Information on Infertility
Causes of Infertility
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Infertility refers to an inability
to conceive after having regular unprotected sex. Infertility can also refer to
the biological inability of an individual to contribute to conception, or to a female
who cannot carry a pregnancy to full term. In many countries infertility refers
to a couple that has failed to conceive after 12 months of regular sexual intercourse
without the use of contraception.
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Studies indicate that slightly
over half of all cases of infertility are a result of female conditions, while the
rest are caused by either sperm disorders or unidentified factors.
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About 40% to 50% of cases of infertility
are due to a sperm problem in the male partner.
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About 40% to 50% of cases of infertility
are due to a problem in the female partner.
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In 30-40% of couples both partners have problems.
Risk Factors of Infertility?
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In medicine, a risk factor is
something that raises the risk of developing a condition, disease or symptom.
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Age - a woman's fertility starts
to drop after she is about 32 years old, and continues doing so. A 50-year-old man
is usually less fertile than a man in his early 20s (male fertility progressively
drops after the age of 40).
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Smoking - smoking significantly
increases the risk of infertility in both men and women. Smoking may also undermine
the effects of fertility treatment. Even when a woman gets pregnant, if she smokes
she has a greater risk of miscarriage.
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Alcohol consumption - a woman's
pregnancy can be seriously affected by any amount of alcohol consumption. Alcohol
abuse may lower male fertility. Moderate alcohol consumption has not been shown
to lower fertility in most men, but is thought to lower fertility in men who already
have a low sperm count.
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Being obese or overweight - in
industrialized countries overweight/obesity and a sedentary lifestyle are often
found to be the principal causes of female infertility. An overweight man has a
higher risk of having abnormal sperm.
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Over-exercising - a woman who
exercises for more than seven hours each week may have ovulation problems.
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Not exercising - leading a sedentary
lifestyle is sometimes linked to lower fertility in both men and women.
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Sexually transmitted infections
(STIs) - chlamydia can damage the fallopian tubes, as well as making the man's scrotum
become inflamed. Some other STIs may also cause infertility.
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Exposure to some chemicals - some
pesticides, herbicides, metals (lead) and solvents have been linked to fertility
problems in both men and women.
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Mental stress - studies indicate
that female ovulation and sperm production may be affected by mental stress. If
at least one partner is stressed it is possible that the frequency of sexual intercourse
is less, resulting in a lower chance of conception.
Causes of Infertility in Women
Ovulation disorders - problems with ovulation are the most common cause of infertility
in women, experts say. Ovulation is the monthly release of an egg. In some cases
the woman never releases eggs, while in others the woman does not release eggs during
some cycles. Ovulation disorders can be due to:
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Premature ovarian failure - the
woman's ovaries stop working (producing eggs) before she is 40.
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PCOS (polycystic ovary syndrome)
- the woman's ovaries function abnormally. She also has abnormally high levels of
androgen (male hormone). About 5% to 10% of women of reproductive age are affected
to some degree. They may be affected by weight gain and abnormal facial hair growth
as well irregular menstruation and cycles without egg production.
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Hyperprolactinemia - if serum
prolactin levels are high and the woman is not pregnant or breastfeeding, it may
affect ovulation and fertility.
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Poor egg quality - eggs that are
damaged or develop genetic abnormalities cannot sustain a pregnancy. The older a
woman is the higher the risk. Patients with reduced egg reserve and low AMH levels
also might have poor egg quality.
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Overactive thyroid gland - hyperthyroidism.
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Underactive thyroid gland - hypothyrodism.
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Some chronic conditions, such
as AIDS or cancer.
The egg travels from the ovary to the uterus (womb) where the fertilized egg grows.
If there is something wrong in the uterus or the fallopian tubes the woman may not
be able to conceive naturally. This may be due to:
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Surgery - pelvic surgery can sometimes
cause scarring or damage to the fallopian tubes. Cervical surgery can sometimes
cause scarring or shortening of the cervix. The cervix is the neck of the uterus.
