The Problem of Infertility (Childlessness) in Africa Gambia no exception

Infertility causes great worry and sorrow for many couples in Africa, especially for the women. Medical evidence shows that men and women usually have the same rates of infertility

Infertility - Unwanted Childlessness

Infertility is typically defined as the inability to achieve pregnancy after one year of unprotected sexual contact. Worldwide more than 70 million couples suffer from infertility, affecting up to 15% of the couples in their reproductive age.

Infertility can be caused by various factors; Male, female, or a combination of the two. In approximately 30% of cases no reason will be found. For couples who have not conceived after one year of trying it may be worth seeing a specialist. The doctor can check for some common causes, evaluate and discuss possible treatment options.

WHAT CAN CAUSE INFERTILITY?

In order to understand the tests and treatments you may be offered, it is important to understand how conception naturally occurs. First, your ovary must release (ovulate) an egg. This usually occurs once a month, approximately mid-way through the menstrual cycle. The egg must be picked up by the fallopian tube. Sperm must travel through the vagina, into the uterus, and up into the fallopian tube in order to fertilize the egg. The fertilized egg, or embryo, then travels down the fallopian tube to the uterus, where it implants in the uterine lining and develops (Figure 1). A problem in any part of this process can lead to infertility.

DEALING WITH INFERTILITY

If you and your partner have been unable to have a baby, you’re not alone. At least one out of seven couples has trouble conceiving. During this time, it is normal to experience feelings of frustration, jealousy, anger and stress. However, once you begin to explore your medical options, you’ll find that fertility treatments offer hope for a successful pregnancy.

Causes of Infertility

Most important reasons for infertility in Africa are infections which may be sexually transmitted, that affect both men and women, and pregnancy related infections. Approximately 20% is caused by ovulatory dysfunction, for example in poly cystoid ovary syndrome, diabetes and or in severe obesity. In a significant number of cases no cause for infertility can be found. Assisted reproductive techniques such as IUI, intra uterine insemination may be successful here.

Since infertility is a shared experience and is best dealt with as a couple, both you and your partner should try to attend the first meeting with your doctor.  Your doctor will review your history and ask you and your partner questions to help identify potential causes for your difficulty in conceiving. Since at least 25% of infertile couples have more than one factor causing infertility, it is very important to evaluate all factors that may affect both you and your partner.

You and your partner might undergo a series of tests including a sperm test (semen analysis) of the male partner, an ultrasound scan and or x ray of the womb for the female partner, blood test for both partners to screen of sexually transmitted diseases and HIV and possibly other tests, depending on any other symptoms that you may have. For example, Hormone tests: Testosterone in the male and Estragon, Progesterone and FSH in the female partner.

Fertility Treatment

Sometimes the factors affecting your fertility are easy to detect and treat, but in many cases a specific reason for infertility may be difficult to identify. After a full evaluation, your physician can give you a reasonable idea of your chances of achieving pregnancy with various treatment options.

Even when no cause for infertility is found there are ways to help you increase your chances of getting pregnant. Examples of these Assisted Reproduction Techniques are ovarian stimulation, intrauterine insemination (IUI) and IVF (in vitro fertilization).

Ovarian stimulation is a hormonal treatment with which the menstrual cycle is regulated. Follicle growth will be monitored and ovulation detected with ovulation test (LH tests) or induced by an injection of Phenyl. This way we will know exactly when ovulation will take place.

Intra Uterine Insemination (IUI) is a procedure in which after ovarian stimulation sperm that is processed in the laboratory is placed directly high in the uterus.

In Vitro fertilization (IVF) involves the culture of eggs with sperm in a laboratory to create fertilized eggs, which develop into embryos. The embryos are allowed to grow up to 4 days and then one or two embryos are transferred into the woman’s uterus.

The choice of which treatment to pursue, if any, is strictly a personal one. Side effects, costs and expected success rates are important factors to consider when choosing a treatment plan.

OTHER FACTORS OF INFLUENCE ON FERTILITY

Lifestyle

For both men and women a healthy lifestyle will contribute to your chances of conceiving.  Tobacco and alcohol are known to have a negative effect on the fertility of both men and women, as well as on the development of a foetus in pregnancy. You have a reduced chance of conceiving if you are very overweight or underweight. Stress has been known to negatively influence libido in men, and the menstrual cycle in women. In general it is advised to keep a healthy diet and have some regular physical exercise. 

Fertility and Age

Fertility declines with age because fewer eggs remain in the ovaries, and the quality of the eggs remaining decreases. Blood tests are available to determine your ovarian reserve, a term which reflects your age-related fertility potential and indicate your chances for pregnancy, especially if you are age 35 or older. Abnormally high FSH levels do not mean that you have no chance of successful conception. However, they may indicate that success rates may be lower, that more aggressive treatment may be warranted, and/or that higher medication doses may be needed.

Vaginal douching

vaginal douching is a commonly used method to wash out the vagina with water or a mixture of water and soap, Dettol or other solutions. Douches that are sold in drugstores and supermarkets may contain antiseptics and fragrances.

