Medical Associates Hospital.
Infertility is a global health issue affecting millions of people of reproductive age worldwide. Available data suggests that between 48 million couples and 186 million individuals have infertility globally – World Health Organization
Infertility presents a myriad of challenges. Let’s start with reviewing some common case scenarios: The names are not real, but the patients and their issues are.
Case scenario No.1
Sonia and Rishi were becoming increasingly concerned and she even said ‘desperate’ because their wish for a family was beginning to seem like an impossible dream. She’s 34 and he’s 40 they had been together for four years. For the first year they used contraception (the ‘Pill” and then condoms but it’s been 3 years with no protection.)
Pressure from family and friends has been relentless (‘what are you waiting on’?) so much so that they almost appreciated the Covid lockdowns which allowed them to avoid social interactions.
A friend who had fertility issues and subsequently became pregnant and had a baby, correctly told them that couples trying unsuccessfully for one year were usually diagnosed with infertility and that they should seek professional help.
Sonia’s medical and gynaecological history:
Sonia has always been a bit overweight, and she has experienced delayed periods and sometimes skipped months (the longest being 3 months) and this occurred 1-2 times per year. She has no excessive facial or other hair growth but occasionally, she resorts to a tweezer for hairs on her upper lip and chin. It seems to affect all the women in her family.
I begin to think of Polycystic Ovaries and request blood hormone tests and an ultrasound test of the ovaries. The latter showed a normal uterus and enlarged ovaries, each containing multiple small circular cysts (more than 12 on each side), arranged around the border (‘string of pearls’ pattern).
Rishi is in good health, is a non-smoker and seldom uses alcohol. He has no significant medical or surgical history.
Semen analysis for sperm count and other characteristics, is normal.
Case Scenario No. 2
My menstrual periods are ‘living hell’!
Jasmine is 28 years old and has never been pregnant and she actually believes that it will never happen because her periods are so painful, with these experiences starting since high school. In fact, she often missed school and now has to miss work for at least 2 days per month. Luckily, she works in her family business so she has easy access to time-off. She has a steady boyfriend and they are hoping to marry soon, but she really wants to know if she can become pregnant.
Diagnostic possibilities are endometriosis, uterine fibroids and polyps and chronic pelvic infection.
Likely management will include: General and pelvic examination, Pap Smear, pelvic ultrasound.
Ultrasound is essential as it will often diagnose cysts on the ovaries, fibroids and raise a flag for potential adhesions in the pelvis.
An X-Ray of the uterus and tubes will help to diagnose polyps in the cavity of the uterus as well as potential blockage of the Fallopian tubes. This procedure is called a Hystero-Salpingo-Gram (HSG).
Another method involves the use of ultrasound while inserting a saline solution into the uterus (Saline Infusion Scan – SIS).
Semen / Sperm Analysis is also required since infertility related to the male is known to occur in over 45% of men in Trinidad and Tobago.
Case scenario No. 3
An unexpected result.
Juanita and Carlos
Juanita is 38 years old and has had 2 children in a previous marriage. She has been married to Carlos for the past 2 years and have no children despite never having used contraception. She has a regular menstrual cycle and has had no illnesses. At a recent routine gynecology check up she was assured that she had no pathology such as fibroids or ovarian cysts and the Pap Smear was negative.
Carlos is also 38 years old and has not fathered any children despite being in two previous ‘long-term’ relationships. He is not overweight, has no past medical or surgical history. He is a moderate smoker. He’s never had his sperm tested but has used hormonal and nutritional supplements in the past.
Juanita: At 38 years old, her chances of pregnancy are getting slim, mainly because of a lowered egg reserve. Additionally, egg quality may be compromised so that the chances of non-fertilised eggs or of fetal anomaly such as Down syndrome are increasing.
A good blood test to assess a woman’s egg reserve is the Anti-Mullerian Hormone (AMH) test. Additionally, other tests we perform are the FSH, LH, Prolactin and Thyroid Function Tests.
Carlos: In view of his story, a sperm analysis was the first requested test.
Comparing his results with the recommended values defined by the WHO, it was noted that his sperm concentration (Count) was low (3 million/mL, and that evidence of progressive motility (swimming) was also diminished at 25%. The % of ideally shaped sperm was also lower than expected.
As a result, the primary concern here is the male factor.
The inability of a couple to achieve pregnancy after 1 year of regular unprotected sexual intercourse is termed infertility and this should lead to investigation.
