Category: For Her

Knowing the possible causes of infertility would help you gain a better understanding of fertility treatments, which in turn would give you a boost of confidence to keep on trying even when you encounter some stumbling blocks along the way. So, let’s take a look at some of these causes.

It’s not always better late than never

Dr Wong Pak Seng points out that people today are having children at a later age, for reasons such as focusing on their careers or wishing to achieve financial stability first. However, the fertility of a woman decreases with age.

Source: Management of the Infertile Woman by Helen A Carcio and The Fertility Sourcebook by M Sara Rosenthal

As can be seen from the chart, a woman’s chances of becoming pregnant begin to decrease sharply after she turns 40.

This decrease in fertility could be due to the fact that the number of good quality eggs produced by the ovaries naturally declines with age.

“At birth, the ovaries contain about 1 million eggs. This number falls to about 400,000 during puberty, and keeps falling with age,” explains Dr Wong. “This is why a 40-year old woman may find it harder to conceive compared to a 30-year old woman.”

This is not to say that a woman over 40 will certainly have difficulties in getting pregnant, of course. A successful pregnancy is not merely biology in motion – a little luck may be involved too, sometimes. But in principle, with declining fertility, there is a higher chance that a woman over 40 may take longer or require fertility treatment to become pregnant. Dr Wong notes that a significant number of his patients are older women.

Having said that, younger women – and their husbands – may also require fertility treatment, as problems in conceiving are not solely due to age and decreased fertility. 

A problem with biology

Problems in the reproductive system could be the reason behind a couple’s inability to conceive. But before we go into these reasons, let’s rediscover how the reproductive system works.

To understand the process behind the creation of new life, let’s take a look at the ovaries first. In the woman’s ovaries, there are a large number of eggs, but only one will win the biological lottery and matures into an ovum. The ovum is released by the ovary around the 9th day of the menstrual cycle into the tunnel-like structure called the fallopian tube, which connects the ovary to the uterus.

If sexual intercourse were to take place around this period, about anything from 40 to 60 million sperm would be ejaculated into the womb, during which most would die immediately. Those that survive swim in the fluids of the uterus, looking for the elusive ovum. The one sperm that reaches the ovum would fuse with it in a process called fertilisation, contributing its genetic material and triggering subsequent development of the fertilised egg.

The fertilised egg continues to travel to the uterus until it implants itself into the thickened wall of the endometrium (the inner wall of the uterus). This occurs within 6 days after fertilisation. Through a series of interactions with hormones, the endometrium has undergone thickening and structural changes to accommodate the implantation. Once the fertilised egg is well-implanted, it continues to develop into a foetus and, eventually, a fully formed baby is ready to enter this world. 

With the exception of fertilisation, the entire process from the development of eggs to the implantation is tightly controlled by the hormones. If you consider the body a well-oiled factory, there are various body parts that monitor the progress and, when action is needed to start, accelerate, slow or stop a process, these body parts will release hormones which act as “workers” to effect the required changes. Here are just some of the many “workers” involved in the reproductive process.

Hormones do not act alone; they often interact with other hormones, either to support or counter the effect of those other hormones. For example:

• High levels of GnRH triggers increased release of LH.
• After LH level reaches a certain amount, the ovaries respond by releasing a mature egg into the fallopian tube.
• The follicle from which the mature egg came reacts to the elevated of LH by producing and releasing progesterone.
• Progesterone causes the endometrium to prepare for implantation and stops production of any subsequent mature eggs.
• If a pregnancy does not occur, high levels of progesterone trigger a decrease in the amount of GnRH released. Decreasing GnRH levels in turn triggers a decrease in LH level, and this in turn inhibits further progesterone secretion.
• The above does not happen when pregnancy occurs. Instead, progesterone level remains high to ensure that pregnancy is maintained during the delivery date.

As you can see, a successful pregnancy is not solely about ensuring a successful fertilisation of an ovum by a sperm. Thus, any breakdown in this complex process can prevent a successful pregnancy. Perhaps there are not enough hormones to trigger production of enough sperm, eggs, or both. Perhaps implantation cannot take place because of the lack of relevant hormones or there are physical abnormalities that prevent the process from taking place.

Diseases and health conditions that affect the womb may also cause damage that interfere or disrupt a successful pregnancy.

As an example, Dr Wong brings up endometriosis. This is a condition in which tissues from the endometrium end up growing in places such as the fallopian tubes and the ovaries. This long-term condition can cause scars, lesions and even cysts to develop in those places, all of which can affect one’s ability to conceive.  

“There are many possible reasons, which could only be determined after a thorough medical examination at the fertility centre,” says Dr Wong.

How is your life?

