How do you know if you are infertile? The medical textbook definition of infertility is the inability to conceive even after trying for a year.

Are you infertile ?

So, when are you planning to have a baby ? This is the commonest question most newly married couples in India are asked - sometimes even as soon as they have returned from the honeymoon ! There is a lot of pressure on couples to have a baby, especially in traditional families, where the wife's role is still seen to be one of perpetuating the family name by producing heirs.

Many couples still naively expect they will get pregnant the very first month they try ( the result of watching too many Hindi films , perhaps !) - and are concerned when a pregnancy does not occur. All of us go through a brief interlude of doubt and concern when we do not achieve pregnancy the very first month we try and we start wondering about our fertility.

Before worrying, remember that in a single menstrual cycle, the chance of a perfectly normal couple achieving a successful pregnancy is only about 25%, even if they have sex every single day . This is called their fecundity which describes their fertility potential . Humans are not very efficient at producing babies ! There are many reasons for this, including the fact that some eggs don't fertilize and some of the fertilized eggs don't grow well in the early developmental stage. Getting pregnant is a game of odds - it's a bit like playing Russian Roulette and it's impossible to predict when an individual couple will get pregnant ! However, over a period of a year , the chance of a successful pregnancy is between 80% and 90%; so that 7 out of 8 couples will be pregnant within a year. These are the normal fertile couples - and the rest are labelled infertile - the medical textbook definition of infertility being the inability to conceive even after trying for a year. Couples who have never had a child are said to have primary infertility ; those who have become pregnant at least once but are unable to conceive again are said to have secondary infertility.

The chances of a couple getting pregnant in a given month will depend upon many things, and the most important of these are: o The age of the woman. As the biologic clock ticks on, the number of eggs and their quality start decreasing o Frequency of intercourse. While there is no normal frequency for sex, the optimal frequency of intercourse if you are trying to get pregnant is about 3 times a week in the fertile period. Simply stated, the more sex the better ! Couples who have intercourse less frequently have a diminished chance of conceiving. o Trying time - that is, how long the couple have been trying to get pregnant. This is an important concept. The longer a couple has been trying to conceive without success, the lesser their chances of getting pregnant without medical help. o The presence of fertility problems.

What happens when a couple has a fertility problem? The chance of their getting pregnant depends upon a number of variables multipled together. Consider a couple where both the husband and wife have a condition that impairs their fertility. For example, the husband's fertility, based on a reduced sperm count is 50 percent of normal. His wife ovulates only in 50 percent of cycles; and one of her fallopian tubes is blocked. With three relative infertility factors, their chance of conception is 0.5 (sperm count) X 0.5 (ovulation factor) less X 0.5 (tubal factor) = 0.125% or 12.5% of normal. Since the chance of conception in normal fertile couples is only 25% in any one cycle, the probability of pregnancy in any given month in the case of this couple without treatment is only 3% (0.125 X 25 = 0.03125)! Even if they kept on trying for 5 years, their chance of conceiving on their own would be 60% only. Thus, infertility problems multiply together and magnify the odds against a couple achieving a pregnancy. This is why it is important to correct or improve each partner's contributing infertility factors as much as possible in order to maximise the chances of conception. If infertile couples had 300 years in which to breed, most wives would get pregnant without any treatment at all ! Of course, time is at a premium, so the odds need to be improved - and this is where medical treatment comes in. When should you start worrying and seek medical advise? If you have been having sexual intercourse two or three times a week at about the time of ovulation, without any form of birth control for a year or more and are not pregnant, you meet the definition of being infertile. Pregnancy may still occur spontaneously, but from a statistical point of view, the chances are decreasing and you may now want to start thinking about seeking medical help. There is no right time to do so - and if it is causing you anxiety and worry, then you should consult a doctor. Even though you may be embarrassed and feel that you are the only ones in the world with the problem, you are not alone. Many couples experience infertility and many can be helped.

Unfortunately, while infertility is always an important problem, it is usually never an urgent one. This often means that couples keep on putting off going to the doctor - we'll take care of it next month . Tragically, many find that time flies, and before they realize it, their chances of getting pregnant have started to decline, even before they have had a chance to take treatment properly. Remember that everything in life comes back - except for time !

A note of caution..... There are certain conditions that warrant seeing a doctor sooner: * Periods at three-week (or less) intervals. * No period for longer than three months. * Irregular periods * A history of pelvic infection. * Two or more miscarriages. * Women over the age of 35 - time is now at a premium ! * Men who have had prostate infections. * Men whose testes are not felt in the scrotum

Tips for Self-help :

