Causes :

Retrograde ejaculation [during orgasm, sperm Enter the bladder & mix With urine ]  No production of sperm in the testes [because of trauma,mumps, Hypogonadism  surgical removal, Chemo or Radiotherapy] of testis, undesanded testis.   sperm production is there, but cannot enter in ejaculated semen. [obstruction at various levels in the path way of genital tract ]

Possible Solutions :- 1) ICSI For obstructive and non-obstructive Azoospermia(Normal spermatogenis, no sperm in     the ejaculate). 2) Sperm donation :           - No sperm in the testis           - can’t afford IVF-ICSI treatment. Oligo Asthenozoosperima [Abnormality in number, morphology and movement of sperm] Causes : Hormone deficiency Hyper prolactanemia Varicocele [abnormal swollen blood vessels around the testicles] Infection Use of certain drugs like antidepressants, anticancer and anti  hypertensive Use of steroids Excess alcohol Heavy smoking Frequent hot baths or saunas Antisperm antibodies Testicular cancer Life style variation [physical, mental stress & strain, pollution, unbalanced diet] Possible solutions : Fertility drugs to increase sperm production Use of Antioxidants invitro or invivo Change in life style Balanced diet IUI IVF-ICSI Use of donor sperms. Impaired sperm fertilization capacity or sperm dysfunction : -Morphologically normal sperms, but fail to penetrate the oocyte[egg]

Causes :

Possible solutions :

• Treatment with antioxidant to reduce the level of free oxygen radicals either invivo or invitro
• ICSI

Inability to ejaculate in the vagina :

Causes :

Penile problems

• very small penis
• obesity
• premature ejaculation
• impotency – psychological or pathological
• hypo and epispadiasis

Possible solutions :

• counseling in case of premature ejaculation
• reduction of weight for obese
• IUI , IVF or ICSI in case of epi or hypospadiasis
• Supportive medicines to sustain erection

Immunological infertility :
Antisperm antibodies can be present in either or both the partners. It can be present in blood, cervical mucus, or ejaculate.

Causes :

• Genital infection
• Trauma to the testicles
• Varicocele
• Vasectomy
• Reversal of vasectomy

Possible solutions : Sperm washing and IUI / IVF/ICSI Immuno suppressive drugs. Coital failure : Causes : 1.Lack of Libido excess physical or mental strain psychological testosterone deficiency High prolactin levels Treatment counseling correction hormones, yoga, meditation, change of life style for stress 2. Physical problem :           - spinal cord injury           - prostatectomy           - bladder neck surgery           - multiple sclerosis           - chronic illness           - side effects of drugs           - excess alcohol           - premature or delayed ejaculation           - failure of erection or anejaculation           - congenital penile abnormalities Treatment psychosexual therapy sex education IUI/IVF Surgical correction of congenital problem of penis Unexplained Infertility : None of the investigations are abnormal through investigations. Possible solution : IUI/IVF / ICSI Varicocele, undescended testis, obstruction in sperm conduction pathway and some time for vasectomized male, recanalization can be done through surgical techniques

Causes For Female infertility :

1. Vaginitis : infections like candidial , fungal, mixed bacterial infections can change the PH alkaline to acidic and in case of Acidic PH sperm cannot survive.

Solution : Treatment of respective infections

2. Cervical mucous hostility :

• The post coital test is used to check for the presence of “hostile” cervical mucus. It is performed up to 12 hours after intercourse. A small amount of mucus is taken and checked for amount of elasticity of the mucus and the number and quality of sperm present in the sample.
• If mucus is not enough, too thick or sticky it won’t allow the sperm to move easily.

Cause : poor estrogen stimulation, cervical glands, or infection of cervical glands, H/o cervical surgery, presence of antisperm antibodies in the mucus.

 Treatment

• correction of infections
• use of condom for 2-3 months to reduce antibody level
• use of immunosuppresants to counter antibodies
• IUI- IVF – ICSI

3. Ovulation problems :

a) Ovulation irregularity or anovulation :
This happens because of Hypothalomo pituitary ovarian axis dysfunction. Some times other hormones like thyroxin, prolactin insulin interfere this process.

Treatment : ovualiton inducing agents Ex : CC, tomoxifen, gonadotrophin injections, oral antidiabetics, correcting the prolactin and thyroxin levels. 

b) Absent ovary :
          - by birth
          - surgical removal
          - premature ovarian failure
          - menopause

Possible solution  : ovum donation and IVF treatment

4. Uterine problems :

a)  Anatomically abnormal
          - different size and shape of uterus by birth ex: septate uterus, bicornuate
             uterus etc.
Solution : some times it contributes for infertility. Thus surgical correction has to be done.

b)  Uterine pathology

• fibroids – surgical removal if necessary
  
  

  Myomectomy [ Removal of Fibroids]

  •  Myomectomy is a surgical procedure that primarily addresses superficial tumors of the uterus or fibroids. For e.g. pedunculated tumors that have a stalk and are separate from the uterine muscle, and easily reachable tumors on the outer surface of the uterus. •  In traditional myomectomy a bikini incision will be used, but for large tumors sub umbelical midline incision will be used to accommodate for the enlarged uterus.

