Clinical Review


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Women older than 35 years should receive expedited evaluation and treatment for infertility if they have not conceived after 6 months, or earlier if clinically indicated. That’s one of the conclusions from a recent ACOG–ASRM joint Committee Opinion on age-related fertility decline.

Age remains a major variable influencing a woman’s fertility and risk of pregnancy loss, and is increasingly important because of the social trend toward deferred child-bearing. The fertility rate peaks in a woman’s mid-20s and decreases by approximately 25% by age 35 and 50% by age 40, with a concomitant (and significant) increase in rates of aneuploidy and miscarriage.

The duration of infertility also is key. Of any given 100 women attempting to conceive:

  • 78 will succeed within 1 year
  • 88 will conceive within 2 years
  • only an additional two or three women will conceive in the third year
  • one more will conceive in each of the fourth and fifth years
  • only three more will conceive over the rest of their reproductive life.
These data suggest that infertility should be investigated after 12 or more months of regular unprotected intercourse, with earlier evaluation and treatment for women who are older than 35 years.

Recurrent pregnancy loss and infertility are separate entities

By definition, recurrent pregnancy loss entails the loss of two or more pregnancies. When the cause is unknown, each loss merits careful review to determine whether specific evaluation may be appropriate. After three losses, thorough evaluation is warranted.1,2

To distinguish infertility from recurrent pregnancy loss, define clinical pregnancy as one documented by US or histopathology.

New technologies remain unproven

Although ovarian tissue and oocyte cryopreservation offer the promise of female fertility preservation, these technologies remain investigational to date.

The greatest benefit to patients who wish to preserve their fertility is appropriate counseling about their reproductive health.3, 4

Fertility can be enhanced with a few patient-friendly strategies

Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility. Fertil Steril. 2008;90(5 Suppl):S1–S6.

Another Committee Opinion from ASRM, in collaboration with the Society for Reproductive Endocrinology and Infertility, offers simple but effective steps for patients to take to optimize fertility. ObGyns should recommend these strategies to any woman planning to conceive in the near future.

Frequent intercourse is best

Intercourse every day or every other day yields the highest pregnancy rate, but intercourse two to three times a week is nearly equivalent. There is a “fertile window” that spans the 6-day interval ending on the day of ovulation, and it correlates with the volume and character of cervical mucus.

Among women who have regular menstrual cycles, frequent intercourse that begins soon after the cessation of menses can help maximize fecundity.

Devices that determine or predict the time of ovulation may be useful for couples who have infrequent intercourse.

Neither specific coital timing, nor position during coitus, nor rest in a supine position after intercourse has a significant impact on fertility.

Caffeine, alcohol OK—in moderation

Moderate caffeine or alcohol consumption (1 or 2 drinks daily) has no demonstrable adverse effect on fertility. Smoking, a higher level of alcohol consumption (≥2 drinks daily), use of recreational drugs, and most commercially available vaginal lubricants should be discouraged among patients who are trying to conceive.

Fertility rates are lower in women who are very thin or obese, but there is little evidence that dietary variations improve fertility or affect the gender of the infant.

Elevated blood mercury levels from heavy seafood consumption have been associated with infertility.

Saunas do not reduce fertility in women. In normal men, attempts to protect the testicles from excessive heat are unjustified.

Avoid solvents and pesticides

  • Fecundity may be diminished in women who are exposed to certain toxins and solvents, such as those used in the dry-cleaning and printing industries.
  • Men who are exposed to heavy metals may be more likely to have abnormal semen parameters.
  • Pesticide exposure may be a problem for both male and female agricultural workers.
  • Despite limited data on exposure to lead and use of industrial microwaves, they are probably best avoided or minimized.
  • Prescription drug use should be carefully controlled and managed on an individual basis.

Recommend 400 µg of folic acid daily

Any woman hoping to conceive should be advised to initiate this regimen to reduce the risk of neural tube defects.


The Centers for Disease Control and Prevention (CDC) held its first Public Health Symposium on Infertility in September 2008. Consensus is growing that infertility is a common disease or disability that has serious consequences for the well-being of families—making it a public health concern.

Because only approximately 50% of patients who have infertility ever seek treatment, it is hoped that new programs will improve access to fertility treatment for many more women.

For more information on the CDC’s initiatives in reproductive health, visit:

WHO focuses on international inequities

The World Health Organization (WHO) held a meeting in Geneva in December 2008 to modify its glossary of ART definitions and develop new terminology to allow the collection of better data on the use of IVF internationally.5, 6

The prevalence of infertility is about the same in all countries of the world, affecting, on average, about 9% of people of reproductive age. However, there is a greater degree of secondary infertility—mostly as a result of infectious disease and obstetric complications—in low-resource (developing) countries.

Infertility is a major burden with serious medical and psychological consequences in American society, but its impact on women in other cultures is often more profound, with loss of personal status, divorce, and social ostracism adding to the burden.


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