Causes of Infertility

Asherman’s Syndrome

Asherman’s Syndrome is an acquired uterine condition, characterised by scar tissue inside the uterus and/or cervix. Often the scar tissue can cause the walls of the uterus to stick to one another.

Causes of Asherman’s Syndrome

Asherman’s Syndrome occurs when trauma to the endometrial lining triggers a wound-healing process, causing damaged areas to fuse. This can often occur after a dilation and curettage (a procedure used to remove tissue from the uterus for diagnostic or treatment purposes of uterine conditions).

Signs & Symptoms of Asherman’s Syndrome

  • Obstructed menstrual flow. Periods can become scanty or absent.
  • Recurrent miscarriages
  • Infertility

Diagnosis & Treatment of Asherman’s Syndrome

Direct visualisation of the uterus through a hysteroscopy (endoscopic surgery) is the most reliable method for diagnosis and treatment. Asherman’s Syndrome should be treated by a well-experienced hysteroscopic surgeon. As adhesions tend to reform, there are different methods to prevent re-scarring after surgery. Estrogensupplementation can be used to stimulate the uterine healing and a balloon can be inserted to prevent apposition of the walls during the healing phase after surgery.

Endometriosis

Referral centre for endometriosis – Aevitas Fertility Clinic, Cape Town, South Africa

What is Endometriosis?

Endometriosis is a pathological condition in which tissue resembling the normal lining of the uterus cavity (endometrium) is found outside the uterus cavity, even in and on the reproductive organs, as well as anywhere in the pelvic cavity.

Endometriosis

Depending on the severity of the condition it can be associated with the following symptoms:

  • infertility
  • dysmenorrhoea (abdominal pain during menstruation)
  • pain during sexual intercourse

Diagnosis of endometriosis

A medical history is taken and a physical assessment is performed. Furthermore, an ultra-sound, MRI or CT-scan can further assist with the diagnostic process.

In the pelvis, three forms can occur:

  • Peritoneal
  • Ovarian
  • Rectovaginal

Treatment of endometriosis

Treatment can be addressed through:

  • pain medication (to control symptoms),
  • hormonal therapy (to slow endometrial tissue growth and prevent new implants of endometrial tissue)
  • gynaecological endoscopic surgery (to remove the endometriosis and preserve the uterus and ovaries).
    If endometriosis needs to be removed through endoscopic surgery, your surgeon will use various techniques, which includes excisions (cutting and removing tissue) or destroying the tissue with a laser beam. In more severe cases, where endometriomas (endometriotic cyst, usually in the ovary) have developed, the cyst is opened, the material is aspirated and the cyst is irrigated. The interior wall is removed to destroy the mucosal lining. This is performed to ensure the cyst does not reoccur.SASREG (SA Society of Reproductive Medicine and Gynaecological Endoscopy) serves as governing body and they have created a contact list of specialists, who can perform surgery to treat endometriosis. The public can contact SASREG (website: www.sasreg.co.za) for more information.

The treatment approach chosen by yourself and your physician, will depend on the severity of your signs and symptoms and whether you wish to become pregnant.

*A pregnancy rate of 55% can be expected in moderate cases and 36% in severe cases, during the first year after appropriate surgery.

Fibroids

Fibroids are the most frequently seen tumours of the female reproductive system. These tumours consist of smooth muscle cells and connective tissue, which develops in the uterus and multiplies due to the influence of oestrogen. In most cases they are benign (non-cancerous).

fibroids

Symptoms of fibroids

  • Heavy or prolonged menstrual periods
  • Abnormal bleeding between menstrual periods
  • Pelvic pain (caused by the tumour pressing on pelvic organs)
  • Frequent urination
  • Low back pain
  • Pain during intercourse
  • A firm mass, often located near the middle of the pelvis, which can be felt by the physician

Diagnosis of fibroids

These tumours can be found through routine pelvic examination and diagnosis can usually be confirmed by ultrasound.

