Infertility - Conclusions

The family physician can often make a positive
impact on a couple’s quest for fertility, using simple
office-based diagnosis and treatment. The physician
can help couples through fertility treatment and also
through the problems and concerns of adoption.

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Infertility - Fitting the child into the family

1. There are many problems including childhood
illness, social and psychological adaptation of the
family and child, and handling of the discussing of
adoption.
2. Foreign or same country adoption both may
produce children with many medical problems,
sometimes unknown until the adoption. These
may be infectious diseases, including hepatitis,
parasites, AIDS, and/or tuberculosis,
malnutrition, lack of immunizations, and sexual
and physical abuse. There are clinics and offices in
larger cities that specialize in adoptive children.
3. The physician can help the family understand
cultural differences and obtain help in doing so,
such as contacting support and ethnic groups.
4. Sooner or later, the family will have to discuss
adoption with the child. There are many books,
websites, magazines, and support groups that can help. Answering the child’s questions honestly is
the best method of discussing adoption.

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Infertility - Care of the adoptive mother

1. The adoptive mother may come to the decision to
adopt through many ways, including primary
choice or failure of fertility programs. She may be
burdened with feelings of failure and grief at the
inability to have a child from her body, or may
choose adoption as a start or addition to her family.
2. The adoptive mother goes through several stages
of emotional lability. She and her husband must
decide to adopt, deal with the stress, lack of
control and insecurity of the adoption process,
and deal with the medical, social, and
psychological issues of incorporating an adoptive
child into the family. Adoption may be a first or
last step, and the woman may have powerful
feeling for and against adoption and urgency to
have a child.

3. The physician may counsel the woman about
adoptions, counsel about particular disease or
children with handicaps, and treat the child once
it is adopted. The physician may need to help the
family integrate the child into the family and help
to give advice about dealing with the stresses of
adoption.
4. The decision to adopt entails many steps.
a. Factors such as infertility, failure to produce
genetic children, need for children with the same
genetic make-up, desire to help needy or
handicapped children, and grief and anger about
failure of her own body are all complex parts of
the decision. As well, the difficulty of single
parenting, gay parenting, and blended families
may be part of the decision. The physician may
counsel the family during this process.
b. The adopting parents must decide if and how
they can deal with a special needs or
handicapped child or a child from another
ethnic background.
c. Women who feel that they have lost control by
inability to have children may jump joyfully
into the obsessive paperwork and details
needed to adopt a child. It may give them a
feeling of control.
d. Preadoption counseling may be as important
as preconceptual counseling. The physician
should inquire into the mother’s daycare and
leave options, her insurance status and
back-up. Have the adoptive parents discussed
their plans with their family? Adopting older
children may entail special arrangements for
daycare or schooling.
5. Preadoption parent physical examination
a. The physician is often asked to perform the
preadoption physical. There are some
conditions that may make an adult hesitate to
adopt (Table 8.3).
b. Any condition that causes an individual to
need caregiving themselves or give it to family
member, or any progressive or terminal
disease, should cause hesitation about ability
to adopt a child.
c. However, it is not the duty of the physician to
judge who can adopt, but just counsel and
document. The judge, county, country, state or
adoption agency will have its own
requirements. Some countries have their own
requirements. In one case, a judge may decide
that grandparents or aunts over age 50 with
some chronic condition would be better
adoptive parents than strangers.
6. The wait
There is an intensely painful period between the
decision to adopt and the arrival of the child.
Anticipation, worry, anxiety, legal, and social
problems are all factors in this time. Because the
womanmay be suffering this wait and does not want
to tell or burden friends and family, the physician
may need to be available for support and ventilation.

