DEFINITION OF INFERTILITY

The inability of a couple to conceive a pregnancy after one year of unprotected sexual
intercourse

PRIMARY VS. SECONDARY INFERTILITY

In primary infertility, pregnancy has never occurred. In secondary infertility, one or both
members of the couple have previously conceived, but are unable to conceive again after
a full year of trying

HYPOFERTILE & STERILE INFERTILITY

Hypofertile couples have trouble conceiving quickly. Their fertility may be less than
ideal or they may be having problems with timing, but they can eventually conceive
without special treatment. For example, the man might have a low sperm count, or the
woman might have endometriosis—roadblocks, but not brick walls.

Sterile couples won't be able to conceive without medical or surgical treatment. For
example, the man might not create enough sperm to fertilize an egg, or the woman might
have blocked fallopian tubes.

HOW IS INFERTILITY DIAGNOSED?

A complete medical history and a physical exam are the first steps in diagnosing a
fertility problem. Both partners need to be evaluated. The couple may also need blood
tests, semen specimens from the man, and ultrasound exams or exploratory surgery for
the woman.

HOW IS INFERTILITY DIAGNOSED IN A WOMAN?

If a woman has an infertility problem, she will be referred to a doctor who specializes in
reproductive endocrinology. Her diagnostic tests may include:
  Blood tests and urine tests to check hormone levels.
 A Pap smear to study the health of the cervix.
 Urine tests to evaluate LH surges.
 A basal body temperature test, which checks whether the woman is releasing eggs
from her ovaries. A woman's temperature rises slightly during the days she
ovulates. The woman will chart her basal body temperature every day for a few
months on a graph. She will take her temperature orally or may take her
temperature vaginally with a special ultra-sensitive thermometer available at most
drugstores.
 An endometrial biopsy, in which the doctor removes a piece of tissue in the
uterine lining. Examining this tissue will tell the physician whether eggs have
been released and whether the corpeus luteum is producing enough progesterone.
This test is often done if the results from the woman's basal body temperature
chart are unclear.
 An ultrasound to look for fibroids and cysts in the uterus and ovaries. This test
uses sound waves to picture the uterus and ovaries, causes little discomfort, and is
very effective.
 A postcoital test, in which the doctor takes a sample of mucous from the woman's
vagina. She must have the test during her fertile days and within 12 hours after
she and her partner have sex. The test will tell the doctor if the man's sperm can
survive in the woman's cervical mucous.

More complex tests include:

• A laparoscopy: If the doctor suspects ovarian or fallopian tube scarring or

endometriosis, a woman may undergo a laparoscopy. The doctor makes two small
incisions at the pubic bone and navel, and carbon dioxide gas is injected into the
stomach to enlarge it.

Then the doctor inserts a laparoscope, a long tube with lenses and a fiberoptic
light, into one incision and a long probe through the other opening in the skin.
With the probe, the doctor can view the ovaries, fallopian tubes and uterus to
 check for scar tissue. In some cases, he may cut away scar tissue discovered
during this operation.

The woman usually has to undergo general anesthesia for the procedure, but the
risks of bleeding, infection and reaction to the anesthesia are slight.

• A hysterosalpingogram: This test checks the condition of the woman's fallopian

tubes.

The doctor clamps the cervix and injects a needle filled with dye into the woman's
uterus. An X-ray is taken to determine whether the dye passes through the open
ends of the fallopian tubes. If the dye emerges from the end of the tubes, they are
not blocked.

The test may also reveal other fertility problems, such as fibroid tumors, structural
abnormalities and endometrial polyps. In some cases, the dye actually clears away
blockages in the fallopian tubes, and restores the woman's fertility.

The dye is harmless and is absorbed by the woman's body after going through her
tubes. The test may be uncomfortable, but is rarely painful. Unfortunately, it is
noted for both false positive and false negative diagnoses.

HOW IS INFERTILITY DIAGNOSED IN A MAN?

The tests for male infertility are fairly simple and easy. After a medical history and an
examination, the man's sperm are tested. He'll be asked to ejaculate into a cup and this
specimen will be evaluated. The man should not ejaculate for several days before he
takes the test, because each ejaculation may reduce the sperm count.

Health workers will check the man's semen for several factors:

• sperm count (20 to 100 million sperm is the normal number)

• movement
• maturity and shape of the sperm (which reveal its quality)
 • the amount of sperm produced (one teaspoon is sufficient)
• acidity (the semen should be slightly acidic)

The man may be asked to undergo this test twice, because some illnesses such as
infections or viruses can affect the sperm. If a man has abnormal sperm, he'll be referred
to a fertility specialist, where he'll experience more tests, such as:

• Hormonal blood tests.

