Female infertility

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Female infertility
Classification and external resources
ICD-10 N97.0
ICD-9 628
DiseasesDB 4786
MedlinePlus 001191
eMedicine med/3535
MeSH D007247

Female infertility refers to infertility in female humans.

Contents

Definition [edit]

There is no unanimous definition of female infertility, but NICE guidelines state that: "A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner."[1] It is recommended that a consultation with a fertility specialist should be made earlier if the woman is aged 36 years or over, or there is a known clinical cause of infertility or a history of predisposing factors for infertility.[1]

Causes and factors [edit]

Causes or factors of female infertility can basically be classified regarding whether they are acquired or genetic, or strictly by location.

Acquired versus genetic [edit]

Although causes (or factors) of female infertility can be classified as acquired versus genetic, female infertility is usually more or less a combination of nature and nurture. Also, the presence of any single risk factor of female infertility (such as smoking, mentioned further below) does not necessarily cause infertility, and even if a woman is definitely infertile then the infertility cannot definitely be blamed on any single risk factor even if the risk factor is (or has been) present.

Acquired [edit]

According to the American Society for Reproductive Medicine (ASRM), Age, Smoking, Sexually Transmitted Infections, and Being Overweight or Underweight can all affect fertility.[2]

In broad sense, acquired factors practically include any factor that is not based on a genetic mutation, including any intrauterine exposure to toxins during fetal development, which may present as infertility many years later as an adult.

Age [edit]
Main article: Age and female fertility

A woman's fertility is affected by her age. The average age of a girl's first period (menarche) is 12-13 (12.5 years in the United States,[3] 12.72 in Canada,[4] 12.9 in the UK[5]), but, in postmenarchal girls, about 80% of the cycles are anovulatory in the first year after menarche, 50% in the third and 10% in the sixth year.[6] A woman's fertility peaks in the early and mid twenties, after which it starts to decline, with this decline being accelerated after age 35. However, the exact estimates of the chances of a woman to conceive after a certain age are not clear, with research giving differing results. The chances of a couple to successfully conceive at an advanced age depend on many factors, including the general health of a woman and the fertility of the male partner.

Tobacco smoking [edit]
See also: Women and smoking#Unique gender differences and health effects for Females

Tobacco smoking is harmful to the ovaries, and the degree of damage is dependent upon the amount and length of time a woman smokes or is exposed to a smoke-filled environment. Nicotine and other harmful chemicals in cigarettes interfere with the body’s ability to create estrogen, a hormone that regulates folliculogenesis and ovulation. Also, cigarette smoking interferes with folliculogenesis, embryo transport, endometrial receptivity, endometrial angiogenesis, uterine blood flow and the uterine myometrium.[7] Some damage is irreversible, but stopping smoking can prevent further damage.[8][9] Smokers are 60% more likely to be infertile than non-smokers.[10] Smoking reduces the chances of IVF producing a live birth by 34% and increases the risk of an IVF pregnancy miscarrying by 30%.[10] Also, female smokers have an earlier onset of menopause by approximately 1–4 years.[11]

Sexually transmitted disease [edit]

Sexually transmitted diseases are a leading cause of infertility. They often display few, if any visible symptoms, with the risk of failing to seek proper treatment in time to prevent decreased fertility.[8]

Body weight and eating disorders [edit]

Twelve percent of all infertility cases are a result of a woman either being underweight or overweight. Fat cells produce estrogen,[12] in addition to the primary sex organs. Too much body fat causes production of too much estrogen and the body begins to react as if it is on birth control, limiting the odds of getting pregnant.[8] Too little body fat causes insufficient production of estrogen and disruption of the menstrual cycle.[8] Both under and overweight women have irregular cycles in which ovulation does not occur or is inadequate.[8] Proper nutrition in early life is also a major factor for later fertility.[13]

A study in the US indicated that approximately 20% of infertile women had a past or current eating disorder, which is five times higher than the general lifetime prevalence rate.[14]

A review from 2010 concluded that overweight and obese subfertile women have a reduced probability of successful fertility treatment and their pregnancies are associated with more complications and higher costs. In hypothetical groups of 1000 women undergoing fertility care, the study counted approximately 800 live births for normal weight and 690 live births for overweight and obese anovulatory women. For ovulatory women, the study counted approximately 700 live births for normal weight, 550 live births for overweight and 530 live births for obese women. The increase in cost per live birth in anovulatory overweight and obese women were, respectively, 54 and 100% higher than their normal weight counterparts, for ovulatory women they were 44 and 70% higher, respectively.[15]

Chemotherapy [edit]

Chemotherapy poses a high risk of infertility.

