. Chances of premature delivery and abortion increase. The complications are likely to continue even after birth.
Most of our women do not smoke; but most husbands do. This would tend to result in faulty sperms, which could result in malformation of the vital organs or in excess growth. When the pregnant mother and the growing fetus are exposed to smoke through the father, they become passive smokers and all the damages are done.
It would be ideal to quit smoking well before conception. Either of the smoking parents should try by refraining from smoking for a day. Then try for two more days. This way the habit can be totally stopped.
Whenever you feel like smoking, try to divert your attention to something else. Try something that will not give you time for even thinking about it.
Avoid
alcohol:
A few women take alcohol in our community too. Alcohol causes damage to the developing fetus during the first three months. Alcohol from the mother’s blood gets transferred to the baby’s blood through the placenta. You have to quit alcohol if you want a healthy baby.
Be alert
whenever you take any medicine:
Most of the allopathic medicines can cause side effects. This can affect the fetus in many ways. Some of the alternate medicines are also likely to cause this. Medicines that you take even without being aware that you are pregnant can also do the damage.
So if you are on medication for a chronic ailment for a long time, inform your doctor well before you plan your conception. Nervous problems and diabetes require extra care during pregnancy.
Even if you were healthy, it would be most ideal to avoid any kind of medication even if prescribed by an efficient doctor.
Hazards from
workplace:
Environment in the working place can also affect the growing fetus, especially, places like, chemical laboratories, factories where noise pollution and vibrations are in excess, atomic and nuclear plants, operation theatres, occupation involving radiation like X-rays etc. If the pregnant woman happens to be working in any of these environments, the chances of their affecting the fetus are very high.
Men, when working in such environments are likely to produce less or faulty sperms or suffer from impotency.
Chemicals involving radiation, lead, mercury and benzene and strenuous jobs are likely to cause more damage.
Those working in such environment should avoid exposure if possible a little before conception and definitely during pregnancy. When there is a doubt of exposure, get yourself examined and try explaining the situation to the higher authorities and try taking a transfer to some other safer sections till the child is born or take leave.
Hereditary
factors:
Features like, the structure of the nose, color of the eye, color and texture of the hair, complexion are transferred from the parents through genes. Similarly, certain other undesirable factors may also be transferred to the next generation. For example, muscle dystrophy, hemophilia etc are diseases that can be transmitted to the baby through genes. You should find out from the doctor what is the likelihood of the baby being affected by this if either of you is suffering from any such transmittable ailments.
Damage to the baby may vary depending on if one or both parents are affected. Some defects can occur if there is change in just one gene. If others in the family have a history of such damages it may well indicate that the children may also affected.
Anemia, pancreatic disorders, erythrocytopenia, nervous disorders, muscle dystrophy, osteoporosis, kidney disorders and diabetes are some common hereditary disorders.
Sometimes the parents may not be affected but the gene would have been transmitted from the previous generation through the parents. When both parents are afflicted, damage is definite in one out of four children. Prominent among them are, Albinism, cystic fibrosis, anemia due to red cell destruction, Wilson’s syndrome etc.
Sex related hereditary disorders could be subdivided into two. Some of them affect both sexes and some are transmitted only the males and not the females. For example, anemia due to red cell destruction.
Changes in the genes are referred to as mutations. If we start listing the diseases that can happen due to gene mutations, it would be too long. Examples are, cleft palate and cleft lip, heart diseases, bent feet, convulsions and fits, depressions and mental instabilities, mental retardation, failure of the kidneys, deafness, disorders in the pelvic bone and the spinal cord etc.
When one of the parents is affected by any of these syndromes, they must definitely take the doctors opinion before planning conception. Consultation with gene biologists can give a better insight.
Earlier, such damages were detected by taking the amniotic fluid or a small piece of the tissue by biopsy. Now a days, it is possible to detect such damages when the fertilized embryo is in the 16-cell stage itself. Facilities for this are available in our hospital itself.
The sperm has a life of 48 to 72 hours. The mature ovum has a life of 24 hours. Conception is possible only when fusion takes place between the ovum and the sperm within their life span or ovulation should occur within the time the sperm is alive and within the uterus.
If you have a regular cycle of 28 days, calculate your next menstrual period. In the same way, the time of ovulation can also be calculated. If you get your periods more or less on the stipulated date, then we can infer that the cycles are regular. If periods are erratic then we should know that there are certain problems associated with it.
Usually, ovulation occurs on the 14th day from the beginning of the cycle of the previous month.
(Figure on Page 14)
Formation of
Mature vesicular
Ovulation
Corpus luteum Ovum
follicle Body temperature Menstruation
period
Calculating the time of ovulation by measuring changes in the body temperature
There is a method to calculate the time ovulation by measuring the body temperature also. The body temperature decreases a little during ovulation and then increases to normalcy. When you have difficulty in conceiving then try the following method. Start recording your body temperature regularly from the first day of the cycle. Consult your doctor regarding this.
There is another method following the mucus secretion that is usually associated with ovulation. There is secretion of mucus from the mouth of the vagina a little before ovulation. Many people assume it to be white discharge. This is actually an alteration to allow free entry of the sperms. This also can be used as a parameter to find the right time for conception.
Many people assume that fertilization occurs immediately after copulation or wish for it. While it is possible in some, it gets delayed in some.
We need to wait for at least a year before we start investigating the delay in conception. The defect may be in either partner. In women it could be a blocked Fallopian tube or improper ovulation etc.
In the male, it could be insufficient or lack of production of sperms or block in the Vas Deference.
Sometimes, the reason could be purely psychological.
Any kind of problem can be treated and eliminated through the modern techniques that are currently available to achieve effective conception.
No. Even the doctor cannot say that. The sex of the fetus is dependant on the type of the chromosomal features of the sperm. Ancient stories and contemporary quacks claim that it is possible to have a baby of desired choice. It would be better to call them baseless than to go researching on them.
Whatever we have said so far are basic facts that both the parents require to know before planning a baby.
Knowledge of these facts would protect you and your future generations from complications, diseases and congenital disorders.
Now you are ready for conception and pregnancy.
Now lets learn about the organs of reproduction in the next chapter. This will improve your knowledge about the functions, importance and care of the body parts.
CHAPTER 2. ORGANS OF REPRODUCTION
Any fusion is possible and is complete only when the two fusing bodies meet. You may remember the first time you both have met and married and the nuptial night. But have you ever thought of the first meeting between the sperm from the male and the ovum in the female?
How does the sperm meet the egg?
Where did it happen?
How did fertilization occur and how did it get implanted?
How does the sperm know to meet the egg?
Knowing answers for these questions would improve your knowledge about the parts of the body in a scientific way. For this, we should first learn about the amazing organs that are involved in this act of reproduction since millions of years.
This will provide an insight into the process of fertilization, chances of conception and methods of contraception etc. More over, you will be amazed to learn about new things about your own body, which would make it all the more interesting.
Female
reproductive system:
The female reproductive system is a wonderful almost magical piece of Nature’s creation. It can be divided into two parts namely, the internal and the external parts.
The external parts The external parts begin with the vulva or the female genital organ. The elevated mound in this region covered with pubic hair is called the mons pubis. Surrounding them are thick lip like structures called the labia majora. Inside them, close to the vulva are situated thick structures called the labia minora.
Anteriorly, where the two lips meet. Just below this meeting point is situated a knot like structure called the clitoris. Below this is the urinary opening namely the urethra and below that is the vulva or the vaginal opening.
All these are referred to as external parts or genitalia.
The internal
parts:
This begins with the vulva. Knowledge of the structure, function and the possible damages to these parts could well make you understand the process of fertilization.
The vulva as we saw is situated between the urethra and the anus. This is the gateway for the female reproductive system.
There is a fine membrane covering this passage called hymen. This is usually intact in virgin women – those who have not been involved in sexual intercourse. But the membrane is porous enough to permit the flow of the menstrual discharge. An intact hymen was thought to prove the virginity of the female.
In reality not all true virgins have an intact hymen. Some may have a nonporous hymen (maturation in delayed in such women). In some pores may be more or bigger in size. In some, the membrane could have ruptured during birth itself. Cycling, athletics and accidents can result in the rupture of the membrane.
The tube following the hymen is called the vagina. This is a muscular structure measuring about 7 – 8 cms in depth.
The tube is constricted before copulation and is capable of expanding a little during copulation and very well during childbirth after which it shrinks back to its original shape.
The vagina is always moist. At the mouth of the vagina is a pair of glands called Bartholin’s glands whose secretion prevents entry of infecting micro organisms into the vagina. It also provides the necessary lubrication during sexual intercourse.
Figure on page 20
Fallopian tubes
Uterus
Ovaries
Endometrium
Cervix
Vagina
Clitoris
Urethra
Vulva
At the end of the vagina begins the uterus, which is the actual reproductive organ. Beyond this is situated the Fallopian tubes and the ovaries. Let’s see about them individually in detail.
Uterus:
This is made of muscle fibers. The anterior is broad and the posterior is narrow. The narrow tapering portion is called the cervix. The broad upper portion is called the fundus. The middle portion is called the myometrium, which has striated muscles. These are responsible for implanting the fertilized ovum and for ensuring regular cycles.
The total length of the uterus is about 7.8 cms; breadth 5.6 cm and thickness 3.4 cm.
When the fertilized ovum gets implanted and grows, the uterus also grows along with it. During labor, the contraction of these muscles causes pain and results in the delivery of the baby.
The uterus has three openings – two anterior and one posterior. The two anterior openings are on either side connected with the Fallopian tubes and the lower opening is connected with the cervix.
Fallopian
tube:
A pair of Fallopian tubes exists on either side of the uterus. Each is of a length of about 10 cms. It can be divided into 4 parts. The portion lying within the uterus measures about 2 cms opens into the uterus and functions as the gateway. The next 2 or 3 cms, is the constricted isthmus followed by the curved and globular ampullae. The end portion is curved and broadens facing the ovary. Through this opening the ovum travels to the uterus.
These tubes are also responsible for ensuring the fusion of the egg and the sperm. The inner lining of the Fallopian tubes are covered with fine hair like cilia. They facilitate the movement of the eggs to the uterus.
Usually, the fusion of the egg and sperm happens within the Fallopian tubes and forms a fertilized zygote. This moves on to the uterus and gets implanted. Block in the Fallopian tubes prevents such functions and as a result conception becomes problematic.
Ovaries:
The ovaries are responsible for maturation and menstruation in a woman. A pair of ovaries is situated behind the uterus, close to the mouth of the Fallopian Tube on either side.
Figure
Fallopian tube, maturation of the ovum
Each ovary measures about 3.5 cm in length and 2 cm in breadth and 1 cm in thickness and weighs about 6 gms. The diameter measures about 15 mm. The ovary is divided into an external cortex and the internal medulla. The external cortex holds millions of immature ova. They mature slowly and reach the anterior of the ovaries in about 2 weeks time and are released. This is called ovulation. When fusion with a sperm occurs at this time, conception occurs.
The medulla is made up of blood vessels, nerves and lymphatic vessels.
The ovaries are generally smooth in a young girl and after maturation, become irregular. Is it not amazing that what paves the way for the propagation of the whole mankind is situated in something that is only 6 gms in weight.
When does the ovary start producing eggs? Many of us think it is only after maturation.
As soon as the sex of the fetus is determined the ovaries start producing eggs. That is when the embryo is only 21 days old and measures only 2 mm in length it starts producing the ova. Imagine an embryo that is only half the size of a match head; it has a pair of ovaries and that produces eggs!!
Though the ovaries are present and are producing eggs, they are not mature which happens only during maturation. When all the organs are mature enough to bear the embryo, the girl undergoes bodily changes and matures into a beautiful young lady.
During this period the hormones are hyper active. The primary endocrine gland namely the pituitary starts secreting the hormones directed towards the ovaries and commands them to get ready for maturation of the ova. Following the secretion of the pituitary hormones, the uterine hormones and those controlling menstruation are secreted and start functioning. Together they are called Follicle Simulating Hormones (FSH).
Stimulated by the hormones, the eggs start maturing and get released from the ovaries. In contrast to the male who releases millions of sperms with one ejaculation, the ovaries release only one mature ovum during a span of 28 days. If it fails to fuse with a sperm it gets degenerated and the ovum releases another mature ovum. But if fertilization occurs, the ovaries stop producing ova but start processes that would facilitate the growth of the embryo.
Following ovulation the empty space gets filled up with follicles and blood and becomes thick. This is the reason why a few women suffer from uterine cramps following ovulation. Sometimes pain can be caused by the increase in size of the follicles. Some women calculate the time of ovulation from this pain. But this is only a crude method.
The thickened follicle and blood take the place of the striated fibers. This is called corpus luteum. In the absence of fertilization, the corpus luteum ruptures in 10 days and the waste material is expelled as menstrual discharge.
In the event of fertilization, it starts producing the necessary hormones required for the growth of the embryo. Till about the 20th week of pregnancy, the corpus luteum performs the function of the placenta, which is formed later. Later the corpus luteum gets degenerated.
The remaining granulosa cells start secreting progesterone, which is essential for the implantation of the embryo in the uterus. In the initial stages, the level of progesterone secreted by the corpus luteum is sufficient for the growth of the embryo. Sometimes degeneration of the corpus luteum results in degeneration of the embryo and subsequent miscarriage.
Hormones:
Hormones play a major role in all the changes that occur within the reproductive system. Knowledge of these hormones and their functions is absolutely essential for understanding the complex processes of conception, pregnancy and childbirth.
Unlike blood that is carried through vessels to all parts of the body, hormones join the blood stream directly. The glands that secrete hormones are called ductless glands or endocrine glands.
The pituitary functions as the chief of all these endocrine glands. This is controlled by the thalamus of the brain. This controls the functions of the body directly through its secretions and indirectly by stimulating other glands.
The frontal portion secretes the gonadotrophine hormone or sex-stimulating hormone. Gonadotrophine in turn stimulates the production of Follicular stimulating hormone (FSH) that triggers maturation of the follicles and the Lutinizing Hormone (LH) that prepares the ovaries for fertilization. In addition it also secretes the hormone prolactine, which stimulates milk production.
When the girl reaches the right age for maturation the pituitaries command the ovaries to prepare for production of ova. At this time, FSH triggers the inactive follicles (immature ova) to grow into mature ova and their release as ovulation.
The ovum that matures rapidly first at the stimulation of the FSH gets released during ovulation. The rest, degenerate at their original site itself.
When FSH triggers the follicles the primary granulosa cells multiply in number. These cells surrounding the ova arrange the follicles in make them perform two types of functions. First, they provide nourishment for the eggs and protect them. The granulosa cells surround every single ovum of the 7 lakhs ova inside the ovary and perform this function.
Secondly, they secrete the female hormone estrogen. This, in turn results in increase in the size of the breasts, reduction in size of the hipbone and other sexual characters.
When estrogen reaches the brain through circulation signaling the maturation of the follicles, the pituitary secretes LH. Ovulation occurs within 36 hours of secretion of this hormone.
This kind of secretion of one hormone resulting in the secretion of another is called as Feed-back Mechanism.
When this process in intact, maturation and ovulation are undisturbed. The ovum would then have the required number of chromosomes, would be capable of closing upon the entry of one sperm. Otherwise, immature and faulty ova get released resulting in the formation of defective fetus.
This is why hormone tests that are done to confirm conception are done only after ovulation.
Let us now see about the immature ova that get released.
Eggs or Ova:
These are the largest among the cells in the human body. We have already seen that the female embryo is capable of producing eggs and has something like 7 lakhs immature ova in it. The size of the ovum is about one tenth of a dot made by a micro tip pen.
How are these eggs formed?
The ovary consists of primordial germ cells. Ova develop from these cells. These cells originate from the yolk sac surrounding the ovary, accumulate and move towards the uterus. They move in to the ovaries and transform into part of the egg cell. Once the ovum gets fertilized they develop into the placenta. Otherwise, they degenerate just like the unfertilized ovum.
When the female embryo is about 5 months old, the germ cells start forming and about 7 million (7lakhs) of eggs are present in it. When the baby is born the number gets reduced to about 3 million. The rest get destroyed. When the girl reaches maturation, about 4-5 lakhs of eggs remain.
Not all eggs mature during the reproductive years. Only about 400-500 eggs reach maturation. Even if the woman bears children continuously, she can produce at the most 30 children.
Every month, on the 14th day after menstruation, when the degenerated eggs and the uterine wastes are expelled another egg matures and gets released. It reaches the uterus through the uterine tubes called the Fallopian tubes.
The tubes in turn are capable of contractions that enable the egg to reach the uterus safely. The egg waits in the uterus for about 24 hours.
What does the egg consist of?
The egg has 23 chromosomes, exactly half of the 46 chromosomes that carry all the traits that we have acquired from our ancestors. All these are the X type chromosomes.
Now lets see in detail about the Male Reproductive System
Only those who have studied subjects that deal with the structure and function of the body parts like anatomy and physiology know that a world operates within every body.
Just like physical functions, the body performs several functions internally also. Be it a big organ or the invisible gene, each one is performing a function of its own between its birth and death. The functions of all the cells and the organs put together constitute the body’s function.
Sperms also perform a similar function. It shares an equal responsibility with the egg in producing an embryo. Just like the egg is formed and gets matured, so also the sperm is produced and reaches maturation in stages.
The male reproductive organs do not perform as many functions like the female reproductive organs. Yet, they produce the sperms that are vital for fertilization and procreation.
The
male reproductive system is made up of the scrotum, the testicles, the
seminal vesicles, the epidydimis, the vas Deference, the
prostates and the penis.
Figure
Urinary bladder
Seminal vesicle
Vas Deference
Prostates
Epidydimis
Prostates
Penis
Scrotum:
This encloses the seminal vesicle, testicles, epidydimis and the vas Deference and protects them. Every male has a pair of these.
The testicles are situated within the abdomen when the male fetus is still in the womb. During delivery, they get distended from the body in to the scrotal sacs.
Why should men have their sexual organ away from the body?
The normal temperature of the scrotum is between 85 to 95o Fahrenheit which is much below the normal body temperature. The blood vessels surrounding the scrotum are in a complex web formation. So when blood reaches this area it is naturally much cooler. At a higher temperature the scrotal sacs get further distended away from the body and become soft and tender. Similarly, when the temperature is colder, they get closer or into the body.
Testicles:
These are responsible for the male characters in men. Growth of facial hair, change in the voice, sexual desires - are all because of these parts.
The testicles of a male fetus are not in the scrotal sacs. Instead they are in the peritoneal cavity but get distended into the scrotum only a few weeks before delivery. This is the reason why in premature male babies, the testicles are not initially seen in the sacs but appear later.
Each testicle is about 1.5 inches long, one inch broad and weighs about an ounce. The diameter is about 1.25 inches.
In most men, the left testicle is heavier than the right one. So it hangs a little more. Though the reason for this is unknown, it prevents them from rubbing each other while walking.
Emotions like, fear, anxiety and stress can also cause the testicles to come closer to the body. It is the same during sexual intercourse, facilitating ejaculation.
Figure
Epidydimis, blood vessels, vas Deference, seminiferous tubules, testicle.
The testicles have two types of functions. First is to generate sperms from teenage till death. Second is to secrete the male hormone androgen.
Each testicle has more than two hundred of tiny minute cavities. Each consists of two or three seminiferous tubules. Sperms are produced in these tubules. The tubules form a complex web, which is called Rete testis. Here all the secretions required for the growth and maturation of the sperms are secreted. These tubes are connected with the efferent ductus. About eight of such efferent ducti join together to form the epidydimis.
Epidydimis:
This measures about 40 feet in length if unwound. This is the training ground for the sperms. Epidydimis secretes the fluids that nurture the sperms, aid their maturation and make them motile. It takes about 2-3 weeks for the sperms to mature. Sperms start moving on their own only when they come out of the epidydimis.
The role of the epidydimis in reproduction is significant. Any block in it or damage to it can affect the sperm production in the testicle on that side. Damage on either side could cause infertility.
vas
Deference:
This is connected to the epidydimis and measures about 16 to18 inches. It is muscular tube about 6 mm thickness. Sperms reach the seminal vesicles through the vas Deference and through the prostates reach the urethra for expulsion. During ejaculation, the urethra and the urinary bladder close. Only then the semen can be released. A healthy male is capable of producing about 200 million sperms a day.
