GYNECOLOGY

In this article, infertility and how to know you are fertile. I will explain the signs and symptoms that will point to the possibility of infertility. Pregnancy is the sure confirmation of fertility. There are no specific symptoms or signs that will guarantee that a man or woman is fertile. However, there are certain symptoms or signs whose presence signifies the woman or man will need assistance for the couple to conceive.

For these symptoms and signs, they may be present at the moment or you might have experienced them in the past. Their residual effects might hinder conception.

SYMPTOMS AND SIGNS of INFERTILITY IN WOMEN

A woman who sees her period regularly and experiences premenstrual symptoms such as mood swing, breasts fullness, breasts tenderness, nausea and bloatedness is most likely to be fertile. If she is infertile, it is not likely due to ovulatory dysfunction, which is the common cause of infertility. During the course of evaluation for infertility, certain questions will be asked by the gynaecologist or urologist. These questions are asked to rule in or out the possibility of any medical condition that can cause infertility.

Apart from the inability to conceive, infertility on its own has no particular symptoms or signs. However, the manifestations of other underlying medical condition that can cause infertility are what you can feel and see as the possible symptoms and signs of infertility respectively.

If a woman is unable to conceive with the following symptoms and signs such as; irregular menses; with or without an anterior neck mass; heat (feels hot in cold weather) or cold intolerance (feels cold in hot weather), and excessive weight loss or gain. Thyroid disease may be responsible for these symptoms and signs. Abnormal thyroid hormone interferes with ovulation.

Also, some infertile women may have breast milk coming from the breasts.  Whether they expressed it or it was spontaneous; with or without headache, dizziness or visual disturbance. The likely cause is due to high blood prolactin levels. This high blood prolactin levels could be as a result of tumour in the pituitary or from nipple stimulation. This stimulation can be from direct suckling on the breasts, nipple piercing or herpes zoster involving the chest wall. High blood prolactin interferes with ovulation.

Furthermore, menstrual irregularities associated with abnormal body hair distribution, excessive weight gain, acne with or without voice change is associated with polycystic ovarian syndrome. Women with this condition have very few menses in a year. Some have to shave not only their legs but also their facial hair. These women have excess androgen; the male hormone which is responsible for their male pattern of hair distribution. Their irregular menses is due to the fact that they do not ovulate.

Chronic cyclical pelvic pain that starts some days before the onset of menses, and wanes with the commencement of menstruation, with or without bleeding from other body parts like the navel, is suggestive of endometriosis. This is when the inner lining of the womb is found outside the womb. It bleeds just like the womb during menses. This condition can cause adhesions to form around the fallopian tubes and block the tubes. Therefore, the egg release at ovulation and the sperm cannot meet because the fallopian tubes are blocked. This will result in infertility.

Similarly, Infertility in a woman with a Prior history of pelvic inflammatory disease is due to tubal blockage. Pelvic inflammatory disease is a gynecological emergency because of it after effect on the fallopian tubes and subsequent infertility. It manifest as fever, lower abdominal pain and or swelling with abnormal vaginal discharge. If poorly treatment, it could result in scarring of the fallopian tubes and subsequent infertility.

In addition, pelvic inflammatory disease caused by Chlamydia trachomatis can run a sub-acute course. It will not manifest with the usual symptoms and signs that will prompt health seeking. Also, some individuals can carrier this infection without manifesting any symptoms but will subsequently transmit it to their sexual partners.

SYMPTOMS AND SIGNS OF INFERTILITY IN MEN

The fact that a man can achieve and sustain erection does not make him fertile. This is contrary to the belief that a fertile man should wake up every morning with an erection. Nocturnal penile tumescence commonly called “morning wood” is the erection that men get while sleeping or waking up in the morning. It might signify sexual capacity but not fertility. Some of the symptoms or signs of infertility might have occurred in the past or the man just began to notice these changes.

There are no specific symptoms and signs that signify infertility in a man. However, the presence of certain symptoms and signs in a man whose wife is having difficulty conceiving should be a cause for concern. These may be suggestive of an abnormality in sperm production or transport. These can result in Infertility and these symptoms and signs include:

• The opening of the urethral may point up or down instead of being at the tip of the penis. This affects proper sperm deposition at the cervix.
• Sudden reduction in sperm volume can follow retrograde ejaculation or obstruction of the sperm duct. This obstruction could be from inflammatory changes associated with infection involving the urethral, vas deferens or seminal vesicles.
• Reduction in testicular volume or size may be due to atrophy following trauma, infection causing inflammation of the testis, testicular torsion or reduction in blood supply and oxygen to the testis from complication of sickle cell disease.
• Inability to achieve and sustain erection may result from diabetes, effect of prolonged priapism (erection) in sickle cell male.
• Testicular discomfort, swelling or pain and the scrotum might feel like it contains a bag of worms. This is suggestive of varicocele, it affects the sperm structure.
• Breasts enlargement
• Discharge of breast milk from a man’s breast, headache and visual disturbances resulting from a tumour in the pituitary gland can result in infertility.
• Reduce sexual drive from reduce testosterone levels. This can be cause by effects of emotional stress, alcoholism or aging.

