CRADLING HOPE: INFERTILITY IN WOMEN
In India, infertility affects one in six couples in urban areas; about 27.5 million couples actively trying to conceive at any given point of time suffer from infertility. Women contribute to about 50% of all infertility cases. In women, common causes of infertility are ovulation-problems, damage to Fallopian tubes or uterus, or cervix-problems. Diagnosis is mainly by urine and blood tests, ultrasound, laparoscopy and hysteroscopy. Treatment is hormones, medication and minor surgery. Safe sex, hygiene and healthy life style and diet may reduce the probability of infertility. With assisted reproductive technology (ART), most of the women can achieve pregnancy. Infertility and its treatment have psycho-social impact which may need counselling and psychotherapy. If a couple is unable to conceive despite trying for one year, they are diagnosed as infertile. Cause of infertility can be either in male or in female partner. When it is in female partner, it is called female infertility. Female infertility factors contribute to about 50% of all infertility cases; and female infertility alone cause about one-third of all infertility cases. In a few cases the infertility remains unexplained, or idiopathic, that is, its cause remains unknown. CAUSES In males, more than 90% of infertility is due to low sperm counts, poor sperm quality, or both. The remaining cases can be for several reasons: anatomical problems, hormonal imbalance, and genetic defects. In women, common causes of infertility are ovulation-problems, damage to Fallopian tubes or uterus, or cervix-problems. Also, as a woman ages, her fertility tends to decrease, and this can cause infertility. Ovulation problems may be caused by one or more of the following: Hormone imbalance Tumor or cyst Eating disorders such as anorexia or bulimia Alcohol or drug use Thyroid gland problems Excess weight Stress Intense exercise that causes a significant loss of body fat Extremely brief menstrual cycles Damage to the fallopian tubes or uterus can be caused by one or more of the following: Pelvic inflammatory disease A previous infection Polyps in the uterus Endometriosis or fibroid Scar tissue or adhesion Chronic medical illness A previous ectopic (tubal) pregnancy A birth defect DES syndrome (The medication DES, given to women to prevent miscarriage or premature birth, can result in fertility problems for their children.) Abnormal cervical mucus can also cause infertility. Abnormal cervical mucus can prevent the sperm from reaching the egg or make it more difficult for the sperm to penetrate the egg. DIAGNOSIS One or more of the following tests/exams are used to evaluate fertility: Urine and blood test to check for infections or a hormone problem, including thyroid function Pelvic exam and breast exam Test of cervical mucus and tissue to determine if ovulation is occurring Laparoscopic examination to view the condition of organs and to look for blockage, adhesion or scar tissue. HSG, which is an x-ray used in conjunction with a dye inserted into the Fallopian tubes to check for blockage of the Fallopian tubes. Hysteroscopy that uses a tiny telescope with a fiber light to look for uterine abnormalities. Ultrasound to look at the uterus and ovaries. May be done vaginally or abdominal. Sonohystogram combines an ultrasound and saline injected into the uterus to look for abnormalities or problems. Tracking your ovulation through fertility awareness will also help your infertility specialist to assess your fertility status. TREATMENT Female infertility is most often treated by one or more of the following methods: Taking hormones to address a hormone imbalance, endometriosis, or a short menstrual cycle Taking medications to stimulate ovulation Using supplements to enhance fertility Taking antibiotics to remove an infection Having minor surgery to remove blockage or scar tissues from the Fallopian tubes, uterus, or pelvic area. PREVENTION Usually nothing can be done to prevent female infertility caused by genetic problems or illness. But several things can be done to reduce the possibility of infertility: Take steps to prevent sexually transmitted diseases Avoid illicit drugs Avoid heavy or frequent alcohol use Adopt good personal hygiene and health practices Have annual check-ups with your GYN once you are sexually active You must contact your doctor in case of any of the following symptoms: Abnormal bleeding Abdominal pain Fever Unusual discharge Pain or discomfort during intercourse Soreness or itching in the vaginal area Some couples want to explore more traditional or over the counter efforts before exploring infertility procedures. However, do consult your fertility specialist about these. ASSISTED REPRODUCTIVE TECHNOLOGY (ART) In recent years, several medical procedures have become available to treat infertility. Collectively, these procedures are called assisted reproductive technology (ART). A few of these procedures are, in vitro fertilization (IVF), intra cytoplasmic sperm injection (ICSI), cryo preservation of gametes or embryos, and/or may involve the use of fertility medication. ART includes "all fertility treatments in which both eggs and sperm are handled. In general, ART procedures involve surgically removing eggs from a woman's ovaries, combining them with sperm in the laboratory, and returning them to the woman's body or donating them to another woman." PSYCHO-SOCI AL IMPACT OF INFERTILITY Psycho-social impact of infertility is often overlooked because the focus is on physical causes of infertility. But this impact is important. And although it affects both the male and the female partner, the impact on women is greater. EMOTIONAL IMPACT Women are astonished, sad and angry when they first find out about their infertility. As the treatments progresses, they are: stressed depressed confused worried angry upset sad pressured grieved SUFFER LOSS OF: self-esteem l self-confidence sense of control over one's destiny Side effects of medication, money worries, and uncertain outcomes heighten the infertility-related stress. Treatment failure, differences between partners on when to stop seeking treatment, decisions on adoption or living childless, cause further stress. COPING WITH STRESS Counselling, Psychotherapy, Medications and Relaxation techniques such as mindfulness meditation, deep breathing, guided imagery, and yoga help cope with the psycho-social impact. Other ways to cope with stress