INFERTILITY

INTRODUCTION
Infertility is the inability to conceive even after trying with unprotected
intercourse for a period of one year for couples in which the women is under 35 years and six
months trying for couples in which the women is over 35 years of age. Infertility commonly
results due to the disease of reproductive system, in either a male or a female, which inhibit
the ability to conceive and deliver a child
DEFINITION
Infertility is defined as a failure to conceive within one or more years of regular unprotected
coitus.
TYPES
 Primary infertility
 Secondary infertility
Primary infertility: Primary infertility is a term used to describe a couple that has never been
able to conceive a pregnancy after a minimum of 1 year of attempting to do so through
unprotected intercourse. Causes of infertility include a wide range of physical as well as
emotional factors.

Secondary infertility: Secondary infertility is the inability to become pregnant or to carry a

baby to term after previously giving birth to a baby. Secondary infertility shares many of the
same causes of primary infertility.

Among the possible causes of secondary infertility are:

 Impaired sperm production, function or delivery in men

 Fallopian tube damage, ovulation disorders, endometriosis and uterine conditions in
women
 Complications related to prior pregnancy or surgery
 Risk factor are age, weight and use of certain medications

FACTORS ESSENTIAL FOR CONCEPTION

 Healthy spermatozoa should be deposited high in vagina at or near the vagina
 The spermatozoa should undergo changes
 The motile spermatozoa should ascend through the cervix in to the uterine cavity and
fallopian tube.
 There should be a ovulation(ovarian factors)
 The fallopian tubes should be patent and the oocyte should be picked by the
fimbriated end of the tube (tubular factor)
 The spermatozoa should fertilize the oocyte at the ampulla of the tube
CAUSES OF INFERTILITY
Many physical and emotional factors can cause infertility. It may be due to
problems in the woman, man, or both. the male is directly responcible in about 30-40%,the
female is about40-50% and both are responsible in about 10% of cases.

MALE INFERTILITY:

 Defective spermatogenesis
 Obstruction of the efferent duct system
 Failure to deposit sperm high in vagina
 Errors in seminal fluids.

Defective spermatogenesis:

Follicle stimulating hormone (fsh) stimulate spermatogensis from basal cells of the
seminferous tubules. Sertoli cells envelope the germ cells and support spermatogensis. sertoli
cell function is controlled by fsh and testosterone.scrotal temperature should be 1-2 of less
than the body temperature.lh is required for the systhesis of testosterone from the leydig cells.
Fsh is also stiumlates the sertoli cells to produce androgen binding proteins (abp) and inhibin
b. Abp bind testosterone and dihydrotestosterone to maintain local high concenteration of
androgen spermatogenesis and sperm maturation need a high adrogenic secretion.
Approximately 74 days are required to complete process of spermatogensis

CAUSES OF MALE FERTILITY

 Congenital
 Undescended testes: the hormone secretion ren=main unaffected but the
spermatogensis is depressed
 Kartagener syndrome: (autosomal disease) there is loss of ciliary functions and sperm
motility
 Hypospodias : causes failure to deposit sperm high in vagina
 Thermal factor
The scrotal temperature is raised in condition such as vercocele. Vercocele probably
interfere with the cooling mechanism
 Infection
 Mumps orchitis after puberty may permanently damage spermatogenesis
 General factors
 Chronic depleting disease Malnutrition smoking reduce spermatogensis
 Alcohol inhibit spermatogenesis
 Endocrine
 Testicular failure due to gonnadotropin deficiency(kallmann’s syndrome)
 Hyperprolactinemia is assosated with impotence
 FSH level is raised in idiopathic testicular failure with germ cell hypoplasia (sertoli-
cell-only-syndrome)
 Geneticgene :deletion have been detected in the long term of y chromosome for
patientswith severe oligospermia and azoospermia
 Latrogenic: radiation, cytotoxic drugs, anti hypertensive, anti convulsant and anti
depressant drugs are likelyto hinder spermatogenesis
 Immunological factors: antigens may cause infertility. this results in clumbing of
spermatozoa after ejaculation

Obstruction of the efferent ducts:

Efferent duct may be obstructed by infection like tubercular, gonococcal or surgical truma
following vasectomy.

Failure to deposite sperm high in the vagina(coital problem):

 Erectile dysfunction
 Ejaculatory defect(premature, retrograde or absence of ejaculation)
 Hypospadias

Errors in the seminal fluid:

 Unusually high or low volume of ejaculate

 Lowfructose content
 High prostaglandin content
 Undue viscosity

Female infertility

 Ovulatory disfunction
 Tubal diseases
 Uterine factors
 Cervical factors
 Pelvic endometriosis

Ovulatory disfunction:
 Anovulation or oligo-ovulation
 Decrased ovarian reserve
 Luteal phase defect(lpd)
 Luteinized unruptured follicle

Tubal factors:

Pelvic infections causing peritubal adhesions, endos alphangeal damage, salphingitis

isthmica nodosa, tubal enometriosis etc.
 Uterine factors:

The endometrium must besufficently receptive enough for effective nidation and growth
of the fertilized ovum. The possible factors

DIAGNOSTIC PROCEDURE FOR INFERTILITY

Many infertile couples have more than one cause of infertility, so it's likely you will both
need to see a doctor. It might take a number of tests to determine the cause of infertility. In
some cases, a cause is never identified.

