'Infertility' primarily refers to the biological inability of a
man or a
woman to contribute to
conception. Infertility may also refer to the state of a woman who is unable to carry a
pregnancy to
full term. There are many biological causes of infertility, some which may be bypassed with medical intervention.
Women who are
fertile experience a natural period of fertility before and during
ovulation, and they are naturally infertile during the rest of the
menstrual cycle.
Fertility awareness methods are used to discern when these changes occur; by tracking changes in cervical mucus or
basal body temperature.
Definition
There are strict definitions of infertility used by many doctors. However, there are also similar terms, e.g. subfertility for a more benign condition and fecundity for the natural improbability to conceive.
Infertility
Reproductive endocrinologists, the doctors specializing in infertility, consider a couple to be infertile if:
★ the couple has not conceived after 12 months of unprotected intercourse if the female is under the age of 35
★ the couple has not conceived after 6 months of unprotected intercourse if the female is over the age of 35 (declining egg quality of females over the age of 35 account for the age-based discrepancy as when to seek medical intervention)
★ the female is incapable of carrying a pregnancy to term.
Fecundity
Healthy couples in their mid-20s having regular sex have a one-in-four chance of getting pregnant in any given month. This is called "
Fecundity".
Subfertility
A
couple that has tried unsuccessfully to have a
child for a
year or more is said to be 'subfertile'. The couple's fecundability rate is approximately 3-5%. Many of its causes are the same as those of
infertility.Such causes could be endometriosis, or polycystic ovarian syndrome.
Prevalence
Infertility affects approximately 10% of people of reproductive age
[1], and 15% of couples. Roughly 40% of cases involve a male contribution or factor, 40% involve a female factor, and the remainder involve both sexes.
[ Male Infertility ]
In the U.S.
According to the American Society for Reproductive Medicine, infertility affects about 6.1 million people in the U.S., equivalent to ten percent of the reproductive age population. Female infertility accounts for one third of infertility cases, male infertility for another third, combined male and female infertility for another 15%, and the remainder of cases are "unexplained"
[2].
Causes
This section deals with unintentional causes of sterility. For more information about surgical techniques for preventing procreation, see
sterilization.
Primary vs. secondary
Couples with 'primary infertility' have never been able to conceive
[3], while, on the other hand, 'secondary infertility' is difficulty conceiving after already having conceived and carried a normal pregnancy. Technically, secondary infertility is not present if there has been a change of partners.
Some women are infertile because their ovaries do not mature and release eggs. In this case synthetic FSH by injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate follicles to mature in the ovaries.
Causes in either sex
Factors that can cause male as well as female infertility are:
★ Genetic
★
★ A
Robertsonian translocation in either partner may cause
recurrent abortions or complete infertility.
★ General factors
★
★
Diabetes mellitus,
thyroid disorders,
adrenal disease
★ Hypothalamic-pituitary factors:
★
★
Kallmann syndrome
★
★
Hyperprolactinemia
★
★
Hypopituitarism
Female infertility
Factors relating only to female infertility are:
★ General factors
★
★ Significant
liver,
kidney disease
★
★
Thrombophilia
★ Hypothalamic-pituitary factors:
★
★
Hypothalamic dysfunction
★ Ovarian factors
★
★
Polycystic ovarian syndrome
★
★
Anovulation
★
★ Diminished
ovarian reserve, also see
Poor Ovarian Reserve
★
★
Premature menopause
★
★
Menopause
★
★
Luteal dysfunction
★
★ Gonadal dysgenesis (
Turner syndrome)
★
★
Ovarian neoplasm
★ Tubal/peritoneal factors
★
★
Endometriosis
★
★ Pelvic
adhesions
★
★
Pelvic inflammatory disease (PID, usually due to
chlamydia)
★
★
Tubal occlusion
★
★ Tubal dysfunction
★ Uterine factors
★
★
Uterine malformations
★
★ Uterine fibroids (
leiomyoma)
★
★
Asherman's Syndrome
★ Cervical factors
★
★
Cervical stenosis
★
★
Antisperm antibodies
★
★ Insufficient cervical mucus (for the travel and survival of
sperm)
★ Vaginal factors
★
★
Vaginismus
★
★ Vaginal obstruction
★ Genetic factors
★
★ Various
intersexed conditions, such as
androgen insensitivity syndrome
Male infertility
Factors relating only to male infertility include
[4]:
★ Pretesticular causes
★
★
Hypogonadism due to various causes
★
★ Drugs, alcohol, smoking
★ Testicular factors
★
★ Bad
semen quality
★
★ Abnormal sperm morphology
★
★ Azoospermia (complete lack of sperm in semen, can be due to scar tissue in testicle)
★
★ Genetic defects on the Y chromosome
★
★
★
Y chromosome microdeletions
★
★ Abnormal set of chromosomes
★
★
★
Klinefelter syndrome
★
★ Neoplasm, e.g.
