Infertility is a problem with the reproductive system that results in the inability of a man or woman to achieve a pregnancy or of a woman to carry a pregnancy to live birth. The accepted definition within the medical profession is the absence of conception after at least one year of regular intercourse without birth control. Regular intercourse refers to intercourse at least two to three times per week. The term is also used to cover women unable to carry a pregnancy to term because of miscarriage . Infertility is not sterility, which is the term used to mean conception is not possible under any circumstances. Infertility is not a new disease or condition, but it appears as if there has been an increase in infertility rates in the past few decades. Some factors that may relate to this increase include an increase in the age of women wanting to conceive, an increase in the spread of sexually transmitted diseases, and the rise in the level of toxic chemicals in our environment. Infertility does affect people of all ages, ethnic backgrounds, socioeconomic groups, and both sexes.
The purpose of fertility treatments is to achieve a successful pregnancy and outcome. Male factors account for approximately 30-40% of all cases of infertility and female factors cause about 40% of cases. Close to 15% of cases are a result of a combination of male and female factors; whereas in 5-10% of cases, no cause can be found.
Many couples may begin their quest for fertility with their primary care physician, who is usually a medical doctor certified in family medicine. The primary physician can do a physical exam on both individuals but should refer the couple to a specialist in obstetrics and gynecology to initiate the infertility evaluation process. Infertility is described as either primary or secondary. A couple who has never achieved pregnancy is experiencing primary infertility, whereas a couple who has had a pregnancy in the past, regardless of the outcome, is experiencing secondary infertility.
For an egg to be fertilized, sperm produced in the testes must not only be present in sufficient number in the semen but they must be capable of moving far enough and fast enough to travel through the female reproductive system (motility), and capable of penetrating the outer layer of an egg. Male infertility may be a result of small quantities of sperm; prenatal exposure to diethylstilbestrol (DES) (a medication given to women to prevent miscarriage in the 1950s); exposure to radiation, certain pesticides or heavy metals (lead); or diseases that reduce the body's ability to produce sperm. Female infertility may be related to irregularities of the fallopian tubes; endometriosis (tissue resembling the lining of the uterus growing in the abdomen); irregular ovulation or lack of ovulation; abnormalities of the uterine cavity; and/or cervical problems such as abnormal mucus.
A couple should consider seeing an infertility specialist (a physician certified in reproductive endocrinology and infertility) for any of the following reasons:
- a woman experiencing irregular menstrual cycles or irregular ovulation
- a woman with a history of three or more miscarriages
- a woman older than 35 years of age
- a woman with a history of pelvic infection or previous pelvic surgery
- a woman who needs microsurgery for endometriosis or for tubal damage
- a man with a poor semen analysis such as low count, poor motility, abnormal appearance, or requiring microsurgery
- a couple with unexplained infertility whose tests came back normal but still have not conceived after two years
- a couple who needs more advanced treatment, such as injectable ovulation-induction medications or assisted reproductive technology (ART)
There are over 300 fertility clinics in the United States and each one has a varying rate of success. A couple should investigate the services of the ones they are considering to save time, money and emotional upheaval. In 1992, Congress passed the Fertility Clinic Success Rate and Certification Act, which requires the Centers for Disease Control and Prevention (CDC) to publish the success rates of clinics throughout the United States where ART is performed. This report is intended for laypersons who are considering using ART to achieve pregnancy and provide an objective review utilizing a common method of reporting success. Besides success rates, a couple should consider the following:
- Is the physician board certified in reproductive endocrinology?
- How much experience has the physician had with diagnosing and treating infertility?
- What are the fees for office visits and are payment plans available?
- What is the policy regarding cancellation of appointments and filing of insurance claims?
- Will a physician or someone else on staff be available twenty-four hours a day, seven days a week, including weekends and holidays?
- Will lab and ultrasound facilities be open seven days a week?
- Will the couple see the same physician for their visits?
- Will decisions on tests, treatments and referrals be made jointly between the couple and the physician?
