Towards less confusing terminology in reproductive medicine

A counter proposal

Roy Homburg

Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Vrije Universiteit Medisch Centrum, Amsterdam, The Netherlands

Corresponding address: Reproductive Medicine, Department of Obstetrics and Gynaecology, Vrije Universiteit Medisch Centrum, De Boelelaan 1117, postbus 7057, 1007 MB Amsterdam, The Netherlands. Email: r.homburg{at}vumc.nl


    Abstract
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
Less confusing terminology in reproductive medicine was the goal of a recent proposal the basis of which was to drop the term ‘infertility’ and replace it with a description. It also contained a prognostic grading system. The present article, arguing against most of these proposals, should not be regarded as nihilism but as constructive criticism to attain more clarity and common understanding. A counter proposal is suggested and includes retention of the term ‘infertility’, disposal of the terms ‘subfertility’ and ‘sterility’ with practical suggestions of when difficulties in conceiving should be investigated and treated.

Key words: infertility/infertility investigation/infertility treatment/prognosis/terminology


    Introduction
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
Reproductive medicine has progressed immensely in the last 40 years. These rapid advances have often outstripped and left in their wake some basic concepts which need to catch up with this progress. The debate article proposing less confusing terminology (Habbema et al., 2004Go) was therefore a timely and welcome attempt to achieve just this. It seems petty, therefore, to argue with many of the points raised by such an eminent collection of international authors who have contributed so much to the field, but argue I will. I hope this will be regarded not as nihilism but as constructive rather than destructive criticism. I have attempted to take a very practical standpoint on the various issues which I will deal with using the same headings as in the original article.


    Background
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
Two main problems are presented here: (i) that the term ‘ínfertility’ is being used in too wide a sense and is being used synonymously with and to also include sterility and (nearly) normal fertility; (ii) that the so-called basic nomenclature issues are causing problems to health care providers, insurance companies and governments.

The first point concerns the definition of ‘infertility’, its common use, dictionary and popular definitions and connotations. I will argue, in the next section, that the use of the term ‘subfertility’ can safely be discarded without loss to clarity or understanding. Similarly, in this day and age, when a vast majority of infertility problems can be solved, the term ‘sterility’, together with its negative connotations, can also be discarded. The use by the authors of the term ‘(nearly) normal fertility’ is unfortunate as they also seem to have fallen into the very trap that they are arguing against, i.e. confusing terminology. The expression ‘nearly normal fertility’ has some parallels to ‘a little bit pregnant’.

Further, I will propose, in contrast to the ideas in the orginal debate article, that the term ‘infertility’ is maintained. This, I believe, will lessen rather than increase confusion and is a better alternative than the descriptive statement of a condition with no name, as suggested in the original debate article. This leaves us with the problem of how long does it take for an involuntary failure to conceive to become ‘infertility’. This is where the descriptive statement should come into play, as in the description of any other medical condition. I can see no problem with, say, a case presentation which starts with the sentence: ‘this couple have been suffering from primary infertility for the past 18 months’. Will any practitioner in the field fail to understand this simple statement?

I dismiss, out of hand, the second statement in the ‘Background’ section that an outstanding problem connected with the basic nomenclature issue is the lack of agreement with health care providers on whether involuntary failure to conceive is a health care problem, deserving insured coverage. In my opinion, this has nothing whatsoever to do with nomenclature but with politics and finance. In many countries, infertility treatment, expensive as it is, has proved a soft target for tight-fisted insurance companies and governments who do not regard infertility as a medical problem. None of them will be convinced by changing the present nomenclature.


    The terminology problem
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
A. Reproductive medicine
A.1. Here it was stated that ‘infertility’ has different meanings giving rise to misinterpretation, errors in communication and confusion. It is true that in common language, infertile and fertile are antonyms and maybe ‘dysfertile’ would be better than ‘infertile’, but hopefully practitoners in the field will continue to use their own common language in which the term ‘infertility’ has long been understood to mean a problem in conceiving. An attempt to reverse this situation would cause many more misconceptions (excuse the pun) than it would clear the air, as would changing the meaning of other commonly accepted terminology. Without wishing to sound condescending, I am less concerned about how the general public interprets ‘infertility’. I do not agree that most will see this as ‘impossible to conceive’, but as a problem or difficulties in conceiving. In addition, the word infertility is not commonly heard or used by patients. When interviewing the couple, in any language, the question is more likely to be ‘how long have you been trying to get pregnant?’ Rather than ‘how long have you been infertile?’

