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Patient Resource Material

  • Basics of human reproduction
  • Pregnancy Planning
  • How to enhance your fertility
  • Care during Pregnancy
  • Understanding infertility
  • Recurrent Miscarriage

Female reproduction

Understanding the basics of female reproduction

In order to have a successful viable pregnancy both the male and female reproductive system has to function properly. In the female the sequence is:

  1. The uterus ,fallopian tubes, ovaries are anatomically normal.
  2. The egg quality is good , the follicle grows maturely ,ovulation occurs and it leads to release of viable oocyte in each cycle.
  3. The fallopian tubes are open and functional .
  4. There is no hindrance in the path of sperm to locate and reach the egg
  5. The endometrial lining is optimal for the embryo to grow.

Female Reproductive System

Vagina

It is a fibromuscular tubular sex organ.The vagina extends from the vulva to the uterus. At the vulva, the vaginal orifice initially is partly covered by a membrane called the hymen, while, at the deep end, the cervix bulges through the anterior wall of the vagina. The vagina facilitates sexual intercourse and child birth.

Uterus

It is a hollow pear shaped organ with an endometrial lining which is home to the developing fetus. The uterus enlarges during pregnancy . The uterus has two parts corpus is the upper part and cervix is the lower part which opens in the vagina.

Fallopian tubes

They are two very fine tubes lined with ciliated epithelia, leading from the ovaries to the uterus.

Ovaries

They are a pair of ovum producing reproductive organ. They secrete estrogen,progesterone and testosterone . Estrogen is responsible for the appearance of secondary sexual characteristic and for the maturation and maintenance of the reproductive organs in their mature functional state. Progesterone prepares the uterus for pregnancy, and the mammary glands for lactation. Progesterone functions with estrogen by promoting menstrual cycle. About 1 million oocytes are present at birth in the human ovary, only about 500 (about 0.05%) of these ovulate, and the rest are wasted. The decline in ovarian reserve appears to occur at a constantly increasing rate with age ,and leads to nearly complete exhaustion of the reserve by about age 52. As ovarian reserve and fertility decline with age, there is also a parallel increase in pregnancy failure and meiotic errors resulting in chromosomally abnormal conceptions.

Male reproduction

Understanding the basics of male reproduction

In order to have a successful viable pregnancy both the male and female reproductive system has to function properly. In the male the sequence is :

  1. The testes produce sperms and testosterone.
  2. Erection is achieved and there is sexual intercourse.
  3. Ejaculation occurs and the semen is expelled out into the vagina.
  4. The sperm count motility and morphology is as per WHO guidelines.

Testes

The testes are two glandular organs that are responsible for making testosterone and to produce sperm.

Epididymis

Is a single, narrow, tightly-coiled tube connecting the efferent ducts from the rear of each testicle to its vas deferens. It transports and stores sperm cells that are produced in the testes. The epididymis also brings the sperm to maturity,

Vas Deferens

The vas deferens connects the left and right epididymis to the ejaculatory ducts in order to move sperm.During ejaculation the smooth muscle in the wall of the vas deferens contracts, pushing the mature sperm toward the penis and into the urethra.

Urethra

The urethra is the tube that carries urine from the bladder to outside of the body and is about 20 cm. It has the additional function of ejaculating semen when the man reaches orgasm. When the penis is erect during sex, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

Accessory Glands

The male accessory glands are: seminal vesicles, prostate gland and bulbourethral glands.

  • Seminal vesicles: these are located within the pelvis and their function is to secrete a significant proportion of the fluid that ultimately becomes semen
  • Prostate gland: the prostate secretes a slightly alkaline fluid, milky or white in appearance, which normally constitutes around 50-75% of the volume of the semen.
  • Bulbourethral glands: the function of these glands is to produce a clear, salty, viscous secretion (pre-ejaculate) during sexual arousal, to help to lubricate the urethra for spermatozoa to pass through. This fluid neutralises traces of acidic urine in the urethra and helps to remove any residual urine or foreign matter.

What is Semen?

Semen, also known as seminal fluid, is an organic fluid that contains spermatozoa. It contains several components besides spermatozoa: proteolytic and other enzymes as well as fructose are elements of seminal fluid which promote the survival of spermatozoa, and provide a medium through which they can move or “swim”.

What is Sperm?

