Perinatal Mental Health Series, Part 2: Infertility Challenges
Oct 8, 2024 By Mackenzie Conner, LPC & Ellen Bee, LCPC
It is estimated that infertility affects 48 million couples and 186 million individuals worldwide, approximately one in six people of reproductive age (World Health Organization, 2021). The rising prevalence of infertility can be attributed to biological factors such as age, hormonal imbalances, reproductive tract infections, socioeconomic, and lifestyle factors. In spite of the prevalence of infertility, discourse and conversation around this topic remains limited in many circles, often due to stigma, discomfort, and misinformation about the pervasiveness and causes of infertility. For individuals and couples facing the challenges of building their families, talking about and receiving support while navigating infertility is imperative. The importance of discussing infertility lies in its profound impact on mental health, relationships, and quality of life. Addressing infertility through open dialogue and education is crucial for raising awareness, reducing stigma, and promoting access to a range of available reproductive health services.
What is the Definition of Infertility?
The World Health Organization (2023) defines infertility as a disease affecting the male or female* reproductive system, characterized by the inability to conceive after engaging in regular unprotected sexual intercourse for a period of 12 months or longer. Further, infertility is marked by the inability to attain a viable pregnancy, as determined by an individual’s age, medical, sexual and reproductive history, physical examination, diagnostic assessments, or any combination of these factors. When couples engage in regular, unprotected intercourse, and there are no identifiable factors indicating impaired reproductive function in either partner, diagnostic evaluation should commence after 12 months if the female partner is under 35 years of age, and after six months if they are 35 years of age or older (American Society for Reproductive Medicine, 2017).
Prevalence of Infertility
Fertility challenges can be a variable experience within family planning, but are generally defined as either difficulty becoming pregnant after one year of trying (“infertility”) or difficulty carrying a baby to term (“impaired fecundity”; Centers for Disease Control and Prevention). Among women of reproductive age (i.e., up to 49 years), nearly 20% have difficulty becoming pregnant after one year, while 26% of women experience difficulty carrying a baby to term. Importantly, fertility challenges can affect individuals of all genders and currently impact about 15% of couples in the United States. Research suggests that male infertility accounts for 50% of conception difficulties and can be the sole cause in up to 20% for infertility cases (Argawal, 2015). Additionally, fertility challenges can occur within couples who may have previously become pregnant without issue. Indeed, approximately the same percentage of couples will have fertility concerns with a subsequent child as did with conceiving their first child (Leslie et al., 2023).
Risk Factors for Infertility
Among both natal males and natal females, fertility challenges can be related to several broad risk factors, including age, poor nutrition and diet, exposure to chemicals and toxins, increased stress, and drug and alcohol use. Socioeconomic status is considered a secondary risk factor for infertility, given the implications on access to healthcare (Bala et al., 2021).
Age and Lifestyle-related Risk Factors for Infertility in Women
The risk of infertility in natal females increases with age, especially for women in their late 30s, due to age-related decline in both the number and quality of available eggs (American College of Obstetricians and Gynecologists). Dietary factors may also pose increased risk of fertility concerns. Inadequate nutrition in women can cause delayed pubertal changes and ovulation disorders, while overnutrition and obesity can contribute to irregular menstruation, diabetes, and polycystic ovary syndrome (PCOS) (Chen et al., 2012; Dag, 2015; Soliman, 2014). Smoking and alcohol use also significantly affect fertility; however, the specific relationship between alcohol consumption and infertility risk remains difficult to quantify (Bala et al., 2021).
Chronic Conditions that can Contribute to Infertility in Women
Among the most common chronic conditions affecting infertility in women include polycystic ovary syndrome (PCOS), endometriosis, tubal disorders, and fibroids. PCOS, a hormonal disorder causing enlarged ovaries with small cysts on the outer edges, impacts around 6-12% of women of reproductive age and is a leading cause of ovulatory infertility (American Society for Reproductive Medicine). Endometriosis, characterized by the growth of tissue similar to the uterine lining outside the uterus, affects approximately 10% of women of reproductive age, with about 30-40% of affected individuals experiencing infertility (World Health Organization, n.d.).
Tubal disorders refer to conditions that affect the fallopian tubes, the structures that play a crucial role in fertility by transporting eggs from the ovaries to the uterus and providing a site for fertilization to occur. Tubal disorders can include blockages, damage, inflammation, or scarring of the fallopian tubes, which can impair their function and interfere with conception (El-Kharoubi, 2023).