is to accept your feelings and to know that it happens to most women undergoing infertility treatment; to allow yourself to be angry, to cry to grieve;to stay connected to, and to communicate with, family and friends and your partner; to share with them your questions and fears. Long invigorating walk, new hobby, listening to soothing music may also help. Also, cut down on intake of sugar, salt, saturated fats, and white flour; reduce or eliminate from diet chemical additives, alcohol, and caffeine, including colas, coffee, black tea, and hot cocoa.If you feel stressed, angry and frustrated during infertility treatment, remember you are not alone. Everyone undergoing such treatment feels that way. The difference is only in the degree to which one is affected. CONCLUSION With ART and other fertility treatments, it is now highly probable for almost all couples to have a baby. Still, fertility is God's gift to women. And to men. But the gift is not equitable. A few have more of it, a few have less of it, and a few have none of it. Fertility treatment is often a long and arduous journey. It generates psycho- social pressures. But don’t lose hope. Don’t give up. Even miracles take a little time. Q&A WITH THE EXPERT Dr Anitha Kunnaiah discusses the link between irregular, painful periods and infertility explaining how they can be overcome with lifestyle changes. She is a senior consultant, obstetrician and gynecologist with a rich professional experience of sixteen years. Currently, she is an Infertility and laparoscopic Surgeon at Citizens Hospital,Nallagandla, Hyderabad. Q How is infertility linked to periods? Length of monthly menstrual cycle varies from girl to girl. It occurs on average at, say, an interval of around twenty eight days but may differ covering days the minimum and the maximum side for around 21-40 days. During regular periods, ovulation time for women is the 14th day. This wouldn't, however, apply to women whose period cycle is shorter or longer than usual. Q How much time do periods normally take to settle down into a pattern after onset? Normally periods settle down right after the onset but it takes around one to two years for the periods to get regularized during which our HPO Axis (Hypothalamic Pituitary Ovarian) mature. Q What could erratic periods, over a longer time, mean? Irregular menstrual cycle is when the length of cycle is more than 35 days. It can occur due to hormone imbalance, change in contraception treatment of irregular periods during puberty and around menopause. If irregular periods occur during the reproductive years, medical advice may be necessary. Q Extremely painful periods- how worrisome are they? Primary dysmenorrhoea occurs in women before and during periods which is quite normal but if a woman has painful periods in later years, it could be secondary dysmenorrhoea that might affect the uterus and other pelvic organs, uterine fibroid. Q What is your opinion about taking medication for such pain? Anti inflammatory pain killers like diclofenac and Ibuprofen can help reduce the pain. These medicines could sometimes have side effects such as stomach problems hence should be avoided. Q Are all such painful periods linked to infertility? Not all painful periods lead to or are a sign of infertility but abnormal periods, cramps can in some cases, affect fertility such as endometriosis. Q How far does diet affect potential infertility especially with reference to periods? Diet, rich in unsaturated fats, whole grains, vegetables and fish have rightly been associated with improved fertility in both men and women. Increased BMI (obesity) due to bad dietary habits may disturb periods, hormonal balance and fertility. Q How is the pattern of periods among teenagers today, different, compared to, say, those of 25 years ago? Pattern of periods remains the same but the up-to-the-minute lifestyle changes in our teenagers do tell upon their physical and mental health resulting in obesity, irregular periods, hormonal imbalance and temperamental issues. Q What are the possible causes of changes, if there are any changes seen? Changes are there and there are specific reasons behind. Balance of hormones is the rudimentary element vis-a-vis the overall well being of a person. When there's a disruption in this, it might result in mood swings, irregular periods, premenstrual syndrome and depression etc. Stress at the workplace, lack of sleep or disturbed patterns of sleep, junk food, excessive use of gadgets in the late hours etc. lead but obviously to irregularities in periods. With increasing use of cosmetics, and other skin care products, women nowadays are aging faster than their actual biological age. Young people, these days, have been facing a higher risk of sexually transmitted diseases due to biological, behavioral and cultural reasons. Unprotected sex is also a major risk factor. Q What lifestyle changes would you recommend to improve the quality of their life with regard to periods and potential infertility? It's not as challenging as it seems to be. One could follow these rules in life : Have balanced diet. Adequate hydration. Regular physical activity. Saying 'No' to tobacco and alcohol. Consistently maintained sleep patterns. Maintaining body weight. Q Do you think Indian society has changed over the last few decades in its views towards both periods and infertility? Standing on the threshold of advancement, modernity and sophistication, it can still be said with a pinch of salt that we still treat periods as a subject to shy away from, as a taboo. Women still hesitate to participate in the day to day activities of life during their menstrual cycles. Moreover, there are dietary restrictions, lack of exercise during periods, inadequate facilities for school going girls, lack of proper sanitation, health and hygiene issues etc, that hinder the overall physical and mental health of youth in India. Q Any other important points that you would like to share with our readers? Dear women, to look and feel best at any age, it is of paramount importance to make smart and healthy choices. Go for a nutritious diet. Exercise daily. Give yourself at least a couple of minutes daily to de-stress. Try yoga, brisk walks, swimming or meditation or anything you are comfortable with, and above all, always remember that you are important. Regular monthly breast self examination. Visit your doctor in case there's anything abnormal related to periods or the like.