INFERTILITY AMONG MARRIED COUPLES: THE ROLE OF THE SOCIETY

CHAPTER ONE

1.1. INTRODUCTION

Infertility is a disease of the male or female reproductive system defined by the failure to

achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse

(WHO, 2018). Infertility affects millions of people of reproductive age worldwide – and has

an impact on their families and communities. Estimates suggest that between 48 million

couples and 186 million individuals live with infertility globally. (Mascarenhas, Flaxman &,

Boermal, 2012, Boivin, Bunting & Collins, 2007, and Rutstein & Shah 2004) In the male

reproductive system, infertility is most commonly caused by problems in the ejection of

semen (WHO,2018). absence or low levels of sperm, or abnormal shape (morphology) and

movement (motility) of the sperm. In the female reproductive system, infertility may be

caus..ed by a range of abnormalities of the ovaries, uterus, fallopian tubes, and the endocrine

system, among others. Infertility can be primary or secondary. Primary infertility is when a

pregnancy has never been achieved by a person, and secondary infertility is when at least one

prior pregnancy has been achieved. Fertility care encompasses the prevention, diagnosis and

treatment of infertility. Equal and equitable access to fertility care remains a challenge in

most countries; particularly in low and middle-income countries. Fertility care is rarely

prioritized in national universal health coverage benefit packages.

Infertility can lead to severe strain in a couple’s relationship, their childlessness is a major

theme of their lives, children are highly desired, parenthood is culturally mandatory &

childlessness socially unacceptable

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1.2. DEFINITIONS OF INFERTILITY

Infertility is defined as the inability to establish a pregnancy within a specified period, usually

one year, in a couple having regular unprotected sexual intercourse (Harzif, Santawi, and

Wijaya 2019; Bayu, Egata, Kefale & Jemere, 2020).

Araoye (2003) defined infertility as a health problem with devastating psychosocial

consequences on the couples. Infertility means failure to get conceived after at least one year

of unprotected intercourse, regularly, usually two to three times a week. Basically, there are

three types of infertility namely: primary infertility, secondary infertility and unexplained

infertility. The primary infertility is a situation that a couple had never conceived after several

attempts of continuous sexual cohabitation.

Alli et. al (2011) defined primary infertility as the failure of the woman to conceive after a

year of having regular sexual intercourse. Hollos and Larsen (2008) asserted that primary

infertility is the state of couples who cannot have babies at all and is usually measured by

failure to achieve pregnancy after years of trying. It is a condition in which a woman is

unable to have a child, as a result of inability to become pregnant or the incapacity to carry a

pregnancy to a live birth. The secondary infertility is the most common type of infertility

across the globe (Inhorn & Patrizio, 2012).

It is often due to reproductive tract infections (RTIs), which if left untreated, damages a

woman’s fallopian tubes and causing irreversible tubal blockages. Secondary infertility arises

when couple is unable to have another child, either due to infection or inability to carry

another pregnancy to live birth after previous birth. Although, the findings of Deshpande and

Gupta (2019) accounted that primary infertility is more prevalent than secondary infertility.

Unexplained infertility is the inability to find the cause of the infertility. In some cases, the

medical profession would conduct physical and laboratory examination on couples that find it

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difficult to achieve pregnancy and communicate to them that, there was nothing wrong with

them. The result may be positive, and it is expected that they will achieve pregnancy shortly

after being diagnosed of being free of infection or anatomical malfunction. This could be

termed unexplained infertility since no cause is identified. Infertility is a very damaging

condition that does not only affects couple but also exposes them to emotional, physical and

financially stress.

1.3. TYPES OF INFERTILITY

The following are the two (2) main types of infertility:

 Primary infertility

 Secondary infertility

Primary infertility:

Primary infertility is a term used to describe a couple that has never been able to conceive a

pregnancy after a minimum of 1 year of attempting to do so through unprotected intercourse.

Causes of infertility include a wide range of physical as well as emotional factors (John et al.,

2022).

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 Fig. 1 Primary infertility

Secondary Infertility

Secondary infertility is the inability to conceive a child or carry a pregnancy to full term after

previously giving birth. To classify as secondary infertility, the previous birth must have

occurred without help from fertility medications or treatments, like in vitro fertilization.

Secondary infertility typically is diagnosed after trying unsuccessfully to conceive for six

months to a year. A related condition is recurrent pregnancy loss where patients and couples

are able to conceive but are unable to carry to term.

Secondary infertility can be traced to either partner or both partners. About one-third of cases

originate in women and about one-third originate in men. In the remaining one-third, the

cause is due to a combination of factors or isn’t known. Increased age, complications from a

prior pregnancy or surgery, increased weight, medications, sexually transmitted infections,

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impaired sperm production, alcohol abuse, and smoking are all examples of secondary

infertility.

