Infertility

Welcome to the August edition of the Ndlalane Health Newsletter! In this vibrant community, we embrace the spirit of lifelong learning with our motto being #BeInTheKnow. What better way to celebrate Women's Month in South Africa than by shining a light on a crucial topic that affects us all, but disproportionately impacts the women in our lives harsher than it does the male counterparts?

In contrast to the rest of the world which celebrates women’s day on the 8th of March, in South Africa it’s on the 9th of August, in-fact the whole of August is celebrated in honor of the brave women who marched against injustice on August 9, 1956. We recognize the significant role women continue to play in shaping our society.

Today, we tackle a critical issue that may weigh heavier on women's minds but requires a collective effort to address. Infertility!

For our new members, I’ll introduce myself again. My name Sakhile, aka DocSakhi and I am the host and curator of these newsletter. I'm passionate about sharing knowledge to empower our community and create a better world for all. In this edition, we'll dive deep into understanding infertility - what it is, the different types, and how it can impact individuals and families. Let's get started

Infertility is a condition where a couple is unable to conceive a child after regular, unprotected sexual intercourse for a certain period of time. The definition of infertility varies, but it is typically defined as the inability to get pregnant after 12 months of regular, unprotected sex for women under 35, or 6 months for women over 35 years of age.

There are several types of infertility:

1. Primary infertility:  - This is when a couple has never been able to achieve a successful pregnancy.

2. Secondary infertility: - This is when a couple who was previously able to get pregnant and have a child but is now unable to conceive again.

There are many potential causes which might be influencing the primary and secondary types noted above. We can further classify these causes according to gender.

Female factors:

• Ovulation disorders

• Tubal or uterine problems

• Endometriosis

• Age-related decline in fertility

 Male factors:

• Low sperm count or poor sperm quality

• Varicocele (enlarged veins in the scrotum)

• Hormonal imbalances

There are certain instances whereby the causes are unexplained, and we don’t know what causes the infertility. In other cases, the cause of the infertility is combined, meaning that the cause is in both the male and the female partners. Age is also a potent cause of infertility especially in women, because as they age, the eggs quality and quantity also diminish.

Let’s try to explain the points above a bit. without getting into deep details, but to give a picture of what we are talking about. We mention female and male factors, and this is what is meant by them.

Female Factors:

Ovulation Disorders: 

Polycystic Ovary Syndrome (PCOS): PCOS is a hormonal disorder that can disrupt the normal ovulation process. It is characterised by the development of small cysts in the ovaries, high levels of androgen hormones, and irregular menstrual cycles (Bolumar et al., 2020).

Premature Ovarian Failure: This condition occurs when the ovaries stop functioning normally before the age of 40, leading to a decline in fertility (Wilkins et al., 2017).

Tubal or Uterine Problems:  

Tubal Blockage: Blockages or scarring in the fallopian tubes can prevent the egg from traveling to the uterus, causing infertility (Choudhary et al., 2021). 

Uterine Fibroids are Noncancerous growths in the uterus that can interfere with implantation or cause other reproductive issues (Lee et al., 2021).

Endometriosis: 

Endometriosis is a condition where the endometrium, the tissue that normally lines the inside of the uterus, grows outside the uterus. This can cause inflammation, scarring, and damage to the reproductive organs, leading to temporary infertility (Nisenblat et al., 2016).

Age-Related Decline in Fertility:

As both men and women age, their fertility naturally declines due to factors like decreased egg/sperm quality and quantity. This is a gradual process that becomes more significant as people approach their late 30s and 40s. Making it more difficult to conceive (Leridon, 2004)

Male Factors:

Low Sperm Count or Poor Sperm Quality: - Factors such as lifestyle, environmental exposures, and medical conditions can affect sperm production and quality, leading to temporary infertility (Mieusset & Bujan, 1995).

Varicocele: - Varicocele is the enlargement of the veins in the scrotum, which can lead to increased temperature in the testicles and impair sperm production (Kantartzi et al., 2007).

Hormonal Imbalances: - Hormonal disorders, such as hypogonadism or thyroid dysfunction, can disrupt the normal production and function of hormones involved in male fertility (Krausz, 2011).

I suppose it is also worth mentioning that there are certain things we might not immediately be aware or know about that may temporarily also affect our ability to conceive. I mention temporarily because the duration and reversibility of these temporary infertility causes can vary depending on these things;

Sexually Transmitted Infections (STIs): Certain STIs, such as chlamydia and gonorrhea, can temporarily impact fertility in both men and women if left untreated. These infections can cause inflammation and damage to the reproductive organs, which can impair fertility.

