Long‐Term Effects of Breast Cancer Surgery,Treatment, and Survivor Care

Women are increasingly surviving breast cancer, but up to 90% experience unexpected long‐term sequelae as a result of treatment. Symptoms may include physical, functional, emotional, and psychosocial changes that can dramatically alter the quality of life for breast cancer survivors. Primary care clinicians, including midwives, are likely to care for these women and should be familiar with common symptoms, treatment, and best practices to avoid permanent dysfunction. A holistic approach to assessment, treatment, and referral as needed is the most effective strategy. Although women experience significant changes after breast cancer treatment, many fail to receive thorough assessment of their symptoms, education about interventions, and treatment options to optimize health promoting strategies. Disparities exist in treatment availability, options, and survivorship. Long‐term physical changes include anatomic changes, chronic pain, phantom breast pain, axillary web syndrome, and lymphedema. In addition, women may have decreased strength, aerobic capacity, mobility, fatigue, and cognitive dysfunction. Emotional and psychosocial changes include depression, anxiety, fatigue, concerns about body image, and issues with sexuality. Treatment should be multifactorial based on thorough assessment of symptoms and can include medication, exercise, counseling, physical and occupational therapy, and alternative and complementary therapies. Primary care and gynecologic clinicians are well positioned to provide thorough evaluation, education, treatment, and referral for the most common sequelae of mastectomy and breast cancer treatments.     

Assisted reproduction and breast cancer

Breast cancer is the most frequent cancer in reproductive age women. Although well known causal link between estrogen and breast cancer, the impact of ovulation induction on the risk of breast cancer still remains to be clarified. One of the recently recognized long term adverse effects of adjuvant cytotoxic chemotherapy given for breast cancer is premature ovarian failure and infertility, both of which significantly compromise the quality of life of a cancer survivor. Thanks to significant developments in assisted reproductive technologies these patients may benefit from a wide range of fertility preservation options. The most established technique is embryo cryopreservation; oocyte cryopreservation can be considered in single women; both of which require at least 2 weeks of ovarian stimulation beginning with the onset of the patient's menstrual cycle. Novel ovarian stimulation protocols using tamoxifen and letrozole can be used to increase the margin of safety in estrogen sensitive breast tumors. When there is no time available for ovulation induction, ovarian tissue can be cryopreserved for future transplantation without delay in cancer therapy. The benefit of ovarian protection by gonadotropin-releasing hormone analogues is unproven and unlikely, and thus this treatment should not be recommended as the sole method of fertility preservation.     

Menopause,andropause and sexual function

After about fifty years of age, at the time of the menopause and the andropause (androgenic deficiency), men as well as women can have the same type of complaint, but it is facing time that women have a different view from men. Time is coded into a woman's body, whereas it is by 'social' time that men are more often determined. On the sexual level there is a slow-down in the sexual reactions of both men and women. One should not forget, however, that the cure for sexual problems in women sometimes involves the treatment of male sexual dysfunction (erection problems, premature ejaculation, absence of ejaculation). Therapeutically, hormonal replacement therapy is undoubtedly a help, if there are no medical contra-indications and if the patient is in agreement. If the complaint is also sexual then a more specific, therapeutic treatment may often be necessary, associating hormone treatment with erection inducers.     

Needs assessment survey to justify establishing a reproductive health clinic at a comprehensive cancer center

IntroductionReproductive health problems, including sexual dysfunction and impaired fertility, are distressing and persistent after cancer treatment. However, recent reports suggest that reproductive health remains neglected in oncology settings.AimsWe conducted a survey to ascertain the prevalence of reproductive health problems in men and women treated in a comprehensive cancer center, and to estimate potential usage of clinical services to preserve fertility or to treat postcancer infertility and sexual dysfunction.MethodsWe mailed 800 questionnaires to men and women treated for cancer at our institution 1 to 5 years previously. Cancer sites and ages were chosen to maximize the risk of reproductive problems. We stratified the sample by living distance from our institution, to see if travel affected service utlilization. To provide a self-selected sample for comparison, another 200 questionnaires were made available in outpatient areas.Main Outcome MeasuresSelf-report questionnaire.ResultsThe return rate for the combined surveys was 29% for men and 26% for women. Cancer sites for self-selected respondents were almost identical to those in the postal cohort. Prevalence and types of sexual dysfunction were typical for surveys of cancer survivors, with 49% of men reporting new erection problems after cancer treatment and 45% of women noting loss of desire for sex and vaginal dryness. About a third of patients aged less than 50 years would have liked a fertility consultation before cancer treatment. Twenty to thirty percent wanted more information about premature ovarian failure or health risks for their children. Twenty-four percent of men and 21% of women would definitely want to visit a reproductive health clinic in the next year. Factors associated with wanting an appointment included self-selection to complete the survey and, for men, having less education.ConclusionIt should be feasible to establish a multidisciplinary reproductive health center in a comprehensive cancer center. Huyghe E, Sui D, Odensky E, and Schover LR. Needs assessment survey to justify establishing a reproductive health clinic at a comprehensive cancer center.     

