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Fertility Testing and treatments: What tests are done and why?

Men's Health, Women's Health, Pregnancy | February 19, 2015 | Author: The Super Pharmacist

women, pregnancy, men

Fertility Testing and treatments: What tests are done and why?

Human fertility testing is carried out to assess the ability of an individual to conceive (i.e. to become pregnant or to impregnate a partner), or to diagnose the cause of an apparent inability to do so. Half of cases of infertility are thought to be associated with male infertility. If an individual upon taking a fertility test finds out that they have fertility problems, he or she may need to seek treatment to help them or their partner become pregnant. Some available fertility treatments include the following. 

Fertility treatments

Egg cell cryopreservation: Eggs (or 'oocytes') are human female reproductive cells. These are released from a part of the ovary known as the follicle once a month from the start of puberty. The surgical removal and 'freezing' of these cells may be a contingency against the loss or dysfunction of the remaining eggs later in life.

Embryo (and other tissue) cryopreservation: This is the prospective freezing of fertilised eggs, (i.e. eggs that have fused with the sperm of a partner) or other tissues such as those of the ovary, as a similar contigency as above.

Sperm cryopreservation: This is the freezing of sperm, in the event of declines in male fertility, or the reversal of family-planning decisions involving procedures such as vasectomy.

Intracytoplasmic sperm injection: This is the insertion of a sperm cell into an egg, performed in laboratory conditions. The fertilised egg may then be implanted into the womb. This technique, often referred to as in-vitro fertilisation (IVF), is available for men with severe fertility disorders (see below). Sperm used in these procedures may be derived from sperm taken from ejaculate or extracted from the testicles. A study of this procedure in 249 couples undergoing a total of 337 IVF cycles found that the rates of fertilisation were approximately 48% when ejaculated sperm were used, and 47% when testicular sperm were used. The live birth rates for testicular sperm and ejaculate-derived sperm were approximately 20% and 23% respectively.

Ovarian transplantation: Transplants of ovarian tissue for women affected by disorders of this tissue from healthy donors.

Sperm donation: The donation of sperm from healthy donors, analogous to the above.

Mitochondrial transfer: Some people cannot conceive due to the dysfunction of mitochondria (the energy centre of the cell, which has its own separate DNA) in their cells. In these cases, they may overcome fertility problems through the insertion of 'normal' mitochondria from donors into reproductive cells. This technology is currently under evaluation for approval as a legalised form of assisted reproduction in the United Kingdom.

Fertility-stimulating drugs: These are pharmaceutical products that treat dysfunctions of egg release or sperm production.

Factors affecting fertility

There are a number of factors that may affect fertility, and/or the motivation to request fertility testing. These may include:

Ovarian reserve

This may be defined as the volume of viable eggs a woman has left to release in her reproductive lifetime. A measure of ovarian reserve is particularly relevant to women of 35 years or older.

AFactors affecting fertility diagnosis of diminished ovarian reserve indicates that women of this age have egg counts that are lower than are reasonably expected at this age, and that the time left for them to conceive is more likely to be reduced in turn.

Diminished ovarian reserve is related to decreased counts of follicles in the ovary, although menstrual regularity is not necessarily affected. It may be associated with the reduced probability of achieving a full-term pregnancy from a single reproductive cycle (but not of conception) and a reduced response to pharmacological fertility intervention.

This may be diagnosed or assessed using several analytical or empirical methods (as recommended by the European Society of Human Reproduction and Embryology), and may include:

  • Antral follicle count
  • Anti-mullerian hormone analysis
  • The response to fertility medication, as above. A failure to respond to two instances of maximal ovarian stimulation is regarded as a strong indicator of diminished reserve.

Younger women may also be at risk of diminished ovarian reserve. A woman's remaining reserve may be influenced by many factors. These may include:

  • Environmental and behavioural factors, including habitual smoking
  • A history of endometriosis
  • A history of metabolic conditions
  • A history of autoimmune conditions
  • Infections
  • Genetic factors
  • Prior cancer treatment (i.e. chemotherapy or radiotherapy)
  • Uterine fibroids

A diagnosis of diminished reserve may be addressed through the use of assisted reproductive treatments as outlined above. Alternatively, a woman with confirmed diminished ovarian reserve may be advised to consider attempts at conception earlier than they had planned if they wish to become pregnant.

Sperm Cell MotilitySperm Cell Motility

Sperm must migrate under their own power (for which they have specific motile components (or 'tails')) from where they are ejaculated in the region of the cervix toward an egg cell within the womb. Male fertility may be adversely affected by reductions in the motility of sperm. This may occur due to abnormalities in the structure of the sperm cell.

Sperm Cell Concentrations

This is the average population of sperm cells present in the seminal fluid of men. It is also known as a 'sperm count'. Men with an average sperm concentration or motility below the reference levels set by the World Health Organisation in 2010 may consider taking measures to try and increase their sperm count. Sperm concentrations and motility may be assessed by laboratory analysis of semen samples. This may also include visualisations of the testicles (where sperm cells are produced) or prostate using imaging technology such as ultrasound.

Reduced sperm function, structure and/or concentrations may be associated with many factors, including:

  • Cancer and cancer treatments
  • Genetic factors
  • Trauma or disease of the scrotum or testicles

However, many cases of male infertility are not found to be associated with an underlying condition or detectable factor. This is known as idiopathic infertility.

Other Factors Related to Fertility Problems

Some other variables have become linked to problems with fertility and pregnancy in recent times. These may include:

Gynaecological Surgery

Some procedures, particularly those involved in the removal of cervical anomalies, have become linked to subsequent reductions in fertility. A study assessed the impact of the excision of cervical intraepithelial neoplasias on this, comparing aspects of fertility in 818 women with a history of one or more of these procedures to 537 without. The results showed no significant differences in latencies to conception, rates of pregnancy or other fertility problems between these groups. However, the 'excision' group was then analysed in terms of which subtype of the procedure (e.g. cold-knife excision) they received. Those who received the large-loop excision of transformation zone- (LLETZ) or cold-knife cone-type excisions had significantly fewer pregnancies, but delays in conception were not significantly different.

Patient education and information

Seeking interventions for impaired conception may be affected by the knowledge of, and education available for, fertility and fertility issues.

Patient education and informationA study on the influence of education on fertility and assisted reproduction awareness found that knowledge scores increased significantly after exposure to online education about factors affecting fertility and on reproductive technologies. However, participant beliefs about these topics were observed to return to near-baseline levels six months later. This may indicate that the uptake of reproductive assistance is affected by a lack of awareness of factors which may affect fertility.

Another study assessed similar awareness in midwifery students. Approximately 93% of its 285 participants were aware of the concept of ovarian reserve, but only 22.5% had an accurate response when asked about the average age at which female fertility starts to decline. Approximately 77% of the (all-female) cohort reported that they would be more likely to accelerate their first attempts at pregnancy in response to a diagnosis of diminished ovarian reserve, and 58% reported they would be amenable to having their eggs frozen.

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References

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Alborzi S, Madadi G, Samsami A, et al. Decreased ovarian reserve: any new hope? Minerva Ginecol. 2015.

Jensen CFS, Ohl DA, Parker WR, et al. Optimizing human semen cryopreservation by reducing test vial volume and repetitive test vial sampling. Fertil Steril. 2015.

Gnoth C, Markhinin V, Maxrath B, et al. Impact of sperm cell source on the results of intracytoplasmic sperm injection. Arch Gynecol Obstet. 2015;291(3):663-669.

Practice Committee of the American Society for Reproductive Medicine. Electronic address Aao. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2015.

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