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Infertility: A practical framework

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Release date: July 1, 2019
Expiration date: June 30, 2020
Estimated time of completion: 1 hour

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ABSTRACT

Fertility concerns are common in men and women of reproductive age, and primary care physicians are often the first line in addressing, assessing, and referring these patients. This article reviews the answers to questions patients often ask, and outlines a practical framework for the evaluation and management of the infertile couple. Up-to-date information is provided on available assisted reproductive technologies for the infertile couple, as well as preserving fertility in the setting of aging-related changes in the female reproductive system.

KEY POINTS

  • A primary care physician can provide advice and testing regarding most fertility concerns.
  • Female reproductive aging is a central threat to fertility, and prompt assessment and referral are warranted for women age 35 and older.
  • Male factor infertility can now often be overcome with assisted reproductive technologies.
  • Polycystic ovary syndrome can cause anovulation and has metabolic effects that can evolve into metabolic syndrome, with serious health consequences.


 

References

For millions of couples, a primary care physician may be the first point of contact for fertility concerns. Statistics from the US Centers for Disease Control and Prevention indicate that 12% of women ages 15 to 44 received fertility services from 2006 to 2010.1 Despite seeking services, most couples requested only advice or testing rather than treatments such as ovulation-inducing medications, surgery, or, rarely, assisted reproductive technologies including in vitro fertilization. Based on these data, primary care physicians are in a unique position to offer guidance and provide fertility services in most circumstances without the need for referral.

This article reviews the answers to questions patients frequently ask, and outlines a practical framework for the evaluation and management of the infertile couple.

MANY PATIENTS SEEK INFORMATION

At least 1 million medical visits per year are for women seeking help in becoming pregnant, with the number increasing over the last several decades.1 Reasons for the increase include delayed childbearing and the effects of aging on the female reproductive system (“female reproductive aging”), as well as the availability of increasingly effective treatments for infertility.

While the prevalence of infertility in US couples is widely quoted as 10% to 15%,2 there is no estimate for the number of fertility-related questions patients routinely pose to care providers. These questions often relate to coital timing, use of lubricants, positioning, and the use of fertility trackers and ovulation predictors.

A 2017 study of women with 12 months of infertility found that only 8% sought subspecialist care vs care from a general physician or provider, indicating that generalists are most often the first point of contact.3 The majority (92%) of women responding to a survey regarding fertility-awareness education indicated a preference for immediate counseling from their general practitioner.4

Although some healthcare providers may consider infertility simply a quality-of-life issue, the World Health Organization classifies it as a disease, and as such it warrants identification, assessment, and intervention.5 Further, patients with infertility are known to experience considerable psychological distress related to their condition. In a comparison study, women with infertility experienced levels of psychological distress similar to the level in patients with cancer and patients with chronic medical illness.6

In the current era, general practitioners and women’s health specialists may also now address patients’ questions about reproductive aging and egg-freezing, which is now an established technology.7

FAILURE TO CONCEIVE AFTER 1 YEAR

Table 1. Common causes of infertility
The American Society of Reproductive Medicine (ASRM) defines infertility as failure to conceive after 1 year of appropriately timed unprotected intercourse8; 85% of couples will have achieved a pregnancy within this time period.9 In practice, some women are evaluated sooner if they are of advanced maternal age (> age 35) or report a history of chemotherapy or radiation exposure, anovulation, or risk factors for obstructed fallopian tubes (ie, endometriosis, fibroids, or pelvic inflammatory disease). Common causes of infertility are listed in Table 1.

As women approach age 40, the potential for fertility decreases rapidly and significantly. Women in their later 30s have only half the fertility of women in their early 20s.10 Misperceptions of aging and female fertility have been fueled by widely publicized celebrity births from women in their 40s and even 50s, without disclosing the use of frozen or donor eggs. This unfortunate fact affects women actively trying to conceive as well as women who wish to delay childbearing due to lack of a partner or for personal or professional reasons. Primary care physicians should be able to provide counseling relevant to female reproductive aging and make suitable and timely referrals for fertility preservation if indicated.

AN EMOTIONAL ISSUE

In approaching the couple with infertility, it is important to proceed with great sensitivity for the socioemotional context of this diagnosis. For both the male and female partner, infertility can be highly stigmatizing, and can be viewed as a personal or relationship failure.

Couples should be encouraged to ask embarrassing or uncomfortable questions. Although this may not be feasible in many circumstances, interviews should ideally be conducted with both partners individually as well as together, to allow sensitive issues to be shared. In some cases, a partner may be unaware of a history of a sexually transmitted infection, a prior abortion, the use of testosterone supplements or medications to enhance male sexual performance, or a vasectomy or tubal ligation during a previous relationship.

It is not unusual that the anxiety of infertility can cause decreased libido and sexual and erectile dysfunction. These issues can further complicate the problem of conceiving, and couples counseling is not uncommonly required.11 Patients are often reassured to know that they are not alone in their diagnosis.

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