Dr. Kalyani Nityanandan, 85-year-old cardiologist, has extensive knowledge and deep understanding of a gamut of health issues. Here, she delves into issues of infertility and childlessness and potential medical treatment in her breezy style.
A couple who have been married for a year or two go to a family function. Till a couple of decades ago, some elderly female relative was bound to ask the wife: What, no news? Irritating, but perhaps inevitable.
Today, the question hangs in the air, unvoiced – even the couple’s own parents hesitate to ask. This is now seen as a purely private matter for the young couple. This secrecy often leads to worry for the prospective grandparents. Are they planning, or is something wrong? Have they sought medical help? And on a darker note: if something is wrong, is it the man’s “fault” or the woman’s?
Involuntary childlessness is sad, but it is nothing to be ashamed about, nor even a cause for dejection. Between them, the medical and legal professions have helped us to take giant steps towards fertility, conception, successful carriage to term, and adoption. I find that the related basic medical information is spottily communicated and often misunderstood. So let us start with a science lesson in simple language.
Reproductive facts
A female child is born already equipped with over 22,000 cells in each ovary, each of which is capable of producing an egg. During the menstrual cycle one of them swells and forms what is called a Graffian follicle and contains the ovum. This happens around midway through the menstrual cycle. Then they swell, burst, and release the egg. The released ovum gets chemically attracted towards the fimbrial end of the fallopian tube and enters it.
Similarly, the testicles which lie inside the male’s scrotum contain cells which are capable of forming spermatozoa, which is the male equivalent of the ovum. During sexual intercourse, the ejaculated liquid called semen contains spermatozoa in many millions. These have a head and tail, resembling microscopic tadpoles. They are capable of making a swimming effort that would make any Olympic champion gasp. Once released into the vaginal tract, they swim up the cervix into the uterine cavity and enter the fallopian tube where they meet the ovum. The single sperm that wins the race loses its tail, and then its head penetrates the outer covering of the ovum. This is the magic moment of mating, when the genetic material of the male bonds with its counterpart from the female to create new life.
When a couple seeks medical help for childlessness, doctors first investigate the woman for general maladies like metabolic diseases, thyroid deficiency and diabetes. They finally seek rarer conditions like pituitary dysfunction. Any of these can disrupt the process of fertility.
Female infertility
Once these health issues are ruled out, attention is turned to the more direct obstacles to childbearing. When a young woman begins to menstruate, many hormones spring into action. They must sustain their activity, and the moment of ovum implantation requires an even more intense burst of hormonal activity. All this can be detected, first by vaginal examination. If a woman is menstruating normally, she is unlikely to be completely sterile. Hormonal activity can be estimated and corrected. Many defects in the menstruating cycle or conditions like a polycystic ovary (where many egg-forming cells swell without maturation) can be easily treated. Many physical defects in the uterus are also correctable.
Related reading: Pre-conception care for a healthy pregnancy
An ultrasound scan of the pelvis and abdomen will enable the doctor to visualize the uterus, ovaries and tubes. The same scan can be done from the seventh day of the menstrual cycle and followed up daily. It will show the formation of the follicle and the maturation and release of the ovum. If all these things are taking place normally, the advice given to the couple is to have sex as many times as possible within these two or three days. That should eventually lead to pregnancy. Any failure of the follicle formation or release can be treated. Stimulating the ovary with medication can result in multiple follicles and hence multiple pregnancies.
Male infertility
The husband will also undergo examination. The main thing is to examine his semen for spermatozoa count, motility (i.e., the ability of the sperm to swim fluently) and defects. A needle biopsy of the testicles will show whether the sperm generation is normal. If the count is low, the semen can be concentrated after expressing, and then introduced into the uterine cavity with a syringe during the correct stage of menstruation. This can be repeated for several menstrual cycles.
Sperm donation
But what if there are no sperm that all? This condition is called azoospermia. In this case, the man should accept that he cannot father a child. The couple can then consider a sperm donor. The emotional implications to the couple should be discussed carefully. At least the ovum will be from the wife, and there is no bodily contact with another man involved in this process. The donor of the sperm will be chosen by the doctor to, as far as possible, physically resemble the husband. The strict secrecy is always maintained. The donor is unaware of the recipient couple, and vice versa. For this to work, the man must have a mindset and a desire to become a father. He must take personal ownership of the child that his partner is carrying, never feeling that it is someone else’s child.
Erectile dysfunction
A common misconception is that a male cannot be sterile if he has full sexual function, called virility. Conversely, a male with erectile dysfunction need not be sterile at all. Even if he performs just once a year, and even if he is only able to perform feebly, depositing the semen on the woman’s external genitalia, his partner can still get pregnant if she is in midcycle. By contrast, a virile male with azoospermia can perform a dozen times a day with no hope of pregnancy.
Viagra and other solutions
In the last century was no solution for this problem. People used to resort to various quack remedies like lehiyam or powdered rhino horn. Now we have several solutions. At first came injections which dilate the blood vessels and produce erections. Then came Viagra and allied drugs. There is even a mechanical solution, a bag filled with gel which is implanted under the skin of the groin. A tube leads from the bag to the penis. When ready to act, squeezing the gel the bag into the tube produces an erection. Once the act is over gel can be squeezed back into the bag.
In vitro fertilization
If the couple have no known problem and there is still no conception taking place, they can consider in vitro fertilization, or IVF. This means that the fertilization takes place outside the body. IVF begins with an ultrasound ovulation study, followed by hormonal stimulation so that more than one follicle forms. Under ultrasound guidance the ova are all removed from the woman’s body. Under a microscope, they are mixed with the husband’s semen, and fertilization takes place in the laboratory – in vitro, meaning in a ceramic or glass container.
When the process is complete, the fertilized ova are kept under suitable conditions and allowed to grow for four or five days. Then one or two of them are introduced into the uterine cavity, which is already prepared to receive them. If there are more fertilized ova, they are frozen to be used when needed. The products of conception are carefully watched and monitored.
Surrogate mother
The other problem can be that the pregnancy is not sustained, resulting in repeated miscarriages. One option in this case is the surrogate mother. This process is very similar to IVF, except that the products of conception get placed into the womb of another woman. She is carefully chosen by the doctor. Strict secrecy is maintained, so that the couple will not know who the surrogate mother is, and she does not know whose baby she will be carrying. The surrogate mother has no legal claim on the baby.
Read more by Dr. Kalyani
Patient Centred Tips For Cardiac Rehabilitation
Staying Afloat During Corona Or Coronary Crisis
3rd Sept 2022: With deep regret we wish to inform our readers that Dr. Kalyani Nityanandan passed away a few weeks back. We will always be grateful for her contributions to the PatientsEngage community.
