Normal fertility or fecundity has not been properly defined significantly more women never had a child.

ad a child. 17% of Dani

(see panel). A couple is said to have decreased fertility if women employed in the financial sector had no children
they have not achieved pregnancy within 12 unprotected the age of 35 / Whether this changing trend in fertility is d
cycles. However, this definition is arbitrary. Very fertile to social or biological factors remains to be seen.
couples achieve pregnancy within the first few cycles, and
others make it just within 12 cycles. There may, in fact, be Causes of female Infertility
important biological differences between couples who The causes of infertility may vary from one geographic a
achieve pregnancy in one or two months and those who social area to another. A WHO task forces revealed t
succeed only after 12 or more cycles.
following causes of infertility in women: tubal factor 36%
The care of the infertile couple must be based on an
ovulatory disorders 33%, endometriosis 6%, and n
accurate assessment of fertility in both partners, so clinical demonstrable cause 40%. A similar distribution was fou
examination and investigation of each partner must be in Asia, Latin America, and the Middle East, whereas
designed with this premise in mind. In taking a history, two Africa most infertile women had tubal infertilit
elements are essential-the age of the woman and the
Unexplained infertility (both partners considered) has be
duration of infertility. Fecundity in women decreases after found in 8 to 28% of couples.6
the age of 30 years, and infertility accelerates after 35 years. Rather than reviewing all known causes, we shall focus o
These observations are supported by the demonstration some common causes of female infertility (table) and al
that the pregnancy rate per single embryo transfer with
emphasise new developments. Male infertility has be
natural cycle in-vitro fertilisation (IVF) is 17% for women addressed in a companion article,7 in which sperm-oocy
younger than 30, 13 % for those aged 31-35, and 11% for fusion, unexplained infertility, and untreatable infertili
those aged 36-40 (I D Cooke, Jessop Hospital for Women, have been discussed.
Sheffield, UK). Duration of infertility is another important
variable in determining the chance of pregnancy.l For
Chromosome abnormalities
example, analysis of the cumulative pregnancy rates in Chromosome abnormalities may cause infertility in bot
couples with male-factor problems, and a short duration of men and women, although they are most common amon
infertility, indicates that substantial spontaneous men. Sex chromosome abnormalities in the phenotypi
2
pregnancy rates still occur. female include variants of gonadal dysgenesis (includi
Turner’s syndrome) and androgen insensitivity, but the
Epidemiology
Most studies from industrially developed countries patients rarely attend fertility clinics. In contrast to patien
with androgen insensitivity syndrome, women wit
indicate that about 15 % of all couples will experience either
gonadal dysgenesis usually have a preserved uterus. Thus
primary or secondary infertility at some time during their they may achieve pregnancy by egg donation and IVF.
reproductive lives,3and about half these couples will never
succeed in having as many children as they wish.4 Most
Ovulatory disorders
epidemiological reports on fertility centre on the USA and
western Europe. Our knowledge on fecundity in the Hypothalamic and hyperprolactinaemic anovulation a
caused by an abnormal pulsatile release of gonadotropi
industrially less-developed countries is limited.
Little is known about secular trends in the prevalence of releasing hormone (GnRH)-probably due to alter
infertility. Although some infectious causes such as endorphinergic or dopaminergic tone. Hypothalami
tuberculosis and gonorrhoea are less common now, anovulation is often reversible when mediated b
infertility due to chlamydia infections and environmental exogenous factors such as stress of weight loss.
Premature ovarian failure may be genetically determine
pollution may be increasing. Inconsistency in
or associated with autoimmune disease. In the resista
epidemiological studies makes it virtually impossible to ovarian syndrome, primordial follicles are present but fa
offer firm conclusions about the trend in infertility rates.
to mature owing to lack of sensitivity to follicle-stimulati
On the other hand, the numbers of patients attending
hormone (FSH). Luteinising hormone (LH) recept
fertility clinics are now so high that it may indeed reflect a
growing problem. In 1990, women were 2-3 years older antibodies, not linked to presence of an autoimmun
when they delivered their first child than in 1970;3 disease, may also be a cause of ovarian failure.
Polycystic ovarian disease is thought to be t
commonest cause of anovulatory infertility. Beside
Department of Obstetrics and Gynaecology (Prof D L Healy FRACOG)
and Centre for Early Human Development (Prof A 0 Trounson PhD), anovulatory disturbances, the condition is associated wit
Monash University, Melbourne, Australia; and hirsutism, obesity, and endometrial carcinoma. The ear
University Department of Obstetrics and Gynaecology, miscarriage rate after induction of ovulation is al
Fertility Clinic, Herlev Hospital, Herlev, Denmark (A N Andersen MD) increased. Weight loss is often followed by the return
Correspondence to: Prof David L Healy, Department of Obstetrics and ovulatory cycles.
Gynaecology, Monash University, Level 5, Monash Medical Centre, Research based on serial hormone measurements an
246 Clayton Road, Clayton, Victoria 3168, Australia ultrasonography has given us new knowledge on the norma

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