INFERTILITY

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.[1]

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.

Contents

• 1 Definition
o 1.1 Infertility
o 1.2 Subfertility
o 1.3 Primary vs. secondary infertility
• 2 Prevalence
• 3 Causes
o 3.1 Causes in either sex
o 3.2 Specific female causes
o 3.3 Specific male causes
o 3.4 Combined infertility
o 3.5 Unexplained infertility
• 4 Assessment
• 5 Treatment
o 5.1 At-home conception kit
o 5.2 At-home assessment
o 5.3 Medical treatments
o 5.4 Complementary and alternative treatments
o 5.5 Tourism
• 6 Ethics
• 7 Psychological impact
• 8 Social impact
• 9 Fictional representation
• 10 See also
• 11 References
 • 12 Further reading

• 13 External links

Definition

The couple has not conceived after months of contraceptive-free intercourse if the female is
under the age of 34. There are also similar terms, e.g. sub-fertility for a more benign condition
and fecundity for the natural improbability to conceive after 12 months of trying. 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. 12 months is the lower reference limit for Time to
Pregnancy (TTP) by the World Health Organization.[2]
• 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).

Alternatively, the NICE guidelines define infertility as failure to conceive after regular
unprotected sexual intercourse for 2 years in the absence of known reproductive pathology.[3]

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 fecund ability 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, [4] 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.[citation needed]
 • 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.[5]

• 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.[5]

• 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.
[6]

• 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.[7]

• In Sweden, approximately 10% of couples are infertile.[8] 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

Data from UK, 2009.[9]

This section deals with unintentional causes of sterility. For more information about surgical
techniques for preventing procreation, see sterilization.

Causes in either sex

Factors that can cause male as well as female infertility are:

• Genetic factors
o A Robertsonian translocation in either partner may cause recurrent spontaneous
abortions or complete infertility.
• General factors
o Diabetes mellitus, thyroid disorders, adrenal disease
 • Hypothalamic-pituitary factors
o Kallmann syndrome
o Hyperprolactinemia
o Hypopituitarism
• Environmental factors
o Toxins such as glues, volatile organic solvents or silicones, physical agents,
chemical dusts, and pesticides.[10][11] Tobacco smokers are 60% more likely to be
infertile than non-smokers.[9] Smoking reduces the chances of IVF producing a
live birth by 34% and increases the risk of an IVF pregnancy miscarrying by 30%.
[9]

German scientists have reported that a virus called Adeno-associated virus might have a role in
male infertility,[12] though it is otherwise not harmful. [13] Mutation that alters human DNA
adversely can cause infertility, the human body thus preventing the tainted DNA from being
passed on[citation needed].

Specific female causes

Further information: Female infertility

The following causes of infertility may only be found in females.

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.[14]

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.

Common causes of infertility of females include:

• ovulation problems
• tubal blockage
• age-related factors
• uterine problems
• previous tubal ligation

Specific male causes

Further information: Male infertility

The main cause of male infertility is low semen quality.

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

Main article: Unexplained infertility

In the US, up to 20% of infertile couples have unexplained infertility.[15] 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. Also, polymorphisms in folate pathway genes
could be one reason for fertility complications in some women with unexplained infertility.[16]

Assessment

Main article: Fertility testing

If both partners are young and healthy and have been trying to conceive for 12 months to one
year 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.[17]

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.[18]

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.[19]

Medical treatments

Medical treatment of infertility generally involves the use of fertility 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, or 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.

Complementary and alternative treatments

Three complementary or alternative female infertility treatments have been scientifically tested,
with results published in peer-reviewed medical journals.
 1. 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.[20]
2. Acupuncture: Acupuncture performed 25 minutes before and after IVF embryo transfer
increased IVF pregnancy rates in a German study published in 2002.[21] In a similar study
conducted by The University of South Australia in 2006, there was no statistically
significant difference in fertility between the group which received acupuncture and the
control group.[22] 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 -
although not necessarily effective - adjunct to IVF.[22][23]
3. 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,[24] and to open and return function to
blocked fallopian tubes in a 2008 study.[25] The therapy was designed to address

Tourism

Main article: Fertility tourism

Fertility tourism is the practice of traveling to another country for fertility treatments.[26] 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.