Frozen Hope: Fertility Preservation for Women With Cancer

Young women diagnosed with cancer have the option of preserving their fertility by using assisted reproductive technology (ART) techniques prior to undergoing cancer treatment. This article presents a composite case of a young woman with cancer who had many unanswered emotional and ethical questions about her future as a parent. Fertility preservation techniques, including preimplantation genetic diagnosis (PGD), and related patient education are described. Current literature regarding reproductive counseling for cancer survivors is reviewed. Resources for providing psychosocial support for decisions about fertility preservation are lagging behind the rapid pace of scientific advancements in cancer treatment and ART. As more young women are surviving cancer and taking steps to preserve fertility, there is great need for the provision of psychologic support services and the establishment of ethical guidelines to aid them on this path. Women's health care providers can provide support to cancer survivors facing fertility and parenting issues by becoming knowledgeable about the long‐term aspects of decision making and developing educational materials and guidelines for these patients.     

Present and future fertility preservation strategies for female cancer patients

As survival rates with cancer treatment are steadily increasing, many women are now facing sterility due to treatment induced ovarian failure. This review will attempt to summarize the options for trying to preserve fertility in these patients. The optimal approach depends on the type of cancer, the type of treatment (e.g., radiation and/or chemotherapy), time available till onset of treatment, patient's age, and whether the patient has a partner. Ovarian transposition remains the standard of care for women undergoing pelvic radiation, although it has been suggested that it may be combined with ovarian tissue cryopreservation. For patients about to receive chemotherapy or whole body radiation, in vitro fertilization (IVF) with embryo cryopreservation is a well established treatment with a good success rate. However, it requires delaying cancer treatment for 2 to 4 weeks and a partner or willingness to use donor sperm. When these criteria cannot be met, more experimental options include oocyte cryopreservation for later IVF and ovarian tissue cryopreservation. The tissue may be autotransplanted back to the pelvis, when the patient is in remission, to attempt spontaneous conception or subcutaneously for easy access of follicle aspiration for IVF. Alternatively, it may be xenografted to immunocompromised mice to induce follicle maturation in preparation for retrieval for IVF. Emerging treatment options for fertility preservation include medication to prevent chemotherapy-induced oocyte damage and oocyte construction from somatic cell nuclei. IVF with donor oocyte remains an established option with a very high success rate for those who fail to conceive with the above measures or who elect not to avail themselves to experimental procedures. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to demonstrate knowledge about fertility preservation when counseling appropriate female cancer patients, recall current clinical strategies to assist women cancer patients to try to maintain their fertility if they wish, and appraise future strategies as they develop.     

Clomiphene citrate and ovulation induction

Clomiphene can be used to treat anovulation due to hypothalamus or pituitary gland dysfunction, and it normalizes the luteal phase in stimulated patients. It can be used to estimate ovarian follicle reserve, and may be predictive of ovulation in women aged >/=35 years or with failed IVF. Contraindications include risk of congenital anomalies, chronic liver disease and visual disorders. Clomiphene may impair fertility through its effects on cervical mucus and in causing various endometrial dysfunctions. However, if clomiphene is administered in 50 mg doses, side-effects are avoided and efficacy is similar to that of a 100 mg dose, although daily dosages of 200 mg/day over 5 days can induce ovulation in approximately 70% of treated patients. Gonadotrophin concentrations increase up to days 5-9 when follicles are selected, and clomiphene is effective in patients with polycystic ovary syndrome (PCOS). Fifty percent of normal patients conceive, a value perhaps biased by the antagonistic effects of clomiphene on cervical mucus in some women. Clomiphene is valuable for IVF, and is used by some clinics in combination with HMG or recombinant FSH. Resistance to clomiphene can develop, and human chorionic gonadotrophin may be needed to induce ovulation in clomiphene cycles. Corticosteroids and human menopausal gonadotrophin (HMG) can be combined with clomiphene for stimulation, its combination with HMG long having been a standard protocol in assisted reproduction. PCOS patients may become insulin resistant, a condition improved by the administration of metformin. Other adverse effects include multiple pregnancies, an increase in the rate of multiple births, ovarian hyperstimulation and unsubstantiated claims of ovarian cancer.     