Causes of secondary infertility in women include:

 Problems in the quantity or quality of eggs: Women are born with a limited supply

of eggs and are unable to create new eggs after birth. As women approach their 40s

and beyond, the numbers of eggs left in their ovaries decrease, and the remaining eggs

have a higher chance of having chromosomal problems. For women where age isn’t a

concern, there are other reasons that they might have a low number of good quality

eggs, including autoimmune or genetic conditions and prior surgery or radiation.

 Problems with the fallopian tubes: The fallopian tubes, which carry eggs from the

ovaries to the uterus, can become blocked due to pelvic infections such

as chlamydia or gonorrhea.

 Problems with the uterus: There are many conditions related to the uterus that can

cause secondary infertility. Scarring can occur during a dilation and curettage

(D&C) or Cesarean delivery that can create adhesions inside the uterus that interfere

with future pregnancies. Fibroids or polyps are benign (non-cancer) growths inside

the uterus that can impair pregnancy. A retained placenta can cause infection and

uterine scarring.

 Endometriosis: Endometriosis is a condition where tissue that normally grows inside

the uterus grows elsewhere in the body, such as on the ovaries or bowel surfaces.

While endometriosis is common, not all endometriosis causes infertility.

 Polycystic ovary syndrome: This is a hormonal disorder characterized by longer-

than-normal or infrequent menstrual periods. A woman with this condition has an

excessive number of male hormones, and the ovaries fail to release eggs regularly.

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  Breastfeeding: If a woman feeds her baby only by breastfeeding, her body stops

ovulating or releasing eggs for potential fertilization.

 Weight gain or other lifestyle changes: Weight gain can lead to ovary dysfunction

in some patients. Certain diets may effect fertility. Medications may also effect

fertility.

The causes of secondary infertility in men

Causes of secondary infertility in men include:

Reduced Testosterone Level: Testosterone plays a key role in sperm production.

Testosterone levels can decline due to aging, injury to urinary or genital organs, or certain

medical conditions. These conditions include: Genital infections, Thyroid diseases, Diabetes,

Tuberculosis, Mumps, Smallpox, Blood diseases, Benign tumors, Emotional stress,

Myocardial infarction, Coma, Stroke, Respiratory failure. Congestive heart failure, Burns,

Sepsis, which is a potentially life-threatening reaction to infection, Surgery in the genital

tract, The presence of mycoplasma, which is a type of bacteria and Anesthesia.

Testicular Varicocele: This is an enlargement of veins in the scrotum, or the sack of skin

encasing the testicles. This condition is a common cause of low sperm production and

infertility in men. About 30% of infertile men have testicular varicocele.

Poor-Quality Semen: Semen is the fluid that carries sperm. After age 40, the quality of

semen tends to decline.

Prostate Enlargement: This can lower sperm count and hinder a normal ejaculation (the

discharge of semen from the body).

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Prostate Removal: The prostate may be removed due to cancer or other conditions. Removal

of the prostate can cause semen to flow backward.

Late-Onset Hypogonadism: This is a condition where there is a reduction of hormone

secretion.

Certain Drugs Affect Sperm Count and Quality: These drugs include some antibiotics and

medication that treat high blood pressure. Sperm quality can also be affected by treatments

for the following conditions: Prostate cancer, Enlarged prostate, Fungal infections, Stomach

acid, Urinary tract infections, Ulcerative colitis, Arthritis, Gout, Pain, Cancers, Seizures and

Schizophrenia.

Use Of Certain Commercial Sexual Lubricants That Are Toxic To Sperm: Nontoxic,

natural lubricants include peanut, safflower and vegetable oils, raw egg white and petroleum

jelly.

Exposure to Certain Chemicals: Being exposed to pesticides, lead, industrial chemicals and

excessive heat can all impact a man’s fertility.

Excessive Weight Gain: This can decrease testosterone levels and increase estrogen levels.

Signs of secondary infertility

If a man and woman 35 or younger have had unprotected sex for at least 12 months (or six

months if older than 35) without getting pregnant, they should suspect secondary infertility.

This especially applies to women older than 30 who have experienced pelvic inflammatory

disease, painful periods, irregular menstrual cycles or miscarriages, and to men with low

sperm counts.

1.4. CAUSES OF INFERTILITY

1.4.1. Male

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Male infertility is responsible for 20–30% of infertility cases, while 20–35% are due

to female infertility,( ART fact sheet, 2014) and 25–40% are due to combined problems in

both parts. In 10–20% of cases, no cause is found. The most common cause of female

infertility is ovulatory problems, which generally manifest themselves by sparse or absent

menstrual periods (NIH, 2017). Male infertility is most commonly due to deficiencies in

the semen, and semen quality is used as a surrogate measure of male fecundity (cooper,

Noonan, Eckardstein, Auger & Behrt, 2010).

