Infertility is a very sensitive and difficult topic to discuss especially in a society like ours. It can be really devastating when a woman finds it difficult to conceive,and this becomes a source of stress, bitterness, anger and could even lead to a breakup of the marriage. Guess what? The stress and bitterness is counterproductive – stress as you will find out later antagonise fertility hormones in both men and women.
Achieving a pregnancy is a complex interplay of factors between man, woman and the environment. For a pregnancy to occur, the woman should:
- Ovulate and produce mature eggs
- Have patent tubes to transport the eggs
- Have a normal shape and size of uterus facing the right position, with a uterine wall unobstructed by fibroids or blocked by fibrosis, and
- A competent cervix, with the right size of hole, producing mucous in the right consistency
The man should:
- Produce sperms in the right quantity, size, shape, swimming at the right speed in the right direction within a seminal fluid of the right consistency
- His tubes should be patent to transport the sperms
For both of them, the egg and a sperm should meet at the right location – in the fallopian tubes for the journey to begin towards the uterine cavity for implantation.When any of these go wrong chances of achieving and maintaining a pregnancy becomes slim. But surprisingly, all these may not be present, yet some couples still manage to achieve and maintain a pregnancy through all the odds, and as we usually say in medicine, ‘never say never’ so don’t lose hope.
It is really difficult to fathom infertility, or some of its causes; for some people the problem may be genetic that is, they are born with it,or they could be acquired along the way, or they may even have no problem at all, just lack of knowledge.An example is not knowing your menstrual cycle or using a vaginal lubricant that slows down or kills the sperms!
Infertility is defined as inability of a couple to achieve a pregnancy after at least one year or more of regular unprotected sex. If the woman is above 35 years, the definition changes to inability to conceive after 6 months of regular unprotected sex. The good thing is, some of these couples end up having babies after more than a year of unprotected sex with or without treatment. There are two main types of infertility:
- Primary: infertility in a couple who have never had a child, and
- Secondary: failure to conceive following a previous pregnancy
Up until a few years ago, infertility was considered to be solely a woman’s problem. It is now known that the causes of infertility vary even in the same person. About 30% causes are due to male factors, another 30% female factors and the rest involve either both partners, and unknown factors.
Infertility can actually go unnoticed if one partner is sub fertile and the other very fertile. I believe you have seen or heard of couples who had infertility issues,divorced and remarried someone else, and had babies; or couples with years of infertility issues conceiving not long after adopting. We have even seen couples who had babies unassisted after over 10 – 20 years of trying. Besides these, there are now better, safer treatment options, and lifestyle modifications to follow/adopt.
Causes of infertility in women
The commonest cause is hormone imbalance and this affects ovulation, implantation of the fertilized eggs and maintenance of the growing baby. A lot of factors that influence hormone imbalance can be modified and these include but not limited to: obesity, Polycystic Ovary Syndrome (PCOS), thyroid disorders, high levels of prolactin in the blood, low progesterone, premature ovarian insufficiency and hypothalamic (brain related) dysfunctions
- Hormone Imbalance
Hormone imbalance is one of the commonest cause of infertility in women. It causes ovulation disorders which prevents the ovaries from releasing mature eggs. What is ovulation? It is a process in which a mature egg is released from the ovary and pushed down the fallopian tubes on its way to fertilization.
Causes of hormone imbalance include but not limited to:
Polycystic Ovary Syndrome– cause unknown, features: overproduction male sex hormones, this interfere with function female sex hormones so you can neither ovulate nor produce progesterone so conception is near impossible. Obesity has a similar effect on fertility. The good news is that both can be treated.
Symptoms of PCOS usually include borderline normal or high blood sugar, overweight, borderline or moderately high blood pressure and high blood bad cholesterol. By the way every normal female produces male sex hormones in little quantities to maintain health and certain processes in the body, but in disease conditions including obesity, excess is formed.This will cause development of male pattern baldness, hairy body, V-shape (broad shoulders and narrow hips), irregular menstruation, deep voice and facial hairs. Likewise in overweight men, they develop big breast, become curvy, lose their facial hairs, develop female voice and lose their body hairs.
Hypothalamic disorders. FSH/LH the 2 hormones responsible for ovulation are produced in the pituitary gland found in the skull. Disorders can be caused by excessive physical and emotional stress, very high or low body weight, recent substantial weight loss or gain can disrupt and affect ovulation.Note how fat, stress hormones and sex hormones are inter-related, this is because they are produced from a common pathway.