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Submucosal fibroids - benign or
non-cancerous tumors found in the muscular wall of the uterus, occurring in 30%
to 40% of women of childbearing age. They may interfere with implantation. They
can also block the fallopian tube, preventing sperm from fertilizing the egg. Large
submucosal uterine fibroids may make the uterus' cavity bigger, increasing the distance
the sperm has to travel.
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Endometriosis - cells that are
normally found within the lining of the uterus start growing elsewhere in the body.
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Previous sterilization treatment
- if a woman chose to have her fallopian tubes blocked. It is possible to reverse
this process, but the chances of becoming fertile again are not high. IVF is useful
if reversal surgery has failed.
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Medications - some drugs can affect
the fertility of a woman. These include:
A. NSAIDs (non-steroidal anti-inflammatory drugs) - women who take
aspirin or ibuprofen long-term may find it harder to conceive.
B hemotherapy - some medications used in chemotherapy can result in
ovarian failure. In some cases, this side effect of chemotherapy may be permanent.
C. Radiotherapy - if radiation therapy was aimed near the woman's reproductive
organs there is a higher risk of fertility problems.
D. Illegal drugs - some women who take marijuana or cocaine may have
fertility problems.
Recent News
Researchers have found that girls who are born unexpectedly small or underweight
are twice as likely to have fertility issues in adulthood than those born at a normal
size. Girls born underweight are 'more likely to be infertile adults' - this is
according to a study published in the journal BMJ Open.
High cholesterol linked to infertility - Prospective parents with high cholesterol
levels could be in for a long wait to become pregnant, a new study published in
the Endocrine Society's Journal of Clinical Endocrinology & Metabolism states.
Cell phones may reduce sperm quality - Men may not realize it, but they could inadvertently
be reducing their fertility through exposure to radio-frequency electromagnetic
radiation (RF-EMR), suggest researchers from the University of Exeter in the UK,
who report their findings in the journal Environment International.
Could household detergents reduce fertility? - Two active ingredients commonly found
in household detergents caused reproductive decline in mice, according to a new
study published in the journal Reproductive Technology, prompting concerns about
how these ingredients affect reproduction in humans
Causes of Infertility in Men
Semen
Semen is the milky fluid that a man's penis releases during orgasm. Semen consists
of fluid and sperm. The fluid comes from the prostate gland, seminal vesicle and
other sex glands. The sperm is produced in the testicles. During orgasm a man ejaculates
(releases semen through the penis). The seminal fluid helps transport the sperm
during ejaculation. The seminal fluid has sugar in it - sugar is an energy source
for sperm.
Abnormal semen is responsible for about 75% of all cases of male infertility.
Unfortunately, in many cases doctors never find out why. The following semen problems
are possible:
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Low sperm count (low concentration)
- the man ejaculates a lower number of sperm, compared to other men. Sperm concentration
should be 20 million sperm per milliliter of semen. If the count is under 20 million
there is a low sperm concentration (oligozoospermia).
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No sperm - when the man ejaculates
there is no sperm in the semen (azoospermia) .
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Low sperm mobility (asthenozoospermia)
- the sperm cannot "swim" as well as it should.
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Abnormal sperm (teratozoospermia)
- perhaps the sperm has an unusual shape, making it more difficult to move and fertilize
an egg.
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Sperm must be the right shape
and able to travel rapidly and accurately towards the egg. If the sperm's morphology
(structure) and motility (movement) are wrong it is less likely to be able to reach
the egg and fertilize it.
The following may cause semen to be abnormal:
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Testicular infection
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Testicular cancer
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Testicular surgery
Overheating the testicles - frequent saunas, hot tubs, very hot baths, or working
in extremely hot environments can raise the temperature of the testicles. Tight
clothing may have the same effect on some people.
Ejaculation disorders - for some men it may be difficult to ejaculate properly.
