Infertility in women

Some couples are lucky and conceive a child at the first attempt; others may have to wait longer-for vears perhaps rather than months. Conception is a very complicated business, and ii a woman is to conceive, a number of’conditions’ must be satisfied: • she must have healthv, active ovaries regularly producing fully ripe eggs – so she must have normal periods. • there must be a clear passageway for the egg to travel down and the sperm to travel up – via the vagina, through the cervix to the womb and along the Fallopian tubes to the ovaries. • there must be a normally developed womb, complete with prepared lining, ready to receive the fertilized egg and nourish it. • last, but not least, there must be healthy sperm deposited high enough in the vagina to make their wav through the cervix to meet and fertilize the egg.”

Not only must all the reproductive organs be in working order, but the hormone messengers which control them must also be operating properly. And that’s not all; even if all these physical requirements are met, timing is crucial. If the sperm don’t arrive within the 24 hours before an egg is released or up to 10 hours afterwards then there is no chance of pregnancy.

Given this, it’s quite surprising that, on average, 90 per cent of married couples conceive a child within one vear of deciding to start a family.

If after one year of trying you still haven’t conceived, it’s well worth while consulting your doctor. It’s estimated that about 40 per cent of ‘infertile’ couples do eventually have children.

But there is a lot you can do to encourage pregnanes’ before you need involve your doctor .

To begin with, your doctor will find out as much about your medical background as possible -including details about your husband and your respective families – so that he can see whether there are any illnesses or disorders (possibly-inherited) which could be preventing you from having a babv. He may well ask about your jobs-particularly your husband’s since some types of work may affect male fertility.

He will certainly enquire in detail about your periods – when they first started, how long each period lasts, how regular they are and whether you experience any pain, so that he can tell if there is anvthing obviously wrong with ovulation. He will also want to know whether anything in vour evcrvday life could be affecting you – stress can affect your hormone balance and if you are worrying about not having children, you may be making things worse. Smoking and drinking can also be contributing factors.

Of course, you will be asked about your sexli’fe too; whether there are any problems and how often you make love. And he will want to know about your previous methods of birth control.

The next thing he will do is examine you from top to bottom. This general examination is to make sure you are not suffering from any obvious illness or disorder and to see if there are any signs of a hormonal imbalance. He will probably look at your general appearance, your skin, your reflexes and pulse and examine your breasts and abdomen.

Finally, your doctor will give you a ‘pelvic’ examination. This won’t hurt you and is nothing to worry about. Firstly, he will examine the area around the vagina, before looking and feeling inside to check the cervix, the womb and the Fallopian tubes. He may take swabs if he sees or feels anything indicating an infection.

Before taking matters any further, your doctor may suggest that your partner’s sperm be tested, so that he can check whether this could be the source of the problem. In 50 per cent of cases of infertility, there are problems with both partners, not just one, and the doctor will want to eliminate any obvious possibilities before suggesting you have any further tests.

Whether or not your partner is willing to provide a sample of sperm for testing, your doctor will probably want to arrange for a post-coital test to make sure that the sperm is being deposited high in the vagina during intercourse in direct contact with the cervical mucus, and that you are producing the right kind of mucus.

You will be asked to make love the night before the test, or first thing in the morning before visiting the surgery. The doctor can then take a sample of the mucus from the canal of the neck of the womb for examination under a microscope.

If all is normal, the mucus will be rather watery and clear, like white of egg, and will contain large numbers of highly active sperm, even up to 18 hours after intercourse (and sometimes much longer).

The doctor may find that there is something wrong with the mucus. Sometimes an infection has made it too thick and sticky for the sperm to swim through, and you will need antibiotic treatment, sometimes not enough of it is being produced, and this could mean that you need extra oestrogen. Very occasionally, the mucus and the sperm won’t ‘mix’ or the cervical cells producing the mucus are inadequate. Treatment tor this is more difficult; if it doesn’t work, artificial insemination (covered in a separate feature) may be the answer.

The post-coital test also gives the doctor an opportunity to test the sperm itself, should there have been any difficulty in obtaining a sample from your partner.

There are three methods available: by a process known as insufflation, with the aid of X-rays or by laparoscopy. All require a visit to a hospital or special clinic as a rule.

