Correspondence
The Infertile Couple
N Engl J Med 1994; 330:1154-1155April 21, 1994
- Article
To the Editor:
The title of the article by Jones and Toner, “The Infertile Couple” (Dec. 2 issue),1 is misleading: the paper focuses almost exclusively on the diagnosis and treatment of female subfertility. The authors imply that nothing can be done to treat male subfertility. They contend that “spermatogenesis cannot readily be altered for therapeutic benefit.” Evidence in urologic and andrologic literature does not support this assertion.
Male subfertility is a contributing, if not primary, factor in 50 percent of infertile couples2. Nearly half of men evaluated for subfertility will present with potentially reversible conditions,3 which include varicocele, excurrent ductal obstruction (epididymal, vasal, or ejaculatory), and endocrinopathy. Treatment of these conditions allows pregnancy in 40 percent,4 35 percent,5 and 70 percent6 of couples, respectively.
The cost of treating reversible causes of male infertility is less than the cost of advanced reproductive techniques such as in vitro fertilization, gamete intrafallopian transfer, and zygote intrafallopian transfer. Furthermore, treatment of reversible male-factor subfertility results in an enduring response: if treatment succeeds, subsequent pregnancies do not demand repeated interventions. Treatment of male-factor subfertility does not preclude the subsequent use of advanced reproductive techniques when the response to therapy is suboptimal.
6 ReferencesJay I. Sandlow, M.D.
James F. Donovan, M.D.
University of Iowa Hospitals and Clinics, Iowa City, IA 52242-10891
Jones HW Jr ,Toner JP . The infertile couple. N Engl J Med 1993;329:1710-1715
Full Text | Web of Science | Medline2
Sigman M, Lipshultz LI, Howards SS. Evaluation of the subfertile male. In: Lipshultz LI, Howards SS, eds. Infertility in the male. 2nd ed. St. Louis: Mosby-Year Book, 1991.
3
Dubin L ,Amelar RD . Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 1971;22:469-474
Web of Science | Medline4
Dubin L ,Amelar RD . Varicocelectomy: 986 cases in a twelve-year study. Urology 1977;10:446-449
CrossRef | Medline5
Fogdestam I ,Fall M ,Nilsson S . Microsurgical epididymovasostomy in the treatment of occlusive azoospermia. Fertil Steril 1986;46:925-929
Web of Science | Medline6
Finkel DM ,Phillips JL ,Snyder PJ . Stimulation of spermatogenesis by gonadotropins in men with hypogonadotropic hypogonadism. N Engl J Med 1985;313:651-655
Full Text | Web of Science | Medline
To the Editor:
The article by Jones and Toner on the infertile couple focuses on the treatment of women and emphasizes technical approaches, specifically techniques of assisted reproduction. References to men are limited to a mention of semen analysis and the processing of sperm.
Infertility is due to male factors in 20 percent of couples and a combination of male and female factors in at least 40 percent1. Numerous factors associated with male infertility are amenable to intervention -- causes such as gonadotoxins, infection of the male accessory glands, and varicocele. A large study of infertile couples supports the concept that varicocele is associated with impairment of fertility, decreased sperm quality, and decreased testicular volume2. Semen indexes have been reported to improve in up to 70 percent of infertile men treated by varicocelectomy, with pregnancy rates ranging from 40 to 50 percent3. However, the efficacy of varicocelectomy remains controversial, in part because of a lack of good randomized clinical trials. The same problem arises with techniques of assisted reproduction. . . .
3 ReferencesMichael G. Oefelein, M.D.
Earl Wendel, M.D.
Northwestern University School of Medicine, Chicago, IL 60611-30081
Mosher WD . Reproductive impairments in the United States, 1965-1982. Demography 1985;22:415-430
CrossRef | Web of Science | Medline2
World Health Organization
Web of Science | Medline3
Dubin L ,Amelar RD . Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 1971;22:469-474
Web of Science | Medline
To the Editor:
Any discussion of infertility is incomplete without a meaningful discussion of adoption. Derogatory references to adoption are a shortcoming of the otherwise excellent review by Jones and Toner: “the formation of families in which the members of the nuclear family have the same genetic lineage” seems an unnecessarily restrictive objective to impose on infertile couples.
