• Options such as adoption, fostering or surrogacy should be considered
In the majority of cultures, having children is seen as fulfilment of a social contract and the obligation of the couple is to meet this expectation. No definition for how long the wait should be is socially enacted, and often ignores personal circumstances such as career aspirations and financial stability. Couples will often make the assumption that insofar as they are sexually intimate, fertility is guaranteed except where a conscious decision to use contraception is made.
Fertility is dependent on four important parameters namely, regular ovulation with patent (open) fallopian tubes in the female partner and normal sperm parameters in the male partner. In addition, there must be regular intercourse to allow the egg and sperm to meet and fertilise. What is often not understood is the chance of conception in one fertile ovulatory cycle, medically known as fecundity. This is the probability that a female partner will conceive in every month of being fertile when they try to. Generally, fecundity stands at about five percent, in other words, for every one hundred fertile females only about five will conceive during each month of trying.
It, therefore, implies that couples ought to consistently and regularly attempt conception over a period of time to be successful. The secular duration of trying is taken as 12 months in which time nearly 85% of couples become successful. Often, there is a tendency that to enhance conception, the attempt is made at specific times of the month, typically at around ovulation.
This is, however, an erroneous assumption because the outward signs of ovulation become apparent after the egg has been released. The female egg, has a very short lifespan typically about 24 hours and quickly becomes dehydrated and desiccates but the sperm cell remains viable for several days in the female genital tract. In essence, couples are advised that trying for two to three times a week gives them the highest chance of conception.
When a couple feel concerned that there may be a problem preventing conception, sometimes it is obvious what the issue could be. In most instances, however, this is unbeknown to them. It requires an explanation from a health worker going over pertinent issues and tests. Attending a medical consultation together provides the opportunity to dispel myths around fertility, remove blame and enhance engagement with treatment. This also offers the chance to signpost the couple to other essential support services such as counselling.
A comprehensive assessment of fertility includes examination of a semen sample to check for correct sperm parameters, testing ovulation and lastly checking the patency of fallopian tubes. The sequence of testing should be logical enough to allow prompt arrival at the right diagnosis and avoid unnecessary testing.
Overall, half of fertility issues may be related to sperm and the other half to female factors including ovulation and tubal blockage. The medical approach, therefore, would be to start investigation by the least invasive tests, that is semen analysis and ovulation check. This means that if the sperm parameters are normal then assessing to check that the fallopian tubes are open is the next logical step as this helps to determine whether a chance of natural conception exists.
Generally, a couple feel more reassured and ready to engage with treatment when their experience is enhanced by an empathetic team who are ready to give as much information and allow shared decision making respecting values and opinions. It may be exasperating going through fertility investigations and may be a roller-coaster experience.
Whereas knowing the factors contributing to subfertility is important, particular diagnoses can be devastating, such as blocked fallopian tubes, severe sperm abnormalities and ovarian failure. Couples may feel frustrated, angry and could tend to want to blame certain situations in their own life experiences. Relationship strain may also occur. This is the moment where the health care team should be very supportive and also engage counselling services.
Options for fertility treatment should then be discussed sensitively paying attention to the individual couple circumstances and offering information based on current best evidence. A greater majority of couples may require assisted reproductive treatment such as in vitro fertilisation (IVF).
This is usually a major decision for a couple to make as it involves financial commitment, uncertainty about success and risks that come with this. It is important that a couple have factual and up-to-date information in an easy to understand rubric. They should never feel rushed to undertake this treatment and counselling support is crucial to making this decision. It helps a great deal when both partners attend clinic for these discussions.
Sometimes effective treatment is faced by certain barriers or constraints. It should never feel the end of the road for the couple as other options must be explored. These include discussing use of donor gametes or alternation parenthood options such as adoption, foster parenthood or use of surrogacy arrangements. It calls for a sensitive and empathetic fertility specialist to navigate around these issues. Whereas individuals may have various coping strategies, important for the couple is family support and also support groups such as Waiting Wombs Trust. Legal opinion may need to be sought in some circumstances.
Dr Charles Muteshi, Fertility Specialist at Aga Khan University Hospital, Nairobi