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¨ When a couple cannot have a baby, it may be because the man, the woman, or both have a fertility problem. It is a problem that few people talk about.

Most men and women assume they will be able to have children. The truth is that about I out of every 10 couples has trouble getting pregnant. Some men and women do not want to have children. But for couples who look forward to having children, infertility can bring sorrow, anger, and disappointment.

Often it is the woman who is blamed if a couple does not have children. But about half the time, it is the man who is infertile. Sometimes a man will not believe it is his problem, or that it may be a shared problem. He may refuse to go for an examination, or he may react with anger. Most often this is because infertility causes shame in communities where a man is expected to produce children as a sign of his manhood.

Infertility has many causes. Some of them can be treated and some cannot. This chapter will help you understand infertility and what you can do about it.

What Is Infertility?

We say a couple is infertile if they cannot get pregnant after having sex together a few times a month for a year, without using a family planning method. A couple may also have a fertility problem if they have had 3 or more miscarriages (lost pregnancies) in a row.

Normal fertility Healthy sperm swim through the womb to the healthy egg.

A man or woman who has already had a child can also become infertile. A problem can develop in the years after the last child was born.

Sometimes the problem is not the man’s or the woman’s alone but a combination of the two. And sometimes both partners seem to be healthy and no doctor or test can find out what is causing the problem.

Habits such as drinking too much alcohol, smoking or chewing tobacco, and using drugs can all affect a man’s or a woman’s fertility.

Infertility in a man

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The main causes of infertility in a man are:

1. He does not produce enough sperm. Or his sperm may not be able to swim to the woman’s tubes or to fertilize the eggs.

2. He had mumps after puberty that harmed his testicles. When this happens, the man can still climax (ejaculate), but the liquid that comes out has no sperm in it.

3. His sperm cannot leave his penis because he has scars in his tubes from a past or present sexually transmitted disease (STD).

4. He has a swelling of the veins in his scrotum (varicocele).

5. He may have problems during sex because:

· his penis does not get hard.
· his penis gets hard but does not stay hard during sex.
· he has a climax too quickly, before his penis is deep in the woman’s vagina.

6. Illnesses such as diabetes, tuberculosis, and malaria can all hurt a man’s fertility.

Infertility in a woman

¨ Infertility caused by infection can be prevented.

Infertility in the woman

1. blocked tube

2. ovary does not produce an egg

3. fibroids

The main causes of infertility in a woman are:

1. She has scarring in her tubes or inside her womb. Scarring in the tube can prevent the egg from moving through the tube, or the sperm from swimming to the egg. Scarring in the womb can prevent the fertilized egg from attaching to the wall of the womb. Sometimes a woman gets scarring but does not know it because she does not feel ill. But years later she learns she is infertile.

Scarring can be caused by:

· an infection from an untreated STD that goes up into the womb or tubes (pelvic inflammatory disease or PID).

· unsafe abortion or problems in childbirth that caused damage or infection in the womb.

· unclean conditions when an IUD is put in that caused an infection.

· problems from an operation of the vagina, womb, tubes, or ovaries.

2. She does not produce an egg (no ovulation). This can be because the body does not make enough of the needed hormones at the right time. If her monthly bleedings are less than 25 days apart, or more than 35 days apart, she may have a problem with ovulation.

Sometimes a woman does not produce eggs if she loses weight very quickly, or if she is too fat.

3. She has growths in her womb (fibroids). Fibroids can prevent conception or make it difficult to carry the pregnancy.

4. Illnesses such as diabetes, tuberculosis, and malaria can also hurt a woman’s fertility.

Family Planning Is Safe Figure Family planning methods are often blamed for infertility. But family planning methods (other than sterilization) do not cause infertility except in some cases when an IUD has not been put in correctly and causes an infection in the womb or tubes. For more information, see the chapter on “Family Planning”.

Dangers at Work or Home That Can Hurt Fertility

These dangers can hurt fertility in many ways - from the making of sperm and eggs to the birth of a healthy baby:

· Contaminated air, food, or water caused by dangerous pesticides or toxic chemicals used in factories and farms.

Pesticides and other harmful chemicals can hurt a man’s sperm while he works...

...and if the woman washes his clothes, the harmful chemicals are passed to her.

