In an effort to better understand infertility, Council staff conducted independent research and reviewed information included in the submissions received. This section discusses the prevalence, treatments, prevention, and risk factors associated with infertility.
The commonly accepted medical definition of infertility is 12 months or more of unprotected intercourse without pregnancy. Under this definition, a National Center for Health Statistics study found that infertility affects 10% of the female population aged 15 to 44 years of age. Applying this percentage to Pennsylvania suggests that infertility affects close to 270,000 Pennsylvania women.
The most common treatments are fertility drugs; artificial insemination; tubal surgery for blocked fallopian tubes; and assisted reproductive technology, a technological approach helping women achieve pregnancy through the transfer of human eggs into the woman's uterus. Assisted reproductive technologies include in vitro fertilization; gamete intrafallopian transfer (GIFT); and zygote intrafallopian transfer (ZIFT).
The simplest form of infertility treatment is the use of fertility drugs. These drugs can cost anywhere from $200 to $3,000 per month, depending on the type of drug used. Women often use fertility drugs for periods of a year or two until they are either successful or try another method. In addition, many women also use these drugs in conjunction with assisted reproductive technology techniques to increase their chance of pregnancy.
Intrauterine artificial insemination (IUI) is the most common form of artificial insemination. In this procedure, the man's sperm is placed by catheter into the woman's uterus shortly after ovulation. The cost for the procedure is between $250 and $350, not counting fertility drugs.
Surgery is an option for women with blocked or scarred fallopian tubes. Since the introduction of in vitro fertilization in 1981, tubal surgeries have decreased by 50%. Tubal surgeries are, however, more likely to be covered by insurance carriers than assisted reproductive technology. The cost ranges from $10,000 to $15,000.
One report maintains that many women have insurance plans which cover tubal surgery but exclude assisted reproductive technology and that patients are often treated with tubal surgery simply because it is covered, though it is expensive. The success rate of tubal surgery is a 2.16% pregnancy rate in the first year after the surgery is performed, 37% pregnancy rate after 4 years.
The next step is one of the assisted reproduction technology (ART) procedures, in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), or zygote intrafallopian transfer (ZIFT). A total of 2,641 assisted reproductive technology cycles were performed in Pennsylvania in 1995.
Approximately 11% of assisted reproductive technology procedures carried out in 1995 also utilized intracytoplasmic sperm injection (ICSI). This procedure, which involves injecting a sperm directly into an egg, is most often used in cases of male infertility. ICSI adds about $2,000 to the cost of a procedure.
The most common services received were advice, tests, and ovulation drugs. Assisted reproductive technology services were much less common. According to the American Society for Reproductive Medicine, most infertility cases (85% to 90%) are treated with conventional therapies, such as drug treatment or surgery. Fewer than 5% of infertile couples in treatment actually use an assisted reproductive technology procedure.
While several methods can be used to assess assisted reproductive technology success rates, most people are interested in the live birth per cycle rate which shows the percentage of cycles started that result in a live birth. This rate was 19.6% in 1995.
The following table shows that assisted reproductive technology pregnancy rate compares favorably with the rate of conception among fertile couples in any given month.
| Source: William Mercer, Infertility as a Covered Benefit | |||
| Rate of Pregnancy in Any One Cycle | |||
|---|---|---|---|
| Fertile Couple | IVF (in vitro fertilization) | GIFT (gamete intrafallopian transfer) | ZIFT (zygote intrafallopian transfer) |
| 25% | 19.7% | 28.5% | 29.1% |
Of all assisted reproductive technology pregnancies in 1995, 78% resulted in live births. The remaining pregnancies resulted in adverse outcomes, including spontaneous abortions (17%), induced abortions (1.5%), ectopic pregnancies (2.7%), and stillbirths (0.7%). Approximately 37% of assisted reproductive technology births were multiple births, compared with 2% of births in the general population.
The age of the woman makes a difference in how successful the assisted reproductive technology procedure will be. The pregnancy success rate for women aged 34 years and younger remained fairly constant at 25%, but declined after age 34.
RESOLVE reports that about 50% of women who complete an infertility evaluation and go on to get infertility treatment of any type will eventually have a baby. The literature notes that infertile couples have a "spontaneous cure rate" of about 5% after a year of infertility.
Infertility treatment is associated with a full range of potentially adverse side effects. These adverse effects include serious immediate medical complications and long term elevated risk for ovarian cancer. One study suggests however, that immediate complications of fertility are very rare when good medical practice is followed. The study also notes that research suggests that the correlation between use of fertility medications and ovarian cancer is actually due to the effect of childlessness rather than the medications.
According to the American Society for Reproductive Medicine, roughly one third of infertility cases can be attributed to male factors, and about one third to factors that affect women. For the remaining one third, infertility is caused by a combination of problems in both partners or, in about 20 percent of cases, is unexplained.
Some of the more common causes of female infertility are blocked fallopian tubes (35% of all female infertility) and irregular ovulation (25% of all female infertility). In addition, 35% of women who have laparoscopy as part of their infertility workup are found to have endometriosis.
The most common male infertility factors are insufficient sperm count or abnormalities in the sperm which cause them to die before they can reach the egg.
Among women, problems in ovulation, blocked or scarred fallopian tubes, and endometriosis are the factors that most often contribute to infertility. Endometriosis and difficulties with ovulation are not amenable to prevention. Infertility resulting from sexually transmitted diseases - an estimated 20% of cases - is the most preventable.
Among men, preventing infertility is difficult. Most cases of infertility are a consequence of abnormal or too few sperm. Factors that contribute to abnormal or too few sperm are largely unknown. For one in five infertile couples, a cause is never found.
Another avenue related to prevention is education about fertility. Results of a survey of college students were reported in the submission by William Panak, Ph.D. Though the survey was designed to elicit the level of willingness to pay for infertility benefits, a striking secondary finding was the perceived risk of infertility in this group of students. The median perceived risk reported by students was 0.1%, whereas the actual risk for infertility is 8%. The emphasis on pregnancy prevention in American society leads many to assume that once contraception is discontinued conception is likely to occur immediately. The probability of infertility increases somewhat after age 30 and significantly after age 35. Many women may be encouraged to avoid delaying childbearing until their mid-to-late thirties if they had a realistic grasp of their increased probability of difficulty in conceiving.
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