Dr Mohamed Ashraf is a visiting consultant (Infertility & Assisted Reproduction) at Aster Medical Centre in Hilal.
Dr Mohamed Ashraf
Procreation is one of the most interesting facets of life. To father or mother a child is one of the most common desires around the world. But, as it is, not all couples conceive naturally in the normal course. Some couples are said to have some sort of problems related to fertility if they fail to conceive even after one year of normal life without any contraceptives or birth control measures. These infertile couples need medical help to have a baby.
Considering that perfect reproductive age for women is below 35 years and for men is 40 years, infertile couples are advised to seek medical advice at the earliest. Complications related to conception and childbirth are more likely to happen with advancing age. Infertility is not just a medical problem as it has long social commitments as well. And you are not alone in this battle. About 7% of the eligible couples are infertile across the globe.
Female infertility
The causes often are:
* Lacking ovulation
* Tubal blockage
* PCO – Polycystic ovary
* Endometriosis
And, there are about 15% of infertile women who owe the condition to none of the factors above. These women are said to have unexplained infertility. These women may/may not bear children in course of time.
Male infertility
Male causes of infertility are usually poor sperm quality. Poor sperm quality can be caused by:
* Lack of sperm production in the testicles
* Non-descended testicles
* Infections
* Fever
* Testicle cancer
* Antibodies in the sperm cells
Apart from the reasons cited above, there are other factors like heavy smoking, alcoholism, irradiation from occupational hazards, over tight clothes, extreme heat and exertion etc. Again, like in women, some men suffer from unexplained infertility.
Managing it
Infertility is an emotionally and psychologically taxing condition for most couples. This leads to a multitude of problems in their personal life as well as occupational life. The stress built up by infertility vents itself as outbursts, physical illness or as a change in attitude to self and others.
These problems can be effectively resolved through psychological support sessions with a counsellor in like couple groups where cognitive therapy to address the problem and sharing of experiences can result in a distressed environment which is more conducive to conception.
Studies have shown that 76% of the couples who partook in stress management sessions were able to conceive in the following year compared to the 28% who didn’t. Supportive family and society go a long way to help couples to respond better to treatments.
Disorders and infertility
Infertility is caused by various factors. Metabolic disorders, lifestyle disorders and eating disorders are some of the commonly found disorders in infertile men and women. Lifestyle disorders like alcoholism, smoking, wearing tight clothes or spending too much time in sauna or steam bath also acts against fertility.
Diabetes
Of metabolic disorders the more widespread disorder is diabetes. The condition is a hindrance to conceive as well as for normal progress of pregnancy and birth of the child. But the condition is also very manageable with the right kind of dietary advice. A recent study has discovered that diabetes affects the sperm quality in males. Around 52% of the DNA in the sperm cells in the sample taken was fragmented in diabetic men compared with 32% in men without the condition. The fragmented DNA is unable to bring about a successful conception.
In women, diabetes is closely associated with PCO or Poly Cystic Ovarian disorder. It is interesting to find that there has been proof of diabetes drugs helping to cure PCO and thereby assist fertility.
Obesity
Obese couples find it very difficult to conceive for various factors like imbalance in hormones and overweight. A BMI above 25 is considered unfavourable for fertility.
Obesity may be because of more calories intake or poor eating habits. As we know, modern lifestyle limits exercise to whole body and thereby can cause obesity.
Eating disorders
These include peculiar lifestyle habits of eating too much or too less at irregular intervals. Eating too much junk food and beverages also affects the reproductive system adversely.
One of the best known eating disorders is anorexia nervosa. People with anorexia deprive themselves of food in an effort to be thin. The condition leads to very irregular periods and imbalance in hormones. Bulimia nervosa is another disorder where the person eats more and purges it later.
Another eating disorder that is not as widely recognised as anorexia and bulimia is compulsive overeating. Often, this extreme eating is accompanied by feelings of guilt and shame.
Associated problems
Just some of the infertility problems associated with eating disorders includes:
* Amenorrhea
* Irregular menstrual cycles
* Reduced egg quality
* Ovarian failure
* Poor uterine environment
* Miscarriage
Thyroid disorders
The thyroid gland is the one that controls basic metabolic rate of a person. If the hormone produced by the gland is less than normal then the condition is called hypothyroidism and if the hormone is above requisite levels, it is known as hyperthyroidism. Both conditions may lead to infertility.
Irregular periods
The menstrual cycles of a woman are indicators of reproductive health. Irregular periods are pointers to gynaecological problems that would need medical help. Irregular periods may be caused by stress, dietary problems, over exertion, drugs and medicines, break in routine, thoughts and emotions, sexual activity -- especially when it is a new occurrence, anxiety about pregnancy or illness or physiological imbalance eg: thyroid conditions.
