In this report, Vincent Kuraun delves into the hidden struggles of many married couples in Nigeria who are facing difficulties conceiving.

THE world over, the joy of marriage is often intertwined with the expectation of starting a family. However, for many couples, the journey to parenthood is fraught with challenges, particularly delays in conception that most times spell a period of uncertainty, worry and sleeplessness for many who find themselves in such situation.

While some find recourse in the continued struggle to find joy ? even if it takes decades ? which is evident in the eventual welcoming of a baby boy or girl, some other families do not survive the struggle as infertility often leads to the crash of some marriage or sometimes lead one or both parties involved to take their lives in extreme cases.

It also goes without saying that once in a while, there are testimonies of couples who welcomed their babies late in their fertile years, but what they endured physically, mentally and even health wise etc. during the period they were trying to conceive remains what others can only envisage.

One such couple living in such painful reality is 36-year-old Dooshima, who was married for 10 years before her husband died. Her dream towards marriage was to have large family with her husband but such dream remains a tall dream because the couple could not conceive in the ten years they were together.

The period was a big trying period for the couple as they turned to medical professionals for help after several unsuccessful attempts to conceive.

Dooshima?s marital journey had begun at the age of 22, and was filled with dreams of a family. Now, at 36, the tranquility and quietness of her home serve as a constant reminder that those dreams that are yet to come to reality, alluding to a popular Yoruba maxim, ki ile toro o ni k?omo ma si nbe (loosely translated as that you want a peaceful house shouldn?t mean the house should be childless).

?The pain of seeing my period month after month while trying to conceive is indescribable,? Dooshima, an educator from North Central Nigeria, said. ?The emotional trauma and overwhelming despair are things I lived with for the ten years of my marriage.?

Sharing her deep personal experience of infertility with Sunday Tribune, she narrated: ?After ten years of marriage, I was devastated by my inability to conceive. In spite of the emotional turmoil and the loss of my husband, I still refuse to let infertility define me.

?I can vividly recall how my once vibrant social circle, filled with friends raising families became distant, as their stories of children became a painful contrast to my own barren landscape. Despite all these challenges, my husband stood by me, and offered unwavering love and support.

?We sought the opinions of doctors after doctors. Even though every appointment offered a flicker of hope, we had to face the same discouraging diagnosis. The murmurs of infertility, once a sensitive subject, transformed into a constant burden in our lives.

?Even after losing my husband a few years ago, I refused to let infertility define me. I have found solace in writing and organising talks for women, sharing my personal story, and offering hope to those struggling in silence.

?During a talk on delayed conception, I came across a group of women who also faced infertility. Their accounts of the emotional ups and downs of fertility treatments, unanswered prayers, and steadfast love amid the pain opened my eyes to the fact that my own dreams, though they may seem unfulfilled, are still valid and deserving.

?Although I haven?t had children of my own, my life is no longer defined by lacking a family. Instead, I serve as a symbol of strength, cherishing life?s joys despite the challenges I?ve encountered. My spirit now embodies a new form of motherhood, one that goes beyond biological connections and embraces the deep love and bonds I?ve formed with others.?

Dooshima?s experience is one faced by many women who are experiencing delayed conception following a year of regular, unprotected sexual intercourse as defined by the World Health Organisation. Such situation is now common nowadays as it affects roughly one in six couples globally, according to WHO. Infertility in Nigeria exhibits at a higher prevalence of 10-30 percent compared to the global average of 5-8 percent.

Factors linked to infertility in men, women

Some experts have, however, argued that the causes of infertility can be linked to factors in man, woman or a combination of both. In some cases, they said the cause may even be unknown.

A leading expert In Obstetrics & Gynaecology at the College of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Professor Cyril Dim, noted that for people to be described as infertile, they must meet two criteria: attempting for at least one year and having adequate penetrative sex about two to three times a week without the use of contraceptives.

Professor Dim disclosed that even in couples without any problem, the probability of getting pregnant in any month or the year is not absolute.

