Why pregnancies by IVF are more prone to miscarriage – Ob-gyn

A professor of Obstetrics and Gynaecological Biology/Reproductive Medicine at the University of Nigeria, Enugu Campus, Uchenna Nwagha, speaks about the causes, diagnosis and management of infertility, in this interview with EMMANUEL OJO

When can someone be said to be infertile?

Infertility is said to occur when a couple has lived together and had regular, unprotected intercourse for about a year without pregnancy.

How can you describe regular, unprotected, intercourse?

Regular, unprotected intercourse is when the couple meets at least two to three times a week, without condoms.

What are the causes of infertility?

The causes can be male-only, female-only or both. Taking the female factor, for example, before the causes can be understood, we must look at what happens during conception. The man produces spermatozoa, the woman produces the egg. Sperm is deposited in the vagina and travels through the uterine cavity to the fallopian tubes. The egg is released by the ovary and is taken up in the tube. So, the sperm and the egg meet in the fallopian tube and that’s where fertilisation takes place. Then the zygote (fertilised egg) is formed and after a few days in the tubes, the zygote travels down to the uterine cavity where implantation occurs. Now, having explained that, let us start with the problem of the woman. If a woman fails to ovulate or releases immature or abnormal eggs, then there is a problem. If the tube is damaged, then there is a problem in transporting the egg and the sperm. There could also be a problem in transporting the zygote (fertilized egg) back to the uterus, and this may be due to a tube that is not patent or open.

Now let us go down to the uterine cavity that I call the ‘soil’. That is where the zygote implants. Problems in the endometrial cavity, like endometrial polyp or adhesions, can result in a problem of implantation. Fibroids distorting the endometrial cavity can also result in infertility by preventing implantation.

Poor receptivity of the cervix (the opening to the womb) or cervical issues can also result in infertility in a woman. The pH of the cervical mucus is alkaline. Therefore, if for any reason the pH of the cervical mucus is acidic, it becomes a problem. Infection and inflammation of the cervix can acidify the cervical mucus.

In our environment, a common thing that we can see affecting ovulation is what we call polycystic ovarian disease. The etiology (cause) of polycystic ovarian disease is unknown. The problem in women may also be due to obesity.

Other factors that cause infertility include other endocrine disorders involving the thyroid, pancreas, and adrenal glands.

In the male, the testicles produce sperm; so if the testicles, for any reason, are unable to produce sperm, then there is a problem. The testicles might produce sperm, but due to other factors like infection, they tend to affect the total count. According to WHO, for a man to be said to be fertile, the man should have a sperm count of at least 15 million cells per ml and the motility should be at least 50 per cent (actively motile) and then 30 per cent should have normal morphology (shape and size of the cell). There are also factors, such as hormonal problems and varicocele. The male testicles descended from the abdomen to the scrotum, where the temperature is lower for optimal sperm production to occur. Thus, we encourage men who desire to have children to avoid situations that will increase scrotal temperature e.g., wearing tight nylon pants and to avoid long-distance lorry driving.

Are there types of infertility?

There are two types, primary infertility and secondary infertility. The primary refers to a woman who has never been pregnant before and is finding it difficult to get pregnant, while the secondary infertility refers to a situation where the woman has been pregnant before, like once or twice, but is now finding it difficult to get pregnant again.

Do they have similarities and differences?

There are similarities and some differences. In primary infertility, there may be congenital issues and genetic problems. For instance, if you have a woman who has Turners syndrome, the woman, of course, will not develop properly or if you have a woman with abnormalities in the uterus. A woman who married as a virgin with no known abnormality may not be able to get pregnant because the husband’s sperm count is low, thus, presenting with primary infertility, which is entirely a male factor issue. The definition above differentiates the two.

How true is the saying that virginity prevents some women from getting pregnant on time because the body is not yet ready?

It’s not correct. Virginity is about a thin membrane called the hymen that covers the vaginal opening. The first sexual intercourse breaks the hymen. Women who marry as virgins are less likely to contract sexually-transmitted diseases, pelvic inflammatory disease, etc. Thus, they are more likely to get pregnant early enough, provided the man has excellent, quality semen. So, that belief is completely incorrect.

Talking about the predisposing factors, what are they?

There are a lot of risk factors that will increase the chances of infertility and one of those risk factors is age. Fertility declines with age. The time a woman has the highest number of eggs (ovarian reserve) is when she is in the womb of her mother. When she is five months old in her mother’s womb, the total number of eggs she has is about 5-7 million. From then on, it is a road toward reproductive extinction because by the time she is born, that number of eggs would have reduced to 1- 1.5 million and by the time she starts seeing her period, it has gone down further to about 300,000 to 500,000. She loses about 20 to 25 eggs per month, so by the time she attains 35 years of age, fertility declines because the quantity and quality of the eggs she is producing tend to decrease. Therefore, age is extremely critical for fertility.

The other factor is the weight (overweight and underweight). The normal range of body mass index (BMI) is 18.5 – 24.9 kg/m2. If she has been exposed to sexually transmitted diseases, she is prone to infertility. STDs are common factors that cause tubal infertility; then, smoking and excessive alcohol are other predisposing factors.

There are also environmental factors. Some people work in factories that produce soap, solvents, pesticides, etc. Furthermore, excessive radiation from the sun hits directly on men and women. That is why today you see women getting to menopause at 40, 45, etc. Stress is particularly another crucial factor that causes infertility.

How common is infertility?

