By Dr Khine Pwint Phyu & Assoc Prof Dr Ganesh Ramachandran
The incidence of infertility is on an upward trend worldwide. The World Health Organisation estimates that one in six people are affected by infertility. There is a similar trend in Malaysia, with a drop in fertility rates from 4.9 children per woman of childbearing age in 1970 to 1.7 in 2021.
Infertility is defined as not being able to conceive after one year of unprotected sexual intercourse. In women above 35, this duration is sometimes shortened to six months. Causes are varied, involving issues in either partner or both and in some cases, the causes are difficult to identify.
Female factors causing infertility
Anovulation, or ovulation disorder, is a situation where no eggs are released from the ovaries during the menstrual cycle which makes pregnancy difficult. Hormonal imbalances including polycystic ovary syndrome (PCOS), excessive prolactin secretion, eating disorders, extremes of body weight, strenuous exercises, stress, and other chronic illnesses can often lead to a woman experiencing anovulation.
Another factor is the blockage of fallopian tubes, caused by previous pelvic infections, inflammation of tubes, and pelvic adhesions which may be related to past surgery at the abdomen and pelvis. When the tubes are blocked, it will affect the transport of sperm to meet the eggs to achieve successful implantation and pregnancy.
Another condition that can affect female fertility is endometriosis, which is the presence of tissue that is normally found in the inner lining of the uterus, outside the uterine cavity, which may affect the function of the ovaries, uterus, and fallopian tubes.
Sometimes, congenital abnormalities (malformations that develop before birth) of the uterus or uterine fibroids (non-cancerous growths which develop in and around the womb) may prevent the successful implantation of a fertilised embryo.
Male factors causing infertility
Low sperm count indicates abnormalities in sperm production or function and can be seen in men with genetic defects, chronic health problems such as diabetes, liver or kidney diseases, or sexually transmitted infections like gonorrhoea. Abnormalities such as undescended testis and varicoceles (swollen veins within the scrotum) can also be causes.
Premature ejaculation, and blockage or injury to the reproductive organs as well as the usage of certain medications can affect sperm movement, quality, or lead to coital dysfunction.
Additionally, environmental and lifestyle factors such as use of tobacco, heavy alcohol, marijuana or steroids, exposure to toxins and exposure of the external genitalia to high temperatures can contribute to male infertility.
Challenges and approach to infertility
The availability, access, cost, and quality of interventions remain a challenge in most countries along with a lack of trained personnel and the equipment and infrastructure necessary to address infertility. While the causes of infertility are varied and can affect both partners, the burden and stigma are often shouldered by the female partner. In our part of the world, both issues are particularly pronounced.
To support health education and increase awareness regarding numerous infertility issues faced by couples across the globe, World Infertility Awareness Month is observed every year in June. Many couples are not even aware they are infertile; hence this month serves to alert them of issues that may affect them as well as their available solutions.
Couples with fertility issues should therefore see a doctor in a timely manner to receive a proper assessment and effective treatment. As age is an important factor in conceiving, early medical intervention often leads to positive outcomes in a couple’s fertility journey.
Both partners should be involved in fertility consultation and management. The primary issues to address include if the woman is ovulating regularly, if the sperm cells in semen are healthy, if there are coital issues and any problems with fertilisation and implantation, and if the woman is able to maintain the pregnancy.
To answer these questions, thorough evaluation should be done through taking a detailed medical and personal history, sexual history and performing a physical examination for both partners. The next steps would then be to test the couple with baseline investigations as well as specific evaluations.
Some common assessments include tests to ensure the fallopian tubes are patent (open and lacking blockage), tests to confirm ovulation, sperm counts, and ultrasound to look for abnormalities in the uterus, fallopian tubes, and ovaries.
Managing and treating infertility issues
Sometimes, simple lifestyle modification measures can solve infertility such as weight management, adequate exercise, cessation of smoking, and the limitation of alcohol consumption. As for natural methods, frequency of sexual intercourse can be an issue and it is recommended that at least 3 times a week increases the probability of conceiving. Timed intercourse during a women’s fertile period may be a strategy as well. Women usually ovulate about 12 to 14 days before the start of a next menstrual cycle and the fertile period is the five days before ovulation, the day of ovulation, and the day after ovulation.
The treatment for fertility issues depends on the cause. For women who experience problems with ovulation, medications to induce ovulation may be employed. As for women with endometriosis, fibroids, or other tubal diseases, surgery may also improve outcomes. For men, prescribing medications to improve sperm quality may help and surgery may be employed for men with structural abnormalities in their reproductive system.
When more simple methods are not successful, complex and expensive procedures may be employed such as intra uterine insemination (IUI), gamete intra-fallopian transfer (GIFT), and intracytoplasmic sperm injection (ICSI). For couples with unexplained infertility, increasing coital frequency in combination with IUI often results in successful pregnancies.
Undoubtedly, infertility is a silent struggle that affects millions of people worldwide. But it is also important to recognise that infertility is a medical condition which can be caused by both male and female factors, and that professional help is available. Early identification usually has better outcomes, and many health systems already provide some number of subsidised treatments to decrease the financial burden.
Dr Khine Pwint Phyu is Senior Lecturer in Obstetrics and Gynaecology, School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University.
Assoc Prof Dr Ganesh Ramachandran is Head of School, School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University.