Uterine fibroids, which disproportionately affect Black women (Stewart & Laughlin-Tommaso, 2016), are noncancerous growths of the uterus that can develop during a woman’s reproductive years. Fibroids can hinder fertility by interfering with the implantation of a fertilized egg or disrupting the flow of sperm or embryos, particularly if they are large or positioned within the uterine cavity or near the fallopian tubes (Stewart & Laughlin-Tommaso, 2016). Moreover, fibroids may distort the shape of the uterus, affecting the ability of a fertilized egg to implant and grow properly. It’s important to note, however, that not all fibroids lead to infertility, and many women with fibroids are able to conceive and carry pregnancies to term successfully.
Additionally, other chronic conditions such as thyroid disorders, autoimmune diseases, and diabetes can also contribute to infertility in women by affecting hormone levels or disrupting reproductive function (American Society for Reproductive Medicine, n.d.). While having a chronic illness does not preclude pregnancy, many of these chronic conditions can disrupt normal menstrual cycles and ovulation, hindering conception. It’s essential for individuals with chronic conditions to discuss their fertility concerns with healthcare providers to explore options for preserving fertility when possible.
Age and Lifestyle-Related Risk Factors for Infertility in Men
For natal males, fertility challenges can also increase over time, with age causing a decline in sperm quality, reduced sperm concentration, and impaired motility (Harris et al., 2011). While studies are somewhat inconclusive about specific diets that may affect male fertility, research conclusively recommends a diet of moderation, with avoidance of foods high in saturated fats (Hayden, 2018). Regarding exercise, moderate physical activity has positive effects on sperm motility; however, excessive or intense exercise has been observed to reduce semen quality (Belladelli, 2023; Vaamonde et al., 2012; Wise et al., 2011). Men who smoke may also experience difficulty with fertility and sperm functioning and smoking cessation is recommended to support family planning (Harley et al., 2015). Research also indicates a strong association between chronic alcohol consumption and reduced semen quality (Finelli et al., 2021).
Chronic Conditions that can Contribute to Infertility in Men
Conditions leading to infertility in men are often comorbid or indicative of other underlying medical concerns. It is not uncommon that impaired fertility in men may, in fact, be the result of another medical condition which causes infertility as a secondary concern. Some of the most commonly occurring conditions that contribute to infertility in men include disrupted endocrine functioning, sexual dysfunctions, urogenital abnormalities (e.g., physical conditions that affect urinary and genital tracts), malignancies and subsequent treatments, and environmental toxins. Idiopathic infertility in men (e.g., infertility with no apparent cause) affects 10-20% of infertile males (Leslie et al., 2023).
While endocrinological infertility affects a relatively small percentage of infertile males (e.g., 1-2%), treatment for these pathologies provide significant results (Sengupta et al., 2021). Impaired endocrine functioning affecting fertility concerns, due to either a hormonal deficiency or surplus, are commonly related to the following conditions: hypogonadotropic hypogonadism (e.g., an absence of hormones that signal production of sex hormones within the testes), hypergonadotropic hypogonadism (e.g., deficient levels of testosterone), androgen excess (e.g., excess of hormones), estrogen excess, hyperprolactinemia (e.g., excess of prolactin sometimes related to increased stress or reduced exercise), and insulin disorders (Sengupta et al., 2021). Current treatment protocols for these pathologies include hormone therapies and lifestyle changes, while emerging research continues to direct effective therapies (Leslie et al., 2023; Sengupta et al., 2021).
Sexual dysfunctions are also frequently associated with male infertility and are characterized by recurrent problems with arousal and intercourse with partners. The most common sexual dysfunctions in men are erectile dysfunction (ED), premature ejaculation, and anejaculation. ED is classified as difficulty to obtain or maintain erection during sexual activity affecting about 52% of men between ages 40-70 in the United States (American Psychiatric Association, 2013; Leslie et al., 2024). Left untreated, ED can have significant psychosocial effects including depression, reduced self-esteem, and interpersonal difficulties with potential partners (Leslie et al., 2024). Premature ejaculation (PE), ejaculation that occurs prior to or shortly after penetration, affects 20-30% of sexually active men (American Psychiatric Association, 2013; Raveendran, 2021). Like erectile dysfunction, PE can cause significant psychological and interpersonal distress. Finally, anejaculation is experienced by individuals as absence of ejaculatory fluid (semen) during climax (Cleveland Clinic, n.d.). In the United States, about 12,000 people seek treatment for anejaculation to support family planning. While there are currently no known treatments for anejaculation, there has been significant success in different sperm retrieval methods (Cleveland Clinic, n.d.). Importantly, none of the above sexual dysfunctions determine complete infertility, especially if sperm counts and quality remains high. Treatment is available to support sperm retrieval that can be used in alternative family planning methods.