• Imaging tests that check for swollen veins or reproductive system blockages.
• A testicular biopsy. This is a procedure done in the office. The doctor takes bits of
tissue from the testes, and this tissue is examined to see whether the cells that
produce the sperm are working properly.
• Anti-sperm antibody tests, which check whether the woman's mucous rejects the
man's sperm. These tests also show whether the man produces antibodies to reject
his own sperm.
• A hamster egg test, which studies the sperm's ability to penetrate a hamster egg.
The outer covering of the egg is removed to allow the sperm to more easily
penetrate. This test cannot result in a living embryo. It's expensive, however, and
sometimes unreliable.
• A human zona penetration test, which tests whether the man's sperm can fertilize
dead human eggs. Again, this test cannot result in a living embryo, and is thought
to be more reliable than the hamster egg test.
• A bovine cervical mucous test, which checks whether the sperm can penetrate
cervical mucous taken from a cow.

TYPES OF INFERTILITY IN WOMEN

The most common causes of infertility seen in women are:

Illness - Certain diseases, such as diabetes, kidney disease or high blood pressure may
cause infertility. Ectopic pregnancy and some urinary tract infections may also elevate
the risk of infertility.
Medications - Many medicines, such as hormones, antibiotics, antidepressants, and pain
killers may bring on temporary infertility. Commonly used medications such as aspirin
and ibuprofen can also impair fertility if taken mid-cycle. Acetaminophen (Tylenol) pills
can reduce the amount of estrogen and luteinizing hormones in the body, impairing
fertility.

Premature Menopause - Some women may experience premature menopause, when

their ovaries stop producing eggs. Often the cause is excessive exercise or anorexia.

Surgical Complications - Scar tissue left after abdominal surgery can cause problems in
the movement of the ovaries, fallopian tubes, and uterus, resulting in infertility. Frequent
abortions may also produce infertility by weakening the cervix or by leaving scar tissue
that obstructs the uterus.

Immune System Problems - Women may develop antibodies or immune cells that
attack the man's sperm, mistaking it for a toxic invader. Certain autoimmune diseases, in
which the woman's immune cells attack normal cells in her own body, may also
contribute to ovarian problems.

Luteal Phase Defect - In a luteal phase defect, a woman's corpus luteum - the mound of
yellow tissue produced from the egg follicle - may fail to produce enough progesterone to
thicken the uterine lining. Then the fertilized egg may be unable to implant.

Fibroids - Fibroids, or benign growths, may form in the uterus near the fallopian tubes or
cervix. As a result, the sperm or fertilized egg cannot reach the uterus or implant there.
Fibroids in the uterus are very common in women over age 30.

Ovulation Disorders: A very fine balance of various hormones such as estrogen,

progesterone, luteinizing hormone, follicle-stimulating hormone is required to timely
ovulate (release of egg from the ovary). The main cause of ovulation disorders is
hormone imbalance. Low levels of progesterone can cause interference in the adhesion of
the embryo to the uterine lining. It also increases the risk of a miscarriage. High levels of
estrogen are also associated with infertility in women.

Ovarian failure Ovarian failure can be a consequence of medical treatments (for ovarian
tumours for instance), or the complete failure of the ovaries to develop or contain eggs in
the first place (for example, Turner's Syndrome).The treatment for ovarian tumours may
involve surgical removal of all or part of the ovary. Ovarian failure can also occur as a
result of treatments such as chemotherapy and pelvic radiotherapy for cancers in other
body areas. These therapies destroy eggs in the ovary.

Endometriosis: It refers to a condition where the uterine lining doesn't form normally. It
grows outside the reproductive tract causing fallopian tubes to become blocked. These
blockages cause infertility in almost 10% of infertile women. In advance cases of
endometriosis, the forward movement of sperm are blocked due to adhesion between
fallopian tubes, ovaries and uterus. This results in infertility. Studies have indicated that
the eggs of women with endometriosis are more likely to have genetic abnormalities than
those who do not have the disease.

Uterine and Cervical Disorders: Benign growths such as fibroids on the uterine wall
can interfere with the attachment of embryo to the wall of the uterus and thereby cause
problems in conception.

Abnormalities in cervix shape or change in the texture of cervical mucus can make
the movement of sperm from vagina to uterus extremely difficult.

Ageing :Age is a critical factor affecting a woman's fertility woman. In our society many
women choose to delay having children. Some of the common reasons for this include
education and career demands, financial stability, second marriages/relationships and
waiting for a suitable partner.