Infertility tests can be expensive and might not be covered by insurance — find out what your
medical plan covers ahead of time.

DIAGNOSING MALE INFERTILITY PROBLEMS USUALLY INVOLVES:

 General physical examination and medical history. This includes examining

genitals and asking questions about any inherited conditions, chronic health problems,
illnesses, injuries or surgeries that could affect fertility.

 Semen analysis. Semen samples can be obtained in a couple of different ways. You

can provide a sample by masturbating and ejaculating into a special container.
Because of religious or cultural beliefs, some men prefer an alternative method of
semen collection. In such cases, semen can be collected by using a special condom
during intercourse. semen is then sent to a laboratory to measure the number of sperm
present and look for any abnormalities in the shape (morphology) and movement
(motility) of the sperm. The lab will also check semen for signs of problems such as
infections.

Often sperm counts fluctuate significantly from one specimen to the next. In most
cases, several semen analysis tests are done over a period of time to ensure accurate
results. If your sperm analysis is normal, recommend thorough testing of your female
partner before conducting any more male infertility tests.

might recommend additional tests to help identify the cause of infertility. These can include:
  Scrotal ultrasound. This test uses high-frequency sound waves to produce images
inside your body. A scrotal ultrasound can help to see if there is a varicocele or other
problems in the testicles and supporting structures.

 Hormone testing. Hormones produced by the pituitary gland, hypothalamus and

testicles play a key role in sexual development and sperm production. Abnormalities
in other hormonal or organ systems also might contribute to infertility. A blood test
measures the level of testosterone and other hormones.

 Post-ejaculation urinalysis. Sperm in your urine can indicate your sperm are

traveling backward into the bladder instead of out your penis during ejaculation
(retrograde ejaculation).

 Genetic tests. When sperm concentration is extremely low, there could be a genetic

cause. A blood test can reveal whether there are subtle changes in the Y chromosome
— signs of a genetic abnormality. Genetic testing might be ordered to diagnose
various congenital or inherited syndromes.

 Testicular biopsy. This test involves removing samples from the testicle with a
needle. If the results of the testicular biopsy show that sperm production is normal,
your problem is likely caused by a blockage or another problem with sperm transport.

 Specialized sperm function tests. A number of tests can be used to check how well
your sperm survive after ejaculation, how well they can penetrate an egg and whether
there's any problem attaching to the egg. Generally, these tests are rarely performed
and often do not significantly change recommendations for treatment.

 Transrectal ultrasound. A small, lubricated wand is inserted into your rectum. It

allows your doctor to check your prostate and look for blockages of the tubes that
carry semen (ejaculatory ducts and seminal vesicles).

INFERTILITY DIAGNOSTIC PROCEDURE FOR FEMALES

There are a number of diagnostic tools available to help pinpoint the cause of infertility. After
a couple has undergone evaluation through a comprehensive physical exam and medical
history, a fertility doctor will recommend specific diagnostic tests.

To diagnose infertility, doctors generally check the following areas: the female hormone
system and ovarian reserve, the female pelvis, the vagina and cervix, and the semen.

Endocrine System Tests

The endocrine system includes all the hormone-producing glands in the body that regulate the
body’s growth, metabolism and sexual development. Sometimes infertility is due to problems
in the endocrine system, and the fertility specialist may perform various tests, which include:

1) Basal Body Temperature Charting (BBT)

BBT charts help predict the time of ovulation. They can also indicate whether or not there are
problems with ovulation. Higher levels of progesterone cause the body temperature to
increase slightly (about 0.5F to 1F). To create a BBT chart, a woman must record her
temperature every morning before getting out of bed.

 A normal BBT includes a slight increase in temperature between days 10 through 21

of the ovulation cycle.
 BBT that shows a relatively constant temperature indicates an absence of ovulation.

There are many tests that help identify the timing of ovulation, such as Ovulation Predictor
Kits (OPK) which are usually Urinary Luteinizing Hormone (uLH) tests. As a result, BBT
charts are much less commonly used today than OPKs.

2) Endometrial Biopsy

A specialist takes a sample of the cells lining the uterus (endometrium) after ovulation
occurs. They then test the sample to look for signs of inflammation, changes in the
endometrium (due to ovulation), and a change in hormones. This test is usually performed
about 7 to 12 days after ovulation. Today, this procedure is much less commonly performed,
because it has limited ability to help with infertility diagnosis and treatment.

