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The journey to conception is a long, difficult road...
Infertility: a priority reproductive health issue.
Sexual Health Exchange, Spring 2002 v2002 i2 p13(2)
Infertility: a priority reproductive health issue. (Special Article). Johanne Sundby.
Full Text: COPYRIGHT 2002 World Health Organization
A few years ago, a woman in the USA gave birth to septuplets (seven children). She had been given
very potent fertility drugs without even trying to become pregnant, because her first child had been
born after prolonged time to pregnancy--although no research has shown that prolonged time in one
pregnancy leads to prolonged time in the next. Treating a potential medical problem because of a
possible minor inconvenience or emotional burden is questionable.
Defining infertility
This case leads us to reflect on the accurate definition of infertility: the medical definition of infertility
refers to women who have tried to become pregnant for at least one year without success. `Time to
pregnancy' is often used to measure fertility: a couple's ability to become pregnant, given that they
have regular sexual intercourse (at least once a week). Prolonged time to pregnancy may be a measure
of reduced fertility in couples. About 80-90% of women conceive within a year, and another 5-10% in
the second or third year of trying. In general, time to pregnancy increases with the woman's age.
Couple fertility should not be confused with individual fertility: the man's or woman's contribution to
reduced fertility can only be assessed through a systematic medical examination of their reproductive
organs. Primary sub- or infertility is established when the couple have been trying for 1-2 years, but
have never conceived before. Secondary infertility is when couples have had one or more pregnancies
in the same union before. This is a problem especially in Africa (up to 15%), because women get
pregnant at a very young age. Social and behavioural factors such as postponement of pregnancy and
childbearing, multiple partnerships and STIs, environmental exposures in workplace or farm fields, or
too low or high body weight can have a strong influence on infertility.
Infertility is not the same in different cultures, contexts and socio-economic environments. It is often
confused with other probabilities of not being able to bear children. In some countries, women who
lose babies during pregnancy or birth, or have a miscarriage, or even lose a live born baby in the first
year of life are called a "childless woman"--a term often used for infertility. In Zimbabwe for example,
a "reproductive failure" is someone who fails to live up to average reproductive norms, including
getting children of only one sex, or failing to become pregnant more than once or twice. The man's
role in the process is often secondary or not even mentioned.
The impact of infertility
Infertility is an important reproductive health problem, with some 3-4% of couples ending up childless
worldwide. Studies in industrialised and nonindustrialised countries show that people suffer from the
consequences of infertility regardless of the context--often leading to serious emotional problems,
such as depression and anxiety--although women in industrialised countries have many more options
in life than women in the South. In most developing countries, women bare the brunt of the burden of
infertility, as their primary role and identity still is to be a mother. In some African countries, women
do not even have the right to an own name, being referred to only as `mother of' or `mamma'. In the
Gambia, women who never carry babies may face divorce, abandonment or become a wife in a
polygamous union. In Zimbabwe, difficulty to get pregnant may lead women on a journey of sexual
encounters in order to get pregnant, putting her at a high risk for contracting HIV. She may also be
deprived of her personal inheritance, or returned to her own family and replaced with a younger sister
of hers.
Treating infertility
Infertile couples worldwide use many kinds of medicine, mixing modern care with alternative and
traditional care. In many countries, people resort to traditional healers, whose explanations and
remedies are often related to relational, spiritual or moral issues: infertility may be a punishment for
sins, or it may a sexual and relationship problem caused by `bad sperm' and failing or `worn out'
reproductive organs. Treatments vary from secret natural sperm donation by the healer himself or a
brother of the affected, to herbal remedies, prayers and payment of duties and sacrifices. Not all
treatments by biomedically-trained persons are evidence-based either; e.g., in West Africa, dilatation
and curettage are applied to almost any reproductive problem (abortion, menstrual irregularity,
infertility). Often, demand for infertility treatment is supply-driven, risking exploitation of the infertile
couple by offering expensive `cures'--from useless to harmful.
