C/ Manuel de Falla, 6-8. 28036 - Madrid (España) Tel. +(34) 914 585 804 - Fax +(34) 914 571 756
What is sterility? What is infertility?
Sterility is usually defined as the inability to conceive naturally after one year of unprotected sex. According to statistics, 85% of young healthy couples conceive after one year of sexual relations; this figures goes up to 93% after two years of trying.
Primary sterility refers to a couple that has never been able to conceive.
Secondary sterility is the inability to conceive again, after having one child.
Infertility is defined as the inability to carry pregnancy to term, which happens when a woman gets pregnant, but later miscarries.
About 15% of the world population is affected. In Spain, it is calculated that there are around 16,000 cases every year. Sterility can have many causes. The most frequent cause in women is age because as the woman’s age advances, the probability of spontaneous pregnancy decreases. Other causes, like genetic problems, aggressive medical treatments (radiotherapy, chemotherapy or immunosuppressant drugs), environment and life-style can all delay achieving pregnancy.
Reproductive problems affect men and women equally; the problem originates 30% of the cases in women and 30% in men. In another 30% of couples, both members have unfavourable fertility factors and in the remaining 10% the cause is unknown.
When should I go to a specialist?
There are many factors that lead to infertility, but age is the most important one. If there is no known disease or medical history, which might suggest a problem, gynaecologists recommend that patients be studied after a year of unprotected sex if the woman is under 35. If the woman is over 35, 6 months of unprotected sex without pregnancy is the recommended time to begin evaluation. If the woman is 40 or older, the assessment should be initiated after 3 months of unprotected sex.
Sometimes consultation is recommended earlier for example if a woman has a previous history of pelvic infection, a hereditary disease or more than one miscarriage. Men with undescended testicles or a hereditary disease are also reasons to consult earlier.
In certain cases (for example, insulin resistance) pregnancy is sometimes achieved simply through oral medication, but in most cases, more sophisticated treatments are needed.
What is done at the first appointment?
In your first appointment, we open a clinical record, carefully including the necessary information of the couple, specially emphasizing personal and family background and any previous medical treatments.
The doctor will study any existing test results and will describe the necessary tests you will need to do in order to complete your medical history. With these results in hand, the doctor will propose the different treatment options, explaining the possibilities of success of each case.
What does the basic fertility study of the couple consist of?
The first step is to perform basic fertility tests and to come up with a correct diagnosis. In many cases, more than one cause is found. So before beginning treatment, it is essential to evaluate the couple.
The medical team will go over the medical history of both members of the couple and will request the necessary tests in order to make a diagnosis. If a male factor is found, a urologist sometimes is needed to be consulted.
Given that most patients who come to our clinic have already been trying to get pregnant for some time, our aim is to complete the study as quickly as possible and we aim to complete the diagnosis within the following menstrual cycle.
There are 4 basic pillars in the initial phase of a fertility study:
- Ensure that the woman ovulates
- Evaluate the ovarian reserve
- Objectively study the permeability of the Fallopian tubes
- Test the quality of the sperm
To determine ovulation we consider the cycle pattern of the patient. Generally speaking when a woman has regular cycles she most likely ovulates regularly.
Under normal conditions, at the beginning of each cycle a follicle begins to grow with an egg inside. The follicle ruptures and the egg is freed into the Fallopian tube in a event called ovulation. After ovulation, progesterone increases and this makes the endometrium more hospitable for the embryo. If we measure the progesterone level in blood 7-9 days after ovulation, we can see if the patient has ovulated or not. Other hormone levels (Prolactin and TSH) that can also interfere with the normal growth process of the follicle, the maturing of the egg and ovulation are measured as well.
The ovarian reserve refers to the number of available eggs in the ovary of a woman. This figure is directly related to her possibility to achieve pregnancy. There are several different ways of evaluating this ovarian reserve: measuring FSH and estradiol in the blood on day 2 or 3 of her cycle, counting the antral follicles using a transvaginal ultrasound scan and measuring the anti-Müllerian hormone. All of these tests enable us to predict a high, normal or low ovarian reserve.
The Fallopian tubes provide the path for the spermatozoa to fertilize the egg in a natural way in a spontaneous pregnancy. If the Fallopian tubes are obstructed, pregnancy will never happen naturally. To study the Fallopian tubes, a hyterosalpingogram is performed, involving x-rays taken as a contrast passes through the Fallopian tubes.
Quality and quantity of spermatozoids
For a pregnancy to exist, the parameters of the semen sample should be within the normal range. The WHO (World Health Organization) established new figures of normality for a seminogram, including the following:
- The quantity of sperm should be over 30 million per ml.
- The volume should be over 1,5 ml.
- Progressive forward movement should be 50% or higher.
- Over 4% normal morphology.