  
  
• Adenomiosys– suppression with pregesteron
• Endometrial Polyps – surgical removal
  Polypectomy [ Removal of poly P]

  •  either by hysteroscpe or by simple D & C procedure poly p can be removed.

  
  
• Infections- treatment of infections
• Thin Endometrium [inner layer of uterine wall]
  • Infections
  • Repeated D&C

Possible solution

• treatment of infections, hydrotubation with drugs, some times to separate the wall of uterus and allow growth of endometrium.
• Copper T is inserted for 2 months.
• Some times supplements of estrogen and progesterone
• If there is thick endometrium i.e endometrial hyperplasia suppress the estrogen hormone oral pills for 3 monhts, or GnRHa Depo injection for 1-2 months, or D&C once.

5. Tubal problems :
          Causes : infections – Ascending
                                     - Systemic

Ascending : through intercourse ex: Gonorrhea, Chlamydia etc, after D&C, Copper T, delivery or abortion either spontaneous or evacuation and curettage.

Systemic : Tuberculosis either directly to genital system or subclinical spread from other parts of the body.
Post infections : any infections damages the tubular structure specially inner layer of tubal wall epithelium. So that transport and nutrition of sperm is affected, and they can get killed due to presence of toxins.

6. Poor Egg quality
          - chromosomal abnormalities
          - exposure to toxins, chemicals, radiation etc

Possible solution : Egg donation

7. Polycystic ovarian syndrome :

Too many follicles, none reaches mature state. Here we find irregular menstrual cycle, hirsutism , presence of Acne, weight gain etc, anovulaiton

Possible solution :

• ovulation induction drugs
• Laparoscopic microcauterisation of ovarian capsule
• Laser Assisted hatching at the time of IVF

8. Endometriosis :

Endometriosis is defined as presence of actopic endometriam other than natural place. It occurs when tissue (which lines the uterus) is found outside the uterus – usually in the abdomen, on the ovaries, tubes, and the area between the vagina and rectum, the outer surface of the uterus and the lining of the pelvic cavity, utero-sacral legaments. Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva and in abdominal surgical scars.

Causes of endometriosis :

Possible solution :

The goal of variety of treatments include relieving pain symptoms, shrinking or slowing endometrial growths, preserving or restoring fertility and preventing recurrence of the disease.

a. Drugs : [for Grade I and II Endometriosis ]Pain relievers may include aspirin, prostaglandin, inhibitors such as ibuprofen, naproxen sodium, 

b.Hormonal Therapy : [for Grade I and II endometriosis] It aims to stop ovulation for as long as possible and may include oral contraceptives , progesterone drugs and GnRH agonist.

c. Surgery : [for Grade III and IV Endometriosis] This procedure can be either done with laparoscopy or with laprotomy. The procedure involves the endometriosis being cut away or burned, and the adhesions divided. Chocolate cysts are removed and their lining destroyed to prevent the cyst from reforming.

d. IUI / IVF/ICSI : women with minimal or mild endometriosis, who have healthy tubes are advised for artificial insemination. For severe to moderate endometriosis IVF / ICSI is an effective treatment.

9. Immunological Infertility :

Affects entry of sperms in the genital tract or into egg. Antibodies against sperm can be there at any level of genital tract. If it is in the tract sperm cannot reach the egg. If there is antibody over zona pellucida of egg – sperm cannot penetrate the egg.

Possible solution :

• Immuno suppression/ IUI/IVF – if Antibody in the genital tract.
• ICSI – antibody over zona pellucida.
• Genital tract infection should be treated

10. Coital Failure :

Causes :

• psychological fear
• congenital abnormalities [ rigid/rough/ hymen, narrow entrance]
• Vaginitis
• Infections
• Endometriosis

Possible solutions :

• psychological counseling
• surgical correction
• use of lubricants , pain killers, tranquilizers
• treatment of infection

11. Unexplained infertility :

Causes :
None after thorough investigations of both partners, however possible causes include

• Defective fimbriae, unable to pick up the egg at ovulation
• Sperm lacking the fertilizing capacity
• Defective endometrium – lack of necessary cascade of chemicals like interferons, interlukins, TNF and growth factors etc.
• Psychological

Possible solutions :

• IUI/IVF /ICSI
• If couple won’t get success through this treatment ovum, sperm or embryo donation are the options
• [Third party reproduction ]- surrogacy