Infertility: when is it recommended to consult a specialist and what procedures will be performed?
It is estimated that one in ten couples will have difficulty conceiving. The prevalence, the number of people affected has not varied much over time, but the demand for infertility consultations has varied a great deal, almost exponentially. This is a consequence of the delay in childbearing; forty years ago, ninety percent of couples had their first child under the age of thirty, and this percentage has been progressively decreasing. At present, the average first child is over thirty years of age, with Spain and Italy being the European Community countries that take the longest to conceive. But this is a global phenomenon, all over the world, because emancipation, leaving home is increasingly later, because there is youth unemployment, because of job insecurity, because of the difficult family reconciliation and the little support for motherhood, because studies are prolonged. Multiple factors. The ideal physiological age to conceive would be below thirty. After that date, what happens is that fertility decreases and progressively decreases until the age of forty, when it plummets. Therefore, there is a mismatch between the biological reality of the woman’s body and the psychosocial reality of the woman. Every year that we exceed that age of thirty, thirty-five the pregnancy rate drops progressively and I have already said that plummeting since the forties. So that since 2017 we are in Spain in negative vegetative growth: there are more deaths than births.
In general we know that couples who maintain regular relations for a year 80% achieve a pregnancy in that first year and even up to 90% percent in the second year. When that has not happened it is time to go to the gynecologist. What happens is that this is in general because it will also depend on the age of the woman, as we have said that age is a very important factor, if she is older than thirty-eight we should not wait more than six months and if she is younger we can wait longer. The tests that we are going to do in the gynecological consultation: we have to make sure that the woman is ovulating and that she does not have any other pathology, we will do a general gynecological examination, we will ask her for a hormonal test to know how her hormones are between the second and third day of the cycle, to rule out endocrine pathology and we will ask her, according to her periods, if they are regular or irregular. Some tests that are very sensitive and work very well for us today is the antimüllerian hormone test, which does not talk about the woman’s ovarian reserve, such as the antral follicle count, which is the number of follicles that have been recruited that are going to be available for the next cycle. Also in the couple we are going to have to look at the semen, the quality of the semen and then we are going to have to see if the sperm and the oocyte can meet and coincide by looking at the integrity of the tubes, with a test called hysterosalpingography, which also gives us other information about how the uterine cavity is, but above all it wants us to see if these tubes are permeable so that the oocyte and the sperm can meet. Another group of people who are coming to infertility clinics nowadays are young people who, and the goal is to get younger and younger, in anticipation of the delay in their childbearing, want to preserve their fertility and so they come to the centers to be able to freeze oocytes beforehand.
What is considered infertility and why, and what factors can influence it?
Although we use the two terms as synonyms, sterility really means the inability to become pregnant after a year of unprotected relations, while infertility is the inability to have a living child and you do have the capacity to become pregnant, but it ends in miscarriage. Both have a remedy. Normally we know that after a year of unprotected intercourse we will achieve in eighty percent of cases a gestation and in the cases that do not cure the causes are multiple: almost 30% of the causes are of male origin, for example with varicocele which is the varicose dilatation of the deep venous plexus of the testicular blood drainage or anomalies of the seminal tract or a hormonal defect or genetic defects, diseases that have appeared or medication that has been received or environmental toxins. This can alter the number of spermatozoa, mobility and morphology, reducing seminal quality. In another 30% of cases the cause is female, the woman’s: due to tubal obstruction and either by disease or congenital, ovulatory problems, because she does not ovulate or ovulates little as in polycystic ovary, for having fibroids or uterine malformations, for having endometriosis. In general, women have ovulation problems due to age after thirty-five years of age, while the deterioration of semen due to age is around forty, fifty years of age. There is a 30% of causes which is a mixed cause, a mixture of the two, and a small margin of 10% of sterility of unknown origin, with no apparent cause. In general and without possibility of error: alcohol, tobacco and drugs are always harmful.
What fertility treatments are available and which will be the most recommended in each case?
The treatments will depend on the pathology in itself that the couple suffers, both the man and the woman. There are treatments that are surgical, such as varicocele, a very large myoma also has to be operated. There are different pathologies that will require specific treatment, but in general, as assisted reproduction techniques, we have from the easiest to the most complicated. It would be the insemination in which we are going to capacitate the semen: we take the couple’s semen, we make the spermatozoa motile, but which did not have very good weakness, become very good motility and at the same time, we give a medication to ensure the woman’s ovulation and another medication that ensures the moment in which this is going to occur. At that moment this semen is introduced through a very fine cannula, like a straw, into the uterus and the semen is deposited there, saving the cervix. In this way the sperm and the oocyte can meet in the tube and thus facilitate fertilization.
Another more complicated procedure is in vitro fertilization. In in vitro fertilization what we try to do is to stimulate the woman’s ovaries with the maximum number of oocytes to be able to later, by ultrasound and with sedation in the operating room, to obtain these oocytes. We are going to inseminate these oocytes in classic fertilization by putting them together with the sperm or, in cases of more severe anomalies, by taking a sperm with this pipette and microinjecting this sperm into this oocyte. With this we obtain an embryo and when we are sure that this embryo is developing well, we will wait three days or five days and we will take it to a blastocyst, we can implant it as before with a very small cannula inside the uterus and deposit it there. We deposit them one at a time or two at a time to avoid a large-scale multiple pregnancy, which is also a problem, and nowadays you even go one at a time to avoid twin pregnancy. This is a technique that allows us to skip the problems of tubal obstruction or in case of very, very, very altered semen.
Success rates of fertility treatments
The rate of spontaneous pregnancy, as we have said, is affected according to the age of the woman: below thirty years of age, it would be around sixteen percent, and from thirty to thirty-four years of age, this sixteen percent would persist. From the age of thirty-five to thirty-nine it would drop by thirteen percent and above forty it would be five percent, being inversely proportional to the number of abortions; in the first range, up to thirty, the rate of abortions is eight percent, while up to thirty-four it is around fourteen, up to thirty-nine it rises to twenty and from forty onwards it is thirty-eight percent.
The reproductive techniques will be more or less successful depending on the age of the couple, both his and hers, the seminal quality, the quality of the oocytes, the selection we make of those embryos that are obtained, having the possibility of freezing and being able to repeat the process, the cause of the infertility, obviously, and the number of embryos transferred. But in general, with all assisted reproduction techniques we achieve a success rate of forty to sixty percent in the twenty to thirty age group, while from thirty-two to thirty-five it drops to thirty-three, fifty percent, from thirty-six to forty it would be between twenty-eight and thirty-five percent and above forty, depending on whether you are a good responder, there is a twenty percent chance or if you are a low responder it is less than five percent. In those cases we can consider an oocyte donation program with a donor under thirty years of age that gives you a forty to sixty percent chance of achieving a pregnancy.