Infertility is far more common than most people think. According to Resolve, The National Infertility Association, approximately one in eight couples in the United States—about 12 percent of the reproductive-age population—experience fertility problems and have difficulty achieving pregnancy.
The truth is that hundreds of variables must coincide precisely for conception to occur and for a woman’s body to successfully maintain a pregnancy for nine months. A healthy, fertile 30-year-old woman who has regular unprotected intercourse has about a 20 percent chance of conception during each menstrual cycle. Once she reaches age 40, the odds drop to about 5 percent each cycle.
There is no “typical” infertile patient. Lack of ovulation and sperm deficiencies are the most common infertility problems.
Ovulation is a complicated communication process between the hormones in a woman’s brain and the eggs and hormones in her ovaries. To understand ovulation problems related to infertility, you must first understand ovulation. As your menstrual cycle begins (day one of your period), your estrogen levels are low.
Your hypothalamus (the area of your brain responsible for maintaining hormone levels) tells your pituitary gland to start producing a hormone called follicle stimulating hormone (FSH). The FSH triggers eggs that are ready to start developing to grow. One of these egg follicles will develop into the dominant mature egg destined to ovulate, and the others degenerate.
Follicles produce estrogen, and when the estrogen levels reach a certain threshold, the egg is mature and ready to be released. The pituitary gland then releases a hormone called luteinizing hormone (LH) that causes the egg to mature and be released from the ovary wall and begin its 48- to 72-hour or so journey through the fallopian tube.
Ovulation problems can occur due to a number of factors:
- The ovaries may no longer contain eggs
- Eggs are present in the ovary but ovulation is disrupted because of a breakdown in the hormonal communication cycle
Age is also a major factor in a woman’s fertility. After age 35, a woman’s fertility rapidly declines. By age 43, there are fewer normal eggs remaining in her ovary, and she is less likely to conceive.
The quality of a woman’s eggs is critical to her chances of becoming pregnant. If a woman is having trouble conceiving, she may have an ovarian reserve test. If it indicates few high-quality eggs or a very low probability of conception, her physician may recommend using donor eggs.
While an older woman is more likely to have poor egg quality than a younger one, the condition can also affect younger women. Each year, about 20,000 in vitro fertilization (IVF) cycles include the use of donor eggs. Less common identifiable fertility problems for women include structural problems or scarring of the fallopian tubes and/or uterus caused by pelvic inflammatory disease (PID) or endometriosis (a condition causing adhesions and cysts), uterine fibroids or, very rarely, birth defects.
Sperm deficiencies can include low sperm production (oligospermia) or lack of sperm (azoospermia). Sperm may also have poor motility—they don’t move properly once inside the female reproductive tract to achieve fertilization. Additionally, sperm cells may be malformed or may not survive long enough to reach the egg.
About one-third of identifiable causes of infertility are due to male factors and about one-third are caused by female factors. Roughly one-third of infertility is couple-related, with a combination of problems in both partners preventing conception
An estimated 20 percent of infertility cases are unexplained; the source of the problem cannot be identified.
The majority of infertility cases are treated with medication or surgery. In vitro fertilization (IVF) and other types of assisted reproductive technologies (ART)—in which barriers to successful conception are overcome in the laboratory—account for a much smaller percentage of infertility treatments.
Most specialists recommend that couples with no known reproductive health problems try to get pregnant through intercourse for 12 months before seeking medical advice.
However, if a woman is 35 or older, has menstrual or ovulatory irregularities, known tubal problems, a history of miscarriages or thyroid conditions, she should consult a specialist much earlier in the process, usually at six months or sooner.
Men with known sperm deficiencies or a history of infections, cancer treatment or scrotal surgery should also consult a specialist early in the process.
If you are worried about fertility, you and your partner should:
- Consult a specialist early on.
- Educate yourself as much as possible about all aspects of infertility.
- Ask questions.
- Know your treatment options and what is financially and emotionally possible.
Some obstetricians/gynecologists may have gained significant on-the-job experience in treating infertility, combined with specialized coursework to enhance their knowledge. There are many fertility tests and treatments a competent ob/gyn can perform.
