Infertility, the inability to naturally conceive a child or to carry a pregnancy to term, is a common condition worldwide and the problem is thought to have increased over the last 30 years due mainly to the social phenomena of late marriages. According to a 1995 survey, infertility affects about 6.1 million women and their partners in the U.S., which constitutes about ten percent of its reproductive-age population. (“Frequently Asked Questions,” American Society of Reproductive Medicine). This research paper defines infertility in general and its cause, and explains its complications, treatment, side effects of treatment, and prognosis. In addition the paper includes the definition, cause, complications, treatment and prognosis of certain individual female and male factors of infertility.
Pathological Problems Associated with Infertility
Definition & Cause of Infertility: Infertility is usually defined as the failure of a couple to conceive a pregnancy after a year of unprotected intercourse or the inability to carry a pregnancy to a live birth; the period of one year being reduced to 6 months if the woman is over 35 years of age because there is a rapid decline in fertility after this age and help should be sought sooner. (“General Infertility FAQ,” 2006)
Causes of infertility include a number of physical as well as psychological factors. About one third of all infertility is attributable to a “female” factor, another one-third to a “male factor,” while the rest (one-third) of infertility cases may be caused by contributing factors from both partners or have unexplained causes.
Female factors may include causes such as endometriosis, ovulation problems such as polycystic ovarian syndrome (PCOS) and premature ovarian failure, hormone imbalance, uterine fibroid or polyps, ovarian cysts, pelvic inflammatory disease, sexually transmitted diseases (such as Chlamydia and gonorrhea), eating disorders such as anorexia nervosa, or other long-term diseases such as diabetes and autoimmune deficiency syndrome..
Male factors for infertility may include hormone deficiencies, low sperm count, impotence, retrograde ejaculation, sexually transmitted diseases, vericocel, cryptorchidism, exposure to environmental pollutants, or chemotherapy and other diseases such as mumps.
There are two types of infertility: primary infertility, in which pregnancy has never occurred and secondary infertility, in which one or both members of the couple have previously conceived, but are unable to conceive again after a full year of trying (Carson-DeWitt and Odle, 2006).
Infertility may also cause emotional and psychological problems in the childless couple. These include clinical depression, sexual dysfunction due to anxiety to conceive, and marital discord.
Treatment: Treatment for infertility depends on the exact cause of the problem, which may be a male factor, female factor or problem(s) in both members of the couple. The treatment could consist of education and counseling, precautionary measures, the use of medication, e.g., to treat infections and enhance fertility, and the use of surgical and other medical interventions such as in-vitro fertilization, artificial insemination, tuboplasty, laser surgery etc. Support groups for infertile couples are also an important source of comfort.
Side Effects of Treatment: The side effects of infertility treatment vary with the particular problem and the treatment being implemented. For example, one of the most common treatments for female infertility (the anovulation — or the inability to release an egg from the ovary) is by Clomiphene citrate (Clomid). The common side-effects of the medicine are: headaches, nausea and vomiting, hot flashes, bloating, abdominal pain, ovarian enlargement, insomnia, nervousness, and visual disturbances. (Musil, 1996) The typical side-effects of another common medicine (Leuprolide acetate) given for treatment of endometriosis are possible bone loss, hot-flashes, headache, insomnia, and vaginal dryness. Side-effects of surgeries for infertility, if carried out by qualified surgeons, are no different than most common surgeries for other ailments.
Prognosis Studies indicate that a cause can be determined for about 85- 90% of infertile couples. Appropriate therapy is successful in 50-60% of previously infertile couples without counting the success rate of advanced techniques such as in vitro fertilization. But even without any treatment, 15-20% of previously “infertile” couples eventually become pregnant. (Smith, 2006 — “Infertility.”)