Chemotherapies with high risk of infertility include procarbazine and other alkylating drugs such as cyclophosphamide, ifosfamide, busulfan, melphalan, chlorambucil and chlormethine.[16] Drugs with medium risk include doxorubicin and platinum analogs such as cisplatin and carboplatin.[16] On the other hand, therapies with low risk of gonadotoxicity include plant derivatives such as vincristine and vinblastine, antibiotics such as bleomycin and dactinomycin and antimetabolites such as methotrexate, mercaptopurine and 5-fluorouracil.[16]

Female infertility by chemotherapy appears to be secondary to premature ovarian failure by loss of primordial follicles.[17] This loss is not necessarily a direct effect of the chemotherapeutic agents, but could be due to an increased rate of growth initiation to replace damaged developing follicles.[17] Antral follicle count decreases after three series of chemotherapy, whereas follicle stimulating hormone (FSH) reaches menopausal levels after four series.[18] Other hormonal changes in chemotherapy include decrease in inhibin B and anti-Müllerian hormone levels.[18]

Patients may choose between several methods of fertility preservation prior to chemotherapy, including cryopreservation of ovarian tissue, oocytes or embryos.[19]

Other factors that can cause acquired infertility [edit]

Genetic factors [edit]

There are many genes wherein mutation causes female infertility, as shown in table below. Also, there are additional conditions involving female infertility which are believed to be genetic but where no single gene has been found to be responsible, notably Mayer-Rokitansky-Küstner-Hauser Syndrome (MRKH).[26] Finally, an unknown number of genetic mutations cause a state of subfertility, which in addition to other factors such as environmental ones may manifest as frank infertility.

Chromosomal abnormalities causing female infertility include Turner syndrome.

Some of these gene or chromosome abnormalities cause intersexed conditions, such as androgen insensitivity syndrome

Genes wherein mutation causes female infertility[27]
Gene Encoded protein Effect of deficiency
BMP15 Bone morphogenetic protein 15 Hypergonadotrophic ovarian failure (POF4)
BMPR1B Bone morphogenetic protein receptor 1B Ovarian dysfunction, hypergonadotrophic hypogonadism and acromesomelic chondrodysplasia
CBX2; M33 Chromobox protein homolog 2 ; Drosophila polycomb class

Autosomal 46,XY, male-to-female sex reversal (phenotypically perfect females)
CHD7 Chromodomain-helicase-DNA-binding protein 7 CHARGE syndrome and Kallmann syndrome (KAL5)
DIAPH2 Diaphanous homolog 2 Hypergonadotrophic, premature ovarian failure (POF2A)
FGF8 Fibroblast growth factor 8 Normosmic hypogonadotrophic hypogonadism and Kallmann syndrome (KAL6)
FGFR1 Fibroblast growth factor receptor 1 Kallmann syndrome (KAL2)
FSHR FSH receptor Hypergonadotrophic hypogonadism and ovarian hyperstimulation syndrome
FSHB Follitropin subunit beta Deficiency of follicle-stimulating hormone, primary amenorrhoea and infertility
FOXL2 Forkhead box L2 Isolated premature ovarian failure (POF3) associated with BPES type I; FOXL2

