More women failing to conceive after first baby

When she got married in 2012 at the age of 24, Rose (not real name) and her husband agreed to have four children. After a year, God blessed them with a baby boy. Her husband and in-laws showered Rose with love and praises.
However, the love started fading when Rose failed to conceive again.

“We have looked for another baby for more than five years without succeeding. I am still struggling to get a brother or sister for my son,” she says.

Rose says she has done several tests, and all results show that her fallopian tubes or oviduct that carries ova for fertilisation and moves embryo to uterus are normal. The last test was done in April.

Whereas her husband understands the situation, the pressure from her in-laws has complicated her marriage life.

Like Rose, several women in Uganda are grappling with secondary infertility, according to gynaecologists and other reproductive health experts.

The World Health Organisation (WHO) defines secondary infertility as failure by a woman to conceive again after a year of regular intercourse. 

Global cases
According to who estimates, up to 48 million couples and 186 million individuals worldwide live with infertility.
Thirty-two-year-old Zauja (not real name),  a mother of two girls, says she has tried to conceive many times, but without success.

“My second born is in Primary Seven. I started looking for another baby when she was in Primary Two but God has not yet answered my prayers. However, the pressure from my husband stresses me. He is demanding a baby boy,” Zauja said.

Dr Joseph Kafuuma, a fertility specialist at Women Hospital International and Fertility Centre in Bukoto, Kampala, says secondary infertility is increasingly becoming a reproductive health challenge in Uganda.

According to him, nearly six in every 10 women who report cases of secondary infertility at the facility have had at least a baby, a miscarriage or an abortion before.

“Before, we didn’t have facilities in Uganda where people could go for investigations. Today, we have many fertility centres. That is why we have been able to identify a high number of women experiencing secondary infertility,” Dr Kafuuma adds.

Ministry of Health statistics show that 10 to 15 percent of the couples in Uganda cannot have children due to infertility.

Dr Kafuuma identifies predisposing factors for secondary infertility in women to include sexually-transmitted infections, fibroids, hormonal imbalance, age, and lifestyle changes such as weight gain.

Fibroids, a more common cause of infertility in women, are tumors that develop in or around the uterus and depending on the size and location, they compress and block the fallopian tubes. This prevents fertilisation from taking place.

And in case the fibroids develop in the uterine cavity, gynaecologists say they may interfere with implantation and development of the embryo, leading to failure by a woman to conceive, and or miscarriages.

Some of the early signs and symptoms of fibroids, according to Dr Kafuuma, are heavy and prolonged menstruation periods, swellings in the lower abdomen, pressure and heaviness in the lower abdomen.  Normal periods range from anywhere between two and seven days.

“You should know your menstrual cycle. If you have been taking four days and suddenly you menstruate for more than seven days, this could be a signal of danger,” he says.

According to other health experts, sexually transmitted diseases such as gonorrhoea and chlamydia can cause tubal blockages and when not detected and treated early, they cause scars and adhesion in or out of the fallopian tubes. The result is a blocked fallopian tube and fertilisation malfunction.

“We have had cases where most women who have failed to conceive go for fallopian tube test (HSG) and their results show that their tubes are patent. The tubes may be open, but not able to pick the egg from the ovary following ovulation due to tubal adhesions or scars on the outside of the fallopian tubes,” Dr Kafuuma says. This can account for as high as 60 percent of infertility in women, according to official statistics.

But there are also other explanations for infertility among couples.
For instance, the WHO estimates that globally, about 50 percent of infertility cases are as a result of a man’s inability to make a woman pregnant.

The causes vary.  It could be that a man has reduced or low sperm (oligospermia) due to, among other things, excessive smoking or weight gain, alcoholism, or failure to detect and treat early sexually-transmitted infections (STIs) such as gonorrhoea.

A normal man’s sperm count ranges between 15 and 200 million sperm per milliliter of semen. In addition, diabetes and medical procedures such as radiotherapy could alter the quality and structure of sperm, leading to infertility in men.

Signs and symptoms of STIs in men can be noticed a few days after infection, while it may take up to 14 days to be noticed by woman through pain in the lower abdomen and back, or coloured vaginal discharges.

WHO links infertility in men to problems in “ejection of semen, absence or low levels of sperm, or abnormal shape (morphology) and movement of the sperm”.

While in women, according to the UN health watchdog, infertility arises from causes such as abnormalities of the ovaries, uterus, fallopian tubes, and the endocrine system.

Family planning side effects
Dr Deogratias Migadde, a senior medical officer in the Health ministry’s Department of Reproductive Health, says many of the cases of secondary infertility are a result of side effects of using some family planning methods, either without expert advice or improperly.

He says there are no official figures about secondary infertility in Uganda, but the problem is prevalent and “causing tension among couples”.

According to Dr Migadde, some family planning methods are associated with delayed return to fertility in some women in which case, if the delay lasts longer than six months, the affected individual should seek medical advice.

Failure to conceive after a first child, one woman, who asked not to be named due to sensitivity of the matter, led her husband to question if the firstborn was his child or an outcome of the wife’s extra-marital affair, a concern which was only resolved through DNA confirmation.

Dr Kafuuma advises couples facing problems of secondary infertility to seek timely medical care together to avoid mistrust.

Infertility causes, treatment

Abortions, miscarriages
These may leave portions of the foetus in the uterus and form scars or attract bacterial infections, blocking the fallopian tubes.

Lower abdominal, pelvic surgeries
Scars may form in the uterus. Further, structures of lower abdomen and pelvic area may bind during healing, impairing a woman’s eggs’ travel from the ovaries to fallopian tubes.

Hormonal imbalances
Possible triggers include lifestyle changes such as weight gain and excessive accumulation of fat in whose cells conversion of hormones occur, leading to imbalances manifested by irregular menstrual cycles and irregular ovulation.

Congenital defects
Undescended testicles can cause infertility in men and early childhood surgery is essential to realign the testes to be able to manufacture sperms.

Woman’s age
The older a woman grows, usually from 35 years and above, the ovaries start to get depleted of eggs, rendering onset of menopause in some women from as early as 38 years instead of the average 45 to 55-year age bracket.

Overcoming infertility
Dr Joseph Kafuuma says women who have failed to conceive naturally, but wish to have children, should not lose hope because there are different treatment options that can be used to help them to get pregnant. They include:

Inter-uterine insemination
 “This is where a man provides doctors with his sperm sample which they prepare and inject in a woman’s uterus following ovulation induction. However, this works for women with normal fallopian tubes. This procedure can also help women who don’t ovulate regularly and those whose partners have a low sperm count,” he says.
•The other option is Invitro Fertilisation (IVF), or test tube baby making, a procedure in which fertilisation happens outside the woman’s body in the IVF laboratory. The woman’s eggs and partner’s sperm are aided to meet in a test tube, then incubated for three to five days to create an embryo that is then transferred back into the uterus.

•A third alternative is surgical interventions such as laparoscopy (keyhole surgery) and hysteroscopy. These involve using a camera with minimal cutting on a woman’s abdomen to diagnose fallopian tube malfunction and rectify the identified defect.