Men with retrograde ejaculation ejaculate semen into the bladder. If the ejaculatory
ducts are blocked or obstructed the man may have a problem ejaculating appropriately./p>
Varicocele - this is a varicose vein in the scrotum that may cause the sperm to
overheat.
Undescended testicle - one (or both) testicle fails to descend from the abdomen
into the scrotum during fetal development. Sperm production is affected because
the testicle is not in the scrotum and is at a higher temperature. Healthy sperm
need to exist in a slightly lower-than-body temperature. That is why they are in
the scrotum, and not inside the body.
Varicocele - this is a varicose vein in the scrotum that may cause the sperm to
overheat.
Undescended testicle - one (or both) testicle fails to descend from the abdomen
into the scrotum during fetal development. Sperm production is affected because
the testicle is not in the scrotum and is at a higher temperature. Healthy sperm
need to exist in a slightly lower-than-body temperature. That is why they are in
the scrotum, and not inside the body.
Hypogonadism - testosterone deficiency can result in a disorder of the testicles.
Genetic abnormality - a man should have an X and Y chromosome. If he has two X chromosomes
and one Y chromosome (Klinefelter's syndrome) there will be an abnormal development
of the testicles, low testosterone, and a low sperm count (sometimes no sperm at
all).
Mumps - this viral infection usually affects young children. However, if it occurs
after puberty inflammation of the testicles may affect sperm production.Hypospadias
- the urethral opening is at the underside of the penis, instead of its tip. This
abnormality is usually surgically corrected when the male is a baby. If it is not
the sperm may find it harder to get to the female's cervix. Hypospadias occur in
about 1 in every 500 newborn boys.
Cystic fibrosis - Cystic fibrosis is a chronic disease that affects organs such
as the liver, lungs, pancreas, and intestines. It disrupts the body's salt balance,
leaving too little salt and water on the outside of cells and causing the thin layer
of mucus that usually keeps the lungs free of germs to become thick and sticky.
This mucus is difficult to cough out, and it clogs the lungs and airways, leading
to infections and damaged lungs. Males with cystic fibrosis commonly have a missing
or obstructed vas deferens (tube connecting the testes to the urethra; it carries
sperm from the epididymis to the ejaculatory duct and the urethra).
Radiotherapy - radiation therapy can impair sperm production. The severity usually
depends on how near to the testicles the radiation was aimed.
Some diseases - the following diseases and conditions are sometimes linked to
lower fertility in males:
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Anemia
A. Cushing's syndrome.
B Diabetes.
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hyroid disease
A Medications.
Sulfasalazine - this anti-inflammatory drug can significantly lower a man's sperm
count. The drug is often prescribed for patients with Crohn's disease or rheumatoid
arthritis. Usually this side effect goes away after the patient stops taking the
medication.
Anabolic steroids - often taken by bodybuilders and athletes; anabolic steroids,
especially after long term use can seriously reduce sperm count and mobility.
Chemotherapy - some medicines may significantly reduce sperm count.
Illegal drugs - consumption of marijuana and cocaine can lower a man's sperm count.
Diagnosing Infertility
Most people will visit their GP (general practitioner, primary care physician) if
there is no pregnancy after 12 months of trying. For anybody who is concerned about
fertility, especially if they are older (women over 35), it might be a good idea
to see a doctor earlier. As fertility testing can sometimes take a long time, and
female fertility starts to drop when a woman is in her thirties, seeing the doctor
earlier on if you are over 35 makes sense.
A GP can give the patient advice and carry out some preliminary assessments. As
it takes two to make a baby it is better for both the male and female to see the
doctor together.
Before undergoing testing for fertility it is important that the couple be committed.
The doctor will need to know what the patients' sexual habits are, and may make
recommendations regarding them. Tests and trials might extend over a long period.
Even after thorough testing, no specific cause is ever found for 30% of infertility
cases.