Couples involved in fertility treatments face many legal, ethical, psychological, emotional and financial questions. It is imperative to explore these issues before beginning a course of treatment in order to maintain a realistic attitude. It is difficult, if not impossible, to identify problems that may arise during treatment, but it is important to make an attempt to set limits, physically, financially, and emotionally, on what can be handled during the course of treatment. It is likewise crucial to consider potential legal, practical and ethical problems associated with each choice of treatment and to contact resources available to individuals with infertility problems for an objective viewpoint. Just because the treatment is available does not mean it has to be utilized. All individuals have their own ethical standards and limitations and need to investigate all courses of treatment before undergoing them.
Informed consent is a medical term that means a patient gives permission for a test or invasive procedure to be performed, after being informed by the physician in clear language exactly what the test or procedure involves. If at any point in the course of treatment a patient does not understand something, he or she should be encouraged to ask questions; and if the answer is not satisfactory, the patient should know that a second opinion may be solicited.
Prior to undergoing assisted reproductive technology (ART), women should be advised to avoid all pain medications other than Tylenol and discuss prescription medications with the specialist. They should not smoke cigarettes or drink alcohol, avoid caffeine-containing beverages, and inform the physician if they have active genital herpes . They should also maintain a healthy well-rounded diet and take a multiple vitamin containing folic acid every day.
Men should report any fevers within three months before ART treatment, as fevers may adversely affect sperm quality. They should avoid hot tubs or saunas for three months, as the heat can affect sperm function. Men should also avoid alcohol, drug use, and cigarette smoking for three months prior to treatment and during the
ART cycle as well. Any prescription drugs should be reported to the specialist along with active genital herpes. It is preferable to avoid intercourse for three days but not more than seven days before collection of semen for an ART cycle.
Assisted reproductive technology (ART) is defined by the U.S. Centers for Disease Control and Prevention (CDC) as "all treatments or procedures that involve the handling of human eggs and sperm for the purpose of helping a woman become pregnant." Types of ART include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), embryo cryopreservation, egg or embryo donation, and gestational carriers. ART does not include intrauterine insemination (IUI) with either partner or donor sperm.
In vitro fertilization (IVF)
This name comes from the fact that fertilization occurs outside the body in a laboratory, instead of in the woman's fallopian tube. In vitro is a Latin term that means 'in the glass' and refers to procedures performed outside of a living body in a laboratory or other artificial environment. Thus, IVF involves joining an egg and a sperm in a laboratory dish; if fertilization occurs, the resulting pre-embryo is transferred into the woman's uterus for possible implantation. IVF was developed as a technique to assist women who had blocked, damaged or absent fallopian tubes to become pregnant. The first successful IVF procedure was performed in the United Kingdom and resulted in the birth of Louise Brown in 1978. Today IVF is utilized to treat infertility caused by endometriosis; certain types of male factor infertility; tubal factors; and unexplained infertility.
The procedure utilized for IVF may vary somewhat from clinic to clinic, but generally it involves the following:
- Stimulating the woman's ovaries to produce multiple eggs during a specific time of her menstrual cycle.
- Detecting the presence of multiple eggs through the use of vaginal ultrasound.
- Retrieving eggs from her ovaries (while under intravenous sedation) by means of guiding a needle through the wall of the vagina and into the follicles and aspirating them.
- Determining the maturity of the eggs and adding sperm to them once mature.
- Transferring the embryo into the uterus by a catheter (long, slender tube with a syringe on one end) is relatively simple and requires no anesthesia.
Stimulating a woman's ovaries to produce multiple eggs may vary by program or patient, but the majority require several days of medications to be given by injection. Two main medications are used in the stimulation phase of an IVF cycle. The first is Lupron, which suppresses the ovaries by shutting down the body's normal production of luteinizing hormone (LH) and follicle stimulating hormone (FSH). Both of these hormones are essential to produce ovulation. Lupron is given by injection subcutaneously (just under the surface of the skin). It shuts down the ovaries completely so that when the induction drugs are given the follicles will mature evenly. The second type of medication is either pure FSH or FSH in combination with LH. It is given by injection to stimulate the ovaries to produce eggs in a controlled but hyperstimulated manner and at a dosage that will produce the highest number of good-quality eggs. With IVF, egg retrieval may take thirty minutes to one hour.
