Introduction
When couples get married, they often view parenthood as the next stage in their family life. They want to have a child, they want to be “mom” and “dad”, they cannot imagine that this may be hard to achieve or may not be a natural process. When several trials to conceive fail, they are shocked. Their basic expectation about family life gets shattered. Most of the couples are desperately looking for medical therapy that will end into a misery. Clearly this is not a struggle to survive; it is a struggle to fulfill a dream, to achieve what they view as a “full life”.
What is needed for pregnancy?
In the male partner, sperms are normally produced in the testes after puberty (after attainment of characters like growth of beard, moustache etc). From the testes, they are carried through the sperm conducting ducts (epididymis, vas, seminal vesicle and prostate gland). Then during sexual stimulation, after proper erection and ejaculation, they come out through penis. During sexual intercourse, these sperms, present in semen, are deposited inside the vagina.
In female partner, the deposited sperms must travel from vagina through the cervix (the mouth of the uterus). The cervix acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as bacteria present in semen, in the uterus. From uterus, sperms reach the Fallopian tubes (the tubes that are attached to the both sides of the uterus) where the sperms must meet the egg (ovum). The eggs are produced only before birth and so, there are fixed number of eggs inside the ovary. The ovum released from the ovary, into the abdomen at the time of ovulation (rupture of the surface of ovary to release the ovum). That ovum must be taken by the tube and thus inside the tube an embryo (earliest form of the baby) is formed, by meeting of the egg and the sperm.
It should be mentioned that out of nearly 200-300 million sperms, in average, deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only one will succeed to form the embryo. The embryo then travels through the tube into the uterus and the uterus attaches the embryo firmly with it and thus the pregnancy starts. So, if there is defect in any one of them there will be difficulty in achieving pregnancy.
Thus, to summarise, pregnancy requires
1. Production of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in adequate number (“Normal Count”) in the testes
2. Transport of these sperms through the sperm conducting ducts from testes to penis
3. Successful Erection and Ejaculation during Intercourse to deposit adequate number of these sperms in the vagina
4. Transport of these sperms from vagina through cervix to the uterus and the tubes
5. Presence of sufficient number of eggs inside the ovary and ability to release the eggs from the ovaries
6. Pick up of the eggs by the tubes
7. Approximation of eggs and the sperms to form the embryo
8. Transport of embryo from the tubes into the uterus
9. Acceptance of the embryo by the uterus and its growth
What is Infertility?
Literally, the word “Infertility” means inability to conceive. But in reality, there are very few couples, who have no chance of natural conception and are called “Absolutely Infertile”. In fact, in many couples who present to infertility clinics, pregnancy may be the matter of time, thus the chance factor.
It should be kept in mind that, if there is factors to question fertility of either male or female or the female is of age less than 35 years; after one cycle (one month) of regular frequent intercourse, the chance of conception in human being is only 15%. That means, out of 100 couples trying for conception, only 15 will be able to succeed after one month of trying. The word “Regular” and “Frequent” are important; because to achieve pregnancy, couples are advised to keep intimate relationships for at least 2-3 times a week and this should be increased particularly around the time of ovulation (Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12 months and 24 months of regular trying are respectively 60%, 80% and 100%.
The word, “Subfertility” seems better and more scientific than “Infertility”, to describe the couples who have reduced chance of conception, due to any cause. However, the word “Infertility”, seems more popular, although it puts pressure on the couples. In most cases, usually we advise to investigate after one year of regular and frequent intercourse, when the couples fail to conceive. However, if there are factors to question fertility; for example female with age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or known diseases like PCOS or endometriosis; or male partner having surgery in scrotum or groin or any hormonal problems or sexual dysfunctions- the wait period is usually reduced and couples can be investigated, even soon after marriage.
What causes Infertility?
Please look at the point “Thus, to summarise, pregnancy requires” where 9 points have been mentioned.