Iodine Deficiency

Iodine deficiency may lead to infertility (Mathews, et al., 2021)

Natural infertility

Before puberty, humans are naturally infertile; their gonads have not yet developed

the gametes required to reproduce: boys' testicles have not developed the sperm cells required

to impregnate a female; girls have not begun the process of ovulation which activates the

fertility of their egg cells (ovulation is confirmed by the first menstrual cycle, known

as menarche, which signals the biological possibility of pregnancy). The absence of fertility

in children is considered a natural part of human growth and child development, as

the hypothalamus in their brain is still underdeveloped and cannot release

the hormones required to activate the gonads' gametes. Fertility in children before the ages of

eight or nine is considered a disease known as precocious puberty. This disease is usually

triggered by a brain tumor or other related injury (Precious Puberty, 2021).

Delayed puberty

Delayed puberty, puberty absent past or occurring later than the average onset (between the

ages of ten and fourteen), may be a cause of infertility. In the United States, girls are

considered to have delayed puberty if they have not started menstruating by age 16 (alongside

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lacking breast development by age 13). (Ferri, 2018). Boys are considered to have delayed

puberty if they lack enlargement of the testicles by age 14. Delayed puberty affects about 2%

of adolescents. (Howard & Dunkel, 2018).

Most commonly, puberty may be delayed for several years and still occur normally, in which

case it is considered constitutional delay of growth and puberty, a common variation of

healthy physical development. Delay of puberty may also occur due to various causes such

as malnutrition, various systemic diseases, or defects of the reproductive

system (hypogonadism) or the body's responsiveness to sex hormones (Ferri, 2018).

Immune infertility

Antisperm antibodies (ASA) have been considered as infertility cause in around 10–30% of

infertile couples (Restrepo & Cardona-Maya, 2013). In both men and women, ASA

production are directed against surface antigens on sperm, which can interfere with sperm

motility and transport through the female reproductive tract, inhibiting capacitation

and acrosome reaction, impaired fertilization, influence on the implantation process, and

impaired growth and development of the embryo. The antibodies are classified into different

groups: There are IgA, IgG and IgM antibodies. They also differ in the location of the

spermatozoon they bind on (head, mid piece, tail). Factors contributing to the formation of

antisperm antibodies in women are disturbance of normal immunoregulatory mechanisms,

infection, violation of the integrity of the mucous membranes, rape and unprotected oral or

anal sex. Risk factors for the formation of antisperm antibodies in men include the

breakdown of the blood-testis barrier, trauma and surgery, orchitis, varicocele,

infections, prostatitis, testicular cancer, failure of immunosuppression and unprotected

receptive anal or oral sex with men (Rao, 2013).

Sexually transmitted infections

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Infections with the following sexually transmitted pathogens have a negative effect on

fertility: Chlamydia trachomatis and Neisseria gonorrhoeae. There is a consistent association

of Mycoplasma genitalium infection and female reproductive tract syndromes. M.

genitalium infection is associated with increased risk of infertility( Lis et al., 2015).

Genetic

Mutations to NR5A1 gene encoding steroidogenic factor 1 (SF-1) have been found in a small

subset of men with non-obstructive male factor infertility where the cause is unknown.

Results of one study investigating a cohort of 315 men revealed changes within the hinge

region of SF-1 and no rare allelic variants in fertile control men. Affected individuals

displayed more severe forms of infertility such as azoospermia and severe oligozoospermia

( Ferraz & Achermann, 2011).

Small supernumerary marker chromosomes are abnormal extra chromosomes; they are three

times more likely to occur in infertile individuals and account for 0.125% of all infertility

cases.[36] .

Other causes

Factors that can cause male as well as female infertility are:

DNA damage

DNA damage reduces fertility in male sperm, as caused by oxidative DNA damage, smoking,

other xenobiotic DNA damaging agents (such as drugs or chemotherapy) or other DNA

damaging agents including reactive oxygen species, fever or high testicular temperature. The

damaged DNA related to infertility manifests itself by the increased susceptibility to

denaturation inducible by heat or acid or by the presence of double-strand breaks that can be

detected by the TUNEL assay ( Gharagozloo & Aitken, 2011).

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1.4.2. Female infertility

The following causes of infertility may only be found in females. For a woman to conceive,

certain things have to happen: vaginal intercourse must take place around the time when an

egg is released from her ovary; the system that produces eggs has to be working at optimum

levels; and her hormones must be balanced (About infertility & fertility problems, 2008).

