Samuel S Ram­se­wak, Pro­fes­sor Emer­i­tus (UWI)

Con­sul­tant, Gy­nae­col­o­gy,

Med­ical As­so­ciates Hos­pi­tal.

In­fer­til­i­ty is a glob­al health is­sue af­fect­ing mil­lions of peo­ple of re­pro­duc­tive age world­wide. Avail­able da­ta sug­gests that be­tween 48 mil­lion cou­ples and 186 mil­lion in­di­vid­u­als have in­fer­til­i­ty glob­al­ly – World Health Or­ga­ni­za­tion

In­fer­til­i­ty presents a myr­i­ad of chal­lenges. Let’s start with re­view­ing some com­mon case sce­nar­ios: The names are not re­al, but the pa­tients and their is­sues are.

Case sce­nario No.1

So­nia and Rishi were be­com­ing in­creas­ing­ly con­cerned and she even said ‘des­per­ate’ be­cause their wish for a fam­i­ly was be­gin­ning to seem like an im­pos­si­ble dream. She’s 34 and he’s 40 they had been to­geth­er for four years. For the first year they used con­tra­cep­tion (the ‘Pill” and then con­doms but it’s been 3 years with no pro­tec­tion.)

Pres­sure from fam­i­ly and friends has been re­lent­less (‘what are you wait­ing on’?) so much so that they al­most ap­pre­ci­at­ed the Covid lock­downs which al­lowed them to avoid so­cial in­ter­ac­tions.

A friend who had fer­til­i­ty is­sues and sub­se­quent­ly be­came preg­nant and had a ba­by, cor­rect­ly told them that cou­ples try­ing un­suc­cess­ful­ly for one year were usu­al­ly di­ag­nosed with in­fer­til­i­ty and that they should seek pro­fes­sion­al help.

So­nia’s med­ical and gy­nae­co­log­i­cal his­to­ry:

So­nia has al­ways been a bit over­weight, and she has ex­pe­ri­enced de­layed pe­ri­ods and some­times skipped months (the longest be­ing 3 months) and this oc­curred 1-2 times per year. She has no ex­ces­sive fa­cial or oth­er hair growth but oc­ca­sion­al­ly, she re­sorts to a tweez­er for hairs on her up­per lip and chin. It seems to af­fect all the women in her fam­i­ly.

I be­gin to think of Poly­cys­tic Ovaries and re­quest blood hor­mone tests and an ul­tra­sound test of the ovaries. The lat­ter showed a nor­mal uterus and en­larged ovaries, each con­tain­ing mul­ti­ple small cir­cu­lar cysts (more than 12 on each side), arranged around the bor­der (‘string of pearls’ pat­tern).

Rishi is in good health, is a non-smok­er and sel­dom us­es al­co­hol. He has no sig­nif­i­cant med­ical or sur­gi­cal his­to­ry.

Se­men analy­sis for sperm count and oth­er char­ac­ter­is­tics, is nor­mal.

Case Sce­nario No. 2

My men­stru­al pe­ri­ods are ‘liv­ing hell’!

Jas­mine is 28 years old and has nev­er been preg­nant and she ac­tu­al­ly be­lieves that it will nev­er hap­pen be­cause her pe­ri­ods are so painful, with these ex­pe­ri­ences start­ing since high school. In fact, she of­ten missed school and now has to miss work for at least 2 days per month. Luck­i­ly, she works in her fam­i­ly busi­ness so she has easy ac­cess to time-off. She has a steady boyfriend and they are hop­ing to mar­ry soon, but she re­al­ly wants to know if she can be­come preg­nant.

Di­ag­nos­tic pos­si­bil­i­ties are en­dometrio­sis, uter­ine fi­broids and polyps and chron­ic pelvic in­fec­tion.

Like­ly man­age­ment will in­clude: Gen­er­al and pelvic ex­am­i­na­tion, Pap Smear, pelvic ul­tra­sound.

Ul­tra­sound is es­sen­tial as it will of­ten di­ag­nose cysts on the ovaries, fi­broids and raise a flag for po­ten­tial ad­he­sions in the pelvis.

An X-Ray of the uterus and tubes will help to di­ag­nose polyps in the cav­i­ty of the uterus as well as po­ten­tial block­age of the Fal­lop­i­an tubes. This pro­ce­dure is called a Hys­tero-Salp­in­go-Gram (HSG).

An­oth­er method in­volves the use of ul­tra­sound while in­sert­ing a saline so­lu­tion in­to the uterus (Saline In­fu­sion Scan – SIS).

Se­men / Sperm Analy­sis is al­so re­quired since in­fer­til­i­ty re­lat­ed to the male is known to oc­cur in over 45% of men in Trinidad and To­ba­go.

Case sce­nario No. 3

An un­ex­pect­ed re­sult.

