| INFERTILITY TREATMENT AT GULU INDEPENDENT HOSPITAL
Male Infertility
The male genital tract includes the testes, the epididymis, the vas, the prostate and urethra. The testes situated in the scrotum are mainly made up of loops of fine tubes (seminiferous tubules) which produce the sperm. The sperm cells mature as they pass through the epidiymis (a narrow system of tubes on the surface of the testes). The vas is a hollow tube, which carries the sperm from the epididymis to the urethra.
It takes 3 - 4 months for sperm to develop, during this time sperm production may be affected by febrile illness, exposure to drugs, toxins, radiation, local trauma or infection.
The primary laboratory test for male fertility is " semen analysis". The sample is obtained by masturbation or collected from a special condom following intercourse. Sterile containers must be used to collect the sample following three days of sexual abstinence.
A normal assessment should show:
- Semen volume - 2-4mls
- Sperm count - more than 20 million per ml
- Sperm motility - more than 50% moving
- Sperm morphology - more than 30% of normal shape
- White blood cells - should be less than 1 million per ml
- Antisperm antibodies test - should be negative
Male Reproductive System
Common Male Infertility Problems:
- Abnormal sperm parameters:
Low sperm count - (oligospermia)
Poor sperm motility - (asthenospermia)
High abnormal forms - ( teratospermia)
- Immunological factors: - Antisperm antibodies may occur following surgery, trauma or infections of the genital tract. Antisperm antibodies impair sperm motility and their ability to penetrate and fertilise an egg.
- Absence of sperm - (azoospermia) May be due to an obstruction at the level of the vas, epididymis, or even the testes, caused by previous infections, trauma or surgery. It may also be due to a bilateral congenital absence of the vas. Azoospermia could also be due to testicular failure caused by hormonal, chromosomal abnormalities, previous infection such as mumps or undesended testes.
A single sperm consists of a head, which contains the man's genetic information and its tip, an acrosome which will help the sperm penetrate the outer shell of the egg; a midpiece, which, supplies the energy need for movement; and the tail which propels the sperm forward.
Assisted Reproductive Techniques for Male Infertility:
- Intrauterine Insemination - IUI combined with superovulation using washed sperm can be considered in mild abnormalities in sperm parameters or in cases of coital difficulties.
- In Vitro Fertilisation - with IVF relatively fewer motile sperm are required for oocyte fertilisation because the natural transport barriers are bypassed; moreover IVF increases the number of sperms in contact with multiple oocytes from superovulation.
- Intacytoplasmic Sperm Injection - ICSI has revolutionized the treatment of severe male factor problems, especially when the sperm is surgically retrieved.
- Donor Sperm Insemination -DI This treatment will always be an option in severe cases of male factor infertility, azoospermia or genetically transmitted disease.
- Surgical Sperm Retrieval - SSR. This is a technique for collecting immature sperm directly from the vas, epididymis or testes. Sperm retrieval may be performed under local anaesthetic, as an out patient procedure, under general anaesthetic or during another operation to repair an obstruction in the vas. The sperm are withdrawn from the vas, epididymis and the testes using a fine needle and gentle suction.
PESA - Percutancous Epididymal Sperm Aspiration.
TESE - Testicular Sperm Extraction.
If sperm are not found, a sample of tissue (testicular biopsy) can be taken from the testes through a small incision, 2 - 3 stitches are placed in the skin which self dissolve in about 10 days. Once the sperm have been collected fertilisation is achieved using Intracytoplasmic Sperm Injection. (ICSI) this involves injecting a single sperm directly into the egg. Excess sperm from the sample can be cryropreserved for possible future use.
Female Infertility
Requirements For Conception to Occur:
In both sexes-
- A normal functioning reproductive system
- An adequate sex drive, and full sexual intercourse
In Women
- A regular ovulatory cycle.
- Fully functioning fallopian tubes.
- The production of watery mucus by the cervix around the time of ovulation, this permits the ejaculated sperm to pass into the uterus from the vagina.
- A uterus which permits implantation of the embryo.
In Men
- Producing semen which contains sufficient numbers of healthy motile sperm.