Speaking extensively on the causes of worry and burden on young couples, Prof Dim said: ?The majority of cases of infertility in Nigeria is as a result of male factors at about 40 percent, followed by female factors which is about 30 percent, then combination of both male and female factors is about 20 percent, while about 10 percent is attributed to unknown factors.

?Unknown is that you have done everything, and you can?t pinpoint any cause. Most of such people will just get pregnant along the line. Then we need to know that the probability that a couple without any problem will get pregnant in a month is not hundred percent.

?It?s actually about 25 percent maximum, and when you extrapolate that probability to one year, the probability that a couple that has no problem and meeting adequately will be pregnant in one year is 85 percent. It is not 100 percent.

?So because 85 percent is near 100 percent that?s why they now say, well, if you don?t get pregnant after one year, we can start investigating you. It may equally interest you to know that the probability of a couple who have no problem and meet regularly getting pregnant after two years is not 100 percent.

?It is 95 percent. And with this, you know that 5 percent, who have no problem, will still not get pregnant. So this information is necessary for everybody, especially those that are married and are looking for babies so that they don?t cause unnecessary anxiety to themselves. I wanted to clear this background.?

Explaining the causes of infertility, particularly the risk factors among Nigerian women, Prof Dim said: ?Now, the older a woman is, the less likely the woman gets pregnant. The reproductive success of a woman aged 35 years and above is less than younger women, that is key. This is physiology and normal.

?Still for women, anything can block the tube, where the baby or the egg will pass through. That?s actually the commonest cause of female-related infertility. Anything in this context means infection, particularly pelvic infection.

?You know antibiotic use in Nigeria is not regulated. So, people easily walk into pharmacies and chemist to buy antibiotics. They won?t take the right dose and won?t take it for the right duration.

?And when you challenge an organism with inadequate dose or wrong type of antibiotics, it causes anit-microbial resistance. So these are the major issues that cause the infection that will block the tube.

?Another thing is the illegal abortion. Many people procure illegal or unsafe abortion that is conducted by a quack or in an unsafe environment. So, because it?s unsafe, people who procure it often have an infection.

?The infection may be poorly treated, and the tubes are so tiny, the calibers of the tubes are so tiny, and they will block. So these are major issues that can cause female infertility.

?Then for male, well, a lot of things are responsible. For one, it has been noted now that the sperm count for men is generally reducing and nobody knows why. There may be habits such as excessive alcohol, excessive smoking, and obesity can really affect the reproductive life of a man and reduce the sperm quality. These are the key ones our people should take notes of.?

Other contributing factors

Buttressing Prof Dim?s claims, an Obstetrician and Gynaecologist at Alpha Assisted Reproductive Klinic (The ARK), Dr Olajumoke Ogunro, also said untreated sexually transmitted infections (STIs) can lead to blocked fallopian tubes, a major cause of infertility.

While emphasising the negative impact of lifestyle choices such as smoking, excessive alcohol consumption, drug use, poor diet, and a sedentary lifestyle on fertility, Dr Ogunro also highlighted the detrimental effects of environmental factors on fertility, saying ?Exposure to certain chemicals, particularly endocrine disruptors, can also contribute to infertility.?

She emphasised that these factors and lifestyle changes affecting fertility are not unique to Nigeria but are becoming increasingly prevalent with the industrialisation and westernisation within our borders.

Looking ahead, she stated that ?Additional factors that may influence a woman?s fertility are conditions like diabetes, thyroid disorders, autoimmune disorders, polycystic ovarian syndrome, endometriosis, genetic disorders such as androgen insensitivity syndrome.?

Addressing the possible factors contributing to male infertility, Dr Ogunro mentioned that ?genetic disorders such as Klinefelter?s syndrome and cystic fibrosis can impact sperm production and quality.?

She also highlighted the role of infections, including sexually transmitted diseases and mumps orchitis, in potentially damaging the male reproductive organs.

?Smoking, excessive alcohol intake, use of recreational drugs, and exposure to toxic chemicals can also have a negative effect on the male reproductive system.

