Infertility primarily refers to the biological
inability of a person 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 in a couple can be due to either the woman or
the man, not necessarily both.
Infertility
Reproductive endocrinologists, the doctors specializing in
infertility, consider a couple to be infertile if:
- the couple has not conceived after 12 months of
contraceptive-free intercourse if the female is under the age of
34
- the couple has not conceived after 6 months of
contraceptive-free 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.
Subfertility
A
couple that has tried unsuccessfully to
have a
child for a
year or
more is said to be
subfertile meaning less fertile
than a typical couple. 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.
Primary vs. secondary infertility
Couples with
primary infertility have never been
able to conceive, while, on the other hand,
secondary
infertility is difficulty conceiving after already having
conceived (and either carried the pregnancy to term, or had a
miscarriage). Technically, secondary infertility is not present if
there has been a change of partners.
Prevalence
- Generally, worldwide it is estimated that one in seven couples
have problems conceiving, with the incidence similar in most
countries independent of the level of the country's
development.
- Fertility problems affect one in seven couples in the UK. Most
couples (about 84 out of every 100) who have regular sexual intercourse (that is, every 2 to 3
days) and who do not use contraception will get pregnant within a
year. About 92 out of 100 couples who are trying to get pregnant do
so within 2 years.
- Women become less fertile as they get older. For women aged 35,
about 94 out of every 100 who have regular unprotected sexual
intercourse will get pregnant after 3 years of trying. For women
aged 38, however, only 77 out of every 100 will do so. The effect
of age upon men’s fertility is less clear.
- In people going forward for IVF in the UK, roughly half of
fertility problems with a diagnosed cause are due to problems with
the man, and about half due to problems with the woman. However,
about one in five cases of infertility have no clear diagnosed
cause
- In Britain, male factor infertility accounts for 25% of
infertile couples, while 25% remain unexplained. 50% are female
causes with 25% being due to anovulation
and 25% tubal problems/other
- In Sweden, approximately 10% of couples are infertile. In
approximately one third of these cases the man is the factor, in
one third the woman is the factor and in the remaining third the
infertility is a product of factors on both parts.
Causes
This section deals with unintentional causes of sterility. For more
information about surgical techniques for preventing procreation,
see
sterilization.
Common causes of infertility:
- Ovulation problems
- tubal blockage
- male associated infertility
- age-related factors
- uterine problems
- previous tubal ligation
- previous vasectomy
- unexplained infertility
- Tuberculosis (TB)
Male Hypospadias
Virus
German
scientists
have reported that a virus called Adeno-associated virus might have a
role in male infertility, though it is otherwise not
harmful.
Causes in either sex
For a woman to conceive, certain things have to happen: intercourse
must take place around the time when an egg is released from her
ovary; the systems that produce eggs and sperm have to be working
at optimum levels; and her hormones must be balanced.
There are several possible reasons why it may not be happening
naturally. In one-third of cases, it can be because of male
problems such as low sperm count.
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.
Problems affecting women include endometriosis or damage to the
fallopian tubes (which may have been caused by infections such as
chlamydia).
Other factors that can affect a woman's chances of conceiving
include being over- or underweight for her age - female fertility
declines sharply after the age of 35. Sometimes it can be a
combination of factors, and sometimes a clear cause is never
established.
Factors that can cause male as well as female infertility are:
- Genetic Factors
- General factors
- Hypothalamic-pituitary factors
- Environmental Factors
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.
Assessment
If both partners are young and healthy, and have been trying for a
baby for 12 months to two years without success, a visit to the
family doctor could help to highlight potential medical problems
earlier rather than later. The doctor may also be able to suggest
lifestyle changes to increase the chances of conceiving. Some
lifestyle changes may include less stress,
less exercise (too much exercise may result in a very light or
nonexistent
period), and eating a healthy
diet.
Women over the age of 35 should see their family doctor after six
months as fertility tests can take some time to complete, and age
may affect the treatment options that are open in that case.
A family doctor will take a medical history and give a physical
examination. They can also carry out some basic tests on both
partners to see if there is an identifiable reason for not having
achieved a pregnancy yet. If necessary, they can refer patients to
a fertility clinic or a local hospital for more specialized tests.