For women, problems with fertilization arise mainly from either structural problems in

the Fallopian tube or uterus or problems releasing eggs. Infertility may be caused by blockage

of the Fallopian tube due to malformations, infections such as chlamydia or scar tissue. For

example, endometriosis can cause infertility with the growth of endometrial tissue in the

Fallopian tubes or around the ovaries. Endometriosis is usually more common in women in

their mid-twenties and older, especially when postponed childbirth has taken place (Lessey,

2000).

Another major cause of infertility in women may be the inability to ovulate. Ovulatory

disorders make up 25% of the known causes of female infertility. Oligo-ovulation or

anovulation results in infertility because no oocyte will be released monthly. In the absence

of an oocyte, there is no opportunity for fertilization and pregnancy. World Health

Organization subdivided ovulatory disorders into four classes:

 Hypogonadotropic hypogonadal anovulation: i.e., hypothalamic amenorrhea

 Normogonadotropic normoestrogenic anovulation: i.e., polycystic ovarian syndrome

(PCOS)

 Hypergonadotropic hypoestrogenic anovulation: i.e., premature ovarian failure

 Hyperprolactinemic anovulation: i.e., pituitary adenoma (Walker &Tobler 2020).

Malformation of the eggs themselves may complicate conception. For example, polycystic

ovarian syndrome (PCOS) is when the eggs only partially develop within the ovary and there

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is an excess of male hormones. Some women are infertile because their ovaries do not mature

and release eggs. In this case, synthetic FSH by injection or Clomid (Clomiphene citrate) via

a pill can be given to stimulate follicles to mature in the ovaries.

Other factors that can affect a woman's chances of conceiving include being overweight or

underweight, or her age as female fertility declines after the age of 30 (Female Infertility,

2020).

Sometimes it can be a combination of factors, and sometimes a clear cause is never

established.

Common causes of infertility of females include:

Ovulation problems (e.g. PCOS, the leading reason why women present to fertility clinics

due to anovulatory infertility) (Balen, Dresner, Scott & Drife, 2006). tubal blockage, pelvic

inflammatory disease caused by infections like tuberculosis, age-related factors, uterine

problems, previous tubal ligation, endometriosis, advanced maternal age and immune

infertility

1.5. MALE INFERTILITY

Male infertility is defined as the inability of a male to make a fertile female pregnant, for a

minimum of at least one year of unprotected intercourse. There are multiple causes for male

infertility. These include endocrine disorders (usually due to hypogonadism) at an estimated

2% to 5%, sperm transport disorders (such as vasectomy) at 5%, primary testicular

defects (which includes abnormal sperm parameters without any identifiable cause) at 65% to

80% and idiopathic (where an infertile male has normal sperm and semen parameters) at 10%

to 20% (Leslie, Siref, & Khan, 2020) .

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The male reproductive system creates sperm that is manufactured in the seminiferous tubules

within each testicle. The head of the sperm contains the DNA, which when combined with

the egg's DNA, will create a new individual. The tip of the sperm head is the portion called

the acrosome, which enables the sperm to penetrate the egg. The midpiece contains the

mitochondria which supplies the energy the tail needs to move. The tail moves with whip-like

movements back and forth to propel the sperm towards the egg. The sperm have to reach the

uterus and the fallopian tube in order to fertilize a woman's egg.

The main cause of male infertility is low semen quality. In men who have the necessary

reproductive organs to procreate, infertility can be caused by low sperm count due to

endocrine problems, drugs, radiation, or infection. There may be testicular malformations,

hormone imbalance, or blockage of the man's duct system. Although many of these can be

treated through surgery or hormonal substitutions, some may be indefinite (Mishail, 2009).

Infertility associated with viable, but immotile sperm may be caused by primary ciliary

dyskinesia. The sperm must provide the zygote with DNA, centrioles, and activation factor

for the embryo to develop. A defect in any of these sperm structures may result in infertility

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that will not be detected by semen analysis (Avidor, 2015). Antisperm antibodies cause

immune infertility. Cystic fibrosis can lead to infertility in men.

Combined infertility

In some cases, both the man and woman may be infertile or sub-fertile, and the couple's

infertility arises from the combination of these conditions. In other cases, the cause is

suspected to be immunological or genetic; it may be that each partner is independently fertile

but the couple cannot conceive together without assistance (Howard & Dunkel, 2018).

Unexplained infertility

In the US, up to 20% of infertile couples have unexplained infertility. In these cases,

abnormalities are likely to be present but not detected by current methods. Possible problems

could be that the egg is not released at the optimum time for fertilization, that it may not enter

the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur,

transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized

that egg quality is of critical importance and women of advanced maternal age have eggs of

reduced capacity for normal and successful fertilization. Also, polymorphisms in folate

pathway genes could be one reason for fertility complications in some women with

unexplained infertility (Dada et al., 2012). However, a growing body of evidence suggests

that epigenetic modifications in sperm may be partially responsible (Aston et al., 2015).