Tests For Males
General physical exam - the doctor will ask the man about his medical history, medications,
and sexual habits. The physician will also carry out an examination of his genitals.
The testicles will be checked for lumps or deformities, while the shape and structure
of the penis will be examined for any abnormalities.
Semen analysis - the doctor may ask for some specimens of semen. They will be analyzed
in a laboratory for sperm concentration, motility, color, quality, infections and
whether any blood is present. As sperm counts can fluctuate, the man may have to
produce more samples.
Blood test - the lab will test for several things, including the man's level of
testosterone and other male hormones.
Ultrasound test - the doctor will determine whether there is any ejaculatory duct
obstruction, retrograde ejaculation, or other abnormality.
Chlamydia test - if the man is found to have Chlamydia, which can affect fertility,
he will be prescribed antibiotics to treat it.
Tests For Females
General physical exam - the doctor will ask the woman about her medical history,
medications, menstruation cycle, and sexual habits. She will also undergo a gynecological
examination.
Blood test - several things will be checked, for example, whether hormone levels
are correct and whether the woman is ovulating (progesterone test).
Hysterosalpingography - fluid is injected into the woman's uterus which shows up
in X-ray pictures. X-rays are taken to determine whether the fluid travels properly
out of the uterus and into the fallopian tubes. If the doctor identifies any problems,
such as a blockage, surgery may need to be performed.
Laparoscopy - a thin, flexible scope with a camera at the end (laparoscope) is inserted
into the abdomen and pelvis to look at the fallopian tubes, uterus and ovaries.
A small incision is made below the belly button and a needle is inserted into the
abdominal cavity; carbon dioxide is injected to create a space for the laparoscope.
The doctor will be able to detect endometriosis, scarring, blockages, and some irregularities
of the uterus and fallopian tubes.
Ovarian reserve testing - this is done to find out how effective the eggs are after
ovulation. Serum AMH is the best test for estimating the egg reserve in a woman.
Hysterosalpingography - fluid is injected into the woman's uterus which shows up
in X-ray pictures. X-rays are taken to determine whether the fluid travels properly
out of the uterus and into the fallopian tubes. If the doctor identifies any problems,
such as a blockage, surgery may need to be performed.
Genetic testing - this is to find out whether a genetic abnormality is interfering
with the woman's fertility.
Pelvic ultrasound - high frequency sound waves create an image of an organ in the
body, which in this case is the woman's uterus, fallopian tubes, and ovaries.
Chlamydia test - if the woman is found to have Chlamydia, which can affect fertility,
she will be prescribed antibiotics to treat it.
Thyroid function test - according to the National Health Service (UK) between 1.3%
and 5.1% of infertile women have an abnormal thyroid.
Hysterosalpingography - fluid is injected into the woman's uterus which shows up
in X-ray pictures. X-rays are taken to determine whether the fluid travels properly
out of the uterus and into the fallopian tubes. If the doctor identifies any problems,
such as a blockage, surgery may need to be performed.
Treatment Options for Infertility
This will depend on many factors, including the age of the patient(s), how long
they have been infertile, personal preferences, and their general state of health.
Even if the woman has causes that cannot be corrected, she may still become pregnant.
Frequency of Intercourse
The couple may be advised to have sexual intercourse more often. Sex two to three
times per week may improve fertility if the frequency was less than this. Some fertility
experts warn that too-frequent sex can lower the quality and concentration of sperm.
Male sperm can survive inside the female for up to 72 hours, while an egg can be
fertilized for up to 24 hours after ovulation.
Fertility Treatment for Men
Erectile dysfunction or premature ejaculation - medication and/or behavioral approaches
can help men with general sexual problems, resulting in possibly improved fertility.
Varicocele - if there is a varicose vein in the scrotum, it can be surgically removed.
Blockage of the ejaculatory duct - sperm can be extracted directly from the testicles
and injected into an egg in the laboratory.
Retrograde ejaculation - sperm can be taken directly from the bladder and injected
into an egg in the laboratory.
