Ebook on Fertility

Infertility:

A Guide





Table of Contents

Introduction................................................................................................................................................3

Part 1: The nature and causes of infertility ................................................................................................4

An overview of the reproductive system...............................................................................................4

Causes common to men and women .....................................................................................................4

Hormonal problems ..........................................................................................................................5

Age and infertility.............................................................................................................................6

Disease and infertility.......................................................................................................................7

Environmental Causes ......................................................................................................................7

Natural substances .......................................................................................................................7

Plant estrogens .............................................................................................................................7

Synthetic chemicals .....................................................................................................................8

Drug use............................................................................................................................................8

Alcohol.........................................................................................................................................8

Smoking .......................................................................................................................................9

Caffeine........................................................................................................................................9

Recreational Drugs ......................................................................................................................9

Lifestyle Causes................................................................................................................................9

Weight and fertility ....................................................................................................................10

Exercise......................................................................................................................................10

Occupational hazards .................................................................................................................10

Other lifestyle causes .................................................................................................................11

Fertility-stunting medicines............................................................................................................11

The Thalidomide and DES scandals ..........................................................................................11

Drugs taken during pregnancy ...................................................................................................12

Causes of male infertility ....................................................................................................................12

Azoospermia...................................................................................................................................12

Obstructive azoospermia............................................................................................................12

Non-obstructive azoospermia ....................................................................................................13

Retrograde ejaculation....................................................................................................................13

Sperm quality and number..............................................................................................................13

Aspermia ....................................................................................................................................13

Varicocele ..................................................................................................................................14

Anti-sperm antibodies................................................................................................................14

Impotence .......................................................................................................................................14

Psychological elements...................................................................................................................15

Causes of female infertility .................................................................................................................16

Endometriosis .................................................................................................................................16

Uterine Fibroids..............................................................................................................................16

Polycystic Ovary Syndrome ...........................................................................................................16

Physical damage to the reproductive system..................................................................................16

Unexplained Infertility ........................................................................................................................17

How common is infertility?.................................................................................................................17

Diagnosing infertility ..........................................................................................................................17

Ovarian reserve tests ..................................................................................................................18

Physical examinations................................................................................................................18

Ultrasound..................................................................................................................................18

Post-Coital Test..........................................................................................................................18

Semen Analysis..........................................................................................................................19

Part 2: Treatments ....................................................................................................................................20

Male infertility treatments ...................................................................................................................20

Obtaining Sperm.............................................................................................................................20

PESA and MESA: sperm extraction from the epididymis ........................................................20

TESE and TESA: sperm extraction from the testicles...............................................................20

Assisted Ejaculation .......................................................................................................................21

Semen storage.................................................................................................................................21

Surgery............................................................................................................................................22

Impotence treatments......................................................................................................................22

Mechanical and surgical treatment ............................................................................................22

Drug treatment of impotence .....................................................................................................22

Other drug treatments: testosterone and hormone injections .........................................................22

Female infertility treatments ...............................................................................................................23

Surgery............................................................................................................................................23

Intrauterine Insemination (IUI) ......................................................................................................23

IVF..................................................................................................................................................23

IVF: The basic procedure ..........................................................................................................23

Variations on IVF ......................................................................................................................24

Assisted Hatching ...........................................................................................................................24

Ovulation-stimulating drugs ...........................................................................................................24

Clomiphene ................................................................................................................................25

Gonadotropins extracted or synthesized ....................................................................................25

Drug treatment of endometriosis ....................................................................................................25

Treatments for couples ........................................................................................................................25

Timing of intercourse .....................................................................................................................25

Style of intercourse.........................................................................................................................26

Alternative Medicine...........................................................................................................................26

Acupuncture....................................................................................................................................26

Aromatherapy .................................................................................................................................26

Herbal Medicine .............................................................................................................................27

Alternatives to fertility treatment .......................................................................................................27

Surrogate Mothers ..........................................................................................................................27

Sperm donation...............................................................................................................................27

Adoption .........................................................................................................................................28

Child-Free Living ...........................................................................................................................28

Part 3: Fertility in the real world: ethical, social, political and religious issues ......................................30

Multiple babies ...............................................................................................................................30

Increased disease in babies .............................................................................................................30

Ethical issues with frozen sperm ....................................................................................................31

The emotional impact of fertility....................................................................................................31

Part 4: Appendices ...................................................................................................................................32

Glossary...............................................................................................................................................32

Where to find more information..........................................................................................................34

Websites..........................................................................................................................................34

Medical Literature ..........................................................................................................................35









Introduction

The test-tube baby must rank alongside the moon landings and the discovery of DNA as one of the

greatest scientific achievements of the 20th century. And, iconic though it may be, this is just one of

dozens of medical breakthroughs that have brought us closer than ever to overcoming what must be one

of the world's oldest miseries.

For, however far back we look into the depths of human history, we can see the misery of the infertile

couple. Sanskrit hymns, Old Testament verses, the Greek epics of Homer and hieroglyph-covered

papyrus found in Egypt: all speak of the loss felt by the infertile. Unable to continue their family line,

to nurture a child, and to have somebody to look after them in their old age, men and women in every

country and every time have turned to priests, shamans, witch-doctors and soothsayers, desperately

seeking a child.

If we can feel their anguish over the gaps of centuries, we can consider ourselves fortunate to be living

in an age where we can understand infertility not as a curse or an act of divine vengeance, but as a

medical problem – and a solvable medical problem at that. The medical profession can't promise

children to everybody, and the route to pregnancy remains long, expensive, and emotionally fraught.

But now, finally, there is a way out for many of us.



The rest of this book is divided into three main sections. In the first section, I will look at the causes of

infertility, and at how doctors can work out what causes lie behind a couple's inability to conceive.

Then I'll move on to look at the treatments available, their advantages and disadvantages, and what

they entail. The third section takes a step back from the purely medical, and looks at some of the

ethical, social and legal issues surrounding fertility treatments. These are questions which continue to

perplex some of the wisest thinkers of our times, be they doctors, politicians, or priests, and I'm not

foolhardy enough to attempt to answer them here. Rather, I will try to sum up the different viewpoints,

in the hope that you can make up your own mind on the subject. The book concludes with a collection

of useful information: some places to look for more information, and a glossary to explain the swamp

of medical terminology that we'll need to wade through.

Before you read on, a warning. This book is not a replacement for the advice of a qualified doctor. It

can help you work out what questions to ask your doctor, and to understand what he or she tells you

about your condition – but that is all. Only a doctor familiar with your own medical background can

give you good personal advice, so please do not make medical decisions based solely on this (or any

other) book.

While I have tried to ensure all the information here is correct, some detail will inevitably turn out to be

wrong. Even if it doesn't, the process of compressing a huge field of medicine into the space of one

ebook means that I've fudged a few of the details, and missed out some of the rarer conditions and

treatments. Meanwhile, the constant progress of medical science means that there will likely be some

medical development between the time when this book was written and the time when you read it.

Techniques improve, new side-effects are found, and new ideas spread from universities into hospitals.

So, if your doctor tells you something that disagrees with this book, believe your doctor.

Part 1: The nature and causes of infertility



An overview of the reproductive system

If you want to understand why something is broken, it's often best to begin by understanding how it

should work when everything is going right. This is true of fertility just as much as for anything else, so

let's begin with an overview of normal reproduction.

The magic moment is when a sperm carrying the father's genes reaches the egg, which carries both the

mother's genes and most of the substances needed to sustain the embryo for its first few days. This

happens in the one of the fallopian tubes, a pair of canals leading from the ovaries to the uterus. The

sperm bumps into the egg at random – it doesn't have any way of seeing where it's going – and latches

on to it. After some half-hour, the sperm forces its way into the egg, which then hardens so no other

sperm can get in. The genetic material from the egg and from the sperm can now mix, leaving the cell

with 46 chromosomes. The egg now has to implant itself on the wall of the uterus, and begin to develop

into a baby.

But let's backtrack a little. How did the egg and the sperm come to be in the same place? The egg is one

of over a million which have spent the woman's entire life in her ovaries. At the right time in the

menstrual cycle, surges of Follicle-Stimulating Hormone and Luteinizing Hormone stimulated the

maturation of the egg, and its release from the ovary.

What about the sperm? The sperm that fertilizes the egg is one of several million which were ejaculated

during intercourse. Unlike many of its fellows, it survived this sudden plunge into an alien, acid

environment, and it swam towards the Cervix, the barrier separating the uterus from the vagina. Around

the time of ovulation – and only then – it is possible for sperm to cross this barrier. The cervix slows

down the sperm and spreads them out in time, meaning that there is a constant stream of them entering

the uterus for many hours. Once they have entered the uterus, some of the sperm will find their way to

the fallopian tube, and one will bump into the egg.

The history of the sperm before intercourse is much shorter than that of the egg. The sperm are only a

few days old: whereas the woman's ovaries store eggs throughout her life, the man's testes are factories,

churning out millions of new sperm every day. These are stored in a small body called the epididymis,

from which they are released during ejaculation.

That, in much shortened and simplified form, is the human reproductive system. Now it's time to look

at what can go wrong with it.



Causes common to men and women

Many of the things that can go wrong with the reproductive system are specific either to men or to

women, and so this book includes a section on each sex. But some factors affect both sexes in a broadly

similar manner, and so it will save space to consider them together. These include









Hormonal problems

Hormonal causes of infertility include:

● CAH (Congenital Adrenal Hypoplasia)

● Physical damage to the hypothalamus or pituitary

● Low fat reserves, usually linked to eating disorders

● Hyperprolactinaemia

● Kallman Syndrome

● Prader-Willi Syndrome

● Bardet-Biedl Syndrome

Hormones are the body's long-term communication system. They are chemicals which circulate

through the body – often, but not exclusively, through the bloodstream – and trigger responses in cells.

