west coast fertility centers

8/2/2019 West Coast Fertility Centers

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West Coast Fertility CentersScience . Solutions . Success!

(714) 513-1399

INFERTILITY CAUSES AND DIAGNOSES

Infertility is defined as the inability to achieve pregnancy after 12 months ofunprotected intercourse when the woman is less than 35 years of ageor after 6months if the women is more than 35 years old. It is generally accepted that afterthis time a couple should consult a fertility specialist to undertake Level 1 of pre-testing.The basic testing can be completed in one month and consists of:

Taking a medical history A physical examination Hormonal blood tests for the woman A hysterosalpingogram (HSG) x-ray to check the fallopian tubes A semen analysis for the male

Depending on the results, additional tests may be recommended. More advancedtesting includes an outpatient surgical procedure called laparoscopy to evaluate thewomans internal pelvic organs or an ultrasound to evaluate the male. See Causesof Male Infertility below for more details.THE NATURAL DECLINE IN FEMALE FERTILITYA frequently ignored or misunderstood factor is the natural decline in fecundity(fertility rate per month) which occurs in women. This is primarily attributed to theongoing attrition or programmed cell death of human eggs. In fact, women are bornwith a fixed number of eggs after which there is no new egg formation. Thus it canbe said there are sufficient favorable eggs for about 20 years of activereproductive life suggesting a woman will ovulate about 300 times per lifetime. Afterage 35, each passing month without pregnancy therefore diminishes thereproductive potential. With physiologic aging, declining egg quality makes itmore difficult for a normal embryo development to occur, accounting forabnormalities, decreased implantation and increased miscarriage rates. This agerelated infertility makes it imperative that prospective parents not wait past age38 to begin trying to conceive. Graph 1 depicts the natural decline in female fertility.POTENTIAL CAUSES OF INFERTILITYTo understand the causes of infertility, it is important to note that fertility in humansis not a very efficient process. Even among fertile couples, the likelihood ofachieving pregnancy is only about 15% per month. This is important because it is

the basis of comparison with the success rate of fertility treatments offered at mostclinics. After Level One Testing is completed, female factors are found in 40%, malefactors in 40%, combined female and male factors are found in 15% andunexplained factors are found in the final 5%. See Graph 2.Graph 2: Causes of Infertility in Humans

CAUSES OF FEMALE INFERTILITY
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There are multiple causes of female infertility including structural factors such asadhesions or fibroids, infectious causes such as Chlamydia resulting in PIDand tubal blockage, hormonal reasons such as polycystic ovaries andovulatory problems, genetic factors causing premature menopause or embryodefects, and declining egg quality due to advancing age.

The most likely causes for female infertility are:Pelvic Inflammatory Disease (PID) - PID is the most common cause of infertilityworldwide. It's an infection of the pelvis involving one or more reproductive organs,including the ovaries, the fallopian tubes, the cul-de-sac, the cervix or the uterus.Sometimes PID spreads to the appendix or to the entire pelvic area.Polycystic ovary syndrome (PCO) - This condition affects 5 million Americanwomen and is another major cause of infertility. In PCO, the ovaries produce highamounts of male hormones, especially testosterone. LH levels may be abnormallyhigh while FSH levels are abnormally low; thus, normal follicle grow and ovulationdo not produce occur. Instead they form fluid-filled cysts that eventually cover theovaries. Other hormonal problems may be linked to PCO like elevated testosterone

which can contribute to medical problems like obesity, diabetes and MetabolicSyndrome.Endometriosis - This disease is another common cause of female infertility.Endometriosis refers to a condition in which sections of the uterine lining implantinside the pelvis. These implants eventually form cysts that grow with eachmenstrual cycle and may eventually create inflammation and scarring that can affectthe egg capture by the fallopian tubes . The scars can then block the passage of theegg, the fertilization of the egg, and possibly the implantation of the embryo.Fibroids - Fibroids, are usually benign growths that may form in the uterine musclenear the fallopian tubes, in the cavity of the uterus or cervix. As a result, the spermor fertilized egg may not be able to reach the uterus or implant there. Fibroids in theuterus are very common in women over age 35.Premature Menopause - Some women may experience premature menopause,when their ovaries stop producing estrogen and progesterone and eggs. Often thecause is unknown or may be due to a lower number of eggs a woman has in her lifetime. If this occurs, donor egg may be the best option for a successful pregnancy. Afew cases may be due to genetic conditions in the female.