Specific Male and Female Factors of Infertility
Female infertility accounts for one third of infertility cases, male infertility for another third, combined male and female infertility for another 15%, while the remainder of cases are unexplained. Some of the most common problems associated with female and male infertility, along with their definition, cause, comlications, treatment, and prognosis are given below:
Polycystic ovarian syndrome (PCOS)
Definition & Cause: The syndrome is a collection of symptoms that results in the non-release of mature eggs at the time of ovulation. The exact cause of PCOS is not known but genetic reasons and being overweight are thought to be responsible. Higher than normal luteinising hormone (LH) levels and constant follicle stimulating hormone (FSH) levels during the menstrual cycle prevent the eggs in the follicles from maturing and being released at ovulation. (Mallari, 2001)
Complications: An excess production of androgen and testosterone may interfere with the balance and function of the other hormones. Apart from infertility, overweight women with PCOS have an increased risk of diabetes, high blood pressure, sleep problems, and heart disease. (Tomlins, 2003, p. 70)
Treatment: Exercise and weight management program. Weight loss helps to restore hormone balance and menstrual periods. Treatment with medications that regulate the menstrual cycle and induce ovulation is also given. (Ibid.)
Prognosis: Once normal ovulation is restored, the PCOS patient has a chance of conceiving naturally.
Definition & Cause: It is a condition in which the ovaries produce only a very small number of eggs/follicles, or the egg/follicle supply is depleted much before the normal age of menopause. The condition has many causes including autoimmune disorders, pelvic surgery, chemotherapy and family history, but in some cases it occurs without any apparent reason. (Tomlins, 2003, p. 71)
Complications: Apart from irregular periods and their eventual complete disappearance, menopause-type symptoms, including hot flushes.
Treatment: Premature ovarian failure cannot be treated with drugs or hormones to induce ovulation because no eggs are present. However donor eggs or embryos can be used to conceive.
Prognosis: About 5% of women with the condition can hope for the resumption of spontaneous activity by their ovaries at some time in the future. The condition is relatively rare, and affects approximately 1 to 5 per cent of women under 40 who have no periods.
Definition & Cause: It is a condition in which the endometrium tissue starts to grow outside the uterus in other parts of the abdominal or pelvic cavities. The exact cause of endometriosis is not known but some theories suggest that genetics, immune system disorders, and delayed childbearing may be possible for the problem. (Martin, 2001 -“Endometriosis”: Treatment & Monitoring)
Complications: The condition can pain, affect normal ovarian function and, in more serious cases, can cause adhesions that block the fallopian tubes. Other complications include blood in urine, difficulty in urination, painful intercourse, nausea and vomiting.
Treatment: Hormones can control the growth of the endometriosis. Oral contraceptives and high doses of progestin may slow abnormal tissue growth. Danazol, a weak male hormone, can shrink cell growth but such treatment is only given to women who do not want to get pregnant. Laser surgery or laparoscopy is an option in severe cases. (Martin, 2001)
Side Effects of Treatment: Treatment with hormones may cause depression and irregular menstrual bleeding. They may also cause weight gain, headaches, and mood swings. Surgery may cause bleeding, infection, or allergic reactions.
Prognosis: Endometriosis recurs in 10% to 30% of cases. After surgery, pregnancy may occur in about 75% of those who had mild disease, 50% to 60% of those who had moderate disease, 30% to 40% of those who had severe disease. (Ibid.)
Uterine Fibroid or Polyps:
Definition & Cause: A uterine fibroid is a non-cancerous growth in the wall of the uterus and may range in size from microscopic to as large as a melon. The cause of uterine fibroid tumors is unknown. However, the growth of a fibroid depends on the hormone estrogen since as long as a woman with fibroids is menstruating, the fibroids continue to grow. (Smith, 2006)
Complications: Fibroids may cause infertility, premature delivery, severe pelvic cramping and pain, heavy menstrual bleeding (menorrhagia). In rare cases, cancerous changes may occur.
Treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are given for cramps or pain. Oral contraceptives are used to help control heavy periods and to stop the fibroid from growing. Iron supplements are given to prevent anemia. Hormonal therapy that reduces the production of estrogen is used to shrink the fibroids. Surgical procedures such as hysteroscopic resection of fibroids for women with fibroids growing inside the uterine cavity, uterine artery embolization for stopping the blood supply to the fibroids, and myomectomy a surgical procedure to remove the fibroids are also used
Side Effects of Treatment: Hormonal therapy may cause hot flashes, vaginal dryness, and loss of bone density. The usual risks associated with surgsery such as post-operative complications including infections.