The results of these tests will help determine which is the best
fertility treatment.
Treatment
Treatment methods for infertility may be grouped as medical or
complementary and alternative treatments. Some methods may be used
in concert with other methods.
At-home conception kit
In 2007 the FDA cleared the first at home tier one medical
conception device to aid in conception.
The key to the kit are cervical caps for conception. This at home
[cervical cap] insemination method allows all the semen to be
placed up against the cervical os for six hours allowing all
available
sperm to be placed directly on the
cervical os. For low sperm count, low
sperm motility, or a tilted cervix using a cervical cap will aid in
conception. This is a prescriptive medical device.
At-home assessment
Prior to undergoing expensive fertility procedures, many women and
couples will turn to online sources to determine their estimate
chances of success. A
take-home baby assessment can
provide a best guess estimate compared with women who have
succeeded with
in vitro
fertilization, based on variables such as maternal age,
duration of infertility and number of prior pregnancies.
Medical treatments
Medical treatment of infertility generally involves the use of
medication, medical device, surgery, or a combination of the
following. If the sperm are of good quality, and the mechanics of
the woman’s reproductive structures are good (patent fallopian
tubes, no adhesions or scarring) physicians may start by
prescribing a course of ovarian stimulating medication. The
physician may also suggest using a conception cap
cervical cap which the patient uses at home by
placing the sperm inside the cap and putting the
conception device on the cervix,
intrauterine insemination (IUI), in which the doctor introduces
sperm into the uterus during ovulation, via a catheter. In these
methods,
fertilization occurs inside
the body.
If conservative medical treatments fail to achieve a full term
pregnancy, the physician may suggest the patient undergo
in vitro fertilization (IVF). IVF and
related techniques (
ICSI,
ZIFT,
GIFT) are called
assisted reproductive
technology (ART) techniques.
ART techniques generally start with stimulating the ovaries to
increase egg production. After stimulation, the physician
surgically extracts one or more eggs from the ovary, and unites
them with sperm in a laboratory setting, with the intent of
producing one or more embryos. Fertilization takes place outside
the body, and the fertilized egg is reinserted into the woman’s
reproductive tract, in a procedure called
embryo transfer.
Other medical techniques are e.g.
tuboplasty, assisted hatching, and
Preimplantation genetic
diagnosis.
Recently, a hormone-antioxidant combination therapy was suggested
to improve sperm count and motility in infertile men, according to
an Egyptian study.Ghanem H et al. Combination clomiphene citrate
and antioxidant therapy for idiopathic male infertility: A
randomized controlled trial. Fertil Steril 2009 Mar 5; [e-pub ahead
of print]. Published in Journal Watch General Medicine March 31,
2009The study included 60 men who were randomly selected to take
either the combination treatment of clomiphene citrate and vitamin
E or a placebo for six months. The pregnancy rate was about 37
percent among men who had taken the combination therapy, compared
with 13 percent for those in the placebo group.The men in the
treatment group also had a greater increase in sperm concentration
and an improvement in sperm progression, the Cairo University
researchers found. Clomiphene citrate is an anti-estrogen drug
designed as a fertility medicine for women but sometimes used to
boost sperm production in men with low sperm counts and poor sperm
motility. Vitamin E helps counter oxidative stress, which is
associated with sperm DNA damage and reduced sperm motility."The
results of this study will be encouraging to male factor patients
and their doctors," Dr. R. Dale McClure, president of the American
Society for Reproductive Medicine, said in a society news release.
"However, more research is needed to determine how the components
of the combination therapy affect the different semen parameters
observed and the advantages of using these drugs singly or in
combination with other drugs not used in this study."
Complementary and alternative treatments
Three complementary or alternative female infertility treatments
have been scientifically tested, with results published in
peer-reviewed medical journals.
- Group psychological intervention: A 2000
Harvard Medical School study examined the effects of group
psychological intervention on infertile women (trying to conceive a
duration of one to two years). The two intervention groups—a
support group and a cognitive behavior group—had statistically
significant higher pregnancy rates than the control group.