Thus the common causes may be
1. Problems in male- total absence of production of sperms, less than adequate number of sperms, problems in morphology and motility of sperms (most sperms not healthy or movable), blockage in transport of sperms and inability to deposit sperms in the vagina (sexual dysfunction- Erectile Dysfunction or less commonly, Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone, thyroid, prolactin), diabetes, liver problems, causes present since birth, chromosomal abnormalities, surgery, infection, sexually transmitted diseases, smoking, exposure of scrotum to high temperature, some medicines or psychological causes.
2. Problems in female- total absence of less than adequate number of eggs in the ovaries, problems in ovulation, problems in picking of eggs by the tubes, blockage of tubes, problems in conduction of sperms or embryo by the uterus, problems in accepting the embryos by the uterus. Examples include causes present since birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age, increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID), tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal problems (thyroid, prolactin) or excessive stress.
3. Unknown causes- Despite thorough investigations, 25-30% causes of infertility remain unknown. This is called “Unexplained Infertility”. The reason may be mere chance factors or there may be some causes which, still medical science has yet to discover. But this should be kept in mind while treating infertility. That means, even with correction of the possible factors (like improving sperm counts or thyroid problems etc) or with proper treatment (IUI, IVF or ICSI), unfortunately the treatment can fail and the exact reason, why the treatment failed, is sometimes difficult to find out.
In general, what are the treatment options for infertility?
To start with, please remember there is no hard and fast rules for infertility treatment. Often medical science fails to understand why couples with very severe form of infertility conceive sooner than those who are having all tests normal. That means, whatever treatment is offered, it’s very important to continue regular sexual intercourse, as the chance of natural pregnancy is usually there in almost all couples. Your doctor will present the facts to you, without pressurizing you on a particular option. After coming to know all pros and cons of different treatment options, you can take decision. Do not hurry. It’s quite natural that you might be in stress.
In general, after the initial tests, a few periods of natural trying is allowed. After that, ovulation induction (giving medicines to release eggs from the ovaries) is offered, failing which IUI and finally IVF is offered. What will be the preferred treatment for you, will depend on your age, duration of marriage, male and female factors and of course, your age. For example, a woman with both tubes blocked or a male with very low sperm count, IVF would be the first line of treatment.
How Sexual Disorders are related to Infertility?
Sex and fertility are not the same thing. Couples with normal sex life may have difficulty in conception (for example couples with PCOS or low sperm count). On the contrary, couples with normal fertility may have sexual disorders. Sexual Disorders and infertility may be related in two ways.
Firstly, the stress of infertility starts to exert its adverse effects in conjugal relationships. Most of the couples, who had very satisfactory sex life, start to lose interest in sex. They feel sex as a “mechanical” tool whose sole aim is only to achieve pregnancy, in contrast to their life just after marriage, when sex was perceived as an expression of love-making process. The continuous advice from doctors, “you should have regular intercourse” makes the scenario worse. Some of them can feel other problems like erectile dysfunction, ejaculatory problems, painful sex, vaginal dryness etc. Remember, this group of couple never faced sexual dysfunction in earlier part of their life.
But, here we concentrate on second group of couples, who had sexual dysfunction from the very beginning. They did not have penetrative intercourse long time after marriage. Initially they ignore the problems because of pressure from professional field and some of them feel too shy to consult doctor for this problem. But when they themselves want to plan for a baby, or due to pressure from the family, they start to realize the importance of having a good sex life. At this point, most of them consult doctor to find the solution. But the problem seems more complicated than the couples in the first group (above paragraph). This is because, the doctors have to treat two problems together- sex and fertility. Apart from the problems in sex life, the stress factors also come into play.
Again, there are some couples, who come to our clinics earlier. They find problems in sexual intercourse but are not planning for pregnancy right now. In these cases, the treatment is relatively simpler, as we get ample time to correct the problems, to help them conceiving naturally.
What are the common types of sexual disorders that can prevent conception?