Stress and Lifestyle Factors: High levels of stress, poor diet, excessive exercise, and other lifestyle factors can disrupt the normal hormonal balance in the body, leading to temporary infertility. This is more common in women, as stress can affect ovulation and menstrual cycles.

Medical Conditions: Conditions like thyroid disorders, polycystic ovary syndrome (PCOS), and pituitary gland issues can temporarily impact fertility by disrupting the normal hormonal balance.

Medications: Some medications, such as certain antidepressants, chemotherapy drugs, and immunosuppressants, can temporarily affect fertility. These medications can interfere with the production or function of hormones involved in reproduction.

Speaking of medications, let’s look at contraception. Here is a Rule of Thumb: - For most women, it typically takes 1-12 months for their menstrual cycle and ovulation to return to normal after stopping hormonal contraception, such as birth control pills, patches, rings, or injections (Grimes & Stuart, 2012). I’ll go a step further and give you specific timeframes:

Oral contraceptive pills: Fertility usually returns within 1 month, with regular menstrual cycles resuming within 3 months.

Contraceptive patch or ring: Fertility and menstrual cycles typically return to normal within 1-2 months (Practice Committee of the American Society for Reproductive Medicine, 2008).

Hormonal injections (e.g., Depo-Provera): It can take 4-12 months for fertility to fully return after the last injection, as the synthetic hormone slowly clears the body (Kaunitz, 2008).

Intrauterine devices (IUDs): Fertility typically returns to normal within 1 menstrual cycle after IUD removal (American College of Obstetricians and Gynaecologist’, 2019).

I hope you are still with me? I might have bombarded you with a lot. So, before we delve into the potential ways, we can venture towards in order to resolve this matter, I just want to say that we need to understand that infertility is a complex and often heartbreaking condition that affects millions of individuals and couples worldwide.  According to the World Health Organization (WHO), infertility affects fertility in South Africa similarly to global trend. 1 in 5 couples worldwide (19% of couples) and 1 in 6 in South Africa (17% of couples) and 33% in Africa as a whole are affected by infertility.  That translates to 48 million couples worldwide or 186 million individuals worldwide and 2.5 million of those are in South Africa.

The emotional impact of infertility can be profound, leading to feelings of grief, depression, and anxiety.

The journey to parenthood is often filled with hope, excitement, and anticipation. However, for those facing infertility, this journey can be fraught with disappointment, stress, and a sense of loss. Infertility can take a significant toll on an individual's mental health, with studies showing that the psychological distress experienced by those dealing with infertility is comparable to that of individuals diagnosed with cancer, HIV, and chronic pain (Domar et al., 2017).

One of the primary emotional challenges of infertility is the sense of loss and grief. The inability to conceive a child can feel like the loss of a dream, and the process of coming to terms with this loss can be a long and arduous one. Individuals may experience a range of emotions, including sadness, anger, and a profound sense of longing.

The social and relational aspects of infertility can be deeply challenging. The constant reminders of pregnancy and parenthood, such as social media posts and baby showers, can be triggering and lead to feelings of isolation and exclusion. Couples may also experience strain on their relationship as they navigate the emotional and financial burdens of infertility treatment.

To cope with the emotional toll of infertility, it is crucial for individuals and couples to seek support and resources. This may include counseling, support groups, and connecting with others who are experiencing similar challenges. Practicing self-care, such as engaging in stress-reducing activities and maintaining a healthy lifestyle, can be beneficial (Domar et al., 2017).

One might say, “Ok! Dr. Sakhile I hear you, and I’ve read up on these things you are telling me. I still have this issue, and I’ve tried everything.  What do I do now?

I am not a fertility specialist, but I've witnessed firsthand the unique challenges many couples face when trying to start a family.  I have eluded above that I understand that Infertility can be an emotionally taxing and isolating experience, but today I'm here to tell you that there are avenues available to overcome this obstacle in most cases unless the person is not anatomical capable of having children such as being transgender or having had a surgical procedure to remove or alter the reproductive system.

Let's begin by addressing the needs of younger couples, those under the age of 35. The first step is to identify the underlying causes of infertility through comprehensive medical evaluations, this mean that your fertility specialist will ask questions to assess what could be the cause of your infertility. Common issues in this age group include polycystic ovary syndrome (PCOS), endometriosis, and male factor infertility. So, by working closely with a fertility specialist, they can develop a tailored treatment plan to address your specific unique circumstance.

