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infertility

[in-fur-tl or, especially Brit., -tahyl]

infertility, inability to conceive or carry a child to delivery. The term is usually limited to situations where the couple has had intercourse regularly for one year without using birth control. The term sterility is restricted to lack of sperm production or inability to ovulate. Approximately 40% of reported cases of infertility are due to problems in the male; another 40% to problems in the female; the remaining 20% are of unknown cause or due to problems in both the male and female.

Causes

Infertility can be caused by any interruption in the usual process of fertilization, pregnancy, and birth, which includes ejaculation of normal amounts of healthy sperm, passage of the sperm through the cervix and into the fallopian tube of the female, passage of an ovum (egg) down the fallopian tube from an ovary, fertilization in the fallopian tube, implantation of the fertilized egg in a receptive uterus, and the ability to carry the fetus to term. In women, the most common problems are failure to ovulate and blockage of the fallopian tubes. In men, low sperm count is the most common problem.

Underlying problems include disease, such as diabetes or mumps in adult men, hormonal imbalances, endometriosis, pelvic inflammatory disease (often caused by sexually transmitted diseases, e.g., chlamydia), the abuse of alcohol and other drugs, and exposure to workplace hazards or environmental toxins. Uterine irritation or infection that sometimes accompanies IUD use can also reduce fertility. Occasionally there is a chemical or immunological incompatibility between male and female. Psychological factors are difficult to evaluate because of the stressful nature of infertility itself.

The number of couples seeking treatment for infertility has increased as more of them have postponed childbearing to a later age. In women, fertility begins to decline in the mid-twenties, and continues to decline, more and more sharply, until menopause. Male fertility declines gradually until age forty, then declines more quickly.

Evaluation and Treatment

Evaluation includes examination of sperm, observation of basal body temperature or luteinizing hormone peaks (see gonadotropic hormone) in the female to determine whether ovulation is taking place, the ruling out of obstructions of the fallopian tubes or vas deferens, and blood tests that measure hormone levels. Treatment is geared to the specific problem. The first step may be treatment of underlying disease and, in men, avoidance of substances that might affect sperm count. Fertility drugs, some of which increase the likelihood of multiple births, are often prescribed. If necessary, surgical correction of blocked tubes can be attempted.

Artificial insemination, in which the man's sperm or donor sperm from a sperm bank is inserted directly into the woman or a surrogate mother may be attempted. Another method is in vitro fertilization, in which an egg is taken from the mother or an egg donor and fertilized outside the body by the father's sperm. The resulting embryo is then inserted into the mother's uterus. Gamete intrafallopian transfer (GIFT) mixes the egg and sperm outside the body, then, using laparoscopic surgery (see endoscope), introduces them into the fallopian tube. For men with low sperm count or sperm of low quality, a procedure called intracytoplasmic sperm injection can help by inserting a single sperm directly into an egg. If none of these measures succeeds, adoption is sometimes considered.

Some controversy has surrounded infertility treatment. Many of the procedures are very expensive, and some question whether insurance plans should be responsible for the cost. The multiple births that sometimes occur with fertility drugs can put great strain on a family's resources. The legal rights of surrogate mothers and sperm donors are also of concern to all parties and have sometimes been resolved only after extended court cases. The wisdom of stretching the definition of "the childbearing years" has come into question as well, as methods used for treating infertility have been used to allow postmenopausal women to have children. Some are uncomfortable with the ability to choose the sex of the child or the screening of sperm or egg donors for characteristics such as height and intelligence.

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 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.

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, whilst 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.

Virus

German scientists have reported that a virus called Adeno-associated virus might have a role in male infertility, though it's 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 a third of cases, it can be because of male problems such as low sperm count.

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 or 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

A Robertsonian translocation in either partner may cause recurrent spontaneous abortions or complete infertility.

General factors

Diabetes mellitus, thyroid disorders, adrenal disease

Hypothalamic-pituitary factors

Environmental Factors

Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts, and pesticides.

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 both 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. He or she may also be able to suggest lifestyle changes you can make to increase your chances of conceiving.

Women over the age of 35 should see their family doctor after six months as fertility tests can take some time to complete, and your age may affect the treatment options that are open in that case.

A family doctor will take a medical history and give you 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 you to a fertility clinic or your local hospital for more specialist tests. The results of these tests will help determine which is the best fertility treatment for you and your partner.

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.

Take-home baby 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 on 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, surgery, or both. 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 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 PGD.

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.

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.