Fertility specialists are subspecialists in the field of obstetrics and gynecology known as reproductive endocrinology. Because the field is so specialized, there are far fewer reproductive endocrinologists in the United States than there are ob/gyns.
Urologists with a subspecialty in andrology are specialists who diagnose and treat male infertility.
Finding board-certified physicians in reproductive endocrinology—which means they completed extensive training and passed both oral and written examinations in the subspecialty—is one way to ensure that your health care professional is truly a specialist.
When looking for a specialist, be sure to ask about his or her training and how long the specialist has been practicing in the field of infertility. As with most medical evaluations, identifying potential fertility problems should begin with the easiest, least expensive and least invasive approach.
An initial evaluation should include:
- Medical histories of both partners, including questions about pelvic infections, sexually transmitted diseases (STDs), cycle length, prior obstetric history, surgeries, etc.
- Blood tests to screen for certain hormonal abnormalities in men or women
- An assessment of how often you ovulate
- Semen analysis (the quantity and quality of the man’s sperm).
- Hysterosalpingogram (HSG). A special dye is injected into the uterus through the vagina during an X-ray. This helps your health care professional to see both the uterine cavity and the fallopian tubes to see if they are open.
- Transvaginal ultrasound. This examination allows your health care professional to look at the thickness of your endometrium and for any abnormalities such as polyps, fibroids or ovarian cysts to see how well an egg could implant in the uterine lining. Newer tests that infuse a mixture of saline and air (Femvue) can also determine whether the fallopian tubes are functioning properly. Additionally, an antral follicle count can be performed during the ultrasound to determine the quantity of eggs remaining in the ovary. This is one of the “”ovarian reserve tests” commonly performed.
- Laparoscopy. During a laparoscopy, the surgeon inserts a thin telescope through a small incision below the belly button to view the outside of the uterus, ovaries and fallopian tubes. If the surgeon finds endometriosis or adhesions, he or she can remove them during the procedure. Laparoscopy is usually performed under general anesthesia.
- Hysteroscopy. During a hysteroscopy, a small telescope is inserted into the uterus. Small fibroids, polyps or scar tissue that may be preventing implantation can then be removed.
Insurance coverage varies for these diagnostic procedures. While some plans may cover some tests and specialized treatments, most are far from comprehensive. Check your insurance coverage carefully so you understand what tests are covered during the diagnosis and treatment stages.
Other medications. These drugs include:
- Leuprolide (Lupron) is a synthetic hormone that mimics gonadotropin releasing hormone (GnRH). Drugs like leuprolide are called GnRH agonists. Though these drugs mimic GnRH in action, their net effect is to suppress the release from the pituitary gland of both FSH and LH and therefore, ovulation. If given early in the cycle these drugs will cause a “flare” of pituitary gonadotropins. Long-term use of an agonist also cuts off estrogen production in the ovaries and prevents a woman from ovulating. These drugs can be used to treat endometriosis and uterine fibroids. In IVF, these drugs are used to prevent a woman from ovulating while she takes gonadotropins to stimulate egg maturation.
- Ganirelix (Antagon) and cetrorelix (Cetrotide) are GnRH antagonists similar in structure to GNRH. These drugs differ from agonists like leuprolide in that theydirectly cut off the production of FSH and LH (in contrast to leuprolide, which overstimulates the pituitary gland so it eventually stops producing FSH and LH). Like leuprolide, the GnRH antagonists help prevent premature ovulation during IVF.
- Metformin (Glucophage) is an insulin-sensitizing drug used to boost ovulation when insulin resistance is a known or suspected cause of infertility. Insulin resistance may contribute to the development of polycystic ovarian syndrome (PCOS). Metformin is sometimes used with clomiphene or FSH.
- Bromocriptine (Parlodel) is a medicine used for women with ovulation problems resulting from high levels of prolactin, a hormone that causes milk production.
