Infertility is the inability of a person, animal or plant to reproduce
by natural means. It is usually not the natural state of a healthy
adult, except notably among certain eusocial species (mostly
In humans, infertility is the inability to become pregnant or carry a
pregnancy to full term. There are many causes of infertility,
including some that medical intervention can treat. Estimates from
1997 suggest that worldwide about five percent of all heterosexual
couples have an unresolved problem with infertility. Many more
couples, however, experience involuntary childlessness for at least
one year: estimates range from 12% to 28%."  20-30% of infertility
cases are due to male infertility, 20-35% are due to female
infertility, and 25-40% are due to combined problems in both parts.
In 10-20% of cases, no cause is found. The most common cause of
female infertility is ovulatory problems which generally manifest
themselves by sparse or absent menstrual periods. Male infertility
is most commonly due to deficiencies in the semen, and semen quality
is used as a surrogate measure of male fecundity.
Women who are fertile experience a natural period of fertility before
and during ovulation, and they are naturally infertile for the rest of
the menstrual cycle.
1.1 World Health Organization 1.2 United States 1.3 United Kingdom 1.4 Other definitions 1.5 Primary vs. secondary infertility
2.1 Psychological 2.2 Social
3.1 Immune infertility 3.2 Sexually transmitted infections 3.3 Genetic 3.4 Other causes 3.5 Females 3.6 Males 3.7 Combined infertility 3.8 Unexplained infertility
4 Diagnosis 5 Treatment
5.1 Medical treatments
6 Epidemiology 7 Society and culture
7.1 Ethics 7.2 Developing countries
8 See also 9 References 10 Further reading 11 External links
"Demographers tend to define infertility as childlessness in a
population of women of reproductive age," whereas "the epidemiological
definition refers to "trying for" or "time to" a pregnancy, generally
in a population of women exposed to" a probability of conception.
Currently, female fertility normally peaks at age 24 and diminishes
after 30, with pregnancy occurring rarely after age 50. A female is
most fertile within 24 hours of ovulation. Male fertility peaks
usually at age 25 and declines after age 40. The time needed to
pass (during which the couple tries to conceive) for that couple to be
diagnosed with infertility differs between different jurisdictions.
Existing definitions of infertility lack uniformity, rendering
comparisons in prevalence between countries or over time problematic.
Therefore, data estimating the prevalence of infertility cited by
various sources differs significantly. A couple that tries
unsuccessfully to have a child after a certain period of time (often a
short period, but definitions vary) is sometimes said to be
subfertile, meaning less fertile than a typical couple. Both
infertility and subfertility are defined as the inability to conceive
after a certain period of time (the length of which vary), so often
the two terms overlap.
World Health Organization
World Health Organization
“ Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (and there is no other reason, such as breastfeeding or postpartum amenorrhoea). Primary infertility is infertility in a couple who have never had a child. Secondary infertility is failure to conceive following a previous pregnancy. Infertility may be caused by infection in the man or woman, but often there is no obvious underlying cause. ”
United States One definition of infertility that is frequently used in the United States by reproductive endocrinologists, doctors who specialize in infertility, to consider a couple eligible for treatment is:
a woman under 35 has not conceived after 12 months of
contraceptive-free intercourse. Twelve months is the lower reference
limit for Time to
These time intervals would seem to be reversed; this is an area where
public policy trumps science. The idea is that for women beyond age
35, every month counts and if made to wait another 6 months to prove
the necessity of medical intervention, the problem could become worse.
The corollary to this is that, by definition, failure to conceive in
women under 35 isn't regarded with the same urgency as it is in those
In the UK, previous NICE guidelines defined infertility as failure to
conceive after regular unprotected sexual intercourse for 2 years in
the absence of known reproductive pathology. Updated NICE
guidelines do not include a specific definition, but recommend that "A
woman of reproductive age who has not conceived after 1 year of
unprotected vaginal sexual intercourse, in the absence of any known
cause of infertility, should be offered further clinical assessment
and investigation along with her partner, with earlier referral to a
specialist if the woman is over 36 years of age.
Researchers commonly base demographic studies on infertility
prevalence on a five-year period. Practical measurement problems,
however, exist for any definition, because it is difficult to measure
continuous exposure to the risk of pregnancy over a period of years.