Seminal
vesicles:
They function as the warehouse for the sperms that are come through the vas Deference. But they cannot hold all the sperms that are produced. When the level exceeds spontaneous or involuntary ejaculation occurs. This is usually thought to be caused by wet dreams and waste of sperms. In reality, it is not a deficiency but only a sign of the normal functioning of the body.
Prostates:
Many people do not know about the existence of this part nor its function. When someone gets prostate cancer after the age of 50, they come to know of the organ.
This is situated around the neck portion where urine comes out of the urinary bladder. This secretes a viscous fluid. The seminal vesicle secretes another fluid. Both together constitute the semen.
About 95% of the semen is secreted here. Damage to the prostate and the seminal vesicle can also cause infertility.
Semen:
The fluids secreted by the prostates and the seminal vesicles together constitute semen. Urinary secretions also play a role in its consistency. It is viscous and slimy.
This provides the sperms motility that is essential to make them move towards the egg. It also helps to keep the sperms stable for about 30 minutes after ejaculation. Semen starts liquefying beyond this time limit. If the sperm is able to reach the ovum within this time, then fertilization can occur.
Sperms:
Sperms are produced only after the age of maturation in the male unlike the female who produces the eggs inside the womb itself. Sperms are the smallest living human cells. They appear like tiny missiles.
It has an oval head, a body and a long tail. The head portion has the chromosomes that are required for transmission of genes. They decide whether the baby is going to be male or female.
Though the female ovum has chromosomes it is the male chromosomes that determine the sex of the fetus.
In 1678, Antony van Leuwenhock examined the semen through his microscope and described the presence of sperms that were capable of moving. In 1667, Louis Home examined the sperms of gonorrhea patients through his microscope.
During the time of this discovery, many people created a flutter by proclaiming discoveries of sperms in their semen and also that they were capable of finding the sex of the sperms through the appearance of the head portion.
Microscopes that are currently available are capable of giving all details about the sperms but not the sex that it is going to determine.
The head of the sperm has a scarf like structure called the acrosome. This is intact till the sperm pierces the ovum. The body of the sperm is highly complicated. It provides the sperm the body and controls it. The tail provides the necessary motility. As the sperm approaches the ovum the movement of the tail increases greatly.
Sperms can be alive up to about 38 hours after ejaculation. But die immediately when they come into contact with water. They can be preserved frozen for years. They can still fertilize the egg.
Penis:
This is not just an organ for excretion of urine but also functions as the vehicle to transport the sperm in to the female system. It is in a flaccid state normally. During intercourse, it becomes thick and erect facilitating entry in to the female organ. It is made up of muscles and nerves.
During the peak of intercourse or upon reaching orgasm, the forcible action at the base of the penis causes the rapid ejaculation of the semen. Rarely, failure of these muscles to function can result in infertility.
Normally about 8 ml of semen is ejaculated. Only then sperms can be transported to the uterus for fertilization to occur. When this volume gets reduced the male’s capability to impregnate the woman is highly reduced.
The penis is not uniform in size in all the males. Many males are of the opinion that sex is possible only when they have a long penis. But this is not true.
Let us now see about the first meeting between the male and the female gametes.
We needed to know in detail about the male and the female reproductive organs in order to understand where, when and how the fusion between the two mature gametes takes place.
If the male or the female harbors both the ovum and the sperms then they can meet at any possible moment. But in humans, the female has the ovum and the male has the sperms. Many a times, the two degenerate without having a chance to meet the other. The degeneration of the ovum is expelled as the monthly menstrual flow.
This represents the readiness of the female reproductive system to bear the child. Every month the uterus prepares itself for the fertilized ovum and in the absence of fertilization, expels the unfertilized degenerated ovum along with other products as menstrual flow in order to clear itself.
Menstruation is nothing but the uterine waste products being expelled from the body. This continues in the female every month unless she is pregnant.
It begins at about the age of 13 and continues till about 50 or 55. The cycle repeats every 21 to 40 days. Only less than 15% of females have the correct cycles of 28 days. In the others it could be anything between 23 to 34 days.
A healthy female has a discharge of about 80ml of blood spread over a period of 5-7days. It is more during the first few days and gradually decreases.
Menstruation can be divided into,
Time
of Follicle stimulation,
Period
of ovulation and
Period of conception.
Follicle
stimulation and proliferation:
The pituitary secretions from the base of the brain that stimulate the ovaries trigger the maturation of about 3 to 30 ova in the ovaries. Each ovary comes up with one mature ovum. The ovaries also secrete the progesteron hormone’ that would enable implantation of the fertilized ovum in the uterus and the corresponding functions.
Ovulation:
This occurs about 2 weeks later when the hormone regularizing fertilization is secreted by the pituitary gland. This facilitates release of one mature ovum from the follicles. The released mature ovum reaches the ovary through the uterine tube.
This refers to the period following ovulation. It extends over a period ranging from a fortnight to the onset of the next menstrual cycle. In the event of fertilization this phase comes to an end. The follicle from which the ovum was released forms the corpus luteum. This facilitates the process of fertilization.
During ovulation the body temperature goes up a little. Coitus during this period can aid in successful fertilization. The corpus luteum secretes the Luteinizing hormone, which controls menstruation. Together with the uterine hormones they aid the uterus to receive the zygote (fertilized ovum) and develop it into the embryo.
If the sperm is able to reach the ovum within 24 hrs after copulation, fertilization would be successful. When the ovum is unfit for fertilization, the corpus luteum gets destroyed. The secretion of the hormones gets reduced. The uterus expels all the waste as menstrual flow.
You must have read in novels or seen in films or in real life, the kind of hardships lovers undergo to see their beloveds. Some of you might have undergone the difficulties yourself.
Similarly, the meeting between the egg and the sperm is also not an easy task.
At the end of sexual intercourse, about 100 to 200 million sperms compete with each other to fertilize the ovum though only one sperm is enough to do so. Each would be carrying different combinations of genetic factors and hereditary aspects. All of them would hurry to reach the ovum first.
Figure
Sperms competing to reach the ovum
The sperms face many hurdles right from the vulva to the mature ovum. The first one is the acidic pH in the vagina of the female due to secretions. Almost 50% of the sperms are killed because of this at the time of ejaculation itself. These secretions are meant to ward off bacterial infections and also to function as lubricants during copulation.
The next are the WBCs, which are positioned in order to protect the reproductive organs. They start engulfing the sperms as though they were foreign bodies. Sperms escaping the WBCs are trapped by the viscous secretions at the uterine cervix. Though these secretions also aid in the movement of the sperms further up, the already damaged sperms die while floating in this fluid. Only about a hundred to two hundred sperms cross all obstacles and reach the Fallopian tubes.
From here, the sperms cannot move on their own. The contractions and relaxations of the tubes safely transport the sperms towards the ovum. This takes from 5 minutes to a few hours.
The chemical odor from the ovum navigates the movement of the sperms. The successful sperms release other chemicals to pierce and enter the ovum. Enzymes are released by the acrosome to rupture the inner Cumulus oophorus and the outer Zona pellucida layers that cover the ovum.Though many sperms pierce the external layer of the ovum only one sperm enters the egg. Immediately after the entry of the sperm the ovum tightly closes itself preventing entry of other sperms. It also releases other chemical substances that prevent further entry. Slowly, the other sperms die lying in wait. In the mean while, fusion of the genetic material namely the 23 chromosomes from each takes place resulting in the formation of 46 chromosomes. This stage is referred to as the zygote. The zygote starts moving towards the uterus.
It takes about 4-5 days for the zygote to reach the uterus. By then, it would have reached the multiple cell stage.
Fusion between the ovum and the sperm is not always possible. The sperm has a life span of nearly 48-72 hours within which time it should have reached the ovum. The ovum has a life span of nearly 24 hrs. It should have taken up the sperm by then. When the two events are not possible fertilization does not occur. The degenerated ovum and the sperms are expelled as menstrual discharge.
We just saw that the zygote takes about 4-5 days to reach the uterus. At this free-floating state it releases certain chemical changes. They are signals that prepare the uterus for implantation of the zygote. It takes a week for the zygote to be implanted in the uterus. This period is characterized by certain symptoms.
These symptoms are caused by hormonal changes that follow conception.
§ Discontinuation of menstrual cycle
§ Nausea and vomiting
§ Fatigue and tiredness
§ Frequent urination during the day and the night
§ White discharge even when there is no ulcer or inflammation
§ Irritability at certain aromas
§ Changes in the breast like increase in size, heaviness, mild pain, color changes in the areola
§ Feeling of constipation
§ Craving for tamarind, mangoes and ash
When such symptoms are seen you should exercise great caution. The initial few months are crucial. This is the period when the babies’ brain, heart and the nervous systems are formed along with limb formation. Consumption of medicines and X-rays should be avoided as much as possible. Habits like smoking and alcohol should be stopped immediately.
The first symptoms usually occur independently or in combination with others. Pregnancy should be confirmed by laboratory tests since even other complications could sometimes exhibit similar symptoms.
Let us see some of them for example.
Discontinuation
of menstrual cycle:
The first symptom of conception is the discontinuation menstruation. But for some women menstruation continues for 2 or 3 months even after conception. Or menstruation stops even without conception.
Physiological disorders or disease conditions may be responsible for this kind of erratic cycles. Situations like moving in to new places, beginning to work in a new environment, end of teenage, tension and anxieties, or hormonal dysfunction preventing the timely ovulation processes can all induce discontinuation of menstruation.
Among disease conditions, chronic diseases, anemia, nutrition deficiencies, obesity, nervous diseases like anorexia nervosa etc can trigger improper menstruation.
Hence, discontinuation of menstruation alone cannot confirm pregnancy. Women who conceive during lactation (while they are still breast feeding their babies) or women who conceive while approaching menopause fail to realize they have conceived.
Fatigue:
Many women experience morning sickness, unusual tiredness, heaviness in the head during evenings. Mostly such symptoms disappear soon. In some women they appear either too early or only in the 12th week of pregnancy.
Morning
sickness:
Women who conceive for the first time experience this. Consecutive pregnancies may not manifest this kind of reaction. Usually this begins during the second month of pregnancy. Morning sickness along with discontinuation of menstruation more or less confirms pregnancy.
It is usually manifested by nausea, vomit or vomiting sensation in the morning or after food. The very thought of food can cause giddiness. This is found only in the morning and becomes all right later but reappears the next morning. The onset can be the next day after the first missed menstrual cycle or two weeks later.
This symptom is caused by the excessive secretion of estrogen, by the follicle after the fusion of the egg and the sperm. The exertion caused by this slows down the function of the stomach as a result of which food appears to have clogged the chest and there is a feeling of puffiness. There is a tendency to avoid food. Despite this, the craving for unusual foods like unripe mangoes, ash and coal continues. This is because the body is tuned to acquire enough food for herself and the growing fetus. So changes occur in the food pattern in the beginning stages of pregnancy. Some women have increased appetite, and some women have loss of appetite.
Frequent
urination:
Pregnant women have urges for frequent urination even when there are no infections or the bladder is not full. This is due to inflammations caused in the pelvic regions due to pregnancy. Such tendency sets in during the second or third month of pregnancy. The uterus expands due to the growing fetus, which presses the urinary bladder as a result of which such a tendency develops. This continues for sometime after which the system gets regularized.
Changes in
the breast:
First pregnancy causes many changes in the breasts. The blood vessels and secretary glands expand in size. The nipple becomes elongated and thick. There is mild pain to touch. There may be secretion of a yellow fluid sometimes.
Such changes in the breasts can occur even in conditions like ovarian cysts. So this symptom also cannot always confirm pregnancy.
Changes in
the body weight and mental make up:
Many women go into depression in the initial stages of pregnancy. Some women experience unusual but perennial headache on one side. Mostly women begin to gain weight but some may begin to lose weight.
Expanding
abdomen:
When the fetus grows the abdomen begins to increase in size above the pelvic region. Many a times, the baby’s movements can be felt especially from the 18th or the 20th week of pregnancy.
Tumors also can result in the enlargement of abdomen and movements.
We now know that all the symptoms can be felt during pregnancy as well as in other conditions too. So it would be ideal to opt for investigations that would confirm pregnancy specifically.
Scientific
methods for confirmation of pregnancy
A doctor can confirm pregnancy by recognizing changes in the female genitalia, growth in the uterus and the texture. Still better are laboratory tests based on urine examination, hormone tests and ultrasound tests.
Urine examination:
There are now kits available for testing the morning urine. These kits are now available in medical shops also. The kit also explains how to read and interpret the results. This can be done to confirm pregnancy.
Hormone tests:
The most reliable test is done two weeks from the date of missed menstrual cycle. The urine of a pregnant woman contains human chorionic gonadotropic hormone. Its presence is tested using its antisera. Formation of clumps when the reagent in the kit and the urine are mixed indicates absence of pregnancy and vice versa.
But we should remember that false positive results could be obtained if the urine is slightly turbid or when mixed with blood.
Ultra sound testing:
This method can accurately detect pregnancy in the fifth week after the date of missed menstruation. The method recognizes fetal heartbeat accurately in the eighth week of pregnancy. The method can also recognize other growth changes within the womb. So this is the most sought after method for confirming pregnancy.
Quickening test:
In the fourth month of pregnancy, the fetus develops a kind of pulse in the mother in the lower abdomen. This helps in calculating the time of delivery. Feeling this pulse intra vaginally or on the abdomen can also help.
CHAPTER
5. WHAT HAPPENS AFTER CONCEPTION
The initial chapters dealt with details about the male and female reproductive systems, fertilization and also certain valuable information for the aspiring parents-to-be.
This chapter is going to present details about what happens during fertilization, how the zygote gets implanted in the uterus and how other factors aid in the development of the fetus.
The primordial follicles in the ovary mature every month and reach the external surface of the ovary.
One of the mature ova gets released during ovulation. It is surrounded by a layer granulosa cells. These are called corona radiata. The ovum is released into the peritoneal cavity with the exuded liquor folliculi. The ovum is then transported to the uterus through the uterine tube. The microscopic hair like structures called cilia remove the granulosa cells. The ovum waits for the sperm in the uterine tube.
Similarly, the sperms developing in the spermatogonia of the male grow into primary spermatocytes and then into secondary spermatocytes. They then develop the head, the body and the tail reach the epidydimis and are ready to meet the ova.
The sperms survive in an alkaline pH and the female vagina maintains an acid pH. So millions of sperms die when they are released in to the acid pH environment of the vagina. Those survive this and reach the uterine cervix, become rejuvenated at the alkaline pH maintained there. They rapidly cross the uterus and reach the uterine tube where fertilization occurs.
We have already seen these details.
Now let us see what happens after that.
Maturation
The ovum needs to be mature for fertilization to occur. Only then the number of chromosomes will be ensured. The sperms cannot penetrate immature ovum. Excessively mature ovum can be penetrated by many sperms resulting in the formation of 69 chromosomes. Such fusion can result in an abnormal child or multiple pregnancies. It is doubtful whether such zygotes can develop into fetus.
An ideally mature ovum has the correct number of chromosomes, which are in a state ready for division when the sperm arrives. It also permits the entry of only one sperm and releases biochemical substances that prevent other sperms from entering.
Zygote formation
The fertilized ovum divides into 2 cells in the first 24 hours. Each of the daughter cells divides into two once every 15 hrs resulting in the formation of 8 cells in 30 hrs. This stage is called as totipotential. The specialty of this cell is each cell in this stage is capable of developing into one human being. If they happen to separate at this stage irregularly then it may lead to babies with fused bodies or identical twins.
In 90 hours, a total of 64 cells are formed.
It takes about 96 hrs for the fertilized ovum to reach the uterus or even more. At this time the number of cells would be doubled. About 85% of the cells turn into those required for the growth of the fetus or into the amniotic sac. The central core grows into the actual baby.
Sometimes, an unfertilized ovum can divide into two. These ova are normal in nature. When the temperature and the environmental factors are affected, they may get degenerated or may cross the regular stages and grow into fetuses.
Frogs eggs have
the capacity to develop into grow into new frogs. This is called as virgin
conception. This process is known as parthenogenesis.
When a female conceives by artificial methods, such ova can create complications. So the doctors monitor the situation very carefully. Within 14 hours after fertilization they usually examine if such twin ova formation has occurred.
The ovum that has reached the uterus floats there without getting planted. At this stage the ovum is a small mass of cells formed as a result of cell division and is filled with fluid. This stage is called as the blastocyte.
How do you think it is possible?
It is possible because the ovum is many sizes larger than the sperm. This is why the egg does not break when the cells divide.
On the sixth or the seventh day, it grows large and gets planted. This is effected by the human chorionic gonadotropin hormone.
The zygote gets embedded in the uterine wall and starts growing like a parasite. The parts also begin to develop.
Let us now see the growth of the fetus at different stages.
4-5 week
This is the stage at which the fertilized and developing ovum gets implanted in the uterus. The external cells of the ovum behave like roots and reach out for contact with the mother’s blood. The internal cells divide and form three layers. One layer develops into the baby’s brain, nervous system, skin, ears and eyes; the second layer forms the lungs, heart, stomach and the bones. At this stage, the fetus measures only 4 mm in length.
In the fourth week, the main blood vessels and the heart would have formed. These blood vessels develop into the placenta that connects the mother and the baby. Oxygen exchange also occurs between the mother’s blood and the baby’s blood.
Most women realize they have conceived only in the fifth week. By then the nervous system would have started developing. Fissures would have formed in the external layer of the internal core. The fissures develop into tubes. These are called as neural tubes. This develops into the brain and the spinal cord of the baby. The fetus now measures about 6 mm.
6-7 week
There is piling up of growth in the heart and the brain region. Buds representing the organs like ears, hands, forelimbs, legs, feet and the toes would have formed. Damage to the fetus at this stage results in conditions like cleft palate etc. The liver of the baby grows large and bloats up the baby’s stomach. Even the sex of the baby would be identifiable.
In the seventh week, the fetus measures 8mm. Eyes that were close to the eyes move towards the front of the head. Nose structures start forming. Even salivary glands and bones have started forming.
8-9 week
In the eighth week the face is fully formed. Eyes, mouth, tongue, hands, legs and fingers have formed. Heart, lungs, kidneys, pancreas, chest cavity are all fully formed. The fetus now measures about 17 mm or about three fourths of an inch.
10-14 week
The tail like structure of the fetus disappears and the fetus is fully formed. In the 10th week the fetus has developed into a baby. From now on, the growth of the baby is rapid.
In the 12th week the sexual organs of the baby are fully grown. The baby starts growing nails.
Though the baby exhibits movement, it is clearly felt in the 14th week. The pulse is strong and is twice as fast. This can be heard accurately by ultrasound. The baby is about 56mm in the 14th week. The mother’s abdomen begins to show.
15-22 week
From the 15th week onwards the baby starts growing fast. The abnormal size of the baby’s head becomes normal. The face is clear and hair would have started growing like eyebrows and eyelashes. The eyes are closed. There is growth of tissue around the nails.
The white coating that is normally observed when the baby is born gets formed at this stage. This is called as vernix caseosa. In the 20th week the bone joints and flesh would have formed and the baby starts to move.
The mother can feel the movement of the baby from the 18th week. In the case of second pregnancy movement can be felt in the 15th or 16th week itself.
Noting down the date of first recognizing the movement could help in calculating the delivery date correctly. In the 22nd week, the size of the fetus is about 160mm that is about 6.5 inches.
23-30 week
Movements are more frequent. The baby can feel your touch. When you speak loudly close to the mother’s abdomen the reaction of the baby can be felt. The baby sometimes develops hiccups as a result of swallowing a little of the amniotic fluid. The mother feels it as kicks. The baby also excretes a little urine.
In the 24th week the boy fetus develops testicles and the female fetus develops ovaries. The baby develops the habits like waking and sleeping.
By the 26th or the 28th week the baby’s eyes open for the first time. Nails start growing. There are high chances of survival of the baby even if born prematurely in the 28th week.
Babies born before this week do not generally survive because in such cases the lungs and other vital organs are not fully formed. They may survive if kept in the incubator and monitored carefully.
