Infertility
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Infertility is the inability to naturally conceive, carry or deliver a healthy child. There are many reasons why a couple may not be able to conceive, or may not be able to conceive without medical assistance.
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Definition
The International Council on Infertility Information Dissemination (INCIID) considers a couple to be infertile if1:
- they have not conceived after a year of unprotected intercourse, or after six months in women over 35;
- there is incapability to carry a pregnancy to term.
Healthy couples in their mid-20s having regular sex have a one-in-four chance of getting pregnant in any given month.
Causes
Primary vs. secondary
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.
A Robertsonian translocation in either partner may cause recurrent abortions or complete infertility.
"Secondary infertility" is difficulty conceiving after already having conceived and carried a normal pregnancy. Apart from various medical conditions (e.g. hormonal), this may come as a result of age and stress felt to provide a sibling for their first child. Technically, secondary infertility is not present if there has been a change of partners.
Female infertility
Factors relating to female infertility are:
- General factors
- Diabetes mellitus, thyroid disorders, adrenal disease
- Significant liver, kidney disease
- Psychological factors
- Hypothalamic-pituitary factors:
- Ovarian factors
- Tubal/peritoneal factors
- Endometriosis
- Pelvic adhesions
- Pelvic inflammatory disease (PID, usually due to chlamydia)
- Tubal occlusion
- Uterine factors
- Uterine malformations
- Uterine fibroids (leiomyoma)
- Asherman's Syndrome
- Cervical factors
- Vaginal factors
- Vaginismus
- Vaginal obstruction
Male infertility
Factors relating to male infertility include3:
- Pretesticular causes
- Endocrine problems, i.e. diabetes mellitus, thyroid disorders
- Hypothalamic disorders, i.e. Kallmann syndrome
- Hyperprolactinemia
- Hypopituitarism
- Hypogonadism due to various causes
- Psychological factors
- Drugs, alcohol
- Testicular factors
- Genetic causes, e.g. Klinefelter syndrome
- Neoplasm, e.g. seminoma
- Idiopathic failure
- Varicocele
- Trauma
- Hydrocele
- Mumps
- Posttesticular causes
- Vas deferens obstruction
- Infection, e.g. prostatitis
- Retrograde ejaculation
- Hypospadias
- Impotence
Some causes of male infertility can be determined by analysis of the ejaculate, which contains the sperm. The analysis includes counting the number of sperm and measuring their motility under a microscope:
- Producing few sperm, oligospermia, or no sperm, azoospermia.
- A sample of sperm that is normal in number but shows poor motility, or asthenozoospermia.
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.
Treatment
- Fertility medication which stimulates the ovaries to "ripen" and release eggs (e.g. clomifene citrate, which stimulates ovulation)
- Surgery to restore patency of obstructed fallopian tubes
- Donor insemination which involves the woman being artificially inseminated with donor sperm.
- In vitro fertilization (IVF) in which eggs are removed from the woman, fertilized and then placed in the woman's uterus, bypassing the fallopian tubes. Variations on IVF include:
- Use of donor eggs and/or sperm in IVF. This happens when a couple's eggs and/or sperm are unusable, or to avoid passing on a genetic disease.
- Intracytoplasmic sperm injection (ICSI) in which a single sperm is injected directly into an egg; the fertilized egg is then placed in the woman's uterus as in IVF.
- Zygote intrafallopian transfer (ZIFT) in which eggs are removed from the woman, fertilized and then placed in the woman's fallopian tubes rather than the uterus.
- Gamete intrafallopian transfer (GIFT) in which eggs are removed from the woman, and placed in one of the fallopian tubes, along with the man's sperm. This allows fertilization to take place inside the woman's body.
- Other assisted reproductive technology (ART):
- Assisted hatching
- Fertility preservation
- Freezing (cryopreservation) of sperm, eggs, & reproductive tissue
- Frozen embryo transfer (FET)
Costs
Not everyone has insurance cover for fertility investigations and treatments, especially when a couple already has children.
2005 approximate costs in US$:
- Initial workup: hysteroscopy (hysterosalpingogram) ~$2,000
- Artificial insemination ~ $500- 900 per. trial
- Sonohysterogram (SHG) ~ $600 - 1,000
- Clomiphene citrate cycle ~ $ 200 - 500
- IVF cycle ~ $10,000 -14,000
- Use of a surrogate mother to carry the child - dependant 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.
Ethics
There are many ethical issues associated with infertility and its treatment.
- High-cost treatments are out of financial reach for some couples.
- Health insurance and infertility treatment.
- The status of embryos fertilized in vitro and not transfered 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' instructions on fertility treatments.
Psychological impact
Infertility may have a profound psychological affects. Partners may become more anxious to conceive, paradoxically 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 cancer4.
A lot of women find themselves to be in-between worlds, so to speak. That is, infertile couples would be abnormal and fertile couples are normal. It’s about “us” vs. “them,” and infertile women would often compare themselves to fertile women. Such social comparisons permitted both self-evaluation and self-enhancement; they allowed women to determine where they “fit into the scheme of things” and to find the “slide rule” that would enable them to measure whether they were better or worse off, or “at least equal to everybody else.”
If infertility treatment is unsuccessful after several attempts, the most difficult decision a couple faces is whether to keep trying this or another treatment, or to discontinue treatment.
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.
There are also legal ramfications as well. Infertility has begun to gain more exposure to legal domains. An estimated 4 million workers used the Family and Medical Leave Act (FMLA) last year 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 you for FMLA leave.
Notes
- Note 1: International Council on Infertility Information Dissemination (INCIID) (http://www.inciid.org/faq/general1.html) (FAQ)
- Note 2: American Society for Reproductive Medicine (http://www.asrm.org/Patients/faqs.html) (FAQ)
- Note 3: 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 0521774748.
- Note 4: 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.
External links
- American Society for Reproductive Medicine (http://www.asrm.org/)
- International Council on Infertility Information Dissemination (http://www.inciid.org) (INCIID)
- Personal accounts of infertility and fertility treatments (http://www.fertilitystories.com)
- RESOLVE: nationwide infertility nonprofit since 1974 (http://www.resolve.org)
- "'Infertility time bomb' warning (http://news.bbc.co.uk/1/hi/health/4112450.stm)" at BBC News, 20 June 2005de:Unfruchtbarkeit