* Infertility often involves both members of a couple.
* STIs are the primary preventable causes of infertility.
* Postpartum and postabortion infections are also associated with
infertility.
* Contraceptive use does not cause infertility.
Infertility is complex. It has multiple causes and consequences
depending on the gender, sexual history, lifestyle, society, and
cultural background of the people it affects.
Partly due to its complexity and to difficulty preventing,
diagnosing, and treating it, infertility is a global public health
concern. More than 80 million people--about 8 percent to 12 percent of
all couples worldwide (1)--are or have been infertile. Although
infertility is considered by some to be primarily a woman's
problem, men often contribute to and are also affected by it (see
article, page 17).
"Infertility is not really an issue of either partner,"
says Dr. Timothy Farley, previously a member of the World Health
Organization (WHO) Task Force on Diagnosis and Treatment of Infertility
and currently coordinator of the Department of Reproductive Health and
Research at WHO. "Infertility is an issue of the couple."
Infertility arises when either one or both members of a couple are
sterile or have severely reduced fertility. Sterility of one partner
will always render the couple infertile. But subfertility, or reduced
fertility, is more complicated. Subfertility in both partners is likely
to lead to infertility, but subfertility in one partner may or may not,
depending on the overall combined fertility of the couple.
A couple is considered clinically infertile only when pregnancy hasnot occurred after at least 12 months of regular sexual activity withoutthe use of contraceptives. At the teaching hospital at the University ofIbadan in Nigeria, gynecologist and senior lecturer Dr. AyodeleArowojolu, who is also a former FHI fellow, says that clients arediscouraged from seeking infertility services until they have failed toconceive for an entire 24 months.
"Clinicians implement these waiting times because otherwise
they would be inundated with people who have subfertility problems for
which little or nothing needs to be done," says Dr. Farley.
Research has shown that many couples seeking infertility treatment are
actually subfertile and may eventually become pregnant without any
intervention. In an evaluation and two-year follow-up of 455 couples
attending an infertility clinic in Chandigarh, India, 14 percent of the
couples became pregnant before treatment even started and another 10
percent before treatment was completed. (2) Two studies from developed
countries have shown even higher rates of pregnancy--35 percent in one
(3) and 72 percent in the other (4)--among 548 and 342 untreated
subfertile couples, respectively.
Preventable causes
Many factors--infectious, environmental, genetic, and even dietary
in origin--can contribute to infertility (see table, below). (5) But
this list includes factors that produce subfertility, which may not
ultimately prevent conception or may subside. An important question,
then, is which of these are the major causes of infertility that likely
will not reverse without clinical intervention.
Between 1979 and 1984, the WHO Task Force on Diagnosis and
Treatment of Infertility supported an evaluation of 5,800 couples who
completed a standard diagnostic work-up for infertility at 33 medical
centers in 25 countries throughout the developed and developing world.
(6) Although the results may not be applicable to all populations, this
was the largest epidemiological study of its kind, providing
unparalleled data on the major causes of infertility.
Results showed no known cause for up to 14 percent of the couples.
But in all regions of the world, the largest proportion of remaining
diagnoses could be attributed to infection. In particular, women who
reported a history of sexually transmitted infections (STIs) had higher
rates of infertility than women who did not. (7)
In fact, STIs are recognized as the most common preventable causeof tubal infertility (see article, page 12). Such STIs as chlamydial infection or gonorrhea in the lower genital tract can ascend into theupper genital tract, causing pelvic inflammatory disease (PID) that canproduce inflammation, scarring, and eventual blockage of the fallopiantubes. ( cool
The WHO study also showed that in every region of the world, a
history of postpartum or postabortion complications was associated with
blockage of both fallopian tubes. In addition, the percentage of women
with both fallopian tubes blocked generally increased if the women had
even ever been pregnant, given birth, or had an abortion, regardless of
whether complications occurred. (9)
Unsafe obstetric practices during delivery or abortion could
introduce new infections that can lead to PID or other problems that
hinder conception. Many cases of infertility after delivery or abortion
may, however, still be due to STIs. If a woman has gonorrhea or
chlamydial infection during pregnancy, her estimated risk of PID
increases 50 percent to 100 percent if she either gives birth or has an
abortion. (10) In these cases, instruments used during obstetric
procedures could carry existing infections into the upper genital tract.