31-40 weeks
Till now, the skin is very thin and devoid of fat. This makes it appear pale red. This changes and as the baby starts growing plump. Six weeks before delivery, fat starts accumulating in the body of the baby. The powdery coating starts to disappear.
In the 32 week, the position of the baby becomes inverted ready for delivery. The baby is about 28 cm long and weighs 1800 grams. In the 36th week it is about 2.5 kg. Survival rate is high at this stage even in case of premature birth.
In the 38th week the weight of the baby is about 3 to 3.5 kg. It positions itself ready for delivery. Doctors usually examine if the head is fixed at this stage for normal delivery. Otherwise, caesarean section is advised.
We have now seen what happens inside the uterus from conception to delivery.
Should we not learn about the factors that aid the growth of the fetus?
Factors aiding the growth of
the fetus
Several structures develop that aid the growth of the fetus. On the 13th day of zygote formation a cavity develops around the zygote. Two layers form around the zygote. The outer layer is called the choreon and the internal layer is called the amnion. The choreon joins the uterus and forms the amniotic sac. From the 21st day of conception blood transport begins between the zygote and the amniotic sac. Placenta develops from this. The baby acquires food, oxygen etc from the mother and also removes toxic wastes.
The fluid surrounding the fetus is called the amniotic fluid. The baby floats in the fluid. This also facilitates the expansion of the reproductive organs and the vagina during delivery. In addition it helps to wash up the passage before delivery.
CHAPTER
6. CHANGES IN THE BODY OF THE
PREGNANT WOMAN
Just like symptoms indicating conception appear, changes begin to show up in the body of the pregnant woman: for example, increase in the body weight, increase in the size of the breasts, increase in the level of blood factors, hyper activity of the endocrine glands.
BREASTS
Changes appearing in the breasts of the pregnant woman are life long. Until conception, the breasts are not fully developed. In the first pregnancy, all the glands and blood vessels and milk canals in the breasts expand.
There is increased blood circulation and during the 2nd or 3rd month there might a pale yellow secretion. The nerves at the base of the breasts become thick and prominent; the nipples and the surrounding areola develop a color change. In the first pregnancy breasts develop line marks.
Pituitary secretes the hormone prolactin, which induces milk production. In the first few days after delivery, a thick fluid called cholestrum is secreted. This is very essential for the baby because it contains many antibodies and nourishments that would protect the baby from many illnesses. If the mother is unable to feed the child or the baby is unable to suckle, then this fluid needs to be removed artificially, or else, it may harden up and cause pain.
Skin
The color of the skin changes and becomes paler. Lighter colored lines may appear near the abdomen, inner thighs and on the back. Patches may form on the forehead, nose, upper lips etc.
During the terminal stages of pregnancy, blackish lines appear from near the naval to the genital area. Most of the skin changes disappear after delivery. Sometimes they remain permanently.
Blood circulation
Pulse increases during pregnancy as a result of which blood circulation also increases. In the first trimester, an increase of about 40% can happen. This rate comes down in the second trimester. Depending on the posture of the mother and her activities blood circulation increases or decreases. This is the reason for swelling in the feet and the face seen during pregnancy.
From the 10th week onwards, the quantity of blood increases. In the 32nd week it becomes very high. Iron deficiency and low hemoglobin during this time results in anemia.
Endocrine glands
The thyroid swells during pregnancy. Thyroxin level also increases. Goiter may result if there is iodine deficiency in the mother. Most of the hormones are in a state of hyper secretion.
Ureter
During pregnancy the increasing uterus, exerts pressure on the kidney and the urinary bladder. So, there is a tendency for frequent urination. Sometimes the flow may be involuntary also. This tendency sets in early during pregnancy and may continue till midway through. Sometimes, it continues even up to 12 weeks after the child is born.
In the second month of pregnancy there is inflammation of the urinary bladder. The same situation reappears during delivery and may cause inconveniences
Changes in the breathing
pattern
The diaphragm gets pressed due to pressure in the abdomen caused by the growing size of the fetus. This may cause difficulties in breathing or breathlessness.
Bones
In the second month of pregnancy, there is pressure on the spine and the pelvic bones. This may lead to pain in the lower limbs.
The hipbones become tender and loosen up. This may lead to pain in the back. Ideal postures can be learnt from the doctor to prevent discomfort.
Change in the size of the
abdomen
Fetus grows everyday. This results in the expansion of the abdomen. If the expansion is not as expected, one may doubt the growth of the fetus and have a proper examination done.
CHAPTER
7. INFERTILITY IN WOMEN
In the previous chapters we discussed about what happens during fertilization and the changes that follow conception. But these are changes that occur naturally and normally. But there are couples who are in anguish because none of these changes have happened to them.
If the percentage of such people throughout the globe is about 10%, about half of them are living in the highly populous country of ours that is India.
Most of the women conceive within the first six months of marriage. Some plan their family in about a year. When conception does not occur even after two years of marriage, then they start suspecting themselves to be infertile.
Many make their lives highly questionable because they constantly pressurize themselves with questions like,
‘Why have I not conceived?’
‘Is there no chance for us to have children?’
‘Will I become a parent like everyone else?’
In the earlier days, when science was not so advanced and investigations and checking methods were not so thorough, the blame of infertility used to be totally laid on the female. This led to even healthy, faultless females to live in the shame and humility of being ‘barren’. Have we reached a stage where we have put an end to this kind of behavior?
The answer is No as yet.
We still continue to blame our women for not bearing children. This practice is still very much there among illiterate people and among the tribes. It is said that in some foreign countries also this practice still exists.
Our society was prompt in accusing the woman of having sinned in her earlier births and what she went through was the result of her karma.
We still see women, who have spent their lives as servants in their own households since the husband is married to some one else because she did not bear him children. Many a times the husband marries a second time again in vain. This male chauvinistic outlook that spoilt the lives of thousands of women, began changing slowly only after the fact that even men can be responsible for the couple being issueless and that the male can be impotent, was established scientifically. This has come to relief of thousands of women blamed of barrenness.
The woman of today is ready to get herself examined and is knowledgeable enough to motivate the husband also for examination and rectification of any fault. So much of awareness has been created in the society. Going one-step ahead, they are now prepared to get even test tube babies.
These are some pleasant changes that have been brought into the lives of women.
Research and estimates say that men and women share 30% of responsibility each, and 20% collectively and 20% is due to other factors.
The reason for this is that many do not understand or admit or reveal one important fact.
What is that fact?
The fact is that the human species reproduces at the least proportion. Further, even in healthy women with regular cycles, complications associated with ovulation are seen. Among all the animal species, only the human species has high level of problems like, block in the Fallopian tube, faulty uterus etc; in men, there are problems like low sperm count, erectyle dysfunction etc.
Many do not consider these facts at all.
In this chapter we shall present the reasons for female infertility and when women realize they might have these problems etc.
Infertility in women
When the woman does not conceive even after months of marriage, the couple begins to worry. Many do not make it into an issue since it is too early in their marriage.
Both of them refrain from speaking openly for fear of being misunderstood. But the neighbors do not keep quiet. They start spinning stories about them; it is natural that one sex blames the other.
Many times, the male is able to ignore the issue and keep minding his business. But the female is not like that. She becomes conscious of the fact that she has not conceived; she feels humiliated. She becomes emotionally disturbed, irritable, anxious and even begins to lose her self-confidence.
Relatives are even one step ahead. In our society, a ‘barren’ woman is not permitted to participate or perform auspicious rites or functions.
In the first year of marriage, the murmurs and anxieties are much less. The couple is more confident. If the situation continues for 2 years, the whole thing turns upside down. The naggings and anxieties increase.
The first to show readiness for check-up is the woman. It is because, the male does not look at the problem scientifically; instead he considers himself to be impotent or that he has lost his manhood. He is ashamed of openly accepting to get himself examined. He feels he has lost his place in the society.
The female is ready to go through the examination and only when she is cleared of any faults she begins to motivate the husband.
In our medical experience, it has been amazing and touching to see how much of trust women have in their husbands and the level of motivation and reassurances that they offer their husbands.
Only when they are fully convinced about the problem and that any fault could be cured can they take the next step and we can proceed with our treatment.
Reasons for female
infertility
v Heredity
v Improper or absence of ovulation
v Hormone deficiencies
v Ovarian cysts
v Premature menopause
v Complications associated with the primordial follicles
v Psychological status
v Damage of the Fallopian tube
v Inflammations due to infections
v Diseases of the abdomen
v Inflammations and weakness due to abortions and use of contraceptives
v Complications due to surgeries
v Abnormal uterus
v Foreign bodies in the uterus
v Fibroids
v Congenital disorders
These are common problems normally seen. But sometimes conception does not occur even when all the above problems do not exist. We should know about those problems and how to handle them.
Heredity
Any problem, be it physical or psychological, it may have hereditary factors as the root cause. It has become customary to investigate if anyone else in the family has such problems. If so, then remedies are sought for those problems.
Improper or inability to
release the ovum
In about 20% of the females who use contraceptive pills, contraception is mainly by prevention of release of mature ova. This continues even after stopping the pill and prevents conception.
This is why, when couples approach us with infertility problems, we always enquire about health, mental make up, cycles and sex. During this time we are able to identify if there are any problems associated with ovulation. If there are no problems with the uterus and cycles are regular, it means that ovulation is also proper. But the hormone functions have to be proper too. Otherwise ovulation may be affected.
How can we recognize the whether ovulation has occurred?
v Pain in the lower abdomen
v Heaviness in the breasts
v Mild bleeding
Early morning temperature recordings can also reveal the time of ovulation since the temperature dips a little during ovulation and then becomes normal.
Hormone dysfunction
Sometimes hormones secreted by the ovaries, the hypothalamus, the pituitary and the thyroids may be deficient in quantity or function. This may also lead to infertility problems. We shall now see some important problems.
Release of immature ovum
The predecessors of the ova are the primordial follicles. Improper growth of the follicles may result in inability of the ovaries to release mature ova regularly, in about 50% of the cases.
When the follicles are not developed fully even if the ova are released, they may be immature. The most important condition in this is the polycystic ovary syndrome. This is caused by the imbalance between the ovarian hormones and the adrenal hormones. Or it may be caused by the complications or deficiencies of the hypothalamus.
Abnormalities of the
hypothalamus
When the brain commands the pituitary, sometimes it wrongly sends out the message through its hormones to the ovary to release immature ovum. About 20% of cases of improper ovulation are due to miscommunication.
Abnormalities of the
pituitary
Deficiencies in the secretion of the pituitary due to damage or accidents, or excess secretions can lead to inability of the ovary to release mature ova regularly. Imbalances between the hormone secretions could also result in a similar situation.
Abnormalities of the thyroids
This is a rare situation and can be detected only by lab investigations. Both hyper (excess) and hypo (reduced) secretions of this hormone could result in infertility problems.
What will happen in such a
situation?
v There is no ovulation when there is a cycle every 36 days or when cycles do not happen at all for several months, or there are frequent cycles followed by mild bleeding with foul smell. Even if the cycle is irregular, complications may occur in ovulation.
v There is increase in weight. There is excess fat accumulation along with inability to ovulate. Such people can modify their diet pattern and try to reduce body fat. But you should remember that total lack of fat intake would also lead to infertility problems.
v Rigorous exercises also have been found to be associated with infertility or ovulation difficulties. Long jump can be pretty dangerous. When the cycles are not regular, it is better to reduce the quantum of workouts.
v Polycystic ovary syndrome is manifested as excess hair growth in the face and the body. These people have difficulties in ovulation, which may cause infertility.
Damage to the ovaries
Damage to the ovaries may lead to improper ovulation. Frequent surgeries done to remove ovarian cysts can sometimes cause scars in the ovarian surface. This along with infections prevents the follicles from maturing. Mostly this situation is seen when someone undergoes radiation treatment near the pelvic region for cancer.
Scars and the ovarian inflammation can be set right by another surgery, which may improve the situation.
Premature menopause
It is normal for the menstrual cycle to stop permanently at a particular age. Bu for some women, menopause occurs much earlier.
This rare phenomenon renders the ovaries inactive. This hereditary condition may sometimes lead to girl babies born with congenital complications associated with the ovaries or sometimes girl babies are born with no ovaries at all. Turner’s syndrome is an example for this.
These girls have growth inadequacies with very low levels of estrogen. If detected earlier before the girl reaches puberty then the problem can be rectified. Otherwise problems due to immature or under developed ovaries arise. In addition, production of ova and ovulation are also affected. Low estrogen level in the blood leads to premature menopause. Before that, symptoms indicating menopause like drying up of the genitals, appearance of red spots all over the body manifest.
Sometimes the ovarian cells are destroyed by one’s own antibodies due to autoimmune mechanisms. This leads to the complete degeneration of the ovaries, which contributes to infertility.
Premature menopause can be identified by,
- Complete stopping of the cycle or very rare occurrence of cycle
- Appearance of red spots all over the body
- Drying up of the genitals
Such symptoms do not necessarily mean that the woman is incapable of producing ova. This problem can be rectified by hormone therapy.
Problems associated with
follicles
Sometimes, in some women follicles mature normally after the cycle. But for some reason the eggs are not released. These eggs remain inside the follicles and degenerate. This is yet an unsolved complication, but intensive research is on to find a solution for this.
Psychological problems
In some women, infertility results from psychological problems. In such cases eggs are not released in time. Specifically, times like examinations, loss of employment or a dear one, highly depressive mental status, have a lot of influence on the maturation and release of ova. Women affected by prolonged mental depression may even fail to produce ova. They suffer from a highly depressive state during their cycle time. Avoiding such attitudes may increase their ability to conceive.
Damage to the Fallopian tube
This is a rare condition. Though this does not affect the woman’s normal health, it may cause problems in her conceiving. This can be rectified by microsurgery.
Damage due to infections
Most of the problems caused by infections are due to STDs. But sometimes women who have no physical contacts have also developed problems. Mostly, microorganisms like bacteria, viruses and sometimes fungi are responsible for infections of this type. Even normal abdominal flora like E. coli and streptococci can cause opportunistic infection of the ovaries and cause inflammations.
Among STDs, gonorrhea is said to be responsible for infertility in about 15% of the population. Mostly, women with single partners are not affected by this disease. But they may get infections if their husbands have multiple partners. Women involved in prolonged sex are likely to get infected. One main reason for this is unhygienic practices and failure to wash the genitals before and after sexual intercourse.
Diseases of the abdomen
Infections of the lower abdomen can reach the Fallopian tube and cause blocks. Especially in case of colon diseases, if the colon ruptures, then the organisms get deposited on the Fallopian tubes causing infection, inflammation and blocks. This prevents the egg from reaching uterus or sperms from reaching the egg.
Damage due to abortions
Immediately after conception, the uterus and the uterine tubes are prone for infection. Or when delivery is effected by use of instruments during a difficult normal delivery, then also infections are likely. Failure to completely remove the contents of the uterus during Medical Termination of Pregnancy (MTP) may lead to infections and improper release of the ova.
In countries where MTP is banned, women go for traditional methods of abortions. Some of these practices are dangerous and may not only cause infertility but also sometimes lead to death.
Proper scientific methods have to be adopted for termination of pregnancy. Otherwise unnecessary problems associated with the reproductive tract may result leading to infertility.
Complications due to
surgeries
Conventional surgeries other than microsurgeries performed on the uterus, ovaries and the Fallopian tubes lead to problems in most of the cases.
Especially, blocks or cuts or scars appear on the Fallopian tube, which prevents the smooth journey of the ova into the uterus. Tube pregnancy (implantation of the zygote in the Fallopian tube instead of the uterus) can damage the tube that may lead to complications of subsequent conceptions.
Endometriosis
The endometrial lining of the uterus creates the environment essential for the implantation and growth of the fertilized ovum.
Release of the ovum leads to the growth and development of the endometrium into secretary endometrium. Such formation inside the uterus is ideal whereas such formation outside the uterus leads to complications of the uterus.
Pain during the menstrual cycle or intercourse, infection in the pelvic region, fibroids and rupture of the colon are all indicative of endometriosis.
Abnormal uterus
About 50% of infertility problems are due to abnormal uterus. The problem may be confined to the uterus alone or to the Fallopian tube also.
Fibroids
Fibroids cause excessive bleeding during menstrual cycle, bloating up of the stomach etc. One in three women are reported to be suffering from this form of problem by the 35th year of age. They do not cause any serious complication, as they are small in size. But if they grow larger, they can block the uterus and prevent fertilization from occurring.
Adenomyosis
This is a kind of tissue growth inside the uterus. Prevalence of this problem is more than expected.
Every month, the endometrium degenerates when fertilization does not occur. In its place a new layer starts forming.
Lesions and inflammations of the endometrium lead to excess growth of the uterine tissue or adenomyosis. This causes excessive bleeding. Normally, it forms in any one spot in the uterus and grows to completely block the uterus. The endometrium in turn grows towards the uterine tube and blocks it either partially or completely. Pus and scar formation further block the tube. All these may lead to infertility.
How can lesions in the uterus be identified?
- continuation of the cycle beyond the stipulated date, continuous numbing pain
- pain and increased size of the uterus
- mild pain during intercourse etc.
Congenital disorders
Some women have congenital disorders of the uterus, or the ovaries involving either one or both; growth and development of these parts may be affected which may lead to infertility.
Mostly, women do not realize that they have congenital problems of the reproductive system. The reason for this is that, many of these disorders do no affect their conception.
Formation of one single uterus with both the tubes being fused; in some women the tubes are fused to individual uterus and they may have a pair of uterus. In some the development is incomplete. Either there is no conception or even if the girl succeeds to conceive, there may be miscarriage.
When there is congenital disorder, there is continuous pain during cycles and during abortions. Even in case of a full term pregnancy, the amniotic sac may not take the correct position during delivery. The baby’s head may not get fixed and complications may result.
Fusion of the inner uterine
walls
About 50% of women complaining about infertility, are suffering from this problem. The inner walls of the uterus get fused together. Pustules and previous conceptions are said to be the causes of this problem.
Conditions like fowl smell during menstrual cycles, absence of bleeding after abortion or miscarriage, complicated delivery, fibroid removal are all associated with fusion of the endometrial walls. The condition is associated with pain. All these can also lead to infertility.
Foreign bodies in the uterus
Any foreign object that blocks the uterine cervix can lead to infertility. Tumors, pustules, cysts in the uterus, failure of the endometrium to degenerate when the ovum is not fertilized, small fibroids, improper removal of intra uterine contraceptives etc can also result in infertility.
There are no symptoms associated with such a condition. So many people do not even realize the reason for their infertile status.
There may be excessive bleeding and pain during the menstrual cycles but they are not specific.
Problems associated with the
cervix
The cervix serves two functions during fertilization. One is that, it secretes a fluid, which traps the sperms and facilitates their movement towards the ovum. Secondly it constricts to close the mouth of the uterus preventing the loss of the fertilized zygote through the mouth, in the event of fertilization.
The prime function of these fluids is to enable the sperms to reach the ovum comfortably. The secretion of these fluids is effected by the hormone estrogen.
Changes in the hormone secretion leads to changes in the consistency of the fluid secreted by the uterine mouth. Estrogen is secreted before the menstrual cycle and progesterone after the cycle. The fluids of the uterine mouth are thick before the cycle and watery after the cycle. When there is a change in the secretions of the hormones or when the balance is not maintained, these fluids may remain thick or may turn to acidic pH or fowl smelling in which case the sperms will not be able to survive.
Sperms, which are trapped by the fluids, die in it.
Sometimes, there may insufficient secretion of these fluids; in this case the sperm is unable to swim in the dry environment to reach the ovum. This also leads to infertile status.
Problems arising out of the
opening of the uterine mouth
As soon as fertilization occurs the mouth of the uterus closes tightly. This ensures that the growing fetus is not disturbed or affected by anything that is foreign to it.
But in rare cases the uterine mouth does not close allowing infectious organisms to gain entry. The fetus may get infected. Sometimes, the tissue layers of the uterus become weak when the zygote starts growing. These layers may rupture and result in the expulsion of the zygote. This leads to miscarriage.
