What is behind the rise in cases of infertility?

Nothing screams, “We are fertile”, more than an average of seven children per woman. Uganda’s high birth rate naturally leads to the assumption that infertility is not a problem here. But what about the couples who have problems conceiving? They may be on the fewer side compared to those bursting with fertility but they are many enough to earn Uganda a place in the sub-Saharan infertility belt. The infertility belt of Africa stretches from Tanzania in the east to Gabon in the west and refers to countries around the continent where infertility rates are among the highest in the world.

Statistics are hard to get
Actual percentages showing infertility rates in Uganda are hard to come by due to what two doctors consulted say is the very nature of the problem. “You will never know because people are not open about it. We do not have data,” Dr Daniel Zaake, obstetrician/gynaecologist and fertility consultant, says. While this means there is no data available on the exact infertility prevalence in the country, the trends, experts observe, can give us an idea. Dr Zaake, who runs Lifesure Fertility and Gynaecology Centre, notes there are more Ugandans seeking help for fertility problems.

“I could say infertility affects roughly six to 10 per cent of the couples,” says Dr Zaake.

Dr Mark Muyingo, a fertility specialist and a lecturer in the department of Obstetrics and Gynaecology, Makerere University Medical School, and fertility specialist says on average he sees 20 new patients at the fertility clinic at Mulago alone. “If I compound with the others I see at the private clinic where I also put in some hours, then I can say I cannot believe how many actually walk through the door seeking help,” he says. Both specialists are, however, keen to explain that seeing more people seeking help may be less an indication of increasing fertility levels and more a result of more people seeking help.

“Infertility problems were always there, but the approach may have been different. Back then, the husband would maybe marry another wife and try having a child with her as opposed to seeking help with his partner,” says Dr Muyingo.

The face of a Ugandan seeking intervention of fertility issues is diverse from affluent to low income earners. But there is a pattern according to the doctors; women first then men come later. “Men are very reluctant to seek fertility care,” says Muyingo.

They cut across all ages, though he notes that more often than not, there is an increasing trend of career women, who are trying to beat the biological clock. Many also tend to be in stable relationships. These women fall under the group whose infertility problems are caused by the delay which Dr Zaake says is one of the leading causes of infertility in Ugandan women. “With more women first following the school and career path, the average girl waits until almost 30 to start thinking about it, as the years go by the window shrinks,” says the doctor.

Fibroids, which arise from delay of the first pregnancy, may block tubes or interfere with conception. However, Dr Zaake stresses that fibroids do not always mean infertility.

The most common type of infertility in Uganda is secondary infertility. According to Zaake, this means a couple or person has difficulty conceiving the second child. “Typically people with this problem have been able to conceive the first time whether they carried full term or it resulted in a miscarriage,” he says.

“There are many causes of infertility. However, the majority of infertility cases in the country are caused by tubal disease,” says Dr Muyingo. Tubal disease is, in turn, a result of scarring from Sexually Transmitted Infections (STI), which are rampant in the countries on the infertility belt. “The infections cause blockage in the fallopian tubes which interferes with the fertilisation process,” says Dr Zaake.

“Infertility due to hormonal causes - in medical jargon Polycystic Ovarian Syndrome (PCOS) - is also on the increase,” says Dr Muyingo. In these cases, the concerned organs do not respond to appropriate stimuli from the brain, for instance, in egg production and thus the conception becomes difficult. The condition is usually but not always characterised by irregular periods.

For men, complications arising from STDs can also cause blockage of sperm. Fertility problems may also arise from issues of sperm quantity and quality. Sports injuries to the groin may also cause a break in the blood barrier causing the production of antibodies, which attack the sperm.

“Infertility could also be cause by congenital issues,” says Dr Muyingo.

WHO defines fertility as the inability to conceive despite regular unprotected intercourse in one year. For women above 35 the trying period is narrowed to six months. “Regular sex means at least three times a week,” says Muyingo.

One step at a time
He says it is not advisable to try intervening before one year, in case one can still conceive. “We avoid putting a person through unnecessary investigations,” he says.

Both experts agree that the most important step if one has trouble conceiving is to get a proper evaluation. “If not, you will be mismanaged,” says Dr Zaake. Dr Muyingo explains, “Allow a specialist to make a diagnosis. Sometimes infertility issues can have multiple factors. For example the lady could be suffering from blocked tubes while her partner also has low sperm count. It is very important to see a gynaecologist or a fertility specialist who will evaluate your condition.”

The doctors advise that one starts with a regular gynaecologist, who will either diagnose or refer you to a fertility specialist. “Sometimes issues can be handled by a gynecologist,” says Dr Zaake. Dr Muyingo notes that all major hospitals have gynaecologists who can give proper diagnosis. Advancements made in science mean there are more options for people finding difficulty to conceive, enough to give fertility specialists the confidence to say “everyone should have a child if they want”. It may not be biological, or even if it is, one may not carry it since adoption and surrogacy are some of the options offered for couples finding difficulty having children, but it is a child nonetheless. Other interventions like In Vitro Fertilisation (IVF) are also available in a few places around the city. And so is medication to correct some hormonal anomalies. More than ever there are solutions for Ugandans having problems conceiving.

However, the specialists will not give you a 100 per cent guarantee. “Sometimes we can try everything and it does not work and we do not know why,” says Dr Zaake. “Research in this area is expensive and we may not get all the information we need,” he says. PCOS according to Dr Zaake is one of the easier infertility causes to control. “It is basically a play on hormones which will improve womb preparation for egg production,” he says.

For tubal blockage, there is an unblocking procedure. In cases where it does not work IVF is offered to couples. The national referral hospital is not equipped with IVF equipment but selected private owned fertility centres do have it.

The success rate of IVF according to Zaake is about 40 per cent. “Sometimes we do all we can to make good embryos and place them and still it does not take,” says the fertility consultant. For a lucky percentage however, one try is enough. Dr Muyingo says that a few attempts may yield better results; for the majority of people, two tries yields success. He also says whether the process will help overcome infertility depends on how long patients are able to keep trying.

Dr Zaake concurs saying sometimes cost implications and general disillusionment may cause some couples to abandon treatment resulting in fewer success stories.

“For sperm problems, we have interventions to increase count, and others where we employ intra-uterine insemination,” says Muyingo.

Additional reporting by Joseph Kato
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