Knowledge and misconceptions
In many cultures, infertility is considered a shameful condition,
something that is not freely discussed. So, not surprisingly, many men
and women either do not know or still have misconceptions about the true
causes of infertility.
Dr. Silke Dyer is the director of infertility services at Groote
Schuur Hospital, a large public tertiary care hospital in Cape Town,
South Africa. "I've begun asking almost all of my patients
'Now why do you think you're infertile?' and many of them
just shrug their shoulders," she says. "So I think they truly
do not know."
Dr. Arowojolu, the gynecologist from the University of Ibadan,
Nigeria, agrees that many patients do not understand what is causing
their fertility problems. "There is also a lot of mystique
surrounding infertility," he says. Because childbearing is viewed
as a natural part of adult life, some have explained infertility as
supernatural. It has been labeled an act of God, a punishment from
unhappy ancestors, or the result of witchcraft. In an urban slum area of
Bangladesh, nearly half of 120 men and women surveyed said evil spirits
caused female infertility. (11)
Another common misconception--that some forms of contraception
cause infertility--may be a powerful disincentive to contraceptive use.
(12) Group interviews with men and women in Cameroon's North West
Province revealed that contraception was thought to "spoil the
womb" and that young, less-educated women were particularly
unlikely to use contraception as long as they felt susceptible to
infertility. (13) In southwest Nigeria, study participants also
suggested that contraceptives can damage the uterus, leading to
infertility. (14)
Even family planning providers sometimes misunderstand the effects
of contraceptives on fertility. In an FHI study in Ghana, many of 97
providers interviewed said they used age or parity requirements to
ensure that only women of proven fertility obtained contraceptives,
mainly because they believed that hormonal methods delay fertility or
cause infertility. (15)
Because contraceptives prevent pregnancy, they may mask underlying
fertility problems, but they do not cause infertility. The risk of
long-term impaired fertility after using any contraceptive method is
low, and fertility usually returns immediately or shortly after
contraceptive discontinuation (see table, this page). (16) In fact, by
preventing unintended pregnancy and thus the potential for either
postpartum or postabortion infections, all contraceptives can help
prevent infertility and improve the chances that women will become
pregnant when they choose to do so.
Expectations
While many couples do not know the true causes of infertility, the
consequences are often apparent, especially for women in the developing
world. Grief and frustration, guilt, stigmatization and ridicule, abuse,
marital instability, economic deprivation, and social ostracism are just
some of the consequences that have been reported in various parts of
Asia and Africa. (17)
Many of these consequences are personal, but others are societal.
Throughout the world women are expected to bear children, but these
social pressures can be particularly intense in parts of the developing
world where voluntary childlessness is rare and opportunities for women,
aside from motherhood, are few. In hopes of becoming pregnant, some
women who consider themselves infertile may even engage in extramarital relations, a behavior that places them at risk of STIs, including HIV.
(1 cool
Clinicians should be aware that infertile couples also have their
own expectations. Dr. Dyer and colleagues from Groote Schuur Hospital,
the University of Cape Town, and South Africa's Medical Research
Council recently conducted research aimed in part to identify
clients' expectations of infertility clinics. The research included
a quantitative study of 120 women and a qualitative study of 30 women.
All were visiting the Groote Schuur Hospital's infertility clinic
for the first time. (19)
When the women were asked about their expectations, three main
themes emerged: hope to conceive; hope to receive information about if,
when, and how they could conceive; and uncertainty about what to expect.
Some women also had unrealistic expectations. Nearly half of the 120
women in the quantitative study thought they would definitely conceive
by attending the clinic, and more than one woman from the qualitative
study thought that she would be pregnant by the end of her first visit.
"Very often infertility services focus mostly on pregnancy
rates, but this research shows us there is a definite role of
infertility care beyond achieving pregnancy," says Dr. Dyer.
"Not everyone is going to conceive, and not everyone will
ultimately be able to access the kind of therapy they want. So,
particularly in communities like ours, there is a separate aim. And that
is providing information, counseling, and empathy."