Miscarriages occurring in the 16th to 26th week are mainly due to this reason. Congenital problems may be the reason for this. Surgeries or MTPs performed could also have damaged the mouth of the uterus.
If detected early, the problem can be rectified and conception may be made possible.
Other factors
Even when the woman is perfectly normal, sometimes conception evades her. Reasons for this may be physical conditions, psychological conditions, pollutions radiations etc.
One should be able to calculate the approximate time of ovulAtion and then get involved in intercourse in the intermediate period.
Some couples have intercourse only once a week or once a fortnight. This will only reduce the chances of conception.
Ovulation takes place in about two weeks after the cycle. In this period the couple should engage in coitus more frequently and continuously. This would improve sperm production in the male. Since there would be enough number of sperms waiting for the ovum, conception would be all the more possible.
These days, any problem leading to infertility can be easily identified and rectified completely through modern technology. One should remember this and approach the doctor as early as possible if they suspect any such problem. There is no need to be humiliated by others.
It is very much possible to enjoy the completeness of motherhood.
CHAPTER
8. INFERTILITY IN MEN
It is not an exaggeration to say that our country is male oriented. Even if the female happens to be Queen of the Nation, within the four walls she is expected to be the most obedient person to the husband. This has been an unwritten law that has been practiced for thousands of years. Women were raised to bear and rear children. She had not been given the due respect she deserved neither at her mother’s place nor at her husband’s place. They have remained as unpaid child bearing machines or maids in the household.
This was the reason when a couple was issueless, the whole blame was thrown on the woman. She was humiliated as a barren woman. At the same time, even if the male happened to have faults he could go ahead and marry again.
Now, times have changed. Women have proved that they are no less than their men folk in all walks of life. Further, science and technology have proven that infertility is not solely a woman’s fault but man also can be infertile. So the women of today are much more blessed than their predecessors.
Still, when a couple is issueless, it is only the female who is subjected to investigations. Only when she is cleared to be faultless, the male agrees to get himself examined.
When the male realizes that his wife is flawless and the problem is with him, the agony that he goes through is immense. He feels totally dejected and rejected. He feels like it is doom’s day. He feels ashamed of his lack of manliness.
He suddenly starts feeling that he can no longer satisfy his wife. Once this feeling of guilt and humiliation happens, the family faces a storm. He becomes self-conscious; he feels he has lost his respect in the eyes of his wife and others. He becomes progressively depressed. He starts losing interest in life.
He fails to even rationally analyze if there could be any connection between infertility and impotency.
He is constantly bothered about what the doctor would think during examination, what the wife would think of him. He develops a kind of inferiority complex and hesitates to even come for the examinations. Such men still exist in our society.
Amazingly even the women prefer themselves to have faults rather than their husbands. They come forward to get their husbands married to some other female and get a child through the second woman and remain a foster mother in the household.
The undercurrent of this entire trauma may be a feeling of insecurity arising out of a fear that the society might reject him because of his inability.
All these reasons drive the woman to first approach the doctor for investigation even without informing anyone at home.
When she is convinced that she is flawless, then she tries and motivates the husband into getting himself examined. When he refuses, a big catastrophe strikes in the family.
In many instances she becomes agitated at the thought that she is suffering for something that is no fault of hers.
She becomes irritated at the husband who could not even give her a baby to fondle. Instead of love, animosity and irritation begins to breed between the two.
As a reflection of all this, the household is always full of arguments, fights, differences of opinion which further complicate life. This further confuses the male. This continues into the bedroom and makes him all the more dysfunctional.
Such people should know everything about,
What is infertility?
Is it the same as impotency?
Why and how does infertility happen?
Can it be rectified?
Only then they would understand that it is only a deficiency and not a deformity. The fact that it could be corrected and rectified is bound to improve their confidence and win back all that he was about to lose.
Male infertility
About 30% of men are estimated to have this problem. This is a global problem.
It is normal for anyone to delay childbirth, when the person is aspiring and working hard to get professionally established and to reach a high position in the society. When they finally decide to have a family and make sincere attempts, which fail to produce the desired results, then they start realizing that one of them could have problems.
Male is likely to be infertile between the age groups of 26 and 45. Most men confuse infertility with impotency and attribute their infertility to their inability to function fully during sexual intercourse. Premature ejaculation and loss of erection are common occurrences during such situations.
But infertility is not these problems. The husband may be perfectly normal in satisfying the wife fully except that he may not be able to make her a mother.
How is this possible?
The semen of an impotent man will have sperms. But the semen of an infertile person will not have sperms in it. This is the difference between impotency and infertility.
Why and how does it happen?
Let us now see.
Reasons
There are many reasons for male infertility. We shall see the important ones here.
1. Absence of sperms
We all know that the testicles are the organs responsible for production of sperms. Lack of production of sperms or inability to release them in semen leads to infertile status.
Failure of the testicle to produce sperms is a rare phenomenon. Just like it is impossible to correct a fully degenerated ovary, it is impossible to correct a completely degenerated testicle.
The reason for the failure of the testicle to produce sperms is not yet fully identified. Normally the testicles are present within the abdomen when the baby is still in the womb. During birth, it descends into the scrotal sacs. Failure of the testicles to descend into the sacs and improper development of the testicles render them incapable of producing sperms.
Severe pox infection during childhood, damage of the blood vessels supplying the testicles, twisting of the testicles on one another can also affect sperm production. The last one can be identified and rectified.
Sperms get released from the testicles and travel through the epidydimis. So, blocks in the tubes can prevent their movement. When the muscles responsible for release of the semen through the urethra, fail to do so, sperms do not get released.
Sperm production does not occur when pituitaries fail to secrete the hormone responsible for inducing the testicles, or when the testicles do not respond to the command for unknown reasons. This also results in infertility.
Infertility caused by conditions like inability of the testicular cells to produce sperms even when sufficient levels of the male hormones are being secreted and congenital abnormalities related to chromosomes cannot be avoided.
In conditions like gonorrheal infection, TB, trauma, blocks in the tiny connecting canals within the testicle, sperms are produced in sufficient quantities. But cannot be mixed with the seminal fluid. This also has been found to be one of the reasons for male infertility.
Sometimes semen flows back into the urinary bladder. This condition that prevents ejaculation during intercourse is found in only about 1% of males. Inability to release sperms is due to this kind of reverse flow of the semen into the urinary bladder resulting in its getting mixed with urine. In this condition the male will not be able to fertilize the female. This condition can be rectified if detected early through a minor surgery performed in the prostate region. Damage to the nerves supplying the prostates and medicines given for treatment of blood pressure have been found to be responsible for this kind of complication.
2. Low sperm count
This condition is responsible for 70% of male infertility. Low sperm count inhibits the swimming movement of the sperms in the semen; they may also get destroyed in the vagina when released; sometimes they may have abnormal characteristics also. This condition in a male may delay the process of conception but if good sperms are present even among the low count, it may still be possible to bring about conception.
3. Defective sperms
This complication presents in many men due to hereditary factors or due to unknown reasons. The biological reasons for this are not yet completely known. Defective sperms with large heads or without tail are seen during old age. This may be due to several reasons.
Let us now see some of the important reasons among them.
Hormone problems:
The nature and characteristics of the sperms are determined by the action of the hormones. Insufficient hormone secretion or defective hormone secretion leads to the production of sperms that are abnormal or incapable of movement.
Abnormalities of the blood
vessels surrounding the testicles:
Excessive thickening of the blood vessels around the testicles or conditions like varicose veins where the fine blood capillaries form knots or get degenerated can affect the production of sperms.
Thick blood vessels increase the temperature of the testicles a state in which sperms will not be produced. Degeneration of the blood vessels also leads to increase in temperature of the testicles. Sexual intercourse is not possible. There is no sensation of pain unless there is injury to the part. At the same time, production of sperms is affected.
Infections:
Infection of the prostates is found to reduce the capacity of the sperms to move or swim. Mycoplasma infection of the prostates can trigger the situation. Sometimes, sperms that appear normal under the microscope also can be affected if they have undergone some chemical changes.
4. Antibodies
Antibodies circulate in our blood to protect us from invading bacteria and viruses. These are normally produced in the body as a result of exposure to that particular foreign substance. But sometimes, some of these antibodies consider sperms to be foreign bodies and actively destroy them; i.e., a person’s sperms are killed by his own antibodies. This is called auto immune reaction. This is responsible for about 5% of male infertilities.
5. Difficulties in sexual
practices
This is a problem that most of the young men are facing today. Premature ejaculation even before getting involved in sexual intercourse makes it impossible to impregnate the woman. Slow and steady relaxed sex will help to overcome this problem. It would also be ideal to get the sexologist’s advice on this; or help can be sought from elderly experienced persons.
6. Physiological reasons
Some men have a congenital condition in which urine is not expelled through the urethra in the penis; instead, urine drains through an aperture at the junction of the penis and the scrotum. Though this condition exists only in 1% of men, it is important because, it can make the man incapable of impregnating his wife.
7. Environmental factors
Smoking, alcohol, excessive exercises or workouts, depressing occupations, obesity, addiction to caffeine containing foods, excessive intake of medicines, drug abuse etc., can cause infertility by interfering with sperm production and sperm count.
Men who are constantly in a state of hypertension have very low sperm counts. The sperms are also abnormal and weak.
Occupations that demand long distance driving, traveling, tough jobs involving contact with chemicals, pesticides etc can also cause infertility.
What should such men do?
Infertility is commonly confirmed at the age of around 27. A boy getting married at the age of 25 usually waits for 2 years before he starts suspecting problem in any of the partners.
The boy should be practical and never give up nor break down if he is found to have any problem, because these days, modern techniques can rectify more than 90% of the problems.
One should remember that any problem other than congenital could be corrected. They should approach the doctor immediately without hesitating.
Such men should come out of their inhibitions and apprehensions as to what the doctor would think or the wife would think when the problem is exposed. They should understand that both are very helpful and very caring.
In the next chapter, we are going to talk about the different examination methods and procedures.
CHAPTER
9. LABORATORY INVESTIGATIONS
Everyday newer lab tests are being launched capable of testing issueless couples. Still, most of the tests are meant only to test the female. Even treatment modalities are more for females than males.
This is because women who are incapable of conceiving usually manifest certain symptoms. Based on these symptoms they approach the doctors for treatment. But do not exhibit any such symptoms. This is the reason why they do not come forward for checkups and treatments.
Even globally, gynecologists or medical practitioners who have specialized in female reproductive system and their infertility problems outnumber others. Those specializing andrology or male reproductive system and functions are much less. This is why in most places, only semen analysis is done to test male infertility.
The right time for check-ups
Failure of the female to conceive up to 6 months of regular sex is not a matter of concern. Women who are less than 30 can wait up to 2 years after marriage for conceiving. Women, who are above 30, should not delay check up in case of their not conceiving.
Some women are capable of guessing their problem on the basis of the symptoms they observe and seek tests related to those problems.
Some such common problems
Women:
Delayed periods – may be due to complication associated with ovulation
Cycle after a long gap - failure to produce mature ovum continuously
Painful periods or pain during intercourse – inflammation or tissue growth in the uterus
Sudden excessive bleeding – uterus problem
In case of previous surgery for ovarian cysts – fusion of the ovarian walls
Previous history of colon rupture – infection and block of the uterine tubes
Infection due to intra uterine contraceptives – improper or incomplete removal of the foreign body
Previous history of infection immediately after conception – inflammation in the pelvic region
Men:
Measles infection during teenage – insufficient production of sperms
Injury to the scrotal sac – impairment of sperm production
Failure of the testicle to descend from the stomach cavity – impairment of sperm production or total failure to produce sperms
If these symptoms are observed, then you need not wait till the doctor advices you to do so; instead, you can go ahead and get yourself checked up.
Other problems that are not recognizable outwardly can be diagnosed earlier by the doctor and confirmed by lab tests.
Knowing the causes
Infertility is not a disease nor is it incurable. This is only an expression of the defect in either one or both partners.
Before opting for treatment it would be ideal to confirm the defect through lab tests. It would be too dangerous to seek self-prescribed medicines without knowing the causes.
Such behavior not only delays conception but also could result in severe irreparable side effects. This may permanently eliminate all chances of conception.
It is as bad as someone going to the pharmacist and asking for medicines for heart attack just because he had chest pain and he presumed it to be a stroke.
Confirming the cause of
infertility
One should not stop with doing the check up only once. They should repeat the check up again after sometime. Doing the test once and seeking medical treatment after sometime may be very misleading. In the intermittent time, the intensity of the problem could have increased or some other associated problem may have occurred.
When one problem is detected it should be totally eliminated by treatment before going to the next problem. Simultaneous treatment may completely destroy the dream of a baby permanently.
Any treatment given or taken without keeping these factors in mind may lead to improper treatment and further complications.
When the doctor suspects a particular problem to be responsible for infertility, then the patients should cooperate in getting it confirmed by tests. It would be pointless to blame the doctor saying that he is getting unnecessary tests done.
Tests should be done in dependable or standard laboratories. Ignoring qualified practitioners and seeking the help of ‘quacks’ (unqualified self-proclaiming traditional practitioners) results in false declaration of their own assumptions as the real causes. People should avoid believing them or else they find themselves duped in the end.
Tests to be performed before
approaching the specialist
It would be ideal for the couple to carry out small and simple tests before approaching the specialist.
1. Recording the body temperature in case of women
We have already seen that body temperature drops a little during ovulation and then becomes normal. Time of ovulation can be calculated through this simple method of recording the early morning temperature from a week after the cycle for about a week. This should be done at least for three months to confirm the actual time of ovulation. Though this is not 100% dependable, it helps in identifying the problem.
2. Blood tests for women
Blood tests can be done during the 2nd or 3rd week after the cycle to find the level of the hormone progesterone. Sufficient levels indicate good chances of proper ovulation and low levels indicate poor chances of ovulation
3. Semen analysis for men
This is a very common examination. Abnormal sperms and insufficient production can be detected through this test
Right time to consult the
specialist
Many couples do not consult the specialist even after remaining issueless for 5 or 10 years. Initially, they adopt religious practices and later fall prey to the ads posted by quacks who spend tons of money advertising in newspapers and television and raising high hopes among public. They lose valuable time by all this.
Finally, they come to the specialist. Sometimes it is too late since the doctor may also not be in a position to rectify the fault easily. So, early consultation with the doctor should be sought if you want good results.
It is not correct for one of the couples to consult the doctor. Both of them should go together. Only then the environment in the clinic, the approach of the doctor, realization of the fact that there are many others suffering from the same problem helps to remove their apprehensions and hesitations. The moral support offered by one another helps to find a common solution.
The first visit
Knowledge of what the doctor is likely to ask helps to a certain extent in preventing the unease or dilemma that commonly occurs during the first visit.
Many people want the doctor himself to find out what they are suffering from. This is a wrong approach.
You should be able to clearly state the symptoms you have observed, their duration etc. This helps the process of diagnosing the problem, suggesting confirmatory tests and prescribing treatment.
Leaving the whole thing to the doctor would only result in loss of precious time, money and effort.
For example,
If you have conceived once but there has been a long gap after the first conception, when you approach the doctor you should clearly state if it was early or delayed or complicated, the kind of complications you faced, whether you continued with the pregnancy or was there any miscarriage or MTPs done etc. Then only the doctor would know that the problem was not there originally but only a recent development.
Some women might have gone for MTPs before marriage or even after marriage without the knowledge of the husband.
It is natural for them to conceal all this from the doctor for fear of being exposed to the husband. But the doctor is a completely trustworthy person. He is bound by oath not to reveal your secrets to anyone, including your husband.
You should have answers ready for questions like,
When was the last menstrual period?
How much was the bleeding?
Was it watery or full of clumps?
Was there any white discharge?
How many times do you have intercourse during a week or month?
Was there any pain during intercourse?
Was there any irritation or burning sensation?
Was there any pain in the pelvic region during or after sex? etc.
These questions may sound ordinary or irrelevant to you. But there are reasons for these questions. Each would give some clue towards the problem. So, you should give correct and true answers to the doctor.
What are the kinds of tests done?
1. Essential ones
Investigations that are needed for confirmation of the cause of infertility are essential ones. These tests are absolutely essential for all kinds of infertilities.
2. Optional ones
When the problems are more than one, priorities are given to tests or options can be made. These tests are done only when the doctor feels it is really going to help diagnosis or treatment. They may be done immediately after deciding to give treatment or after giving a time of 6 months for conception to occur or when common tests fail to point or confirm the problem.
3. Unimportant ones
These tests may not tell us a lot but may be helpful in confirming certain doubts. There is a saying that “No two doctors agree”. Truly, the sequence with which each doctor recommends these tests may vary. Some may prefer to do a particular test where as others might prefer other tests. In any case, it is better to go ahead and get the test done rather than wasting time consulting different specialists and debating the issue.
So far, we were discussing about the ideal way to approach the problem. Now, we shall see the tests that are specifically meant for men and women individually.
Tests
for men
Semen analysis
This is the first test prescribed by any doctor for a male to rule out infertility problems.
We have read that sperm production is not uniform throughout even in the same individual. Factors like depression can alter the characteristics of the sperms significantly. All the sperms from a person need not have the same qualities. Each one may differ or some of them may be normal and some abnormal. These defects may also vary with time. Some times the semen may not have sperms at all. All these or even one of these factors may interfere with conception.
It is essential to find the cause of the problem by repeated semen analysis.
The test can definitely say whether a male is capable of fertilizing a female or not.
Method:
It would be better for men who propose to do semen analysis to know a few details.
It is essential to abstain from sex at least for two days prior to the test.
The fluid should be collected in a wide mouthed container and handed over to the lab for analysis within 2 hours of collection. Any spillage or loss of the fluid during collection should be intimated to the lab person and the doctor. Otherwise, the result may be wrongly interpreted.
Seminal fluid should not be collected in condoms for testing. The chemicals in the article may kill the sperms and result in a wrong sperm count.
In the lab the following analyses of the semen are done;
- consistency of the fluid
- sperm count
- motility of the sperm
- normal or abnormal nature of the sperms
- presence of microorganisms
- chemicals and antibodies
The normal sperm count is about 40 million per milliliter of the fluid. Anything less than 20 million per mL could mean low count. It should be noted that some men are capable of fertilizing the female even with counts as low as 2-3 million.
Motility of the sperms are tested since at least 40% of the total number should be capable of moving. Only then it would mean that sufficient number would reach the ovum within the female’s body. Any number less than this, showing motility indicates faulty sperms.
At least 65% of the sperms should look normal. A less percentage indicates problem.
It is essential to test the presence of biochemical constituents of the sperm through chemical tests.
Presence of microorganisms indicates infection. This would have altered the sperms considerably.
Presence of antibodies could indicate auto immune reactions where the antibodies in the blood of the person kill his own sperms.
Since all these provide vital information, one should not be careless about semen analysis.
Any kind of result outcome should be accepted. Even anxiety can alter and make the sperms faulty. So keep your mind relaxed and calm.
Semen analysis should be repeated after a time interval to find if there are chances to produce better sperms.
Tests after intercourse
This test is done between 6 to 36 hours after intercourse. Sample of the fluid from the cervix of the female’s uterus is removed and tested for presence of sperms under the microscope.
It would be ideal to perform this test 14 days after the menstrual cycle. Since there is a chance for ovulation during this time, the cervical fluid would be watery allowing the easy movement of the sperms through the fluid.
This test is not essentially a test for the male alone. Questions related to the female like, Has ovulation occurred? Is the cervical fluid normal? Are the sperms normal in this region? Are they able to swim through the fluid? etc are also bound to be answered by this test. But most couples hesitate to undergo this test.
Sometimes, the test can give false results when,
- if it is too long after ovulation, the uterine secretions would have dried up
- it is not ideal to perform the test at a time when its secretion is not yet stimulated by the hormone estrogen. Since the quantity of the fluid would be too less it may not give the actual picture.
- When the egg has not been released
- When the sperms are abnormal or defective
- When sufficient numbers of sperms are not present or when most of them are damaged
- Impairment of timely ovulation
- When the mouth of the uterus is large, the secretions are also more in quantity. This also can give a false result.
- Infection of the cervical area, fowl smell of the cervical fluid
- Release of antibodies by any one of the partners
- Failure to release the sperms (ejaculation) properly in the vagina of the female.
