Infertility. A silent problem of modern families

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A popular skipping rhyme when I was in primary school advised us that:
“First comes love, then comes marriage, then comes baby in the baby carriage…”

But today’s young women are adding several other lines to this verse: “then comes career, the first home and financial security”. Inserting these in the right order is the dilemma facing my future daughter-in-law and her friends, who want everything just right when the baby(ies) arrives to complete their domestic happiness.

Making a baby may seem simple enough and although many couples are able to conceive naturally relatively fast, there are hundreds of couples who are trying to conceive and are battling with infertility.

Both genders affected

It is estimated that one in six couples are affected by infertility, defined as the failure to conceive after one year of unprotected intercourse. Infertility is a silent problem with no overt disability or symptoms. In about 35-40% of cases the causes are related to male factors; female factors are the cause in another 35-40% of cases. In the remaining 20-35% of cases, infertility is either unexplained or thought to be due to a combination of both male and female factors. Infertility is a couple’s problem.

It is also well known that as women get older, they have a lower chance of conceiving, as well as a greater chance of miscarrying. Young women in their 20s, without fertility problems have about a 25% chance per month of having a baby naturally if they try at the right time of the month. This falls to about 12% at age 37 and 5% at age 42. This is because both the number and quality of a woman’s eggs decline with age.

A few weeks after conception eggs are present in the female embryo. By the end of the second trimester of pregnancy, the number of eggs will have reached their maximum at around 7 million. This number has dropped to about 2 million by the time the baby is born. By puberty there are only a few hundred thousand eggs. In our 30s, there are around 20,000 eggs. And by the mid-40s, less than 100.

Not only are there fewer eggs. After our 30s the egg quality has reduced, increasing the likelihood of miscarriage and chromosomal abnormalities, such as Down’s Syndrome.

What causes infertility?

The commonest causes of female infertility remain tubal damage (mostly following pelvic infection), endometriosis and disorders of ovulation, such as Polycystic Ovarian Syndrome (PCOS). As women delay pregnancies into their 30s, mostly using hormonal contraception, these disorders may be masked. The pill doesn’t cause infertility but it may hide the symptoms of these conditions. In fact, the pill and the Mirena IUCD are commonly used to treat symptoms of endometriosis and PCOS.

Most causes of infertility in men relate to sperm quality and numbers. Zero or low sperm counts and poor sperm motility (swimming prowess) are due to a variety of environmental or inherited factors.

Fertility markers

Nowadays, women receiving help from a fertility clinic will be offered an AMH test. AMH stands for Anti Müllerian hormone, a hormone made in the egg-containing follicles of the ovary. AMH is a female fertility marker that gives an estimate of the remaining egg supply, or “ovarian reserve”. The lower the AMH, the fewer eggs remaining. This test assesses the response to IVF in terms of how many eggs remain in the ovary that can be stimulated, and does not test for other causes of infertility. Therefore, a woman with high ovarian reserve does not necessarily mean ‘easy unassisted fertilisation’ of these eggs. The test should not be used to reassure older women they can delay having families.

The message is that the best time to plan a family is in your 20s. If you haven’t conceived after a year of unprotected intercourse, you should seek fertility advice from your medical practitioner. If you have a condition such as endometriosis or PCOS, or are over 30, you may need to seek help earlier.

Fertility Fitness advice

There is growing evidence of the impact of lifestyle factors on both female and male fertility.

For men and women:
▪ Avoid smoking, alcohol and excess caffeine – more than one strong coffee per day is probably too much
▪ Attain a healthy weight – BMI 19 to 25 ideally, but certainly below 32
▪ Undertake sensible levels of exercise
▪ Avoid recreational drugs
▪ Eat a healthy balanced diet
▪ Find a way to manage any stresses in your life
▪ Men – avoid overheating the testicles, wear boxers and loose clothing.
▪ If possible, do not ‘delay’ trying to achieve a pregnancy – the age of the woman is particularly important.
For women hoping to become pregnant, it is advisable to take folic acid and iodine supplements for three months before a pregnancy.

Words Dr Morag Baruch