WHAT IS INFERTILITY?
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.
Definition
The International Council on Infertility Information Dissemination (INCIID)
considers a couple to be infertile if:
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:
Kallmann syndrome
Hypothalamic dysfunction
Hyperprolactinemia
Hypopituitarism
Ovarian factors
Polycystic ovary syndrome
Anovulation
Diminished ovarian reserve
Luteal dysfunction
Premature menopause
Gonadal dysgenesis (Turner syndrome)
Ovarian tumor
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
Cervical stenosis
Antisperm antibodies
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)
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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, blood tests ~$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.
Most insurances do not cover the cost of infertility treatment. Many states are
starting to mandate coverage.
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 heart disease or 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 ramifications 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.
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