Infertility

Sam Thatcher MD, PhD,
Director Center for Applied Reproductive Science Johnson City TN & Asheville NC

The material within represents an opinion offered by Dr. Thatcher alone for the purpose of stimulating thought and discussion. This material is not intended to replace, define, or dictate standard of care. Material is for personal use only. Permission for other use must be obtained from the author.

Infertility Demographics and Epidemiology

The traditional definition of infertility is twelve months of unprotected sexual intercourse without establishing a successful pregnancy. This definition was derived in studies showing that 90% of couples will achieve a pregnancy during that period. Approximately 50% of otherwise healthy reproductive age women should be pregnant in the first three or four months of attempts.

About 70% should be pregnant by six months and of the remaining 10% not pregnant after twelve months, still about one third will become pregnant in the following two years. It is, however, an injustice to our patients not to discuss of fertility at routine health visits, or to wait a year before starting education and counseling.

It seems perfunctory to begin any discussion of infertility by stating that about one in six American couples is infertile. The true incidence of infertility is not known. It is estimated that over 50% of infertile couples never seek therapy. When taking medical histories for problems unrelated to infertility, it is commonplace to hear of years of attempts before a pregnancy is successfully established or in between pregnancies.

A useful exercise is to imagine 50% of the couples with no children are childless not by choice. It has been debated whether the incidence of infertility is increasing. Certainly, two trends may add to a definite increased risk of infertility. The first of these is that the number of sexual partners has increased and with this, the risk of pelvic infection and subsequent tuboperitoneal disease.

The second of these is delayed child bearing. Many women are postponing childbearing until the late 20s to late 30s while other life objectives are met. Maximum female fertility occurs in the mid-twenties at a time when menstrual cycles are most regular and ovulatory. Before age 20 and after age 30, fertility is slightly decreased and individuals under over age 37 are much less fertile. Presently, age forms our largest barrier to successful fertility therapy.

The Infertility Mind Set

There are several mistakes commonly made in the approach to the infertile or potentially infertile couple. The first is to assume that young couples are still "kids" and that there is plenty of time to start a family. Once it has been decided that a pregnancy is desired, it becomes a foremost and very pointed pursuit. The strength of this desire is unrelated to age, social class, or etiology of the infertility.

A second mistake has been a dismissal by physicians of patients who want to discuss the possibility of infertility even though they have only tried for several months. "Go home and relax there is plenty of time" is never an answer. There is no time too soon to discuss the basics of the normal menstrual cycle and ovulation testing. If a specific history is obtained of menstrual cycle irregularity, potential male factor, or if the female partner is over age 35, there should be no delay in the first stages of an infertility investigation.

Assume that women over 35 have a significant decrease in their fertility. Assume that women with cycles over thirty-five days apart are not ovulating well and that it is a waste of time to spend in detection of ovulation. When to begin therapy or intensive investigation is related to each individual case.

Although not universally true, many couples can be comforted by knowing that infertility in women under age 38 is imminently treatable. Education and information can be significant stress reducers. Men and women handle the stress of infertility differently. Women may become so preoccupied with their fertility that it is the first thing thought of arising in the morning and the last thing before sleeping at night. It will often seem that every other female with whom she comes in contact is pregnant, or has recently had a child.

This is often translated into "pregnant women are successful and I'm a failure." There is a feeling of helplessness and hopelessness often with self-imposed isolation. Males typically address the fertility issue differently, but it is a mistake to believe they are ambivalent or do not have very strong feelings about childbearing. Women are often the first to want to become pregnant, first to seek therapy and first to want to move to aggressive therapy. If a woman is told that she doesn't ovulate, she will say "fix it," while a male who is told his sperm count is low may have an emotional meltdown.

Men often identify semen parameters with potency and potency with virility. Some couples will rebuke any attempt at any intervention on the psychological and emotional aspects of therapy. Some will seek to compensate by learning every new technique and the possibility of therapy.

Psychological services are becoming increasingly and specifically available for infertile couples. These may take the form of a psychologist or support group. Very often infertility patients are using the Internet where they correspond with numerous individuals and may participate in chat rooms. It is impossible to know of the toll that stress takes on infertility. Stress itself has not been shown to conclusively alter success rates. However, reduction of stress can easily be translated in reduction of emotional suffering and therefore it should be a therapeutic goal.

 

 

    

 

    


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