Dr Ajayi’s Interview: Unexplained Infertility Doesn’t Mean There Is No Problem
Dr Ajayi’s Interview: Unexplained Infertility Doesn’t Mean There Is No Problem
Published July 2014
The name Dr. Abayomi Ajayi is a household name in the world of gynaecology, especially in the management of fertility issues. Dr. Ajayi is a trained in-vitro fertilization (IVF) specialist from the Iscare Centre for Assisted Reproduction, Bratislava, Slovak Republic, Institute of Human Reproduction Symbion, Fruebjergvej (a research centre) and the Fertility Clinic of Copenhagen University, Herlev Hospital, both in Coppenhagen, Denmark.
This Fellow of the West African College of Surgeons in Obstetrics and Gynaecology worked with Lagoon Hospital, Apapa as Consultant Obstetrician/Gynaecologist for over a decade before he left to start Nordica Fertility Centre, Lagos. Today, the services of Nordica Fertility Centre, is fast spreading to other parts of the country, having branches in Asaba, Abuja and Lagos.
In this interview with CHIOMA UMEHA (HEALTH EDITOR) he discusses assisted reproductive health, fertility treatment and other issues. EXCERPTS:
Q: What informs choice of fertility treatment given to a particular patient?
A: When a patient comes in, we carry out a test and then this is what points us to the kind of treatment the patient requires. When we identify the problem, we can now know how to fix it. If we see that there is no problem at all (what we call unexplained infertility); then we ask their age and suggest that they start from the basic thing. For example: insemination. The fact that it is called unexplained infertility does not mean that there is no problem at all. We look at the cause of the infertility and then we go on to look at the characteristics of the couple and that is what determines the kind of infertility treatment they get.
Q: Assuming you try insemination, and it fails, what next?
A: Each time we have a failure, it is an opportunity for us to examine it critically and find out what we didn’t do well. We would modify the insemination again. If we know that the patient is 38, there is no point carrying out IUI again on the patient. But if this patient is less than 35 years old, then we can do IUI two to three times.
Q: Intrauterine insemination and how it works
A: Intrauterine insemination (IUI) involves a laboratory procedure to separate fast moving sperm from more sluggish or non-moving sperm.
The fast moving sperm are then placed into the woman’s womb close to the time of ovulation when the egg is released from the ovary in the middle of the monthly cycle.
Your clinic may recommend IUI if: there is unexplained infertility; there are ovulation problems; male partner experiences impotence or premature ejaculation. Then, you do not have any known fertility problems but may not have a male partner and are trying for a baby using donated sperm.
It is essential that your fallopian tubes are known to be open and healthy before the IUI process begins. A tubal patency test is usually carried out as part of your assessment by the fertility clinic.
The typical method for assessing the health of your pelvis and the patency of your fallopian tubes is laparoscopy and dye testing. At laparoscopy a direct view of the pelvis is obtained by inserting a telescope into the abdomen.
When the pelvis and tubes are healthy, dye passes freely through both tubes. There should be no adhesions present that might prevent an egg from having access to either tube from the ovaries. This is performed under a short general anaesthetic.
The test may show that you only have one open healthy tube although you may have both ovaries. IUI treatment can then only be carried out when there is evidence that ovulation is about to occur from the ovary that is on the same side as the open tube. The second essential requirement is that there is no significant problem with sperm numbers or sperm quality.
If your clinic has recommended IUI treatment, you may want to discuss the following options with your clinician:
IUI with or without fertility drugs – as IUI can be given with or without fertility drugs to boost egg production, you should discuss the risks involved in using fertility drugs and whether IUI without fertility drugs might be suitable for you.
IUI with partner’s sperm or donor sperm – instead of using your partner’s sperm, if your partner is unable to provide sperm, or if you do not have a male partner, you may want to consider using donated sperm.
If IUI is unsuccessful – you may want to talk to your clinician about other procedures such as in vitro fertilisation (IVF).