Lifestyle choices can affect fertility. Smoking is an example of a habit that could reduce fertility, according to Dr Wong. This is because the chemicals present in tobacco can damage sperm cells. As the effect can occur even when the man only inhales cigarette fumes, many fertility specialists encourage a couple to stop the habit, even if it is the wife, not the husband, who is the smoker.

What you consume and how much exercise you do each day can affect your fertility as well, since they affect your body weight. Overweight and obese people tend to have increased risk of diabetes and other health conditions that can affect fertility. Dr Wong also points out that the use of recreational drugs and excessive alcohol drinking can negatively affect fertility and these habits should be avoided.

Dr Wong adds that should one or both partners have had multiple sexual partners in the past, any sexually transmitted infections (STIs) they contracted can also affect their fertility. For instance, certain STIs such as chlamydia infection can cause pelvic inflammatory disease (PID) in the woman. If left untreated, PID can lead to formation of scar tissue or blockage of the fallopian tubes and subsequent infertility.

Therefore, when the fertility specialist team makes enquiries on your lifestyle and sexual history, it is best to answer honestly, as the more they know about the possible causes of your infertility, the easier it would be for them to devise a suitable treatment programme to help you conceive. They will not judge or reveal your potentially embarrassing answers to anyone – privacy is very important in the relationship between a doctor and his or her patients!

Other forms of health problems

Aside from STIs, there are other types of infections that may affect fertility too. Dr Wong mentions mumps as an example – men who had mumps when they were younger can have lower fertility rate because the virus can cause the testicles to become inflamed (a condition called orchitis) and sperm production to stop.

There are various health conditions that can also negatively affect fertility. A woman with polycystic ovarian syndrome (PCOS), for instance, often has difficulties getting pregnant because her hormonal system is out of balance. She may have too much male sex hormone, for example, and this would hamper egg production in her ovaries.

A complete mystery

Dr Wong points out that it is possible that a fertility specialist team may not be able to discover the exact reasons why a couple is infertile even after thorough testing and examination. It is estimated that 20% of couples undergoing fertility fall under this category.

This is because, as you have seen, the reproductive system is controlled by a very complex series of interactions with hormones and other substances (including those in our food, drinks and the environment), and we are still discovering new things to this day. Therefore, it is possible that a couple’s infertility is caused by something that we have yet to identify.

Fortunately, treatment can still proceed even if the exact cause is unknown. The fertility specialist can fall back on his or her knowledge and experience to devise the most appropriate treatment.

Now, let’s take a look at making that first step to having a baby despite the odds: booking that appointment with a fertility specialist.

References:

Collins J A. (2004). Evidence-based infertility: evaluation of the female partner. International Congress Series; 1266:57-62. Retrieved at 8 April, 2015, from http://www.researchgate.net/publication/248213025_Evidence-based_infertility_evaluation_of_the_female_partner.

Patient.co.uk. The Female Reproductive System. Retrieved at 8 April, 2015, from http://www.patient.co.uk/health/the-female-reproductive-system.

WebMD. Your Guide to the Female Reproductive System. Retrieved at 8 April, 2015, from http://www.webmd.com/sex-relationships/guide/your-guide-female-reproducti

[1] Patient.co.uk. The Female Reproductive System. Retrieved at 8 April, 2015, from http://www.patient.co.uk/health/the-female-reproductive-system.

[2] WebMD. Your Guide to the Female Reproductive System. Retrieved at 8 April, 2015, from http://www.webmd.com/sex-relationships/guide/your-guide-female-reproductive-system

[3] Patient.co.uk. The Female Reproductive System. Retrieved at 8 April, 2015, from http://www.patient.co.uk/health/the-female-reproductive-system.

[4] Collins J A. (2004). Evidence-based infertility: evaluation of the female partner. International Congress Series; 1266:57-62. Available at http://www.researchgate.net/publication/248213025_Evidence-based_infertility_evaluation_of_the_female_partner; accessed 8 April 2015.

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Things were going well for young mother Alana. With a doting husband, an adorable two-year-old son and a baby on the way, she couldn’t be any happier. But unbeknownst to her, a storm was brewing on the horizon.

Recalling the day when her life took a 180° turn, she says, “I was in midst of reading a story to my son when I noticed a lump in my breast. I hoped that it was one of those things which normally occur during pregnancy but I had a bad feeling about it.” Acting on her gut instinct, she decided to get herself checked.

“Initially, the doctor didn’t think it could be serious but he suggested that I undergo an ultrasound scan, followed by a biopsy just to be sure.” Nothing could prepare her for the results that came back: she was diagnosed with stage 3 breast cancer. “I was stunned. It seemed so impossible. I was too young to have cancer,” she says. After the initial shock, came panic. What was going to happen to her unborn child? “I was terrified. I kept wondering if I would be able to keep my baby.”