The term sperm is derived from the Greek word sperma (meaning “seed. sperm develops in the testes and is released from the penis . They are the male reproductive cell that binds and fertilises a womens egg to produce an embryo. It consists of a head, mid-piece and tail. Sperm also carry the X or the Y chromosome that will determine the sex of the resulting child. The tail gives the sperm cell movement and helps it to travel to, and then penetrate the egg. Sperm cells may survive in the female reproductive tract for two to three days.

menstrual cycle

The average length of a menstrual cycle ranges from 25-35 days. It is necessary for the production of eggs and preparation of the uterus for a pregnancy to occur. It occurs monthly from puberty to menopause.

It is divided into two types of cycle i.e. ovarian cycle and uterine cycle and each can be further divided into three phases. The ovarian cycle consists of the follicular phase ,ovulation and the luteal phase while the uterine cycle is divided into menstrual proliferative and secretory phase .These cycles are controlled by the normal hormonal changes .

The ovarian cycle describes changes that occur in the follicles of the ovary and the uterine cycle describes the changes in the endometrial lining of the uterus.

OVARIAN CYCLE-

The Ovarian Cycle consists of the Follicular Phase, Ovulation and Luteal Phase.

Follicular Phase

This is the first part of the ovarian cycle . Under the influence of FSH (follicle stimulating hormone ) the follicles are stimulated which lead to the formation of one dominant follicle .

The follicle that reaches maturity is called a tertiary, or Graafian, follicle, and it contains the ovum

Ovulation

This is the second phase of the cycle in which a mature egg is released from the follicle. Under the influence of rising Oestrogen levels, produced by the maturing follicle, a rapid surge of Luteinising Hormone (LH) is released by the anterior pituitary gland, which triggers Ovulation and causes the dominant mature follicle to release an oocyte. LH surge, occurs 24-36 hours before Ovulation..This occurs between day 12-15 of the average 28 day cycle.

After the oocyte is released from the ovary it is taken up by the fallopian tube . The sperm meets the oocyte and an embryo starts developing in the fallopian tube. The developing embryo may take three to five days to reach the uterus and implant into the endometrium which may result in a pregnancy. If the egg is not fertilised within 12-24 hours of Ovulation, it will dissolve and be absorbed in the fallopian tube.

Luteal Phase

The follicle in the ovary that produced the egg becomes the corpus luteum, which produces the hormone Progesterone and Oestrogen to provide nutrition to the endometrium (lining). If the embryo implants into the endometrium it produces HCG . If there is no fertilisation and implantation the ovary stops producing Progesterone and this fall in hormones causes the uterine lining to shed and a menstrual cycle starts.

UTERINE CYCLE

The Uterine Cycle consists of Menstruation, the Proliferative Phase and the Secretory Phase.

Menstruation

Menstruation is the start of the Uterine Cycle symbolically called the weeping uterus as it has failed to achieve pregnancy.

Proliferative Phase

This is the second phase of the cycle when hormones cause the endometrial lining in the uterus to grow or proliferate. As the ovarian follicles start to mature Oestradiol is released; this causes the formation of a new layer of the endometrium. This coincides with the follicular phase of the ovarian cycle.

Secretory Phase

This corresponds with the Luteal Phase of the Ovarian Cycle. During the Secretory Phase, the follicle that released the egg (corpus luteum) produces the hormone Progesterone, which allows the endometrium to be receptive to implantation of the developing embryo and support early pregnancy.

Fertility window

The fertility window is that phase in a menstrual cycle during which sexual intercourse leads to pregnancy.

  • The most fertile period in the menstrual cycle is that which leads to ovulation.
  • The egg can survive for 24 hrs after ovulation occurs and sperm is able to survive for 2-3 days in the fallopian tubes.
  • You have greater chance of conceiving if you time having intercourse 1 to 3 days before ovulation or every 2 days around ovulation.
  • The cervical mucus changes during the ovulation time it becomes more clear and slippery like egg white.
  • Calculating fertility window

    It is done in a female having regular menstrual cycles . You are supposed to count the number of days from the first day of your last period, to the first day of bleeding in your next one. Subtract 14 days from the end of your current cycle to determine the day you ovulate.

    OVULATION PREDICTION KIT

    These are designed to detect a hormone (luteinizing hormone or LH). A couple days before ovulation, LH levels surge.An OPK will pick up this increase in LH and gives a positive result.Once there is a positive result, ovulation should occur in the next 12 to 36 hours.

