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Infertility



 
 
 
About infertility
Infertility is an inability to conceive after 12 months of unprotected sexual intercourse in an effort to become pregnant. It refers to a state in which a couple has a diminished capacity to conceive. It should not be confused with sterility, which is a physical inability to become pregnant.
 
About one-third of infertility cases can be attributed to males, another one-third to females and the remaining one-third to both members of a couple, or to causes that go unexplained. The latter make up roughly 20 percent of infertility cases.

Infertility occurs because the human reproductive process is so intricate that even a minor disruption may be enough to derail conception. Each month, hormones produced in the woman’s pituitary gland signals the ovaries to prepare an egg for ovulation. These hormones are called follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

Women are most fertile during this period of ovulation, which occurs around the 14th day of the menstrual cycle. However, the exact time of ovulation varies among women because of normal differences in the length of the menstrual cycle. After a woman ovulates, the egg is captured by the fallopian tube and begins its passage to the uterus. For fertilization to occur naturally, the sperm and egg must unite in the fallopian tube. The greatest odds of fertilization occur in the first 12 hours. Sperm can fertilize the egg for up to 72 hours after ejaculation. If fertilized, the egg moves and implants into the uterus two to four days later.
 
For conception to occur, hundreds of variables must develop in just the right way. When no fertility problems are present, the average couple between the ages of 29 and 33 has about a 20 to 25 percent chance of becoming pregnant during any given menstrual cycle, according to studies carried out abroad.
 
Infertility results when something disrupts this process and prevents conception. This can be due to problems with the hormones, the egg or sperm or with transport, penetration of the egg by sperm and fertilization. It can be due to medical or mechanical issues. There are many treatments that can help couples overcome obstacles to conception. Although not always successful, these methods often result in fertilization and the eventual birth of a healthy child.
 
 
 


 
 


Check out our page on the Infertility Support Group - a branch of the Cana Movement.
 
 
  
There are many potential causes of infertility. Overall, about one-third of infertility cases can be attributed to males, another one-third to females and the remaining one-third to both members of a couple. At least 20 percent of infertility cases go unexplained, although these couples often later succeed in becoming pregnant.
 
Ovulation abnormalities in women and sperm deficiencies in men are responsible for two-thirds of infertility problems. When ovulation fails to occur, there is no egg available for fertilization.
 
 In some cases, this is a result of a breakdown in a woman’s hormonal communication cycle. This disruption takes place in the part of the brain that regulates ovulation, known as the hypothalamic pituitary axis. This can cause deficiencies in the production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Specific causes of this disorder include:
  • Direct injury to the hypothalamus or pituitary gland
  • Pituitary tumors
  • Excessive exercise
  • Anorexia nervosa

Ovulation problems may also occur when the ovaries no longer contain eggs to be fertilized, or scar tissue prevents ovulation from occurring. Signs of ovulation problems include irregular menstrual periods or the absence of menstruation (amenorrhea).

Smoking may contribute to infertility in men and women. In women, smoking is harmful to the ovaries, and in men smoking lowers sperm count and impairs sperm motility.

Difficulties with a man’s sperm can also cause infertility. Most cases of male infertility are associated with:

  • Low sperm production (oligospermia).
    Lack of sperm (azoospermia).
  • Poor sperm motility. Sperm may not move properly inside the female reproductive tract (poor motility) or may be malformed or die before reaching the egg.
  • Variocele veins. Varicose veins in the scrotum that may prevent normal cooling of the testicles and raise temperature, preventing sperm from surviving.
  • Undescended testicle. Occurs during development and may cause mild to severely impaired sperm production.
  • Testosterone deficiency. May be caused by testicular disorders or an abnormality that affects the pituitary gland in the brain that produce the hormones and control the testicles.
  • Infection. Infection may affect sperm motility. Repeated incidents of sexually transmitted diseases (STDs) can cause scarring and block sperm passage, and are most often associated with male infertility. A mumps infection after puberty may cause inflammation of the testicles that can impair sperm.
  • General health and lifestyle. Lifestyle factors that can affect fertility include obesity, emotional stress, tobacco and alcohol use, drug use, other medical conditions, and age over 35 years.
    Factors that impair the delivery of sperm from the penis to the vagina can also cause infertility (e.g., erectile dysfunction, misplaced urinary opening in the penis with sometimes retrograde ejaculation).