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Infertility - Caring for the birthmother

1. The birth mother is no longer likely to be an
unmarried adolescent who travels to a distant
town to deliver her unwanted child. Yet, the
decision to place a child for adoption is difficult
and emotional. The physician may counsel
pregnant or just delivered women. The counseling
may take time and involvement and additional
social service and/or psychological counselors
may be needed.
2. The decision may change several times in the
course of the pregnancy and postnatal period.
Financial, social, medical and personal reasons are
all likely to be involved.
3. A complete social, family, medical and personal
history is essential, including drugs and alcohol
use. The woman may be afraid to be specific.
4. A woman considering placing her child for
adoption may be at higher risk for STDs and
social problems. She may require additional
medical and social supports, even after the
placement of her child.
5. Care during delivery should be the same as for all
mothers. However, delivery may not be joyful; in
fact, the mother may show signs of grief and
bereavement. The mother may not want to see her
child or stay on the labor and delivery floor. These
wishes should be honored.
6. The adoption may be private or through an
agency. Mothers may have had significant input
into the choice of adoptive parents, even having an
“open” adoption. In this, the birthmother may
visit the adoptive parents before and after
adoption.
7. All legal work should be completed in advance.
The physician does not need to get involved in the
legal work, unless she feels the woman is being
forced or unduly pressured.

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Infertility - Adoption

Impact
1. Adoption has become a more visible choice. In the
USA, approximately 35,000 are adopted yearly,
with more than 10,000 from foreign countries.
2. Five percent of children born to unmarried
mothers during the 1990s were placed in
adoption.12
3. Although adoption has become discussed in the
media, it is essentially a private choice, both for
the birthmother and the adopting family.

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Infertility - Psychological effects of infertility

1. Most couples cope well with the rigorous and
intricate therapies of infertility.
2. Most couples assume that they will be able to
become pregnant when they desire. The inability
may lead to frustration, sadness, depression, and
distancing between the couple. Women who have
postponed childbearing to have a career may be
used to being in control of many parts of their life. When they are unsuccessful in becoming
pregnant when they want, they may feel frustrated
and angry.
3. The effect of the infertility depends on the age of
the couple, their personality and coping styles,
pre-existing psychopathology, medical causes, and
motivations for pregnancy.
4. Infertility can lead to a sense of failure and guilt,
that something is wrong with them because their
body does not function correctly. Body image may
be altered.
5. There may be sexual difficulties, avoidance of
intercourse, and inability to perform, especially
with seemingly mechanical tests like postcoital
and semen specimens. Anorgasmia, impotence,
and decreased libido may occur.
6. Avoidance of friends and family who have
children can occur, further isolating the couple.
7. Psychological counseling, before, during and
after IVF, may be indicated. The stress of
infertility and its treatment may exacerbate
other psychiatric conditions, such as mood or
anxiety disorders. The ovulation inducing agents
may also exacerbate psychological problems or
reduce the effectiveness of psychotropic
medications.

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Infertility - Assisted reproduction

1. The success rate has been increasing, and may
reach 25%. Actually, the success rate of in vitro
fertilization (IVF) exceeds that of normal
conception in a fertile couple in one cycle.
2. In vitro fertilization (IVF) consists of the egg
and sperm united in a test tube, and then the
pre-embryo is transferred to the uterus.
3. GIFT (gamete intrafallopian transfer) consists of
placement of egg and sperm in the fallopian tube.
4. ZIFT is zygote intrafallopian transfer where the
fertilized eggs are placed in the uterus or tubes.
5. Ovum conations combined with the man’s sperm
and IVF or GIFT can be used for women with
premature ovarian failure, ovarian dysfunction
caused by cancer, chemotherapy, radiation,
maternal chromosomal or genetic abnormalities,
or in women who have responded poorly to
ovulation inducers. Older women’s eggs are more
likely to have genetic abnormality and aneuploidy.
6. Sperm donation can come from the male
partner or donor. The sperm is then placed in
the uterus or used in IVF or GIFT. This may be
used for male infertility, male ejaculatory
dysfunction, post-radiation, chemotherapy or
surgery for cancer, chromosomal abnormalities,
or for women without a male donor.