Factors Contributing
to Infertility
Anatomical problems
Endocrinological problems
Genetic problems
Immunological problems
Increasing age
Infectious and parasitic diseases
Genital tuberculosis
Malaria
Schistosomiasis
Malnutrition
Potentially harmful substances
Aflatoxins
Arsenic
Pesticides
Tobacco, alcohol, or caffeine
Reproductive tract infections
Postabortion infections
Postpartum infections
Sexually transmitted infections
Contraception and Return to Fertility
Contraceptive Method Time to Return of Fertility
Abstinence immediate
Condoms (male and female) immediate
Female barrier methods,other than condoms immediate
Implants immediate
Injectables
Combined monthly immediate
Progestin-only
Depot-medroxyprogesterone acetate average 10 months
(DMPA)
Norethisterone enanthate (NET-EN) average 6 months
Intrauterine devices immediate
Oral contraceptives * immediate
Sterilization no return to fertility
* Although return to fertility may be immediate, a delay of a few
months has been observed in several studies.
Note: Because all contraceptives protect against pregnancy, they also
protect against postpartum and postabortion infections that are
associated with infertilty.
Source: World Health Organization. Improving Access to Quality Care in
Family Planning. Medical Eligibility Criteria for Contraceptive Use.
Geneva, Switzerland: World Health Organization, 2000.
References
(1) Program for Appropriate Technology in Health (PATH).
Infertility. Overview/lessons learned. Reproductive Health Outlook 2002.
Available: http://www.rho.org/html/infertility.htm.
(2) Khaliwal LK, Khera KR, Dhali GI. Evaluation and two-year
follow-up of 455 infertile couples--pregnancy rate and outcome. Int J
Fertil 1991;36(4):222-26.
(3) Collins JA, Wrixon W, Janes LB. Treatment-independent pregnancy
among infertile couples. N Engl J Med 1983;309(20):1201-6.
(4) Snick HK, Snick TS, Evers JL, et al. The spontaneous pregnancy
prognosis in untreated subfertile couples: the Walcheren primary care
study. Hum Reprod 1997;12(7):1582-88.
(5) Program for Appropriate Technology in Health (PATH).
Infertility in developing countries. Outlook 1997;15(3):1-6;
Mascie-Taylor CGN. Endemic disease, nutrition and fertility in
developing countries. J Biosoc Sci 1992;24(3): 355-65; Hassan MA,
Killick SR. Effect of male age on fertility: evidence for the decline in
male fertility with increasing age. Fertil Steril 2003;79(Suppl
3):1520-27.
(6) Cates W, Farley TM, Rowe PJ. Worldwide patterns of infertility:
is Africa different? Lancet 1985;2(8455):596-98.
(7) World Health Organization. Infections, pregnancies, and
infertility: perspectives on prevention. Fertil Steril
1987;47(6):964-68.
( cool Cates W Jr, Rolfs RT, Aral SO. Sexually transmitted diseases,
pelvic inflammatory disease, and infertility: an epidemiological update.
Epidemiol Rev 1990;12:219-20.
(9) World Health Organization.
(10) McFalls JA, McFalls MH. Disease and Fertility. London,
England: Academic Press, 1984.
(11) Papreen N, Sharma A, Sabin K, et al. Living with infertility:
experiences among urban slum populations in Bangladesh. Reprod Health
Matters 2000;8(15):33-44.
(12) Inhorn MC. Global infertility and the globalization of new
reproductive technologies: illustrations from Egypt. Soc Sci Med
2003;56(9): 1837-51; Okonofua F. The case against new reproductive
technologies in developing countries. Br J Obstet Gynaecol
1996;103(10):957-62.
(13) Richards SC. "Spoiling the womb": definitions,
aetiologies and responses to infertility in North West Province,
Cameroon. Afr J Reprod Health 2002;6(1):84-94.
(14) Okonofua FE, Harris D, Odebiyi A, et al. The social meaning of
infertility in southwest Nigeria. Health Transit Rev 1997;7(2):205-20.
(15) Stanback J, Twum-Baah KA. Why do family planning providers
restrict access to services? An examination in Ghana. Int Fam Plann
Perspect 2001;27(1):37-41.
(16) Huggins GR, Cullins VE. Fertility after contraception or
abortion. Fertil Steril 1990;50(5): 451-60; Hatcher RA, Trussell J,
Stewart F, et al. Contraceptive Technology, Seventeenth Revised Edition.
New York, NY: Ardent Media, Inc., 1998.
(17) Papreen; Okonofua; Dyer SJ, Abrahams N, Hoffman M, et al.
"Men leave me as I cannot have children": women's
experiences with involuntary childlessness. Hum Reprod
2002;17(6):1663-68; Gerrits T. Social and cultural aspects of
infertility in Mozambique. Patient Educ Couns 1997;31(1):39-48.
