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Resource Description: 
The American Fertility Association (AFA) is a national consumer organization that offers support for men and women dealing with infertility. Their purpose is to educate the public about reproductive disease, and support families during struggles with infertility and adoption.
An organization for "the advancement of the art, science, and practice of reproductive medicine," the American Society for Reproductive Medicine (ASRM) facilitates and sponsors public educational activities for professionals who are engaged in the practice of and research in reproductive medicine. The Society Web site includes answers to frequently asked questions on infertility, downloadable information booklets, statistics on the success of assisted reproductive technologies and links to doctors and adoption sites.
This site includes the 2005 Assisted Reproductive Technology (ART) Success Rates Reports
This nonprofit organization helps individuals and couples explore family building options. The organization's Web site includes up-to-date information on the diagnosis, treatment and prevention of infertility and pregnancy loss and offers guidance to those considering adoption as well as childfree options.
See: 18 Ways to Make a Baby Fertility Throughout Life
RESOLVE: The National Infertility Association, established in 1974, is a non-profit organization. The site includes comprehensive information on the broad range of fertility issues, including diagnosis, treatment, costs and coping.
The Society for Assisted Reproductive Technology (SART) promotes and advances the standards for the practice of assisted reproductive technology to the benefit of patients, members and society at large.
Episode number: 
308
Transcript: 
Fertility (transcript)

There's been a revolution in the field of reproductive medicine during the second half of the 20th century – first to help couples prevent conception and then to help them achieve it. 

Advances, especially in preventing unwanted pregnancies, have been hugely successful and have allowed us to feel a heightened sense of control.  We talk about "family planning" and take it for granted that we'll be able to reproduce at the time of our choosing.  Yet, figures from the American Society for Reproductive Medicine reveal that up to one in ten Americans will experience infertility at some point during their reproductive years.  This gap between perception and reality is significant.  For people to make fully informed family planning decisions, they need a clear understanding of all the issues that can affect fertility over the course of their lifetimes. 

Conception and successfully carrying a baby to term is a complex process.  It's dependent on sufficient numbers of healthy sperm traveling through open pathways so one can penetrate a healthy egg.  The fertilized egg must implant itself in the lining of the uterus and the uterine environment must remain hospitable for the egg to develop.  When any one of these factors is impaired, infertility can result.

What is infertility?  Physicians define infertility as the inability to conceive a child despite trying for one year.  The definition also applies to women who are able to get pregnant but then have repeat miscarriages. 

Infertility is not necessarily synonymous with sterility. There are degrees of infertility with the majority of infertile couples actually being sub-fertile, meaning they produce eggs and sperm but have difficulty conceiving.  A diagnosis of infertility means that becoming pregnant may be a challenge but not impossible. Being sterile means you're unable to conceive a child because no eggs or sperm are produced.  

Infertility may be temporary or permanent, depending on the cause and available treatments to correct it. It may be due to factors affecting the woman, the man, or both.  It may be due to a single cause or a combination of factors. In some cases, a specific cause can't be identified. No one can be blamed for infertility any more than anyone is to blame for having allergies or ulcers.

Treatment for infertility may range from simple education and counseling, to the use of medications that treat infections or promote ovulation, to highly sophisticated medical procedures such as in vitro fertilization.

New advances in medical technology are being envisioned and realized every year, giving hope to more couples.  These same advances are also raising troubling questions about ethical and legal issues – like genetic enhancement and sex selection, the fate of unused embryos, the consequences of multiple births and the changing nature of the family.

 

Quick Facts

  • A cause can be determined for about 85 to 90 percent of infertile couples.

  • Without any treatment intervention, 15 to 20 percent of couples previously diagnosed as infertile will eventually become pregnant.

  • More than half of couples who seek infertility treatment get pregnant without advanced techniques such as in vitro fertilization.