· Smoking or chewing tobacco, or drinking alcohol or strong coffee. Women who smoke or chew tobacco, or who drink a lot of alcohol or strong coffee take longer to become pregnant and have more miscarriages. Men who smoke or drink a lot have fewer sperm, and these are often damaged or weak.

Working in hot places, like sitting near the hot engine of a truck for many hours, can kill sperm and cause a man to be infertile.

· High temperatures. A man’s sperm need to stay cool. That is why the testicles hang in the scrotum outside a man’s body. When the testicles get too warm they can stop making healthy sperm. For example, this can happen if a man wears tight clothes that press his testicles up inside his body, or if he takes a hot bath, or works near hot things such as boilers, furnaces, or the hot engine of a long-distance truck - especially if he drives for many hours without a break. Once the testicles become cool, they start making healthy sperm again.

· Medicines. Some medicines can hurt fertility. The best choice is for you and your partner not to use any medicines while you are trying to become pregnant. If you must use medicines because of illness, talk to a health worker and tell her you are trying to get pregnant.

What to Do for Infertility

If you or your partner think you have a fertility problem:

1. Try to have sex during your fertile time. Although a man makes millions of sperm every day, a healthy woman releases only one egg a month. This is called her fertile time - the only time during the month when she can get pregnant. For most women their fertile time starts about 10 days after the first day of the monthly bleeding and lasts about 6 days.

The body has several signs that tell you when you are in a fertile time. The easiest signs to check are the changes in the mucus in your vagina.

Checking your mucus During your fertile time, your cervix makes mucus that helps sperm get into the womb. This mucus looks clear and wet, like raw egg white, and can be stretched between your fingers. Later in your monthly cycle, you may see sticky or dry mucus. This kind of mucus stops the man’s sperm from getting into the womb. Figure See The mucus method and the rhythm method to learn how to check your mucus. Write down the changes every day on a chart. During the week that you see wet, shiny, clear mucus, try to have sex every day.

When you have sex, the best positions for getting the sperm close to the opening of your womb are:

· to lie on your back with the man on top.
· to lie on your side.

Then, after having sex, lie flat on your back for about 20 minutes. This will help the sperm swim into your womb and find the egg.

¨ Try not to worry if you do not get pregnant right away. Many couples get pregnant within a year if they continue to have sex during the woman’s fertile days.

Avoiding these things can also help:

· Do not use oils or creams during sex. They can kill the sperm or stop it from reaching the egg.

· Do not douche or wash inside your vagina. Douching before or after sex can change the wetness inside your vagina, making it harder for the sperm to live.

· Your partner should not have a hot bath before having sex. Heat on the testicles kills sperm.

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2. Treat any health problems.

Both you and your partner should have medical exams and be checked for STDs. If either of you has an STD, both of you must be treated. Be sure to finish all the medicines you are given.

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3. Practice good health habits:

· Eat good, healthy food. If you do not have regular monthly bleeding and you are very thin or very fat, try to gain or lose weight.

· Avoid smoking or chewing tobacco, using drugs, or drinking alcohol.

· Avoid caffeine in drinks like coffee, black tea, and cola drinks.

· Get plenty of rest and regular exercise.

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4. Try to see a health worker if you are not pregnant after one year. There are some simple tests that do not cost much that may be able to tell you what the problem is. For example, the health worker may look at your partner’s sperm under a microscope to see if they are healthy. She may give you a pelvic exam to check your vagina, womb, and tubes for infection or growths. Or she may teach you to tell if your ovaries are releasing an egg by taking your temperature every morning.

It is important to remember that these tests only tell you what the problem is - they will not solve it. Even the most expensive medicines and operations often cannot cure infertility.

Losing a Pregnancy (Miscarriage)

For many couples, the problem is not getting pregnant but staying pregnant. Losing I or even 2 pregnancies is common. It can be the body’s way of ending a pregnancy that is too weak to survive.

But if you have lost 3 or more pregnancies, there may be another problem, such as:

· unhealthy eggs or sperm.
· a problem with the shape of the womb.
· growths (fibroids) in the womb.
· the wrong balance of hormones in your body.
· infection in the womb or vagina.
· an illness, such as malaria.

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The warning signs of miscarriage are:

· small amounts of brown, red, or pink blood from your vagina.
· pains or cramping, no matter how small.