    MAINTAIN A FERTILITY CHART

    -A fertility chart by measuring basal body temperature tells whether you have ovulated. ovulation.The drawback with a fertility chart is that you can’t see when ovulation occurred until a few days after you’ve ovulated. record your temperatures daily on a chart, you will see your temperatures shift about .4 degrees after you ovulate.If the shift is sustained for 3 days, you can assume that ovulation has occurred.

    How long Should I Take to Conceive?

    If you have not achieved a pregnancy after 12 months (or six months if you are over 35 years) of unprotected intercourse, you should seek our help.

    Please select the first day of your last menstrual period: / / Usual number of days in your cycle:

    Preconception care

    A healthy lifestyle is very essential prior to you to conceive. Your diet, lifestyle and environment all have a profound bearing on your reproductive health and on the health of the baby. It is that part of the reproductive cycle that is never taken care of – We make sure that there is an adequate supply of all factors essential to the health of sperm, eggs, fertilisation, a healthy pregnancy and including delivery of a healthy baby.

Female fertility enhancement

Weight

Ideal weight is calculated by a formula known as the Body Mass Index (BMI). It is calculated using the following formula: Weight (kg)/Height (m2)

The optimal BMI range for fertility health is between 20-25. A BMI of under 20 is considered underweight and over 25 is considered overweight. A BMI over thirty is considered obese. Fertility decreases with a high as well as low BMI .Women with a high BMI put themselves and their babies at risk of miscarriage and complications during pregnancy, the post partum period and their long term health. 5-10% reduction in weight can make a significant difference to ones fertility .

Diet and Exercise

A healthy balanced diet rich in proteins, fresh fruit and vegetables is recommended. Half an hour of moderate-intensity physical activity is recommended for patients.

Folic Acid

Folic Acid supplementation (0.5 mg daily) three month before conception and for the first three months of pregnancy, can reduce the chance of having a baby with neural tube defects such as Spina Bifida and Anencephaly (a congenital abnormality of the skull and/or brain).

Folic Acid is found in many fruits (particularly oranges, berries and bananas) and leafy green vegetables such as spinach, silverbeet, broccoli, brussel sprouts, cabbage and avocados. It is also found in cereals, legumes and liver.

Immunisation and General Health Screening

Before conception is planned we recommend a few tests

  • Check for HIV, Hepatitis B and C, Syphilis and your Blood group.
  • Determine your immunity to Rubella (German measles) and Varicella (Chickenpox).
  • Hb electrophoresis

Immunisation can help protect an expecting mother from infectious diseases, which can cause birth defect in their unborn child and prevent transmission to their child once the child is born. Following some immunisations it is recommended to wait 28 days before trying to conceive.

Try to undergo a Pap smear test and a breast screening.

Recreational Drugs

These drugs can increase the risk of birth defects and also cause medical problems in the mother.

Stress

Infertility is one of the most stressful events in a couple’s life. women under stress produce prolactin, which can interfere with regular ovulation.It is important to ensure you get adequate rest and relaxation. A positive state of mind improves ones health and chances of a successful pregnancy. A degree of stress in life is inevitable, but to deal with it in a positive way is very important.

Toxins

Avoid toxins and repeated X ray exposure .

Caffeine

Caffeine is present in coffee , tea, some soft drinks, energy drinks, chocolate, some foods and medicines.

It increases the risk of miscarriage, so you should limit your daily consumption to no more than one to two cups of coffee per day.

Smoking

Women who smoke have: increased miscarriage risks, decreased live birth rates and lower birth weight.It negatively affects fertility and it has several long term health risks.

Alcohol

Women who consume alcohol have increased risk of miscarriage . Quitting drinking and smoking is the safest option.

Male fertility enhancement

Smoking

Men who smoke have: reduced sperm count, poor sperm morphology (quality).

Alcohol

In men, studies have shown that as little as one beer per day can affect the sperm and in turn increase the risk of miscarriage and decrease the chance of a live birth, so you should restrict alcohol intake if trying to conceive.

Caffeine

Caffeine can affect sperm motility and morphology (sperm quality); therefore you should limit your daily consumption to no more than one to two cups of coffee per day.

Weight

As with the female, there is a clear relationship between weight and fertility. Men who are significantly overweight may have decreased sperm count and quality.

Diet and Exercise

Diet and exercise play an important role in the production of healthy sperm. A healthy balanced diet rich in lean proteins, fresh fruit and vegetables is recommended.

Exercise is good for the body and it should be included in your life style changes.

What to avoid

Because of overheating, sperm quality can be affected. The testes are outside the body to keep them cooler for a reason. Avoid hot spas, saunas, tight jeans or even sitting with your laptop on your lap.

