| Infertility | |
|---|---|
| Classification and external resources | |
| ICD-10 | N46, N97.0 |
| ICD-9 | 606, 628 |
| DiseasesDB | 21627 |
| MedlinePlus | 001191 |
| eMedicine | med/3535 med/1167 |
| MeSH | D007246 |
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.
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Definitions of infertility differ, with demographers tending to define infertility as childlessness in a population of women of reproductive age, while the epidemiological definition is based on "trying for" or "time to" a pregnancy, generally in a population of women exposed to a probability of conception.[2]
One definition of infertility that is frequently used by reproductive endocrinologists, the doctors specializing in infertility, to consider a couple eligible for treatment if:
These time intervals would seem to be reversed; this is an area where public policy trumps science. The idea is that for women beyond age 35, every month counts and if made to wait another 6 months to prove the necessity of medical intervention, the problem could become worse. The corollary to this is that, by definition, failure to conceive in women under 35 isn't regarded with the same urgency as it is in those over 35.
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.[4]
A couple that has tried unsuccessfully to have a child after a certain period of time (often a short period, but definitions vary) is sometimes said to be subfertile, meaning less fertile than a typical couple. Both infertility (see above for definitions) and subfertility are defined as the inability to conceive after a certain period of time (the length of which vary), so often the two terms overlap.
Couples with primary infertility have never been able to conceive,[5] 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). Secondary infertility is not present if there has been a change of partners (this follows tautologically from the convention of speaking of couples, rather than individuals, as being infertile; if there is a change of partners, then a new couple is created, with its own chances to be infertile.)
This section deals with unintentional causes of sterility. For more information about surgical techniques for preventing procreation, see Sterilization (surgical procedure).
Factors that can cause male as well as female infertility are:
German scientists have reported that a virus called Adeno-associated virus might have a role in male infertility,[14] though it is otherwise not harmful.[15] Mutation that alters human DNA adversely can cause infertility, the human body thus preventing the tainted DNA from being passed on.
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.[16]
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, or her age as 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:
The main cause of male infertility is low semen quality.
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.
In the US, up to 20% of infertile couples have unexplained infertility.[17] 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.[18]
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.[19]
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 methods for infertility may be grouped as medical or complementary and alternative treatments. Some methods may be used in concert with other methods.
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.[20]
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.[21]
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.
Three complementary or alternative female infertility treatments have been scientifically tested, with results published in peer-reviewed medical journals.
Fertility tourism is the practice of traveling to another country for fertility treatments.[28] 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.
There are several ethical issues associated with infertility and its treatment.
Many countries have special frameworks for dealing with the ethical and social issues around fertility treatment.
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.[32]
Infertility may have profound psychological effects. Partners may become more anxious to conceive, ironically increasing sexual dysfunction.[33] 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.[34] Even couples undertaking IVF face considerable stress.[35]
Emotional stress and marital difficulties are greater in couples where the infertility lies with the man.[36]
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.[37]
In an effort to end the shame and secrecy of infertility, Redbook in October 2011 launched a video campaign, The Truth About Trying, to start an open conversation about infertility, which strikes one in eight women in the United States. In a survey of couples having difficulty conceiving, conducted by the pharmaceutical company Merck, 61 percent of respondents hid their infertility from family and friends. [38] Nearly half didn't even tell their mothers. The message of those speaking out: It's not always easy to get pregnant, and there's no shame in that.
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.
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.[39] 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.[39]
Any individual examples are referred to individual subarticles of assisted reproductive technology
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