This article includes discussion of infertility that may be challenging for some readers.

November 27, 2023
By Ashlyn Byers, Drexel University College of Medicine

According to the American Society of Reproductive Medicine (ASRM), “Infertility is the result of a disease (an interruption, cessation, or disorder of body functions, systems, or organs) of the male or female reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery” (Practice Committee of the American Society for Reproductive Medicine, 2022). An infertility evaluation should be initiated after one year of unprotected intercourse without pregnancy. The evaluation may be initiated after six months when the female partner is greater than 35 years old, “as advanced maternal age decreases fertility rates and increases spontaneous miscarriage and chromosomal abnormality rates” (Jose-Miller, et al., 2007). Additionally, evaluation should not be delayed if there are pre-existing medical conditions, such as irregular menstrual cycles, structural abnormalities or known medical diseases, that could cause infertility. According to the American Academy of Family Physicians, evaluation for both female and male patients should include medical history, physical exam and laboratory tests for hormone function. Female patients should also be assessed for ovulatory dysfunction, ovarian reserve and anatomical abnormalities, while male patients should undergo semen analysis, post-ejaculatory urinalysis and scrotal ultrasonography. During evaluation, both partners should be counseled to avoid alcohol, tobacco and fertility-impairing medications. These recommendations, in combination with healthy weight, diet and exercise, should promote fertility.

Following evaluation, infertility can be treated with medicine, surgery, intrauterine insemination or assisted reproductive technology (ART). Individual treatment is recommended based on age of the partners, duration of infertility, factors contributing to infertility and goals for family planning (Centers for Disease Control and Prevention, 2022). In women, common medicines used to induce ovulation include clomiphene citrate, letrozole and human menopausal gonadotropin. Medications can also be used to treat underlying conditions that affect fertility, such as polycystic ovarian syndrome, hypothyroidism and hyperprolactinemia. The surgical treatments for female infertility include repairing blocked or damaged fallopian tubes, treating endometriosis, or removing polyps or fibroids in the uterus. For male infertility, surgical treatment includes repairing varicoceles, which are swollen veins in the scrotum (American College of Obstetricians and Gynecologists, 2021). If the patient pursues intrauterine insemination (IUI), sperm is introduced into the uterus at the time of ovulation. Alternatively, ART processes both the sperm and egg outside the body. This involves in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), where the sperm and egg are combined in a laboratory before the embryo is transferred into the uterus.

In the United States, there are sixteen states that have infertility coverage mandates for private insurers. However, only six states provide comprehensive coverage that includes all or most costs associated with IVF. The ASRM reports that the average cost of one IVF cycle is $12,400. Additionally, there are fees for embryo genetic and chromosomal testing at $2,000-4,000, as well as fees for egg or embryo freezing and storage at $1,000 (Practice Committee of the American Society for Reproductive Medicine, 2022). In addition to the psychological effects, emotional stress, and relationship strain of infertility, the financial cost is a barrier to care (Ethics Committee of the American Society for Reproductive Medicine, 2015). Therefore, it is important to consider how the diagnostic workup, treatment options, and financial planning for infertility have significant psychosocial effects on patients.

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Sources/Resources:

• American College of Obstetricians and Gynecologists. “Treating Infertility.” Accessed February 21, 2023. https://www.acog.org/patient-resources/faqs/gynecologic-problems/treating-infertility
• Centers for Disease Control and Prevention. “Reproductive Health.” U.S. Department of Health and Human Services. Accessed February 20, 2023. https://www.cdc.gov/ reproductivehealth/index.html
• Ethics Committee of the American Society for Reproductive Medicine. “Disparities in Access to Effective Treatment for Infertility in the United States.” Fertility and Sterility, 104, 5 (2015). Accessed February 21, 2023. doi:10.1016/j.fertnstert. 2015.07.1139
• Jose-Miller A, Boyden J, and Frey M. “Infertility.” American Academy of Family Physicians, 75, 6 (2007). Accessed February 20, 2023. https://www.aafp.org/afp/2007/0315/p849.html
• Practice Committee of the American Society for Reproductive Medicine. “Fertility Evaluation of Infertile Women.” Fertility and Sterility, 116, 5 (2021). Accessed February 20, 2023. doi:10.1016/j.fertnstert. 2015.07.1139