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Infertility - what works?
For one in every six people of childbearing age, infertility will define a stage of their lives.
Nicole Fritz explores the problem and the treatments.
Fertility treatment has existed for as long as humans have attempted to reproduce. Stone age people carried fertility-invoking talismans. In the 17th century, chemists believed that human sperm and manure, mixed and burned, would transform into a man, and artificial insemination has been conducted for over 200 years. Today, extensive scientific treatments provide better than ever chances of having children.
What should couples requiring fertility assistance look for? Dr Merwyn Jacobson of Vitalab Fertility Clinic insists that couples seeking treatment undergo evaluation of ovulatory function, sperm production, and the pathway along which sperm and egg travel: "You can't pass any evaluation comment without testing these areas," he says. "If your given pronouncements without such evaluation, change your practitioner. These investigations can be completed in a short time - generally over one menstrual cycle if the woman has normal cycles." Couples should also undergo a detailed medical history examination. 
Women are not necessary more likely than men to be the cause of infertility: in about 40% of cases, the problem lies with the man, while, an equal number of times, the problem is female orientated. The other 20% of cases may result from combined factors or be inexplicable. A couple is considered infertile when there has been no conception after a year of unprotected sex. By 35, a woman should seek assistance if conception has not occurred within six months. However, Dr Jacobson notes that investigations should begin when a biological problem is identified: "It's no use telling a woman that, because she's 27, she must try to conceive for a year when she obviously has a problem."
Time for action
If you have unsuccessfully attempted conception for six months and suffer from any of the following, consult a specialist:
- Menstrual difficulties like irregularity and infrequency may indicate ovulatory problem.
- Painful intercourse can suggest pelvic infection or endometriosis (where the tissue which normally lines the uterus begins to grow outside the uterus).
- Sexually transmitted disease.
- Previous operations for ovarian cysts.
- Infections during earlier pregnancies and miscarriages may indicate infertility.
- Other considerations, which include exposure to radiation and toxic chemicals, and infection with mumps during adulthood
A woman's weight can also pose problems. The difficulty, notes Dr Jacobson, "is determining whether excessive weight indicates hormonal problems or causes the hormonal imbalance. Many academic units will treat women over 10% their ideal mass."
Although oral and mechanical contraception are not thought to adversely affect fertility, intra-uterine devices can increase infection risk which may negatively affect fertility.
In men, undescended or injured testicles and previous genital area surgery may adversely affect sperm quality or could cause blockage in the testicular tubes. Post-pubertal mumps may lead to sterility. Impotence also reduces fertility potential. Notes Dr Dennis Cronson of the Men's Clinic International: "Men who experience difficulty achieving and sustaining erections are relatively infertile, simply because there is no penetration, no ejaculation within the vagina and thus no fertilization".
An age old problem
For men and women, age might be the first consideration. Women under 30 have a 20% chance of conceiving in any one month; women over 40 have only a 5% chance. During puberty, our ovaries contain approximately 300 000 eggs. Every month, for every egg that matures and is released by the ovaries, between 500 and 1000 eggs do not fully develop and are absorbed by the body. Because we are born with our eggs already formed and stored in our ovaries, our eggs, like the rest of our bodies, struggle to withstand the march of time. By the age of 40, remaining eggs respond poorly to the release of the hormones which trigger ovulation. The production of oestrogen and progesterone, essential for the development of the uterus lining and to which the embryo must attach, declines. Age also negatively affects egg quality, increasing the risk of genetic disorders such as Down's Syndrome. Genetically defective embryos are less likely to survive, thus increasing the risk of miscarriage.
Apparently, time has given men a better deal . Men who maintain good health throughout their lives may experience only insignificant changes in fertility. Nevertheless, age does present unique challenges: sperm quality declines as the testes shrink and soften, and men may experience decreasing libido and difficulty maintaining erections. The contemporary environment is also a problem. Research indicates that men born after 1970 have a sperm count 25% lower than those born before 1959, and Danish scientists have identified a decline of nearly 50% in average sperm counts over the past half century. While stress, smoking and drug use are definite factors, environmental chemical pollutants could also be responsible.
Fertile Strategies
Combined variables cause fertility problems and it is difficult to predict which treatment is best for most couples. It is the role of fertility units to tailor make treatment, which range from relatively standard procedures like artificial insemination to more complex assisted reproduction like In Vitro Fertilization (IVF) and Gamete Intrafallopian Transfer (GIFT).