What is Male Infertility?As many as 40 percent of couples experience infertility associated with the malepartner. Usually, a man must produce healthy, actively moving sperm cells. Thesespecialized cells must pass freely from the testes, through the penis, and be

capable of traveling through the uterus into the fallopian tubes. Male infertility maybe associated with several conditions such as low sperm count or low motility of thesperm cells.Causes of Male InfertilityThe etiology of male infertility can be classified into structural, infectious, congenital,anatomic and hormonal and more rarely, genetic causes. Listed below are amongthe most common problems.Vas deferens obstruction - The vas deferens that carries sperm from the testiclesto the penis can be blocked for a variety of reasons including prior vasectomy,injury, infection or physical anomaly.


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Infections - There are many types of infections that might cause sterility or lowsperm counts in men. These can be recent infections or from childhood. Commoninfections can be mumps or certain types of sexually transmitted infections (STI).Chronic Disease - Diseases that can affect hormonal controls and spermproduction, particularly when not controlled are also causes of infertility. Diabetes,

hypertension and other problems can all affect the fertility of men.Erectile Dysfunction (ED) - Problems maintaining an erection or ejaculatorydifficulties will result in sperm transport problems. This may be caused by chronicillnesses like diabetes, hypertension or heart problems. Some medications used totreat chronic illnesses can contribute to these types of male factor. Spinal cordinjuries may damage the nerves which assist in normal sexual function.Failure to Produce Sperm - If the body isn't producing sperm there can be manyreasons. Some may be from hormonal dysfunction or testicular failure. Geneticillnesses and certain medications may also impact sperm production.Exposure to Harmful Substances - Environmental or work hazards such assolvents, radiation and high temperatures can affect sperm production.

Injury - Traumatic injury to the testicles may lead to destruction of sperm producingcells.Varicocele - This is a varicose vein located in the testes and can interrupt normalblood flow or increase the temperature surrounding the testes.Each male factor patient will receive individual recommendations for treatmentoptions in conjunction with our staff Urologist.Testing for Male InfertilityTesting for infertility in the male begins with a complete medical history and physicalexamination. A complete semen analysis is scheduled for the male following threedays of abstinence. Unlike sperm testing performed at a commercial lab, the semenanalysis at WCFC is interpreted by a reproductive biologist with advanced expertisein the subtle forms of male infertility.A semen sample is collected and analyzed in our special Andrology laboratories.The sample is checked for sperm count, motility, sperm shape and other factors. Asingle semen analysis is only a screening test and does not provide a diagnosis,and thus, more advanced testing may be required.

It is important to recall that infertility is a couple's condition and at times, both maleand female factors may be present. For example, the female partner may developanti-sperm antibodies or suboptimal cervical mucus against her partner's spermcells. This underscores the need for both male and female partners to be tested

simultaneously when searching for the causes of infertility.Male Fertility TreatmentFor a long time male infertility was a mystery. Today, however, an accuratediagnosis can be made in about 80 percent of cases, and treatment issuccessful in more than half of these. Only when the cause of the man's infertilityis isolated can effective treatment begin. A low sperm count or low motility may becaused by a hormonal imbalance or by damaged sperm-producing cells due toinfection, trauma or a varicocele. Abnormalities associated with varicoceleoccasionally respond to surgical correction.The ability to deliver the sperm into the woman's vagina may also be a problem.This may be due to obstruction of the man's sperm passages resulting from trauma,

surgery or genetic malformation. Micro-surgery may correct theseproblems. PESA at West Coast Fertility is a highly successful technique used to
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collect sperm in cases of obstruction of the ejaculatory duct or after aprior vasectomy. It is performed in our Surgi-suite under anesthesia and involvesusing a fine aspirating needle to collect sperm directly from the testes. The sperm isfrozen and later it is injected directly into the female egg cell usingICSI, thusachieving fertilization.

