What is infertility?

Infertility is a problem of the reproductive system. It affects the body's ability to reproduce. It could be caused by a problem with the man’s system, the woman’s system, or both. For a pregnancy, the following must happen:

• The man must have healthy sperm.
• The woman must have healthy eggs.
• The fallopian tubes must be open to let the sperm to reach the egg.
• The sperm must be able to fertilize the egg.
• The fertilized egg must implant in the uterus.
• The embryo must be healthy.

Infertility is not just a woman's concern. Half the time, a male problem causes or contributes. Many couples have more than one factor that plays a role.

In a few cases, a cause for infertility can’t be found.

If you think you are not able to get pregnant, see your healthcare provider early. The age of the woman and how long the couple has been trying to get pregnant may affect treatment.

What causes infertility?

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Many things can cause infertility. It can be a problem in the female reproductive system, the male reproductive system, or a mix of the two. The following are things that can affect infertility:

Female factors

• Ovulation problems. The woman doesn’t make enough hormones to develop, mature, and release a healthy egg.
• Anatomical problems. A problem with the woman’s anatomy can prevent the egg and the sperm from meeting. The most common problem is blocked fallopian tubes. Other problems may include scar tissue in the pelvis from past surgeries or infections.
• Endometriosis. The tissue that lines the uterus implants outside the uterus in this condition. It usually implants on other reproductive organs or in the belly. Each month, this misplaced tissue reacts to the hormone changes of the menstrual cycle. This means it builds up, breaks down, and bleeds. This can cause scar tissue to form and affect fertility.
• Birth defects. Certain birth defects can affect fertility such as uterine septums that devide uterus and hinder implantation of the embryo. Fortunately these septums can be resected with todays technological advances and normal preganancy can be achieved.
• Infection. Pelvic inflammatory disease (PID) is caused by a type of bacteria such as gonorrhea and chlamydia. PID can affect the uterus, fallopian tubes, the ovaries, or all three. It causes scar tissue to grow between organs. This leads to ongoing pelvic pain and raises the risk for an ectopic pregnancy. This is when the fertilized egg implants outside the uterus.
• Immune system problems. A problem with a woman's immune system can lead to pregnancy loss. Antibodies in a woman's system can fail to recognize a pregnancy. Or there may be an abnormal immune response to the pregnancy. Women can also develop antisperm antibodies, which attack and destroy sperm.

Male factors

• Low or absent sperm production. Without enough healthy sperm, the chance of fertilization is decreased.
• Abnormal sperm function. Sperm must be able to swim and penetrate the egg.
• Varicocele. This is a condition in which varicose veins develop around the testes. It’s a very common cause of infertility in men. It’s usually treatable with surgery.
• Hormone disorders. Abnormal male hormone or endocrine function can affect sperm production and fertility.
• Chromosome defects. Certain chromosome defects are linked to male infertility.
• Birth defects. Abnormalities in a man's reproductive system can happen during fetal development that can lead sometimes to "Obstructive Azospermia".
• Immune system problems. A man may have antisperm antibodies, which attack and destroy sperm.

These lifestyle habits can also affect sperm quality and function:

• Use of recreational drugs such as marijuana or cocaine
• Heavy alcohol use
• Smoking
• Taking certain medicines
• Too much heat to the genital area, such as using a hot tub

What are the symptoms of infertility?

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A couple is believed infertile if conception does not happen:

• After one year of unprotected sex
• After 6 months in women over age 35
• If there are known problems causing infertility

How is infertility diagnosed?

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To diagnose infertility, both the man and the woman are tested.

Some healthcare providers can do a basic infertility evaluation. But, many causes of infertility are best treated by a subspecialist in the field. This is an OB/GYN physician who has had education and training in infertility and is certified to treat the infertile couple.

Generally, the subspecialist will test both partners to find the cause of subfertility and looks for answers to these questions:

• Is the female ovulating regularly?
• Is the male making healthy sperm?
• Are the female's egg and the male's sperm able to unite and grow normally?
• Are there any problems with implantation?
• Is the mother able to maintain the pregnancy?

These fertility tests are often part of the basic workup for infertility:

Both partners

Health and sexual history to look for any physical causes of infertility and find out if they have sex at the right time.

