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20th December 1998

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Beating infertility

By Wathsala Mendis

Barren! Childless! These are 'dreaded' words that leave many people with a feeling of inadequacy, particularly in Asian societies. But did you know that male and female infertility has been increasing over the past 50 years, so much so that in Britain, as many as one in six couples may seek specialist help? Did you also know that apart from genetic factors, pollution, smoking, alcohol, and sexually transmitted diseases are also believed to play a role? Therefore, it does seem as if low fertility is here to stay.

Two major social changes have been attributed to this recent trend in childlessness:

Delayed childbearing due to an increasing number of women opting for careers and education and the increasing opportunity for people to separate the pleasure of sexual activity from its reproductive function or in other words the prevelants of contraception.

Changing disease patterns in the reproductive system amongst different communities and countries also play their part.

How should infertility be defined? A couple in the reproductive age group who have not conceived after 12 months of normal sexual practice, without contraception, should be regarded as potentially infertile and deserve an evaluation. The management of such a couple involves four areas: the diagnostic evaluation; the treatment programme; the adjustment to infertility and the choosing of an alternative avenue to parenthood.

It is important for both husband and wife to be investigated simultaneously. Openness and a willingness to answer questions regarding personal matters such as the stability and cooperative basis of the couple's relationship, the adequacy of their sexual adjustment, their readiness for parenthood, and the genuineness of their motivation to have children are also important factors.

According to researchers the percentage of women with infertility differs with age:

15-24 4.1%
25-34 13.1%
35-44 21.4%
(National Center for Health Statistics Magazine, August 1993)

Male infertility is also known to increase after 40 years of age. (Chatelaine Magazine, November 1993, pg.26)

* Inadequate egg production : Some women fail to ovulate (produce eggs) and may also not menstruate. Other women menstruate, but do not produce eggs. After menopause (when menstruation ceases) no eggs are produced and in some women this can occur as early as 25-35 years. This is known as 'premature menopause.'

* Abnormal fallopian tubes: An infection in the tubes can result in the closure of the mouths at one or both ends, thus stopping the sperm reaching the eggs. Tubes can also be open but fixed by adhesions from old infections or a disorder known as 'endometriosis,' in which the endometrium grows in other parts of the pelvis. This sets off inflammation which tethers the tubes and stops them from picking up the eggs.

* Cervical problems: The cervix is the narrow outlet at the bottom opening of the uterus through which sperm have to pass. The cervix produces mucus which, by changing its character, can enhance or prevent the passage of sperm through it.

* Problems in the uterus: The embedding of the fertilized egg in the uterus also depends upon several critical developments, some of which are not yet fully understood. Sometimes the lining is too thin, while in other instances the uterus is affected by tumours such as fibroids or by infection.

* Problems with the sperm: The production of sperm is a complex process. A fertile man produces a semen sample with a volume of 1-3ml, and has an excess of 20 million sperm per ml, a sperm motility of 60 percent and only 20-30 percent abnormal forms (abnormalities in morphology). Many men have caused pregnancies with sperm counts well below these ideal standards. Sperm counts also vary considerably from day to day or week to week. And a good sperm count does not necessarily ensure that sperm will have the ability to fertilize eggs. Men with low sperm counts are referred to as 'oligospermic' and those without any sperm are defined as 'azoospermic.'

* Unexplained infertility: Strangely enough this is a relatively common condition in which extensive tests have failed to identify any obvious abnormality in either partner. Many couples classified as suffering from 'unexplained' infertility do bear children over a period of time. It seems, however, that after two years the chances of this happening are less likely. The success rate is also reduced with increasing age of the female partner. The overall fertility of women over the age of 40 is reduced even if they have had babies before.

(Source: IVF and Fertility Centre)

Diagnosis and treatment of infertility

A routine diagnostic workup includes taking a thorough history a complete and detailed family history, past medical history, sexual and social history and doing a complete physical examination which would detail abnormalities found in systems other than the reproductive one. The minimum investigations required are a semen analysis for the husband and an assessment of ovulation and tubal patency in the wife. It is important for the basic infertility evaluation to be completely and thoroughly explained to the couple.

A final verdict of infertility is always traumatic and is accompanied by feelings of low self-esteem, guilt, despair, and confusion. Once a couple work through and resolve their emotional reactions to infertility, they can choose from among a number of options:

* Receive treatment for diagnosis

* Attempt assisted reproductive technologies such as Artificial Insemination - husband or donor (if the male partner is infertile), In Vitro Fertilization (IVF) or Gamete Intra Fallopian Transfer (GIFT)

* Adopt a child in their own culture

* Adopt trans-culturally

* Become foster parents

* Remain childless

Assisted Reproductive Technologies

* In Vitro Fertilization (IVF) This was a breakthrough for women who had blocked fallopian tubes, preventing the egg from fusing with the sperm. This method is used where tubal surgery would not be successful. More recently, IVF has been used to help couples with other problems such as endometriosis, hostile cervical mucus, anti-sperm antibodies, and oligospermia.

How is IVF performed? Eggs are collected in the vaginal route by inserting a fine needle with ultrasound guidance, whilst the patient is anaesthetized or sedated. Originally, IVF was performed by collecting eggs by laparoscopy under general anaesthesia. In this procedure a small cut is made just below the navel so that the laparoscopic telescope can be inserted. This method is now mainly used on those undergoing the GIFT procedure.

How is GIFT carried out?