?Certain medications, such as antibiotics, antidepressants, and anabolic steroids, can impact sperm production and quality. Additionally, cancer treatments can also affect sperm production. Medical conditions like diabetes, thyroid disorders, and autoimmune disorders may also influence sperm production and quality,? she said.

Dr Ogunro also discussed additional factors that could influence male fertility. These include varicocele, which is characterised by enlarged veins in the scrotum, undescended testis where a testis fails to descend into the scrotum, retrograde ejaculation where sperm goes into the bladder instead of being ejaculated, heat exposure which can affect sperm production, especially with prolonged exposure to heat from a source such as the sun or hot tubs, and obesity which can impact hormone levels and sperm production negatively.

In her contribution, a resident doctor, department of Obstetrics and Gynaecology at the Lagos University Teaching Hospital in Idi-Araba, Lagos, Dr Margaret Obienu, also fingered late marriage which has become commonplace in the country today as one of the factors contributing to delayed conception.

?First and foremost, late marriage plays a significant role, as many individuals today are choosing to marry later in life. Additionally, the pursuit of higher education and a strong focus on career advancement can shift priorities away from starting a family. Geographical separation between partners also poses a challenge; when couples reside in different locations, it can hinder the natural processes of conception.

?Furthermore, the couple?s financial situation cannot be overlooked, as economic stability is often a significant consideration when planning for children. Personal choices also factor into the equation, as some individuals may consciously decide to delay parenthood for various reasons, whether they are personal aspirations or other life circumstances.

?Moreover, a lack of awareness regarding the fertile periods can lead to unintentional delays in conception, highlighting the need for better education on reproductive health. Lastly, infertility can manifest due to various factors, which may include issues related to the male partner, female partner, a combination of both, or even undiscovered causes. Each of these elements contributes to the challenges faced by couples hoping to conceive, underscoring a complex interplay of social, personal, and medical influences.?

In discussing the potential reasons behind delayed conception, particularly in relation to female factors, Dr Obienu explained to Sunday Tribune that, ?Infertility is define? as the inability to achieve pregnancy after a year of consistent unprotected sexual activity. However, this timeframe is adjusted for certain groups; for women who are 35 years old or older, as well as those diagnosed with polycystic ovarian syndrome (PCOS). The window for seeking medical advice is reduced to just six months. This highlights the importance of timely intervention for these specific categories, as age and certain medical conditions can significantly impact fertility outcomes.

In Vitro Fertilisation (IVF)

When discussing the possible risks and benefits of fertility treatments, Professor Cyril notably focused on in-vitro fertilisation.

While he acknowledged that risk is inherent in any endeavour, he emphasised that IVF, being an assisted reproductive technique, carries minimal risk when protocols are strictly followed.

However, pregnancies resulting from IVF or embryo transfer are often associated with a higher likelihood of complications compared to naturally conceived pregnancies.

?Complications like hypertension in pregnancy especially the one that is called preeclampsia. But these are not things one can?t manage but then, IVF treatments carry a risk of multiple pregnancies, including twins, triplets, and even larger multiples. The increased number of babies in the womb significantly raises the risk of complications for the mother during pregnancy and delivery.?

While regulations in developed countries generally restrict the transfer of more than one embryo during assisted reproduction, he explained that regulations in Nigeria allow for the transfer of two, explaining that ?Abroad, most regulations say you don?t transfer more than one fetus, but here, the regulations say two, but people still transfer more than that, thereby causing more complications.

?But when rules are followed, we don?t face many complications, but the key implication in assisted reproduction is that it is a failure, too. But because our people pay so much, they think when you pay, you must get pregnant, but it is not true. The chances of them getting pregnant are just as the chances of getting pregnant naturally. That failure of not getting pregnant is also a major complication of IVF.?

He explained the reasons behind the lack of effective fertility treatments, stating, ?There are no effective treatments for fertility. When a couple is having this challenge, what they need to do is to seek proper medical care.

?They should start with a general gynaecologist who will review them. Interact with them and they may be able to find out what the issue is. You know women don?t meet their husbands regularly, or they only meet them when they think they can get pregnant, which may not be adequate.