Infertility is said to occur when a couple have regular unprotected sexual intercourse of reasonable frequency and are still unable to conceive after one year. A great number of couple will conceive within one year, the remaining small percentage will conceive in the second year. However, evaluation starts after one year for younger women, those ≥35years should be evaluated after 6months of trying to conceive.

The shorter period for evaluating older women has to do with the reduction in the quality of their eggs with age. This affect their chance of conception and also increase their risk of having babies with congenital malformation. A woman’s ability to conceive reduces as she ages.

The period of evaluation will involve extensive history into the sexual and medical history of the couple. The history and examination alone may reveal the cause of the infertility. Both couple are encouraged to attend at least the first consultation. This is where they will be educated on the fertile period where conception is highly likely and also to avoid use of oil based lubricant. This is also an opportunity to commence pre-conception counselling and care.

It is worthy of mention that no sex position increases the chance of conception. Also, there is no need for the women to remain lying either face down or up after intercourse. This does not affect the ability of the sperm to get to the egg. It is also normal to see some seminal fluid coming out of the vagina after sex. The fluid must have serve their purpose; providing the medium for the sperm to swim up to the egg.

As already mentioned in the first article of this series, a couple’s inability to conceive maybe be from one partner or contributed equally by both of them. In certain couples, the cause is not known and this is called unexplained infertility. While the cause of infertility could be sex specific, some of the causes can be found in both sexes.

CAUSES OF INFERTILITY IN MALE

For a man to successfully get a woman pregnant; the testis must be in a state of good health to produce adequate, healthy, motile sperm, the vas deferens must be patent to conduct the sperm and he must be able to achieve erection and ejaculate into the woman’s vaginal. The following are some of the causes of male infertility;

Hormonal disorders: male infertility could result from been born with the absence of the hormone gonadotrophin releasing hormone. The pituitary gland could fail either from the effect of a tumour, radiation or surgery resulting in infertility. Other hormonal causes of male infertility include; thyroid disease, diabetes and high blood prolactin level.

Abnormality of sperm formation: small deletion of one or all the three region on the Y-chromosome that controls the process of sperm formation call spermatogenesis will result in infertility. This deletion could be so small that it may not be detected on karyotyping. Affected males will have reduced sperm or no sperm at all. This may progress from reduced to total absence of sperm resulting in secondary infertility. Other causes of abnormal sperm formation are; mumps infection of the testis, exposure to radiation and testis that fails to descend to the scrotum.

Abnormality of sperm movement: some individuals could be born with defective cilia (Kartagener syndrome); this manifest as male infertility with chronic respiratory infection due to absence of the cilia needed to clear mucus. This also affects the ability of the sperm to move.

Abnormality of sperm passage: some individuals may be born without a vas deferens or their vas deferens may be obstructed later.

Varicocele: the veins in the scrotum are dilated and could give the sensation of a ‘bag of worm’ when felt. This is believed to cause infertility by increasing the temperature in the scrotum. The scrotum by God’s design was kept outside the body for a reason; to have a temperature far less than that of the body. The scrotum need to be at the right temperature for sperm production, motility and proper structure and varicocele interferes with these. Varicocele could manifest with scrotal discomfort or pain.

Sexual dysfunction: reduce sexual desire, retrograde ejaculation (backward emission of semen into the bladder) and erectile dysfunction (inability to achieve and sustain penile erection sufficient for sexual satisfaction) result in infertility. Erectile dysfunction could result from alcoholism as it inhibits sexual response by interfering with testosterone production.

CAUSES OF INABILITY TO CONCEIVE IN FEMALES

For a female to successfully conceive; ovulation must take place, the egg picked up by a fallopian tube, fertilization must occur, transport of a fertilized egg to the womb and implantation of the zygote into the womb. Anything that interferes with this process or passage of sperm into the female genital tract will cause female infertility. The following are some of the causes of female infertility;

Cervical causes: abnormality of the cervix could result from infection, surgical procedure or exposure to radiation. These can result in abnormal narrowing of the cervix or alteration in the production of cervical mucus. The cervical mucus helps the sperm to undergo the changes necessary to penetrate the egg. Some medication such as hormonal contraception, thickens the cervical mucus interfering with sperm passage.

Uterine causes: uterine adhesion from infection, D & C, fibroids in the inner lining of the womb and fibroid removal surgery may result in a partial or complete closure of the cavity of the womb. This interferes with the implantation of the fertilized egg. The uterus may be absence in certain instance or badly malformed in a way that it interferes with implantation.

Ovarian causes: the ovaries may be absent or present but fails to release eggs. Ovulatory dysfunction could result from some endocrine conditions like; thyroid disease, polycystic ovarian syndrome, pituitary disorders (resulting in high prolactin or deficiency of the follicle stimulating and luteinizing hormones), disorder of the hypothalamus resulting in gonadotrophin releasing hormone(GnRH) insufficiency. Other conditions could also alter the release of the GnRH such as high level of stress, starvation, malnutrition, chronic diseases (liver disease, renal failure).

