The definition of infertility

For couples that are trying hard to become parents the name of Professor Bağış draws immediate attention and brings hope. With 16 years of experience in the reproductive medicine, around 15.000 IVF cycles performed, and a very interesting point of view on the immunological infertility theory the head of Assisted Reproduction Department in ACIBADEM Altunizade Hospital is a world renowned specialist in this delicate and challenging field. In the following material Prof. Tayfun Bağış speaks clearly about the definition of infertility – not all people know exactly when can we diagnose it – , the main causes of this problem named by the World Health Organization a global health issue and the solutions that medicine can offer at this moment.

Let’s talk about the diagnosis of infertility. You say that so many couples dismiss the real diagnosis. What is the real diagnosis?

Prof. Dr. Tayfun Bağış: For example, a couple wants to have a baby. In the first month, the chance is nearly 20%. So, it means that not all of the couples become pregnant when they want. But when we are following these couples, for example we take 100 couples and we follow them 6 months, we see that nearly half of them become pregnant. It doesn’t mean that every month 20% of the couples become pregnant. In the first month, it is 20%, in the 6th month, it is 50%. When we follow these couples 1 year, after that year the chance to have a baby is 85%. If you cannot catch 85%, if you are not in that percentage, it means that you have a problem becoming pregnant. So we are asking why you are on the other side. The diagnosis of infertility is no pregancy in spite of having regular sexual intercourse for 12 months. Maybe we should also clarify what is regular intercourse. When a couple has two times per week sexual intercourse, it’s a regular intercourse. Why does medicine consider this regular? Because the sperm survives in the body nearly 72 hours and the female egg only survives 24-48 hours after ovulation. So if you have a sexual intercourse today, the sperm is in your body for 3 days. And so on, if you have sexual intercourse two times per week, you will cover all the ovulating period even if you cannot guess the exact day of the ovulation.

So, in spite of regular sexual intercourse, if the couples cannot become pregnant, the diagnosis is infertility. Why does infertility appear?

Prof. Dr. Tayfun Bağış: Basically we can say that 40% of the causes are women related, 40% men related and 20% couple related and we cannot explain it – this condition is diagnosed as unexplained infertility. We cannot explain it, but it doesn’t mean that the problem doesn’t exist. We don’t know whether the sperm arrives inside the cervix, we don’t know whether fertilization takes place, we don’t know whether the patient has a problem with implantation or not. This is unexplained infertility. Now let’s go back to women related causes of infertility. In the women’s side, the most common situation that does not allow a pregnancy is when these tubes are blocked. Actually, this is the reason why IVF has been developed in the first place. There were some women back in 1978 who could not conceive naturally, their tubes were blocked, and the doctors said how we can help them? Oh, we can take the oocyte outside, we can fertilize them and we can put it again inside of the future mother. So, this is the basic concept, the basis of in vitro fertilization. Other women have an ovulation problem, they cannot ovulate and this is the reason for their infertility. Some women have endometriosis. And in some women the age factor plays the most important role in infertility. When women become older and older, each year the fertility decreases. Step by step. After 36, the decreasing rate is very dramatic. When we look to the men’s side, we have the following causes: the low number of sperm count or motility or sperm problems. There are many diseases that can decrease the sperm count, but in the majority of cases we actually don’t know the reason for this decrease.

How do we find out the exact cause for every couple?

Prof. Dr. Tayfun Bağış: We have to do some tests. In this area there are a lot of tests, you can do this, you can do that, also there is this… But the most important tests that are directly correlated with pregnancy chances are three tests: you should show that woman has ovulation or not. For this, you can make a progesterone test, you are looking for progesterone one week before of the expected menstruation. If the progesterone is high you can say ok, there is an ovulation. In the second test, you have to look whether the tubes are open or not. This is called hysterosalpingography. If the tubes are open and the ovulation is evident, you have to look at sperm also. I recommend that these tests should be done together. Maybe it’s better to talk a little bit about the sperm test also. So, to take a sperm test, the man should have a sexual diet – sexual abstinence for three days, and he should come to the clinic and give a sperm sample by masturbation. So, if you’ve done these three tests, maybe you can look at the ovarian reserve also. In man, sperm production is continuous in all age. When the man is going to be 85 years old, if he is going to marry with a young woman, he can make her pregnant. But it is not same in the woman because the egg is being developed when the she is in her mother’s womb. The number increases nearly 4 to 6 million eggs in intrauterine life and after 20 weeks of gestation these numbers decrease very sharply. When the baby girl is born, she will have only 1-2 million egg cells. After this time, due to decreasing levels or elimination or atresia, when the girl has the first menstruation, she will have left 400.000 or 500.000 egg cells. This is the only egg cells that she can count on for having a baby. So each month the woman loses nearly 1000 egg in order to ovulate one. So it means that in the reproductive life of the woman, she can ovulate nearly 400 or 500 times. So during this period, she will try to have a baby. Then this follicles finish and we say that menopause has installed. In some women, the age of menopause could be normal after 45, but for nearly 1 in 10 women the menopause becomes evident between 40 and 45. And for 1 in 100 women the menopause comes before 40 years old. So this is general population we are talking about. But when we look to the women who couldn’t become pregnant, maybe this ratio is higher. We can know the follicle number left by making an ultrasonography, or more specific blood tests that shows how’s your reserve. Maybe this test could not affect natural pregnancy rates, but it could help us in deciding which treatment is going to be done to the couple.

When the results arrive what is the plan for every scenario?

Prof. Dr. Tayfun Bağış: If the woman has an ovulation problem, it’s very basic for us. We are giving some drugs to produce ovulation and we are waiting for the pregnancy, 6 months. If the woman’s tubes are blocked, we can say you should have IVF. If the woman has endometriosis, we think there are two options: in some cases we perform surgeru and wait for 1 year and if they cannot become pregnant we offer IVF, or we recommend directly IVF. So you see that in each position the treatment is different. When we are looking at male factors, so spermogram, we are calculating how many motile spermatozoids does the man have. If the number of motile sperm, in spite of low number, is higher than 10 million, maybe we say that “ok, wait a little bit more”. If it is lower than 5 million, we are directly talking to the patients about IVF. Let’s also approach the 20% unexplained infertility. So we know that if the patient’s age is younger age, younger than 35, if the infertility duration is not very long, for example after 1 year and we couldn’t find anything, we know that in these couples in the next year nearly half of them will become pregnant. So you don’t need to do anything. We tell them to wait, wait a little bit more, 6 months, and if you cannot become pregnant, we are going to help you. If 6 months or one year passes and they couldn’t conceive, now there are two options: one option is insemination, the other option is IVF. This is a controversial issue in medicine: which is better? Because many doctors take the patient to the IVF directly. Another part, like myself, advises them that nearly three insemination equal one IVF. Many studies support this affirmation. But to have an insemination, you should have unexplained infertility or only mild male factor infertility, not very serious infertility problems. In these serious cases, we are telling the costs, time and the success rates and we give the couples the opportunity to select one of them – insemination or in vitro fertilization. They are the ones making the decision, each couple’s decision is different.