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By Dr Charles Muteshi
What every couple planning to conceive should know about timing, testing and treatment.
In the majority of cultures, having children is seen as the fulfilment of a social contract, and the couple is obliged to meet this expectation. There is no socially agreed definition of how long the wait should be, and expectations often ignore personal circumstances such as career aspirations and financial stability.
Couples will often assume that, as long as they are sexually intimate, fertility is guaranteed except where a conscious decision to use contraception is made. However, there are instances in which couples may experience challenges with conception. Here is what every couple planning to conceive needs to know.
What determines a couple’s fertility?
Fertility depends on four important parameters, namely regular ovulation and patent (open) fallopian tubes in the female partner, normal sperm parameters in the male partner, and regular intercourse to allow the egg and sperm to meet and fertilise.
What is often not understood is the chance of conception in one fertile ovulatory cycle, medically known as fecundity. This is the probability that a female partner will conceive in any given fertile month when they try to.
Generally, fecundity stands at about five percent; in other words, for every one hundred fertile women, only about five will conceive during each month of trying. This implies that couples ought to attempt conception consistently and regularly over a period of time to be successful.
How often should a couple attempt conception?
The standard duration of trying is taken as 12 months, during which nearly 85% of couples conceive. There is often a tendency to time attempts at specific points in the month, typically around ovulation, in order to enhance conception.
This is, however, an erroneous assumption because the outward signs of ovulation become apparent after the egg has been released. The female egg has a very short lifespan, typically about 24 hours, and quickly becomes dehydrated and desiccated. Nature devised an adaptation around this: the sperm cell can remain viable for several days in the female genital tract. In essence, couples are advised that trying two to three times a week gives them the highest chance of conception.
At what point should we be worried about conception?
When a couple is concerned that there may be a problem preventing conception, the cause is sometimes obvious. In most instances, however, it is unknown to them. Finding it requires a health worker to go over the pertinent issues and tests.
Attending a medical consultation together provides the opportunity to dispel myths around fertility, remove blame, and enhance engagement with treatment. This also offers the chance to signpost the couple to other essential support services such as counselling.
What exactly does the doctor examine to diagnose fertility challenges?
A comprehensive assessment of fertility includes examining a semen sample to check for normal sperm parameters, testing ovulation, and checking the patency of the fallopian tubes. The sequence of testing should be logical, allowing a prompt and accurate diagnosis and avoiding unnecessary tests. Overall, about half of fertility issues may be related to sperm and the other half to female factors, including ovulation and tubal blockage.
The medical approach would therefore be to start the investigation with the least invasive tests, that is, semen analysis and an ovulation check. This means that if the sperm parameters are normal, then checking that the fallopian tubes are open is the next logical step, as this helps to determine whether there is a chance of natural conception.
The commonly performed test for tubal patency involves passing a special dye through the tubes and taking an X-ray film. This is known as a hysterosalpingogram (HSG).
To avoid exposure to radiation (X-rays) and the need for a separate ultrasound scan, a novel test known as HyCoSy is now available. HyCoSy involves having an ultrasound scan to look at the uterus and ovaries (information not gained from HSG) and then passing a special dye through the tubes to check patency during the same visit. This avoids multiple visits and can be done at any time of the cycle. It is far more comfortable than HSG, though it requires a specially trained practitioner to perform.
What fertility treatment options are there?
Generally, a couple feels more reassured and ready to engage with treatment when their experience is enhanced by an empathetic team that is ready to give as much information as possible and to allow shared decision-making that respects their values and opinions.
Going through fertility investigations can be exasperating and may feel like a roller-coaster. While knowing the factors contributing to subfertility is important, some diagnoses can be devastating, such as blocked fallopian tubes, severe sperm abnormalities, and ovarian failure. Couples may feel frustrated and angry, and may tend to blame certain situations in their own life experiences. Relationship strain may also occur. This is the moment when the healthcare team should be very supportive and engage counselling services as well.
Options for fertility treatment should then be discussed sensitively, paying attention to the couple’s individual circumstances and offering information based on current best evidence.
Many couples may require assisted reproductive treatment such as in vitro fertilisation (IVF). This is usually a major decision for a couple to make, as it involves financial commitment, uncertainty about success and the risks that come with it. It is important that a couple have factual and up-to-date information in an easy-to-understand format. They should never feel rushed to undertake this treatment, and counselling support is crucial in making this decision. It helps a great deal when both partners attend the clinic for these discussions.
Sometimes effective treatment is limited by certain barriers or constraints. It should never feel like the end of the road for the couple, as other options must be explored. These include discussing the use of donor gametes or alternative parenthood options such as adoption, foster parenthood, or surrogacy arrangements.
It calls for a sensitive and empathetic fertility specialist to navigate these issues. While individuals may have various coping strategies, what matters for the couple is family support and support groups such as Waiting Wombs Trust. Legal opinion may need to be sought in some circumstances.
Dr Charles Muteshi is a Consultant Fertility Expert at Aga Khan University Hospital.