IVF involves the retrieval of eggs from the ovaries - either by ultrasound probe, which is inserted through the vagina, or by laparoscopy (a long, thin telescope-like tube inserted in or below the naval). Once mature eggs are identified in the ovaries, the doctor, when using ultrasound, guides a needle through the vagina and into the ovary. When egg capture occurs by laparoscopy, the needle is guided through the abdominal wall into the ovary. Eggs are removed from the ovary through the needle by suction. Neither procedure is pain free, but while egg retrieval by ultrasound probe is a minor surgical procedure, with painkillers for discomfort, retrieval by laparoscopy involves a general anaesthetic. "Once the eggs have been retrieved," explains Cecile Bezuidenhout, embryologist at Wilgeheuwel Hospital, "they are graded according to maturity." The most mature are placed with the sperm in a laboratory dish, and once fertilized, approximately four embryos are transferred into the uterus. This, says Bezuidenhout, "increases a woman's chance of becoming pregnant, but we are reluctant to transfer more than four embryos during one procedure as the chance of multiple births increases exponentially." After transfer, doctors often recommend a short period of bed rest. With GIFT, eggs are retrieved by laparoscope, under general anaesthetic. Then, the sperm and the eggs are directly transferred to the fallopian tubes where fertilization may the take place - as it does in unassisted reproduction.
Variants of IVF include Intracytoplasmic Sperm Injection (ICSI), during which a single sperm is injected directly into the egg, and micro-insemination in which sperm are concentrated around the egg to increase the chance of fertilization. Assisted hatching is a new technique often used for older women undergoing IVF treatment. After fertilization, the egg's protective outer shell is thinned or interrupted chemically, allowing the embryo to be released more easily from the shell.
Zygote Intrafallopian Transfer (ZIFT) and Tubal Embryo Transfer (TET) combine the IVF/GIFT techniques, involving the transfer of fertilized eggs into the fallopian tubes. With these procedures, doctors can determine whether the sperm is capable of fertilizing the egg. Because these techniques involve addition procedures, they are usually more expensive than IVF/GIFT. On average, a woman undergoing technology treatment will pay a minimum of R12000 to R15000. Individually tailored ovulation medication can drastically inflate these costs. While some women may respond to a course of injections costing R250 each over a 10-day period, others may require a R700 injection every day for two weeks. Any woman considering fertility treatment should check her medical aid policy; many South African medical aids do not regard infertility as a health issue and will not pay for fertility treatment.
As with any surgical procedure, assisted reproduction techniques entail risks. Egg removal by ultrasound probe or by laparoscopy carries the risk of bleeding, infection and puncture of the bowel, bladder or a blood vessel. Transferring more than one fertilized egg into the uterus or fallopian tube increases the risk of multiple pregnancies and the associated health risks. According to Bezuidenhout, in 11 years of operation, the Wilgeheuwel's fertility unit has been involved in the birth of some five sets of triplets, comparing favourably to unassisted reproduction. Twins, however, are more frequent. More common than physical risk are the psychological risks posed by assisted reproduction. The procedures are lengthy and involve intense commitment, and as the procedure is more likely to fail than succeed in any one cycle, high expectations are often crushed. Anger, depression and frustration may follow failed attempts at IVF or GIFT.
Miraculous Medication
Often, ovulation drugs are prescribed prior to attempts at assisted reproduction in order to induce the ovaries to produce more than one mature egg per cycle. Capturing several mature eggs increases the likelihood that at least one egg will be fertilized. Although controversy has surrounded ovulatory drugs because of occasions when they have apparently defied human reproductive capacities with as many as nine embryos being fertilized and implanted in the uterus, they are a much needed adjunct to infertility treatment. Their function, note Dr Merwyn Jacobson, is not to foil nature: "A woman is put on a preparation which makes her ovulate, in order to restore her own fertility or fertility potential." Ovulatory drugs aim to increase the frequency of ovulation in women who ovulate or ovulate infrequently, and those who don't menstruate. Where the luteal phase (post-ovulation and before menstruation) is shorter than normal, or the ovaries do not secrete sufficient progesterone, the uterus lining does not mature and so implantation of the embryo cannot occur. Ovulation drugs can enhance progesterone production and thus prepare the uterus lining.