Insufflation consists of passing carbon dioxide through the reproductive tract to see if the gas flows freely through or fails to do so because of blockage. Depending on the results, the doctor may want to conduct a further test to find out exactly where any blockage is occuring. He may suggest you (or’salp’ for short). This is nothing to worry about. A narrow tube will be inserted into the cervix and a liquid which is opaque to X-rays will be syringed into the reproductive tract, filling the vyomb and passing along the tubes. The X-ray picks up the fluid as a solid image, so any blocks in the tubes or abnormalities inside the womb will show up.

This involves a slightly more complicated pro-cedure, since you may need a general anaesthetic, and for this reason, many doctors usually wait until after a’ salp’ has been done and either failed to find any blockage, or produced an unclear result. A special telescope known as a laparoscope is inserted into the abdominal cavity through a small cut just below the navel. Through it, the doctor can see the various pelvic organs and if a special dye is injected into the uterus (via the cervix) he will be able to check whether it passes along the tubes and emerges at the other end of them – showing that the passageway is clear. But in order to see properly, your abdomen has to be slightly ‘inflated’ with carbon dioxide, so you may feel a little discomfort for a day or two after this procedure.

Even though you have periods, you may not, in fact, be producing an egg, and your doctor will first check to see whether this is your problem. One of the most straightforward ways to do this is to see whether progesterone has been released to prepare the womb, which should happen auto-matically once the egg has left the ovary. Since your temperature rises once progesterone has been released, a daily record of your temperature will help your doctor immensely. But the simplest way to tell is by taking a blood sample about six days before your period is due to start.

In some cases, this test will also be used to check the other hormones – from the thyroid, adrenal and pituitary glands – when no other obvious cause of infertility can be found.

Occasionally, your doctor may take a sample of the lining of your womb (an endometrial biopsy) shordy before your period is due, for examination under a microscope.

First of all, hormone treatment will only be used if there is some disorder of the endocrine glands causing infertility, particularly if it’s affecting ovulation. Of course, this can only work if the reproductive organs themselves (including the ovaries) are normal. Treating infertility isn’tjusta matter of prescribing ‘fertility drugs’ as if they were a magic potion.

Successful ovulation depends on all the various hormones working properly in relation to each other. That means that the hypothalamus has to give the correct signals to the pituitary gland and the pituitary gland to the ovaries.

I( the body is producing too much (a hormone from the pituitary gland which stimulates milk production), the necessary signals will not be given. Treatment with will nearly always bring ovulation back to normal by suppressing the production of prolactin.

If the hypothalamus is failing to regulate ovulation properly and it is not sending out the right signals to the ovary, a hormonelike drug called clomiphene may be prescribed. This stimulates the pituitary gland and makes it secrete more FSH (follicle-stimulating hormone) so that the egg can ripen.

Sometimes, the problem is more complicated, and although the pituitary is responding to the clomiphene and the egg is being ripened, the hypothalamus doesn’t release the hormone which will stimulate the egg’s release. It may be necessary to give an injection of another hormone -chorionic gonadotropin (HCG) to send the egg on its way- and the timing of this will, of course, be very important.

Sometimes the pituitary gland itself cannot secrete the hormones (gonadotrophins) which stimulate the ovaries, so no amount of clomiphene will be of any help. The ovaries have to be stimulated direcdy with gonadotrophins, initially to ripen the egg and then to release it.

The first stage is to give a series of injections of FSH in the form of HMG (human menopausal gonadotrophin) – either daily with tests to see how the ovaries are responding or three times on alternate days, again checking on results each time. Once tests show that there is a ripe follicle, an injection of HCG is given to release the egg; mere than one injection may be necessary.

Normally, once the ovaries have been stimulated and an egg begins to ripen, a complex ‘feedback’ system stops any further eggs from being ripened; occasionally, of course, two or even more eggs may be released, and lead to twins or triplets. But when ovulation is defective and treatment has to be given, this self-regulating mechanism may not be working, and so the ovaries may be ‘over-stimulated’ which means that a larger number of eggs are ripened.