All the above conditions are likely to influence the result of the test.
Different opinions exist among doctors regarding the validity of the test.
Some such differences of opinion among doctors
Some doctors are of the opinion that the uterus turns inwards after sexual intercourse and this is the reason for false results of the test. But in almost 25% of women the uterus itself is positioned like that; so this cannot be taken as an explanation for false results.
Leakage of the semen out of the vagina is also said to be responsible for giving false results. This also cannot be the correct explanation, because sufficient amount of semen would have reached the vagina.
Improper posture while ejaculation is said to result in false results. Further, it is said that doing the test within 2-3 hours of sexual intercourse could give false results. The test is usually done in 2-3 hrs of ejaculation; but actually the lifetime of the sperms is 72 hours. In some laboratories, the test is done even 8 hrs after collection.
Couples face difficulties and are under stress while indulging in sexual intercourse for sample collection since they have been instructed to hand over the specimen immediately after collection. In many cases this is done in the clinic itself. Hurried sex and new environment can result in anxiety in the male leading to temporary impotency.
The chemical nature and the acidic environment of the female vagina are likely to kill the sperms. This also has been enumerated to be one of the causes for wrong results. But this is not true in all cases.
When the test in done by the doctor who has expertise in the field, knowledge and skill in performing the test, the result is accurate and dependable.
So far, we saw some tests that were done for males; now let us see some important tests done for females.
Tests for females
We have already said that lab tests for females are in plenty.
Women should know certain facts before going for these tests. This would help them understand the treatment methods and their importance. This would help them prepare themselves for treatment.
Blood tests
This is an important test done to find out if ovulation has occurred.
The ovary secretes the hormone progesterone 2 weeks after the menstrual cycle. High level of this hormone in blood indicates successful ovulation.
The level is highest on the 21st day after the cycle. Hence, the test is also done on the 21st day only. Sometimes the test is done repeatedly at different time points to find any increase in the level of the hormone.
Some doctors advice the test to be done on the 2nd or 3rd day after the cycle and declare them to have low hormone level, which leaves the couple depressed.
Those who use contraceptive pills are known to have fluctuating levels of the hormone progesterone in the blood. In some women, the hormone level increases even if there has been no ovulation. Many doctors tend to ignore this fact and there is delay in conception.
Temperature monitoring
This test can be done by the woman independently without the help of the doctor. It is simple and requires recording the early morning temperature as soon as getting out of bed even before coffee or tea is being taken.
Record the temperature by keeping the thermometer under the tongue for about a minute. Continue doing this for about a month. The body temperature is constant in the first two weeks after menstrual cycle.
During the time of release of the ovum, the body temperature dips a little and then becomes normal the next day or the third day. The rise in temperature could be anything between 0.4 to 0.8o Fahrenheit. This way the body temperature of the woman is stable before menstrual cycle at one particular temperature and at a different temperature after the cycle.
This recording of temperature should be done at least for two months to confirm the possible time of ovulation between the cycles. Based on this table, doctors suggest the ideal time for sexual intercourse to ensure conception. But ideally couples should involve in sexual intercourse at least 12 to 48 hours before ovulation that too repeatedly.
Proper use of this table can help in conceiving even without the help and expense of the doctor.
Women who monitor their temperature can accurately calculate their cycle timing and ovulation timing. Some women are known to use the table very efficiently.
Sometimes the table may tend to go wrong. So it should be used only in consultation with the doctor.
Let us now see under what circumstances the test could go wrong.
- The table may be incorrect in women with erratic cycles
- Those who are on travel, those who remain awake work in early or late hours
- When the couple get involved in sex in a hurry so as not to miss the time of ovulation
Dilation and curettage
A tiny portion of the endometrial tissue is scraped and tested. The endometrial lining develops and become secretary only when ovulation has occurred. Or else, it will still remain unchanged without any change.
In women who have cycles once every 28 days, the test can reveal whether ovulation has occurred but may not be able to tell when it would occur.
Testing the uterus and the
Fallopian tube
Uterus and the Fallopian tubes are tested by means of an Xray called ‘histero salpingogram.
A small amount of dye is injected into the uterus and the path of the injected dye is monitored to find if there is any block in the Fallopian tube. Since the inner structures are clearly revealed, any blocks in the uterus or uterine tube, cysts, ulcers and scars can be easily detected.
The Xray reveals the complete picture of the uterus and the uterine tube. This helps to detect any defect in growth, size, nature and damage to any of the two. The location of the fault is also accurately detected. Any such detected fault can be eliminated or rectified by surgery later.
The test when taken during menstrual cycle can result in undesirable excess growth of the endometrium. On the other hand, conception might have occurred during the second week after the cycle. So the test should be done ideally, in the first two weeks of the cycle.
In a situation demanding postponement of the Xray for two weeks, contraceptives should be used to avoid any pregnancy.
The test takes about 10 minutes to complete. The dye is injected in to the uterus and Xray is taken. Many people do not even realize that the test is finished.
Many doctors perform this test after testing by laparoscope.
Laparoscopy
Many doctors feel that this test is the most ideal to detect the reason for failure to conceive.
A small aperture is made at the naval. Through this tiny hole, the uterus can be reached, observed and viewed clearly through the laparoscope fitted with a telescope. Or the hole could be made at the base of the folds of the lower abdomen for better viewing of the uterus. During laparoscopy, a little of carbon di oxide is injected in to separate the organs from one another. This way, only the organ to be seen can be seen and defects determined.
For example, all sorts of problems like damage to the uterine tube, hernia, excess growth of the endometrium, fibroids, congenital disorders, ovarian cysts, etc., can be accurately gauged.
When this test is done on the third week after the cycle, even changes due to ovulation can be identified.
There is no need to stay in the hospital for this test.
Many doctors perform this test, under general anesthesia while some use local anesthesia. General anesthesia is preferred because the woman’s body is completely motionless and facilitates clear and undisturbed view by the doctor.
The test does not cause any great discomfort afterwards. Some may develop rashes near the stitches. Take care to avoid the area from getting wet during the first 48 hours. The wound heals by itself. Nowadays, self-dissolving thread is used for stitching to avoid rashes from developing. This dissolves in one day.
There may be mild pain sometimes after the test. Rest may be needed for one or two days. Since the uterus is tossed a little to the sides, there may be some little bleeding also.
To prevent the above inconveniences, it is better to stay in the hospital for one or two hours and take rest.
It is notable that the test followed by proper treatment has resulted in immediate conception in many couples.
So far we saw the specific kinds of tests done for men and women. Now we can see the tests that are optional.
OPTIONAL
TESTS OR INVESTIGATIONS
The following tests are optional ones and should be done only if the doctor feels it is essential.
Tests
for men
Sperm sorting test:
This test is done to find out or estimate the function of the sperms. The semen is collected and mixed in a special buffer. The sperms that exhibit normal motility are separated from faulty ones and evaluated for their capacity to fertilize the egg. For this test, the specimen collected should be fresh. Many clinics and hospitals have exclusive areas meant for sample collection for men.
Computerized analysis of the
sperm:
In most of the sophisticated laboratories, computerized equipments fitted with a television camera are being used to monitor the movement and the activity of the sperms. Through this equipment it is possible to test the structure and function of one single sperm.
Test for autoimmune
reactions:
In many cases sperms clump together in response to the body’s auto immune reaction. In this, the person’s WBCs, which generally act to kill any invading microorganisms, tend to kill his own sperms since they consider them to be foreign bodies. In response, the sperms clump together when these body defense cells confront them. This in turn affects their motility. This kind of autoimmune reaction is tested by a test called MAR using the semen and.
When autoimmune reaction is absent but still the sperms are clumped, then it may be due to infection. To find this, a special test called ‘sperm culture’ is done to detect any infection, in some hospitals.
Fructose level:
The seminal vesicles in the testicles secrete the sugar fructose. This is usually present in the semen in a particular level. When the level of fructose in the semen is found to be low it may be indicative of blocks in the anterior or posterior portion of the seminal vesicles. Sperms will be absent in semen with low fructose.
Ejaculation test:
The first fluid that is released during ejaculation is usually abundant with normal or highly active sperms. The fluid that follows later usually contains faulty sperms or low number of sperms. The first ejaculate is collected and used for artificial insemination of the female where in the fluid is injected into the uterus of the female through a syringe for effecting conception.
Hamster test:
To test the capability of the sperms to penetrate and fuse with the egg, the collected sperms are mixed with hamster’s eggs. If they successfully penetrated the egg, then they are considered virulent ones and vice versa.
But recent research has found and proved that this test is not very reliable because, sperms, despite being capable of penetrating the hamster eggs, they may still be incapable of impregnating the woman.
In some labs, eggs from the ovaries of women undergoing hysterectomy (removal of uterus) are taken and stored. These immature dead eggs are mixed with sperms to test their capacity to penetrate the eggs. When penetration is there, then the sperms are considered virulent. Further, the number of sperms capable of penetration is also determined. Apart from the fact that only some sophisticated fertility centers are capable of performing the test, there is nothing very special about this test.
Hormone test:
Men with low sperm count may have hormone problems. Measuring the level of hormones like testosterone can be used to detect problems associated with sperm production. Sometimes, level of prolactine can also be used for this purpose.
Biopsy:
A tiny piece of tissue from the testicle can be taken and seen under the microscope to find if they are capable of sperm production. This test has been useful for many men. At the same time as performing the test, a dye is injected in to the vas Deference and X-rayed to detect any block in the tube.
Thermography test:
This test is done to detect the temperature of the testicle. A small plate that detects temperatures is kept on the testicles. When the plate turns blue it indicates thickening and projection of the testicular veins, which in turn means that the testicles have reached a very high temperature.
Chromosome test:
Some men have low production of sperms due to hereditary problems. Chromosome testing is done to detect this. But unfortunately, even if detected no particular remedy has been so far successfully developed for this fault.
Test tube method:
In this method, the ovum is taken out of the body and fertilized by the sperm outside the body in a test tube. The fertilized ovum is implanted artificially in the uterus after it reaches a particular stage of development. When the sperms compete with each other to reach the ovum then they are considered virulent ones. This is the most successful method that has been developed so far.
Optional
investigations for women
These tests are done when the reasons for infertility are not clearly identified, or when the doctor suspects one particular reason to be responsible for it.
Ultra sound scanning of the
uterus:
Ultra sound waves are sent through the genitals or the abdominal wall. The reflected waves are monitored in a computer screen. Modern ultrasound systems are capable of making highly accurate measurements and evaluation.
Through this test it is possible to find out,
Whether the follicles are developed normally?
Whether ovulation has occurred?
Are there any ovarian cysts? Etc.
It is also possible to find out if fertilization and conception has occurred in the initial stages itself.
Hormone table:
The hormone level in the blood or urine from the first day of the cycle to the first day of the next cycle is tested and tabulated. This helps to identify hormone deficiencies and any other hormonal reasons for conditions like failure to release the ovum etc.
If the individual’s normal levels of estrogen, Luteinising hormone and progesterone is recorded and known already, then it is possible to detect any abnormality at any given time.
Low levels of Luteinising hormone and the Follicle stimulating hormone indicate pituitary dysfunction. Hence, pituitary treatment is recommended. Slightly higher levels of these hormones may be indicative of cysts.
Very high levels of these hormones indicate total absence of ova in the ovaries of the female and that she is in a stage approaching menopause.
Testosterone levels:
In conditions like ovarian cysts and diseases of the adrenals, there may be increased production of the male hormone testosterone in the female. If the level of the progesterone is normal there may be no problem in the release of the ovum. An increased or decreased level may be the reason for complication.
Excess secretion of the milk secretion stimulating hormone prolactine may interfere with the normal function of ovulation. This means that the pituitaries are hyper active. An Xray of the back of the head may be helpful in confirming the problem. Since high levels of the pituitary hormones also lead to vision problems, sight investigations are also done.
Thyroid levels:
Thyroid complications contribute to only 1% of ovulation problems. Still, many doctors advice this test.
Chromosome tests:
We have seen that hereditary factors impair the production of sperms in the male. Similarly, faults in the chromosomes interfere with the production of ova or result in the production of abnormal ova. But this is a very rare phenomenon. Ordinary blood tests are done to detect this condition.
Testing the Uterus and the
Fallopian tubes:
a) Investigating the uterus
An instrument called histeroscope is introduced into the uterus and through this the uterus is scanned for cysts, fibroids, congenital disorders, endometriosis or ulcers and scars in the endometrium. This is a very small instrument. But it helps in both investigation and treatment since microsurgeries and rectification treatment can be done with this by introducing tiny instruments through this.
b) Tuboscopy:
This is an instrument about 3 mm in diameter. This is helpful in finding faults in the Fallopian tubes. This is inserted into the uterus up to the area where the mouth of the ovaries are situated.
c) Falloposcopy:
This is also similar to Tuboscopy. This testing can be done in the outpatient wing itself.
Apart from all this, less important tests like D &C, testing Vitamin deficiencies, tests using carbon-di-oxide administration are also done.
Currently, testing a little of the vaginal secretion is more common to identify problems faced by the couple. This helps to find out if any one of them has more of immune cells capable of destroying sperms.
Infertility
due to unidentifiable reasons and tests for them
Even in this age of modern techniques and novel testing methods, it has been difficult to identify the actual problem faced by many couples regarding conception.
When the actual cause has not been identified, recommending a treatment becomes impossible. In many cases, when the reasons are psychological or compulsions any amount of testing will not yield results.
Very often we see individuals where the complication appears temporarily due to unknown reasons and disappears in due course. Similarly, complication arises suddenly after a period of normalcy.
Impairment of the moving capacity of the sperm is one such. When the problem disappears then we see highly virulent sperms produced in the same individual.
It is estimated that about 30% of men suffer from temporary infertilities at some point of time in their lives and revert to normalcy later.
Offering treatment would not help when the uterus is not fully developed or when the complication is due to some other problem associated with the uterus. Examining them completely and investigating all possible reasons would help them to conceive.
Unknown reasons account for about 20% of infertilities. Some women are not able to release the ova due to hormone problems. Repeated blood tests to monitor the hormone levels and ultra sound scans can increase the possibility of conception.
Medicines that trigger hormone production do not help in the case of some women. These problems result in permanent infertility in the case of about 15% of women.
In about 15% of those suffering from infertilities due to inflammations of the Fallopian tube and endometriosis, conception can be effected through repeated laparoscopic trials.
Deficiencies in the secretions of the vaginal cervix also result in infertility in some women. These secretions are either too dilute and watery or too thick for the sperms to swim through it.
Some couple may have minimal level deficiencies. For example, the husband may have sperms that are capable of normal motility but may have low count. The wife may have slow maturation of ova. Such couples will not be able to achieve conception by natural trials for a long time; they would definitely require treatment.
When both the partners or one of the partners is too old or at the stage of menopause then they also cannot achieve conception.
Apart from all this, faults in the genes or chromosomes are not outwardly manifested. But may cause infertility. They would require special investigations and monitoring. Sometimes the same investigations can be repeated at regular intervals for identification of the problem.
Till now, we saw some of the investigation procedures done for couples who for some reason have been issueless. Let us now see some treatment methods given for them.
CHAPTER
10. TREATMENT METHODS
It is painful to see that many people are still unaware of the advancement that has been made in all walks of life due to the innumerable and amazing modern discoveries of the current world.
Even in the field of reproduction, we have come to the stage of cloning having started with test tube babies. But we still follow the traditional methods and waste time and money on false claims proclaimed by quacks in the form of herbs and concoctions. We find this behavior not only among the poor and the illiterate but also among the educated.
We are in an age where we opt for digital photo prints or Polaroid prints since we have no time to wait for even developing and printing the film roll. We have no time to even walk the distance of half a kilometer and we use the vehicle.
Our people are prepared to use the scientific advancements for such small and possibly trivial things, but for a very important issue like infertility they are hesitant to approach the fertility consultant and get a remedy as soon as possible. Instead, we take upon pilgrimages or perform gigantic religious rites or worse still, approach quacks, who put forth attractive and false advertisements claiming to cure all sorts of sexual and infertility problems. Only in the end we see the fact and come to the consultant.
Instead, the situation should change in such a way that the consultant is approached as soon as the need is felt or when there is a significant delay in conception.
Remember that this is the only way where all the possible reasons that prevent conception can be detected through extensive methods and complete remedy could be given.
Most of the couples, who opt for indigenous medicine initially, try it for 6 months or one year but ultimately approach the fertility consultant as the last resort.
But even among them, there is a tendency to expect imminent results as soon as investigations are over and treatment is only at the preliminary level.
Some couples succeed in conceiving immediately after starting treatment; but unfortunately in some, even after prolonged treatment it does not happen.
We need to look at the problem holistically and try to find a solution patiently instead of jumping to conclusions and frequently shifting treatment methods.
Even an experienced consultant cannot assure pregnancy without doing the preliminary tests and evaluating the reasons. He can only say if there is a possibility of childbirth or not.
This is because even the modern treatment methods have their limitations.
We can now move on to the types of treatment that are given to couples with different types of problems. We shall also discuss their usefulness and limitations.
TREATMENT
METHODS FOR MEN
Lab investigations meant for men are very simple but the treatment methods are very tough and hard. This needs trained and skilled doctors in addition to modern well-equipped laboratories.
Above all this, the patient who comes for treatment should have a lot of patience. Only a combination of all this will ensure successful treatment for the male.
You should know by now that semen analysis is the first investigation that is done for any male seeking treatment for infertility. Treatment depends on the kind of result obtained. Further, there are situations when the sperms are abnormal at one time but are completely normal at other times. The reason for this is yet an unsolved riddle. This is why even repeated semen analysis is being recommended.
Men who opt for treatment should follow the following rules. Only then the outcome will be desirable.
General physical parameters
Infertility or its degree also varies in the male who is healthy. Those who are capable of impregnating the female suffer from temporary infertility.
For example, measles, injury to the testicles, under developed scrotal sac are some of the conditions that can cause temporary infertility. It requires about 70 days to detect these kinds of conditions before commencing treatment. Even after taking treatment the sperm count does not increase for about 4-6 months. Chances of the count increasing become higher only after this period.
Increase in body weight
Obesity or over weight results in different types of complications; especially psychologically. So proper diet control should be maintained and body weight should be reduced. Again it should be a gradual process and one should try to lose weight by about 2 pounds a week instead of a hectic exhaustive attempt.
Undesirable habits
Smoking has a great effect on a male’s capacity to fertilise a female. The sperm count in a smoker’s semen is very low. Taking treatment on one side and simultaneously smoking 8-10 packets of cigarettes daily will not help.
Those attempting test tube babies should definitely avoid smoking. It should be remembered that stopping smoking would not bring back normalcy to the count and the nature of the sperms immediately. It will again be a slow process.
Men with low count of sperms should give up on alcohol too. Alcohol is known to cause extensive damage to the count and the nature of sperms.
Medicines, drugs and
exercises
Those who are on medications should consult the doctor regarding the side effects of the medicines. Doses of the drugs that cause maximum side effects should be adjusted. Jogging long distances daily and exhaustive workouts should be avoided. When these are stopped or controlled, the sperm count starts increasing.
Reducing the temperature of
the scrotum
The testicles are situated in the scrotal sacs that are kept distended away from the body because they have to be maintained at a temperature less than the normal body temperature. This is the reason why doctors advice men with low sperm count to wear loose dresses and take bath in cold water.
It is better that all men irrespective of their sperm count should take bath in cold water only. Hot water is highly detrimental to sperm production. In fact, bathing in hot water is practiced as a contraceptive procedure.
The fact that tight undergarments increase the temperature of the testicles and in turn affect sperm production should always be borne in mind.
Treatment methods
Hormone treatment plays a major role in treating infertility in males. Remember to follow the doctor’s advice strictly. Failure to be monitored by the doctor may result in unpleasant results.
Testosterone
High level of testosterone can cause low sperm production. The fact that sperm count and production could decrease greatly with hormone treatment has come to light. The number becomes normal after treatment. This kind of fluctuation is only temporary. Synthetic testosterone components have been found to increase the sperm count and their swimming capacity. But this treatment needs to be taken only under doctor’s supervision.