At the moment GIFT can only be carried out by means of laparoscopy, since this is the only safe way to reintroduce the eggs and sperm into the fallopian tubes. A general anaesthetic is, therefore, required and there is little more discomfort after the laparoscopy than with vaginal egg collection.

Advantages of GIFT

Results worldwide report a success rate of approximately 25 per cent which is roughly five per cent higher than IVF. This is probably because the fallopian tube provides a better environment for fertilization and for the fertilized egg to develop.

The disadvantages

Since the procedure involves a laparoscopy it does carry a slightly increased risk of injury to the bowel and blood vessels of the pelvis. The risk of hyperstimulation of the ovaries is just the same as with IVF.

Theoretically it might be expected that more ectopic pregnancies occur (pregnancies in the fallopian tubes or elsewhere in the pelvis). In practice, however, this does not seem to be the case.

* Artificial Insemination (AI) There are two forms of AI AIH, ie Artificial Insemination using freshly prepared semen from the husband or partner and DI, ie Artificial Insemination using frozen prepared donor semen. The semen is injected directly into the uterine cavity through the cervix.

The indications for AIH and DI

AIH is useful to couples who have unexplained infertility, where no obvious abnormality can be detected, or in selected cases of sperm-mucus hostility problems. This is useful where the male partner has a serious sperm problem, either severe oligospermia or azoospermia.

Results of AIH and AID

Inevitably this method is not as successful as IVF or GIFT. Each attempt, however, achieves a pregnancy rate of between 5-15 percent. As with IVF and GIFT, with increased attempts there is an increased chance of pregnancy so that after 10 attempts the chance of pregnancy is 50 per cent. Clearly this method per cycle is less successful than IVF and GIFT, but it is much cheaper and over a period of time can achieve good results. The number of eggs, however, is unknown and the ability of the sperm to fertilize the eggs is unknown.

(Source: IVF and Fertility Centre)

Of the above reproductive technologies, only Artificial Insemination and sperm processing with Intra Uterine Insemination are available in Sri Lanka.

Infertility treatment can be effective for many couples, provided that the full range of appropriately utilized diagnostic and treatment facilities are available.

However, the situation in Sri Lanka is far from ideal and leaves much to be desired.

Controlling pests with a local touch

Neem to the rescue as a super biopesticide

A view from the hillsAt a recent Workshop sponsored by GTZ and UNIDO and conducted by the PGIA and Gemi Seva Sevana at Peradeniya, Professor H.P.M Gunasena said that Neem, which was used for various purposes by the rural committees, is a superb biopesticide agent. The pesticide and medical applications of Neem have aroused growing interest world-wide but the tree still needs to be exploited here.

While we continue to import large quantities of pesticides which are harmful to the people and the environment, the Neem tree's potential is largely ignored.

As Professor Gunasena observed, "The tragedy began when we chemicalised agriculture, using packages from abroad. Our indigenous knowledge of tree products were never used and anything indigenous was never considered." He stressed the need to develop products of Neem and called for a national research agenda with private sector participation.

Dr. C Kudagamage, Research Officer with the Department of Agriculture, said that Neem could be used to control insect pests of vegetables such as cabbage and brinjal at a cost far lower than that of synthetic pesticides.

GTZ representative, Dr. Peter H. Forster of the Pesticide Service Project, said that Sri Lanka has high potential to use Neem for crop protection and also in the encouragement of Neem plantations. It made sense because of the ecological and economic benefits.

Indeed, GTZ, has been interested in Neem for several years for plant protection, forestry, rural development and health programmes.

Well, we all know of the Neem's healthy properties. Here, in Kandy, many believe that a Neem tree standing in the garden before the house means good health.

PGIA's external links

The Post Graduate Institute of Agriculture, Peradeniya, has developed external links with CAB International; the Systems Group Institute of Agriculture, University of Sterling, U.K and the M.S Swaminathan Foundation of Chennai, India.

Professor H.P.M. Gunasena, the Institute's Director, tells me that these links are strengthening the research undertaken by PGIA staff and students and will lead to staff exchanges and the formulation of joint research proposals.

As it is, an external review of the PGIA is under consideration, where the aim will be to improve quality of student output, determine mission policies and strategy and reassess the quality of relevance of degrees offered, the effectiveness of management and a better state of inputs and accomplishment.

The UNDP has accepted a PGIA proposal and will assist in revising existing courses and programmes.

Were those figures over scanned?

Talked with Dr. Jayasinghe, Kandy General Hospital's Radiologist last week. Actually, he was scanning me, but that's another kettle of fish altogether.

He is rather irked by a report in a Sinhala newspaper about the Total Body Scan facilities at the hospital. As he said, the report had got its figures a trifle over-scanned. Kandy hospital has had this CT Scan facility for the past four years and it was not long ago that the Government authorised the hospital to serve private paying patients as well. This has been a great service to those who have hitherto paid or been asked to pay big money for head and abdominal scans.

Normally, Dr. Jayasinghe said, the hospital charges outside paying-patients Rs 2500 for a head scan and Rs 4500 for an abdominal scan.

These rates are low compared to the rates charged by certain other private institutions. In some places, I was told, an abdominal scan can cost up to Rs 7000 and a head scan Rs 3000 or more.

Also, he said the report claims that the hospital can only perform a very limited number of scans per day. "This is not correct. We can take in any number of patients for scanning each day."

So was the story planted to deter patients from seeking scanning at the Kandy hospital? Your guess is as good as mine!

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