There is nothing more heart breaking for a sexually active couple than having to give up their hopes on having a baby, after not using any birth control measures. Although not as common a problem as in the US, where it is said that infertility affects more than 3 million couples, the prevalence rate is nevertheless on the rise in Sri Lanka.
Consultant Gynaecologist and a former President of the College of Obstetricians and Gynaecologists Dr. Marlene Abeyewardene however believes new technologies now available in Sri Lanka can help realise the dream of childless couples having their own child. She shares her expertise on how infertility occurs, how to deal with it and the wider options childless couples now have, in this interview with the Sunday Observer.
Excerpts …
Q. An Infertility Awareness raising week was observed worldwide and in Sri Lanka recently. Although a fairly common problem, many people still do not fully understand the meaning of infertility and how to deal with it. What exactly do you mean by Infertility?
A. Infertility is the inability of a couple to conceive after 12 months of regular unprotected sexual intercourse without using birth control. Globally 8%-12% of couples experience fertility problems.
Q. What causes a woman to be infertile ?
A. Infertility in women may be due to several causes. They include:
a) Smoking, significantly increases the risk of infertility and may undermine the effects of treatment. Passive smoking, i.e. continuously being exposed to cigarette smoke has been linked to lowering fertility.
b) Age, ability to conceive declines from around 32 years as the maturation of ova starts to decline at this time.
c) Alcohol consumption can lower fertility.
d) Obesity and overweight can decrease fertility.
e) Eating disorders such as Anorexia Nervosa leading to serious weight loss leads to infertility. Lack of minerals and vitamins such as Folic Acid, Iron, Zinc and Vitamin B12 could affect fertility.
F) Women on a total vegan diet need advice on supplements.
g) Exercise, too little or too much leads to infertility.
h) Sexually transmitted diseases, such as Pelvic Inflammatory disease caused by Chlamydia etc. can damage the fallopian tubes leading to infertility.
i) Exposure to some chemicals, e.g. pesticides, herbicides, metals like lead are linked to infertility.
j) Mental stress may affect ovulation as well as reduction of sexual activity.
k) Medical conditions such as ovulation disorders appear to be the most common cause of infertility in women, e.g. Polycystic ovaries syndrome. The incidence of Polycystic ovary disease in Sri Lanka is around 5%.
Problems of the cervix or neck of the womb is associated with infertility such as unfavourable cervical mucus, cervical stenosis or surgical absence of the cervix can also lead to infertility.
Q. Is being obese a risk factor in a woman who wants to become pregnant?
A. Obesity is an important health issue and a common problem among women of reproductive age. If the body mass index (BMI) of a woman is greater than 30kg./M2 she is considered to be obese. Obesity is an abnormal and excessive accumulation of fat in the body. It plays a significant role in reproductive disorders in women, such as causing anovulation, menstrual disorders, infertility, miscarriages, difficulties in carrying out assisted reproductive technology.
Obesity is also associated with adverse pregnancy outcome as such patients are prone to develop non communicable diseases such as, Hypertension and Diabetes Mellitus. Infertility in obese women may be due to changes in the neuro-regulation of the hypothalmo pituitary gonadal axis. Obese womenface a problem of less implantation of fertilized eggs during pregnancy. Thus there is a higher rate of miscarriages and increased maternal and fetal complications during pregnancy.
Q. Can stress be a contributory factor?
A. Yes, stress can cause infertility in both males and females due to its effects on the brain as well as the Hypothalmo-pituitary axis. In females this may suppress ovulation and in males erectile dysfunction of the penis as well as ejaculatory problems.
Q. If a young girl is anaemic due to poor diet will this lead to infertility once she wants to start a family?
A. Poor nutrition can cause infertility due to the lack of essential nutrients such as proteins, carbohydrates, fats and essential vitamins and minerals.
It is necessary that parents are aware of this and ensure that their young girls have a well balanced diet. Excessive dieting which is sometimes fashionable in modern society can lead to such problems.
Q. When does infertility start in women?
A. Infertility can start at any time after menarche (i.e. onset of the first menstrual period). Early menstrual periods are usually an ovulatary i.e. they do not shed the ova and thus young girls do not become pregnant during the first two to three years after menarche. Ovulation cycle starts later and a healthy girl can become pregnant if she wants to.