In contrast to the nervous system (which shoots messages across the body in fractions of a second, to

be acted on and then instantly forgotten), hormones act over a period of minutes, hours, or days. The

patterns of rising and falling levels of hormones determine many of the cycles that our bodies follow –

not least those of the reproductive system. Estrogen and testosterone, the female and male sex

hormones*, are probably the best-known hormones in the body. The supporting cast - follicle-

stimulating hormone, gonadotropin-releasing hormone, and the like – don't get as much attention, but

our reproductive systems depend heavily on them and their interactions with each other.

It's no surprise, then, that when this chemical soup of hormones has too much or too little of some

ingredient, our bodies can fail to do what we expect them to. The relevant hormones are produced in

the genitals, and in two small regions of the brain called the hypothalamus and the pituitary. Disruption

to these two regions can cause hormonal problems which lead to sub-fertility.

What would cause this disruption? Obviously, physical damage such as a head injury could do it. More

commonly, the hypothalamus is affected indirectly. Drugs can do it – the contraceptive pill works by

reducing the amount that the hypothalamus produces Gonadotropin Releasing Hormone. The

hypothalamus is also affected by an unhealthy lifestyle. Extreme loss of fat deposits, commonly caused

by anorexia, bulimia, or excessive exercise, can also cause the disruption.

Another mechanism is through a condition called hyperprolactinaemia, where too much of the

hormone prolactin is produced in the body. Prolactin usually works on the breasts, encouraging them to

produce more milk. But it also has an effect on the hypothalamus, reducing the amount of other

hormones that it produces. So having too much prolactin in your body reduces the amount of

Gonadotropin-releasing Hormone, which can cause infertility.

Yet another imbalance can come in the form of problems with the adrenal glands. As the name

suggests, these glands produce adrenaline, but they also produce other hormones called cortisol and

aldosterone, and androgens. The androgens are male sex hormones, and so they affect the reproductive

system. In a genetic condition called Congenital Adrenal Hypoplasia (CAH), these androgens are

produced at too high a level. The mechanism leading to the over-production is a typical case where the

body notices a problem, corrects it, and in doing so causes a second problem. Let's look at it in stages:

1. The initial problem is a genetic defect within the adrenal glands, which causes under-

production of cortisol and aldosterone.

2. The body's response is to create a hormone called ACTH, which tells the adrenal glands to

produce more hormones. However, this doesn't tell it to produce more of one particular

hormone, just to generally step up production.

3. The side effect is that the adrenal glands start to produce more hormones – not just more



* Its not quite as simple as 'testosterone for boys, estrogen for girls', but the complexities needn't worry us here

cortisol and aldosterone (the desired response), but also more androgens (the undesired side-

effect)

4. The result is a higher circulation of androgens in the body. These changes begin before birth

(remember that CAH is genetic), and lead to abnormal growth of the genitals in girls.

CAH as a full condition affects only one in 15,000 people, although it has been claimed that a milder

form affects one in every hundred of us.

There are many other rare genetic conditions which cause infertility, through an imbalance of some

sex-related hormone. They end up separated into exotic-sounding syndromes – Kallman Syndrome,

Prader-Willi Syndrome, Bardet-Biedl Syndrome – depending on the underlying causes. These

syndromes are mostly genetic, and usually they affect more than just the reproductive system. Prader-

Willi Syndrome, for example, is caused by a problem with one particular gene, and leads to obesity,

and small hands and feet. If you suffer from one of these conditions, it's unlikely that fertility problems

will be the first that you hear of it. They're also very rare, each only affecting one person in many

thousands.



Age and infertility

The functioning of the reproductive system worsens over the years. That's true for both men and

women, but especially for women. One study has found that 29% of married women aged 40-44 are

infertile, compared to just 7% of married women aged 20-24.

Declining fertility with age is built into the very workings of the female reproductive system. Your

body only contains a certain number of eggs, and once they're gone no more can be created. Some of

these eggs will be ovulated and thus could be fertilized – but this only accounts for about one in every

3000 of the eggs you were born with. Most of your eggs will degenerate over time, in a process called

atresia. Once you have no more viable eggs, you have reached menopause. As you approach this point,

with declining numbers of eggs, fertilization will become more and more unlikely.

The menopause does not happen at a set time for every woman. This

Male fertility shows a shallower and less complete decline with age. 70-year-old men have sometimes

succeeded in fathering children, whereas a woman of this age would have absolutely no chance of

becoming a mother.

The decline in male fertility is partly caused by decreasing sperm production and worsening sperm

quality over the years, but is just as much tied to general health problems which impact on fertility. For

example circulatory problems can be connected to impotence, incontinence can lead to retrograde

ejaculation, and surgery in the pelvic region can have side-effects touching on the reproductive system.

This link between general health and fertility is true of women as well as men. As with many other

aspects of your health, if you take care of your body over the course of your life, it is less likely to let

you down later on.

This link between age and infertility is one of the reasons for the apparent rise in infertility in recent

decades. It isn't so much that people are getting less fertile, more that they are waiting until their

fertility declines before attempting to conceive. To some extent this trend is counter-balanced by the

increased ability of medicine to help us overcome the imperfections of our bodies – but assisted

reproduction techniques aren't immune to the effects of age, either. Almost any fertility treatment will

have a lower chance of success the older you are.

Disease and infertility

Some diseases can affect the reproductive system. Tuberculosis is a particularly strong example of this.

It is quite a rare cause of infertility in the developed world simply because of the rarity of the disease.

In other countries, where tuberculosis is common, it is a significant cause of infertility. The mechanism

is that tuberculosis spreads from the lungs to the reproductive organs. Here it can damage fallopian

tubes in woman, and, less commonly, the sperm ducts in a man.



Environmental Causes

Our bodies are constantly affected by the substances with which we come into contact in the outside

world, and the reproductive system is particularly sensitive to this. We may never manage to catalogue

the near-infinite complexity of the ways in which chemicals in the air, in our food, and in objects we

touch affect us. But what we do know is enough to understand the importance of environmental factors.



Natural substances



Lead was possibly the first chemical to be linked to lower fertility. In the middle of the 19th century, it

became obvious that the wives of men working with lead had lower fertility than would be expected

otherwise. Since then the link has been examined in great detail, and lead poisoning has been linked to

lower sperm counts and to higher rates of miscarriage.

This is only one of the many medical problems linked to lead, and it is one of the reasons for

increasingly tight legislation to control the use of lead. The addition of lead to petrol, for example, has

now been made illegal in many countries, and industrial processes using lead are strictly regulated. We

can only speculate as to the harm done by lead in centuries past – think not just of the 19th-century lead

workers, but of the Romans with their elaborate systems of lead pipes.



Plant estrogens



The story of plants with contraceptive powers is one of the more fascinating cases of evolution in

action. Humans have known for millennia that certain plants can prevent pregnancy. In the fourth

century BC Hippocrates, a Greek medical expert, wrote that 'Queen Anne's Lace' (also known as wild

carrot) had contraceptive powers. Other ancient cultures used plants in the fennel family, and possibly

also the pomegranate, for much the same reasons. Modern tests have found that these plants do contain

chemicals similar to estrogen. But why?

The answer, as we are only now coming to understand, is that this was a defense mechanism for the

plants. Plants have evolved many ways to prevent animals eating them. Some use sharp barbs to hurt

animals; others contain poisons to make the herbivores sick. And it now seems that some developed

contraceptives.

It works like this. A plant evolves to contain a substance which renders animals eating it infertile.

Animals that eat it have no offspring, whereas animals that do not eat the plant are as fertile as they

would be otherwise. Over the generations, the animals that are predisposed to avoid the contraceptive

plant will prosper, and so the animals will evolve to avoid the plant. The plant, therefore, manages to

avoid being eaten.

That explains why plants might contain these estrogen-like substances. What we don't know is how,

and how much, plant estrogens affect human reproductive health. Doubtless more news will come in

the future, but for now don't worry too much about this unless you eat inordinate amounts of one

particular plant.



Synthetic chemicals



One hundred thousand synthetic chemicals are on the market worldwide, being used in industrial

processes, as pesticides and for cleaning, even added to food. Testing facilities can barely keep up:

there is a legal requirement to conduct some tests before selling a new chemical, but these required

tests only scratch the surface of the impact chemicals can have on human health. Worse still, chemicals

manufactured in countries with lower regulatory standards can traverse the globe, affecting human (and

animal) health in other lands regardless of the laws there. In short the rise of the chemical industry over

the course of the twentieth century has brought some pretty big risks to human health.

Particularly worrying are those chemicals which mimic the effects of hormones. The first, and still the

most famous, case of this is DDT, a chemical created in 1938 and marketed as a pesticide. Though

DDT was hailed as a great breakthrough, and its creator won a Nobel Prize, it brought with it some

immense problems.

DDT, it turned out, acted like estrogen in the bodies of animals. DDT in the environment has caused

reproductive problems in chickens, polar bears, gulls, seals, whales, and many, many other species of

animal.



Drug use



Alcohol



Alcohol abuse (and, to a lesser extent, even moderate drinking) harms the fertility of both sexes.

Alcohol damages the liver, and this in turn disrupts the balance of hormones in the body, for example

by increasing the amount of estrogen produced by men. Such hormonal imbalance affects the entire

body, but particularly harms the production of sperm. Alcohol can also have a direct toxic effect on the

cells in the testes which produce sperm.

For women, drinking alcohol can disrupt both ovulation and the menstrual cycle. But the biggest

damage is done through drinking after conception – those who drink when pregnant risk miscarriage or

stillbirth, as well as a range of birth defects. So, in short, both men and women need to cut back on the

alcohol if they're having trouble conceiving, and if they do succeed then abstinence over the course of

pregnancy is a must.



Smoking



Smoking causes infertility, according to the warnings many countries require on cigarette packets.

They're telling the truth, and although scientists haven't yet untangled all the connections between

smoking and fertility, we already know enough to know that it's bad news.

