The World Health Organisation, WHO (2019) defines infertility as “A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” Despite the research and information we have, infertility still remains a social and biological crisis as our world is becoming afflicted with childless civilisations hovering on the brick of collapse.
“To all outward appearances, Louise Brown looked exactly the same as thousands of other babies when her blinking, slightly quizzical gaze met newspaper readers on the morning of July 25, 1978. But as the first child born using the technique of in-vitro fertilisation (IVF), she was utterly unique in the history of humankind” (Loughran, May, 2018).
Exactly forty years later, the media is saturated with articles, journals, reports and interviews of common people and celebrities discussing their struggles with infertility. There is ongoing, global debates on infertility, its causes and its treatment in the modern world. By analysing recent debates, we will catch sight of contemporary perspectives and broaden our knowledge by getting familiar with recent statistics and data.
The situation in Malta
As reported by the Times of Malta (2018), the fertility rates in Malta dropped to the fourth lowest in all countries in the European Union, according to statistics published by the Eurostat. Malta lies level with Cyprus, with a fertility rate of 1.37 births per woman in 2016, while Spain and Italy lie behind with 1.34 births per woman.
“The statistics revealed that when it comes to the age at which women have their first child, the situation in Malta is at par with that in the EU, where the average was 29 years, compared to 29.1 years here.” Dr Michelle Wellman, a Fertility Specialist and Surgical Gynaecologist at Fertility SA says that although we do not know what is causing the decline in fertility, age, lifestyle and the environment certainly play a role.
Changing gender relations
According to the WHO, one in every four couples had been found to be affected by infertility in 2004. Repeated studies in 2010 showed relatively same findings. Global infertility prevalence remains difficult to determine because both male and female factors are present and this might complicate any estimate that might only address the woman and an outcome of pregnancy. In the past, women were ashamed if they were unable to become pregnant and they were regularly accused for childlessness.
Today, more people are aware that males incur reproductive problems too, yet, infertility still remains a social female burden. A robust meta-analysis of studies published in Human Reproduction Update (2017) shows that sperm counts have been in a free fall in Western countries over the last 10 years and in 2010, an estimated 48.5 million couples worldwide were infertile. We don’t know how many people suffered from infertility in past generations because the numbers were never set down in black and white. In spite of that, there are fears that rates are now rising.
Environment versus fertility
Some say that this sudden rise is due to environmental factors and chemical substances produced by expanding industries. NICHD's Longitudinal Investigation of Fertility and the Environment (LIFE) Study is examining whether exposure to persistent organic pollutants affects the length of time it takes for couples to become pregnant, a measure of fecundity.
It is the only study to measure chemicals in both partners and to follow couples trying to become pregnant for one year. Till now, the study found out that some kinds of organochlorine pesticides and many polychlorinated biphenyls (PCBs) were associated with increased time to become pregnant or decreased couple fecundity (Buck Louis, G. M., Barr, D. B., Kannan, K., Chen, et al., 2016).
The same study also found that many chemicals only affected time-to-pregnancy when found in high levels in the male, whereas other chemicals only affected fecundity when detected in the female. “EDCs [endocrine-disrupting chemicals] alter the function of the hormonal system, a key component in fertility.” The LIFE study shows that while phthalates and the UV filter benzophenone-2 affect fertility in men, the EDC methyl paraben affects female fertility (Buck Louis, G. M., Sundaram, R., Sweeney, A. M., Schisterman, et al., 2014).
The LIFE study aims to find chemicals that disrupt the endocrine system. Unregulated positive feedback systems, in both males and females, produce a disequilibrium which causes a hormonal imbalance. The latter predisposes the individual to possible infertility. The hypothalamus receives and acts upon various signals corresponding to the reproductive organs. Signals are only possible if the endocrine system is working as it should be. Some say that the endocrine system, a collection of glands controlling functions of cells, tissues and organs through the secretions of hormones (The American Heritage Science Dictionary, 2011), is the basis of fertility.
Changing family structure and infertility
While considering environmental factors as major contributors to the rise in fertility problems, we simply cannot ignore the impact of the sudden, sweeping change in family structure and lifestyle. Very recently, there has been a lot of debates about late parenthood. Some scientists state that the problem is not arising from medical issues, but rather from the demographic perspective of childbearing. There exists a biological clock and in this day and age it is taken for granted because of the technologies available. While the age at which people are having children is increasing, the biology of conception hasn’t changed, and the chances of conception for decrease quickly with age.
“The problem is particularly urgent in the west, where couples are having families much later in life. In 2014, 52% of all live births in the UK were to mothers aged 30 and over (67% of fathers fell into this age group)…At the same time, more and more men now have sperm counts low enough to impair their fertility” (Robin McKie, 2017).
Single person and single parent households are increasing. Same sex cohabitee has become popular and accepted in many places. Extended families are decreasing even in poorly developed countries such as Kenya, Nigeria and Zamiba. Polygyny rates are decreasing while women’s age at their first marriage is increasing. It is with no doubt that women are most of the time choosing their careers over motherhood. Because education is being offered to teenage girls all over the world, women are making more responsible choices and less selfish choices. As a nation, we are finally speaking openly about birth control and family planning measures and this might be one of the reasons why statistics show a decrease in the quota of children per couple all over the world. There might be a relationship between empowered women, access to education and the decrease in fertility.