3) Testing for Luteinizing Hormone

Ovulation Predictor Kits (OPKs) detect the ovulation-triggering hormone, lutenizing

hormone (LH), in the urine. Levels of LH reflect the presence or absence of ovulation. It can
help a specialist time diagnostic procedures and inseminations and intercourse. OPKs are
generally effective about 90% or more of the time.

4) Ultrasonography

Ultrasonography uses sound waves to image and closely examine the uterus, ovaries,
endometrium and ovarian follicles. The imaging test can be performed via the woman’s
abdomen or vagina. The specialist can also use ultrasonography to look for signs of
ovulation, which include:

 Smaller follicle size

 Loss of clear follicles
 Fluid in the follicle sac
 Sufficient thickness of the endometrium

The presence of multiple small follicles may be signs of polycystic ovarian disease.
5) Testing the Health of the Ovaries

Fertility doctors may use a combination of the following tests to check the health of a
woman’s ovaries and the ‘supply’ of eggs (ovarian reserve):

 Follicle Stimulating Hormone (FSH) test, a hormone made inside the pituitary gland.
Levels of FSH increase as the number of eggs decreases. Thus, FSH levels increases
with age. Levels are checked between days 2 and 4 of the woman’s menstrual cycle.
FSH levels below the range 10 IU/L are considered normal. FSH levels above 15
IU/L are linked with lower pregnancy rates.
 Estradiol test, a hormone produced by the ovary. Levels are checked between days 2
and 4 of the woman’s menstrual cycle. Levels less than 85picograms/mL is
considered healthy. While higher levels can indicate problems in ovulation, many
women with a slightly abnormal result will still be able to get pregnant.
 Anti-Mullerian Hormone (AMH) test, which is made inside the follicles, can be tested
at any time in the menstrual cycle. AMH levels decrease with age since the number of
follicles decrease. Levels above 0.9 nanograms/mL is generally considered normal.
 Clomiphene Citrate Challenge Test (CCCT): A more sensitive test in which the doctor
checks both FSH and estradiol levels between days 2 and 4 of the menstrual cycle.
Between days 5 and 9, the woman is then given a 100mg dose of the fertility drug,
clomiphene citrate. FSH levels are also checked, which should be below 10mIU/mL.
The CCCT is more sensitive in picking up decreased ovarian reserve than only testing
for FSH and estradiol levels alone. It is only indicated in a few patients.
 Ultrasound to determine the number of antral follicles (small follicles) in the ovaries
and help diagnose decreased ovarian reserve (DOR). Usually, a woman shows signs
of DOR if she has less than 8 antral follicles and the ovaries are less than 3ml in
volume.

It is important to remember that even women who experience a slightly abnormal result will
often still be able to get pregnant.

When is Ovarian Testing Performed?

These tests are usually performed if a woman is about 33 years of age or older, or if she has
other risk factors, such as:

 a cigarette smoker
 family history of early menopause
 ovarian or extensive pelvic surgery
 signs of premature ovarian failure
 recurrent pregnancy loss

6) Laparoscopy

Laparoscopy is a surgical procedure that uses a thin, lighted tube (a laparoscope) to see and
closely examine the uterus, fallopian tubes, ovaries and pelvic surfaces. A common sign of
ovulation is the appearance of follicular cysts, which are non-harmful, fluid-filled sacs that
appear on the ovaries. Follicular cysts suggest that ovulation is occurring. Laparoscopy can
be very helpful in diagnosing infertility in women.
7) Other Female Endocrinology Tests

Testing the levels of other endocrine hormones can help indicate the causes of infertility.
These may include checking the levels of:

 Thyroid Stimulating Hormone, to help determine diseases of the thyroid gland

 Serum Prolactin (PRL), a hormone normally produced in large amounts during
pregnancy but which can interfere with normal ovulation in a woman who is not
pregnant
 Androgen hormones, particularly testosterone, which can help detect polycystic
ovarian disease, a disorder in which the ovaries become enlarged and contain
numerous cysts

Tests for Pelvic Disorders

Your fertility doctor may suspect a problem within the pelvis or the tissue that lines the
abdomen, uterus, bladder and rectum (peritoneum). One or more of the following diagnostic
tests are likely to be used:

1) Ultrasonography and Sonohysterography

Ultrasonography is an ultrasound-based imaging technique that helps doctors visualize the

structure of organs. It is useful in detecting abnormalities in the pelvic region often associated
with infertility. For example, ultrasonography can diagnose a condition called
hydrosalpinges, in which the fallopian tubes are blocked by scarring (often due to previous
pelvic infection). Problems in the pelvis and ovaries can also be detected using a similar
technique called sonohysterography, which is a special ultrasound technique to check the
inside of the uterus for abnormalities such as scar tissue, fibroids or polyps (growths attached
to the inner wall of the uterus).

