Chapter 1b
Do you have an infertility problem? When to start worrying!

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Tip for Self-help

Before seeking medical help, remember some of the things you can do to enhance your own fertility potential.

Body weight, diet and exercise. Proper diet and exercise are important for optimal reproductive function and women who are significantly overweight or underweight can have difficulty getting pregnant. Although most of a woman's estrogen is manufactured in her ovaries, 30% is produced in fat cells. Because a normal hormonal balance is essential for the process of conception, it is not surprising that extreme weight levels, either high or low, can contribute to infertility. Body fat levels that are 10% to 15% above normal can contribute to infertility, with an overload of estrogen throwing off the reproductive cycle. Body fat levels 10% to 15% below normal can completely shut down the reproductive process, so that women with eating disorders, such as anorexia nervosa or bulimia, or those who are on very low-calorie or restrictive diets are at risk, especially if their periods are irregular. Female athletes, marathon runners, dancers, and others who exercise very intensely may also find that their menstrual cycle is abnormal and their fertility is impaired.

Stop smoking. Cigarette smoking has been associated with a decreased sperm count in men. Women who smoke also take longer to conceive.

Stop drinking alcohol. Alcohol (beer and wine as well as hard liquor) intake in men has been associated with low sperm counts.

Review your medications. A number of medications, including some of those used to treat ulcer problems and high blood pressure, can influence a man's sperm count. If you are taking any medications, talk with your doctor about whether or not it can affect your fertility. Many medications taken during early pregnancy can affect the fetus. It is important to tell your doctor or pharmacist that you are attempting to become pregnant before taking prescription medications or over the counter medications, such as aspirin, antihistamines, or diet pills.

Stop abusing drugs. Drugs such as marijuana and anabolic steroids decrease sperm counts. If you have used drugs, discuss this with your doctor. This is confidential information. Both partners should stop using any illicit drugs if they want a healthy baby.

Limit your caffeine (tea, soft drinks and coffee) intake.

Start vitamin supplements. Taking folic acid regularly helps to reduce the risk of the baby having a birth defect.

Frequency of intercourse. The simple rule is - as often as you like; but the more often you have sex, the better your chances. Thus, for couples who have sex only on weekends (often the price they pay for a heavy work schedule) the chance of having sex on the fertile preovulatory day is only one-third that of couples who have sex every other day - which means they may take three times as long to conceive. Many couples complain that they are too stressed out to have frequent sex. Here are some simple measures you can take to increase sexual frequency.

1. Use sexual toys like vibrators or body massagers, to make sex more fun

2. Using a lubricant like liquid paraffin can help to make sex more exciting

3. Playing sex games can help – try taking turns seducing each other !

I tell all my patients – it’s much more fun making a baby in your bed room than coming to me ! ( And think of all the money you’ll be saving – it’s like being paid to make love to your wife !)

Timing of intercourse. Unlike animals, who know when to have sex in order to conceive (because the female is in "heat" or estrus when she ovulates), most couples have no idea when the woman ovulates. The window of opportunity during which a woman can get pregnant every month is called her "fertile phase" – and is about 4-5 days before ovulation occurs. Timing intercourse during the "fertile period" ( before ovulation) is important and can be easily learnt . This is described in greater detail in Chapter …..However, some couples are so anxious about having sex at exactly the right time that they may abstain for a whole week prior to the "ovulatory day " - and often the doctor is the culprit in this overrigorous scheduling of sex. This over attention can be counterproductive (because of the anxiety and stress it generates) and is not advisable. As long as the sperm are going in the vagina, it makes no difference which day they go in , so you can have sex daily as well, if you so desire!

Position and technique of intercourse. Pigs are very efficient at conserving semen - the boar literally screws his penis into the cervix of the vagina, obtaining a tight lock prior to ejaculation, to ensure that no semen leaks out. Humans do not have such well-designed mechanisms of technique - and perhaps this is because they are really not necessary. Leakage of semen after intercourse is completely normal. While many women worry that this means that they are not having sex properly or that their body is rejecting the sperm, actually leakage is a good sign – it means that the semen is being correctly deposited in the vagina ! Of course, you can only see what leaks out , and not what goes in ! Most doctors advise a male superior position; and also advise that the woman remain lying down for at least 5 minutes after sex; and not wash or douche afterwards. A number of products used for lubrication during intercourse, such as petroleum jelly or vaginal cream, have been shown to affect sperm quality. Therefore, these products should be avoided if you are trying to get pregnant (a suitable alternative is liquid paraffin).

Balancing a career and fertility

Women pursuing a career often have a hard time balancing their biologic urge to have a baby and the demands of their professional career. Unfortunately, Indian companies still do not give a high priority to family building, and many bosses frown on women employees who are trying to get pregnant, because they are concerned that this will cause them to spend more energy on their family, and detract from their ability to perform their job efficiently. For a minority, putting off getting pregnant means that their fertility declines as they age, and they often regret their earlier decision to postpone childbearing. Professionals often have a harder time coming to terms with their infertility, because this is usually the first time they are forced to confront their own biological frailty and limitations.

Which is the "right time" to plan a baby ?

While there can be no simple answer to this question, remember that a woman’s fertility is maximal between the ages of 20 and 30. Beyond the age of 30, fertility starts to decline; and this drop is quite sharp after the age of 35; and precipitate after the age of 38. From a purely biologic point of view, nature has designed women’s bodies so that they have babies between the ages of 20 and 35. However, the right time to have a baby is a very personal and individual decision, which each couple needs to make for themselves. Public anxiety over infertility is fueled by countless magazines articles warning couples not to wait too long to start a family. We now see many patients who are "pre-infertile" , who assume they’ll have trouble conceiving even before difficulties actually arise , just because they are more than 30 years old !

Is fertility lower at present?

Has the fertility of couples declined in modern times? Possibly. The reasons for this include:

1. the increasing age of women at the time of marriage and childbearing

2. the increased incidence of sexually transmitted diseases or STDs which damage the reproductive tract in both men and women

3. decreasing sperm counts in men which is a worldwide phenomenon. An interesting observation made recently, has been that men's sperm counts worldwide have been falling in the last few decades . Whether this is due to environmental pollution; or to the stresses of modern day life remains unclear.

The good news is that there is definitely an increasing awareness about infertility in society today. It is no longer a taboo topic, and couples, supported by their families, are much more willing to seek medical assistance.

Where to get help.....

Most couples consult their family physician who will refer them to an obstetrician - gynecologist when infertility is a concern. This first visit should include both partners . The physician will usually outline the possible causes of infertility, and provide an evaluation plan. The first step should be to achieve an accurate diagnosis to try to find out why pregnancy isn't occurring. Once a diagnosis has been determined, the couple and physician should talk again about a treatment plan. For difficult problems, referral to an infertility specialist may be suggested.

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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