Urogenital abnormalities affect the anatomy of an individual primarily in the urinary and genital tracts. These conditions are usually assessed at birth and can often have surgical corrections to support fertility later in life (Cleveland Clinic, n.d.; Punjami & Lamb, 2020). The most common urogenital abnormality affecting fertility is cryptorchidism or undescended testes (unilateral or bilateral) diagnosed at birth. This condition affects between 1-3% of newborn and up to 30% premature males and affects sperm motility “azoospermia” (Chung & Brock, 2011). Males who are born with this condition can undergo surgery to correct the undescended testicle(s) with low complication rates (Chung & Brock, 2011; Cleveland Clinic, n.d.; Punjami & Lamb, 2020).
Malignancies and subsequent treatments, including tumors and other masses treated by radiation, chemotherapy, or surgery, can have effects on fertility. Specifically, genitourinary cancers, which have increasing survivorship, make an effort to preserve fertility essential. In these types of cancers, both the tumor mass itself and subsequent treatment methods can impair fertility by obstructing mechanisms related to erection or damaging sperm (Polland & Berookhim, 2016). However, fertility preservation or restoration methods have shown promising results and are emphasized ahead of treatment to support family planning.
In recent decades, notable decreases in male fertility have occurred, yet these changes cannot be otherwise accounted for by other causes previously discussed. Research suggests a relationship between increased chronic exposure to environmental toxins and declining fertility, specifically those toxins that have become ubiquitous to daily life (Krzastek et al, 2020). Substances including pesticides, heavy metals, plastics, radiation, pollution, and endocrine disruptors have all been acknowledged as teratogens in utero, giving the impression that these substances also likely impact fertility of an individual prior to conception (Krzastek et al, 2020). While additional study is needed, it is becoming increasingly clear that environmental toxins have deleterious effects on fetal development in utero and fertility among men and women.
LGBTQ+ Populations and Fertility
The LGBTQ+ Family Building Survey indicates that up to 3.8 million LGBTQ+ individuals (aged 18-35) are considering expanding their families in the coming years (Family Equality, 2019). However, the journey to parenthood is often more challenging and complex for LGBTQ+ individuals. While family building via intercourse still remains an option for some individuals in the LGBTQ+ community, particularly for couples that identify as transgender or bisexual individuals in different-sex relationships, many individuals in same-sex relationships lack the necessary biological components for conception (RESOLVE, n.d.).
LGBTQ+ individuals seeking to start a family have several family-building options available to them. One option is assisted reproductive technologies (ART), such as in vitro fertilization (IVF) or intrauterine insemination (IUI), which allow individuals or couples to conceive using donor sperm, eggs, or embryos. LGBTQ+ individuals may also choose to pursue adoption or foster care, providing loving homes to children in need of permanency. Additionally, reciprocal IVF enables female same-sex couples to participate equally in the conception process, with one partner providing the eggs and the other partner carrying the pregnancy.
However, LGBTQ+ individuals may face legal, financial, and social barriers when accessing fertility treatments or adoption, including discriminatory laws, lack of LGBTQ+-friendly healthcare providers, and limited access to reproductive technologies or adoption agencies that cater to LGBTQ+ families (RESOLVE, n.d.). Furthermore, the cost of fertility treatments and adoption can be prohibitive, often exceeding tens of thousands of dollars, which may necessitate financial planning or pursuing insurance coverage, grants, or fundraising opportunities.
Conclusion
Infertility is a complex and multifactorial condition that affects millions worldwide. Both biological and lifestyle factors contribute to fertility challenges, with age, chronic health conditions, environmental exposures, and behavioral factors influencing reproductive capacity. Additionally, infertility in LGBTQ+ populations presents unique challenges due to biological, legal, and social considerations. Open conversations about fertility, access to evidence-based information, and supportive interventions can help individuals and couples navigate these challenges while reducing stigma and promoting reproductive health. Increased awareness, education, and equitable access to fertility care are essential in supporting individuals and couples in their family-building journeys.
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