2) Hysterosalpingogram

Hysterosalpingogram is a radiology procedure that examines the health of the uterus and
fallopian tubes. A radio-opaque fluid is injected into the uterus and fallopian tubes and
photographed via x-rays to check the shape of the uterus for fibroids, and scar tissue, and
whether the tubes are blocked. It is relatively safe, simple, inexpensive and reliable test. It
can cause cramping in some women.

3) Hysteroscopy

Hysteroscopy is a minimally invasive procedure in which a fiberoptic ‘telescope’ is passed

through the vagina into the uterus to examine and check for abnormalities. It can be used to
find polyps, fibroids, scar tissue or other abnormalities inside the uterus.
4) Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging is an imaging technique that uses a magnetic field and radio
waves to develop pictures of organs inside the body. MRIs can be helpful in some situations,
such as identifying lesions or rare abnormalities inside the pelvis and uterus.

5) Laparoscopy

Laparoscopy is an out-patient surgical procedure that uses a thin, lighted tube (a

laparoscope). It can also be used to look for abnormalities inside the pelvis. It is generally
accurate in diagnosing infertility. It can be used to treat problems that cause infertility such as
scar tissue, endometriosis, ovarian cysts, fibroids and endometriosis, a condition in which
uterine lining tissue grows outside the uterus.

Tests Related to the Cervix

Very occasionally infertility in women is related to difficulty the sperm  has getting from the
vagina to the inside of the uterus and fallopian tubes. This can occur because the woman’s
cervical mucus (which is a sticky fluid made by the endocervical canal that connects the
vagina to the inside of the uterus) may not function normally as a result of surgery or other
problem, or that not enough sperm are deposited at the cervix by intercourse at the right time
to get pregnant. To determine if there is a problem with the cervical factor as this is called, a
fertility doctor may run the following procedures or tests:

1) History of Sexual Intercourse

Your fertility specialist will talk to you about your sexual history with your partner.
Questions such as the frequency and timing of intercourse are critical. Intercourse should
occur every 1.5 to 2.5 days, starting about 3 to 4 days before expected ovulation. Additional
factors such as the type of lubricants that can interfere with sperm, ejaculatory problems and
other issues that can affect the delivery of sperm to the cervix at the right time will be
explored. This sexual history will also look carefully at your medical history, including:
abnormal Pap smears, cervical or vaginal operations, and other surgeries. The lack of high
quality mucus can mean the cervix has problems producing mucus or it may reflect poor
timing (of sexual intercourse). Prior surgery of the cervix can also affect cervical mucus
production.

2) Tests for Sexually Transmitted Disease

Doctors will test for sexually transmitted diseases, such as HIV1, Hepatitis B and Hepatitis C,
Syphilis, Chlamydia and Gonorrhea. These tests are mandatory in some States before a
fertility doctor can perform Intrauterine Insemination (IUI).

3) Post-Coital Test

A post-coital test analyzes cervical mucus within a few hours of sexual intercourse to inspect
the interaction between sperm and cervical mucus. However, in recent years, fertility doctors
have stopped using the test. Many studies show it cannot help predict pregnancy. In some
situations, the test can at least confirm that the sperm is near the cervix after intercourse.
4) Antisperm Antibody Tests

Sometimes, the woman’s immune system may produce proteins that attack sperm (antisperm
antibodies). Doctors can test for these proteins in the man’s sperm. They can also check to
see if the partner’s sperm can move through a woman’s cervical mucus to reach the fallopian
tubes. However, these tests are now rarely performed because they do not help predict
pregnancy. Fertility doctors may run this test if a male has previously undergone a
vasectomy.

ETHICAL AND LEGAL ASPECTS OF ASSISTED

REPRODUCTIVE TECNOLOGY
Assisted reproductive technologies include any fertilization
involving manipulation of gametes/ embryos outside the human body and transfer of
gametes/embryos into the body. They offer biomedical parenthood to various infertile
couples who have often spent years trying to have a child and have exhausted all other
avenues to have a child of their own. The new reproductive technologies give great help to
infertile couples and Make many new reproductive arrangements possible. The possibilities
available for couples contemplating parenthood in unconventional ways under these new
reproductive techniques are Artificial Insemination, In-vitro Fertilization, Surrogate
Motherhood

Artificial Insemination
It involves manipulation of fertilization by injecting of a sperm artificially through a needle
into the uterus of the wife directly without sexual intercourse. When a man cannot produce
sperms or his sperm count is low, the wife is artificially inseminated with the sperm of an
anonymous donor or the husband. Where the husband's sperm count is low or because of a
disease can not ejaculate, the artificial insemination is done with the sperm of the husband
[AIH] .But where the husband is not able to produce sperms the sperm can be taken from an
anonymous donor [AID]