Survey after survey has shown that smokers have more fertility problems than non-smokers. Smokers

have lower sperm counts and higher levels of abnormal sperm, and stopping smoking leads to an

increase in sperm count. But it's one thing to know smoking harms fertility, and another to untangle

which of the dozens of toxic chemicals in cigarette smoke is responsible, and why. Some of these find

their way into the semen where, of course, they wreak their toxic damage on the sperm. Meanwhile, the

negative effects of smoking on other parts of the body will be increasing blood pressure and bringing

hormones out of balance – both factors linked to reduced fertility.

Smoking damages DNA in the body, including in sperm cells. If sperm with smoke-damaged DNA

fertilizes an egg, there is an increased risk of childhood cancer and other health problems in the child.

The good news is that fertility increases once you stop smoking, although it may, for example, take a

few months for sperm counts to return to a normal level.



Caffeine



Despite ever-increasing evidence of the negative health impact of caffeine consumption, our culture

does not treat it as a drug. But a drug it certainly is, and its effects on the body can be dramatic. This

may include effects on fertility: some studies have found statistical evidence for a link, but we have no

understanding of why there would be one. The evidence seems to suggest that drinking a daily cup of

coffee can increase the time taken to get pregnant, while another survey claims that drinking 2-3 cups

each day when pregnant increases the risk of a miscarriage.



Recreational Drugs



Other recreational drugs may have equal or greater impacts on fertility. These have been less

intensively studied than alcohol and tobacco, not least because of the practical difficulties of

conducting human tests with banned substances.

Smoking marijuana, according to a team of researchers from Buffalo University, reduces the quantity

of semen, the number of sperm in the semen, and the percentage of those sperm that are functional.

Marijuana seems to have an adverse effect on the ovaries when smoked by women. Unlike with

smoking tobacco, there is no evidence to indicate whether fertility will increase again if you stop

smoking marijuana.

During pregnancy, illegal drug use can easily affect the baby, leading to miscarriage, stillbirth, and

birth defects.



Lifestyle Causes

Almost any aspect of our lives can have some effect on our fertility – although the story that wearing

tight jeans reduces your sperm count doesn't seem to be true. But broadly speaking, anything that is

generally bad for you is likely to reduce your fertility somewhat.



Weight and fertility



Being overweight or underweight reduces fertility, especially in women. Pregnancy, and in some cases

even menstruation, will not take place if the body does not have enough fat to support it. Think about it

in terms of evolution – a starving animal would need to concentrate on getting through the immediate

future, rather than worrying about reproduction. Now our lifestyles can simulate starvation - in

anorexics the situation may be so extreme that they stop menstruating, let alone being able to conceive.

Weight, for the purposes of fertility as well as for much else, is analyzed by means of the Body Mass

Index (BMI). This is a simple calculation: your weight in kilograms, divided by the square of your

height in meters. This will give you a number, which you can compare to averages over a population. A

figure of between 20 and 25 is usually seen as medically ideal. Remember, though, that this isn't a

universal truth, and you should consult a medical professional for advice on your particular

circumstances.

Obesity wreaks its damage to fertility by means of hormones. Chemically, cholesterol (which is often

found at high levels in the obese) is very similar to estrogen (the hormone controlling much of the

menstrual and female reproductive cycles). If there is too much cholesterol in the body, the adrenal

gland will convert some of it into ' androstenedione', which in turn gets converted into estrogen. The

body will therefore contain too much estrogen, which will disrupt reproduction.

Even if you are a perfect weight now, if you have been obese or underweight in the past, this could still

have an impact on your fertility. There is particular evidence that teenage obesity has an ongoing

impact on fertility.

There is believed to be a link between female obesity and Polycystic Ovary Syndrome (PCOS),

although it remains unclear how this interacts with the genetic basis of the condition. If you do succeed

in conceiving, being overweight can lead to complications during pregnancy, increasing the risk of

miscarriage and birth defects.



Exercise



Excessive exercise can reduce fertility for both sexes. The key word here is 'excessive': taking regular

moderate exercise is unlikely to harm your fertility. In fact, moderate exercise will, if anything,

improve fertility by way of improving your general health. We still don't understand why exercise

affects fertility. One theory is that exercise uses up energy. The body might plausibly interpret an

energy deficiency as an indication that it does not have enough spare energy to engage in the energy-

intensive business of reproduction.

This theory, though, has suffered a blow from evidence that exercise harms fertility even in people who

are getting a good diet. We are left without much idea of what it is about exercise that reduces fertility.



Occupational hazards



Looking at people's fertility in connection with their occupation is a bit of a cheat. Rather than directly

trying to find specific chemical, medical or social causes of infertility, we compile statistics on the

fertility of people in different walks of life, and try to spot the careers which are bad for your fertility.

What the statistics tell us is that miners, farmers, construction workers and car mechanics have an

elevated risk of fertility problems. Women, in addition to these risks, can also have their fertility

reduced by looking at computer screens.

These findings need to be taken with a large pinch of salt. Remember the adage that "correlation does

not equal causation". Just because two things are seen together, we can't assume that one causes the

other. It is almost impossible to separate out the effects of different factors which are associated with

occupation. Are farmers less fertile because they are unusually likely to suffer depression? Does the

physical exercise involved in being a miner account for their lower fertility? Some of these links are

easy to spot, but eliminating them all is painstaking work.



Other lifestyle causes



Radiation, if you are unlucky enough to be exposed to it, will affect the reproductive system even more

than it affects the rest of the body. Fortunately, this is a reasonably rare problem except in a few limited

situations.

Fertility-stunting medicines

Very many prescription drugs will affect the reproductive system. If you are taking any of these, you

will need to discuss with your doctor what effect they are likely to have on your fertility, how to

minimize these side-effects, and whether it is worth stopping treatment with some drug in order to

improve your fertility. Drugs known to affect fertility include:

● Tranquilizers

● Antibiotics (possibly)

● Cortisone

● Treatments for the common cold







The Thalidomide and DES scandals



Prescription drugs, too, can have side-effects which impact on fertility and reproduction. In a couple of

cases, these have emerged in dramatic public health scandals, such as that surrounding thalidomide. In

the early 1960s, thousands of pregnant women were prescribed a drug called thalidomide, as a

tranquilizer. When they gave birth, it was to babies with terrible deformities: lacking arms or legs,

some with hands growing directly from their shoulders, others blind, deaf, or brain-damaged.

Other drugs can cause side-effects at a greater remove. Drugs taken by a pregnant mother can affect the

fertility of her children – an effect that might not become obvious for another twenty years. The classic

case of this is DES, a drug which, ironically, was prescribed for infertility. It didn't have significant

side-effects in the mother, and it was many years before doctors realized that it had dramatically

affected the children of mothers who took DES during pregnancy. Some suffered from a very rare

cancer of the vagina, others have been left with severe deformities of the uterus. Male "DES children"

have escaped more lightly, but they too suffer higher rates of abnormal sperm, undescended testicles

and stunted penises.

Tragic episodes like those with DES and Thalidomide are rare, but unfortunately they are almost an

inevitable outcome of the progress of medical science. Despite the ever-increasing battery of tests to

which every new drug is subjected, it remains impossible to know everything that a drug does to the

human body. Laboratory tests usually only find what they're looking for, and animal tests will never

find situations where the human and the animal cases differ.



Drugs taken during pregnancy



Drugs taken during pregnancy pose a particular problem to the chances of a successful birth. For many

decades, the placenta was believed to shield the fetus from most of the substances in the mother's

bloodstream, protecting it from the effects of drugs. This belief collapsed in the 1960s, and since then

we have found dozens of chemicals which can cross the placenta to affect an unborn baby, perhaps

causing birth defects or miscarriage. What's worse, it takes a much smaller dose to affect a fetus than it

would to affect an adult. Almost unmeasurably small doses of some chemicals – doses which must be

counted in parts per trillion – can destroy the health of a fetus.

Don't take this as an argument to avoid doctors! The tragedies are massively outnumbered by the

positive miracles wrought in hospitals, and people lose far more than they gain when they shun

medicine from fear of what happens when it goes wrong.

Causes of male infertility

For a man to be fertile, he has to be able to produce large quantities of functional sperm, and get them

into his partner. Problems at any stage can mean infertility – so let's look at them each in turn.



Azoospermia

Sometimes the semen is produced does not contain any sperm. This is given the name 'Azoospermia'. It

can be divided into two forms, obstructive and non-obstructive. The nature of these is so different that

it is best to consider them separately:



Obstructive azoospermia



Obstructive azoospermia is when men produce sperm, but have some physical blockage preventing

them from combining the sperm with semen. This can be caused by:

● CBAVD (Congenital bilateral absence of the vas deferens). This is a genetic defect, in which

the vas deferens, part of the chain of vessels bringing sperm from the testes to be ejaculated,

does not form properly. When this affects only one of the two ducts, (congenital unilateral

absence of the vas deferens), the condition is only a mild problem, since sperm will still pass

through the other duct. The bilateral form leads to complete lack of sperm in the semen.

● Cystic Fibrosis. This is very closely connected to CBAVD – both are caused by a defect in the

same gene. However, they are different conditions: cystic fibrosis is a much more serious

condition, affecting more than just the reproductive system. Sufferers of cystic fibrosis usually

– though not always – suffer from CBAVD.

● Other genetic causes

● Injury. It is quite rare for injury to sever the sperm ducts themselves. More often, injury to this

region will cause inflammation and the formation of scar tissue, which will block the ducts.

● DES Exposure. Children of mothers who took the drug DES during pregnancy appear to have a

higher likelihood of obstructive azoospermia. The mechanism is not yet understood, but this

would be only one of many serious reproductive side-effects caused by DES.

● Vasectomies. Technically a form of injury- an intentional blocking of the sperm ducts

● Tuberculosis. If tuberculosis spreads from the lungs to the reproductive system, infection can

cause blockage of the sperm ducts





The usual treatment for obstructive azoospermia is not to fix the ducts, but rather to bypass the

problem. The sperm can be removed from the testes or the epididymis, a process described in detail

later. One exception is vasectomy reversal, which can now be done with a reasonable likelihood of

success (well over 50%, if the reversal takes place within a few years of the vasectomy). The sperm

retrieved in this way can then be injected into the man's partner using either IVF or ICSI

(intracytoplasmic sperm injection).



