The majority of couples worldwide expect to have children, and few ever contemplate the possibility that they will be unable to do so. Yet at least 1 in 10 couples experiences difficulty in becoming pregnant, a stressor that can rank among the most emotionally taxing crises of adulthood.
What Is Infertility?
About one fourth of couples will conceive after 1 month of regular, unprotected sexual intercourse, and 80% are likely to conceive within 12 months. Couples are considered infertile if they are unable to conceive after 1 full year of unprotected sex. Couples who have never conceived are considered to have primary infertility, whereas couples who cannot conceive despite prior successful conception are defined as having secondary infertility.
The prevalence of infertility varies considerably across countries. In the United States, 10% to 14% of couples experience infertility, a rate that has been stable since 1965. Rates of infertility in developing countries tend to be higher, due in part to a greater prevalence of contributing infectious diseases. In some regions of sub-Saharan Africa, for example, rates of infertility have been reported to be as high as 30%.
What Causes Infertility?
The World Health Organization has estimated that less than half of infertility is attributable to inherent genetic and biological factors (e.g., anatomical or endocrinological abnormalities). More often, infertility is due to preventable factors, which include sexually transmitted and other infectious diseases, inadequate or unsafe health care, and harmful environmental substances.
Maternal age is an important determinant of fertility, and the tendency in Western countries for women to delay childbearing has likely contributed to the misperception that infertility is on the rise. Unlike men, whose decline in fertility is not thought to occur until age 50, and even then may be slight, women’s fertility begins to decrease in the late 20s or early 30s, with a steeper drop after age 35. By age 40, approximately 1 in 3 women is likely to be infertile, and by age 45, only 1 in 10 women is likely to conceive.
Physiologically, this decline is explained by a gradually diminishing supply, and weakening quality, of oocytes (unfertilized eggs).
Although infertility has historically been perceived as a “women’s problem,” male factors are the specific cause of at least 20% of infertility cases and a contributing factor in another 30%. (Many cases of infertility are the result of multiple factors, and some, of course, are unexplained.) The most frequent basis for male infertility is an abnormality of sperm, in particular, oligospermia (low numbers of sperm), problems with sperm motility (movement), or irregular sperm morphology (shape). The precise reason for impairments in sperm production and function is often unclear, but genetic disorders, diseases, infections, environmental factors, and even nutrition are thought to play a role.
The most common physiological female factor contributing to infertility is infrequent or absent ovulation, implicated in up to one third of infertility cases. A primary cause of ovulatory dysfunction is polycystic ovarian syndrome, an endocrine disorder affecting at least 5% of U.S. women. Blocked or damaged fallopian tubes, often due to pelvic inflammatory disease or endometriosis, are another frequent cause of female infertility.
How Is Infertility Treated?
Infertility is often treated by reproductive endocrinologists, physicians with a specialization in obstetrics and gynecology who have completed advanced training and research in infertility. Treatment begins by testing both partners in order to determine the most likely cause or causes of infertility. Women with ovulatory problems are typically treated with ovulation-inducing medication, sometimes referred to as “fertility drugs.” Two different classes of drugs may be used: clomiphene citrate, which is taken orally, or gonadotropins, which must be injected subcutaneously or intramuscularly. Clomiphene successfully induces ovulation in the majority of women for whom it is prescribed (estimates range from 60 to 90%); however, less than half will conceive within 6 months, the recommended maximum treatment period. When clomiphene is ineffective, the more expensive gonadotropins are used. Although gondadotropin injections are more likely than clomiphene to result in pregnancy, they also have more significant side effects, including a greater increase in the likelihood of multiple births.
Surgery is a second treatment approach. Women with fallopian tube blockages may benefit from surgical attempts to reopen or repair the tubes. Likewise, some male factor causes of infertility can be corrected by surgery. Finally, microsurgical procedures can be performed to reverse prior tubal ligation surgery in women as well as vasectomies in men.