Surgery for epididymal blockage - if the epididymis is blocked it can be surgically
repaired. The epididymis is a coil-like structure in the testicles which helps store
and transport sperm. If the epididymis is blocked sperm may not be ejaculated properly.
Fertility Treatment for Women
Ovulation disorders - if the woman has an ovulation disorder she will probably be
prescribed fertility drugs which regulate or induce ovulation. These include:
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Clomifene (Clomid, Serophene)
- this medication helps encourage ovulation in females who do not ovulate regularly,
or who do not ovulate at all, because of polycystic ovary syndrome (PCOS) or some
other disorder. It makes the pituitary gland release more FSH (follicle-stimulating
hormone) and LH (luteinizing hormone).
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Metformin (Glucophage) - women
who have not responded to Clomifene may have to take this medication. It is especially
effective for women with PCOS, especially when linked to insulin resistance. More
recently, other alternative medications to metformin are available.
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Human menopausal gonadotropin,
(hMG) - this medication contains both FSH and LH. It is an injection and is used
for patients who don't ovulate on their own because of a fault in their pituitary
gland.
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Follicle-stimulating hormone (FSH)
- this is a hormone produced by the pituitary gland that controls estrogen production
by the ovaries. It stimulates the ovaries to mature egg follicles.
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Human chorionic gonadotropin (hCG)
- this medication is used together with clomiphene, hMG and FSH. It stimulates the
follicle to ovulate.
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Gn-RH (gonadotropin-releasing
hormone) analogs - for women who ovulate prematurely, before the lead follicle is
mature enough during hmG treatment. This medication delivers a constant supply of
Gn-RH to the pituitary gland, which alters the production of hormone, allowing the
doctor to induce follicle growth with FSH. These may be agonists (lupride or busarlin)
or antagonists (cetrorelix or ganirelix)
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Bromocriptine (Parlodel) - this
drug inhibits prolactin production. Prolactin stimulates milk production in breast
feeding mothers. If non-pregnant, non-breast feeding women have high levels of prolactin
they may have irregular ovulation cycles and have fertility problems. A more effective
medicine is cabergolin which needs to be given just twice a week and has fewer side
effects than the conventional bromocriptine.
Risk of Multiple Pregnancies
Injectable fertility drugs can sometimes be the victims of their own success and
cause multiple births - when the woman gets pregnant she has twins, triplets, or
perhaps more babies in one go. Oral fertility drugs also raise the risk of multiple
pregnancies, but much less so than injectable ones. It is important to monitor the
patient carefully during treatment and pregnancy. The more babies the mother carries
inside her the higher is her risk of premature labor.
If a woman needs an HCG injection to activate ovulation and ultrasound scans show
that too many follicles have developed, it is possible to withhold the HCG injection.
Couples may decide to go ahead regardless if the desire to become pregnant is very
strong.
Multifetal pregnancy reduction is possible if too many babies are conceived - one
or more of the fetuses is removed. Couples will have to consider the ethical and
emotional aspects of this procedure.
Surgical Procedures for Women
Fallopian tube surgery - if the fallopian tubes are blocked or scarred surgery may
repair them, making it easier for eggs to pass through them.
Laparoscopic surgery - a small incision is made in the woman's abdomen. A thin,
flexible microscope with a light at the end (laparoscope) is inserted through the
incision. The doctor can then look at internal organs, take samples and perform
small operations. For women with endometriosis, laparoscopy removes implants and
scar tissue, reducing pain and often aiding fertility.
Assisted Reproductive Technologies
IUI (intrauterine insemination) - a fine catheter is inserted through the cervix
into the uterus to place a sperm sample directly into the uterus. The sperm is washed
in a fluid and the best specimens are selected. This procedure must be done when
ovulation occurs. The woman may be given a low dose of ovary stimulating hormones.
