Authors: Azoma Chikwe and Nkiru Odinkemelu
When in 2002, Emeka Nnamere, then 35 was about to wed his wife, Ifeoma, an accountant, 39, the news did not go down well with his relatives. Aside the fact that the family thought it abnormal for their son to tie the nuptial with an older lady, they also thought it was insensitive of him to marry a lady who was almost past her productive years. Many people thought she might not be able to bear children. The couple never had it smooth, trying to convince the groom’s family that all would be well. Eventually the couple stuck to each other and conquered.
At a point, the husband’s family mounted pressures on the wife after years of waiting. Given the circumstances that led to their marriage, no one immagined that the fault could come from the man, all blames were directed at the woman whom they felt, was no longer fertile because of her age. Ifeoma also did not find it easy convincing her husband to accompany her for thorough medical check-up.
Eventually, when he did, it was discovered that the source of the problem was Emeka who happened to be a heavy smoker, a drunk and womanizer. Worse still, he was suffering from and low sperm count.
Mrs Eunice Nwankwo, a teacher, was 34 years old when she got married to Dennis, a trailer driver, in 1999. They waited for the fruit of the womb for five years which did not come. They went for series of tests and it was discovered that the man’s sperm was like water. There was little or no gametes in his semen, the sperm count was very low. It got to a point that Dennis agreed that his wife could go outside and get a baby for him. She went out as agreed and got pregnant through another man. She gave birth to a bouncing baby boy who incidentally died after one year.
After the tragedy, the couple decided to adopt children and today they are proud parents of two adopted children, a boy and a girl. They decided against spending more money treating the low sperm count since the man could not desist from his promiscuous lifestyle even as the treatment gulped more money.
On Wednesday, February 19, 2015, a group of women from the Rido community in Kaduna State, had taken to the streets to publicly complain about their husband’s sexual weakness, demanding that their hubbies step up their conjugal responsibilities or face mass divorce.
The women, who converged at the NDA Junction in the state capital, blamed the Kaduna Refining and Petrochemical Company (KRPC) for their husband’s inability to impregnate them as a result of the chemical waste and fumes from the company which polluted their environment.
Some of the women complained bitterly that some of the men in Mararaba Rido community had become impotent due to the toxic waste from the KRPC. They complained that their husbands suffered from weak erection and infertility.
One of the married women, Jummai Isaac, 27, said she has not been able to conceive since she got married in 2000. “I haven’t conceived since I got married infourteen years ago. On several occasions, doctors had confirmed to me, there was no known cause of my inability to get pregnant.
“Initially, doctors thought I had fibroid in my womb, but after several scans and medical tests, they dispelled that notion.”
Men take front row in latest infertility survey
The stories of these two families are just two out of millions out there who are suffering from infertility. From the first account, one could deduce how the society has unjustly tied the bulk of infertility cases on women. Some beliefs in the society go as far as affirming that a man can never be infertile.
However, according to a medical expert, the days of ignorance are past. Times and technology have successfully proven otherwise as more men are now coming down with infertility compared to their female counterparts.
Speaking on this, Dr. Gabriel Akilo, Medical Director, Good Tidings Hospital, Surulere Lagos who conducted a survey on the prevalence of infertility among about 100 couples who presented themselves for checks said, there has been a paradigm shift from what the case used to be.
“Before now, we used to say that 40 to 60% of infertility is due to female factor while 40% due to male but recently, we found out that there has been a sharp increase in the prevalence among men; more men are presenting with constant factor being the cause of infertility than women and the reasons are many.
“I did a study here and looked at the last 100 cases of infertility I treated, I was to give a talk to members of the Association of General and Private Medical Practitioners of Nigeria (AGPMPN) on infertility. I found out that 60% of them were below 20million, which was the cut off for infertility. Generally, it will be like that in the population,” he said.
Dr. Gabriel Omonaiye, Medical Director, God’s Goal Hospital, Ojo, Lagos, also agreed with his colleague when he said, “commonly in our environment, it may not even be that it is the woman that is having problem, it may be the man but you would found it difficult to convince men to go for test because they believe that once the man can perform sexually, he is alright. There is even a quote in Yoruba that men can never be barren. But by the time you subject the man to investigation, you will find out that the reason for the infertility is the male factor.”
Experts agree that why male factor infertility has refused to go down is that nobody can identify the cause of low sperm count which is the commonest cause of male infertility. Most low sperm count cases are referred to as idiopathic which means cause, unknown. “Now, it is 60% male, 40% female as compared to those days. Major causes of female infertility like unsterile abortion that leads to infection and blocked tubes has been taken care of by advancement in science and technology and late female marriages has gone down”, they disclosed.