Cancer risks associated with the diagnosis of infertility

The effects of infertility and its treatment on cancer risk are of concern to many infertile couples. Infertile women appear to be at no higher risk for breast cancer although they may be more at risk for cancers of the uterus, particularly if they have ovulation disorders. Most studies show no increase in the risk of invasive ovarian cancer in infertile women, but ovarian tumours of borderline malignancy are more common. There seems to be no overall increase in cancer risk associated with fertility drug treatment, but questions remain about risk in subgroups of infertile women. Male infertility has been associated with an increased risk of testis cancer. Cancer incidence in children born after fertility treatment appears to be similar to that in the general population. Discussion of cancer risks in the context of other reproductive and community risks can be helpful to patients.     

Banking sperm is only the first of many decisions for men: what healthcare professionals and men need to know

Sperm banking is recommended for all males prior to cancer treatment where there are risks of infertility. Subsequent decisions about monitoring fertility, use of banked sperm or disposal are less well understood, with adverse consequences for men and cost implications. We review the literature around key decision points: Diagnosis of cancer, monitoring fertility, use of banked sperm and sperm disposal. The results suggest that decisions about banking are compromised by concerns to initiate treatment quickly; subsequent decisions about monitoring fertility, use of banked sperm or disposal are coloured by the views of family members, men's failure to understand the longer-term implications and their reluctance to avail themselves of health care generally. Methodological limitations of current research include low response rates, increased focus on germ cell cancers and a lack of research outside North America. There is evidence that men and oncologists could use sperm banks more "wisely". Lack of longitudinal work means it is not possible to determine the long-term consequences of banking for men's general health and well-being, or identify barriers to fertility monitoring or disposal. We argue that sperm banking should be considered as a series of decisions, all involving implications for fertility, contraception and social and psychological adjustment to cancer.     

The effect of endometriosis on in vitro fertilization outcome

AIM: Endometriosis is a leading cause of pelvic pain and infertility. Implantation of endometrial cells to the peritoneal surface can lead to a spectrum of disease severity with the most severe causing extensive pelvic adhesions and anatomic distortion. Infertility can result from anatomic abnormalities as well proinflammatory cellular and immune factors. Treatment options for women seeking pregnancy include surgical removal and/or in vitro fertilization. The aim of this study was to review current literature on the pathogenesis of endometriosis and treatment options for infertility. METHODS: Recent published articles regarding infertility and endometriosis have been reviewed analyzing PubMed and Cochrane databases. RESULTS: In vitro fertilization (IVF) is a valid option for patients after surgical management has not restored fertility. IVF may be offered sooner to older patients or to those with more severe disease. It is unclear if prior surgical treatment has deleterious effects on IVF outcomes. It does appear, however, that surgical removal of endometriomas may lead to decreased ovarian reserve. This may not affect fertility outcomes. CONCLUSION: Endometriosis is a leading cause of pelvic pain and infertility. The most accepted theory of how endometriosis develops is the retrograde transplant theory by Sampson, but a constellation of numerous other factors are involved. The gold standard for diagnosis is operative; therefore, the true prevalence of this disease is uncertain. Many women with endometriosis will seek fertility treatment. In this case if endometriosis is found, it should be treated.     

