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Fertility Issues


Infertility is a unique medical condition because it involves a couple, rather than a single individual. It is defined as failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35 years of age; and after six months of regular intercourse without use of contraception in women 35 years and older.

CAUSES OF INFERTILITY — The World Health Organization (WHO) task force on Diagnosis and Treatment of Infertility performed a study of 8500 infertile couples and utilized standard diagnostic criteria to determine the medical conditions contributing to infertility. In developed countries, female factor infertility was reported in 37 percent of infertile couples, male factor infertility in 8 percent, and both male and female factor infertility in 35 percent. Five percent of couples had unexplained infertility and 15 percent became pregnant during the study. This study illustrates that infertility should not be assumed to result primarily from disorders in the female partner.

Some causes of infertility are easily identifiable, such as azoospermia (no sperm cells in the ejaculate), longstanding amenorrhea, or bilateral tubal obstruction. However, the situation is less clear in most couples: the sperm may be reduced in number, but are not absent; there may be oligomenorrhea with some ovulatory cycles; the woman may have partial tubal obstruction; or a menstrual history may suggest intermittent ovulation. It is often difficult to weigh or prioritize these findings when counseling infertile couples or planning treatment programs.

Adding to the complexity of the situation, there are few data regarding the predictive validity of these tests despite their widespread use. Thus, short of the absolute infertility factors mentioned (eg, azoospermia or bilateral tubal obstruction), an abnormal test result cannot be said to be the cause of infertility in a particular couple.

The uncertain causal relationship between an abnormality on infertility testing and the actual cause of infertility makes it difficult to estimate the relative frequency of the causes of infertility. Nevertheless, it is instructive to estimate the frequency with which various factors are found in association with infertility as a rough proxy for their relative importance. One population-based study reported the following results [14]:

  • Male factor (hypogonadism, post-testicular defects, seminiferous tubule dysfunction) — 26 percent
  • Ovulatory dysfunction — 21 percent
  • Tubal damage — 14 percent
  • Endometriosis — 6 percent
  • Coital problems — 6 percent
  • Cervical factor — 3 percent
  • Unexplained — 28 percent

Both partners of an infertile couple should be evaluated for factors that could be impairing fertility. The infertility specialist then uses this information to counsel the couple about the possible etiologies of their infertility and to offer a treatment plan targeted to their specific needs.

It is important to remember that the couple may have multiple factors contributing to their infertility; therefore, a complete initial diagnostic evaluation should be performed to detect the most common causes of infertility, if present. When applicable, evaluation of both partners is performed concurrently [1].

The recognition, evaluation, and treatment of infertility are stressful for most couples [2]. The clinician should not ignore the couple’s emotional state, which may include depression, anger, anxiety, and marital discord. Information should be supportive and informative.