IUI is more commonly done when the man has a low sperm count, decreased sperm motility,
or when infertility does not have an identifiable cause. The procedure is also helpful
for males suffering from severe erectile dysfunction.
IVF (in vitro fertilization) - sperm are placed with unfertilized eggs in a Petri
dish; the aim is fertilization of the eggs. The embryo is then placed in the uterus
to begin a pregnancy. Sometimes the embryo is frozen for future use (cryopreserved).
Louise Brown, born in England in 1978, was the world's first IVF baby. Before IVF
is done the female takes fertility drugs to encourage the ovaries to produce more
eggs than normal.
ICSI (Intracytoplasmic sperm injection) - a single sperm is injected into an egg
to achieve fertilization during an IVF procedure. The likelihood of fertilization
improves significantly for men with low sperm concentrations.
Donation of sperm or egg - if there is either no sperm or egg in one of the partners
it is possible to receive sperm or eggs from a donor. Fertility treatment with donor
eggs is usually done using IVF. The clinic is associated with premium banks for
supply of egg donors, sperm donors and surrogate mothers.
Assisted hatching - this improves the chances of the embryo's implantation; attaching
to the wall of the uterus. The embryologist opens a small hole in the outer membrane
of the embryo, known as the zonapellucida using a laser. The opening improves the
ability of the embryo to leave its shell and implant into the uterine lining. Patients
who benefit from assistant hatching include women with previous IVF failure, poor
embryo growth rate, and older women. In some women, particularly older women, the
membrane is hardened, making it difficult for the embryo to hatch and implant. There
are conflicting reports about the benefit of routine assisted hatching for all patients
and not recommended.
Electric or vibratory stimulation to achieve ejaculation - ejaculation is achieved
with electric or vibratory stimulation. This procedure is useful for men who cannot
ejaculate normally, such as those with a spinal cord injury.
Surgical sperm aspiration - the sperm is removed from part of the male reproductive
tract, such as the vas deference, testicle or epididymis.
Complications of Infertility Treatment?
Ovarian hyperstimulation syndrome (OHSS))
The ovaries become very swollen, leaking excess fluid into the body. The ovaries
produce too many follicles (small fluid sacs in which an egg develops). OHSS usually
occurs as a result of taking medications to stimulate the ovaries, such as clomifene
and gonadtrophins, and can also develop after IVF. Symptoms can include:
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Bloating and swelling of the abdomen
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Constipation / loose motions
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Concentrated and dark urine
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Nausea / vomiting
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Pain in the abdomen
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In most cases symptoms are mild and easy to treat. On very rare occasions the patient
may develop a blood clot (thrombosis) in an artery or vein, liver or kidney problems,
and respiratory distress. Hospitalization with monitoring and IV fluids might be
required in some cases. Our clinic has a "safe IVF" policy and patients are counselled
about the possibility of cycle cancellation or alternate protocols with embryo freezing
to prevent this complication.
Ectopic pregnancy
This is a pregnancy when the fertilized egg does not implant in the womb but elsewhere
- in most cases the fertilized egg grows in the fallopian tube. This can sometimes
result in severe pain and rupture of the tube causing internal bleeding. The patient
needs urgent attention as it could become life threatening.
Women receiving fertility treatment have a slightly higher risk of having an ectopic
pregnancy. An ultrasound scan can detect an ectopic pregnancy. Usually, diagnosis
is possible at an early stage as most patients on treatment are being monitored
during early pregnancy for such complications.
Coping emotionally and psychologically
As it is impossible to know how long treatment will go on for and how successful
it will be, coping and persevering with treatment can be stressful. The emotional
toll on both partners might be considerable and can have an impact on their marital
and sexual relationship. Some people find that joining a support group helps - being
able to talk to others who share similar problems, aspirations and anxieties can
be uplifting. It is important to tell your doctor if you are suffering mentally
and/or emotionally. Most fertility doctors have access to counselors, as well as
other people (acupuncturists) and professionals who can offer helpful support.