Infertility is defined as the inability to conceive after 1 year of regular unprotected sexual intercourse in individuals of reproductive ages. It can also refer to the inability of a female to carry pregnancy to full term.
The word fecundability refers to the probability of achieving pregnancy in a given month or menstrual cycle and the term fecundity is defined as the ability to achieve a live birth within 1 menstrual cycle. Healthy couples under the age of 30 who have regular sexual intercourse without contraception have 25% to 30% chance of getting pregnant each month. The age when fertility starts to decline vary from woman to woman. A woman is most fertile in her early 20s and the chances of a woman getting pregnant drops greatly after age 35.
The incidence of the various factors which cause infertility varies among different populations all around the world. Generally, males contribute about 30% of the cause of infertility, females contribute about 30% and both males and females contribute 30% of the problem. 10% is attributed to unknown causes which cannot be explained (unexplained infertility).
Infertility have both social and psychological effects on the couple suffering from it. The consequences are manifold and can include a lot of emotional effect which can lead to the couple getting greatly distressed and loss of control which is being compounded by social stigmatization. Marital discord can develop and depression can also set in especially for the women involved.
The scope of infertility in women encompasses when
- The ovaries cannot produce eggs or
- Eggs are produced but cannot travel from the ovaries to the uterus or
- Fertilised eggs are able to travel to uterus but cannot implant (attach to the lining of the uterus) or
- Fertilised eggs implant in the uterus but does not survive through the pregnancy.
Risk factors for infertility in females include the following :
- Age >35years
- Excessive smoking and alcohol
- Obesity or overweight
- Weight loss or low BMI
- Diet insufficiency of folic acid, iron, zinc and vitamin B12
- Excessive exercise
- Mental stress
- Delay of childbearing by “career women”
Medical causes of female infertility
Any condition that can interfere with ovulation, tubal patency and implantation can cause infertility.
Ovulatory causes account for about 25% of cases and include premature ovarian failure before age 40, polycystic ovarian Syndrome, poor follicles quality, hyperprolactinemia, thyroid problems (hyperthyroidism and hypothyroidism), chronic conditions like AIDS and cancer and hypthalamic-pituitary disorders cause hormonal imbalances which interferes with ovulation process and hence, fertility.
Tubal problems as a result of pelvic inflammatory disease (from gonorrhoea and chlamydia) is the most common cause of female infertility in Africa with about 60% of all cases. Other sources of tubal cause of infertility are pelvic surgeries that scar the Fallopian tubes and previous female sterilisation.
Uterine causes are from previous dilatation and curettage or therapeutic abortion which result in intrauterine adhesions. Uterine fibroid, endometriosis, and congenital uterine anomalies can lead to recurrent abortions. Cervical scarring from D&C, cervical incompetence and other factors that reduce the quantity and quality of cervical mucus may reduce sperm viability and ultimately cause infertility.
Radiation exposure especially of the pelvis, chemotherapy and long term use NSAIDs are co-factors for infertility in women.
Sperm problems like low sperm count, low motility or mobility of the sperm and abnormal sperm shape are responsible for infertility in males.
In addition, semen problems arising from testicular infection, cancer or surgery as well as overheated testicles from undescended testes, varicose veins in scrotum, tight clothes and hot environment, can cause infertility in males.
Ejaculation disorders from blocked ejaculatory ducts are causative factors. Hypogonadism can lead to testesterone deficiency. Bladder neck or prostrate surgery and vasectomy contribute to make infertility.
Some other male risk factors for infertility include
- Genetic disorders
- Mumps infection during childhood
- Cystic fibrosis affecting vas deferens
- Other conditions like cushing’s syndrome, diabetes and thyroid disease
- Mental stress
- Age >40years
- Excessive alcohol and hard drugs use
- Use of body building steroids
WHEN TO INVESTIGATE INFERTILITY
- When conception does not occur after 1year of unprotected sexual intercourse.
- Before 1 year if the woman is >30years.
- Immediately if there is history of previous STD, mumps, orchitis, surgery for undescended testes, PID, post abortal sepsis, previous TB, laparatomy for peritonitis, appendicitis or any pelvic study.
APPROACH TO INVESTIGATION AND DIAGNOSIS OF INFERTILITY
- History taking of couple together and individually
- General physical examination for both man and woman and pelvic physical examination for the woman. Check size of testes for the man.
- Semen analysis for the man to check PH, sperm concentration, total sperm count, motility, morphology and survival rate of sperm.
- Test for ovulation in the female through basal body temperature chart. 21 day serum progesterone test, endometrial biopsy and serial ultrasound to see follicular development. Check for tubal patency through laparoscopy and do post coital test to monitor cervical parameters and active sperm.
TREATMENT OF INFERTILITY
Conventional treatment methods involve
- Treating infections where indicated
- Better timing for sexual intercourse
- Eat better diet rich in vitamin c and k
- Wear loose pants
- Correct varicosy and improve testosterone levels where indicated
- Treat female causes as presented (ovary, tubal or uterine)
- Fertility drugs and hormones like clomiphene citrate, human Menopausal Gonadotropin (hMG), Follicle stimulating hormone (FSH), human chorionic gonadotropin (hCG), Gonadotropin releasing hormone (GnRH) analogues and metformin.
Counselling for Assisted Reproductive Therapy (ART) is indicated where conventional methods are not sufficient. Available ARTs include
- Intrauterine insemination (IUI)
- Invitro Fertilisation (IVF)
- Intracytoplasmic sperm injection (ICSI)
www.medlineplus.gov : “infertility ”
www.medicalnewstoday.com : “infertility ”