Non-obstructive azoospermia



The other form of azoospermia, 'non-obstructive azoospermia', is a more serious problem. It is

normally caused by hormonal imbalances, such as an unusually high level of Follicle-Stimulating

Hormone (FSH), and most sufferers also have unusually small testes.

For many years, doctors considered it untreatable, advising patients to adopt or use a sperm donor.

Recently, however, so-called Testicular Sperm Extraction has been used to obtain some sperm in some

cases of non-obstructive azoospermia.



Retrograde ejaculation

Retrograde ejaculation is a condition usually linked to sphincter problems (including those associated

with diabetes or the aftermath of surgeries). It can be a side-effect of some drugs. In retrograde

ejaculation, semen is not ejaculated through the urethra, but instead finds its way into the bladder.

Drugs such as imipramine or pseudoephedrine can be helpful in this situation. If drugs don't work,

sperm can be collected from your urine, and then used in artificial insemination.



Sperm quality and number

For normal fertilization, a man needs to produce a very large number of sperm. Something on the order

of 40 million is considered normal for one ejaculation! In most cases of male infertility, some sperm

are produced, but they aren't enough in number, or most of them are badly-formed and so unable to

fertilize an egg. If your doctor uses the tongue-bending term 'oligoasthenoteratozoospermia', he's

talking about this shortage of functional sperm.

Of the factors which researchers have identified as affecting the number and quality of sperm produced,

many are related to lifestyle, drug use, or environmental factors. These have been discussed above,

since many affect both men and women. Here, we will look at male-specific problems:



Aspermia



Aspermia refers to the complete failure to produce semen. It is quite rare – in most cases of apparent

aspermia, the semen has actually been produced, but has not been ejaculated. Retrograde ejaculation

(see above) is a common example of this. True aspermia is frequently the result of genetic problems,

and is typically very hard to treat.



Varicocele



This is a swelling of certain blood vessels in the testes. It has not been proven to cause fertility

problems, but men suffering from varicocele do, on average, have lower sperm counts and poorer

sperm quality. This, though, could just mean that both the varicocele and the sub fertility are symptoms

of some underlying genetic problem. It has been suggested – though not proved – that varicocele

affects fertility by changing the temperature of the testes. The process of sperm production is highly

sensitive to temperature – the reason why the testicles hang outside the body is to keep them cool. If

blood circulation through the testes is impaired, the body loses an important method of regulating the

temperature, and it might then fail to keep the testes at that ideal, cool temperature.



Anti-sperm antibodies



The immune system is responsible for identifying and destroying harmful intruders in the body –

bacteria, viruses, and the like. The reproductive system is a challenge for the immune system. It needs

to accept sperm as harmless, while continuing to protect the body against genuine intruders. But sperm

are very different from ordinary cells – for a start, they have half the number of chromosomes.

The male body gets around this problem by taking a short-cut. It doesn't even try to teach the immune

system to recognize sperm as friendly. Instead it keeps them separate: the blood-sperm barrier divides

the blood (which contains immune cells) from the sperm. If this barrier breaks down, the immune

system will produce antibodies targeting the sperm. These antibodies seize hold of the sperm and cause

them to be killed. Since the number of sperm produced is so high, the antibodies will not affect all of

them. However, they will cause a noticeable decrease in fertility.

What can cause this damage to the blood-sperm barrier? Infection of, or physical injury to, the testes

can allow blood to meet sperm. Having a vasectomy will also break the barrier. This means that even

men who have a successful vasectomy reversal will have lower fertility than otherwise, since their

sperm will contain anti-sperm antibodies.

More rarely, women occasionally develop anti-sperm antibodies which target their partner's sperm.



Impotence

Impotence (erectile dysfunction) covers the range of conditions that can result in the failure to have an

erection. This can make natural conception difficult or impossible. Erectile dysfunction isn't the kind of

condition that you either have or don't have. There is a wide spectrum of impotence problems, from the

very minor to the serious, and most cases fall somewhere in between. The various causes of impotence

act together, each causing its own small drop in erectile ability. Known causes of impotence include:

● Smoking

● Alcohol

● Obesity

● High blood pressure

● Problems with the circulatory system

● Problems with the nervous system:

Alzheimer's Disease

Parkinson's Disease

● Damage to the spinal cord or nerves in the pelvis, caused by:

Injury

Surgery

● Diabetes

● Hormonal problems

● Psychological factors

Depression

We can understand these causes more fully by grouping them by how they affect the ability to form

erections. The largest group are physical problems involving the blood. This makes sense: the penis

becomes erect by filling with blood, so if the blood circulation is unusual the penis may find it harder to

function properly. We can think of smoking and diabetes as causing impotence by affecting the

bloodstream, although the real picture is more complicated.

But the penis will only become erect when it receives a nerve signal telling it to do so. If this nerve

signal unable to get through, or if the penis is unable to react to it, then there will be no erection even

though the penis is physically capable of it. This explains why injury to the spinal cord can prevent

erections, and why surgery can accidentally cause impotence by disrupting the nerves running to the

penis. Similarly, Alzheimer's and Parkinson's, both disorders of the nervous system, can stop these

nerve signals reaching the penis.

Finally, there is the need for that nerve signal to be sent to the penis. This is the role of psychology, and

there is some dispute about how important psychiatric factors are in causing impotence. Intuitively, it

might seem obvious that our arousal depends on our brains, and most men would say there is a link

between their mental state and their capacity for physical arousal. But psychological factors are hard to

measure, and it is all to easy to succumb to temptation and use 'psychology' as a catch-all explanation

for anything we can't pin down to another cause. Even where there is a psychological element to the

cause of impotence, this does not mean that it must be treated through psychiatric therapy. It might be

easier and more effective to use drugs or surgical methods to enhance what capacity for erection there

is already.

Even complete impotence isn't usually a barrier to conception, although it can render natural

conception impossible. In the treatments section, we will see that it is possible to extract sperm from

the testes or from the epididymis, and then to use this for artificial insemination. We'll also see that

there are several highly successful drug treatments for impotence, Viagra being the best-known but not

the only option.

Successful treatment for impotence does not necessarily require us to understand what is causing the

problem.



Psychological elements

Sometimes there is a psychological element in infertility, particularly in impotence. But doctors

disagree on how great this is. In the past, it was believed that a large percentage of erectile difficulties

came down to psychology, and psychologists and psychoanalysts dedicated their efforts to solving

them through therapy. Now, fashion has swung the other way, and many doctors would say that only a

small fraction of erectile problems (perhaps one in ten) is caused by psychology.

That said, the social stigma attached to impotence combines with medical problems to exacerbate sub-

fertility. Many men who are insecure about their sexual performance – perhaps because of a history of

infertility – will feel extreme 'performance anxiety', which can both reduce the pleasure of intercourse,

and also exacerbate erectile problems.



Causes of female infertility



Endometriosis

Endometriosis is one of the most common reasons for female infertility, and a problem which increases

with age. The tissue which usually lines the uterus begins to form in other areas of the body, such as the

uterus or the bowel. The cause seems to be during menstruation, when tissue falling off the uterus gets

caught elsewhere. It can then begin to grow where it lands.

This in itself might not be such a great problem. However, since these tissues are originally from the

uterus, they try to bleed during menstruation. But, since they aren't in the uterus, it is difficult for the

tissues to leave the body. Thus some of the fluid which would otherwise be menstruated is trapped, and

leads to inflammation and irritation. While endometriosis does not inevitably lead to infertility, in many

cases it does block the ducts or make it impossible to reach the sperm.

Uterine Fibroids

Uterine fibroids are a common but usually harmless condition, affecting perhaps one woman in four.

They are non-cancerous tumors within the uterus, most of which are small and can be easily ignored. In

a few cases, however, the fibroids block the fallopian tubes, meaning that sperm cannot gain access to

fertilize the egg. The presence of fibroids on the uterus may also make the lining less able to receive the

embryo when it is ready to be implanted. It is worth emphasizing how rare this is: even if you are

infertile and suffer from uterine fibroids, the two factors are not likely to be connected.



Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS), also known as Stein-Leventhal syndrome after the doctors who

firs t described it back in the 1930s, is a problem which affects some 5-10% of women, most of whom

do not realize that they have it. As well as infertility and irregular menstruation, PCOS is characterized

by obesity, acne, and hairiness caused by high levels of male hormones in the blood. The causes are

believed to be partly genetic, but the condition remains poorly understood, and it is likely that our

understanding of it will change significantly in the coming decades.

How does PCOS cause infertility? Hormone imbalances mean that the ovary does not correctly release

follicles. This leaves the ovary with many cysts, which develop from the unreleased follicles. And

naturally, since the eggs are not released from the ovaries, they cannot be fertilized.

Suffering from PCOS will not necessarily make you completely infertile.



Physical damage to the reproductive system

Any kind of physical damage to the reproductive system can cause infertility. The fallopian tubes are

particularly vulnerable, since injury can easily lead to them being blocked. In Pelvic Inflammatory

Disease the fallopian tubes are infected by chlamydia or other bacteria. Infection causes inflammation

of the fallopian tubes, which scars the lining. Sometimes this leads to an adhesion, where two sides of

the fallopian tubes stick together.



Unexplained Infertility

Even after exhaustive tests, it is quite possible that fertility doctors will be unable to find anything

medically wrong with you. This is the case for some 10% of couples seeking fertility treatment.

Whether you take it as good or as bad news depends somewhat on your temperament. The former

attitude takes it as a hint that perhaps there isn't anything wrong, that you have just been unlucky and

will be able to conceive if you keep trying. This isn't entirely foolish – some one in three couples with

unexplained infertility do later manage to conceive. But, as the pessimists will see, it could equally be

that you are suffering from some medical problem which has simply not been recognized.

The lack of a clear medical diagnosis will be taken by some as indication that the problem is

psychological in nature. This is hard to prove one way or the other, and whether you believe it is in

large part determined by whether you see analysts as saints or charlatans.