In simple words, absence of penetrative intercourse will prevent pregnancy. It may be problems due to lack of desire or problems in physical performance.
Few men and women do not feel any urge (libido) to have intercourse. Others may have the libido but find problems because of erectile dysfunction (lack of hardness) during intercourse. Uncommonly, some men may be able to insert the penis inside the vagina but cannot ejaculate (discharge) the sperms during intercourse. Some women may feel severe pain during attempted intercourse, that prevents them to participate in it.
What are the reasons behind sexual disorders?
It’s a common misconception that all the sexual dysfunctions are due to psychological factors. Indeed, most of such problems may be related to some physical factors.
Life-style factorscontribute a lot. Stress due to various reasons (financial, professional, family related) affect sexual performance and libido. People working in stressful life, particularly marketing, banking and IT sectorsare badly affected. Previous “bad” experience with sex (like previous history of erectile problems, pain, bleeding) often come into play and this performance anxiety makes the situation worse. Relationship conflict also plays important role. Excessive use of alcohol can affect the orgasm and erection. Smoking, apart from its harmful effect on fertility, can affect libido, erection and orgasm. Excessive use of caffeine can also be responsible. Some medicines, particularly medicines used to control blood pressure and abusive drugs like cannabis can create such problems. Excessive weight can affect libido, erection, ejaculation, vaginal dryness and orgasm; in addition to delay in conception.
Sexual dysfunction can be the first sign of serious diseases like diabetes. Other hormonal problems like imbalance in sex hormones (low testosterone in male and female, low estrogen in female, high estrogen in male), high prolactin, thyroid diseases can be responsible for sexual problems and are easily treatable.
Diseases of heart (high blood pressure, heart failure), liver (cirrhosis), kidney (renal failure), nerves (diseases in brain, spinal cord) and blood (sickle cell disease, anaemia) can be responsible for sexual problems. This is another reason, why people with sexual disorders should not think that it’s a disease of reproductive system only.
Some operations (in spine, abdomen, pelvis, hernia, vagina, scrotum) and injuries (spine, pelvis) can have long-lasting serious side-effects on sexual function.
Infections, tumours, endometriosis can be responsible for pain and bleeding during intercourse.
Finally, lack of proper technique, improper knowledge and unrealistic expectations are also responsible.
In general, what are the treatment options for sexual disorders?
The first and foremost action is to find out the underlying cause responsible for sexual dysfunction. That’s why its important to have thorough check up by doctor to find out the cause. The check up includes asking question by the doctor (history taking), physical examination and then if needed, some tests (like blood, ultrasoundetc). It’s important for you to be honest and to disclose all your problems and raise any concerns to the treating doctors.
If the cause is found, the treatment is simply, the correction of the cause, if possible (like correction of blood sugar in diabetic patient).
Even if no cause is found or when the cause cannot be corrected, the couple can have satisfactory sexual life. It involves proper counseling and sometimes “sensate focusing” (initial focusing on perception of the touch, rather than intercourse). Stress reduction and life-style modification (controlling weight, stopping smoking, reducing alcohol) cannot be overemphasized.
Pelvic floor exercise (“Kegel’s exercise”) can help both men and women to improve blood flow to pelvic organs and optimize the pelvic muscle functions, thus in turn, improving sexual function.
Next comes the role of medicines. There is a common misbelief that sexual dysfunction can ne corrected by steroids only. This is totally wrong, because steroids can rather worsen the sexual problems. Another misconception is that, once started, you need to take medicines throughout the life. The fact is that majority of the patients need medicines only for the time being. Majority of the couples respond well to these methods of treatment.
In very few cases, some additional measures can be needed like corrective surgery or vacuum device for erection problems.
What are the options for fertility treatment in presence of sexual disorders?
As mentioned before, if a couple with sexual problems want pregnancy, the doctors have to deal with two problems- sexuality and fertility. So, proper investigations are needed for both, to find out the cause. Then the treatment decision is taken, based on age and weight, underlying problems, how severe is the sexual problems, the treatment response, affordability and of course, the wish of the couples.