In most industrialised countries, women and men have access to a wide range of advanced
technologies to treat infertility. In developing countries, however, lack of access to medical care and
reproductive technologies is a big problem. Studies in Zimbabwe and the Gambia show that many
health workers have limited knowledge of infertility. Failure to investigate the husband is common, and
health workers often fail to do basic investigations, or they may ask for payment to continue an
investigation. Lack of counselling and negative attitudes may hamper patients' ability to cope with a
definite negative outcome. Appropriate referral is rare and lack of cooperation with traditional healers
is the rule. In the context of an overwhelming demand for other reproductive health services and a
structural lack of most resources, infertility is not a priority issue and infertility services--if available at
all--are usually ineffective. However, even in a country such as Norway, efficacy of treatment is often
limited, with 30-40% of referred patients failing to get a live born child.
Infertility: a priority issue
The desire to have children is universal. Nevertheless, infertility--with its serious emotional and social
consequences--still is an often-overlooked reproductive health problem. Its underlying (often
biomedical) causes require specific reproductive health services. In developing countries, a basic
package of infertility treatment would include STI treatment services for both partners, clinical genital
evaluation, fertility and emotional counselling, sperm tests, and menstrual cycle recordings. Prevention
of STIs (especially chlamydia) and pelvic infection in young adults is essential. HIV infection cannot
be overlooked as a cause or consequence of infertility. Infertility deserves a status as a health problem:
a good definition, proper investigation and treatment, and empathic counselling. Health-care workers
have to be the driving force behind this.
For further reading: A.O. Runganga, J Sundby & P. Aggleton (2001) "Culture, Identity and
Reproductive Failure in Zimbabwe", in: Sexualities--Vol 4(3): 315-332: London: SAGE Publications.
Johanne Sundby, Section for International Health, University of Oslo, P.O. Box 1130, Blindern,
N-0318 Oslo, Norway; Tel: +47-22-85.05.98; Cell: 90.55.87.04; Fax: +47-22-85.05.90; e-mail:
johanne.sundby@samfunnsmed.uio.no; Web: http://www.med.uio.no/ism/inthel/
Sexual Health Exchange, Spring 2002 v2002 i2 p13(2)
Infertility: a priority reproductive health issue. (Special Article). Johanne Sundby.
Full Text: COPYRIGHT 2002 World Health Organization
A few years ago, a woman in the USA gave birth to septuplets (seven children). She had been given
very potent fertility drugs without even trying to become pregnant, because her first child had been
born after prolonged time to pregnancy--although no research has shown that prolonged time in one
pregnancy leads to prolonged time in the next. Treating a potential medical problem because of a
possible minor inconvenience or emotional burden is questionable.
Defining infertility
This case leads us to reflect on the accurate definition of infertility: the medical definition of infertility
refers to women who have tried to become pregnant for at least one year without success. `Time to
pregnancy' is often used to measure fertility: a couple's ability to become pregnant, given that they
have regular sexual intercourse (at least once a week). Prolonged time to pregnancy may be a measure
of reduced fertility in couples. About 80-90% of women conceive within a year, and another 5-10% in
the second or third year of trying. In general, time to pregnancy increases with the woman's age.
Couple fertility should not be confused with individual fertility: the man's or woman's contribution to
reduced fertility can only be assessed through a systematic medical examination of their reproductive
organs. Primary sub- or infertility is established when the couple have been trying for 1-2 years, but
have never conceived before. Secondary infertility is when couples have had one or more pregnancies
in the same union before. This is a problem especially in Africa (up to 15%), because women get
pregnant at a very young age. Social and behavioural factors such as postponement of pregnancy and
childbearing, multiple partnerships and STIs, environmental exposures in workplace or farm fields, or
too low or high body weight can have a strong influence on infertility.
Infertility is not the same in different cultures, contexts and socio-economic environments. It is often
confused with other probabilities of not being able to bear children. In some countries, women who
lose babies during pregnancy or birth, or have a miscarriage, or even lose a live born baby in the first
year of life are called a "childless woman"--a term often used for infertility. In Zimbabwe for example,
a "reproductive failure" is someone who fails to live up to average reproductive norms, including
getting children of only one sex, or failing to become pregnant more than once or twice. The man's
role in the process is often secondary or not even mentioned.