?So it is when you go through their history, you will examine the couple, begin to do some investigation. There are certain investigations starting with the man which have to be done to look at all the reproductive functions. How you now manage depends on what you find.

?So, there is nothing like effective treatment. Personally, I give a timeline; it could be three months or six months, and when you can get the desirable results, I advise assisted reproduction because the woman?s reproductive life is limited, unlike the man.?

In the same vein, Dr Ogunro highlighted how IVF has made a significant difference in the lives of many infertile couples, enabling them to fulfill their dreams of becoming parents.

She highlighted the reduction of shame and stigma associated with infertility in our society. However, she also cautioned about the risks associated with IVF, such as increased likelihood of multiple pregnancies, higher risk of ectopic pregnancy, and the potential for ovarian hyperstimulation syndrome.

Additionally, Dr Ogunro talked about different options for fertility treatments, including the use of medications, surgical procedures, intrauterine insemination, and assisted reproductive technologies like IVF, intracytoplasmic sperm injection, the use of donor eggs and sperm as well as surrogacy, among other options.

She clarified that there isn?t a single best treatment for fertility but rather, the most effective approach depends on the individual?s specific needs and circumstances, as determined by a comprehensive clinical assessment.?

Echoing Prof Dim?s sentiment on effective fertility treatments, Dr Ogunro emphasised that there is no single magic bullet. Instead, she stressed the importance of identifying the specific cause of infertility. ?Only then that treatment plans can be tailored to address the underlying issue. For cases where the cause remains unclear, factors such as the woman?s age and the length of time trying to conceive help guide treatment options.?

Infertility and fibroid

Prof Dim further clarified the relationship between fibroids and infertility, explaining that while basic medical training emphasises that fibroids do not cause infertility, they can be associated with it.

He stated that fibroids are common, affecting approximately 50 percent of women of reproductive age, adding, however, that removing them can improve a woman?s chances of pregnancy.

?While it?s commonly believed that fibroid causes infertility, basic medical training teaches that this isn?t always true. Fibroids and infertility are often linked, but they are not the same thing.

?In women experiencing infertility, if fibroid is discovered during assessment, its removal can sometimes lead to successful pregnancy,? the professor said.

Nutrition and stress

On whether nutrition and stress can also have a negative effect on fertility, Prof Dim stated that the ?Reproductive life of a woman is tied with nutrition. For instance, a young girl needs to have an appropriate weight to be able to start menstruating because what regulates menstruation is in the body fats of the woman. Likewise, if you are starving yourself, you can lose the ability to menstruate. Nutrition is key.

?For women who are too large, that is obesity. In some women who are predisposed, it can cause them to develop a condition which is called polycystic ovary syndrome (PCOS), where they won?t be ovulating like other women, which is equally a problem. Appropriate nutrition is good for a woman to develop normal menses and sustain it.? He expressed the significance of nutrition.

Regarding stress, he mentioned that ?The female reproductive function is a complex system control from the brain down to the ovary. The hypothalamus is the sensor of the body system. So, when there is real stress, the woman may stop ovulating and that is the fact just like if you go to universities or even secondary schools, some girls when they are challenged with exams and they are working so hard, they won?t menstruate. So stress can limit the reproductive functions.?

Coping mechanism

On the various strategies for couples trying to overcome the emotional and psychological challenges of infertility, Dr Obienu highlighted the importance of support from one?s partner.

?Regularly and deliberately reassuring one another that you?re in this together and will stand by each other throughout the journey,? she said.

Additionally, she noted, ?It?s important to steer clear of blame games and to shield one another from the accusations of outsiders. Joining support groups and seeking guidance from professionals can significantly help in navigating this challenging chapter of their lives.?

Similarly, Prof Dim advised couples experiencing delays in conceiving to seek professional medical advice from a gynaecologist.

He emphasised the importance of open communication with a qualified healthcare professional, acknowledging that such consultations may come at a cost.

He cautioned against seeking alternative or potentially risky treatments without proper medical guidance, adding that a gynaecologist can conduct the necessary tests and provide appropriate management based on a comprehensive clinical evaluation and test results. (Sunday Tribune)

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