While pharmacists can assist with contraception management, they can also play a role in discussing the factors that can impact fertility
According to the Department of Health, infertility is an increasing occurrence with one in six couples in Australia experiencing fertility problems.
The potential causes of infertility are complex, with many factors potentially playing a role. This includes overall health and the presence of illness, age, weight, as well as several lifestyle factors.
Dr Karin Hammarberg, senior research officer, Victorian Assisted Reproductive Treatment Authority (VARTA) and Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, explains there are five key modifiable factors that can greatly affect the chance of having a baby. These are: age, obesity, smoking, alcohol consumption, and timing of intercourse.
“For women, fertility starts to decline around the age of 30. By the time a woman reaches the age of 40, it’s estimated her fertility has fallen by half. Some say the monthly chance of conceiving is about 20% at age 30, but by age 40 this drops to 5%.
“Risk of miscarriage is greater if you conceive when you’re older. The chances of neonatal complications also increase with age.
“While the male drop in fertility is subtle, sperm quality and fertility does still decrease with age, usually at around 45 years for men.”
In a study conducted by Dr Hammarberg and her colleagues regarding factors that influence fertility among Australians, the participants underestimated the age at which fertility starts to decline by about 10 years.
“About a third of the women and half of the men who participated in the study either didn’t know when fertility starts to decline or they thought it happened after the age of 40.”
Aside from age, she says lifestyle factors, such as obesity and smoking, can affect fertility. Indeed, obesity in females can alter the hormonal milieu, interfering with ovulation and reducing fertility. Plus, compared to women in the healthy weight range, obese women take notably longer to conceive.
We also know that people who smoke face increased risk of infertility and women exposed to passive smoke take longer to conceive.
“The other factor, that is perhaps less recognised but does influence the chance of conceiving, is whether people are aware of the fertile window and menstrual cycle.
“Studies have shown that generally there’s poor awareness of how the menstrual cycle operates and that there are limited days when conception is possible. This could be addressed through education,” explains Dr Hammarberg.
When it comes to public education on fertility, pharmacists are well placed to provide contraception advice, lifestyle guidance, as well as discuss STI screening. They can also assist women to future plan by educating on the fact that fertility starts to decline after the age of 35 and that delaying conception is a risk factor for female infertility.
The facts about fertility
“For younger people, fertility and reproductive health is often something they just don’t think about. However, people tend to make assumptions and have a few misconceptions, so it’s certainly something that should be discussed,” says Dr Terri Foran, sexual health physician and lecturer with the School of Women’s & Children’s Health at the University of New South Wales.
Many couples might not understand what it means to be fertility fit. Pharmacists can educate on the modifiable factors that can affect fertility. These include:
- having a healthy BMI;
- not smoking;
- reducing alcohol intake;
- eating a healthy diet, rich in antioxidants;
- visiting a GP for medical review;
- recognising that men are half of the equation, so men must be fertility fit too; and
- knowing the fertile windows, which might mean tracking ovulation and understanding the menstrual cycle.
“There are several factors that pharmacists can address; one of the obvious ones is smoking. Every woman I’ve ever spoken to who smokes talks about the fact she’ll give it up when she falls pregnant, but it’s really hard to do that. There’s also the fact that most women are pregnant for at least two weeks before they actually know it.
“So it pays to talk about the things that can impact the pregnancy. This includes the amount they smoke and the amount of alcohol they drink. These are important factors that need to be considered before falling pregnant, not after the event.
“The other factor is vaccination awareness. The major problems in pregnancy are with regards to rubeola and varicella. Because these vaccinations are live vaccines they need to be given before a woman falls pregnant, so these are things that healthcare professionals can discuss.
“When we’re talking fertility it’s also important not to forget men; men also have fertility issues. If a man smokes, drinks heavily, is overweight or has other health issues, this can impact the couple’s chances of falling pregnant,” says Dr Foran.
“There’s a lot of emphasis on women and fertility, but it takes two to tango—the male contributes half the genetic material needed to conceive!
“Engaging men, not just females, in fertility discussions is a really important issue. Men need to know that the sperm they’re producing now was actually made six weeks ago; if they were ill or stressed six weeks ago, this has the potential to impact the sperm that’s available for fertilisation now.
“Similarly, the ‘biological clock’ applies to men too. Even if the woman is young, it takes an average four months to conceive with a partner who is under the age of 25; if the man is aged over 40, the average time to conceive increases to two years.
“For couples having IVF, the risk of not having a baby is more than five times higher if the male partner is aged 41 or older.”
Awareness of the ‘fertile window’ in the menstrual cycle is perhaps a less recognised factor affecting pregnancy success.
Studies have shown in general a poor awareness of how the menstrual cycle operates and the fact that conception is only possible on a limited number of days. There are also misconceptions around how long it should take to fall pregnant, which pharmacists can help address through education and open discussions.
Dr Foran explains, “People tend to concentrate on the day they ovulate, without understanding that the egg only last 12 hours but sperm can last 3–5 days. The key is to have sex regularly throughout the cycle and for couples not to put too much pressure on themselves.
“My message is if pregnancy hasn’t occurred by 12 months, or six months if aged over 35, then that’s a good time for the couple to chat to their doctor.
“Pharmacists are in the unique position in that people will often open up to them if they have a problem or concern. They are frequently used as a sounding board and can help pinpoint when things don’t seem right.”
Preventing unplanned pregnancy
Of course, while pharmacists have a key role to play in educating people about fertility fitness, they also have an essential role to play in contraception management.
While oral contraception is the most widespread method of birth control among Australian women, followed by the use of a condom, it is not the most effective method of preventing pregnancy.
In fact, contraceptive implants are considered to be 99% effective as a method of contraception, compared to the combined oral contraceptive pill, which is 91% effective, and the male condom, which is 82% effective.
Dr Foran tells the AJP, “Contraception use varies from country to country. In Scandinavia, for example, there is a long tradition of using IUDs, so it’s much more mainstream.
“In Australia there’s a stronger tradition of using the oral contraceptive pill. The pill, if used correctly, is effective but it also has some non-contraceptive benefits. It can help prevent skin breakouts. It allows you to manipulate your menstrual cycle so you can have a period when you want to and it can make periods shorter and less painful, which is why many women like it.
“There’s also inertia; if a women starts the pill and it works well for them, there’s not much impetus for them to change—unless someone they trust suggests doing so.
“That’s where doctors and pharmacists come into play. Every opportunity we have around contraception—be it when prescribing the pill or at the point of dispensing—is a chance to check in with people and make sure they know there’s a range of contraception options they can consider.
“Many people have misconceptions around the different forms of contraception, which healthcare professionals can address and correct.
“However, doctors and pharmacists need to be proactive in educating people on the range of contraceptive choices available. We don’t need to push one method over another, but simply provide the right information so people can make an informed decision.”
She adds that it’s important to note, “Condoms are practically the only method of contraception that provide any protection against STIs.
“Ideally people should use them in addition to another contraceptive. If a person is in a relationship where they’re potentially at risk of STIs, they can use whatever method of contraception they choose but they should be advised to use a condom as well. I think this is an important message to send out,” says Dr Foran.