The first step treatment, is obviously to trying for natural conception, by regular penetrative penile-vaginal intercourse. So, the first line of treatment is to correct the sexual problems, as mentioned in the above section. Majority of the couples can have successful sex life after proper treatment and a large number of them conceive in the course of time, provided there is no major fertility problems (sperm, fallopian tubes, uterus, ovaries). If they fail to conceive, the treatment is just like other couples (those without sexual problems). That is, they can be offered ovulation induction, intrauterine insemination (IUI) and in vitro fertilization (IVF).
However, if the sexual problems cannot be corrected, this is not the end of the world. If the man can collect sperm by masturbation, he or the female partner can perform self-insemination. This can be done at home by the couples and can be coordinated with ovulation time and, even with ovulation drugs. This has success rate of 15% per cycle per couple (if 100 couples are trying it, in one month, 15 can conceive).
If self-insemination fails, or is not possible (for ejaculation problems), or is not acceptable to the couple, the option is IUI. For men with ejaculatory problems, sperms can be collected by Vibro-ejaculation (putting a simple instrument over penis, without pain) or by collecting sperms from the urine which is taken immediately after masturbation (‘post-masturbation urine’- for retrograde ejaculation). IUI has the success rates of 20% per cycle, depending on the age, sperm count and other fertility factors. For women feeling severe pain during intercourse, IUI can be done under anaesthesia.
Self-insemination and IUI can only be successful in couples with normal fallopian tubes (at least one tube must be open), normal perm count or sperm counts mild to moderately abnormal, normal ovulation or ovulation done with medicines (as in PCOS). However, if these are not possible, because of fertility factors (very low sperm count, tubes blocked) or IUI fail, then the option is IVF. In one IVF cycle, 40% of the couples conceive in average. IVF can even be done, in men having no ejaculation but who can produce sperms inside the testes (by putting needle in the scrotum).
In very few cases, when these treatment options are not feasible, donor sperm, donor ovum or surrogacy treatment can be done.
What are the reasons behind low sex desire (Libido) in men or women?
The main reasons are life-style factors, hormonal imbalance and anxiety for poor performance.
How low libido is treated?
Treatment is simple, as stated above. It includes life style changes, sensate focusing and correction of the underlying disease.
How can a person with low libido become a parent?
Majority of the couples can conceive naturally after successful treatment of low libido. If the above-mentioned measures fail to correct the libido, then self-insemination, IUI or IVF can be done, depending on the cause.
What are the reasons behind Erectile Dysfunction (ED) in men?
The main reasons are life-style factors, hormonal problems, disorders in heart/ nerve/ blood, operations or injury; as mentioned earlier.
How ED is treated?
Majority of the men respond well to the correction of underlying cause, stress reduction, life style changes, Kegel’s exercises and medicines.
How can a man with ED become a father?
If the treatment of ED is successful, the couples can conceive naturally. However, if these fail, they can try self-insemination, failing which IUI, and occasionally IVF need to be done.
What are the reasons behind Ejaculatory Problems in men?
Ejaculatory dysfunctions are not common, apart from premature ejaculation (discussed below). It can be due to anxiety, diabetes, problems in nerves or prostate gland, after surgery or operation in spine or pelvic area and sometimes infection.
Majority of such men are able to ejaculate during masturbation or are feeling normal nocturnal emission (“night fall”) but fail to do so during intercourse. In these cases, usually no definite cause is found. This is called “situational anejaculation”. A portion of them can have ejaculation with some particular partner, but not with other(s).
Few men are suffering from “absolute anejaculation”. This means, they cannot have ejaculation during masturbation or intercourse. The cause is usually related to problems in nerve, diabetes, surgery or injury. A portion of them may have “retrograde ejaculation”, that is, during orgasm, the sperms are carried back towards urinary bladder (the sac that stores urine), rather than towards the penis. A post-masturbation urine sample can reveal sperm in such cases and diagnoses this condition.
