Today in the United States, or so the media would have us believe, we are in the midst of a major infertility epidemic. Although statistics do not quite bear out that hypothesis, infertility is increasing. Surveys taken by the National Center for Health Statistics in 1995 suggest that 10.2 percent of American women of childbearing age (15-44 years) have impaired fertility. Of these women, 2.5 million have never had children and 3.4 million have had at least one child. Similar surveys in 1988 show only 8.4 percent of American women with infertility problems.

While only 15 percent of couples will succeed in their first month of trying, within six months about 50 percent will be pregnant. And by the end of the first year about 80 percent will be, which explains why physicians use the standard of one year of unsuccessful trying as the benchmark for infertility. During the second year another 5-10 percent will conceive a child, which leaves a core infertility rate in the range of 10-15 percent in the general population. These figures have not changed drastically over the past thirty years, though several factors have somewhat increased the infertility rate in both sexes.

The Causes Of Infertility

About 20 percent of women who have difficulty becoming pregnant have a problem with ovulation: the egg is not maturing and being released properly from the ovary. Another 25 percent have tubal problems: egg and sperm cannot get to their designated meeting place in the fallopian tube. About 5 percent of women have a problem with cervical mucus, which may kill the sperm or impede their progress. Another cause is endometriosis, a condition in which the kind of tissue that normally lines the uterus grows in the pelvis outside the uterus and continues to respond to hormonal stimulation. Endometriosis may not actually block a fallopian tube, but it may alter the tube’s ability to push the egg toward the uterus. It may also have subtle hormonal effects that somehow interfere with the process.

Infertility in men may come from having too few sperm, sperm that are not active enough, or sperm that are abnormal in some other way. Men can have anatomical defects or abnormal chromosomes that cause infertility. And sexual dysfunction can contribute to infertility in both sexes.

What possible causes could there be for the 15 percent of infertile couples who are diagnosed with “unexplained” infertility?

Although research in infertility has advanced a great deal in the last generation, there is still much that we do not understand. We do not know, to take one example, how a particular sperm penetrates a particular egg. You may be ovulating perfectly, and your husband or partner may be making plenty of very vigorous sperm, but for some reason the sperm do not penetrate the egg.

How many couples who are infertile for unexplained reasons eventually get pregnant?

Half of these couples, and some couples whose infertility can be attributed to a known cause, eventually do become pregnant. I encourage people not to give up hope.

Ann Marie and Richard adopted two children because they seemed unable to have their own. Richard’s sperm count was extremely low and despite everyone’s best efforts remained so, less than 1 million, when about 20 million is considered the lower level of fertility. After some discussion they decided to adopt rather than using donor sperm. Subsequently and unexpectedly, Ann Marie became pregnant, not once but twice.

Although this couple did conceive children after they adopted, the two events are unrelated: the success rate of couples who adopt is statistically the same as that of couples who do not.

Infertility In The Population

Several studies have suggested that during the past twenty years, men in the industrialized world have statistically experienced a decline in the quality, concentration, and vigor of sperm. Although no one knows for sure, occupational hazards and environmental pollution, medications, and sexually transmitted diseases maybe risk factors.

The causes of lowered fertility among women are more apparent. The first factor is age. Women are much more fertile at 18 than they are at 38. As more women put off child-bearing into their 30s and beyond, it stands to reason that the population will have lower fertility rates. Women in the 35-44 age group are about twice as likely to have fertility problems as women in the 30-34 bracket.

Another important issue for women is that the incidence of pelvic inflammatory disease (pelvic inflammatory disease) has soared over the past generation in the United States, with 3 million to 4 million cases of chlamydia every year. Women may be unaware that they have this silent sexually transmitted disease, even as it scars their fallopian tubes and makes them infertile. Years later many of these women, trying unsuccessfully to become pregnant, have a laparoscopy that suggests past pelvic inflammatory disease and a blood test that reveals a past infection with chlamydia.