Primary vs. secondary infertility
Primary infertility is defined as the absence of a live birth for
women who desire a child and have been in a union for at least 12
months, during which they have not used any contraceptives. The
World Health Organisation also adds that 'women whose pregnancy
spontaneously miscarries, or whose pregnancy results in a still born
child, without ever having had a live birth would present with
Secondary infertility is defined as the absence of a live birth for
women who desire a child and have been in a union for at least 12
months since their last live birth, during which they did not use any
Thus the distinguishing feature is whether or not the couple have ever
had a pregnancy which led to a live birth.
The consequences of infertility are manifold and can include societal
repercussions and personal suffering. Advances in assisted
reproductive technologies, such as IVF, can offer hope to many couples
where treatment is available, although barriers exist in terms of
medical coverage and affordability. The medicalization of infertility
has unwittingly led to a disregard for the emotional responses that
couples experience, which include distress, loss of control,
stigmatization, and a disruption in the developmental trajectory of
Infertility may have psychological effects. Partners may become more
anxious to conceive, increasing sexual dysfunction. Marital
discord often develops, especially when they are under pressure to
make medical decisions. Women trying to conceive often have depression
rates similar to women who have heart disease or cancer. Emotional
stress and marital difficulties are greater in couples where the
infertility lies with the man.
Older people with adult children appear to live longer. Why this
is the case is unclear and may dependent in part on those who have
children adopting a healthier lifestyle, support from children, or the
circumstances that led to not having children.
In many cultures, inability to conceive bears a stigma. In closed
social groups, a degree of rejection (or a sense of being rejected by
the couple) may cause considerable anxiety and disappointment. Some
respond by actively avoiding the issue altogether; middle-class men
are the most likely to respond in this way.
In the United States some treatments for infertility, including
diagnostic tests, surgery and therapy for depression, can qualify one
Family and Medical Leave Act
Diabetes mellitus, thyroid disorders, undiagnosed and untreated coeliac disease, adrenal disease
Hyperprolactinemia Hypopituitarism The presence of anti-thyroid antibodies is associated with an increased risk of unexplained subfertility with an odds ratio of 1.5 and 95% confidence interval of 1.1–2.0.
Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts, and pesticides. Tobacco smokers are 60% more likely to be infertile than non-smokers.
German scientists have reported that a virus called Adeno-associated
virus might have a role in male infertility, though it is
otherwise not harmful. Other diseases such as chlamydia, and
gonorrhea can also cause infertility, due to internal scarring
(fallopian tube obstruction).
Further information: Female infertility
The following causes of infertility may only be found in females. For
a woman to conceive, certain things have to happen: vaginal
intercourse must take place around the time when an egg is released
from her ovary; the system that produces eggs has to be working at
optimum levels; and her hormones must be balanced.
For women, problems with fertilisation arise mainly from either
structural problems in the
ovulation problems (e.g. polycystic ovarian syndrome, PCOS, the leading reason why women present to fertility clinics due to anovulatory infertility.) tubal blockage pelvic inflammatory disease caused by infections like tuberculosis age-related factors uterine problems previous tubal ligation endometriosis advanced maternal age immune infertility
Further information: Male infertility
The main cause of male infertility is low semen quality. In men who
have the necessary reproductive organs to procreate, infertility can
be caused by low sperm count due to endocrine problems, drugs,
radiation, or infection. There may be testicular malformations,
hormone imbalance, or blockage of the man's duct system. Although many
of these can be treated through surgery or hormonal substitutions,
some may be indefinite.
Infertility associated with viable, but
immotile sperm may be caused by primary ciliary dyskinesia. The sperm
must provide the zygote with DNA, centrioles, and activation factor
for the embryo to develop. A defect in any of these sperm structures
may result in infertility that will not be detected by semen
Antisperm antibodies cause immune infertility. 
In some cases, both the man and woman may be infertile or sub-fertile,
and the couple's infertility arises from the combination of these
conditions. In other cases, the cause is suspected to be immunological
or genetic; it may be that each partner is independently fertile but
the couple cannot conceive together without assistance.