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 CHAPTER TWO

2.1. THE ROLE OF SOCIETY TOWARDS INFERTILITY

Infertility is regarded by the society and sometimes the people affected as a sociocultural

problem rather than the biomedical view the healthcare providers have of it. Infertility does

not just affect the couple as the families become involved and the family unit forms the core

of the society. Since a healthy society usually depends on a healthy family structure, any

disorder that affects the family also affects the society. Infertility is not solely a medical

problem because resultant psychosocial consequences such as anxiety, depression, marital

difficulties, societal stigmatisation have been reported (Daar & Merali, 2002). Public health

has recently stressed the need for there to be an intricate communal relationship between an

individual and the environment and since infertility affects the complete living experience

both qualitatively and quantitatively. It goes beyond individual problems but it is a societal

problem as about 1 in 10 of those in the reproductive age group experience different forms of

involuntary childlessness (Evans, 2004).

2.2. THE IMPACT OF INFERTILITY ON COUPLES

Infertility represents a major crisis for most couples, with both partners experiencing loss in

ways that affect them as individuals, as family members, and as members of society as a

whole. Examples of these losses include:

 Loss of the experience of pregnancy and birth

 Loss of the opportunity to pass on family genetics

 Loss of the chance to contribute to the next generation

 Loss of the chance to parent or become a grandparent

 Low self-worth and self-esteem

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  Loss of family stability

 Loss of sense of control over destiny

 Loss of sense of hope for the future

 Loss of work productivity

Infertility can have a highly negative impact on self-esteem, with individuals who previously

had successful and well-planned lives, suddenly feeling that they have lost control over their

destiny. A combination of the body failing to respond as expected, a sense that life has been

put on hold, and having to face the disappointment of failure to conceive month after month,

can leave both partners at an increased risk of depression (Sally Robertson, 2022).

2.3. SOCIAL AND CULTURAL IMPACTS OF INFERTILITY ON MARRIED

COUPLES

All human beings are expected to be treated with respect and dignity. That is why section

(18) of the 1999 Nigeria constitution, dealing with the fundamental principles of state policy

reflects the nation‘s commitment to equality of all irrespective of race, sex or gender

(Osokoya, 2008). According to Nwosu (2010) the number of children a man has determines

the socio-economic importance of the man. Childlessness demoralizes some of the affected

couples‘ zeal to accumulate wealth; this is because they view that wealth accumulated would

go to the community when they die. Because of this, most of the couples squander their

money while they are still alive, and as culture measures the political strength by the number

of children a man has, childless couples are not recognized in the society they find

themselves in a political desert. Nwapa (2004), explained that children help to render

valuable services and this create source of income on their father‘s farm land, cattle, rearing

and in agricultural pursuit, besides this, the females are source of income to their parents

when they get married. Childlessness seems to have major psychological and social

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implications for affected persons, especially in settings where fertility is highly valued.

However, childlessness is perceived in these societies and the multitude of adverse

consequences suffered by affected individuals, studies have not made a clear distinction

between voluntary and involuntary childlessness in these settings (Rasak & Oladipo, 2017).

Childlessness is not only a medical condition but it is also a social-cultural construct. The

weight of the crisis of involuntary childlessness cuts across socio-economic and religious

boundaries. Although couples might be clinically proven to be unable to have children, it

remains a socio-cultural issue where parenthood is ―given a pride of place‖ (Nwaomah &

Dube, 2018). The perception of these wishes is that society expects much from every

marriage than just the mere grand occasion that is witnessed on the day of marriage.

Problems arise when after a year or two and such marriages do not produce children. This

spells danger for the woman, and may lead to a replacement for another wife that is deemed

capable of procreating. Childlessness leads to stigmatization and the feelings of inferiority.

2.4. THE EFFECT OF CHILDLESSNESS ON THE COUPLE RELATIONSHIP

Childlessness often comes as an unexpected shock to most couples. For many, having

children is not a question of if, but when. Gayle (2014). The experience of childlessness by

childless women in most Nigeria communities is marked by various kinds of social,

economic and emotional consequences. Those experiences are in many ways similar to those

of childless women in other cultures. What most Nigerian childless women share with other

childless women is the feeling of low self-esteem due to their childlessness? They are often

described as being hollow, empty, barren or wasted and arid. Gray (2002) observed, that vast

majority of these childless women made no distinction between failed bodies and failed

selves. They seem to experience childlessness as a generalized role failure, not just as a

failure of the body. The feelings of guilt accompanying distress have also been found in

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studies of childless women in many Nigeria communities. Divorce, abandonment and

remarriage by husbands are more frequent outcomes of childless women. Mariano, (2004)

explanation of the status of married women in the family identifies the root cause of the

problem. In her ethnographic study on marriage, she points to the „stranger‟ role of a newly-

wed woman in her in-laws‟ house. This woman must prove her usefulness as a woman, in

order to contribute to the prosperity of her in-laws‟ family. The main way to show this is to

give birth to a baby. If she fails in this task, she remains a permanent stranger in the family,

and continues to hold a low status. Through bearing a child a newly-wed woman gains

acceptance and this is an experience that a childless woman never feels.