Although it is difficult to obtain exact statistics, researchers estimate that having one episode of pelvic inflammatory disease lowers fertility in women by about 12 percent, two episodes by about 20 percent, and three episodes by about 50 percent. The increase in pelvic inflammatory disease also seems to account for an increasing rate of pregnancy outside the uterus. Surveys formerly rated ectopic pregnancy at about 0.5 percent of all pregnancies; now the rate has climbed to somewhere between 1 and 2 percent. These statistics give a compelling reason for young women to protect themselves by using condoms, not only to avoid pregnancy but also to protect themselves from disease and preserve their fertility.

Are there environmental causes of infertility?

Few reliable statistics are available, but we know some answers to this question. Cigarette smoking reduces fertility, for both men and women. In men, smoking appears to lower sperm count; in women, it may interfere with the function of the fallopian tubes. Caffeine has been implicated in decreased fertility in women, as have alcohol and illegal drugs, including cocaine and marijuana. Exposure to pesticides, chemical solvents, and other occupational hazards can affect fertility in both sexes.

Trying On Your Own

In theory, you are not having fertility problems until you have tried for a year, so you should wait that long before you consult your gynecologist. However, I bend the rules according to the woman’s age. If she is 24,1 do counsel her to wait a year before having an infertility work up; if she is 37,1 start testing after six months. I use age 35 as the cutoff point and counsel women younger than that to wait longer. Some doctors choose a different age. The decision about when to start testing and what tests to do may also have something to do with your health insurance coverage. Some managed-care companies cover some tests, but not all; some cover none at all.

When are your most fertile times of the month?

Your most fertile period is just before and around the time of ovulation. If you have fairly regular twenty-eight-day cycles, you are likely to ovulate on day 14 (counting the first day of your period as day 1). If your cycle is longer or shorter, the interval between ovulation and the beginning of the next period is still fourteen days, but the first part of the cycle is longer or shorter. If you have a thirty-two-day cycle, you will probably ovulate on day 18; if you have a twenty-six-day cycle, ovulation is likely to take place on day 12.

Protecting Your Fertility

Many of the causes of infertility are beyond your control. There is little you can do to assure that you will not get endometriosis or have an incompatibility with your partner’s sperm. But the factors within your control are certainly worth your attention.

• Consider having children in your 20s or early 30s, if your life situation permits this choice.

• Protect yourself from sexually transmitted diseases. Use condoms during intercourse unless you and your partner are 100 percent mutually monogamous. The fewer different sexual partners you have, the less chance you have of meeting up with someone who carries an sexually transmitted disease.

• If you have any symptoms that suggest infection (for example, pelvic pain), get treatment right away.

• Don’t smoke. If you do smoke, quit. Smoking shortens your reproductive life; nicotine is toxic to the ovaries; and women who smoke often have early menopause.

• Limit your caffeine intake to two or three cups of coffee daily (or the equivalent).

• Decrease your alcohol intake or stop drinking altogether. In addition to causing possible problems with fertility, two or more alcoholic drinks per day during pregnancy can cause fetal alcohol syndrome.

How often should you have intercourse to maximize your chances of getting pregnant?

Frequency of intercourse is important. You should have intercourse at least every other day, especially around your fertile time of the month. Having sex once a month, even when you think you are ovulating that day, probably will be unsuccessful. In fact, the definition of infertility means that the couple is trying and not succeeding. “Trying” means having frequent intercourse.

Sometimes a woman will tell me that she knows exactly when she ovulates and can time her intercourse perfectly. If this is the only time that month that she has sex, she lowers her chances of getting pregnant, in that she may be a day or two early or late ovulating.

Another justification I have heard in recent years is that the woman and her husband are too busy to have intercourse frequently. To me this statement indicates less than total commitment to having a child. After all, it takes a great deal more time to care for a child than it does to have sexual intercourse. So when I hear this explanation, I ask the couple to reassess their motivation.

Does very frequent intercourse make conception less likely?

Once a day is fine. Infertility specialists suggest that more than once a day may be too frequent if you are interested in becoming pregnant, since it lowers your partner’s sperm count.