402C --> G mutations associated with human granulosa cell tumours
FMR1 Fragile X mental retardation Premature ovarian failure (POF1) associated with premutations
GNRH1 Gonadotropin releasing hormone Normosmic hypogonadotrophic hypogonadism
GNRHR GnRH receptor Hypogonadotrophic hypogonadism
KAL1 Kallmann syndrome Hypogonadotrophic hypogonadism and insomnia, X-linked Kallmann syndrome (KAL1)
KISS1R ; GPR54 KISS1 receptor Hypogonadotrophic hypogonadism
LHB Luteinizing hormone beta polypeptide
LHCGR LH/choriogonadotrophin receptor Hypergonadotrophic hypogonadism (luteinizing hormone resistance)
DAX1 Dosage-sensitive sex reversal, adrenal hypoplasia critical region, on chromosome X, gene 1 X-linked congenital adrenal hypoplasia with hypogonadotrophic hypogonadism; dosage-sensitive male-to-female sex reversal
NR5A1; SF1 Steroidogenic factor 1 46,XY male-to-female sex reversal and streak gonads and congenital lipoid adrenal hyperplasia; 46,XX gonadal dysgenesis and 46,XX primary ovarian insufficiency
POF1B Premature ovarian failure 1B Hypergonadotrophic, primary amenorrhea (POF2B)
PROK2 Prokineticin Normosmic hypogonadotrophic hypogonadism and Kallmann syndrome (KAL4)
PROKR2 Prokineticin receptor 2 Kallmann syndrome (KAL3)
RSPO1 R-spondin family, member 1 46,XX, female-to-male sex reversal (individuals contain testes)
SRY Sex-determining region Y Mutations lead to 46,XY females; translocations lead to 46,XX males
SOX9 SRY-related HMB-box gene 9 Autosomal 46,XY male-to-female sex reversal (campomelic dysplasia)
TAC3 Tachykinin 3 Normosmic hypogonadotrophic hypogonadism
TACR3 Tachykinin receptor 3 Normosmic hypogonadotrophic hypogonadism

By anatomic location [edit]

Hypothalamic-pituitary factors [edit]

Ovarian factors [edit]

  • Anovulation. Female infertility caused by anovulation is called "anovulatory infertility", as opposed to "ovulatory infertility" in which ovulation is present.[29]
  • Luteal dysfunction[30]

Tubal (ectopic)/peritoneal factors [edit]

  • Endometriosis[31] Endometriosis can lead to anatomical distortions and adhesions (the fibrous bands that form between tissues and organs following recovery from an injury). However, the link between infertility and endometriosis remains enigmatic when the extent of endometriosis is limited.[32] It has been suggested that endometriotic lesions release factors which are detrimental to gametes or embryos, or, alternatively, endometriosis may more likely develop in women who fail to conceive for other reasons and thus be a secondary phenomenon; for this reason it is preferable to speak of endometriosis-associated infertility[33] in such cases.
  • Tubal dysfunction

Uterine factors [edit]

Cervical factors [edit]

Vaginal factors [edit]

Diagnosis [edit]

Diagnosis of infertility begins with a medical history and physical exam. The healthcare provider may order tests, including the following:

  • Examination and imaging
    • an endometrial biopsy, to verify ovulation and inspect the lining of the uterus
    • laparoscopy, which allows the provider to inspect the pelvic organs
    • fertiloscopy, a relatively new surgical technique used for early diagnosis (and immediate treatment)
    • Pap smear, to check for signs of infection
    • pelvic exam, to look for abnormalities or infection
    • a postcoital test, which is done soon after intercourse to check for problems with sperm surviving in cervical mucous (not commonly used now because of test unreliability)
    • special X-ray tests

There are genetic testing techniques under development to detect any mutation in genes associated with female infertility.[27]

Diagnosis and treatment of infertility should be made by physicians who are fellowship trained as reproductive endocrinologists. Reproductive Endocrinologists are usually Obstetrician-Gynecologists with advanced training in Reproductive Endocrinology & Infertility (in North America). These highly educated professionals and qualified physicians treat Reproductive Disorders affecting not only women but also men, children, and teens.

Prospective patients should note that reproductive endocrinology & infertility medical practices do not see women for general maternity care. The practice is primarily focused on helping their patients to conceive and to correct any issues related to recurring pregnancy loss.

Prevention [edit]

Some cases of female infertility may be prevented through identified interventions:

  • Maintaining a healthy lifestyle. Excessive exercise, consumption of caffeine and alcohol, and smoking are all associated with decreased fertility. Eating a well-balanced, nutritious diet, with plenty of fresh fruits and vegetables (plenty of folates), and maintaining a normal weight are associated with better fertility prospects.
  • Treating or preventing existing diseases. Identifying and controlling chronic diseases such as diabetes and hypothyroidism increases fertility prospects. Lifelong practice of safer sex reduces the likelihood that sexually transmitted diseases will impair fertility; obtaining prompt treatment for sexually transmitted diseases reduces the likelihood that such infections will do significant damage. Regular physical examinations (including pap smears) help detect early signs of infections or abnormalities.
  • Not delaying parenthood. Fertility does not ultimately cease before menopause, but it starts declining after age 27 and drops at a somewhat greater rate after age 35.[42] Women whose biological mothers had unusual or abnormal issues related to conceiving may be at particular risk for some conditions, such as premature menopause, that can be mitigated by not delaying parenthood.

