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Understanding infertility in men and women

One of the major characteristics of all living things is the ability to reproduce. Among human beings, the birth of a child is almost always a moment of celebration. It among other things, gives the father and the mother an heir, their parents a grandchild, and more importantly ensures the progression of their lineage. While majority of people have no issues getting pregnant and giving birth, many others are struggling to achieve pregnancy, and quench their humanly thirst for a child. This inability to achieve pregnancy and childbirth has led so many people into developing several forms of mental illnesses and has destroyed relationships.

According to the World Health Organization (WHO), about 17.5% of adults globally are suffering from infertility. In sub-Saharan Africa, the prevalence of infertility varies from 10-30% according to a report in 2016.

In this article, we’ll delve into infertility in as basic a level as possible in order to have a grasp of it and dissipate some myths associated with this condition.

What is infertility?

According to WHO, Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. The definition also includes women who were able to conceive but unable to carry any pregnancy to term.

Contrary to societal beliefs where the burden of infertility is usually placed on women, research has shown that 40-50% of the cases of infertility are due to male factors.

Requirements for normal fertility

  • Male factor: sperm must be deposited at or near the cervix, at or near the time of ovulation, ascend into the fallopian tubes and have the capacity to fertilize an egg.
  • Ovarian factor: Release of a mature oocyte must occur ideally on a regular, predictable, cyclic basis.
  • Cervical factor: the cervix must capture, filter, nurture and release sperm into the uterus and fallopian tubes.
  • Uterine factor: the uterus must be receptive to embryo attachment along its wall, and capable of supporting subsequent normal growth and development.
  • Tubal factor: the fallopian tubes must capture released eggs and effectively transport sperms and embryos.

Any deviation from any of the above factors can result into infertility, and they must be evaluated in any couple thought to be infertile.

Types of infertility

  1. Primary infertility: This is diagnosed in a woman who has never conceived despite having fully met the criteria stated in the definition of infertility.
  2. Secondary infertility: This is diagnosed in a woman who’s had at least one successful pregnancy, but unable to get another despite having fully met the criteria in the definition.
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Causes of Infertility in the male

Infertility in male revolves around the sperm cells, and it happens due to:

  • Ineffective production of sperm cells in the testes
  • Decreased number of sperm cells in semen
  • Abnormal shapes of sperm cells
  • Dysfunctional movement of sperm cells along the reproductive tract

It is worthy of note that sperm and semen mean two different things. Sperm is the reproductive cell produced in the testes by a specialized group of cells. Millions of these cells swimming in mixture of different fluids secreted by several glands along the male reproductive tract is what’s called semen.

Risk factors of male Infertility

  • Obesity
  • Age: fertility decreases with advancing age
  • Alcohol
  • Prolonged exposure to toxins.
  • Cigarette smoking

Conditions associated with male Infertility

  • Undescended testes: The testes normally develop in the abdominal cavity and later descend into the scrotum, which provides the testes a temperature lower than the core body temperature, perfect for the production of sperm. In Undescended testes, there is failure of descent and failure of production of sperm.
  • Retrograde ejaculation: There is failure of forward movement of the semen along the male reproductive tract, and therefore, the semen does not enter the vagina.
  • Low testosterone
  • Auto antibodies that destroy the sperm cells.

Some drugs are also implicated in the aetiology of male fertility, and they include:

  • Calcium channel blockers: usually used in managing hypertension.
  • Chemotherapy: in the treatment of cancers.
  • Radiotherapy
  • Tricyclic antidepressants
  • Cocaine, etc.

Causes of female infertility

In women, Infertility results from abnormality in ovulation; which involves release of an egg, fertilization; which involves fusion of an egg with a male sperm, and implantation involving attachment of the fertilized egg to the uterine wall. It can also be as a result of blockage along the female reproductive tract, especially the fallopian tube.

The risk factors of female infertility are almost identical to those in the male, but a history of sexually transmitted infection is also a strong risk factor here.

Conditions associated with female infertility

  • Pelvic inflammatory disease, usually as result of untreated or poorly treated STIs.
  • Polycystic Ovarian Syndrome
  • Endometriosis, which is the presence of cells of the uterine lining outside the endometrial cavity
  • Uterine fibroids
  • Thyroid Hormone disturbances
  • Pituitary tumours associated with prolactinoma

Chemotherapeutic drugs, antipsychotics, and prolonged use of NSAIDS are some of the iatrogenic causes of infertility in women. Radiotherapy also falls here.

Diagnosis and work up

For male Infertility, diagnosis is made if an individual is unable to conceive after one year of trying. A doctor’s appointment must be made where there are problems with ejaculation, erectile dysfunction, low sex drive, etc.