Treatment of fibroids

Most of these tumours stop growing or shrink over time and therefore management depends on the symptoms, location and size, as well as the patients desire to conceive. However, these tumours usually don’t interfere with getting pregnant, it is possible that it — especially if submucosal — could cause infertility or pregnancy loss.These tumours may also raise the risk of certain pregnancy complications, such as:

  • placental abruption
  • fetal growth restriction
  • preterm delivery

*These tumours can be managed by means of gynaecological endoscopic surgery. It has been established through research, that gynaecological endoscopic surgery is the best treatment option for symptomatic women with uterine fibroids, who wish to maintain their fertility.

Male Infertility

Aevitas Fertility Clinic – pioneer in the field of male infertility – Cape Town, South Africa and internationally

Research in the field of male infertility is a big focus point for the Aevitas team as there are many unanswered questions and male infertility is often overlooked, even though infertility affects both men and women equally.  Aevitas team’s biggest scientific contribution to male infertility has been in the field of sperm morphology (shape) which causes male infertility. The criteria created by this research is now used worldwide and recognised by the World Health Organisation (WHO) as an international standard.

Signs & symptoms of male infertility

The main, sometimes only sign, of male infertility is the inability to conceive a child. In other cases, an underlying problem such as, an inherited hormonal imbalance or a condition that blocks the passage of sperm, may cause signs and symptoms. Signs & symptoms associated with male infertility, may include:

  • Problems with sexual function — for example, difficulty reaching orgasm (delayed ejaculation), premature ejaculation, or difficulty maintaining an erection (erectile dysfunction).
  • Pain, swelling or a lump in the testicle area.
  • Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality.

Semen analysis, also known as ‘the sperm count test’, can be used to assess the health of male sperm. Furthermore, it can assess whether low sperm count or sperm dysfunction is the reason behind male infertility.

Diagnosis of male infertility

Male infertility can be evaluated through semen analysis. Semen analysis involves the examination of the semen ejaculate of the male partner and the different sperm parameters within:

  • Motility – percentage of sperm that are moving. Normal: more than 30%.
  • Forward progression – speed at which the sperm are moving forward. Normal: more than “2”.
  • Concentration – number of sperm per milliliter of semen. Normal: more than 15 million per milliliter.
  • Normal morphology – the percentage of sperm cells with normal forms. Normal: more than 4%.
  • Anti-sperm antibodies (“MAR”) – factors that bind to sperm resulting in the agglutination (sperm-sperm binding) and immobilisation of sperm. Normal: less than 60%.
  • Presence of infection – indicated by white blood cells or a positive pathogen culture.

A fertility diagnosis is made by comparing the values obtained for the male partner’s sperm, with standard fertility values. A small percentage of men may have no sperm in their ejaculate and this is called Azoospermia.

Azoospermia

Azoospermia is often referred to as ‘no sperm count‘.

Treatment for Azoospermia

A Testis biopsy can be performed for both diagnostic purposes, to evaluate sperm production, as well as for treatment purposes. Testicular Sperm Aspiration (TESA) is used to obtain sperm directly from the testis where it is produced. The obtained sperm can then be used for Intracytoplasmic Sperm Injection (ICSI), in conjunction with IVF. The procedure involves injecting a single sperm into an egg using microscopic instruments. Within a couple of days, embryos are selected and can be transferred back into the female’s uterus in hopes of achieving pregnancy.

*The Aevitas team is also a proud leader in the field of male infertility in South Africa, as they are responsible for the 1st successful pregnancy and birth in South Africa and Africa resulting from the treatment of TESA and ICSI, in conjuction with IVF in 1995.

Polycystic Ovarian Syndrome (PCOS)

What is PCOS?

Polycystic ovarian syndrome (PCOS) is a common endocrinopathy (disease of an endocrine gland resulting in hormal problems) among infertile women and it affects approximately 6% of the general female population.

The most prominent presenting characteristics are:

  • absence of menstruation (due to an-ovulation)
  • signs of excess androgen, which causes acne and hirsutism (unwanted male patterns of hair growth in woman).

PCOS Diagnosis

Polycystic ovaries can usually be diagnosed by ultrasound (sonar), physical examination and hormonal tests.

