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
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Abstract |
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Key words: infertility/infertility investigation/infertility treatment/prognosis/terminology
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Introduction |
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Background |
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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.
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The terminology problem |
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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) 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 womenend 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.
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Relevant aspects of reproduction |
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A proposal |
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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) 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.
Comment
Before elaborating my counter proposal, I submit that much of the confusing terminology quoted by Habbema et al. (2004) 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.
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Counter proposal |
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References |
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Submitted on August 13, 2004; accepted on October 22, 2004.
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