Parameter such as changes in pH, the presence of leucocytes or bacteria and changes in volume may indicate the presence of pathologies that must be treated before beginning a fertility treatment.
How is a sterility-infertility study done?
With the results of the tests and analyses, the medical team will be able to offer a diagnosis and will suggest the patients a therapeutic plan. Treatments will be scheduled at the convenience of the couple to make the process compatible with their work and social lives.
Often a diagnosis of sterility can not be clearly established after doing the basic study; however, we recommend beginning the appropriate protocol so as not to delay the treatment unnecessarily.
What are the main causes of female sterility?
A woman is said to be the most fertile up into her mid-twenties In this day and age, however, very few women choose to have children at that age. In general, fertility starts to decrease from the age of 25. Approximately one third of women who wait until 35 will have problems to conceive, and approximately half of women 40 and over will have difficulties.
Ovulation disorders and polycystic ovary syndrome
Ovulation disorders are due to an endocrine imbalance that makes it impossible for the ovary to work properly. Often ovulation disorders are linked to obesity or being underweight, acne and having excessive hair growth. One of the most frequent causes of this disorder is the Polycystic Ovary Syndrome (PCOS). It is estimated that 3%-10% of the female population has PCOS. The woman usually suffers from irregular cycles, which may be associated with fertility problems and excessive hair growth.
Women who suffer from PCOS ovulate less frequently than fertile women and some don´t ovulate at all. If there is no ovulation, pregnancy cannot be achieved. The goal of treatments for women with PCOS is to make them ovulate at a predictable time.
Obstructed fallopian tubes
Fertilization (when the sperm penetrates the egg) takes place in the Fallopian tube. If both tubes are obstructed, no sperm can reach the egg to fertilize it.
The tubes may become obstructed for many reasons. Sometimes the obstruction is due to a previous infectious process like pelvic inflammatory disease or abdominal surgery. The patient usually has no symptoms. Obstructed Fallopian tubes are diagnosed by hysterosalpingography.
The treatment recommended after tube obstruction has been confirmed will depend not only on if one or both tubes are obstructed but on many other factors.
Sometimes on the ultrasound scan, accumulated liquid in one or both Fallopian tubes is observed. This is called hydrosalpinx and can be the cause of infertility, as well as increasing the risk of infection. Studies show that there is a higher pregnancy rate when hydrosalpinx is removed before fertility treatment.
Cervical mucus helps prevent infections and kills bacteria except during ovulation. At ovulation, the cervical mucus becomes more fluid to enable longer sperm survival. Sometimes there are fertility problems when the cervical mucus is not the correct consistency or there is a problem in the anatomy of the cervix.
Endometriosis is a chronic disease involving the presence of endometrial tissue outside the uterine cavity. These implants of endometrial cells create cyst-like formations called endometriomas. Endometriosis is more common in women with fertility problems than in fertile women and is one of the known causes of infertility.
Symptoms of endometriosis run from an asymptomatic process to crippling menstrual pain, long periods or painful sex. Some women live in constant pain. There is no correlation between symptoms and the degree of development of the disease. Sometimes it is necessary to operate before a fertility treatment is initiated in order to treat the symptoms and improve the success of the treatment.
Fibroids are benign smooth muscular tissue tumors that are found within the walls of the uterus. A woman can have just one or multiple fibroids. Fibroids can be located on the internal surface, external surface or the inside of the uterine wall. Gynecologists often find fibroids in asymptomatic women. Sometimes fibroids cause heavy and/or painful periods. Other times they cause pain and problems because of their size and cause pressure on the structures in the pelvis like the bladder or intestine. If symptoms affect the person´s life, fibroids need to be removed.
The relationship between fibroids and fertility is not completely clear. In general if the fibroid does not deform the endometrium, it is not necessary to operate, but if the fibroids are big or cause symptoms like pain or excessive bleeding, sometimes it is better to operate before starting fertility treatment.
What are the causes of male sterility?
Problems of male sterility can involve the low number of sperm or abnormalities in the movement or shape of the sperm. Sometimes male infertility is related to varicose veins of the scrotum called varicocele, which can affect sperm production. Testicular trauma, undescended testicles and hormone imbalance can all cause infertility. Sometimes the presence of diseases like diabetes, central nervous system diseases and pituitary gland tumors can hinder fertility.
If a male fertility factor is found, sometimes it is necessary to consult a urologist to rule out anatomical anomalies and test hormone levels. This consultation can help us determine the pregnancy prognosis and the best treatment options.
There are other studies that can help us evaluate the parameters of sperm quality such as FISH (Fluorescence in situ hybridization) and DNA fragmentation testing of the sperm. If any of these studies are altered, we can resort to therapeutic techniques like Magnetic Activated Cell Sorting (MACS) or Preimplantation Genetic Diagnosis (PGD). At ProcreaTec, we can offer you the best genetic orientation thanks to our staff´s expertise and our history of excellent results in genetic testing.