Q. How does a woman know she is infertile?
A. If a woman does not get pregnant after frequent sexual intercourse with her husband for a period of 2 years without the usage of any contraception she and her husband should go and get themselves investigated for infertility.
Q. Can female infertility be cured? How?
A. At present there are many reproductive techniques available to treat defective ovulation tubal problems and cervical causes.
Q. What is the treatment procedure?
A. There are standard treatment procedures for various problems which can cause infertility in women as well as in men. These standard methods are modified to suit each individual both male and female.
Q. Most people blame the woman when a couple is unable to have a baby. How far is this true?
A. It has been shown that the male factor contributes around 30%-40% to the problem of infertility.
Q. What are the causes of male infertility?
A. The common causes of male infertility are :
a. Low sperm count that is below 15 million. 1/3 of male infertility may be due to this.
b.Low Sperm Motility, the sperms although present in adequate numbers cannot swim as well as they should to reach the ovum.
c. Sperms may have an unusual shape making it hard to move and fertilise the egg as they cannot travel rapidly and accurately towards the egg. Up to 2% of men are thought to have this problem.
d. Hormonal imbalance hypogonadism can lead to testosterone deficiency.
e. In Hypospadias : The urethral opening is under the penis, instead of its tip. This abnormality is usually surgically corrected in infancy. If the correction is not done, it may be harder for the sperm to get to the female’s cervix. Hypospadias affects about 1 in every 500 new born boys.
Q. Drugs?
A. Illegal drugs such as Cocaine and Marijuana can also cause infertility in males .
Q. Age?
A. Male fertility falls after 40 years. Excessive alcohol consumption, overweight and obesity and mental stress also contribute to male infertility.
Q. More childless couples are now turning to Invitro fertilisation (IVF) to have a child. As a specialist in this field tell us what is IVF? What does it involve?
A. IVF or invitro fertilization and related assisted reproductive technologies have attained a prominent role in the management of infertility since the first IVF done in 1978. Indications for Assisted reproductive technology includes: i) infertility due to diseases of the fallopian tubes, ii) pelvic endometriosis, iii) sperm defects, iv) unexplained infertility and v) ovarian failure.
The procedure involves stimulating the patient using IM Human Menopausal Gonadotrophis to stimulate the growth of the ovarian follicles. Thereafter, Follicular growth is monitored by transvaginal ultra sound scan and serum oestrogen levels until follicular maturity is reached. Then, follicular aspiration is performed trans vaginally under ultra sound guidance. This has to be done in a perfectly sterile laboratory environment.
Q. Where is this procedure usually performed?
A. In a hospital environment by Obstetricians and Gynaecologists who have the experience to carry it out.
Q. Are there risks or side effects for the mother and baby?
A. The procedure of IVF has risks to both, mother and baby. Hyperstimulation of the ovaries in response to the Follcular Stimulating Hormone Injections which are used can occur in some mothers.
This can lead to enlargement of the maternal ovaries, fluid collection in the abdomen or ascites which may be dangerous to the mother and may even cause cardiac failure in her. Thus, a patient needs to be carefully monitored after such injections are given. Any sign of this complication occurring must be looked for and the patient immediately treated. IVF can lead to multiple pregnancies due to the effect of the hormonal injections causing the growth and maturity of more than one follicle leading to fertilisation of more than one ovum. At times, this may result in twins, triplets, quadruplets or even 5-6 babies. Quadruplets and 5-6 babies may cause fetal demise or complications of multiple pregnancies to the mother such as pregnancy induced hypertension or diabetes mellitus.
Q. Ideal age for a woman (and man) to undergo this procedure to ensure its success?
A. Under 40 years.
Q. You have witnessed so many of these births in the past few years. What is the success rate?
A. Success rate of IVF is around 40% in Sri Lanka.
Q. Where are these techniques available to the public?
A. There are facilities for management and treatment of infertile couples by IVF and other technology in Kandy and Galle, besides Colombo.
Q. Any new technologies you already have or hope to introduce regarding Infertility to Sri Lanka?
A. Almost all the new forms of assisted reproductive techniques are available in Sri Lanka.
Q. Your message to all childless couples?
A. At present assisted reproductive technology is available to overcome many of the issues leading to infertility. All these methods are best carried out before the age of 40 and thus it is important that treatment should be sought before they reach this age.