Low sperm count, the doctors further argued, could be due to sexually transmitted diseases (STDs), that is infection of the sperm. However, the causes of 60 to 70% of low sperm count are not known. “But infection is still common in the society, so, we can say that many men have STDs and that is what causes low sperm count. Other causes of low sperm count is varicocie: some abnormal veins coming down to the testicles and bringing hot and poisonous blood to the testicles and kill the sperms. There are also hormonal factors in men too, due to hormones from the brain.”
Experts define infertility as difficulty in procreation. That is when a man and a woman get married but find it difficult to have a baby within one year. After three to six months, if the woman is unable to get pregnant, it is not seen as infertility, it is assumed that they are studying each other. Akilo said, “for most people, when they get married and they don’t get pregnant within four months, and they begin to lament, it needs not be so. You must recognize that procreation is not like computer that you can press keys and something comes out. You must recognize that God is in the midst. So, if a wife is not pregnant within six months, you need not worry.” Experts also say 50% of newly married couples will be pregnant within six months naturally without any much ado, in another six months, another 30% will get pregnant, that is to say that 80% will delay, 30% will get pregnant within one year. Another 10% will be pregnant in another year, that is 90% in two years. “So we say that infertility rate is about 10%. But it is a pity that most couples, within few months of marriage get worried and start going from one place to another,” Akilo added.
He noted that for newlyweds, especially the females, six months might be such a long time to wait. Some start to expect pregnancy from the first month and by the time they have lived for 183days without conception, their hope would have been overstretched and they would think that something was wrong. But for the gynaecologist, six months could be considered a time of acquaintance for both couples. He advised couples to wait for one year before seeing inability to procreate as a problem.
Giving credence to why female infertility has reduced as against what it was, Akilo explained, “In the olden days, women do septic, non-sterile abortion and as a result, they used to block their tubes. Nowadays, people carry out abortion in cleaner ways, there are better facilities. Although chances of blockage of tubes exist, they are not as bad as those days where three quarter of those who carry out abortion will have their tubes blocked because there were no antibiotics, no generators to sterilise the instruments. They to call it wash and wear, they just put the instruments inside disinfectant and water, some of them would have a score waiting for them so they just do it without minding and infection rate was so high. Many of them died, many had complications. “Then also, more women were getting married at older age and the incidence of fibroid was increasing but these days, they are a bit younger. Incidence in women has gone down compared to that of male.” On why male infertility is on the increase, Akilo said, “the reason why that of male has refused to go down is that nobody knows the cause of low sperm count which is the commonest cause of male infertility. Most of them, we will just call them idiopathic which means unknown. So now it is 60% male, 40% female as compared to those days.”
Causes of infertility
On causes of infertility, he said, “here, we talk of the male and female causes. Under female causes, we talk of ovarian factors: those ovaries and hormones that are not working well. We also call it ovarian dysfunction. There are causes that can be traced to the womb itself and those traceable to the tubes. Under those due to the ovarian factors, the commonest is anovulation – when a woman is not ovulating, that is when the ovaries are not producing eggs again. There are many causes. “We talk of hormonal problems like polycystic ovarian syndrome, hyperprolac
tinaemia, this is a condition in which a woman produces milk in her breast. I always tell women when milk is coming from their breast if they press it, they should find out from their doctor because they are treatable. “Blocked tubes is another common cause of infertility because when the tubes are blocked, the egg cannot pass through to the womb to meet the sperm so those women cannot get pregnant. “Commonest causes of blocked tubes are infections from abortion, some people would have prolonged labour, women who have had ectopic pregnancy, some of them, the tubes are damaged. “Then, there is endometriosis that can also affect and block the tubes. We talk of the womb itself. The commonest cause is the uterine fibroids and fibroids are quite common and they are the commonest causes of infertility in this part of the world because most women marry late and by that time, the fibroids are already big and prevents them from getting pregnant. “Other causes include what we call Ashaman syndrome, of which the womb gums together when a woman goes for D&C, they scrape it so much, then the womb gums together. We have myoma, similar to fibroids where the womb is big.
Also lending his voice, Dr. Emmanuel Enabulele noted that there are about three factors responsible for infertility or low sperm count namely: the pre-testicular factors, the testicular factor, and the post-testicular factor.
Explaining this, he said, “the pre-testicular factor is responsible for the infertility that has nothing to do with the testes. There is the testicular factor that is as a result of the problem of the testes -the testes is where sperm is produced. Then we have the post-testicular factor that is after the testes has been certified to be without problem. We can categorize these into the three main factors responsible for this.