seminoma
★
★ Idiopathic failure
★
★
Cryptorchidism
★
★
Varicocele
★
★
Trauma
★
★
Hydrocele
★
★
Mumps
★
★
Testicular dysgenesis syndrome
★ Posttesticular causes
★
★
Vas deferens obstruction
★
★ Lack of
Vas deferens, often related to genetic markers for
Cystic Fibrosis
★
★ Infection, e.g.
prostatitis
★
★
Retrograde ejaculation
★
★
Hypospadias
★
★
Impotence
★
★ Acrosomal defect/egg penetration defect
Combined infertility
In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility arises from the combination of these conditions. In other cases, the cause is suspected to be immunological or genetic; it may be that each partner is independently fertile but the couple cannot conceive together without assistance.
Unexplained infertility
In about 15% of cases the infertility investigation will show no abnormalities. In these cases abnormalities are likely to be present but not detected by current methods. Possible problems could be that the egg is not released at the optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization.
Diagnosis
Male infertility
The diagnosis of infertility begins with a medical history and physical exam by a urologist, preferably one with experience or who specializes in male infertility. The provider may order blood tests to look for hormone imbalances or disease. A semen sample will be needed. Blood tests may indicate genetic causes.
Efficiency
In the majority of cases of male infertility and low sperm quality, no clear cause can be identified with current diagnostic methods.
Medical history
The cornerstone of the male partner evaluation is the history. It should note the duration of infertility, earlier pregnancies with present or past partners, and whether there was previous difficulty with conception.
The history should include prior testicular (penis) insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors (excessive heat, radiation, chemotherapy), medications (anabolic steroids, cimetidine, and spironolactone may affect spermatogenesis; phenytoin may lower FSH; sulfasalazine and nitrofurantoin affect sperm motility), and drug use (alcohol, smoking, marijuana). Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility experiences are important. Loss of libido and headaches or visual disturbances may indicate a pituitary tumor. The past medical or surgical history may reveal thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply).
Physical examination
A complete examination of the infertile male is important to identify general health issues associated with infertility. For example, the patient should be adequately virilized; signs of decreased body hair or gynecomastia may suggest androgen deficiency.
The scrotal contents should be carefully palpated with the patient standing. As it is often psychologically uncomfortable for men to be examined, one helpful hint is to make the examination as efficient and as matter of fact as possible.
The peritesticular area should also be examined. Irregularities of the epididymis, located posterior-lateral to the testis, include induration, tenderness, or cysts.
Sperm sample
The volume of the semen is measured, as well as the number of sperm in the sample. How well the sperm move is also assessed. This is the most common type of fertility testing
[5].
Blood sample
A blood sample can reveal genetic causes of infertility, e.g. a
Y chromosome microdeletion, cystic fibrosis.
Female infertility
Diagnosis of infertility begins with a medical history and physical exam. The healthcare provider may order tests, including the following:
★ an endometrial biopsy, to verify ovulation and inspect the lining of the uterus
★ hormone testing, to measure levels of female hormones at certain times during a menstrual cycle
★ day 2 or 3 measure of fsh and estrogen, to assess
ovarian reserve
★ measurements of thyroid function (a thyroid stimulating hormone(TSH) level of between 1 and 2 is considered optimal for conception)
★ laparoscopy, which allows the provider to inspect the pelvic organs
★ measurement of progesterone in the second half of the cycle to help confirm ovulation
★ Pap smear, to check for signs of infection
★ pelvic exam, to look for abnormalities or infection
★ a postcoital test, which is done soon after intercourse to check for problems with sperm surviving in cervical mucous (not commonly used now because of test unreliability)
★ special X-ray tests
Diagnosis and treatment of infertility should be made by physicians who are fellowship trained as reproductive endocrinologists.
