–Dr Abayomi Ajayi, Consultant Obstetrician,Gynaecologist and infertility specialist
By Oge Okafor
Dr Abayomi Ajayi, Consultant Obstetrician, Gynaecologist and infertility specialist is the Managing Director of Nordica Fertility Clinic, Lagos.
In this interview, he explains what infertility means, its causes and when to seek treatment. He also talked about the latest technology in assisted conception.
At what point in marriage can a couple be seen as having infertility challenges?
Well, the World Health Organisation (WHO) defines infertility as the inability of a couple to achieve conception after trying for one year but this is also dependent on the age of the woman. If a woman is over 35 years and she is not able to conceive despite regular unprotected intercourse, that is three intercourse exposures per week and without any form of family planning or contraception and she’s tried for six months, then, she should seek medical help. If she is below 35, if she has tried for one year, then she should seek help. Since we are aware that the age of the woman is so important in fertility, that is why there has been a caveat to differentiate between cases, depending on the woman we are talking about and her age. We can’t just have a universal definition and say after one year, because if it is a woman that is over 35, it is better for her to seek medical help after about six months though the standard definition of infertility is inability to achieve conception after one year.
But there are situations where couples who have been married for about eight months worry that they have been unable to achieve conception. What do you make of that?
Like I said, it depends on the age of the woman we are talking about. All these things came from statistics. We know that if there is no problem at all, if 100 couples decide that they want to have babies and they have been trying, after six months, 57 per cent of them would have succeeded; after one year, 75 per cent of them would have succeeded. That is why we say that after one year, if you have not succeeded, then that means something might be wrong. So, it depends on the age of the woman that has been trying for about eight months. If she is more than 35, then she should be worried but if she is below 35, she can decide to try for a few more months.
But there are some people who should not wait at all. For example, if your menstrual cycle is irregular initially, what are you waiting for? You probably are not exposed to the tendency of getting pregnant. If you know that for example you had endometriosis, a diagnosis that have been made before, then you shouldn’t wait; you probably will need help and should start as soon as possible. Also, the couple should seek help if, for example, the husband lost one of his testicles either while he was playing football at school or he has had an injury or surgery. There are obvious things like that and you shouldn’t continue to wait for godot, you should seek help fast. So, there is no-one-case-fits-all for this issue. It depends on whom we are dealing with.
What predisposes people to infertility?
Well, we look at it and say that for infertility, some people have some factors that they are born with and some people have factors that they acquired later on in life. For example, majority of people with low sperm count might be born with it; they might have inherited it. People with polycystic ovaries might have inherited it. People with endometriosis might have inherited it but infection is not something you inherit, it is acquired. We know that infection is also a very common thing in this part of the world especially sexually transmitted infection. This could either be not properly treated or not treated at all, which can block the tube either in the man or the woman and can then lead to infertility. Of course, there are some instances in a man like injuries also. Falling into a manhole or having undergone a surgery hitherto, especially those who came from the village where there is just a dispensary and they needed to have a surgery done like hernia treatment and the doctor doesn’t know anything about it and ties the tubes that transport sperm together with the hernia sac. This is getting rare now but it is possible. There are also men who have had mumps during childhood when they were teenagers, some of them could also suffer not only mumps in their cheeks but it could affect their testes, which might result in infertility.
Is it correct to say that the lifestyle of an individual also predisposes them to infertility?
Yes, it definitely can, but it is more of preventing you from suffering infertility, if you live healthy. If you don’t live healthy, it can also predispose you to infertility. For example, alcoholism, smoking and hard drugs definitely affect fertility as well as not having a good BMI when the man and woman are obese. Then, there are some vocations that can predispose you to infertility, like people who work in fuel stations, people who ride okada, long distance truck drivers or some people who work in some factories like paint factories. There are so many things that can predispose couples to infertility.
Which is more common, male or female infertility?
Both are equally predisposed. It doesn’t depend on gender.
Can we talk more about male and female factors in infertility before the treatment options?
