The term ‘Family Planning’ is usually taken to be synonymous with contraception. But an important aspect of Family Planning is helping a childless couple beget a child. Approximately 10% of the couples in the reproductive years are unable to have children. For many of these couples, the psychological, social and economic consequences of being childless unwillingly are considerable. Temporary inability to produce children is known as infertility. If the condition is permanent, it is termed as sterility.

Causes

Successful conception depends upon various factors. It occurs only when conditions are favourable. Intercourse has to take place around the time of ovulation so that an egg is present for fertilisation. The woman’s reproductive organs must be healthy and fertile. Once the egg is fertilised, conditions must be right for it to implant itself in the uterus lining for foetal development to proceed.

If there is a disturbance in any of these factors, infertility may result.

Infertility may result from disorders in men (30 – 35 %), in women (50 – 55 %) and in both (15 %).

Infertility in Men

• One of the causes is being unable to producing good quality semen. The semen may have:
  • Low sperm count
  • Abnormal sperms
  • Poor motility

  This may be due to:

  • Undescended testes
  • Infection of testes – mumps
  • Obesity
  • Poor diet
  • Sedentary or stressful life
  • Over tight underwear
  • Prolonged abstinence from intercourse
• Infertility may be due to problems pertaining to the sexual act:
  • Impotence
  • Extravaginal ejaculation – premature ejaculation. -
  • Failure to ejaculate – retarded ejaculation
  • Retrograde ejaculation
• It may be due to problems of coital frequency:
  • Infrequent sexual intercourse (less chance of sperms being available to the egg – during ovulation)
  • Frequent intercourse (several times a day) due to the misconception that it will help conception. This lowers sperm count. This impact is greater on men with marginal fertility. Normal counts generally are not lowered into the infertile range by daily ejaculation.
• Errors in sexual techniques may result in infertility:
  • Intravaginal use of lubricants due to weak spermicidal nature.
  • Frequent douching makes the vaginal environment hostile to sperm.
  • Improper coital postures reduce the number of sperms that reach the mouth of the cervix.

Infertility in Women

Infertility in women may be caused by:

• Failure of ovulation due to hormonal disorder or emotional stress.Lack of or reduced sexual interest.
• Failure of implantation of the fertilised egg in the uterus due to hormonal imbalance and endometrial inflammation.
• Problems in sperm transportation, increased vaginal acidity, hostile cervical environment.
• Blockages of fallopian tubes, congenital infections, gonorrhoea, T.B., etc.
• Spasm of the fallopian tube due to emotional stress.
• Diseases of the reproductive organs such as:
  • STD
  • Fibroids
  • Cancer
  • Cyst
• Malformation of the reproductive organs such as:
  • Fused labia
  • A hymen too strong for penetration
  • A narrow or divided vagina
  • A tilted or divided uterus

Problems that both sexes may face

• Sexual orientation problems like homosexuality, lesbianism, bisexuality and transexualism.
• Body image concerns - under developed breasts, genitals, secondary sex characters etc.
• Faulty sex techniques leading to infertility.
• Paraphilias - abnormal sexual behaviour etc

Methods of Diagnoses

As a general guideline, if the couples have been having sexual intercourse regularly without contraception for about a year and conception has not occurred, then they should seek medical advice.

The following investigations are performed to diagnose the cause of infertility:

• Semen analysis
• Post Coital Test 6-18 hours after sexual intercourse to find out whether the sperms are surviving in the vagina and cervix. This should be done around the time of ovulation.
• Scraping or Dilatation& Curettage (D&C) of uterus
• Hysterosalpingography to detect any structural abnormality
• A gas or insufflation test with carbon-di-oxide to detect blockages of the fallopian tube and to clear them, if possible.
• Tests of ovulation to measure progesterone level in blood or urine and daily charting of the body temperature.
• Laparoscopy, to examine the uterus and fallopian tubes and for corrective measures.

Treatment

Advice and Counselling

One of the first points to be considered before treatment is offered is whether the couple is actually having sexual intercourse. Strangely enough, even today in India, non-consummation is a frequent cause of infertility. If the couple is having intercourse, it must be made aware of timing and techniques.

• If a woman has a regular 28-day menstrual cycle, the most fertile phase is usually between days 11 and 16.
• If periods are irregular, say cycles of between 27 and 35 days, the chances of conception increase if intercourse takes place on five alternate days starting with the 13th day.

Certain positions can also aid fertility. These can be advised for cases of:

• Obesity
• Undue vaginal tightness
• A tilted or retroverted uterus

As a general rule, chances of fertilisation improve if the woman remains fairly still for about half an hour after intercourse.

Some problems cannot be solved by advice or counselling. In these cases a suitable method of treatment from the following is adopted:

• Psychiatric help
• Medication (as in case of infections)
• Overcoming hostility to sperm
• Operations
• Fertility drugs
• Assisted reproduction techniques
• Artificial insemination

Coping with Infertility

In a tradition bound society like India, infertility may result in any of the following reactions:

• The woman is stigmatised
• Family and peers taunt the couple, or trigger off a lot of negative emotions
• Spouses blame each other for inability to conceive
• Pressures (sometimes explicit) for more frequent sexual activity may create a situation of diminished spontaneity.
• Men may unnecessarily equate their sexual ability with the ability to father a child and thus experience anxiety or depression.
• Many women become despondent during their period as menstrual flow signals lack of success in achieving a pregnancy.

These frustrations can precipitate psychosexual problems in the concerned couple. These problems will further aggravate the basic problem of infertility and thereby start a vicious cycle. Diminished sexual desire, impotence in men, lack of orgasm in woman may be encountered in these distressed couples.

Whatever may be the source of problem, the childless couple will be under terrible emotional stress. A sympathetic attitude from the healthcare professional will go a long way in helping them to overcome their problem. Even if the couple cannot have children, they can be helped to take stock of the situation in its proper perspective and lead a happy married life.