When treatment involves clomiphene this is less likely to happen, but with HMG injections, the chances are much higher because this drug acts directly on the ovaries. Some women are more sensitive to these drugs than others, their ovaries responding more readily, so special precautions have to be taken to try and avoid this happening. Often the difference between an effective dose and one that will over-stimulate the ovaries is so small that it’s almost impossible to make the ovaries release just one egg at a time and so a multiple pregnancy may well result.

Where surgery can be very helpful is in removing obstructions in the reproductive tract caused by adhesions or endometriosis, .although there is a danger that adhesions will return. If the tubes are blocked in this way, results are often quite disappointing because even though surgery here is done with great care it can result in the formation of scar tissue, which may well block the tubes again. Modern micro-surgery has helped to improve the success rate for some (but not all) tubal operations, and future developments may give better results.

Benign growths in the womb (fibroids) or cysts of the ovaries can also be treated surgically, and certain other malformations in the womb may be tackled too. If the womb is displaced and this also pulls the ovaries down, a doctor may well suggest that surgery be used to correct this. Although the displacement doesn’t in itself affect fertility, it does tend to make love-making very painful, and this of course will cause problems.

Only under one set of circumstances can surgery do anything to correct problems with ovulation itself, and that’s when the ovaries are ‘polycystic’ (full of cysts). If they fail to respond to hormone treatment, an operation known as ‘wedge resection’ may help to restore egg pro-duction and release.

The day when any woman can have a test tube baby is still long distant.

For the moment, the only time that test-tube babies may even be a possibility (and then only as a last resort) is if there has been a blockage in the tubes which surgery has not overcome. At the moment, doctors won’t even consider it as a way of overcoming other causes of infertility- a low sperm count for instance- and the whole process is still experimental and not yet available as a practical alternative to other options, such as artificial insemination.

First a ripe egg has to be removed from the ovary (by means of a laparoscope) – a delicate operation itself- then it must be fertilized with the man’s sperm in a sterile glass dish before it can be incubated in a special ‘tissue culture’ for some three days. If this is successful, the egg must then be replaced in the mother’s womb so that the foetus can develop normally- and this is the most difficult part of the whole operation. Even if the egg is implanted successfully in the lining of the womb, success isn’t guaranteed.

The woman lies on an examination table and an instrument called a is inserted into her vagina, extending it to give easier access to her (the neck of the womb). A syringe containing a quantity of semen is inserted, and the semen is expressed into the mucus at the entrance of the cervix. Alternatively, the semen may be deposited actually inside the womb by means of a fine tube. Then the syringe and speculum are removed and the woman rests on her back, pelvis raised, for about half an hour. This allows the semen to bathe the womb completely.

The timing of the procedure is critical. In-semination has to be performed at the time of ovulation, when the ripe egg is ready to be released by the ovary. This marks the peak o( a woman’s fertility, and is usually determined by keeping a daily record of her body temperature first thing in the morning. When ovulation is imminent there’s a slight drop in temperature, followed almost immediately by a marked upward shift. Sometimes, though, the temperature chart method doesn’t provide a clear enough indication of when ovulation is about to take place. If this is the case there is a simple test which can be carried out to measure the levels in the blood or urine of — this is known to be present in very high quantities just prior to ovulation.

Complete success can never be guaranteed. It’s estimated that between 50 and 70 per cent of couples will conceive following a six-month course of treatment with AID. Over half the conceptions occur within the first two months of treatment – if a woman hasn’t conceived by the sixth month then she is unlikely to do so.

There are two main reasons why this should be so. First, the woman’s Fallopian tubes may be damaged, thus preventing fertilization of the egg by the donor sperm. This can be verified by an X-ray or a simple operation. Secondly, the woman’s monthly pattern of ovulation may have been disrupted. Artificial insemination is quite stressful, and this frequendy upsets the normal menstrual cycle. For a start, the procedure is not a natural one – many women even find it distasteful, although they are prepared to go through with it. Added to this, a number of women are conscious of the fact that AID represents their last chance of having a child; this in itself understandably creates a great deal of stress.

The first clue that the woman has successfully conceived comes when her period following insemination doesn’t arrive. If she has been keeping a record of her basal body temperature it should show a fall, followed by a rise at the time of insemination, with the temperature remaining high after the date of the missed period. A test carried out on an early morning urine sample, four weeks after the insemination, may confirm that she is pregnant.

