Infertility: The Important Missing Piece in Health Education Classes

Why would adolescents need to be concerned with infertility, one might wonder? The answer is that, since fertility is precarious, decreases with age, and is negatively impacted by common adolescent behaviors, it is important to be cognizant of these risk factors to avoid than anguish of infertility.

"Abstinence Only" sexuality education curriculum is mandated in order for American public schools to obtain federal funding. Opting out of this curriculum, one that lacks a great deal of information youngsters need to make healthy choices, is very costly. Yet, even more progressive and comprehensive sexuality school curricula focus on pregnancy and disease avoidance, making infertility seem an odd topic to include.

Infertility affects both men and women, is devastating, heartbreaking, and often extremely expensive, and many of the risk factors are rooted in behavior that begins in adolescence. Teaching reproductive health without mentioning infertility does teens and young adults a disservice.

What is Infertility?

Resolve, the National Infertility Association that provides support and advocacy, defines infertility as the inability to conceive after one year of unprotected intercourse (six months if the woman is over age 35) or the inability to carry a pregnancy to live birth. Resolve states:

Infertility is a disease that results in the abnormal functioning of the male or female reproductive system. The World Health Organization, the American Society for Reproductive Medicine (ASRM), and the American College of Obstetricians and Gynecologists (ACOG) recognize infertility as a disease.

The inability to have a family when one is wanted is agonizing. Alison O'Callaghan, a medical sales representative, and her husband first tried aromatherapy, reflexology, and homeopathy through crystals and moonstones before turning to more traditional treatments

Being childless and watching everyone else produce offspring is extremely distressing. It is almost like bereavement: a continuous grieving, but for something not yet created.

Four out of five working days I'm asked if I have children.

... We've had four IVF attempts so far and only once did we get through a full cycle. IVF is like an obstacle course, with many unforeseen hurdles to trip you up....

Each attempt brings a new surge of optimism. Maybe next time will be the one that works. In spite of the hardship and the vast amount of money we've spent... there was no choice.

• 7.4 million women, or 11.9% of women, have received infertility services in their lifetime. (2006-2010 National Survey of Family Growth, CDC)
• 1 in 8 couples (or 12% of married women) have trouble getting pregnant or sustaining a pregnancy. (2006-2010 National Survey of Family Growth, CDC)
• Approximately one-third of infertility is attributed to the female partner, one-third is attributed to the male partner, and one-third is caused by a combination of problems in both partners or is unexplained. (American Society for Reproductive Medicine)
• Couples between 29 and 33 years of age with normally functioning reproductive systems have only a 20-25% chance of conceiving in any given month (National Women's Health Resource Center). After six months of trying, 60% of couples will conceive without medical assistance. (Infertility as A Covered Benefit, William M. Mercer, 1997)
• Approximately 44% of women with infertility have sought medical assistance. Of those who seek medical intervention, approximately 65% give birth. (Infertility as A Covered Benefit, William M. Mercer, 1997)
• Approximately 85-90% of infertility cases are treated with drug therapy or surgical procedures. Fewer than 3% need advanced reproductive technologies like in vitro fertilization (IVF). (American Society for Reproductive Medicine)

Male infertility can occur due to any combination of the following:
- absence of sperm or low sperm count (azoospermia),
- abnormal sperm shape,
- obstruction in the duct system,
- problems with sperm movement,
- completely immobile sperm, and problems with erections or other sexual problems.

Risk Factors of Infertility

Many of the risk factors for both male and female infertility are the same. According to the Mayo Clinic, risks include:

Age. A woman's fertility gradually declines with age, and this decline becomes more pronounced in her mid-30s. Infertility in older women may be due to the number and quality of eggs as they age or to health problems that may interfere with fertility. Men over age 40 may be less fertile than younger men are.
• Tobacco use. A couple's chance of achieving a pregnancy is reduced if either partner uses tobacco. Smoking also reduces the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can increase the risk of erectile dysfunction and low sperm count in men.
Alcohol use. For women, there's no safe level of alcohol use during conception or pregnancy. Avoid alcohol if you're planning to become pregnant because you may not realize you're pregnant for the first few weeks. Alcohol use increases the risk of birth defects, and it may also make it more difficult to become pregnant. For men, heavy alcohol use can decrease sperm count and motility.
• Being overweight. Among American women, an inactive lifestyle and being overweight may increase the risk of infertility. In addition, a man's sperm count and testosterone levels may be adversely affected if he is overweight.
Being underweight. Women at risk of fertility problems include those with eating disorders, such as anorexia or bulimia, and women who follow a very low calorie or restrictive diet.
Exercise issues. Lack of or not enough exercise contributes to obesity, which increases the risk of infertility. Less often, ovulation problems may be associated with frequent strenuous, intense exercise in women who are not overweight. lists the risks above and adds:
• Poor diet - this means that whether your weight is over, under, or right on target for your height, your diet may be lacking in proper nutrition. This also includes both bulimia and anorexia, which can cause amenorrhea.
• Athletic training
• Sexually transmitted infections (STIs).

Chlamydia and gonorrhea, for example, are important preventable causes of pelvic inflammatory disease (PID) and infertility. Untreated, about 10-15% of women with chlamydia will develop PID. Chlamydia can also cause fallopian tube infection without any symptoms. PID and "silent" infection in the upper genital tract may cause permanent damage to the fallopian tubes, uterus, and surrounding tissues, which can lead to infertility.