Fallopian tube causes: fertilization takes place in the fallopian tube. The fallopian tubes may be absent or blocked due to infection or from effect of other pelvic tumour. Smoking also interferes with the ciliary action of the cells needed to pick up and move the release egg.

Pelvic causes: pelvic adhesion from previous pelvic surgeries, pelvic inflammatory disease or endometriosis (when the inner lining of the womb is also found outside) can block the fallopian tube or interferes with it motility.

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“Infertility has never been the fault of the man”; I don’t know what to call this, a myth or a lie. This has been planted into the psyche of most women that they do unthinkable things to prove how true this generational lie is. You should know that both male and female may contribute to their inability to conceive equally. The cause of the infertility could be due to a male factor, female factor or both. At times, it may be difficult to convince a woman in an African setting that she is not responsible for their childlessness. This belief has permeated our society that even our home movies clearly depict that. 

Also, the attendance of the male partners of couples with infertility to the gynaecology clinic speaks volume. In my facility, patient with complaint of inability to conceive are first seen at the gynaecology clinic. They may be referred to our fertility centre on need basis. It is rare to see a man accompany his wife to the clinic. We have to insist many times we want the spouse to take a seminal fluid analysis test. Sometimes, the woman will finish her evaluation and the man is yet to do his sperm analysis.

At one consultation, after reviewing the woman’s test results, she was told she was fine based on her results. She was not convinced and went ahead to tell me how strong the husband is and that he ‘last long’ in bed. She also brought up another complaint attributing her vaginal discharge to infection and therefore the probable cause of her inability to get pregnant. After another examination, she was found to have a normal vaginal discharge. For this patient, the husband had been invited twice to the clinic which he never showed up. He was also yet to do his sperm analysis.

INFERTILITY; WHEN IS A COUPLE SAID TO BE UNABLE TO CONCEIVE?

The word barren is often erroneously associated with a woman who is unable to bear children, whether it is her fault or not. The real meaning of this word should apply to either the male, female or the couple in a sexual relationship. A couple is declared infertile if they are unable to conceive after one year of regular, unprotected, sexual intercourse. For women who are advanced in age, ≥35years, 6months is used instead of one year. One year is used because about 90% of couples will conceive within one year. It should be noted that the ability to conceive in one menstrual cycle is less than 50% for a fertile couple.

WHEN SHOULD A COUPLE SEEK HELP FOR INFERTILITY?

Generally, after one year of actively trying to conceive, a couple should seek help if they are unable to conceive. For older women, their evaluation should start after 6months of actively trying to conceive. This consideration has to do with the average age of menopause, which is about 45years and the fact that the quality of the woman’s eggs begins to depreciate. While for younger women, their evaluation starts after one year.

However, if the couple feel they have a problem, they can seek help earlier. it is not in all cases that the couple have to wait for 6months or one year. If there is an obvious cause for the couple’s inability to conceive, they will be evaluated and treated. Your gynaecologist will not ask you to mandatorily wait when the cause of the infertility is already known.

WHO SHOULD BE EVALUATED FIRST FOR INFERTILITY?

Contrary to what I have seen in my practice, the male should be tested first. Ideally, the couple should be seen together and their evaluation can go on concurrently. If for any reason one of the couple must be tested first, the male should be the first. This is because it is easier and cheaper to test the male than the female. The evaluation of the female is more expensive, discomforting and takes a longer time. Some of the tests must be carried out at specific periods in her menstrual cycle. For the male, the test can be done at any time except for the sperm analysis that will require a brief period of abstinence.

TYPES OF INFERTILITY

Basically, infertility is classified into two; primary infertility and secondary infertility. A couple is said to have primary infertility if the man had not impregnated his partner in his previous or current relationship, and the woman had not been pregnant ever in her life. Infertility is secondary if either the man had impregnated a woman in the past or his current partner had been pregnant in the past. The outcome of the pregnancy does not matter; whether it resulted in child birth or ended as a miscarriage.

Infertility can also be classified based on which partner is the cause; male factor infertility, female factor infertility, both male and female factors infertility and unexplained infertility.

WHAT ARE THE CAUSES OF INFERTILITY?

For conception to take place; it requires a healthy sperm, healthy egg, normal fallopian tube for the egg to pass and unite with the sperm, and a normal womb for the developing baby to implant and grow. Abnormality that interferes with any of these will result in infertility. One minor but often neglected cause is inadequate sexual exposure.

I once asked a patient how many times in a week she has sexual intercourse since she started trying to conceive. The response was quite funny, she said may be once. If I may ask, for a couple trying to conceive, how many times per week is sex deemed adequate? If your answer is three, you are right, yes you need that much. It is worthy to note that too much of everything is bad including sex. Non-stop daily sex is not recommended, the sperm need some break to accumulate again, a day or two break is fine.

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