How common is infertility?

The rate of infertility is very high, and probably higher than you would imagine from your personal

experience. It is likely that several of your friends are infertile, but the social stigma of infertility

remains such that many infertile couples choose not to talk about it. A commonly-quoted figure says

that 15% of the population are infertile.

In any case, statistics for a condition as multifaceted as infertility will often only tell you part of the

story. This is doubly so when it is a condition which treads so closely on our dreams and values. The

usual measure of infertility is the failure of a couple to conceive after a year of trying. Many couples

don't try for a year, though, not least those who are not in a stable relationship.



Diagnosing infertility

Tests and investigations to find the causes of infertility include:

● Levels of Follicle-Stimulating Hormone (FSH)

● Ultrasound

● Hysteroscopy

● Laparoscopy

● Semen analysis

● Post-Coital Test







Ovarian reserve tests



Several tests attempt to determine the level of the ovarian reserve – that is, how many eggs there are

left in the ovaries. This is an important factor in the fertility of older women. One test measures the

levels of Follicle Stimulating Hormone (FSH) in the body. FSH, along with another hormone called

Luteinizing Hormone (LH), controls the menstrual cycle. As the ovarian reserve declines, the body

increases production of these hormones, in an attempt to push the last few eggs out of the ovaries. So a

high level of follicle-stimulating hormone means that your ovarian reserve is low, and you will likely

have difficulty conceiving.



Physical examinations





Physical problems in the female reproductive system can be identified by X-ray. The normal procedure,

known as a hysterosalpingogram, involves injecting dye into the uterus. This dye will show up on the

X-ray, and you and your doctor will be able to see if the uterus is normal, and identify problems such as

blockages in the fallopian tubes.

Two slightly more invasive techniques are also available to identify physical problems in the uterus. In

a hysteroscopy, a lens or camera is pushed through the cervix, so that a doctor can look at the inside of

the uterus. In a laparoscopy, the camera is inserted through a hole made in the belly. Both procedures

are usually carried out under anesthetic – a local anesthetic for hysteroscopy, and general anesthetic for

laparoscopy.





Ultrasound



Ultrasound is another option. The same technology that allows pregnant mothers to see their unborn

babies can let doctors visualize the female reproductive system, and so identify problems there. It

works by bouncing sound waves off the body, and measuring how long it takes for the echo to come

back. The ultrasound waves will pass through some tissues and be blocked by others, so the timing of

the echoes can be fed into a computer, which then builds up a picture of the body underneath the probe.

This is basically the same way that bats see, although sound of a different (and inaudible) wavelength is

used.

The ultrasound probe (which sends out the ultrasound waves) can either be placed on the abdomen, or

inserted into the vagina. The second technique is, perhaps surprisingly, less uncomfortable. This is

because when the probe is placed on the abdomen, there is a problem with the bladder getting in the

way. The solution is to drink a lot of water to fill up the bladder, which will move it out of the way.



Post-Coital Test



The post-coital test has a reputation as one of the more invasive elements of reproductive medicine.

The aim of the test is to check that it is possible for sperm to pass through the mucus of the cervix. The

sperm must be able to pass through the mucus if it is to reach the uterus and then the fallopian tubes, in

order to finally fertilize an egg.

Unfortunately, the usual way to test the receptivity is to have a test of the mucus shortly after

intercourse. The window of time between intercourse and getting the post-coital test may be as little as

5 hours, and the test has to be performed at a clinic. As if this didn't bring enough logistical

complication and invasion of privacy, the test will only work if the intercourse has taken place near to

the time of ovulation.

Useful though the test may be, the awkwardness and regimentation of the procedure reminds one of

ancient witch-doctors, producing astrological charts and demanding intercourse and rituals at set times.

At least now the rituals are backed by medical science, and so we can have at least some faith in them

working.



Semen Analysis



Many forms of male factor infertility can be diagnosed by examining a sample of sperm. From this, a

laboratory can diagnose several problems. Insufficient quantity of semen, or low concentration of

sperm within the semen, can be easily noticed. So too can an in appropriate pH of the sperm – unless

sperm is slightly alkaline, it risks being destroyed by the acidity of the vagina. Other tests can check

that a majority of the sperm are alive, and that not too many are misformed or unable to move. If anti-

sperm antibodies are in the semen, these can also be identified by a special test.

Part 2: Treatments



Male infertility treatments



Obtaining Sperm

In male-factor infertility, the great challenge is often to extract sperm from the male body. Once sperm

has been obtained, it can then be used for IUI, ICSI, or IVF (described below). The various sperm-

collection procedures must all overcome the same difficulties:

1. Getting enough sperm. Typically, 5-8 million sperm are needed for IUI. If it is not possible to

get this number of sperm, it may be necessary to use more difficult techniques like ICSI, so as

to make the most of the sperm which have been obtained.

2. The sperm must be functional. If the sperm are dead (necrospermia) or otherwise ineffective,

extracting them will be useless.

3. The procedure should involve as little risk and discomfort for the patient as possible.

Now we've seen what sperm extraction techniques must achieve, let's see what the options are. There

are three forms of surgery to extract sperm, which are collectively known as 'sperm aspiration'. These

are:

● PESA sperm extraction

● MESA (Mirosurgical Epididymal Sperm Extraction)

● TESE (Testicular Sperm Extraction)

● TESA (Testicular Sperm Aspiration)



PESA and MESA: sperm extraction from the epididymis



PESA and MESA extract sperm from the epididymis, an organ just above the testes which stores

sperm. With PESA, this is done by inserting a needle into the epididymis more or less at random. The

hope is that the needle will randomly find some sperm. This does work reasonably often, but it rarely

succeeds in getting enough sperm for use in insemination. PESA also carries the risk of hitting a blood

vessel, which can cause all kinds of complications.

MESA is an alternative to PESA which is more invasive, but generally results in more sperm being

collected. In MESA, the epididymis is opened through surgery, and examined under a microscope. The

doctor can then cut open one Sf the tiny tubes which store the sperm, and can then extract large

quantities of sperm. As MESA requires surgery and specialized equipment, it is more expensive than

PESA, and there are less clinics capable of performing it.



TESE and TESA: sperm extraction from the testicles



The other two procedures, TESE and TESA, take sperm from the testicle itself rather than from the

epididymis. This is essential when the sperm never reaches the epididymis (this situation is true in most

cases of non-obstructive azoospermia). Otherwise, it is not ideal, since if something goes wrong here it

would affect the testicle itself.

The difference between TESE and TESA is similar to that between MESA and PESA. In TESA, a

needle is used to remove a small section of the testicle. This section can then be taken off to a

laboratory, where the sperm is extracted from it. The problem is that, as with PESA, it is hard to tell

exactly what the needle will catch. Again, there is a risk of hitting a blood vessel, something which is

made more serious by the risk that this could cut off the blood supply to the testicle.

TESE is also a biopsy of the testicle, but it is an open rather than a needle biopsy. In other words, the

doctor will manually cut off a small section of the testicle.



Assisted Ejaculation

Sperm aspiration is not usually used to deal with a simple inability to ejaculate. As explained above,

damage to the spinal cord or to the rest of the nervous system can inhibit ejaculation, even when the

genitals themselves are perfectly healthy. In theory, it would be possible to extract sperm with MESA

or the other techniques discussed above, but this is not necessary. Instead, mechanical means are used

to stimulate ejaculation.

In the simplest case, a mechanical vibrator can be used on the penis. This stimulates the nerves in the

region, and can provoke ejaculation as a reflex reaction. The method here is basically the same as that

which makes you jerk your leg when you are tapped on the knee: the nervous system for that part of the

body works by itself, without needing to deal with the brain.

This simple system will not always work. In particular, it requires a complete reflex arc: the nerves

running from the genitals to the spinal cord must be intact. When basic vibratory stimulation fails, the

next tool is called Electro-ejaculation. Under general anesthetic, an electrical anal probe is used to

stimulate the nerves around the prostate.



Semen storage

There are many cases in which a man can anticipate becoming infertile in the future. A typical example

is if you are undergoing cancer treatments which involve chemotherapy. Chemotherapy usually targets

fast-dividing cells in the body, because this is the best way to target cancer. A significant side-effect of

chemotherapy is therefore damage to other fast growing cells. Chemotherapy patients lose their hair

and gut linings – and their sperm production grinds to a halt.

Another example is a vasectomy. While it is not advisable to undergo vasectomy unless you are

convinced that you will never want to father a child, storing sperm allows at least some room for

reconsideration if you change your mind later in life. Many clinics will therefore advise men to store a

sperm sample before they undergo vasectomy.

Men who are undergoing one of the artificial sperm extraction techniques described above will often

have the extracted sperm stored. This enables them to undergo the extraction procedure only once, but

store enough sperm for several attempts at insemination. This is crucial given the relatively low success

rates of some infertility treatments, and the risks and hassle involved in sperm extraction procedures.

Finally, sperm which will be used for donor insemination is generally frozen after collection. As well

as avoiding the logistical nightmare of trying to procure 'just-in-time' sperm for immediate fertility

treatments, this allows more time to monitor the health of sperm donors, and so to screen out any

donors whose sperm might be carrying defects.

The process of freezing sperm is now well understood, and can be done with very little adverse impact

on the quality of the sperm. Frozen sperm can be kept for many years.

Surgery

Surgery is an option in some cases of obstructive azoospermia – that is, in situations where the sperm is

being held back by a physical blockage. The most common case of this is vasectomy reversal. The

sperm ducts which were tied off during the original vasectomy are repaired or bypassed, and a good

number of patients are then able to conceive through normal intercourse.



Impotence treatments



Mechanical and surgical treatment



When impotence is only partial, it can often be overcome by the use of special equipment at the time of

intercourse. Typically, this involves a vacuum pump. The low pressure in the vacuum makes it easier

for blood to flow into the penis, and so an erection is possible within the vacuum. The user can then

place a rubber ring around the base of the penis, which will stop blood flowing back out of the penis.