Gonadotropic hormones
Stimulating hormones of the pituitary like LH and FSH are given as injections. They function to increase the number of sperms rather than increasing their capacity to move. This treatment helps mostly those who have impaired pituitary secretion. Giving treatment without finding which hormone is lacking will not help much.
Tablets that are given to women in order to stimulate the pituitary can sometimes affect the ovaries and the uterus. Similarly, such stimulating tablets that are given to induce production of testosterone could result in undesirable side effects.
Antibiotics
Antibiotics are given when the doctor feels that the nature and the moving capacity of the sperms are affected due to infection. Taking this treatment for 4-6 months completely eliminates all infections in the reproductive tract.
Steroid treatment given to
increase immunity
Steroids are given to those whose sperms are affected by body’s immune cells. The dosages may vary and the period of treatment could extend for several months. Steroids may result in increase in body weight, depression, inconveniences and abdominal bleeding etc. So, careful monitoring by the doctor is absolutely necessary.
Surgical methods
Treatment methods involving surgical correction of any faults after careful evaluation of the problem are becoming more and more common. We now present the kinds of problems for which surgery is sought.
Blocks in the blood vessels
Blocks in the blood vessels due to damage caused by injury, formation of knots or thickening are treated by surgical removal of the blocks.
About of 20% of men irrespective of their fertility status are found to be suffering from this kind of problem.
Men who have been capable of fertilizing their women due to low-level manifestation of this problem are not greatly affected. Complications arise only when the problem is manifested.
Increased blood flow through the blood vessels that causes an increase in the temperature also can cause infertility.
Usually chemicals that are capable of causing dilation or constriction of the damaged blood vessels are given as injections under general anesthesia. Immediately after the surgery an Xray is taken to find out if the correction has effectively removed the block. In about 70% of men who had undergone this treatment, sperm production was restored within 3 months of surgery.
Opening up of the vas
Deference
The tubes that carry the sperms are very narrow in bore. The epidydimis measures only about 0.2 mm in diameter. Similarly, the vas Deference that looks thick externally is actually very narrow internally. This requires surgical correction under general anesthesia where in the blocked portion is cut away and the remaining two ends are stitched together. This is done by microsurgery.
Since the wound heals very fast there is no problem in sexual functions. But the result and remedy depends on the method adopted during microsurgery.
Prolonged blocks in the vas Deference would have permanently stopped sperm production in the testicles. When the whole production has stopped even microsurgery cannot restore sperm production completely. About 80% of men suffering from infertility have this type of complication.
When surgery is done by an expert, sperm production has been found to be restored in about 40% of such men.
Block in the epidydimis causes low sperm production. The sperms are sucked up using a very tiny needle and syringe after which surgery is done under general anesthesia.
The testicles are opened and the tubes pierced. Many times the sperms that are sucked up from the epididymis is used for artificial insemination. Surgeries performed more than twice on the epididymis can permanently damage these fragile tubes.
Artificial insemination
When sperm production is low and conception is impossible by the natural way, sperms are collected and tested for virulent movement; these sperms are made to fertilize the mature ovum collected from the female, inside a test-tube. The fertilized ovum is reintroduced into the uterus of the female at a particular stage of development. This is done by three methods.
a. introducing the sperms at the mouth of the uterine opening
When the uterus or its mouth is situated in an abnormal position then the sperms are introduced at the mouth of the uterus through a very tiny plastic tube inserted through the vagina and the cervix.
b. introducing the sperms in an exclusive method
Semen is obtained by masturbation. It is analysed and dead sperms and cells are removed. The virulent ones are separated, purified and introduced near the uterine cervix. Any antibody producing cells are removed during the purification process.
Semen is obtained by split ejaculation method and the first ejaculate is used for this purpose.
c. direct implantation in the uterus
When there are problems associated with the uterine mouth then the sperms are directly placed inside the uterus for fertilization to occur in the uterine tube. Virulent sperms are removed from the semen and mixed in a special buffer prepared in the laboratory. This is then introduced in to the uterus through the cervix.
Only sophisticated laboratories are equipped to separate and purify the sperms from the semen. This method may not be successful in one attempt and several attempts may be needed.
All these methods of artificial insemination require the full understanding and cooperation of the couple involved in addition to blood tests, ultra sound scans and other investigations.
Let us now see the treatment methods for women
We know that investigations and treatment methods for women outnumber those meant for men.
Usually women’s problems are treated by hormone therapy or surgery.
Failure to release the ovum
Most of the treatment methods for women are centered upon the ovum. Egg production is normally low in women in the menopausal age and in women ailing from premature menopause. Hormone therapy can be successful in about 80% of cases. About 65% of these women successfully conceive.
Hormone tablets that can induce egg production and increase the chance of conception are freely available in the market. These tablets individually stimulate the secretion of particular hormones that induce the production of eggs. Some hormones are given as injections also.
A method called ‘pump therapy’ is also used in hormone treatment. Usually the pituitary releases the sex hormones LH and FSH once in 90 minutes. Similar pattern is followed in this therapy and hormones are given as injection once every 90 minutes to induce egg production.
We know that the pituitary secretes LH and FSH only under the command of the hypothalamus. Impaired relation between the hypothalamus and the pituitary can in turn affect production of ova. Such problems are treated by hormone therapy once the cause is well established by lab investigations. Such treatment triggers the production of ova by the ovaries. This treatment is called LHRH.
There are also hormone therapies available to inactivate the pituitary gland. During the beginning of the treatment the pituitary releases a very high level of these hormones, which gradually gets reduced in amount. This causes a decrease in the production of estrogen as a result of which the ovaries are totally inactivated. At this time, the hormone ‘human menopausal gonadotropin’ is given as injection. The ovaries accept this and act fast releasing a large number ova. These eggs are collected and used for artificial insemination. This method is employed extensively in test-tube fertilization.
In some women, secretion of the hormone progesterone that occurs normally after ovulation is impaired. As a result of this the endometrium does not develop fully and loses its ability to receive the ova. This also has been found to be one of the reasons for infertility. Such a condition is treated by progesterone injections that trigger the ovaries as well as development of the endometrium.
Tumors and cysts in the pituitary may cause increased production of the milk hormone prolactine. This not only causes infertility but also causes vision problems. The actual cause is determined using Xrays and treatment is given either as injections or medicines or through surgery.
Factors to be remembered
while on treatment
Hormone levels are to be tested everyday while on hormone therapy. The levels of hormones during the period of ovulation also need to be checked.
The effectiveness of hormone therapy can be recognized by symptoms like pain in the breast, abdominal cramps, white discharge or fluid discharge through the genitals, painful periods etc. Ultra sound scanning at this time helps to confirm proper ovulation.
Hormone treatment may sometimes result in side effects like irregular periods, fatigue, nausea etc. It is better to get proper information from the doctor regarding the side effects of the treatment and the drugs.
Damages of the uterine tubes
Diseases of the uterine tubes, hernia or fusion of the tissues, inflammation in the middle or distal portion of the tube may result in damage to the uterine tube. Rectification of such damages when other parts of the reproductive system are intact restores chances of conception.
Diseases of the uterine tube or fusion of the parts like the ovaries or the uterine tube to the abdominal organs require surgical correction of the fault. Surgeries performed on the uterus, uterine tube or the ovaries, is called as tubal microsurgery. The surgery is performed using extremely tiny surgical instruments through the laparoscopic instrument.
Blocks in the tube and fusion of the walls of the uterine tube are majorly treated by this type of surgery.
The diameter of the uterine tube measure about 0.4 mm. This is the path that the ovum has to take to get fertilized and transported to the uterus. Blocks caused by constriction of the tube or fusion of the walls of the tube prevents free passage of the ovum to the uterus. As a result, the ovum released by the ovaries never gets a chance to be fertilized and finally gets degenerated.
On many occasions the fused portions are removed in portions. Chances of fusion are highest in the region of the outward end of the uterine tube.
This portion is close to the ovaries and takes in the released ovum. When the end is blocked it is filled with fluids and gets swollen. During surgery the fused walls are separated and fluids are drained after which correction is made.
Fibroids or absence of fissures inside the tube that usually facilitate the movement of the ova through the tube or complete damage of the portion of the tube may also result in infertility.
Such faults can be accurately diagnosed by Xrays. Surgery involves removal of the damaged portion after which the free end of the tube is connected with the uterus through an aperture made in the uterine wall.
When the middle portion of the tube is damaged, two incisions are made on either side of the damaged portion and the portion removed. The remaining two ends are then stitched together after which the tube is sterilized to prevent infection. This method increases the chances of conception to about 65 to 95%.
This surgery takes about 45 minutes. Performing the surgery through a microscope increases the chances of success.
A small incision is made in the lower abdomen during surgery. Normal routine activities can be taken up in a week’s time. Care should be taken to avoid strained cough and strenuous excretion of feces. This helps in rapid healing of the wound.
Following microsurgery it is advised to consult the doctor regularly for 3 months or till conception occurs. Infection or inflammations following surgery can be treated by a gynecologist.
Figure on page 136
(Abnormal conditions in which the zygote gets implanted and grows in the uterine tube or other areas instead of the uterus)
If conception occurs immediately after microsurgery then the doctor should be informed. Since the uterine tube is corrected and cleaned by surgery, there is a chance of the zygote getting implanted in the tube itself instead of the uterus. Such a condition can be identified by ultra sound scan or repeated blood tests and corrected later.
Failure to conceive even after 2 years of treatment should indicate refusion of the walls of the tube. This again needs confirmation by investigations. We should remember that such measures can only improve the chances of conception but cannot promise it 100%.
Laparoscopic surgery of the
uterine tube
A small incision is made within the naval and surgery is performed using tiny surgical instruments introduced through the laparoscope. This method can rectify many faults including blocks in the distal end of the tube. Some doctors use laser treatment also while performing laparoscopic surgeries.
This is a simple, strain free method that has been found to be highly successful. The patient recovers fast. There is no need to stay in the hospital unless advised by the doctor.
Introduction of balloon
inside the uterine tube
Balloons are used for removing the blocks and expanding the uterine tubes just like in angioplasty where similar treatment is given to remove blocks in the blood vessels.
Inflammation of the
endometrium
This condition is called endometriosis. This condition mostly affects the uterus. It can be rectified through laparoscopic surgery. The inflamed endometrium develops rapidly due to hormonal stimulation and causes blocks in other parts due to fusion resulting in damage to those parts. But this cannot prevent ovulation.
Such a condition results in cysts and tumors in the uterus affecting the chances of conception. This can be removed at the time of examination itself by microsurgery.
Complications of the uterus
Most of the problems associated with the uterus are corrected by the doctors in the outpatient section itself excepting a few conditions which require surgeries.
Fibroids
Fibroids are capable of filling the whole uterine cavity up to the region of fusion with the uterine tube. Hence, this requires surgery.
Small or tiny fibroids do not interfere with conception. But since they acquire blood circulation from the uterus they grow in size like any other organ. When the growth is likely to damage the uterus and its function, it can be surgically removed and the uterus cured.
Congenital disorders
Hypolastic uterus is a condition in which the uterus is grown abnormally. Septate uterus is a condition in which the uterus is divided into compartments. In addition there are conditions called bicarnuate uterus etc that occur as congenital complications of the uterus. All these conditions require surgical corrections.
Fusion of the uterine walls
When the walls of the uterus are stuck together, they are surgically separated by introducing special instruments like histeroscope through the vagina. This surgery takes only about a day to perform. Sometimes to keep the walls from joining together, a special plastic coil is kept in position. Antibiotics, estrogen and sometimes steroids are also given. When the problem is completely rectified, chances of conception are very bright.
Polyps
Polyps, which are full of fluids frequently, develop in the uterus. This is usually removed by dilation and curettage (D&C). Such treatment completely eliminates any infertility caused by polyps.
Adenomyosis
This is caused by excess growth of the muscles of the uterine wall. Though this is difficult to treat it is usually treated in the same way as for treating inflammation of the endometrium.
Complications of the cervical
glands
Sometimes infertility results from the secretions of the cervical glands. We know that sperms enter the uterus only after passing through these secretions. When these secretions are very thick the sperms will not be in a position to pass through them. When the pH is acidic it results in the death of the sperms. Surgical correction can be done to make the fluids dilute and capable of protecting the sperms so that they are safely transported across the uterus to effect fertilization.
Hormone estrogen is responsible for making this fluid less viscous. This fact can be evidenced by testing the fluid after sexual intercourse.
Estrogen supplement in the form of tablets or vaginal creams are used. But they help more in the release of the ovum rather than having any effect on this fluid.
Steroids
Steroids in the form of cortisone tablets are administered to prevent the killing of the sperms by the autoimmune antibodies, when they approach the secretions.
Steroids can be taken for this purpose only for about one or two weeks. It is not safe to continue taking steroids indefinitely since it can cause ulcers, changes in the osteo densities, loss of calcium, infections and mental depression.
In the case of life taking infections steroids may be continued for a while.
Cryo therapy or laser
treatment
When the secretions of the glands are very thick or almost in clots the cells of the glands are completely frozen or burnt by laser treatment, which completely destroys the old secretions and the cells. The new cells that form are likely to produce secretion of normal consistency. This treatment is very simple.
Fig on page 141
Correction of the cervical glands through cryo therapy.
Antibiotic treatment
When the secretions carry microorganisms due to infection of the glands, sperms will not be able to penetrate them. These infecting microorganisms are killed by giving antibiotics. These organisms are normally found in the cervical region of even healthy fertile females. But in such women their presence does not harm the chances of conception.
Artificial insemination
When normal sexual functions are not possible or impaired, sperms from the husband can be collected and introduced into the uterus of the wife. But normally couples do not come forward for this kind of treatment. They do not want to advertise the fact that their sex life is not complete. Motivating and counseling may help such couples. But every time artificial insemination is attempted, testing the cervical fluid for consistency and infection is a must.
CHAPTER
11. TEST – TUBE BABIES
The most modern method of treatment for infertility can be said to be test-tube babies. This is otherwise called as in vitro Fertilization (IVF).
The female’s ovum and the male’s sperm are taken out of the body and mixed in a test-tube where fertilization is brought about. The fertilized ovum is placed again inside the uterus for fetal development. In short the test tube performs the function of the uterine tube outside the body.
For this, the man’s sperms are collected and the virulent ones are separated and stored in the laboratories. The female’s mature ova are collected and both are mixed to bring about fertilization inside a test tube. On the second day the fertilized ovum or the zygote is implanted in the uterus of the female.
At this stage the zygote is in the four- cell stage. Careful introduction and manipulation facilitates firm implantation of the zygote in the uterine wall.
Many couples do not understand the difference between IVF and artificial insemination. Many women fear that they may be fertilized using sperms from some other male.
When the husband’s sperms are normal but there are difficulties in sexual conduct, semen is collected from the male and introduced into the female’s vagina or the uterus directly. This is called as artificial insemination.
Instead, when both the eggs and the sperms are removed from the body and allowed to fuse within a test-tube for reintroduction of the fertilized ovum into the female, it is called as test tube baby method.
Couples waiting for conception should know these facts.
Let us now see the steps involved in the development of the test-tube baby. This may help to clear all your doubts.
Stage in the development of test tube babies
I. Checking the eligibility
of the couples:
Most couples are under the impression that it is possible for everyone to get children by the test tube method. But the truth is that, the method may not by suitable for everyone. Further, not all the females for whom the method is recommended are treated in the same way. Instead each one is treated by different method. This is the reason for confirming the eligibility of the couples for treatment by test tube method.
Before starting treatment, important investigations like sperm count, testing the hormone levels are done at different stages to confirm the possibility of successful conception in case of this treatment.
If the depth of the uterus is not tested previously then that is done by an Xray. This helps to determine whether the uterus is strong enough to sustain the pressures of pregnancy and whether it would aid the growth of the implanted zygote.
Some women may require tablets to facilitate ovulation. In addition how much this treatment would help the woman is also ascertained before giving tablets.
II. Inducing the production
of ova
Sometimes the fertilized ovum or the zygote fails to grow into a fetus. Instead, it gets degenerated. The main reason for this is the insufficient maturity of the ovum.
It may be possible to isolate one ovum for fertilization by sperm in a test tube. But it is impossible to predict whether it would grow into a baby within the womb. To prevent any such loss, doctors induce the production of many such mature ova by the ovaries by giving hormone tablets.
Hormone treatment for such women is given after studying the woman’s body nature, ovulation time etc, beginning a few days after the menstrual period.
The pituitary gland may be temporarily commanded not to secrete the hormones meant for inducing the release of the ovum. This method is adopted to get more number of ova.
Instead of tablets progesterone is administered to obtain mature ova.
Some hospitals follow the practice of procuring the ova in a short time and some hospitals try to obtain the ova over a longer period. This enables the team to get as many ova as possible within a short time. Though all of them may not develop in to fertilizable ova, the eligible or the ideal ones can be selected and used for in vitro fertilization.
III. Estimating the
development of the egg
The time of ovulation should be accurately estimated and ova collected at that time. Otherwise it may not be possible to effect conception. Hormone testing is done repeatedly to confirm the time of ovulation.
To collect the mature ova, doctors employ four methods. An inexperienced person may not be accurate in any of these techniques.
a. Hormone testing
When the follicles start swelling there is an increased secretion of progesterone and estrogen. This stage can be identified by repeated blood tests.
The pituitary hormone LH that stimulates the ovaries and induces maturation of the ovum is also secreted and therefore found in the blood.
Repeated blood tests done for testing hormone levels help in the identification of the time of ovulation.
Many clinics fail to correctly identify this period. As a result, conception is delayed due to inability to obtain mature eggs.
b. Ultrasound
Ultra sound scan done daily can help in predicting the time at which the follicles start developing. If the diameter of a follicle measures about 20 mm we can infer that the egg is likely to be released immediately. Since this method can accurately predict the time of ovulation, the ultra sound scan called ‘vaginal ultra sound’ is being adopted more and more by doctors.
c. Injection
Just before the egg is going to be released, HCG hormone is given as injection. This induces the ovaries to get the follicles ready to release the ovum. In about 37 hours from the time of injection the follicles mature and release mature ova. The injection helps in the maturation of the ovum before the egg is released normally.
This injection is given even before the pituitary secrets the hormone LH that is meant for stimulating the ovaries.
Many doctors find it difficult to collect ova by injections. Because, any delay in the collection may result in the degeneration of the ovum. Collecting them earlier may not give enough time for the ova to mature fully. Hormone tests need to be performed regularly to avoid any problem.
d. Normal menstrual cycle
Only in a few clinics artificial induction of the ovaries to collect ova is not practiced. Many a times it is attempted to hasten the release of the ovum that would be normally released during the cycle, through a single dose injection of the sex hormone HCG.
It is very doubtful whether this method would yield the desired results. Though it is possible to collect the ovum that is normally released without any induction and effect sterilization, it may not be successful in the first attempt. It may require further attempts and one may have to wait for another month.
IV. Collection of mature ova
Collection of mature ova is done by either laparoscopy under general anesthesia or by ultra sound. This requires vaginal ultrasound. A special device which is very small is inserted into the vagina through the ovaries are scanned.
The mature ova are collected by suction through a syringe into a test tube and handed over to the specialist for analysis. This can be done using local anesthesia. Special care and skill is required during collection or since lack of skill may result in failure to collect even one ovum.
V. Culture of the germ cells
(artificially preparing the ovum and the sperm for fertilization)
Eggs once collected are not stable and may degenerate fast. So usually the collected ova are examined under the microscope inside the operation theatre itself and the selected ones are placed immediately in the special medium (fluid) prepared for storing them. This special medium has chemical preservatives and the woman’s serum in it that are capable of maintaining the ova in a viable state.
The medium containing the eggs is incubated at body temperature (37oC) in an incubator. This provides an environment that the eggs are accustomed to within the body.
Just before collection of the eggs, the male is requested to collect the semen through masturbation. In case the male finds it difficult to collect semen under these circumstances, semen collected previously and stored in the deep freeze is used.
A fresh sample of semen is always ideal because, it is not easy to bring about fertilization using the frozen sample.