2.5. SOCIO-CULTURAL PERCEPTION OF CHILDLESSNESS AND MARITAL

STABILITY

Perceptions of childless individuals and community members, limit level of awareness about

the medical causes of and solutions to infertility (Amakwa, 2013). The Nigerian setting is

clouded with severe stigmatization, abuse of childless women. Childlessness has

socioeconomic and emotional consequences, in many families the husband may decide not

attend to the women financial or even regard her as anything. Other extended women calls

the childless woman different names, such as woman-man, just eating without fruitfulness,

and many of such women are excluded from their women age group. Childless women are

not passive victims as they have developed different coping strategies to seek solutions for

their childlessness and to deal with the stigma. Cultural, environmental and economic factors

influence the prevalence of childlessness due to infertility especially in countries where

poverty and infections are widespread (Sampson & McCormick, 2014)

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 CHAPTER THREE

DIAGNOSTIC AND CLINICAL EXAMINATION OF INFERTILITY AMONG

MARRIED COUPLES

3.1. Diagnosis

If both partners are young and healthy and have been trying to conceive for one year without

success, a visit to a physician or women's health nurse practitioner (WHNP) could help to

highlight potential medical problems earlier rather than later. The doctor or WHNP may also

be able to suggest lifestyle changes to increase the chances of conceiving (infertility Help,

2008).

Women over the age of 35 should see their physician or WHNP after six months as fertility

tests can take some time to complete, and age may affect the treatment options that are open

in that case.

A doctor or WHNP takes a medical history and gives a physical examination. They can also

carry out some basic tests on both partners to see if there is an identifiable reason for not

having achieved a pregnancy. If necessary, they refer patients to a fertility clinic or local

hospital for more specialized tests. The results of these tests help determine the best fertility

treatment (Lasa et al, 2014).

Diagnosing male infertility problems usually involves:

 General physical examination and medical history. This includes examining your

genitals and asking questions about any inherited conditions, chronic health problems,

illnesses, injuries or surgeries that could affect fertility. Your doctor might also ask

about your sexual habits and about your sexual development during puberty.

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Semen analysis. Semen samples can be obtained in a couple of different ways. You can

provide a sample by masturbating and ejaculating into a special container at the doctor's

office. Because of religious or cultural beliefs, some men prefer an alternative method of

semen collection. In such cases, semen can be collected by using a special condom during

intercourse (Lasa et al, 2014).

The semen is then sent to a laboratory to measure the number of sperm present and look for

any abnormalities in the shape

Additional tests to help identify the cause of your infertility. These can include:

 Scrotal ultrasound. This test uses high-frequency sound waves to produce images

inside your body. A scrotal ultrasound can help your doctor see if there is a varicocele

or other problems in the testicles and supporting structures.

 Transrectal ultrasound. A small, lubricated wand is inserted into your rectum. It

allows your doctor to check your prostate and look for blockages of the tubes that carry

semen.

 Hormone testing. Hormones produced by the pituitary gland, hypothalamus and

testicles play a key role in sexual development and sperm production. Abnormalities in

other hormonal or organ systems might also contribute to infertility. A blood test

measures the level of testosterone and other hormones.

 Post-ejaculation urinalysis. Sperm in the urine can indicate the sperm are traveling

backward into the bladder instead of out the penis during ejaculation (retrograde

ejaculation).

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  Genetic tests. When sperm concentration is extremely low, there could be a genetic

cause. A blood test can reveal whether there are subtle changes in the Y chromosome

— signs of a genetic abnormality. Genetic testing might be ordered to diagnose various

congenital or inherited syndromes.

 Testicular biopsy. This test involves removing samples from the testicle with a needle.

If the results of the testicular biopsy show that sperm production is normal your

problem is likely caused by a blockage or another problem with sperm transport.

 Specialized sperm function tests. A number of tests can be used to check how well

your sperm survive after ejaculation, how well they can penetrate an egg, and whether

there's any problem attaching to the egg. These tests aren't often used and usually don't

significantly change recommendations for treatment.

Female Fertility tests might include:

 Ovulation testing. An at-home, over-the-counter ovulation prediction kit detects the

surge in luteinizing hormone (LH) that occurs before ovulation. A blood test for

progesterone — a hormone produced after ovulation — can also document that you're

ovulating. Other hormone levels, such as prolactin, also might be checked.

