INFERTILITY-OVERVIEW

What is Infertility?

In the simplest of terms, Infertility may be described as the inability to conceive despite conscious attempts.

However, as gynaecologists, we are more specific while defining Infertility. It is the inability to conceive even after two year of unprotected intercourse.

It is estimated that about 84% of couple conceive spontaneously within one year of unprotected intercourse while another 7% conceive over the next 12 months, such that the cumulative pregnancy rate is about 92% at the end of 24 months. Hence, it is justified to investigate apparently healthy, young couple after 2 years of inability to conceive.

 However, the time frame of two years is made less stringent if the couple are elderly (the woman more than 35 years) or either of them has a pre-existing problem. Example- the woman having polycystic ovaries or endometriosis or her partner having abnormalities of the semenal parameters.

What is not infertility?

Young, healthy couple who have not been able to conceive within 12 to 18 months of staying together.

Couple who are using contraceptives to avoid pregnancy, obviously!

Couple who have difficulty in their sexual performance. Example-Problems of erection or ejaculation in men and sexual aversion disorders in women.

Couple who are beyond the reproductive age.

Why is it important to define if a couple is or not infertile?

Without a set definition, we may unnecessarily be investigating many normal couple and of course, get credited for helping them achieve pregnancy... when in reality, they would have conceived anyway over the next few months!

However, branding a couple as infertile puts them under a great deal of mental tension. We all know that the hormones secreted in the brain play an important role in maintaining normal sexual cycles and hence stress may interfere with the normal functioning of the brain and secretion of hormones. The classical example quoted is that of many childless couple who, after years of trying, finally give up and adopt a child. As the stress of trying to conceive is lifted, many of them find that the woman has conceived spontaneously over the next few months!

With the advent of modern Medicine and methods, the treatment of infertility has become varied, complex and very individualistic. Treatment is often exacting in terms of money, time and interventions. Hence, it is always with great caution and consideration that a couple must be labeled as infertile.

The patient load on Medical personnel is also greatly reduced with proper definition and classification of Infertility.

Finally, despite all the modernization, Infertility often carries a social stigma, which is very traumatic, especially to the woman, affecting her mental well-being and curtailing her social activities.

Types of Infertility

Primary infertility is when the couple has been unable to conceive at all.

Secondary infertility is when the couple, irrespective of the outcome of pregnancy, has achieved pregnancy at least once. Example: Couple not able to have another child after years of their first or couple who have had at least one miscarriage is secondarily infertile.

Infertility can be also categorized as due to male factor or female factors or combined factors and finally, as unexplained Infertility (when no apparent cause can be detected in either partner)

Further, female infertility can be classified as due to Ovarian Cause (problems of inappropriate ovulation-production of eggs by ovary), Tubal cause (blockage or other diseases of the uterine tubes), Uterine causes, Hormonal causes and finally as due to Endometriosis (multiple cause)

Male factor infertility can be due to Semenal abnormalities (Complete absence of sperms-Azoospermia, reduction in sperm numbers-Oligospermia, insufficient motility of sperms-asthenospermia, abnormal physical characterisitics-teratospermia or a combination of these), Drugs(including tobacco, alcohol and cancer therapy), defective genes(as in Klinefelter’s syndrome or Cystic Fibrosis), Past infections of the testes(Mumps, tuberculosis), Auto immune conditions, exposure to irradiation or chemicals ;or certain medical disorders etc.

Combined factor infertility is when both partners have problems pertaining to fertility.

Unexplained Infertility or Idiopathic infertility is when all the tests in both the partners are apparently normal. Needless to say, with advancing investigative technologies the percentage in this category is expected to diminish.

Can infertility be classified as curable or correctable?

This is obviously an Ethical question. If the solution for infertility is having a child, then this can be most easily corrected by adopting a child! Only when pregnancy has been achieved after correcting the underlying medical condition, can infertility be technically termed to be ‘cured’!

Other Ethical and Social aspects in Infertility:

In India, it is very common for childless couple to resort to various religious practices in the hope of propitiating the Unknown to bless them with children.

Also, a vast majority of people believe childlessness is because of a defect in the woman only. The basic knowledge that it takes a man and a woman to make children is completely lost on them! Even educated families believe so and infertility is a very easily accepted reason-by both parties and families- for the man to re-marry! I know many women who are normal but have remained childless because their husbands refuse to be examined, or even have one Semen analysis done (Which if carried out at all, always shows that it is defective). Men have re-married hoping the second wife will conceive only to find out years later that they had no sperms in their semen!

Management and treatment of Infertility in the Allopathic field of Medicine scales new heights every hour! The IVF-ET (Test-tube babies) is so commonplace these days and scientists are looking at Designer babies now. Yet, even educated people resort to dangerous practices, believing it to be alternative medicine.

Ethically, many issues concerned with artificial reproduction (Like Donor insemination, surrogacy, egg/embryo donation) have not been addressed at all. This could lead to serious problems in later life for all the parties concerned.

In India, there is no authentic body responsible for the regulation and monitoring of the treatment of infertility and this has led to the abuse of advanced technologies by both patients and the treating doctors.

CONCLUSION:

It is therefore very important to recognize infertility, categorize it as best as possible and counsel the couple on all the possible ‘treatments’ and ‘cures’ available. Finally, treatment must be tailored to the needs of individual patient.

The patients, doctors and the families must acknowledge that management and treatment of infertility is unlike that of any other disease. Because the result impacts the lifetime of two generations, the society and the profession of the treating doctor.