Infertility is a condition of the reproductive system that impairs the conception of children. The diagnosis of infertility is usually given to couples who have been unable to conceive a child after 12 months of regular sexual intercourse without birth control.

• Primary infertility means they have never had a child.
• Secondary infertility means that the infertile person has had one or more children in the past, but a medical problem is impairing fertility.

Many people may be infertile during their reproductive years. They may be unaware of this because they are not seeking to create a pregnancy. At any given cycle, for a normally ovulating woman who tries to conceive on D12-D16, her chance of conceiving is 25%.This explains why conception does not take place every month even when all other factors are normal. However the chances tend to increase every cycle and within 6-10 cycles, the couple’s chance of making a pregnancy reaches about 95%.If nothing has happened, and then medical advice should be sought.Factors which explain why pregnancy does not happen each time a woman has sexual intercourse on good fertility days and she has ovulated may be as follows:

• The fallopian tubes may not have picked up the egg/s
• The egg( oocyte), may be of poor quality
• The fertilised egg may not cleave and further development within the fallopian tube may cease
• The embryo within the fallopian tube as it moves in the direction of the uterus may die
• The endometrial cavity, may not be receptive to the incoming embryo
• The sperms may not have reached the fallopian tube. This can be due to poor cervical mucus , sperm antibodies,etc

More than one sperm may have fertilised the egg. When this happens, of no conception will take place. There will be more than 46 chromosomes. A normal human being has 46 chromosomes(23 from the egg and 23 from sperms).If two sperms enter the egg, there will be 69 chromosomes and therefore this is not compatible with life

Conception and pregnancy are complicated processes that depend upon many factors namely: 1) the production of healthy sperm by the man; 2) healthy eggs produced by the woman; 3) unblocked fallopian tubes that allow the sperm to reach the egg; 4) the sperm's ability to fertilize the egg when they meet; 5) the ability of the fertilized egg (embryo) to become implanted in the woman's uterus and; 6) sufficient embryo quality. In order for the pregnancy to continue to full term, the embryo must be healthy and the woman's hormonal environment adequate for its development. When just one of these factors is impaired, infertility can occur.

The natural conception
When does conception take place under natural conditions?
The natural conception takes place when the sperm cells, after intercourse, swim up through the neck of the uterus and into the uterine tubes where they meet the egg and fertilise it. After the fertilisation of the egg in the uterine tube the egg leaves, and after a couple of days the fertilised egg has moved down though the uterine tube and into the uterus. In the uterus the egg adheres to the endometrium and develops into a baby. This process is illustrated below:

In order for this process to take place it is important that the woman produces mature eggs, has an ovulation, has passage through the uterine tubes, and that the man’s sperm quality is all right.
The Causes of Infertility
In any given community, 15% of the people will suffer from infertility .However the aetiologies may vary from country to country depending upon the causes prevailing in that community. In the developing world, for example, there is likely to be more infectious causes that in the developed world. The causes of infertility for example in East Africa can be outlined as follows:
1. Blocked or non functioning fallopian tubes (due to infection or prior pelvic surgery) - 35%
2. Male factor (this includes, low sperm count/azoospermia/ sperm antibodies) -20%
3. Unexplained causes (this is defined when no apparent cause can be identified)-25%
4-PCO &anovulation (PCO=polycystic ovaries)-15%
5-Endometriosis (when cells of the lining of the womb are outside the uterus)-5%
6-No eggs (oocyte).This may be due to premature ovarian failure, early menopause or menopause-(after 45years)
Life style can also contribute to infertility. For example it has been shown by researchers that Obesity and heavy smoking (both passive and active) can reduce the chances of conceiving.
People used to think that hot baths and tight under pants contributes to infertility, but the majority of fertility experts including myself do no think so.
It is important tat the couple who are trying for a baby knows exactly the reproductive anatomy and physiology. They should know the best fertility days and try to have sexual intercourse around these days. For example women who menstruate every 28 days or so, will normally ovulate around day 14 prior to her next period. So if sexual intercourse is performed around D12-D16, there is a good chance that she is likely to conceive.D1 is the first day of the menses. A woman should make herself a calendar and be able to know when likely to try is based on the days as shown above.
There are some kits which can also help, e.g. LH ovulation kits and Basal temperature charting
Research shows that having sex every day or even several times each day both before and during ovulation is the best way to achieve pregnancy. The sperm count may be lower when sex is this frequent, but the constant release of semen may be more likely to fertilize the egg.
During the menstruation the ovaries contain several small follicles, each of them containing an egg. The pituitary gland releases the hormone FSH (Follicle stimulating hormone – this is formed in the pituitary gland and stimulates the growth of the follicles) which mature the eggs which leads to the development of one single follicle to be approximately 20mm in size. When the follicle is mature, the ovulating hormone LH is released. (Luteinizing Hormone – this is formed in the pituitary gland and causes ovulation). The hormones are interdependent, and for some hormones the rule is that an increase in one hormone results in a decrease in another
Women who have problems with maturation of the eggs and the ovulation can often be helped through medication. For some women irregular menstruation can be compared with a clock that is wrong. We set the clock right through medication, and the menstruation and the ovulation will become regular. Usually we combine the medical treatment with insemination (IUI) or in vitro fertilisation (IVF).

Male causes of infertility
Male causes of infertility are usually poor sperm quality.
Poor sperm quality can be caused by:
Lacking sperm production in the testicles
Non-descended testicles
Infections
Fewer
Testicle cancer
Antibodies in the sperm cells
Congenital absence of Vas (tube that takes sperms to a reservoir)

Conclusion
Proper understanding of the causes of infertility and with proper educative awareness will go a long way to reduce this problem in any community. For example since 90% of tubal blockage is due to termination of pregnancies, avoidance of this menace through educational awareness by parents and schools will for sure reduce this problem. Also women should be encouraged to get children early enough before they reach the age of 40.After the age of 40, fertility decreases sharply.

Treatment
This depends upon the causative nature of the problem. For blocked tubes, one should carry out a laparoscopy to determine the nature of the problem. And where possible to carry out pelvic salpingolysis.Where this technique is not available, then IVF (test tube baby treatment) is the only choice.Tubal washing-has no place in the modern management of tubal blockage. It is not even mentioned in the modern text book of infertility. At times it can even cause tubal infection. Men with low sperm count can be helped with IUI (intra uterine insemination) and IVF/ICSI and an ovulation can be helped with drugs like clomiphene, FSH etc
For more information, please contact:
Dr Tamale Sali FRCS; FRCOG (UK)

Women’s Hospital International, Ntinda Road, Bukoto, Kampala.
Tel: +256 414 541361. Mobile: +256 772 520248. + 256782227393(Fertility Co-ordinator)
Email: info@womens-hospital.net or drsali@hotmail.com
Website: www.womens-hospital.net