 |  | Healthy Women, Healthy Mothers - An Information Guide - Second Edition (FCI, 1995, 241 p.) | ||
 |  | Chapter Nineteen - INFERTILITY | ||
|  | (introduction...) | ||
| | Causes of Infertility | ||
| | Tests and Counselling for an Infertile Couple | ||
| | Treatment of Infertility | ||
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A couple is described as infertile if the woman has not gotten pregnant after having normal sexual intercourse two or three times a week without using any contraception for at least one year. Normally, 85 out of 100 young couples who want to have a child can do so within a year of trying. The chances are slightly lower if the woman is over the age of 30, and significantly lower if she is over the age of 40.
Sexually transmitted diseases and other infections of the reproductive organs are fairly common (see Chapter 18). These infections can cause permanent damage to the reproductive organs of both men and women. As a result of these diseases, as many as one in four couples in Africa may experience some difficulty getting pregnant. In a culture where fertility is highly prized and children are seen as gifts from God or a sign of approval from ancestors, infertility may be regarded as a great misfortune for the couple. It can be especially hard for a woman. She may suffer unhappiness, social rejection, and a sense of personal failure in a society where childbearing is seen as one of the most valuable contributions a woman can make to the family.
This chapter will review some of the common causes of infertility. It will also review tests and investigations that can be conducted to try to find the causes of infertility, as well as possible treatments and their chances of success.
Infertility is a problem involving two people. On average, the cause of the problem lies with the man 40% of the time and with the woman 40% of the time. In the remaining 20% of cases, both the man and the woman contribute to the problem.
CAUSES OF INFERTILITY IN MEN
As discussed in Chapter 3, the man's role in reproduction involves producing sperm and transporting them into the woman's vagina. Male infertility has two main causes:
POOR QUALITY OF SEMEN: Most infertile men have poor quality semen, especially a low number of sperm or sperm that cannot move. There may be too little semen (the normal amount in each ejaculation is about one spoonful), or it may be too thick or too watery. The causes of poor semen quality include:
· Physical factors such as excessive heat due to wearing tight underwear or working for long periods near ovens or furnaces; direct injury to the testes; excessive smoking and drinking; drug abuse, especially the use of marijuana, heroin, cocaine, etc.; any general and prolonged illness; and certain specific diseases such as diabetes or thyroid disease.· Infection or disease of the testes; for example, mumps infection after puberty.
· Failure of the testes to descend from the abdomen at an early age.
· Abnormally small testes.
INABILITY TO DEPOSIT SEMEN IN THE VAGINA:
The failure to deposit semen in the vagina can be due to a number of reasons. Sometimes the semen cannot come out of the testes because the passage is blocked (see Figure 19.1). This can result from a sexually transmitted disease, especially gonorrhoea or chlamydia (see Chapter 18). Tuberculosis can have the same effect. Impotence, the inability to have an erection or to maintain it during sexual intercourse, is another fairly common cause of infertility. It can be caused by emotional, psychological, or physical stress. Sometimes the man ejaculates his semen before the penis is inside the vagina; this is called premature ejaculation.
Figure 19.1: Blockage of the
Vas Deferens
A common cause of infertility in men is blockage of the vas deferens, the tube that carries sperm out of the penis. It is usually caused by a sexually transmitted disease such as gonorrhoea or chlamydia.
CAUSES OF INFERTILITY IN WOMEN
For a woman to become pregnant, several things must happen, as described in Chapter 4:
· An egg must be released from the ovaries (ovulation);· The egg must find its way into the fallopian tube where fertilisation takes place;
· After fertilisation, the egg must be moved along the fallopian tube to reach the womb within seven days;
· The lining of the womb must be properly prepared for the egg to attach itself securely.
If for some reason any of these conditions is not met, pregnancy cannot occur. The common causes of infertility in women include the following:
FAILURE TO OVULATE (ANOVULATION): Ovulation is a complicated process, which involves parts of the brain, the ovaries themselves, and several chemicals produced by different organs in the body. A problem with any of these organs can make ovulation irregular or infrequent, or cause it to stop altogether. In most cases, a woman's menstrual periods will be irregular or stop altogether if she is not ovulating. Failure to ovulate is the cause of infertility for about 20% of infertile women.
TUBAL BLOCKAGE: By far the most frequent cause of infertility in women in Africa (about 75% of cases) is blockage of the fallopian tubes. The blockage may prevent the sperm from reaching the egg, or it may prevent the fertilised egg from reaching the womb (see Figure 19.2). It is usually caused by infection, which in turn is most often due to:
Figure 19.2: Blockage of the
fallopian Tubes
The most common cause of infertility in women is blockage of the fallopian tubes. It is usually caused by repeated cases of gonorrhoea or chlamydia.
· STDs, particularly repeated attacks of gonorrhoea and chlamydia (see Chapter 18).· Infection of the reproductive organs following miscarriage or, more often, unsafe induced abortion. Infection can damage the fallopian tubes as described above, or it can damage the lining of the womb and make it difficult for the fertilised egg to implant itself. Infection can also cause constant pain in the pelvis; this pain may be so severe that sexual intercourse is not possible.
In order for the testing or investigation of infertility to be complete, both the man and the woman must cooperate and participate fully. Often they must also cooperate for the treatment to be successful. A couple should understand that the proper investigation may take a year or even longer. It involves many tests, so it can cost a lot of money, cause a lot of inconveniences, and take a lot of time. For many of the tests, the couple must have immediate access to the hospital or clinic where the investigation is being done. For these reasons, it would be very difficult, if not impossible, for a couple who is poor or who lives far from the hospital to go through the investigation. Finally, the couple must be prepared to accept an unfavourable outcome of the tests without blame.