Reproductive function declines as a woman ages, particularly after the age of 35. Women
are born with a finite number of eggs, unlike men who produce sperm most of their adult
life. In the years approaching menopause, there are fewer and fewer eggs left in the
ovary. The quality of eggs also diminishes as a woman gets older. When a woman is in
her late thirties, there is an increase in chromosome abnormalities that can result in birth
defects like Down syndrome.

Ageing can also affect other reproductive organs and functions, such as the uterus,
hormone production, and ovulation. There is also a higher incidence of miscarriage in
women in their late thirties.

Infertility treatments cannot reverse the ageing process and should not be thought of as a
safeguard that will ensure a pregnancy at some point in the future. The success rates of
IVF for women over 35 are much lower than for younger women.

Polycystic ovaries: Polycystic ovaries contain lots of small cysts, making the ovary
larger than normal. The condition, called polycystic ovarian disease (PSOD), is also
associated with high levels of androgen and estrogen. Women with PSOD have irregular
periods and may not ovulate, resulting in infertility.

Immunological factors: The presence of antibodies to sperm in cervical mucus can

cause infertility. In other cases, the mother's immune system prevents the embryo from
attaching to the wall of the uterus and so causes a miscarriage.

Fallopian tube damage: It is in the fallopian tube that fertilization takes place, after the
egg is released from the ovary into the tube and is met by sperm. Full or partial blockage
of the fallopian tubes will prevent fertilization taking place.

Fallopian tubes can be damaged by inflammation that results from viral or bacterial
infections, some types of sexually transmitted diseases, or complications of surgery such
as adhesions or scarring.

MALE INFERTILITY

Sperm defects
A low sperm count is the most common cause of male infertility. Abnormalities in sperm
shape or their ability to swim can also cause infertility problems. These can be due to
hormonal imbalances, infection, or testicular varicocele.

A total absence of sperm (known as ' azoospermia') in the ejaculate can be caused by
testicular damage, mumps, anatomical disorders, or lack of hormones.

Immunological factors

Some men produce antibodies to their own sperm, which prevent the sperm from
penetrating the egg. The exact cause is not known but may be due to infection or
vasectomy.

Spermatic cord occlusion

The spermatic cord is the tube that transports the sperm from each testis to the penis and
any blockages will cause infertility. Common causes are vasectomy, infection and some
sexually transmitted diseases.

Ejaculation disorders

Some ejaculation disorders such as retrograde ejaculation – where the semen is ejaculated
backwards into the bladder – can prevent proper transfer of sperm into the vagina without
the man being aware of the problem.

Under-developed testes-usually arising after a mumps infection, a hernia surgery, an

injury or birth defect.

Swollen veins in the scrotum.

Undescended testes-a problem often present from birth in which the testes remain in the
body cavity. Normally they descend into the scrotum before birth.
Infections, such as gonorrhea or tuberculosis, that block the ducts through which the
sperm travel.

Injury to the testicles

Chronic prostate infections

Ageing

Until recently, ageing was considered a risk factor only for female fertility. However,
recent research shows ageing affects sperm function too. Sperm that swim in a straight
line have a far better chance of making their way through the female reproductive tract to
reach the egg. But the swimming ability of a man's sperm declines as the man ages. The
older a man gets the greater the chance of genetic abnormalities in the sperm itself.

UNEXPLAINED INFERTILITY

In approximately ten per cent of couples, both partners may appear fine but are still
unable to become pregnant. While it is easier to treat couples where the cause of
infertility is obvious, couples with unexplained infertility can also be treated

HOW IS INFERTILITY IN A WOMAN TREATED?

After the physician has determined possible causes of the infertility, a course of treatment
can then be planned. Sometimes simple instructions, like knowing when having sex is
most likely to produce a pregnancy, are all that is needed. In many cases, medications are
indicated, while in other cases, the woman may require surgery or other forms of
treatment.

If medications are unhelpful or surgery is not appropriate, other specialized techniques

will be offered.
Medications can help solve hormonal problems and ease infections in women with
fertility problems. Surgery to repair reproductive organs may also resolve a woman's
infertility.

WHAT MEDICINES TREAT FEMALE INFERTILITY?

If the woman isn't producing eggs, often she can be helped with fertility drugs. Fertility
drugs are fairly safe, although some researchers have voiced concern that they may
increase the risk for ovarian cancer. Several of the most recent studies, however, have
found no increased risk of ovarian cancer and suggest that the drugs may even protect
against cervical cancer. Fertility drugs include:

Clomiphene: This drug triggers the release of FSH and LH, boosting egg growth and
helping the ovaries release a monthly egg. The drug is considered safe, is fairly
inexpensive, and carries less risk of multiple births than other drugs. Women who have
polycystic ovary syndrome or menstruate irregularly apparently benefit most from this
drug. Sixty percent of women on clomiphene successfully ovulate, and about 30 percent
of women become pregnant in the first three months of being on the drug. Side effects
may include nausea, insomnia, breast tenderness and headaches.

