Infertility

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Infertility
Classification and external resources N46. ICD-10 , N97.0 606 ICD-9 , 628 21627 001191 med/3535 eMedicine med/1167 D007246

DiseasesDB MedlinePlus

MeSH

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

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1 Definition o 1.1 Infertility o 1.2 Subfertility o 1.3 Primary vs. secondary infertility 2 Prevalence 3 Causes o 3.1 Virus/Mutation o 3.2 Causes in either sex o 3.3 Combined infertility o 3.4 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 External links

[edit] Definition
There are strict definitions of infertility used by many doctors. However, there are also similar terms, e.g. subfertility for a more benign condition and fecundity for the natural improbability to conceive. Infertility in a couple can be due to either the woman or the man, not necessarily both.

[edit] 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. 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). the female is incapable of carrying a pregnancy to term.

[edit] 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 fecundability 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.

[edit] Primary vs. secondary infertility

Couples with primary infertility have never been able to conceive,[2] 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.

[edit] 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. 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. [3] 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 mens fertility is less clear.[3] 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 [4] 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 [5] In Sweden, approximately 10% of couples are infertile.[6] 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.

[edit] Causes

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

Ovulation problems tubal blockage male associated infertility age-related factors uterine problems previous tubal ligation previous vasectomy unexplained infertility Tuberculosis (TB) Male Hypospadias

[edit] Virus/Mutation
German scientists have reported that a virus called Adeno-associated virus might have a role in male infertility[7], though it is otherwise not harmful[8]. Mutation that alters human DNA adversely can cause infertility, the human body thus preventing the tainted DNA from being passed on. This could explain why some radiation victims from Chernobyl incident could not produce children.

[edit] Causes in either sex

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.[9] There are several possible reasons why it may not be happening naturally. In one-third of cases, it can be because of male problems such as low sperm count. 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. Factors that can cause male as well as female infertility are:

Genetic Factors

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]
o

[edit] 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.

[edit] Unexplained infertility

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

[edit] Assessment
If both partners are young and healthy, and have been trying for a baby for 12 months to two years 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. [12] 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.

[edit] 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.

[edit] 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. [13]

[edit] 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.[14]

[edit] Medical treatments

Medical treatment of infertility generally involves the use of medication, medical device, surgery, or a combination of the following. If the sperm are of good quality, and the mechanics of the womans 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, 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 womans reproductive tract, in a procedure called embryo transfer. Other medical techniques are e.g. tuboplasty, assisted hatching, and Preimplantation genetic diagnosis. Recently, a hormone-antioxidant combination therapy was suggested to improve sperm count and motility in infertile men, according to an Egyptian study. Ghanem H et al. Combination clomiphene citrate and antioxidant therapy for idiopathic male infertility: A randomized controlled trial. Fertil Steril 2009 Mar 5; [e-pub ahead of print]. Published in Journal Watch General Medicine March 31, 2009 The study included 60 men who were randomly selected to take either the combination treatment of clomiphene citrate and vitamin E or a placebo for six months. The pregnancy rate was about 37 percent among men who had taken the combination therapy, compared with 13 percent for those in the placebo group. The men in the treatment group also had a greater increase in sperm concentration and an improvement in sperm progression, the Cairo University researchers found. Clomiphene citrate is an anti-estrogen drug designed as a fertility medicine for women but sometimes used to boost sperm production in men with low sperm counts and poor sperm motility. Vitamin E helps counter oxidative stress, which is associated with sperm DNA damage and reduced sperm motility. "The results of this study will be encouraging to male factor patients and their doctors," Dr. R. Dale McClure, president of the American Society for Reproductive Medicine, said in a society news release. "However, more research is needed to determine how the components of the combination therapy affect the different semen parameters observed and the advantages of using these drugs singly or in combination with other drugs not used in this study."

[edit] 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 grouphad statistically significant higher pregnancy rates than the control group. [15] 2. Acupuncture: Acupuncture performed 25 minutes before and after IVF embryo transfer increased IVF pregnancy rates in a German study published in 2002.[16] In a 2006 similar study conducted by The University of South Australia, the acupuncture groups odds (although not statistically significant) were 1.5 higher than the control group. [17] 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 adjunct to IVF.[17][18] 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, [19] and to open and

return function to blocked fallopian tubes in a 2008 study. [20] The therapy was designed to address adhesions restricting function and mobility of the reproductive organs. [19][20]

[edit] Tourism
Main article: Fertility tourism Fertility tourism is the practice of traveling to another country for fertility treatments.[21] 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.