Once the semen is collected the sperms are separated and counted under the microscope. Hours after the eggs are collected, the sperms are mixed in the same medium and placed back in the incubator for fertilization to occur.
Sometimes the sperms may not attain or may lose the capacity to fertilize the ovum in the last minute. To avoid this, nowadays, millions of sperms are collected and used for fertilization within the tube.
VI. Growing the fertilized
ovum (zygote)
In standard test tube baby centers, the medium containing the sperms and the ova is tested 18 hours after the germ cells are mixed. Examination at this point would indicate if fertilization has occurred successfully. At this time, some of the cells may divide even without fertilization. This kind of division of cells without fusion is called as ‘parthenogenetic cleavage’. Implantation of the unfertilized ovum into the uterus will not yield results. To avoid all this, testing for fertilization is essential.
In about 48 hours the zygote would have reached the four-cell stage. Sometimes, the cleavage may be even faster.
The nature of the zygote is tested before implantation of the zygote within the uterus. In case of any doubt, the procedure is postponed for another 24 hours and the zygote further incubated. In some clinics it is standard practice to transfer the zygote to the uterus only after 60 hours. If any abnormality is detected in the zygote it is discarded and not used for implantation.
The whole procedure is repeated after the next cycle.
To avoid all this complication, several eggs are collected fertilized and more than one zygote is implanted. This does not affect the growth of the embryo. In short, implantation depends on how the zygote develops within the test tube.
VII. Transfer of the zygote
to the uterus
This is an intricate procedure. The growing zygote is taken in a tiny thin plastic tube along with a little of the medium and carefully introduced into the uterus through the cervix. This can be done even without anesthesia. The woman is made to lie back comfortably on the table and the plastic tube inserted through the vagina.
Some people consider it ideal for the woman to lie in the same position for sometime. This may not be necessary. Some even recommend hormone injections to create the ideal environment for the zygote to grow. All this depends on the woman’s health and the discretion of the specialist.
Despite successful fertilization of the ovum and its implantation in the uterus, sometimes complications may develop during later stages. If menstrual cycle occurs then there is a possibility of the zygotes being expelled. Improper development of the zygote is also one of the reasons for this condition to develop. This can be identified by microscopic examination of the zygote. To prevent this from happening urine is tested to confirm implantation of the zygote. Treatment and preventive measures are taken to avoid expulsion of the zygote.
It is estimated that one in fifty babies that are born by natural mode of fertilization tends to have congenital disorders of some kind. But we can definitely say that this is not the case with test tube babies. Similarly, possibilities for chromosome disorders are not much. Likelihood of any such problem existing is eliminated by testing the ovum at the embryo stage itself. So, most of the complications are prevented.
Many people are of the opinion that more of miscarriages are being reported. This is because most of the women who undergo such conception belong to the ‘high risk’ group.
While transferring the fertilized ova to the uterus, even if one of the ova is lost there should be another available to grow into a fetus. This is why more than one zygote is usually implanted in the uterus.
Sometimes both the zygotes grow into healthy fetuses. This may sometimes lead to miscarriages or premature babies. This becomes unavoidable.
This mode of conception is always associated with administration of hormones in the form of tablets or injections meant for inducing the ovaries. Sometimes this may lead to ovarian polyps or cysts. This is called as ‘hyper stimulation syndrome’.
Ultrasonic method of ovum collection is better than laparoscopic method since there are fewer complications.
Great expectations are associated with test tube babies. Sometimes patients come from far away places. Fatigue due to traveling, fatigue due to the wait for collection of ova can result in mental instability or disturbances in the women who undergo this. But these are only manageable problems.
The man does not have to face any of these problems. His responsibility is over with donating his semen.
Many a times, the couples are fully counseled before the start of the treatment itself as to be ready to face all these difficult situations. In fact, this is said to bring the couples closer.
More than one method is being employed in many infertility centers to bring about fertilization. But standard laboratories and clinics begin the treatment only after making all necessary preparations in the couple both mentally and physically.
It is interesting to know how the egg that is recovered from the ovary is transferred to the test tube.
First, the ovaries are induced through ultra sound and the eggs are collected and kept in a compact 12 volt incubator. More than one egg is collected this way.
Leaving the ova in a safe environment, the husband is requested to collect semen by masturbation. The sperms are checked, selected, separated and mixed with the ova.
After fertilization occurs, the zygote is kept in a simulated environment resembling the uterus. The zygote is exposed to a similar temperature and body factors including hormones and the mother’s serum.
Two days later, the zygote is implanted into the uterus of the mother. Though the process of implantation seems very easy, it is very difficult to effect successful implantation. Any kind of negligence may result in failure of implantation.
Keeping in mind all these factors, protocols have been developed in which about 15 ova are collected, mixed with the sperms. One or two best ones among the zygotes formed are used for implantation. The rest are stored carefully in the freezer. In the event of the failure of the first attempt, the procedure is tried another time.
Conditions
that require in vitro fertilization
Many couples are not aware of the conditions, which demand in vitro fertilization. Only under the following conditions in which natural method of conception cannot happen, IVF should be sought.
When both the Fallopian tubes are damaged extensively, normal fertilization may not occur. If these are not rectified even after correction surgeries are done then IVF could be recommended for them.
When the reproductive processes of production of ovum, maturation and release are normal in the female and yet conception does not occur due to the male’s low sperm count or faulty sperms then IVF can be recommended. Care is taken to carefully select the ideal sperms in such cases.
· Problems associated with the cervical secretions and fluids
IVF is advised in conditions in which the secretions of the cervix are too viscous preventing the entry of the sperms into the uterus or the secretion being too acidic that may be lethal to the sperms.
· Failure in fertilization despite proper ovulation
Sometimes ovulation is effected by means of artificial methods. But when even after that fertilization does not occur then IVF can be suggested.
Women with endometriosis or unexplained infertilities may require IVF.
The male having low count or faulty sperms and the female having ovulation faults or faults in the Fallopian tubes, is a situation that only IVF could help.
If the first child is born with congenital disorders and there is a possibility of the second baby also being born with similar disorders demand IVF as the only way of remedy.
Those not eligible for IVF
v Those who have undergone hysterectomy (removal of the uterus)
v Those with severe adenomyosis or severe scarring of the endometrium
v Those with severe tuberculosis infection of the uterus
v Those with severely damaged ovaries
v Those in whom the reproductive organs are fused with the abdominal organs
v Those past the age of 45 and are weak
v Those with sperm counts less than a lakh and / or with faulty sperms
These people do not have a chance for getting babies by the test tube method.
So far, we have seen problems that are seen in women with respect to IVF. Let us now see the kind of problems seen in men.
Men with infertility problems are treated in many ways to get babies by the test tube method.
Sperms from men with very low counts are collected and mixed with the ova contained in a very small quantity of the medium. This allows better chance for the few available sperms to reach the ova. Fertilization is mostly successful by this method.
When there is a block in the vas Deference, the sperms from the epidydimis is taken by suction through a syringe and used for test tube fertilization.
In some men sperms would have lost their capacity to even move or may be having very low motility. These sperms may not be in a position to penetrate even the outer layers of the ovum let alone being capable of fertilizing it. But modern technology has solved this problem also. The outer layer of the egg called the zona is lysed using chemicals to facilitate entry by the sperms.
The zygote formed by fusion between the ovum and so weak a sperm should be tested for growth, congenital disorders etc. This is done when it is at the 16cell stage itself.
In such a procedure there is a possibility of the ovum being infected when its outer coating is lost due to treatment with chemicals. This may result in the loss of the ovum. This is prevented by making a small aperture in the outer covering of the ovum through laser, which allows only a sperm to enter.
These measures make it safe for the sperm to do its job without much effort.
Highly sophisticated microscopes are used to monitor these processes of making micro pores on the walls of the ovum and making the sperm enter through it. The ovum is held under the microscope and the sperm is introduced into it using a micropipette.
Freezing the zygote
The fertilized ovum or the zygote can be kept frozen in liquid nitrogen at –196oC. Zygote so preserved can be used even 100 years later. This is called “cryo preservation”. Such zygotes can be made to develop into babies 50 years later in some other foster mother also. It is amazing how science has come to manipulate Nature by making a zygote as old as the grandmother to be born as a granddaughter.
How is the zygote preserved?
The normal temperature maintained in our household refrigerators can maintain temperature between 4-20oC only. Even food kept in this temperature is likely to get spoilt after a few days. How can a zygote be preserved in this? A special kind of refrigerator that maintains a temperature extremely cold by using liquid nitrogen has been developed and used for this purpose.
Liquid nitrogen freezes and forms ice. The zygote kept in this will also be in a frozen state. When it is brought to normal room temperature it may get thawed or torn into pieces. This may result in damage to the chromosomes.
To avoid this, the zygote is kept in a special medium that contains several chemicals. These chemicals help to maintain a space around the zygote. This prevents any damage to the zygote however cold the temperature is.
The advantages and
disadvantages of freezing the zygote
Amazing things have happened after this most modern technology of cryo preservation of the zygote came into practice. Some are advantageous or disadvantageous.
Advantages:
More than one egg can be collected and preserved for any future necessities. By this, even if one attempt at implanting the zygote in the uterus fails, others would be available for subsequent attempts.
Couples with difficulties in having babies the natural way can attempt to develop zygotes and preserve them for use.
Zygotes are even donated nowadays for couples for whom there is absolutely no possibility of having children.
Women who undergo D and C as treatment for uterine cancer and fibroids can safely prepare the zygotes before hand and have them preserved.
Disadvantages:
Cryo preservation may not be successful always. Sometimes it may totally fail. The test tube zygote prepared and preserved may not be as ideal as the fresh one.
They need to be stored in an ideal environment especially the hormone factors of the mother. Failure to do so may render them unfit for implantation. Cyropreservation of zygotes can be expensive. Any chemical changes during preservation can result in congenital disorders.
Sometimes even carefully prepared test tube zygotes become unfit for implantation in the uterus.
- When the woman is under treatment for cancer the ovum can be frozen and zygote can be prepared later
- If the woman develops serious infections or high fever at the time of implantation then the zygote can be preserved and used after she recovers completely
- When the woman is past the age of forty, one attempt of IVF may not be successful. In such cases spare zygotes can be kept preserved for any eventualities
Sometimes, the zygote is implanted into the uterus of foster mothers who donate their uterus.
Factors that influence successful natural conception after
IVF attempt.
There have been many instances when IVF treatment had failed to result in successful results. But amazingly, a few couples had succeeded in conceiving naturally after undergoing treatment. Many people consider this a disgrace to medicine and that they had been going through unnecessary treatment. But the truth is that the injections and tablets that were given during treatment, the surgeries that were done to remove blocks in the reproductive parts had finally aided natural way of conception.
Among the many factors that are responsible for successful completion of IVF resulting in the birth of the baby are the following:
- standard infertility clinic and the standard operating procedures followed there
- careful implantation of more than one zygote
- careful monitoring of hormone levels etc.
Not only the doctor but also the lab staff are vigilant in monitoring the correct time of ovulation since success is very much dependant on this crucial step. About 12 –15 mature ova are collected for IVF and about three or four are used for implantation.
Reasons for failure of IVF
Despite careful selection of couples and preparing them well for IVF, it fails sometimes.
What could be the reasons for them?
Sometimes, tumors or cysts develop in the ovaries instead of primordial follicles. The treatment has to be suspended in such cases. About 8 – 20 % of patients develop this complication. Treatment is given to completely eliminate the tumors or cysts and ovaries are given sufficient rest. IVF is attempted later.
Sometimes, it is impossible to collect ova by both laparoscopy and ultrasound.
If the sperms are in a weak state at the time of being mixed with the ova, then fertilization does not occur. It is common to see patients in whom sperms had been found to be normal in consecutive tests but had lost their virulence during the time of collection. This fluctuation in male potency is a very important reason for failure of IVF.
When eggs do not mature normally or are in a state of degradation then there is a possibility of failure of IVF.
If the zygote is transferred to the uterus in an under developed state or not implanted correctly, it may degenerate. This has been found to be the most common reason for failure of IVF where inexperienced doctors perform the procedures. About 15% of IVF failures are due to degeneration of the zygote in a few weeks due to improper development.
This is the reason why couples who approach us for treatment are thoroughly examined and counseled before start of treatment.
Selecting the best
infertility clinic
Nowadays advertisements and interviews given through different media like magazines, newspapers and televisions are considered as criteria for selecting the doctors. But many a times, such an approach fails.
Then how to select the best clinic?
Find out details about the fertility clinics in your city. Note down their rates of success or failure. Visit the clinic once. Watch if the doctor and the lab staff are working as a team or as two different entities.
When consulting the doctor see,
- if he is patient with the ‘patient’
- if he is easily available
- are you made to wait for long
- in case of a problem would he be available easily
- do they perform all the necessary tests like urine test, hormone test and scans etc that are required
- do they do only IVF or are they doing any other method of treatment too
- how do those who have already undergone treatment feel
- what is their opinion
- what kind of treatment and what kind of tablets have been prescribed earlier
Most importantly find out if any agents are operating to obtain patients. If all these queries give you satisfactory answers then go ahead with that clinic and the specialist.
Situations
where treatment is suspended half way through
When you are going through treatment in a particular place, suddenly there may be a situation, which may not be compatible for you to continue treatment there.
The doctor may not be receptive to your problems; semen analysis might not have been done properly; the doctor may have insisted on a particular type of treatment knowing fully well that it may not work; collecting ova without anesthesia, not performing ultrasound or laparoscope during ova collection etc. These are instances where continuing treatment there would be a waste.
The doctor must be in a position to answer and explain when one attempt had failed earlier. He must be approachable. If he is going to elusive then there is no point in continuing treatment there.
There are many reasons for the high rates of success of IVF methods in a few hospitals. Main reasons are,
- attempting to fertilise not less than three eggs at a time
- making sure that the age of the female is less than 38 years
- most of the patients would have only blocks as main reasons for their infertility
- careful selection of couples for IVF
If you do not fall under any of these categories it is better to drop the idea of attempting IVF treatment.
Other
methods of fertilisation
Many modern techniques have been developed under for test tube fertilization of the ovum. All these methods have increased the success rates of IVF.
Let us see some of the important ones.
GIFT
In this method, instead of the conventional method of waiting for the
zygote to grow in the medium for 48 – 60 hours before implantation in the
uterus, the ova and sperms are mixed and immediately placed inside the uterus.
This is called Gamet
Intra Fallopian Transfer.
This method facilitates fusion of the two germ cells and the growth of the zygote thus formed, in a natural environment. Since more than one ovum is used, chances of success is increased greatly.
Medicines are required for inducing the production of ova. But there may be no need for ultrasound since laparoscopy itself has been found to be very useful for collection of ova as well as replacement of the zygote within the uterus.
This method is very useful when infertility is due to unidentifiable reasons or when the cervical secretions are the causes of infertility or when there are problems associated with normal intercourse.
No method is perfect. Each one has its own set of requirements or disadvantages. Likewise, a few problems are there in this method of treatment also.
- Though it is easy to bring about conception through this method, the Fallopian tubes need to be strong and free of any damages or ailments for success of this method.
- We can only confirm that the two germ cells have fused but we cannot ensure that the zygote formed is growing normally and is without any disorders.
Many clinics that have limited facilities follow these procedures. Hence, the success rate is always less than that of IVF.
ZIFT
This method is called ‘Zygote Intra Fallopian Transfer’. In this method, the growing zygote is directly transferred to the Fallopian tube.
TSET
This method is called Tubal Sperm and Egg Transfer. This is also similar to ZIFT but instead of the zygote, the sperms and the eggs are transferred to the Fallopian tube.
PROST
This is called Pro nuclear Oocyte Transfer. The transfer depends on the stage of development of the zygote.
POST
This is called Peritoneal Oocyte and Sperm Transfer. In this method, the eggs and the sperms are introduced through the abdominal cavity. The Fallopian Tube is believed to accept the cells from the cavity for natural fertilization to occur.
DIPSI
This is called Direct Intra Peritoneal Sperm Injection. In this, the sperms are introduced into the abdominal cavity of the woman by an injection through the walls of the female organ.
TUFT
This method is called Trans Uterine Fallopian Transfer. The ova and the sperms are mixed and introduced into the Fallopian tube through passage of the uterus by means of a thin catheter. This method is helpful for women with husbands ailing from consistent impotency problems.
DOT
In this Direct Oocyte Transfer method, the ova and the sperms are introduced into the uterus.
VEST
This method is known as Vaginal Egg and Sperm Transfer. In this method the eggs and sperms are mixed externally in a tube but placed in the vagina for normal fertilization to occur.
SHIFT
This method is called Synchronized Histeroscopic Intra Fallopian Transfer. In this method, the sperms are placed in the Fallopian tube through the uterine device histeroscope.
Though all these methods are available, they are no longer in use since the most modern technique of fertilization using laser is fast replacing the older modalities.
The laser technique
We have already seen that sperms may be so weak that they may not be in a position to even pierce the outer wall of the ovum. The outer wall of the egg protects the ovum in the following ways:
- accepting and allowing the sperm to enter
- preventing the entry of other sperms once one sperm has entered
- protecting the ovum from penetration by bacteria and viruses
- facilitating the movement of the ovum through the Fallopian tube to the uterus
In the event fertilization, when the zygote is in the developed stage of more than 100 cells the zygote ruptures the outer layer, gets released and attaches itself to the uterine wall on the fifth day.
One of the most important causes of infertility is inability of the sperm to penetrate the ovum or inability of the zygote to rupture the outer covering for further attachment to the uterine wall. All this can be prevented by treating the ovum with laser so that its thickness is slightly reduced. This method has increased the possibility of conception to 50% from a mere 10%.
Cloning
Cloning refers to creating a person identical to another person. We have read about identical looking persons in stories and epics. We have read that some ‘Asuras’ (demons) had the capacity to be generated from each drop of blood that fell on the ground from their body.
All this has been made possible by science today. The technique of collecting the stem cell from a human being, converting it into a zygote and making it grow into a human being identical to the original human being is called cloning.
So far the method was tried only in animals successfully. Very soon we may have cloned human beings around us.
The only specialty of this method is the modification of Nature’s rule that for a life to be formed we need an egg and a sperm. In this method it is enough if we have only one egg. We can create life from any ‘body cell’ by making it into a zygote without the help of a sperm and make it grow. Science has worked miracles.
CHAPTER
12. MOTHERHOOD IN OLDAGE
Our country has been famous child marriages and childbirth at a very early age. But now bearing children in old age is becoming more and more common. One main reason for this is the awareness among the public that motherhood can be had at any desired time due to advances in science.
Apart from the above there are other reasons also like,
- The tendency to establish oneself in life before getting married or planning to have a family
- Using contraceptives for a long time with the hope of postponing pregnancy till reaching a well established economic status in life
- Separation of husband and wife for long periods due to economic and professional reasons
All the above reasons result in women opting for motherhood at a later age. There are a number of reports that say that motherhood beyond the age of 30 could lead to complications due to hormone imbalances, physiological problems, ailments etc which could diminish chances of motherhood in later years.
There are women who have had hassle free pregnancies after getting married beyond the age of 30. There are women who got married at 20 but postponed pregnancy till 30 and conceived at the menopausal age. At this age not all of them bear children the normal way. Both the mother and the child are affected by complications.
On the other hand, motherhood does not happen to everyone who is past the age of thirty. What are the reasons for these? How does medicine handle these problems? These are the questions that we are going to deal with in this chapter.
Problems associated with
pregnancy in old age
About 7% of those who get married early in life are suffering from childbearing inabilities. About one in three women who get married at an age of thirty five have not been able to have children. About 60% of women who get married at the age of 45 have confirmed infertility problems.
Why?
It is because of the decreased capacity in all respects of reproduction
Loss of health
Just like the body’s capacity to function gets reduced with aging, the capacity of the reproductive organs to function also decreases with aging.
At this age, there are changes in the hormone levels; there may be hypertension, fibroids or cysts in the uterus, dysfunction of the ovaries, loss of immunity, diabetes, obesity, anemia etc.
Specifically at this age, sexual performance is much lower. Young couples are capable of sexual intercourse even four times a day. This number diminishes with age. Chances of fertilization increase with regular sex. But in old age, these chances are much less because they may be physically disabled though mentally they may be prepared. In addition there are certain communities where religious constraints restrict sex to only twice monthly. There is also a tendency to think about the uselessness of having children at that age.
