Wednesday 16 August 2017

Infertility: Struggling to conceive

Infertility affects around one in six couples. But what causes it and what steps can be taken to try to overcome it? Karina Corbett reports

ACCORDING to the World Health Organisation, infertility is the inability to conceive a child. It notes that 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).

Primary infertility is infertility in a couple who have never had a child, while secondary infertility is failure to conceive following a previous pregnancy. Infertility may be caused by infection in the man or woman, but often there is no obvious underlying cause.

Infertility is thought to affect one in six couples and according to Dr Mary Wingfield, consultant obstetrician gynaecologist at the Merrion Fertility Clinic, which is linked to the National Maternity Hospital, Holles Street in Dublin, that figure is about right in the western world.

So what are the primary causes? "The biggest factor is the woman's age," Wingfield explains. "Fertility starts to reduce at 35 and dramatically so at 38. We would see a lot of couples coming in where the woman is 40 or 41. By the time she gets to 43 it's unlikely she'll become pregnant. The age tends to be older in Ireland in general."

Dr Rachel Mackey, women's health specialist with the Women's Health Clinic in Dun Laoghaire, Co Dublin, agrees that one in six couples will struggle to conceive. She is seeing more and more infertility issues all the time.

"It's more common now, partly because people also tend to have higher expectations these days and are not likely to want to wait three or four years.

"Another reason is the increased incidence of chlamydia, which has skyrocketed in the last 15 years. This affects fertility because if the woman had it her tubes would have been damaged."

Mackey also points to the age factor. "Age is a major cause of infertility because a huge issue is the quality of the woman's eggs. So people who defer pregnancy to a later stage in life are more likely to run into problems. The typical profile of one of my patients would be a working professional of around 33. The general advice is that a woman under 35 should be trying to get pregnant for a year before seeking medical help but a woman over 35 should seek help after six months.

What can be done?

So what should a couple who may be experiencing infertility do?

"Generally we would say to people to talk to their GP first," advises Wingfield. "The GP will look then for anything specific such as endometriosis, chlamydia or if either had surgery in the past – gynaecological in the woman's case and for the man if he had any surgery on his testes. So basically anything that might increase their chances of being infertile. Whether a woman has a regular cycle or not will be looked at. If her periods are more spaced out there may be a problem with ovulation."

In her own practice Mackey says the first steps taken are blood tests on the woman, carried out on day three and 21 of her cycle.

"She will also have an pelvic ultrasound done while a semen analysis will be carried out on the man. All these tests confirm whether ovulation is taking place and if there is a male factor involved such as a low sperm count. A third of infertility cases, however, are unexplained. There's a theory that both partners possibly have subfertility issues and that combined they are causing a problem."

The Women's Health Clinic offers a limited amount of treatments. "We do induction of ovulation," continues Mackey. "So if the woman isn't ovulating we give her Clomid, which causes her to ovulate by acting on the pituitary gland. And if she is ovulating we give it to her so it gives her an extra boost."

Some clinics would then give the woman Clomid combined with intrauterine insemination (IUI) – known to most people as artificial insemination. In this procedure, the woman is injected with specially prepared sperm.

"This isn't very invasive and not particularly expensive either," adds Mackey.

The IVF route

Of course when it comes to infertility most people immediately think of IVF (in-vitro fertilisation) and this is indeed another route couples having difficulty conceiving can take.

IVF is when eggs are retrieved following follicular stimulation and processed in a laboratory/clean room environment dish. The eggs are mixed with washed, prepared partner or donor sperm. Fertilisation takes place within 24 hours of egg retrieval and any resulting embryos are cultured for two to three days, after which one or two are transferred to the female partner.



Clane Fertility Clinic, which is affiliated to Clane General Hospital in Co Kildare has over 25 years' experience in fertility issues.

According to Martina Kelly, clinical nurse manager, the clinic is seeing the same need for IVF now as it did in the past, but because the procedure is not covered under any health insurance scheme (except for the drugs), many patients are only able to afford one round of treatment rather than a number of them.

The nature of IVF means that some couples might be lucky enough to get pregnant on the first attempt; however, it generally takes more than that, often with no success at all.

From the medicines and injections to egg collection and embryo transfer, Kelly says that IVF can be physically trying, although the body can cope with great demands. But the psychological aspects can be harder to deal with.

"We would always tell people to be prepared," she advises. "They have to be positively optimistic but also protect themselves. It's about staying realistic and grounded through treatment.

"That can be difficult because often people are visualising the baby in their arms at the end and forgetting about the steps in the middle.

"But it's something that needs to be taken step by step. If all you can see is a baby at the end and you fail, it can be harder to start the process all over again. There's a lot of psychological depletion after failure if things aren't dealt with along the way".

Clane Fertility Clinic educates all its patients about the process involved, continues Kelly, making sure they all have the correct support systems in place.

"We have a counsellor who we would encourage all clients to speak to so they can get intensive advice."

"It can be massively traumatic for the couple," Mackey says of IVF.

"I find that a lot of couples come to me and just want to talk it through initially. They want to hear their options. So they are better off learning as much as possible from someone with an interest in the area. Counselling is a good idea too.

"I would advise people to think about it, take their time and get as much information as they can without panicking. Take a deep breath and have a chat with someone about it.

"That said, when age is not on the couple's side, they do need to move as quickly as they can because overwhelmingly it's the age of the woman's eggs that's a factor."

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