For women receiving donor eggs, a combination of two or three hormonal medications is used to manipulate the menstrual cycle. The goal is to keep the egg recipient on the same cycle as her egg donor so her uterine lining is prepared to support the embryo once it is ready for implantation. Leuprolide is used to suppress the menstrual cycle, and estrogen supplements are used to get the cycle in synch with the donor’s cycle. Progesterone is usually used to prepare the uterus for implantation when the donor is ready for retrieval.
Fertility drugs may cause a variety of physical and emotional side effects. There was also some concern that they may increase the risk of ovarian cancer, but the most recent research shows this isn’t the case. However, infertility itself is a risk factor for ovarian cancer, while having children and using oral contraceptives protects against ovarian cancer.
Intrauterine Insemination (IUI)
Intrauterine insemination (also called artificial insemination) is a procedure in which the woman is injected with specially prepared sperm. In some cases, the woman takes medications to stimulate ovulation before the IUI procedure. IUI is a treatment option for couples in which the male has mild male factor infertility or the woman has problems with her cervical mucus, or in cases of unexplained infertility.
Assisted Reproductive Technologies (ART)
Assisted reproductive technologies offer another step in infertility treatment.
- In vitro fertilization (IVF). During this procedure, the ovaries are stimulated with one or more fertility drugs so they produce multiple eggs. The developing eggs are then removed in a minor surgical procedure lasting only a few minutes; mild anesthesia is usually given.
- Intracytoplasmic sperm injection (ICSI). ICSI is used when there are problems with sperm function or number or to improve chances of fertilization. With ICSI, an embryologist injects a single sperm directly into each egg. ICSI is a highly specialized procedure performed in conjunction with IVF.In IVF and ICSI, the eggs and sperm are then combined in a petri dish, which is placed in an incubator in specialized media to promote fertilization. After about 24 hours, the eggs are examined to see if they have been fertilized.
- If fertilization occurs, one or more embryos are transferred to the uterus during another procedure several days later or frozen for later use. According to the 2012 Assisted Reproductive Technology National Report from the U.S. Centers for Disease Control and Prevention (CDC), the success rate for IVF using fresh non-donor eggs or embryos is 40 percent of cycles for women under ages 35; 31 percent for women ages 35 to 37; 22 percent for women ages 38 to 40; 12 percent for women 41 to 42; 4 percent for women 43 to 44; and 2 percent for women over 44.
- Donor egg. Donor eggs are an option for women who cannot produce eggs or for whom egg quality is an issue. Another woman donates her eggs to be used for an IVF procedure. A woman using a donor egg becomes the biological mother to the offspring, but she doesn’t share the child’s genetic makeup. However, if the male partner’s sperm was used in the fertilization process, the child shares his genetic background. Each year, about 20,000 IVF cycles include the use of donor eggs. This procedure is most often recommended for women over 40 and for younger women with poor quality eggs.
- Donor sperm. Tested, screened and quarantined donated sperm is available with many sperm banks. The sperm can be used for IVF or related procedures.
- Gestational carrier. This is an option for women who cannot carry a pregnancy. A couple’s egg and sperm, or embryo, are placed in another woman’s uterus; she is known as the gestational carrier, who will carry the pregnancy and deliver the baby. However, she has no genetic relationship to the baby.
- Assisted hatching. This procedure is sometimes done in addition to IVF. After the embryo forms but prior to its transfer to the uterus, a special solution or laser is used to thin or make a hole in the outer covering of the embryo (called the zona pellucida). This might improve implantation by helping the cells of the embryo emerge from the outer shell, or hatch. This method is usually suggested for women over the age of 40 who have failed one or more IVF attempts or to remove fragments of cells from the embryo, but its use is still considered controversial and benefits have not been proven.
- Preimplantation genetic testing (PGT): With PGT, it’s now possible to screen embryos created by IVF for genetic diseases or defects before implantation. The goal is to decrease the chances of miscarriages or births with genetic abnormalities or genetic diseases such as cystic fibrosis or Tay Sachs disease. There are two types of PGT: preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS). PGD is done when parents carry a genetic condition to determine whether that condition has been transmitted to the egg or embryo. PGS is done when parents have no known genetic abnormalities but want to screen for chromosomal abnormalities (aneuploidy) such as Down Syndrome.