Society and culture [edit]

Social stigma [edit]

Ethnographic research into female infertility within “pronatalist developing societies”[43] has shown that women who are infertile may be stigmatized, reflecting a deep-seated patriarchal belief system. In these societies, the vocation of motherhood is considered to be intrinsically linked to the notion of womanhood, so in effect, a woman’s infertility conflicts with normative concepts of gender identity. The woman’s inability to adopt this “mandatory status”[44] and “gain entrance to the cult of motherhood”[45] often leads to dysfunctional relationships with the in-laws, extended family and community members, culminating in feelings of “isolation, loneliness and despair”.[46] Furthermore, this cultural milieu can impact negatively on “marital dynamics”,[47] possibly leading to “divorce or polygamous remarriage”.[48]

See also [edit]

References [edit]

  1. ^ a b Section "Defining infertility" in: Fertility: assessment and treatment for people with fertility problems. NICE clinical guideline CG156 - Issued: February 2013
  2. ^ http://www.fertilityfaq.org/_pdf/magazine1_v4.pdf
  3. ^ Anderson SE, Dallal GE, Must A (April 2003). "Relative weight and race influence average age at menarche: results from two nationally representative surveys of US girls studied 25 years apart". Pediatrics 111 (4 Pt 1): 844–50. doi:10.1542/peds.111.4.844. PMID 12671122. 
  4. ^ http://www.ncbi.nlm.nih.gov/pubmed/21110899
  5. ^ http://vstudentworld.yolasite.com/resources/final_yr/gynae_obs/Hamilton%20Fairley%20Obstetrics%20and%20Gynaecology%20Lecture%20Notes%202%20Ed.pdf
  6. ^ Apter D (February 1980). "Serum steroids and pituitary hormones in female puberty: a partly longitudinal study". Clinical Endocrinology 12 (2): 107–20. doi:10.1111/j.1365-2265.1980.tb02125.x. PMID 6249519. 
  7. ^ Dechanet C, Anahory T, Mathieu Daude JC, Quantin X, Reyftmann L, Hamamah S, Hedon B, Dechaud H (2011). "Effects of cigarette smoking on reproduction". Hum. Reprod. Update 17 (1): 76–95. doi:10.1093/humupd/dmq033. PMID 20685716.  edit
  8. ^ a b c d e FERTILITY FACT > Female Risks By the American Society for Reproductive Medicine (ASRM). Retrieved on Jan 4, 2009
  9. ^ http://dl.dropbox.com/u/8256710/ASRM%20Protect%20Your%20Fertility%20newsletter.pdf
  10. ^ a b Regulated fertility services: a commissioning aid - June 2009, from the Department of Health UK
  11. ^ Practice Committee of American Society for Reproductive Medicine (2008). "Smoking and Infertility". Fertil Steril 90 (5 Suppl): S254–9. PMID 19007641. 
  12. ^ Nelson LR, Bulun SE (September 2001). "Estrogen production and action". J. Am. Acad. Dermatol. 45 (3 Suppl): S116–24. doi:10.1067/mjd.2001.117432. PMID 11511861. 
  13. ^ Sloboda, D. M.; Hickey, M.; Hart, R. (2010). "Reproduction in females: the role of the early life environment". Human Reproduction Update 17 (2): 210–227. doi:10.1093/humupd/dmq048. PMID 20961922.  edit
  14. ^ Freizinger M, Franko DL, Dacey M, Okun B, Domar AD (November 2008). "The prevalence of eating disorders in infertile women". Fertil. Steril. 93 (1): 72–8. doi:10.1016/j.fertnstert.2008.09.055. PMID 19006795. 
  15. ^ Koning AM, Kuchenbecker WK, Groen H, et al. (2010). "Economic consequences of overweight and obesity in infertility: a framework for evaluating the costs and outcomes of fertility care". Hum. Reprod. Update 16 (3): 246–54. doi:10.1093/humupd/dmp053. PMID 20056674. 
