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Two Years and Counting and Still No Baby – Infertility: Perceptions and Causes (pt. 1/3)

by Dr. Nwamaka Osakwe

“Two years and three months after my marriage, and I still wasn’t pregnant,” said Nnenna, a housewife living in southeastern Nigeria who battled infertility for years. Like Nnenna, many men and women are searching for help getting pregnant.

According to participants in a study involving women of reproductive age, the couple is usually not the only one counting down how long it has been since the wedding night. Family, friends, and neighbors all count too. The study was conducted in Ogbomoso, a city in Oyo State, Nigeria. In Nigeria, a common parting comment at most weddings is, “we will be returning in nine months to carry our baby.” Sometimes even the father of the bride says a prayer calling for twins before departing from the occasion. These practices put a lot of pressure on couples.

What is infertility?

The World Health Organization (WHO) defines infertility as failing to achieve a pregnancy after 12 months or more of regular unprotected intercourse. According to WHO, about 48 million couples have fertility problems.

Infertility may be primary or secondary.

Primary infertility is when there is no previous pregnancy. Secondary infertility is when pregnancy has been achieved in the past. The prevalence of primary infertility is lower in developing countries compared with developed countries. In contrast, the majority of secondary infertility is higher in developing countries than in developed countries.

Infertility frustrates couples all over the world. In sub-Saharan Africa, where marriage is closely linked to childbearing, infertility can be devastating to couples. Children guarantee continuity of a lineage and ensure social status and security. Children run errands in the home, secure inheritance, and take care of their parents when they are old. A child is a proof of “being a man or a woman.”

Perceptions about infertility.

Infertility is a serious issue that many people have to face. However, in Nigeria, it’s an even bigger problem for women. In general, women are blamed when they can’t give birth because the traditional belief is that infertility is the woman’s fault. In addition, grave consequences are associated with infertility including, economic impact, depression, violence, and divorce. Listen to the story of three Nigerian women who had to deal with infertility.

Dr. Ayo Okwuosa, a consultant gynecologist, said, “although there are male and female causes of infertility, it is the women we see in the clinics. The men don’t come. They say they are fine. Some will even claim to have fathered other children. These men don’t realize that certain lifestyles affect the quality of the sperm. Moreover, who’s to say if those children they claim to have fathered are really theirs.”

The perception that infertility is a problem of the woman has no scientific basis. There are reports of male factors contributing to infertility in up to 50% of cases. A pooled analysis of studies conducted in Africa found that male factor infertility was responsible in 22.6% of the cases. However, a survey of 314 Nigerian couples found male factor was responsible in 42.4% of the cases. Experts attribute the varied prevalence of male infertility to several factors, including the low evaluation rate.

Some people believe infertility is not merely a medical problem but also a spiritual problem. Witches and evil spirits are perceived to cause infertility. In the study conducted in Ogbomoso, Nigeria, a woman said, “[infertility] runs in some families due to ancestral curses.” However, ancestral spirits aren’t the only spirits said to cause infertility. Some participants explained that a woman who previously terminated a pregnancy may be plagued by the spirit of the aborted foetus.

But what is the medical reason behind infertility?

To understand the causes of infertility, it is necessary to understand the process of fertilization.

  • Every month, the brain releases a hormone that causes some ovarian follicles to begin to mature.
  • Maturing follicles release estrogen that causes the lining of the uterus to thicken in preparation for a baby.
  • Midcycle, one follicle (occasionally more) releases an egg. This process is called ovulation.
  • The fallopian tube captures the egg and conveys it to the uterus.
  • With intercourse, the man deposits sperms in the vagina.
  • Some of the sperms swim up to the fallopian tube, where one of them fertilizes an egg.
  • The fertilized egg (a zygote) moves to the uterus and implants in the thickened uterine lining, where it grows and matures.

A problem in any of the above steps could lead to infertility.

During our conversation, Dr. Okwuosa said, “a woman isn’t fertile throughout her cycle. Usually, the couple has a window of about five days. From the moment the egg is released, it lives for 24 hours only. But the sperm can survive for about 72 hours or so.” She went on to point out that the problem of infertility may sometimes be an issue of timing. Sex outside the fertile period is unlikely to result in pregnancy.

Female infertility

Nnenna recounted her frustrations during a chat. She had her periods and had never had an abortion, so she did not understand why she has not become pregnant. “The fact that there is a period does not automatically mean there is ovulation. Some women have anovulatory cycles. For example, polycystic ovary syndrome causes anovulatory cycles,” said Dr. Okwuosa at the gynecology clinic where we had our discussion. Anovulatory cycles are periods where ovulation did not occur.

Polycystic ovary syndrome is a condition where a woman has high levels of male hormones associated with irregular periods, anovulatory cycles, cysts in the ovaries, and sometimes obesity. Other causes of ovulatory dysfunction include:

  • Problems with the hypothalamus or the pituitary glands
  • Thyroid disorders
  • Eating disorders
  • Stress
  • Anxiety

Even when ovulation occurs, the fallopian tube needs to be healthy to capture the egg and convey it to the uterus. If the tubes are blocked, the sperm cannot get to the egg. Therefore, a woman requires at least one healthy fallopian tube to achieve pregnancy.

Causes of tubal dysfunction include:

  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Infections such as gonorrhea, Chlamydia, or other infections following unsafe abortions are causes of tubal and uterine dysfunction.

Uterine problems also cause infertility. For example, fibroids may make it difficult for the sperm to get to the egg. Fibroids can also make it difficult for the fertilized egg to implant in the uterus.

Other uterine problems are:

  • Congenital uterine anomalies
  • Asherman syndrome
  • Endometriosis
  • Endometritis

Male infertility

The male factor is often overlooked or ignored in conversations about infertility. But, Dr. Okwuosa said, “we need to educate our people more. Some men don’t realize that their lifestyle can affect fertility. Smoking, for example, affects all parameters that determine the quality of the sperm.” Smoking lowers sperm count and alters sperm motility and shape.

For a man to impregnate his partner, he requires:

  • Adequate sperm count
  • Adequate motility
  • Sperms with normal shape

In addition, these healthy sperms also need to get to the vagina. So, a man with ejaculatory problems like retrograde ejaculation may have difficulties depositing the sperm in the vagina.

Other causes of male infertility are:

  • Infections like mumps and sexually transmitted diseases
  • Abnormal urethral opening
  • Recreational drugs like cocaine, marijuana, methadone, and heroin
  • Hormonal problems
  • Medical conditions like diabetes mellitus and thyroid disorders.
  • Heavy metals, pesticides, and other environmental factors can affect male fertility.

“Even age is a problem,” Dr. Okwuosa said towards the end of our conversation. “People say a man can father a child even when he is old, and that is true. But age also affects male fertility.” Experts report that male fertility drops after the age of forty.

What next?

With an enormous list of possible causes, couples with fertility problems need the proper care and treatment to conceive successfully. Fortunately, there are several options for people who want children but have not been successful in conceiving. However, a study at Barau Dikko Teaching Hospital in Kaduna, Nigeria, found that the majority of women made unnecessary visits to several hospitals for infertility care with little positive results. In fact, 70% of the women did not have adequate investigations done to determine the cause of their infertility. Infertility comes with an enormous psychological, social, and economic burden. It is essential to do the most appropriate diagnostic evaluations and carefully look for potentially treatable causes of infertility. Therefore, the quality of infertility care needs to be improved to assist couples desiring a child a chance to conceive.

To learn more about 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.