Tapasya and her husband are upset and angry. They have just returned from a family function and it seemed that every one of their relatives had only one question. “You have been married for six months, and you are not pregnant yet?” Tapasya feels unnecessary pressure: is there anything wrong with her?
Tanvi has been married for the past 2 years. For the first year, she had used birth control pills to avoid a pregnancy. Now it has been a little more than a year after stopping birth control but she has not conceived yet. Should she and her husband seek advice from a gynaecologist?
Unfortunately, culturally the onus for not being able to conceive is placed squarely on the woman. In many instances, the wife may be asked to undergo many expensive and invasive investigations and treatment cycles before any attempt is made to investigate the husband. The first step in investigation should always be the sperm count for the husband. This is a simple test and allows the couple and the treating gynaecologist to make decisions about further modes of management.
Modern lifestyles are also playing an important role in infertility. Many young couples are in jobs which have odd hours or require one or both to travel extensively. In this situation, the inability to conceive is primarily due to an erratic lifestyle.
What is infertility?
If a couple has not achieved a pregnancy after having regular sexual intercourse for a year without using contraception, they may be considered infertile. If the woman is 35 or older, investigations may be started after six months of trying. Approximately 15-20 per cent of couples may not be able to conceive and may require investigations and treatment to achieve a pregnancy.
How does pregnancy happen?
During each normal menstrual cycle, one egg ( ovum ) is usually released from one of the ovaries, about 14 days before the next menstrual period. The process is called ovulation. The fallopian tubes have finger like projections ( fimbriae ), which pick up the egg and transport it into the funnel-shaped end of the tube.
At ovulation, the mucus in the cervix becomes thinner and watery, facilitating the entry of a sperm into the uterus. Within a short time, usually minutes, the sperm may swim rapidly from the vagina through the cervix into the uterus and into the fallopian tube — the usual site of fertilisation. If fertilisation does not occur, the egg degenerates and passes through the uterus with the next menstrual period.
Fertilisation occurs if a sperm penetrates the egg. Once fertilisation occurs, the egg starts dividing to form a zygote, a solid ball of cells. Tiny hair-like cilia lining the fallopian tube propel the zygote through the tube toward the uterus.
What causes infertility?
In very simple terms, infertility happens when there is:
*A problem in ovulating
*Fallopian tube damage or block
*Low sperm counts or abnormal sperms
Sometimes infertility may be caused by more than one factor. Factors related to the woman may be the reason for infertility in 65 per cent of cases. A male factor may be the sole cause of infertility in 20 per cent of cases and may be an important contributing factor in 20-40 per cent of cases. Frustratingly, no cause can be found in either partner in 15 per cent of couples undergoing investigations for infertility.
Age can be a major factor in infertility. For healthy, young couples, the chance of conceiving during each menstrual cycle is approximately 20 per cent. This number starts to decline in a woman's late 20s and early 30s and decreases even more after the age of 35. A man's fertility also declines with age, but not as early.
When a woman is 35 or more, it is important to start investigations and treatment for infertility if pregnancy has not occurred in 6 months. The reasons for this are that:
* The ovaries become less able to release eggs
* There are a lesser number of eggs left in the ovaries
* The eggs are older and therefore not as healthy
* There may be other health conditions (e.g. diabetes) which may make it more difficult to conceive
* There is an increased likelihood of miscarriage
The investigations for infertility will be discussed in my next column.
(The author is an obstetrician and gynaecologist)