There are many different sources of female infertility. The most common include:

  • Fallopian tube damage or blockage. Most often results from inflammation of a fallopian tube, a condition known as salpingitis. The STD chlamydia is the most common source of this disorder, which may cause pain or fever, but sometimes does not cause symptoms. About 20 percent of infertility cases are the result of fallopian tube damage. Symptoms include pelvic pain, unusual vaginal discharge, bleeding and fever.
  • Endometriosis. Occurs when the tissue that makes up the lining of the uterus is found outside the uterus on the ovaries, fallopian tubes, bladder or bowel. Symptoms include painful menstrual cramps, very heavy menstrual flow, diarrhea or painful bowel movements, painful sexual intercourse and chronic pelvic pain. Between 30 and 40 percent of women with endometriosis are infertile. Infertility increases with the severity of the disease. The fertility of women with mild disease may not be compromised. In some cases, infertility in endometriosis is due to:
    • Ovarian cysts (endometriomas). These may indicate advanced endometriosis. The cysts can usually be removed with surgery.
    • Scar tissue. In some cases, endometriosis causes rigid webs of scar tissue (adhesions) between the uterus, ovaries and fallopian tubes. This may prohibit the transfer of the egg to the fallopian tube. It is the presence of significant adhesions that can impair fertility in women with endometriosis.
  • Hormonal imbalances. The normal variation in the length of the menstrual cycle in women may cause difficulties in determining the time of ovulation. Some imbalances may cause unpredictable cycles. In addition, elevated levels of the hormone prolactin (hyperprolactinemia) – which may indicate a pituitary tumor – may affect ovulation in women who are not breastfeeding.
  • Polycystic ovarian syndrome (PCOS). A type of reproductive disorder in which excessive amounts of androgens (male hormones such as testosterone) are produced by the ovaries. This may prevent the follicles of the ovaries from producing a mature egg.
  • Sexually transmitted diseases. Left untreated, some STDs can lead to pelvic inflammatory disease (PID), and infection of the upper genital tract that may hamper fertility. Other complications include scarring, adhesions, blocked fallopian tubes, ectopic pregnancy and miscarriage. The STDs chlamydia and gonorrhea are the most important preventable causes of infertility, according to the U.S. Centers for Disease Control and Prevention.
  • Early menopause. This is defined as the absence of menstruation and the depletion of ovarian follicles before age 35. The cause is often unknown, but may include autoimmune disease, radiation or chemotherapy, or smoking.
  • Uterine fibroids. These small noncancerous (benign) tumors of the uterine wall may block the fallopian tubes as well as affect the lining of the uterus which may prevent implantation.
  • Pelvic adhesions. Bands of scar tissue that bind organs after pelvic infection, appendicitis, and abdominal or pelvic surgery. They may limit the ability of the ovaries and fallopian tubes to function.
  • Thyroid problems. Disorders of the thyroid gland can disrupt the menstrual cycle and trigger infertility.
  • Cancer. Certain cancers – particularly gynecological cancers – can impair fertility. In addition, cancer treatments such as radiation and chemotherapy may affect a woman’s ability to conceive.
  • Maternal exposure to DES. Diethylstilbestrol (DES) is a synthetic estrogen that was developed in 1938 to supplement natural estrogen production. Women who were exposed to DES in the womb, known as DES daughters, are at an increased risk of gynecological problems, including infertility.
  • Diseases associated with amenorrhea (absence of menstruation) or delayed puberty. These include Cushing’s disease, sickle cell disease, HIV and AIDS, kidney disease and diabetes. In addition, girls who have eating disorders such as anorexia and bulimia often develop menstruation irregularities that can lead to infertility.
  • Multiple miscarriages. Two or more losses of pregnancy can lower the odds of further pregnancies.
  • Being overweight. Infertility can result from a sedentary lifestyle and being overweight or obese. These issues can affect many aspects in the process including ovulation.

