For a male to be fertile, the sperm must be produced and it must be viable and motile. Although only one sperm is required to fertilise an egg, a huge number of sperm is required to assist in fertilisation. The sperm may be formed but not released due to block in the male genital tract due to infection, injury or congenital absence of the duct named vas deference. The man may be impotent and unable to ejaculate or the ejaculation can be released in the backward direction.

The block can be even in the female genital tract due to block in the fallopian tube, or the sperm may be unable to penetrate the coverings of the egg and thereby unable to fertilise. Even if the egg is fertilised on its way back into the uterus it may be stuck in the fallopian tube or it may not be implanted in the uterus.

Male infertility is on the rise due to environmental pollutants and unhealthy lifestyle. Smoking and drugs are detrimental for fertility.

Low socioeconomic condition leading to poor bygone and sexually transmitted diseases, termination of first pregnancy by MR (menstrual regulation) and poor post-abortal care and post delivery care are important factors for female infertility in our country.

Infertility evaluation and treatment is planned at least after one year of normal conjugal life. Early interference is done if there is some known problems of the couple.

Investigation can reveal problem in the women, men, or both or the usual investigation may reveal no problem in any of the couple, but still they may need help to achieve a pregnancy. Waiting may be rewarding for some, but not for all, rather long waiting can make a treatable condition untreatable due to aging process of the couple especially the women's age since with the increase of age, the number of egg depletes as well as the quality of eggs also deteriorates. Elderly women are prone to develop tumours in the uterus and affected by disease process like endometriosis.

Sometimes small lifestyle modification can do the trick and solve the problem. Knowledge about the fertile period of the cycle and advice regarding sexual frequency can do the trick. Body weight adjustment both for the under and over weight can be beneficial. Avoidance of environmental pollution and understanding risk factors in different profession can help some of the patients.

Patients may require medication or surgical procedures to overcome their infertility. Stepwise fertility treatment may be enough for most of the couples. Only a small percentage will require advanced technology to overcome their treatment.

Ovulation induction is done with oral medication and injections, which are costly and the cost depends on the requirement of the women to develop mature eggs.

Intrauterine insemination can be done for patients with at least one patent tube in the females and moderate to mild male factor infertility and in patients in whom earlier treatment has failed. During this procedure, mature eggs are produced with drugs and then the husband’s semen is processed to separate and enrich the sperms so that the fertilisation potential is increased and then it is introduced into the womb.

Conventional in-vitro fertilisation is done in couples where there is problem in the female as for example if both the fallopian tube is blocked or there is severe endometriosis or simpler measures has failed to help the couple and the male partner has a normal seminogram. It is quite a safe procedure as it mimics the nature for the selection of the sperm and penetration of the ovum. If the quality of eggs and sperms are good it a safe procedure.

In couples where male partners have moderate to severe problems found in the semen analysis; or no sperm is present in the semen but sperm is present in the testis of the males; or during IVF cycle fertilisation is documented to be poor, intra-cytoplasmic sperm injection (ICSI) can be done where one sperm is injected into the ovum with a fine needle under a special microscope. ICSI has allowed men with extremely low sperm count to become the father of children which is not possible by any other means.

As a backup procedure Cryopreservation of semen and embryos helps in providing proper service to the patients. On the day of IVF, the husband may be unable to give a sample of semen for the procedure or for some undue reasons, cannot come to the clinic. In those situations the prior cryopreserved sample can solve the problem. There can be excess of embryos produced in a particular cycle which can also be cryopreserved and used in latter cycles or embryo transfer can be deferred for latter cycle to avoid the risk of hyperstimulation.

Assisted hatching is done in patients where the covering of the embryo is thick and in patients with previous failed IVF cycles to increase the chance of pregnancy.

Healthcare policy makers, medical insurance companies and banks may rethink their policies to help people.

A lot of simple steps can help in prevention of infertility. Proper weight management should start from puberty and thereby many long term complication of adulthood can be prevented. Nutrition, smoking environmental pollutants, personal hygiene, unsafe abortion or poor postpartum care, previous MR, sexually transmitted discases are some of the preventable steps for developing infertility.

Dr Parveen Fatema is an assisted reproduction specialist.