Infertility Awareness Month

June is World Infertility Awareness month and a great time to talk to your doctor and partner about your fertility and health. So, let’s get to the bottom of it- what is infertility?

Infertility is a medical condition characterized by the inability of a person or couple to conceive a child or carry a pregnancy to full term after a year or more of regular and unprotected sexual intercourse. It is important to note that infertility can affect both men and women.  The prevalence for this is about 50 percent of our couples. We would usually advise a couple if you’ve been having regular intercourse – and when we talk about regular intercourse it is twice a week- that within a year’s time if you have not conceived then you should seek medical advice. The main objective is to understand what the reason is for why you have not conceived so far is.

 What’s the prevalence of infertility? How many people does this affect?

In our population it’s around fifteen percent, and we do get this question a lot from our patients as well. It feels like there are more couples suffering from infertility, but the prevalence has been remaining fifteen percent in the last couple of decades. Sometimes when we do see couples, they will ask us and say “but doctor maybe we’ve just been unlucky”, so we usually tell them that if you’ve been having intercourse for one year, you’ve got about 85 percent chance to be pregnant within that year. After two years of trying, you should have about a 90 chance and after three years 95 percent, so again over time if it does not happen then you should seek medical attention just to understand and figure out what the reason for you not conceiving is.

What kind of tests are we looking at to determine whether infertility is an issue?

It is very important to consider both partners when it comes to infertility. It is not only a female issue as is often perceived.

It is very important that if the female started the investigations that the male would also do these investigations right from the start so that you don’t just focus on one party and then forget about the other party.

If we look at males,  usually we would start by just doing a sperm functionality test for sperm count and in the sperm count as well we would be able to see first of all what is the volume that’s being produced and what is the concentration – very important how many sperm there is per ejaculate and then thirdly what your system looks like because sometimes we observe the effects of stress that the male is experiencing, then the sperm also starts looking abnormal and we know that sperm does not swim very easily . 

In the females it is just as important to understand the system and we use the ultrasound to make sure the woman has got a good normal uterus. The second thing is when you look at her ovaries you can see what that female egg count is, and this is very important: you get your chronological age, but you also get your fertility age as well on that scan. Thirdly, what you would want to establish is if the patient has open tubes so usually we would just do an x-ray for that, and then fourthly it is to cover the other bases that includes a Thyroid Gland test and also to test and make sure these females are ovulating. Again, what you usually say for a female is that if she’s got a regular cycle and if she doesn’t experience excessive pain during a cycle then it is very high likely that she’s ovulating and that we should just focus on the timing.  So, these are the basics. Usually with a good thorough investigation and a clinical examination we can start excluding things like Endometriosis that can also play a role in fertility.

So, what would be some of those causes of infertility?

We look at both males and females. Unfortunately 50 percent of infertility is female related, male infertility contributes to abiut thirty percent and then twenty percent we would then say is unexplained. Even in the 20 percent of the cases where there is unexplained infertility, there are ways that we can deal with that.

If you just look at the males – someone with low sperm count- we must first establish have there been previous injuries, previous medication, or is it just purely related to work stress or smoking or being overweight? In females we can identify more issues and deal with them.  40 percent of the female patients the causes are related to ovulation- either due to polycystic ovaries or if there might be a Thyroid issue, and these are the easy cases that we deal with. In these cases, we recommend ovulation induction tablets to help you to ovulate. In another 40 percent of patients it might be due to blocked tubes, or it might be something like Endometriosis which we see in about 20 percent of cases. We know that Endometriosis can lower your chances of conceiving, and that after treatment that about 50 percent of the patients will conceive spontaneously. It is very important when you do see a couple, to make a diagnosis and just to make sure that this couple understands the reason for infertility. Nowadays people are well informed and there’s a lot of information out there as well to empower the patient to say well this is the cause, it’s not something you are doing wrong this is the real cause of why you’re not conceiving and then to deal with those issues as well.