- Egg freezing. Another option is to freeze some of your eggs to help preserve your fertility. You may want to consider egg freezing if you will be undergoing radiation or chemotherapy for cancer treatment or if you want to store younger eggs for the future. Many fertility treatment centers now offer egg freezing. Ask your health care provider if egg freezing may be a good option for you.
If you decide to undergo fertility treatments and are choosing a treatment center, here are some questions you may want to ask:
- What is your center’s clinical pregnancy rate? Keep in mind that the success rates of an IVF center depend on many factors, and a comparison of clinic success rates may not be meaningful because patient characteristics and treatment approaches vary from clinic to clinic.
- What exclusion criteria does your center use to select patients for in vitro fertilization?
- What is the cancellation rate of patients my age? (Most fertility centers have a criteria that determines when they will cancel the IVF process before egg retrieval. For example, a center may cancel a cycle in which a woman produces too few follicles or follicles that are too small). Centers that have a very low cancellation rate may be highly selective in who they accept as patients.
- How many embryos does your center routinely implant for IVF? (Centers that implant more than two or three may have good pregnancy rates, but they will also have more multiple pregnancy rates, which can be risky to mother and babies).
- What are the center’s success rates for different types of procedures, particularly those I might face? (Figures should represent live birth rates, not just pregnancies.)
- Is the center still working with the same laboratory and specialists as when the statistics were generated?
There is no way to prevent infertility because there are many factors that contribute to your ability to ovulate, conceive and carry a pregnancy to term. Likewise, your male partner also has numerous factors—natural and environmental—that can contribute to infertility. The condition is not exclusively a woman’s problem. About one-third of infertility cases involve male factor problems alone, and approximately one-thirdinvolve problems with both partners.
For women, factors that could lead to infertility include:
- Being very overweight or very thin, either of which can affect ovulation and fertility.
- Chronic, debilitating diseases, such as unregulated diabetes, lupus or thyroid problems that can interfere with normal ovarian function. Also, some medications such as high-dose steroids can interrupt ovulation. If you have a chronic health condition, be sure to discuss it with your health care professional. Most women with chronic conditions can become pregnant, have a healthy pregnancy and deliver a healthy baby.
- Polycystic ovarian syndrome (PCOS). Symptoms include irregular or infrequent periods, excessive facial hair and acne.
- Surgeries on the cervix, abnormal Pap smears including cryosurgery or cone biopsy that can affect the function of the cervix.
- Hormonal imbalances that cause abnormalities in your menstrual cycles.
- Multiple miscarriages (two or more early pregnancy losses).
- Environmental factors, such as cigarette smoking, alcohol consumption, illegal drugs and exposure to workplace hazards or toxins.
- Medication including herbal or natural medication.
- Age. Even if your fertility does not seem at risk now, remember that fertility declines with age. A healthy, fertile 30-year-old woman who has regular unprotected intercourse has about a 20 percent chance of conception during each menstrual cycle. Once she reaches age 40, the odds drop to 5 percent each cycle.
- Sexually transmitted diseases (STDs), which occur at a rate of nearly 20 million cases each year in the United States. Some STDs don’t cause symptoms at first but, if left untreated, can lead to pelvic inflammatory disease (PID)—an infection of the upper genital tract that may compromise fertility by scarring and blocking the fallopian tubes; it can also lead to an ectopic pregnancy. To reduce your risk of STDs, use latex condoms during sex, avoid having sex with multiple partners and see a health care professional if you have any unusual symptoms such as pain, fever or vaginal discharge. Also make sure your partner is treated if you do have an STD. The best way to avoid STDs is abstinence or monogamy.
- Fallopian tube disease accounts for about 25 percent of infertility cases. If you are having trouble conceiving or are worried about your future fertility, consult with your health care professional. Make sure you disclose if you have ever had pelvic pain, unusual vaginal discharge, bleeding or fever; pelvic surgery for ruptured appendix, ectopic pregnancy or an ovarian cyst.