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Infertility - Indications for referral for infertility consultant

1. If the woman is older than 35, or definitely 40,
immediate referral may be indicated, especially
if the couple has already tried for more than
one year.
2. If the couple has not conceived within three years
of stopping contraceptives, the likelihood of
pregnancy in the next year is less than 25% and
referral is indicated.
3. Ovarian failure, failure to achieve ovulation within
three to six cycles or pregnancy within one year,
would suggest the need of referral.
4. Other suggested indications for immediate
referral include serum chlamydia levels in either
partner of greater than 1:256, follicular
stimulating level in the woman’s early follicular
phase more than 10 IU/L, or abnormal sperm
analysis (sperm motility less than 25% or less than
20 million/mL).

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Infertility

Infertility is the inability of a sexually active couple
who desire a child to become pregnant within one
year.
Impact
1. Approximately 10 to 15% of couples have
difficulty becoming pregnant. Approximately
9 million American women have impaired
fertility, either primary (never having a child)
or secondary (trouble having as many children
as desired).
2. Family and general physicians can work with
couples to help them achieve a pregnancy.
Consultation to fertility specialists may be needed
sooner or later.
Etiology
1. Infertility is a couple’s problem. Most couples
conceived within 6 months of trying.1 Infertility
increases with age (Figure 8.1).
2. Half of the couples who have failed to get
pregnant in six months conceive within the next
six months.2
3. In retrospect, approximately 40% of infertility is
caused by ovulation problems. Ten to thirty
percent may be caused by multiple factors, and
male factors make up the remaining of the causes
(Table 8.1).
4. Chronic disease of either partner may cause
infertility.
5. Women’s causes of infertility include ovarian and
tubal or mechanical factors.
a. Ovarian failure may be caused by
malnutrition, anorexia, diabetes, or renal
failure.
b. Ovarian failure can be temporary or
permanent and can be caused by an
endocrinopathy or polycystic ovarian
syndrome or can be idiopathic.
c. Tubal factors include scarring from
endometriosis, PID or infections, especially
gonorrhea or chlamydia.
d. Cervical and uterine factors can include an
abnormally shaped uterus (bifid, bicornuate,
or anatomy changed by fibroids) or inimical
cervical mucus.
e. Use of certain medications, smoking, alcohol,
and obesity all reduce a woman’s fertility.
A recent retrospective study of more than 400
Danish couples found that drinking as little as
one to five alcoholic drinks weekly
significantly decreased the likelihood of
pregnancy (RR ¼ 0.6) and more than five
drinks weekly decreased the likelihood to less
than one-third (RR ¼ 0.3).3
6. Male causes of infertility include erective
dysfunction and other sexual dysfunction, a low or
absent sperm count, abnormal sperm, epidydimal
scarring from infection, or medication use.
Antidepressant use can cause reduced sperm
numbers and motility.4
Evaluation
1. The duration of the infertility and the age of the
woman are the most important factors influencing
the success rate for fertility5 (Figure 8.2).
2. The history of medications and alcohol use are
important factors.
3. Contraceptive history is important. After
hormonal contraception, return to normal ovulation patterns can take months. After
stopping OCPs, amenorrhea and anovulation can
last 6–12 months. After use of depot
Medroxyprogesterone acetate (DMPA),
anovulation can last 12–24 months (Figure 8.3).
4. Sexual history is important. Approximately 5% of
infertility is caused by sexual dysfunction.
5. A complete physical examination of both men and
women is essential.
a. In the woman, medical and medication
history, sexual history, gynecological and
obstetrical history including pregnancies,
abortion, surgeries, episodes of PID, and
menstrual history. Physical examination of
women includes gynecological exams
including vaginal, uterine and bimanual
examination. Examining hair and skin for
changes of a hormonal disorder or PCOS is
important.
b. In the man, medical and medication history,
sexual history and history of infections or
surgery are important. Physical examination
of scrotum, testes and penis is important.
Phimosis, balanitis, small testes, or varicoeles
may interfere with fertility. Varicoeles do not
interfere with normal sperm counts and
assessment; how they reduce fertility is not
well defined.
c. Both partners should be examined and
cultured for sexually transmitted disease,
especially chlamydia.
Counseling
Counseling the couple about the normal menstrual
and ovulation cycle, about the effects of medications
and alcohol on fertility, and about expectations about
coming pregnant is important. A survey study of
approximately 250 women who were trying to
become pregnant found that many were having intercourse
at times other than ovulation. After teaching
these women how to use a “fertility monitor,” almost
half conceived in the first month, and 90% within
three months.6 Other important counseling includes
the following.

