Describe infertility with its causes and management.

Infertility

• Primary infertility means the couple has never conceived; secondary means they have conceived previously, whatever the outcome of that pregnancy
• Evaluation may begin earlier than one year where the woman is over 35, or where there is a known cause such as amenorrhoea or previous pelvic surgery
• The causes, and their distribution is the point to lead with — roughly a third are female factors, a third male factors, and the remainder combined or unexplained
• That distribution IS the most important single fact IN the topic, because in India the woman is almost invariably blamed, investigated first and treated first, while the man may never be tested at all
• The practical consequence is that the male partner must be evaluated at the outset, not after the woman has undergone extensive investigation — and semen analysis is simple, cheap and non-invasive, so there is no defensible reason to defer it
• Female causes — ovulatory dysfunction, including polycystic ovary syndrome, thyroid disease and hyperprolactinaemia; tubal disease, of which the commonest cause in India is pelvic inflammatory disease and genital tuberculosis; endometriosis; uterine causes such as fibroids, adhesions and congenital anomaly; cervical factors; and advancing age
• Genital tuberculosis deserves particular mention as an Indian cause, since it is frequently silent, damages the tubes and endometrium irreversibly, and must be actively considered
• Male causes — abnormalities of sperm production — oligospermia, asthenospermia, teratospermia and azoospermia; varicocele; infection, including mumps orchitis and sexually transmitted infection; undescended testis; obstruction; endocrine causes; occupational exposure to heat, pesticides and heavy metals; tobacco, alcohol and anabolic steroids; and erectile or ejaculatory dysfunction
• The preventable causes are what a community medicine answer should emphasise — sexually transmitted infection and pelvic inflammatory disease; unsafe abortion and unhygienic delivery causing pelvic sepsis; genital tuberculosis; mumps, preventable by vaccination; occupational and environmental exposure; tobacco and alcohol; and obesity
• Prevention of these is a legitimate public health activity, and is far cheaper than treating the infertility they cause
• The basic evaluation — history from both partners, including frequency and timing of intercourse, which is occasionally the whole problem; examination of both; semen analysis; confirmation of ovulation; assessment of tubal patency by hysterosalpingography or laparoscopy; and hormonal and ultrasound assessment
• The social consequences in India are severe and must be stated — the woman is blamed regardless of the cause; she may face marital discord, desertion, threat of a second marriage, domestic violence, social ostracism and loss of status; and there is considerable psychological distress, depression and anxiety
• There is also exploitation by unregulated and expensive clinics offering treatment of unproven value to desperate couples
• The approach that follows — counsel and investigate the couple together, never the woman alone; explain the distribution of causes explicitly, which itself relieves the woman of blame; provide realistic information about success rates and cost; address the psychological burden; and discuss adoption as a legitimate option
• The regulatory framework — the assisted reproductive technology (Regulation) act, 2021 and the surrogacy (Regulation) act, 2021, which register and regulate clinics and banks, and permit only altruistic surrogacy, prohibiting commercial surrogacy
• Their purpose is to protect both the surrogate and the couple from exploitation, in a field previously unregulated
• A third male, a third female, the rest combined, which is the fact to lead with and the one that changes practice
• Test the man first or at the same time, since semen analysis is cheap and non-invasive
• Saying the distribution aloud is an intervention, since it relieves the woman of blame she would otherwise carry
• Genital tuberculosis is a silent Indian cause, damaging tubes and endometrium irreversibly before it is suspected
• Pelvic inflammatory disease is preventable, which makes STI control a fertility intervention
• Mumps orchitis is vaccine-preventable, which links immunisation to later male fertility
• Ask about frequency and timing of intercourse, which is occasionally the whole of the problem
• Investigate the couple, never the woman alone, which is both better medicine and better ethics
• Begin earlier if the woman is over thirty-five, or where a cause is already known
• Unsafe abortion and unhygienic delivery cause sepsis, and hence secondary infertility, which is entirely preventable
• Discuss adoption as a legitimate option, which is rarely raised and is frequently welcomed when it is
• Unregulated clinics exploit desperate couples, which is what the 2021 Acts were introduced to control
• Only altruistic surrogacy is permitted in India, with commercial surrogacy prohibited to prevent exploitation