On the statistics, we have one out of seven in Europe and America and that is about a 14 to 15 per cent prevalence rate. In Nigeria, there is no national study yet but from studies done in other regions, it is about 20 to 30 per cent, a value that is twice the Caucasian value.

Can infertility be inherited?

Infertility can be inherited but it is rare. Genetic factors can be present but cannot be inherited. That is why you must distinguish between hereditary and genetics. They are not really the same. Most genetic disorders frequently lead to recurrent miscarriages.

What is the difference?

The difference is that a man can have a genetic disorder but may not be able to transfer it to the offspring. A man may have a recessive genetic disorder (not manifested) and a woman may also have that same recessive genetic disorder, but when they come together, that’s when it can be transferred to the offspring but if the man, for instance, has a recessive genetic disorder and the woman doesn’t have at all, the child may not manifest because it (the child) did not get any genetic disorder from the woman. Thus, a feature can be genetic without being hereditary.

Are there complications with infertility?

For me, the first complication with infertility in our environment is stigmatisation. Sometimes stress will lead to insomnia and depression. There is also marital disharmony that culminates into separation or outright divorce. It causes hypoactive sexual desire disorder in the female. The desire to have sex is not there for the female and for the male, it causes impotence. It is psychological impotence, which I call situational impotence that can lead to severe depression and suicide. There are many women whose disunity in their marriages, childlessness, divorce and remarriage have forced them into severe depression. Also, some complications come with infertility treatment.

How is infertility diagnosed?

The first thing to do is to check that the man produces adequate semen. We do a full sperm analysis by checking the sperm count, motility, and morphology. We do a culture test to make sure that there is no infection. If after checking all these in the man, everything is fine, then, we leave the man alone and face the woman.

For the woman, we first perform a general body check, to make sure that she does not have any sexually transmitted disease, HIV, hepatitis B and C, etc. Then we check the uterus to make sure that there are no fibroids, endometriosis and so on. Then, we check if she is ovulating, check for tubal patency to make sure that the tubes are open.

Is it treatable?

We treat the cause. For male fertility, we refer to the urologist. Urologists are specialised surgeons who take care of the urological aspects of the man –  the urinary and reproductive parts of the man.

We stimulate ovulation if it is discovered that the woman is not ovulating. For mild tubal issues like adhesions that held the tube down, those adhesions can be separated surgically or if there are mucus-like substances blocking the tubes, they can be flushed out. However, most women with tubal disease will benefit from assisted reproduction. In assisted reproduction, we stimulate the woman, collect her eggs, get the man’s sperm, fertilise the egg externally and incubate the baby in an incubator. After a few days, we transfer the embryo into the woman’s uterine cavity, which is known as In Vitro Fertilisation and Embryotransfer (IVF-ET).

Many women who have gone through IVF have recorded cases of miscarriages. Are there more chances of having a miscarriage with an IVF than with a normal pregnancy?

Yes. One thing about unassisted conception is that the zygote is implanted naturally, unlike IVF where you’re only trying to prepare and stimulate the uterine cavity with drugs directly or indirectly to mimic the natural environment. Sometimes the compatibility of the donor egg and donor sperm used is not known. Again, there are chances of multiple pregnancies. With multiple pregnancies, the chances of miscarriages are higher. Another reason is that sometimes at the time of IVF, the woman is 40 and above and at that age, the eggs are old. The uterus may have been invaded by fibroids and adenomyosis, making implantation difficult.

People talk about traditional herbs used to treat infertility. Are there possible complications that come with the use of herbs or what do you have to say about such practice?

Some herbs work but the problem I have with herbs is that they use crude extract. When they use alcohol, they extract everything, including the ones that are active and the ones that are dangerous unlike how it is in China, India, and other climes. What they do is to just go for the active ingredients and leave out those alkaloids that will damage the liver and the kidney. So herbs are effective, but the problem is that there are no regulations in this country.

Are there complications associated with assisted forms of reproduction?

Definitely. There are no forms of treatment that do not come with complications. The only thing is that we look at the risk-benefit analysis. Some complications include higher-order pregnancies, miscarriages, ectopic pregnancies, ovarian hyperstimulation syndrome and injury to internal organs.

Are there ways to prevent infertility?

One can only prevent what can be prevented. It starts with lifestyle. Avoid being overweight and underweight, reduce alcohol, eat healthily, and stop smoking. Exposure to environmental hazards should also be avoided. Males should avoid wearing nylon pants.

Avoid sex before marriage or practice safe sex if you must indulge. Ensure that you get pregnant before age 35 (marry at a young age). What people do now is that if they cannot get pregnant early, they come and donate their eggs for preservation.

How safe is the egg freezing practice?

Very safe. You can freeze eggs using liquid nitrogen and when she is ready to start giving birth, she can come for IVF. Some women have cancer and are under anti-cancer therapy (drug or radiation). Before they start the therapy, they come to donate their eggs for preservation.

What is the concept of ectopic pregnancy and effects they have on fertility?

An ectopic pregnancy occurs because of the inability to move the zygote to the uterus (womb) after fertilisation, hence, the zygote stays and begins to grow in the tubes which have limited space for its growth. The zygote eventually overgrows the tube, bursts the tube and the patient presents with internal bleeding and abdominal pains. If the tube has ruptured, the doctors will have to remove the tube, then, the woman is left with only one tube.

There should be no problem if the other tube is normal but if the other tube is diseased, fertility is affected.