by Patrick J. Rowe

nfertility is a problem that affects never conceived despite cohabita­ is produced by the pituitary. Hor­ men and women of reproductive tion, regular and mone injections or special drugs can I ages in all areas of the world. Al­ exposure to for 2 years. often restore the normal menstrual though estimates of how common in­ Secondary infertility: the woman cycle and in such cases. fertility is are not very accurate and has conceived previously but is sub­ is one of the most com­ vary from region to region, some 8 to sequently unable to conveive. mon causes of infertility in women. It 15 per cent of couples experience Pregnancy wastage: the woman is may result in adhesions around the problems in achieving a pregnancy able to conceive but unable to pro­ ovary and tube, preventing the pas­ during tl;leir reproductive lives. This duce a live birth. sage of the ovum into the tube. The represents some 50 to 80 million Subfertility: Clinicians define this tube itself may be affected by the in­ people, and it is well recognised that as the difficulty experienced by some fection and become blocked. infertility can cause considerable per­ couples, both of whom may have re­ and delivery are particular occasions sonal suffering and disruption to duced fertility, jointly to conceive. for the or tubes to be damaged family life. Demographers define it as the inabil­ by infection, especially where the The rate of population growth ity of a group to maintain a birth abortion has been criminally induced worldwide has undergone a rapid rate equal or superior to the general or either abortion or delivery takes decline through international and mortality rate. place in unsanitary conditions. national governmental pressure, the To understand the more frequent A large research study conducted increased provision of contraceptive causes of infertility, it is necessary to by WHO in 25 countries has shown services, and a re-evaluation of the outline the process of reproduction in that the results of previous infection traditional need for large family sizes. the male and female . in the genital tract play a very impor­ Against this background, infertility Classically, each type of infertility tant role in causing infertility. One has not received as much emphasis as can be attributed to congenital causes third of the women in developed fertility regulation and it has been or acquired causes. The former stem countries complaining of infertility questioned whether scarce medical from abnormalities in the develop­ showed evidence of previous pelvic resources should be devoted to the ment of the genital tract in either the infection, including blocked tubes. prevention, diagnosis or treatment of male or female. Examples ofthis are Similar numbers were found in Asian infertility. absent ovaries and hence no ovula­ and Latin American countries, but in However, tl;le changes in popula­ tion, absent vagina and hence no in­ the African centres nearly twice as tion growth over the past 50 years in tercourse. Obviously these causes re­ many women (63 per cent) had the developed countries, and over the sult in primary infertility. There are causes related to previous infection. past 20 years in some developing congenital causes of , In fact 40 per cent of African women countries, make infertility a more but these are more usually detected who had been pregnant had tubal urgent problem. In other developing before sexual maturity and are there­ blockage. countries, that have not been through fore infrequently counted as cases of There is a well established connec­ the population change from high infertility. For example, normally the tion between gonorrhoea and subse­ death rates in childbirth and infancy testes reside inside the abdomen and quent infertility due to tubal block­ to smaller family sizes and increased migrate downwards to fill the scro­ age. This is particularly important in health and social opportunities for tum in early childhood. In some cases view of the almost epidemic propor­ the smaller family unit, the problem this fails to happen and the testis fails tions of the post-World War 11 out­ of infertility is closely linked to the to mature and produce sperm. break of this , its increasing introduction and the extent of use of Among acquired causes in women, resistance to antibiotic therapy and contraceptive services. If couples are there may be a deficient production the fact that it is frequently symp­ asked to voluntarily restrict their own oftwo key hormones - follicle stimu­ tomless or produces only transient fertility, they must also have access lating hormone (FSH) and luteinising symptoms. to services for the diagnosis and hormone (LH) - by the pituitary Recently, a newly identified bacte­ treatment of infertility when the gland, in which case the patient will rial organism called has couple wish to have their first or not ovulate at all or only very infre­ been shown to be more important another child. quently. Or there may be an exces­ than gonorrhea in causing infertility. A couple's inability to have a living sive production of the hormone which Like gonorrhea, Chlamydia is a sex­ child may stem from: stimulates the breast to produce milk ually transmitted disease; but infec­ Primary infertility: the woman has - prolactin. As with FSH and LH this tion with this organism may cause no

20 W oRLD HEALTH, November 1987 and indeed tight-fitting underwear has been suggested as one cause of male infertility. These varicose veins can be treated surgically, but it is not yet clear whether this will result in an improvement in sperm production and an increased chance of the female partner becoming pregnant. Men suffering from alcoholism have reduced libido and thus reduced fertility. Certain drugs, including some antibiotics and anti-depres­ sants, are known to reduce sperm production. Less is known about male causes of infertility than female and, of those causes that can be identified in the male, fewer are open to corrective treatment. What is known is that the male is responsible for the couple's infertility in at least 40 per cent of cases. There remain a number of couples who, when investigated, appear nor­ mal but still fail to conceive. There are many unanswered questions about infertility although recent re­ search into the mechanism of ovula­ tion, fertilization and implantation has resulted in many couples now be­ ing successfully treated for their in­ fertility. In vitro or the "test tube baby" technique has been used mainly for women with blocked tubes, but is now being used for more and more cases where the cause of in­ fertility cannot be determined. This treatment has received enormous publicity over the past decade, but is very expensive and requires highly trained personnel and causes consi­ Modern and traditional garb in a North underlying psychological fears about derable inconvenience to the patient. African street. Mothers who want to intercourse held by the woman. Although in developed countries plan their families must also have Among acquired causes of infertil­ there are now many centres offering access to treatment for infertility. ity in men, the testis can be infected this treatment, the best results have Photo WHO/UNICEF/B. Wolff by the mumps virus. Tuberculosis shown no more than a one in four or and syphilis can affect the testis and five chance of pregnancy. the duct leading from the testis, caus­ The cornerstone to the manage­ ing an obstruction to the passage of ment of any disease, including infer­ symptoms in either the female or her sperm. tility, is prevention. Obviously it male partner. Such can be Improperly performed surgical would be very difficult, if not impos­ effectively treated with antibiotics, operations to correct testes that have sible, to prevent the congenital but successful treatment carries no not descended into the scrotum, or causes of infertility and the disorders protection against reinfection. the repair of inguinal hernias in rare of sperm production or not Tuberculosis may affect the lining instances, may damage the blood caused by drugs, the environment or of the uterus and prevent implanta­ supply to the testis and so impair its . But genital tract tion of the fertilised ovum as well as function. infection in either partner can be causing blocked tubes. It is held to be One of the more frequently recog­ prevented. The major causes of these the cause of female infertility in up to nised causes of male infertility is a va­ infections are sexually transmitted 5 per cent of cases. ricocele which takes a form of vari­ such as Chlamydia and gon­ In some cases of infertility, normal cose veins around the testis. These orrhoea, but it will take a major sexual intercourse has never taken can increase the amount of blood effort in health education and signi­ place and therefore ejaculation has surrounding the testis and raise its ficant changes in social behaviour never occurred in the vagina. This temperature. It is well known that and sexual practices to make a signi­ may result from ignorance on the part sperm production is greatly reduced ficant reduction in these preventable of both partners, or there may be by increasing testicular temperature, causes of infertility. •

W oRLD HEALTH , November 1987 21