Q: Link between conception and fertilization
A: Conception happens when the male and female gamete comes together in what we call fertilization and the fertilized embryo becomes attached to the endometrium. In other words, the woman has to ovulate every month to release one egg at least. We know that women come to the world with all the eggs that they would use and on a monthly basis, about 20 to 30 eggs would start this journey and the body has a way of making only one, most of the time, to become ripe. This is the one that is ovulated and the others that started the journey just die off naturally. When a woman now releases this egg from the ovary, it is picked up by the tube and then it is transported into the uterus. Along the way that it is transported along the tube, it meets with a sperm in a particular part of the tube and fertilization occurs. Now, when this egg is fertilized, it is now transported into the uterus and it stays in the uterus until it becomes attached to the uterus. That is what is called implantation.
When we look at these processes, we can divide them into two processes: the fertilization and implantation. For Fertilization to take place, the sperm and the egg has to come together. If anything happens along this route that does not make the two to come together, we would not have fertilization; and those are the causes of infertility. It could be the pathway is not clear or the tube is blocked. It could be that the sperm cannot make the journey or it is of low quality. It could also be that the there was no egg released, which we say that there was no ovulation. So these are the things that can make a woman not be able to conceive. But once this hurdle is crossed and the egg and sperm meet, there is fertilization. The quality of the embryo produced also depends on the quality of raw materials that is being used. That is the quality of the egg and quality of the sperm. This is what determines the quality of the embryo.
Q: There are a lot of misconceptions about when life begins…
A: Nature is such that it is not particularly very efficient. We know that about 11 per cent of the embryos formed will not implant and this also raises the point: when does life begin? Some people say that life begins at fertilization but we know that some embryos that get fertilized will not even implant and we know that without implantation, there is no pregnancy. Now after the embryo has been fertilized and it gets to the uterus, there is a conversation between the endometrium of the uterus and embryo. And unless they speak the language that each of them understands, there is no implantation. Now, when this happens, we know that there are a lot of chemicals involved in this produced by the body and there are a lot of wars going on. Some people even call it the ‘black box of reproduction’ because very little is known about implantation. Even in IVF, we know that fertilization rate is high but implantation rate is still almost the same thing and, therefore, a lot of work is still being done on implantation. But, once implantation takes place, we can now start up, the formation of the placenta and from the placenta, a particular hormone is released which makes us to be certain that a woman is pregnant by the hormone that is measured either in the blood or in the urine which we call Human Chorionic Gonadotropin (HCG).
That is what we look at when we want to determine if a woman is pregnant or not. That is the hormone that is produced by the placenta. It is at this point that we can talk of the quality of the pregnancy. Because by nature, some pregnancies would just not survive, either because the raw material is not very good or there might be a problem with the endometrium. For instance, if there is scar formation from a previous surgery, it would be likely that there would be a miscarriage: the chances that the pregnancy will be lost are high because the embryo will not be able to implant properly in that place. If everything is okay then we move on to have the pregnancy.
Be that as it may, whether it is by whatever route, some pregnancies would be lost in the first trimester and on these ones, there is very little that the doctors can do. The best that we can just say is that the patients should rest. It is a way that nature gets rid of embryos that are defective. They can be likened to saying taking a kidney from somebody else, the body can reject it. This is because a pregnancy is composed of two people. To the woman, the component that the husband contributes is a foreign body and despite the fact that you are looking for the pregnancy, what the body first does is to reject it because of the foreign component. It is only when the body is unable to do this that you can have a pregnancy stay. That is all that happens between when the egg is formed and when conception happens.
