As a considerable portion of infertility is due to preventable causes, primary prevention is an important and cost-effective component to combating unwanted childlessness. Many governments and public health care providers consider prevention a priority and a 1988 report by the US Office of Technology Assessment concluded that “With the personal, familial, and societal losses caused by infertility so great that infertility is better prevented than treated.” Similarly, a recent unpublished World Health Organisation (WHO) Reproductive Health and Research Department Strategy document listed prevention and treatment of infertility as important elements of
sexual and reproductive health. Prevention is especially vital in developing countries where the majority of causes are due to infections resulting from STIs, unsafe delivery or unsafe abortion. In areas where a large percentage of infertility is the result of infection, the situation would be best addressed through prevention and treatment of infection, in combination with basic health education to provide information on sexual and reproductive health and infertility awareness. These messages could be incorporated into existing family planning and reproductive health programs within primary and secondary health care services. Despite the key role of prevention, not all cases of infertility can be avoided, and the need for treatment clearly exists.
A range of medical treatment options exist for infertility, which fall into two broad categories. Low tech treatments, which account for more than 95% of modern, medical infertility treatments, are those that do not involve the retrieval of oocytes or fertilization outside the body. These often include the use of fertility drugs to stimulate “superovulation”, the development and release of more than one egg per ovulation cycle, and intrauterine insemination, a process by which sperm are placed inside a woman’s cervix to facilitate fertilization and pregnancy. High-tech treatments, also called assisted reproductive technologies (ARTs), are treatments or procedures that involve the handling of human eggs or sperm for the purpose of helping a woman become pregnant. Common ARTs include in vitro fertilization (IVF) a procedure in which a man’s sperm and a woman’s egg are fertilized in a laboratory and the resulting embryo is transferred into a woman’s uterus, and intracytroplasmic sperm injection (ICSI) in which a single sperm is injected into a single egg during IVF.
The success rates for ARTs vary according to multiple factors including: patient age, diagnosis, length of infertility, number of previous IVF attempts, and the size and quality of the facility where treatment is being provided. The American Society of Reproductive Medicine estimates that more than half of couples in United States pursuing treatment eventually become pregnant, however success rates vary greatly both with the United States and abroad. Since the birth of the first human baby resulting from IVF in 1978, there have been over one million babies born as a result of ARTs with Europe leading the world in terms of number of treatments; in some European countries up to 5% of all births are due to ARTs. Medical treatment of infertility has advanced dramatically, making parenthood possible for many who would have until recently been unable to achieve this goal.
Despite the potential of ARTs, there is considerable debate over the cost and accessibility of infertility treatment. In the United States one cycle of IVF costs and average of $12,4oo and comes with an average success rate of less than thirty percent -29.4% of women deliver for every egg retrieval performed. Success rates generally increases with the number of ART cycles attempted, up to 4 cycles. While IVF itself is used with less than 5% of infertile couples who seek treatment, amounting to only 0.003% of health care cost in the United States, other treatment can also be expensive with public funding and insurance coverage varying widely worldwide. In United States, treatment is usually not covered by private insurance and never included in public insurance schemes. Other developed countries generally provide some funding for treatment within the context of a socialized medical system. Most women experiencing infertility do not seek medical help. In the United States those who do seek specialized services for infertility are more likely to be white and of higher socioeconomic status than those who do not seek treatment despite the fact that the prevalence of infertility does not vary by race/ethnicity or socioeconomic status.
When medical treatment for infertility is available it carries its own risk. In addition to the risk inherent in any invasive medical procedure, superovulatory fertility drugs can cause ovarian hyper-stimulation syndrome, a condition marked by enlargement of the ovaries which can, in severe cases, be life threatening. Another potential risk for women who have undergone ART using ovarian stimulation medications is an increased risk of ovarian cancer; this is controversial however and substantial disagreement exists over the causation of these cancer cases.
The most commonly discussed risk of infertility treatment concerns only those whose treatment is unsuccessful, the increased risk of multiple births. In 1996, 38% of ART births in the United States were multiples, compared to just 2.7% of the general population. For a couple who has undergone infertility treatment, multiple births may seem like a thrilling conclusion to a difficult process however, multiple births bring significant risks. Multiple births have higher rates of neonatal complications such as prematurity, low birth weight, congenital anomalies, respiratory distress syndrome, and infant mortality. For higher order multiples, rates of infant mortality are up to 15 times higher than singleton birth. Mothers of multiple also suffer increased complications including hypertension, anaemia, post-partum hemorrhage, and increased rates of depression. Multiple births exact additional familial costs such as extreme sleep deprivation, increased anxiety, depression, financial strain, and lack of parent-child time. In addition to effects on the infants, mothers, and families of multiples there are significant additional delivery and are costs for health care systems.
