Chapter 25

Counseling Clients With Fertility Problems

  • Counsel both partners together, if possible. A man may blame his partner for infertility if he doesn’t understand that the problem could be on his side or may lie with both partners.
  • Explain that a man is just as likely to have fertility problems as a woman. In more than 40% of couples with fertility problems, it is because of semen or sperm abnormalities, or other health problems of the male partner. In 20% of couples with fertility problems, both male and female factors reduce fertility. Sometimes it is not possible to find the cause of the problem.
  • Recommend that the couple attempt pregnancy with unprotected sex for at least 12 months before they suspect infertility. Provide educational materials and guidance on risks to fertility. (See the section on Safer Conception for HIV Serodiscordant Couples, in Chapter 22 – Sexually Transmitted Infections, Including HIV)
  • The most fertile time of a woman’s cycle is several days before and at the time of ovulation (when an ovary releases an egg) (see the job aid, The Menstrual Cycle). Fertility awareness methods can help couples identify the most fertile time of each cycle (see Chapter 18 – Fertility Awareness Methods). Provide educational material about these methods and/or refer the couple to a fertility care provider or specialist.
  • If, after 1 year, following the suggestions above has not resulted in a pregnancy or live birth, refer both partners to a qualified fertility care provider for evaluation and assessment, if available. Referral to a fertility care provider or specialist may be particularly helpful in the following situations: the couple is affected by HIV or suspected genital TB; the woman is age 35 or older; she has polycystic ovary syndrome or has been diagnosed with endometriosis; the woman or the man suspects they had an STI and it was not treated; either had been treated for a cancer or had surgery that may have affected the reproductive tissues or organs.
  • The couple also may want to consider adoption or other alternatives to having children or more children of their own, such as taking in nieces and nephews.
Contraceptives Do Not Cause Infertility
  • With most modern contraceptive methods, there is no significant delay in the time to desired pregnancy after contraception is stopped. On average, pregnancy occurs after 3 to 6 months of unprotected sex. There is great variation around this average, however, related to the age and the health status of the individuals in the couple. When counseling couples who stop contraception and want to have a child, aging and other factors affecting the fertility of the woman and the man need to be considered.
  • The return of fertility after injectable contraceptives are stopped usually takes longer than with most other methods (see Chapter 4 – Progestin-Only Injectables, Questions 7 and 8, and Chapter 5 – Monthly Injectables, Questions 10 and 11). In time, however, a woman will be as fertile as before using the method, taking aging into account.
  • Among women with current gonorrhea or chlamydia, IUD insertion slightly increases the risk of pelvic inflammatory disease in the first 20 days after insertion. However, research has not found that former IUD users are more likely to be infertile than other women (see Chapter 10 – Copper-Bearing Intrauterine Device, Question 4).