Around one in seven couples may have difficulty conceiving. However, the number of couples who are actually infertile is very low, about 5% globally. In this study session, you will learn about the problems associated with the fertility of couples. Infertility can occur in both men and women, and sometimes in both partners. It can have a debilitating effect on a family, and even lead to divorce. Family planning can help couples by providing appropriate counselling to identify and manage any infertility problems.
In this study session you will cover the definition, types, causes, associated factors, prevention, and treatment of infertility.
When you have studied this session, you should be able to:
12.1 Define and use correctly all of the key words printed in bold. (SAQs 12.1 and 12.2)
12.2 Explain the main types of infertility. (SAQ 12.2)
12.3 Identify the causes and risk factors of infertility. (SAQs 12.3 and 12.4)
12.4 Describe different approaches to help infertile couples. (SAQ 12.5)
12.5 Explain the preventative measures for infertility. (SAQ 12.5)
12.6 Explain the management and counselling of infertile couples. (SAQ 12.5)
Infertility is the inability to conceive a child after having unprotected sexual intercourse for a period of at least one year. Although often the woman is blamed, infertility occurs in both men and women (Figure 12.1). In many developing countries, including Ethiopia, having children is one of the principal mechanisms maintaining the cohesion of the family. If a couple is unable to have children, it can create an unhappy marriage and result in divorce, even when both the husband and wife are infertile. In most African countries, a man’s wealth is measured by the number of children he has. In rural areas, children are an important asset, as they will work on the land and care for their aged parents.
Do the above circumstances apply in your community or village? How could you help?
You will be able to help couples by providing appropriate counselling to help them manage their infertility problems.
There are two types of infertility: primary and secondary.
Primary infertility is when a couple have never had children, or have been unable to achieve pregnancy after one year of living together despite having unprotected sexual intercourse.
Secondary infertility is when a couple have had children or achieved pregnancy previously, but are unable to conceive at this time, even after one year of having unprotected sexual intercourse.
Secondary infertility occurs more commonly than primary infertility, especially in developing countries where sexually transmitted infections are common. In many countries, induced abortion (intentionally done) contributes much to secondary infertility. Generally, it accounts for 60% of the total number of infertility cases.
The causes of infertility are varied and complex. According to studies from around the world, both men and women are affected by infertility: about 40–60% of causes are linked to female factors, and 20–40% are related to male factors.
It is important for you to understand the anatomical, physiological and psychological conditions affecting fertility in women and men, both of whom should normally be able to conceive. Firstly, a man has to have normal functioning reproductive organs (Figure 12.2) capable of producing normal sperm in sufficient numbers, and he has to be able to transfer them successfully to the woman’s reproductive system through sexual intercourse.
Similarly, the woman’s reproductive system should function normally and be able to produce healthy eggs, have normal fallopian tubes and uterus and produce normal cervical mucus. See Figure 12.3 of the female reproductive organs.
To achieve normal physiological functions and processes, the endocrine (hormone-producing) glands of both the man and woman involved in reproduction must function normally. In addition, psychological and social conditions can influence the timing and frequency of sexual intercourse, which in turn can influence the chance of getting pregnant.
Age is an important factor in both women and men. In many women fertility declines as they age, especially over 35 years of age when the quality of eggs remaining in the ovaries is lower than when the women were younger. In men, sperm motility is reduced as they age, but overall fertility is not affected as much. There are many case reports describing men having children even after the age of 90 years.
This section covers some of the main causes of infertility in men.
Many diseases can cause inflammation of the vas deferens, or sperm tube, and result in scarring which can block the tube passing sperm from the testicles or testes. Infections from untreated sexually transmitted infections, such as gonorrhea and chlamydia, can also ascend via the urethra. Other conditions which can cause inflammation of the epididymis in the testes and disrupt the production of sperm are tuberculosis, schistosomiasis, and the abnormal growth of tumours in the testicles.
Many disorders lead to abnormal or reduced sperm production, and can result in it stopping altogether. For example, mumps (in Amharic, joro degif) contracted in childhood can lead to inflammation and/or shrinking of the testes, thereby stopping sperm production in adulthood. Drinking large amounts of alcohol can also reduce production of testosterone (the male hormone) and cause shrinking and/or weakness of the testes. Other factors such as the testes failing to descend from the abdomen, excessive smoking and drug abuse, excessive heat due to wearing tight underwear, or working for long periods near a heat source, can reduce the production and motility of sperm.
Certain psychological conditions, like emotional, psychological or physical stress, can result in the inability to maintain an erection, and the inability to ejaculate normally inside the vagina. Impotence and premature ejaculation, where the man ejaculates before the penis is inside the woman’s vagina, are another common cause. Other factors which contribute to a man not achieving normal sexual intercourse include neurological damage due to leprosy, taking medications such as methyldopa (an anti-hypertensive drug), surgery involving the penis, scrotum, prostate or pelvis, that can cause nerve damage, and alcohol consumption. In addition, certain chronic diseases like diabetes can reduce the ability to have, and maintain, an erection due to vascular changes.
There are many reasons which are responsible for infertility in women.
Sexually transmitted infections (STIs) are one of the major causes of infertility.
In women, there are many diseases which cause inflammation of the reproductive tract, resulting in scarring and the sticking together of tissue to create blocks. In this regard, sexually transmitted infections are one of the major causes of infertility. If it is left untreated, gonorrhoea and chlamydia can infect the fallopian tubes, the uterus and ovaries. These can cause pelvic inflammatory disease (PID), which occasionally has no symptoms and so goes unnoticed (silent PID), causing scarring of the fallopian tubes and blocking the egg from travelling down the tubes to meet the sperm. After one episode of PID, a woman has an estimated 15% chance of infertility, while after two episodes the risk rises to 35%, and after three episodes the risk of infertility is nearly 75%.
