INFERTILITY

Fertility is important to all societies and fertile couples are perceived to be more important to the society as great premium is placed on the place of children in the society.

African general practitioners and gynecologists are becoming convinced that infertility is a problem of great magnitude that they think it must be given a very high priority in reproductive health issues.

Infertility is generally defined as the inability of a couple to conceive within a certain period of time, usually one year, despite regular unprotected sexual exposure.

 Fecundability is the probability of having a pregnancy within one menstrual cycle to the likelihood of conception per month of exposure. Fecundity is ability to achieve a live birth from one cycles exposure to pregnancy.

primary infertility implies that the woman has never conceived despite living with a man, being exposed to the possibility of pregnancy and wishing to become pregnant for at least 12 months (WHO) .

Secondary infertility implies that the woman has previously conceived irrespective of the outcome but is subsequently unable to conceive despite cohabitation with a man, being exposed to the possibility of pregnancy and wishing to become pregnant for at least 12 months.

Infertility is a condition affecting 1-6 couples and the prevalent rate is 6% in United Kingdom, 10% in United States of America, and >  15% in sub-saharan Africa.

Factors affecting the natural conception rate are: age > 35years (decline in oocyte quality and number), body mass index > 29, alcohol, smoking, malnutrition, sexually transmitted infections, occupational hazards and drugs(chemotherapy, NSAID, and injections).

Causes of infertility in Africa is in 40% of the case, a male factor, 40% of the case, a female factor, 15% of the case, both male and female factor and 5% of the case of unexplained factors.

CAUSES OF MALE INFERTILITY

Pre-testiculare causes: this refers to conditions that impede adequate support of the testes and includes situations of poor hormonal support and poor health condition. These are: hypogonadotrophic hypogonadism, obesity, drugs (cimetidine, phenytoin, tobacco, and nitrofuratoin) and genetic abnormalities.

Testicular factors a condition in which the testes produce semen of poor quality despite adequate hormonal support. These can be due to a genetic defect on the Y chromosomes, varicocele, mumps infection, testicular cancer, trauma and radiation.

Post-testicular factors: are those that affect the male genital system after testicular sperm production. Examples of these are : defects in the genital tract as well as problems with ejaculation and ejaculatory duct obstruction. Others include: chronic medical conditions( e.g liver cirrhosis, diabetes) and congenital anormalies like undescended testes.

CAUSES OF FEMALE INFERTILITY

Ovulation is affected by endocrine problems like dysfunction of the pituitary, adrenal or thyroid gland and systemic diseases like diabetes and hypertension. Ovulation could also be affected by physical disorders like obesity and ovarian disorder like polycystic ovaries, ovarian cyst/tumours, hypogonadotropism and ovarian endometrosis.

Affecting implantation are fibroids, infections, hormonal imbalance and congenital anormalies. The transport of the ovum can be affected by infection (e.g inflamatory diseases, gonorrhea and fimbrae adhesions. The transport of sperm within the female reproductive system can be affected by congenital anomalies, vaginal problems e.g gyneatresia, unconducive cervical environment and antibody reaction to sperm.

Hyperprolactinaemia with or without galactorrhea is the second most common cause of anovulation in African women.

CAUSES INVOLVING MALES AND FEMALES

These are immunological factors, wrong timing of coitus, infrequent sexual intercourse and ignorance.

 Investigations that can be carried out include semen analysis, hormonal assays tests for tribal potency (laparoscopy, hysterosalpingogram, hysterocontrastsynography) and assessment of ovulation status basal body temperature, endometrial biopsy and folliculometry.

SOLUTIONS FOR MALE INFERTILITY

i.                     Improving sperm count and motility weight reduction, ceasation of smoking and alcohol consumption, low fat diet, wearing loose fitting boxers or trousers.

ii.                   Treatment of infections with appropriate antibiotics

iii.                  Intervention from urologist for specific treatment. Although controversial, varicocele may warrant treatment especially when it is large enough to cause symptoms such as aching and dragging sensations.

SOLUTIONS FOR FEMALE INFERTILITY

         i.            Adhesiolysis can be done in cases of peritubal or periovarian adhesions.

       ii.            Hysterosalpingogram can be done to check the patency and or extent of proximal tubal occlusion.

      iii.            Assisted reproductive technology (in vitro fertilization/embryo transfer, intra cytoplasmic sperm injection, gamete intra fallopian transfer, gamete intra fallopian transfer, zygote intra fallopian transfer and intrauterine insemination).

     iv.            For polycystic ovary disease (major source of anovulatory infertility). The use of weight reduction(behavioural intervention), metformin, clomiphene citrate (medical interventions) and laparoscopic ovarian drilling (surgical intervention) can be helpful.

       v.            Bromocryptine can be used for hyperprolactinemia (another source of anovulatory infertility).

     vi.            For managing infertility related to uterine factors. Intrauterine adhesiolysis and insertion lippes loop can be done in case of intrauterine adhesions or ashermans syndrome with use of oral contraceptive pills for 3 months and removal of lippes loop after 6months.

Hysteroscopic adhesiolysis under direct vision is the treatment of choice giving best results. Uterine fibroids can be resolved with mymectomy but reserved for symptomatic cases.