Low Progesterone: the main function of progesterone is to regulate the menstrual cycle. It also supports developing embryo, maintains uterine lining to aid implantation, makes cervical mucous sperm friendly, and prevents immune rejection of the developing baby. Low progesterone is seen in PCOS, excess estrogen/xenoestrogens, stress, or artificial progesterone.
Thyroid disorders whether high or low causes an imbalance in the production of sex hormones, this in turn will affect ovulation, increase risks miscarriages, and poor pregnancy outcome. Symptoms of neck swelling may not be present. This can also be treated
High prolactin in the blood,may be caused by medications or an abnormality in the pituitary gland; this will cause you to produce milk even though you are not pregnant and this will prevent ovulation. Prolactin inhibit hormones that trigger ovulation (FSH/LH). Our home advice: get treatment, wear a tight bra, do not stimulate the nipples and no suckling in any form – it worsens the situation remember, breastfeeding is a form of contraception for some women.
Pre-mature menopause (also known as Primary ovarian insufficiency), is a condition in which the ovaries stop working and menstruation ends before age 40. Causes are largely unknown but may be related to emotional stress, autoimmune response where your body mistakenly attacks your ovarian tissues, genetic disorders leading to premature release of eggs, environmental insults, radiation or chemotherapy treatment, and smoking.
Even if you are planning for assisted reproductive therapies, you will still need balanced hormones to achieve success.
2. Structural defects are the second commonest cause of infertility
Uterine or cervical abnormalities: Disorders of the uterus are one of the commonest structural causes of infertility. The disorder may be something you are born (genetic) or acquired:
Position of the cervix – face backward;heart shaped uterus, or one with a septum, opening of the cervix may be unusual – tiny or absent. The cervix may produce abnormally thick cervical mucus and thus retard the sperms journey towards the egg. The abnormal cavity or distorted shape of the uterus interferes with implantation of a fertilized egg or may lead to recurrent miscarriages.
Acquired disorders include but not limited to:
- Fibroid which distort the shape of the uterus, also interferes with implantation of a fertilized egg, sometimes, the position of the fibroid could even block the Fallopian tubes preventing transportation of either egg or sperm.
- Endometriosis is another structural disorder in which endometrial tissues grow outside of the uterus — often affecting the function of the ovaries, uterus and Fallopian tubes.
- Uterine synechiae simply means the walls of the uterus stick together either completely or partially, thus the uterine cavity is occluded because they are gummed. Cause is usually as a result of infections, prior surgeries or abortions.
- Uterine prolapse usually one of the causes of secondary infertility, the uterus is much lower down than it should be making you prone to infections.
Fallopian tube damage or blockage: This can result from pelvic inflammatory disease, usually caused by sexually transmitted infection, endometriosis or adhesion from previous surgeries. Tuberculosis of the tubes also cause damage and blocks.
Pelvic adhesion: these are bands of scar tissue that bind organs after pelvic infection, appendicitis, caesarean section, abdominal or pelvic surgery
3. Medical conditions and treatment
Certain cancers particularly female reproductive cancers, often severely impair female fertility. Both radiation and chemotherapy may affect a woman’s ability to reproduce. By destroying the ovaries or blocking the tubes. Medical conditions or treatment associated with the absence of menstruation (amenorrhea), include but not limited to type 2 diabetes, hypertension, Cushing’s disease, sickle cell disease, or kidney disease. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped. Ibuprofen or aspirin used over a prolonged period cause increased uterine tone making the uterus not quiet for implantation.
