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The Doctor Said To Come Together ….. But I Went Alone – Infertility (pt. 2/3)

Evaluation in sub-Saharan Africa: In Conversation with a Fertility Expert

By Dr. Nwamaka Osakwe

“I’m thinking I should go to the hospital,” Nnenna, a housewife living in southeastern Nigeria, said to her husband one night as they sat in the living room watching TV.

“Why?”

“Which one is why? Is this baby thing not worrying you?”

An infertility evaluation is usually recommended after one year of trying to get pregnant without success despite regular unprotected sexual intercourse. However, for women older than 35 years, it may be appropriate to begin the evaluation process earlier.

The goal of fertility testing is to rapidly determine the cause of infertility and provide treatment.

Infertility may be caused by a male factor, a female factor, a combination of male and female factors, or the factors may be unknown. As such, it’s ideal to evaluate both partners at the same time.

Very often, women are the first to seek help. When Nnenna had difficulty conceiving, she went to the clinic alone. “The doctor told me I’m supposed to come with my husband, but I told him to check me first.” For some women, it’s not a question of choice but rather because their partners refuse to be evaluated. This leads to inadequate care.

Dr. Elijah Onwudiwe, a consultant gynecologist and the medical director of Pink Petals Fertility Clinic, says, “It’s very important to evaluate both the male and female at the same time. We are beginning to see an increase in male factor infertility, especially secondary infertility. Sometimes, the men will say I have fathered other children before and don’t realize there is secondary infertility. These things are dynamic.” Secondary infertility is when a pregnancy has been achieved in the past.

Other barriers to good fertility care are:

  • Personal: Ignorance, misconceptions, and religious beliefs can interfere with fertility care.
  • Cost: Finance is a significant barrier to fertility care. Fertility testing can be expensive, and so high-income earners tend to seek care earlier.
  • Community: Fear of infertility and stigmatization in the community can prevent fertility care seeking behavior.
  • Access: Geographic barriers can limit access to assisted reproductive technology.

Despite the high prevalence of infertility, for many couples, it is a private problem. As such, they dread public awareness that they are seeking fertility care. One woman in a study carried out in Ghana said, “You go to [the] hospital, and they will announce that those with infertility should go [to] this consulting room telling everybody your problem. The next thing you see is that people are pointing fingers at you in town.”

Evaluation of infertility requires a systematic approach. The first is a comprehensive history followed by a physical examination. Next, tests investigate possible causes of infertility. Dr. Onwudiwe says, “Investigations are individualized. If you perform all the investigations, then you will be increasing the cost of treatment.” In addition, some of these tests are invasive and may be unnecessary in certain circumstances.

Diagnostic tests should be prioritized based on their level of invasiveness and their ability to target the most likely cause of infertility. Unfortunately, reports show that fertility care in the public health sector is often uncoordinated and incomplete.

That day at the clinic, the doctor went ahead to begin evaluating Nnenna.

Evaluating female infertility

At the first consultation, a detailed history should be obtained, and it should include

  • Menstrual history: Questions about menarche, premenstrual symptoms, cycle duration, cycle length, and cycle regularity.
  • Pregnancy history: Prior pregnancies, pregnancy outcome, any history of termination of pregnancy.
  • Infections: Sexually transmitted infections, genital tract infections, postpartum infections.
  • Duration of infertility: How long since attempts has been made to get pregnant.
  • Previous use of contraceptives: What kind of contraceptive was used? When was it stopped?
  • Medical history: Any underlying medical illness, current medication, previous use of chemotherapy, or pelvic irradiation.
  • Social history: Tobacco use, work history, diet.

Examination

Important things to look out for include:

  • Weight and BMI
  • Blood pressure
  • Evidence of androgen excess
  • Thyroid enlargement
  • Pelvic tenderness

Investigations

These are usually ordered systematically. The decision to perform one or more laboratory tests is generally based on history, physical findings, and common causes of infertility in the environment.

Dr. Onwudiwe says, “You need four things for pregnancy to take place – the ovary, the fallopian tubes, the womb, and the sperm. So, your tests should consider these four areas.”