Let us first see some important factors associated with old age.
Impaired menstrual cycle
Old age associated with erratic or irregular menstrual cycle. Mostly this is due to fluctuating levels of hormones. The cycles are irregular: the ovaries are unable to produce eggs. If the cycles are regular and the ovaries are functional then there is a bright chance of conception
Inability in sexual
performance
Mostly women marry men who are older than them. In such a situation when the woman herself is facing difficulties due to age, what can be said of the male who is older?
Most of his sperms are likely to have chromosomal abnormalities, abnormal shapes and mostly less in number. It is almost an impossibility to fertilize the woman. Even if the woman conceives and delivers the babies they are likely to have congenital problems.
Miscarriages
There is a high rate of miscarriages in older women. Many women do not even realize that they have conceived at this age.
Older women have fewer chances of producing quality or ideal eggs for IVF. The only few that are produced are fertilized in the test tube and placed back in the uterus. This only reduces the chances of miscarriage but there is no guarantee that it can be totally eliminated.
Environmental factors, travel, mental status etc. are factors that can influence pregnancy more than in the young age. These only increase the chances of miscarriage.
Complications of the uterus
The uterus of an elderly woman is more prone for fibroids and polyps. This only diminishes the chance of conception. When the endometrium is abnormal in growth or when it is non-functional then it may not be able to support the growth of the embryo.
Blood supply to the uterus in older women is also said to be on the decrease. This increases the chances of miscarriage and generally contributes to infertility.
About one in three of women past the age of forty is said to be suffering from fibroids. Though they may not affect conception they may definitely interfere with the growth of the embryo. Excessive growth of the fibroids may lead to miscarriage.
Abortions and congenital
disorders
The eggs of an elderly woman are not likely to be as strong as those of a young woman. So even in the event of fertilization, it may not be able to continue growing within the womb. As a result they get expelled in the form of abortions.
An elderly woman, unlike a young mother is suffers more from agitation, anxieties and fatigue.
The babies born have a high likelihood of developing Down’s syndrome apart from other congenital problems. Such babies have heart problems, cleft lip or cleft palate, mental disabilities, low resistance capacity etc. Generally, their life span is reduced.
Problems like failure to expel the placenta, excessive bleeding are all more common in old age.
Pseudo pregnancy is also more common in old age. Babies born to mothers with hypertension or less blood supply to the uterus have less than average body weight and are very small-made. Babies born to diabetic mothers are more in weight. Maintaining such babies also pose problems.
Many complications arise during normal delivery. The women are more worried if they would withstand the pain? This only helps to increase the pain.
In older women, chances of normal delivery become less due to the loss of elasticity of the pelvic bones. Caesarian sections become inevitable. This is one main reason for infant mortality in areas with less medical facilities.
These are some of the disadvantages faced by women during old age pregnancies. All these are based on scientific evidences; so even doctors discourage pregnancy in older women.
Old age and modern methods of
conception
The most important reason for women to think about pregnancy during old age is the advancement in science and medicine.
Modern methods have improved so much that there is a remedy for anything. In vitro fertilization, hormone injections to stabilize the reproductive system, caesarean method of delivery etc have increased the chance of childbearing. Even women without any eggs can receive eggs by donation.
Since more than one zygote is made available through IVF, these women can go ahead with pregnancies without any hassles.
Suggestions
It is important for women beyond the age of 35 to follow the instructions of the doctor than younger women. They should be very regular for check-ups.
Investigations like hormones testing, temperature monitoring and hormone treatment require fullest cooperation of the patient.
Even after successful conception, they need to be constantly under the supervision of the doctor throughout the period.
Traveling long distances, lifting heavy weights, involving in strenuous jobs or unpleasant events should be avoided. Steps to prevent miscarriage should be strictly adhered to.
Following all these suggestions would enable even elderly women to have babies.
Not only elderly women, all those men and women suffering from infertility problems should strictly follow the advice of the doctor in order to have healthy babies.
CHAPTER
13 INCURABLE AILMENTS AND DONATIONS
All human beings especially women would like any donation except sperm donation.
Most women prefer to bear only the children of their husbands. Most men prefer their wives to carry only their progeny. However much the problem, it is very difficult for the men to accept the children born out of sperm donation from an unknown donor as his own, despite the fact that his wife is blameless in all this.
Similarly, the wife may not accept the baby not generated from her own egg.
When do all this happen?
When the male or the female is absolutely incapable of reproducing!
That is, when the male is faulty and the female is normal or vice versa, chances of conception become impossible.
To rectify this situation, medicine has found a solution by accepting sperms or ova as donation and develop the zygote which could be implanted in the female to continue with the normal course of pregnancy.
For example the female may not be in a position to produce eggs. In such instances, ova from some unknown donor are fertilized by the husband’s sperms and the resultant zygote used. When the husband is unable to produce virulent and active sperms, the wife’s ova are fertilized by sperms from an unknown healthy donor and implanted in the wife’s uterus.
This method is very common in foreign countries. Though cultural restraints have prevented widespread acceptance of this method it is not so uncommon especially among desperate couples.
In such cases, if the husband has normal sperms, then the possibility of introducing it inside the uterus or near the cervix is first examined. Semen collected by several attempts of masturbation is pooled and the sperm count increased to increase the possibility of conception. Men with impotency problems are helped by fertilizing the wife through these methods.
When fertilization is brought about by artificial methods it is called artificial insemination. When the ova are obtained and used it is called ovum donation.
When the husband is incapable of producing sperms totally, then the option to use other donors’ sperms is thought of.
Getting sperms through sperm donation has a few points to be remembered;
Semen donation
Semen is collected from men who are thoroughly examined to rule out genetic disorders, infections etc and the collected sperms are preserved in sperm banks.
When women or couples approach them the details are given for acceptance. The woman is made to undergo tests like ultrasound and blood tests to calculate the ideal time for artificial insemination.
Women abroad prefer to receive sperms from men belonging to the same religion and origin. Some women prefer to receive sperms from known men.
There is no doubt that these actions also land them in practical difficulties.
Ovum donation
Ova are donated and received for IVF methods. Zygotes thus formed are used for implantation.
Women with extensive damages to the ovaries, those incapable of producing ova, those in whom the ova have a tendency to degenerate fast or those with hereditary disorders can be the recipient of zygotes formed using donated ova and the husband’s sperms.
In such cases the recipient’s uterus is induced and prepared for receiving the zygote by hormone treatment for at least three months prior to implantation.
A woman who is continuously on menstrual cycle will never be in a position to even retain the zygote received by IVF.
Many women are not aware of the possibility of receiving eggs by donation. In the West, ova collected for IVF and kept in cryo preservation in infertility clinics are donated after getting the consent of the donor. But such things may not be possible here. Mostly ova collected from one woman are used for the same woman.
Most of the problems associated with artificial insemination are common in this also.
Donating the zygote
During IVF only a few of the zygotes formed are used for uterine implantation. All the additional zygotes formed are used for research purposes only. Sometimes, even these are donated after obtaining the consent of the donor.
This is almost like giving a child in adoption.
Disadvantage of such
donations
In our country, infertility is still a taboo. Couples face a lot of humiliation when others come to know that they are incapable of reproducing even by artificial methods. Unfortunately similar humiliation is likely to be meted out to the children later on if the secret of their origin comes to light.
CHAPTER
14. HEREDITARY DISORDERS AND MODERN TREATMENT
You now have a fair knowledge of infertility, methods of fertilization and their advantages and disadvantages. We shall now see about hereditary factors and how modern technology has come to provide relief from them.
Hereditary disorders
Most couples worry about the health of their babies whether conception had been by natural method or by artificial method especially about hereditary disorders.
Couples with congenital or hereditary disorders do not like to pass on their faults to their children and prefer to have babies unaffected. They are daunted by fears of having to look after such children with deformities for a lifetime and consumed by anguish that all their efforts had been wasted.
Congenital disorders like cleft lip etc are simple ones that could be rectified by surgery. But what if the disorder is a serious one and that cannot be rectified by even treatment?
What are hereditary or congenital disorders? How do they happen? Can they be eliminated?
These questions may sound new to those born normally? But what about others who were not so blessed?
Hereditary disorders
These are disorders, which the parents have and can be passed on to the children. These can be mental or physical disorders.
There are two types of hereditary disorders. They are:
a. Congenital disorders
b. Genetic disorders
Congenital disorders are those the child may be born with. The parents may not be affected by it directly. But the children may inherit it from some one close to the parents. Apart from this, genetic disorders may develop within a fraction of a second due to mutations within the genes. These are called genetic disorders. The child may be born with deformities due to these changes.
Generally, one in about 100 children is born with some kind of disorders. Globally, about 25% of children admitted to the hospital for pediatric treatment are said to have congenital disorders.
The intensity of the problem may not be visible when the child is young but may start manifesting at a later date.
Cells and genetic makeup
Our body is made up of millions and millions of cells. Each cell has a nucleus. Nucleus bears the chromosomes that carry the genetic material. This genetic material contains all the information about the nature, function and characteristics of the cell. Growth or maintenance depends division of cells. For cells to divide, the chromosomes bearing the genes that are situated within the nucleus, need to divide. Division of the genetic material is followed by division of the cell into two daughter cells. Each one resembles the mother cell exactly. Such division helps in the multiplication of the cells in to millions and such huge number may form organs depending on the type, location and function. Hence, the characteristics of the ultimate human being are engraved in the genes.
Every cell in our body has 23 pairs of chromosomes in them. One set in each pair is derived from the mother and the other set from the father. Among them 22 are called autosomes. They carry genetic information regarding general functioning etc. The 23rd chromosome decides whether the baby is a boy or a girl.
Figure 6: Different views of the chromosomes
These genetic material derived from the parents may not be identical. One may be a dominant gene and the other may be a recessive gene, which means only the characteristic of the dominant gene will be expressed and seen and that of the recessive gene will be suppressed.
Characters like the color of the eye, skin, and body make up, in short, every physical and mental character is determined on the basis of the expression of the dominant gene. This is how the child either resembles the mother or the father.
If both these sex determination chromosomes are free of genetic disorders then the child may not be affected by any disorder. Any alteration in the number or the structure of these chromosomes may result in genetic disorders. It is estimated that mutation in one gene could result in about 4000 types of disorders. Dominant genes cause about 50% of the problems and sex chromosomes and recessive genes cause the remaining 50%.
Important hereditary
conditions
Night blindness, leucoderma, Vitamin D deficiency, hemophilia, specific blindness to colors like red or green, congenital jaundice, baldness, microcephaly, inability to face bright light, convulsions and fits, allergies, heart problems or problems of the blood vessels (vascular), low IQ, deformities in the facial bones, cleft in the spinal cord, etc are some of the hereditary conditions that are passed on to the children also.
Hereditary problems can be prevented by the following methods:
- Avoiding marriages between close relatives especially when one is know to have such problems
- Consultation with the doctor before marriage
- Performing blood tests and other important investigations before marriage
Importance of modern
treatment
When couples get married without knowing about the possibilities of hereditary disorders affecting the children, problems are bound to occur. So treatment becomes inevitable.
Every year, the World Health Organisation (WHO) declares the standard value for estimating the capacity of the male to bring about effective fertilization. According to this standard, a count of about 20 million sperms in the semen is enough to successfully bring about fertilization.
About 70% of the sperms in the semen need to be normal for successful conception to occur. It is enough if about 50% is able to exhibit movement and 30% is without any faults.
Some hospitals and clinics that do not have any proper operational guidelines believe that a count of 60 million is essential for fertilization to occur. This results in many of the males considering themselves to be impotent.
Collecting semen for analysis after repeated sexual intercourse on the same day will naturally result in very low counts. Similarly, if the semen has been collected without having had a release at least by masturbation for three months earlier, may show sperms that are incapable of moving.
So ideally semen is collected after a gap of two days to a week after normal sex between the partners.
If the sperms are required for artificial insemination or IVF, then the semen should have,
- At least 10 to 20 lakhs of sperms if semen is to be directly injected into the uterus
- About 5 –10 lakhs of sperms at the rate of 1 lakh good quality sperms per egg, if required for IVF
- About 5 lakhs of sperms for fertilization through ICSI
It should be noted that the modern technology of cloning does not require sperms at all for creating a new life.
We have seen in the earlier chapters about test tube methods of fertilization. We shall now see how they are used for treatment.
ICSI
By the test tube method about 1lakh sperms are taken in a drop of semen maintenance medium and mixed with 1 mature ovum. When this method fails, the most modern method of Intra Cytoplasmic Sperm Injection is tried. This method is ideal for those with low sperm counts due to hereditary factors, those with less than 5 lakhs count, those who have faulty sperms, those with more than 40% sperms in a state of nonmotility and those with abnormal sperms.
In this method, a single high quality sperm is separated and is injected directly into the ovum by means of a thin instrument after making a small hole in the wall of the ovum. This method ensures about 100% success.
Figure:
Pipette, micro syringe with the sperm, ovum
Let us consider someone without any sperms. The reasons for inability to produce sperms need to be analyzed first. If the inability is due to any blocks in the tubes through which semen escapes, then that needs to be rectified. A biopsy of the sperm producing tissue can also be done. In all these investigations even if one sperm is available it is enough. Going a step further, even if just the acrosome (head portion) is available that also could be used.
This can be very carefully inserted into the finely pierced ovum for effecting fertilization.
We have already seen about the laser method and the cloning method.
Whichever method is being used we should make sure that the baby is born without any disorders. The following tests are done to check that:
Sampling the amniotic fluid
In earlier days, a sample of the amniotic fluid used to be taken by piercing the amniotic sac for testing any disorder. If any chromosomal faults were found the embryo was destroyed before 19 weeks. Careful monitoring is required while taking the sample by piercing the amniotic sac. Any carelessness would result in the complete draining of the amniotic fluid and death of the embryo.
Choreanic Villus Sampling
The outer layers of the amniotic sac are tested. This is usually done within 8 weeks of pregnancy. If care and caution is not exercised while doing this test, it may result in deformities of the limbs.
Ultrasound scan
This is very helpful in accurately measuring the growth of the fetus. The method can detect many faults especially any faults associated with the brain, heart or the spine.
Fetoscopy
A tiny telescope is inserted through the uterus to examine the fetus. Disorders of the pancreas and the skin can be identified by this method.
Figure: fetoscopic examination of the growing fetus
Hormone test and other
biochemical test
Biochemical tests and hormone tests are done on the mother’s blood sample.
Test done before implantation
of the zygote
All the above tests are done when the fetus is growing within the uterus. Not many women come forward for these tests; sometimes complications may develop during the examination. The woman has to face inconveniences every time the examination is done.
Figure:
Cell biopsy done for testing hereditary disorders
Micropipette, mature ovum, instrument for biopsy, cells
The zygote formed by the test tube method without having to go through all these hassles is examined prior to implantation in the uterus. This is called PGD. This method has come as a blessing to those parents suffering from congenital and hereditary disorders.
The ova are obtained by stimulation of the ovaries through injections and tablets. They are then fertilized in the test tube using the sperms. They are maintained in the medium kept in the lab. When the zygote is in the 8 cell stage, one or two of the cells are separated and the remaining cells are put back again in the same medium.
The separated cells are examined using highly sophisticated microscopes for hereditary disorders, genetic mutations etc. If any such disorders are found then they are discarded. In the absence of any such disorder the examined zygote is implanted into the uterus.
This method has 100% success rate.
Our center, Aakash Institute of Infertility and Research, is functioning with a team of dedicated doctors, nurses and staff, with the sole motive of providing this 100% success to patients. Our center is equipped with the most sophisticated instruments and is considered one of the best centers in India.
No one who visits us returns empty handed. Those who come to us with dreams of a child go back with smiles on their faces. This is what we have been observing during all these years of service.
We promise that our service will continue helping those thousands without children, especially the poor and the middle-income groups with equal dedication, care and love.
Professor. Dr. T. Kamaraj
BIO-DATA
Name : Prof. Dr. T. Kamaraj
Graduation : M.B.B.S., Stanley Medical College
Post Graduation : M.D., Coimbatore Govt. Medical College
Specialisation : D.M.R.D, Stanley Medical College
Professor : Fertility Centre, Apollo Hospitals,
M.G.R. University
Professor : Sexual Medicine, I.B.M.S,
Center for Reproductive Studies
Government : Omandur Public Health Centre,
Marakkanam Public Health Centre
Asst. Professor : Madurai Medical College-Hospital
Royapettah Hospital, Chennai
Kilpauk Medical College and Hospital
Professor : IBMS, Institute of Psychology, Mumbai
Founder Director: Aakash Institute of Infertility and Research, Chennai
Indian Institute of Sexual Medicine, Chennai
Director : Stem Cell Research Unit, Akash Institute of Fertility and Research,
Chennai - 26
Publisher : New World Publications, Chennai – 26
Gold Medal in M.D Neurology
v Indian Medical Association
v Council of Sex Education and Parenthood International
v
Indian
Andropaus Society
v Fellow, Association of Professional Psychology
v Indian Association of Radiology and Imaging
v Aging, Gender, Andrology and Sexual (sciences) Society of India
v The first Reader in Sexual Medicine in India
v Importing the most modern laser device ‘Saturn Active’ for the first time in India and serving the public.
v Giving free advice on infertility and sexual problems through Internet and SMS and Telephone.
v Conducting exhibitions on fertilization and sexual problems in the whole of India for seven consecutive years.
v
Foreign
body in the Respiratory Tract,
The Indian Radiological and Imaging Association
v
Patency of
Biliary Ductal System in Patient with Jaundice – Demonstration by Ultrasound
and Percutaneous Transabatic Colingiography, 48th Conference????
v
Sexual Problems and Treatment – meeting the challenges
of mental health and family life, Ministry of Social Unity and Social Development,
Malaysia.
v Erectyl Dysfunction – Modern Treatment, – First International Conference on Sexology, Chennai
Articles
and columns published in:
English
dailies:
The Hindu, Indian Express
Tamil
dailies:
Dinathanthi, Dinakaran, Dinamalar, Dinamani, Eenadu, Dinaboomi, Tamilmurasu, Malai Murasu, Makkal Kural and Malai Malar.
Weeklies and
monthlies in English and Tamil:
Kumudam, Kungumam, Ananda Vikatan, Rani, Devi, Kalki, Mangaiyar Malar, Vasantham, Health and Beauty, Health Time, Health and Fashion, Arogya etc.
Other
services:
Aakash Institute of Fertility – research on treatment for infertility problems and stem cell research
Indian Institute of Sexual Medicine – research on finding cure for sexual deficiencies and drug discoveries
Indian Association for Sexology – active member of the association that includes eminent members from all walks of life and strives to impart awareness on AIDS
New World Publications – publishing quality books
Hormone points – distribution of medicines that would benefit issueless couples
************
Back Wrapper
AUTHORS
Dr. K. S. Jeyarani Kamaraj
Dr. T. Kamaraj, Vice-President, Asia Oceanic Federation for Sexology
Dr. T. Kamaraj and his wife Dr. Jeyarani Kamaraj, founded the Aakash Institute of Infertility and Research in Chennai, which is considered to be one of the foremost fertility centers in the country and have been creating records in the field of Infertility and Sexual Medicine.
True to the words of the Tamil lyricist Shri. Vairamuthu, who said,
“Now a days, issueless couples
Do not go around the arasa maram;
They only go around the Akash Infertility Centre”, they have been striving hard to make the dreams of the middle class come true.
Together they conducted the first International Conference on Sexual Medicine in Chennai. They conducted the first Exhibition on ‘Infertility and Modern Treatment’ and have been conducting Symposia for creating awareness on ‘Sexual Medicine’ for ten consecutive years. They have been giving free counseling and advice on infertility and sexual problems through all kinds of media (television, radio, telephone: 98412 66666 and magazines). They jointly treat patients who come to them with infertility, sexual and marital problems.
Dr. Kamaraj is the Vice-President of the prestigious and internationally acclaimed medical association of sexologists, Asia Oceanic Federation for Sexology.
This book is one more addition to his list of contributions to serve the public.