Infertility | Medical Science Optional Notes for UPSC PDF Download

Unexplained Infertility

Often, infertility remains unexplained, possibly due to insufficient or ineffective investigations and the inability to identify the biological capacity of sperm to fertilize an egg.
In cases of unexplained infertility, abnormalities may be present but go undetected using current methods and investigations.

Causes

• Genital Tuberculosis and Unexplained Infertility: Genital tuberculosis contributes to 5% of cases of unexplained infertility in our country.
• Immunological Factors and Male Infertility: Immunological factors may play a significant role in the etiology of male infertility, affecting up to 5% of patients.
• Timing Issues with Egg Release: The egg may not be released at the optimal time for fertilization.
• Obstruction to Egg Movement: The egg may fail to enter the fallopian tube after release.
• Challenges in Sperm-Egg Interaction: Sperm may encounter difficulties reaching the egg.
• Failure of In Vivo Fertilization: Fertilization may not successfully occur within the body.
• Disrupted Zygote Transportation: Transportation of the zygote may be disturbed.
• Issues with Implantation: Failure of implantation may occur.
• Genetic Variations in Folate Pathway: Polymorphisms in genes related to the folate pathway can be a causative factor.
• Epigenetic Changes in Sperms: Epigenetic modifications in sperms may contribute to infertility.
• Maternal Immune Response: Reduced maternal immune tolerance toward the embryo is a potential cause.
• Quality Compromises in Egg: Impaired quality of the egg is another identified factor in infertility.

Investigations

• Immunological Tests: This includes assays for antisperm antibodies and other relevant tests.
• Ovarian Reserve Tests: Evaluation of ovarian reserve is conducted as part of the investigative process.

Management

• It has been observed that 20% of couples with unexplained infertility eventually achieve pregnancy with time.
• Advanced technologies may increase the pregnancy success rate to 40-50% in the future, albeit at a higher cost.
• In cases where conventional treatments fail, and couples are eager to conceive, adoption is recommended.
• Recently, oral administration of aspirin (75 mg) during the premenstrual phase has demonstrated improved implantation rates and increased pregnancy rates. This is particularly recommended for cases of unexplained infertility, assuming implantation may be a contributing factor.

Techniques in Managing Unexplained Infertility

• Artificial Insemination:
  • DIPI (Direct Intraperitoneal Insemination)
  • ICSI (Intracytoplasmic Seminal Insemination)
  • ICS (Intracervical Insemination)
• Assisted Reproductive Technologies (ART):
  • In Vitro Fertilization (IVF)
  • Gamete Intrafallopian Transfer (GIFT)

Assisted reproductive technology (ART)

Assisted reproductive technology (ART) comprises a group of procedures that have in common the handling of oocytes and sperms outside of the body

Indications

• Blocked or absent fallopian tubes
• Endometriosis
• Unexplained infertility
• Male Infertility.
• Sperm count less than 5 million/mL.
• Decreased or absent motility of sperms
• Many abnormal sperms
• Immunologic infertility
• Failure of ovulation

Contraindications

• Age > 44 years
• Menopausal transition or menopause
• Mullerian duct anomalies
• Asherman syndrome
• Estrogen resistance of the endometrium
• Menometrorrhagia
• Unclear ovarian cysts
• Status post genital tract or breast malignancy
• Acute or subacute infections of the internal genitals
• Severe systemic-Progressive, genetic, neurotic or psychotic diseases
• Use of teratogenci drugs
• Alcohol or tobacco abuse
• Drug abuse
• Social evils

Types of ART Procedures

• IVF (In Vitro Fertilization):
  • Ovulation induction -> Retrieval of oocytes -> Laboratory fertilization -> Culture of embryos for 3-5 days -> Transcervical transfer of fertilized oocytes.
  • Low-Cost IVF (INVO): Fertilization and early embryo development occur in a gas-permeable, air-free plastic device placed in the vaginal cavity.
• GIFT (Gamete IntraFallopian Transfer):
  • Laparoscopically guided transfer of a mixture of two ova and 50,000 sperms into each fallopian tube.
• ZIFT (Zygote IntraFallopian Transfer):
  • Laparoscopic transfer of day 1 fertilized eggs (zygotes) into the fallopian tube.
• ICSI (IntraCytoplasmic Sperm Injection):
  • Direct injection of one sperm into each mature egg before intrauterine transfer of the fertilized eggs.
  • Sperms obtained via MESA (Microsurgical Epididymal Sperm Aspiration), PESA (Percutaneous Epididymal Aspiration), TESA (Testicular Sperm Aspiration).
• Ovum Donation:
  • Donor eggs provided to women with low egg numbers or poor egg quality, as well as elderly women.
• Future Possibilities:
  • Ovarian transplant and stem cell culture agar are potential advancements.
• Surrogacy and Adoption:
  • Options for couples facing challenges in conception.