Main article: Unexplained infertility
In the US, up to 20% of infertile couples have unexplained
infertility. In these cases abnormalities are likely to be present
but not detected by current methods. Possible problems could be that
the egg is not released at the optimum time for fertilization, that it
may not enter the fallopian tube, sperm may not be able to reach the
egg, fertilization may fail to occur, transport of the zygote may be
disturbed, or implantation fails. It is increasingly recognized that
egg quality is of critical importance and women of advanced maternal
age have eggs of reduced capacity for normal and successful
fertilization. Also, polymorphisms in folate pathway genes could be
one reason for fertility complications in some women with unexplained
infertility. However, a growing body of evidence suggests that
epigenetic modifications in sperm may be partially
Main article: Fertility testing
If both partners are young and healthy and have been trying to
conceive for one year without success, a visit to a physician or
women's health nurse practitioner (WHNP) could help to highlight
potential medical problems earlier rather than later. The doctor or
WHNP may also be able to suggest lifestyle changes to increase the
chances of conceiving.
Women over the age of 35 should see their physician or WHNP after six
months as fertility tests can take some time to complete, and age may
affect the treatment options that are open in that case.
A doctor or WHNP takes a medical history and gives a physical
examination. They can also carry out some basic tests on both partners
to see if there is an identifiable reason for not having achieved a
pregnancy. If necessary, they refer patients to a fertility clinic or
local hospital for more specialized tests. The results of these tests
help determine the best fertility treatment.
Male infertility § Hormonal therapy
Treatment depends on the cause of infertility, but may include
counselling, fertility treatments, which include in vitro
fertilization. According to
Infertility rates have increased by 4% since the 1980s, mostly from problems with fecundity due to an increase in age. Fertility problems affect one in seven couples in the UK. Most couples (about 84%) who have regular sexual intercourse (that is, every two to three days) and who do not use contraception get pregnant within a year. About 92 out of 100 couples who are trying to get pregnant do so within two years. Women become less fertile as they get older. For women aged 35, about 94% who have regular unprotected sexual intercourse get pregnant after three years of trying. For women aged 38, however, only about 77%. The effect of age upon men's fertility is less clear. In people going forward for IVF in the UK, roughly half of fertility problems with a diagnosed cause are due to problems with the man, and about half due to problems with the woman. However, about one in five cases of infertility has no clear diagnosed cause. In Britain, male factor infertility accounts for 25% of infertile couples, while 25% remain unexplained. 50% are female causes with 25% being due to anovulation and 25% tubal problems/other. In Sweden, approximately 10% of couples wanting children are infertile. In approximately one third of these cases the man is the factor, in one third the woman is the factor, and in the remaining third the infertility is a product of factors on both parts.
Society and culture Perhaps except for infertility in science fiction, films and other fiction depicting emotional struggles of assisted reproductive technology have had an upswing first in the latter part of the 2000s decade, although the techniques have been available for decades. Yet, the number of people that can relate to it by personal experience in one way or another is ever growing, and the variety of trials and struggles is huge. Pixar's Up contains a depiction of infertility in an extended life montage that lasts the first few minutes of the film. Other individual examples are referred to individual subarticles of assisted reproductive technology Ethics There are several ethical issues associated with infertility and its treatment.
High-cost treatments are out of financial reach for some couples.
Debate over whether health insurance companies (e.g. in the US) should
be required to cover infertility treatment.
Allocation of medical resources that could be used elsewhere
The legal status of embryos fertilized in vitro and not transferred in
vivo. (See also Beginning of pregnancy controversy).
Pro-life opposition to the destruction of embryos not transferred in
IVF and other fertility treatments have resulted in an increase in
multiple births, provoking ethical analysis because of the link
between multiple pregnancies, premature birth, and a host of health
Religious leaders' opinions on fertility treatments; for example, the
Roman Catholic Church
Many countries have special frameworks for dealing with the ethical and social issues around fertility treatment.
