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Introduction
For the purpose of the following report the author will explore treatments, the influencing Bio-psycho-social factors in addition to wider influences such as legal and ethical issues, and the importance of the promotion in health and education in relation to female infertility. The World Health Organization (WHO) defines infertility as a disease of the reproductive system resulting in the failure to achieve clinical pregnancy after twelve months or more of regular unprotected sexual intercourse (World Health Organization, 2019). Data released in 2016 revealed Ireland as having the third highest fertility rate in Europe (Ec.europa.eu, 2017) which signifies a decline in fertility rate, as in 2012 the Central Statistics Office released data that Ireland had the second highest fertility rate in Europe (The Irish Times, 2014). Furthermore, the decline in infertility is supported by 2017 CSO figures which identify a continuous decline in Irish birth rates over the past decade. Additionally, to the increase in the age of first-time mothers which now stands at 31 years of age there is also a decline in the number of women in younger ages. (CSO, 2017).
Treatments
Treatments for infertility are constantly evolving but can generally be subdivided into three categories consisting of medication and surgical treatment to improve or restore fertility and Assisted Reproductive Technology (ART) such as In Vitro Fertilization (IVF). The type of treatment is dependent on the cause of infertility. Updated NICE guidelines recommend infertility treatments in instances of unexplained infertility and mild endometrioses and IVF treatment for those who have not conceived after two years of vaginal intercourse. For the first-time guidelines are inclusive of women over the age of 39 (40-42 years), same-sex couples, those carrying an infectious disease or those unable to have intercourse due to disability and patients about to undergo cancer treatment that wish to preserve their eggs (NICE, 2013).
Fertility restoration drugs are typically used to treat ovulation disorders affecting fertility. Clomiphene citrate is an oral medication which mechanism of action is to stimulate the pituitary gland to increase the level of the follicle stimulating hormone (FSH) and the Luteinizing Hormone (LH) to fortify the growth of an ovarian follicle containing an egg. Alternatively, gonadotropins are injected to encourage the production of multiple eggs or to mature the eggs and trigger their release at ovulation. Metformin is another pharmacological treatment which may be used when insulin is considered as a contributing factor in women with a diagnosis of polycystic ovary syndrome (PCOS) to improve insulin resistance and thus increasing the chances of ovulation. Aromatase inhibiters or dopamine antagonist may be administered to induce ovulation in a similar manner to clomiphene, when excess production of prolactin by the pituitary gland interrupts ovulation (mayoclinic.org, 2019).
Due to the effectiveness of alternative treatments surgical interventions are rare. Laporscopic and hysteropic surgery can correct or remove abnormalities affecting fertility as a result of endometrial polyps, uterine or pelvic adhesions, fibroids or correcting the abnormal shape of the uterus. Surgery can also create a tubal opening in fallopian tubes that are blocked (Mayoclinic.org, 2019).
There are many variants of Assisted Reproduction Technology (ART) but, the two most common methods are Intrauterine insemination (IUI) and IVF. IUI involves the process of placing millions of healthy sperm inside the uterus at the time of ovulation to facilitate fertilization through the increase in the number of spermatozoa that reach the fallopian tubes. IVF consists of retrieving a mature egg from the woman and fertilizing them in a petri dish in a laboratory with sperm, once fertilization has been established the fertilized embryo is transferred into the uterus. IVF is the most effective form of ART of which the cycle takes several weeks requiring frequent Full Blood Counts (FBC) and hormone injections (Mayoclinic.org, 2019). Although a successful form of treatment, in Ireland it is currently only available privately meaning undergoing IVF can be expensive, even with the tax relief for medical expenses scheme and the drugs payment scheme, average costs are estimated in the region of ¬4000 (National Infertility and Support Group, 2019). In 2018 the Irish Government announced that plans to allocate funding to IVF treatment had been set aside and legislation delayed for regulatory measures, and that couples seeking treatment would have to meet certain criteria and be means tested, prioritizing those who are childless over existing parents (The Irish Times, 2019).
Legal, social, ethical, psychological issues and sexual behavior.