Ethical and legal concerns in AIH and AID

AID raises ethical questions that are not raised by AIH as it takes place between husband and
wife .Even though it is through advanced biomedical techniques and not by natural
procedure, most of the people have no moral difficulty to accept it. It maintains the integrity
of family and there is continuity between procreation and parenthood. Most people agree that
there are no morally significant differences between AIH and procreation by intercourse. It is
simply viewed as a medical technology providing assistance to what could not be
accomplished by normal sexual intercourse.
Whereas AID introduces a third party into the reproductive matrix. Someone who donates
sperm to be used for AID, is now contributing genetic material without the intent to parent
the child that will be produced through the use of his genes Most of the religions also don't
accept the impregnation of one's wife by the sperm of a third person as it doesn't make the
child one's own and is looked down upon as illegitimate even in man made laws. The
donation is, however, always made anonymously so that the father could not be traced by the
child, nor can the father elect to make contact with the child, potentially disrupting a
harmonious family. Still it is redefining the concept of family and turning traditional notions
of reproduction upside down.

surrogate Motherhood
Surrogate motherhood involves a woman bearing the child of another woman. Where the
woman can not produce eggs, they enter into a contract with another woman to be artificially
inseminated with the husband's sperm and she bears the child for them. Also where the
woman can produce eggs but she is unable to carry a child to a term, the embryo is externally
formed by in-vitro fertilization of husband's sperm and wife's ova, the embryo is implanted in
surrogate mother's womb and she bears the child for them. This can be done in two ways-
either the husband's semen is squirted in the vagina of the surrogate or the fertilization is
done externally in the lab by IVF and the embryo is implanted in the uterus of the surrogate
mother. The surrogate mother is paid by the married couple for renting her womb. In this case
the child would inherit the genetic code of the contracting couple and the sanctity of marriage
is maintained. Still the surrogate motherhood is the most controversial of the new
reproductive techniques.
Legal and Ethical Concerns in Surrogate Motherhood
Subrogation involves a contract of sale between the married couple and the surrogate.
Certainly the most serious ethical objection to commercial surrogacy is that it reduces
children to objects of barter by putting a price tag in them. Legally also, it is no less than
selling or trafficking of human beings violating the basic fundamental rights of a human
being. Some women could be pressurized into surrogacy by their husbands for money.
Pregnancy is a complicated and risky procedure. In India, the surrogate does not enjoy the
same rights as in the west. The Indian medical guidelines allow doctors to implant five
embryos into a surrogate, whereas in Britain, the maximum is two and many European
countries are moving towards a single embryo implant. In India, the surrogate mother's right
to the child is not on the same footing as in the west .Under British laws a surrogate mother
who has provided an egg can claim the baby back within two years of child's birth. However
in India, she has no right over the child after delivery. She can cancel the contract only when
it is proved that it was not a valid contract according to section 23 of Indian Contract Act.
Surrogacy throws up another problem of post partum blues if the mother and the baby bonds.
Ethically also subrogation raises many issues like tempering with the normal process of
procreation, undermining the institution of marriage and family life, treating children as
objects of sale etc. Most of the religions also don't approve of the idea of subrogation. There
is no law concerning this issue until very recently arising from surrogacy. The Indian Council
for Medical Research has laid down certain guidelines for clinics practicing ART and their
handling of surrogates in India.

In-vitro Fertilization

fertilization that is artificially performed outside the woman's body ‘‘in a test- tube'‘. The
procedure involves extraction of a number of eggs from the woman .To do this she is given a
drug that enables her to ‘‘super ovulate,’‘ or to produce more eggs in one cycle than she
normally does. The eggs are than surgically removed and fertilized outside the body in the
laboratory normally with the sperm of the husband
Concerns regarding In-vitro Fertilization

 The fact that these techniques have been developed and have a certain success rate does not
make them morally acceptable. The ends do not justify the means. Donation of sperms and
ova, and the use of surrogate motherhood to bear the child are both contrary to the unity of
marriage and the dignity of procreation of human being. Furthermore these procedures lend
themselves to commercialization and exploitation when people are being paid for sperm, ova
and for surrogate motherhood The in-vitro fertilization is acceptable within limits. Some of
the ethical issues involved in this technology are Bypassing the natural method of conception,
Creating life in laboratory, Fertilizing more embryos than will be needed, Discarding excess
embryos, Unnatural environment for embryos, Expensive technology, not affordable for
common man Creating embryos, freezing them and keeping them in limbo, Destroying
embryos in research, Potential to select embryos, Selective termination of embryos etc.

RECENT ADVANCEMENT IN INFERTILTY

MANAGEMENT

Recent advances in infertility treatment. Recent advances in assisted reproductive

technologies (ART) have provided greater possibilities for successful infertility treatment.

Assisted Reproductive Technology (ART):

                        ART encompasses all the procedures that assist the process of reproduction by
retriving  oocytes from the ovary or sperm from the testis or epididymis (or) It refers to any
fertility treatments in which the gametes (sperm & eggs) are manipulated.