The transfer process takes only about ten to twenty minutes and results in the transfer of one or more embryos because the presence of multiple embryos makes it more likely that at least one embryo will attach to the uterine lining. The transfer of multiple embryos also increases the chance of multiple pregnancy . A couple may choose to maintain additional embryos before the transfer procedure so that they can be frozen, thawed and transferred at a later date. In the United States in 1996, 300 clinics reported doing over 64,000 ART cycles, and 92% of these were IVF.
Gamete intrafallopian transfer (GIFT)
With GIFT, conception takes place in the fallopian tube. This technique should be utilized only when sperm quality is adequate and at least one fallopian tube is open and functional. The steps involved in this technique are similar to those with IVF up to the egg retrieval. As with IVF, egg retrieval occurs under general anesthesia and eggs and sperm are transferred immediately to a catheter that is used to inject the eggs and sperm into the fallopian tube during laparoscopy . There is no ability to document fertilization or to evaluate embryo quality in a GIFT procedure. This procedure requires two small incisions, one just outside the woman's navel and the other deep in her abdomen where a probe is inserted.
Zygote intrafallopian transfer (ZIFT)
This procedure is a combination of IVF and GIFT. Eggs are retrieved by transvaginal ultrasound aspiration, as with IVF, and are fertilized in a laboratory dish. The next day, before the fertilized eggs begin cell division , they are transferred into the woman's fallopian tubes by laparoscopy. This procedure is sometimes referred to as pronuclear stage transfer (PROST). Zygote is a term used to describe an egg that has been fertilized but has not yet undergone cell division, but now it is more commonly referred to as a pronucleus.
Tubal embryo transfer (TET)
This procedure involves the transfer of a more developed embryo than that used in GIFT or PROST. In this case, a fertilized egg that has reached the four-to eight-cell stage of division is transferred into the fallopian tube. This transfer usually occurs about 24 hours after fertilization and the developing embryo then proceeds to move into the uterus as in an unassisted pregnancy.
Techniques utilized to enhance fertilization or implantation include:
- Intracytoplasmic sperm injection (ICSI) uses a micro-surgical needle to inject a single sperm directly into the egg to achieve fertilization.
- Microinsemination concentrates sperm into a small drop of fluid and placing it around the eggs to increase chances of fertilization.
- Assisted hatching is a micromanipulation technique performed after fertilization with IVF, designed to improve the implantation of the embryo by making a microscopic hole (with a microsurgical needle or chemicals) in the zona pellucida (the tansparent, noncellular, secreted layer surrounding an ovum) to facilitate the release of the embryo from the egg membrane.
The micromanipulation techniques are relatively new procedures that may not be available in all fertility clinics. Their success depends on the quality of the man's sperm, the age of the woman, and the experience of the clinic.
Progesterone supplements are started the day after egg retrieval and continued until the pregnancy test is negative or throughout the first trimester of pregnancy. Vaginal suppositories or gel, intramuscular injections, and oral capsules are the form of progesterone used during IVF. Clinics vary regarding instructions about activity after embryo transfer. Some may suggest a few hours of bed rest and others suggest two to three days of minimal physical activity. The patient may also have her own opinion and choose to rest longer. About 10-12 days following embryo transfer, the physician will order a hCG (human chorionic gonadotrophin) test to determine pregnancy. If the test result is borderline, another blood test will be taken in two to three days. Five weeks after the transfer, an ultrasound is performed to document a heartbeat and confirm pregnancy.
Hyperstimulation syndrome is usually mild when it occurs, but it can become potentially serious. This is a result of ovaries that are extremely responsive to the medications, thereby causing them to become quite large. Hyperstimulation syndrome can lead to severe weight gain from fluid accumulation in the abdomen and low output of urine as well as potentially serious changes in blood chemistry. It is rare for a woman to experience such severe hyperstimulation that hospitalization occurs, but the syndrome can become serious enough to require close monitoring of intravenous fluids and weight, urine output, and blood chemistry.