The impact of infertility
Infertility is an important reproductive health problem, with some 3-4% of couples ending up childless
worldwide. Studies in industrialised and nonindustrialised countries show that people suffer from the
consequences of infertility regardless of the context--often leading to serious emotional problems,
such as depression and anxiety--although women in industrialised countries have many more options
in life than women in the South. In most developing countries, women bare the brunt of the burden of
infertility, as their primary role and identity still is to be a mother. In some African countries, women
do not even have the right to an own name, being referred to only as `mother of' or `mamma'. In the
Gambia, women who never carry babies may face divorce, abandonment or become a wife in a
polygamous union. In Zimbabwe, difficulty to get pregnant may lead women on a journey of sexual
encounters in order to get pregnant, putting her at a high risk for contracting HIV. She may also be
deprived of her personal inheritance, or returned to her own family and replaced with a younger sister
of hers.
Treating infertility
Infertile couples worldwide use many kinds of medicine, mixing modern care with alternative and
traditional care. In many countries, people resort to traditional healers, whose explanations and
remedies are often related to relational, spiritual or moral issues: infertility may be a punishment for
sins, or it may a sexual and relationship problem caused by `bad sperm' and failing or `worn out'
reproductive organs. Treatments vary from secret natural sperm donation by the healer himself or a
brother of the affected, to herbal remedies, prayers and payment of duties and sacrifices. Not all
treatments by biomedically-trained persons are evidence-based either; e.g., in West Africa, dilatation
and curettage are applied to almost any reproductive problem (abortion, menstrual irregularity,
infertility). Often, demand for infertility treatment is supply-driven, risking exploitation of the infertile
couple by offering expensive `cures'--from useless to harmful.
In most industrialised countries, women and men have access to a wide range of advanced
technologies to treat infertility. In developing countries, however, lack of access to medical care and
reproductive technologies is a big problem. Studies in Zimbabwe and the Gambia show that many
health workers have limited knowledge of infertility. Failure to investigate the husband is common, and
health workers often fail to do basic investigations, or they may ask for payment to continue an
investigation. Lack of counselling and negative attitudes may hamper patients' ability to cope with a
definite negative outcome. Appropriate referral is rare and lack of cooperation with traditional healers
is the rule. In the context of an overwhelming demand for other reproductive health services and a
structural lack of most resources, infertility is not a priority issue and infertility services--if available at
all--are usually ineffective. However, even in a country such as Norway, efficacy of treatment is often
limited, with 30-40% of referred patients failing to get a live born child.
Infertility: a priority issue
The desire to have children is universal. Nevertheless, infertility--with its serious emotional and social
consequences--still is an often-overlooked reproductive health problem. Its underlying (often
biomedical) causes require specific reproductive health services. In developing countries, a basic
package of infertility treatment would include STI treatment services for both partners, clinical genital
evaluation, fertility and emotional counselling, sperm tests, and menstrual cycle recordings. Prevention
of STIs (especially chlamydia) and pelvic infection in young adults is essential. HIV infection cannot
be overlooked as a cause or consequence of infertility. Infertility deserves a status as a health problem:
a good definition, proper investigation and treatment, and empathic counselling. Health-care workers
have to be the driving force behind this.
For further reading: A.O. Runganga, J Sundby & P. Aggleton (2001) "Culture, Identity and
Reproductive Failure in Zimbabwe", in: Sexualities--Vol 4(3): 315-332: London: SAGE Publications.
Johanne Sundby, Section for International Health, University of Oslo, P.O. Box 1130, Blindern,
N-0318 Oslo, Norway; Tel: +47-22-85.05.98; Cell: 90.55.87.04; Fax: +47-22-85.05.90; e-mail:
johanne.sundby@samfunnsmed.uio.no; Web: http://www.med.uio.no/ism/inthel/