Bromocriptine: This drug suppresses a hormone called prolactin, which, if released in

excessive amounts, may cause a woman to stop ovulating. Ninety percent of women on
bromocriptine release eggs while on the drug. It's considered fairly safe, but side effects
may include nausea, dizziness, headaches and low blood pressure.

Human Menopausal Gonadotropins (HMG): If other drugs don't work, the doctor may
prescribe HMG. This drug is comprised of hormones extracted from the urine of
postmenopausal women and contains large amounts of LH or FSH. Women who have
trouble ovulating, endometriosis, infertility caused by cervical problems or unexplained
infertility are good candidates for this drug. To monitor the woman's progress, the doctor
will order regular ultrasounds to check the quality and number of eggs being released.
Luteinizing Hormone-Releasing Hormones (LH-RH): LH-RH drugs are used when
the pituitary or hypothalamus gland is not producing hormones. They are also used to
treat endometriosis. Most women must administer these drugs themselves with a portable
pump, and the equipment is unwieldy and expensive. Risks include an increased chance
of infections and clotting, and multiple births.

Human Chorionic Gonadoptropin (hCG). Chorionic gonadoptropins are often

prescribed with HMGs, and sometimes with clomipheme, to stimulate the release of the
egg. They may also be used to treat endometriosis. One of these drugs, Humegon, has
resulted in pregnancy in more than 26 percent of cases in clinical trials. Possible side
effects are ovarian enlargement, ovarian cysts and multiple births.

Urofollitropin (FSH): This drug is made up of FSH taken from the urine of
postmenopausal women. It can be used with hCG to bring on the release of an egg. It's an
effective drug for women with polycystic ovary syndrome, for whom clomiphene has
been ineffective.

Other medications that may cure fertility problems include:

Antibiotics - They may cure infections in the reproductive system, such as in the cervix
or lining of the uterus, and some sexually transmitted diseases.

The hormone progesterone - This hormone develops the lining of the uterus and helps a
fertilized egg implant.

Corticosteroids -These may be prescribed for the treatment of endometriosis.

Oral contraceptives, antiandrogens, and drugs to reduce insulin levels - These drugs
are used in women with polycystic ovary syndrome to restore regular periods and
ovulation and to reduce symptoms stemming from an oversupply of male hormones.

Drugs to treat thyroid disease, benign tumors or to improve poor quality cervical
mucous.
WHAT SURGERIES TREAT FEMALE INFERTILITY?

If investigations suggest that surgery may cure infertility, then depending on the cause,
surgery may be used to deal with:

• Fibroids or defects in the woman's uterus.

• Endometriosis in the woman. In these surgeries, the doctor removes the uterine
tissue that has grown outside the uterus.
• A scarred fallopian tube in the woman. In surgeries for this problem, the scarred
tissue is removed or the entire scarred section of the tube may be cut out. The tube
is then rejoined and reattached to the uterus.

HOW IS INFERTILITY IN A MAN TREATED?

WHAT MEDICINES TREAT MALE INFERTILITY?

A number of drugs can be prescribed to ease male fertility problems, but their
effectiveness varies widely. Here's a look at some of them:

Hormones - Though hormones can be quite successful in women, they are only
occasionally effective in men. Hormone drugs for men include testosterone, menotropins,
GnRH medications, bromocriptine, clomiphene citrate and human chorionic
gonadotropin (hCG). Many of these drugs are quite expensive, however.

Antibiotics - These may help treat sexually transmitted diseases and other infections.

Corticosteroids - These drugs can aid men who make antibodies to reject their own
sperm, but they may also have serious side-effects after long use.

Viagra - This is a newly developed medicine for male impotence. The man takes Viagra
an hour before having sex. The medication improves blood flow to the penis, resulting in
an erection. Studies have revealed that 70 percent of men who used Viagra improved
their ability to maintain an erection. The drug can have severe side effects for certain
men, however, especially those with heart disease. Men with heart disease, who have had
a heart attack, or those with low blood pressure should not take the drug.

WHAT SURGERIES TREAT MALE INFERTILITY?

If investigations suggest that surgery may help with male infertility, then depending on
the cause, surgery may be used to deal with:

• Varicose (or swollen) veins in the man's scrotum, helping to restore proper
sperm movement.
• An obstruction in the man's reproductive organs, including the epididymis,
vas deferens and ejaculatory duct. These blockages can halt the sperm's passage
or prevent it from mixing with semen.

