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Family Health Magazine - MODERN LIVING

The Trouble with Making a Baby
An overview of common issues with fertility

Many couples assume that they will one day have a family. However, many factors go into whether or not a pregnancy occurs. Some, such as family obligations, tradition, expressing of love, passing on genes, desire to nurture, career, finances and lifestyle, may simply be influences. Others, including chronic illness or infertility, can be true challenges.

According to the 2011 Canada Census, 45 per cent of all Canadian couples are childless. Overall, the fertility rate in Canada has dropped by more than 50 per cent, from 3.9 children per woman in the 1960s to 1.5 in recent years. Roughly one in six couples experience infertility.

In Canada, we are privileged to have access to both family planning options and infertility treatments. This allows significant freedom when making decisions about reproduction.

If you do choose to make the leap into parenthood, remember that it takes an average couple six months of trying before becoming pregnant. Infertility is suspected if pregnancy does not occur after a year of having intercourse without birth control. Many pregnancies end in miscarriage at the time of the next usual period. A woman may not even be aware that she was a few days pregnant. Problems with the egg, sperm or implantation end the pregnancy.

If you have tried to become pregnant (conceive) for at least a year with no success, there may be a problem with your fertility or your partner’s fertility. Women who are 35 years old or older should see a doctor after six months of trying to get pregnant. Your age makes problems with fertility more likely, as does having more than one miscarriage.

The first step is to visit your family doctor to begin looking for causes. You may also be referred to a reproductive specialist for more tests and treatment. Infertility can be traced to either the man or woman, or a combination of both:

• three times out of 10, the cause is in men
  
• four times out of 10, the cause is in women
  
• two times out of 10, the cause is a mix of factors from both the man and woman
  
• one time out of 10, at first, no specific cause can be found.

Your family doctor and the fertility specialist will make sure that all these factors are checked. They will consider which step or steps of becoming and staying pregnant are not working properly.

The male factor

Sperm is made in the two male testicles, which are suspended in a pouch called the scrotum. If a heterosexual couple is having trouble becoming pregnant, the male partner’s sperm should be checked. A test can show how many sperm are in the fluid (ejaculate) that the man releases during sex. Certain features make sperm more likely to be able to swim to find the female egg and penetrate to fertilize it. A man may have too few sperm, or the sperm may not be working properly. Average healthy semen has up to 500 million sperm. Only one of these sperm will reach and fertilize the female egg.

While a man may have healthy sperm, his reproductive organs may have a blockage. The issue could also be that the sperm is not able to get mixed in with the ejaculate. As well, other parts of the ejaculate may not be made properly to support the sperm.

The male body makes new sperm all the time. It also absorbs sperm that are not released. Sperm quality can be affected by age, chronic illness, certain prescription medications, smoking, alcohol consumption, exposure to pesticides or lead, illicit drug use, and anabolic steroid use. An urologist who specializes in male fertility is the best source of information and treatment.

The female factor

Ovulation is the release of an egg into the fallopian tube, where it can be fertilized by sperm. One of the two ovaries releases an egg, usually once a month during the menstrual cycle. The cycle starts with the first day of a period (bleeding from the vagina). Menstruation typically lasts five to seven days. Ovulation often occurs around day 14 of the 28-day cycle, or 14 days before the first day of the next period.

Complex hormone surges must happen to be able to have a predictable, regular menstrual cycle and to ovulate. Several medical conditions can interrupt these hormone signals. In this case, the egg may not be released at all. Women with these conditions usually have irregular periods, or long unpredictable breaks between periods. These conditions include polycystic ovary syndrome (PCOS), functional hypothalamic amenorrhea (FHA), diminished ovarian reserve, premature ovarian failure, and menopause. You can buy an over-the-counter ovulation tracker to help track hormone surges. A woman also can track her daily morning body temperature patterns to estimate when her ovary releases an egg.

Females are born with a set number of eggs. At birth, a baby girl has about one to two million immature eggs (follicles) in her two ovaries. By the time of her first period, there are only 400,000 eggs left. This happens because as the female body ages, many eggs are absorbed. About 1000 immature eggs are lost over each menstrual cycle. Only one usually matures to become an egg that can be fertilized.

Most women reach peak fertility between ages 23 and 31. Fertility starts to drop off slightly in the later 20s. The chance of becoming and staying pregnant reduces by about three per cent every year. After age 35, this rate of fertility decline increases.

As the eggs age, more of them may become damaged. They are less likely to mature, be fertilized, and turn into a healthy pregnancy. By the time a woman reaches her 35th birthday, her chance of miscarriage goes up significantly. So does the possibility that she will have a baby with an abnormality of the chromosomes, such as Down syndrome. An option exists for women who want to delay pregnancy until later in life, or who must take strong medications (like chemotherapy for cancer) that can damage the eggs. They can harvest their eggs for storage outside of their bodies, preserving the quality. Fertility specialists are the best help for reviewing this fertility option.

Women should know that as they age, becoming pregnant is less likely even when using assisted reproductive technology. The chance of pregnancy is 40 per cent in women younger than age 35, 31 per cent in women aged 35 to 37, and 22 per cent in women 38 to 40.

The egg factor

Once released from the ovary during ovulation, the mature egg floats into the fallopian tube. It parks there for about 12 to 24 hours before the body absorbs it. Sperm must swim from the vagina, through the cervix, into the uterus and up to the fallopian tube. Blockages along this sperm travel route can cause infertility. These blockages may be present from birth, as with an unusually shaped uterus. They can also develop over time, as with fibroids or endometriosis. As well, reproductive organ infections or procedures can create blockages.

A fertility specialist will do a thorough pelvic exam. Certain tests, including a pelvic ultrasound or hysteroscopy, can help tell whether there is a blockage. A hysterosalpingogram is an x-ray that uses dye to look inside the uterus and fallopian tubes, and the area around them.

The couple factor

In order for the egg to be fertilized by sperm, both must be in the same place at the same time. This meeting usually happens through intercourse, where a penis injects semen into the vagina. For many different reasons, this arrangement may not be possible. Some reasons include sexual function problems, same sex couples, or those without a partner. Infertility specialists are a great source of the latest available treatments and procedures that help make a baby possible. These procedures include:

• intrauterine insemination (IUI) and assisted reproductive technology (ART) such as vitro fertilization (IVF)
• use of donor eggs, donor sperm, previously frozen embryos, or donor embryos
• impregnating a woman (called a surrogate mother or gestational carrier) who will carry the baby in her uterus.

Once the sperm unites with the egg, they form an embryo. The embryo settles in the uterus. It implants in the lining of the uterus, called the endometrium. The endometrium is a spongy tissue very well supplied with blood. The embryo develops its own placenta, which gathers all the nutrients and other resources from the endometrium. This process is necessary for the embryo to grow into a baby ready to be born. Any problem with the many steps needed to implant an embryo and maintain a healthy placenta can lead to infertility.

Fertility concerns

If you have been trying to become pregnant without success, talk with your family doctor. A referral to a specialist may be helpful. At a fertility specialist visit, you can expect to be asked about:

• your sexual development and sexual function history
  
• your history of genital (reproductive organs) and sexually transmitted disease
  
• abnormal Pap tests
  
• any past procedures involving your reproductive or urinary systems
  
• medication and surgery history, as well as general health history.

Many factors must come together in just the right manner, at just the right time, to make and grow a baby. Many are beyond our control. However, advances in fertility science mean we may be able to fix or adjust some of them to help treat infertility. The chances of overcoming this issue have never been better.

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