What the body does is to look at life threatening errors and reject them and that is why we have miscarriages mainly in the first trimester. But there are some mistakes that go through because most of the time they are not life threatening. The body does not recognize them sometimes. It is like there is a Quality Control system in the body. Just like we have in Toyota when we can detect that this one is not well painted or there is a fault. Sometimes, this Quality Control System in the body also fails. It does not detect some especially the ones that are not life threatening and that is why we sometimes have babies with congenital abnormalities. But they do not occur frequently because of the Quality Control System in the body. Most of the congenital abnormalities you see may not be life threatening, but of course, we have some of them that are life threatening. It is the ones in the first trimester that are really not compatible with life that the body rejects and, therefore, the doctor cannot do much about it. When it now comes to the second trimester (that is after the first three months of life) at this point, most of them would have passed through the normal control system in the body and most of the time, what happens is that there is a defect in the reproductive system of the woman. Because at this point, the foetus has reached a significant weight and if the cervix cannot bear that weight, then it can let go. And that is why we see the doctors put cerclage or shirodkar stitch to strengthen the cervix in order to take it. And even here, you cannot underestimate the value of bed rest.
Then of course one of the things which can make a woman lose her pregnancy is if there are problems in the uterus. Then we talk about scanning. Also, there are women with problems in their uterus who are born that way. It is usually abnormally shaped: the space in the uterus is compromised so they can lose pregnancies. There are some people who have such problems and unless they are detected, you cannot understand.
Q: How can it be managed?
A: For someone who has septum in the uterus, it can be removed; especially through endoscopy. Unless you have a septum or something that compromises the space, you do not want to do anything. If it comes really down, then you do not have a choice, you are better off dividing this and then even despite the fact that you will have a small scar, it is even better off than not having any space at all. But, when the problem is with the embryo, there is little that can be done. There are some specific genes that if you do not have, you will be prone to miscarriage with the endometrium. They are dependent on hormones. If you do not have them with your endometrium, you can detect with either Heterogoscopy (HSG) or 3D Ultrasound which is the best thing now. That is the latest thing about miscarriages now, especially in people who have recurrent miscarriage.
If the problem is with the foetus; then you need to take a sample and see what the problem is. Sometimes, it can be the egg and other times, it can be traced to the sperm. Sometimes, it can be infection that would make people lose conception.
Q: How does obesity affect pregnancy?
A: In Nigeria, some things are just labelled wrongly. Some people might not have a miscarriage and yet they are labelled as miscarriage. Some pregnancies might not be established and yet they would say that you had a miscarriage. It is easier for you to deal with miscarriage than infertility. Until we see that the pregnancy is already established and you lose it that is when we term it as a miscarriage. But there are some people that always have a miscarriage, almost every month; the problem is not miscarriage the problem is that they are not always getting pregnant.
Q: Why do you say so?
A: Most of the times, it is the doctor that confuses them. They give them some concoctions and then they tell them that they have lost the pregnancy. Meanwhile, you were never pregnant. That is why we need to be strict about the question: when does life begin. How can you say that you have lost a pregnancy that was never there? We believe that it is only when we can see the heartbeat of a baby that we know that you are pregnant.
Q: Factors that affect foetal development
A: Drugs: the ones that are taken as regards medical reasons or the ones that are taken as a habit. We always advice that pregnant women should not take drugs that is not prescribed. This is because some drugs can affect their baby.
Q: What could enhance effective growth of a baby?
A: Sometimes, the doctor could give out some drugs that can be taken (hemantinics). This is because we know that the baby derives all its ingredients from the pregnant woman and, therefore, we do not want your blood level to be low and also that is good for delivery too because sometimes, a little blood is lost in the course of delivery. In pregnancy, there is a physiological anaemia; that is your blood level increases and therefore, the concentration decreases. We have drugs to top this up so that the density can remain normal.
For the baby, their size is pre determined before pregnancy. It depends on the father and the mother. So, negative things can happen to them but they are not likely to increase the quality because the quality is already predefined by the genes of the father and the mother. What we do most of the time is to preserve what is already there. There is nothing that can be done as regards improvement. For instance, if the mother and father are small, it is not likely that they have a bulk age baby. If the woman likes, she should eat as much as possible; it is her blood sugar that will increase and if her pancreas is not working well, she would have diabetes. Well, the baby might become excessively big but he will not be well because he has been exposed to too much sugar. By the way, there is a difference between maintaining and improving the baby’s size.