"Infertility is a medical and social condition that can cause considerable social, emotional and psychological distress."

The estimated one in six couples in Ireland who are affected by infertility would heartily agree with this statement from the Commission on Assisted Human Reproduction in 2005.

Indeed, irishhealth.com's discussion forum on infertility and IVF (view here) pays testament to the emotional and psychological roller-coaster that those who decide to undergo fertility treatment must endure and to the practical difficulties many of them face.

This is highlighted in two recent reports from the Women's Health Council (WHC) on infertility and its treatments.(View the full reports here)

The WHC says infertility has been ranked as one of the great stressors in life, comparable to divorce or a death in the family.

It has been pointed out that unlike grieving because of bereavement, the grieving caused by infertility does not follow a sequential pattern but is recurrent and triggered by life events, such as the birth of other people's children and grandchildren as well as the cyclical nature of the menstrual cycle.

The effects of infertility and its treatment has been poignantly described as a series of losses, including loss of relationship with one's spouse, loss of health and sexual pleasure, loss of status, loss of confidence and loss of hope.

Launching the report recently, WHC director Geraldine Luddy said as a society, we need to be more aware of the issue of infertility and become more sensitive towards it.

"Infertilty can cause a major disruption in people's lives because it interferes with people's desires and cultural expectations. We hope that our reports will help-to raise awareness of this important issue and bring information to patients, service providers and policy-makers in this very complex area."

Infertility is medically defined as a lack of conception following at least one year of unprotected sexual intercourse.

The term subfertility is often preferred to describe any form of reduced fertility that results in a prolonged or unwanted lack of conception.

It is estimated, according to the WHC, that a third of infertility cases are caused by a male factor, such as low sperm count. Almost another third are linked to a female factor, such as blocked fallopian tubes.

The remainder consists of either a combination of both male and female factors, or unexplained infertility - the latter comprising 19% of cases.

One of the WHC's reports, on the psycho-social issues relating to infertility, says while there is contradictory evidence, there is a perception that the rate of infertility is on the increase because of social and medical reasons.

This could include a desire to delay parenthood to pursue career and financial security, and an increase in obesity and sexually transmitted infections. Improvements in the diagnosis of infertility have also contributed to the perceived increase in rates.

The report says in developed countries, usually 50% of those affected by infertility seek medical care, although this tends to represent the better-educated grloups.

Whether infertility should be designated as a chronic health condition or a disability is still unclear, but what is clear is that some patients perceive that the suffering from infertility is very real and infertility is generally recognised as a source of diminished health and social well-being.

The literature consistently indicates that infertility is a condition that may cause significant pain and distress and which many people go to great lengths to overcome.

The report notes that while it is a deepy private experience, fertility is intrinsically linked with our social identity.

"Parenthood is perceived in most cultures as a central developmental milestone towards adulthood."

Infertility, therefore, can cause a major disruption in people's lives because it interferes with the established and desired life course, the report notes.

The psychological and emotional repercussions of infertility are considerable. While most infertile people do not experience severe or clinically significant distress, some do.

Often cited consequences are depression, anxiety, sexual anxiety/difficulty, relationship problems with partner/family/friends and an increased sense of self-blame and guilt.

Fortunately, it has been found that when depression occurs it is relatively short-lived, often peaking between the second and third year of infertility. Anxiety is a common consequence of infertility, usually shown in worry, restlessness, difficulty concentrating and fatigue.

The WHC says an increase in public awareness and information is crucial in order for couples to feel supported during their difficulties.

Maternal age is considered the most important determinant of conception, and much attention has been dedicated in the public arena to the increasing age of full-time mothers, who often feel they have to wait until their career is well-established before trying to start a family.

The report says much could also be done to promote younger motherhood through policy measures to support parents economically and socially, for example, by strengthening measures to combine work and family responsibilities.

The report provides an overview of current fertility services. It points out that a significant aspect of infertility treatments in Ireland is their controversial nature due to the unresolved questions about the legal status of the embryo.

It also points out that Ireland has no official body or legislation for the regulation and licensing of clinics offering IVF or other assisted reproduction technologies (ART).

The WHC says the greatest risk attached to IVF is its relatively low chance of success, and couples often have unrealistic expectations.

The increased availability and perceived effectiveness of reproductive technologies may lead to even greater psychological and social consequences for the couple if their attempts to conceive are unsuccessful.

There is consensus in research that the emotional and psychological impact of treatment is more difficult to cope with than common physical repercussions. However, psychological supports are often not integrated into services.

Unsuccessful treatment is strongly associated with depression, anxiety, anger, helplessness, increased marital relationship tensions, grief and isolation. One of the factors that appears to aggravate the effects of fertility treatment is the lack of a clear endpoint.

Research shows that the most commonly given reason for ending treatment is psychological distress, while finances and medical reasons are usually secondary considerations.

The WHC stresses that access to accurate and up-to-date information on success rates is essential. Its report says that in Ireland at present , there is no standard format that allows for comparison of success rates among infertility clinics.

As there is no regulatory body for clinics, the data released by them is not monitored or evaluated for accuracy, the report states.

However, according to the WHC, the most recent figures, from 2005, show that the percentage of deliveries per IVF cycle is 21.1% for a fresh cycle and 11.3% for a frozen cycle, which is line with European figures.

Success is dependent on many factors, including patient age, weight and pregnancy history, and variations of IVF procedures, such as the number of embryos transferred and the method of embryo transfer.