WHAT IS ARTIFICIAL (PARTNER) INSEMINATION?

If the man's semen is fertile but can't reach the cervix because of premature ejaculation or
an inability to maintain an erection, partner insemination may be considered. Men with
low sperm count, women with poor quality mucous, and couples with reproductive
abnormalities may also benefit from this procedure.

Even if the man has erection problems, he may collect his sperm through a partial
erection. The woman also takes fertility drugs to increase her output of eggs. During a
day when she is ovulating, she places the man's semen in her cervical canal with a
syringe. The doctor may also perform this simple procedure in his office.

If the man has low sperm count, his sperm can be "washed" to instill it with more energy
beforehand. In this procedure, the sperm is separated from semen and then placed in the
woman's cervix. Adding calcium to the sperm washing solution or storing it briefly in a
liquid containing warm egg yolk may also enhance the sperm's movement.
For women with cervical mucous that is too thick, or for partners with reproductive
abnormalities or unexplained infertility, the sperm may be placed in the uterus or
fallopian tubes instead of the cervix.

Unfortunately, partner insemination is not always a guaranteed success. A couple may

have to go through the procedure six to 12 times before pregnancy occurs.

WHAT IS DONOR INSEMINATION?

Donor insemination uses sperm from a donor male that is placed in the woman's cervix,
fallopian tubes or uterus. This procedure may create pregnancy if the partner has few or
no sperm, or an untreatable illness that affects his reproductive system. Single women
who wish to have a child without a partner often use this method to achieve pregnancy.

Donors are screened for illnesses such as sexually transmitted diseases, for blood types,
and for sperm that may react to the woman's mucous. Routine use of frozen semen also
may reduce the risk of sexually transmitted diseases.

ASSISTED REPRODUCTION

Assisted reproduction refers to a number of advanced techniques that aid fertilization.

These techniques are often used for women who have irreversible damage to their
fallopian tubes or cervical mucous problems. It can also benefit couples with unexplained
infertility.

IVF (In-Vitro Fertilization)

IVF is the most well known of assisted reproduction techniques. In this method, the
woman takes fertility drugs to stimulate her ovaries to produce more eggs. The physician
then retrieves one or more of the eggs by laparoscopy or by passing a needle through the
vaginal wall. The partner's sperm is then mixed with the eggs in a petri dish, and
fertilization may take place.
If fertilization occurs, the embryo is allowed to develop outside the womb for a few days.
Then it is implanted in the lining of the woman's uterus with a small plastic tube. Most
centers now place two to four embryos in the womb in the hope that one will burrow into
the lining and begin to develop normally. Any leftover embryos are frozen to be used
later, should the first IVF procedure fail to work. IVF increases the risk of multiple births.

In a variation of IVF called ovum transfer, a donor egg is fertilized with the partner's
sperm and then placed in the woman's uterus. This technique is often used when the
woman has not been able to produce eggs, even with fertility drugs.

The effectiveness of IVF has improved in the past few years but the chance of pregnancy
is still only 20 to 40 percent. It costs as much as $12,000 and usually is not covered by
insurance, although some states require coverage of infertility treatment.

GIFT (Gammete Intrafallopian Tube Transfer)

In this method of assisted reproduction, the woman's eggs are retrieved but not fertilized.
Instead, they are mixed with the man's sperm and immediately placed into the woman's
fallopian tubes. The woman must have healthy tubes for GIFT to work.

ZIFT (Zygote Intrafallopian Transfer)

ZIFT involves placing the fertilized egg itself into the fallopian tubes. This procedure can
be more successful than GIFT because the doctor has a greater chance of ensuring that
the egg is fertilized. Again, the woman must have healthy tubes for ZIFT.

ICSI (Intracytoplasmic Sperm Insertion)

In this technique, a single sperm is injected into the egg, and the embryo is placed in the
fallopian tubes or uterus. This method is often recommended when the male partner has
very few sperm or other fertilization methods are not suitable for the couple.
FASIAR (Follicle Aspiration, Sperm Injection, and Assisted Follicular Rupture)

In a new method known as FASIAR, the physician punctures the follicle, and then
removes the eggs with a syringe that also holds the sperm. This mixture is then
immediately injected back into the follicle. FASIAR may reduce the risk of multiple
births and is less expensive than other procedures.

PREVENTION

For having positive effects on fertility incorporating the following into lifestyle before
and during the time males & females are trying to conceive could be beneficial:

Quit smoking. Smoking has been linked to low sperm counts and sluggish sperm
motility in men and an increase in miscarriage in women.