Women still bearing the blows in reproductive health

Only women can experience the health threats of pregnancy and childbirth. Responsibility for the survival, growth, and development of children falls mainly on their shoulders. Sexually transmitted diseases cause more severe effects in women than men. Women are 3 times more likely to use contraceptives than men Yet female contraceptive methods are more of a threat to health an are male methods. Even though infertility occurs in both men and women, in most countries, women face its negative social and psychological effects more often than do men. Besides, almost everywhere, social and economic indicators show women to be of lower status than men. For example, female literacy rates in developing countries are 33% lower than those of male, even though leaders have known for a long time that female education improves use of health care and family planning services. Furthermore, females are at a disadvantage from birth in terms of education, nutrition, and society which places them at high risk of adverse health. Some societies even endorse method to prevent women from enjoying sexual intercourse. Premarital sex and adolescent pregnancy are increasing worldwide, which adds to women's already high burden. In Argentina, women less than 18 years of age, especially those in rural areas and little education, have higher fertility rates than those older than 18 years. They tend to be ignorant of reproductive processes, but familiar with contraceptives; yet, only 40% of sexually active adolescents had ever used them. Besides, teenage males think that concern about becoming pregnant is the female's responsibility. Indeed, women's status and reproductive health are interrelated. Ability to regulate their own fertility strengthens women's status, but if they cannot do so, they cannot go to school, be employable, or make their own decisions.     

Radiation damage to the uterus — Review of the effects of treatment of childhood cancer

At the present time approximately 1 in 1000 young people aged between 16 and 35 years will have been cured of cancer in childhood and some of the treatment regimens used will have predictable effects on their future fertility prospects. In young women who have been exposed to radiotherapy below the diaphragm, the reproductive problems include the risk of ovarian failure and significantly impaired development of the uterus. The magnitude of the risk is related to the radiation field, total dose and fractionation schedule. Premature labour and low birth weight infants have been reported after flank abdominal radiotherapy. Female long-term survivors treated with total body irradiation and marrow transplantation are also at risk of ovarian follicular depletion and impaired uterine growth and blood flow, and of early pregnancy loss and premature labour if pregnancy is achieved. Despite standard oestrogen replacement, the uterus of these young girls is often reduced to 40% of normal adult size. Uterine volume correlates with the age at which radiation was received. Regrettably, it is likely that radiation damage to the uterine musculature and vasculature adversely affects prospects for pregnancy in these women. It has been demonstrated that, in women treated with total body irradiation, sex steroid replacement in physiological doses significantly increases uterine volume and endometrial thickness, as well as re-establishing uterine blood flow. However, it is not known whether standard regimens of oestrogen replacement therapy are sufficient to facilitate uterine growth in adolescent women treated with total body irradiation in childhood. Even if the uterus is able to respond to exogenous sex steroid stimulation, and appropriate assisted reproductive technologies are available, a successful pregnancy outcome is by no means ensured. The uterine factor remains a concern and women who are survivors of childhood cancer and their carers must recognize that these pregnancies will be at high risk.     

Schilddr��sendiagnostik und -therapie in der t?glichen Praxis

Thyroid dysfunction and structural changes of the thyroid are common diseases which affect women more often than men. A distinction is made between latent and overt thyroid dysfunction. In cases of overt dysfunction the concentrations of free thyroid hormones are altered. Both hypothyroidism and hyperthyroidism can be caused by a variety of mechanisms. A manifest failure is always an indication for therapy. In cases of fertility desire or pregnancy a latent hypothyroidism also needs therapy by thyroid hormone substitution. In Germany one third of the population have structural changes such as an enlarged thyroid or adenomatous goitre. Medicinal treatment, radioiodine therapy and thyroid surgery are available for treatment.     

Radiation damage to the uterus -- review of the effects of treatment of childhood cancer

At the present time approximately 1 in 1000 young people aged between 16 and 35 years will have been cured of cancer in childhood and some of the treatment regimens used will have predictable effects on their future fertility prospects. In young women who have been exposed to radiotherapy below the diaphragm, the reproductive problems include the risk of ovarian failure and significantly impaired development of the uterus. The magnitude of the risk is related to the radiation field, total dose and fractionation schedule. Premature labour and low birth weight infants have been reported after flank abdominal radiotherapy. Female long-term survivors treated with total body irradiation and marrow transplantation are also at risk of ovarian follicular depletion and impaired uterine growth and blood flow, and of early pregnancy loss and premature labour if pregnancy is achieved. Despite standard oestrogen replacement, the uterus of these young girls is often reduced to 40% of normal adult size. Uterine volume correlates with the age at which radiation was received. Regrettably, it is likely that radiation damage to the uterine musculature and vasculature adversely affects prospects for pregnancy in these women. It has been demonstrated that, in women treated with total body irradiation, sex steroid replacement in physiological doses significantly increases uterine volume and endometrial thickness, as well as re-establishing uterine blood flow. However, it is not known whether standard regimens of oestrogen replacement therapy are sufficient to facilitate uterine growth in adolescent women treated with total body irradiation in childhood. Even if the uterus is able to respond to exogenous sex steroid stimulation, and appropriate assisted reproductive technologies are available, a successful pregnancy outcome is by no means ensured. The uterine factor remains a concern and women who are survivors of childhood cancer and their carers must recognize that these pregnancies will be at high risk.     

