Dr T. Mhlanga Specialist Gynaecologist
Sub-fertility is defined as the inability to achieve pregnancy after 12 months of regular unprotected intercourse, 15 percent of all couples are affected. The chance of conception in an individual cycle is about 20 percent thus in a year, 85 percent of all couples would have achieved pregnancy.
Expectation of a married couple that they will eventually have children is profound in our society. It is devastating for many to want to have children and fail. Infertility is a life time crisis which brings about social and psychological problems which tends to result in a woman having low self-esteem.
Causes of female factor sub-fertility are:
- Blocked tubes;
- Disorders of ovulation;
- Unexplained sub-fertility;
- Ovarian failure;
- Endometrial abnormalities;
- Uterine abnormalities;
Affects 32 to 35 percent of infertile patients. Tubal disease impairs the ability of the tubes to effectively transport an egg or embryo to the uterus.
History of the following is suggestive of tubal disease:
- Pelvic inflammation disease;
- Septic abortion;
- Ruptured appendix;
- Tubal surgery;
- Ectopic pregnancy.
Sexual transmitted disease and pelvic inflammatory disease:
STDs are diseases that are transmitted from sexual activity with an infected partner. They often don’t cause symptoms. With the risk of failure to get proper treatment, this will result in fallopian tubes being blocked.
Is presence of endometrium (lining of the womb) outside the uterine cavity. It is prevalent in the reproductive years affecting 10 percent of women in reproductive age patients with endometriosis commonly present with severe period pain, chronic pelvic pain, infertility, dyspareunia (pain during intercourse), menstrual irregularities, cyclical dysuria (pain when urinating) and dyschezia (pain when defecating). The main cause of sub-fertility from endometriosis is as a result of scarring and adhesions that results in a blocked tube.
Polycystic Ovarian Syndrome
Is defined as the presence of two out of three of the following criteria:
- Oligo-ovulation or anovulation (irregular or absent periods).
- Hyperandrogenism (acne, hirsutism which is presence of terminal hair growth in a male pattern of distribution including chin, upper lip, chest and upper and lower back)
- Polycystic ovaries on scan or enlarged ovaries bigger than 10cm3.
Less than 25 percent of women suffering from this disorder have been diagnosed of the disease because the symptoms do not appear connected to each other up until one is investigated for sub-fertility.
Sub-fertility results from absence of ovulation.
Disturbances in ovulation affects 20 percent of couples with sub-fertility this usually presents with irregular period. This can be caused by excessive weight gain or loss, stress or thyroid diseases. Presence of abnormally high prolactin levels in blood causes infertility by increasing the release of dopamine from hypothalamus which inhibits gonadotrophin-releasing hormone resulting in anovulation.
Premature Ovarian Failure
This happens when a woman stops menstruating before 40 years. This can be caused by genetic diseases such as Turner’s syndrome, exposure to medicine such as chemotherapy or radiotherapy, and lastly it can be as a result of autoimmune diseases.
As a woman matures, fertility decreases and the odds of miscarriages increase. It’s important to note that the chance for pregnancy is 5 percent for women above 40 compared to 25 percent at 20 years.
Luteal Phase Defect
This is caused by inability of the ovaries to secrete progesterone hormone that supports pregnancy or it can be as a result of the endometrium being resistant to progesterone that is being secreted.
Some conditions that affects the womb such as fibroids, uterine structural abnormalities such as uterine didelphys (born with a womb with two parts with a wall dividing them) affects a woman’s ability to conceive by impairing the uterine lining, and distorting the uterine cavity
Abnormalities in Cervix Shape
Abnormal cervix or texture of the cervical mucus can affect movement of sperms from the vagina to the uterus. This results in few sperms reaching the egg for fertilisation.
Endometrial polyps are among the most common cavity lesions that cause uterine texture abnormalities. They are a result of overgrowth of endometrial glands and stroma. Polyps have been found to interfere with fertility in natural conceptions.
This happens when a couple has sub-fertility but there is no test to identify the cause. This tends to affect one in five of sub-fertile couples.
Life style and Infertility
Tobacco and alcohol intake contribute to infertility. Cigarette smoking affects folliculogenesis, embryo transport, endometrial receptivity, uterine blood flow and uterine myometrium. Alcohol is associated with elevated oestrogen levels and this levels reduces FSH secretion resulting in reduced folliculogenesis which results in anovulation.
Principles of evaluation of sub-fertile couple:
- Both partners should be seen together.
- Patients should be provided with Privacy and sufficient clinical time.
- History taking should be adequate with emphasis on exploring a couple’s anxieties.
- Counselling of patients is an important component of evaluation.
- Each stage in investigation and treatment of infertility should be fully explained to the couple.