The male factor infertility is when the man is responsible or is contributing to the infertility in the union. The commonest reasons, or, what we see most, is that the sperm count is not very good. The characteristics of the sperm may harm motility. Some of the characteristics are deranged and infection is commonly the cause. And then of course, like I said, trauma or injuries can also cause it. But sometimes also, it could be something that shows you that something is going wrong in the testes that is not healthy. For example, there can be some growth, some of which can be cancerous in the testes and the sperm count is poor. What we say sometimes is it’s when the sperm count is grossly reduced that the doctor should examine the testes. In females, it shows itself mainly in this environment as blocked tubes. Of course, other things like not ovulating regularly is one of them but the commonest in this environment is blocked tubes. Infection and endometriosis are leading causes of blocked tubes. Of course, infection from the appendix can also affect the tubes. So, those are the leading causes of infertility in women.
Now, if you talk about treatment, we may look at four options. They entail from drugs to surgery and then we can look at assisted conception. We can probably add another option where you don’t even do anything; all you just do is advise them. This is often because some couples don’t even understand when they can achieve conception and they have it all twisted, especially people living apart. And so, sometimes, we have cases where the only thing you do is just advise the couple on when to have intercourse and they achieve conception. So, we try to put everything together, all the methods that can help people to achieve conception. We don’t just rush people to go and do IVF. That’s why it is always dependent on the couple especially when you have their test results and there seems to be nothing wrong, then you ask them when they are having intercourse especially these days that couples live apart and you see that they are just doing it all wrong and then a little advice might just help.
Now, the other thing is with drugs. Drugs play very limited role in fertility management. For the woman, yes, when the woman is not ovulating and like I said, in this environment, the commonest reason for female infertility is blocked tubes and drugs have nothing to do with blocked tubes but when the woman is not ovulating regularly, drugs can help when that is the only reason there is infertility. These drugs can either be tablets or injectables depending on what the couple/woman needs at that point in time. But for the man also, drugs also help cure infection but sperm boosters are stupid and you can quote me in capital letters. They are a bloody waste of time because as of this year 2016, there is still no proven sperm booster. So, that is with drugs.
Then, with surgery, only a few patients require it, don’t forget I said that the commonest reason is blocked tubes. So, a few patients might benefit from surgery and especially laparoscopic surgery is available. If just a small thing is holding the tubes together, you can just perform what we call removing the scars. Pregnancy might be achievable with that, but generally, with tubal surgery, pregnancy rates are very bad. It is about five to 10 per cent you get from tubal surgery. But that is because in those days, everybody was having tubal surgery. Now, for you to benefit from tubal surgery, you would have had a laparascopy done and the doctor would have concluded that this person can benefit from tubal surgery and a few people can also benefit from it. The mainstay of fertility treatment especially in any environment where the common factors are bad sperm parameters and blocked tubes is assisted conception and the flagship of assisted conception is IVF. It is just like saying cola, the flagship is coca-cola, that doesn’t mean that is the only one available but the flagship is IVF. There are some spin-offs from IVF like IMSI, ICSI and PICSI as well as so many things that have spun off from IVF. So, it depends on what the couple needs and what facilities are available in the clinic that you have approached. It is like you are buying a car and there are options and you can have all the added options. So, that is why it’s important for patients to choose their clinic carefully and be sure that clinics have all the latest technology for their treatment. We can’t over-emphasise the importance of this because we know that male factor infertility is very common in this environment and we have some of the worst sperm counts and so you need to have the latest technology on sperm issues.
Like I said, IVF is the flagship and that was the first one that was done in 1978 and then we know now that from about 1990, we have been doing what we know as ICSI. IVF normally is a remedy for blocked tubes and peculiar to female infertility. When the sperm count is bad, you need ICSI- Intracytoplasmic Sperm Injection, whereby you pick one sperm and you inject it into one egg. This is like doing surgery on the egg since the egg is microscopic. So, this is very delicate surgery but that is what is done in the laboratory. What we saw with ICSI is that for men who normally are not able to father children, they started fathering children, but we also saw something, that we were using sperms that normally will not fertilize eggs because they are bad to fertilize eggs. So, we were getting more pregnancies but we were losing them in form of miscarriages because like you know, they say garbage-in-garbage-out. Since we were using bad sperms, the embryos were burning out quickly; they were not becoming babies. It was taking us a long time to know that for us to have babies, the sperm needs not only to be healthy, it also has to be genetically good and the embryo has to be genetically okay for us to be able to achieve conception and healthy babies.