Congenital disorders
These may be evident or hidden. Conditions like undescended testicles in men and tubal blocks in women are some cases which can be rectified with surgery to an extent. Hypogonadism is one of the most common disorders.
Diseases and infertility
Many diseases are known to be fertility hinderer. Of these the most common are the Sexually Transmitted Diseases (STDs). But various viral, parasitic and bacterial infections also affect both male and female fertility. Cancers affecting not only reproductive organs also affect as these are treated with strong drugs and involves chemotherapy at times.
STDs are the leading cause of infertility. Chlamydia and gonorrhea cause infertility in both men and women. HPV can damage the cervix. Other STDs can also cause damage.
Common STDs are chlamydia, gonorrhea, hepatitis B, herpes, HIV/Aids, human papilloma virus (HPV) and genital warts, syphilis, trichomoniasis.
Less common STDs are bacterial vaginosis, chancroid, granuloma inguinale, lymphogranuloma venereum, molluscum contagiosum, mucopurulent cervicitis (MPC), nongonococcal urethritis (NGU)
Related conditions are candidiasis and pelvic inflammatory disease (PID).
Parasites and other diseases
Toxoplasmosis, malaria, leprosy, or tuberculosis can be a cause of infertility. Mumps can cause infertility in a small fraction of men.
Toxoplasmosis is an infection that can threaten the health of an unborn child. It is caused by a parasite called toxoplasma gondii. The parasite multiplies in the intestine of cats and is shed in cat feces, mainly into litter boxes and garden soil. You can get the parasite by handling cat litter or soil where there are cat feces. You can also get the parasite from eating undercooked meat (such as rare beef) from animals infected with the parasite.
Cancer
Cancer affects both men and women. For men it is either testicles cancer or prostate cancer. For women it is cervical cancer or cancer in ovaries or even breast cancer. But even other cancers affect fertility considering the strong medications and radiation treatment. It is advisable to couple who have been diagnosed with cancer to have their eggs/sperm frozen if they are planning a family.
Hereditary factors
Though infertility is not considered a hereditary problem, some diseases and disorders that contribute to infertility are hereditary. Both males and females can experience infertility due to genetic factors. Also mutant genes can be a reason for infertility. Cancers in family, conditions like cystic fibrosis and endocrine disorders like diabetes, thyroid problems, obesity etc are problems that can put one to infertility risk.
Males are at more risk than females as far as these hereditary problems are concerned. Many autosomal recessive genes affect men while women are just carriers. Azoospermia in men is one such disorder where the semen is devoid of live spermatozoa altogether.
Endometriosis in women is a proven hereditary disease and the chances of these women developing breast or ovarian cancer at a later stage in life is probable.
Occupational hazards
Both men and women are subjected to occupational hazards that can cause infertility or sub fertility. Mostly these affect child birth and health of child too. Classic occupational hazards are irradiation, working with heavy metals, pesticides etc. Stressful work demanding long hours of standing or sitting also have various drawbacks.
Hazards for men
Environmental agents can adversely affect germ cell development at many different stages from proliferating spermatogonia to mature spermatozoa. Possible different toxic effects include cell death, sub lethal cell damage or genetic change. Nonlethal germ cell damage will be repaired or leave permanent effect on structure or function of mature spermatozoa, including possibility of genetic defects.
Occupational exposure to sex steroids such as estrogens can exert negative biofeedback on FSH secretion and result in decreased sperm production, sexual dysfunction, gynaecomastia and hypogonadotropic hypogonadism, and potentially to cryptorchidism and testicular cancer.
Prenatal exposure to estrogens could potentially inhibit fetal gonadotropins secretion and reduce Sertoli cell proliferation which mainly nurtures the immature sperm cells to maturity.
Direct testicular toxicity may potentially affect separate cell types within testis with subsequent affect on spermatogenesis and steroidogenesis in general. No specific human Sertoli cell toxins have yet been established. Ionising radiation and alkylating agents (eg. nitrogen mustard, vincristine, procarbazine, prednisone) were found to have most profound toxicity to human germ cells. The most sensitive cells are spermatogonia. Nonproliferating spermatogonia A0, if destructed, leads to irreversible spermatogenic damage, while proliferating spermatogonia can be replaced from stem cell reserves.
