Our struggle began when our son was two years old,’ says Melinda*. ‘We tried for another child for months, and then our gynae attempted two artificial inseminations (AIs). When these failed, he referred us to a fertility clinic. We tried another three AIs and I still didn’t fall pregnant. Then we tried in vitro fertilisation (IVF). Up to this point, I believed all I needed was just that one IVF, that one magical push and we’d be there. After all, I had a child already. So when it failed, I was crushed. Most people have an average of three IVFs and then get it “right”, so we went for number two. ‘That failed too. ‘So did numbers three, four and five. Then I fell apart. I quit my job and took time out. ‘We eventually attempted IVF another four more times. The results are still negative.’
What is secondary infertility?
According to Dr Stephan Volschenk, fertility specialist and medical director at Vitalab Clinic for Assisted Conception in Jo’burg, ‘secondary infertility is the inability to conceive after having conceived successfully once before’. It is irrespective of whether the pregnancy was ectopic, ended in a miscarriage or went to full term. Dr Volschenk adds that ‘for women below 35, this relates to a period of one year of unprotected intercourse and for women above 35, six months’. ‘Sometimes incidents after the birth of a baby can cause secondary infertility,’ says Prof Thinus Kruger, head of the Reproductive Biology Unit, Life Vincent Pallotti Hospital. ‘This can include a pelvic infection or complications during the birth that lead to adhesions in the pelvis or in the case of a post-partum bleeding with surgical intervention, adhesions inside the uterus. The husband or partner could have contracted a viral infection, such as mumps, which leads to a low sperm count. ‘According to Dr Mohamed Cassim, a fertility specialist at BioArt Fertility Centre, tubal factors remain the most common cause of secondary infertility. ‘With time, ovulatory causes - endometriosis and polycystic ovaries - as well as uterine problems, such as fibroids, need to be considered, but the longer the time before the next attempt of conception, the more closely the underlying cause approximates that of primary infertility.’
‘I’d had surgery on one of my Fallopian tubes when I was in my early 20s,’ says Rachel*, ‘and my doctor told me at the time that I might struggle to fall pregnant, but this wasn’t the case. When the time came to try for our second child, I assumed that it would be as easy. ‘Seven months passed, and when I still wasn’t pregnant, IVF was recommended as the only option. The fertility specialist found that the tube that had been operated on previously was badly damaged and shrivelled, and the other one, although healthy, was blocked. He figured that the right tube had been out of action since the surgery and that the left one must have become blocked at some point since having my son. I sought a second opinion, which was no different, so we had our first IVF. I really believed that because, through IVF, we’d overcome the structural issues, we would get the result we wanted - a BFP (big fat positive). Unfortunately, the result was a BFN - a Big Fat Negative. I was completely devastated.’
Is age the problem?
According to a report published recently in the British Medical Journal, on average, women up to the age of 25 have a conception rate of 60% within six months and 85% within a year. At age 35, that rate is more than halved. And men older than 35 have half the chance of achieving a pregnancy compared with men younger than 25. The average age of mothers at first birth in Western countries is now 29,5 years - four and a half years older than two decades ago. ‘This leads to an advanced maternal age for the second or third child,’ explains Dr Volschenk. ‘I suggest that woman try to have their family completed by the time they are 35,’ recommends Dr Klaus Wiswedel, director and founder of The Cape Fertility Clinic. ‘If you do require IVF, the chances of success start to drop from the age of 32, but this becomes statistically significant from the age of 35.’
Can you preserve your own eggs if you intend having a baby later in life?
According to a clinical review by Adam Balen, professor of reproductive medicine and surgery, and Anthony Rutherford, consultant in reproductive medicine and surgery, the cryo preservation of eggs and ovarian tissue has raised interest in women who wish to ‘bank’ until they need them, but these techniques are still relatively inefficient. ‘Women have to undergo the same hormonal stimulation as when having IVF; the survival rate is relatively low and subsequent pregnancy is not guaranteed. On average, using standard stimulation regimens, eight to 12 mature eggs are reproduced per cycle, which currently provides a modest live birth rate of 18,3%; much lower than with conventional IVF.’
Is it all about women?
Although there are no statistics available for South Africa, reports state that the average sperm count in Europe dropped by 3,1% each year from 1971 to 1990, and in the US it dropped by an astounding 50% from 1982 to 1992. ‘I know that male infertility is increasing,’ says Dr Wiswedel. ‘I have the feeling that it’s now higher than female infertility. ‘Various scientific reports lay the blame on environmental factors such as the increased exposure to plastic products and exhaust gases; however, there is no conclusive evidence. Either way, infertility is not only relevant to a woman’s reproductive ability. ‘I have seen so many cases where women have had laparoscopies, operations, everything, but no sperm test was done on her husband. It’s not fair to send a woman to an operation when her husband has not been checked. And it happens again and again, ’says Dr Wiswedel.
