INFERTILITY By Joan Meade November 2006

1. INFERTILITYBy Joan MeadeNovember 2006

2. Fertility Normally Couple has approximately 25% chance of conception per month In 1 year 85-90% of couple will have conceived In prolonged infertility there is approximately 2% chance of spontaneous pregnancy

3. Definitions Infertility: Failure to conceive after one year of frequent, unprotected sexual intercourse Primary Infertility: Woman has never been pregnant despite frequent, unprotected sexual intercourse Secondary infertility: Woman has had at least one pregnancy but has failed to conceive subsequently despite frequent, unprotected sexual intercourse

4. Issues in Treatment Investigation and treatment costly Financially Emotionally No guarantee of success

5. Incidence of Infertility Affects both men and women Affects approximately 15% of all couples Varies from country to country Worldwide ranges from 12 – 20% WHO study found: Female causes 25-37% Male causes 8-22% Both male & female 21-38% No identified cause 5-15%

6. Study found that most infertile couples suffer from primary infertility Latin America has fairly high incidence of secondary infertility – 40% About 5% of couples suffer from anatomical, genetic, hormonal, and immunological causes Remainder relate to preventable causes: STIs, infectious and parasitic diseases, poor health care practices, exposure to toxic substances.

7. Major Female Factors Tube problems Ovulation disorders Problems in second half of Cycle Pituitary Gland Problems Pelvic problems and endometriosis Problems of the cervix

8. Major Male Factors Varicocele Ejaculatory problems Pituitary problems Genito-urinary tract infections Hormonal problems

9. Investigations - Female History Physical examination Post-coital test X-rays of the tubes Looking into the uterus Biopsy of the lining of the uterus Measuring progesterone levels

10. Investigations - Males Semen analysis Urological examination to look for: anatomical abnormalities infections endocrine disorders varicocele

11. Impact of Infertility Psychological reaction: frustration feeling less of a man/woman feeling of loss decreased self-esteem, self- confidence guilt or apportioning blame disappointment

12. Emotional Responses Guilt Depression Anger Isolation

13. Impact on Relationships Questioning of the meaning of the relationship Fear that the relationship will not survive Approximately 68% of women threatened with divorce Conflict - study found: Approximately 10% of women abused by husband Approximately 16% abused by in laws Onset of sexual dysfunctions

14. Treatment Hormonal therapy for stimulation Abstinence or condom use if hostile cervical mucus Surgery to correct abnormalities Use of Assisted Reproductive Technologies (ARTs)

15. Assisted Reproductive Technologies Drugs to stimulate ovulation Intrauterine insemination (IUI) where prepared sperm placed inside uterus In vitro fertilization (IVF) where eggs are extracted, fertilized in a laboratory and the embryo transferred to the uterus

16. Assisted Reproductive Technologies (contd.) Gamete intrafallopian transfer (GIFT) where unfertilized eggs and sperm are placed in the fallopian tubes Zygote intrafallopian transfer (ZIFT) where eggs are fertilized in the laboratory and the fertilized eggs (zygote) placed in the fallopian tubes

17. Assisted Reproductive Technologies (contd.) Intracytoplasmic sperm injection (ICSI) used for male infertility where a sperm is injected directly into an egg and then the embryo is transferred to the uterus

18. Assisted Reproductive Technologies (contd.) Sorting sperm allows doctors to select only those that will produce girls and do not carry x-linked chromosomal diseases Preimplantation diagnosis allows DNA testing of embryonic cells to confirm that only healthy embryos are transferred to avoid genetic diseases

19. Issues Can ARTs be justified in third world countries like Jamaica? What are the legal and ethical considerations?