An Introduction to Infertility

By Dr M I Cassim

The need for successful reproduction is basic to the survival of all living organisms, from the simple unicellular amoeba to the most complex of mammals, human beings. In humans, the desire to procreate transcends the biological needs and the inability to conceive may lead to emotional, psychological and spiritual consequences, negatively altering the way these affected individuals function. Feelings of worthlessness, guilt, anger, fear and blame may directly or indirectly impact on relationships, not only within the confines of marriage but may include extended families and society as a whole. The longer the problem persists, the greater the consequences.

Individuals differ in the way they react to the problem. Some individuals may withdraw and gradually isolate themselves from society. Some may suffer depression whilst others may become obsessive and even aggressive. Yet others, through denial, will plough their energies into unrelated labour such as their careers or hobbies. Whatever the method of expression, there is little doubt that failure to conceive leads to stress and stress in turn may aggravate the fertility problem.

Infertility is defined as the inability to conceive after one year of regular unprotected intercourse. It is estimated that nearly 1 in six couples in the reproductive age group suffer from infertility, with strong evidence to suggest that the rate is steadily rising. The increasing incidence is partly due to the fact that more and more affected individuals are willing to shed the negative stigma attached to infertility and to openly seek medical help. There is also, however, a very real increase in the actual incidence of infertility, with a greater number of males and females suffering from conditions which contribute to the fertility problem.

The proportion of male factor to female factor as a cause of infertility has changed significantly in recent years, with a growing number of males contributing to the fertility problem. It is now estimated that proportionately male factor causes accounts for 40%, female factor 50% and the remaining 10% are classified as unexplained infertility.

The growth in the male factor component is of grave concern. Studies have shown a 40% decline in semen parameter since 1938. A variety of causative factor, singularly or in combination, may be responsible.  Included in this may be lifestyle factors such as smoking and alcohol abuse as well as drug abuse. Dietary factors may also play a prominent role, particularly the ingestion of meat and dairy products containing traces of steroids used by farmers to enhance growth of their livestock.

The widespread use of oral contraceptives results in steroid by- products excreted in the urine, which may find its way into effluent and river systems and eventually drinking water.

Other factors contributing to sperm abnormalities include the wearing of tight undergarments and jeans, excessive hot baths/ saunas and steam showers or any factor that causes even the slightest increase in scrotal temperature. Even the use of laptops on or around the pelvic area may increase heat transmission to the testicle and scrotum.

The age of the female is the single most important determinant of reproductive potential. Women under the age of 35 have a 30% chance of natural conception per menstrual cycle, with a cumulative conception rate of 80% at the end of 6 months. That is, only 20% will not conceive after trying for 6 months. Alarmingly, this figure is twice as high for women aged 35 years and older, with a conception rate of only 15% per cycle and 40% at 6 months. Therefore, nearly 60% of women over 35 years of age would not have conceived after trying for 6 months.
To understand the reason behind this phenomenon we need to appreciate that women are born with a fixed complement of eggs, ‘ the egg / ovarian reserve’. From this egg basket or ‘gift ‘ from their mothers, women will continue to consume and deplete the egg reserve throughout reproductive life, culminating in the menopause. The most fertile eggs are released first, at a younger age. Hence, as a woman gets older, the quality of the eggs progressively worsen, making it more and more difficult for conception to occur and also resulting in a rise in foetal abnormalities and miscarriages, particularly in the above 35 age group.

Some less fortunate females may be ‘short-changed’ at birth, being born with less than a full complement of eggs. Others may be affected by an accelerated loss of eggs due to various factors. In either case, fertility problems may be encountered at a younger age and many will experience early menopause (premature menopause or premature ovarian failure). Many females, particularly in the Western World, delay conception until the mid- thirties and beyond, in pursuit of careers and personal interests. These individuals often find themselves faced with fertility issues at a time when their biological clocks are ticking really fast. Furthermore, delaying conception into the thirties allows for a greater risk of developing pathological conditions such as endometriosis, adding to the already significant age related impediment.

Until recently there was no sure method of determining the egg reserve levels inside the ovaries. However,  the recent advent of a new biological marker called AMH (Anti Mullerian hormone)  and together with more advance internal trans-vaginal ultrasound screening, we are now able to more accurately determine ovarian reserves and hence fertility potential.

AMH can be likened to the fuel gauge of a motor car, predicting how much distance can be covered before coming to a halt. However, unlike a car, the ovarian ‘tank‘ cannot be refilled once empty.

table 1 (2)

 For successful natural conception to occur there are certain essential requirements. Ovulation, or the release of an egg is fundamentally important. There must be at least one healthy patent fallopian tube and the uterus (womb) has to be appropriately receptive and by and large normal. The cervical mucous at the entrance to the uterus has to be ‘sperm friendly” and there should be reasonably healthy sperm parameters. Each of these factors is subject to numerous possible abnormalities and pathologies. For example, many females suffer from ovulatory dysfunction which may be due to a host of conditions including hypothalamic pituitary factors in the brain, thyroid abnormalities, adrenal gland disorder, and ovarian disease such as PCOS (polycystic ovarian syndrome).  Even egg are subject to variations. Not all eggs are created equally.  Some eggs may be of such poor quality that fertilization is almost impossible. Also, the fertile lifespan of an egg, once released is limited to 24 hrs. After this time, the egg, if not fertilized,  will simply disintegrate. 

Tubal blockage may be as a result of previous pelvic infection, either sexually transmitted  (venereal disease) , or non-sexually acquired such as appendicitis , ulcerative colitis, Crohns disease  and other inflammatory bowel conditions. Pelvic tuberculosis, endometriosis and previous pelvic surgery may also alter the structural and functional integrity of the fallopian tubes.

Endometriosis is an increasingly common condition affecting pelvic structural integrity and may affect all pelvic organs to a greater or lesser extent, depending on the degree of severity or stage of the condition.

Abnormality of the uterus (womb) may be congenital (arising from birth) or acquired (develop later due to a disease process).

Acquired condition may be due to certain diseases causing growths or tumours such as fibroids or adenomyosis.

These conditions are relatively easily detectable by pelvic ultrasound and are generally benign. The impact of these benign growths on fertility will depend on their size, numbers, and position within the uterus. Other abnormalities of the uterus are more subtle and microscopic such as chronic inflammation or infection of the endometrium (inner lining of the uterus where implantation occurs) eg. Endometritis (not to confused with endometriosis)

There may be other even more intricate conditions affecting the implantation process such as immunological blood factors and endometrial blood flow abnormalities.

Finally genetic factors may also contribute to infertility, either through abnormal embryo production or implantation failure.

 

 table 2

 

 

Whatever the physiological or pathological cause for the fertility problem, there is little doubt that infertility is a major source of emotional and psychological trauma and stress. Adequate counselling and emotional support is essential before starting any form of treatment. Notwithstanding the fact that even the most advanced treatment options will only yield a 60% success despite substantial financial costs, the 4 out of 10 couples who fail will require even further supportive care. Due to these highly emotional situations and patient vulnerability, the fertility market is filled with charlatans and profit taking racketeers who will promise success with all sorts of non- scientific alternatives. Multivitamins and supplements play a limited role in a small highly select group of patients but they are often marketed as the panacea cure irrespective of the underlying causes. Likewise, the liberal use of ovulation inducing pills without medical supervision or clear indication may not only prove to be dangerous, futile but also costly in terms of time, financially and emotionally.                

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