Late and Long‐Term Effects of Breast Cancer Treatment and Surveillance Management for the General Practitioner

ObjectiveTo examine the most common long‐term and late effects of breast cancer treatment, the American Society of Clinical Oncology guidelines for surveillance, and recommendations for the primary care provider's role in delivering breast cancer survivorship care.Data SourcesA comprehensive literature review was conducted using CINAHL, PubMed, Google Scholar, and hand searches using the search terms breast cancer, survivor, and long‐term or late effects.Study SelectionArticles published in English from 2002 to 2012 that addressed the long‐term or late effects of adults with breast cancer were included.Data ExtractionFindings are discussed categorically, including the most common late and long‐term psychosocial effects from relevant studies.Data SynthesisTopics relevant to survivors included challenges to psychosocial, emotional, and cognitive well‐being; satisfaction with life; sexuality; body image; anxiety; fear of recurrence and post‐traumatic stress disorder; depression; cognitive dysfunction challenges to physical well‐being; adverse cardiovascular events; fatigue; lymphedema; musculoskeletal symptoms; accelerated bone loss and fractures; pain; skin changes due to radiation; disease recurrence; and new breast cancers.ConclusionsWith earlier detection methods and improvements in treatment options making breast cancer a highly survivable disease, there are more survivors of breast cancer than ever. The clinicians’ role in survivorship care is more important than ever to manage the potential long‐term and late effects of treatment, physical and emotional well‐being, and recurrent disease surveillance. However, the clinician's role in cancer follow‐up care is often poorly defined leading to a lack of awareness about the needs of survivors of breast cancer, suboptimal communication between providers and survivors, and an overall deficiency in quality care.     

Fertility drugs and risk of ovarian cancer: dispelling the myth

PURPOSE OF REVIEW: Worldwide 50-80 million people suffer from infertility. Assisted reproductive technology has provided a way of overcoming infertility and childlessness.The current article will focus on data linking infertility and its treatment to ovarian cancer. RECENT FINDINGS: Ovarian cancer risks associated with fertility drug treatment are encouraging, but not decisive. In view of the limited ability to evaluate drug effects on borderline tumors, given their rare occurrence, studies involving patient reports of prior drug exposures have noted an elevated risk of borderline tumors associated with fertility drugs. Nevertheless, the risk of invasive ovarian cancer appears to be restricted to those women who remain childless despite the infertility treatment. SUMMARY: As long as doubt persists, it might be advisable to reflect on a few clinical recommendations: identify high-risk infertile patients for ovarian cancer, investigate preexisting cancer before fertility treatment, inform patients regarding potential risks, obtain an informed consent, avoid exposure to long periods of ovulation induction cycles that are given before patients are referred for in-vitro fertilization and embryo transfer for women at greater risk and monitor women who have been treated with these drugs, especially those who failed to conceive, regularly and thoroughly.     

Technical and ethical challenges of fertility preservation in young cancer patients

As cancer treatment improves, more young men and women survive, but they suffer from infertility as a major sequel of cancer treatment. Gamete and embryo cryopreservation are the only options available to these patients for preserving their fertility. Although cryopreservation of spermatozoa and embryos are already established, oocyte banking is still experimental. The advent of testicular tissue cryopreservation and spermatogonial stem cell transplantation in men, and ovarian tissue cryopreservation and in-vitro follicular maturation in women, has started a frenzy of experiments worldwide trying to demonstrate their potential use in fertility preservation. Although major improvements have been made in tissue cryobanking in the past decade, there are still many unresolved technical issues related to these procedures. Furthermore, the intersection of cancer and fertility preservation in young patients raises ethical, legal and policy issues for oncologists and cancer survivors. Informed consent of minor patients, legal parentage and medical negligence claims are some of the potential legal challenges faced by society and healthcare providers. This review summarizes the technical and ethical challenges of gamete cryopreservation in young cancer patients.     