Success… finally?
‘My husband and I had a barrage of blood and semen tests and everything came back normal,’ says Denise*. ‘We tried our first AI with Clomid in December 2007 and, to our surprise, I fell pregnant. Not with one, but two babies - identical twins. We felt so blessed. I went to a conference and when I got back, I rushed excitedly to my scan. Then I saw my gynae’s face. We’d lost our twin boys. Ten months have passed and it’s taken a long time to heal. I’ve stopped questioning why we can’t have a second baby, but unexplained infertility is not a good enough answer for me.’ Dr Cassim explains that a growing body of scientific evidence suggests that embryo abnormality plays a significant role in recurrent pregnancy losses and repeated IVF treatment failures. ‘The focus of scientific research is towards the early identification of affected eggs and embryos and the screening of couples who are at risk. The technique of pre-genetic diagnosis holds great promise for future fertility treatments. Only healthy embryos are selected for transfer into the uterus, thereby significantly enhancing the prospects of successful pregnancy outcomes.’
The emotional journey
Women experiencing secondary infertility are consumed by feelings of guilt. Is it fair to feel hard done by when they already have a child? Add to this a sense of inadequacy and the loss of control over their ability to conceive and the experience is emotionally debilitating. Many stop working and sink into depression. ‘I never imagined that I’d want something this badly,’ says Rachel. ‘For the first time in my life when I’ve wanted something so badly, what I have done hasn’t made a difference. As a typical type-A personality, it’s difficult for me to accept that I’m not in control of everything in my life. ‘After three years of trying to fall pregnant, Sindi* had had enough. ‘After being as regular as clockwork for the last six months, finally I was late! I was excited and hopeful and thought that maybe this was it. But it wasn’t. I cried myself to sleep and cried even more at 3am that morning. I have had enough. This is it. I will be doing no more counting, no more hoping and praying. I am no longer a TTC (Trying To Conceive) Infertile. ‘Subsequent to that interview, Sindi went back to work. She was ‘late’ again in the first month - only to have her hopes dashed again, five days later. ‘This has taken its toll on our marriage,’ says Melinda. ‘When you are on all these drugs and everything is so medically controlled, there is no desire for anything natural. And why have sex? If you can’t fall pregnant with IVF, then why on earth bother? My husband also had to “do his bit” with every IVF and that’s hardly an intimate experience. Fortunately he can do the deed in the privacy of our bedroom while I rev the car outside. ‘I once had to drop our son off at school on the way to dropping off a specimen. As Murphy’s Law would have it, he decided to have a “bad” morning and was extra clingy. All I could think was, “Hurry up, Jack. I have your brothers and sisters in a jar in my bra!”.’
Does a doctor ever say that it’s not going to work?
‘Yes we do,’ says Dr Wiswedel, ‘but this relates to a certain stage of treatment.’ It might not work the way they want it to, but for 98% of women there is a solution.’ ‘I had my first baby after trying for six months and having one month of Clomid - as easy as that,’ says Amanda*. ‘Little did I know that, two years later, when I started trying for baby number two, it would be a different story. My gynaecologist found that my uterus had a “gap” in it from the Caesarean I had to have. ‘A fertility specialist found that I usually only ovulated from the right ovary and managed to fix the “gap” in my uterus. We decided to go ahead with AI and after numerous attempts, we were so pleased when it worked. Weeks later I was in a lot of pain and we found it was ectopic. I went into surgery, and lost my right Fallopian tube. In the end, I was extremely fortunate and my first IVF worked. After a very complicated pregnancy (I had another ectopic pregnancy and had to have surgery again), my little girl survived. I am now the very happy mom of two gorgeous girls.’ ‘We try with a woman’s own eggs first, and see what the response is from her ovaries,’ says Dr Wiswedel. ‘If she gets very poor embryos repeatedly, we have to say that it’s not going to work, but we can suggest that she go to the next step, which is the egg donation programme.
At the moment, the chance of falling pregnant with egg donation is 80%. The difficulty for couples is getting over the threshold of accepting that it’s not going to happen with their own eggs. If they can accept that, then yes, it can work.’
* Names have been changed
Questions and Answers
Q Does long-term use of the contraceptive pill lead to fertility problems?
A The resounding opinion from the medical profession is ‘no’. Dr Monica Jarrett from the University of Washington believes that, since the pill inhibits the release of an egg each month and we are born with a certain number, women who have been on the contraceptive pill may actually have benefited from conserving their eggs. [Source: The Fertility Diet by Sarah Dobbyn (Simon & Schuster)]
Q Does exercise affect your ability to fall pregnant?
