Infertility

If you are having difficulty getting pregnant, you are not alone. Infertility, defined as the inability to become pregnant (conceive) after one year of unprotected sex, is common among women in the United States, affecting about 11 percent of married and unmarried women aged 15 to 44. If you are more than 35 years old and have not conceived after six months of trying, consider making an appointment with a reproductive endocrinologist today.

Causes of Infertility

A problem can occur in any one of the steps in the conception process: ovulation, fertilization, or implantation. In some instances, a cause may not be identified, and you may be given a diagnosis of unexplained infertility.

A reproductive endocrinologist will evaluate both you and your husband or partner. Men are as likely as women to have a problem with fertility:

“A CDC study analyzed data from the 2002 National Survey of Family Growth and found that 7.5 percent of all sexually experienced men younger than age 45 reported seeing a fertility doctor during their lifetime — this equals 3.3 – 4.7 million men.” (Centers for Disease Control and Prevention, 2013)

Infertility in Men

Your partner will most likely undergo a semen analysis, which will check the concentration (sperm count), motility (movement), and morphology (shape) of his sperm. This will not necessarily determine whether a man is infertile, but rather how his semen may be affecting conception and whether further testing may be required.

Certain conditions can cause abnormal semen:

• Varicocele (enlarged testicles)
• Underlying disease (such as diabetes, cystic fibrosis, infection, testicular failure, or cancer treated with chemotherapy or radiation)
• Testicular trauma
• Drug abuse (alcohol, testosterone supplementation, anabolic steroid use, and illicit drug use)
• Exposure to pesticides and lead

Infertility in Women

Your reproductive anatomy—your ovaries, fallopian tubes, and uterus—must be intact in order for you to become pregnant. A number of conditions can affect these organs and contribute to female infertility. A specialist can determine whether one of these conditions may be a contributing factor by reviewing your medical and sexual history and administering various tests.

No test is 100 percent accurate—diagnosis is usually based on a combination of factors. Your evaluation will include one or more of the following:

• Review of your medical history: You will be asked about your general health and the regularity of your periods—i.e., whether they occur every 24 to 32 days, with a typical menstrual cycle occurring every 28 days. Your specialist will also want to know whether you have risk factors for blocked fallopian tubes (tubal occlusion), such as pelvic infection, ruptured appendicitis, gonorrhea, chlamydia, endometriosis, or abdominal surgery.
• Blood testing for sexually transmitted diseases: Gonorrhea and chlamydia can affect fertility in both men and women.
• Measurement of your progesterone level: Ovulation can be predicted by using an ovulation predictor kit, and can be confirmed with a blood test to measure the woman’s progesterone level. This may be done at different times during your menstrual cycle to determine whether you are ovulating.
• Blood tests for hormone levels: Measuring the levels of follicle-stimulating hormone, anti-müllerian hormone, and estrogen on the second, third, or fourth day of the menstrual cycle can determine ovarian reserve.
• Clomiphene citrate challenge test and ultrasound assessment of follicle numbers, called the antral follicle count: This is another way of testing ovarian reserve.
• Transvaginal ultrasound examination: This test is used to evaluate ovarian function and look for fibroids in the uterus or other anatomic abnormalities.
• Sonohystogram or hysteroscopy: One of these tests may be performed to further evaluate the uterine environment if you have fibroids and your specialist suspects that the fibroids may be entering the endometrial cavity.
• Hysterosalpingogram (HSG): In this test, a radiologist injects dye into the uterus through the cervix and simultaneously takes X-ray pictures to see if the dye moves freely through the fallopian tubes. This helps evaluate tubal caliber (diameter) and patency. This test is often performed in women who are considering intrauterine insemination (IUI).
• Chromopertubation: This test is similar to an HSG, but is done in the operating room at the time of a laparoscopy. Blue-colored dye is passed through the cervix into the uterus, and spillage and tubal caliber (shape) is evaluated.

Factors That Increase the Risk of Infertility

Women who have had irregular periods or no menstrual periods, very painful periods, endometriosis, pelvic inflammatory disease, or more than one miscarriage may have an increased risk of infertility. Excessive physical or emotional stress that results in absent periods (functional hypothalamic amenorrhea) is known to affect female fertility. Smoking, alcohol abuse, and extreme changes in weight are other risk factors.

If you have irregular periods, you may not be ovulating. Anovulation may be caused by several conditions. One potential cause of anovulation is polycystic ovary syndrome. This is a hormone imbalance problem that can interfere with normal ovulation, and it is the most common cause of female infertility.

A woman’s chance of getting pregnant naturally declines with age. Today, many women are waiting until their thirties and forties to have children, and age is a growing cause of fertility concerns.

“Each month that she tries, a healthy, fertile thirty-year-old woman has a 20 percent chance of getting pregnant. That means that for every 100 fertile thirty-year-old woman trying to get pregnant in one cycle, twenty will be successful and the other eighty will have to try again. By age 40, a woman’s chance is less than 5 percent per cycle, so fewer than 5 out of every 100 women are expected to be successful each month.” (American Society of Reproductive Medicine, 2012)

Women over the age of 35 have fewer eggs, and their eggs may not be as healthy. The ovaries become less able to release eggs. Older women are more likely to have health conditions that can cause fertility problems and are more likely to have miscarriages.

Treatment for Infertility

Whatever the cause of your problem, a variety of treatment options exist. Treatments include medicine, surgery, IUI, and assisted reproductive technology (ART), and are often combined to optimize results. Your doctor will help you and your partner decide which treatment is best for your situation, and will recommend treatments based on the specific factors contributing to your problem, and on your age. You will be counseled about the success rates, risks, and benefits of each treatment option.

Male Infertility Treatments

Medical and surgical treatments for male infertility are usually managed by an urologist who specializes in this area. A reproductive endocrinologist may offer IUIs or in-vitro fertilization (IVF) to help overcome the problem.

Female Infertility Treatments

The first four treatments listed below are typically options for women who would like to conceive using their own eggs and their partner’s sperm. Surrogacy may be an option for a woman with no eggs or unhealthy eggs.

• Fertility drugs: Many fertility drugs are available. These include clomiphene citrate, human menopausal gonadotropin or hMG, follicle-stimulating hormone or FSH, gonadotropin-releasing hormone (Gn-RH) analog, metformin, and bromocriptine. While these medicines are helpful, they can increase a woman’s chance of having multiples. Having multiple fetuses is considered a high-risk pregnancy because of the risk of premature birth and health and developmental problems.

• Intrauterine insemination (IUI): Also called artificial insemination, IUI is performed by inserting specially prepared sperm into the woman’s uterus. You may receive fertility medicines, such as clomiphene citrate and human menopausal gonadotropin, to stimulate ovulation before IUI. IUI is often used to treat male factor infertility and couples with unexplained infertility.
• Assisted reproductive technology (ART): In ART, both eggs and sperm are handled outside the body. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. IVF is the main type of ART.
• Gestational carrier: This may be an option for a woman with ovaries but no uterus, or for a woman who shouldn’t become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by her partner’s sperm and the embryo is placed inside the carrier’s uterus.
• Surrogacy: This involves injecting the man’s sperm into a surrogate—a woman who agrees to become pregnant with her own egg. The child will be genetically related to the surrogate and the male partner.