- The ability to achieve erection and ejaculate semen into the vagina.
Normal Cycle
At the beginning of the menstrual cycle the pituitary gland in your brain releases follicle - stimulating hormone (FSH) which stimulates the ovary to produce follicles. One of these follicles grows faster to become the " dominant follicle". It is from this follicle that the egg will be released.
The ovaries also produce many hormones, the most important ones are oestrogen and progesterone. Oestrogen promotes growth of the follicles and development of the endometrium, while progesterone, which is released after ovulation, is important in preparing the endometrium for pregnancy.
When the egg is released, it is swept into the fallopian tube, then begins to move slowly down the tube to be fertilised in the outer third of the fallopian tube, and then continues to the uterus to implant in the lining ( endometruim ) resulting in a pregnancy. If the egg is not fertilised, the endometium is shed as a menstrual period approximately 14 days after ovulation.
Common Causes of Infertility in the Female:
Ovulatory disorders
This occurs as a result of hormonal imbalance either within the hypothalamus, the pituitary or in the ovaries. Common causes of this includes stress, excessive weight loss or weight gain, and polycystic ovaries. Polycystic ovaries (POC) can affect up to 30% of women with infertility problems. The ovaries contain many tiny cysts and although the majority of women with PCO have normal regular cycles and have no problems conceiving, others may experience menstrual irregularities, fertility problems, excessive growth of body hair, acne and obesity. Treatment usually involves the use of drugs to correct the hormonal imbalance and stimulation of the ovaries. Alternatively, laparoscopic ovarian drilling using diathermy or laser may be performed.
Fallopian Tube Blockage
May occur as a result of previous infection or abdominal surgery complicated by adhesions. Fluids collecting in the tube (hydrosalpinx) may become a potential source of chronic infection and may also be detrimental for the development and implantation of the embryos. Some blockages can be treated surgically; otherwise IVF treatment might be the best option
Endometriosis
Is a condition where the tissue, which normally lines the uterus, is found at other sites in the pelvis. Bleeding occurs from these tissues at the time of menstruation causing pelvic pain and painful periods. Blood filled cysts may develop within the ovaries (chocolate cysts) also pelvic scarring may affect the motility or the patency of the fallopian tubes leading to infertility.
Treatment of endometriosis is either medical using drug therapy or surgical treatment either laparoscopically or by open surgery depending on the extent of the disease. IVF is an appropriate treatment for infertility associated with endometriosis where other methods have failed.
Cervical Factors
Some women have antisperm antibodies within their cervical mucus or produce very little unfavorable mucus at the time of ovulation which interferes with sperm migration through the cervical canal. Hostile mucus may be by passed by intrauterine insemination with or without superovulation.
Unexplained Infertility
Affects 20 - 25% of infertile couples, caused by factors which cannot be assessed by using conventional tests. It is not always possible to determine if, the eggs are actually released from the follicles, if the fallopian tubes are able to pick up the egg, if the sperm is capable of reaching the site of fertilisation and fertilising the egg. Intrauterine insemination using washed sperm suspended in culture medium combined with ovarian stimulation offers a simple relatively non-invasive procedure. If pregnancy does not occur within the three cycles alternative methods such as IVF should be considered which will be both diagnostic and hopefully therapeutic.
Infertility Investigations:
- Full monitored cycle to check for ovulation
- POST coital test
- Hysterosalpingogram
- Hysteroscopy
- Diagnostic laparoscopy
Assisted Reproductive Techniques:
- Ovulation induction
- Artificial insemination (Intracervical or intrauterine) using husband's or donor sperm
- Peritoneal oocyte and sperm transfer ( POST )
- In vitro fertilization (IVF)
- Gamete Intrafallopian transfer (GIFT)
- Intra-cytoplasmic sperm injection ( ICSI )
- Surgical sperm retrieval, PESA, TESE or Vas aspiration
- Assisted Hatching
- Blastocyst Culture Transfer
- Cryo-preservation of embryos and frozen embryo replacement.
- Egg donation and an active Shared Egg Program
- IVF ( HOST ) surrogacy
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The integra machine,
one of the technologies used for ICSI in our lab. 