Vitamin Supplements

Zinc deficiency can reduce testosterone levels and semen production. Taking a supplement can improve DNA quality.

We give supplements with antioxidants and zinc. These can be given three months prior to conception.

Recreational Drugs

Marijuana and anabolic steroids can affect sperm counts and sperm quality. It is not advisable to use any form of recreational drugs when trying to conceive or after conception

Ejaculation Frequency

There is a common misconception that if you ‘save it up’ and don’t ejaculate until ovulation then you will have more sperm and achieve fertilisation. This is definitely not the case. If you ‘save it up’ the sperm becomes sluggish and tend to have more chance of DNA damage. You need to ejaculate regularly to keep the sperm healthy and motile.

Stress

Studies have shown that the semen quality declines during period of stress. Find ways to lower your stress levels,

Toxins

We are faced with a myriad of environmental toxins on a daily basis. If you work with paints, diesel fumes or pesticides to name a few, you need to be using protective equipment.

Pollution can cause DNA damage to sperm. Take all safety measures possible whilst using them

Couple

Try to be positive and make lifestyle changes together.

Body Changes in pregnancy

A woman’s body undergoes many changes during the first 12 weeks of pregnancy .Sometimes, early signs of pregnancy can be confusing. This is because many of the early physical signs of pregnancy (swollen tender breasts, feeling tired, cramping and/or pelvic pain, feeling bloated), can be similar to normal pre-menstrual signs. It can be even more confusing in the early days if there is an ‘implantation bleed’ and/or light bleeds or ‘spotting’ during the first few weeks. These are often mistaken for normal periods or abortion.

It is common to feel unsure about what is ‘normal’ during early pregnancy and anything that feels unfamiliar can often cause concern about your health or the baby’s. Some women also become concerned if they don’t experience any of the ‘typical’ pregnancy signs and symptoms like morning sickness and feeling overly tired. Not feeling these things can also be very normal. Every woman’s body will react differently to being pregnant.

Exercise during pregnancy

Being pregnant can be both mentally and physically demanding. Regular exercise can help cope with these demands .Exercise is also great for relieving stress.

Maintaining a healthy level of fitness is all part of staying well during pregnancy and will also help to keep control of your weight gain. It can also help improve your general mood and self-image, along with assisting in the prevention of some pregnancy conditions like preeclampsia and gestational diabetes. If you have difficulty sleeping at night, you may also find that a workout during the day helps you sleep better.

The benefits of exercising throughout your pregnancy will continue after your baby is born, making it easier for you to get back into shape.

The best types of exercise during pregnancy is as long as you don’t overdo it, walking, jogging are all considered good, safe forms of exercise. Yoga is also very good but from a trained person.

Diet during pregnancy

Pregnancy Eating

  • Eat vegetables every day; mix the colours – you get lots of vitamins that way.
  • Choose water as a drink.

Eat healthy food and vegetable and fruits as much as you can .It is the best way to increase intake of minerals and vitamins. Take more of water in the diet .

Foods to Avoid During Pregnancy

There are some foods not to eat during pregnancy as they can potentially cause problems during pregnancy and for the child:

  • Foods that may contain a bacteria called Listeria: soft cheeses, uncooked desi style meats, sushi and unpasteurised milk and milk products.
  • Foods that are high in mercury: raw and predatory fish (shark, barramundi, swordfish) are high in mercury and should be avoided.
  • Salmon is a good alternative as it is relatively low in mercury.
  • Alcohol and caffeine should be avoided.

Trouble becoming pregnant

Infertility is the inability to conceive after one year of unprotected intercourse in a couple less than 30 yrs of age . If the couple is more than 35 yrs (female) then they should seek help after six months of unprotected intercourse.

Infertility is primary as well as secondary . In primary infertility a couple has never conceived before but in a case of secondary infertility couple has conceived before but is unable to conceive now.

Couples have to understand that even if they are doing everything right to conceive a baby still they might not become pregnant . If you are not becoming pregnant ,you are not alone in this ordeal, almost 1 out of every 6 couples experience this problem .There are many causes for it.

