Changing course
13:50 (GMT+2), Wed, 20 July 2011
Changing course
Text: Xanet van Vuuren
Illustration: Donnie Steyn
Infertility is a problem that can affect both men and women, and a treatment plan can't be implemented before both partners have been examined and tested.
In the past, men were very reluctant to have their fertility tested, as the possibility that they weren't strong and virile was something they weren't willing to accept. Therefore, the female partner was often blamed for the problem. Women are, however, not necessarily more likely than men to be the cause of infertility. Dr Merwyn Jacobson of the Vitalab Fertility Clinic, says in about 40% of cases the problem lies with the man, while 35% of the time it is the woman who has the problem. The other 25% of infertility cases may be due to a combination of factors.
The 'modern' man is, however, more open to testing their fertility nowadays. Jacobson says more and more couples are willing to visit fertility specialists, because they are more comfortable with the idea and because there are better facilities available for this. Infertility can be a very touchy subject between partners, who sometimes blame each other for the problem. Infertility is not a diagnosis and it doesn't mean that nothing can be done to 'fix' the problem.
Are we infertile?
Jacobson says a person's fertility may depend on his or her partner's fertility. "Before you have been tested for fertility, you can't determine infertility; you may simply have altered fertility." Jacobson advises couples to seek the help of a fertility specialist if they are unable to conceive after a year of unprotected sex. If a woman is older than 35, she should seek advice if no conception has occurred within six months.
Finding the problem
Firstly, the specialist will take a careful history of the woman and her partner. He then will probably examine both partners. The examination must include a vaginal ultrasound for the woman. The fertility specialist will conduct specific blood tests at various times and a semen analysis will be done as well. Jacobson says the pathway along which sperm and eggs travel has to be tested too. This is done with an X-ray, which shows the normality of the womb and tubes.
It is very important that a couple should realise that after a specific period of, say, a year of unsuccessfully trying to conceive, they should consider making an appointment with a fertility specialist. Jacobson goes on to explain that fertility specialists are specifically trained to focus on the investigation and treatment of the infertile couple.
CAUSES OF INFERTILITY
Infertility can be the cause of a wide range of physical and/or emotional factors. Jacobson says infertility is a couple's problem and shouldn't be blamed on either one of the partners. "The cause of you or your partner's infertility may be anything from problems with ovulation and egg production, sperm production or the pathway along which the egg and sperm travel." You can't blame anyone for being infertile or make any decisions regarding a treatment plan if the above-mentioned factors haven't been evaluated.
Ovulation
"Problems with ovulation are the most common cause of infertility in women," says fertility specialist Dr Marienus Trouw of the Pretoria Infertility Centre. Before any treatment plan can be started, it has to be established whether or not ovulation occurs. Many women don't ovulate at all, or their cycles are irregular, or they skip them altogether. The most common cause of infertility in women is polycystic ovarian syndrome (PCOS), where cysts (fluid-filled sacs) on the ovaries prevent the ovaries from functioning normally.
Fallopian tube blockage or damage
Tubal damage is a major risk factor of a pregnancy, in which the fertilised egg is unable to make its way through the fallopian tube to implant in the uterus. A previous ectopic pregnancy (an abnormal pregnancy occurring outside the womb), pelvic inflammation, past surgery or an infection such as chlamydia may cause blocked or damaged tubes, which can prevent natural conception.
The uterus and the cervix
The uterus may be congenitally abnormal in shape. It may have scars or have been damaged by previous surgery or fibroids.
The cervix makes very special mucus, which regulates the passage of sperm into the womb. If the mucus is unfavourable, it may prevent sperm from getting to the egg.
Endometriosis
Endometriosis is a condition where tissue, similar to that lining the womb, grows outside of the womb. It may affect the mechanical and chemical functioning of the pelvis. It may cause pain (both during intercourse and menstruation) and affect ovulation and the way in which eggs are collected.
Problem Sperm
The most common cause of male infertility is a problem with the sperm. There are various problems sperm may have, such as impaired movement or shape or low concentration. There are many possible causes for these problems. Women might be treated unsuccessfully for years without having this information, while a single sperm-count test can identify the cause immediately.
Unexplained infertility
Trouw says in 10 to 15% of cases of infertility, no diagnosis can be made. "This doesn't mean nothing is wrong with either one of the partners. It simply means that the fertility specialist is not able to make a diagnosis for the condition at that particular moment."
Factors than can influence your fertility
• Smoking affects male- and female fertility. A woman can have problems with ovulation if she smokes.
• Your lifestyle may also influence your fertility. It is important to eat healthily and to exercise.
• Use alcohol moderately (ideally less than two units per day).
• Certain medications can influence a male's sperm count.
• Genetic factors can also play a role in infertility.
• A woman's age has a significant influence on her fertility. The older a woman gets, the more her fertility declines and the chances of getting pregnant after 40 are very much lower.
TREATING INFERTILITY
"You or your partner's problem will dictate which treatment you receive," explains Jacobson. There is no quick solution when a couple has a fertility problem. As soon as the couple has been evaluated, the treatment options can be presented. The treatment should be a plan with specific goals linked to a time frame. If, for instance, a woman doesn't ovulate, the first step would be to treat her with medication to stimulate ovulation. If the woman hasn't fallen pregnant after a desired period of time, the circumstances should be re-evaluated and a new plan made.