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).
• Pro-life 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 adopted 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 [27]

• Regulatory bodies are also found in Canada [28] and in the state of Victoria in Australia [29]

Psychological impact

The consequences of infertility are manifold and can include societal repercussions and personal
suffering. Advances in assisted reproductive technologies, such as IVF, can offer hope to many
couples where treatment is available, although barriers exist in terms of medical coverage and
affordability. The medicalization of infertility has unwittingly led to a disregard for the
emotional responses that couples experience, which include distress, loss of control,
stigmatization, and a disruption in the developmental trajectory of adulthood.[30]

Infertility may have profound psychological effects. Partners may become more anxious to
conceive, ironically increasing sexual dysfunction.[31] 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.
[32]
Even couples undertaking IVF face considerable stress.[33]

Emotional stress and marital difficulties are greater in couples where the infertility lies with the
man.[34]

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.[35]

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.[36] 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.[36]

Any individual examples are referred to individual subarticles of assisted reproductive

technology

References

1. ^ Makar RS, Toth TL (2002). "The evaluation of infertility". Am J Clin Pathol.

117 Suppl: S95–103. PMID 14569805.
2. ^ Cooper TG, Noonan E, von Eckardstein S, et al. (2010). "World Health
Organization reference values for human semen characteristics". Hum. Reprod. Update
16 (3): 231–45. doi:10.1093/humupd/dmp048. PMID 19934213.
3. ^ [1] Fertility: Assessment and Treatment for People with Fertility Problems.
London: RCOG Press. 2004. ISBN 1-900364-97-2.
4. ^ MedlinePlus Encyclopedia Infertility
5. ^ a b NICE fertility guidance
6. ^ HFEA Chart on reasons for infertility
7. ^ Khan, Khalid; Janesh K. Gupta; Gary Mires (2005). Core clinical cases in
obstetrics and gynaecology: a problem-solving approach. London: Hodder Arnold.
pp. 152. ISBN 0-340-81672-4.
8. ^ Sahlgrenska University Hospital. (translated from the Swedish sentence: "Cirka
10% av alla par har problem med ofrivillig barnlöshet.")
9. ^ a b c Regulated fertility services: a commissioning aid - June 2009, from the
Department of Health UK
10. ^ Mendiola J, Torres-Cantero AM, Moreno-Grau JM, et al. (Jun 2008).
"Exposure to environmental toxins in males seeking infertility treatment: a case-
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6483(10)60151-4. PMID 18549695.
11. ^ Smith EM, Hammonds-Ehlers M, Clark MK, Kirchner HL, Fuortes L (Feb
1997). "Occupational exposures and risk of female infertility". J Occup Environ Med. 39
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12. ^ http://www.newscientist.com/article.ns?id=dn1483
13. ^ "Virus linked to infertility". BBC News. 2001-10-27. Retrieved 2010-04-02.
14. ^ About infertility & fertility problems
15. ^ Unexplained Infertility Background, Tests and Treatment Options Advanced
Fertility Center of Chicago
16. ^ Altmäe, S.; Stavreus-Evers, A.; Ruiz, J.; Laanpere, M.; Syvänen, T.; Yngve, A.;
Salumets, A.; Nilsson, T. (2010). "Variations in folate pathway genes are associated with
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doi:10.1016/j.fertnstert.2009.02.025. PMID 19324355. edit
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18. ^ http://www.newsrx.com/pr_details.php?type=1&id=2904
19. ^ http://www.formyodds.com
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PMID 10731544.
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26. ^ wordspy.com
27. ^ http://europa.eu/scadplus/leg/en/cha/c11573.htm EU Tissues and Cells directive
28. ^ Assisted Human Reproduction Canada
29. ^ ITA
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36. ^ a b chicagotribune.com Heartache of infertility shared on stage, screen By