Besides making them feel fresher, women say they douche to get rid of unpleasant odours, wash away menstrual blood after their period, avoid getting sexually transmitted diseases and prevent a pregnancy after intercourse. However, health experts say douching is not effective for any of these purposes. On the contrary, it can actually increase the risk of infections, pregnancy complications and other health problems.

Regular vaginal douching changes the delicate balance of vaginal flora (organisms that live in the vagina) and acidity in a healthy vagina. These changes can cause overgrowth of bad bacteria which can lead to infection. Douching itself can push existing infections further up into the uterus, fallopian tubes and ovaries.

It is strongly advised you should avoid vaginal douching. Having some vaginal discharge is normal however, if you notice a very strong odor, it could be a sign of infection. The acidity of the vagina naturally controls bacteria, and simply washing the outside of the vagina with warm water and mild soap is enough to keep clean.

PSYCHOLOGICAL IMPLICATIONS

Infertility is a medical condition that has many emotional aspects. Feelings such as anger, sadness, guilt, and anxiety are common and may affect your self-esteem and self-image. You may find it difficult to share your feelings with family and friends, which can lead to isolation. It is important to know that these feelings are normal responses to infertility and are experienced by many couples. Although a doctor will describe various treatments and realistic odds of success with treatments, you must decide how far you will go in your attempts to conceive. Coming to a joint decision with your partner about goals and acceptable therapies is important.

Infertility in Africa

Even with the population booming over Africa, infertility is still a big problem.

Infertility is typically defined as the inability to achieve pregnancy after one year of unprotected sexual contact. Worldwide more than 70 million couples suffer from infertility, affecting up to 15% of the couples in their reproductive age. In Africa, the situation is worse. WHO demographic studies from 2004 have shown that in sub-Saharan Africa, more than 30% of women aged 25–49 suffer from secondary infertility, the failure to conceive after an initial first pregnancy.

The Impact of Infertility

In Africa, the inability to conceive is frequently considered a personal tragedy as well as a curse for the couple, impacting on the entire family and even the local community.  In addition to the personal grief and suffering it causes, infertility can create broader problems, particularly for the woman, in terms of stigma, economic hardship, social isolation, and even violence.

Unlike the Western world, where infertility is openly discussed and help and information is widely available, in most African societies the topic is taboo, and help is scarce, contributing even more to the agony and isolation these women suffer. Seeking fertility care often means a lonely path for women wishing to conceive.

Main cause of infertility in Africa is the result of genital infection, which may have been sexually transmitted, or caused by traditional practices, such as female genital mutilation or unsafe abortions and home deliveries in unhygienic circumstances. These infections, if left untreated often result in bilateral tubal occlusion.

Other causes of infertility include ovulatory dysfunction (approximately 20%), for example in poly cystoid ovary syndrome (PCOS), diabetes and or in severe obesity. In a significant number of cases no cause for infertility can be diagnosed.

Fertility Treatment

Fertility care, if available is very basic in the Gambia. Conventional methods of infertility treatment involve the surgical repair of blocked fallopian tubes and hormonal stimulation with Clomid.

Highly controversial is the procedure of D&C (dilation and curettage). D&C as an infertility treatment has long been eliminated from the reproductive medicine textbooks, and government hospitals and most private clinics no longer offer this procedure as infertility treatment. Still, many Gambian women feel that the process of ‘cleaning out the womb’ or ‘stomach washing’ will remove any blockage that might prevent a pregnancy or affect its viability and some are willing and able to offer large sums for the procedure. Sadly as of to date some doctors still perform D&C for these reasons.

In the West infertility care is highly standardized and a number of treatments are available. These ‘Assisted Reproduction Techniques’ such as intrauterine insemination (IUI) and in vitro fertilization (IVF) can be very expensive. It is not uncommon for these treatments to cost up to thousand dollars per cycle in London and New York. Those who can’t afford this go to Algeria, Tunisia and India. Still, out of reach for most Africans.

Low Cost IVF

The Walking Egg Foundation, a charity sprang from the Genk Institute for Fertility Technology in Belgium has developed a Simplified Culture System (SCS), which is an enclosed culture system in a shoe-box size environment. This technology allows IVF to be carried out without the need for a full laboratory, therefore massively reducing the cost and making it a real possibility in African settings. Results so far indicate that SCS works at least as well as conventional IVF systems. As of to date 16 healthy babies have been born from this initiative. Presented to the European Society of Human Reproduction and Embryology conference, the Walking egg low cost IVF method showed a pregnancy rate of 30% – approximately the same as conventional IVF

Dimbayaa, a collective of fertility professionals based in Holland and the Gambia strives to raise awareness for the problem of infertility and help make fertility care available and affordable for people in the Gambia. Aiming to provide for high quality fertility care including low cost IVF in cooperation with the walking Egg Foundation on the one hand, but also to develop outreach programs on infertility awareness and prevention. Prevention should cover both primary prevention; sexual education of young people on how to avoid STD’s, as well as secondary prevention; early and appropriate diagnosis and treatment of STD’s.

 Author Dr Cynthia Witsenburg, MD Fertility physician, Medical Director Sunnu Medical services

www.dimbayaafertilityafrica.com Sunnu Medical Services, East Fajara telephone 2196809

Africmed Medical Services, Brusubi telephone 7332101