THE separation of sex and procreation has already affected the way we live and led to the halving of the average Irish family from four children to two, the freeing of women for lifelong careers and their ability to conduct their sex lives as they see fit. But have there been hidden consequences of the sexual revolution: could one of them be the current rise in ectopic pregnancies, which can lead to infertility?
The causes of this type of problem pregnancy include damage to the fallopian tubes due to infection or surgery: such damage being linked to pelvic inflammatory disease (PID) arising in some cases from sexually transmitted diseases, inter-uterine contraceptive devices (IUCD), sterilisations or abortions.
Traditionally, one in every 200 pregnancies is ectopic, but Dr Paul Bowman, consultant obstetrician and gynaecologist at the Coombe Women's Hospital in Dublin, says that among his patients the incidence has risen from one in 100 pregnancies to between three and four in 100.
"If someone already has had a tubal infection, the three to four per cent can rise to 10 per cent: two attacks of infection can increase this to 25 per cent and three attacks to 50 per cent, so your chances of an ectopic pregnancy rise to one in two," says Dr Bowman.
A total of 6,301 babies were born in the Coombe Women's Hospital in 1995, and there were 35 ectopic pregnancies. The corresponding figures for 1994 were 6,367 births and 19 ectopic pregnancies. In 1995 the National Maternity Hospital had 6,718 births and 35 ectopic pregnancies. In 1994 there were 6 324 births and 33 ectopic pregnancies.
"Going back 20 years, the ectopic figure would have been under 20," says Dr Peter McKenna, Master of the Rotunda Hospital.
Betty Edgeworth is the founder of the National Infertility Support and Information Group, formerly known as Issue Ireland. She cites a British study which indicated an 82 per cent increase in ectopic pregnancies between 1977-1986 from 2.5 per cent to 4.6 per cent of all pregnancies.
"Risk factors quoted were age, the IUCD, infection in the tubes which was largely traceable to sexually transmitted disease. A 1994 study of ectopic pregnancies in England and France concluded that half were down to sexually transmitted diseases," she says.
"The rise in ectopic pregnancies is a universal experience in the medical world and the incidence is increasing," says Dr Peter Boylan, Master of the National Maternity Hospital. "However, if you put all ectopics down to promiscuity you would be incorrect. The egg becomes fertilised in the tube and can become stuck there for random reasons not necessarily due to infection. Also a woman can have one sexual encounter and contract a sexual disease. Or have 100 such and contract none.
An ectopic pregnancy is one which develops outside the uterus.
It happens when a fertilised egg implants itself on some other organ, often the fallopian tubes, or more typically becomes stuck in the fallopian tubes.
Such difficulties can now be picked up very early by laparoscope before the tube ruptures. Modern conservative medical techniques make it possible to remove the foetus but leave the tube attached for future pregnancies. These can include making a hole in the tube and extracting the foetus or chemotherapy which shrinks the foetus so that it dies. Another response may be to remove the tube.
A more dangerous outcome is that the egg continues to grow and bursts in the tube. Ectopic pregnancies cause maternal deaths in the developing world and can still cause deaths in Britain because of the relatively high incidences of ectopic pregnancy there. Such deaths are rare in Ireland.
PID is a broad name used for any infection which affects the fallopian tubes, ovaries and/or uterus. The main sexually transmitted diseases which contribute to fertility problems by affecting the fallopian tubes are chlamydia and gonorrhoea. Many such diseases may, if untreated, lead to PID. An acute phase of PID is normally treated with antibiotics, or if abscesses occur, by tubal drainage. "Most infections heal up and settle," says Dr Bowman, "the problem is the adhesions and scar tissue which may cause fertility problems later on."
FERTILITY problems may also occur for sexually active women who seek to end their reproductive lives and then change their mind. Up to seven per cent of women who undergo sterilisation want to reverse the operation. "I have had a number of approaches in the last few years from women whose husbands now have better jobs and who decide they can afford another baby," says Dr Bowman. "Or someone is into another relationship and wants a baby. The greater number of sterilisations you do the greater the numbers who come back wanting it to be reversed."
Female sterilisation is achieved by either clipping and tying or burning the fallopian tubes. The former method is capable of reversal but any pregnancy which may result has a higher than normal chance of being ectopic due to tubal damage.
Abortion too can lead to infertility or ectopic pregnancy. "Typically a woman has had a therapeutic abortion and some years later wants to start a family and finds she can't," says Dr Bowman. "She goes to her GP who sends her to a gynaecologist who will often find blocked tubes. It's not a question that the abortion has been badly done. I'm not talking about a back street affair: it's one of the consequences that can happen. For some women abortion has caused tubal adhesions which can lead to infertility."
Alternatively a woman can become pregnant but the tubal damage contributes to an ectopic pregnancy. "This is very sad because she may already be into her late 20s or early 30s which is considered elderly in reproductive terms," says Dr Bowman. "Adoption is no longer an option because the supply has all but dried up. Often the only recourse for such a couple is in vitro-fertilisation IVF"
Betty Edgeworth says: "I have heard from women who have had abortions and who later discovered that the abortion had made them infertile. Some partners may not be aware of their wife's sexual history and some women are unwilling to tell their husbands the reason for their infertility."
The inter-uterine contraceptive device (IUCD) has also been linked with ectopic pregnancy due to its siting near the fallopian tubes. It works by hampering the fertilised egg from implanting in the uterus.
A sizeable proportion off ectopic pregnancies would be reduced, Dr Bowman says, if the level of sexually transmitted diseases in the population could be reduced. "The humble condom is to be recommended in so far as it helps to prevent pregnancy and also helps such transmission."
Dr Peter McKenna agrees that safer sex now will help to avert fertility problems later. "I've just come from a clinic where most of the women were under 22, single and pregnant with a second baby," he says. "If you tell young people not to have intercourse you might as well tell them not to breathe. But if you don't have a steady partner, use condoms. If you are in a steady relationship, use thee pill.
Betty Edgeworth says: "I don't think girls of 16 and 17 who are becoming sexually active are concerned with their future fertility. They're more worried about not getting pregnant. I think young women need facts but we are reluctant to give out this type of relevant information."
Dr Bowman echoes this point. He believes that few women know the possible long-term consequences of sexual promiscuity: "We need to find some way of getting through to young teenagers. They seem to be concerned only about the immediate consequences of their actions, that is, not to get pregnant, but they are not aware of how they may be affecting their fertility down the road. I saw a teen magazine recently. It had an article entitled `Twenty Ways to Seduce Your Fellow'. This is the kind of message being targeted at 13-year-olds today."