Pregnant with cancer

Someone once said, “Pregnancy and motherhood are the most beautiful and significantly life-altering events that I’ve ever experienced.” And it really should be for mothers everywhere. But while pregnancy is a joyous occasion for many, it can be a difficult journey for those who have been diagnosed with cancer. To find out about this predicament and what it entails for both mother and child, we speak to an expert on the matter: Consultant oncologist Dr Mastura Md Yusof.

When asked how common this predicament is in Malaysia, Dr Mastura says, “We don’t have specific statistics but I would say that cancer during pregnancy is something that may be on the rise. An increasing number of women are postponing childbearing to a later age; more women have picked up smoking; obesity is a growing problem among women – all these factors can play a role.”

In Alana’s case, it was a lump in her breast that set off alarm bells. What other symptoms should pregnant women look out for? “The symptoms depend on the type of cancer and its stage of presentation,” she replies. Will these tell-tale signs differ between someone who is expecting and someone who isn’t? “No, the symptoms are often similar. In the case of breast cancer, women will typically have a breast lump or nipple discharge whereas for those with cervical cancer, they are likely to experience abnormal per vaginal bleeding. Always remember, if in doubt, see your doctor. Don’t wait,” she emphasizes.

‘Will my baby be safe?’

As with other chronic diseases, diagnostic tests are necessary to confirm if patients do indeed have cancer – pregnant women included. “It’s popular belief that diagnostic tests will harm the pregnancy but it’s actually not true. Biopsy is a simple procedure which entails taking an extremely tiny amount of tissue from the tumour area. This is so we can examine the tissue under the microscope for any presence of cancer. It doesn’t involve radiation of any kind so it won’t harm the foetus. It’s also safe for expecting mothers to undergo biopsies under anaesthesia,” Dr Mastura assures.

Listing down other forms of diagnostic methods, she says, “Other tests that are considered safe include ultrasound, magnetic resonance imaging (MRI), blood tests and lumbar puncture.” What about things like chest x-rays and mammograms? “They can be safe as long as an abdominal shield is utilized to protect the foetus from exposure to radiation,” she clarifies.

Diagnostic tests may be safe for pregnancies but now it begets the question: can pregnancies compromise the diagnosis process? “In breast cancer, pregnancy does cause the breasts to enlarge. Therefore, it may be difficult to feel for the lump upon examination – both by the patient and the doctor. But other than that, pregnancy generally won’t affect the process.”

‘What are my options?’

Like many things in life, there is no one-size-fits-all strategy when it comes to cancer treatment. “The treatment options that are available to a patient depend on various factors,” Dr Mastura explains. These factors include:

Patient history

“Firstly, it depends on the patient herself. Does she have any pre-existing medical conditions? How is her physical fitness and organ function? Is this pregnancy her first? Does she have any other kids? How far along is she?”

Type of cancer

“Another factor we take into consideration is the type and stage of cancer she has. Once those details have been confirmed, we can look into the treatment (eg, surgery, chemotherapy, etc) that is indicated for her exact condition. Surgery can be performed at any time during the pregnancy while most chemotherapy drugs can be administered during the 2nd and 3rd trimesters. Patients who undergo chemotherapy aren’t allowed to breastfeed. Instead, they will be given medications to halt breast milk production. Radiotherapy, on the other hand is not given during pregnancy.”

‘Can I keep my baby?’

The few first questions to cross every patient’s mind are likely to be ‘Can I keep my child? Can I undergo treatment while pregnant? Will treatment jeopardize my pregnancy? Must I abort my baby?’ However, Dr Mastura has encouraging words to offer.

“Abortion is only considered if the patient’s cancer is advanced, treatment has to be given acutely or she is still in her 1st trimester whereby treatment like chemotherapy will put the baby at risk,” she says.

“Battling cancer whilst pregnant can be terrifying but it’s not a dead end. It is a treatable condition. If a patient is managed in a multidisciplinary setting by a team of specialists (eg, oncologists, surgeons, radiologists, pathologists, anaesthetists, neonatologists, etc) all the way, the outlook is usually good. Additionally, an obstetrician will regularly review her at the antenatal clinic every two weeks or so until delivery to ensure the foetal progress is good. We’ve had many women opting to continue with their pregnancies – and they have gone on to give birth to healthy babies. In fact, some actively share their experiences with the hopes of allaying the fears that new patients have. So, don’t lose hope!”

Is it preventable?

When asked if early screening can help lower the risk of cancer during pregnancy, Dr Mastura says, “As of now, there’s no evidence that screening before conception can either reduce that risk or improve a cancer patient’s survival. What women should actually do is firstly check their family’s medical history for any types of cancer. Then of course, they must live healthily – meaning no smoking, no alcohol, be physically active, eat a well-balanced diet, have a healthy weight, etc. Having kids before turning 30 plays a significant role too.”

Reference:

Health at Iowa. Available at www.medcom.uiowa.edu

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