Chapter 389: Infertility and Contraception

INFERTILITY

DEFINITION AND PREVALENCE

Infertility is the inability to conceive after 12 months of unprotected sexual intercourse or after 6 months in women ≥35. This revised definition is based on data indicating that 50% of apparently normal couples will conceive within 3 months, 75–82% within 6 months, and 85–92% within 12 months, but recognizes the age-related decrease in fertility. In the United States, the overall rate of infertility in married women aged 15–44 is 6.7% based on the recent National Survey of Family Growth. The infertility rate has remained relatively stable over the past 30 years in most countries. However, the proportion of couples without children has risen, reflecting both higher numbers of couples in childbearing years and a trend to delay childbearing. This trend has important implications because of the age-related decrease in fecundability, the ability to conceive and carrying a baby to term; the incidence of primary impaired fecundability increases from ~15% between the ages of 15 and 29 to 18% between the ages of 30 and 35, and 40% between the ages of 35 and 44. It is estimated that 12% of women in the United States have received medical assistance for infertility, although this represents <50% of women with current fertility problems. Both infertility and the use of medical services increase with age and both are affected by race and ethnicity. There is increased infertility in non-Hispanic black women and lower use of fertility services among Hispanic and non-Hispanic black women, suggesting disparities in access to care.

GLOBAL CONSIDERATIONS

The World Health Organization (WHO) considers infertility as a disability (an impairment of function) and thus access to health care for this indication falls under the Convention on the Rights of Persons with Disability. Thirty-four million women, predominantly from developing countries, have infertility resulting from maternal sepsis and unsafe abortion. In populations <60 years old, infertility is ranked the fifth highest serious global disability.

CAUSES OF INFERTILITY

The spectrum of infertility ranges from reduced conception rates or the need for medical intervention to irreversible causes of infertility. Infertility can be attributed primarily to male factors in 20% of couples and female factors in 38% of couples and is unexplained in about 15% of couples (Fig. 389-1). Both male and female factors contribute to infertility in 25% of couples. Decreases in the ability to conceive as a function of age in women has led to recommendations that not only should women ≥34 years old seek attention sooner, but that they also receive an expedited workup and approach to treatment.

APPROACH TO THE PATIENT