Reduce your alcohol intake. Alcohol (especially binge drinking or chronic abuse),
affects the fertility of both men and women trying to conceive either naturally or through
infertility treatments. Alcohol is toxic to sperm, reduces sperm counts, can interfere with
sexual performance, disrupt hormone balances and increases the risk of miscarriage.

For women, no more than one to two standard drinks a day is recommended. For men,
the limit is slightly higher – three to four standard drinks a day.

Eat a balanced diet. A well-balanced diet includes carbohydrates, protein and fibre. All
women should increase folic acid intake (found in green leafy vegetables, fruit, cereals,
but also available as supplements) prior to and during the first three months of pregnancy.

Exercise moderately. Excessive exercise can lead to menstrual disorders in women and
affect sperm production in men due to the heat build-up around the testicles.

Avoid environmental poisons and hazards such as pesticides, lead, heavy metals, toxic
chemicals, and ionizing radiation.
Check with your doctor that any medication or herbal remedies (prescribed or over-the-
counter) that you may be taking do not affect fertility.

Give up recreational drugs such as marijuana and cocaine as these have been linked to
low sperm counts in men and infertility in women.

Women in particular should:

Lose weight if you are overweight. Being overweight can decrease your chances of
becoming pregnant. This can be achieved through moderate exercise and a balanced diet,
both of which have positive effects on fertility.

Men in particular should:

Wear loose-fitting underwear such as cotton boxer shorts. Tight-fitting underwear can
lower sperm production.

Prevent overheating. Stay clear of saunas, spas and hot baths, as heat around the
testicles impairs sperm production.

COST AND LEGAL ISSUES

HOW MUCH DOES IT COST?

The cost of a stimulated IVF cycle – where hormones are used to boost egg numbers –
varies between clinics but is approximately $3000. There are additional costs for services
such as donor programs, ICSI, PGD, artificial insemination, freezing of sperm and
embryos.

Medical appointments and most infertility treatments are covered by Medicare.

If one have private medical insurance then hospital day surgery fees are covered
(providing IVF is included in the level of private health insurance that one have).
The "Medicare Plus Safety Net" provides a rebate of approximately 80 per cent of "out of
pocket " fees paid for out-patient services that are provided outside a hospital . It is not
applicable for procedures such as oocyte retrieval or ICSI.

LEGAL REQUIREMENTS

The laws regarding infertility treatments differ in each state.

Victoria has the most stringent legislation regulating the use of IVF in clinics and for
research purposes. In 1995 the Victoria Parliament passed the Infertility Treatment Act
1995. It also set up a regulatory body called the Victorian Infertility Treatment Authority
(ITA) to oversee the use of infertility treatments in clinics and research into infertility
within Victoria. Doctors, scientists and counselors involved in infertility treatments in
Victoria must obtain approval from ITA.

In Western Australia, the Human Reproductive Technology Act 1991 governs the use of
infertility treatments. Likewise in South Australia there is the Reproductive Technology
Act, 1988. The remaining states do not have specific legislation but clinics adhere to
strict guidelines set out by the National Health and Medical Research Council.

All infertility centres are inspected and accredited by a body of professionals and
consumers (patients) established under the auspices of The Fertility Society of Australia.
This body is called Reproductive Technology Accreditation Committee and is
responsible for the setting of best practice guidelines and standards for infertility
treatment in Australia and New Zealand. Failure to achieve accreditation status from this
body means that treatment offered by the infertility centre is not covered by the Medicare
rebate.

Storage of eggs, embryos and sperm

There are laws that govern how long gametes (eggs and sperm) and embryos can be
frozen. These laws are enforced to ensure the decision-making process regarding the use
or disposal of gametes and embryos is kept with the couples who produced them.
In Victoria, eggs and sperm can be stored for a maximum of ten years, and embryos for a
maximum of five years (although the ITA can grant an extension).

If one has stored eggs or embryos she has the following options:

• use them yourself

• donate them to another couple
• dispose of them
• Donate them to research.

Donor eggs, embryos and sperm

Where legislation exists, donor gametes (eggs and sperm) can only be used if defects in
the gametes will not allow fertilization to occur or if there is the possibility that a gamete
carries a genetic abnormality that can be passed onto the child.

In Australia, it is against the law to buy eggs from donors. Some clinics offer an egg
donation service where women may donate their eggs to infertile couples. However, due
to lengthy waiting lists and very few donors, clinics will encourage you to find your own
donor.

With regard to parental rights, the law recognizes that the woman who gives birth to the
child is the mother, regardless of the child's genetic origins.

There is different legislation for freezing sperm depending on the intended use. If sperm
is to be used to fertilize your partner's eggs to produce a child, then you will have legal
and social obligations to care and support that child. If the sperm is to be donated, the
only obligations you have are to undergo counseling and testing for transmissible
diseases prior to donating.