Some sexual practices advocated by certain religions seem to take into consideration the issue of sperm count. Orthodox Judaism says that a woman is “unclean” during her menstrual period and until the seventh day afterward. If a woman and her husband abstain from sex for the first twelve days of a twenty-eight-day cycle as their religion requires, and then have intercourse, the husband by then has a very high sperm count and the wife is quite likely to become pregnant. The practice certainly helps account for the large size of orthodox Jewish families.

Of course, these rules do not work as well for women with very short or very long cycles. Suppose a woman has a twenty-four-day cycle and a five-day menstrual period. She and her husband are not allowed to have intercourse on day 10, when she is likely to be ovulating. By day 12, when they resume intercourse and he is at his peak sperm count, she has already ovulated. Her egg is past its prime, and conception is much less likely to take place. We treat such women with Clomid, a drug that stimulates ovulation and can delay it until a better time, thereby changing her pattern of ovulation so that it fits the religious requirements.

Other religious conditions, for example the prohibition against masturbation, also work to increase the likelihood of conception.

How long should you remain lying down after intercourse?

Somewhere between fifteen and twenty minutes should be sufficient. You should not jump up immediately after the act, though you can still become pregnant if you do.

Psychological Issues

No one who has experienced it doubts for a second that infertility puts stress on both husband and wife and on their relationship. I see intelligent, motivated, highly successful couples become frustrated, bewildered, and filled with self-doubt because they cannot conceive a child. Everyone likes to believe that the world is a fair and just place, and that we have some control over the important issues in our lives. So it can be devastating to discover that your fertility is not entirely within your control. In fact, once you decide to become pregnant (whether you end up dealing with infertility or with pregnancy and children), you can no longer control many aspects of your life.

Some women feel that infertility diminishes their femininity, but I think it is even more common for men to equate their infertility with lack of masculinity. Of course, fertility and masculinity are no more synonymous than are femininity and fertility. Some men who are great historical symbols of masculinity have not been able to father children. Think of George Washington,/after of our country, a man known for his physical courage and qualities of leadership. (Modern medicine suggests that he had a disease called Kline-felter’s syndrome, a chromosomal abnormality that may have made him sterile.) Some male athletes who take extra testosterone to bulk out look very virile but cannot father children.

From talking to couples undergoing fertility workups, it seems to me that often women want children more than men do. I don’t think too many men blame their wives so strongly for infertility that the marriage falls apart — unless they belong to a religious group that believes in copious reproduction. I see very few cases where the husband is devastated by his wife’s inability to conceive, but I see many brokenhearted women.

Because couples dealing with infertility must have intercourse on demand, sex necessarily loses its spontaneity and often its pleasurable qualities. Understandably, the anxiety builds through the month and if at the end of the month the wife has her period, she is disappointed and distressed. I get monthly calls from women in tears because of their frustration. Infertility can be an emotional roller coaster, with swooping highs and lows that continue for years.

It is certainly appropriate to have counseling at this stressful time. Any well-run assisted reproductive technology program should have a social worker who can help couples individually or together. Most often, I find, it is women who seek help. In addition to local support and self-help groups, RESOLVE, a national nonprofit organization, helps people cope with infertility, offering information and support for both the medical and emotional aspects.

Can anxiety on a woman’s part cause infertility?

It is certainly possible that for some women stress can interfere with ovulation, but most women being treated for infertility continue to ovulate, as fertility tests show. If the woman is ovulating, it is unlikely that fertilization would fail to take place simply because she is anxious. Although people may tell you that you are “trying too hard” and that you should “just relax and you will get pregnant,” this well-meant advice is insensitive and lacks a basis in reality.

Stress can cause performance anxiety. The wife may become so tense that she and her husband cannot have intercourse, or the husband is so anxious that he cannot achieve or maintain an erection. More than once I have scheduled a postcoital test (the wife comes in after intercourse for an examination of her cervical mucus) that was canceled because the couple could not manage to have intercourse on demand.

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