Hormone therapy for younger patients with endometrial cancer

The relationship between hormones and endometrial cancer is well known because disease states, such as chronic anovulation and endogenous estrogen production from hormone-secreting tumors (for example, granulosa cell tumor of the ovary), are related to excess estrogen, and unopposed estrogen use might lead to endometrial overgrowth, hyperplasia, and subsequent development of endometrial carcinoma. Therefore, the possibility of using antihormone therapy in endometrial carcinoma and/or its precancer lesions, such as simple hyperplasia with and without atypia and complex hyperplasia with and without atypia, is always supposed, as in the management of breast cancer. In addition, if women in whom endometrial cancer is diagnosed are very young, some critical issues should be considered, including the possibility of ovary preservation-partial preservation of fertility and the possibility of both ovary and uterus preservation-complete preservation of fertility. Other factors are also important to consider and include oncologic risk, appropriateness of candidates for treatment, type of hormone use, response rate of hormonal therapy, appropriate surveillance, and additional counseling for issues such as anxiety about relapse and metastasis, distress about side effects, advice of the family, advice of the medical staff, and economic burden.This review will be focused on updated information and recent knowledge of the use of hormones in the management of younger women with endometrial cancer who want fertility preservation.     

Long‐Term Testosterone Treatment in Elderly Men with Hypogonadism and Erectile Dysfunction Reduces Obesity Parameters and Improves Metabolic Syndrome and Health‐Related Quality of Life

IntroductionLate‐onset hypogonadism (LOH) is diagnosed when declining testosterone concentrations in the aging male cause unwanted symptoms such as erectile dysfunction (ED), reduced bone density and muscle strength, and increased visceral obesity. Testosterone deficiency is also associated with insulin resistance and the metabolic syndrome (MetS). Restoring testosterone to physiological concentrations has beneficial effects on many of these symptoms; however, it is not known whether these effects can be sustained in the long term.AimsTo investigate whether treatment with testosterone undecanoate (TU) has a long‐term and sustained effect on parameters affected by the MetS in men with LOH and ED, to determine whether long‐term testosterone treatment can improve the overall health‐related quality of life in these men, and to establish the safety of long‐term testosterone treatment.MethodsTwo hundred sixty‐one patients (mean age 59.5 ± 8.4 years) diagnosed with LOH and ED were treated with long‐acting TU in a prospective, observational, and longitudinal registry study. Men received intramuscular injections of 1,000 mg TU at day 1, at week 6, and every 3 months thereafter.Main Outcome MeasuresParameters affected by the MetS, including obesity parameters (body weight, waist circumference, and body mass index [BMI]), total cholesterol, low‐density lipoprotein (LDL), high‐density lipoprotein (HDL), triglycerides, glucose, HbA_1c (glycated hemoglobin), and blood pressure, as well as total testosterone levels and health‐related quality of life, were assessed.ResultsWe found TU significantly improved obesity parameters (body weight, waist circumference, and BMI) and lowered total cholesterol, LDL cholesterol, triglycerides, fasting blood glucose, HbA_1c, and blood pressure over the 5‐year study. HDL cholesterol was increased. TU treatment resulted in a sustained improvement in erectile function and muscle and joint pain, which contributed to an improvement in long‐term health‐related quality of life. Furthermore, we found a relationship between health‐related quality of life and waist circumference. Finally, we found no evidence that long‐term treatment with TU increases the risk of prostate carcinoma.ConclusionLong‐term TU in men with LOH and ED reduces obesity parameters and improves metabolic syndrome and health‐related quality of life. Yassin DJ, Doros G, Hammerer PG, and Yassin AA. Long‐term testosterone treatment in elderly men with hypogonadism and erectile dysfunction reduces obesity parameters and improves metabolic syndrome and health‐related quality of life. J Sex Med 2014;11:1567–1576.     

Unmet fertility expectations and the perception of fertility problems in a Malawian village

This study analyses in-depth interviews with 15 women and 11 men living in a rural Malawian village to know how fertility problems are identified and interpreted in a context of high fertility demand. Results of the analysis show that although ideal family size may be falling, expectations to quickly achieve pregnancies remain high. Individual and social expectations about childbearing inform the perception of fertility problems if more than a few months pass without a noticeable pregnancy. Such problems are usually attributed to women, especially if the male partner has proven his fertility with another spouse/sexual partner. Community education on variation in the time to conception is needed, as is an understanding of how perceived infertility, regardless of actual waiting time to pregnancy, can lead to treatment seeking and risky sexual behaviour.