Infertility is a multidimensional global health issue that affects both developed and developing countries. There are so many different factors that influence fertility: from being born with reproductive dysfunctions to modern life and social context. The diagnosis of infertility impacts patients on a psychological level likewise, increasing the risk of developing depression and anxiety. Today we will be focusing on female infertility and share stories of women struggling with it. What is infertility, what causes it and how can it be treated? Let’s find out!
What is infertility?
Infertility is characterized by the inability to conceive after 12 months of regular unprotected intercourse in women before 35, and after 6 months for women after 35. Infertility can be classified as first infertility (difficulty to conceive) or second infertility (difficult to conceive the desired number of children).
Based on a study performed by the WHO (World Health Organization), female infertility is estimated to account for 37% in infertile couples, male infertility for 8%, and male and female infertility in the same couple for 35%.
Percentages and causes of infertility can differ by region and economical situation. 15% of the population in developed countries is struggling with infertility, while in developing countries the number can go as high as 30%. A study conducted between 1994-2000, shows the following percentages of secondary infertility in women aged 25-49 by region: Middle Africa (30%), South Asia (26%), USA (15%), Europe (15%), South America (14%). In developed countries, advanced age is the main responsible cause for infertility while in developing countries the main causes are sexually transmitted diseases.
Advanced age enormously affects the chances of conceiving. The chance of getting pregnant for a fertile woman is 20% per month and it decreases by age (with a significant drop after the age of 35). The period of time that it takes to conceive is associated with the increasing age of the couple. Studies show that women older than 35 years were 2 times more likely to get pregnant after 2 years of trying than women below 25.
What are the factors of female infertility?
Lifestyle factors
Pregnancy at a later stage in life. The decision to get pregnant at a later stage in life, is influenced by the change of social and economic context, especially in developed countries. As women wish to pursue a career, be financially stable and independent before starting a family, the social and work environment context pushes them to decide between a career or having children at a suitable reproductive age. By the time these goals are achieved, women may be already in their 30s, when fertility is starting to drop. According to a study, the majority of people undergoing assisted reproduction programs had a high educational level and higher income.
Low body weight. Low body weight disrupts the hormonal balance and ovulation with a negative impact on fertility.
Obesity. Overweight and obese women have a higher risk of developing menstrual and conception dysfunctions. It is also associated with other conditions that can occur after pregnancy: gestational diabetes and hypertension.
Smoking. Nicotine affects the function of the fallopian tube, preventing the transportation of the egg and the interaction with the sperm cell. Active as well as passive smokers are at a risk of developing ectopic pregnancies (pregnancy outside the uterus) and secondary infertility.
Alcohol consumption. Alcohol is a teratogen (causes birth defects) if consumed during pregnancy. Moderate levels of consumption (around 7 drinks per week) has been linked to reduced infertility and miscarriages.
Caffeine consumption in high quantities. Some studies suggest that for heavy consumers it is twice as hard to get pregnant and during pregnancy they are at risk of having miscarriages or give birth to babies with low weight. This effect is still controversial as other studies didn’t find any conclusive results.
Psychological stress. Even though it is not completely proven, some studies suggest that a high level of stress might influence fertility negatively.
Exposure to environmental pollutants and chemicals. Exposure to radiation and toxic substances can cause temporary or permanent infertility.
Genital tract infections and sexually transmitted diseases (especially in developing countries).
Cancer medicine. Annually, many children are diagnosed with cancer and their undergone treatment can have future consequences on their reproductive health. The fields of cancer and reproduction need to collaborate, in order to find ways to treat cancer and preserve fertility without affecting the survival chances.
Use of oral contraceptives. Since the development in the 1960s of reliable contraceptive measures, women had the option to postpone their maternal plans. As a consequence of global use of oral contraceptives, a rapid decline in fertility happened. As the age of women to give birth increased so did the incidence of age-related infertility.