(1 cool Gerrits.
(19) Dyer SJ, Abrahams N, Hoffman M, et al. Infertility in South
Africa: women's reproductive health knowledge and treatment-seeking
behavior for involuntary childlessness. Hum Reprod 2000;17(6):1657-62.
One Couple's Story: The Uncertainty of Infertility
Each case of infertility is unique in its causes, consequences, and
outcomes. One such individual story comes from Jamaica, where
36-year-old Maria (fictitious name) and her husband are trying to
conceive.
"My family was asking how come I am married so long and have
no children," says Maria. After seven years of having unprotected
sexual intercourse with her husband without becoming pregnant, she
finally decided to visit her gynecologist.
Maria says that, before the visit, she had no idea what could be
causing her infertility. But a series of tests revealed that she is an
ovulatory (that her ovaries are not producing and releasing eggs).Her
husband also went to the clinic to have his semen analyzed and
discovered that he is oligospermic (has a suboptimal number of sperm in
his semen).So in this case, as in many throughout the world, the
couple's infertility can be attributed to both partners. But when
asked about the causes of the couple's infertility, Maria never
mentions that her husband is also contributing to the problem. "It
seems to me that she has assumed full responsibility for the
infertility," says Maria's gynecologist, who prefers to remain
anonymous to protect Maria's privacy.
In many countries, infertility is perceived as a woman's
problem, perpetuated by community beliefs. Maria's gynecologist
says that in some areas of Jamaica, a woman who does not conceive within
a defined period is considered a "mule," the name for the
usually sterile offspring of a donkey and a horse. "Some
communities do not accept that a man is sterile until they have
proof," she says. "Once, when I shared with a woman the
results of her partner's semen analysis, she asked for a copy of
the results so that she could show his family that she was not the
mule."
Because of Maria's personal characteristics--Christian,
Caucasian, and middle class--she may not suffer the same social
consequences of infertility that women of many other backgrounds
experience. In fact, she says she is coping with infertility
"satisfactorily."
Since her diagnosis, Maria has been taking medicine to stimulate
ovulation, and she has now been referred for assisted reproduction (see
article, page 7). Her husband has been referred to a urologist.
Results from a study of more than 2,000 infertile couples from
Canada estimate that about 42 percent of women who are treated for
ovulation disorders and almost 30 percent of wives of men who are
treated for oligospermia will eventually give birth to a live infant.
(1) But additional research has also predicted that couples who have
been infertile for three or more years are less likely than others to
conceive, and that women who are at least 30 years old and have never
been pregnant are less likely to eventually have a live birth. (2)
So what does this mean for this Jamaican couple?
"I am still being treated," Maria says. Meanwhile, like
many infertile couples, she and her husband will continue waiting in an
emotional limbo, harboring the hope that they will eventually have the
good fortune to conceive.
* Kerry L. Wright
References
(1) Collins J, Burrows E, Willan A. Infertile couples and their
treatment in Canadian Academic Infertility Clinics. In Royal Commission
on New Reproductive Technologies. Treatment of Infertility: Current
Practices and Psychosocial Implications. Volume 10. (Ottawa, Ontario:
Minister of Supply and Services, 1993)233-329.
(2) Hunault CC, Eijkemans MJ, te Velde ER, et al. Validation of a
model predicting spontaneous pregnancy among subfertile untreated
couples. Fertil Steril 2002;78(3):500-6.
The Possibility of Assisted Reproduction.
Infertility management is an important component of reproductive
health services. When infertility occurs, couples should not be denied
treatment, including assisted reproductive technologies.
Assisted reproductive technologies are most often used to treat
infertility caused by damage to or blockage of a woman's fallopian
tubes, male infertility, and persistent infertility for which other
treatments have not worked. One of the best-known and most common
technologies is in vitro fertilization (IVF), a procedure in which a
man's sperm and a woman's egg are fertilized in a laboratory
and the resulting embryo is transferred into the woman's uterus.
Other technologies include intracytoplasmic sperm injection (ICSI), in
which a single sperm is injected into a single egg during IVF, and
gamete intrafallopian transfer, an alternative to IVF in which sperm and
unfertilized eggs are surgically placed in a woman's fallopian
tubes.
