I INFERTILITY ^648
Approximately 12% of women of childbearing age in the United States have received infertility services (including counseling and diagnosis) in their lifetime. Infertility affects women and men and typically is defined as the inability to achieve pregnancy within 1 year of appropriately timed, unprotected intercourse or therapeutic donor insemination.
According to the American Society for Reproductive Medicine, earlier evaluation and treatment is recommended for women older than 35 years who fail to conceive after 6 months of unprotected intercourse and may be warranted in other women based on medical history or physical findings (such as a history of oligomenorrhea or amenorrhea; known or suspected uterine, tubal, or peritoneal disease or stage III to stage IV endometriosis; or known or suspected male subfertility). It has long been recognized that infertility increases with advancing age. As today’s society emphasizes delay of childbearing, not only are many couples who seek fertility services older, they also have acquired diseases and maintained lifestyles that can adversely affect their fertility. These factors, which include endometriosis, sexually transmitted infections, smoking, and obesity, compound the naturally decreasing fertility associated with age.Three major potential etiologic factors are assessed to uncover the causes of infertility: 1) male factor dysfunction, 2) ovulation dysfunction, and 3) female anatomic abnormalities. Although the specific causes of infertility differ depending on the population studied, in general, one third of infertility is due to female factors alone, one third is due to male factors alone, and the remaining third either is due to a combination of male and female problems or remains unexplained after evaluation. It is common for couples to have more than one cause of infertility. If so, earlier and more aggressive treatment may be indicated.
It is important for health care providers to understand and accept the emotional and educational needs and demands of patients with infertility.
Physicians should appraise their own interests, personality, training, and experience and be prepared to refer patients to subspecialists when appropriate. A team approach is frequently helpful in ensuring that patients receive an adequate evaluation and appropriate counseling. Counseling of patients with infertility who are treated with assisted reproductive technologies (ART) should include, among other things, information regarding the risk of multiple gestation; the ethical issues surrounding multifetal pregnancy reduction; and obstetric and neonatal risks; as well as alternatives to ART, including adoption. In addition, clinicians should be familiar with any state laws regarding infertility services and treatment or insurance coverage.
Supporting services for couples with infertility may include the following:
• Reproductive endocrinology
• Assisted reproductive technologies
— In vitro fertilization
— Intracytoplasmic sperm injection
— Donors (oocyte, sperm, embryo)
— Gestational carriers and surrogate mothers
— Preimplantation genetic testing
— Oocyte cryopreservation (for women facing infertility that is due to chemotherapy or gonadotoxic therapies and for couples who are unable to cryopreserve embryos)
• Psychologic support
• Legal assistance and support
• Urologic and andrology services
• Adoption agencies
• Infertility support groups
• Family counseling
Bibliography
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Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology.
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Resources
American College of Obstetricians and Gynecologists. Evaluating infertility. Patient Education Pamphlet AP136. Washington, DC: American College of Obstetricians and Gynecologists; 2012.
American College of Obstetricians and Gynecologists. Treating infertility. Patient Education Pamphlet AP137. Washington, DC: American College of Obstetricians and Gynecologists; 2012.
American Society for Reproductive Medicine. Adoption: a guide for patients. Birmingham (AL): ASRM; 2006. Available at: http://www.asrm.org/uploadedFiles/ ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/ adoption.pdf. Retrieved August 12, 2013.
American Society for Reproductive Medicine. Fact sheets and info booklets. Available at:http://www.reproductivefacts.org/FactSheetsandBooklets. Retrieved August 12, 2013.
Criteria for number of embryos to transfer: a committee opinion. Practice Committee of the American Society for Reproductive Medicine. Practice Committee of Society for Assisted Reproductive Technology. Fertil Steril 2013;99:44-6. [PubMed] [Full Text]
RESOLVE: The National Infertility Association. Available at: http://www.resolve.org. Retrieved August 12, 2013.