Infertility: General Considerations

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Chapter 32 Infertility: General Considerations

THE CHALLENGE

To assist couples who experience difficulty conceiving through normal means.

Scope of the Problem: The inability to conceive and bear children affects 8% to 18% of the American population. Under ordinary circumstances, 80% to 90% of normal couples conceive during 1 year of attempting pregnancy. Infertility is generally defined as failure to conceive after 1 year of regular, unprotected intercourse. Infertility may be further subdivided into primary and secondary types based on the patient’s past reproductive history; patients with infertility who are nulligravid are in the primary infertility group; those who have achieved a pregnancy more than 1 year previously, regardless of the outcome of that pregnancy, are grouped in the secondary infertility group. Slightly more than one half of infertility patients fall into the primary group.
Objectives of Management: To establish the relevant cause or causes and develop strategies that result in conception and delivery. With improved understanding of the physiology of conception and a wide range of technologies that may be brought to bear to assist with procreation, 85% of “infertile” couples may be helped.

TACTICS

Relevant Pathophysiology: The male partner brings to the union sperm-laden semen, which is deposited in the vagina during intercourse. The average ejaculate has a volume of between 1 and 15 mL and contains more than 20 million spermatozoa. The survival of sperm in the female genital tract is thought to be at least 96 hours and may be as long as 8 days. However, it is probable that sperm are capable of fertilizing an egg for only the first 24 to 48 hours after ejaculation. The woman’s gametic contribution, the oocyte, is released from the ovary during the mid-cycle process of ovulation, 14 days before the onset of menstruation, regardless of the total cycle length. Progesterone is produced by the luteinized follicle, producing a characteristic increase of between 0.5°F and 1°F in basal body temperature. The oocyte may be fertilized during the first 24 hours after ovulation only. Generally, fertilization takes place in the distal portion of the fallopian tube. Pregnancy does not result unless the zygote passes into the uterine cavity at the correct time (3 to 5 days after fertilization), encounters a receptive endometrium, and can successfully implant and grow.
Strategies: To achieve pregnancy, three critical elements must be in place: (1) a sperm must be available, (2) an egg must be available, and (3) the sperm and egg must meet at a time and place conducive to fertilization. It is the investigation of these three elements that constitutes the evaluation of the infertile couple.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Booklet AP136 (Evaluating Infertility), AP137 (Treating Infertility).

IMPLEMENTATION

Special Considerations: While the evaluation of infertility proceeds, couples should be instructed to continue to attempt pregnancy through intercourse timed to the most fertile days of the cycle. Between one third and one half of all infertility problems may be diagnosed in the first phase of evaluation. The medical definition of infertility differs from that of fecundity, which refers to the physical ability of a woman to have children. Women with impaired fecundity include those who find it physically difficult or medically inadvisable to conceive and those who fail to conceive after 36 months of regular, unprotected intercourse. In short, fecundity deals with childbearing ability and fertility deals with childbearing performance. When dealing with the question of infertility, establishing the diagnosis is not the problem; the problem is identifying the underlying pathophysiologic causes. Unlike most areas of medicine, the provider must deal with two patients at the same time because it is the couple that is infertile, not the man or woman. When the relative frequency of causes is considered, it is apparent that male and female factors are present in roughly equal proportion, with a small remainder that are idiopathic. This is important to keep in mind during counseling. The distribution of causes is also helpful in designing a logical and efficient strategy for the evaluation of the infertile couple.

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