Laboratory and radiologic investigations are often grouped into the following categories:

  • Tests of ovulation
  • Tests of ovarian reserve
  • Tests of tubal patency; tubal factors are a significant cause of infertility
  • Tests of the uterus and cervix

Home ovulation test kits can be used to test for ovulation, although they are not 100% accurate. Hormone assays and transvaginal ultrasounds can also be used to test for ovulation, and for ovarian reserve.

Dr. Onwudiwe identifies tubal factors as the most common cause of secondary infertility in the woman. The hysterosalpingogram (HSG) is the most popular test for tubal patency. It involves injecting a dye into the uterus and taking x-rays. If the tubes are open, the dye will move into the tubes and be visible on imaging. If the tubes are blocked, the dye will remain in the uterus.

“HSG may be painful,” says Dr. Onwudiwe. “Some women have cramps. An alternative to HSG is the saline infusion ultrasound. We infuse saline into the womb and then perform a transvaginal ultrasound. Another alternative is the laparoscopy and dye.”

Ultrasound is readily available and is often the initial investigation for assessing the uterus.

Other investigations that may be requested when evaluating female infertility are:

  • Serum prolactin
  • Thyroid function tests
  • Hysteroscopy and laparoscopy

Nnenna’s workup showed she had fibroids. She wondered if she should have it removed. But the doctor insisted Nnenna’s husband had to be evaluated too.

It’s important to exclude male factor infertility.

Evaluating male infertility

Male fertility should also be evaluated systematically. Careful questioning may reveal:

  • Erectile dysfunction
  • Retrograde ejaculation
  • Low sex drive and infrequent intercourse
  • Previous genital surgery
  • History of mumps, chemotherapy, or pelvic irradiation.

Examination

Men with fertility problems should be examined carefully, paying attention to the habitus. Other things to note include:

  • Presence of gynaecomastia
  • Size of the penis
  • Presence of the testes in the scrotum and its volume

Investigation

“The basic test that should be requested in men is the semen analysis. It is simple. It’s not invasive like some of the tests done in women, and it can give us a lot of information,” says Dr. Onwudiwe.

Semen analysis requires abstinence for 2-3 days. After that, the man produces semen by masturbation. The sample should get to the laboratory within an hour of being produced.

Researchers report that some men may find it difficult to produce semen by masturbation.

Another obstacle to a semen analysis is the fear of infertility diagnosis. Men describe profound guilt, shame, and loneliness on learning they are infertile. Although women are often blamed for infertility in sub-Saharan Africa, men may be at higher risk of disgrace if they are confirmed to be the cause of infertility. In addition, reports from developing and developed countries describe male infertility as emasculating. When Bradley Goldman, a health and fitness consultant in the United States, got the results of his semen analysis, he said it was “earth-shattering.” James, a young Malawian man, described it as “a big and sorrowful event.” When Nnenna’s husband found out that he had a low sperm count, he could not sleep or eat.

A semen analysis is an essential investigation in evaluating a man for infertility. It can show if the sperm count is adequate and whether they are moving actively or sluggishly. Semen analysis also provides information about the structure of the sperm.

Other investigations that may be requested include:

  • Follicle stimulating hormone and testosterone level
  • Thyroid function test

Conclusion

In Sub-Saharan Africa, although some of the tests for infertility are not readily available many basic tests are available and relatively cheap. So, it’s essential to order investigations appropriately. The place of a detailed history and examination cannot be overemphasized. A proper evaluation allows doctors to rapidly diagnose the cause of infertility and offer treatment. This way, couples with infertility can have a good chance of having their babies.

To learn more about evaluating infertility, click here. If you’re a health practitioner looking to improve the care of your patients with fertility problems, a CPD course on Reproductive Health is coming soon.

Nwamaka Osakwe, MBBS, is a physician who loves writing about health and wellness. You can reach her here.

The Missing Link to Improved Health Outcomes (MiLHO) Initiative provides online CME courses that recognize and consider Africa’s unique medical practice environment by developing evidence-based and relevant content. The initiative aims to expand opportunities for CME to assist healthcare practitioners in staying current with evidence supporting patient care in their local setting. Courses are certified by the CPD Certification Service. Visit the MiLHO Initiative to learn more.