Different methods of ART:

IUI            : Intra uterine insemination
IVF – ET  : In vitro fertilization & embryo transfer
GIFT        : Gamete intra – fallopian transfer
ZIFT         : Zygote intra – fallopian transfer
POST      : Peritoneal oocyte & sperm transfer
SUZI       : Sub zonal insemination
ICSI        : Intra – cytoplasmic sperm injection/insemination
Methods of sperm recovery :
TESE       : Testicular sperm extraction
MESA    : Micro surgical epididymal sperm aspiration
PESA     : Percutaneous epididymal sperm aspiration

Indications :
                          
The common indications for ART procedures includes the following ;
 Abnormal  fallopian tubes : blocked tubes (or) absent tubes (surgical removal)
 Endometriosis adversely affecting tubo – ovarian pick up function
 Idiopathic (or) unexplianed infertility
 Male sub fertility
 Immunologic infertility
 Failure of ovulation – donar ovum

INVESTIGATION  PRIOR TO  ART :

¨     Semen FSH on days 3 of cycle , FSH > 25 ml U/ml indicates poor prognosis.
¨     Semen oestradiol on day 3 of cycle. Semen oestradiol > 75pg/ml indicates poor
prognosis.
¨     Maternal age > 40 yrs. Success rates drop. Prior to considering ART, asses “ovarian
reserve”.
¨     Test for ovarian reserve :This is indicated in women > 35yrs of age, smokers, presence of
only one ovary & in explained infertility.
(It involves standard day 3 laboratory tests as mentioned above, along with administration of
100mg CC from day 5 to 9, repeat FSH on day 10. FSH values must be the same as on day 3
of the cycle.
¨     Serologic evidence of chlamydial infection is associated with reduced birth rates &
increased perinatal loss.
¨     Enhanced sperm penetration test using test – yolk buffer.
¨     Testing both partners for anti sperm antibiotes.
¨     Asses uterine cavity – Hystero salpingography / hysteroscopy / trans vaginal sonography.
¨     Complete seminogram & treatment of male partner prior to ART procedure.
¨     Diagnostic laparoscopy to assess tubal patency & treat any subtle causes of infertility
present such as lysis of adhesions, treatment of endometriosis, etc.
 
Types of ART procedure in practice:
 
 Intra uterine insemination (IUI)
 In Vitro Fertilization And Embryo Transfer (IVF-ET)
  Gamete Intra – Fallopian Transfer (GIFT)
  Zygote Intra – Fallopian Transfer (ZIFT)
  Intra – Cytoplasmic Sperm Injection/Insemination (ICSI)
  Sub Zonal Insemination (SUZI) Micro Assisted Fertilization (MAF)
  Micro Surgical Epididymal Sperm – Testicular Aspiration and Biopsy
 Ovum donation
 Surrugacy & Posthumas Reproduction 
 
HEALTH HAZARDS OF ART :-
♠       Mostly not associated with risk of fetal hazards/congenital anomalies.
♠       Increased number of pregnancy loss, multiple pregnancy, ectopic pregnancy, perinatal
mortality & morbidity.
♠       Ovarian hyper stimulation syndrome is a rare but known health risk.
♠       Psychology stress & anxiety of the couple are severe , specially when there is failure in
the treatment or with a pregnancy loss.
→ Inspite of excellent advances in field of infertility management, expectations are not
fulfilled &  Adoption I an alternative for many couples.

