What is Infertility?
Infertility is a disease or condition of the reproductive system often diagnosed when a couple has had one year of unprotected, well-timed
intercourse, or when a woman has experienced multiple miscarriages and is under 35 years of age.
Infertility is defined as the inability to conceive or carry a pregnancy to term after 12 months of trying to conceive. One-third of
infertility cases are due to male factors, and about one-third are due to female factors. In about 20% of cases, infertility is unexplained,
and the remaining 10% of cases is due to a combination of problems in both partners.
There are various causes of infertility that can occur in both men and women.
What Causes Infertility in Women?
For three in 10 couples, the woman doesn’t produce enough eggs (ovulation). This may be a permanent problem for some women, but only a periodic
problem for others. Causes of ovulation problems include:
- Early menopause: This is when menopause occurs before the age of 40.
- Polycystic ovary syndrome (PCOS): PCOS occurs when complex changes take place in the hypothalamus, pituitary gland and ovaries, resulting in a hormone imbalance, which affects ovulation.
- Hormone imbalances: Imbalances such as an increase in the prolactin hormone or an increase or decrease in the thyroxine hormone may cause infertility.
- Medications: Certain medications and illegal drugs can decrease female fertility.
- Genetic disorders: Disorders such as inherited chromosome abnormalities or single-gene defects passed from parent to child can lead to infertility.
Female fallopian tube, cervix or uterine problems occur in approximately two in 10 couples with infertility. Problems include:
- Endometriosis: Responsible for one in 20 cases of infertility, endometriosis is a disorder that causes tissue that normally grows in the uterus to grow in other locations. This extra tissue growth, and surgical removal, can cause scarring that blocks the fallopian tube and keeps the egg and sperm from uniting. Endometriosis can also affect the lining of the uterus and prevent a fertilized egg from implanting.
- Pelvic inflammatory disease (PID): PID is an infection of the uterus and fallopian tubes caused by sexually transmitted infections.
- Damage to fallopian tubes: When the fallopian tubes become damaged, they can prevent contact between the egg and sperm. Pelvic infections and surgeries can lead to scar formation and fallopian tube damage.
- Large fibroids: Benign polyps or tumors can impair fertility by blocking the fallopian tubes or by disrupting implantation.
What Causes Infertility in Men?
Problems with male fertility can be caused by a number of health issues and medical treatments. These include:
- Infection: Current or past infections can affect sperm production or sperm health.
- Tumors: Nonmalignant tumors and cancers can affect the male reproductive organs or the glands that release reproductive hormones.
- Undescended testicles: Decreased fertility is more likely in men whose testicles have not descended properly.
- Medications: Certain medications and illegal drugs can affect sperm production and decrease male fertility.
- Testicle overheating: Increased scrotal temperature can reduce semen quality, but it is still unclear whether underwear type makes a significant difference in fertility.
- Varicocele: A varicocele is a swelling of the veins in the testicle. This can prevent normal cooling of the testicle and lead to reduced sperm count.
- Hormone imbalances: Infertility can result from problems with the pituitary gland in the brain, leading to Cushing’s disease or hyperprolactinemia.
Additional Risk Factors
Many of the risk factors for both male and female infertility are the same. They include:
- Age: With increasing age, the quality and quantity of a woman’s eggs begin to decline. Men over the age of 40 may be less fertile than younger men.
- Exercise: Lack of exercise can contribute to obesity, which increases the risk of infertility. Less often, ovulation problems may be from frequent, strenuous and excessive exercise.
- Alcohol use: For men, heavy alcohol use can decrease sperm count and motility. For women, there’s no safe level of alcohol use during conception or pregnancy. Alcohol use may make it more difficult to become pregnant.
- Weight: Women at risk of fertility problems include those with eating disorders or who follow a very restrictive diet. An inactive lifestyle or being overweight may increase the risk of infertility. In addition, a man’s sperm count may be affected if he is overweight.
- Long-term (chronic) illness: A long-term illness may affect fertility, as the body is not functioning normally.
Unexplained Infertility
In some instances, the cause for infertility is never found. It’s possible that the infertility is due to a combination of several factors in both partners. In approximately
three in 10 couples with infertility, no cause can be found.
Diagnosing Infertility
There are a number of tests available to help determine the cause of infertility. After a couple has undergone a comprehensive physical exam and medical history, a fertility
specialist will begin a series of tests based on the suspected source of infertility.