 Hysterosalpingography. During hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-

fee), X-ray contrast is injected into your uterus and an X-ray is taken to check for

problems inside the uterus. The test also shows whether the fluid passes out of the

uterus and spills out of your fallopian tubes. If any problems are found, you'll likely

need further evaluation.

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Hysterosalpingography

A doctor or technician places a slender catheter inside the cervix. It releases a liquid contrast

material that flows into the uterus. The dye traces the shape of the uterine cavity and fallopian

tubes and makes them visible on X-ray images.

 Ovarian reserve testing. This testing helps determine the quality and quantity of eggs

available for ovulation. Women at risk of a depleted egg supply — including women

older than 35 — might have this series of blood and imaging tests.

 Other hormone testing. Other hormone tests check levels of ovulatory hormones as

well as thyroid and pituitary hormones that control reproductive processes.

 Imaging tests. A pelvic ultrasound looks for uterine or fallopian tube disease.

Sometimes a sonohysterogram, also called a saline infusion sonogram, or a

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 hysteroscopy is used to see details inside the uterus that can't be seen on a regular

ultrasound.

3.2. TREATMENT

Treatment depends on the cause of infertility, but may include counselling, fertility

treatments, which include in vitro fertilization. According to ESHRE recommendations,

couples with an estimated live birth rate of 40% or higher per year are encouraged to continue

aiming for a spontaneous pregnancy (Baird et al., 2013).

Treatment methods for infertility may be grouped as medical or complementary and

alternative treatments. Some methods may be used in concert with other methods. Drugs used

for both women and men include clomiphene citrate, human menopausal

gonadotropin (hMG), follicle-stimulating hormone (FSH), human chorionic

gonadotropin (hCG), gonadotropin-releasing hormone (GnRH) analogues, aromatase

inhibitors, and metformin (Sabanegh, 2010).

3.3. MEDICAL TREATMENTS

Medical treatment of infertility generally involves the use of fertility medication, medical

device, surgery, or a combination of the following. If the sperm is of good quality and the

mechanics of the woman's reproductive structures are good (patent fallopian tubes, no

adhesions or scarring), a course of ovulation induction may be used. The physician or WHNP

may also suggest using a conception cap cervical cap, which the patient uses at home by

placing the sperm inside the cap and putting the conception device on the cervix, or

intrauterine insemination (IUI), in which the doctor or WHNP introduces sperm into the

uterus during ovulation, via a catheter. In these methods, fertilization occurs inside the body.

23
If conservative medical treatments fail to achieve a full-term pregnancy, the physician or

WHNP may suggest the patient to undergo in vitro fertilization (IVF). IVF and related

techniques (ICSI, ZIFT, GIFT) are called assisted reproductive technology (ART) techniques.

ART techniques generally start with stimulating the ovaries to increase egg production. After

stimulation, the physician surgically extracts one or more eggs from the ovary, and unites

them with sperm in a laboratory setting, with the intent of producing one or more embryos.

Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's

reproductive tract, in a procedure called embryo transfer.

Other medical techniques are e.g. tuboplasty, assisted hatching, and preimplantation genetic

diagnosis.

In vitro fertilization

IVF is the most commonly used ART. It has been proven useful in overcoming infertility

conditions, such as blocked or damaged tubes, endometriosis, repeated IUI failure,

unexplained infertility, poor ovarian reserve, poor or even nil sperm count.

A depiction of the procedure of in-vitro fertilization

24
Intracytoplasmic sperm injection

ICSI technique is used in case of poor semen quality, low sperm count or failed fertilization

attempts during prior IVF cycles. This technique involves an injection of a single healthy

sperm directly injected into mature egg. The fertilized embryo is then transferred to womb.

Fertility tourism

Fertility tourism is the practice of traveling to another country for fertility treatments. It may

be regarded as a form of medical tourism. The main reasons for fertility tourism are legal

regulation of the sought procedure in the home country, or lower price. In-vitro fertilization

and donor insemination are major procedures involved (Bergmann, 2011).

Laparoscopy

Laparoscopy is performed when less-invasive surgery is desired. It is also called Band-Aid

surgery because only small incisions need to be made to accommodate the small surgical

instruments that are used to view the abdominal contents and perform the surgery (John et al.,

2022).

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Stem cell therapy

Nowadays, there are several treatments (still in experimentation) related to stem cell therapy.

It is a new opportunity, not only for partners with lack of gametes, but also for same-sex

couples and single people who want to have offspring. Theoretically, with this therapy, we

can get artificial gametes in vitro. There are different studies for both women and men

(Vassena et al., 2015).

 Spermatogonial stem cells transplant: it takes places in the seminiferous tubule. With this

treatment, the patient experience spermatogenesis, and therefore, it has the chance to

have offspring if he wants to. It is specially oriented for cancer patients, whose sperm is

destroyed due to the gonadotoxic treatment they are submitted to (Hermann et al., 20120.