From a legal perspective the Children and Family Relationship Act 2015 includes laws on assisted human reproduction (AHR) following on from the commission of AHR in 2005 to establish regulations but have not yet come into force. Additionally, fertility services are generally only available to those who are in a stable relationship i.e. married heterosexual couples (HSE.ie, 2018). However, demand for the treatment is expected to rise due in part to the marriage referendum in 2015 and the Equal Status Act 2000 to prevent against discrimination on the grounds of preferred sexual orientation, however the Childrens and Family Relationships Act must first be amended to clarify parentage as a result of donor-assisted human reproduction (Oireachtas.ie, 2018). Recently ethical issues have surfaced surrounding the advancements in IVF treatment in regard to genetic selection, IVF clinics can already identify which embryos are predisposed to developing certain disease and illness such as cystic fibrosis due to genetic data that has been collected, however controversially the same methods can be used to predict the eventual height, skin tone and even intelligence of an embryo (Regalado, 2018). However, IVF is not alone, as legal issues are increasingly being identified in alternative options for having children through a surrogacy and donor assisted human reproduction retrospectively in recognition of parenthood. Issues surrounding statutory requirements related to maternity leave and maternity benefit was emphasized by the courts in the case of G v. The Department of Social Protection where the claimant was neither entitled to parental leave or adoption leave as she did not come within the confinements of the statutory requirements, requiring the necessity for legislation and amending what constitutes motherhood in the Irish constitution to address the lacuna in the law (Healy 2017). Also, for consideration is the topic of secondary infertility whereby a woman is unable to bear a child through an inability to conceive or an inability to carry a pregnancy to a live birth or who repeatedly spontaneously miscarry or pregnancy that results in stillbirth following previous pregnancies (World Health organization, 2019). We should also consider societal expectations or pressures surrounding fertility. Research carried out by VHI in conjunction with the Lets talk about Fertility campaign identified that 47% of surveyed women feel there is stigma associated to infertility and one in four linking that to lack of open dialogue surrounding the issue. An additional 20% believed that women are stereotyped in that they should want children (Ring, 2016). Is it expected that all women naturally want more children, or want children at all? And what is it like for those women who decide to go against the norm or lack maternal instincts? Would addressing these societal and cultural notions linking womens identity with procreation ease the burden on those experiencing difficulties with fertility? (infertility and its treatments, 2009). As a result of this it is important to consider the psychological impact on those faced with infertility. Infertile women experience more depression and anxiety and reduced marital satisfaction than those of their fertile counterparts as well as lower confidence in their parenting abilities post IVF. Due to the cyclical nature of infertility feelings of hope, loss and despair are recurrent, in 1980 Barbara Eck Menning examined these emotional stages categorising them into: surprise, denial, anger, isolation, guilt, grief and resolution likening the stages to Kubler-Ross’s stages of grief (Allan and Mounce, 2015). This highlights the need for psychological and emotional support for women and their partners as they journey through infertility and its treatments. It is evident that women are delaying pregnancy into their thirtys, perhaps in order to establish careers, women aware that pregnancy and child rearing can negatively impact career progression and wrongly rely on reproductive technologies like IVF as a cure for fertility issues (Fauser et al, 2019)
Due to the complexities and personalized responses to infertility it is difficult to conduct comparative studies to establish the effects, thus highlighting the importance of health promotion and education on fertility, causes and symptoms of infertility (Appendix 1) and the limitations of Assisted reproductive Technology. In order to achieve pregnancy, the steps of the human reproduction process must happen correctly. Ovulation must occur where the egg is released from the ovary into the fallopian tube where it meets the spermatozoa and is fertilized. The fertilized egg then travels down to the uterus where it implants into the endometrial lining and grows in the uterus (Mayo Clinic, 2019). According to Tsevat et al. Untreated sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhea are attributed to tubal factor infertility which causes inflammation, scarring and damage as well as Pelvic Inflammatory Disease (Tsevat et al, 2017). In the first six weeks in Ireland in 2019 there were 216 cases of Chlamydia and 73 cases of gonorrhea reported (HPSC, 2019). A survey conducted by Durex in 2017 exposed the attitude towards sex in Ireland revealing that 59% of women surveyed had never had an STI check with 53% (ironically) reporting that they were more concerned about getting pregnant than contracting an STI that may result in infertility (Irishexaminer.com, 2017). Weight also has an impact on fertility with the Healthy Ireland report identifying that 31% of women are overweight and 22% obese, subsequently half of all women are overweight or obese at pregnancy booking visit (HSE.ie, 2019). Overweight women have an increased risk of infertility, miscarriage and pregnancy complications and have poorer outcomes in terms of natural and ART (Ozcan and Dilbaz 2015). One out of seven Irish couples will have difficulty conceiving with a third of those attributed to female infertility with age being the biggest contributing factor. Other influencers include athletic training, stress, alcohol and tobacco (women’s health clinic, 2019). One should also consider the influence media has on womens perceptions of age-related infertility through misleading media reports about older celebrities being able to conceive without considering that they may need assisted reproductive technology (Mac Dougal et al. 2012).National fertility awareness week is held annually from the 17th – 24th of July to raise awareness and educate people on the growing issue of infertility (Celebration of National Fertility Awareness Week 2018).
Conclusion
As depicted in the above document the effects associated with infertility are as emotionally, socially and legally complex as the causes and treatments of infertility itself. Due to the rising global prevalence and incidences of female infertility it is evident that there needs to be more of an emphasise on education in order to combat the deficit on knowledge on the impact of fertility issues. Education and open dialogue may help decrease the perception of social stigmatisation felt by infertile women, as well as enabling women to make better lifestyle choices that may impact their fertility. The lack of legislation surrounding AHR in Ireland needs to be addressed to better facilitate those who are faced with no other option than surrogacy to help ease the emotional and psychological burden associated with infertility. Additionally, there is also a need to address the lack of funding in relation to assisted reproductive technology to ensure those who are involuntarily childless have better access to treatments, inclusive of amending current legislation as to not discriminate against those in same sex relationships.
References
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