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The treatment of infertility poses many controversial issues, ranging from religious
objections to questions of fraudulent inducement by unscrupulous fertility clinics that
misrepresent their actual success rate. Infertility treatment has become a big business
as the number of couples defined as infertile has increased. Some of this increase is
related to the increased age at which many women attempt to conceive their first child.
This delay shortens the period available to have children. Women who might have
conceived by age 35 if they had begun trying to have children at age 20 are out of time
if they start trying to conceive at age 35. Modern birth control methods allow women
to be sexually active without becoming pregnant. This increases the probability that the
woman will suffer complications of a sexually transmitted disease (STD) that will
impair her fertility. Perhaps the greatest increase in infertile couples has come from a
more liberal definition of infertility.
Current statistics indicate that more than 14% of couples who desire a child are unable
to conceive within a year. [ACOG Technical Bulletin 120. Medical Induction of
Ovulation. September 1988.] It is recommended that fertility treatment not be started
(in the absence of a specific problem) until the couple have tried to conceive without
using birth control for one year. [ACOG Technical Bulletin 142. Male Infertility. June
1990.] This is considered a conservative time period and was recommended because
some fertility clinics were beginning treatment only a few months after a couple had
begun to try to conceive. In earlier periods, however, a couple would not see
themselves as having a medical problem until they had tried to conceive for several
years. It is impossible to know how many of the 14% who did not conceive in a year
would eventually conceive without intervention. Thus, it is impossible to determine
what component of the infertility epidemic represents changed expectations and the
ready availability of fertility services for those able to pay for them.
1. Patient Privacy
When genetic counseling a pregnant or potentially pregnant woman, the physician
should include her husband or other family members only at her request. Violating
the patient’s privacy can have devastating results. Legal and social paternity do not
necessarily imply biologic paternity. Although it would be proper to discuss these
matters with the patient, this type of information should not be disclosed to others.
If the patient is a child, the situation is somewhat different. A father and mother who
are married to each other have equal authority over their children. If the legal father
does not question his biologic paternity, there is usually no problem. If a father asks
whether he is the child’s biological father, a physician should be cautious. Both
mutation and test variability can confound any genetic test of paternity. It is better to
address the question of whether the child has a genetic disease than whether the
disease came from the man asking the question.
2. Fitness
Although treating infertility is undoubtedly a medical benefit in many cases, there are
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