CHAPTER 12 Fertility Challenges
Infertility is defined as the inability to conceive after 12 months of unprotected intercourse in a couple of reproductive age attempting to conceive. Approximately 90% of couples achieve conception within this time, and a further 15% of normally fertile couples take longer than 12 months to become pregnant. Research has shown that even couples in their late thirties have a 91% chance of conceiving naturally within 2 years, and recent studies estimate that an average of 25% to 40% of women have a live birth without treatment during the 3 years after the first infertility consultation, even without treatment. 1 2 3 Nevertheless, of the approximately 60 million women of reproductive age in the United States in 1995, about 1.2 million, or 2%, had had an infertility-related medical appointment within the previous year and an additional 13% had received infertility services at some time in their lives.4 This number has increased in recent decades because of societal demographic changes, particularly the aging of the baby boom generation, leading to an increased size of the reproductive age population, and more couples delaying fertility for the sake of careers.1
Infertility is not synonymous with sterility and it is important to differentiate these terms. Sterility is defined the inability to achieve pregnancy and affects only 1% to 2% of couples.2 Primary infertility refers to those who have never before conceived and secondary infertility to those who have achieved conception some time in the past (regardless of pregnancy outcome) and thereafter became infertile.5
FEMALE FACTORS AFFECTING FERTILITY
The main types of female infertility include ovulatory disorders (25%) and tubal disease (20% to 25%), including endometriosis (10%). Ovulatory factors are suspected when menstrual abnormalities are reported. Male infertility is the primary cause in approximately 25% of cases and contributes to an additional 15% to 25% of cases. Infertility results from unexplained causes in up to 20% of cases.1 Thorough evaluation of the couple will point to a probable cause in 85% to 90% of cases.2 Ovarian factors are primarily associated with follicular phase disruptions. An inadequate luteal phase is said to account for only 3% to 4% of fertility failure. Examples of all of the factors that account for fertility challenges are listed in Table 12-1.
| FACTOR | EXAMPLES |
|---|---|
| Ovulatory |
Data from Kaider A, Kaider B, Janowicz P, et al.: Immunodiagnostic evaluation in women with reproductive failure, Am J Reprod Immunol 42(6):335-346, 1999.
MALE FACTORS AFFECTING FERTILITY
Male factors affecting fertility include:
DIAGNOSIS
Evaluation of Male Factors
A secondary evaluation is recommended and usually includes more holistic measures:
Evaluation of Female Factors
Primary evaluation should include:
A secondary evaluation is recommended, especially for unidentified infertility:
In a tertiary evaluation for pelvic factors, minor surgery is often required. These tests require referral to a reproductive medical specialist. These tests and procedures, although sometimes necessary, are invasive, painful, and expensive:
Noninvasive Home Evaluation and Patient Participation: Thermo-Symptal Monitoring and Mucus and Cervical Evaluation for Detection of Ovulation
Basal Body Temperature Monitoring
Monitoring Cervical Mucus Changes
Daily monitoring of the texture, quality, and quantity of cervical mucus secretions can be useful to predict ovulation. Cervical mucus secretions change throughout the cycle under the influence of estrogen and progesterone. Approximately 2 or 3 days before ovulation occurs, the estrogen levels peak and the nature of the mucus changes from a pasty thick or milky consistency to a distinctive “spinnbarkeit”: stretchy mucus (usually 6 to 10 cm) of wet consistency and opaque color. It resembles a similar texture and nature to raw egg white. At this stage of the cycle, the mucus is an optimal reservoir to nourish sperm and encourage their survival for conception. When seen under a microscope, fertile spinnbarkeit mucus dries into a distinctive crystalline fernlike pattern. Small, inexpensive ovulation predictor microscopes for home use are available to assist couples in predicting ovulation. Saliva is usually used on the microscope as an alternative to cervical mucus, because saliva mimics the ferning pattern of the spinnbarkeit at the ovulation time. When estrogen levels are lower in the early follicular phase and midluteal phase of the cycle, the mucus secretions are thin, milky, and sparse in nature. When a woman is monitoring cervical mucus, it is recommended she feel the texture of the mucus (at the vaginal opening) between the forefinger and thumb and not use toilet tissue to collect the sample. It absorbs moisture and may lead to misinterpretation of the mucus viscosity. Home test kits that measure urinary LH levels are available for ovulation prediction. These are single use tests and their disadvantage is the expense when used regularly.
CONVENTIONAL TREATMENT APPROACHES
Despite developments in fertility knowledge and technologies, the overall prognosis for achieving childbirth with reproductive technologies is approximately 50%, and declines as women age. Each treatment option has overt and hidden costs, including emotional, physical, and financial burdens, often without justification because of lack of success. Couples entering fertility treatment need to be fully cognizant of the potential price of treatment in all of these areas, and the benefit vs. costs must be evaluated. Patients must also consider the high frequency and implications of a multiple pregnancy, a common outcome with assisted reproductive technologies. Psychological support should be available to all couples considering reproductive technologies, with no blame laid upon either partner, and a realistic appraisal of the chances for success and failure of treatment honestly provided. Reproductive expert Marcelle Cedars advises, “The option of child-free living should also be included in any discussion. At times couples must be advised to stop treatment if the likelihood for success is quite low. Frequently this is a very difficult time for both the patient and the physician, but fruitless treatment should be avoided.”1
Ovarian Stimulation Therapy
When elevated prolactin levels are causing amenorrhea or luteal phase defects are confirmed (e.g., in PCOS), bromocriptine is used. In this circumstance, thyroid function is also evaluated, as primary hypothyroidism can cause elevated prolactin levels. Many pharmaceutical drugs can also cause hyperprolactinemia as a side effect. This needs to be considered and ruled out. Hyperprolactinemia is treated using bromocriptine, a dopamine agonist. Administration is either oral or vaginally at doses of 2.5 mg twice daily or 0.5 mg twice a week. Bromocriptine does not increase the risk of inducing multiple pregnancies. Side effects include weakness, nausea, and nasal congestion.
Pelvic Factors
Endometriosis and the effects of salpingitis are the most common problems causing infertility related to pelvic factors. These affect the structural health of the fallopian tubes, as well as uterine and endometrial tissue. Salpingitis is usually caused by infections with microorganisms such as Neisseria gonorrhea and Chlamydia trichomatosis; other infective organisms include Escherichia coli, Mycoplasma hominis, and Ureaplasma urealyticum.7 Bacterial vaginosis is common among these women. Antibiotic drugs are the usual treatment for these infections.8 The treatment option for moderate and advanced endometriosis is usually surgical; at the time of a laparoscopy, resection and ablation is performed. Fibroids are usually left untouched and are only addressed if multiple miscarriages have been a problem. ART is available for those who are unable to conceive after surgery for common pelvic factors.