In addition to irregularities, aging can also reduce a woman’s fertility. After age 35, a woman’s fertility rapidly declines as her ovaries produce fewer viable eggs. Egg quality is a major factor in whether a woman becomes pregnant. Women can increase their odds of becoming pregnant by trying to conceive earlier in life. Most women are about 30 percent less fertile in their late 30s than they were in their early 20s.
 
Women who take birth control pills over many years do not become infertile. Once they stop taking the pill, they can become pregnant, although initially there may be lingering effects from the last use that could prevent conception. This lag period can last for up to three months after the last use.
 
 


Most experts suggest that couples who have no known fertility problems should wait until one year after trying regular unprotected sexual intercourse to get pregnant before they seek out help. However, it is recommended for women over age 35 who are seeking their first pregnancy and women with certain disorders to seek assistance prior to attempting to become pregnant. These disorders include:
 
  • Menstrual or ovulatory irregularities
  • Tubal problems
  • Miscarriages
  • Thyroid conditions
  • Sexual dysfunction
  • Pelvic disease

In addition, couples may want to seek fertility help if the man has known sperm deficiencies or a history of illness or surgery in the genital region.

Fertility specialists are a group of experts in the field of reproductive endocrinology who have received special training in issues relating to treating infertility. During a visit to a fertility specialist, a physician is likely to obtain a medical history of both partners, including previous history of sexually transmitted diseases (STDs), pelvic infections and other illnesses.

A physical examination of the fallopian tubes, cervix and uterus will be performed on the woman. In addition, blood tests may be performed to check for hormonal imbalances in both the female and male partner. An assessment of a woman’s ovulatory regularity will be undertaken, as will an x-ray with a dye of the fallopian tubes and uterus – called a hysterosalpingogram. Finally, a qualitative and quantitative examination of a man’s sperm will be completed.

Sperm motility may be evaluated through the use of the postcoital test. The couple is asked to have unprotected sexual intercourse about eight hours before the test is scheduled. The test examines the female partner's cervix for the presence of sperm in the mucus. It provides information about sperm pickup, motility and storage within the cervical canal. This test is no longer widely used.

In some cases, a woman will also undergo an examination known as laparoscopy. Performed using general anesthesia, it involves inserting a thin viewing device through an incision and into the abdomen and pelvis to examine the fallopian tubes, ovaries and uterus.

A similar procedure, hysteroscopy, also can be done whereby the inside of the uterus is examined with an illuminated instrument to detect the presence of polyps, fibroids, septums or other barriers to successful pregnancy implantation.

Between 75 and 85 percent of fertility problems are diagnosed after a patient’s initial evaluation. When a diagnosis is not made, additional testing may be necessary. In some cases, insurance will cover diagnostic testing. Couples should consult with their provider before undergoing tests if insurance coverage is a concern. In some cases, testing can take up to three months or longer.

Many couples also find preconception counseling to be beneficial. This is especially true of women over age 35, who are at increased risk of giving birth to children with chromosomal abnormalities (e.g., Down syndrome).
 
 
 


 

 
In most cases, couples struggling with infertility will have options that may increase the odds of becoming pregnant.

In 85 to 90 percent of all cases, infertility is treated with either medication or surgery, according to the American Society for Reproductive Medicine. Less than 5 percent of infertility treatments involve in-vitro fertilization or other kinds of assisted reproductive technologies (ART), in which a laboratory is used to try to help a couple become pregnant.