Prognosis: Fibroids usually grow slowly. They sometimes block the fallopian tubes and prevent sperm from reaching and fertilizing eggs or may prevent a fertilized egg from implanting in the uterine lining. However, proper treatment may restore fertility. During pregnancy, existing fibroids may grow at a greater pace due to the increased blood flow and estrogen levels but they usually return to their original size after delivery.
Pelvic Inflammatory Disease
Definition & Cause: Pelvic inflammatory disease (PID) is a general term for infection of the lining of the uterus, the fallopian tubes. It is a very common disease and in the United States alone, nearly 1 million women develop PID each year and more than 100,000 women become infertile as a result of PID (NAID Fact sheet, 2005). It is caused in a majority of cases through sexually transmitted diseases such as Chlamydia and gonorrhea but PID-causing bacteria may also cause infection through other means such as during childbirth, abortion, or IUD insertion.
Complications: PID can damage the fallopian tubes, ovaries, uterus, and cervix, leading to chronic pelvic pain and serious damage to the reproductive system. The risk for infertility through adhesion or blockage of fallopian tube increase manifold with each episode of PID. It may also cause ectopic pregnancy — an abnormal pregnancy that occurs outside the uterus and in which the baby cannot survive.
Treatment through oral or intravenous antibiotics is usually effective for most types of PID. Hospitalization is sometimes necessary in severe cases for proper treatment. If the symptoms persist after such treatment or there are complications of PID such as chronic pelvic pain and scarring, surgery may be required. Prevention of PID is most important through abstinence, careful choice of sexual partners, and/or concurrent treatment of sex partners.
Complications of Treatment: There are no significant complications of treatment except that some bacteria that cause PID are resistant to antibiotics and complications of PID such as chronic pelvic pain and scarring are difficult to treat.
Prognosis: In a minority of cases (about 15% of cases), the initial antibiotic therapy fails, and about 20% of cases experience a recurrence of PID in future.
Low Sperm Count:
Definition & Cause: Low sperm count is the most frequent cause of infertility in men. The normal sperm count varies from 20 to 150 million sperm per milliliter of semen; hence any number significantly lower than 20 million may be defined as low sperm count. There are many biologic and environmental factors that can lead to low sperm count; these include aging, genetic factors, testicular exposure to high temperatures, exposure to chemicals such as lead, mercury, pesticides, industrial cleaning products, adhesives, and fertilizers or heavy metals, including aluminum, copper and selenium. Certain prescription medicines for depression, blood pressure, or ulcers also affect sperm production, which is usually reversible. Exposure to radiation or chemotherapy treatment for testicular cancer can also cause a low sperm count. (Tomlins, 2003, p. 86)
Complications: Possible infertility is the main complication of a low sperm count.
Injections with hormones is the basic treatment for low sperm count since abnormal levels of certain hormones such the follicle stimulating hormone (FSH) hinders the development of sperm in the testes or insufficient luteinising hormone (LH) affects the production of testosterone, which is needed to help maintain the sperm. Other treatments consist of changes in lifestyle such as getting regular exercise and maintaining a healthy weight, avoiding stress, avoiding hot baths and wearing of tight underwear, avoiding exposure to heavy metals and harmful chemicals. (Ibid 83)
Complications of Treatment: Hormonal treatment should be carried out only under the supervision of a qualified doctor.
Prognosis: Although a “low sperm count” may cause infertility but a man with a low sperm count can still father a child, naturally. Change in lifestyle can also improve sperm count.
Definition & Cause: Also called “male erectile dysfunction;” it is a condition in which a man cannot get or keep an erection long enough to have sexual intercourse. It is a common problem and about 25% of all men over the age of 65 suffer from some degree of impotence. (Sisson, 2001). Impotence can be caused by either mental or physical problems, or a combination of both. For example depression or some other emotional problem may affect interest in having sex. Physical problems include the way in which blood flows into the penis and is kept there during an erection. Diseases such as diabetes, high blood pressure, heart conditions, poor circulation, low testosterone, and injury can also cause impotence.
