Infertility: Causes and treatment -An interview with Dr. ‘Dayo Ayegbusi (FWACS Gynecology & Obstetrics)
Infertility is as old as the world itself.
It might interest you to know that the first recorded case of infertility occurred in the bible (Sarah and Abraham); this led to probably the first IVF performed to enable Sarah conceive at a very old age.
A major challenge we presently have in this country (Nigeria) and Africa at large is the sad fact that some men believe infertility is due to problems or issues with the women’s reproductive systems only. The general belief in some quarters is that any couple unable to achieve pregnancy must be as a reason of failings on the woman’s part.
In other (developed) climes, couples seeking fruits of the womb visit clinics together to resolve this issue.
For men, the fact that you impregnated a woman last year / month does not mean you can do it again.
What then is infertility?
Infertility is the inability of a couple to achieve conception after at least 1 year of living together, in spite of having unprotected, ejaculatory, peno-vaginal and adequate ( 3 – 5 times / week evenly spread) sexual intercourse.
Unprotected implies that no family planning or pregnancy preventive measure is in place; ejaculatory refers to adequate seminal discharge occurring during the act and not before or after; Peno-vaginal means the discharge occurred in the vagina by the penis, not outside.
Statistics for infertility
Unknown causes otherwise called idiopathic: 10%
Various statistics exist but the above appears to be the most agreed upon and as we can see, both male and female contribute equally to infertility incidences.
Please note that regular menstruation does not imply that you ovulate every month and the fact that you do not menstruate does not mean that you do not ovulate; Fertility specialists are however happier when you say you still menstruate monthly.
Also worthy of note is the fact that inability to menstruate does not prevent a woman from getting pregnant.
If the above definition is fulfilled but the couple is not able to achieve conception, the following factors could be responsible:
- No release of eggs.
- Poor quality,
- Inability of sperm to fertilize the eggs (e.g something preventing the sperm from meeting the egg such as a blockage or the woman’s body seeing the sperm as a foreign body thereby reacting abnormally to it).
- Weak sperm; too small or inadequate (the man is not producing enough sperm or he is making enough but there is blockage probably due to infection which has constituted a barrier preventing the sperm from coming out),
- Fertilization occurs but no healthy environment to thrive and grow.
Infertility can be classified into 2 – Primary and Secondary.
Infertility is primary if the couple has been married and trying for a baby for over 1 year and still unable to get pregnant despite fulfilling the above mentioned factors.
On the other hand, it is secondary if after having 1 or 2 babies; a couple is unable to have more babies in spite of doing everything to have more.
There are also other bends on the journey.
Contributory factors to infertility:
- PID which is one of the leading causes in our environment (and other infections affecting men and their genitals),
- Fibroid: this on its own does not cause infertility. If 10 women are randomly sampled, 6 – 7 are likely to have fibroid but it is the location and size of the growth that could stop or prevent pregnancy,
- Poor knowledge of fertile periods or cycles,
- Poor fertility hormones or hormonal in-balance,
- Previous abortions carried out by quacks or incompetent hands,
- Previous deliveries handled by quacks or incompetent hands,
- Previous poorly done / managed surgeries or body reacting adversely to healing resulting in distortion of regular anatomy / structure both in men and women
- Chronic medications
- Alcohol consumption
- Tight pants worn by men
- Long distance driving by men, etc
Majorly, the best thing to do is to prevent these causes as much as it depend on us, especially the modifiable causes.
The good news today is that nearly all cases of infertility are treatable and redeemable.
- It is highly imperative that genital infections are recognized and treated early before things get out of hand.
- If a woman has fibroids and is not getting pregnant, she should be accessed fully for possible surgery.
- Avoid quackery at all times and in all situations, even outside medicine.
- Do not self-medicate or take drugs not prescribed by a qualified medical personnel.
- Get full knowledge about your fertility periods.
Again, majority of these conditions and even extreme cases can be treated although a little ‘bend’ from normal can be explored.
For instance, let us consider a 60 years old woman who is desirous of being pregnant. You know such a woman would have had her eggs mostly dead if not entirely depleted. If any are viable, babies made from such are likely to come with congenital abnormalities and conditions. Such older women are advised to use donors but she would still be able to carry the pregnancy herself. Some cultures and religions however do not look subscribe to this.
Question: Some women have surgeries done to remove fibroid but are still unable to conceive, what could be the reason for this?
Answer: It is not out of the ordinary and that is why it is important to access the location of the fibroid, carry out further investigations to check the tubes before going ahead with the surgery.