  16. ^ a b c Brydøy M, Fosså SD, Dahl O, Bjøro T (2007). "Gonadal dysfunction and fertility problems in cancer survivors". Acta Oncol 46 (4): 480–9. doi:10.1080/02841860601166958. PMID 17497315. 
  17. ^ a b Morgan, S.; Anderson, R. A.; Gourley, C.; Wallace, W. H.; Spears, N. (2012). "How do chemotherapeutic agents damage the ovary?". Human Reproduction Update 18 (5): 525. doi:10.1093/humupd/dms022.  edit
  18. ^ a b Rosendahl, M.; Andersen, C.; La Cour Freiesleben, N.; Juul, A.; Løssl, K.; Andersen, A. (2010). "Dynamics and mechanisms of chemotherapy-induced ovarian follicular depletion in women of fertile age". Fertility and Sterility 94 (1): 156–166. doi:10.1016/j.fertnstert.2009.02.043. PMID 19342041.  edit
  19. ^ Gurgan T, Salman C, Demirol A (October 2008). "Pregnancy and assisted reproduction techniques in men and women after cancer treatment". Placenta 29 (Suppl B): 152–9. doi:10.1016/j.placenta.2008.07.007. PMID 18790328. 
  20. ^ a b Ten Broek, R. P. G.; Kok- Krant, N.; Bakkum, E. A.; Bleichrodt, R. P.; Van Goor, H. (2012). "Different surgical techniques to reduce post-operative adhesion formation: A systematic review and meta-analysis". Human Reproduction Update 19 (1): 12–25. doi:10.1093/humupd/dms032. PMID 22899657.  edit
  21. ^ a b Codner, E.; Merino, P. M.; Tena-Sempere, M. (2012). "Female reproduction and type 1 diabetes: From mechanisms to clinical findings". Human Reproduction Update 18 (5): 568. doi:10.1093/humupd/dms024.  edit
  22. ^ Middeldorp S (2007). "Pregnancy failure and heritable thrombophilia". Semin. Hematol. 44 (2): 93–7. doi:10.1053/j.seminhematol.2007.01.005. PMID 17433901. 
  23. ^ Qublan HS, Eid SS, Ababneh HA, et al. (2006). "Acquired and inherited thrombophilia: implication in recurrent IVF and embryo transfer failure". Hum. Reprod. 21 (10): 2694–8. doi:10.1093/humrep/del203. PMID 16835215. 
  24. ^ Karasu, T.; Marczylo, T. H.; MacCarrone, M.; Konje, J. C. (2011). "The role of sex steroid hormones, cytokines and the endocannabinoid system in female fertility". Human Reproduction Update 17 (3): 347–361. doi:10.1093/humupd/dmq058. PMID 21227997.  edit
  25. ^ Chapter on Amenorrhea in: Bradshaw, Karen D.; Schorge, John O.; Schaffer, Joseph; Lisa M. Halvorson; Hoffman, Barbara G. (2008). Williams' Gynecology. McGraw-Hill Professional. ISBN 0-07-147257-6. 
  26. ^ Sultan C, Biason-Lauber A, Philibert P (January 2009). "Mayer-Rokitansky-Kuster-Hauser syndrome: recent clinical and genetic findings". Gynecol Endocrinol 25 (1): 8–11. doi:10.1080/09513590802288291. PMID 19165657. 
  27. ^ a b Unless otherwise specified in boxes, then reference is: Fauser, B. C. J. M.; Diedrich, K.; Bouchard, P.; Dominguez, F.; Matzuk, M.; Franks, S.; Hamamah, S.; Simon, C. et al. (2011). "Contemporary genetic technologies and female reproduction". Human Reproduction Update 17 (6): 829–847. doi:10.1093/humupd/dmr033. PMC 3191938. PMID 21896560.  edit
  28. ^ Female Infertility
  29. ^ Hull MG, Savage PE, Bromham DR (June 1982). "Anovulatory and ovulatory infertility: results with simplified management". Br Med J (Clin Res Ed) 284 (6330): 1681–5. doi:10.1136/bmj.284.6330.1681. PMC 1498620. PMID 6805656. 
  30. ^ Luteal Phase Dysfunction at eMedicine
  31. ^ Tomassetti C, Meuleman C, Pexsters A, et al. (2006). "Endometriosis, recurrent miscarriage and implantation failure: is there an immunological link?". Reprod. Biomed. Online 13 (1): 58–64. doi:10.1016/S1472-6483(10)62016-0. PMID 16820110. 
  32. ^ Speroff L, Glass RH, Kase NG (1999). Clinical Gynecologic Endocrinology and Infertility (6th ed.). Lippincott Willimas Wilkins. p. 1057. ISBN 0-683-30379-1. 