One of the best known is the HFEA – The UK's regulator for fertility treatment and embryo research. This was set up on 1 August 1991 following a detailed commission of enquiry led by Mary Warnock in the 1980s A similar model to the HFEA has been adopted by the rest of the countries in the European Union. Each country has its own body or bodies responsible for the inspection and licensing of fertility treatment under the EU Tissues and Cells directive  Regulatory bodies are also found in Canada  and in the state of Victoria in Australia 
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Infertility is often not seen (by the West) as being an issue outside industrialized countries. This is because of assumptions about overpopulation problems and hyper fertility in developing countries, and a perceived need for them to decrease their populations and birth rates. The lack of health care and high rates of life-threatening illness (such as HIV/AIDS) in developing countries, such as those in Africa, are supporting reasons for the inadequate supply of fertility treatment options. Fertility treatments, even simple ones such as treatment for STIs that cause infertility, are therefore not usually made available to individuals in these countries. Despite this, infertility has profound effects on individuals in developing countries, as the production of children is often highly socially valued and is vital for social security and health networks as well as for family income generation. Infertility in these societies often leads to social stigmatization and abandonment by spouses. Infertility is, in fact, common in sub-Saharan Africa. Unlike in the West, secondary infertility is more common than primary infertility, being most often the result of untreated STIs or complications from pregnancy/birth. Due to the assumptions surrounding issues of hyper-fertility in developing countries, ethical controversy surrounds the idea of whether or not access to assisted reproductive technologies should comprise a critical aspect of reproductive health or at least, whether or not the distribution and access of such technologies should be subject to greater equity. However, as highlighted by Inhorn  the overarching conceptualisation of infertility, to a great extent, disguises important distinctions that can be made within a local context, both demographically and epidemiological and moreover, that these factors are highly significant in the ethics of reproduction. An important factor, argues Inhorn, is the positioning of men within the paradigm of reproductive health, whereby because rates of general infertility mask differences between male and female infertility, men remain a largely invisible facet within the theorisation and discourse surrounding infertility, as well as the related treatments and biotechnologies. This is particularly significant given that male infertility accounts for more than half of all cases of infertility  and moreover, it is evident that the attitudes and behaviours of men have profound implications for the reproductive health of both individuals and couples. For example, Inhorn  notes that when couples in Egypt are faced with seemingly intractable infertility problems - due to a range of family and societal pressures that centre around the place of children in constituting the gender identity of men and women - it is often the women who is forced to seek continued treatment; this continues to occur, even in known instances of male infertility and that the constant seeking of treatment frequently becomes iatrogenic for the women. Inhorn states that infertility often leads to “marital demise, physical violence, emotional abuse, social exclusion, community exile, ineffective and iatrogenic therapies, poverty, old age insecurity, increased risk of HIV/AIDS, and death” Significantly, Inhorn demonstrates that this phenomenon can not simply be explained by a lack of knowledge, rather it occurs in a complex interaction between the centrality of children in the male gender identity as a symbol of maturity and the relative lack of power of women in Egyptian society, whereby they effectively become scapegoats for a culturally accepted narrative as a site of blame for the lack of childlessness. It should be emphasised that this is not simply an issue of “women oppressed by men” but rather, that men and women both share the burden of this narrative, but in different, unequal and highly complex ways. Therefore, while the notion that reproductive health is a ‘women’s issue’, may have powerful social currency, especially within popular discourse and indigenous systems of meaning, the reality of infertility suggests that medical and health paradigms have a significant part to play in challenging the validity of this entrenched belief . Moreover, the effectiveness of any therapeutic intervention, medical or otherwise will be contingent on such outcomes and has an important part to play in the alleviation of gendered suffering, especially the burden imposed on women, who continue to suffer disproportionately from the effects of infertility. High costs may also be a factor and research by the Genk Institute for Fertility Technology, in Belgium, claimed a much lower cost methodology (about 90% reduction) with similar efficacy, which may be suitable for some fertility treatment. At the 1994 United Nations International Conference on Population and Development (ICPD) in Cairo, the prevention and treatment of infertility was accepted into the program of action for reproductive healthcare. Infertility has shown to have a greater effect on developing nations than on birth rates or population control, but also on a social level as well. Reproduction is a large aspect of life for many cultures within developing nations, and infertility can lead to social and familial problems such as rejection or abandonment as well as personal psychological issues. Currently, fertility treatment options and programs are only available through private health sectors in developing nations and little-to-no treatment is available through public health sectors. The fertility treatment options offered through the private sectors are often costly or not easily accessible. Additionally, counseling is considered an essential aspect of fertility treatment, and due to lack of education and resources such forms of therapy remain scarce as well. While quality fertility care is not readily available in developing nations (such as sub-Saharan African countries), a standard procedure of care could be easily implemented for a low cost as a basic intervention. The lack of fertility treatment is problematic, and high birth and population rates are every reason to implement treatment options rather than reject them. See also
Advanced maternal age Childlessness Conception device Inherited sterility in insects Medical ethics Oncofertility, fertility in cancer patients Sterility Surrogate marriage
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Fertility: Assessment and Treatment for People with Fertility Problems. London: RCOG Press. 2004. ISBN 1-900364-97-2. Anjani Chandra et al. (2013). Infertility and Impaired Fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth. Hyattsville, Md.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Pamela Mahoney Tsigdinos (2009). Silent Sorority: A Barren Woman Gets Busy, Angry, Lost and Found. BookSurge Publishing. p. 218. ISBN 1-4392-3156-7.