A.2. This section deals with the term ‘unexplained infertility’ and states that the term is used, ‘indicating the existence of an as yet unknown biological mechanism implying that in other categories the cause of the infertility is explained’. The examples given are the terms tubal infertility and male infertility, suggesting that the infertility is caused by tubal disease and a sperm disorder, respectively. The objection here is that ‘these apparent abnormalities may well co-exist with unknown biological mechanisms that are more influential than the apparent defect’. I completely failed here, in my ignorance, to grasp the point that was being made. If we have failed to identify the co-existing biological mechanisms which may be involved in the cause of the failure to conceive, then what are we to call it? Of course there may be very influential co-existing factors with tubal or sperm disorders, but if they are unknown, and probably undetectable, ‘biological mechanisms’, what are we supposed to do about that? Ignore the tubal or sperm disorders? Or simply change the nomenclature to a failure to conceive due to mainly unknown and undetectable biological mechanisms?

A.3. This section deals with the descriptive use of infertility to indicate the length of delay in conception after starting regular unprotected intercourse. For clinical purposes, the gold standard has become 1 year, although epidemiologists and the World Health Organization (WHO) will often use 2 years. As long as the infertility is qualified by stating the duration, I do not think this difference is as misleading as the authors seem to think. As for their statement that the clinically meaningful range is from 6 months to 5 years rather than theoretical non-conception which can vary from 1 month to >35 years, the term infertility is well and widely understood and accepted to mean difficulties in conceiving rather than pure non-conception. Again the argument only centres on what duration of time of unprotected intercourse constitutes infertility, not on the understanding of the word itself. This is also true for the last statement of this section regarding the connotation of infertility as ‘impossible to conceive’ and that many clinicians assume ‘that after 1 year of infertility the probability of conception is close to zero, which would justify immediate treatment’. Immediate treatment maybe not, but a basic interview, inquiry and maybe some basic examinations, yes!

A.4. The term ‘infertility’ can safely be substituted for ‘subfertility’ which has no meaning over and above or separate from ‘infertility’.

A.5. According to the strict definition of disease in Dorland's Medical Dictionary 1988: 481, infertility is not a disease as it is not ‘manifested by a characteristic set of symptoms or signs............’ However, for it not to be recognized as a medical problem which may sometimes require treatment, is bordering on the ridiculous. I accept that government and private health planners will take every opportunity to border on the ridiculous but, unfortunately, it is not confusing nomenclature that drives them to this. The suggestion that the unwanted non-conception should be considered as the symptom for which the couple seek health care ‘as in ...back pain, fever or sleeplessness’ is a good one. The comment, however, that ‘non-conception, contrary to other conditions is a negative complaint in that the absence of something (i.e. pregnancy) bothers the patient’, is strange. A few lines above that, ‘sleeplessness’ is quoted as a comparable condition, also a ‘negative’ complaint in that the absence of something (i.e. sleep) bothers the patient.

B. Demography and reproductive medicine
Demographers have totally misused the term infertility. In their ‘book’, infertility has come to mean no birth over a certain period of time, whether the couple wanted children or used birth control! This stems from the fact that their data are mostly collected from birth registers. Habbema et al. (2004)Go propose that infertility in the demographic sense should always be qualified by time. This does not, however, correct the demographers' mistake of lumping together voluntary and involuntary childlessness. If they could be entreated to use the term ‘birth rate’ rather than ‘fertility rate’, this would surely solve the problem. ‘Birth rate’ would have no implications on further fertility or medical conditions and would simply express the number of babies born to a certain number of women—end of confusion.

I am in complete agreement with the authors' definition of fecundity and fecundability in reproductive medicine. Obviously, some work will be needed to have these accepted by widely accessible references such as medical dictionaries.


    Relevant aspects of reproduction
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
I do not agree with Habbema et al. (2004)Go that the definition of infertility should incorporate the likelihood of conception with or without treatment. If a couple has failed to conceive within, say, 1 year, then the need for therapeutic intervention can be weighed up. In the same way, a skin rash is a skin rash whether or not you decide that it deserves treating.


    A proposal
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
1. Descriptive statement
The authors are simply substituting the unwieldly Americanized term ‘non-pregnancy experience’ for what every practising physician understands as infertility. Of course a descriptive statement regarding the age of the woman and whether this couple ever had a pregnancy before (secondary) or not (primary) is important useful information which can always be added. However, it must be added to something, and ‘infertility’ is by far the most acceptable, widely used and understood expression. Why not call a spade a spade rather than ducking the issue by not calling it anything or referring to it as an implement which may or may not be used for shovelling soil, sand or other material from one location to another or for digging a hole (but not half a hole) in the ground?

2. Diagnostic statement
A diagnostic statement made following the diagnostic work-up is of course widely practised in the way suggested by the authors of this proposal. However, using the world ‘infertility’ as a prefix to the description is avoided and ‘non-conception’ is substituted. What advantage does this confer?

3. Prognostic statement
After diagnostic work-up, decisions have to be taken with regard to further action. In order to do this, Habbema et al. (2004)Go propose a grading system: grade 0, (almost) normal fertility; grade 1, slightly reduced fertility; grade 2, moderately reduced fertility; grade 3, seriously reduced fertility; and grade 4, sterility.

