The causes of fertility problems, and how to find medical help and support.
This issue's column was guest-written for Dr. Tom Ferguson—by a contributor to Medical Self-Care magazine.
An estimated three and a half million married couples in the United States—one-sixth of all married couples in this country—are currently infertile. The figure represents an increase of almost 50% during the past 20 years.
However, thanks in large part to recent medical advances, the situation is anything but hopeless for the millions of Americans now being treated for infertility. The success rate for solving the problem has risen from 50% in the 1960's to about 70% today. And when having children is simply impossible for a couple, there are support groups that can help them deal with the emotional complexities that accompany the situation.
In addition, physicians as a group are becoming more enlightened about the subject than they were in the past. Traditionally, infertility was viewed as a woman's malady . . . but doctors now estimate that 40% of all couples' organic fertility problems rest with men. The woman is judged infertile in half the cases, and in 10% the cause is either shared or unknown.
But why has infertility become so prevalent in recent years? Several factors account for the increase.
Maternal age. The social changes and economic pressures of the last decade have caused a large number of couples to delay parenthood. This trend may be beneficial as a move toward parenting from a more secure emotional and financial base . . . but for many women it also diminishes their chances of conceiving. Women reach peak fertility in their early 20's. From the mid-30's on, their reproductive potential gradually diminishes.
Infections. Reproductive-system infections in both men and women take a considerable toll on fertility. They can inflame delicate tissue and leave obstructive scarring. A woman's fallopian tubes, for instance, are especially susceptible to such injury. Sexually transmitted diseases (STD's)— particularly untreated gonorrhea in women are the most damaging of all. This is disturbing, since STD's now strike more than 15 million North Americans—including 3 million teenagers—every year. The widespread incidence of these infections among adolescents suggests that we may see an even further increase in infertility among young couples in the years to come.
One major cause of infertility in women is pelvic inflammatory disease (PID), which is brought on by bacteria that enter the reproductive tract . . . often as a result of untreated gonorrhea or in association with an intrauterine device. PID can be a "silent" infection, wreaking its damage on the fallopian tubes before any symptoms appear.
Environmental and occupational factors. Drugs, radiation, pollutants, and other toxic chemicals can impair fertility. The testicles are particularly sensitive to toxic chemicals, including such infamous compounds as Kepone, DBCP (dibromochloropropane), and dioxin (the well-known contaminant in Agent Orange, the herbicide used widely in Vietnam during the war). These and other spermatotoxic substances are suspected contributors to a dramatic decline in the average sperm counts of American men during the past 50 years. [EDITOR'S NOTE: For a detailed discussion of the male infertility problem, see The Sperm Crisis.]
Stress also can impair reproductive ability. Studies have shown that anxiety can interfere with sperm production and with the female reproductive cycle. Ironically, then, the severe stress of dealing with infertility may actually add to the problem.
Contraceptives. Birth control pills were intended to prevent conception only when taken as prescribed, but some women experience "post-pill amenorrhea", an inability to resume a normal ovulatory cycle after quitting the pill. At highest risk are women who had irregular cycles before they started taking oral contraceptives.
Endometriosis. This disease, long associated with infertility in women, involves overgrowth of the uterine lining, the endometrium. When this happens, endometrial cells appear elsewhere in the body . . . for example, on the ovaries or in the fallopian tubes, which may become blocked. Up to 20% of infertile women—most typically, individuals in their 30's and 40's who have never had children—have endometriosis. Severe menstrual pain is commonly the major symptom, but one-third of those with the condition experience no significant discomfort. Laparoscopy, a relatively simple surgical procedure that uses a small instrument to examine the abdominal cavity, is necessary to obtain a definitive diagnosis. Treatments include analgesics, sex hormones, and/or surgery, but all have significant failure rates. Frustratingly enough, pregnancy—if it can be achieved—seems to cure the disease.