ADOPTION PROCEDURE

Infertile couples consider various alternative methods for resolving their infertility: adoption
is one option that will be considered at several points during the treatment process.
Irrespective of different types of families, adoption brings a number of challenges to the
adopting parents and the child, as well as the other family members.
Methods of adoption
Agency adoption
In traditional agency adoption, a couple usually contacts an agency by first attending an
informational meeting. If the couple decides to apply to the agency, they are then put on a
waiting list for processing. The process includes extensive interviewing and a home visit by
an agency social worker to determine whether the couple can provide a safe and nurturing
environment for an adopted child. Once approved by the agency, the couple is placed on a
second waiting test. Then the child has been located for them depending on couple’s
particular requests (<1 year to 5-6years).
 International adoption
This can often provide a baby in less time than a traditional agency adoption, but there may
be unanswered questions about the prenatal health care or the birth parents background. The
couple who are waiting for international adoption must be ready at moment’s choice either to
travel to the foreign country or a neutral location to pick up the child. The couples must
examine their feelings ahead of time about how they feel about having a child from a
different culture and how the neighbours and family deal with the cultural diversity of
adopting child. Many of the international adoption agencies provide follow up support.
 Private adoption
With the private adoption, the adopting parents usually agree to pay a certain amount of
money, part of which goes to the birth mother’s prenatal and medical expenses. Some
pregnant women prefer to place their child for adoption directly with a couple rather than
through an agency. The adopting parents might even attend the child’s birth if the birth
mother wishes.
Adoption procedure
Adoption involves a lot of paper works and documents that are to be submitted by the couple
to the adoption agency. The social workers involved come for regular home visits. This takes
a long time, sometimes 3 – 6 months.
1. Child welfare agency: to know more about adoption and its procedures the couples
involved should take help from any of the child welfare agency.
2. Registration: After getting all the relevant informations it is important that the couple
register in an agency they are comfortable with. To avoid confusion it is necessary to
register in only one agency.
3. Documents: In the process of adoption there are many formalities and documents to be
completed. It’s important to study completely the documents before doing an agreement.
4. Home visits by social worker: The social workers conduct home visits and interview as a
pre adoption counseling. During these visits the couple should clarify all their fears and
doubts they may have in their minds.
5. Patience waiting: The agency concern would then locate a suitable child for the couple
which might take as long as 6 months or more. This process is like a waiting period and
requires a lot of patience.
6. Meeting the child: After a long wait arrangements are made by social workers to see the
child chosen for them. The agency will take care to match a child meeting the description
desired by the couple. In case of placement of older children (above age 6), both verbal
and written consent of the child will be obtained.
7. Medical checkup: To reassure the child’s health the adoptive parents should go for a
complete medical checkup.
8. Formalities in the court: before the child could be taken home, the couples have to submit
the important papers to the court with the help of a hired lawyer. The social worker also
assists the couple with all the formalities required in the court.
9. Court decree: after the court decree the adoption procedure is complete and all the
important papers and documents will be given to the couple by the lawyer.
10. Follow-up visits: even after the long process of adoption procedure, the social workers
will continue their regular follow-up visits and post adoption counselling till the child is
adjusted in the new environment. The follow-up visits should preferably be for a period
of one year at least or a directed by the court.
Criteria for prospective adoptive parents
 Marital status, age, financial status and clear police record should be evident in the home
study report by the social worker.
  Couples having composite age of 90 years and less and where neither parent has crossed
45 years can be considered for adoption of Indian children.
 In case of special needs children with medical problems, the age limit of adoptive
parents may be relaxed by the central government.
 Single persons who have not crossed the age of 45 years and who fulfill the other criteria
can adopt.
 The prospective parents should have a regular source of income with a minimum
average monthly income of Rs 3000/-. However low income will be considered taking
into account other assets and support systems (own houses etc.).
 All the criteria mentioned above will also apply to single parents with the additional
requirements:-
 Age should be above 30 and below 45 years.
 The age difference between the adoptive single parent and child should be 21
years.
 The single parent should have additional family support system.
Criteria for eligible children
 The child should be legally free for adoption.
 Siblings/ twins/ triplets etc. should not be separated.
 The consent of children above 6 years should be taken for the adoption.
Safeguards to child in In-Country adoption
 The child should be legally free for adoption.
 All the efforts to trace the biological parents should be made as per the prescribed
framework for abandoned children.
 Priority should be given to applicants already registered and regularly inform of the
status of their application.
 The child study report should be signed by both the adoptive parents.
 The parents should be advised the child assessed by their own doctor in case of doubts.
 Older children above age 6 years- special clearance from state government should be
obtained.
 In case of couples willing to adopt a child with disability/health problems, a document
stating the same shall be obtained.
 Placement of girls with a single male is not allowed as also placement of children with
same sex couple.
 Siblings and twins etc. should not be separated.
 The prospective parents should fulfill the laid down criteria of age, income etc.
 Above all, the agency must satisfy itself that the proposed adoption is in the best interest
of the child.
Adoption laws in India
The Hindu Adoption and Maintenance Act, 1956 (HAMA)
This Act covers Hindus, Buddhists, Jains or Sikhs. Some relevant parts of the Act are:
 Married couples or single adults can adopt.
 Legally the man adopts with the consent of his wife.
 A single man or woman can adopt.
  If a biological child already exists in the family, a child of the opposite sex has to be
adopted.
 Children adopted under this Act get the same legal rights as a biological child might.
 Children under the age of 15 years can be adopted.
 A single man adopting a girl should be at least 21 years older than the child.
 A single woman adopting a boy should be at least 21 years older than the child.
 Adoption under this act is irrevocable.
The Guardians and Wards Act, 1890 (GWA)
Before the Juvenile Justice (Care and Protection) Act of 2000, this was the only legislation
that allowed non-Hindus to adopt. However, this act ended up being the first secular law that
allowed for a child to be adopted in India. The salient points of this Act are:
 The parent adopting is a ‘guardian’ and the child is a ‘ward’, meaning that the same
rights of a biological child aren’t inherent.
 Anyone under the age of 18 years can be a ward.
 The guardianship can be revoked by the courts or by the guardian.
 A will is required for any property/goods to be bequeathed to the child.
 This will can be legally contested by ‘blood’ relatives.
 Both spouses can legally be guardians (versus HAMA where the man adopts with the
consent of his wife).
 Single people can adopt without any age difference restrictions.
The Juvenile Justice (Care and Protection) Act of 2000, amended in 2006 (JJ Act)
The JJ Act is meant mainly for the care and rehabilitation of children in conflict with the law.
There was the need for a law that would allow children the same rights, whether they were
adopted or biological. There was also the need for a law that delinked adoption from the
religion of the adoptive parent(s). The JJ Act filled this space and a tiny section was added on
for adoption.
The Amendment Act of 2006 has since expanded the provisions. The main strengths of this
Act are:
 Any Indian citizen can adopt a child who is legally free for adoption.
 The adoptee gets the same rights that a biological child might.
 The religion of the adoptive parent(s) is not relevant.
 Single people can adopt.
 The adoption is irrevocable.
 Some time limits have been set to ensure that children are considered legally free for
adoption earlier.
 The thrust is on the best interest of the child.
Adoption for those who already have a child
The provisions of our legal statutes portrays that a person can adopt a child even if he/she has
a child already, upon one condition that the child adopted must be of the opposite gender to
the one already they have (Hindu Adoption and Maintenance Act). But in other two adoption
laws, there are no such conditions that a person must satisfy while adopting. But these laws
also state that the original child of the person, who is adopting, if old enough, must express
his/her views regarding the adoption, in writing.
Fundamental principles governing adoption
 The child’s best interests shall be of paramount consideration, while processing any
adoption of children from India.
 Preference shall be given to place the child in adoption with Indian citizens, with due
regard to the principle of placement of the child in his own socio- cultural environment,
as far as possible.
Reliable Indian adoption agencies
 SOS Children’s Villages in India
 Holy Cross Social Service Center
 Missionaries of Charity
 Church Of North India
 Welfare Homes for Children
 Delhi Council for Child Welfare
 Matri Chhaya
 Children of the World
 Right to Life Society
 Asharan Orphanage