Fertility drugs are usually the first option for couples. Up to 90 percent of women who seek fertility treatment will use medications at some point. These drugs are intended to correct hormonal imbalances and to stimulate the production of mature eggs. They include:

  • Clomiphene citrate. Causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg. About 60 percent of women who use this drug will ovulate following treatment, and 40 percent of these women will go on to become pregnant. The drug is taken in pill form and is easy to use. It tends to be more effective in women who experience abnormal ovulation cycles than in those who regularly ovulate. It can cause side effects such as swelling of the ovaries, multiple pregnancies, hot flashes, mood swings, weight gain, water retention, depression and irritability.
  • Gonadotropins. These drugs can correct many ovulation problems except ovarian failure and generally have a higher rate of success than clomiphene citrate. Pregnancy rates can reach 100 percent for some ovulation problems. However, gonadotropins are much more likely to cause multiple births. In rare cases, they may also cause severe medical complications. Examples of gonadotropins include:
    • Human menopausal gonadotropin (hMG). This drug is used for women who do not menstruate because of the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, hMG is an injected prescription medication that directly stimulates the ovaries instead of stimulating the pituitary gland. This drug contains both FSH and LH.
    • Human chorionic gonadotropin (hCG). Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to ovulate.
    • Gonadotrophin-releasing hormone (GnRH) analogs. A treatment used in women with irregular ovulatory cycles or who ovulate prematurely during hMG treatment. GnRH analogs deliver constant GnRH to the pituitary gland, which alters hormone production. This allows a physician to induce follicle growth with FSH.
  • Follicle-stimulating hormone (FSH). This drug is essentially hMG without the LH. Like hMG, it also works to stimulate the ovaries to mature egg follicles.
  • Letrozole. Sometimes prescribes for women who do not ovulate on their own and who do not respond to clomiphene citrate treatment. The drug is normally used in treatment of advanced breast cancer.
  • Metformin. May be used to boost ovulation when insulin resistance is known or suspected.
  • Bromocriptine. Used when high levels of prolactin – the hormone that stimulates milk production in new mothers – causes irregular ovulation cycles. This drug lowers prolactin production.
    Fertility drugs work for many women but the use of fertility drugs raises the risk of having multiple births. In addition, there is some speculation that using these drugs may increase the risk of developing ovarian cancer. This link has not been conclusively established.

If medications fail to help a woman become pregnant, other options remain. Most involve implantation of the fertilized egg into the woman’s uterus. Such techniques are known as ART.

Several factors can reduce the odds of successful fertilization using ART. These include advanced maternal age, presence of large submucous fibroids or polyps, abnormal endometrial development and the presence of a hydrosalpinx (collection of watery fluid in the fallopian tube).

To ensure a woman is a good candidate for ART, she may receive several tests, including:

  • Hysterosalpingogram (HSG). Uses radio-opaque dye during fluoroscopy (x-ray) of the abdomen and pelvic region. This procedure allows the physician to examine the uterine cavity and to note whether the fallopian tubes are blocked (tubal patency).
  • Saline-infusion sonogram (SIS). Sterile saline is inserted into the uterus to allow the physician to evaluate the contour of the uterus during an ultrasound. It differs from HSG in that it does not expose the patient to radiation, but it does not provide as clear a picture of tubal function and patency as HSG.
  • Transvaginal ultrasound. Reveals the thickness of the endometrium and uterine blood flow in relation to the ability of an egg to implant. Blood flow should rise during implantation, and some research has indicated that high uterine blood flow rates are associated with high implantation rates.