Intrauterine insemination (IUI), in combination with fertility medications, is often the first intervention in cases of infertility caused by sperm abnormalities or infertility that is unexplained. This procedure involves collecting a semen sample from the male partner, removing and preparing the sperm, and then, by way of a thin catheter, placing the sperm directly in the woman’s uterus. IUI must be carefully timed with ovulation to maximize effectiveness. Scientific studies of IUI success rates report pregnancy rates per cycle ranging from 4% to 15%. (In interpreting success rate statistics, keep in mind that a small percentage of technically “infertile” couples will conceive without any intervention—as many as 3% per cycle.) Because most couples attempt IUI up to six times, the overall pregnancy rate, across all attempts, is higher, with estimates ranging up to 25%. Several factors influence effectiveness, for example, maternal age, the number of ovarian follicles (sacs that contain the eggs) at the time of the IUI, and sperm motility.
Assisted reproductive technologies (ART) are defined by the Centers for Disease Control (CDC) as a group of therapies that involve the “handling” of both eggs and sperms. Although ART has received considerable attention from the media, less than 5% of infertile couples in the United States undergo ART, typically only after all other treatment options have been exhausted. It is also still a relatively new treatment, introduced in 1978. In general, ART involves stimulating a woman’s ovaries, surgically removing her eggs, combining the eggs with a man’s sperm, and then transferring any resulting fertilized eggs, or embryos, back to the woman’s body.
By far the most commonly practiced type of ART is in vitro fertilization (IVF). “In vitro” comes from the Latin “in glass,” referring to the laboratory dish in which the eggs and sperm are combined to facilitate fertilization; the embryos are then placed directly into the woman’s uterus. Gamete intrafallopian transfer (GIFT) is similar to IVF except that the woman’s eggs are transferred to her fallopian tubes and fertilized there, rather than outside her body. A third type of ART is zygote intrafallopian transfer (ZIFT), which combines laboratory fertilization of a woman’s eggs with embryo transfer to the fallopian tubes. ART procedures tend to be expensive, and, in the United States, the cost is only rarely covered by health insurance.
The CDC collects data from fertility clinics in the United States each year in order to track the effectiveness of ART. Among 384 clinics that provided data in 2001, 33% of ART cycles that used fresh, nondonor eggs resulted in a pregnancy. Success rates decline as maternal age increases; the likelihood of pregnancy in women over 40 was 23%. The success of ART has gradually increased over time, helped in part by the introduction of intracytoplasmic sperm injection (ICSI) in 1992, a technique that allows a single sperm to be directly injected into an egg, thereby increasing the chance that fertilization will occur.
Third party reproductive techniques refer to the donation of eggs, sperm, or embryos to infertile couples. Donors may be acquainted with the couple or anonymous. Surrogacy, the carrying of an embryo throughout pregnancy by another woman, is also considered a third party reproductive technique. As noted by the American Society for Reproductive Medicine, third party techniques present significant psychological, ethical, and legal issues and, with the exception of sperm donation, are still quite new approaches to the treatment of infertility.
How Does Infertility Affect Mental Health?
The experience of infertility, as well as its treatment, can be profoundly distressing. For nearly one half of women who undergo IVF, infertility is seen as the worst experience of their lives. Studies based on descriptive interviews with infertile couples reveal many emotional consequences, including feelings of loss of control, a lowered sense of personal competence, perceptions of alienation and hopelessness, and a sense of social stigma. For some couples, infertility is viewed as a strain on their relationship, although other couples report that the jointly experienced stressor of infertility serves to bring them closer. In addition, couples, and particularly women, find themselves immersed in the treatment process, and the invasive nature of infertility therapy exerts additional stress.
Empirical investigations of the impact of infertility have demonstrated that infertile couples tend to experience greater anxiety, depression, and self-esteem than their peers, and a subset of couples are at risk of developing clinically significant mental health problems. Women tend to struggle more than men and consequently are more apt to avoid day-to-day reminders such as contact with babies and pregnant women. Women are also more likely than men to seek out information about infertility, initiate treatment, and desire to continue treatment.
Although psychological studies in this area are far from perfect, experiences of infertile individuals who have opted to undergo medical treatment clearly indicate that, overall, infertility is a highly disruptive life crisis. Consequently, many infertility practices employ mental health professionals who can address emotional aspects of infertility with clients. In addition, many infertility patients have found comfort in support groups, national infertility organizations, and Internet chatrooms and newsgroups.
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