  • Assisted reproductive technology (ART) success rates are highly dependent on the age of the woman.  A 2003 Centers for Disease Prevention report showed the average percentage of ART cycles that led to a healthy baby were as follows:
    • 37.3% in women under the age of 35
    • 30.2% in women aged 35-37
    • 20.2% in women aged 37-40
    • 11.0% in women aged 41-42

  • Pregnancy rates begin to decline slowly, beginning in the early 30s.  Throughout the late 30s and early 40s there is an even greater decline in pregnancy rates.  Only 2 percent of babies are born to women over the age of 40.

  • 25 percent of couples have more than one factor contributing to infertility.

  • Even if a woman has successfully conceived before, she might have fertility issues later in life.

  • Infertility problems can be attributed to both the female and the male in roughly the same proportion.

  • Age is the single most important factor in whether a woman can conceive and deliver a baby.

  • In men, injury to the testicles or tubes which carry sperm are common reasons for male infertility.

  • Sexually transmitted diseases can cause both female and male infertility.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

  • What diagnostic tests do you recommend? What is the likelihood that they will yield a diagnosis?

  • Are there risks associated with the testing?

  • What is my (or my partner's) diagnosis?  How does this condition specifically interfere with fertility?

  • Might this condition change over time?  How?

  • How likely is fertility treatment to be successful for me?

  • What types of treatments should I consider?  What are the risks and success rates for each?

  • Which treatment do you recommend for me?

  • In your practice, how often does this treatment result in a live birth?  What is the national success rate?

  • What does treatment cost? Does my insurance cover any of the medications, hospital charges, or doctor's visits? If I must pay out-of-pocket, do you offer any special payment plans?

  • What is your training in infertility? Are you board certified as a reproductive endocrinologist?

  • Can you put us in touch with former patients who have undergone similar treatments?

Key Point 1

Having difficulty getting pregnant can have many causes – some of them you cannot change, such as age, and some of them you can change.  If you want to get pregnant, the first step is working with your doctor to find out what your fertility issues are. 

Throughout history, failure to conceive was assumed to be a problem with the woman. We now know that's not the case as infertility problems are no more common in one sex than the other.  About 30-to-40 percent of infertility is diagnosed as a female problem, 30-to-40 percent as a male problem, 10-to-20 percent related to both and the remainder remains unknown. 

Couples are generally advised to seek medical help if they've been unable to conceive after having regular, unprotected intercourse for at least one year.  Women and men are usually advised to consult with a doctor sooner if:

 

Women

Men

  • Are over 30
  • Have a history of irregular or painful menstrual cycles – or haven't had a menstrual flow for longer than six months
  • Have had pelvic pain, endometriosis, pelvic inflammatory disease or repeated miscarriages
  • Have a low sperm count
  • Have a history of testicular, prostate or sexual problems                     



Risk Factors for Infertility
Risk factors include:

  • Age.  Women's fertility generally begins to decline much earlier than we think. Peak fertility occurs during the early 20s, begins to decline in the early 30s and accelerates after age 35.  Few unassisted pregnancies are recorded after the age of 45.  It's estimated that up to 1/3 of couples over 35 won't be able to have a successful pregnancy without assistance.  As women age the quality and quantity of eggs that remain in the ovary decrease while their chances of having health problems that may interfere with fertility increase.  A gradual decline in fertility is possible in men older than 35, too.  While the changes may not be as clearly defined as they are in women, age 50-and-over males often may find a decline in their quality of sperm, and sometimes discover a slight drop in testosterone levels and a dwindling libido.

  • Weight extremes and poor nutrition. Being overweight or underweight can affect hormone production.  Infertility problems can be caused by a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid.

  • Alcohol, tobacco and street drugs. These substances may impair your ability to conceive or produce a healthy child. Miscarriages are more frequent in women who smoke.  Men who smoke may have a lower sperm count than do those who don't smoke.

  • Prescription and over-the-counter medications.  Both prescription and nonprescription drugs can decrease your chance of getting pregnant or maintaining a pregnancy.

