Infertility is generally defined as the inability to achieve pregnancy after at least one year of regular sexual activity without the use of contraception. If a pregnancy has never occurred, the condition is called primary infertility, but if a couple cannot initiate another pregnancy after the first pregnancy or child, it is called secondary infertility. The causes of primary and secondary infertility may differ. Infertility is fairly common, and about one out of every six couples is infertile at any given time.
A woman reaches the height of her fertility in her mid-20s. Her ability to conceive slowly declines until age 30 and drops more rapidly after that. A man’s fertility decreases slowly until about the age of 40, and then decreases more rapidly. Women unable to conceive in their 30s should seek help more quickly than younger women because their chances of getting pregnant are declining more rapidly. Those not menstruating regularly may want to seek treatment as well, since irregular cycles may indicate lack of ovulation; such women are not likely to conceive without treatment. A woman with a history of pelvic disease or a man who had mumps as an adult might also want to seek help quickly.
The first step
Doctors who treat infertility first take a family “history” of each partner to investigate possible genetic disorders and medical conditions that might affect fertility, such as mumps, measles, whooping cough, diphtheria, rubella, thyroid disease, tuberculosis, epilepsy, and the presence of infections. The doctor asks about use of certain medications that may be spermicidal, as well as the use or abuse of alcohol, tobacco, tea, coffee, or recreational drugs, all of which affect sperm count. A sexual history of each partner follows. Women are asked about when they first menstruated and what their periods are like; whether they suffer pelvic pain between periods (indicative of ovulation); previous pregnancies, miscarriages, and therapeutic abortions.
Information is taken about the use of lubricants during intercourse (some, such as Vaseline, retard the movement of sperm) or contraceptives, pain during intercourse, and pelvic infections. (Pelvic inflammatory disease may cause blockages that interfere with the passage of ova through the fallopian tubes.) Questions for men include whether there were problems in the normal descent of testicles; whether surgery (orchiopexy) was necessary to help them descend; whether and at what age circumcision took place; and whether reproductive tract infections have occurred. Both partners will likely be asked about their sexual behaviour: knowledge of mid cycle coitus. A few infertility cases are solved on the spot when it is learned that the couple is not engaging in intercourse properly or at the appropriate times.
Physical examination
Both partners undergo extensive physical examinations, during which a doctor looks for normal development of sexual organs and secondary sex characteristics (pubic hair growth and breast development). A careful examination of the woman’s abdomen may reveal scars from operations she has not mentioned. A pelvic examination will confirm the presence of a healthy uterus and ovaries, or reveal any problems of shape and size. The man’s genitals are examined for abnormal development or displacement of organs. Blood and urine are tested for the presence of sexually transmitted diseases. As the work progresses, more sophisticated tests are done.
An infertility workup, or series of tests, is trying for both men and women. Often, they wonder whether their problem is psychological, a reasonable concern that can be resolved only by going through the workup. When couples are having sexual intercourse continually in an effort to start a pregnancy, the goal of pregnancy may come to dominate their lives and sometimes leads to depression. Intercourse may then become less an expression of interest and affection than a job to be done in preparation for tests or when it is most likely to result in pregnancy. At this time, a woman sometimes becomes less interested in sex and enjoys it less. She develops a new point of view toward her partner, seeing him either as supportive or unsympathetic, co-operative or difficult. Their relationship may be permanently altered by the revelations of this ongoing crisis.
A man sometimes questions his own virility because fertility and manliness may be closely intertwined in his mind. Sex-on-schedule becomes a problem for the male partner, who just may not feel like it at the necessary time. Sometimes he develops performance problems or feels anger and resentment toward his partner.
Each partner may feel at various times like a failure. The fertility specialist and the health care team may or may not be sensitive to these problems. Some fertility practices now include a nurse practitioner whose job it is to provide facts and empathic support.
Infertility in men
During an infertility evaluation the male is evaluated first. If the couple’s infertility is due to him, the most likely cause is his sperm. A sperm analysis is therefore the first step.
Infertility in women
When no evidence of reproductive dysfunction can be found in the male partner, study of the woman begins. The initial test, the Huhner test, collects cervical mucus, in the doctor’s office, within 2 hours of sexual intercourse. Mucus is examined under a microscope to see if sufficient live sperm are present and whether enough mucus is present to ease the passage of sperm through the genital tract and into the fallopian tubes, where fertilisation takes place.
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