- Acupuncture: Acupuncture performed 25 minutes
before and after IVF embryo transfer increased IVF pregnancy rates
in a German study published in 2002. In a 2006 similar study
conducted by The University of South Australia, the acupuncture
group’s odds (although not statistically significant) were 1.5
higher than the control group. Although definitive results of the
effects of acupuncture on embryo transfer remain a topic of
discussion, study authors state that it appears to be a safe
adjunct to IVF.
- Manual physical therapy: The Wurn Technique, a
manual manipulative physical therapy treatment, was shown in peer
reviewed publications to improve natural and IVF pregnancy rates in
infertile women in a 2004 study, and to open and return function to
blocked fallopian tubes in a 2008 study. The therapy was designed
to address adhesions restricting function and mobility of the
reproductive organs.
Tourism
Fertility tourism is the practice of traveling to another
country for fertility treatments. It may be regarded as a form of
medical tourism. The main reasons
for fertility tourism are legal regulation of the sought procedure
in the home country, or lower price.
In-vitro fertilization and
donor insemination are major procedures
involved.
Floatation therapy
Stress is a factor in some cases of difficulty with conceptionand
floatation therapy is a powerful
stress relief technique requiring no drugs or major lifestyle
changes.--
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.
- Allocation of medical resources that could be used
elsewhere
- The legal status of embryos fertilized
in vitro and not transferred in vivo. (See also Beginning of pregnancy
controversy).
- 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.
Many countries have special frameworks for dealing with the ethical
and social issues around fertility treatment.
- One of the best known is the HFEA - The
UK's regulator for fertility treatment and embryo research. This
was set up on 1 August 1991 following a detailed commission of
enquiry led by Mary Warnock in the
1980s
- A similar model to the HFEA has been adoped by the rest of the
countries in the European Union. Each country has its own body or
bodies responsible for the inspection and licencing of fertility
treatment under the EU Tissues and Cells directive
- Regulatory bodies are also found in Canada and in the state of
Victoria in Australia
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. Even couples
undertaking IVF face considerable stress.
Emotional stress and marital difficulties are greater in couples
where the infertility lies with the man.
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 .
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.
Fictional representation
Perhaps except for
infertility in science fiction,
films and other fiction depicting emotional struggles of
assisted reproductive
technology have had an upswing first in the latter part of the
2000s decade, although the techniques
have been available for decades. Yet, the amount of people that can
relate to it by personal experience in one way or another is ever
growing, and the variety of trials and struggles is huge.
Any individual examples are referred to individual subarticles
of assisted
reproductive technology
See also
References
- NICE fertility guidance
- HFEA Chart on reasons for infertility
- Sahlgrenska University Hospital. (translated from the Swedish
sentence: "Cirka 10% av alla par har problem med ofrivillig
barnlöshet."
- http://www.newscientist.com/article.ns?id=dn1483
- http://news.bbc.co.uk/1/hi/health/1620174.stm
- About infertility & fertility problems
- Infertility Help: When & where to get help for
fertility treatment
- http://www.newsrx.com/pr_details.php?type=1&id=2904
- http://www.formyodds.com
- wordspy.com
- article on stress and fertility
- Anette Kjellgren, 2003, The experience of floatation REST
(restricted Environmental stimulation technique), subjective stress
and pain, Goteborg University Sweden,
- http://europa.eu/scadplus/leg/en/cha/c11573.htm EU Tissues and
Cells directive
- Assisted Human Reproduction Canada
- ITA
- Donor insemination Edited by C.L.R. Barratt and I.D. Cooke.
Cambridge (England): Cambridge University Press, 1993. 231 pages.,
page 13, citing Berger (1980)
- Donor insemination Edited by C.L.R. Barratt and I.D. Cooke.
Cambridge (England): Cambridge University Press, 1993. 231 pages.,
page 13, in turn citing Connolly, Edelmann & Cooke 1987
- chicagotribune.com --> Heartache of infertility
shared on stage, screen By Colleen Mastony, Tribune reporter.
June 21, 2009
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