Harmful traditional practices, like female genital cutting, can cause trauma and infections which lead to infertility.
Similarly, postpartum and post-abortion infection can also cause PID, which may lead to infertility. Additionally, non-sexually transmitted diseases, such as genital tuberculosis, schistosomiasis and endometriosis, and harmful traditional practices like female genital cutting, can cause trauma and infections which lead to infertility.
Ovulation disorders in the hypothalamus-pituitary-ovarian system are associated with an absence of ovulation. For example, when there is a high level of the hormone prolactin, produced by the pituitary gland, it inhibits ovulation (hyper-prolactinaemia). Other factors that can prevent or inhibit ovulation include ovarian tumours, thyroid gland disorder, stress and malnutrition.
When there is abnormal development of the uterus (congenital malformation), or abnormal growths in the uterus (fibroids), adhesion of the uterus due to infection or abortion can affect the possibility of pregnancy, either by interfering with the transport of male sperm, or with embryo implantation.
In a few cases, the cervical canal is too narrow and prevents the passage of sperm into the uterus. Hormone imbalances (such as low oestrogen levels) can cause inadequate cervical mucus, or make it so thick that it blocks sperm transport. In rare cases, the cervical mucus and fluids in the vagina may contain chemicals (antibodies) that paralyse or inhibit sperm.
In extremely rare cases, conditions like a vaginal septum (a tissue in the vagina developing abnormally in the womb) that inhibits sperm transportation, and even the congenital absence of the vagina, can be causes of infertility. Finally, extreme spasm of the vaginal muscles (vaginismus) during intercourse can prevent penetration of the penis, and so result in infertility.
If there is no known cause of infertility identified in the evaluation of an infertile couple, then it is termed unexplained infertility. This occurs in 5% to 10% of couples trying to conceive. It is more common in males than females for unknown reasons. See Box 12.1 for a summary of the main causes of primary and secondary infertility in men and women.
In many societies people, believe that infertility comes from natural processes. However, you should understand that there are known socio-cultural factors that are associated with the occurrence of infertility, either directly or indirectly, in addition to the established causes listed previously.
As you have learnt, fertility markedly decreases in women over 35 because they will have older and/or fewer eggs. As they have lived longer, they may have had increased exposure to STIs, or have had induced abortions leading to the development of PID, which can cause tubal damage. As their ovulation becomes less frequent, the eggs produced may be defective, resulting in pregnancy wastage. Untreated gonorrhoea and chlamydia in women can spread into the pelvic area and infect the uterus, fallopian tubes and ovaries leading to PID.
Other factors may include having sexual intercourse less frequently than two to three times per week, due to a husband having more than one wife (polygamy), and having more frequent and multiple sexual partners which can predispose a couple to acquiring sexually transmitted infections.
In developing and poorly resourced countries, where the level of malnutrition is high, the onset of menstruation may be delayed, resulting in menstrual irregularities and even preventing ovulation altogether, thus limiting opportunities for conception.
Infertility is one of the most commonly occurring problems that you may encounter when you perform your daily activities in the community. The initial contact with an infertile couple is very important in outlining the general causes of infertility, and discussing the subsequent evaluation at your level. If a couple comes to you for the first time, you should ask for the medical and surgical history of both partners, as shown in Box 12.2.
If you find any abnormalities which need further evaluation, you can refer the couple to the health centre or hospital. In the meantime, explain the basic requirements for conception to the couple.
Infertility is often preventable. You can counsel clients about STIs, and encourage them to seek treatment if they think they might have been exposed. If a client comes to you with the signs and symptoms of an STI, or with other manifestations of PID you should refer them to a health centre for treatment.
There is no universal treatment or cure for infertility. Any treatment depends on the specific causes of infertility for a couple. The majority of couples who seek advice, testing and treatment for infertility might conceive within 12 to 18 months following investigation. Usually, you would expect to counsel a couple after having identified the causes or risk factors you think may have contributed to the couple being infertile.
As much as possible you should try to counsel both partners together, because men often blame women for infertility when they themselves might be responsible.
What can you tell a couple when you are counselling them?
A man is just as likely to have fertility problems as a woman. Try for pregnancy for at least 12 months before worrying about infertility.
Suggest she have sex more often during her most fertile time, using fertility awareness methods as covered in Study Session 4. The most fertile time of a woman’s cycle is about three days before the egg is released from the ovary, or more specifically 12–16 days after her previous menstruation in a normal menstrual cycle. Advise the couple about their general health, importance of regular exercise, and avoiding excessive alcohol drinking and smoking. If the couple fail to conceive after trying for an appropriate time, both partners need to be referred for evaluation.
In Study Session 12, you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Is infertility more common in women or men?
Both men and women are affected by infertility: about 40–60% of causes are linked to female factors and 20–40% are related to male factors.
List two types of infertility and explain the meaning of each type.
Primary infertility is when the couple have never had children, or have been unable to achieve pregnancy after one year of living together and having unprotected sexual intercourse.
Secondary infertility is when a couple who already have children, or have achieved pregnancy previously, are unable to conceive after one year of having unprotected sexual intercourse.
List the causes of infertility in men and women.
Can you describe the main factors associated with male and female infertility?
Ato Belay comes to you and tells you he has married three wives, but had no children yet. When you take his medical history from him, you find out he had mumps during late adolescence.