Hazards for women
Occupational reproductive hazards to women pertain to sub fertility, delayed conception, early pregnancy loss, and menstrual cycle dysfunction. Occupational exposure to solvents does appear to increase the risk of dysmenorrhea and Spontaneous Abortion (SAB), particularly with exposure to organic solvents. Increased risk of adverse reproductive outcomes has also been observed among women working in agricultural settings, but no link has been made to specific exposures.
In addition, physical stressors such as shift work, long hours standing and lifting have been fairly consistently associated with increased risk of SAB or preterm birth. Finally, while complete agreement among studies is lacking, many have observed an increased risk of sub fertility or SAB associated with work in medical occupations and with some specific medical exposures, such as nitrous oxide, anesthetic gases and antineoplastic drugs.
Recent observations have brought to light the increasing incidence of infertility in the IT sector professionals. The long hours and stress adversely affects the biological clock.
And sedentary lifestyle also doesn’t help. Career plans also make women opt for starting a family only by 30s and studies have shown that fecundity decreases by then.
Mental health
The relevance of mental health is more on how mental health is affected by infertility. Though studies have been carried out on mental patients and their reproductive health, we shall limit ourselves to the mental health during the efforts to overcome infertility or finally come to terms with it.
Mental health professionals with experience in infertility treatment can help a great deal. Their primary goal is to help individuals and couples learn how to cope with the physical and emotional changes associated with infertility, as well as with the medical treatments that can be painful and intrusive.
For some, the focus may be on how to deal with a partner’s response. For others, it may be on how to choose the right medical treatment or how to begin exploring other family building options. For still others, it may be on how to control stress, anxiety, or depression.
By teaching patients problem-solving strategies in a supportive environment, mental health professionals help people work through their grief, fear, and other emotions so that they can find resolution of their infertility.
A good therapist can help you sort out feelings, strengthen already present coping skills and develop new ones, and communicate with others more clearly. For many, the life crisis of infertility eventually proves to be an opportunity for life-enhancing personal growth.
Alcoholism/smoking
Cigarette smoking is associated with modest reduction in sperm concentration (13-17%), motility and morphology. Smoking may alter hormone levels in males. Limited studies suggested smoking to be mutagenic to human spermatozoa and lead to cancer, birth defect and genetic diseases in offspring.
Excessive alcohol intake is associated with direct testicular toxicity.
Alcohol abuse and alcoholism are associated with hypothalamic-pituitary-ovarian dysfunction resulting in amenorrhea (absence of menses), anovulation (lack of ovulation), luteal phase dysfunction (abnormal development of the endometrial lining) and hyperprolactinemia. The adverse reproductive consequences of alcohol range from infertility and increased risk for spontaneous abortion to impaired foetal growth and development.
In women, the ovarian reserve and quality of eggs deteriorate with smoking. Tobacco contains hundreds of substances, many of them toxic. One study showed that the chance for an IVF pregnancy was 2.7 times higher for women who have never smoked as compared to women that do (or have previously). The same study showed that if the woman smoked for over 5 years, the risk was increased to 4.8.
There is also some evidence that male smoking decreases success rates with IVF. It is not known whether this effect would be caused directly by the sperm, or whether it represents a negative effect on the egg and embryo quality through passive exposure (second hand exposure).
Drugs and medicine
Medicines taken to treat cancers and endocrine disorders some cause infertility. Medicines taken as part of a surgery may also affect the fertility of a person. Anabolic steroids have been used by athletes to improve strength and performance for many years Among other side effects; anabolic steroids induce hypogonadotropic hypogonadism with associated azoospermia or oligospermia, abnormal sperm morphology, motility and testicular atrophy. These effects result from negative feedback of androgen on hypothalamo-pituitary axis and possible local suppressive effect of excess androgens on the testis.
The management of cases with infertility secondary to anabolic steroid abuse is controversial and range from watchful waiting with spontaneous recovery of spermatogenesis to hormonal intervention. The spontaneous recovery of spermatogenesis has been documented with high variability. Eventual successful return of fertility may be suspected by slow recovery of gonadotropins (FSH and LH). The hormonal treatment of hypogonadal hypogonadism with intramuscular injection of HCG and HMG and subsequent maintenance HCG injection has been proposed, if no improvement occurs longer than six-24 months after discontinuation of steroids.
Little is known of the effect of antibiotics on human fertility. The common manifestations are spermatogenic arrest and impaired sperm motility and morphology. Examples of evaluated drugs are nitrofurantoin, erythromycin, gentamycin, neomycin, tetracycline, sulfasalazine, penicillin G, and ampicillin.
Limited human studies address the effect of recreational drugs on fertility. Sperm concentration and motility were found to be low in cocaine and marijuana addicts. Consistent use of contraceptives is known to bring down natural fecundity.