Juani­ta and Car­los

Juani­ta is 38 years old and has had 2 chil­dren in a pre­vi­ous mar­riage. She has been mar­ried to Car­los for the past 2 years and have no chil­dren de­spite nev­er hav­ing used con­tra­cep­tion. She has a reg­u­lar men­stru­al cy­cle and has had no ill­ness­es. At a re­cent rou­tine gy­ne­col­o­gy check up she was as­sured that she had no pathol­o­gy such as fi­broids or ovar­i­an cysts and the Pap Smear was neg­a­tive.

Car­los is al­so 38 years old and has not fa­thered any chil­dren de­spite be­ing in two pre­vi­ous ‘long-term’ re­la­tion­ships. He is not over­weight, has no past med­ical or sur­gi­cal his­to­ry. He is a mod­er­ate smok­er. He’s nev­er had his sperm test­ed but has used hor­mon­al and nu­tri­tion­al sup­ple­ments in the past.

Juani­ta: At 38 years old, her chances of preg­nan­cy are get­ting slim, main­ly be­cause of a low­ered egg re­serve. Ad­di­tion­al­ly, egg qual­i­ty may be com­pro­mised so that the chances of non-fer­tilised eggs or of fe­tal anom­aly such as Down syn­drome are in­creas­ing.

A good blood test to as­sess a woman’s egg re­serve is the An­ti-Mul­ler­ian Hor­mone (AMH) test. Ad­di­tion­al­ly, oth­er tests we per­form are the FSH, LH, Pro­lac­tin and Thy­roid Func­tion Tests.

Car­los: In view of his sto­ry, a sperm analy­sis was the first re­quest­ed test.

Com­par­ing his re­sults with the rec­om­mend­ed val­ues de­fined by the WHO, it was not­ed that his sperm con­cen­tra­tion (Count) was low (3 mil­lion/mL, and that ev­i­dence of pro­gres­sive motil­i­ty (swim­ming) was al­so di­min­ished at 25%. The % of ide­al­ly shaped sperm was al­so low­er than ex­pect­ed.

As a re­sult, the pri­ma­ry con­cern here is the male fac­tor.

The in­abil­i­ty of a cou­ple to achieve preg­nan­cy af­ter 1 year of reg­u­lar un­pro­tect­ed sex­u­al in­ter­course is termed in­fer­til­i­ty and this should lead to in­ves­ti­ga­tion.

What can cause In­fer­til­i­ty?

Gen­er­al­ly, the caus­es are di­vid­ed in­to 3-4 groups:

1) Re­lat­ed to lack of egg pro­duc­tion and re­lease (Lack of ovu­la­tion)

2) Lack of sperm in ad­e­quate num­bers which show for­ward move­ment and are prop­er­ly shaped

3) Block­age or in­ad­e­quate func­tion of the Fal­lop­i­an tubes

4) Pelvic ab­nor­mal­i­ties such as uter­ine fi­broids, ovar­i­an cysts and en­dometrio­sis

Sperm is­sues ac­count for at least 40% of cas­es while fe­male caus­es ac­count for 40% with the rest be­ing com­bined.

Lack of egg pro­duc­tion is of­ten a fac­tor of ad­vanc­ing age. The fe­male is known to be born with a quan­ti­ty of eggs which are uti­lized but not re­plen­ished. A large num­ber of eggs al­so un­der­go a nat­ur­al process of death and elim­i­na­tion dur­ing each year of life. Dur­ing the re­pro­duc­tive years, eggs con­tin­ue to be re­leased and con­tin­ue to die, so that af­ter the age of around 34 years, their avail­abil­i­ty and qual­i­ty di­min­ish and fer­til­i­ty rates fall.

Poly­cys­tic ovaries oc­cur in an en­vi­ron­ment of in­sulin re­sis­tance. With car­bo­hy­drate in­take, the nor­mal re­sponse of the body is to re­lease in­sulin which ef­fec­tive­ly utilis­es these carbs in the tis­sues. In some women, the tis­sues ex­hib­it in­sulin re­sis­tance so that car­bo­hy­drate uti­liza­tion is pre­vent­ed – this caus­es fur­ther in­sulin pro­duc­tion over long pe­ri­ods of time. In this en­vi­ron­ment of ab­nor­mal in­sulin ac­tiv­i­ty, poly­cys­tic ovaries de­vel­op and the ovary can­not re­lease its eggs.