Longer-term options include several forms of surgical implant. The most basic of these involves

placing a hard implant inside the penis, so as to keep it permanently in a semi-erect state. The

inconvenience of having a permanently erect penis soon led to variations in which the implant can be

inflated and deflated as required.



Drug treatment of impotence



Viagra, famous though it may be, isn't the only drug treatment for erectile difficulties. Most impotence

drugs, Viagra included, work by making it easier for the penis to fill with blood and so become rigid

and erect. There are two main routes to achieving this: a drug can either increase the blood flow to the

penis, or it can dilate the blood vessels inside the penis. Let's take a look at the drugs available:

1. Viagra: the 800-pound gorilla of impotence treatments, which has largely lived up to its

reputation as a 'wonder drug'. Viagra works by increasing the blood supply to the penis. There

are side-effects, but in many cases these are easily outweighed by the benefits which Viagra

offers. The drug is marketed under several different names.

2. Prostaglandin. This drug must be injected into the penis. It works by dilating the blood vessels

in the penis. Although effective, the awkwardness of carrying out injections is a significant

downside.

3. Phentolamine. Not yet widely available, and less tested than other drugs, but it works in a

similar fashion to Viagra.



Other drug treatments: testosterone and hormone injections

Testosterone has been used in the past as a treatment for male infertility, but it is now believed that the

side-effects are too great to be effective. The principle behind this treatment is that testosterone

suppresses sperm production. This is, of course, exactly the opposite of what is wanted – but the theory

is that when testosterone treatment stops, sperm production will rise up to a higher level than it was

before treatment.

If a case of male infertility is known to be caused by a hormone deficiency, then it can sometimes be

treated by injections of that particular hormone. This might include drugs such as Humegon and Profasi

Female infertility treatments



Surgery

When infertility is the result of physical problems with the uterus or fallopian tubes, these can often be

repaired by means of surgery. Surgery is commonly performed to deal with blocked fallopian tubes or

with endometriosis, but it is not limited to these situations.



Intrauterine Insemination (IUI)

In IUI, sperm are inserted directly into the uterus. The aim of treatment is that, once in the uterus, the

sperm will be able to fertilize an egg without further assistance. This is particularly appropriate when a

post-coital test has identified that sperm are not managing to pass the cervix.

Prior to intrauterine insemination, the sperm can be prepared in a number of ways. This is known as

'washing' the sperm, and can involve increasing the concentration of sperm in the fluid to be injected.

The washed sperm are then inserted using a catheter.

IUI is a good solution when a couple is sub-fertile but may be able to conceive. It will not be of any use

if functional sperm cannot be obtained (e.g. in some cases of total aspermia or azoospermia), nor if the

woman is not ovulating.



IVF

IVF, 'in vitro fertilization', is the fertility treatment that still regularly makes headlines, even decades

after its first introduction. IVF is now very common – in the UK alone, 10,000 babies are born each

year as the result of IVF.



IVF: The basic procedure



The process begins with the collection of eggs from the ovaries. This is done surgically, usually under

local anesthetic. Beforehand, doctors will have checked that eggs are present, and will probably have

prescribed drugs to cause ovulation. It is normal to use enough drugs to cause multiple ovulation,

because the IVF process will only work with a small fraction of eggs. Sperm is also collected (this

process being much simpler than collecting eggs), and the egg and sperm are combined 'in vitro'

(meaning 'in glass', or 'in a test tube'). The fertilized egg is grown in the laboratory for a while, in which

time it will divide once or twice. It is then inserted into the womb.

Commonly, multiple eggs are fertilized during IVF treatment, and several will be inserted into the

womb at the same time. It is expected that most of the embryos will fail to develop (even with multiple

implantations only 20-25% of IVF procedures result in pregnancy), and so inserting several improves

the odds that at least one will make it. The downside is that occasionally more than one survive, leading

to the controversial phenomenon of multiple births following IVF.

While the IVF success rate is currently low, it is likely to increase slowly in the future, as new

techniques are developed to improve the process. February 2007 saw reports of a technique called

"Comparative Genomic Hybridization", which one trial suggests could raise the IVF success rate to

70%. It involves checking each egg for likely problems before it is implanted into a patient.

Variations on IVF



IVF has spawned a couple of similar procedures.

● GIFT ('Gamete Intrafallopian Transfer')

● ZIFT ('Zygote Intrafallopian Tranfer')

● ICSI ('Intracytoplasmic Sperm Injection')

GIFT, 'gamete intrafallopian transfer', could be described as IVF which isn't 'in vitro'. As in IVF, eggs

are extracted and then fertilization is artificially induced – but with GIFT this takes place inside the

fallopian tubes, rather than in a laboratory. This means that, unlike IVF, GIFT requires healthy

fallopian tubes. The advantages of GIFT over IVF are mainly ethical. Some couples object to the idea

of human embryo culture in vitro, on religious or other ethical grounds, and consider that GIFT

achieves the same end without putting them in a moral conundrum. ZIFT (Zygote Intrafallopian

Transfer) is something of a compromise between GIFT and IVF. With ZIFT, the egg is fertilized in

vitro, but it is then immediately transferred to the fallopian tube.

Standard IVF puts sperm and egg in close proximity, but relies on them to achieve fertilization without

artificial assistance. If this turns out to be ineffective (for example when there is a severe problem with

the mobility of the sperm), then it is possible to inject the sperm directly into the egg. This is what

happens during ICSI (intracytoplasmic sperm injection).

Egg donation is another option, mainly appropriate for couples in which the man is fertile but the

woman is not. An egg donor is given medication which stimulates hormones, and then her eggs are

surgically extracted. They can then be inseminated with sperm and implanted.



Assisted Hatching

Yes, you read that right, 'hatching'. Human embryos don't really have shells to hatch from, but they are

enveloped in something called the zona pellucida, which they must leave before they can implant in the

uterus. This normally happens around the fifth day after conception. The problem is that the uterus is

only ready to have an embryo implant itself for a certain period of time, and in some women this time

will often end before the the fifth day. This is particularly common in the aftermath of drug treatments

to stimulate ovulation. Assisted hatching overcomes this problem by encouraging the embryo to 'hatch'

at an earlier time. It must be performed on the embryo in vitro, and is so most suitable as an addition to

assisted reproduction, rather than a treatment in its own right. It remains a new treatment, and the

evidence as to how effective it is remains divided.



Ovulation-stimulating drugs

Drugs which can be used to encourage ovulation include Clomiphene, which works by inhibiting the

effects of estrogen, and a class of drugs called gonadotropins, which mimic the hormones which

stimulate the gonads.



Clomiphene



Clomiphene, also known as Serophene, Clomid, and Milophene, is used to increase ovulation. It works

by inhibiting the effects of estrogen. That might sound like a bizarre way to increase ovulation, but it

makes sense. The pituitary gland is tricked into believing that there is not much estrogen in the body.

The pituitary responds by increasing the levels of female hormones, which encourages ovulation.

Treatment with Clomiphene usually takes place for only a few days – just long enough to stimulate

ovulation. After that it is safe to stop taking it, thus reducing the severity of the side-effects.

Clomiphene side-effects are rarely serious or long-lasting: nausea, mood swings and pain are not

uncommon, but these will go away once you stop taking Clomiphene.

Incidentally, you might sometimes come across media reports of Clomiphene being used by body-

builders. They do this because, after taking various steroids, they end up with too much estrogen in

their bodies, causing unpleasant effects like the growth of breasts on men.



Gonadotropins extracted or synthesized



The most powerful ovulation-stimulating drugs are those which are identical to the body's own

hormones. Hormones which affect the gonads, whether natural or synthetic, are given the name

gonadotropins.

Natural gonadotropins can be extracted by filtering the urine of menstruating women, which contains

large doses of these hormones. This gives us drugs such as Humegon (also known as Pergonal), which

is not a synthetic chemical, but rather a cocktail of genuine human hormones. Humegon is taken by

injection.

Alternatively, genetic engineering has now made it possible to create Follicle-Stimulating Hormone in

the laboratory. This is marketed under the names Puregon and Gonal-F. It is very successful in

stimulating ovulation – in fact, its biggest side-effect is being too successful. Even when special

precautions are taken, multiple pregnancies are a real risk.



Drug treatment of endometriosis

If endometriosis is suspected to be taking place, drugs can be used to alleviate its effects, and so to

counter infertility. The usual approach is to use drugs which prevent menstruation. This stops the

creation of more inflamed tissue. The contraceptive pill is commonly used for this purpose. Another

drug which achieves the same effect is Danazol, also known as Danocrine. This works by stopping the

brain from creating Follicle-Stimulating Hormone, which in turn stalls the cycle of ovulation.



Treatments for couples

It is quite possible for the infertility of a couple to result from the combination of factors in both

partners. This is particularly likely in older couples, and to some extent the problems facing each

partner can be treated separately. In this section we are concerned with something slightly different:

ways of improving fertility that involve both partners as a couple.



Timing of intercourse

Understand your menstrual cycle: fertilization of the egg is far more likely within the 24 hours after

ovulation than at any other time. The average woman ovulates on the 14th day of the ovulation cycle –

but there is no such thing as the average woman! That is, your own menstrual cycle likely doesn't

match the textbook situation, and so you will need to work out how your own body operates. You can

do this by constructing a 'fertility calendar' based on observations of your own body. You can start a

basic fertility calendar by working out the length of your menstrual cycle and the date of your last

period. If you want more accurate information, you can buy self-testing kits which will help you work

out what stage of the menstrual cycle you are in.

Style of intercourse

Changing your sexual practices can affect your chances of conceiving. The chances of fertilization are

maximized by getting the sperm as close to the cervix as possible. The missionary position and sex

'doggy style' are both ideal for this, and any position in which the woman is underneath will use the

force of gravity to keep the semen near to the cervix. It is also best to keep the sperm in this area

following intercourse, which can be achieved by keeping the hips raised for a short while. Finally, the

spasms associated with orgasm help move sperm through the cervix, so having good sex is great to

enhance conception.



