In recent years, the recognition, prevention and treatment of fertility challenges in both low- and high-resource settings has garnered increased attention as a human rights issue in global health and development circles due to the potentially adverse impacts of infertility on both an individual and community level.
However, in practice, sexual and reproductive health programs often neglect infertility -- and lack the resources to comprehensively assess, much less address, this concern. Even in the U.S., technically a high-income nation, infertility treatment is priced as a luxury item and rarely considered a public health issue. Further, despite current knowledge of treatment as prevention and staggering success in effectively eliminating vertical HIV transmission, women living with HIV report a deplorable lack of counseling from providers on their reproductive desires and options.
Natasha Davies, MBChB, M.P.H., found herself facing these twin challenges as lead clinician of a low-cost, low-technology safer conception service that she and her colleagues launched in June 2015 at the Wits Reproductive Health and HIV Institute (RHI) in Johannesburg, South Africa. "We seemed to be having a selection bias for couples who have underlying infertility or subfertility. I suspect that that is because there are no services for them anywhere else," Davies explained during a scientific workshop on evaluation and management of HIV and infertility at AIDS 2016 in Durban. "As soon as they saw an advert saying that there was a safer conception service, they flooded our doors. ... Not only did I need to work on their HIV risks because they had already been engaging in trying to get pregnant, but I also needed to come up with a way to assess whether there was an underlying problem."
Davies, a longtime HIV clinician, does not have an OB/GYN background or infertility specialty, and in the primary care setting of Wits RHI, resources such as hormone testing, sperm analysis and sonography are not available. To better support the reproductive desires of clients living with HIV, Davies consulted with fertility specialists and developed a detailed checklist to assess the fertility of individuals and couples living with HIV, flag potential fertility problems and support realistic discussion and tailoring of reproductive options with clients. The tool can easily be applied in low-resources settings as it is based purely on thorough discussion of patients' medical histories.
Overview of Fertility Assessment Questions
Fertility potential drops rather dramatically for women age 35 and older. Women in their mid-20s have a 25% chance of conceiving per cycle, Davies noted; in her late 30s, a woman has about a 10% chance; by her early 40s, that drops to about 5% per cycle. Davies stressed the importance of preparing patients to have realistic expectations based on the age of the woman trying to conceive; for men, age is a factor in infertility, but a far less significant one than for women.
Body Mass Index (BMI)
Obesity is a serious health concern and is more prevalent among U.S. women living with HIV than in the general population. Weight also has implications for reproduction: For every increasing unit of body mass index (BMI), an obese woman may experience an approximate 5% drop in fertility. Women ought to know that lowering their weight even by 5% to 10% can increase their chances of conceiving. Davies also stressed that weight management, unlike other fertility enhancements, is a plausible intervention in low-resource settings. Obesity in a patient can also be linked to underlying polycystic ovarian syndrome, Davies noted, and can indicate the need to refer the patient to a gynecologist.
Menstrual History and Problems
Davies' tool assesses the following aspects of a woman's menstrual cycle:
- Variability/Irregularity: While few women (and none of Davies' patients) have textbook-regular 28-day menstrual cycles each month, if a woman's cycle varies in length by five days or more from month to month, or averages 21 or fewer days or 35 or more days, then she may have trouble identifying her "fertile window" -- the handful of days of a woman's cycle surrounding ovulation when she is most likely to conceive. Having this information is key for timing intercourse or insemination during peak days of fertility and for further reducing risk of HIV transmission in serodifferent couples by confining instances of condomless sex to certain days per month. Irregular cycles may also indicate anovulation -- the woman is not releasing an egg every month -- which also presents a challenge to conception.
- Pain/Dysmenorrhea: Severely painful periods might be a sign of endometriosis, a common cause of infertility. However, endometriosis can be treated, so if a patient can be referred to a gynecology service and diagnosed and treated for endometriosis, this could have a favorable impact on her fertility.
- Amenorrhea (no periods for more than 3-6 months): Women experiencing this condition are likely to have great difficulty conceiving. If the absence of periods is due to the woman coming off long-acting injectable contraceptive methods, she can be assured that it could take a year to 18 months of patience before her cycles resume regularity.
If the female partner has not had any previous pregnancies (including miscarriage, ectopic pregnancy or terminated pregnancy) and/or the male partner has not created a pregnancy before, those are "big red flags," as Davies put it, and may indicate primary infertility if they have been trying to conceive.
It's also important to note here that, while previous questions have focused on a woman's reproductive potential, the likelihood of male-factor infertility is about equal to the chance of infertility on the woman's side.
History of Miscarriages, Ectopic Pregnancy or STIs
Looking more closely at past miscarriages, ectopic pregnancies or terminations can uncover underlying reasons for infertility. The definition of infertility, after all, encompasses inability not only to achieve pregnancy but also to have a live birth. If a woman has had three or more miscarriages, she may be able to become pregnant but may need additional support to sustain the pregnancy to full term.
Previous ectopic pregnancies or other pelvic surgeries could indicate the presence of scarring or have bearing on the health of the fallopian tubes. In addition, a provider can inquire as to whether a pregnancy termination was medically safe or informally accessed; the former should have no effect on fertility, but the latter may mean there was uterine scarring or infection following the procedure.
While it's ideal to know a person's history of sexually transmitted infections (STIs) and important to ask, responses may not be reliable as the rate of asymptomatic STIs is quite high, and individuals may not know that they have had an STI before.
If a patient
- smokes cigarettes daily,
- drinks more than socially,
- consumes high amounts of caffeine,
- regularly smokes marijuana, or
- copes poorly with stress,
then managing these factors, while not a guarantee of increased fertility, may improve likelihood of conceiving. For instance, frequent marijuana use has been shown to have a negative impact on sperm health, Davies noted. Once again, these are factors within the control of a patient in a low-resource environment.
Stress may be unavoidable for couples in these situations, since while stress can contribute to infertility, infertility also causes stress. In men, this can manifest as erectile dysfunction when attempting to conceive. Strong, supportive counseling can relieve some of the effects of stress on the individual or couple.
Frequency and Time Period of Condomless Sex
It is not surprising, given both the aggressive push for condom use in serodifferent couples and the general sorry state of comprehensive sexual and reproductive health education in many areas that Davies has found in her safer conception practice that some individuals who are trying to conceive must be reminded that this requires having sex regularly and that sex must be condomless.
Circumstances such as engagement in migrant labor can keep couples living apart from one another for significant periods and complicate the task of having sex during the woman's fertile window. If a couple has had the intention to conceive for a long time but has actually only tried to conceive for a few cycles during the woman's peak fertile days, then there is less cause for concern regarding fertility.
Further, to get an accurate history of condomless sex, couples must be asked directly and without judgment, as they may have been trying for much longer than they initially indicated but fear getting negative feedback if they share how long they have been having condomless sex. On the other side of the spectrum, couples who have been told repeatedly to always use condoms and have not been well counseled on their reproductive options may continue to do so even as they are trying to get pregnant.
Davies' service is designed to be a safe space for individuals and couples living with HIV to have their reproductive desires honored and supported. However, an HIV primary care clinician need not have "Safer Conception" written on their door to provide that safe space. This fertility assessment checklist can only come into play once a provider has realized that a patient wants to explore conception. Considering mounting evidence of the paucity of counseling offered to people living with HIV regarding their reproductive options, perhaps a key question that must become more routine is: "Are you thinking about having a baby someday?"