En­dometrio­sis is a con­di­tion where bits of the lin­ing of the uterus (called the en­dometri­um) find them­selves at­tached to struc­tures in the pelvis (the ovaries, pelvic lin­ing, in­testines, blad­der etc). These de­posits bleed with­in the pelvis dur­ing men­stru­al ac­tiv­i­ty and cause se­vere pelvic pain as well as scar­ring with­in the pelvis. En­dometrio­sis is a cause of se­vere men­stru­al pain, heavy men­stru­al bleed­ing and in­fer­til­i­ty. Di­ag­no­sis is made from the symp­toms above, from pelvic ex­am­i­na­tion, pelvic ul­tra­sound and MRI. Some­times, a sur­gi­cal pro­ce­dure is rec­om­mend­ed of­ten us­ing a key­hole tele­scop­ic ap­proach (called la­paroscopy). This is a min­i­mal­ly in­va­sive means of con­firm­ing the di­ag­nos­ing the ex­tent of the dis­ease and al­so per­form­ing sur­gi­cal ex­ci­sion.

Uter­ine fi­broids a re growths de­vel­op­ing from the mus­cu­lar lay­er of the uterus. De­pend­ing up­on their lo­ca­tion, they may cause no symp­toms but the com­mon­est symp­toms are painful and heavy pe­ri­ods which can be suf­fi­cient to cause anaemia. In­fer­til­i­ty is al­so seen with fi­broids.

Scar­ring and block­age of the Fal­lop­i­an tubes may oc­cur be­cause of pelvic in­fec­tions, par­tic­u­lar­ly re­lat­ed to chlamy­dia, gon­or­rhoea and oth­er pelvic bac­te­ria.

What Treat­ment Op­tions are avail­able?

Lack of ovu­la­tion can be treat­ed by us­ing tablets or hor­mon­al in­jec­tions and their ef­fect can be mon­i­tored us­ing ul­tra­sound eval­u­a­tion.

Apart from very few in­stances, low sperm count and oth­er ab­nor­mal sperm char­ac­ter­is­tics sel­dom re­spond to med­i­cines, and cer­tain­ly will not show im­prove­ment with the use of testos­terone and oth­er sim­i­lar sup­ple­ments.

Treat­ment by In­trauter­ine In­sem­i­na­tion (IUI) or In vit­ro Fer­til­iza­tion (IVF) may be re­quired.

At Med­ical As­so­ciates Hos­pi­tal, we were for­tu­nate to achieve the first suc­cess­ful IVF preg­nan­cy in the Caribbean in 1996. The pro­ce­dure in­volves the fol­low­ing steps:

1) stim­u­la­tion of egg pro­duc­tion by us­ing ovary stim­u­lat­ing med­i­cines, usu­al­ly dai­ly for 10-14 days, and col­lec­tion of these eggs by in­sert­ing a de­vice via the vagi­na un­der se­da­tion

2) mix­ing the eggs and sperm in an in­cu­ba­tor (some­times a sperm can be in­ject­ed in­to each egg)

3) as­sess­ing fer­til­iza­tion and em­bryo for­ma­tion over a few days

4) trans­fer of a suit­able em­bryo(s) in­to the uterus

Suc­cess rates are de­pen­dent up­on the cause of in­fer­til­i­ty as well as the age of the woman. Younger women have high­er rates of suc­cess while those over 36 years old have low­er rates.

Pro­fes­sor Samuel Ram­se­wak

Pro­fes­sor Samuel Ram­se­wak is a Fel­low of the Roy­al Col­lege of Ob­ste­tri­cians and Gy­nae­col­o­gists (FRCOG), Fel­low of the Amer­i­can Col­lege of Ob­ste­tri­cians and Gy­ne­col­o­gists (FACOG), Fel­low of the Roy­al Col­lege of Physi­cians and Sur­geons (Glas­gow), Fel­low of the Amer­i­can So­ci­ety for Re­pro­duc­tive Med­i­cine (AS­RM) and Mem­ber of the Eu­ro­pean So­ci­ety for Re­pro­duc­tive Med­i­cine (ESHRE).

Pro­fes­sor Ram­se­wak has au­thored 60 sci­en­tif­ic pub­li­ca­tions, pri­mar­i­ly in ob­stet­rics, gy­nae­col­o­gy and in­fer­til­i­ty. He was ap­point­ed Pro­fes­sor at the UWI in 2001. He is rec­og­nized as the pi­o­neer of ad­vanced re­pro­duc­tive med­i­cine in the Caribbean and was re­spon­si­ble for the start­ing its first In Vit­ro Fer­til­iza­tion (IVF) Clin­ic and for his team’s achieve­ment of the first suc­cess­ful preg­nan­cy in this Re­gion.

Amongst his awards are the Cha­co­nia Medal of Trinidad and To­ba­go, a Na­tion­al Hon­or, for con­tri­bu­tions to Med­i­cine in his coun­try, the Com­mon­wealth Re­search Fel­low­ship (1989), Rhodes Trust Schol­ar­ship (1994), Amer­i­can Col­lege of Ob­ste­tri­cians and Gy­ne­col­o­gists award for Dis­tin­guished Ser­vice (2001), the An­nu­al Re­search Award of the Trinidad and To­ba­go Med­ical As­so­ci­a­tion and its Scroll of Ho­n­our.