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History is then taken; physical examination is performed, and the doctor will determine the cause of infertility. If there is no identifiable cause, a seminal fluid analysis is done to ascertain the number, volume, shape and the ability of your sperm to move properly.

If there is still no identifiable cause, hormonal and imaging tests are carried out. Genetic testing may also be done.

For women, age is an important factor in the diagnosis of infertility.  This is because, from 30 years of age, fertility for women begin to decrease. Therefore, women above 30 years must not wait a whole year to see a doctor, 6 months is reasonable.

History and examination are then carried out to rule out any underlying disease; fibroid, endometriosis, PID, etc that may be responsible.

A test for ovulation may then be done either by keeping a temperature chart at home, because ovulation brings about slide rise in temperature from the baseline, or a blood test may be carried out to ascertain that.

  • Abdomino—Pelvic ultrasound scan may also be used to look for abnormalities in the ovaries and the uterus.
  • Ovarian reserve testing; which is a group of hormonal tests to determine if a woman will be able to conceive.
  • Hysterosalpingograhy; which is an imaging test used in evaluating the fallopian tube and the uterus, their patency or other abnormalities.
  • Laparascopy may also be done.

Treatment

There are several different treatments for infertility, choice is made based on age of the couple, cause of infertility, length of time a couple has been trying, general health of the individuals.

Treatment of male infertility

In men, treatment could be surgical, medical, or the relatively new Assisted Reproductive Technology (ART).

Drugs can correct hormonal imbalance such as low testosterone, reproductive tract infections, or erectile dysfunction.

Where it is amenable to surgery, e.g varicoceles where there is swelling of the veins around testes, or any obstruction preventing sperm from entering the ejactulate, surgery is performed.

Assisted Reproductive Technology has brought in a fresh hope for an infertile couple. It Involves handling of sperm and eggs outside the body. There are several of them, but the commonest is called in-vitro fertilization. The sperm and the eggs are collected from the intending couple, fertilization is done outside usually, and the embryo is transferred to the woman’s womb.

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The sperm may be collected from ejactulate, extracted from the testes or in some instances where the individual does not have sperm cells, a donor’s sperm may be used.

A study conducted about the success rate of ART in male Infertility has shown 78% success rates after 5 years of treatment, and depending on the technique used, the co-morbidities of the patient, it could be much better.

Treatment of female infertility

All the modalities of treatment used for men may also be applied to women.

Myomectomy may be done to remove fibroid. Blocked fallopian tubes as well may be amenable to surgery.

Medications may also be used to enhance ovulation

There are several forms of ARTs for women as well;

  • Intrauterine Insemination involves injecting millions of sperm into the uterus near ovulation.
  • IVF+Embryo Transfer is another commonly used option.

Nutrition and infertility

According to research carried out to demonstrate the relationship between nutrition and fertility, it was observed that the rate of infertility is low among people consuming Mediterranean Diet which consists mainly of fruits, vegetables, fish and less of polyunsaturated fatty acids. The Western-style diet which is less in vegetables and consists more of red meat, polyunsaturated fats, animal derived proteins show an inverse relationship with fertility.

The topic of infertility is one with many sad stories, as many families have been affected, and relationships have been destroyed.

The idea that women are always to blame for infertility is not substantiated by available evidence, as several research have shown that both men and women are equally responsible.

Lifestyle and dietary modification play a crucial role in the management of infertility.

Co-operation of the couple with their health service provider goes a long way.

Assisted Reproductive Technology has shown massive success rates in the management of infertility.

References

Chimbatata, N. B. W., & Malimba, C. (2016). Infertility in Sub-Saharan Africa: A woman’s issue For how long? A Qualitative Review of literature. Open Journal of Social Sciences, 04 (08), 96–102. https://doi.org/10.4236/jss.2016.48012

Sexual and Reproductive Health and Research (SRH). (2023, April 3). Infertility prevalence Estimates, 1990–2021.

Silvestris, E., Lovero, D., Palmirotta, R.. (2019). Nutrition and Female Fertility: An Interdependent Correlation. Front Endocrinol (Lausanne). 346. doi: 10.3389/fendo.2019.00346. PMID: 31231310; PMCID: PMC6568019.

Zarinara, A., Zeraati, H., Kamali, K., Mohammad, K., Rahmati, M., Akhondi, MM. (2020). The Success Rate and Factors Affecting the Outcome of Assisted Reproductive Treatment in Subfertile Men. Iran J Public Health. 49 (2):332-340. PMID: 32461941; PMCID: PMC7231713.

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