¨ Miscarriage often happens no matter how careful you are. Do not blame yourself.

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What to do when signs start:

Once a miscarriage starts there is usually not much that can be done to stop it. If you are bleeding slightly, without pain:

· lie down and rest for 2 or 3 days.
· do not have sex.

If bleeding continues or becomes heavy, or if you are more than 4 months pregnant, go to a hospital and tell them you are pregnant.

IMPORTANT
If you are in the first 3 months of pregnancy and you have severe pain, feel faint, and have some bleeding, you could have a pregnancy in the tube. Go to a hospital immediately. Be sure to tell them you are pregnant.

Before you try to get pregnant again:

· Follow the guidelines about treating health problems and practicing good health habits. It is especially important to avoid caffeine, to stop smoking or chewing tobacco, and to stop drinking alcohol or using drugs. These things can all help cause miscarriage.

· If your miscarriages always happen after you have been pregnant for 3 months, it may be that the opening to your womb is weak. This can sometimes be treated by having a doctor put a small tie around the cervix to keep it closed. Make sure that the doctor has experience giving this treatment. When it is time to give birth, the tie has to be removed.

If you do become pregnant:

· try not to lift heavy things.
· try not to have sex for the first 6 to 8 weeks of your pregnancy.
· rest when you can.

Losing a pregnancy is common. If it happens to you, it does not mean you cannot have a healthy pregnancy the next time.

Living with Infertility

Infertility can make a woman or man feel sad, nervous, alone, frustrated, or angry.

When this happens, it is important to know you are not alone. Try to talk with people who love and care about you. You may also be able to find other couples with the same problem and learn to help each other.

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The stories below describe some ways that people have coped with infertility:

Adopting a child: Lina’s story Lina was 25 years old and had been married 3 times. She was very unhappy because each of her husbands divorced her when she did not become pregnant. In the village, people spoke about her and blamed her, saying that she must have used some magic to avoid pregnancy before she was married, and that it must have been so strong it had made her infertile. Her sisters all had children, and sometimes Lina cared for them. Her older sister had tuberculosis (TB) and she was very ill when she gave birth to twins. Lina asked if she might adopt one of the twins and her sister agreed. Lina went to the health center and asked the health worker to help her find a way to feed the baby. The health worker taught Lina how to feed the baby from a cup and spoon and arranged to have the baby breastfed during the day by a healthy woman in the village with another baby. At night Lina fed her baby from a cup, with breast milk that another sister gave her each evening. Lina’s friends and neighbors were not sure that her baby would be healthy. But when they saw the baby grow strong, they were pleased and proud of Lina. In fact, Lina came to be seen as an expert in raising adopted babies. When a village mother died in childbirth, her baby was given to Lina to care for. Figure The twins have grown up now, and people often say that the one Lina adopted is taller and stronger than the other. They credit this to Lina’s loving care. - Bundoora, Australia

Building a life without children: Sara and Tito’s story Sara and Tito tried for many years to have children, but they were not able to. At first they were sad, because in their community, couples were expected to have as many children together as they could. But then they decided to stop thinking that their lives were not complete without children and to plan a future for themselves. They decided to start a business and to travel from town to town, market to market, selling pots and pans and other goods. With children, it would have been very difficult for them to travel in this way. Figure Now that Sara and Tito are older, people say they look alike in their faces and attitudes. They care for each other, share many laughs and many friends. They are not grandparents like their neighbors, but they have many interesting stories to tell. They are respected by everyone in the community. - Lima, Peru

Working for Change

To help others with infertility problems:

· be kind and sympathetic. It is a difficult time, and they need support and understanding. Do not blame couples who cannot get pregnant.

· teach couples to value and respect each other as companions.

· help a couple who cannot have children to look for other ways to be with children or to make peace with their lives.

Health workers can also:

· provide information on ways to adopt children.

· teach young people about STDs and how to prevent them.

· make sure your local health center is prepared to diagnose and treat STDs and to take women’s complaints about pelvic pain seriously. Too often women are sent home without treatment after being told there is nothing wrong with them.

· teach women the signs of pelvic infection and the importance of getting immediate and complete treatment.

· teach men and women the signs of STDs, the importance of getting treated right away, and the importance of treating all partners.

There are many causes of infertility, but STDs are the easiest to prevent