What is Infertility?
Infertility is defined as the
incapacity to fulfil pregnancy after a reasonable time of sexual
intercourse with no contraceptive measures taken. It implies a
deficiency that does not compromise the physical integrity of the
individual, nor is it life-threatening. It may negatively impact the development
of the individual, bringing about frustration and weakening the personality,
since most couples consider having children as a vital
objective. Infertility is a common problem affecting one couple in six.
Fertility efficiency in
human being
As compared to other species,
the human being is highly inefficient in terms of reproduction. The fertility
rate per cycle is about 20% and the accumulated pregnancy rate in couples with
proven fertility is ~90% after 12 months and 94% after 2 years. Delayed
childbearing, alterations in semen quality due to habits such as cigarette
smoking and alcohol, changes in sexual behaviour and eliminations of most
taboos are some of the modifiable factors of infertility. The study of
infertile couple has always been focussed on different factors: ovulatory
factor (present in about 20% of couples), utero-tubal peritoneal factor
(present in ~30% of couples), semen migration factor (10% of cases) and male
factor (30% of couples). Around 40% of all infertile
couples exhibit a combination of factors and about 15 % of couples may not
display any objective alteration leading to a definite diagnosis.
Waiting period for
conception
Fecundity is the probability
of becoming pregnant in one particular menstrual cycle and is about 20%,
depending on the age of the woman. This entails that the average time to
develop pregnancy is around 4 months. The concept of
"reasonable time" is debatable; the World Health Organisation (WHO,
1992a) as well as the European Society of Human Reproduction and Embryology
(ESHRE, 1996) in their
recommendations mention a 2year minimum deadline for developing pregnancy. Most physicians initiate
study of an infertile couple following 1 year of failed pregnancy attempts. When
the woman is >39 years, it might be advisable to begin the study after 6 months of
unsuccessful attempts. The waiting time should be related to the age of the
woman, the history of alterations that affect fertility, the desires and wishes
of the couple.
Delayed decision for
pregnancy and the consequences
There is an increase in the
number of visits to infertility clinics in the last few years. This may be due
to increased awareness and declining fertility. The average age at which women
wish to become pregnant has increased due to postponement of the decision about pregnancy. Marital
instability like divorce and seeking stability with new partners implies waiting longer before
making the decision to have any children.
Alterations in semen quality
can influence the need for advice on infertility. Habits such as cigarette
smoking and alcohol abuse are harmful for semen quality. There have been
changes in sexual behaviour like changing partners and use of proper contraception
among younger couples. This may lead to higher incidence of sexually
transmitted diseases (ST) to tubal–peritoneal infections that have consequences
for fertility. Elimination of most taboos about fertility results in a higher
frequency of visits by couples to the doctor.
A desire to become pregnant
at ~40 years of age does not only entail a low possibility of success, but
also an increased risk of developing maternal pregnancy ailments such as
pre-eclampsia, hypertension and diabetes, as well as foetal chromosomal abnormalities and
miscarriages.
The negative effect age has
on the ovum is mainly its inefficacy to complete a normal first meiotic
division and perhaps adequately to start the second meiosis In addition to ovum quality,
age also affects the number of follicles available for ovulation.
In addition to age, other
factors also affect follicular availability, such as genetic factors, chromosomal abnormalities,
autoimmune diseases, smoking, ovarian surgery, endometriomas, chemotherapy,
radiation therapy, pelvic adhesions, chlamydia exposure, and others. Many men with normal seminal parameters
are infertile due to defects in the spermatic function. Several conditions are known
to invoke alterations in the amount and quality of the sperm sample.
These include varicocele, genital infections, trauma, surgeries, gene
dysfunctions, toxic substances, etc. This situation occurs in about 30% of
couples. Around 40% of all couples who seek help for infertility usually exhibit
a combination of factors; i.e. a female factor combined with a male disorder.
Approximately 15% of couples,
even when all the above factors have been considered, may not display any
objective alterations leading to a definite diagnosis. They are then
classified as patients with
unexplained infertility, at least at the time of the diagnosis.
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