PCOS Treatment

If women with Polycystic ovarian syndrome present with obesity, weight loss is the first treatment requirement.  After 10% weight loss, ovulation may return in many obese women with Polycystic ovarian syndrome. Lifestyle intervention should always be regarded as the best initial treatment.

The second treatment requirement of Polycystic ovarian syndrome can be addressed through the medication Clomiphene Citrate (CC). In certain cases patients with Polycystic ovarian syndrome are resistant to CC, resulting in numerous cycles where CC is unsuccessful. If this is the case, your physician may decide to prescribe Metformin (Glucophage), in addition to CC. Metformin is however associated with side effects and 30% of women may stop Metformin treatment due to the side effects thereof.

At Aevitas Fertility Clinic, we manage our patients according to the most recent evidence based literature (references available on request), which indicates the following treatment options for Polycystic ovarian syndrome:

  • Weight loss
  • Clomid/Fertomid
  • If Clomid resistant, add Metformin
  • If still no ovulation, replace Clomid with Femara
  • If still no ovulation, consider ovarian drilling
  • If still no ovulation, consider the use of gonadotrophins

Recurrent implantation failure

Recurrent implantation failure (RIF) can be defined as the failure to achieve a pregnancy after the transfer of four embryos in three or more IVF cycles, for woman under the age of 40 years. Implantation of the embryos is very dependent upon a well-developing embryo and a healthy endometrium.

Causes of Recurrent implantation failure

Maternal- and paternal factors could include chromosomal impairment, which can be evaluated through genetic analysis.

When evaluating maternal factors contributing to RIF, maternal age plays a big role. Furthermore, various forms of anatomical impairment could be the cause of RIF. Therefore, ovarian function should be assessed and uterine pathology should be excluded through ultrasound and hysteroscopy. Typical uterine pathology could include:

  • Fibroids
  • Endometrial polyps
  • Congenital anomalies
  • Intrauterine adhesions

*Surrogacy may be an alternative option if there is no success with further IVF attempts.

Recurrent miscarriages

Recurrent miscarriages, also known as Recurrent Pregnancy loss (RPL) is defined as three or more consecutive failed clinical pregnancies.  Having a miscarriage is surprisingly common, as miscarriages occurs in 15 – 25% of all pregnancies. 1% of women may experience three or more consecutive miscarriages and in up to 50% of cases a clear cause cannot be found.

5% of women will experience two consecutive pregnancy losses and investigations for a possible cause is recommend at this stage. The main cause of loss before 10 weeks gestational age is random chromosome abnormalities, such as trisomy 13, 18 or 21. The incidence of these abnormalities rises with the increase in age of the woman.

Diagnosis of recurrent miscarriages

In order to evaluate the reason for your recurrent miscarriages, an Aevitas fertility specialist may decide to do certain tests, including:

  • Chromosome analysis (karyotyping) of the parents.
  • Blood tests on the mother for antiphospholipid syndrome, as well as some hormonal conditions (such as undiagnosed Diabetes Mellitus, and untreated thyroid disease). Increased clotting risk (“thrombophilia”) is also found in some women.
  • Hysteroscopy (looking inside the cavity of the uterus, under anaesthesia) in order to exclude and treat anatomical abnormalities, such as adhesions or the presence of a congenital septum (abnormal shape of the cavity of the uterus) and/or Hysterosalpingogram (an X-ray test).

Immunological factors, such as the presence of “Natural Killer Cells” are unproven as a cause of pregnancy loss and most experts advise against such tests due to extra costs. Research in this field, is an ongoing process.

Lifestyle factors and recurrent miscarriages

The following lifestyle factors could be linked to an increased risk of pregnancy loss:

  • Cigarette smoking 
  • Obesity
  • Alcohol consumption
  • Increased caffeine consumption
  • Recreational drug use 

Support

We encourage couples to make use of psychological counselling and support during these trying times!

*There is hope in knowing that even after three consecutive miscarriages, most women will not experience a miscarriage again.