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INTRODUCTION

Infertility is defined as the inability to conceive after 1 year of unprotected intercourse of reasonable frequency. It can be subdivided into primary infertility, that is, no prior pregnancies, and secondary infertility, referring to infertility following at least one prior conception.

Conversely, fecundability is the ability to conceive, and data from large population studies show that a monthly probability of conceiving is 20 to 25 percent (Table 20-1) (Guttmacher, 1956; Mosher, 1991). In those attempting conception, more than 85 percent will be pregnant by 1 year.

TABLE 20-1Fecundity of Normal Couples over Time

Infertility is common and affects 10 to 15 percent of reproductive-aged couples. Of note, even without treatment, approximately half of women will conceive in the second year of attempting. According to the National Survey of Family Growth, the percentage of married women who reported infertility fell from 8.5 percent in 1982 to 6.0 percent in 2006 to 2010. In comparison, the percentage of women aged 15 to 44 years who had ever used infertility services rose from 9 percent in 1982 to 12 percent in 2002 (Chandra, 2013, 2014). Rates of fertility measures for men and women remained similar from 2011 to 2015 (Martinez, 2018). Interpretation of these data is complicated by ongoing changes in marriage rates, intentional delays in childbearing, and socioeconomic and educational status changes. Nevertheless, well-publicized successes in infertility treatment now give patients greater hope that medical intervention can help them achieve their goal, and this has prompted them to seek evaluation and treatment in growing numbers.

Several factors result in substantial disparities in access to infertility care. Diagnosis of conditions in men may be delayed or missed due to social factors that hold the female primarily responsible for conception and childbearing. Also, infertility insurance coverage is unequal between the sexes (Chu, 2019; Dupree, 2016; Farland, 2016). In addition, marked disparities in access to fertility care have been noted for unmarried, homosexual, and transgender individuals. The ethical concerns raised by these discrepancies are addressed in several recent reports by the American Society for Reproductive Medicine (2013a, 2015a, d).

Most couples are more correctly considered to be subfertile, rather than infertile, as they will ultimately conceive if given enough time. This concept of subfertility can be reassuring. However, there are obvious exceptions, such as the woman with bilaterally obstructed fallopian tubes or the azoospermic male. In general, infertility evaluation is offered to any couple that has failed to conceive in 1 year. But, several scenarios may prompt earlier intervention. For example, delayed assessment in an anovulatory ...

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