Infertility Definitions

One of the most common questions that arises in infertility is: How long should a couple try to achieve a pregnancy before they seek medical attention? When should a woman consider herself infertile?

This is not an easy question to answer as you might believe. The standard textbook definition states that a woman has a fertility problem if she has been unable to conceive after one year of unprotected intercourse. This is a statistically valid definition but I believe it is incorrect. The reasons for this are as follows.

If you talk to your friends who are not infertile — those women who almost get pregnant without thinking about it — ask yourself how long does it take for these women to achieve a pregnancy? In the vast majority of cases, women are pregnant within two to three months of trying. Many get pregnant the first month. Therefore, I believe if a woman has attempted a pregnancy for six months and has not conceived, she ought to seek medical attention.

For younger couples, if they have tried for six months and have not been successful, they will begin to become aware that something may be wrong. Given the emotional circumstances surrounding a fertility evaluation, it may take several more months for that couple to get up enough courage to even seek medical attention. There may be another month or two of waiting before they can actually get to see the physician. It is therefore easy to see that the better part of a year will have passed anyway. If you wait one year before deciding to seek medical attention, you simply drag out the entire process that much longer.

As will be discussed later, age plays a significant role in infertility. Everyone knows about a woman’s biological clock. Men have one too but it takes a little longer to slow down. A good rule-of-thumb about when to seek infertility care is as follows.

If the woman is under 30 and her partner is under 35, trying for a year is not unreasonable although seeking help sooner is not wrong.

If the woman is between 30 and 35 and her partner is over 35, help should be sought after 6 months of trying.

If the woman is between 35 and 40, she should seek help after trying for 3 months.

If the woman is over 40 or her partner is over 40, a baseline evaluation should be immediately undertaken to determine whether a pregnancy is even possible.

These definitions and guidelines really apply only to those couples where they have no reason to believe they have a fertility problem in the first place. It makes absolutely no sense for a couple who already has one or more “red flags” to fulfill some arbitrary textbook definition of infertility before seeking help.

For instance, if the woman has significantly irregular menstrual cycles, she is either not ovulating at all or is ovulating very infrequently and probably isn’t ovulating normally. Why waste time trying in vain to have a baby when it seems fairly obvious that some sort of medical help is necessary?

If a woman has anything in her history that would indicate she has pelvic pathology, she too should seek help immediately rather than delaying unnecessarily. Such “red flags” for pelvic disease include significant pain with the menstrual period, significant pain between periods, any pain with intercourse, a history of pelvic surgery (whether done through a laparoscope or “open”), a history of an ectopic pregnancy, a history of a pelvic infection or anything else that would suggest to that woman that she has a problem with her reproductive organs.

A couple who suspects there may be a male factor should also seek help immediately rather than delaying. “Red flags” in the husband’s history include an undescended testicle, a twisted testicle, late puberty, a known varicocele, or early baldness (under age 30).

Men with Hypertension who are being treated with “Calcium Channel Blockers” may have impaired fertility.

Men who are into body-building and are taking steroids and other medications often have impaired fertility.

Another red flag would be if either the man or woman has a significant weight problem.

Another red flag for the husband would be if he were married before, unable to father a child and his first wife was remarried and able to become pregnant without difficulty. This would also suggest that perhaps there is a male factor present.

One question that is frequently asked is whether age affects fertility and to what degree. We have known for years that a woman’s fertility declines as she gets older. A woman is most fertile in her mid-20’s. There is a slight drop at age 30, a larger drop at 35, and an even more significant drop at 40. Nonetheless, as we will often repeat, the majority of women at any age who wish to become pregnant are able to do so.

One question that has always been hard to answer is what effect age has on male fertility. First, most older men are not interested in fathering children. Second, older men tend to be married to older women. It is therefore difficult to separate the two. Is their infertility more due to his older age or hers?

Further complicating the situation are the much older men who have been able to father children with much younger women. Certainly male fertility declines with age but we really do not worry too much until the man reaches age 45.

A study from England published in the summer of 2000 did provide compelling evidence that as men get older, they have a harder time impregnating their partner. Furthermore, this decline begins much earlier than we had suspected.

The British researchers showed that the likelihood of a man’s partner become pregnant within 6 months decreased by 2% for every year that man is over age 24!

The study also showed that a woman whose partner is 5 or more years older than she is has a lesser chance of conceiving within in a year than if her partner were the same age or younger.

The study found that if the man is under age 25, only about 8% of the time will his partner not conceive within 1 year. However, if he is over 35, that number jumps to 15%. The study showed that as a woman goes from age 30 to age 35, her fertility decreases 10-20%. However, a man’s fertility drops by 50% when he goes from age 25 to age 35.

Data from a French IVF clinic further illustrates this point. The study showed that in women going through IVF, the percentage of eggs that fertilized was 60% if the man was under 39 but only 51% if the man was over 39. Other studies looking at other indicators of semen quality have shown similar findings.

The numbers indicate that while women have a significant drop off in their fertility at age 40, men just dwindle away slowly. Therefore, if an older man is married to a younger woman, it just may take longer to establish a pregnancy. However, if the woman herself is older, that couple should seek help sooner since the woman’s decline in fertility with age becomes the more significant issue.

In summary, a younger couple should try to achieve a pregnancy for six months, having intercourse often enough (two to three times a week) to allow them a reasonable chance of a pregnancy. If after six months that woman has not become pregnant, they should seek medical attention - sooner if there are any “red flags” or if age would mandate an earlier visit.

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