Some fertility facts:

  • In six months, only 60% of fertile people conceive.
  • By 12 months, 80% of fertile people will have conceived.
  • By two years, 95% of people (female aged less than 38) will have conceived.
  • Once a woman is over 35 years, her chances of becoming pregnant reduce significantly

Myths and facts about infertility

  1. Just relax. Infertility is a psychological problem that’s all in your head.
  2. Psychological problems ARE NOT a major cause of infertility. Maybe your friends or family members have told you to stop trying so hard and simply “relax.” Although stress has been shown to contribute to infertility in some cases, it’s more likely that infertility is causing anxiety, depression, and sexual problems than the other way around.

  3. Infertility is primarily a female problem.
  4. Infertility is no longer regarded as “her” problem. In fact, approximately 40 percent of cases of infertility are due to problems that occur in the man. Another 40 percent are due to problems that occur in the woman. In approximately 20 percent of all infertile couples, both partners have physical problems contributing to their infertility. Modern infertility treatment focuses on the couple as a unit, recognizing they are a team who will work together to resolve this problem.

  5. Adoption increases the chances of becoming pregnant.
  6. Almost every couple that has had difficulty becoming pregnant probably has heard the story about someone who became pregnant shortly after adopting. This myth is an offshoot of the “just relax” myth, assuming that adoption relieves the anxiety and stress that presumably were causing the infertility. In fact, infertile couples who adopt are no more likely to become pregnant than couples who do not: Though adoption is a wonderful way to build your family, no one should adopt because they think they will get pregnant naturally because of it.

  7. It’s not complicated. Getting pregnant is simple and easy.
  8. For any given month, the pregnancy rate for couples without infertility issues is around 20% per month. For subfertile and infertile couples the rate drops even lower. It may seem even more complicated for the couple who is having difficulty conceiving because it becomes compounded by feelings of anxiety and frustration. But infertility treatments, from the simple to the most advanced, provide hope by dramatically increasing pregnancy rates, pushing them well beyond the normal rate per month.

  9. ‘I don’t have to worry about my eggs until I’m 40.’
  10. At birth, a woman has 7 million eggs, which slims down to 400,000 at the onset of puberty. During a woman’s lifetime, approximately 400 to 500 eggs will be released. As a woman ages, the ovarian reserve declines. A woman’s egg supply takes a rapid decline in the late 20s, again in the 30s and then most notably after age 35.

  11. ‘I do yoga and exercise. I’m in great shape. Age won’t affect my fertility.’
  12. A healthy body and mind can boost fertility, but it cannot reverse the age of ovaries and semen. For both men and women, age is a critical component of fertility potential.

  13. ‘I know we could stand to lose weight, but …’
  14. When men or women carry extra weight, hormonal shifts occur in the body that can affect ovulation and semen production. The great news is that couples can team up to lose weight, become active together and boost their fertility.

    Although it is estimated that 70% of women with infertility are also obese, losing as little as 5% to 10% of body weight can boost fertility in men and women.

  15. ‘Only women need to take supplements before a pregnancy.’
  16. It has long been known that women should take folic acid to prevent certain birth defects, but folic acid is now known to be an important supplement in male fertility.

    Researchers at the University of California, Berkeley found that men had a higher rate of chromosomal abnormalities in their sperm when their diet was low in folic acid. Coenzyme Q10 has also been found to increase sperm count and sperm motility, and vitamin E also improves low sperm count.

  17. ‘STDs affect my health, but they don’t affect trying to have a baby.’
  18. For both men and women, sexually transmitted diseases can affect the ability to have children. STDs can cause scarring and blockage of the male reproductive structures. If STDs go untreated in women, they can lead to an episode of pelvic inflammatory disease, which is a leading cause of infertility.

  19. ‘It doesn’t matter how much coffee I drink.’
  20. One study found that “women who consumed more than the equivalent of one cup of coffee per day were half as likely to become pregnant, per cycle, as women who drank less.”

    Caffeine can decrease fertility, so be sure to limit intake. It’s better to opt for decaffeinated or half-caffeinated coffee, and remember there is caffeine in tea, colas and chocolate.

Factors contributing to infertility

Age

Conception rates for normal healthy couples are, at best, 20-25% per menstrual cycle. Once a woman reaches the age of 35, her fertility begins to decline. By age 40, it is estimated that her conception rate is in the range of 8-10% per month and at age 43, the pregnancy rate is thought to be as low as 1-3% per month.

Why Does Fertility Decline With Increasing Age?

Ageing of the ovaries is the most prominent factor and is part of the normal ageing changes that affect all organs and tissues.

Most women have about 300,000 eggs in their ovaries at puberty. For each egg that matures and is released (ovulated) during the menstrual cycle, at least 500 eggs do not mature and are absorbed by the body. As the woman ages, the remaining eggs in her ovaries also age, making them less capable of fertilisation and their embryos less capable of implanting.

