Lifestyle and Medical Management of Infertility

A menopausal woman has no retrievable eggs of her own, but she can still conceive using a donor egg, which is a common and well-established approach even at a young age. After menopause the ovary is no longer producing estrogen, so hormones are given from outside to prepare the uterine lining, a donor egg is used, and the pregnancy proceeds and can be carried to delivery without issue.

It is used as a screening tool before starting any infertility treatment, whether ovulation induction, IUI or IVF, to know whether the woman carries an abnormal haemoglobin such as haemoglobin S or C, or is a thalassaemia carrier. If she is found to be a carrier, the male partner needs to be evaluated too, because of the inheritance risk: if both partners are thalassaemia minor carriers, for example, there is a 25% chance of a child being thalassaemia major. Couples in this situation may need genetic counselling or pre-implantation genetic testing, screening embryos for these conditions before transfer.

Sperm found in urine points to retrograde ejaculation, which usually follows a pelvic, perineal or urological surgery, or occasionally occurs in diabetes. Natural conception is not possible in this situation. The approach is to give the male partner an alkalinizing agent, then collect a urine sample immediately after ejaculation, centrifuge it and separate the sperm. Depending on the concentration recovered, those sperm can then be used for IUI or for IVF with ICSI. Any underlying epididymitis should be treated with antibiotics first, and the infection cleared, before using the sperm collected this way.

For oligospermia, the approach depends on how low the concentration is: a genetic evaluation including karyotyping and Y-chromosome microdeletion testing is warranted, alongside correcting modifiable lifestyle factors such as smoking and alcohol, and giving antioxidants. Because sperm production takes about 90 days from formation to transport, semen analysis should be repeated after 8 to 12 weeks. If genetics are normal and the count improves, IUI is reasonable; if not, assisted reproduction is the next step. For azoospermia, a full hormonal evaluation is needed to distinguish hypergonadotropic from hypogonadotropic causes. A hypogonadotropic pattern can often be managed medically with gonadotropins. A hypergonadotropic pattern means the testes themselves have failed, and the approach then is surgical sperm retrieval, such as TESA or micro-TESE, followed by ICSI.

In a natural cycle, a cohort of follicles starts to grow under the influence of FSH, but only the most FSH-sensitive one becomes dominant and ovulates while the rest undergo atrophy. After ovulation, the corpus luteum releases progesterone, fertilization takes place in the fallopian tube, and around the fourth day the resulting embryo enters the uterine cavity and implants. Through the same cycle, estrogen from the growing follicle has been building up the endometrial lining in preparation. If pregnancy does not occur, that lining sheds, and that shedding is menstruation. Menstruation happens precisely because pregnancy has not occurred; if it has, the lining is not shed.

A healthy weight through diet and exercise, complete cessation of smoking and alcohol for both partners, limiting caffeine, and stress reduction through yoga or meditation, since these factors affect sperm function, egg quality and implantation potential.

Only in specific situations identified by hormonal testing: gonadotropins help when both testosterone and FSH/LH are low, and aromatase inhibitors help obese men with a low testosterone-to-estradiol ratio. When the testes themselves have failed, medical treatment has little role and assisted reproduction is generally needed.