SPECIFIC TREATMENTS
Induction of ovulation
The goal of this treatment is to stimulate ovulation in a woman who doesn't ovulate. The treatment can be simple, such as giving the woman hormone tablets, or it can be more sophisticated with the need for injections.
Intra Uterine Insemination (IUI)
This procedure is usually performed in certain cases of male-factor infertility, as well as unexplained infertility. After the woman has been stimulated to ovulate, sperm is processed in an attempt to improve the quality. The processed sperm is then placed in the uterus with a small catheter to allow natural fertilisation.
In Vitro Fertilisation (IVF) with Embryo Transfer (ET)
Fertilisation doesn't take place naturally in one of the fallopian tubes during this procedure, but in a test tube in a laboratory. During this process, controlled hyperstimulation of the ovary takes place, after which the eggs are retrieved transvaginally under ultrasound guidance. The sperm is then processed, followed by fertilisation of the eggs in the laboratory. A number of embryos created during this process are then placed in the uterus later on for potential implantation.
Intracytoplasmic Sperm Injection (ICSI)
ICSI is an in vitro fertilisation procedure in which a single sperm is injected directly into an egg. ICSI is used to treat severe male infertility where there is a low sperm count or if the sperm quality is very poor.
Assisted Hatching (AH)
The assisted hatching procedure involves thinning or making a small hole in the layer that surrounds the embryo, known as the zona pellucida (pZP). Before an embryo can implant in the uterus, it must hatch from the pZP.For more information, ask your gynaecologist to refer you to a specialist in your area who treats infertility, or contact the infertility unit nearest to you.
Thanks to Dr Marienus Trouw and Dr Merwyn Jacobson for their help with this article.
Additional resource
living and loving, April 2008 ('An inconceivable idea' by Tessa Möller)
Real moms share their stories for the road to parenthood
"I am now 56 and the best gift I ever got was my daughter, Jade, who is now 20. I only got married at 29 and about two years later, decided it was time to have a baby. That was when the problems started. I discovered that when my appendix burst and I subsequently got peritonitis at the age of 13, the damage caused inside my body had caused terrible adhesions. That meant that though I was technically fertile, everything inside was stuck together, so my eggs had no chance of ever getting into my tubes. That was a real blow! The gynae told me to adopt because I would never conceive. However, I am not someone to whom you say 'never'! So began my year of despair and hope. IVF was still reasonably new in SA and not many doctors had much faith in it.? I went for all the tests and we were told that at that stage, the success rate was about 15%. My husband thought it was crazy to go ahead with the odds so stacked against us, but for me it was the only hope I had, and I was sure it would work. It was very expensive and of course, medical aid would not pay a thing.
We had very little money at that time, and whatever I managed to have left at the end of the month, went towards the 'baby fund'. Eventually I had my first attempt in about 1985 – it failed because I was such a mess inside; the doctor said it was difficult to even find my ovaries! He told me then that there was no help for me in South Africa, as I needed a special machine, not available in the country, which would insert a probe through the vagina to get to the ovaries. Three years later (we had started adoption proceedings), the doctor phoned me up and asked if I would like to be a 'guinea pig' free of charge – they had borrowed a special transvaginal probe from the United States and were trying it out for a month. I was so excited! The treatment is very stressful and at that time, it was painful too. I had many injections and blood tests daily, but I did it gladly. This time they managed to extract eight eggs and six were fertilised!
Two days later they wanted to put only three embryos back – in those days they had no freezing techniques and I would not hear of throwing away three good embryos, so I insisted that they put all six back, to their alarm! I am so glad I did – only one eventually 'took' and what if that had been one I had thrown away! Two weeks later the pregnancy was confirmed and you can imagine the party we had! I will never forget my anxiety when the doctor phoned me with the test results. The pregnancy was the first in SA to be conceived using this new transvaginal method. I was the only one of all the guinea pigs to fall pregnant at this time. The doctors were very excited and when Jade was born on 8 June 1988, she was perfect. Unfortunately I never had another child, even though I had six more IVF attempts. But the main thing was, I was a mother – able to take my own child to nursery school and watch her get ready for her matric farewell – all the things that so many mothers take for granted, I never will. This year Jade will be 21 and my husband and I love her to bits. We are so proud of her and we are a very close family."
– Colleen Oates from Johannesburg
"My husband John and I had decided that we wanted children, so as soon as we were married, we let nature take its course and do away with contraception. After a year of nothing happening, we thought that we had better start taking things a bit more seriously – we started counting days, taking ovulation tests and even my temperature. Just before leaving South Africa to go and live in Uganda, we decided we had better go for fertility tests, only to find that we both had problems and these two conditions together made natural conception highly unlikely. We had to come to terms with the fact that we needed an assisted conception. Our move to Uganda also meant a lot more planning, as we would have to come back to SA for treatment and the full procedure. We had six IVF attempts and one gamete intra-fallopian transfer (GIFT), although it was an IVF that eventually worked, the difference being that they put the embryos back laparoscopically with IVF. We eventually succeeded on our seventh attempt. We had at this point also decided that enough was enough, and that this would be our last attempt. We are now back in Johannesburg and we have a wonderful daughter, Courtney, who is 4 years old. We are so blessed!"
– Ralayne Donnachie from Johannesburg