Before seeking medical help, remember some of the things you can do to enhance your own fertility potential. Body weight, diet and exercise. Proper diet and exercise are important for optimal reproductive function and women who are significantly overweight or underweight can have difficulty getting pregnant. Although most of a woman's estrogen is manufactured in her ovaries, 30% is produced in fat cells. Because a normal hormonal balance is essential for the process of conception, it is not surprising that extreme weight levels, either high or low, can contribute to infertility. Body fat levels that are 10% to 15% above normal can contribute to infertility, with an overload of estrogen throwing off the reproductive cycle. Body fat levels 10% to 15% below normal can completely shut down the reproductive process, so that women with eating disorders, such as anorexia nervosa or bulimia, or those who are on very low-calorie or restrictive diets are at risk, especially if their periods are irregular. Female athletes, marathon runners, dancers, and others who exercise very intensely may also find that their menstrual cycle is abnormal and their fertility is impaired. Stop smoking. Cigarette smoking has been associated with a decreased sperm count in men. Women who smoke also take longer to conceive. Stop drinking alcohol. Alcohol (beer and wine as well as hard liquor) intake in men has been associated with low sperm counts. Review your medications. A number of medications, including some of those used to treat ulcer problems and high blood pressure, can influence a man's sperm count. If you are taking any medications, talk with your doctor about whether or not it can affect your fertility. Many medications taken during early pregnancy can affect the fetus. It is important to tell your doctor or pharmacist that you are attempting to become pregnant before taking prescription medications or over the counter medications, such as aspirin, antihistamines, or diet pills. Stop abusing drugs. Drugs such as marijuana and anabolic steroids decrease sperm counts. If you have used drugs, discuss this with your doctor. Both partners should stop using any illicit drugs if they want a healthy baby. Limit your caffeine (tea, soft drinks and coffee) intake. Frequency of intercourse. The simple rule is - as often as you like; but the more often you have sex, the better your chances. Thus, for couples who have sex only on weekends (often the price they pay for a heavy work schedule) the chance of having sex on the fertile preovulatory day is only one-third that of couples who have sex every other day - which means they may take three times as long to conceive. Many couples complain that they are too stressed out to have frequent sex. Here are some simple measures you can take to increase sexual frequency. 1. Use sexual toys like vibrators or body massagers, to make sex more fun 2. Using a lubricant like liquid paraffin can help to make sex more exciting 3. Playing sex games can help - try taking turns seducing each other ! 4. I tell all my patients - it's much more fun making a baby in your bedroom than coming to me ! (And think of all the money you'll be saving - it's like being paid to make love to your wife !) 5. Viagra can also be helpful for some couples.

Timing of intercourse. Unlike animals, who know when to have sex in order to conceive (because the female is in heat or estrus when she ovulates), most couples have no idea when the woman ovulates. The window of opportunity during which a woman can get pregnant every month is called her fertile phase - and is about 4-5 days before ovulation occurs. Timing intercourse during the fertile period ( before ovulation) is important and can be easily learnt . However, some couples are so anxious about having sex at exactly the right time that they may abstain for a whole week prior to the ovulatory day and often the doctor is the culprit in this overrigorous scheduling of sex. This overattention can be counterproductive (because of the anxiety and stress it generates) and is not advisable. As long as the sperm are going in the vagina, it makes no difference which day they go in , so you can have sex daily as well, if you so desire!

Position and technique of intercourse. Pigs are very efficient at conserving semen - the boar literally screws his penis into the vagina of the sow, obtaining a tight lock prior to ejaculation, to ensure that no semen leaks out. Humans do not have such well-designed mechanisms and perhaps this is because they are really not necessary. Leakage of semen after intercourse is completely normal. While many women worry that this means that they are not having sex properly or that their body is rejecting the sperm, actually leakage is a good sign it means that the semen is being correctly deposited in the vagina ! Of course, you can only see what leaks out and not what goes in ! Most doctors advise a male superior position; and also advise that the woman remain lying down for at least 5 minutes after sex; and not wash or douche afterwards. A number of products used for lubrication during intercourse, such as petroleum jelly or vaginal cream, have been shown to affect sperm quality. Therefore, these products should be avoided if you are trying to get pregnant (a suitable alternative is liquid paraffin).

Balancing a career and fertility :

Women pursuing a career often have a hard time balancing their biological urge to have a baby and the demands of their professional career. Unfortunately, Indian companies still do not give a high priority to family building, and many bosses frown on women employees who are trying to get pregnant, because they are concerned that this will cause them to spend more energy on their family, and detract from their ability to perform their job efficiently. For a minority, putting off getting pregnant means that their fertility declines as they age, and they often regret their earlier decision to postpone childbearing. Professionals often have a harder time coming to terms with their infertility, because this is usually the first time they are forced to confront their own biological frailty and limitations.

Which is the right time to plan a baby ?

While there can be no simple answer to this question, remember that a woman's fertility is maximal between the ages of 20 and 30. Beyond the age of 30, fertility starts to decline; and this drop is quite sharp after the age of 35; and precipitate after the age of 38. From a purely biological point of view, nature has designed women's bodies so that they have babies between the ages of 20 and 35. However, the right time to have a baby is a very personal and individual decision, which each couple needs to make for themselves. Public anxiety over infertility is fueled by countless magazine articles warning couples not to wait too long to start a family. As a result we now see many patients who are pre-infertile who assume they'll have trouble conceiving even before difficulties actually arise just because they are more than 30 years old !

Is fertility lower at present?

Has the fertility of couples declined in modern times? Possibly. The reasons for this include: 1. the increasing age of women at the time of marriage and childbearing 2. the increased incidence of sexually transmitted diseases or STDs which damage the reproductive tract in both men and women 3. decreasing sperm counts in men which is a global phenomenon. An interesting observation made recently has been that men's sperm counts worldwide have been falling in the last few decades . Whether this is due to environmental pollution or to the stresses of modern day life remains unclear.

The good news is that there is definitely an increasing awareness about infertility in society today. It is no longer a taboo topic, and couples, supported by their families, are much more willing to seek medical assistance.

Where to get help?

Most couples consult their family physician who will refer them to an obstetrician - gynecologist when infertility is a concern. This first visit should include both husband and wife. The doctor will usually outline the possible causes of infertility, and provide an evaluation plan. The first step should be to achieve an accurate diagnosis to try to find out why pregnancy isn't occurring. Once a diagnosis has been determined, the couple and physician should talk again about a treatment plan. For difficult problems, referral to an infertility specialist may be suggested. Some studies show that it may actually be more cost - effective for couple to seek treatment by an infertility specialist right at the outset. This may be because an infertility specialist can design and implement a treatment plan more efficiently than a general gynecologist.

Authored by : Dr Aniruddha Malpani, MD and reviewed by Dr Anjali Malpani.

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