Workplace environmental contaminants may also decrease fertility, as can bicycle riding and constricting underwear for men.

It is easy to see from these risk factors why it is important for young people to know that their present behavior may cause them heartache later in life when they are ready to have a family.

For decades women have been encouraged to postpone childbearing until they complete their education, and in some cultures, they are expected to get a good foothold in a designated career before having a family. Many young women have been led to believe that thirty is an acceptable age to begin to consider marriage and family. However, first pregnancies over 30 are more difficult to achieve and maintain and also add to increased risk for the health of the baby. The risk of Downs Syndrome is directly related to maternal age:

The risk of having a child with Down syndrome increases in a gradual, linear fashion until about age 30 and increases exponentially thereafter. The risk of having a child with Down syndrome is 1 in 1,300 for a 25-year-old woman (age at delivery); at age 35, the risk increases to 1 in 365. At age 45, the risk of a having a child with Down syndrome increases to 1 in 30.

Since it is never too late to pursue higher education and career, it is worth considering delaying those pursuits instead of delaying childbirth. The infertility industry in America has grown into a multibillion-dollar industry profiting from these preventable behaviors.

Infertility Treatments and Costs

Many treatments can improve the chances of getting pregnant. They include:
• hormone treatments, including Estradiol (Estrace), Clomiphene (Clomid), Leuprolide by injection (Lupron), testosterone through the skin (Androgel), and progesterone (Prometrium). Another treatment is Gonadotropin-releasing hormone analogue.
• fertility drugs
• surgery

In addition, various medical procedures may be used to fertilize an egg, such as artificial insemination, ovulation induction, and in vitro fertilization (IVF). Both egg quantity and egg quality are very much related to female age, which can make such treatments less effective.

IVF success rate statistics for all reputable clinics are available on the web from the Centers for Disease Control, SART, and Advanced Fertility reveal that IVF success rates drop at about age 28 and drop faster starting at about age 31 - and even faster after age 37.

As women age, the probability of successful egg retrieval or embryo transfer drops. This is because the rate of IVF cycle cancellation increases with aging.

With aging, the probability of pregnancy and live birth drops even more. This is because the rate of embryo implantation decreases with age. Decreased embryo implantation is due to embryo quality issues. Miscarriage rates also increase with age.

A single round of IVF costs, on average, $8,158--but costs go up dramatically when the couple uses frozen genetic material, together with several rounds of medications. A federal report released in 2014 estimates the average cost to be more than $12,000 for each cycle of infertility treatment. Many couples need several cycles in order to produce a child--and some never do. Costs may or may not be covered by insurance. 

The Affordable Care Act (ACA) does not require coverage for infertility treatments.

Sperm Donations, Egg Retrieval, Surrogacy, and Adoption

Infertility is a multibillion-dollar industry and relies on "donations" of sperm and eggs.

Young women, especially college students and military wives, are targeted for advertising and recruitment by infertility clinics that rely on egg donors for infertile and same-sex couples. It is important for women to investigate the risks to their health and their own future fertility. Young women away from home at college can be lured by the promise of money and the idea of helping others desperate to achieve a goal of having a child.

Infertility clinics may downplay the side effects - short and long-term - of the hormones required for both egg retrieval and surrogacy. According to the Council for Responsible Genetics, drugs used to hyperstimulate the ovaries have negative effects, most notably a condition called Ovarian Hyperstimulation Syndrome (OHSS). Serious cases involve the development of cysts and enlargement of the ovaries, along with massive fluid build-up in the body. The actual egg retrieval is a surgical procedure performed under anesthesia, which carries its own risks. 

While sperm donation has no physical risks, there are the complications that come with having large numbers of children (in some cases more than a hundred), who are likely to locate you at some point, or who could put children you someday choose to have at risk of unknowingly committing incest.

When other means have failed, infertility doctors suggest surrogacy, a controversial practice that is Illegal in most of the industrialized world because it exploits low-income women in the US and overseas. Surrogates are subjected to similar hormonal risks as egg donors, besides the risks involved in childbirth, and many legal complications involving the custody of surrogate-born children. Litigation has resulted from the standard practice of requiring surrogate contracts that make abortion or pregnancy reduction mandatory in the event of twins or triplets, etc., which are common in IVF- produced pregnancies. Abortion is also mandated at the will of the "intended parents" in the event that one of the fetuses appears to have any disability that those parents feel is undesirable. More information on the controversies of surrogacy can be found here, here,and here. State laws regarding surrogacy can be found here and here.

Many young women today think that they can put off childbearing and that, if all else fails, they can always "just adopt." Some may hear this from friends or family. Many adoption promotion events (such as an annual Christmas special called Home for the Holidays) may leave people with the impression that there are babies just waiting to be brought home. There are older children, sibling groups, and disabled children who can be adopted, but there are also 30-35 couples and individuals vying for each baby. Because the demand so outstrips the supply, the adoption industry is plagued by corruption, trafficking, and scams, all with little oversight or regulation. It is by no means an easy alternative. For more about adoption trafficking read articles on Intercountry Adoption; Child Laundering; Child Trafficking; International Adoption by David Smolin. adoption scandals here and Finding Fernanda by Erin Siegal.

Just as we teach adolescents the health risks of smoking, it is imperative to make them aware of the extreme emotional distress and pain infertility causes, and the risk factors that begin in youth. It is vitally important for our youth to be made aware that their behavior may cause them grief and costly, risky treatments later in life. Health classes need to include this important information.