Breaking the silence around infertility in women and men

(TEASER) “… For those 11 years, it has been difficult. Dealing with relatives who do not understand the struggle and friends who think I am not trying hard enough to get a baby.”

Alice has been trying for a child for more than 11 years now. It has been a tough journey, which she remembers with tears in her eyes. This is the story of many couples struggling to get a baby. We shall be listening to more of Alice’s story later in the program.

A note to the audience: Alice is not her real name. For this program, she requested that we do not use her real name for privacy purposes.

SIG TUNE UP THEN UNDER

Welcome to the program Your Health. My name is Winnie and today we are going to learn about infertility. What is it, what causes it, and is there treatment for it? We shall be hearing from Professor Koigi Kamau, an obstetrician\gynecologist and director of the Nairobi Fertility Clinic; Ms. Pauline Kibui, a clinical embryologist in Nairobi; and Alice, who will share her journey through infertility.

SIG TUNE UP THEN UNDER

Did you know that in sub-Saharan Africa, 85% of infertility is as a result of infections? Did you also know that men and women are affected equally by infertility? To learn more, stay with us.

First things first: what is infertility? I asked Pauline Kibui, who is a clinical embryologist in Nairobi.

Infertility is medically defined as an inability to conceive following more than 12 months of unprotected regular sexual intercourse. In women, it may be caused by blocked Fallopian tubes or non-receptive endometrium as a result of infections such as sexually transmitted infections. The infections can also affect the ovaries and result in poor quality eggs. Pelvic inflammatory disease and endometriosis that affects the pelvic region can also cause infertility in women because of the effects on the ovaries, uterus, and Fallopian tubes. Other causes include hormonal imbalance which can disrupt production of eggs, being overweight or underweight, and late bearing of children.

Professor Koigi Kamau is an obstetrician, gynaecologist, and director of the Nairobi Fertility Clinic. I visited him at his office to talk about infertility. Outside his office, there was a long queue of both men and women waiting to be served. I was curious to know if men also suffer infertility, so my first question to him was: “How common is infertility among men?”

Male infertility is as common as female infertility. It is only that men are silent and hardly seek medical assistance. One-third of infertility cases are caused by women’s reproductive problems, another one-third are due to the man. The other cases are caused by a mixture of male and female problems or by unknown problems, so at least 50% of the people presenting with infertility are men.

What are the causes of infertility in men?

A man requires at least 40 million sperm for fertilization to occur. There are many factors that may cause a reduction in sperm quality. These include environmental factors, dietary factors, and infections. Infections can affect any part of the genital tract, which is a tube-like structure from the sperm factory which is the testes. So the testes may be affected as well as the storage and delivery system. Men can also be born without some aspects being functional, like the process of making sperm. These are the main causes of infertility in men.

According to Professor Koigi, two out of 10 couples suffer from infertility in Kenya, and almost five million Kenyan couples require interventions to conceive. That is a large number. Alice is a woman who has been trying to conceive for the past 11 years.

Without children, a married woman is not considered complete in African cultures. I have been ridiculed by family and friends because after more than 10 years, I cannot conceive.

When did you know that you could not conceive?

We got married and gave ourselves a year before we started trying for a baby. At first, we thought it was normal to try for one year—and even the doctor encouraged us to give ourselves a year of actively trying. But each month after the one year elapsed was a disappointment.

I sought help on my own first because my husband was not really ready to seek medical help. They could not find anything wrong and so I was put on vitamin and mineral supplements and asked to relax and continue trying. Six months later, I was tired and almost depressed and asked my husband to go with me to a fertility doctor. We went through so many tests and eventually, I was told that an infection had caused my Fallopian tubes to become blocked. That was so devastating for me. I went into depression.

Professor Koigi says that there are treatments, but that prevention is always better than cure because the cost of treatment is too high for most couples.

In both men and women, the majority of the causes of infertility are related to infectious diseases, especially sexually transmitted diseases but also tuberculosis, mumps, and undescended testicles in men.

So the trick is to be safe. Protect yourself from infections by having safe sex, which may also mean abstaining. That way, you increase your chances of remaining fertile. Prevention also means maintaining a healthy diet, and not too much alcohol or smoking. For men, activities like driving hot cars or motorbikes, or taking very hot baths create a very hot atmosphere in the scrotum area which may affect sperm production. Of course, age reduces functionality for both men and women: a woman does not produce as many eggs to aid in fertilization and a man’s sperm quality reduces with age.

Alice sought medical attention for her condition, and she says the journey was very long and sometimes very disappointing. Some of the people who were close to her did not understand and would say hurtful things about her status.

My husband was very supportive and I always went to the fertility doctor with him. However, the stigma from family and friends was too much. I stopped attending baby showers because it was too discouraging for me—sometimes I would end up being the subject of sympathy and discussion.

In Kenya, a mother is referred to as mother to their child’s name. It felt bad not to be known as a mother to someone. It is also common for the woman to be blamed for not being able to conceive, even though there are men who are infertile. In my case, I did not realize that I had recurring bacterial infections which led to pelvic inflammatory disease and hence the infertility.