Infertility treatment usually does not come cheap. For example, an average cost for one IVF cycle is in the region of €4,000 and for IUI is €800. Using donor sperm usually adds between €300 and €800 to the overall cost, while using egg donation is considerable more expensive, costing between €5,000 and €12,000.

Also, fertility drugs can cost up to €3,000 depending on how a woman responds to treatment.

ARTs and their effectiveness:

IVF 

In vitro fertilisation means fertilisation outside the body. It involves taking medication to stimulate the ovaries to produce more eggs than usual. When these eggs have formed, an operation is needed to retrieve them. The eggs are mixed with the sperm in a lab dish and incubated for a few days in order for embryos to form. One or two of these embryos are then placed in the uterus. Any other embryos that have formed in the dish can be frozen for future use by the couple who produced them. The most recent figure show that the percentage of deliveries per IVF cycle is 21.1% for a fresh cycle and 11.3% for a frozen cycle.

Intrauterine insemination (IUI) 

This is the process of inserting sperm into the woman's uterus through a plastic tube passed through the cervix and into the uterus. This is timed to coincide with the release of an egg or eggs (ovulation) in a natural or stimulated cycle. This technique requires that the woman have normal fallopian tubes and a uterus. IUI is reported to be useful where  women have deficient cervical mucus, ovulatory dysfunction or in men, where there is male factor infertility or unexplained infertility. It is often used before  resorting to more complex ART such as IVF. IUI with donor semen is far less commonly conducted in Ireland. A pregnancy rate per procedure of 9.2% has recently been reported in Irish figures for IUI.

Intracervical insemination (ICI) -

This is an alternative method of insemination involving the injection of semen high into the cervix.

Gamete intrafallopian transfer (GIFT) & Zygote intrafallopian transfer (ZIFT)

A gamete is an egg or a sperm, and GIFT involves collecting eggs and sperm in the same way as for IVF. The eggs and sperm are then mixed together in a dish and immediately transferred to the fallopian tubes. This is done laparoscopically through an incision in the abdomen or by a catheter passed through the cervix. This allows the sperm to "naturally" fertilise the egg inside the fallopian tubes or uterus. ZIFT is fairly similar to GIFT, although the newly-fertilised egg is returned to the woman's fallopian tubes instead of a mixture of eggs and sperm. IVF  has almost completely replaced GIFT and ZIFT and they are now rarely carried out. The pregnancy rates following GIFT are similar or slightly higher than with IVF treatment; however there is extra inconvenience and discomfort associated with GIFT/ ZIFT.

Intracytoplasmic sperm injection (ICSI)

This involves injecting a single sperm directly into the cytoplasm inside the egg. The egg containing the sperm is then placed in the uterus. It is regarded as a useful technique for couples who have been unsuccessful with IVF. ICSI improves fertilisation rates compared to IVF alone, but once fertilisation is achieved, the pregnancy rate is no better than with IVF.

Donor insemination

When there is a problem with the sperm, sperm from a donor can be used. However, with the availability of ICSI there has been a reduction in the use of donor sperm.  In Ireland, the pregnancy rate per IUI procedure is higher with donor sperm compared to IUI with male partner sperm.

Preimplantation genetic diagnosis and screening (PGD/PGS)

This involves removing some cells from an embryo and examining the genetic material in the laboratory. PGD aims to prevent the birth of affected children infertile couples with a high risk of transmitting genetic disorders, for example, cystic fibrosis. PGS aims to improve pregnancy rates in subfertile couples undergoing IVF/ICSI; for example women of advanced maternal age, couples with repeated IVF failure or repeated miscarriages. It appears to significantly reduce the incidence of spontaneous abortions.

In vitro maturation (IVM)

This involves taking immature eggs from unstimulated or minimally-stimulated ovaries and maturing them in the laboratory in vitro for one or two days. When the eggs have matured they are fertilised using ICSI and transferred to the womb a few days later. IVM eliminates the risk of ovarian hyperstimulation syndrome (OHSS) as it does not require ovarian stimulation. It is useful for women with polycystic ovarian syndrome. It is also less expensive and has a shorter treatment span than IVF. The use of IVM is increasing; however, the evidence on the effectiveness of IVM to date in terms of research is limited.

Natural treatment

Natural procreative (NaPro) technology is based on a detailed study of events occurring during ovulation and throughout the menstrual cycle, and by informing couples about their fertility and how to monitor their own fertility cycles. Abnormalities of the reproductive cycle are investigated and treatments are provided. Many of the medications used with NaPro are widely used in other fertility programmes although the precise timing and monitoring of such treatments are unique to NaPro technology. The aim of NaPro technology is to allow conception through natural intercourse. Again, the evidence provided on effectiveness at this stage is limited.

Medicines

Medicines can also be used to improve fertility. Clomifene is an effective first-line treatment for women with PCOS, while gonadotrophins apear to be more effective than clomifene but are associated with significantly higher multiple pregnancy rates compared to clomifene. GnRH analogues are often used to prevent spontaneous ovulation whern gonadotrophins are given to women undergoing IVF.

Surgical treatment

Women with OCOS who have not responded to clomifene should be offered laparoscopic ovarian drilling (LOD) since itis as effective as gonadotrophin treatment and is not associated with an increased risk of multiple pregnancy. The introduction of IVF hs led to a reduced need for tubal surgery.

Around 3 in 10 women with uterine fibroids may be infertile; myomectomy is currently regarded as the best treatment for removing fibroids while leaving the uterus in place. The chances of conceiving after surgery for endometriosis-related infertility are increased by 10% to 25%.

View more details of the Women's Health Council report here

You can contact the National Infertility Support and Information Group at Lo-call 1890 647 444

 

 


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