Reproductive Endocrinologists are usually Obstetrician-Gynecologists with advanced training in Reproductive Endocrinology & Infertility (in North America). These highly educated professionals and qualified physicians treat Reproductive Disorders affecting not only women but also men, children, and teens.
Prospective patients should note that reproductive endocrinology & infertility medical practices do not see women for general maternity care. The practice is primarily focused on helping their patients to conceive and to correct any issues related to recurring pregnancy loss.
Treatment
Treatment of infertility usually starts with medication.
In vitro fertilization (IVF) in addition to various forms and developments of it (ICSI, ZIFT, GIFT) is another solution. They all include that the fertilization takes place outside the body. On the other hand, an insemination can make a fertilization inside the body. Other techniques are e.g. tuboplasty, assisted hatching and PGD.
Prevention
Male infertility
Some cases of male infertility may be avoided by doing the following:
★ Avoid smoking as it damages sperm DNA
★ Avoid drugs and medications known to cause fertility problems, like steroids and some antifungal medications.
★ Avoid excessive exercise.
★ Avoid exposure to environmental hazards such as pesticides and heavy metals such as lead, mecury and cadmium.
★ Avoid frequent hot baths or use of hot tubs.
★ Avoid tight underwear or pants.
★ Eat a diet with adequate folic acid, vitamin C, Zinc, calcium, magnesium, selenium, iron loaded food.
★ Get early treatment for sexually transmitted diseases.
★ Have regular physical examinations to detect early signs of infections or abnormalities.
★ Keep diseases, such as diabetes and hypothyroidism, under control.
★ Practice safer sex to avoid sexually transmitted diseases.
★ Take a
lycopene supplement.
★ Wear protection over the scrotum during athletic activities.
Female infertility
Some cases of female infertility may be prevented by taking the following steps:
★ Avoid excessive exercise.
★ Avoid smoking.
★ Control diseases such as diabetes and hypothyroidism
★ Eat a well balanced nutritious diet with plenty of fresh fruits and vegetables (plenty of folates).
★ Follow good weight management guidelines.
★ Practice safer sex to avoid sexually transmitted diseases.
★ Get early treatment for sexually transmitted diseases.
★ Have regular physical examinations (including pap smears) to detect early signs of infections or abnormalities.
★ Limit caffeine and alcohol intake.
★ Ask your mother (biological) to share any unusual or abnormal issues she had related to conceiving. For example, premature menopause in your mother can be genetic and passed on to you, which limits the years in which you will have optimal egg quality.
★ Do not unnecessarily delay having children if the options are available to you. Fertility starts declining after age 27 and drops drastically after age 35
[http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2002/04/30/MN182697.DTL]
Costs
United States of America
Not everyone in the U.S. has
insurance coverage for fertility investigations and treatments. Many states are starting to mandate coverage, and the rate of utilization is 277% higher in states with complete coverage.
[6]
There are some health insurance companies that cover diagnosis of infertility but frequently once diagnosed will not cover any treatment costs.
2005 approximate treatment/diagnosis costs (United States, costs in US$):
★ Initial workup:
hysteroscopy,
hysterosalpingogram,
blood tests ~$2,000
★ Artificial insemination ~ $200- 900 per. trial
★ Sonohysterogram (SHG) ~ $600 - 1,000
★ Clomiphene citrate cycle ~ $ 200 - 500
★ IVF cycle ~ $10,000 -30,000
★ Use of a
surrogate mother to carry the child - dependent on arrangements
Another way to look at costs is to determine the cost of establishing a pregnancy. Thus if a clomiphene treatment has a chance to establish a pregnancy in 8% of cycles and costs $500, it will cost ~ $6,000 to establish a pregnancy, compared to an IVF cycle (cycle fecundity 40%) with a corresponding cost of ($12,000/40%) $30,000.
United Kingdom
In the UK all patients have the right to preliminary testing, provided free of charge by the
National Health Service. However, treatment is not widely available on the NHS and there can be long waiting lists. Most patients therefore seek help from private clinics
[7].
Ethics
There are several ethical issues associated with infertility and its treatment.
★ High-cost treatments are out of financial reach for some couples.
★ Debate over whether health insurance companies should be forced to cover infertility treatment.
★ The legal status of
embryos fertilized
in vitro and not transferred
in vivo.
★ Anti-abortion opposition to the destruction of embryos not transferred
in vivo.