Global demand for such help is undeniable. But some experts are
concerned about the cost and difficulty of providing such interventions
in the developing world. (1) In Nigeria, for instance, one cycle of IVF
is estimated to cost between U.S. $2,000 and U.S. $2,700, but the
minimum wage in Nigeria is typically no more than U.S. $720 a year. (2)
Nonetheless, examples from Africa demonstrate that assisted
reproductive technologies are feasible and successful in low-resource
settings where staff are trained and equipment is available. In Mombasa,
Kenya, an IVF center was created in 1995, and nearly 50 patients had
attended by early 2003, according to Dr. Abdallah Kibwana, an
obstetrician/gynecologist from Mombasa's Coast General Hospital. At
a regional obstetrical and gynecological conference, he reported that 19
of the patients seen at the IVF center have conceived with the help of
simple ovarian stimulation, and two babies have been born using IVF. (3)
Also, two cases of successful ICSI have recently been reported from
a private IVF clinic in Lagos, Nigeria. (4) In one case, a man had no
sperm in his semen, so sperm were extracted from his testes. ICSI and
transfer of the resulting embryo into the uterus of his 38-year-old wife
resulted in the birth of a healthy baby boy. In the other instance, a
31-year-old woman who had tubal infertility and whose husband had low
sperm counts delivered twins after ICSI was performed.
* Kerry L.Wright
References
http://www.youtube.com/watch?v=cKRhKQNHqDg
(1) Inhorn MC. Global infertility and the globalization of new
reproductive technologies: illustrations from Egypt. Soc Sci Med
2003;56(9):1844; Okonofua F. New reproductive technologies and
infertility treatment in Africa. Afr J Reprod Health 2003;7(1):7-11.
(2) Giwa-Osagie OF. ART in developing countries with particular
reference to sub-Saharan Africa. In Vayena E, Rowe PJ, Griffin PD, eds.
Current Practices and Controversies in Assisted Reproduction. Geneva,
Switzerland: World Health Organization, 2002.
(3) Kibwana AK. Assisted reproductive technology (ART): experience,
current and future status. The 5th International Scientific Conference
of the East, Central and Southern African Association of Obstetrical and
Gynaecological Societies, Mombasa, Kenya, February 23-27, 2003.
(4) Ajayi RA, Parsons JH, Bolton VN. Live births after
intracytoplasmic sperm injection in the management of oligospermia and
azoospermia in Nigeria. Afr J Reprod Health 2003;7(1):121-24.
Web Resources
http://www.who.int/reproductivehealth/ infertility/index.htm
Current Practices and Controversies in Assisted Reproduction is the
report of an expert meeting on "Medical, Ethical and Social Aspects
of Assisted Reproduction" held at World Health Organization
headquarters in Geneva, Switzerland, in September 2001. This 31-chapter
book examines these issues and presents experts' recommendations
for clinical practice and research.
Harmful Traditional Practices Can Hinder Conception
Various traditional practices can lead to a narrowing of the
v****a, also known as acquired vaginal stenosis (gynetresia), that makes
it difficult for some couples to conceive a child, decades of research
from Nigeria indicate.
Scarring from female genital cutting was the leading cause of
vaginal narrowing among 78 women with vaginal stenosis who took part in
a retrospective study conducted between 1980 and 1989 at the University
of Nigeria Teaching Hospital in Enugu. (1) In a second retrospective
study, conducted from 1967 to 1996 among 126 women with vaginal stenosis
at the University College Hospital in Ibadan, most cases were due to
chemical vaginitis from insertion of vaginal pessaries (suppositories)
that are caustic, a common practice promoted by traditional healers. (2)
Stenosis, if left untreated, can make sexual intercourse
uncomfortable or even impossible. In both studies, infertility was
recorded as a symptom of the condition for about a quarter of the women.
Authors of both studies emphasized that acquired vaginal stenosis
is a public health concern requiring community-based education programs
to teach couples about these harmful traditional practices. The lead
author of one of these studies and also a former FHI fellow, Dr. Ayodele
Arowojolu of Nigeria, reports that obstetricians and gynecologists in
that country are using the media to warn members of the public about
some of these harmful practices and inform them of modern medical
programs to manage infertility.
* Kerry L. Wright
References
(1) Ozumba BC. Acquired gynetresia in eastern Nigeria. Int J
Gynecol Obstet 1992;37(2):105-9.
(2) Arowojolu AO, Okunlola MA, Adekunle AO, et al. Three decades of
acquired gynaetresia in Ibadan: clinical presentation and management. J
Obstet Gynaecol 2001; 21(4):375-78.
