There are a lot ofavailable nowadays that cover both male and female causes. Most normal women who have sexual intercourse two or three times a week without contraception, become pregnant within a year. There is, however, no need to worry if pregnancy does not occur immediately after starting to try for a baby. If nothing has happened by the find of a year, a doctor should be consulted. In means being unable to conceive and may result from a number of causes which will need investigation.
THE BEST TIME TO CONCEIVE
Conception is most likely to occur when intercourse takes place about the time of ovulation. When a woman has a normal twenty-eight day menstrual cycle, ovulation usually occurs on the fourteenth day, counting the first day of the menstrual period as day number one. Intercourse about this time is most likely to be successful, especially if the man is ‘rested’, i.e., has not had intercourse for a few days before this time.
Many normal women have a longer cycle, five or six weeks from the start of one period to the start of another, In these women, ovulation is delayed and occurs, on average, fourteen days before the start of the next period. Although conception is most likely to occur following intercourse on the expected day of ovulation, it is important to realize that pregnancy can result from intercourse at any time during the menstrual cycle because ovulation does not always take place at the expected time.
IMPROVING CHANCES OF CONCEPTION
The younger and healthier a couple is, the greater their chances of starting a family when they want to. Couples who are overweight, overtired, worried, who eat, drink or smoke too much, will find it both more difficult to achieve a pregnancy and to have a really healthy baby. Some women who do not become pregnant as quickly as they wish become over-anxious. This, in turn, makes pregnancy even less likely.
Reassurance from a doctor, proper investigations and treatment, if necessary, are, of course, important. Equally important, however, is the necessity to remain calm and to get on, as philosophically as possible, with the business of living and loving. Couples who plan to have sexual intercourse too strictly in accordance with achart may become too tense to cope.
CAUSES OF INFERTILITY
It is a fact that many couples who fail to achieve a pregnancy are normal by all present-day tests. This indicates that there is still a great deal to be learned about human infertility. Of the known causes, the following are the most important:
Too few sperm
This may be a con- genital defect or may be the result of an earlier infection, especially gonorrhoea or mumps which involves inflammation of the testicles. A low sperm count may also result from poor general health.
The inability to have sexual intercourse is usually due to a temporary psychological upset.
Failure to Ovulate
The failure of the ovary to produce an egg results from a hormonal disturbance involving the pituitary gland. In this instance the gland fails to stimulate the ovary to ovulate.
This results from an infection in the tubes (salpingitis). It may occur as a complication of gonorrhoea or after a termination of pregnancy or spontaneous abortion.
Cervical mucus In some women the mucus secreted by the glands of the cervix is abnormal, and prevents the sperm from passing through into the uterus.
As infertility can be caused by either partner, it is vital for both to be investigated. Likewise, it is important that the problems and proposed investigations or treatment should be discussed with both partners.
The husband should be seen and examined by a male fertility specialist. The most important test is an examination of the seminal fluid. For this a sample of semen, obtained by masturbation, is analysed to ascertain the number of sperm present. The activity of the individual sperms and presence of abnormal sperms are also noted.
The wife should be seen and examined by a gynaecologist who has a special interest in infertility problems. There are tests which are designed to show if and when ovulation is occurring. The tubes are also tested to see if they are open. Quite often, nowadays, the tests are combined in a single procedure called laparoscopy.
In this instance, the woman is admitted to hospital for forty-eight hours, a few days before a period is due. Under an anaesthetic a pencil-sized telescope (laparoscope) is passed into the abdomen through a tiny cut that is made just below the umbilicus. The gynaecologist can then inspect the tubes and ovaries to see if they are normal and, at the same time, take a blood sample and a sample from the lining of the womb – endometrium – to check that ovulation is occurring.
A post-coital test can also be carried out on the woman a few hours after intercourse has taken place at the time of ovulation. A sample of the secretion in the neck of the womb-cervix-is taken and examined under the microscope to see if living sperm are present. In a normally fertile woman plenty of active sperm can be seen, but in some women the secretion is too sticky or contains some substances harmful to the sperm (sperm antibodies) so that only a few dead sperm are present.
When no abnormality is found, no treatment is necessary. In fact, pregnancy often follows soon after the investigations have been completed and reassurance given.
Drugs can be given to the man to improve his sperm count and quality of semen. Occasionally a minor surgical operation may be needed. Psychological difficulties, which have resulted in impotence, can often be overcome by discussion between the couple and a sympathetic psycho-sexual counsellor.
Failure of ovulation can be treated by fertility drugs. With some drugs twins are the worst hazard! With other much stronger stimulants greater care is needed to avoid multiple ovulation resulting in multiple births. Such drugs should only be given in specialized clinics that have the facilities to get the dose exactly right.
When the cervical mucus is hostile to the husband’s sperm, a small dose of the female hormone, oestrogen, given in the middle of the menstrual cycle can improve the receptivity of the mucus. Blocked tubes can sometimes be unblocked surgically and, with modern techniques using an operating microscope, results are improving all the time.
The success rate of tubal surgery is, however, still low. The best way to avoid blocked tubes is to avoid the inflammation – salpingitis – which causes them. For this and other reasons do not risk gonorrhoea or have a pregnancy terminated unnecessarily. If a termination is essential or if a spontaneous abortion does occur, make sure that it is properly dealt with by an expert.
When all reasonable investigations and treatment have failed to enable a couple to have a baby of their own, adoption can, of course, be considered as an alternative. It is important, however, not to leave the consideration of adoption too late. It is often extremely difficult to adopt a child these days and the sooner a couple begin the procedure and get on to the waiting list of an adoption society, the better.
Adoption societies, currently faced with too great a demand for too few babies, tend to favour young couples whose only medical problem is infertility. Handicapped babies or babies of mixed racial origin are easier to adopt than other babies. It is not true that adopting a baby is often followed by the couple producing one of their own, although this does sometimes happen. It is true that it does not matter if the eventual family consists of adopted and natural children, provided the children are told the truth and provided that love is seen to be fairly distributed.
Artificial insemination can be performed using either the husband’s semen or semen from a donor. Artificial insemination, using the husband’s semen, AIH, is rarely of value except when the man is unable to have intercourse properly with his partner because of an anatomical abnormality or a psycho-sexual problem which cannot be resolved.
AIH may also be used when the woman’s cervical mucus is hostile to the husband’s sperm and cannot be improved with hormone treatment. Putting the husband’s semen directly into the uterus, so that contact with the cervical mucus is avoided, does sometimes result in pregnancy. The results of this approach, however, have so far been disappointing.
Because of the difficulties involved in adoption nowadays, artificial insemination, using donor semen, AID, is being increasingly used in cases where the husband has no sperm or only a very small number of sperm. For AID, semen from anonymous donors of proven fertility is injected into the wife’s vagina at the time of ovulation. Selection of infertile couples for this method of treatment has to be done very carefully and can only be carried out if both husband and wife are in full agreement about its desirability.
An attempt is usually made to match the donor’s physical characteristics such as race, height, colouring, with that of the husband, The success rate in properly selected women is high and, so far, no obvious disadvantages have emerged. The legal and ethical problems, however, remain to be fully resolved.