  • Excessive exercise. Very intense exercise can cause menstrual irregularities and even amenorrhea (having no periods at all).

  • Emotional stress. It's believed that stress may interfere with certain hormones needed to produce sperm and healthy eggs. 

  • Environmental factors. Exposure to toxins and chemicals can reduce reproductive function by altering the hormonal system.

Diagnosing Infertility
Identifying a cause for a couple's infertility is key to recommending treatment. Both partners are involved in the process and the cause may be linked to either the man or woman or both.  

Common infertility problems in women include:

  • Tubal disease and damage.  This accounts for approximately 1/3 of all causes of infertility in women.  Damage to the fallopian tubes can be caused by inflammation as a result of viral or bacterial infections, some types of sexually transmitted diseases, or complications of surgery.

  • Ovulation disorders.  Hormone imbalances, the presence of cysts or tumors and ovarian failure can cause infertility in women. 

  • Uterus and cervical disorders.  These include uterine fibroids or polyps, endometriosis, abnormalities in the shape of the cervix or changes in the properties of the cervical mucus.

Common infertility problems in men include:

  • Low sperm volume.  A normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of less than 20 million sperm per milliliter of semen indicates low sperm concentration.  Low sperm volume may be caused by undescended testicles, testicular injuries and testosterone deficiency but, in many instances, no cause for reduced sperm production is found.

  • Low sperm motility.  If movement (motility) is impaired, sperm may not be able to reach the egg.

  • Abnormal sperm.  If the shape and structure of the sperm are abnormal, a sperm may not be able to penetrate an egg.

  • Sperm antibodies.  Some men produce antibodies to their own sperm, which prevent the sperm from penetrating the egg.

  • Blockage of sperm delivery ducts.  Blockages can be a result of a birth defect, vasectomy, infection and some sexually transmitted diseases.

  • Retrograde ejaculation. This occurs when semen enters the bladder during orgasm rather than emerging out through the penis and may be caused by diabetes, bladder, prostate or urethral surgery, and the use of psychiatric or antihypertensive drugs.

  • Varicocele. This is a varicose vein in the scrotum that may prevent normal cooling of the testicle and raise testicular temperature, preventing sperm from surviving.

  • Previous vasectomy. Although surgery to reverse vasectomies is possible, risks are involved that could affect fertility in other ways.
    

Key Point 2

Assisted reproductive technology can be successful.  However, it is not a cookie cutter approach, and it is not guaranteed.  Your best treatment option will depend on your specific fertility issue, your age and your overall health.

Both infertility testing and treatment can be long, complicated and very emotional processes.  Couples need to be aware of all the implications up front so they can understand the commitment they will need to make.  Tests may reveal a cause right away and the solution may be relatively simple.  On the other hand, diagnosis may extend over several months and treatment, at its most extreme, over several years.  Evaluation and treatment is usually expensive and may involve uncomfortable procedures and even surgery.  Costs are not covered by many insurance plans. Finally, there's no guarantee that conception will occur in the end.

A variety of causes can produce infertility, each with its own treatment and each with its own chance of success.  As options increase from the most simple to the most sophisticated assisted reproductive technologies, the rate of success for couples seeking treatment is going up. 

Infertility treatment success is defined as the birth of a healthy infant.  Here are some commonly quoted statistics:

  • A cause can be determined for about 85 to 90 percent of infertile couples.

  • Without any treatment intervention, 15 to 20 percent of couples previously diagnosed as infertile will eventually become pregnant.

  • More than half of couples who seek infertility treatment get pregnant without advanced techniques such as in vitro fertilization.