Laws governing information access vary in each state. In Victoria, legislation dictates
that a compulsory register must be kept detailing identifying information of donors and
their offspring. Donors can find out how many children have been born from their
donations. And children born from donated gametes or embryos can apply for their birth
origin information once they reach the age of 18.

In NSW, there are no laws regarding identification issues for gamete and embryo donors
or children. However, IVF clinics recommend that the donor be someone you know in
order for the child to maintain some level of contact with their genetic 'parent'.

PSYCHOLOGICAL & EMOTIONAL ASPECTS OF

INFERTILITY

Most people simply take it for granted that they will be able to have children. In fact, one
in six couples trying to have a baby will experience problems in doing so. Infertility is
often described as a life crisis, creating upheavals similar to those associated with a death
in the family or divorce. People are often shocked when they discover that they are
infertile and commonly go through a period of disbelief. Others rush into treatment
without first coming to terms with the diagnosis. The overall impact of infertility on
individuals differs greatly, and is influenced by factors such as cultural background and
the importance a person places on having children in their life.

INFERTILITY AND WOMEN

Individual women have different experiences of infertility but there are several feelings
that are common. Women may feel a sense of anger at not being able to have children
and resentment towards other pregnant women. They may also have feelings of guilt,
regarding their infertility as punishment for putting their career first, using contraception,
or for a previous termination.

Some women may feel uncomfortable around children and consequently start to isolate
themselves from family and friends who have children. Increasing isolation leaves the
women without social support networks to help them overcome the feelings of depression
and frustration commonly associated with infertility. Christmas, Easter, Mother’s and
Father’s Day become painful reminders of their infertility instead of celebratory
occasions.

A woman may develop feelings of hatred or disgust towards her body, perceiving it as
inadequate, dysfunctional and diseased. Similarly, a woman’s sense of femaleness is
often closely associated with pregnancy and motherhood. Infertility, therefore, may have
a serious impact on a woman’s sexual identity, leaving her feeling less sexually attractive
or asexual.

Infertility and attempts to overcome it can lead to a loss in perspective. Women may put
everything else in their lives on hold, putting all their energy and time into getting
pregnant. They may delay making changes in everything from their careers to their
current housing situation, deciding to wait until after they have 'had the baby'.

Infertility and, in particular, medical treatment programs can place women on an

emotional rollercoaster of hope and then despair. Women may often go through a cycle
of hopefulness leading to disappointment at the arrival of their period.

INFERTILITY AND MEN

Many of the medical treatments for infertility focus on the woman’s body which can
leave men feeling helpless and left out of the process. If the couple’s infertility is due to a
sperm dysfunction, the man may feel that he is impotent or lacking in masculinity. The
strong societal link between fertility and virility causes many men to keep their infertility
a secret, in turn increasing their feeling of isolation. While women may find some support
from female friends, it is not uncommon for men‘s male friends to show little
understanding.

INFERTILITY AND RELATIONSHIPS

Infertility can also place a great strain on a relationship, particularly in cases in which the
problem lies with one partner. The infertile partner may constantly fear being left for
another (fertile) person, while the fertile partner may blame or feel anger towards their
partner. Frequently there are differences in couples’ expectations concerning children,
with women more likely to express a greater need for a child. Differing levels of
enthusiasm are often apparent in couples where one partner has children from a previous
relationship. Coming to an agreement on what fertility tests to perform, what treatment
options to pursue and when to stop treatment can all cause conflict in the relationship. If
one partner does not want to begin or continue with treatment, the other partner may feel
as though they are being denied the chance to have a child and become resentful.

Treatment for infertility also frequently interferes with a couple’s normal sex life. The
initial discussions to identify possible fertility problems involve disclosing many personal
details regarding one’s sex life. Similarly, the loss of privacy associated with tests such as
sperm counts and the post-coital test can destroy feelings of intimacy. Timing sex around
ovulation can make it feel like a chore than something pleasurable. The lack of
spontaneous sex and sex for enjoyment rather than procreative purposes can lead to
sexual dysfunction such as erectile problems in men and vaginal dryness in women.

Although infertility is potentially the source of much strain on a relationship, many

couples also report that going through the experience has made their relationship
stronger. Couples that have shared the physical and emotional stresses of infertility may
feel that it has brought them closer together and has cemented their relationship.
Successfully coping with infertility can result in couples feeling confident that they can
tackle any future problems.

