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.

Causes

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.

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

There are various treatments for infertility, depending what the problem is. These treatments include:

• 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.
• Use of a surrogate mother to carry the child.

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.

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.

Notes

• International Council on Infertility Information Dissemination (INCIID)] (FAQ)
• Note 2: American Society for Reproductive Medicine (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
• International Council on Infertility Information Dissemination (INCIID)