I have several comments to make regarding this proposal.

  1. As somebody once said: ‘a scoring system is a system in which meaningful clinical data are translated into a meaningless number’. The wording is, again, unfortunate. Even taking into account that we are dealing with a prognostic statement, the use of the terms ‘(almost) normal fertility and ‘almost fertile’ suggests that there is (almost) no problem. However, a problem has been encountered; this particular couple have failed to conceive in X months. As for the definition of grade 4, it was earlier agreed not to use the word ‘sterility’.
  2. Reliance on the prognostic models quoted and on the results of the large upcoming definitive OFO study being performed in The Netherlands seems a reliable way of deciding whether to intervene or not. These will obviously be of great help in predicting the chances of pregnancy with non-intervention. Preceding this, however, is the decision of whether and when to investigate. A brief history and examination can probably settle this point. An obvious history of severe oligo- or anovulation, pelvic inflammation or operational intervention in the female pelvis, operations on the testes, sexual dysfunction or even advancing female age would prompt me to, at least, investigate after even a mere 6 months of attempted conception.
  3. The cases presented as examples of descriptive, diagnostic and prognostic statements are, I fear, going to be more misleading than helpful. For example, case 1 is (descriptive) 36 months of primary non-conception, (diagnostic) bilateral tubal obstruction and (prognostic) grade 4 (i.e. ‘sterility’, if you have already forgotten what the number 4 stands for) and refers only to the prognosis of achieving an unaided spontaneous pregnancy, in this case close to nil and therefore urging intervention. The real prognosis, of interest to the physician and patients, is the chance of pregnancy following intervention, in this case IVF. Classifying this case, especially if she is relatively young, in the worst possible prognostic classification, is going to be very misleading and confusing.

Comment
Before elaborating my counter proposal, I submit that much of the confusing terminology quoted by Habbema et al. (2004)Go is mere semantics. Here we should differentiate between absolute dictionary-defined meanings of terms we use, often from Latin or Greek origins, and between the everyday understanding of the term, e.g. infertility, by practising physicians, researchers and others working in the field. In my opinion, changing or eliminating the latter will not improve, but will confuse the situation. Disposing of synonyms, mostly in non-medical language, will obviously be helpful.

To carry my point to an absurd extreme, I will employ two phrases used in the original debate article. (i) a WHO report quoted uses the expression ‘exposure to pregnancy’. This does not mean taking the unfortunate patient by the hand to meet pregnant women. It is commonly accepted by workers in the field to mean sexual intercourse without the use of contraceptive measures. (ii) Similarly,‘unprotected intercourse’ does not mean the absence of a guard at the bedroom door.


    Counter proposal
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
The authors of the original proposal very rightly suggest that terminology in medicine should be lucid, understandable, consistent and unambiguous. I would therefore like to propose the following:

  1. The use of the term ‘infertility’, meaning difficulties to conceive, should be maintained.
  2. Infertility as an entity can be descriptively qualified by, e.g. primary or secondary, duration of trying for a pregnancy, etc., and, following the diagnostic tests, by the type(s) of probably causal disturbance(s) found.
  3. The terms ‘subfertility’ and ‘sterility’ should be abandoned.
  4. The decision of whether and when to investigate can be taken on the strength of the history and examination and cannot necessarily be measured in time, e.g. there is still little point in waiting a full year with a history of amenorrhoea, total impotence, previous male or female sterilization, etc. If no fertility-disturbing factor is obvious from the history and physical examination, investigations can be commenced after 12 months of attempted conception.
  5. The decision of whether and when to institute treatment can also be taken on the strength of the history and results of diagnostic tests, using evidence from prognostic models (and good common sense). If these all reveal a good prognosis for a natural conception, then no intervention may be needed for the following 12 months. If not (e.g. less than an estimated 20% chance of natural conception in that time), then the treatment indicated by the type(s) of causes of the infertility discovered should be initiated.
  6. An effort will need to be made to ensure that the meaning and use of the word ‘infertility’ is uniform and that almost universally understood by workers in the field, i.e. difficulty in conceiving. The WHO and publishers of dictionaries should be approached to adopt this meaning and to expunge the terms ‘subfertility and sterility’ from their lexicon.


    References
 Top
 Abstract
 Introduction
 Background
 The terminology problem
 Relevant aspects of reproduction
 A proposal
 Counter proposal
 References
 
Habbema JDF, Collins J, Leridon H, Evers JLH, Lunenfeld B and te Velde ER (2004) Towards less confusing terminology in reproductive medicine: a proposal. Hum Reprod 19, 1497–1501.[Abstract/Free Full Text]

Submitted on August 13, 2004; accepted on October 22, 2004.





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