How ejaculatory problem is treated?
Unfortunately, ejaculation problem is somehow difficult to cure. Some medicines can help few men. Vibroejaculatorcan be helpful in some men.
How can a man with ejaculatory problem father a baby?
Ejaculatory problems may not be cured, but such men can father their own baby. This is possible by collecting sperms by various means. If he can masturbate, self-insemination is possible. Alternatively, with vibroejaculation, sperms can be collected at home and self-insemination can be done. IUI and IVF are also possible in such cases.
However, if there is no ejaculation during masturbation, post-masturbation urine can be tested and if there is adequate number of sperms (Retrograde Ejaculation), IUI can be done. If the sperm counts are not enough, a special form of IVF (ICSI- Intra-cytoplasmic sperm injection) can be done.
Even if post-masturbation urine reveals no sperms, the sperms can be collected from the testes and ICSI can be done successfully.
Thus, although ejaculatory problems are uncommon and are difficult to treat itself, successful conception is quite possible.
Can Premature Ejaculation (PE) be related to Infertility?
Premature ejaculation is usually not a cause for infertility, though it can cause inadequate satisfaction during intercourse.
However, if the PE is severe degree, that means the sperm is discharged before vaginal penetration, it ca cause problems in conception. Sometimes, it can be due to some problems in the penis (opening not in proper place- hypospadias). In such cases, if conventional treatment of PE (exercise and medicines) are not helpful, self-insemination, IUI or IVF can be done successfully.
What are the reasons behind painful intercourse in women?
The reasons are mostly related to anxiety or fear. It can be due to some factors like vaginal dryness (when ovaries are not functioning properly, some medicines or local glands are not working) and infection (including sexually transmitted infections). If the pain occurs at deep penetration, it may be due to some tumours (occasionally cancers) in cervix, uterus or ovaries, infections, endometriosis and enlarged ovaries.
How painful intercourse is treated?
Again, the treatment depends on the cause. Counseling, sensate focusing, life-style changes play important role. Medicines and hormones are helpful in selective cases.
How can a woman with painful intercourse get pregnant?
It’s important NOT to use any vaginal lubricants (including saliva) as any lubricants can potentially kill the sperms. However, some external moisturizers are there, which are sperm-friendly. If the simple measures fail, IUI can be done under anaesthesia. IVF can be done if IUI fails or is unacceptable.
Will my problem in conjugal life remain confidential?
Yes, except you and your partner and the treating doctors, nobody else (even your parents or friends) have any right to know about your personal life. Self-insemination can be done at home, without going to clinic, thus maintaining your privacy. If you have to go for IUI or IVF, you will be treated just like other couples (who fail to conceive despite normal sexual life)
How such problems are treated in the clinic of Dr Sujoy Dasgupta?
We believe in patient’s autonomy. So we want to give time on discussion and presentation of facts and figures to the couples. We encourage questions from the couples and take utmost care so that no question remains unanswered.
We do not take decisions and impose it on the couples. We advise the couples to take time before taking decision on a particular treatment. If the couple decides, we respect and support their decision.
We try to take nominal charges and help couples to collect medicines (particularly injections) at lower prices than MRPs.
We try to find out the root cause of the problems in the couples and try to solve them first. If that is possible we encourage them to try for pregnancy naturally. If these attempts fail, we discuss with the couple, the options, that include self-insemination, IUI, IVF and ICSI. We do not pose any of our decision on the couples, rather we discuss with them and help them to make their own decision.
Conclusion
Infertility is a peculiar thing. Very few men or women are absolutely infertile. That means they do not have ability to achieve pregnancy naturally. Majority of them are subfertile. That means most of them have lower than normal chance (compared to healthy couples) to achieve pregnancy in a normal menstrual cycle. Sexual problems are not uncommon but are easily treatable. Pregnancy is quite possible in couples who are not able to have penetrative intercourse.