Varicocele. This common cause of infertility in men involves a structural abnormality of the blood vessels in the scrotum. Blood collects in the affected area and its heat impairs sperm production and morphology (shape). Fortunately, varicoceles can often be corrected surgically: About 50% of those who have the operation are able to father children.
When attempting to conceive, try to have intercourse several times a week. Only 16% of fertile couples who make love less than once a week conceive within six months, but the proportion rises to 80% for couples who have intercourse four or more times a week. And be sure not to miss the periovulatory period: the 36 to 48 hours after ovulation when the egg travels down the fallopian tube, and when the cervical mucus becomes most hospitable to sperm. A physician, family-planning clinic, women's health center, or book on "fertility awareness" can help you identify this most receptive time.
To further increase your chances, do not use commercial lubricants during intercourse. Even such products marked "not for contraceptive use" can slow sperm, decreasing the chance for fertilization. And although saliva is still widely recommended as the best and safest natural lubricant, a recent research report reveals that it, too, impairs the movement and activity of sperm. The study's authors suggest using petroleum jelly, glycerin, or egg white instead.
There is no "magic" lovemaking position for conception, but sperm do need time to reach the fallopian tubes, where conception should occur. Since this journey takes 10 to 20 minutes, regardless of the couple's position, the woman can increase the likelihood of conception by lying on her back for about 30 minutes after intercourse. And don't douche . . . this disrupts the sperm.
If you have trouble conceiving, most doctors recommend continuing to try on your own for at least six months. If you're in your 20's, even a year may be a reasonable length of time. Older couples, however, should keep the maternal age factor in mind and not delay seeking help for too long.
Once you've decided to get a physician's assistance, you may want to start with your gynecologist or family doctor. On the other hand, you can go directly to a fertility specialist: a gynecologist or urologist with additional training in reproductive endocrinology.
Among the many diagnostic tests available to infertile couples, semen analysis is basic, as is a pelvic exam for the woman. If two physicians are involved in the fertility workup—a urologist for the man and a gynecologist for the woman—make sure they stay in close touch. And remember, you should feel free to ask whatever questions you may have about infertility and the procedures your doctor recommends: You have the right to get satisfactory answers, and to have a full explanation of any tests-including their costs—and possible side effects. If you don't feel satisfied and confident with your physician, find one with whom you do.
Infertile couples typically experience strong feelings of guilt, sadness, alienation, and anger. According to San Francisco fertility gynecologist Dr. Robert Nachtigall, "Anyone who has worked with infertile couples soon realizes that universal psychological burdens accompany the condition. Infertility is a potential loss of a basic human expression, and the mind deals with that loss in many ways."
Nachtigall says that fertile couples are often unsupportive of infertile couples. And those experiencing difficulty having children usually find it hard to discuss their feelings even with their closest friends.
For this reason, peer support groups have formed in recent years to help people deal with infertility. Perhaps the best-known organization that offers such assistance is Resolve. Most of Resolve's members have all but exhausted the possibilities for traditional biological parenthood, so the organization's goal is to help them deal with their pent-up feelings about infertility, and to make them aware of alternatives, such as adopting a child, trying artificial insemination (by spouse or donor), attempting test-tube conception, or simply learning to accept childless living.
Obviously, infertility is traumatic . . . but more couples than ever who seek appropriate medical and emotional aid can now achieve conception that results in birth. And even those who must remain childless can nevertheless find understanding and support that—in time—can help them adjust to the situation.
Your physician may be able to provide you with—or refer you to—helpful literature on infertility an achieving pregnancy. In addition, you might want to read any or all of the following books on the subject.
Infertility, A Guide for the Childless Couple by Barbara Eck Menning
They Say You Can't Have A Baby: The Dilemma of Infertility by Madeline Blais
What to Do When you Think You Can't Have A Baby by Karol White
EDITOR'S NOTE: Medical Self-Care is Dr. Tom Ferguson's quarterly journal. Dr. Ferguson also has a book titled Medical Self-Care.