Infertility and its treatment is plagued by a lack of information and research. While we know a certain amount about the immediate medical causes, particularly in the case of women, we know very little about the wider causes. We know virtually nothing, for instance, about the link between infertility and such issues as standard of living, employment background and lifestyle. We don't know whether particular groups in the population are at greater risk than others, though there is evidence linking some occupations with a higher incidence. There is known to be a relationship between the temperature of the testicles and male infertility, and some occupations appear to encourage postures which 'overheat' the testicles. Long-distance lorry drivers, taxi drivers and pilots are all said to suffer from this problem, though they are surely not unique in spending large parts of their working day sitting in one position. Men in other occupations probably suffer from similar hazards.

One of the causes of infertility which is commonly cited is a woman's age. The argument runs that unlike a man, who produces fresh sperm continuously, a woman is born with her full quota of eggs. By the time she reaches thirty-five or forty these have become old and less easily fertilised. A great deal can be made of this association, including the idea that women should have babies before they have careers. As one newspaper article put it: 'Women who want to combine a family and a career should not concentrate on work until they are in their forties.' By which time, it fails to mention, most careers are well and truly closed.

In any case the evidence is a good deal less clear. An editorial in The Lancet queried:

Does the fall in fertility with age reflect a decline in female and male [fertility] or both. . . And to what extent can it be explained by behavioural factors such as a reduction in coital frequency as couples grow older? Moreover, it is not clear whether the reduction in [fertility] is manifest mainly by the lengthening of the time taken to conceive or whether there is a parallel increase in the proportion who cannot conceive.

The magazine goes on to point out that in addition very little is known about the magnitudes involved. How much does fertility drop off, assuming it does, and at what age: thirty, thirty-five, forty or even forty-five? There is now some consensus in the medical profession that a woman's fertility does not begin to drop off until at least thirty-five. Significantly The Lancet suggests that men may also be responsible for the link between a decline in fertility and age, but here we are in almost uncharted territory.

Faced with ignorance like this there is no easy guide to prevention, but below is a limited guide to how to keep out of the infertility clinic.

VD and infertility

Several of the more serious venereal diseases are known to damage the reproductive tubes in men (the vasa deferentia) and women (the fallopian tubes), causing temporary or permanent infertility. Gonorrhoea and syphilis are two of these. The effects are particularly serious if the diseases are left untreated for any length of time. Early treatment substantially reduces the risks. In very rare cases, the vaginal infection trichomonas (which women often experience as a vaginal infection and which men can carry but normally without experiencing symptoms) can find its way into a man's semen and affect fertility. Once treatment for trichomonas is given to the man, his fertility is immediately restored.

Stress

Stress has been linked with infertility for many years. It can inhibit ovulation in women and sperm production in men. The increased stress of undergoing infertility investigations can itself make the problem more serious. Up to thirty per cent of women are said to experience irregular periods as a direct result of the stress associated with being infertile. In British research with rats the researchers concluded that a stressed group had a 44-per-cent pregnancy rate compared with one of ninety per cent in a non-stressed control group: Tt would seem that stress does alter the endocrine balance of the body, thereby making a range of pathologies more likely to occur. It may also be associated with more directly noxious effects, if, for example, it raises alcohol or cigarette consumption, depresses adequate nutrition or causes insomnia.'

Abdominal surgery There may be a strong link between poorly performed abdominal surgery and infertility. Doctors at Hammersmith Hospital in London claim to have found a substantial correlation between 'rough' abdominal surgery on women and damaged reproductive systems including blocked tubes and damaged ovaries. In 1979 they looked at 108 women who attended an infertility clinic at the hospital and found that 79 had had previous abdominal surgery ranging from an appendix operation through abortions to treatment for ovarian cysts. Dr Robert Winston, one of the Hammersmith team of doctors, said:

We found that nearly all [the women we treated] had marked adhesions or damage, often of extreme severity, which could be largely attributed to inappropriate tissue handling, avoidable post-operative infection or removal of potentially viable organs. [Adhesions involve scar tissue where parts of the body adhere to each other where they should be separate.]

The Hammersmith infertility clinic is primarily concerned with physical rather than other causes of infertility and is therefore bound to attract women who have the sort of 'mechanical' infertility problems likely to be created by poor surgery. This would suggest that its findings are almost certainly higher than one would expect to find in the population as a whole. Nevertheless, the findings are disturbing and it is clear that general surgeons should think carefully before operating on women and take particular care when they do. Perhaps significantly, only one per cent of general surgeons are women. It should be emphasised that infertility as a result of an induced abortion is a significant risk only when the operation is badly performed. A properly performed abortion is far safer than childbirth.

Drugs and alcohol Some drugs are known to affect fertility, but for the most part we know very little about their effects on reproductive functions. Alcohol consumption is believed to increase the risks of miscarriage.

Smoking

Cigarette smoking is strongly associated with general ill-health and both are associated with fertility problems.

The American Medical Association has compiled a convincing dossier which also shows a strong link between long-term heavy use of cannabis and infertility. The research points to a link between cannabis and a lowered sperm count and an increased number of abnormal or damaged sperm in men, and irregular ovulation in women.

Weight

Overweight in men and women has been found to reduce fertility as has severe underweight, at least in women. Social pressures on women to reduce their weight below its natural inclination may have something to answer for here.

Endometriosis and infertility Endometriosis is a painful and relatively common condition of the female reproductive system which can cause scarring and adhesions in and around the fallopian tubes. If the condition becomes severe, infertility may result. This is believed to happen to about forty per cent of endometriosis sufferers, though the incidence is thought to be far less with prompt treatment.

We don't know what causes the condition. Tissue resembling the lining of the uterus (endometrium) appears elsewhere in the abdomen, becoming attached to the ovaries, for example. Responding to changes that control menstruation, the tissue therefore bleeds, sometimes causing severe pain and/or leading to scars and adhesions. Ironically, the best treatment is considered to be pregnancy, which stops the menstrual cycle. But if it has already created infertility problems this is not much help. There are drug and surgical treatments available but neither guarantee success and endometriosis may return after the treatment has been completed. Drug treatments, which are aimed at creating pseudo-pregnancies (i.e. stopping menstruation), can have unpleasant side effects.

For many years endometriosis has been taken to be associated with age and childlessness, and it has even been called the 'working woman's condition'. Many doctors have argued that the best way to avoid infertility problems associated with it is therefore for women to have children when they are younger. This link between age and endometriosis is now being challenged, and there is good evidence that it appears in women of all ages from teens through to the menopause. Some women have set up a self-help group for endometriosis sufferers.

Nutrition

There is a suggested relationship between diet and infertility. Studies in South Africa and Japan, for example, suggest that women fed on a diet of refined foods appear to secrete smaller quantities of the hormone responsible for ovulation than women who have a diet rich in unrefined cereals and fresh vegetables. We do not know, though, whether the difference is sufficiently large to affect rates of fertility.

*24\343\2*

Women's Health