Did you try any of the available interventions to get pregnant?

Yes, after saving money for about five years, we went for in vitro fertilization. My eggs were fertilized by my husband’s sperm in the lab and then the embryo was implanted in my uterus. It was a long and gruelling process for my husband and I and it was also very, very expensive because it was still a very new procedure in the country. When the embryo did not grow to full term, my husband and I decided not to try in vitro fertilization again because of the financial and emotional strain it put on us.

Pauline Kibui deals with couples like Alice and her husband every day. I asked her what interventions are available.

First, we have to find out what is causing someone not to conceive. Sometimes the reason can even be the sexual act itself—is the sexual contact frequent enough around ovulation time when the woman is most fertile? Are there stress-related factors and health-related factors like poor diet, drug or substance abuse, too little or too much weight?

Once we establish that these factors are not causing infertility in the couple, then we have tests to determine whether the eggs are being produced as they should be and whether the man’s sperm count and quality is okay. And if the eggs and sperms are not enough for conception, what is the cause.

For women, if the Fallopian tubes and uterus are fine, intra-uterine insemination or artificial insemination is the first line of intervention. Unfortunately, if the uterus has growth or large amounts of scar tissue, surgery is required to remove any growth. followed by in vitro fertilization. Also, if the Fallopian tubes are blocked, then even surgery may not help. This may call for in vitro fertilization, which is a lengthy and expensive process that may require several tries.

Not all couples conceive with in vitro fertilization, so what other treatments are available?

You will be surprised that many couples conceive at the first level of fertility intervention. This involves changing habits toward a healthy lifestyle, avoiding stress and activities that can prevent production of healthy sperm and eggs, and having sexual intercourse when the woman is most fertile. In cases where the woman is not producing enough eggs or no eggs at all due to a hormonal imbalance, then the first step is to stabilize her hormones and stimulate the reproductive system and ensure that her system is producing as many eggs as she is supposed to. Many couples will not require in vitro fertilization. IVF would be the last resort in fertility treatments. If the couple has tried IVF several times and it has failed, they have the options of donated eggs, donated sperm, donated embryo, and surrogacy.

How about for men—what kind of interventions are there for them?

Unfortunately for men, treatment options are limited because the cause of infertility is related either to the quality or quantity of sperm—in other words, to either making the sperm or moving the sperm. A semen analysis is done to identify either of the two factors. If there is indeed a problem, the fertility doctor will recommend assisted reproductive technologies. These are not treatments as such, but assistance to achieve pregnancy. This could be intra-uterine insemination, where the man’s sperm is washed in the laboratory and then injected into the woman’s uterus during ovulation. It could also involve testicular biopsy or intracytoplasmic sperm injection, a laboratory procedure where a single sperm is injected through a tiny needle into an egg which is then implanted in the uterus.

After 11 years of trying unsuccessfully to conceive, Alice decided to choose adoption.

We had done all we could, including going for in vitro fertilization. We had agreed that if it didn’t work the first time, then we could still love and care for a child that is not biologically ours. We started the process of adoption, although I still get ridiculed by some friends because the child is not biologically mine. My husband and I are happy and satisfied and we love our five-year-old daughter as if she was our biological child.

Does that mean you have stopped trying?

Well, no, but I am content. If it happens, great. If it does not, I am still happy. It is not stressing me anymore.

The good news is that research has shown that as many as 25-35% of infertile couples will go on to eventually have a child without any treatment. However, both Professor Koigi and Pauline Kibui agree that preventing the causes of infertility is key, and consulting your physician once you want to conceive may make the wait shorter.

Professor Koigi also has some encouragement for men who are afraid of seeking medical assistance.

Don’t confuse libido and infertility. If you have been unable to conceive, don’t make the mistake of thinking that it has something to do with your ability to please a woman sexually. Seek medical assistance with your partner once you realize it is taking longer than 12 months to conceive. The problem may be solved faster and it may not cost you so much.

That was Professor Koigi encouraging men to seek medical assistance about infertility.
On today’s program, we have been learning about infertility. We have heard from Professor Koigi, an obstetrician and gynaecologist, and from Ms. Pauline Kibui, a clinical embryologist. We learnt some of the main causes of infertility in men and women, including: blockage of reproductive tubes; hormonal imbalances; abnormal production and dispensing of sperm or eggs; an unhealthy diet; being overweight or underweight, especially for a woman; high consumption of alcohol and smoking; prolonged exposure of the genital area to heat for men; and genetic abnormalities.

We have also learnt about reproductive technologies like intra-uterine insemination, where the man’s sperm is injected into the woman’s uterus during ovulation, or intracytoplasmic sperm injection, a laboratory procedure where a single sperm is injected directly into each egg using a fine glass needle and then implanted in the woman’s uterus.

We also heard from Alice, who. together with her husband, has tried to conceive for 11 years without success. The couple eventually decided to adopt and are happy with their five-year-old daughter.