What role do hereditary diseases play in sterility?
Genetic abnormalities may cause sterility for two reasons. The first is due to a deficit in gamete production (egg and sperm) for example in Turner syndrome in women or Klinefelter syndrome in men. In these cases, sterility is caused by the absence or irregularity of gametes and their impossibility to generate a viable pregnancy.
The second reason comes from genetic alterations that, even though the parents didn’t show any symptoms, are incompatible with the formation of a new embryo or produce defects that lead to miscarriage. This is the case of chromosomal translocation or inversion.
Monogenetic diseases, in which the parents are carriers or are affected, do not usually cause sterility problems but rather miscarriages or offspring with the disease. Preimplantation Genetic Diagnosis (PGD) can help the couples with genetic problems have healthy children.
What are repeated miscarriages and how are they treated?
Around 60% of miscarriages are attributed to genetic causes. If a couple has had two or more miscarriages, the probability of another one is very high. In these cases, a study needs to be made of the couple in order to find the cause and allow an effective treatment to be prescribed to avoid another miscarriage.
The study of the couple looks for infectious, immunological, coagulation or genetic issues that could be the cause of repeated miscarriages. However, today cases of repeated miscarriages exist without a clear diagnosis. Many times the precise cause of repeated miscarriage remains undiagnosed.
What is sterility of unknown origin?
It is reported that 10% of the couples who consult a fertility expert no specific cause can be found. This is called Unexplained Infertility. Once fertility treatments begin, a diagnosis of most of these couples can be given.
Nevertheless, in spite of not having a specific diagnosis, a treatment plan can be established based on the data collected in the basic study of the couple.
Are food and eating habits important in fertility treatments?
Dietary habits influence heart disease, hypertension and diabetes, but until recently it was not known to what degree they affect fertility.
Recent studies carried out at Harvard University confirm dieting can influence patients don´t ovulate correctly which make up almost 25% of patients who have fertility problems. It is also known that testosterone levels in overweight men are lower and this can also decrease their reproductive potential.
Being overweight in women is associated with a decrease in embryo implantation during reproduction treatments.
Why are there more fertility clinics now than before?
Social factors have changed over the past 20 years. In the past couples used to get married and have children at a much younger age than at present. Life 20 years ago didn´t have as much stress and people didn´t travel as much as now. Stress, travel and both members of the couple working full-time make pregnancy more difficult. Other times women who have had their tubes tied or men who have undergone a vasectomy later decide they want children again.
Has fertility decreased in the last 20 years ago?
There are factors that have undoubtedly contributed to a decrease in fertility. Smoking, alcohol and drugs can decrease sperm counts and egg quality. It is thought that pollution and food with additives also influence fertility. However, a major factor that contributes to an increase in sterility is the fact that couples are delaying parenthood until they are older.
Is it true that infertility is always the woman’s fault?
This is false. First of all, we don’t like to blame anybody. The couple needs to realize that this is a process that they have to get through together. The female factor contributes to infertility in 30% of the cases, men in 30%, while both have problems in 30%. The remaining 10% are cases of unexplained infertility.
How can I know if I ovulate or not?
In a 28-day cycle, ovulation takes place around day 14. About 24 hours later, the woman’s temperature rises if ovulation has taken place. At present, pharmacies sell ovulation kits and it is possible to check and see when is the best time to have sex.
In our assisted reproduction clinic, ovulation is monitored by transvaginal ultrasound scans on different days of the cycle and hormone levels in the blood are checked to see if the necessary hormone surges have taken place to ovulate. This helps spontaneous conception.
My doctor says I don’t ovulate every month. How can I have my period if I don’t ovulate?
Most women with a regular cycle (26-35 days) ovulate every month. To have regular cycles the hormones that make the endometrium grow and mature have to synchronize with ovulation in the middle of the cycle. In patients with longer or irregular cycles (30-90 days) their bodies are secreting hormones all this time so that the endometrium grows. If ovulation does not occur, the endometrium sheds spontaneously. This process causes long and irregular cycles and sometimes in these cycles there is no ovulation.
I had my tubes tied. Is there any way I can get pregnant?
Life is unpredictable and sometimes a woman decides she wants to have more children, after having had her tubes tied. The easiest option is to undergo in vitro fertilization. In this process, first the woman undergoes ovarian simulation, then egg retrieval; the egg and the sperm are mixed in the lab for fertilization, and 2 to 5 days later, the embryos are transferred. In this process, the egg does not have to go through the Fallopian tubes and the woman can achieve pregnancy with tied tubes.
How many fresh embryos are transferred in each cycle?
At present, the tendency is to replace fewer embryos. For women under 35 in their first IVF cycle we recommend transferring one and no more than two high quality embryos. For patients over 35 and younger women who have failed to conceive in a previous IVF cycle, usually two embryos are transferred. The transfer of three embryos is done only occasionally due to the high risk of multiple births.