One thing that couples find frustrating is when they are just being given tablets as in when doctors say, “Well, try these tablets for six months or a year and then if you’re not pregnant come and see me after that year.” If someone has a headache and you just keep on giving them headache tablets you know that you might not find the underlying cause for the headache. That is similar for  infertility as well so empower your patient, give an accurate diagnosis and then treat it systematically according to that as well.

Has the COVID 19 pandemic affected fertility?

Initially we had quite a lot patients that, in females especially , when they initially got COVID there was an irregularity with their cycles so they had some months where they did not menstruate, so we were able to pick that up, but one thing we have not seen is COVID 19 affecting the egg reserve and in the long run it does not have any long-term sort of consequences. In males, where males were very ill during COVID we did see in a few of our patient’s sperm analysis that it took three months for that sperm count to get back to where it used to be before the COVID infection . So, the effects of COVID on fertility are temporary and we don’t predict them to be permanent.

What treatment options do we have?

The first and most important step is to get a diagnosis. Firstly to understand what the reason is. 

In younger patients we would say, well you need a laparoscopy to go with that Endometriosis and then you should be expecting the year there after. What we’ve been seeing in a lot of our younger patients is that soon after their surgeries within the next three to six months they will conceive adequately so that’s for Endometriosis. If someone struggles with the fallopian tubes that have been blocked due to infection or previous surgery or Endometriosis, then sometimes those functions depending on the damage of these tubes can be rectified and opened. If that is not possible, then you do not need to struggle and go for repeated surgeries, rather just know this is the issue and I need in-vitro fertilisation to address this issue.

A female suffering from an ovulation issue where she does not ovulate requires medical treatment so we would give them medication and again, when you do give medication you need to make sure that this medication is working. You need to monitor her ovulation. You need to make sure that this medication is working. Every individual has their own sort of formula that gets everything going so you need to identify which formula will help that patient to ovulate.  

When we look at a male issues, many of the males come and you can see that in his sperm count especially the way the sperm is formed the morphology- the way the sperm is looking – is thick and with abnormal tails- this is all stress related. So again, now you need to discuss with the patient to start looking at their health – the sperm now is just showing that there is stress on the system and there we would say: “well stop smoking or reduce smoking, look at your weight because weight lowers your sperm count and increases abnormal sperm and start looking at your lifestyle.” Looking at work related stress there’s not much we can do about that, but maybe just to take some antioxidants and to try and improve the effect that stress has on your sperm count as well.

There are many things that you can do yourself to try and increase fertility but yes, we treat, and we try and identify the reasons. The best advice for females is- if you’re about 32 years of age, seek fertility advice to know what your egg count is and what the follicle count is. We see a lot of females that present to us that have been treated for years and years with either medication or just given reassurance and then when we do see them, we say well they’ve got a lower egg count and there might be various reasons for this as well but once your egg count starts to decline at a certain point it can take longer to produce that golden egg. Ask your doctor about the AMH test- an AMH test measures levels of anti-mullerian hormone, which corresponds to a person’s egg count. 

Where would be the best place to go to get these tests done and who do we talk to and who’s the right doctor to go and see?

Fertility issues are a speciality area of expertise – so it is best to see someone who specializes in infertility care. There are so many things that can be done just from the first assessment to get a diagnosis- that’s the first thing you want to do because it empowers you as the patient to say “well now that I identified the issue and now, I’m going to deal with it.” In South Africa there are plenty of accredited fertility units throughout the country and so usually and it’s all combined under SASREG. SASREG is an abbreviation for the Southern African Society of Reproductive Medicine and Gynaecological Endoscopy.  It promotes quality fertility care in South Africa. It aims to serve and protect the interest of the patients undergoing assisted reproductive treatment (ART), specifically through in vitro fertilization (IVF) treatment. When considering fertility treatment, it is very important that patients choose a SASREG accredited facility.

Infertility requires specialist help so choose an accredited unit that focuses on fertility.

Interview- Dr Venter