Multiple gestation is another potential complication of ART and one that can have a long-term impact on a family. These pregnancies are physically and emotionally challenging to the mother and also have the potential of severe health risks associated with premature birth, which is quite common with multiple gestation. ART procedures have resulted in multiple gestation pregnancies about 43% of the time in women younger than 35 years. The risks to a woman carrying multiple fetuses include high blood pressure , gestational diabetes , increased risk of bleeding, premature labor, and cesarean section birth. Risks to the infant include prematurity, low birth weight, and respiratory and eye complications. Premature infants are also at higher risk for congenital (from birth) abnormalities and learning disabilities. The
Cryopreservation —Maintenance of the viability of excised tissue or organs by storing at very low temperatures.
Ectopic —Arising or produced at an abnormal site or in a tissue where it is not normally found.
Endometriosis —A condition in which tissue more or less perfectly resembling the endometrium (the mucous membrane lining the uterus) occus outside the uterine cavity, usually in the pelvic cavity.
Follicle stimulating hormone —One of the hormones that promotes the formation of follicles within the ovary for ovulation.
Laparoscopy —Examination of the peritoneal cavity with an endoscope.
Luteinizing hormone —One of the hormones that promotes follicle formation within the ovary for ovulation.
Pronucleus —The haploid nucleus of a sex cell.
Ultrasound —A procedure in which high-frequency sound waves are used to create an image of a baby. Ultrasound can be used alone or with other antepartum testing.
risks of complications to the mother and the fetus increase dramatically with the number of fetuses carried. Couples may sometimes choose to undergo a procedure called multiple gestation reduction (MGR), which involves reducing the number of fetal sacs to improve the chance of having a healthy pregnancy and a healthy baby. This decision is an individual one that must be based on ethical, moral, and personal beliefs as well as medical information.
Another potential complication is the fact that a small number of ectopic, or tubal, pregnancies can occur after embryo transfer in an IVF cycle as a result of embryos traveling out into the fallopian tube from the uterine cavity. The chance of this occurring, however, is less than one percent. Twenty percent of all pregnancies, regardless of how established, are lost, and all patients should be aware of this statistic prior to treatments as well. Individuals who do become pregnant are sometimes unable to enjoy the pregnancy because of the fear surrounding the treatments needed to achieve it and fear of potential problems or adverse outcomes.
If all goes well, the best result would be a healthy pregnancy and a healthy baby. If any of the complications occur, the individuals could undergo the procedure again, but it is essential that they have counseling to determine their expectations and emotional status.
Health care team roles
All health care workers who take part in assisted reproductive technology and care for the patients should be trained in bereavement counseling. Although it is essential to provide the appropriate physical care necessary to achieve pregnancy, the psychological and emotional impact of the treatments and adverse outcomes are much more difficult to handle. Nurses usually spend more time with the patients, and it is their responsibility to be a patient advocate. Patients will often tell the nurse things they would not discuss with the physician. In such a situation, the nurse needs to intercede for the patient to make the physician aware of problems and concerns. Often the patient simply needs a hand to hold during treatments and an understanding heart to listen, which every nurse can provide.
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Cooper, S. L. & Glazer, E.S. Choosing Assisted Reproduction. Indianapolis, IN: Perspectives Press, 1998.
Olds, Sally B., London, Marcia L., Ladewig, Patricia A. Maternal-Newborn Nursing: A Family and Community-Based Approach. Upper Saddle River, NJ: Prentice Hall Health, 2000.
American Society for Reproductive Medicine (ASRM), 1209 Montgomery Highway, Birmingham, AL 35216-2809. (205) 978-5000. <http://www.asrm.org>.
International Fertility Center, 2601 East Fortune Circle Drive, Suite 102B, Indianapolis, IN 46241. (317) 243-8793. <http://www.fertilityhelp.com>.
Resolve, 1310 Broadway, Somerville, MA 02144-1779. National HelpLine: (617)623-1156. <http://www.resolve.org>.
Fertility Net. <http://www.ferti.net>.
Linda K. Bennington, CNS