Does your clinic have a program of egg donation? Is there a waiting list?
In our clinic we have an egg donation program with no waiting list. The waiting period before initiating treatment can vary depending on the time it takes to find the most adequate donor for the recipient and it also depends on how long it takes to synchronize their periods.
Is there a high probability of congenital anomalies in children born from frozen embryos?
Many long-term studies exist today about children born through frozen embryo transfer. There is no greater probability of congenital anomalies is these children than in children born with other assisted reproduction techniques.
Is there a higher probability of congenital anomalies in children born using assisted reproduction techniques than in spontaneously conceived children?
At present this question is under debate. Some scientific reports find no difference between the two groups of children and others find a slight increase in children who were born using assisted reproduction. What is unclear is if the alterations found in some studies are due to reproduction techniques or to the profile of subfertile people who may have issues such as the older age of the mother, being overweight or having other diseases. The debate is still open is to whether it is nature or nurture i.e. if the quality of the gametes are not as good as in spontaneous pregnancy or if the fact that the embryo goes thru the lab affects it in any way.
Does the couple together or one member often need psychological support during the process?
Frequently one member or both feel overwhelmed, stressed and hopeless. It is important to talk about these feelings so they don’t spin out of control. Our psychologists are specialized in treating fertility patients. Support is a vital part of fertility treatments so that the patients do not suffer pathologically during the process.
Is it possible to select the sex of my child?
Spanish law does not currently allow the selection of the sex of your child. However, it is permitted in other countries, such as the United States.
Does Spanish law contemplate the possibility of using surrogate mothers?
In Spain, the law does not currently permit surrogate motherhood. However, it is possible in countries such as India, Russia and the United States.
Does being overweight affect my sperm?
Overweight men may have more estrogen hormones (the female hormone) and less testosterone (the male hormone), leading to a decrease in sperm production and lower fertility.
How does my body produce sperm?
Every 72 days, new sperm is produced. This process is cyclical and takes place continually in different parts of the testicles, thus always assuring the presence of spermatozoids in the ejaculate of healthy men.
How can I know if my sperm is good?
The parameters for seminal quality are determined by the WHO (World Health Organization). In the last few years, the seminal quality in all men all around the world has decreased. ProcreaTec recommends a sperm analysis analyze the male factor. With these results, a diagnosis and prognosis of the probability of pregnancy can be made.
What is measured in a Sperm Analysis?
In a sperm analysis the morphology, motility and concentration of spermatozoa per milliliter of semen is analyzed.
- Normal sperm morphology means the head should be round and smooth, the tail should be three times the length of the head and joined correctly to it.
- Motility is defined as the speed with which the spermatozoon advances (micrometers per second) in a straight line.
- Sperm concentration should be over 10 million/ml.
All these parameters need to be within the limits established by the WHO in 2010.
How do you define a healthy spermatozoon?
The spermatozoon is the male gamete that defines the genetic gender of the future baby.
It is a germinal cell composed of a flagellum (a tail), an intermediate piece (the neck) and a head. An anomaly in any of these parts implies a decrease in the probability that this spermatozoon will be able to fertilize an egg.
What is oligozoospermia?
Oligozoospermia is when the concentration of spermatozoa per milliliter in the ejaculate is less than the parameters of normality set by the WHO. Currently this condition represents a concentration of less than 15 million per milliliter.
The quantity of spermatozoa in the ejaculate of the man is a fluctuating parameter and can be affected by medication, stress or illness such as an infection. So if a serious alteration in sperm concentration is detected, it is very important to do another test at a later date to make sure that the results are correct.
What is azoospermia?
Azoospermia is the absence of spermatozoa in the ejaculate. If no sperm is found in the ejaculate it is imperative to repeat the sperm analysis to be able to confirm the diagnosis.
Azoospermia can have two origins. Secretory azoospermia is caused by an alteration in the testicle that impedes the formation of spermatozoids. Obstructive azoospermia is caused by the obstruction of the ducts through which the sperm travels.
Treatment depends on the type of azoospermia and goes from a testicular biopsy to obtain sperm directly from the testicle (when obstructive azoospermia is diagnosed) to the use of donor semen (in the case of secretory azoospermia).
What is astenozoospermia?
Astenozoospermia is when spermatozoa move slower than normal. Currently the WHO considers normal a 32% progressive motility in the ejaculate.
Alterations in motility may be caused by previous medical treatments and by unhealthy habits.
There are treatments to improve sperm motility such as antioxidant vitamins.
What is teratozoospermia?
Teratozoospermia when the percentage of abnormal spermatozoa in the ejaculate is higher than 4%, the parameter considered normal set by the WHO.
When teratozoospermia is found more testing is usually needed to determine if there is a genetic or hormonal cause.