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Infertility and Having a Family
By Dr. Shafiq Qaadri, MD

What are your concerns about the terminology of infertility?
I personally don’t like the term infertility, because it’s a very negative connotation. The majority of the patients that we treat, with some degree of divine intervention in addition to our medical science, are sub-fertile, not really infertile…and we should avoid the term sterile completely.

Which physicians treat infertile or sub-fertile couples?
Many physicians treat infertile couples. Family physicians, the obstetrician-gynecologist, and the reproductive endocrinologist—all treat infertile couples.

What is the first approach with the infertile couple?
When couples present with infertility, the first thing that jumps into their mind is the issue of in vitro fertilization and all the new reproductive technologies. Everybody thinks test-tube babies are the way you have to go if you can’t get pregnant.

But many couples—and it is a couples’ issue—may only need counselling. For example, when we ask couples how frequently they have intercourse, they may say, “Well, we have intercourse only twice a month, but we do it at the right time.” But there is no right time.

According to the definition, infertility is the failure to conceive after regular, unprotected intercourse for one year…Though twice a month may be regular for some people, it’s not enough if you want to conceive. So counselling is an important issue.

Do you have concerns about the definition, the “one-year of trying to conceive?”
Yes, for example, that may be too restrictive for a woman who is 22 or 23 years of age, whose husband is not home at the time of ovulation. So perhaps two years would be reasonable for a young couple.
For a woman at 40, one year is already a long time, because we know that egg quality begins to decrease as women become older…And that’s our most difficult problem, problems related to the aging of eggs.

Are the problems causing infertility equally shared by the male and female?
About 45% of the causes are female-related, 40% are male-related, 15% can be combinations, but in some cases we can find no definable cause.

One sidelight, perhaps this is part of the chauvinistic society that we’ve grown up with. Twenty-five years ago, it would have been heresy to suggest that the male was infertile. And that is so wrong, because men are equally responsible, and must learn to bear their share.

What are the female-factors causing infertility?
There may be disorders related to ovulation, so a woman may not ovulate on a regular basis, or at all.
That’s one of the reasons you might have to stretch that definition, that window of trying for one year, because if a woman only has two periods a year, she may need to see her physician much sooner.
Blocked Fallopian tubes is another cause, and this also raises the issue of prevention. We may actually be able to help prevent infertility. It’s difficult, for example, to tell a man that we’re going to prevent him from having a low sperm count.

But if we educate women about the risks of sexually transmitted diseases—Chlamydia is a very common cause of tubal infertililty—then we may be able to prevent this condition.

Endometriosis may be associated with infertility, but it is not necessarily so. For example, we find minimal degrees of endometriosis in many women that are having a tubal ligation because they don’t want to have any more children.

But the presence of advanced endometriosis is often associated with infertility, when we find anatomicaldistortions, why the tubes aren’t functioning normally.

An important factor is the premature loss of egg quality or ovarian function. Generally, this occurs in women as they get into their forties. But more and more we are finding that women are showing signs of loss of ovarian reserve function—which we equate to egg quality—in their thirties, some even in their twenties.

These are all different considerations of the female-factors that we would need to consider.

What are the male-factors causing infertility?
As far as the male is concerned, there may be problems with sperm quality or quantity.
There may be problems related to sperm production; for example, the testicle fails to produce sperm just as the ovary fails to produce eggs.

There may be abnormalities with sperm function. One of the things that we have learned with the new reproductive technologies is that there are some couples where the sperm look normal, the eggs look normal, but the sperm won’t penetrate the egg.

There’s also the issue of vasectomy-reversals. Sterilization has become such a popular form of contraception, but nothing is carved in stone. There are many couples where there is a marriage break up, the male has had a vasectomy, and he has had a reversal.

Reversal of a vasectomy can be very good, especially if it has not been in place for very long. But men can also form antibodies against their own sperm, which can cause sperm to function abnormally.

What are the treatment options?
As I stressed, prevention is an important issue, the issue of STDs…Counselling before vasectomies and tubal ligations, so that couples are as sure as they can be, that they are not desirous of future pregnancies.
And then there are a number of medical and surgical options.

So if men have an obstruction to the outflow of sperm, if they’ve had a vasectomy reversal that failed, or if they were born with a congenital absence of the vas deferns, we can now retrieve sperm from above the site of obstruction. We may then inject those sperm directly into a woman’s eggs, a procedure known as ICSI, Intracytoplasmic sperm injection.

Women are often asking for the ‘fertility pill.’ Can you comment?

There’s no such thing as a fertility pill or a fertility medication. That would be magic. The medications that we refer to, either pills or injections, make women produce more eggs--they induce ovulation. These are also used to increase the number of eggs that a woman produces in a cycle, but they don’t make someone fertile just because they take these medications.

Empiric treatment, or Super-ovulation, is one technique that we use in couples with no definable cause, when we’re trying to maximize a couple’s fertility potential. We’re just increasing the number of eggs, because you can’t make tubes more open than open, and you can’t make sperm better than good. That may increase the chance that at least one of the eggs will be fertilized, and may lead to multiple pregnancies.

Is artificial insemination better than natural insemination?
No. Intrauterine insemination, putting the sperm inside the uterus—many couples will ask us to do this, because they’re not getting pregnant. I tell my patients that your partner is as good an inseminator as what is done in a clinic. Our putting the sperm inside the uterus doesn’t make it any better…we would usually use this in combination with super-ovulation, when we use it at all.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

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