Ageing does not just affect women, but also men to a much lesser degree. It affects sperm and coital frequency. There is no maximum age at which men are not capable of conceiving a child.

Irregular Menstrual Cycles

The average length of the menstrual cycle is 28 days, but can range between 25-35 days. The length of the menstrual cycle is calculated from the first day of the period to the day before the period starts.

The female menstrual cycle is determined by a complex interaction of hormones, so any hormone imbalance can make your period irregular. Although, in most cases, irregular cycles are not dangerous, it is important to determine what is causing the irregularity. Irregular periods can indicate that ovulation isn’t taking place every month.

Women with irregular cycles, suggesting a problem with ovulation, should consider evaluation and treatment as soon as this problem is identified.

Lifestyle and fertility

You may be surprised to learn that your diet, lifestyle and environment all have a profound bearing on your individual reproductive health. There are a number of things that you can do to maximise your chances of conception and encourage a healthy pregnancy.

Common causes of infertility in females

For pregnancy to occur, every part of the complex human reproduction process has to take place just right. The steps in this process are as follows:

  • One of the two ovaries releases a mature egg.
  • The egg is picked up by the fallopian tube.
  • Sperm swim up the cervix, through the uterus and into the fallopian tube to reach the egg for fertilization.
  • The fertilized egg travels down the fallopian tube to the uterus.
  • The fertilized egg implants and grows in the uterus.

In women, a number of factors can disrupt this process at any step. Female infertility is caused by one or more of these factors.

Ovulation disorders

Ovulation disorders, meaning you ovulate infrequently or not at all, account for infertility in about 25 percent of infertile couples. These can be caused by flaws in the regulation of reproductive hormones by the hypothalamus or the pituitary gland, or by problems in the ovary itself.

  • Polycystic ovary syndrome (PCOS):In PCOS, complex changes occur in the hypothalamus, pituitary gland and ovaries, resulting in a hormone imbalance, which affects ovulation. PCOS is associated with insulin resistance and obesity, abnormal hair growth on the face or body, and acne. It’s the most common cause of female infertility.
  • Hypothalamic dysfunction:The two hormones responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are produced by the pituitary gland in a specific pattern during the menstrual cycle. Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt this pattern and affect ovulation. The main sign of this problem is irregular or absent periods.
  • Premature ovarian insufficiency:This disorder is usually caused by an autoimmune response where your body mistakenly attacks ovarian tissues or by premature loss of eggs from your ovary due to genetic problems or environmental insults such as chemotherapy. It results in the loss of the ability to produce eggs by the ovary, as well as a decreased estrogen production under the age of 40.
  • Too much prolactin:Less commonly, the pituitary gland can cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility. Most commonly this is due to a problem in the pituitary gland, but it can also be related to medications you’re taking for another disease.

Damage to fallopian tubes (tubal infertility)

When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or block the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include:

  • Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea or other sexually transmitted infections
  • Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of the uterus
  • Pelvic tuberculosis, a major cause of tubal infertility worldwide, although uncommon in the United States

Endometriosis

Endometriosis occurs when tissue that normally grows in the uterus implants and grows in other locations. This extra tissue growth — and the surgical removal of it — can cause scarring, which may obstruct the tube and keep the egg and sperm from uniting. It can also affect the lining of the uterus, disrupting implantation of the fertilized egg. The condition also seems to affect fertility in less-direct ways, such as damage to the sperm or egg.

Uterine or cervical causes

Several uterine or cervical causes can impact fertility by interfering with implantation or increasing the likelihood of a miscarriage.

  • Benign polyps or tumors (fibroids or myomas) are common in the uterus, and some types can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids or polyps can become pregnant.
  • Endometriosis scarring or inflammation within the uterus can disrupt implantation.
  • Uterine abnormalities present from birth, such as an abnormally shaped uterus, can cause problems becoming or remaining pregnant.
  • Cervical stenosis, a cervical narrowing, can be caused by an inherited malformation or damage to the cervix.

  • Sometimes the cervix can’t produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.
  • Unexplained infertility In some instances, a cause for infertility is never found. It’s possible that a combination of several minor factors in both partners underlie these unexplained fertility problems. Although it’s frustrating to not get a specific answer, this problem may correct itself with time.