Complications: Although impotence is a cause of infertility because impotent men cannot have satisfactory sex with a woman, an impotent man who is unable to maintain an erection is still usually capable of producing sperm that could fertilize an egg. Emotional effect (feelings of inferiority) is another major complication.
Several treatment options are available for impotence. They include medicines taken by mouth, injections into the penis, vacuum devices, and surgery. Pills such as Sildenafil (Viagra), and vardenafil (Levitra) are popular remedies. Testosterone is prescribed if the problem is related to age. Other treatments include use of a vacuum pump or penile implant.
Side Effects of Treatment: Viagra and other impotence medications are harmful for men with heart condition and blood pressure especially for those who take nitroglycerin.
Prognosis: Impotence is treatable in most cases now and should not be a major barrier for fertility.
Definition & Cause: These are small varicose veins in the scrotum can affect the temperature of the testes, which in turn can affect the development of sperms. It occurs when the valves within the veins along the spermatic cord fail to work properly and the defective valves prevent normal blood flow and cause blood to backup in the veins. (Knowles, 2005)
Complications: Varicoceles are a common cause of infertility. May also cause pain an discomfort due to swelling. In older men, it may also be caused by a kidney tumor.
It can be managed with a scrotal support. In more serious cases, further treatment such as surgical removal, laparoscopic removal, and catheter embolization is done. (Ibid.)
Side Effects of Treatment: Possible complications of surgery in particular include blood clots, infection, or injury to the scrotal tissue. Injury to the artery that supplies blood the testicle is another possible side-effect of surgery.
Prognosis: A varicocele is usually harmless and usually requires no treatment. Even if surgery is required because of infertility or testicular concerns, the treatment is usually successful.
Carson-DeWitt, R., and Odle, T.G. (2006). “Infertility..” The Gale Encyclopedia of Medicine. Third Edition. Jacqueline L. Longe, Editor. 5 vols. Farmington Hills, MI: Thomson Gale, 2006.
Frequently Asked Questions About Infertility.” (2006). American Society of Reproductive Medicine. Retrieved on November 6, 2006 at http://www.asrm.org/Patients/faqs.html
General Infertility FAQ.” (2006). The InterNational Council on Infertility Information Dissemination (INCIID). Retrieved on November 6, 2006 at http://www.inciid.org/faq.php?cat=infertility101&id=1
Mallari, B. (2001). “Polycystic Ovarian Syndrome.” 3 RX.com. Retrieved on November 6, 2006 at http://www.3-rx.com/polycystic-ovarian-syndrome/default.php
Martin, E. (2001). “Endometriosis: Treatment and Monitoring.” 3-rx.com. Retrieved on November 6, 2006 at http://www.3-rx.com/endometriosis/treatment.php
Musil, J.D. (1996). “Infertility Treatments, Side Effects, and Cost.” Surrogacy.com. Retrieved on November 6, 2006 at http://www.surrogacy.com/medres/article/infertil.html
Knowles, D.R. (2005). “Varicocele.” Medeline Plus Medical Encyclopedia. Retrieved on November 6, 2006 at http://www.nlm.nih.gov/medlineplus/ency/article/001284.htm
Sisson, E.M. “Erectile Dysfunction.” 3-rx.com. Retrieved on November 6, 2006 at http://www.3-rx.com/erectile-dysfunction/default.php
Smith, M.N. (2006). “Infertility.” Medeline Plus Medical Encyclopedia. Retrieved on November 6, 2006 at http://www.nlm.nih.gov/medlineplus/ency/article/001191.htm
Tomlins, J. (2003). The Infertility Handbook: A Guide to Making Babies. Crows Nest, N.S.W.: Allen & Unwin.
Doctors recommend that couples who have known barriers to fertility, such as endometriosis, polycystic ovarian syndrome, male factor infertility, irregular cycles, etc., should not wait for such period(s) before seeking expert advice for infertility
Some publications put the figure attributable to females as 40% of all infertility
Vericocel are small varicose veins in the scrotum
Cryptorchidism is a condition in which the testes fail to descend into the scrotum of an infant
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