WHEN SHOULD TESTING BEGIN AND WHAT WILL IT INVOLVE?
If a woman has not conceived after having regular sexual intercourse (without contraception) for one year, she may want to begin investigations, especially if she is more than 25 years old. Testing will involve the following steps:
COUNSELLING: The first meeting with the doctor is extremely important, and both husband and wife must attend. The doctor will want to have a full and frank discussion with the couple about their general health, past medical history, social habits, and attitudes towards children in general and their specific problem in particular. They will be asked questions about their sexual relationship: the frequency and timing of sexual intercourse, and whether or not they have any problems. After this general discussion, the doctor may talk to each member of the couple alone because there may be things one partner does not want to say in front of the other.
PHYSICAL EXAMINATION: After discussions with the couple, the doctor will examine the man and woman separately to rule out any illness or other obvious medical explanation for infertility. After these examinations, the couple and doctor need to decide whether further tests are needed and when to start. Some of these tests are described briefly below. A specialist should be consulted for more information.
TESTS FOR INFERTILITY IN MEN: It is easier to find out whether it is the man who is infertile, so tests should usually begin with him.
· Semen analysis: The aim of semen analysis is to find out if the man is producing enough normal sperm capable of fertilising an egg. The most important things to look for are number of sperm and the percentage of sperm that is active. The doctor will explain how the semen is collected.· Biopsy of the testes: Since the sperm are produced by the testes, the doctor may suggest an examination under a microscope of the tissue of the testes. This involves making a small cut in the skin and the testes and removing a tiny bit of tissue.
TESTS FOR INFERTILITY IN WOMEN: Many tests can be carried out on women who have difficulty getting pregnant. To understand some of the tests described here, it will be helpful to look again at Chapter 4 where the processes of menstruation, ovulation, fertilisation, and implantation are described. It will also be helpful to read Chapter 17 on family planning.
· Tests for ovulation: Chapter 17 described several ways to identify a woman's "fertile phase", that is, the phase during her menstrual cycle when she can become pregnant. These methods - the calendar, temperature, and cervical mucus methods - provide some indication that she has ovulated. However, the tests take a lot of time, and are not very reliable.· Tests for tubal patency: There are two tests that can be done to find out whether the fallopian tubes are blocked. They require advanced equipment or an operation, and are therefore expensive. For more information, a specialist should be consulted.
· Cervical mucus test: The mucus or fluid produced by the cervix can either help or hinder the movement of the sperm into the cervix, through the womb, and into the fallopian tubes. On rare occasions, the cervical mucus and the fluids in the vagina may contain chemicals (antibodies) that paralyse or inhibit sperm.
· Tests after intercourse: For this test, the woman goes to the hospital within six hours of having sexual intercourse. A specimen of semen combined with cervical and vaginal fluids is examined under a microscope to detect the number of live and mobile sperm.
There is no general treatment or "cure" for infertility. In general, treatment depends on the specific cause of infertility for that couple. The majority of couples who seek advice, testing, and treatment for infertility do conceive. As many as 50% of the women become pregnant within 12 to 18 months of starting the investigation, most of them even before investigations are completed or treatment has started. Another 20% of couples achieve pregnancy and have a baby when the cause of their infertility is treated.
When no obvious explanation can be found for infertility, counselling may improve the couple's chances of achieving pregnancy. For example, advice on general health, regular exercise, and avoiding excessive drinking and smoking can sometimes help. The couple can also be taught how to identify the most fertile phase in the woman's menstrual cycle, when sexual intercourse is most likely to result in pregnancy.
Unfortunately, about three out of ten couples (30%) who come for help do not conceive. In these cases, adopting a child to love and raise is an option.
TREATMENT OF INFERTILITY IN MEN
The majority of infertile men produce too few sperm, or no sperm at all. A few men who have this problem can be helped by treatment with male hormones, but in general not much can be done to increase the number of sperm.
TREATMENT OF INFERTILITY IN WOMEN
ANOVULATION: When a woman does not ovulate regularly, she can be treated with drugs or hormones to induce ovulation. This treatment can be expensive, however, and only about 40% of women who receive it and begin ovulating regularly become pregnant. There is also a high chance that women who receive treatment for anovulation will produce twins or multiple births. For reasons that are not fully understood, pregnancies that result from this treatment often miscarry.
TUBAL BLOCKAGE: Most cases of infertility in women are due to blockage of the fallopian tubes caused by previous infection. Such women often need an operation to try to open up the fallopian tubes. An operation may also be needed to repair problems in the womb. The chances of becoming pregnant after such operations are not very good.
Summary: Infertility
Many factors can make a couple unable to have children. The problem can be either with the woman or with the man. The major causes of infertility are:
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CAUSES OF INFERTILITY IN MEN |
CAUSES OF INFERTILITY IN WOMEN |
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Poor quality of semen: Not enough sperm Inability to put semen in the vagina, caused by: Blockage of the tube in the man's penis that carries the semen. This is usually due to sexually transmitted diseases TREATMENT: The most common cause of infertility in men is inadequate sperm. Some men can be treated with male hormones, but in general not much can be done. |
Failure to ovulate (release an egg) Blockage of the fallopian tubes that carry the egg to the womb, usually due to infection of the reproductive organs, caused by: Sexually transmitted diseases, especially gonorrhoea or chlamydia (see Chapter 1 8) TREATMENT: If the problem is with ovulation, some women can be treated with hormones. This is not always successful. If the problem is blocked fallopian tubes, an operation can be tried, but again this is not often successful. |
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