A ‘Anything in life in excess is detrimental,’ says Dr Volschenk, ‘and this includes over-exercising, which leads to ovulatory dysfunction and even to a total lack of ovulation with cessation of menstruation.’ Exercise should be seen as a means to control your BMI, ideally between 20 and 24. Women with a BMI of 25 to 27 are still fertile but would benefit from losing a little excess weight. A BMI below 20 can result in ovulatory dysfunction and above 30 is a known cause for miscarriage. Dr Wiswedel adds a cautionary note on the role of exercise in male infertility: ‘We find that very often, long-distance runners and cyclists who train a lot on the road and breathe in noxious substances at a much faster rate than someone just sitting in the car have poor semen quality and the lead in their blood is increased. Lead is definitely a sperm poison. It doesn’t help to do something healthy in an unhealthy environment. It’s just as important to exercise in a healthy environment.’
Q Do alcohol consumption and smoking affect fertility?
A Research states that drinking alcohol can reduce a woman’s fertility by 50%. Limit your alcohol to no more than two units a day or preferably don’t drink at all. It is approximated that up to 13% of infertility can be attributed to smoking; if you smoke 20 cigarettes a day, your natural fertility is reduced by over 20%. Smokers require nearly twice as many IVF attempts to conceive. If you smoke and drink, the chances of miscarriage are four time higher than if you didn’t. Caffeine has also been linked to infertility and should be limited to one cup a day or decaf.
Q Can stress cause infertility?
A Apart from the physical effects of the hormone adrenalin, - produced when we’re under stress - one hormone out of sync throws the others out too. This includes hormones directly related to fertility. Stress also triggers the pituitary gland which results in a disturbance of FSH, another hormone related to fertility. In The Fertility Diet, Dobbyn cites the findings of Dr Alice Domar, a psychologist at Harvard: 34% of a group of infertile women became pregnant within six months of doing a stress-management, mind-body programme. According to a study by Dr Sarah Berga, head of Emory University Department of Obstetrics and Gynaecology, ovulation was restored in seven out of eight women who under went cognitive behavioural therapy. Stressed men also have a lower sperm count and more abnormal sperm with decreased mobility.
According to Jackie Wildish, a nutritional therapist, ‘Optimum nutrition, supplementation and healthy lifestyle practice can restore balance to your endocrine system. This includes hormones regulating blood sugar, thyroid function, stress reactions and female reproduction, all of which are important in restoring fertility’.
Foods to eat
Hormones can be reabsorbed into the body in cases of constipation and oestrogen can be converted into harmful metabolites by bacteria in the bowel. Fibre ensures that ‘old’ hormones are eliminated efficiently.
- Complex carbohydrates with a low glycaemic load
(so no white rice and pasta, white bread, biscuits, cakes, sweets, muffins and pastries) This will keep your blood sugar levels balanced. Choose wholegrain bread, brown rice, barley, rye, beans, fruits and vegetables.
Found in wholegrains, these vitamins are needed for hormonal balance, stress control and blood sugar balance.
Drink eight glasses of water every day to help transport waste out of the body.
Found in nuts, seeds and oily fish, these are a precursor to prostaglandins which help regulate many body functions, including hormonal release and production.
These naturally occurring substances in plant foods have a regulating effect on oestrogen. Found in beans, lentils, chickpeas, soy products, flaxseed, berries, oats, barley and rice.
- Plenty of fruits and vegetables
Especially cruciferous vegetables such as broccoli, cauliflower, brussel sprouts. They aid liver function. The liver breaks down and eliminates excess or used hormones from the body so it needs to function efficiently.
Eating organic will help you to avoid consumption of additional hormones and xenoestrogens such as those found in insecticides and preservatives and plastic containers.
- Vitamins, minerals and herbs
Useful for balancing hormone levels include vitamin C, zinc, vitamin B6, agnuscastus, saw palmetto, don quai, DIM, black cohosh, false unicorn root and white peony.
Foods to reduce or avoid
- High-glycaemic load sugars
They contribute to blood sugar imbalances, insulin resistance and weight again. Insulin resistance and being overweight are associated with polycystic ovary syndrome, one of the many syndromes that lead to a hormone imbalance and infertility. Excess body fat accentuates insulin resistance and contributes to high insulin levels and excess male hormone production.
- Certain meat and dairy products
These can contain hormones which, when eaten, may upset the balance of hormones in the body. Intake of these foods should either be reduced or replaced with an organic option.
- Food additives, preservatives and chemicals.
- Saturated fats from animal products
They contribute to inflammation in the body and interfere with EFA absorption, vital for hormone production.
- Trans and hydrogenated fats
Found in fried foods, some shop bought biscuits and margarine, these interfere with the functioning of normal hormone systems.
What to read
- A few good eggs: Two chicks dish on overcoming the insanity of infertility by Julie Vargo and Maureen Regan (Regan Books) R225
- The Fertility Diet by Sarah Dobbyn (Simon & Schuster) R259,95
Contacts
Written by: Shannon Smith Beauty & Wellness Editor