Alternative Medicine



Every human culture has tried to find its own ways of dealing with infertility. It's easy to think of these

as pre-scientific dead ends that have been superseded by the development of medical science. But the

grab-bag of of traditional treatment that comes under the heading of 'alternative medicine' might have

something to offer. It's not so much that the treatments provably work – because, once something has

been demonstrated to work well, it moves out of the 'alternative' and into the mainstream of medicine.

It's more that these treatments offer a different outlook on fertility. Having wider cultural reference

points than mainstream medicine, alternative therapies can help patients emotionally deal with their

situation. Doctors may dismiss this as a 'placebo effect' – but they won't deny that the placebo effect

can really benefit patients.



Acupuncture

Acupuncture is one of the more common, and more medically-respected, alternative treatments for

infertility. In this procedure, derived from traditional Chinese medicine, thin needles are inserted into

precise points in the body, in the belief that this will affect the 'channels' said to run through the body.

While many doctors (perhaps a majority) doubt the effectiveness of this, there is a significant group

within the medical community who do consider it beneficial. It is claimed that acupuncture can

increase the amount of blood reaching the endometrium, the membrane lining the uterus, and thus can

increase female fertility.

Acupuncture treatments can also maximize the placebo effect – the fact that patients benefit from being

given even an ineffectual treatment. Even if acupuncture is ineffectual as a fertility aid, it is very

unlikely to cause any harm, and can safely be combined with most other treatments.



Aromatherapy

Aromatherapists claim that their form of alternative medicine, which involves smelling, bathing in, or

having a massage with oils taken from plants. This, it is claimed, promotes relaxation, can function as

an aphrodisiac, and may even help maintain a regular menstrual cycle. Rose, Chamomile and Basil are

among the oils commonly suggested as helping with infertility.



Herbal Medicine

There exist a bewildering range of herbal fertility treatments – a natural consequence of the fact that,

before the advent of scientific fertility treatments over the course of the last century, this was the

closest infertile couples could come to medical treatment.

It is important to understand that herbal medicine is not entirely risk-free. It is much less regulated than

mainstream medicine, and the effects of many herbal remedies on the body remain poorly understood.

Taking herbal remedies is akin to taking drugs that are untested and have not been investigated by

scientists – it might work, but it could just as well turn out to be ineffective or even harmful. Even if

you know other people who have successfully taken herbal remedies, you should be cautious: the

effects of these herbs can vary between people, and it is possible for any other drugs you are taking to

interact badly with herbal remedies.

Monk's Pepper (also known as chasteberry, or by its Latin name Vitex angus-castus) has traditionally

been suggested as an aid to fertility, both male and female. Science does not fully understand how this

effect happens, or how important it is, but this herb is believed to have an effect on levels of

testosterone and luteinizing hormone. Traditional Chinese and Korean medicine suggests the use of

Danggui (angelica sinensis). The scientific evidence for this herb being effective in fertility is less

clear, although it does have sedative and anti-inflammatory effects.



Alternatives to fertility treatment



Surrogate Mothers

Surrogacy arrangements involve paying another woman to carry a child. In most cases, the surrogate

mother is artificially inseminated with sperm. In a few cases, mainly where a woman has healthy eggs

but would have difficulties during pregnancy, the surrogate has her eggs implanted, so that the child is

biologically not hers at all.

The advantage of surrogacy is that it is the only option in cases where the cause of infertility is a

woman's inability to carry an embryo to term. There are, though, practical difficulties. Finding a

woman willing to bear a baby for somebody else is not hard, and in many countries this can only be

achieved through making large financial payments to the surrogate mother. In the UK this is illegal –

surrogate mothers can only be used if they are not being paid. The small number of people willing to

endure the difficulty of pregnancy without some personal benefit has kept the number of surrogate

pregnancies quite low in the UK. In the US, where surrogacy is legal in some states, surrogacy is

limited by the high cost. Overall, surrogacy can cost tens of thousands of dollars.

Surrogacy also has a reputation for being emotionally traumatic for both the parents and the surrogate

mother, and in some cases the surrogate mother has been unwilling to give up the baby as planned.

Admittedly, this reputation is based in large part on media reports of particularly unsuccessful cases.



Sperm donation

Sperm donation is an option where a couple's failure to conceive is caused by male infertility. In

medical terms, the process of using donated sperm is basically identical to that of artificially

inseminating a partner's sperm.

If you choose this route, you'll need to decide where to obtain the sperm. "Sperm banks" are now well

established, offering sperm from vetted, anonymous donors. The other option is using a "known sperm

donor" – that is, requesting a sperm donation from a personal friend. The emotional entanglement this

involves is clearly intense, but not necessarily negative. In particular, the potentially traumatic

experience when a child discovers him- or herself to be the product of donated sperm can be

diminished if they can be told that their biological father is somebody they already know. The process

of storing semen is discussed above, in the 'semen storage' section.

Adoption

Adopting a child needn't be seen as a last chance for when fertility treatment fails. Many couples with

biological children choose to adopt, and many infertile couples see adoption as preferable to

undergoing the rigors and expense of infertility treatment.

Finding a child to adopt usually requires you to go through some kind of intermediary, either state or

private, and to deal with a good deal of administrative work. The law covering adoption varies from

country to country (and from state to state in the USA), so it isn't possible to cover all the possibilities

here. Almost every country does have a state adoption system, and adoption through this system can be

the simplest option, legally and bureaucratically. Still, many parents choose to use a private agency,

such as one connected to their church.

Different intermediaries will place different requirements and restrictions on those wishing to adopt. At

a very minimum, there is usually a legal requirement for the new parents to demonstrate that they

understand and accept the commitment involved in adoption, and that they will make competent

parents. Most intermediaries impose a maximum age limit on those who can adopt. Many will only

place children with long-term heterosexual couples, although there are now some opportunities for

adoption by same-sex couples and by singles.

Don't underestimate the emotional and social difficulty of adoption. You'll have to consider whether

you want an open or confidential adoption – that is, whether you would like any contact with, or

knowledge about, the biological parents of your adopted child. And you'll need to think through some

of the issues that will arise over the course of childhood, such as how to answer the child's questions

about his or her adoption, and how open to be with the rest of the world.

It's important to realize that adoption isn't a cure for the distress of infertility. Even with an adopted

child, it is normal to feel grief at the inability to have a biological child. There is a danger of treating

adoption as an imperfect substitute for a biological child, rather than as a wonderful experience in its

own right. This is particularly true when a couple decide on adoption after the failure of fertility

treatment, and is one reason why some people decide to pursue adoption instead of, not after, fertility

treatment.



Child-Free Living

When you are embroiled in the complexity of fertility treatment, it's easy to lose sight of the fact that it

is possible to have a fulfilling, caring life without raising children. What has in recent years come to be

known as the 'childfree movement' tries to highlight this possibility, although the same ideas have also

been expressed in different ways in other cultures.

You don't need to become a parent to care for children. Many schools, play-groups and other

organizations welcome adults who want to spend some time looking after children, and you will find

no shortage of couples who welcome another child-concerned adult to help them out from time to time.

Even more so than with adoption, it's important not to treat this as a complete substitute for parenthood,

but as an alternative with its own benefits, drawbacks, and activities.

Part 3: Fertility in the real world: ethical, social, political and

religious issues

Medicine always has an impact beyond the walls of the clinic, and this is doubly true of fertility

medicine. Aspects of some fertility treatments remain controversial, and will probably always remain

so: they touch on basic elements of human culture, and in a very real sense are too important to be left

to the doctors. There are few right answers here, and not even any obvious ways to balance the interests

of the parents, the child, and society as a whole. So this final section does not attempt to give any

answers, but simply to point you towards some of the big questions.



Multiple babies

The practice of implanting multiple embryos in IVF and related treatment means that a few cases

treatment will be too successful, and several embryos will survive. This is a large part of the reason for

a 50% increase in the number of twins born in the USA since the beginning of IVF treatment. Multiple

births are some 20 times more likely after IVF treatment than in the population as a whole, with the

difference being even higher for triplets and larger groups.

The issue of multiple births can cause ethical concern for several reasons. Firstly, multiple pregnancies

are much more likely to end in miscarriage, stillbirth, or premature birth. Over half of multiple

pregnancies end in premature birth – some 7 times the level in non-multiple births. Partly because of

this, the children of multiple births have much greater risk of dying in childhood. Secondly, multiple

pregnancies can be very dangerous for the mother.

Multiple births also involve serious financial costs, including on the state. Britain's National Health

Service spends an average of £32,000 on a set of triplets, compared to just £3000 for a singe birth.

All these problems have resulted in a legal drive to reduce the number of multiple pregnancies coming

about through fertility treatments. In the UK and Europe, it is now illegal to implant more than two

embryos at a time, except in women over 40. The argument for this exclusion is that older women

already have a much lower chance of success in IVF treatment, and so the likelihood of several embryo

implants being successful is very low.



Increased disease in babies

Babies conceived as a result of fertility treatments are particularly susceptible to certain health

problems. Some thinkers question the ethics of doing everything to conceive, at the cost of producing a

child with a much higher likelihood of illness. Health problems linked to infertility treatment (or to

giving birth at an older age, something facilitated by fertility treatment) include:

● Beckwith-Wiedemann Syndrome

● Angelman Syndrome

● Down Syndrome

Different forms of fertility treatment cause different diseases. Where artificial insemination is used, the

baby seems to be at greater risk of a class of genetic disorders known as 'imprinting defects'. These

include Beckwith-Wiedemann Syndrome, a disorder involving overgrowth, which one report claims is

six times more common among the children of assisted reproduction than in the population as a while.

Another genetic defect, Angelman Syndrome, which involves retardation and physical deformities, and

is caused by the inactivation of genes from the maternal chromosome, may also be more common in

children conceived through Intracytoplasmic sperm injection.

There is a major problem in interpreting these findings. The genetic conditions mentioned above are all

very rare, and so a report of increased likelihood of them may refer only to a handful of extra cases.

