The most important fertility factors have little to do with biology

Infertility often has more to do with gender and class constructs than biology alone.
Infertility often has more to do with gender and class constructs than biology alone.
Image: AP Photo/Teresa Crawford
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In my decades as an obstetrician, gynecologist, and surgeon, I’ve heard it all when it comes to the many myths associated with infertility. Often, fertility has much more to do with gender and class barriers than it does with pure physiology. We need to combat these misconceptions in order to better understand the many influencing factors.

When it comes to infertility, the amount of information out there feels particularly hard to resist. The internet allows us to get answers quickly, but those answers can also devolve into a place of misdiagnosis, fear, and confusion.

This is a huge problem, and one that patients and doctors need to combat together.

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Fears and misconceptions about infertility

  • Even though 20% of people with ovaries in the US experience infertility issues, the correct definition of infertility is often unclear to many: Infertility is defined as spending 12 months trying to conceive without conception.
  • After you have unprotected vaginal intercourse, the sperm remains in your system. There is no need to do pelvic lifts or headstands if you’re hoping to conceive.
  • Not all delays in conceiving mean you’re dealing with infertility issues. There is a gradation throughout your reproductive lifecycle, you can experience a delay conceiving no matter what age you are.
  • Prolonged, untreated sexually transmitted infections (STIs) can result in infertility, particularly the contraction of STIs like chlamydia and gonorrhea. That condition is called tubal factor infertility. (It should be noted that men rarely experience infertility as a result of untreated STIs.)
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What people with fertility questions should know before they enter an exam room

For a person with ovaries, the rate of miscarriage goes up 50% after the age of 40, because the eggs are older. Older eggs are more problematic and more likely to experience chromosomal defects. Under the age of 30, the likelihood of miscarriage is about 10% to 15%; at 40 years old, the chances approach 25%; and by mid-40s, it can reach 50%.

When facing infertility, it’s important to consider other health factors. Obesity, for example, is a common condition across the country, and it increases the risk of:

  •     Pregnancy loss;
  •     Pregnancy complications, such as gestational diabetes, pre-eclampsia, and blood clots in the legs or lungs;
  •     Cesarean section;
  •     Childhood obesity, asthma, autism spectrum disorders, childhood developmental delay, and attention-deficit/hyperactivity disorder.

Pregnancy is not the time to lose weight, so weight management (via things like a healthy diet, limited alcohol consumption, and regular exercise) is important to establish prior to trying to conceive.

If you live with a chronic disease (such as asthma, hypertension, rheumatoid arthritis, or Lupus, for example) schedule a preconception consult so your physician can ensure you’re receiving care from a high-risk obstetrician, to mitigate concurrent or unexpected health problems.

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Don’t get wooed by false promises

Many people are in their most vulnerable state when struggling with infertility, and are desperate to find solutions. Some treatments, such as IVF add-ons, are marketed to people having difficulty conceiving even though we don’t have scientific evidence that they actually work.

I get angry about this issue of IVF add-ons. Emotionally vulnerable patients seeking answers, help, and hope are completely misled. These add-ons are costly and have sketchy clinical benefits.

Ultimately, the goal of fertility treatment is to maximize the take-home baby rate. Standard treatments often involve ovulation stimulation and monitoring, IVF itself (sometimes via intracytoplasmic sperm injection (ICSI), or injection of a sperm into an egg) followed by replacement of resulting embryos or blastocysts into the uterus.

🎧 For more intel on fertility care, listen to the Quartz Obsession podcast episode on egg freezing. Or subscribe via: Apple Podcasts | Spotify | Google | Stitcher.

Beyond those processes, a la carte add-ons, which includes treatments like endometrial scratching, implanting embryo glue, treatments involving steroids, etc., won’t serve patients. They are not based on evidence of effectiveness, can be extremely costly, and usually provide false hope to the couple.

It’s hugely problematic that because clinicians are paid per service, some may be incentivized to put patients through additional treatments.

Patients should demand information based on the best available evidence, citing sources including the American Society of Reproductive Medicine guidance where appropriate, and should ask about the limitations of what is known about both standard and a la carte add-ons.

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Social pressures

We’re seeing an increase in the number of employers offering egg freezing for fertility preservation and family planning as a benefit to employees. This is a costly service, and on one hand can be a good option for people who are not ready to have children, yet want to exercise their options. On the other hand, the benefit can be viewed as a form of coercion and commercial exploitation.

It should be noted that there are significant uncertainties regarding the efficacy, appropriate use, and long-term effects of egg freezing through the process of cryopreservation. Data from a study that includes donors whose eggs were split into two groups has shown that embryos from previously frozen eggs show rates of fertilization, implantation, and clinical pregnancy that are comparable to those for embryos from fresh eggs. This is to say that uncertainties in cryopreservation still exist. Patients should ask their IVF providers for their own clinic-specific statistics—or lack thereof—for successful freeze-thaw outcomes and for live birth rates.

However, the data on long-term egg storage and on long-term offspring health is incomplete. That fact makes egg freezing much more of a nuanced consideration than just a transactional HR perk, like commuter benefits or 401k matching. Why are employers offering to pay for egg freezing in lieu of extended postpartum leaves with job guarantees?

The body is amazingly complex, and fertility is not something that can be extended perfectly. That conversation, of what egg freezing actually allows—as well as the limitations—is often not as pronounced as the perk itself.

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Fertility is not just a women’s issue

There are two primary factors at play when it comes to fertility: gender and class.

On gender, there is a cultural onus and blame placed on women, when in reality, and in the doctor’s office, men and women are equally considered and examined for infertility. Women are given basic pelvic exams and ultrasounds, and get blood drawn for various hormone levels, and men undergo semen analysis.

But the more rampant problem within infertility is the class framing. We consider infertility—the condition, and thus the treatment—to be an upper or upper-middle class issue, because fertility patients tend to be people who have the means to identify and try different methods to solve the problem. This industry is largely dependent on cash pay or insurance, and has astronomical costs associated with treatments, not to mention the host of a la carte treatment options. The process is incredibly limiting and leaves so many people out.

Beyond that, this kind of thinking perpetuates the idea of fertility treatment as a luxury service, like getting Botox or a facial. In reality, it’s a condition that afflicts people of all genders, from all kinds of socioeconomic and sexual backgrounds. And it afflicts more people than you’d think.

If we truly value families as a culture, as an economy, and as a nation with an aging population, it is in the collective best interest to create more access to fertility services, and to normalize treatment so it’s as common as a getting flu shot or a pap test.