Female

• Physical exam. You will have a complete physical exam including a Pap test and testing for infection.
• Ovulation evaluation. You can check to see if you are ovulating by keeping a basal body temperature chart. This is your morning body temperature. Other ovulation prediction methods use urine samples.
• Hormone testing. Hormone testing may be recommended. Certain hormones increase and decrease at various times in the monthly cycle.
• Ultrasound. Ultrasound can show the follicles, which are the sacs that contain the developing eggs. It can also show the thickness of the uterine tissues. Your healthcare provider can also check for problems such as ovarian cysts or fibroids.
• X-rays. A hysterosalpingogram may be advised. For this test, a dye is injected into the cervical opening to see inside the uterus. This lets the radiologist see if the fallopian tubes are open.

Male

• Semen analysis. A semen sample is taken and tested in the lab. The healthcare provider can:
  • Check the sperm count
  • Test sperm motility
  • Check how many and the shape of sperm
  • Evaluate the ejaculate liquid

Other tests may be done that test the sperm's ability to penetrate the egg, as well as male hormone testing.

Men may be sent to a urologist for further testing.

How is infertility treated?

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Your subspecialist will discuss the best treatment with you based on:

• How old you are
• Your overall health and medical history
• How well you can handle specific medicines, procedures, or therapies
• How long the condition is expected to last
• Your opinion or preference

Once a diagnosis is made, you can work with a fertility expert to find the best treatment. Most people with infertility are treated with conventional therapies. This includes treatment with medicine or surgical repair of reproductive abnormalities. Depending on the cause of infertility, there are many choices to offer an infertile couple.

Types of treatments for women may include:

• Intrauterine insemination. This method uses a small flexible tube called a catheter to place specially washed and prepared sperm directly into the uterus. It may be used for low sperm count or cervical mucus problems. This method is often used along with ovulation medicines.
• Ovulation medicine. These medicines help regulate the timing of ovulation. They stimulate the growth and release of mature eggs. They can also help correct hormone problems that can affect the lining of the uterus. Ovulation medicines can stimulate more than one egg to be released. This raises the chance of having twins and other multiples. Some of the common medicines include:
  • Clomiphene citrate
  • Human menopausal gonadotropins. Medicines with follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)
• Surgery. Surgery may be used to treat or repair a condition such as blocked fallopian tubes or endometriosis. This may be done using laparoscopy. In a laparoscopy, a small telescope inserted into the abdominal or pelvic cavity lets the healthcare provider see internal organs. Some methods to treat infertility can be done using instruments inserted through the laparoscope.
• Assisted reproductive technology (ART). For some couples, more extensive treatment is needed. With most forms of ART, the sperm and egg are joined in the lab. The fertilized egg is then returned to the woman's uterus where it can implant and grow. While ART procedures are often costly, many are being used with success. These include:
• In vitro fertilization (IVF). This involves removing a woman's eggs and fertilizing them in the lab with sperm. The embryo is then transferred into the woman's uterus through the cervix. Most couples transfer two embryos. More may be transferred in certain cases. IVF is the most common form of ART. It is often the treatment of choice for a woman with blocked, severely damaged, or absent fallopian tubes. IVF is also used for infertility caused by endometriosis or male factor infertility. IVF is sometimes used to treat couples with long-term unexplained infertility who have not been able to get pregnant with other treatments.
• Intracytoplasmic sperm injection (ICSI). In this procedure, a single sperm is injected directly into an egg. This method is most commonly used to help with male factor infertility problems.
• Donor eggs. This involves transferring an embryo from a donor to an infertile woman. The donor gives up all parental rights to any resulting children. ART using donor eggs is more common in older women. The chance of a fertilized egg implanting is related to the age of the woman who produced the egg. Egg donors are typically in their 20s or early 30s.
• Embryo cryopreservation. In this method, the embryos are frozen for transfer at a later date. This is often used when an IVF cycle produces more embryos than can be transferred at one time. The remaining embryos can be transferred in a future cycle if needed.

In addition to Assisted reproductive technologies (ART) that is used to treat male subfertility as well by using ICSI as a form of microsurgical fertilization technique, there is also a range of treatment choices available for male factor subfertility depending on the cause.This type of treatment may include:

• Medicine therapy. A few infertile men have a hormone problem that can be treated with hormone therapy. Hormone imbalances caused by a problem with the hypothalamus, the pituitary gland, and the testes directly affect the development of sperm. Medicine therapy may include gonadotrophin therapy, antibiotics, or another medicine.
• Surgery. Surgery for male infertility is done to repair anatomical problems that impede sperm production and maturation or ejaculation. Surgery to remove varicose veins in the scrotum (varicocele) can sometimes improve the quality of sperm.