Handling Infertility

Thirty one year-old Uma wants to have a baby, she has been married for five years and is really desperate now. Her menstrual cycles are irregular, have always been that way – going on for seven days – every 50-60 days. Her BMI is 28 (BMI=Wt in kilogram/Ht in (metre)2).

Thirty two year-old Reema has had two miscarriages, four years ago and has not conceived after that. Her menstrual cycles are regular, her BMI is 23 (normal BMI is 18-23).

Couples who experience the trauma of infertility need special attention by a gynaecologist, reproductive endocrinologist and sometimes a psychiatrist/psychologist. In our culture, a couple who has not had a child for two to three years after their marriage are put through a lot of stress and the pressure takes a toll on their relationship. The in-laws immediately think that the problem is only with the daughter-in-law, and add to the stress.

Infertility is defined as the failure to conceive after one year of unprotected sexual intercourse. Primary infertility is the inability to conceive in a couple, who has had no prior pregnancies. Secondary infertility is the inability to conceive in a couple, who has had at least one prior conception, which may have resulted in a child or abortion or ectopic pregnancy. Eighty percent of women conceive in the first year of marriage and 90% in the second year. Infertility is prevalent in about 10-15% couples of reproductive age.

Infertility can be due to problems in the male (30%), female (40-55%), both partners (10-20%), and sometimes unexplained (10%). The female factors could be at the ovarian level (ovary dysfunction 40%), tubal level (40%), or uterus level (10%), cervix level (5%).

Ovulation is critical to conception. Absence of ovulation, infrequent ovulation, reduced ovarian reserve due to advanced maternal age (the number of oocytes or eggs and their quality decreases with increase in age, and becomes critical after 35 years of age). Normal menstrual cycle occurs once in 28 days, though cycle length from 21-35 days is considered normal, with a mean blood loss of 30-40ml, lasting two to eight days. The first day of menstruation is referred to as day one of menstrual cycle. Ovulation, the process by which an oocyte/ egg is released from the ovary, occurs on day 14. There is a rise in body temperature, 0.2-0.40F soon after ovulation. Date of the last menstrual period (LMP) is essential to rule out pregnancy.

The most common cause of ovulation problem is PCOS – Polycystic Ovarian Syndrome, usually presenting with irregular cycles, infertility, obesity, acne, hirsutism. The treatment here is weight reduction, and combination oral contraceptive pills (under the advice of a gynaecologist).

Tubal factors are mainly due to tubal damage, secondary to pelvic infections, tubal/ectopic pregnancies, endometriosis or pelvic surgeries in the past. Endometriosis is a common gynaecological problem, seen in 8-10% 0f the population. The person presents with severe crampy pain during menstruation, pain during ovulation, pain during intercourse, heavy bleeding, infertility and chronic pelvic pain … 30-45% of infertile women have endometriosis. Treatment is with NSAIDs (Mefenamic acid) and hormones.

Uterine factors could be congenital or acquired—uterine polyps and intra uterine adhesions following repeated D&C’s (dilatation and curettage-gynaecological procedure).

Nearly 70% of the conditions that cause male infertility can be diagnosed with history, physical examination and semen analysis, with the last one being the single most important test in the evaluation of male infertility.

In young couples who don’t show any of the above causes for infertility, advice may be given regarding timing of intercourse. More frequent intercourse is advised from day 12-16 of the 28-day cycle.

It is good to learn to remain calm and stop running from doctor to doctor. Couples, especially the woman often become depressed and lose all joy of living. This is beyond their control and the sooner they accept and adjust their mindset to shift their focus on God and begin to get interested in other things they may enjoy life more. The sooner they can come out of their depression they can be blessed with other joys of life.

Adoption is another option. There are many orphans out there who long to know the comfort of parental love.

Dr. Shanthini David MBBS., PG Dip in Family Medicine, is a graduate of CMC Vellore and is a family practioner. She has worked in Baptist Mission Hospital, and several NGOs with particular interest in urban slums. She is currently serving women with systematic health care in the poor communities.