infertility - Definition, Causes, Symptoms and Signs, Treatment, Costs, Ethics, Psychological impact, Social impact, Sources

The inability of a couple to conceive, affecting about 10% of couples, with a wide range of causes affecting both partners. In the female, failure of ovulation is common, and ovaries may be stimulated to produce ova by giving gonadotrophic hormones or by drugs which simulate their action in the body. Infection of the cervix, obstruction of the uterine (Fallopian) tubes, and abnormalities in the uterus are also recognized factors. In the male, factors include the absence or inadequate production of sperm, and the clumping of sperm (agglutination) with impaired mobility due in some individuals to sperm antibodies in the male serum.

Infertility is the inability to naturally conceive a child or to carry a pregnancy to full term. (Note: although some aspects of this article may be generalizable, it deals primarily with infertility as pertains to human couples.)

Definition

The International Council on Infertility Information Dissemination (INCIID) considers a couple to be infertile if:

they have not conceived after 12 months of unprotected intercourse, or after 6 months if the woman is over 35 years of age.

Infertility affects approximately 15% of couples.

Healthy couples in their mid-20s having regular sex have a one-in-four chance of getting pregnant in any given month. There are some health insurance companies that cover diagnosis of infertility but frequently once diagnosed will not cover any treatment costs.

Causes

This section deals with unintentional causes of sterility. 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".

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. Technically, secondary infertility is not present if there has been a change of partners.

Some women are infertile because their ovaries do not release eggs.

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 neoplasm 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 Insufficient cervical mucus (for the travel and survival of sperm) Vaginal factors Vaginismus Vaginal obstruction Genetic factors Various intersexed conditions, such as androgen insensitivity syndrome

Male infertility

Factors relating to male infertility include:

Pretesticular causes Endocrine problems, i.e. Kallmann syndrome Hyperprolactinemia Hypopituitarism Hypogonadism due to various causes Psychological factors Drugs, alcohol Testicular factors Genetic defects on the Y chromosome Y chromosome microdeletions Abnormal set of chromosomes Klinefelter syndrome Neoplasm, e.g.

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.

In the majority of cases of male infertility and low sperm quality, no clear cause can be identified with current diagnostic methods. Microdeletions in the Y chromosome have been found at a much higher rate in infertile men than in fertile controls and the correlation found may still go up as improved genetic testing techniques for the Y chromosome are developed. The gold standard test for genetic mutation, namely complete DNA sequencing of a patient's Y chromosome, is still far too expensive for use in epidemiologic research or even clinical diagnostics.)

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.

Unexplained infertility

In about 15% of cases the infertility investigation will show no abnormalities. 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.

Symptoms and Signs

Male Infertility

The history should include prior testicular (penis) insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors (excessive heat, radiation, chemotherapy), medications (anabolic steroids, cimetidine, and spironolactone may affect spermatogenesis;

Female Infertility

Female infertility occurs when the woman does not conceive after one year of attempting to become pregnant. Other signs and symptoms depend on the underlying cause of the woman's infertility. Tests

Male Infertility

The diagnosis of infertility begins with a medical history and physical exam.

The cornerstone of the male partner evaluation is the history. It should note the duration of infertility, earlier pregnancies with present or past partners, and whether there was previous difficulty with conception.

A complete examination of the infertile male is important to identify general health issues associated with infertility.

The scrotal contents should be carefully palpated with the patient standing.

The peritesticular area should also be examined.

Female Infertility

Diagnosis of infertility begins with a medical history and physical exam. The healthcare provider may order tests, including the following:

an endometrial biopsy, which tests the lining of the uterus hormone testing, to measure levels of female hormones laparoscopy, which allows the provider to see the pelvic organs ovulation testing, which detects the release of an egg from the ovary Pap smear, to check for signs of infection pelvic exam, to look for abnormalities or infection a postcoital test, which is done after sex to check for problems with secretions special X-ray tests

Diagnosis of infertility should be made by physicians who are fellowship trained as reproductive endocrinologists. Infertility. These specialized professionals treat primarily, infertility for both sexes.

Perspective patients should note that reproductive endocrinology & infertility practices do not see women for general maternity care.

Treatment

Fertility medication which stimulates the ovaries to "ripen" and release eggs (e.g. 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; Acupuncture was also reported to be effective in the treatment of female anovular infertility, World Health Organisation, Acupuncture: Review and Analysis of Reports on Controlled Trials (2002). Diet and supplements Healthy lifestyle

Most health insurance plans do not cover the cost of IVF (in vitro fertilization). Since IVF treatment is expensive and not often covered by health plans the InterNational Council on Infertility Information Dissemination, Inc. Expectations

Male Infertility

Some cases of male infertility may be avoided by doing the following:

Avoid drugs and medications known to cause fertility problems, like steriods and some antifungal medications.

Although more research needs to be done, parents may want to consider alternatives to disposable diapers for male infants.

Female Infertility

Some cases of female infertility may be prevented by taking the following steps:

Avoid excessive exercise.

Costs

Not everyone in the U.S. has insurance coverage for fertility investigations and treatments, especially when a couple already has children.

2005 approximate treatment/diagnosis costs (United States, 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 - dependent 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.

In the UK all patients have the right to preliminary testing, provided free of charge by the National Health Service.

Ethics

There are many ethical issues associated with infertility and its treatment. Debate over whether health insurance companies should be forced to cover infertility treatment. 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.

Psychological impact

Infertility may have profound psychological effects. Marital discord often develops in infertile couples, especially when they are under pressure to make medical decisions.

Social impact

In many cultures, inability to conceive bears a stigma.

There are also legal ramifications as well. Infertility has begun to gain more exposure to legal domains. Many treatments for infertility, including diagnostic tests, surgery and therapy for depression, can qualify one for FMLA leave.

Sources

Male Infertility from Armenian Medical Network

Female Infertility

Male Infertility