  • Assisted reproductive technology (ART) success rates are highly dependent on the age of the woman.  A 2003 Centers for Disease Prevention report showed the average percentage of ART cycles that led to a healthy baby were as follows:
    • 37.3% in women under the age of 35
    • 30.2% in women aged 35-37
    • 20.2% in women aged 37-40
    • 11.0% in women aged 41-42

Doctors usually start the evaluation process with physical exams and health and sexual histories. In some cases, they uncover an obvious problem that can be easily corrected – such as the couple's use of lubricants that are toxic to sperm or simply poorly timed intercourse.  They investigate sexual issues such as sexual technique, problems with erectile dysfunction, premature ejaculation or painful intercourse, and psychological or relationship issues that contribute to problems with intimacy.  They then proceed to more specific evaluations such as semen analysis, confirmation of ovulation and more.

Once doctors have a specific diagnosis they can recommend appropriate treatments from medical therapy to reproductive surgery to intrauterine insemination to assisted reproductive technology. 

  • Medical therapy.  Fertility drugs are the primary treatment for women who are infertile due to ovulation disorders.  These medications regulate or induce ovulation.  Fertility drugs significantly increase the chance of multiple births. 

  • Surgical therapies.  Blockages or other physical damage in both the man and woman can often be surgically repaired.

  • Assisted reproductive technology (ART).  IVF (in vitro fertilization) is the most common and the most effective ART and is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm.  Other techniques such as ICSI (intracytoplasmic sperm injection), ZIFT (zygote intrafallopian transfer), and GIFT (gamete intrafallopian transfer) may also be used.  ART procedures sometimes involve the use of donor eggs, donor sperm, or previously frozen embryos.
    

Key Point 3

While assisted reproductive technology gives hope to couples who otherwise could not conceive a child, there are many factors to consider such as ethical decisions you may have to make, financial investment, the time it may take to conceive and the stress on a relationship.   

Embarking on the path of assisted reproductive technology is not for the faint of heart.  People must navigate a whole myriad of difficult issues, not the least of which is its emotional toll.  It can be a roller coaster of hope and disappointment.  The resulting stress can negatively impact everything – a couple's general health, their job performance, and even their marriage.  Most couples can benefit greatly from ongoing counseling and participation in support groups.

The costs can be high financially as well as emotionally.  Costs for vitro fertilization (IVF) can range from $5,000 to $15,000 – and up. And it's difficult to make financial decisions in the midst of emotional turmoil.  However, while costs can be substantial, they can be managed when couples do their homework and create a plan.  The steps they can take include:

  • Learning all they can about treatment
  • Analyzing their finances
  • Learning the ins and outs of insurance
  • Investigating sources of funding
  • Making decisions early on about how far they are willing to go
  • Investigating the alternative of adoption

Finally, couples need to be aware of the physical and ethical issues that come up during and after treatment. 

There are physical risks to many of the procedures.  If surgery is required, there are all the normal risks associated with it.  Ectopic pregnancy (a pregnancy in the fallopian tube or outside the uterus lining) is possible.  Some preliminary studies have suggested that fertility drugs may lead to an increased risk of ovarian cancer.  Women carrying multiple pregnancies are more likely to need to spend weeks or months in bed and are more likely to miscarry or give birth prematurely.

Ethical issues, in particular, can be devastating for couples to face.  For instance, when multiple babies are conceived, it may become necessary to remove one or more fetuses to improve the survival odds for the others.  Sometimes "extra" embryos are cryopreserved for later use but are not needed.  What are the ethics and emotional repercussions of disposing of something that has the potential to become human life?  Couples who are considering infertility treatment need to discuss these possibilities and others before starting treatment. 

Complex moral and societal questions are being asked and debated by lawmakers, scientists and religious leaders alike.  

  • Is infertility a disease?  And if so, should treatment be covered by medical plans?
  • What counts as fair and equitable access to infertility treatment?  Should it be available only to those who can afford it?
  • What is the moral status of a human embryo?  

As is often the case with advances in technology, the scientific strides made in infertility treatment will continue to raise dilemmas of policy, law, regulation and philosophy that have never before faced humankind.

Medline Plus

Medline Description: 

Conduct an off-site search for Fertility information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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