- Endometriosis, a disease in which endometrial tissue is found outside of the uterus, typically on the ovaries, fallopian tubes bladder and bowel, occurs in reproductive age women. While the connection between endometriosis and infertility is not clearly understood, advanced-stage endometriosis makes it very difficult for the egg and sperm to reach each other. Treatment of early stage endometriosis doesn’t seem to make a difference in pregnancy rates, but knowing you have it may influence your choice of reproductive technology. Be sure to report these symptoms to your health care professional: painful menstrual cramps that get worse over time, extremely heavy menstrual flow, diarrhea or painful bowel movements (especially around the time of your period) and painful sexual intercourse.
For men, a variety of factors can lead to infertility.
Many researchers believe the causes of declining sperm count during this century are environmental, including pesticide and chemical exposure, drug use, radiation and pollution.
Specific risks include:
- Exposure to toxic substances or hazards on the job, such as lead, cadmium, mercury, ethylene oxide, vinyl chloride, radioactivity and X-rays
- Cigarette or marijuana use
- Heavy alcohol consumption
- Prescription drugs for high blood pressure (calcium channel blockers), ulcers and psoriasis
- Chronic exposure of the genitals to elevated temperatures as may occur in some occupations can diminish sperm counts. Occasional visits to the sauna or hot tub will have no effect, however. Though some men may prefer boxers over briefs, boxers aren’t any better for sperm production.
- Medical conditions, including hernia repair, undescended testicles, history of prostatitis or genital infection, and mumps after puberty
- Some STDs can lead to epididymitis (inflammation of the duct that carries sperm). Ultimately, infertility can be a consequence of STDs. To decrease this risk, practice safe sex by using latex condoms. Also have any unusual symptoms checked out and treated early—and make sure both partners are treated simultaneously.
Infertility research is robust. Recent efforts include:
- Oocyte cryopreservation. This is now offered at many fertility centers to preserve a woman’s fertility, either for medical or social reasons. Freezing eggs can be performed without having to first fertilize them. This means that patients at risk of becoming infertile from cancer treatments or aging can preserve some eggs to retain the possibility of reproduction even after their eggs would have been either destroyed by chemotherapy or depleted due to aging.
- Ovarian tissue cryopreservation. This can be performed before chemotherapy or radiation treatments for cancer patients who do not have time to undergo an IVF cycle and freeze eggs. While some babies have been born as a result of this tissue being replaced back into the body, it is still considered experimental.
- Genetics and male factor infertility. The more we learn about the origins of male fertility problems, the more we find they have a genetic origin. Understanding the genetic errors that lead to poor semen quality and sperm production can lead to better management of these conditions.
- Embryo selection methods. These have been improving with the goal of being able to one day select the single embryo to transfer that will have the greatest probability of developing, thereby reducing the risk of multiple pregnancy. The latest advancement is development of the Embryoscope, an incubator that maintains the necessary conditions required to support a living embryo in the IVF lab. A special camera captures time-lapse images of an embryo’s development and records them in a video.
Facts to Know
- Infertility affects 6.7 million American women and their partners—about 12 percent of couples of reproductive age.
- Disorders of both the male and female reproductive systems cause infertility with almost equal frequency.
- Some infertile couples have more than one factor contributing to their infertility.
- Recent improvements in medication, microsurgery and in vitro fertilization (IVF) techniques make pregnancy possible for about half of couples pursuing treatment.
- Fallopian tube blockage or disease accounts for approximately 25 percent of all female infertility problems.
- Irregular or abnormal ovulation accounts for approximately 25 percent of all female infertility cases.
- Up to 30 percent of couples who have a complete fertility assessment are diagnosed with unexplained infertility because no specific cause is identified.
