Advice and information for the infertile couple

Infertility and spontaneous abortion

Information about the chances of conceiving spontaneously may be of great help to the couple. For couples who have been trying for less than a year, the success rate is between 80% and 90%. For couples who have been trying to conceive for up to 3 years, the success rate is about 40% in a 1-year period (equivalent to a monthly fecundity rate of 4-5%). For couples who have been trying for more than 3 years, the success rate is still up to 25% in a 1-year period. If a male or female subfertility factor has been identified, there is still a likelihood of spontaneous conception, although the success rates may be lower [NHS CRD, 1992; Himmel et al, 1997; Hargreave and Mills, 1998; Te Velde and Cohlen, 1999].
Assessment and investigations for infertility are not generally advised until the couple has been unable to achieve a pregnancy after a year of unprotected intercourse. Some people who present with concerns about their fertility need only simple reassurance that the chance of conception is 84% in the first year if they do not use contraception and have regular sexual intercourse. About half of couples who do not conceive in the first year will conceive in the second year (a cumulative pregnancy rate of 92%) [National Collaborating Centre for Women's and Children's Health, 2004].
Regular sexual intercourse (two or three times a week) throughout the cycle should ensure that intercourse falls within the fertile period. Timing of intercourse using temperature charts and luteinizing hormone detection methods causes stress and has not been shown to improve conception rates. They are therefore not recommended [Hargreave and Mills, 1998; National Collaborating Centre for Women's and Children's Health, 2004]. Timing intercourse to conceive.
Folic acid supplements should be taken whilst trying to conceive and for the first 12 weeks of pregnancy in order to reduce the risk of neural tube defects. Most women should take 400 micrograms daily. A higher dose of 5 mg daily is recommended for women who either have a family history of neural tube defect, who have had a baby with a neural tube defect, who are taking antiepileptic medication, or who have coeliac disease [Wald, 1991; Lumley et al, 2003; National Collaborating Centre for Women's and Children's Health, 2004].
Rubella status should be checked. If seronegative, rubella vaccination is indicated and the woman should be advised not to become pregnant within 1 month of the vaccination [CMO, 2003].
Smoking cessation is advisable for both men and women. Smoking, including passive smoking has been shown to be detrimental to fertility in women [Hughes and Brennan, 1996; Augood et al, 1998; Hull et al, 2000; BMA, 2004]. In men, although there is no clear evidence that smoking delays conception or affects fertility, it may affect sperm quality and general health [BMA, 2004].
Alcohol limitation
- Women should be advised to limit alcohol to 1 to 2 units once or twice a week. The evidence for a link between alcohol and female infertility is conflicting, and the limits for safe consumption are not known, but until more is known, low consumption of alcohol when trying to become pregnant and during pregnancy is advisable [DH, 2003; National Collaborating Centre for Women's and Children's Health, 2004]. A unit of alcohol is about the same as a small glass (125 ml) of wine or a half-pint of beer.
- Men should be informed that alcohol consumption within the Department of Health's recommendations of 3 to 4 units a day is unlikely to affect their fertility. Excessive alcohol consumption can be detrimental to semen quality [National Collaborating Centre for Women's and Children's Health, 2004].
Weight
- Weight loss should be encouraged in women with a body mass index (BMI) greater than 29, as this is likely to increase their chance of ovulation and therefore conception. There is no proven association between male obesity and infertility, although obesity is associated with poorer general health, a reduction in sperm motility and increased DNA fragmentation [Rich-Edwards et al, 2002; Kort et al, 2003a; Kort et al, 2003b; National Collaborating Centre for Women's and Children's Health, 2004].
- Women who have a body mass index of less than 19 and either amenorrhoea or irregular menstruation should be advised that gaining weight is likely to increase their chance of conception [National Collaborating Centre for Women's and Children's Health, 2004].
Nutrition
- A well-balanced diet will contribute to general good health for both partners. Although there is little research on nutritional factors in infertility, there have been studies suggesting that nutritional deficiencies may play a role; e.g. vitamins C, D, E, selenium, zinc, and folate deficiencies may affect sperm quality [Wong et al, 2000].
- There is no consistent evidence to link consumption of caffeinated beverages (tea, coffee, and cola) and infertility [National Collaborating Centre for Women's and Children's Health, 2004].
Clothing. Men should be informed that although there is an association between an elevated scrotal temperature and reduced semen quality, it is uncertain whether wearing loose-fitting underwear improves semen quality [Tiemessen et al, 1996; Munkelwitz and Gilbert, 1998; National Collaborating Centre for Women's and Children's Health, 2004].
Counselling and information on infertility
- It is important to involve both partners in all aspects of management. Discussion of wishes, plans, beliefs, and motives are important [Himmel et al, 1997].
- Counselling should be made available to all infertile couples, and may cover these different aspects:
  - Implications of investigations and treatments
  - Emotional support for social and psychological issues such as stress
  - Help with ethical and legal issues, especially for assisted conception
  - Therapeutic counselling to help people accommodate the feelings they have about their infertility.

Source : Infertility (Prodigy, UK)

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Edited by Aldo Campana,