What can cause Infertility?
Generally, the causes are divided into 3-4 groups:
1) Related to lack of egg production and release (Lack of ovulation)
2) Lack of sperm in adequate numbers which show forward movement and are properly shaped
3) Blockage or inadequate function of the Fallopian tubes
4) Pelvic abnormalities such as uterine fibroids, ovarian cysts and endometriosis
Sperm issues account for at least 40% of cases while female causes account for 40% with the rest being combined.
Lack of egg production is often a factor of advancing age. The female is known to be born with a quantity of eggs which are utilized but not replenished. A large number of eggs also undergo a natural process of death and elimination during each year of life. During the reproductive years, eggs continue to be released and continue to die, so that after the age of around 34 years, their availability and quality diminish and fertility rates fall.
Polycystic ovaries occur in an environment of insulin resistance. With carbohydrate intake, the normal response of the body is to release insulin which effectively utilises these carbs in the tissues. In some women, the tissues exhibit insulin resistance so that carbohydrate utilization is prevented – this causes further insulin production over long periods of time. In this environment of abnormal insulin activity, polycystic ovaries develop and the ovary cannot release its eggs.
Endometriosis is a condition where bits of the lining of the uterus (called the endometrium) find themselves attached to structures in the pelvis (the ovaries, pelvic lining, intestines, bladder etc). These deposits bleed within the pelvis during menstrual activity and cause severe pelvic pain as well as scarring within the pelvis. Endometriosis is a cause of severe menstrual pain, heavy menstrual bleeding and infertility. Diagnosis is made from the symptoms above, from pelvic examination, pelvic ultrasound and MRI. Sometimes, a surgical procedure is recommended often using a keyhole telescopic approach (called laparoscopy). This is a minimally invasive means of confirming the diagnosing the extent of the disease and also performing surgical excision.
Uterine fibroids a re growths developing from the muscular layer of the uterus. Depending upon their location, they may cause no symptoms but the commonest symptoms are painful and heavy periods which can be sufficient to cause anaemia. Infertility is also seen with fibroids.
Scarring and blockage of the Fallopian tubes may occur because of pelvic infections, particularly related to chlamydia, gonorrhoea and other pelvic bacteria.
What Treatment Options are available?
Lack of ovulation can be treated by using tablets or hormonal injections and their effect can be monitored using ultrasound evaluation.
Apart from very few instances, low sperm count and other abnormal sperm characteristics seldom respond to medicines, and certainly will not show improvement with the use of testosterone and other similar supplements.
Treatment by Intrauterine Insemination (IUI) or In vitro Fertilization (IVF) may be required.
At Medical Associates Hospital, we were fortunate to achieve the first successful IVF pregnancy in the Caribbean in 1996. The procedure involves the following steps:
1) stimulation of egg production by using ovary stimulating medicines, usually daily for 10-14 days, and collection of these eggs by inserting a device via the vagina under sedation
2) mixing the eggs and sperm in an incubator (sometimes a sperm can be injected into each egg)
3) assessing fertilization and embryo formation over a few days
4) transfer of a suitable embryo(s) into the uterus
Success rates are dependent upon the cause of infertility as well as the age of the woman. Younger women have higher rates of success while those over 36 years old have lower rates.
Professor Samuel Ramsewak
Professor Samuel Ramsewak is a Fellow of the Royal College of Obstetricians and Gynaecologists (FRCOG), Fellow of the American College of Obstetricians and Gynecologists (FACOG), Fellow of the Royal College of Physicians and Surgeons (Glasgow), Fellow of the American Society for Reproductive Medicine (ASRM) and Member of the European Society for Reproductive Medicine (ESHRE).
Professor Ramsewak has authored 60 scientific publications, primarily in obstetrics, gynaecology and infertility. He was appointed Professor at the UWI in 2001. He is recognized as the pioneer of advanced reproductive medicine in the Caribbean and was responsible for the starting its first In Vitro Fertilization (IVF) Clinic and for his team’s achievement of the first successful pregnancy in this Region.
Amongst his awards are the Chaconia Medal of Trinidad and Tobago, a National Honor, for contributions to Medicine in his country, the Commonwealth Research Fellowship (1989), Rhodes Trust Scholarship (1994), American College of Obstetricians and Gynecologists award for Distinguished Service (2001), the Annual Research Award of the Trinidad and Tobago Medical Association and its Scroll of Honour.