- I’ve been taking birth control pills for 10 years. Will that affect my ability to become pregnant when I’m ready?The birth control pill itself doesn’t affect long-term fertility. In the short term, a small number of women will have a delay after stopping the pill until they start ovulating again. This is more likely if the woman is either under- or overweight or engages in heavy aerobic exercise. For most women, ovulation resumes about two weeks after the last pill is taken. There is no need to wait to try to get pregnant after pill use. The common recommendation to wait three months has no scientific basis.Depo-Provera is an injectable form of hormonal contraception. One injection provides protection against pregnancy for up to four months. But its effects on fertility can last up to two years. This is not a rapidly reversible contraceptive and shouldn’t be used by women who wish to get pregnant within one year.
- I’ve had chlamydia and was wondering if this sexually transmitted disease affects my fertility?Chlamydia is one of the most common STDs in the United States. This STD frequently has no symptoms, especially in women. According to the CDC, only 5 to 30 percent of infected women experience symptoms. If left untreated, chlamydia can lead to pelvic inflammatory disease (PID), which can cause scarring of the fallopian tubes and eventually infertility. Infection without any symptoms can persist for years without detection. It is important for women to be screened for chlamydia through blood testing or cervical DNA testing.Chlamydia can be treated with oral antibiotics, though chronic infections may require a longer than typical treatment period. Acute infections with chlamydia can be treated with intravenous (IV) antibiotics. Despite proper treatment, ectopic pregnancy is more common in patients with a history of an STD.Other sexually transmitted diseases (STDs) can also affect fertility and, if you get pregnant, affect the health of a baby. Women who have had a history of STDs or known exposure to infection should discuss this issue with their health care professional to determine how fertility may be affected. Screening for STDs is a good idea at any time, but especially if you’re considering getting pregnant. Remember, a Pap test is not a test for STDs. Ask your health care professional specifically for an STD screen.
- My husband and I are ready to have a family. What can we do to ensure a healthy pregnancy?When planning a pregnancy, couples should begin by pursuing a healthful lifestyle. Eliminating cigarettes, alcohol and other recreational drugs, and increasing your focus on good nutrition, stress reduction and moderate exercise are the first steps to achieving a healthy pregnancy. Talk with your health care professional about your plans.
- Are hot tubs really bad for men?Not if the exposure is limited to a few minutes daily or less. Still, high temperatures can decrease sperm production. That’s why the scrotum is located outside the body—sperm production occurs at 95 degrees, cooler than normal body temperature. Thus, it’s a good idea for a man to avoid prolonged exposure to hot tubs, saunas and steam rooms when a couple is trying to become pregnant.
- What’s the most common cause of female infertility?Anovulation, when a woman fails to ovulate. Other causes include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a condition causing adhesions and cysts). Congenital anomalies (birth defects involving the structure of the uterus) and uterine fibroids are associated with repeated miscarriages.
- What is IVF and how much does it cost?In vitro fertilization (IVF) is used when a woman has blocked or absent fallopian tubes or when a man has a low sperm count or for other causes of infertility not responding to conventional treatment. In IVF, drugs are given to stimulate multiple eggs to develop, and then eggs are removed from the ovary and mixed with sperm outside the body in a petri dish. After about 24 hours, the eggs are examined to see if they’ve been fertilized and are growing. After an additional one to four days, some of these fertilized eggs (embryos) are then placed in the woman’s uterus. According to the American Society for Reproductive Medicine, the average cost of an IVF treatment in the United States is about $12,400.
- When is a donor egg used?Donor eggs are an option for women who cannot produce eggs or who have problems with the quality of their eggs. A woman using a donor egg becomes the biological mother to the baby, but she doesn’t share the child’s genetic makeup. However, if the male partner’s sperm was used in the fertilization process, the child shares his genetic background. Approximately 20,000 IVF procedures per year involve use of donor eggs.
- I have lupus and was wondering if that means I won’t ever be able to conceive?Chronic, debilitating diseases, such as unregulated diabetes, lupus or thyroid problems, can interfere with normal ovarian function. Also, some medications such as high-dose steroids can interrupt ovulation. On the other hand, if you don’t get pregnant, your chronic condition may not be the cause; many other things can affect fertility. Optimizing your health by treating your condition is critical before you conceive a pregnancy. Discuss your condition with your health care professional so that he or she can work with you to determine the real cause of your infertility—and don’t assume anything!
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