When the numbers of sufferers are so small, it is hard to determine whether the increased numbers are

just chance. As more evidence becomes available over the years, we could well see a 'regression to the

mean', as the reports turn out to be just overemphasizing something that is the result of chance. In any

case, it is not clear that the risks facing children born through assisted reproduction are any greater than

those incurred through other non-ideal situations like conceiving at an old age or when drunk.

There's another element to genetic problems with children born from fertility treatments. There is a

clear and well-researched link between older mothers and more genetic defects in children. For

example a child born to a mother aged 49 has a 1 in 11 chance of having Down Syndrome. If the child

is born to a mother aged 25 the risk is massively lower, at just one in 1,250.



Ethical issues with frozen sperm

The use of sperm banks brings with it complications to the normal standards of sexual consent. The

legal situation governing the use of frozen sperm varies from country to country but, at a minimum, the

written consent of the donor will be needed before stored semen can be used. Some areas remain highly

controversial – for example the use of a man's sperm after he has died. The legal, social, and political

battles over this area are far from being settled, and will doubtless be a source of dispute for years to

come.



The emotional impact of fertility

Don't underestimate the havoc that infertility can wreak on your emotions, and the stress it can put on

your personal relationships. Many people experience the feeling that their infertility makes them

failures, or less acceptable than couples with children. Even when intellectually we know that these

feelings are unfounded, it can be very hard to move beyond them. There are many good resources that

can help you get through this stress. They aren't just medical, although access to a professional

psychiatrist will be a great help.

Infertility support groups exist in many cities. Your local fertility clinic will probably be able to put

you in touch with them. Since infertility remains almost a taboo subject, these support groups can be

your best opportunity to share your feelings with others.

Friends and relatives can be an invaluable emotional resource. Remember that it is quite possible that

some of your friends have personal experience of infertility, even if they have not mentioned it to you.

Many people find it difficult to bring up the subject of infertility – other members of an infertility

support group might well have good ideas on how you can do it in your circle of friends. Some fertility

clinics provide special information resources to help friends and relatives understand what you are

going through, and a few even provide special clinics for friends and relatives.

The emotional problems which complicate infertility become, if anything, even more serious when a

couple considers using an egg or sperm donor, or a surrogate mother. This commonly causes feelings

of inadequacy, combined with regret at the inability to become a biological parent.

You should be aware that, in the short term, undergoing fertility treatment can make the emotional

situation worse rather than better. Commonly, initial diagnosis will find that one partner is infertile

while the other is fertile, and it can be hard to avoid feelings of shame, insecurity, and inequality in the

relationship – however irrational or unfounded these might be. Moreover, the process of undergoing

treatment will often involve a roller-coaster, where hope is followed by disappointment time after time.

This can be particularly hard when a couple undergoes a long series of treatments, all of which fail,

before finally resigning themselves to being childless. These couples can easily find themselves feeling

anger at having put themselves through the trials and expenses of treatment, all to no avail.

But for all the hardships, stress and uncertainty, fertility treatment brings more joy than it does sorrow.

It has allowed allow millions of couples worldwide to embark on the life-changing journey of

parenthood, which would otherwise have been denied to them. I can only hope that this book has given

you some idea of what lies ahead of you, should you choose to embark on some form of fertility

treatment.



Part 4: Appendices



Glossary

This is not a complete glossary of fertility or medical terminology, but an aid to understanding the

book. Terms are explained in more detail within the main text the first time they are used, but following

that they are used without further explanation.



● Aspermia. Total lack of sperm production.

● Atresia. The gradual decline in quality of a woman's eggs as she grows older

● Azoospermia. Condition in which semen is produced, but it does not contain any sperm.

Subdivided into obstructive azoospermia (caused by blockages or failures of the sperm ducts)

and non-obstructive azoospermia (caused by anything else, such as genetic defects)

● Blood-sperm barrier. This is what prevents the immune system from developing antibodies

that target sperm.

● Body Mass Index. A measure of weight in relation to height, used to identify the over- and

under-weight. A Body Mass Index of 20-25 is considered healthy.

● CAH (Congenital Adrenal Hypoplasia). Genetic condition in which the adrenal glands

produce too many androgens

● Cervix. The entrance to the womb. During pregnancy, the job of the cervix is to hold the baby

inside the uterus. At other times, its main function is to keep the uterus free of infection, while

allowing sperm to pass through to fertilize an egg

● DNA (DeoxyriboNucleic Acid). A massive chemical, present in almost every cell in our

bodies, which carries our genetic code.

● Endometriosis. The growth of uterus-lining tissue in other parts of the body. Can lead to

internal scarring, and sometimes to infertility.

● Estrogen. Hormone commonly regarded as responsible for female sexual development. The

reality is somewhat more convoluted.

● Fallopian tube. A duct connecting the uterus to an ovary. In normal reproduction, the egg is

fertilized within the fallopian tube

● FSH (Follicle-Stimulating Hormone)

● GIFT (Gamete Intrafallopian Transfer). A technique similar to IVF, but in which the egg is

artificially fertilized within the fallopian tube.

● GnRH (Gonadotropin-Releasing Hormone). A hormone produced by the hypothalamus,

governed by levels of estrogen in the body. GnRH tells the pituitary to produce LH and FSH

● Gonadotropin. Any hormone which has an effect on the gonads

● HCG (Human Chorionic Gonadotropin). A hormone produced by the placenta during

pregnancy

● Hormones. Chemical messengers circulating in the body. Cells react in certain ways when they

come into contact with a hormone, and so by raising or lowering the levels of hormones the

body can control the reproductive cycles and other bodily processes. Key hormones affecting

reproduction include estrogen, testosterone, FSH, LH, and GnRH.

● Hyperprolactinaemia. Overproduction of the hormone pro-lactin, leading to a reduction in the

production of GnRH

● Hysterosalpingogram. An x-ray of the female reproductive system, taken with the aid of a dye

injected into the uterus.

● Hysteroscopy. Medical examination of the uterus, by means of an instrument pushed through

the cervix.

● Infertility. For the sake of standardization, doctors use this word to mean 'inability of a couple

to conceive after one year of trying'.

● ICSI (Intracytoplasmic Sperm Injection). A form of IVF in which sperm are injected directly

into the egg.

● IUI (Intrauterine Insemination). The injection of sperm into the uterus

● In Vitro. Latin term for 'in glass', referring to any procedure carried out in a laboratory rather

than inside the body. Compare in vivo

● In Vivo. Latin term for 'in a living being', referring to any procedure carried out in a body rather

than inside a laboratory. Compare in vitro

● IVF (In Vitro Fertilization)

● Laparoscopy. Medical examination of the female reproductive system, by means of a camera

inserted through the belly.

● LH (Luteinizing Hormone). Hormone involved in control of the menstrual cycle

● Necrospermia. Condition in which the sperm are dead

● Oestrogen. See Estrogen

● Oligoasthenoteratozoospermia. A shortage of functional sperm – either a shortage of sperm,

or non-functional sperm

● Ovaries. The two ovaries in a woman's body produce eggs, as well as the hormones estrogen

and progesterone

● PCOS (Polycystic Ovary Syndrome). A common but poorly-understood condition, in which

women suffer infertility, irregular menstruation, obesity, acne, and hairiness

● PID (Pelvic Inflammatory Disease). Condition in which the fallopian tubes are blocked as a

result of infection

● Retrograde ejaculation. Condition in which semen is not ejaculated out through the urethra,

but backwards into the bladder.

● Stein-Leventhal Syndrome. Alternate name for PCOS

● Uterine Fibroids. Non-cancerous tumors on the uterus lining. Very common, and occasionally

leading to infertility.

● Uterus. The area in which the embryo will develop during pregnancy

● Varicocele. Swelling of blood vessels in the testicles

● Womb. See Uterus

● ZIFT (Zygote Intrafallopian Transfer). A form of IVF, in which the fertilized egg is placed

immediately in the fallopian tube.

● Zona Pellucida. The 'shell' covering the egg



Where to find more information

There is an overwhelming, and ever-increasing, amount written on fertility. It would be impossible for

you to read this entire literature, even if you devoted your entire life to it. Also, remember that reading

isn't the only – or even the best – way to learn about fertility. For advice on your personal medical

situation you really need to talk to a doctor. For discussion of the ethical and social issues, you will

often benefit more from talking to friends, relatives and religious leaders than you will from books

alone.



Websites



● Http://www.theafa.org – American Fertility Association

● http://infertility.about.com: A collection of articles on fertility treatments can be found at

about.com

● http://www.americanpregnancy.org – American Pregnancy Association

● http://www.ihr.com

● http://fertility-online.co.uk – A collection of articles written by a British medical student,

mainly about the causes of infertility

● http://www.asrm.org – American Society for Reproductive Medicine. This association of

doctors working in the field of fertility also has a collection of online booklets and fact sheets

aimed at the general public

● http://www.hfea.gov.uk – Human Fertilization and Embryology Authority. The UK government

body responsible for fertility treatment. Among the information on this site is a three-part 'guide

to infertility', talking patients through their options and explaining the services available in

Britain.



Medical Literature

There is a massive scientific literature on fertility, but it is daunting and impenetrable to the non-expert.

If you have some background knowledge of biology or medicine – or if you are feeling very brave –

you could try the following sources. A few of the journals may now have archives available online, but

for the most part you will need to visit an academic library.

Standard textbooks of fertility medicine include:

● Carr, Textbook of reproductive medicine

● Symonds, Obstetrics and Gynecology

General scientific and medical journals (compared to the specialist journals these are easier to obtain

and easier to read. Many of the landmark articles on fertility will be printed in their pages):

● British Medical Journal

● The Lancet

● Nature

● New Scientist (magazine reporting on scientific developments. The most accessible way to

follow the 'cutting edge' of fertility or other science news)

● Science

Fertility Journals

● Biology of Reproduction

● Fertility and Sterility

● Journal of reproduction and fertility

● Reproduction, fertility and development