- Written information in a range of languages should be available where appropriate.
Evaluation of Pelvis
Is done by a trans-vaginal ultrasound scan to rule out abnormalities of the pelvis that might cause infertility or affect treatment of sub-fertility, abnormalities such as fibroids, PCOS, endometriosis (endometrioma) and Endometrial polyps can be picked up.
Evaluation of Fallopian Tubes
Is done by hysterosalphingography (HSG).
This involves instillation of a contrast medium through a cannula attached to the cervix then fluid being radio-opaque can be visualised under X-ray screening. This allows assessment of normality of uterine cavity and patency of fallopian tubes.
Laparoscopy and dye studies is also used to evaluate the fallopian tubes. Patient is put to sleep and a small camera is introduced through the naval and a dye is introduced through the cervix. Failure of the dye to pass through the tubes indicates blocked tubes. Laparoscopy has an advantage of direct visualisation of pelvis which permits identification of fibroids, endometriosis, ovarian cysts and other abnormalities and also offers immediate treatment of these conditions.
Other methods of evaluating tubes are hysterosalphingo-contrast-sonograhpy and tubal insufflation.
Evaluation of Ovarian Reserve
The size and quantity of the remaining ovarian follicular pool at a given time (quantity of woman’s remaining eggs). Aims to identify women who will respond poorly to IVF medicine with associated Low chances of success, whose treatment cycle is most likely to be cancelled. This information is important in counselling couples and planning their treatment.
Age is the initial predictor of overall success in ART (2013).
Use one of the following to evaluate ovarian reserve:
- Total antral count of less than or equal to 4 for low response and greater than 16 for high response.
- AMH of less than or equal to 5,4pmol/l for low response and greater than or equal to 25pmol/l for high response.
- Day 3 FSH greater than 8,9IU/l for low response and less than 4IU/L for a high response.
Evaluation of Hormones
This is usually done in women with irregular periods, hormones evaluated are the following.
- Thyroid function test,
- Prolactin levels;
- Testosterone levels,
- Progesterone levels.
Screening for Infection
Couples being evaluated for sub-fertility should be offered HIV, Hepatitis profile, chlamydia, rubella and syphilis screening.
People found positive should be offered specialist advice, counselling and appropriate clinical management.
Cervical Cancer Screening
Cervical cancer screening should be offered to all women with sub-fertility not up to date with national guidelines.
Prevention of Sub-fertility
- Treatment of STDs;
- Not delaying parenthood;
- Abstinence or practice of safe sex;
- Healthy lifestyle avoid smoking and alcohol;
- Management of chronic illness such as thyroid diseases.
In Zimbabwe there is hope for sub-fertile patients with the introduction of assisted reproductive technology and birth of first IVF baby since the IVF program resumed at Avenues hospital. Most of the causes of female factor sub-fertility can be treated with assisted reproductive technology.
Assisted reproductive technology is a term used to describe treatments used to achieve pregnancy by handling the gametes (sperm and egg).
1 In Vitro Fertilisation (IVF)
Means fertilisation occurring outside the body. Woman is given medicines that causes ovaries to make multiple eggs and once these eggs are mature they are then removed from the body and fertilised with husband sperms in the laboratory, pool of embryos develop and only one or two are transferred back into the womb after 3 to 5 days of development, excess embryos are frozen for future use.
IVF is treatment for the following conditions:
- Tubal disease;
- Unexplained sub-fertility;
- Treated endometriosis;
- Male factor infertility;
- Failed intrauterine insemination;
- Failed ovulation induction;
- Fertility preservation for cancer patients.
Is used for couple in which there are serious problems with sperms, low sperm count, reduced motility and abnormal morphology. Its advanced form of IVF .A single sperm is injected into a mature egg then the embryo is transferred back into the uterus. This procedure is available in Zimbabwe.
- Intrauterine insemination
Is placing a sperm in woman’s uterus at the time of ovulation. The rationale behind intrauterine insemination is to increase gamete density at the site of fertilisation.
Used In to assist couple with the following conditions to achieve pregnancy:
- Prevention of HIV transmission in sero-discordant couples.
- Cervical factor infertility.
- Male factor sub-fertility(mild to moderate).
- Unexplained subfertility.
- Sexual disorders (hypospadias, vaginismus, retrograde ejaculation.
Other Treatments of Sub-fertility
- Ovulation induction with clomiphene, letrozole,gonadotrophins in conditions such as PCOS.
- Bromocriptine, cabergoline in hyperprolactinemia.
- Weight reduction in obese anovulatory infertile women, a loss of 5-10 percent of body weight has been associated with improvement in reproduction function in 55 percent of women in six months.
To conclude sub-fertility is a disease that can be treated, IVF brings hope to all childless couples.