Anatomical and genetic factors
Secondary amenorrhea (lack of menstruation). Secondary amenorrhea is frequently associated with chronic stress, when the hormones necessary for reproduction reach the levels of prepubertal girls.
PCOS (polycystic ovary syndrome). PCOS is a hormonal condition where a woman has a higher quantity of male hormones, which results in hormonal imbalance, irregular menstruation and difficulty in getting pregnant. 25% of women with PCOS suffer from infertility.
Uterine myomas (uterine fibroids). Uterine myomas are tumors that grow in/on/outside the uterus. This condition is very common in women of reproductive age, with an approximate 25% prevalence (many women don’t have symptoms). With advancing age, they can grow and affect fertility, induce miscarriages, require cesarean delivery and preterm delivery.
Endometriosis. Endometriosis happens when the same tissue as the uterine lining (that gets discharged when menstruation happens) grows outside the uterus (on the fallopian tube, ovaries, or other organs such as lungs or bladder). It is one of the most common conditions in women of reproductive age. Annually, it represents an economic impact of $25000 billion for the public health institutions.
PID (pelvic inflammatory disease). PID is a sexually transmitted disease caused by an infection with Chlamydia trachomatis. This disease affects the fallopian tubes producing inflammation and affecting fertility.
Congenital (present from birth) uterine malformations. In case of uterine malformations the uterine cavity is modified (eg.: septate uterus) leading to frequent miscarriages, preterm labor and infertility.
POI (primary ovarian insufficiency)/premature ovarian failure. POI is a condition in which ovaries stop functioning properly before the age of 40.
X chromosome abnormalities. Abnormalities on an X chromosome (DNA molecule) level can lead to recurrent fetal loss.
Intersexuality. Intersexuals are individuals that are born with characteristics from both sexes. Some intersexuals do not have functioning reproductive systems and are infertile.
Infertility and psychological conditions
Infertility has a big impact on a patient's life as they can experience depression, anxiety and distress. Multiple studies showed that a significant number of patients undergoing ART (assisted reproductive technology) was diagnosed with depression or anxiety. These symptoms were high in women, as well as in men.
Besides as a psychological consequence of infertility, these depression and anxiety can also appear as side effects after taking some medications for infertility.
Depression plays a crucial aspect in a patient’s attempt to try fertility treatments. A higher level of depression is associated with a faster termination of the treatment. Despite a good prognostic and available finances, psychological reasons are the main reasons why patients discontinue treatment.
Treatments and prevention
Implementation of programs that encourage a healthy lifestyle and behaviour, and awareness of methods that decrease the spread of STDs
Lifestyle changes: exercise, weight loss, healthy diet
ART (assisted reproductive technology): all methods used for conceiving, that cannot be achieved through sexual intercourse: ovulation induction, IVF (in vitro fertilization), ICSI (intracytoplasmic sperm injection) and ovum donation cycles.
Endocrine (hormone) disorders have to be addressed
Oocyte (cell in the ovary that can be transformed into an egg) or ovarian tissue cryopreservation
IVF (in vitro fertilization): fertilization of the female egg with a male sperm cell in a laboratory. The first successful human fertilization in the laboratory happened in 1978. Even though it is a medical revolution that helped and is still helping many patients, there are still risks of developing complications such as multiple pregnancy, premature birth, malformations or OHSS (ovarian hyperstimulation syndrome). Another downside of IVF is that it is a very expensive procedure. Couples with low income approach this method only after years of trying naturally, due to the high cost of the treatment or small insurance coverage. This approach has negative prognostics as it causes a delay in time and fertilization may occur even harder.
Tubal reconstructive surgery: surgery on the fallopian tubes in order to regain fertility functions. This method can have more advantages than IVF as it is a curative method and allows for women to conceive naturally and more than once without further treatment.
In case of obesity, the standard treatment is weight loss but the ART treatment should not be delayed because of increasing age.
As infertility is a global health concern that affects the future of humankind, the need for further research is imperious.
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