Some herbs have contraceptive properties e.g. dogon yarrow (neem), be careful what you ingest as alternative medicine.Alcohol, smoking – first or second hand smoking, recreational drugs and coffee to mention but a few affect fertility one way or the other
4. Ignorance and lifestyle causes
Not knowing your cycle! A lot of women believe they all ovulate on day 14 of their menstrual cycle. This is not so, except if you have a regular 28 day cycle. A cycle is counted from the first day of one period to the first day of the next period. A menstrual cycle can range from 21 to 35 days in an adult, even in the same person at different times; and in young teens, the period can range from 21 to 45 days. You need to have a record of your Last Menstrual Period (LMP), for at least 4 – 6 months to enable you calculate your fertility window. Wrong timing of intercourse becomes a fertility issue, this may not make a difference if both couples live in the same town but when they live apart…timing becomes a problem
Using vaginal lubricants. Like I said earlier, stress is counterproductive when it comes to fertility, it will contribute to vaginal dryness necessitating the need for a lubricant. Some women use lubricants without checking if they contain spermicides. Apart from this, some lubricants may be so thick it hinders the sperm from swimming or overworks it so much that they die before they get to the goal post. Sometimes the use of certain lubricants may predispose you to infections, thus worsening the situation
Being vegan– We don’t really have strict vegans in Nigeria, but if you are, make sure you supplement your diet with iron, folic acid, zinc and vitamin B-12, otherwise your fertility may become affected
5. Antibodies to sperm: In this case your body destroys certain people’s sperm but not others
6. Environmental toxins: Examples include pesticides, benzene, all affect fertility hormones
7. Genetic causes: These are the most difficult to treat. Once we know the major causes, treatment becomes easier, but for the genetic causes in which case the solution lies in surrogacy and adoption.
8. Unknown causes: These vary and may be related to your gut health, immune status or no problem at all
Causes of infertility in men
- The commonest causes of male infertility is abnormal sperm production or function
These could be due to various problems, such as:
- Undescended testes, this means the testes remain in the abdomen, rather than move down into the scrotal sac. In this case, heat in the abdomen will distort or destroy sperms formed because proper sperm formation require slightly lower than body temperature that is why the testes are located outside the body
- Genetic defects
- Health problems such as – diabetes, trauma or straddle injury from falls, excessive cycling; prior testicular surgeries or repair of hernias
- Infection such mumps at a younger age, gonorrhea, syphilis, typhoid, tuberculosis,
- Enlarged veins in the testes will cause increased blood flow and heat, this affects the number and shape of sperm
- Testicular torsion
2. Problems with the delivery of sperm, such as:
- premature ejaculation
- semen flowing backwards into the bladder instead of emerging through the penis during orgasm (retrograde ejaculation)
- failure to ejaculate
- infrequent sex
- abnormal opening of the penis – the urethral opening is at the underside of the penis, instead of its tip. This abnormality is usually surgically corrected when the male is a baby. If it is not the sperm may find it harder to get to the female’s cervix
- certain genetic diseases and structural problems, which cause blockage of the part of the testicle that contains sperm, or damage or injury to the reproductive organs due to prior surgery, infection or trauma
prostate problems or surgery
3. Overexposure to certain chemicals and environmental toxins,may impair sperm production, an example of such are:
- pesticides, radiation, tobacco smoke, alcohol, marijuana, and steroids (including testosterone)
- frequent exposure to heat, such as in saunas or hot tubs, tight clothes can increase testicular temperature, impairing sperm production
4. Damage related to cancer and its treatment. Treatment for cancer can impair sperm production, sometimes severely. Even removing one testicle due to cancer may also affect male fertility.
5. Hormone imbalance – prolactin excess, thyroid dysfunction, excess female hormones sometimes due to obesity, excess stress hormones.
6. Hypogonadism – testosterone deficiency can result in a disorder of the testicles. These will decrease libido and may even lead to impotence. Decreased libido means less frequency of sex.
7. Gluten sensitivity, gut health affect production of hormones, minerals and vitamin deficiency – zinc, selenium, vitamin C play a role.
8. Unhealthy habits such as smoking, illicit drugs, excessive alcohol ingestion. Anabolic steroids – often taken by bodybuilders and athletes; after long term use can shrink the testes and this seriously reduce sperm count and mobility akin to what menopause does to women.
9. Sulfasalazine – this anti-inflammatory drug can significantly lower a man’s sperm count. The drug is often prescribed for patients with rheumatoid arthritis. Usually this side effect goes away after the patient stops taking the medication.
10. Genetic abnormality – a man should have an X and Y chromosome. If he has two X chromosomes and one Y chromosome (Klinefelter’s syndrome) there will be an abnormal development of the testicles, low testosterone, and a low sperm count (sometimes no sperm at all).
This has been a long one, yet some things are still left out but would be dealt as separate topics. I needed to list out these causes so you know one size does not fit all, that there are different treatments and remedies for infertility and sometimes do nothing may be a treatment; lifestyle modifications, healthy eating and stress handling play a big role in treatment. The next article will be on diagnosis and treatment.
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