Infertility: The real issues
- Part 1 -

Dr Victor Khuman *

It's a common perception today that the problem of infertility is on the rise. The current trend of late marriages, delayed childbirth, focus on education and career, small family, gap between pregnancies, contraception, increasing stress in this maddening consumerist society may definitely be playing a role.

But the rise may also only be apparent because of the increasing awareness and willingness to come forward for consultation regarding infertility. The techniques for evaluation and treatment of infertility have considerably improved over the years.

In most cases Infertility is more of a misnomer and a more appropriate term should be sub fertility. As such efficiency of fertility in humans is very low as compared to other animals, including primates. Efficiency of fertility (more appropriately cycle fecundity) means the possibility of pregnancy in one menstrual cycle.

Efficiency is barely 20% and improves to only 35% despite carefully timed coitus. Timed coitus is where the partners have intercourse during the most fertile period of the female's menstrual cycle. Roughly 85% of couples become pregnant within one year of unprotected regular coitus and 90% within the next year. Majority of these however conceive within the first six months.

By convention a couple is deemed infertile if pregnancy fails despite one year of unprotected regular coitus. So actually those couple who are labelled infertile are the 15% who fail to achieve pregnancy in the first year and as mentioned earlier they reflect the low fertility efficiency in human beings.

Certain couples can be sterile, where there is absolutely no possibility of getting pregnant. Barring these individuals, most of the so labelled infertile couples are actually sub fertile and will most possibly achieve pregnancy eventually.

But consultation with a fertility expert will definitely increase this chance of achieving pregnancy and also much sooner. There is also the need to detect the cause or causes of infertility and do a correction wherever possible. Consultation also offers scope to clear up lots of doubts and apprehensions regarding their situation.

As highlighted, infertility or more accurately sub fertile couples, may eventually achieve pregnancy if given time, without any treatment. So the obvious question arises as to why and when to evaluate an infertile couple. The chances of achieving a live birth decreases with advancing age and duration of infertility.

It has been found that the majority of spontaneous pregnancies in infertile couples happen within the first three years thereafter it declines significantly. In younger couples, in whom there are no obvious reasons to suspect infertility time may be given for spontaneous conception. But the situation is entirely different in an elderly couple where evaluation should be initiated early on. It has been common knowledge for long that the fertility in women falls considerably as she ages.

It is because the number and quality of eggs fall substantially with age. Earlier age wasn't considered a significant factor in male infertility, but recent studies have linked advanced age to poor semen quality. Evaluation should be offered in all couples who have failed to conceive after one year of regular unprotected coitus.

But it's not mandatory to wait for a year before initiating evaluation. Evaluation should be offered to women with infrequent or irregular menses, and with certain gynaecological histories (pelvic infection, endometriosis) or having a male partner with suspected poor semen quality. Evaluation should also be offered in women over 35 year of age failing to conceive after six months of regular unprotected intercourse.

Herein is the need to emphasise the infertility workup of the couple and not for only one of the partners or the other. Both partners should be encouraged to attend each visit together during evaluation. The fault could be in either partner.

The failure to conceive may be a result of unnecessary anxiety and stress due to misinformation and misunderstanding. Here comes the major role of the clinician to help overcome the misinformation from mass media or friends by providing the right information to this couples.

Valuable time and effort should not be wasted by evaluating only a single partner, who may not be the infertile partner. Whereas when both partners participate, each will get the opportunity to voice their own doubts, information and perspectives which the other may be unaware of or has overlooked.

It also provides a platform for each to have their queries addressed directly. Both get an understanding of the problem and the solutions, information or recommendations directly from the consultant. Moreover it promotes a sense of involvement of both partners and may help dispel feelings of guilt in the affected partner.

Failure to conceive may be due to fault in the reproductive capacity of either partners or both. At times, with the available tests for evaluation of infertile couples, no defect is found in either. Such cases are labelled as unexplained infertility. Pregnancy is achieved after fertilisation, (that's union of the male sperm and the female egg) and the resultant embryo gets implanted in the uterus. Any obstacle to the fertilisation and to the implantation will result in infertility.

Here is a list of the causes of infertility and the percentage of cases contributed by each.

Male factors: 30-40%,
Ovulatory dysfunction: 20-40%,
Tubal and peritoneal causes: 30-40%,
Uterine causes: uncommon,
Cervical causes: uncommon, and
Unexplained: 10-15%.

to be continued....