Once it has been established that a woman has conceived following artificial insemination, then her pregnancy will progress normally, just like any conception by natural means. In other words, she runs the same risks of complications in her pregnancy as any other mother.

Obviously there is a theoretical risk that the child born as a result of AID may subsequently be rejected by the husband. The present legal position of AID does litde to decrease this risk, because legally such a child should be registered as ‘father unknown’, which in effect makes him illegitimate. But because insemination is usually performed privately, with the mother’s subsequent pregnancy being monitored completely separately by an antenatal clinic in the normal way, only the child’s ‘parents’ and the AID clinic need know of the manner of his conception. Many parents, therefore, decide to keep their child’s illegitimacy secret, and, as a child born within a marriage is presumed to be legitimate, no one would think of questioning this. However, to be on the safe side, many couples overcome the problem by having the child adopted by his modier’s husband who then legally becomes his father.

To minimize the chances of rejection, doctors recommend that a couple continue to make love regularly diroughout the treatment period, as there is just a chance that the egg will be fertilized by the husband. Alternatively, some doctors often prefer to mix donor sperm with the husband’s sperm for the same reason.

However, perhaps the most important factor in reducing the risk of rejection is to give the couple thorough counselling before they embark on die treatment. It’s vital that the husband and wife attend the first consultation together, so that they can discuss with the specialist just what is involved, and also voice any reservations or fears they may have. Both have to give their written consent to the insemination.

Not surprisingly, some couples decide at this stage not to proceed with the treatment, and others will drop out once the insemination programme has started. However thoroughly a couple are counselled prior to AID, there is always the risk that, faced with what is to all intents and purposes another man’s child, the father may be unable to come to terms with this fact. This may take the form of being unable to show the child affection which would cause enormous problems to all three of them. However, the couples who actually go ahead with AID form a highly motivated group. _ .

A donor is very carefully selected. For a start he has to be of good general health with no family history of hereditary disease. He is then screened to make sure that he is free of syphilis and hepatitis, both of which could be passed on through artificial insemination. The donor must also be highly fertile – that is, his semen must contain a large number of good quality, mobile sperm. The race of the donor and the husband must, of course, be the same, and where possible the physical characteristics of the donor- height, hair and eye colour – are carefully matched with those of the husband. The donor must also be reasonably intelligent.

Anyone can be a donor, as long as he satisfies the basic requirements, but most doctors prefer to limit the number of pregnancies fertilized by each individual donor. A large proportion of donors are medical students, since they provide a readily available supply of semen for many university-based AID centres. Probably the attraction of being a donor is the additional source of income. Men who are about to be sterilized often decide to donate their sperm.

Occasionally, relatives of a couple who have decided to have AID offer to donate their sperm, so that the resulting baby has mostly family genes, instead of 50 per cent of those of a total stranger. But most doctors would advise against this as it could cause considerable complications within the family later on.

Complete confidentiality is always maintained. Neither the donor nor the woman receiving his sperm is even aware of each other’s identity. However, the doctor who arranged the artificial insemination keeps records of them both.

Insemination using the husband’s sperm, known as AIH, is used only rarely. Compared with AID, the success rate of AIH is disappointingly low -only about 10 to 15 per cent or couples conceive after six months of treatment. This is due to the considerable variation in the quality of the sperm that is available for use.

However, there is a number of situations in which AIH has proved useful. For example, a man may be producing normal, healthy sperm but is unable to fertilize his wife because her cervical mucus is too acidic and destroys the sperm before they reach the egg. Another, less common, cause of infertility- but with a similar effect- has been found to be the presence of anti-sperm antibodies in either the husband’s semen or his wife’s cervical mucus. In the latter case AIH has been performed by injecting the husband’s sperm directly inside the womb, thus by-passing the local action of the antibodies in the mucus. When it’s the husband who is affected, it’s sometimes possible to ‘wash’ the antibodies out of the semen prior to insemination.

AIH has proved successful in bringing about conception in cases where normal intercourse is not possible – when, for instance, a husband is impotent. And a few artificial insemination centres use the technique in cases where the husband’s sperm count is low, where sperm mobility is reduced, or where the volume of sperm produced is low. But the chances of conceiving are no greater than by normal intercourse, so the value of the treatment in this instance is doubtful.