Conclusion
Although infertility in common in both male and female, the latest treatment methods and
techniques have proven to be effective how ever you may want to seek the help of a medical
expert using an infertility treatment method

ROLE OF NURSE IN INFERTILITY

 Receiving the patient and family, and make them accessible and comfortable for
counseling
 Fertility nurse specialist provide care for the individuals and couples before, during,
and after fertility treatment
 Nurses need to obtain history as a prenatal,and other relevant information regarding
patients of reports
 Give physiological support throughout the counseling.
 Collect other information about tests reports and documents.
 Establish plan of care with family and coordinate care with other health care
professionals.
 Maintain privacy and confidentiality of all cases.
 Perfoming insiminations
 Ensure follw-up @ supportive services to individual and family during counseling

REVIEW OF LITERATURE
 (RELATED STUDIES)
In research funded by the NICHD Reproductive Sciences (RS) Branch, investigators studied
whether obesity prior to and during early puberty also increased androgen hormone
production. Researchers compared androgen levels in normal-weight and obese girls between
ages 8 and 14 years. Girls who were obese had higher androgen levels throughout puberty
compared with normal-weight girls. The results of this study demonstrate that childhood
obesity affects normal hormone production and that these early hormone level changes could
influence fertility later in life.

The cross-sectional analysis. was conducted at general clinical research centers. The
objective of the study was to assess the degree of hyperandrogenemia across puberty in obese
girls and assess overnight sex steroid changes in Tanner stage 1-3 girls of Thirty normal-
weight (body mass index for age < 85%) and 74 obese (body mass index for age >or= 95%)
peripubertal girls.The intervention measured by blood samples (circa 0500-0700 h) were
taken while fasting. Samples from the preceding evening (circa 2300 h) were obtained in 23
Tanner 1-3 girls. Peripubertal obesity is associated with abnormal sex steroid concentrations,
but the timing of onset and degree of these abnormalities remain unclear.the result of the
study Compared with normal-weight girls, mean free testosterone (T) was elevated 2- to 9-
fold across puberty in obese girls, whereas fasting insulin was 3-fold elevated in obese
Tanner 1-3 girls (P < 0.05). Mean LH was lower in obese Tanner 1 and 2 girls (P < 0.05) but
not in more mature girls. In a subgroup of normal-weight Tanner 1-3 girls (n = 17), mean
progesterone (P) and T increased overnight 2.3- and 2.4-fold, respectively (P <or= 0.001). In
obese Tanner 1-3 girls (n = 6), evening P and T were elevated, and both tended to increase
overnight [mean 1.4- and 1.6-fold, respectively (P = 0.06)].The main outcome measures is
hormone concentrations stratified by tanner stage were measured Peripubertal obesity is
associated with hyperandrogenemia and hyperinsulinemia throughout puberty, being
especially marked shortly before and during early puberty. P and T concentrations in normal-
weight Tanner 1-3 girls increase overnight, with similar but less evident changes in obese
girls.

a cross-sectional analytic study using Yazd Health Study (YaHS) data in

2014-2015, conducted on 10,000 residents aged between 20-69 yr old. The
sampling method was population-based, random and multi-stage stratified.