  33. ^ Buyalos RP, Agarwal SK (October 2000). "Endometriosis-associated infertility". Current Opinion in Obstetrics & Gynecology 12 (5): 377–81. doi:10.1097/00001703-200010000-00006. ISSN 1040-872X. PMID 11111879. 
  34. ^ Guven MA, Dilek U, Pata O, Dilek S, Ciragil P (2007). "Prevalence of Chlamydia trochomatis, Ureaplasma urealyticum and Mycoplasma hominis infections in the unexplained infertile women". Arch. Gynecol. Obstet. 276 (3): 219–23. doi:10.1007/s00404-006-0279-z. PMID 17160569. 
  35. ^ García-Ulloa AC, Arrieta O (2005). "Tubal occlusion causing infertility due to an excessive inflammatory response in patients with predisposition for keloid formation". Med. Hypotheses 65 (5): 908–14. doi:10.1016/j.mehy.2005.03.031. PMID 16005574. 
  36. ^ Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, Pellicer A (1997). "Reproductive impact of congenital Müllerian anomalies". Hum. Reprod. 12 (10): 2277–81. doi:10.1093/humrep/12.10.2277. PMID 9402295. 
  37. ^ Magos A (2002). "Hysteroscopic treatment of Asherman's syndrome". Reprod. Biomed. Online 4 (Suppl 3): 46–51. PMID 12470565. 
  38. ^ Tan Y, Bennett MJ (2007). "Urinary catheter stent placement for treatment of cervical stenosis". The Australian & New Zealand journal of obstetrics & gynaecology 47 (5): 406–9. doi:10.1111/j.1479-828X.2007.00766.x. PMID 17877600. 
  39. ^ Francavilla F, Santucci R, Barbonetti A, Francavilla S (2007). "Naturally-occurring antisperm antibodies in men: interference with fertility and clinical implications. An update". Front. Biosci. 12 (8–12): 2890–911. doi:10.2741/2280. PMID 17485267. 
  40. ^ Farhi J, Valentine A, Bahadur G, Shenfield F, Steele SJ, Jacobs HS (1995). "In-vitro cervical mucus-sperm penetration tests and outcome of infertility treatments in couples with repeatedly negative post-coital tests". Hum. Reprod. 10 (1): 85–90. doi:10.1093/humrep/10.1.85. PMID 7745077. 
  41. ^ Wartofsky L, Van Nostrand D, Burman KD (2006). "Overt and 'subclinical' hypothyroidism in women". Obstetrical & gynecological survey 61 (8): 535–42. doi:10.1097/01.ogx.0000228778.95752.66. PMID 16842634. 
  42. ^ Hall, Carl T. "Study speeds up biological clocks / Fertility rates dip after women hit 27". The San Francisco Chronicle. Retrieved 2007-11-21. 
  43. ^ Inhorn, M. C. (2003). "Global infertility and the globalization of new reproductive technologies: illustrations from Egypt." Social Science & Medicine (56): 1837 - 1851.
  44. ^ Inhorn, M. C. (2003). "Global infertility and the globalization of new reproductive technologies: illustrations from Egypt." Social Science & Medicine (56): 1837 - 1851.
  45. ^ Inhorn, M. C. (2003). "Global infertility and the globalization of new reproductive technologies: illustrations from Egypt." Social Science & Medicine (56): 1837 - 1851.
  46. ^ Inhorn, M. C. (2003). "Global infertility and the globalization of new reproductive technologies: illustrations from Egypt." Social Science & Medicine (56): 1837 - 1851.
  47. ^ Inhorn, M. C. (2003). "Global infertility and the globalization of new reproductive technologies: illustrations from Egypt." Social Science & Medicine (56): 1837 - 1851.
  48. ^ Inhorn, M. C. (2003). "Global infertility and the globalization of new reproductive technologies: illustrations from Egypt." Social Science & Medicine (56): 1837 - 1851.
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Infertility
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