Tests for Women
- Basal body temperature (BBT) charting: BBT is the lowest temperature of the body during rest, which usually occurs during sleep. BBT is generally measured immediately after waking and before taking part in any physical activity. In women, ovulation causes a temperature increase of one-half to one degree Fahrenheit in BBT. Monitoring of BBT is one of the most common ways to estimate the day of ovulation. Women generally have lower temperatures before ovulation and higher temperatures after ovulation. Charting of this pattern may be used to aid fertility awareness.
- Endometrial biopsy: This test can diagnose problems in the endometrium (lining of the uterus) and allows the doctor to see if hormone levels that affect the endometrium are in balance.
- Urinary luteinizing hormone (uLH) detection: This test is very helpful for timing diagnostic procedures, inseminations and intercourse.
- Ultrasonography: This test uses sound waves to show the internal status of the uterus, ovaries and ovarian follicles. It is very useful in evaluating follicular development and ovulation. The loss of follicular size, loss of clear follicles, and appearance of fluid all suggest ovulation. The presence of multiple small follicles indicates polycystic ovarian disease.
- Hysterosalpingogram (HSG): A small amount of radio-opaque fluid is injected into the uterus and fallopian tubes, which are then x-rayed. It is useful to determine if the uterus is normal and ensure the fluid spills out of the fallopian tubes. Blockage or other problems can be located during this test.
- Magnetic resonance imaging (MRI): This procedure can help differentiate adenomyosis (uterine thickening that occurs when endometrial tissue moves to the outer muscular walls of the uterus) from myomas (non-cancerous, benign tumors that grow within the muscle tissue of the uterus). It can also help identify complex congenital uterine abnormalities as well as rare uterine abnormalities or pelvic masses.
- Post-coital test: This has been the standard test for evaluating cervical factor infertility. It can help identify difficulty in timing intercourse, sexual dysfunction, poor cervical mucus, infection, low sperm count and/or motility, and the presence of antibodies. However, the test is not very accurate.
- Female cervical and male urethral cultures: This procedure tests for the presence of infections like E. coli, gonorrhea, chlamydia and mycoplasma.
Tests for Men
- Semen analysis: Semen analysis is the most direct, simple and cost-effective test of male fertility. A laboratory analyzes a semen specimen for sperm and semen fluid health.
- Sperm function tests: These tests can help assess the ability of sperm to penetrate the egg.
Treating Infertility
Treatment of infertility depends on the cause, the couple’s age and how long the couple has been infertile. Fertility treatment can be grouped into three categories:
- Medication: Medications for infertility can be used in addition to assisted conception.
- Surgical treatments: These may be used when a cause for infertility is found and can be corrected through surgery.
- Assisted conception: This includes techniques such as intrauterine insemination (IUI), in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT) and intracytoplasmic sperm injection (ICSI).
Medications
Controlled ovarian hyperstimulation (COH) is an integral part of many infertility treatments because the development of a single follicle with a good egg,
or the development of multiple follicles, improves pregnancy rates. There are numerous ways (protocols) to achieve COH. The most widespread protocols involve
the use of fertility drugs, including:
- Clomid®, Serophene® (clomiphene citrate) is an oral tablet that stimulates ovulation for women with irregular menstrual cycles or stimulates the development of extra eggs.
- Follicular stimulating hormone injections (Bravelle®, Follistim®, Gonal-f®) replace deficient or abnormal FSH serum levels in patients with ovulation problems. These agents act directly on the ovaries and are often prescribed to stimulate the development of multiple eggs during IVF or GIFT cycles. FSHs are often prescribed for patients who don’t respond to clomiphene or for assisted reproductive treatment (ART) procedures.
- GnRH agonists (Cetrotide®) are injections that prevent premature ovulation before egg retrieval during IVF, GIFT or other ART retrieval cycles.
- Human menopausal gonadotropin (hMG) (Menopur®, Ovidrel®, Repronex®) is an injection that contains both FSH and LH. These agents act directly on the ovaries and are often prescribed to stimulate the development of multiple eggs during IVF or GIFT cycles.
- Human chorionic gonadotropin (hCG) (Pregnyl®) is an injection used to mimic LH surge in ART cycles to induce exactly timed ovulation.
- Progesterone (Endometrin®) is the hormone that supports development of the uterine lining in the luteal phase and prepares the embryo to implant. It is often administered during the luteal phase of ART cycles or to treat inadequate luteal phase.
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