Infertility work up going bizarre

By Surafel K Gebreselassie

A man in his 30s and a woman in her 20s knocked at the patient’s room at the outpatient clinic.

Please come on in.

She was the first to enter the room. He followed hesitantly.

Tenayistilign.

“Tenayistilign,” she answered me back and sat in the two chairs next to each other.

It was in the late 90s, in Addis Ababa, Ethiopia. As a young and energetic general medical practitioner (GP), I was ready for every challenge. Medical school had prepared me well within the scope of the spectrum of the common diseases in any developing country. Although we joined medical school at a very young age, by the time we graduated we had enough whipping in the 6 years of training and one more year of internship to accept responsibility to help fellow human beings. We had a bit of everything in those years of training. Specialty and sub-specialty trainings were limited in Ethiopia’s higher education which is true even today. So as a GP, we were up there for every challenge thrown at us. Where I worked, a modest hospital in Addis Ababa, there was only one physician assigned to cover calls that often started around 5 pm and will go on to the next morning. So when I was on call, I covered the emergency department, delivered babies when the on call midwives needed help, put out the fire for any emergencies among hospitalized patients, did minor outpatient surgeries and many more. My modest monthly salary of about 900-1000 birr (in today’s exchange $50-60) plus the 20-30 birr ($2-3) I used to make per night (not per hour) for call nights didn’t make me miserable although would have liked to get a better compensation to afford rent for a modest studio with no kitchen and shared detached bathroom (300 birr/month), food, clothing, you name it. But then being a doctor was more than money.  It was walking tall in the neighborhood, making your parents proud. A friend you grew up playing soccer with would stop by to ask you about a head ache or a muscle cramp or on occasions about a nagging cough.  Or a woman who knew you growing up, who cried when you were about to die of some persistent nausea or vomiting, cheered when you made it out of a bout of a childhood illness, would stop by for a few changes for a grocery or a taxi fare. And not to mention our parents who exuded confidence that out of that poverty, they were able to guide us successfully to higher education.

I want to be a doctor like him,

I want to be a doctor like her.

Here again we played role models to our siblings, other children in the neighborhoods.

Hence I was a content guy, even a happy guy when I was a GP in Addis.  When I met the couple for the first time that needed help because they were not able to conceive, I truly wanted to help. There was no infertility clinic that I could have referred them, at least then. He was 35 and she was 22. They were married over 2 years and were not able to conceive. She was tired of the gossips and naggings from her in laws and made the initiative to have a checkup. He was not happy but came along with her any way.

Infertility is not about a single individual, it involves a couple so in that sense the evaluation is unique. It is often defined as failure of a couple to conceive after 12 months of regular intercourse without use of contraception. The time can be shorted to 6 months in women 35 years and older to initiate the evaluation process early. According to recent data (1), in the US the frequency of primary infertility in married women varied based on age 15 to 34 years (7.3 to 9.1 percent), 35 to 39 years (25 percent), and 40 to 44 years (30 percent). The prevalence of infertility is even higher in South Asia, Sub-Saharan Africa, North Africa/Middle East, and Central/Eastern Europe and Central Asia (2).

It was the appropriate thing for her to seek medical attention even if her husband was not interested. Childlessness in the first marriage along with early marriage are risk factors for divorce in Ethiopia.  A study by Tilson D et al (3) showed that 95% of women in Ethiopia who did not have a child within their first marriage divorced within 20 years. Eighty-five per cent of these women divorced within the first 5 years. On the other hand only 23% of women who did have a child within first marriage divorced within 20 years. Failure of the first wife to bear children is often cited as a reason for the husband to take an additional wife. Male factor infertility which plays a significant share of causes of infertility either alone or as combined with woman factors is not often appreciated in Ethiopia and the burden is left on the woman.

After a discussion about the factors involved in infertility, I obtained detailed history and complete physical exam. Nothing was obvious so I proceeded to initiate work up starting with the husband.  He was not happy. He felt threatened with his manhood. After several minutes of persuasion he finally agreed to give specimen for semen analysis.

2 years would pass before I saw the husband again. He never bothered to come and obtain the test results.  In that office visit, he wouldn’t even say a word.

He pulled out a picture of a boy, about a year old.

“That is my son,” he said.

He went ahead and picked up another wife, I figured.

He slammed the office door and left.

Wait a minute, something wasn’t making sense.

I pulled the old chart.

Heh, his sperm count was zero.

Either we had the test wrong or …

I run to catch him but had disappeared among the crowds.

This blog is based on a true story. I have used the following references for facts mentioned in the article.

1.Thoma ME, et al. Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach. Fertil Steril. 2013;99(5):1324.

2.Mascarenhas MN et al. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 2012 Dec;9(12):e1001356.

3. Tilson D, Larsen U.Divorce in Ethiopia: the impact of early marriage and childlessness. J Biosoc Sci. 2000 Jul;32(3):355-72.

About Tenayistilign

I am a physician trained at Jimma Institute of Health Sciences ( now Jimma University, in Jimma, Ethiopia) and Wayne State University ( Detroit, MI, USA). I teach and practice General Nephrology/Hypertension and Kidney Transplantation in the USA.
This entry was posted in Memoir. Bookmark the permalink.

2 Responses to Infertility work up going bizarre

  1. IW says:

    Additional thoughts Dr G: I assume the sperm count was very low but not zero, otherwise I would doubt if he gave semen sample. But I had another thought: What if, in an attempt to conceive, the husband visited uninformed professional/clinic and was given repeated injections of exogenous testosterone that decreased his sperm count? I heard it is customary to get a shot of testosterone in some parts of the country/Eastern on the night of wedding and people even call it ‘Yemushira Medhanit’! I do not believe a single dose is enough to cause reduction in sperm count but it shows that testosterone could be used indiscriminately…May be Dr Abay will write an article on this
    happy thanksgiving.

  2. IW says:

    Hi Dr G, what were you going to tell the man if you were able to get hold of him? Or rather how ?

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