Alongside medical interventions, lifestyle modifications can also play a significant role. Maintaining a healthy weight, managing stress, and quitting smoking and drinking are all lifestyle changes that can dramatically improve fertility. For many younger couples, a procedure called intrauterine insemination (IUI) can be an excellent starting point. IUI is a relatively affordable and minimally invasive option that has shown promising success rates in our region.

As couples progress in age, the sense of urgency often increases. For those between 35 and 40, it's crucial to seek medical attention promptly, as fertility declines over time, especially for women. In these cases, advanced fertility treatments like in vitro fertilization (IVF) may be the next step. IVF has become increasingly accessible in South Africa, with success rates continuing to improve. We also have the option of utilizing donor eggs or sperm, as well as surrogacy, for those who require these advanced solutions.

For couples over the age of 40, I understand the challenges can feel even more daunting. However, I want to assure you that there is still hope. While fertility rates do decline with age, the advancements in assisted reproductive technologies have made it possible for many older individuals to conceive. Donor eggs or sperm, and even surrogacy, are viable options worth considering. Additionally, adoption can be a tremendously rewarding alternative for those who are unable to conceive biologically.

Throughout this journey, emotional support and counseling are invaluable. I encourage all my patients to seek out local support groups and resources to help navigate the complex emotional and psychological aspects of infertility. Remember, you are not alone in this struggle.

I'm confident that you can overcome the challenges of infertility and welcome a new life into the world.

Thank you reading up to this far, we have come to the end of today’s informative session. You may direct comments or questions to [email protected] or just respond to the email if you are a subscribed member. Our subscription is free and all you need to do is click here and use your valid email to subscribe to receive our newsletters, directly into your mailbox.

References:

Bolumar, D., Romero, J. L., Martínez-Moya, M., Landeras, J., Fernández-Shaw, S., & Cabezas, J. L. (2020). Polycystic ovary syndrome: A global public health problem. International Journal of Environmental Research and Public Health, 17(15), 5526. https://doi.org/10.3390/ijerph17155526

Choudhary, A. K., Botchu, R., Lakhoo, K., & Rodrigues, J. C. L. (2021). Tubal infertility: Imaging and diagnosis. Seminars in Ultrasound, CT and MRI, 42(2), 169-179. https://doi.org/10.1053/j.sult.2020.12.005

Kantartzi, P. D., Goulis, C. D., Goulis, G. D., & Papadimas, I. (2007). Male infertility and varicocele: Myths and reality. Hippokratia, 11(3), 99-104.

Krausz, C. (2011). Male infertility: Pathogenesis and clinical diagnosis. Best Practice & Research Clinical Endocrinology & Metabolism, 25(2), 271-285. https://doi.org/10.1016/j.beem.2010.08.006

Lee, H. J., Kim, M. K., Kim, M. L., Song, J. E., & Yun, B. S. (2021). Uterine fibroids and infertility. Obstetrics & Gynecology Science, 64(3), 176-191. https://doi.org/10.5468/ogs.20220

American College of Obstetricians and Gynecologists. (2019). Long-acting reversible contraception: Implants and intrauterine devices. ACOG Practice Bulletin, 186.

Grimes, D. A., & Stuart, G. S. (2012). Fertility and contraception after childbirth: Physician knowledge and practice. Journal of the American Medical Association, 307(3), 311-312.

Kaunitz, A. M. (2008). Depot medroxyprogesterone acetate contraception and the risk of breast and gynecologic cancer. Journal of Reproductive Medicine, 53(1 Suppl), 27-32.

Practice Committee of the American Society for Reproductive Medicine. (2008). Hormonal contraception: Recent advances and controversies. Fertility and Sterility, 90(5 Suppl), S103-S113.

Domar, A. D., Gross, J., Rooney, K., & Boivin, J. (2015). Exploratory randomized trial on the effect of a brief psychological intervention on emotions, quality of life, discontinuation, and pregnancy rates in in vitro fertilization patients. Fertility and Sterility, 104(2), 440-451. https://doi.org/10.1016/j.fertnstert.2015.05.009

Greil, A. L., Slauson-Blevins, K., & McQuillan, J. (2010). The experience of infertility: a review of recent literature. Sociology of Health & Illness, 32(1), 140-162. https://doi.org/10.1111/j.1467-9566.2009.01213.x

Martins, M. V., Peterson, B. D., Almeida, V., Mesquita-Guimarães, J., & Costa, M. E. (2014). Dyadic dynamics of perceived social support in couples facing infertility. Human Reproduction, 29(1), 83-89. https://doi.org/10.1093/humrep/det403