Fertility healthcare is an important component for human development. Fertility health is affected by many factors, such as age, lifestyle, underlying medical conditions, genetics among many other things. Having a complete and functioning fertility healthcare is cardinal for both, mental and physical health – and can potentially avert many health complications. ZAGO’s Inside health radio program looked at this important topic with Dr Whyson Munga [Gynaecologist/Obstetrician Consultant and Mrs Masozi Bweupe (Midwives Association of Zambia founding member) and had this to share:

Question: What is fertility healthcare and what is involved in this area of medical practice?

Dr Munga: Fertility issue is a very serious issue that affect a lot of people from all walks of life anywhere in the world. So, when we are talking about fertility and healthcare, we are simply talking about a branch of medicine or a branch of medical practice that looks into people who desire to have a child… the ability to conceive. It’s a wide field because it does not just deal with one person, it deals with both female and male. So, we are talking about this female person being in optimal health with the ability to conceive to become pregnant and carry the pregnancy until to the point of delivery. We are also talking about this man, the ability to impregnate the female person when time is ready to have a child.

Question: In detail, kindly share with us factors that can affect fertility in both male and female?

Dr Munga: I will start with the female. The factors that can affect the female fertility include any issues to do with the uterus or the womb. The womb was naturally made at one stage to carry a baby, and you know, to be in a good situational environment where the baby would grow up to nine months; until it is given out as a birth. So, one of the factors is what we call uterine factor: meaning that its issues to do with the womb. How is this womb? How is the uterus? Is there anything in the womb, for example abnormal growths like fibroids that can interfere with the womb being receptive to pregnancy?

The second factor that can affect fertility in a female is the tubal factor/the fallopian tube factor. The inside of the uterus are two tubes: which at the end have finger-like things, we call the embryo. The role of these tubes is to pick the eggs when the eggs are ovulating or being released. And when the egg is moving in the tube, the sperms are also supposed to be coming in all the way to the tube. So, the actual conception or fertilisation takes place in [the] tube. Which means if there is any problem with the tube, maybe the tubes are blocked or have infection, then you find that fertilisation may not take place.

The third factor is the ovarian function (the ovaries). The ovary is part of the female that contains eggs. These eggs at some stage in the month are supposed to be recruited, prepared for release. Release of the egg is called ovulation. There are factors around these ovaries that may temper with that process of egg release and egg recruitment, the ovulation. Some of the commonest factors could be the hormones which play a specific role in the body. There are hormones that are responsible for fertility; some of these hormones are responsible for recruitments of the follicles of eggs, while some of the hormones are responsible for the actual release of the eggs. Some of the hormones, if they are higher than usual, they may block the whole process of ovulation and release of the eggs, for example, follicle stimulating hormone [this hormone triggers the growth of the egg in the ovaries and get the eggs ready for ovulation]. But if it’s in higher amounts, it can block ovulation. We also have another hormone called prolactin, it’s a milk hormone – a hormone that is responsible for milk production, and when it’s also high, it can block ovulation. There is another hormone, testosterone, the one we know the most for us men.  In female, testosterone is supposed to be in very small levels naturally. If they exceed a certain level, they can also affect fertility. In summary, in female, there is uterine womb factor, the tube factor, and the ovarian factor that can affect fertility.

For the males, the factors that can affect fertility is usually the production of semen. The semen is the fluid that is produced by the prostate grand, and this is the fluid within which the sperms swim. The factors that can affect male fertility will have to do with how this seminal fluid is, as well as the quality of the sperms. [In] some males, you may find that they have a problem with the production of the sperms. No production, zero sperms! For others, there is production, but the sperms are in lower amounts than they should be…where you have low sperm counts. For some, you may find that the sperms have different problems, from the shape of the sperms to the movement of the sperms. Sometimes, sperms maybe produced, but the tubes (sperm ducts) where the sperms flow maybe blocked. So, you may find that someone is producing good sperms but the tubes where the sperms move are blocked. Sometimes the actual seminal fluids may have problems; have an infection or maybe what we call the PH [the measure or acidity or alkalinity]. Instead of having alkaline, maybe the semen is acidic. All those can lead to problems. So, these are the commonest factors for both male and female.

Question: What is infertility?

Mrs Bweupe: Infertility is a state in a couple that has been married and has been having regular sexual intercourse, at least on average 3 sexual intercourse per week plus or minus, and the women has not been taking contraceptives, and this couple has not been diagnosed with any infection that may lead to a woman or a man not getting pregnant – however, pregnancy has not been forthcoming.

Question: What are the common risk factors of infertility?

Mrs Bweupe: The most common risk factors in both women and men are infections, and/or could be conditions which this man or woman may have been born with. With infections, we are talking about pelvic inflammatory diseases. This is a sexual transmitted disease and a number of young men and couples might have suffered to this and may only realise later after they are married and want to conceive. Other infections include peritonitis. For women, this can even spread to the fallopian tubes. When this infection spread to the fallopian tubes, as the peritonitis is healing, she would have undergone surgery, and as the condition is healing, it would affect the healing of the fallopian tubes which were affected. But this in the process, they can heal by attaching to each other, which we call fibrosis.

Once the fallopian tubes are healed by attaching to each other, they will not allow the passage of the egg or passage of the sperms.

The other risk factor may include conditions which this man or woman might have been born with. You know sometimes, this woman while in the mother’s womb, the uterus might not have grown to full-fledged uterus or womb, or the tube did not grow to a normal stage to allow the passage of the eggs and sperm. Those conditions, you cannot see when they are still babies, but can only be discovered at the time when the woman and her partner are trying to get pregnant.