Common causes of infertility in males

Male fertility is a complex process. To get your partner pregnant, the following must occur:

  • You must produce healthy sperm.Initially, this involves the growth and formation of the male reproductive organs during puberty. At least one of your testicles must be functioning correctly, and your body must produce testosterone and other hormones to trigger and maintain sperm production.
  • Sperm have to be carried into the semen.Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated out of the penis.
  • There needs to be enough sperm in the semen.If the number of sperm in your semen (sperm count) is low, it decreases the odds that one of your sperm will fertilize your partner’s egg. A low sperm count is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
  • Sperm must be functional and able to move.If the movement (motility) or function of your sperm is abnormal, the sperm may not be able to reach or penetrate your partner’s egg.

Medical causes

Problems with male fertility can be caused by a number of health issues and medical treatments. Some of these include:

  • Varicocele:A varicocele is a swelling of the veins that drain the testicle. It’s the most common reversible cause of male infertility. This may prevent normal cooling of the testicle, leading to reduced sperm count and fewer moving sperm. Treating the varicocele can improve sperm numbers and function, and may potentially improve outcomes when using assisted reproductive techniques such as in vitro fertilization.
  • Infection:Some infections can interfere with sperm production or sperm health, or can cause scarring that blocks the passage of sperm. These include some sexually transmitted infections, including chlamydia and gonorrhea; inflammation of the prostate (prostatitis); and inflamed testicles due to mumps (mumps orchitis). Although some infections can result in permanent testicular damage, most often sperm can still be retrieved.
  • Ejaculation issues:Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra. Some men with spinal cord injuries or certain diseases can’t ejaculate semen, even though they still produce sperm. Often in these cases sperm can still be retrieved for use in assisted reproductive techniques. Antibodies that attack sperm.Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to eliminate them.
  • Tumors:Cancers and nonmalignant tumors can affect the male reproductive organs directly or can affect the glands that release hormones related to reproduction, such as the pituitary gland. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.
  • Undescended testicles:In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
  • Hormone imbalances:Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.
  • Sperm duct defects:The tubes that carry sperm (sperm ducts) can be damaged by illness or injury. Some men experience blockage in the part of the testicle that stores sperm (epididymis) or a blockage of one or both of the tubes that carry sperm out of the testicles. Men with cystic fibrosis and some other inherited conditions may be born without sperm ducts altogether.
  • Chromosome defects:Inherited disorders such as Klinefelter’s syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann’s syndrome and Kartagener syndrome.
  • Problems with sexual intercourse:These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.
  • Certain medications:Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), certain antifungal medications, some ulcer drugs and certain other medications can impair sperm production and decrease male fertility.
  • Prior surgeries Certain surgeries may prevent you from having sperm in your ejaculate, including vasectomy, inguinal hernia repairs, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers, among others. In most cases, surgery can be performed to either reverse these blockage or to retrieve sperm directly from the epididymis and testicles.

Environmental causes

Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm production or sperm function. Specific causes include:

  • Industrial chemicals:Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead may contribute to low sperm counts.
  • Heavy metal exposure:Exposure to lead or other heavy metals also may cause infertility.
  • Radiation or X-rays:Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.
  • Overheating the testicles:Frequent use of saunas or hot tubs may temporarily lower your sperm count. Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and slightly reduce sperm production. The type of underwear you wear is unlikely to make a significant difference in male fertility.

Health, lifestyle and other causes

  • Illegal drug use:Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.
  • Alcohol use:Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.
  • Occupation:Certain occupations can increase your risk of infertility, including those associated with extended use of computers or video display monitors, shift work, and work-related stress.
  • Tobacco smoking:Men who smoke may have a lower sperm count than do those who don’t smoke. Secondhand smoke also may affect male fertility.
  • Emotional stress:Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, including problems with fertility, can affect your sperm count.
  • Weight:Obesity can cause hormone changes that reduce male fertility.
  • Prolonged bicycling:Prolonged bicycling is another possible cause of reduced fertility due to overheating the testicles. In some cases, bicycle seat pressure on the area behind the testicles (perineum) can cause numbness in the penis and erectile dysfunction.

It can be heartbreaking to miscarry one baby after another. Each new pregnancy brings both hope and anxiety. And each new loss may be harder to bear, especially if you feel that time is running out. The experience can place great strain on even the strongest relationships. You and your partner might react differently from each other and that can cause great tension. Family and friends may find it harder to support you with each miscarriage; they may even think you’re getting used to loss and able to cope. And all the time there may be a sense that your life is on hold while you try – and try again – for a baby.