While the results of ovulation drugs may appear miraculous, they often involve considerable discomfort. Hot flushes, nausea, breast tenderness, headaches, blurred vision, depression and mood swings are among the common side effects. There is also increased risk of multiple births, premature delivery and miscarriage. Recent studies also indicate that ovulation medication may increase the risk of ovarian cancer. Any woman experiencing ovulatory problems would have to think carefully before undergoing this treatment. Against this, however, must be weighed the chance of motherhood and the fact that unassisted pregnancies also have attendant health risks.
Donor Debate
Assisted reproductive techniques offer limited help to women whose fertility problems are age-related. "Results of the test-tube technology," says Dr Jacobson, "are vastly better in the 37 year and younger age group than they are for 42-year-olds and older." For women whom assisted reproduction has failed , using egg donors and surrogates may be options. Younger women's eggs are more likely to result in pregnancy and are less likely to end up in miscarriage, even when carried by older women. However, both processes intimately involve a third person in a process which traditionally involves only two: with surrogacy, another woman may act as the gestational carrier, using the couple's egg and sperm, or as a traditional surrogate using her own egg and male partner's sperm.
In South Africa, neither surrogacy nor the use of egg donors is common. For many, the ethical dilemmas surrounding these practices rule them out. Equally prohibitive is the extent of the involvement. Unlike sperm, unfertilized eggs cannot be preserved, so it is essential that the egg donor and the recipient's menstrual cycles match. The egg donor undergoes much the same treatment as a woman undergoing test-tube technology: her ovaries are induced to release mature eggs which are then retrieved, fertilized with sperm and inserted in the recipient's uterus. By law, she receives no remuneration. Nor are sperm donors permitted to receive payment, although they are entitled to a inconvenience allowance to compensate for the time and the energy expended in delivering sperm.
For some couples, having a child related biologically to one parent, or adoption, are more desirable options than having no children at all. For others, a biological child is the only choice. "It's not nice to say or to hear," says Dr Jacobson, "but there is a time when treatment should stop." Fortunately, new advances in fertility treatment are made everyday. Current research is focused on embryo implantation and facilitating embryo growth, meaning even better prospects for more couples.
One woman's success
Rosalind Heard, 40, has benefitted from the latest treatments. After seven years of treatment she is five months pregnant. While she is elated, the process has taken it's toll.
"I started with a gynaecologist who tested me and recommended artificial insemination. I had several artificial inseminations when you should have about four at most
"Eventually I sought specialist help, but this was equally frustrating because after extensive testing they were unable to diagnose anything wrong. I underwent In Vitro Fertilization during which 16 eggs were taken from my ovaries and four returned to my uterus. None survived and I went into a period of mourning. My situation was exacerbated by the fact that people around me had very little understanding. 'Why don't you just relax and it will happen,' was a frequent and insensitive response. Continual focus on fertility treatment affected my relationship with my husband and my own emotional well-being. For emotional stability, I began to break for periods from my treatment and registered with the Catholic Adoption Agency because I wanted another open door. Eventually I decided to give it one last chance at a clinic of which I'd heard positive reports. My husband had seen my despondence and he didn't want further disappointments. But, at the clinic, they discovered a 3cm fibroid which previous treatments had never picked up. It was removed and , with assisted reproduction technology, I became pregnant, having been given a 25% chance of conceiving."
One woman's disappointment
After marrying, at the age of 38, a man who had a child from his first marriage, Sharon (not her real name) decided she wanted a child.
"After four years of which my life revolved around my menstrual cycle, ovulation and the next phase of treatment, I didn't want to experience more crushing disappointments. I couldn't concentrate at work, couldn't give the people I cared about the attention they deserved and felt resentful towards women who could and had conceived. It was so all-consuming and isolating that I was in tears practically every day.
"With the help of my husband and my doctor, I finally appreciated that this couldn't continue. My husband and I went on a long holiday to consider our options. He was less concerned than I, because he already has a daughter. I decided not to apply to adoption agencies. I know that many children need loving parents and the experience could be immensely rewarding, but I've come to accept a child-free lifestyle. It will never replace having my own child, but my husband and I try to fill our lives with the experiences we could never have if we had a child. We scuba dive often and travel extensively and I maximise the satisfaction I get from my career and family. But I still make excuses if I'm invited to a christening or baby-shower and I try to avoid conversations about babies and children".
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