And Dr Munga adds: We group infertility in two types: primary and secondary. Primary are those from the word go, have never managed to conceive, whether a lady or a man. Secondary or sub infertility is where you were able to have babies or able to impregnate a woman, then later things change, and you are no longer able. But in all cases, the factors remain the same because a lady will only be affected with infertility issues if the womb has a problem, the tubes have a problem, and the ovaries are not functioning well. Similarly, even a man, no matter how many children you have had, you can still develop a secondary problem – the factors do not change. It’s either to do with sperms or the semen. Why I have brought out this issue is because in our community out there we are fond of blaming infertility on the female person as though she can conceive on her own, when 30% of fertility challenges can be with the female, another 30% can be with the male; the other 30% can be combined [both male and female]: the male as a problem, and the female as a problem, whether primary or secondary. So, there is nothing like me I have two children. Even you (male) with your five children you can develop secondary problems and fail to conceive. This issue should be handled by couples and not finger pointing each other. When a couple fails to conceive, we treat it as a couple problem, not a female problem or male problem.

In addition, unsafe abortion is another risk factor. If an abortion is conducted in an unsafe manner/environment, or it was acquired from a ‘mbuya’ [grandmother], etc., the woman will be exposed to infections. These are some of the cases we encounter that they are unable to conceive.

Question: Can age affect fertility?

Dr Munga: Fertility in women is limited by age. The woman is fertile from the time she starts ovulating up to the time she reaches menopause. But before she reaches menopause, she may be having her menstruation, yet she stopped a long time ago producing eggs. On average, the best time to have children is between age 18 and age 35. After 35, she is still fertile, but the fertility will start going low. Worse after the age of 40. So, for our female folks, natural fertility will cease between the age of 43 and 45. Very few women, actually one in a thousand will conceive after the age of 45. Women must know that fertility is time bound as opposed to a male. Of course, for male, the quality of sperms will change with age but for our women it’s so definitive. After a certain age, you can no longer have a child naturally because by normal functioning, the ovaries will stop producing or releasing the eggs. The reserves will be depleted of eggs.

When you are born as a female child, you are born with a fix number of follicles. These are small growth like where the eggs lives inside. Since you are born with a fix number of follicles, the eggs too are fixed. Now, when you reach puberty, a certain number of follicles will be recruited, and a certain number of eggs will be lost during menstruation. And since no new follicles can be formed after you are born, every month of menstruation, the reserves are going lower and lower. By the time you reach 45, 46 years, even if you continue having your menstruation, all the follicles and the eggs from you reserves are depleted.

And Mrs Bweupe chips in a man can be infertile yet he is very strong and agile when it comes to bedroom issues, and unable to produce the real seed that is required. We talk of the shape of the sperm which cannot fertilise an egg. There also who are unable to produce any sperm and only produce semen, but able to perform very strongly. And here is a man who is unable to sustain an erection to satisfy a woman, but he will be health and able to have children because the moment he releases into the woman, fertilisation takes place.

Question: When is the right time for treatment and what are the treatment options for infertility?

Dr Munga: You don’t treat that which we don’t know. So, this couple has to come to the health facility, and we do an investigation. In the investigation, we do a scan to see if the womb and the uterus is okay. We also do a special X-ray to check if the fallopian tubes are blocked or not. We will also do a full hormonal fertility to see if the ovaries are functioning well in terms of the eggs and the ovulation.

For the male, we are going to do a full seminal analysis to see if the semen is okay, and if the sperms are okay. In the semen, we check the appearance of the semen, the volume of the semen, we look at the sperm count; we look at the sperm shape; the sperm movements; any infection and so on. And when we know the problem, we treat an identified problem. It should be evidence-based, no guess work.

The question of the right time to seek medical care for infertility: people are supposed to come for fertility screening even before conceiving – what we call pre-conception. There is pre-conception and screening. But the correct time is pre-conception. In any case, if you are a couple and have been having uninterrupted sex for one year, come to the health facility as a couple to seek help. Don’t wait for ten years. Remember, the woman is time bound in terms of fertility.

Question: What is IVF, what is it?

Dr Munga: We harvest the eggs from the woman, then get sperms and inject the sperms into the eggs in the lab. And at a certain level, we take the fertilised egg into the womb. It’s a process that involved artificial fertilisation outside the body. The beauty with IVF is that it has got no age. Even if you are 60 years can use donated eggs, others reserve or freeze the eggs and can use them anytime. The actual fertilisation is 100% but whether it succeed after putting it inside the body is between 35 to 60%

Question: How does hepatitis cause infertility?

Dr Munga: Hepatitis disease is infectious, it’s a virus but it can also be by sweat or sexually transmitted. Luckily, it’s not very active; it’s usually in a dormant form. The immune system contains it in a dormant form. But once you have, it doesn’t change. The status remain positive. Can hepatise cause infertility? It would be farfetched it’s not one of the causes of infertility.

Question: What prevents a woman from ovulating properly and can this cause infertility?

Mrs Bweupe: When a woman is not ovulating, definitely cannot conceive. There are so many causes: one of them is the inability to ovulate naturally, reasons being that’s how their hormonal make up is. There are also women with irregular ovulation or periods like polycystic ovarian syndrome (PCOS) – women that ovulate at any time. The other reason is women who are on contraceptives. There are some contraceptives that when you take, they actually prevent a woman from ovulating. So, if a woman is taking this contraceptive, she will not ovulate. Also, pregnant women will definitely not ovulate and also those who constantly breastfeeding.