What is recurrent miscarriage

Recurrent miscarriage means having three or more miscarriages in a row. It affects about one in every hundred couples trying for a baby. Sometimes a treatable cause can be found, and sometimes not. But in either case, most couples are more likely to have a successful pregnancy next time than to miscarry again.

Testing after recurrent miscarriage

If you have had three miscarriages in a row, you should be offered tests to try to find the cause. This should happen whether or not you already have one or more children. Testing is not usually offered after one or two early miscarriages (up to 14 weeks) because these are often due to chance. But you might be offered tests after two early miscarriages if you are in your late 30s or 40s or if it has taken you a long time to conceive. If you had a late (second trimester) miscarriage, where your baby died after 14 weeks of pregnancy, you should be offered tests after this loss.

Why recurrent miscarriage happens

Your risk of recurrent miscarriage is higher if:

  • you and your partner are older: the risk is highest if you are over 35 and your partner over 40;
  • you are very overweight: Being very underweight may also increase your risk. Each new pregnancy loss increases the risk of a further miscarriage. But even after three miscarriages, most couples will have a live baby next time

Known causes

  • Antiphospholipid syndrome (APS) This blood clotting problem is the most important treatable cause of recurrent miscarriage. It happens when your immune system makes abnormal antibodies that attack fats called phospholipids in your blood. This makes the blood more ‘sticky’ and likely to clot, which is whyAPS is sometimes called ‘sticky blood syndrome’. It is also known as ‘Hughes syndrome’ after the expert who named it. It is not clear why these antibodies cause miscarriage. They may stop the pregnancy embedding properly in the uterus (womb);or they may interfere with blood flow to the placenta, which supports the baby.
  • APS can also lead to problems in later pregnancy, including the baby not growing enough, pre-eclampsia or stillbirth. Other blood clotting problems Some inherited blood clotting disorders can cause recurrent miscarriage, particularly after 14 weeks. These include factorV Leiden, factor II (prothromobin), gene mutation and protein S deficiency

  • Abnormal chromosomes The chromosomes in every cell of your body carry hereditary information in the form of genes.
  • Everyone has 23 pairs of chromosomes, and 22 of these are the same in men and women. The 23rd pair are different because they determine gender. Men normally have one X and oneY chromosome and women two X chromosomes. A baby inherits half its chromosomes from each parent. About half of all miscarriages happen because the baby’s chromosomes are abnormal. This is not usually an inherited problem: it happens when the egg and sperm meet or soon after the egg is fertilised. The older you are the more likely this is to happen. Much less commonly (in less than five in one hundred couples with recurrent miscarriage), one partner carries a chromosomal defect called a ‘balanced translocation’. This doesn’t cause a problem for the parent, but it can be passed on to the baby as an ‘unbalanced translocation’.

    This means that some genetic information is duplicated and some is missing.

  • Cervical weakness (also known as ‘incompetent cervix’) Some women – probably less than one in a hundred – have a weakness in the cervix that allows it to dilate too early.
  • This is a known cause of late (second trimester) miscarriage.

Possible causes

  • Abnormally-shaped: uterus Some miscarriages, particularly late ones, are thought to happen because the uterus (womb) has an abnormal shape.
  • It may be divided down the centre – known as ‘bicornuate’ or ‘septate’ uterus; or just one half of the uterus may have developed – known as ‘unicornuate’ uterus. It is not clear from research how many women with recurrent miscarriage have these abnormalities. Also we don’t know how common these problems are in women who don’t miscarry. This makes it impossible to be sure that they cause miscarriage

  • Polycystic ovary syndrome (PCOS): Women with this condition have many small cysts in their varies. They also tend to have hormonal problems, including high levels of insulin and male hormone in the blood. It is these problems that are thought to play a part in recurrent miscarriage, but it is not clear how.
  • Infection: Some serious infections can cause or increase the risk of single miscarriages. These include toxoplasmosis, rubella, listeria and genital infection. But it is not clear whether infection plays a role in recurrent miscarriage.
  • Immune: problems Raised levels of uterine NK (uNK) cells may increase the risk of recurrent miscarriage, but more research is needed to prove this. It’s important to know that these uNK cells are different from the NK cells found in general circulating blood (e.g. from your arm). Diabetes and thyroid problems Uncontrolled diabetes and untreated thyroid problems can cause miscarriage. But well-controlled diabetes and treated thyroid problems do not cause recurrent miscarriage
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