By Dr. Sudath Senaratne
Subfertility is defined as a condition where a couple cannot conceive after trying for one year. It is important to note that they should have adequate exposure during the fertile period of each cycle. Subfertility is defined as delay and infertility as the inability in conceiving after a period of one year.
The causes of subfertility are broadly divided as female, male, and unexplained causes. Female causes can be attributed for 45% to 50% of cases, male causes are around 35% to 40%, and unexplained fraction is about 5% to 10%.
There are many modes of treatment for subfertility: medical ovulation induction, intrauterine insemination, surgical treatments, and in vitro fertilisation (IVF) and embryo transfer. So there is a lot to do before calling a couple “infertile” as the end of the tunnel is a little too long.
The female causes are mainly advanced female age, failure of ovulation, tubal factors, endometriosis, uterine abnormalities including fibroids, failure of implantation, and miscarriage. Male factors are due to the lack of an adequate number of good quality sperms, erectile problems, and sexually transmitted infections (STIs). The unexplained fraction is getting smaller with the development of technology; it was more than 20% a decade ago and is now about 10% and getting smaller.
Stigma and myths
As fertility is not a topic discussed openly in society due to stigma, there are a lot of myths about the reasons and treatment of the issue, and this secrecy keeps people in the dark. Culturally, we blame the female when a couple fails to have a child, but as I have mentioned earlier, it is not her fault most of the time. For that reason, sometimes only the female pursues medical advice for infertility, whereas the presence of both parties is essential to manage the issue.
Some couples assume that they don’t have any concerns with regard to fertility, and they postpone having a child and seeking advice from specialists till their personal goals are achieved – especially the educated and upper social class – till a later age where the fertility rate deteriorates rapidly in females after the age of 35 years. So it is important to evaluate your capacity to conceive if you are planning to postpone pregnancy and use appropriate methods of contraception. Some try to compare themselves with others, mostly with their siblings, and assume that their “fertile health” is normal, but one should know that most couples do not disclose whether they have undergone treatment to accomplish success, especially if they have used assisted reproductive techniques.
Some are reluctant to seek medical advice assuming that subfertility treatment is expensive and unaffordable. But a significant portion doesn’t need any expensive interventions, but maybe simple lifestyle modifications and minor interventions. Unfortunately, those consume time and the couple must present early for advice.
Most people from younger generations believe that their general health and sexual practices have no effect on future fertility, especially men. However, drug abuse, smoking, heavy alcoholism, and recurrent sexually transmitted infections are major contributory factors of infertility. In addition to this, maintenance of a reasonable body mass index, good food habits and regular exercise preserves the ability to have an uncomplicated pregnancy in the future.
Impact of subfertility
Women and men after trying for some time are alleged to be “defective” and socially “not fitting” and these negative social attitudes contribute to their distress. In both men and women, factors such as low spousal support, financial constraints, and social coercion in early years of marriage forecast infertility-related distress.
While infertility is not a disease, it can cause disorders in physical and mental health of partners and its treatment can affect all aspects of people’s lives, which can cause various psychological-emotional disorders or consequences, including turmoil, frustration, depression, anxiety, hopelessness, guilt, and feelings of worthlessness in life. The frustration caused by inability to “bring a baby home” affects their quality of life, impairs the quality of marriage, and leads to separation and divorce, loss of self-confidence, feelings of grief, depression, guilt and frustration, emotional distress.
One of the main reasons for delaying seeking medical advice is the social stigma of being labelled as “infertile”. Most men fear that they will be found guilty and deliberately delay being investigated. Comparing expenses and practicability, men’s investigations are low in cost and easy to do.
In conclusion, to evade these concerns it is sensible for a couple to consult a specialist preferably three to four months before marriage and design the timing and number of children they desire to have. Then a couple can get an awareness of their fecund ability, and if needed, undergo few tests and prioritise their necessities according to the financial and social circumstances of the family. It is very important to understand each person’s abilities and boundaries and make modifications before social pressures interfere and create avoidable constraints.
(The writer is a consultant in subfertility and IVF and a specialist obstetrician and gynaecologist. He is a council member of the Sri Lanka College of Obstetricians and Gynaecologists [SLCOG] and has a Master’s certificate in reproductive medicine and IVF from the Homerton University, UK)