Fertility specialists would tell couples to attempt to get pregnant actively for at least 6 months before fibroid removal surgery.
For such couples, they should get detailed surgery report and hand over to qualified fertility specialists. Thankfully, there is always a way out.
Question: Popular cultural belief absolves men of infertility, laying the blame squarely on women in this part of the world. In situations where women seek medical interventions with the men refusing to do same, can experts help such a couple?
Answer: This could be difficult because ideally, both parties are expected to present themselves for investigations. However, the lady can present herself immediately after having sexual intercourse and samples of residual sperm deposits obtained from the vaginal for investigations and assessment.
Question: Many affected couples are unwilling to seek medical advice for fear of the cost of treatment (IVF, etc), is there any new treatment procedures that are not as ‘expensive’ as IVF?
Answer: It is imperative that experts’ opinion is sought before anything is done in life. The truth is that before most couples approach fertility experts, they have most likely visited quacks that have either done further damages or drained their financial resources. It can be likened to a case of being penny wise, pound foolish.
Thorough questioning and investigations would help to understand better so that only relevant tests would be carried out before even considering IVF. There is also the option of IUI.
People perish due to lack of knowledge. Knowledge comes at a cost and we must also bear in mind that there is a cost attached to everything, even things we consider freebies.
Question: Is it possible for couples to get tested and nothing is discovered and yet no pregnancy?
Answer: Yes, it is.
Those are the 10% unknown causes referred to earlier on. However, if they are below 35years and no traceable cause(s), pregnancy would still occur.
Intrauterine insemination may be considered for them but if the woman is above 35 – 37, IVF may be more appropriate.
Question: Does age and diet affect sperm motility?
Answer: It depends really. An old man with no history of chronic illnesses has no problem.
Any food in the absence of diabetes would cause no problem but do avoid alcohol. In all, you need your sperm count to be at least 39 million, a concentrate of 15 million and just 40% motility of these to impregnate a woman.
Question: When stats are low, what is the remedy?
Answer: Let the concerned party avoid alcohol, check if he’s on any chronic drug, hypertensive or diabetic. His doctor should examine him and also carry out seminal fluid analysis.
Question: What are the remote causes of low sperm count in men?
Answer: From experience and literature, infection is the main culprit after ruling out hypertension and diabetes. People should run away from ‘casual sex’ and if it must happen, make use of condom. If you fail to take precautions and infection occurs, treat yourself immediately.
Science is beautiful because even men for whom infection has blocked reproduction, we go to aspirate these sperms, prepare them and inseminate when the woman ovulates.
Question: Why do IVF patients have multiple babies?
Answer: IVF involves taking sperm and fertilizing eggs outside the woman’s body with the aim of transferring later back into the womb.
Considering that IVF is very expensive with success not fully (100%) guaranteed, in order not to waste patient’s resources, most fertility specialists attempt to transfer more than one fertilized eggs into the woman’s womb. In the event that one fails, the others would most likely survive.
But sometimes after transferring the eggs, some of these go on to divide or multiply or all that are transferred survives often leading to multiple gestations.
But in Centers where freezing facilities are available, one fertilized egg can be transferred while the others are preserved by freezing them. If the one transferred fails, the frozen ones can then be utilized and introduced in subsequent months or cycles without the patient having to spend more.
Also, we are just developing our protocols here in Nigeria unlike other developed countries. This is being done by the National committee of which I am a member.
The primary goal is to regulate the practice which includes ensuring that every Fertility Center has a freezing facility and also to restrict the transfer of more than 2 embryos per cycle among others.
There is also a provision for reduction which we call ‘Fetal Reduction’ in IVF but it is technically abortion which is frowned at by most people and religions.
This means after transferring fertilized eggs and multiples are observed to be growing, the number is ‘reduced’ under ultrasound guidance without affecting the ‘needed’ one(s).
Besides ethical and religious reservations, it has numerous complications which include outright loss of all the eggs / babies.
So in effect, when you see or hear couples giving testimonies in churches with 2, 3 or more babies conceived after many years of infertility / trying to conceive, this is most likely what enabled it.
But like I always maintain, without God, none of these would be possible.
Question: With IVF, can sex of the baby be determined?
Answer: Yes, this can be checked using DNA before transferring but it comes with additional cost implications.
Dr. ‘Dayo Ayegbusi works presently at OAUTH, Ile-Ife, Osun State, Nigeria.