How Age Affects Fertility The Impact of Age on Female FertilityWhat is the Biologic Clock?The "Biologic Clock" is a collective term that refers to the incessant winding down ofthe reproductive organs along with the physiologic wear and tear occurringthroughout the normal aging process.Few topics related to infertility arouse so much anxiety and confusion as the effectof aging on fertility and ultimately pregnancy. It is a source of internal stress that canbe overwhelming as a woman worries about her "biologic clock", which cansometimes lead to additional medical problems like anxiety and depression. Duringthis time it can be helpful to become well informed in order to best understand howthe physiologic process of aging affects fertility.What Happens to Reproduction as Women Age?Although it is not frequently discussed, reproduction in humans is very inefficient atbest. Even during peak human fertility in the teen years and the 20's, the chance ofpregnancy is about 20% per month, assuming a woman has regular ovulation, withopen Fallopian tubes and a partner with normal sperm production. Dysfunction inany of these factors can lead to infertility or may prolong the time needed to becomepregnant.Additional gynecologic problems such as endometriosis, pelvic scarring and uterinefibroid tumors can occur at any time and may interfere with the normal process ofegg entry into the Fallopian tubes or failed implantation of the embryo.

How does Aging Affect Human Eggs (Oocytes)?One of life's greatest ironies is that just at the right time when a woman is preparedemotionally and personally to begin her family, she may be confronted by theobstacles associated with infertility (Life is just not fair!)Note that the terms "eggs" and "oocytes " will be used interchangeably in thisdiscussion. At birth, most women (but not all) are born with about 2 millionoocytes (eggs) that are stored in their ovaries. Each egg is a microscopic, fluidfilled cell lying in a protective capsule called a follicle, which in turn is located withinthe ovaries.Each oocyte is formed with a pre-determined lifespan that cannot be altered andmay be as brief as a few days or up to many years. From the time of birth until

menopause, there is a natural, unrelenting loss or attrition of the oocyte number asthey are eliminated from the resting pool.The magnitude of egg loss is truly staggering, such that by adolescence, 90% of theeggs available for ovulation has been lost, leaving about 100,000 from the original 2million at birth (see graph 1). Unlike ongoing fresh sperm production in men, thereis no new formation of fresh, healthy eggs in women. (Again, life is not fair).Natural Egg (Oocyte) Decline in Women

Age Related Changes in the Internal Structure of Human EggsThe cytoplasmic fluid within the egg contains many tiny organelles along withmicrotubules collectively known as the cytoskeleton which control critical

internal motion and alignment. Certain organelles, like the mitochondria, are theenergy powerhouses of the oocyte and are essential for normal egg function.
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Disturbances within the structure of microtubules and aging of the maternalmitochondria can interfere with normal fertilization and growth. This may lead to thedevelopment of sub optimal embryos that fail to develop normally, leading toimplantation failure or loss of the pregnancy (miscarriage) during the first fewweeks.

Chromosomal and Genetic Abnormalities Associated with AgingAmong the most common types of errors related to aging is ANEUPLOIDY, a termgiven to numerical abnormalities in the number of chromosomes Physiologicaging can disturb the function of a delicate barrel shaped internal organelle calledthe SPINDLE resulting in uneven distribution of chromosomes as the embryobegins to grow. This can lead to the loss or abnormal duplication of entirechromosomes. This will lead to failed implantation of the embryo or may result inmultiple miscarriages. The most well known of these types of chromosomal errors isDown Syndrome where one extra chromosome is seen in the 21st pair ofchromosomes (Trisomy21).Chromosomes contain thousands of gene sequences that form the

"genetic blueprint" controlling every aspect of human life. Spontaneous errors orgenetically linked diseases can be transmitted in some families where the parentsare "carriers" of the genetic mutation. This may lead to a birth defect or an earlypregnancy loss because vital DNA information necessary for the development of anormal child is abnormal. An example of a genetic mutation is the disease calledCystic Fibrosis.These types of abnormalities can be diagnosed with In-Vitro Fertilization using aspecialized technique called Pre-Implantation Genetic Screening (PGS).

THE NATURAL PROCESS OF EGG SELECTIONOnly the Strongest Egg SurvivesEach month, at the start of a new menstrual cycle, the ovaries initiate recruitment of40 to 50 eggs from the resting oocyte pool. An elimination process begins such thatby ovulation time 14 days later, only the most favorable oocyte is released eachmonth.Even with this rigorous selection, an oocyte can still have undetectableabnormalities, which can slip by nature's protective screening mechanisms. Thesechecks and balances help minimize abnormal pregnancies, insuring that only thehealthiest embryos can implant.Unsuitable eggs may fail to become fertilized or not divide properly leading to failedimplantation or abortion. Unfortunately, the changes discussed above cannot be

reversed and with advancing age, even IVF may not overcome the eggabnormalities. In these cases the physician may recommend the use ofdonor eggsto bring about a healthy pregnancy and a happy family.
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