 Ovarian stem cells: it is thought that women have a finite number of follicles from the

very beginning. Nevertheless, scientists have found these stem cells, which may generate

new oocytes in postnatal conditions (2004). Apparently there are only 0.014% of them

(this could be an explanation of why they were not discovered until now) (Hong et al.,

2022). There is still some controversy about their existence, but if the discoveries are

true, this could be a new treatment for infertility.

Stem cell therapy is really new, and everything is still under investigation. Additionally, it

could be the future for the treatment of multiple diseases, including infertility. It will take

time before these studies can be available for clinics and patients.

26
3.4. PREVENTION

Preventing STIs, such as gonorrhea and chlamydia, may reduce the risk of infertility.

Maintaining a healthy diet, weight, and lifestyle may increase the chance of getting pregnant

and having a healthy pregnancy. Avoiding the use of lubricants during sex may help improve

sperm function.

Prevention of infertility in male

Avoid Being Overweight: Excess weight has often been associated with sperm production

problems. To prevent this from becoming an issue, maintain a healthy weight as per your

body type (Cashmere, 2019)

Overcome Additions to Alcohol, Smoking and Drugs: Addictions tend to disrupt the

proper functioning of biological processes. Anything in excess can become an addiction and,

therefore, one must monitor their intake (Cashmere, 2019).

Maintain an Optimum Testicular Temperature: Wearing tight clothes can affect the

circulation of blood in the genital region and raise the temperature of the testicles. Higher

testicular temperature has been associated with infertility by affecting sperm

production(Cashmere, 2019).

Avoid Mobile Phone and Laptop Radiation: Electronic gadgets emit low levels of

radiation which can affect sperm production. Ensure that you do not sit with the laptop

27
directly on your lap for long periods of time. Also keep your mobile phone in your shirt

pocket rather than in the pant pocket or hooked to your belt (Cashmere, 2019).

Eat Nutritious Food: A lack of nutrients, zinc and vitamin C in particular, can cause

problems in sperm production. Ensure that you eat a healthy and balanced diet and take

supplements if the food is not supplying you with proper nutrition (Cashmere, 2019).

Exercise to Maintain High Immunity: Infections and inflammations may completely stop

the production of healthy sperm. Exercising regularly is a means by which you can ensure a

healthy immune system (Cashmere, 2019).

Prevention of female infertility

The following are the preventions of infertility in female:

 Maintain a healthy weight. Overweight and underweight women are at increased risk of

ovulation disorders. If you need to lose weight, exercise moderately. Strenuous, intense

exercise of more than five hours a week has been associated with decreased ovulation

(Mayo Clinic, 2022).

 Quit smoking. Tobacco has multiple negative effects on fertility, as well as your general

health and the health of a fetus. If you smoke and are considering pregnancy, quit now

(Mayo Clinic, 2022).

 Avoid alcohol. Heavy alcohol use may lead to decreased fertility. And any alcohol use

can affect the health of a developing fetus. If you're planning to become pregnant, avoid

alcohol, and don't drink alcohol while pregnant (Mayo Clinic, 2022).

28
 Reduce stress. Some studies have shown that stress can cause couples to have poorer

results with infertility treatment. Try to reduce stress in your life before trying to become

pregnant (Mayo Clinic, 2022).

29
 CHAPTER FOUR

CONCLUSION AND RECOMMENDATION

4.1. Conclusion

Infertility is a difficult reality for individuals and couples who would like to have a family

that includes children (and, for some, preferably children with whom they have a genetic

link). Cultural beliefs are major determinants in the prevailing explanation of infertility from

the lay perspectives in Nigeria. These create divergence in the etiological explanation of

infertility between the patient and the professional health care provider which has

implications for care provision and compliance of the patient to treatment. With the continued

pressure, due to infertility in the absence of quality support from the hospital system in form

of adequate counseling and from the significant others, a number of the women under

pressure could become susceptible to high risk sexual behavior, depression and other

psychological problems

4.2. Recommendation

This study recommended that regular enlightenment programme should be organised for

couple on the risk factors of infertility. The section should include means of managing

various stress and challenges associated with infertility. In addition, sensitisation should be

provided on preventable ways of addressing infertility such as reduced smoking and

consumption of alcohol. Modern and assisted methods of conception such as intra-uterine

insemination (IUT), Invitro fertilisation and embryo transfer (IVF/ET), gamete intra fallopian

transfer (GIFT) and some others should be encouraged by medical personnel and

implemented by couples suffering from infertility. Improvement of medical facilities in the

30
hospitals which can improve reproductive and fertility scheme should also be encouraged.

Counselling services should be organised regularly for couples to alleviate the impacts of

infertility on the well-being of the couple.

31
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