Culture and stemming the tide of infertility
The month of June, every year, is designated as the World Infertility Month. It is a period to move the issues that pertain to infertility to the front burner of the world’s discourse. The World Infertility Month (WIM) was initiated by the American Infertility Association to raise their collective voices against the growing stigma and shame that have come to surround infertility in the world. The celebration is growing as many patient organisations, medical professionals and pharmaceutical companies all over the world have come to endorse the month.
Infertility is defined by the World Health Organisation (WHO) as “the inability to conceive a child.” For WHO, a couple may be considered infertile if, after two years of regular sexual intercourse, without contraception, the woman has not become pregnant and there is no other reason, such as breastfeeding or postpartum amenorrhoea (inability to menstruate as a result of breastfeeding). It classified infertility into two – primary and secondary. Primary infertility is the infertility in a couple who have never had a child, while secondary infertility is the failure to conceive following a previous pregnancy.
Infertility is pervasive the world over as statistics shows that one in four couples suffer from infertility – primary or secondary. What makes this figure less obvious is that people tend to define infertility using only the primary infertility index. Many couples from Nigeria who have one or two children may actually have suffered from secondary infertility.
Infertility could be caused by a variety of factors – male and female related – and, depending on these causes, could have various treatment options – drugs, lifestyle changes, surgery, etc. For female related causes, age is one of the major factors that affect fertility in women. As women age, their fertility status goes down and sharply drops after she reaches the age of 35 years. To underscore this fact, reproductive endocrinologists and doctors specialising in infertility advise women who are above 35 years of age not to wait for one year but to seek fertility assessment from qualified fertility physician after six months of contraceptive-free sexual intercourse without conception.
Other female related factors that affect conception include tubal issues resulting in the blockade or damage of the fallopian tube; ovulatory disorders, caused by hormonal imbalances, eating disorders, and other medical disorders, and resulting in the failure of ovulation to occur (anovulation), or occurs on an infrequent or irregular basis (oligo-ovulation). Uterine-related factors refer to those conditions in the uterine cavity and endometrial lining that inhibit the uterus from conception and maintenance of a pregnancy. One of the most prominent of the uterine factors that cause infertility is endometriosis, a condition resulting from the appearance of endometrial tissue outside the womb and causing menstrual pain.
Medical conditions such as diabetes, epilepsy, and thyroid and bowel diseases, as well as lifestyle factors such as stress, being overweight or underweight, and smoking could also contribute to infertility in women.
On the male-related factors, we have sperm-related issues, tubal issues as well as erectile and ejaculatory issues. On sperm-related factors we have issues like sperm density, motility and morphology. According to WHO, a fertile man must have a sperm density of at least 15 million sperms per millilitre of the seminal fluid, and any man who has less is said to have low sperm count.
Other sperm-related factors that affect infertility are the sperm’s ability to move (motility) and the shape of the sperm (morphology). For the achievement of conception, there must not only be sperms in the seminal fluid, but these sperms must be able to swim actively and must be of normal shape – head, body and tail.
Like women, blocked tubes could also cause infertility in men as a past bacterial infection could cause scarring and blockage of tubes within the epididymis as it joins the vas. Other factors that could also cause infertility in men include genetic problems, undescended testes or twisted testicles, some medical treatment such as drug, radiotherapy or hernia surgery. Also, diabetes and some lifestyle factors such as obesity or having a job that involves contact with radiation or some chemicals could impact on male fertility.
Stemming infertility in the community, on the face value, could just be as simple as treating the causative factors as listed above but experience has shown that this approach is as simplistic as ‘belling the cat.’ While medicine can help detect and treat most of the causative factors of infertility as well as offer solution options when these factors are not treatable, the major issue in overcoming infertility in the society is the society itself.
Our society has defined child bearing as the major reason for existence in general and marriage in particular. Some religions regard child bearing as the first and foremost charge of God “be fruitful and multiply”. At every marriage ceremony – Christian, Muslim or traditional – the main prayer for the newlyweds is for the fruit of the womb, male and female. This definition demonises infertility and condemns anyone with fertility challenges as either accursed or unfortunate.
The first reaction of people with fertility challenges to this prejudice is denial, then shame and dejection, feelings that will dissuade them from seeking early medical help. Those who seek help do so secretly, and in some cases come with pseudonyms so as to ‘protect their dignity.’ Seeking early medical attention for infertility issues, like many other disease conditions, could have numerous benefits. It could make for quick and successful resolution of the issues and avoid complications as well as reduce the cost implications of managing infertility.
As practitioners, we understand these nuances and respect the wishes of these patients during and post treatment periods, but we try to make them understand what infertility really is – medical condition or ill health. We hear people acknowledge they have a cold, malaria, typhoid fever, cough and catarrh every day and they go about openly seeking medical treatment of their conditions. And this is one of the reasons these disease conditions are not serious health issues.
One of the major fallouts of the demonisation of infertility is absence of the desired open discussion of fertility issues. Open discussion of infertility will not only create awareness for the issues, but would also create awareness for the available solutions as well as centres where concerned people could access these solutions. Until patients and the society at large understand that infertility is just like any other health condition, it will be very difficult stemming the tide of infertility in Nigeria.
If we are to stem the infertility tide, society must drop the prejudice against people dealing with infertility. This will encourage open discussion of infertility issues, causes and solutions as well as enable people access treatment for their infertility and enjoy the joy that comes with child bearing.
• Dr Akinajo is a Consultant Gynaecologist with The Bridge Clinic, Lagos.