Infertility: the problem might not be the woman

By Yankuba Jatta 13th cohort University of The Gambia Medical School In our society today among newly married couple, the woman, not the man, would be asked by her friends, sisters, mother, mother-in-law, or even sisters-in-law, when is she ready to get pregnant and unfortunately for some the community might also ask too. Disproportionately having an effect on women, the burden of disease of infertility is often assumed to be the fault of the woman, as pregnancy and child birth are manifested in the woman. Yet, “the male reproductive capacity was found to be deficient in not less than 50% of infertile couples.”((WHO Manual 2012) for the standardized investigation and diagnosis of the infertile couple). It is imperative that each case of infertility is considered clinically as a couple. In some societies, discrimination in the case of the female may take a form of denial of passage to adulthood: a girl will not pass into womanhood (regardless of age) if she cannot prove her fertility. This girl may no longer be considered marriageable and may become viewed as a burden on families, communities or societies. Thus, childlessness or building a family is a choice – a sensitive choice which is framed and altered by society and environment – thus providing access to community and health care support to help realize a child-bearing choice remains a sensitive but important global public health challenge. Eighty percent (80%) of the couples achieve conception if they so desire, within one year of having regular intercourse with adequate frequency (at least 3 days a week). Another 10 percent will achieve the objective by the end of second year. It is estimated that about one in ten couples have difficulty in conceiving successfully (DC Dutta’s Textbook of Gynecology, 2013). The prevalence of infertility was estimated at 14.3% in the Gambia (Anyanwu M, 2017) which was an increase from 9% in 1998. Many things can explain this and among them are couples are now willing to come to the hospital to report their problem and now women marriage late compared to time back. In the UK, infertility affects 1:7 couples which was similar to Gambian prevalence of 14.3% (1 in 7) couples. In sub-Saharan Africa, the prevalence vary widely from 9- 30%. Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO-ICMART Revised Glossary, 2009). Fecundability is defined as the probability of achieving a pregnancy within one menstrual cycle. In a healthy young couple, it is 20 percent. Fecundity is the probability of achieving a live birth within a single cycle. Infertility can be primary or secondary. Primary infertility denotes those women who have never conceived. Secondary infertility indicates previous pregnancy but failure to conceive subsequently, irrespective of the outcome of the previous pregnancy. Natural conception: For a woman with a normal menstrual cycle of 28 days, ovulation occurs around day 14. The average survival time of the oocyte (egg) is around 18 hours, while after ejaculation sperm may survive for up to 48 hours in the female reproductive tract. Several general factors may adversely affect the natural conception rate. These are: i) Age: natural conception declines significantly in the female after 35 years of age. This is due to the decline in oocyte (egg) quality and numbers. ii) Smoking: reduces fertility in females and semen quality in males. iii) Coital frequency: stress and anxiety may affect libido and coital frequency and thus impact on fertility. iv) Alcohol: excessive alcohol is harmful to the fetus, and can also affect sperm quality. v) Body weight: Over or under weight can affect ovulation; women with a body mass index (Body Mass Index) of >29 or <19 kilogram per meter square might have difficulty conceiving. vi)Drugs: non- steroidal anti-inflammatory drugs (inhibit Ovulation), chemotherapy (destroys rapidly dividing cells e.g. gametes); cimetidine, sulphasalazine, androgen injections (affects sperm quality). vii) Occupational hazards: exposure to chemicals and radiation adversely affects male and female fertility (Gynaecology by Ten Teachers, 2015). The causes of infertility can be i) Female factor ii) Male factor iii) Both Female and Male factor combine or iv) Unexplained. Conception depends on the fertility potential of both the male and female partner. The male is directly responsible in about 30–40 percent, the female in about 40–55 percent and both are responsible in about 10 percent cases. The remaining 10 percent, is unexplained, in spite of thorough investigations with modern technical knowhow. It is also strange that 4 out of 10 patients of unexplained category become pregnant within 3 years without having any specific treatment. It is also emphasized that the relative subfertility of one partner may sometimes be counterbalanced by the high fertility of the other (DC Dutta’s Textbook of Gynecology, 2013). The Female factors include any pathology that interfere with: the ovulation (releasing of the egg from the ovary), the patency of the fallopian tubes for the sperm to meet the egg, the transportation of the fertilized egg into the uterus (womb), the implantation of the fertilized egg into the endometrium (inner layer of the uterus (womb)), the cervix (the mouth of the womb), and the balance of reproductive hormones. Tubal factor, mostly from pelvic infections was the most common cause of infertility in The Gambia (17.4%) (Anyanwu M, Idoko P, 2017). The Male Factors include any pathology that interfere with: the healthy production of sperm, the transportation of sperm from the epididymis, the presence of the vas deferens, the patency of the urethra, the deposition of sperm high in the vagina at or near the cervix, and the ascend of the sperm through the cervix into the uterine cavity and the fallopian tubes. The male factors of infertility was seen in 8.9%. Similarly, most cases of male factor infertility are caused by previous infections of the male genitourinary tract. Unexplained infertility was estimated at 10% (Anyanwu M, Idoko P, 2017). When to investigate? As per the definition, the infertile couple should be investigated after one year of regular unprotected intercourse with adequate frequency (at least 3 days a week). The interval is however, shortened to 6 months after the age of 35 years of the woman and 40 years of man. It should be understood that infertility is not solely the woman’s fault because the man might be the one having the problem. It is quite a belief by many or even women themselves that they are the one with the problem. Infertility is the couple’s problem and should be seen as such. Studies have shown that, infertile couples encounter various challenges in different emotional, psychosocial, communicative, cognitive, spiritual, and economic aspects that can affect various areas of their life and lead them to new concerns, problems and demands. Thus, addressing infertile couples’ needs and expectations, there is need to incorporate effective psychological services by development of patient-centered approaches and couple-based interventions can improve their quality of life and treatment results and also relieve their negative psychosocial consequences. The basic investigation mostly done are: Semen analysis for men to know the sperm volume and count, its motility, and its morphology. Semen analysis should be performed after the man have abstained from sexual intercourse for 3–4 days. Two abnormal test results are required to diagnose male infertility.?Ovulation test and Tubal patency test for women to know whether the ovaries are releasing the eggs and to know whether the fallopian tubes are patent respectively. NB: other investigation are done if the need arise like Testosterone levels, Luteinizing Hormone/Follicular Stimulating Hormone levels, Prolactin, Thyroid Stimulating Hormone levels, Cystic fibrosis, Karyotyping etc.?The management of infertility comprises of a lot of approaches which can be best decided by the Gynecologist based on the condition of the patient and what is available.?? The mainstay of management of infertile couples is the treatment of the cause. ? Reassurance?? Counselling and support?? Adoption?? Childlessness Prevention: Majority of the cases of infertility in our part of the world is caused by pelvic infections which could later block the fallopian tubes and most of this infections are sexually transmitted. Any measures taken to prevent those pelvic infections would drastically reduce the prevalence of infertility. The measures include: ? Prevention of sexual transmitted diseases?? Provision of reproductive health education?? Promotion of abstinence or use of condoms?? Early treatment of sexual transmitted diseases ? Avoid multiple sexual partners at the same time ? Prevention of unsupervised abortions ? Prevention and treatment of puerperal sepsis. In conclusion, infertility is an agony that our women should not be left alone in fighting it. Infertility has cost some women into polygamy, divorce, loss of]]>