★ IVF and other fertility treatments have resulted in an increase in
multiple births, provoking ethical analysis because of the link between multiple pregnancies,
premature birth, and a host of health problems.
★ Religious leaders' opinions on fertility treatments.
★ Infertility caused by DNA defects on the Y chromosome is passed on from father to son. If
natural selection is the primary error correction mechanism that prevents random mutations on the Y chromosome, then fertility treatments for men with abnormal sperm (in particular
ICSI) only defer the underlying problem to the next male generation.
Psychological impact
Infertility may have profound psychological effects. Partners may become more anxious to conceive, ironically increasing
sexual dysfunction. Marital discord often develops in infertile couples, especially when they are under pressure to make medical decisions. Women trying to conceive often have
clinical depression rates similar to women who have heart disease or cancer
[8]. Even couples undertaking IVF face considerable stress, especially the female partner
[9]
For those who don't desire to have children, infertility may have a positive psychological impact, particularly in areas where emergency contraception and abortion services are difficult to obtain.
Social impact
In many cultures, inability to conceive bears a stigma. In closed social groups, a degree of rejection (or a sense of being rejected by the couple) may cause considerable anxiety and disappointment. Some respond by actively avoiding the issue altogether; middle-class men are the most likely to respond in this way
[10]. Groups like INCIID
[1] provide social support and disseminate information to lessen the burden.
There are legal ramifications as well. Infertility has begun to gain more exposure to legal domains. An estimated 4 million workers in the U.S. used the
Family and Medical Leave Act (FMLA) in
2004 to care for a child, parent or spouse, or because of their own personal illness. Many treatments for infertility, including diagnostic tests, surgery and therapy for depression, can qualify one for FMLA leave.
See also
Infertility in science fiction
References
1. “Frequently Asked Questions About Infertility” (2006). American Society for Reproductive Medicine.
2. American Society for Reproductive Medicine (FAQ)
3. http://www.nlm.nih.gov/medlineplus/ency/article/001191.htm
4. Rowe PJ, Comhaire FH, Hargreave TB, Mahmoud AMA. ''WHO Manual for the Standardized Investigation, Diagnosis and Management of the Infertile Male''. Cambridge University Press, 2000. ISBN 0-521-77474-8.
5. Fertility Testing
6. Jain T, Harlow BL, Hornstein MD. "Insurance coverage and outcome of ''in vitro'' fertilization." New England Journal of Medicine. 347(9):661-6.
7. Infertility Treatment, NHS Direct Online (NHS Direct Online Health Enyclopaedia)
8. Domar AD, Zuttermeister PC, Friedman R. ''The psychological impact of infertility: a comparison with patients with other medical conditions.'' J Psychosom Obstet Gynaecol. 1993;14 Suppl:45-52. PMID 8142988.
9. Beutel M, Kupfer J, Kirchmeyer P, Kehde S, Kohn FM, Schroeder-Printzen I, Gips H, Herrero HJG, Weidner W. ''Treatment-related stresses and depression in couples undergoing assisted reproductive treatment by IVF or ICSI.'' Andrologia. 31 (1999): 27-35.
10. Schmidt et al. "The Social Epidemiology of Coping with Infertility." Human Reproduction. 20 (2005): 1044-1052.
★ Brugh VM 3rd et al: Male factor infertility: evaluation and management. Med Clin North Am 2004;88:367.
PMID: 15049583
★ Hirsh A: Male subfertility. BMJ 2003;327:669.
PMID: 14500443
★ Makar RS et al: The evaluation of infertility. Am J Clin Pathol 2002;117(Suppl):S95.
PMID: 14569805
★ McGuckin I: Pink for a Girl: Wanting a baby and not conceiving - my personal story
★ Sayre J: ''
The Waiting Womb''. ISBN 1419642480
★ Shepperson Mills D, Vernon M: Endometriosis a key to healing and fertility through nutrition. ISBN 0-00-713310-3
External links
★
IVF information and Tips
★
A free Guide to infertility
★ "
'Infertility time bomb' warning" at
BBC News
★
CBC Digital Archives - Fighting Female Infertility
★
FertilityProRegistry NetworkFrom general information about infertility procedures, to finding a well-trained physician who can treat them
★
Infertility Doctors & Clinics Find Infertility Doctors & Clinics in the U.S.
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