INFERTILITY AND FAMILY/FRIENDS/EMPLOYERS

Infertility can also place a strain on relationships with family and friends. Families, in
particular prospective grandparents, may place added pressure on people by publicizing
their expectations for grandchildren. Enquiries from in-laws can be especially stressful
and the daughter or son-in-law may feel that the comments are intrusive. Friends who are
unaware of the full implications of infertility may appear unsympathetic and offer
unhelpful suggestions such as "go on a holiday". Friends and family with children may
assume that people with infertility do not wish to be reminded about children and so will
avoid announcing their own pregnancies or issuing invites to social events like children’s
birthday parties and baby showers.

Employers may not fully understand the issue of infertility and are, therefore,
unsupportive. An employee may find it difficult to arrange time off work to undergo
diagnostic tests and treatment. Similarly, they may not feel comfortable revealing why
they require the time.

POSITIVE STRATEGIES

For some couples and individuals, becoming informed, consulting a counsellor or

therapist and joining a support group can help in coming to terms with infertility and
coping with the stresses of treatment programs. Different coping strategies will suit
different people and be appropriate for particular stages of the infertility experience.

Becoming informed
Obtaining information about infertility and the various treatment options available helps
people to feel that they are more in control of the situation. Reading material on the topic
also allows people to make informed choices about tests and treatments and to
confidently ask their health practitioner any questions they may have.

Counseling:
Visiting a counselor who is experienced in infertility issues will enable people to openly
discuss their feelings about being infertile. They can also voice their fears and concerns
about approaches to treatment, as well as the possibility of remaining childless.
Counseling may be particularly beneficial to couples whose relationship has suffered as a
result of infertility. For couples experiencing disruptions to their normal sex life, advice
from a sex therapist may be useful.

Support groups:
Many people confronted by infertility find that consulting or participating in a support
group can be very helpful. A support group can provide information on infertility and
infertility treatments as well as contact with other people with similar problems. Being
able to talk to people who have been through the same ordeal reduces feelings of
isolation. Support groups offer strategies for coping with particular problems associated
with infertility and can also offer a sense of hope through sharing other people’s success
stories.

PREVALENCE

• Generally, worldwide it is estimated that one in seven couples have problems

conceiving, with the incidence similar in most countries independent of the level
of the country's development.

• Fertility problems affect one in seven couples in the UK. Most couples (about 84
out of every 100) who have regular sexual intercourse (that is, every 2 to 3 days)
and who do not use contraception will get pregnant within a year. About 92 out of
100 couples who are trying to get pregnant do so within 2 years.

• Women become less fertile as they get older. For women aged 35, about 94 out of
every 100 who have regular unprotected sexual intercourse will get pregnant after
3 years of trying. For women aged 38, however, only 77 out of every 100 will do
so. The effect of age upon men’s fertility is less clear.

• In people going forward for IVF in the UK, roughly half of fertility problems with
a diagnosed cause are due to problems with the man, and about half due to
problems with the woman. However, about one in five cases of infertility have no
clear diagnosed cause

• In Britain, male factor infertility accounts for 25% of infertile couples, while 25%
remain unexplained. 50% are female causes with 25% being due to an ovulation
and 25% tubal problems/other

• In Sweden, approximately 10% of couples are infertile. In approximately one

third of these cases the man is the factor, in one third the woman is the factor and
in the remaining third the infertility is a product of factors on both parts.
INFERTILITY: PROGNOSIS

It is very hard to obtain statistics regarding the prognosis of infertility because many
different problems may exist within an individual or couple trying to conceive. In
general, it is believed that of all couples who undergo a complete evaluation of infertility
followed by treatment, about half will ultimately have a successful pregnancy. Of those
couples who do not choose to undergo evaluation or treatment, about 5% will go on to
conceive after a year or more of infertility.
REFERENCES:

• Hornstein, Mark D., and Daniel Schust. "Infertility." In Novak's Gynecology. 12th
ed. Ed. Jonathan S. Berek, et al. Baltimore: Lippincott, 1996.
• Martin, Mary C. "Infertility" In Current Obstetric and Gynecologic Diagnosis
and Treatment, ed. Alan H. Decherney and Martin L. Pernoll. Norwalk, CT:
1994.
• ^ Khan, Khalid; Janesh K. Gupta; Gary Mires (2005). Core clinical cases in
obstetrics and gynaecology: a problem-solving approach. London: Hodder
Arnold. pp. 152. ISBN 0-340-81672-4.
• Hull, M et al qtd in Prosser, C. Determining the causes of fertility problems
Nursing Times 1997 Vol 93 No 45 p48-50
• Harkness, C. The inFertility Book: A Comprehensive Medical and Emotional
Guide San Francisco: Volcano Press 1987 p16-17
• Zoldbrod, A. Psychosocial aspects of male infertility ACCESS National
Newsletter Spring 1997 p5