Infertility: Don’t wait until it’s too late

Parenthood is undeniably one of the most universally desired goals in adulthood, and most people have life plans that include children. However, not all couples who want a pregnancy will achieve one spontaneously and a proportion will need to seek medical treatment to help resolve underlying fertility problems. It’s therefore understandable that infertility has been recognised as a public health issue worldwide by the World Health Organisation (WHO).

“Infertility is when you cannot get or stay pregnant after trying for at least a year and you are under the age of 35,” says Dr Sulaiman Heylen, President of the Southern African Society of Reproductive Medicine and Gynaecological Endoscopy (SASREG).

One in every four couples in developing countries is affected by infertility, while one in six couples worldwide experience some form of infertility problem at least once during their reproductive lifetime. The current prevalence of infertility lasting for at least 12 months is estimated to affect between 8 to 12% worldwide for women aged 20 to 44.

In recent years, the number of couples seeking treatment for infertility has dramatically increased due to factors such as postponement of childbearing in women, development of newer and more successful techniques for infertility treatment, and increasing awareness of available services. This increasing participation in fertility treatment has also raised awareness and inspired investigation into the psychological ramifications of infertility. It can cause stress, depression and anxiety, which is why it is important to know that there are options available for treatment.

Age is a key factor

“Up to 50% of all patients who visit a fertility centre are 35 or older. We cannot stress enough how important it is for people not to wait too long when they consider having children. Young women need to be aware that there is a slow decline in fertility from their 20s until the age of 35, after which it starts to decrease rapidly until the age of 45,” says Dr Heylen.

“It’s extremely important for couples to investigate fertility options and fertility preservation earlier in life, rather than leaving it too late. A woman who is not ready to have a child can choose to freeze her eggs to try to preserve her ability to have a child later,” says Dr Heylen.

It’s estimated that 20 to 30% of infertility cases are explained by physiological causes in men, 20 to 35% by physiological causes in women, and 25 to 40% of cases are because of a problem in both partners. In 10 to 20% no cause is found. Infertility is also associated with lifestyle factors such as smoking, body weight and stress. A woman’s age is one of the most important factors affecting whether she is able to conceive and give birth to a healthy child. This is due to several changes that are a natural part of ageing:

• The number and quality of eggs (ovarian reserve) decreases naturally and progressively from the time a woman is born until the time she reaches menopause.
• It is not only more difficult to get pregnant (conceive), but miscarriage and chromosomal abnormalities in the child (such as Down syndrome) are more common in older mothers.
• Fibroids, endometriosis, and tubal disease are more common and can affect fertility.
• Women who become pregnant at an older age have a higher risk of complications during the pregnancy, such as gestational diabetes and preeclampsia.

The decrease in a man’s fertility appears to occur later in life than in a woman’s fertility. In their mid-to-late 40s, men experience changes in their sperm that can cause issues with fertility, and chromosomal or developmental problems with their children.

Lifestyle and family history

If you have any of the following risk factors, you may also consider seeking advice earlier:

• Family history (i.e., mother or sister) of early menopause (before age 51)
• History of cigarette smoking in either partner
• Previous ovarian surgery
• Exposure to chemotherapy or radiation to treat cancer in either partner
• Shortening in the time between periods
• Skipped or missed periods
• History of injury to the testicles
• Exposure to toxic chemicals (certain pesticides or solvents)

Pregnancy is a complex process

Pregnancy is the result of a process that has many steps. To get pregnant:

• A woman’s body must release an egg from one of her ovaries (ovulation).
• A man’s sperm must join with the egg along the way (fertilise).
• The fertilised egg must go through a fallopian tube toward the uterus.
• The fertilised egg must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps. For the pregnancy to continue to full term, the embryo must be healthy and the woman’s hormonal environment adequate for its development. When just one of these factors is impaired, infertility can result.

Couples, dependent on the ages of the partners, are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. The doctor will conduct a physical examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility. Usually both partners are interviewed about their sexual habits in order to determine whether intercourse is taking place properly for conception.

If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of ovulation, x-ray of the fallopian tubes and uterus, and laparoscopy. For men, initial tests focus on semen analysis.

“Based on the results of the specific tests, a treatment plan will be made which can include medication, surgery or assisted reproduction,” says Dr Heylen.

Treatment options

Not all couples who desire a pregnancy will achieve one spontaneously and some will need medical help to resolve underlying fertility problems. It is now estimated that more than 9 million babies have been born worldwide since the first IVF baby was born in 1978.

Most assisted reproductive technology (ART) treatments take place in women aged between 30 and 39. The most common fertilisation technique is ICSI (intracytoplasmic sperm injection). Overall, ICSI accounts for around three-quarters of all treatments worldwide, and conventional IVF around one-quarter. Success rates from frozen embryo transfer are increasing, as are the number of frozen cycles. Vitrification, as an efficient cryopreservation technique, has improved the outcome of both embryo and oocyte (immature egg cell) freezing.

Infertility often creates one of the most distressing life crises that a couple has ever experienced together. The long-term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples.

“If you find yourself feeling anxious, depressed, out of control, or isolated, you are not alone,” says Dr Heylen. “Infertility is more common than you may think, but there is no reason to lose hope. Visit a fertility clinic near you to speak to a doctor about the options available to you and your partner.”