As the world keeps on developing, women of childbearing age are choosing to focus on their dreams and aspirations while they keep other matters, such as childbearing, at the back of their minds. Many reports have shown the costs of leaving it later. Fertility debates often argue on how late is too late. Some believe that non-coital, birth control methods such as the Pill, are the main cause for infertility. In fact, Sinclair (2017), writes in the Vogue, “There’s no doubt that we are the generation who reaped the benefits of the Pill, equality and feminism to go on to have the kind of full, independent lives our mothers didn’t. Careers do play a role, but are rarely at the heart of the reasons to delay motherhood.”
The postponement of first births has implications on the ability of women to conceive and parents to produce additional offspring. Massive postponement is attributed to the clash between the optimal biological period for women to have children with obtaining additional education and building a career.
Ongoing reproductive problems linked to obesity
As claimed by the WHO, “Overweight and obesity are…abnormal or excessive fat accumulation that presents a risk to health. A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.” Overweight and obesity are major risk factors for a number of chronic diseases, including infertility.
As we are becoming more health conscious as a nation, a lot of debates have concluded and proved that there is a direct link between obesity and infertility. It has been shown that an obese person has greater chances for hormonal changes and imbalances. As we have discussed earlier on, hormonal imbalances bring about reproductive problems since hormones control signals, in both males and females. Moreover, obesity leads to insulin resistance. Apart from preparing a smooth road for diabetes, this resistance can lead to anovulatory cycles. The excess insulin can sometimes cause a sudden surge of testosterone as the body strives to right itself and this completely halts ovulation.
Obesity makes it more challenging to become pregnant, whether you’re trying by natural or artificial means such as IVF. In fact, couples are encouraged to lose weight before going for an IVF procedure because the odds are higher when the couples BMI is over 30.
For men, obesity may cause a drop in testosterone which may in turn lead to erectile dysfunction. In fact, a new debate was published in December, 2017 and it talks about whether weight-loss programmes in infertility clinics should be offered to couples instead of women only. They argue that “Couples tend to have similar body mass indices, and weight change in one partner can go hand in hand with weight change in the other. A systematic review (Di Castelnuovo et al., 2009) found correlations between partners with regards to BMI (r = 0.15 across 34 582 couples in 19 studies) and weight (r = 0.11 across 6765 couples in 9 studies)” (Best, Avenell, Bhattacharya, Stadler, 2017).
This debate discussed the ever growing problem of obesity in both men and women attending infertility clinics. “Accumulating evidence demonstrates the effects of weight on reproductive function, and the benefits of weight loss in both sexes. Individual interventions for weight loss in women are often unsuccessful—mainly due to lack of compliance. A couple-based intervention may achieve more efficient weight loss at little additional cost and promises considerable public health benefits.”
The ongoing debate of Artificial Reproductive Technologies (ART) in respect to infertility – ethical, social and legal aspects
Millions of infertile couples all over the world have been treated successfully with ART. Nonetheless, the quick spread of this technology has introduced a myriad of new social, ethical, and legal challenges. As we discussed in the beginning, infertility used to be a stigma in the past. At the present moment, infertility is known and considered as a medical condition. This openness offered a second chance to helpless couples and ever since ART has been existing, infertility belonged to both partners and not solely to the woman.
While giving hope to many couples, ART will still remain a controversial subject that is viewed differently by various people. While ART is a step forward, it is still unavailable in some countries and still very expensive in other places. This means that ART is not exclusively aiding in reducing infertility problems. Couples need to wait to be able to pay the expenses and hence the rates of failure of ART keep on increasing as the couples keep on aging.
Should governments fund assisted reproductive techniques? This debate is evolving but never comes to a halt and agreements are never reached especially in highly religious countries, where religion is a powerful institution. Moreover, further work needs to be done to establish the reliability and validity of certain techniques. There are still ongoing debates all over the world, discussing the issues of womb transplants, embryo freezing and also surrogacy which are other ART techniques and so certain statistics are still unavailable.
To recap everything that has been discussed above, infertility is still a relatively new subject and since ART has been available, debates in favour and against these evolving technologies have been going non-stop. New data provides means to end and statistics show what might be increasing infertility rates globally. Although fertility rates are decreasing, options available for infertile couples are increasing.
As argued, advancements might be the main cause for infertility. Nonetheless, we cannot be quite sure of that since we don’t have accurate statistics of the past. Infertility is a subject undergoing intense studies and one debate might prove the other one wrong in a couple of days. The latter is acceptable because the human body involves biological processes on which data is emerging all the time. Up to date statistics are expected, now more than ever. Fertility businesses are blooming and so investors are ploughing huge amounts of money as they seek to find new information that has not been published to the world, as yet.
Neonatal outcomes and maternal health are adversely affected following the time of infertility as well as assisted reproduction, but it is unclear whether the fertility treatments themselves or underlying factors contributing to infertility, such as maternal age, are responsible. The psychological effects of fertility treatment vary for individuals. As healthcare professionals, midwives should remain aware of the continuing developments in the field of assisted reproduction. New techniques such as pre-pregnancy screening and the ethical dilemmas around infertility and embryo research raise social and legal issues which are likely to affect our future midwifery practice.