So, we were having a lot of miscarriages from ICSI when it first started. But we were also happy that we were able to get men who normally will not be able to father children to father children and probably what we just did was do more and one will stay. But now from about 2004, another method has cropped up which is called IMSI. It is Intractyoplasmic Morphological Selected Sperm Injection. In other words, we use what the sperm looks like. Now, when we were doing ICSI, in order to identify the sperm cells, we magnified them to times 400, but now with IMSI, we magnify them to times 8,000. So, it’s like we see the whole component of the sperm- the head, neck and tail and look at whether there are abnormalities and we were shocked at what we saw when we started doing IMSI; that some of the sperm cells that we were using before actually looked like monsters. When we looked very closely, they had holes in their heads and stuffs like that. So, this reduced the miscarriage/abortion rate but our pregnancy rate wasn’t so much different from ICSI. So, what we were doing with IMSI was looking at what they look like. Morphology! Then, somebody now wondered why is it that nature is the most perfect thing? That in nature, the sperm that fertilizes the egg is usually selected as probably the most competent out of all the sperms the man has deposited in that lot.
So, what does that sperm have that the others don’t have? And so, they were able to identify the protein that the normal sperm should have, which is what binds it to the envelope of the egg. And so, they were now able to know that and put in dishes and you can put your sperm samples in dishes and the sperm that attaches to the protein are the ones that are healthy. So, that is why we call it PICSI- Physiological Intracytoplasmic Sperm Injection. So, in choosing the sperm, our problem is still being able to produce embryos that are genetically normal and being able to transfer them so that we can have normal babies. That is why the world is now doing, in some places, single embryo transfer, because the more you can identify the embryo that is normal, the more you can get the chances of success because we all want to have healthy babies anyway. So, that is what we do now and sometimes also, because you do all these, you still have to resort to what we call Pre-implantation Genetic Diagnosis (PGD) to be able to choose the embryos that are normal but that is at the Ferraris of IVF. Ferraris are not for everybody.
So, we can say that IMSI is a better technology than ICSI?
Well, we can’t just say that, it depends on whether you need it or not. It depends on how bad the sperm count is and the age of the man we are talking about. We also do some tests; we do DNA fragmentation for men because we discovered that some men have normal sperm count as it were but this sperm has been destroyed because what the man contributes when there is fertilization is the DNA and the DNA is contained in the sperm head. Now, if this DNA has been fragmented, you will have fertilization but the embryo is not going to be a healthy embryo and after sometime, you can even achieve pregnancy but the woman would miscarry. So, that is why now we can also determine that and you will see that some men who have very bad sperm count, majority of their sperm have their DNA denatured or fragmented for so many reasons. We have seen that men above 45 have fragmented DNA than younger men; we know that men who smoke have DNA fragmentation. Men who carry their laptops around their waist have fragmented DNA; men who probably play golf for a long period of time and those who are exposed to pesticides have more DNA fragmentation; men who work in oil companies might have more DNA fragmentation. But the good thing about this is that it is reversible and when we just see them, we just tell them especially when we see the cause or we can sometimes give antioxidants to help. So, yes, there are so many good things that can be done in male factor infertility.
So, why is it that there appears to be more cases of infertility now than decades ago?
Well, in Nigeria, it might be difficult to say, because we don’t have very good figures, but worldwide, it appears to be so. So, Nigeria might not be an exception especially with male factor infertility. Male factor infertility appears to be contributing more to infertility all over the world. We also did a study here that showed us that men who came to our clinic 10 years ago compared to the men we are seeing now had better sperm. And we looked at it and saw that actually there was 30 per cent decline in the parameters. So, we inferred that sperm parameters were declining at three per cent every year.
But we need to be able to do larger studies in communities for us to be able to say that with a lot of confidence because we have just looked at people who came to us and not people who are living normally in their communities. That might be a little bit biased. I don’t know whether it is commoner but again, the fact that we are able to treat cases now also makes people come forward and talk more about infertility.
So, how reliable is IVF as an infertility treatment option?
Well, in 2016, it is still the best way to treat infertility. It is the surest way to treat infertility and unfortunately, it is still not 100 per cent potent but there have been a lot of improvement in IVF treatment especially the success rate. From the media and drugs we use to the techniques, our scanners are much better than what they used to be.
So, we know more about so many things now and knowledge base has improved since we started in 1978. So, definitely, it can only get better. We are understanding more about implantation, but it is still a big black box to us but more and more knowledge is coming even from implantation.