“Lifestyle has overwhelmed those three occurrences but some of them are genetic, while some are hormonal. The pre-testicular causes are sometimes due to the ageing process because people do not remember that there is a male menopause. As you grow older, there is a gradual decrease in the production of the testosterone, there is a gradual decrease in spermatogenesis leading to this. But the truth about the male factors is that the male gender will never stop the reproductive life until they pass on, so you can still see a man at the age of 90 still getting married and reproducing.
“Let us say the testicular factor can be numerous, it is the failure of sperm to produce, it could be as a result of the failure of the foliticular stimuli hormones to make the follicles to produce better sperm. Each time, we do lay emphasis on infection but infection is not particularly dangerous because some of them are treatable, so it could be as a result of hormonal failure. Also gradual decrease and it could be genetic, a lot of people don’t know that.
“Most of these causes can be as a result of blockages, the duct that carries sperms, there can be disease in the testes, then we now talk about the other thing that are also popular within the testicular causes, when we have enlarged veins, what we call varicocele veins. The testes is designed to be outside the body with a lower body temperature which is conducive for producing sperms, if you have this vein surrounding it and keeping it warm, it can lead to defective sperm production.
“There are other social habits like smoking of cigarette, drinking alcohols; they however could not have been the cause of the high rate of these factors.”
Treatment of infertility
On management and treatment of infertility, Akilo said, “when a couple comes in, first thing we do is to take a good history. We ask questions, we want to know if a woman has been married before, she may have been pregnant or had a baby before. Then if there is a man who has had three wives and there is no pregnancy from any of them, then we think more of male factors. If there’s a woman who has fibroid and the man may have a baby outside, that is woman factor. So we take a good history, ask them what is happening and then from there, we do a physical examination, that is examine the couple. We examine the woman if there is fibroid, ovarian tumour and we also examine the man if there is any infection, we check to ensure there are no varicocle. When we are done, we can go on to do a scan for the woman to see if there is any cyst or fibroid. Then we want to do X-Ray of the womb (HSG)- to find out if the tubes are blocked, hormonal test to know if she is ovulating or not. “For the man, we do the sperm test and then maybe we do the hormone test. We can do a scan too of the testicles if necessary.
“This depends on the cause. If we find during the scan that the woman has fibroid, then to remove the fibroid, that is the next line of action. We remove the fibroids and hope for the best; if it is ovarian tumour, we remove it too; if it is due to blocked tubes, we flush the tube. Many of the ones we flushed, some of them do get pregnant as against the notion that blocked tubes are like death sentence. If it is a hormonal factor, those who are not ovulating, we find out. One of the things we do to detect those who are not ovulating is what we call inside body temperature chat, we use that to monitor them and see if they are not ovulating, we treat accordingly. On the hormonal aspect, the hormonal test will still guard us on which kind of hormonal problems they have. “For the male it is the same, if there is infection, we treat it, if there is varicocle, we operate them, if it is hormonal, we treat and hope for the best.”
What next after treatment?
Dr Akilo said if initial treatment for both husband and wife fails to produce pregnancy, the next possible solution is offered. “If the problem still persists after we have done all that, then we think of IVF, we have many sectors doing it in Nigeria and abroad. In this case, we collect the sperm of the man and the egg of the woman and mix and fertilize them outside the body, and the embrayo is transferred into the womb and pregnancy continues. However, the success rate for IVF is quite low, about 30% in the best centres, some are less than that and it is very expensive, most people can’t afford it. “We have what we call IUI intra uterian insemination of sperm, we can also do that if the woman is not getting pregnant after many time and she is ovulating. We can inseminate the sperm into the womb hoping there will be a better chance of getting pregnant. One of the reasons for this is what we call cervical hostility, some women have hormones, chemicals that kill the sperms. When we do IUI, we can bypass those chemicals and the woman can get pregnant. “There is what we call donor egg and donor sperm; for the IUI, we can do that for them. Some of them, the sperm is too weak to perform and for some women who are getting to menopause, they can get donor eggs for IVF.”
IVF and religion
Speaking on IVF and religious acceptability, he said that it is controversial. “Personally as a Christian, I see it as a medical treatment but some pastors call it adultery. If a woman uses another man’s sperm but adultery according to the Bible is when a man sees a woman and his mind is thinking of having sex with her. This is medical treatment not medical adultery. I call it medical technology. The woman never saw the man, the man doesn’t know the woman; how can you commit adultery without seeing the woman. This is just technology.
The renown gynaecologist says if all medical efforts fail, all hopes are not lost. “Finally, if all have failed, we advise adoption. It is the last court of appeal if the IVF didn’t work.”
He noted that women who get pregnant at 50 stand a great risk. “It is very risky but you know when a woman wants a baby, she is very daring. Success rate is low too. Some of these claims are equally not true; some adopt and claim they had the baby. But for those who get pregnant that late, it is quite risky. IVF centres don’t want to do it after 50.”