V · T · D
ICD-10: N46, N97.0 ICD-9-CM: 606, 628 MeSH: D007246 DiseasesDB: 21627
MedlinePlus: 001191 eMedicine: med/3535 med/1167
Wikimedia Commons has media related to Infertility.
RCOG clinical guidelines for infertility (concise guidelines) Fertility: Assessment and Treatment for People with Fertility Problems, 2004 (extensive guidelines) GeneReviews/NCBI/NIH/UW entry on CATSPER-Related Male Infertility Infertility not just a Female Problem Assisted Reproduction in Judaism Facing Life Without Children When It Isn’t by Choice Patient Voices – Infertility
v t e
Compulsory sterilization Contraceptive security Genital integrity
Circumcision controversies Genital modification and mutilation Intersex
Genetic counseling Pre-conception counseling Sex education
Assisted reproductive technology Birth control Childfree/Childlessness Parenting
Adoption Childbirth Foster care
Reproductive life plan Safe sex
Self-report sexual risk behaviors
Disorders of sex development Infertility Reproductive system disease Sexual dysfunction Sexually transmitted infection
China India Iran Ireland Pakistan Philippines Singapore United Kingdom
Teen pregnancy Birth control
One-child policy Two-child policy Financial
Baby bonus Bachelor tax Birth credit Child benefit Tax on childlessness
v t e
Assisted reproductive technology
Female Male Fertility clinic Fertility testing Fertility tourism
aromatase inhibitor clomifene
FSH GnRH agonists Gonadotropins
Assisted zona hatching
Autologous endometrial coculture
embryos oocyte ovarian tissue semen
Gamete intrafallopian transfer Reproductive surgery
Donor registration Donor Sibling Registry Egg donation Embryo Sperm Sperm bank Ova bank
Accidental incest Genetic diagnosis of intersex Religious response to ART Mitochondrial donation Sex selection
See subsection in sperm donation Reproduction and pregnancy in speculative fiction
v t e
Female diseases of the pelvis and genitals (N70–N99, 614–629)
Anovulation Poor ovarian reserve
Mittelschmerz Oophoritis Ovarian apoplexy Ovarian cyst
Corpus luteum cyst Follicular cyst of ovary Theca lutein cyst
Ovarian hyperstimulation syndrome Ovarian torsion
Hematosalpinx Hydrosalpinx Salpingitis
Asherman's syndrome Dysfunctional uterine bleeding Endometrial hyperplasia Endometrial polyp Endometriosis Endometritis
Amenorrhoea Hypomenorrhea Oligomenorrhea
Menometrorrhagia Menorrhagia Metrorrhagia
Cervical dysplasia Cervical incompetence Cervical polyp Cervicitis Female infertility
Atrophic vaginitis Bacterial vaginosis Candidal vulvovaginitis
Dyspareunia Hypoactive sexual desire disorder Sexual arousal disorder Vaginismus
Ureterovaginal Vesicovaginal Obstetric fistula
Rectovaginal fistula Prolapse
Cystocele Enterocele Rectocele Sigmoidocele Urethrocele
Other / general
Pelvic congestion syndrome Pelvic inflammatory disease
Bartholin's cyst Kraurosis vulvae Vestibular papillomatosis Vulvitis Vulvodynia