Woman’s use of folic acid prophylactically to
reduce incidence of spina bifida is suggested.

Reducing or quitting smoking and decreasing
alcohol consumption should be advised. Smoking
reduces fertility. Medications should be reduced
or changed as needed (Table 8.2).

Weight should be lost if possible.

Vaginal lubricants or gel that may cause sperm
immobility and impede infertility should not be
used.
Treatment
1. The woman should start a three to six month basal
body temperature log, or use LH predictors to determine whether she is ovulating. Although this
seems simple, an accurate record takes
thoroughness and consistency. A biphasic curve
with a 0.4 to 0.5 degree elevation is consistent with
the day of ovulation. Over the counter LH surge
predictors cost $35–50 per cycle.
2. The man should have a semen analysis. Examined
within 60 minutes of ejaculation, normal semen
contains 2 mL or more of 20 million motile sperm
per mL, or more. The motility of sperm should
show that more than half progress in a forward
direction, with more than 25% progressing
rapidly. Thirty percent or more should have
normal shape. One study of more than 100 fertile
men undergoing vasectomy found that the mean
volume was 3.31 ml (range 0.6–11 mL), with
a sperm count average of 81 million per mL
(range 4–318 million). The percent of active
sperm averaged 63% (range 10 to 95%).7
3. If these tests are normal, a postcoital test is
suggested, although its prognostic value has been
questioned by a meta-analysis.8 Within eight
hours after coitus, a cervical specimen is analyzed
for sperm motility and morphology. One RCT
found that postcoital tests increased the number
of tests, but not the overall pregnancy rate.9
4. If the woman is not ovulating, the family
physician (if she stays up-to-date on the literature
and treatment) or a consultant can help induce ovulation with clomiphene, Pergonal®,
gonadotropin agonists or pulsatile gonadotropin
releasing hormone administration. Only
physicians experienced in using these drugs
should attempt ovulation induction.
a. Clomiphene, a selective estrogen receptor
modulator (SERM), is contraindicated in
women with liver failure, ovarian cysts, PCOS,
and undiagnosed abnormal uterine bleeding
or pregnancy. It is associated with an increase
in multiple births. There may be severe
menstrual and intermenstrual pain, nausea,
bloating and premenstrual syndrome
associated with its use.
b. The next step may be the use of menotropins
incluing human menopausal gonadotropins
(hMG, Pergonal). These can cause high serum
estradiol concentrations and ovarian
hypertrophy with multiple follicles. These
follicles can rupture and cause
hemoperitoneum, ascites, and hypovolemia in
as many as 25% of women using the
medication.
5. If the semen analysis is abnormal, there are
methods of increasing the concentration, number
and motility of sperm, called “capacitating.”
6. Alternatively, the sperm can be introduced
directly into the uterus with a catheter, especially
if the postcoital test is abnormal.
7. Women with PCOS may be treated with
metformin which induces ovulation in
approximately 50%, as it reduces insulinemia,
improves glucose control, and decreases weight
and hirsuitism. In early studies metformin was
given to 43 women who were hyperinsulinemic
and euglycemic. Ninety-one percent resumed
menses.

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