Infertile couples receive most of their information about starting a family from doctors. Physicians are usually expected to inform patients of all options for treatment of any given condition, particularly options that have the highest success rate, cost less, require less time, and carry less risk. The adoption procedure is no different. Think of adoption in the same way as we do any medical procedure. According to Adoptive Families of America, the adoption procedure generally takes 18 to 24 months, with expenses generally ranging between $10,000 and $15,000 (Humerickhouse S, Adoptive Families of America: personal communication).
Adoption should be discussed at the same time as any new treatment for infertility, as part of a couple's making an informed decision. It is inappropriate to discuss adoption seriously for the first time after all medical interventions have failed. At this point, most couples are physically, emotionally, and financially depleted, and much time has been lost. The adoption process itself can be taxing. Such timing would be insensitive and would stigmatize adoption as second-rate.
Couples undergoing evaluation and treatment for infertility are capable of deciding for or against adoption. Factual information about adoption should be presented in a sensitive and nonjudgmental fashion, just as any other infertility-related procedure should. Physicians are privileged to assist in forming families, whether of the same genetic lineage or adoptive. Couples can and should decide for themselves.
Donald Clark, M.D.
Jemez Indian Health Service, Jemez Pueblo, NM 87024To the Editor:
The review article by Jones and Toner outlines an impressive array of techniques for assisting infertile adults to have children who are genetically related to them. The only mention of adoption is very brief and disparaging, since it is described as “unwelcome news” that physicians sometimes needed to convey, before more advanced techniques were developed. There is no mention of fertility specialists' recommending adoption to their patients. Given the overall success of adoption as a method of having children1 (including frequent instances when it is the first rather than a second choice), it is disturbing that the gynecological profession appears to offer little support to those who wish to adopt and may fail to suggest adoption early on as a viable alternative for those who are facing difficult choices.
Surely there are many people for whom a biologic connection with their children is supremely important. It is their right to pursue this goal as far as they wish. Physicians, however, should be aware that their own view of the importance of biologic parenting is not necessarily shared by all patients who present with fertility problems. Patients often take their lead from their physicians, and if doctors were more accepting of adoption, many patients might be grateful for a medically sanctioned choice between biologic and nonbiologic parenthood.
Approximately 2 percent of children in this country grow up in adoptive homes. Adoption should regularly be mentioned by gynecologists to their patients as an acceptable alternative to procreation -- an alternative that carries risks, as do some techniques of assisted reproduction, but that is also associated with the resolution of existing social problems.
1 ReferencesSteven L. Nickman, M.D.
Massachusetts General Hospital, Boston, MA 02114Author/Editor Response
The authors reply:
To the Editor: The nub of the comments of Sandlow and Donovan and of Oefelein and Wendel concerns the efficacy of varicocelectomy. There is, of course, a very large literature on this subject. Our position was reached after a complete review and coincides with the attitude expressed in an editorial in the Journal of Urology1: “Varicocelectomy remains a controversial issue. Many andrologists still question the role of varicocele and the efficacy of varicocelectomy as a treatment for male infertility.”
Since our own institute has been heavily involved in improving male fertility,2,3 it was disappointing to have to say that “spermatogenesis cannot readily be altered for therapeutic benefit.” Treatment short of altering spermatogenesis does help in selected cases. The use of follicle-stimulating hormone and in vitro fertilization are examples.
It is quite true that more attention could have been given to the alternative of adoption. Furthermore, attention could have been given to the alternative of childlessness. Patients and physicians can find a marvelous consideration of this alternative in Sweet Grapes, by Jean and Michael Carter (Indianapolis: Prospective Press, 1989).
3 ReferencesHoward W. Jones, Jr., M.D.
James P. Toner, M.D., Ph.D.
Eastern Virginia Medical School, Norfolk, VA 235071
Goldstein M . Surgical therapy of male infertility. J Urol 1993;149:1374-1376
Web of Science | Medline2
Acosta AA ,Khalifa E ,Oehninger S . Pure human follicle stimulating hormone has a role in the treatment of severe male infertility by assisted reproduction: Norfolk's total experience. Hum Reprod 1992;7:1067-1072
Web of Science | Medline3
Menkveld R, Swanson RJ, Oettle EE, Acosta AA, Kruger TF, Oehninger S. Atlas of human sperm morphology. Baltimore: Williams & Wilkins, 1991.