Implantation techniques include:
  • In-vitro fertilization (IVF). The patient receives fertility drugs that ensure that enough eggs are available to be removed for the IVF procedure. The eggs are removed from the ovary through the vagina using an ultrasound-guided aspiration technique. The procedure is usually performed in a physician’s office using a local anesthetic. The eggs are then combined with sperm in a Petri dish that is placed in an incubator. Once fertilization occurs, the resulting embryos are either frozen for later use or placed in the uterus in a separate procedure.
  • Gamete intrafallopian transfer (GIFT). Uses the same stimulation process as IVF except that the eggs and sperm are combined and immediately transferred into the fallopian tube. This allows fertilization to take place in the body. The procedure can be performed only on women who have normal fallopian tube function. GIFT is usually performed using general anesthesia.
  • Zygote intrafallopian transfer (ZIFT). This procedure is a combination of IVF and GIFT and has a similar success rate to those procedures. Eggs are retrieved from the ovaries via a laparoscope and combined with sperm in a Petri dish. The fertilized egg is then placed in the fallopian tube 24 hours later. As with GIFT, general anesthesia is used and a woman’s fallopian tubes must be functional for the procedure to work.
  • Intracytoplasmic sperm injection (ICSI). Used when sperm function or number of sperm are inadequate for fertilization. It can also be used when a fertilization defect is discovered when attempting IVF. In this procedure, sperm is injected into the cytoplasm (cell matter, excluding the nucleus) of a single egg.
  • Donor egg. Women who cannot produce their own eggs or who have poor-quality eggs may use an egg donated by another woman as part of an IVF process. In this method, the woman gives biological birth to the child, but the child does not share the woman’s genetic makeup. The procedure is successful between 30 and 60 percent of the time, according to the NWHRC.
  • Donor sperm. If the father’s sperm is inadequate – or if the mother does not have a male partner to father her baby – donor sperm can be used to fertilize the woman’s egg.
  • Gestational hosting. Some women cannot carry a pregnancy. In such circumstances, a couple’s egg and sperm may be placed in another woman’s uterus. The woman who gives birth to the baby does not share her genetic makeup with the child. In a variation on this procedure, the surrogate mother may also donate her egg. In such instances, the woman who gives birth to the child also shares her genetic makeup with the child.

In some IVF or combination IVF/ICSI procedures, a technique known as assisted hatching can be used to improve implantation rates. Once the embryo has formed, the outer covering (zona pellucida) is thinned with a special harmless solution. This helps in the hatching process, allowing the cells of the embryo to emerge from the outer shell and implant in the uterus. The method is most likely to be used in women over age 35 or women who have experienced repeated failure of IVF attempts.

Similar to fertility drugs, ART techniques come with some risks. These include higher incidences of:

  • Multiple births
  • Enlarged ovaries (ovarian hyperstimulation syndrome)
  • Bleeding or infection
  • Low birth weight
  • Birth defects

Many couples are unprepared for some of the obstacles that accompany fertility treatments. Treatments can be costly and many times they require multiple procedures for a successful pregnancy. Treatments often can be emotionally draining and may cause significant mood swings in women. In addition, patients may find that the physical and emotional toll of treatment impacts their professional and social lives.

All that effort is often rewarded in the birth of a child. More than 70,000 babies have been born in the United States using assisted reproductive technologies, including 45,000 born as a result of in-vitro fertilization, according to the National Women’s Health Resource Center.

However, in other cases treatments may fail. It is not unusual for couples to find that the stress of treatments has a negative impact on their relationship. At some point, couples may find themselves having to accept that conception is not going to occur, and that it is time to stop treatments and choose another option, such as adoption or child-free living. Good communication and mutual support can help couples get through this trying time.
 
 


 
 

In many cases, there is no way to prevent biological infertility. However, there are several factors that can contribute to infertility in women. Some can be prevented or treated, thereby enhancing the odds of fertilization, including:
 
  • Weight irregularities. Excessive or deficient levels of body fat may affect ovulation.
  • Environmental factors. Cigarette smoking, alcohol consumption and exposure to workplace hazards or toxins can reduce fertility.
  • Overexertion during exercise. Women who exercise too intensely (e.g., ballet dancers, gymnasts) are at risk for having menstrual cycles that are infrequent or absent, impairing fertility.
  • Limit use of medications. Use of certain medications also can interfere with fertility. Consult with a physician to determine if a medication can affect fertility. In many cases, a woman will regain her fertility once medication use is stopped.
 
 
 
 



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