Infertility is defined as the inability to conceive after 12 months of unprotected sexual intercourse. Infertility may be attributed to the man, the woman, or both partners. Infertility does not mean that a couple is sterile. Approximately half of all couples who seek help for infertility will eventually conceive a child.
Several factors play a role in infertility. These may include:
- Female or male partner over 35 years old
- Physical injuries to the reproductive organs
- Female physical conditions such as endometriosis, pelvic infection, polycystic ovarian syndrome, or polyps
- Male physical conditions such as low sperm count or varicoceles
- Genetic disorders such as Tay-Sachs disease, thalassemia
- Lifestyle conditions such as smoking, alcohol, lack of exercise, or nutritional deficiencies
- Previous treatments such as cancer radiation therapy
- Previous history of unsuccessful pregnancies
Once a couple is diagnosed as infertile, the doctor will perform tests to determine the cause or causes. Then treatment can begin. Today's technology often allows even truly infertile couples to conceive a child, sometimes with the assistance of a third party donor or surrogate.
A couple under 35 years old should consult a physician if they are unable to conceive after 12 months of sexual intercourse. If the male or female is over 35 years old, they should consult a physician after six months if they are unable to conceive.
Initial tests that may be performed on both patients include the following:
- Physical exam, including a Pap test, or a testicular exam
- A complete medical history
- Blood or urine tests
These tests can rule out any physical, hormonal, or disease-related issues that may inhibit fertility. Other lifestyle factors may also be identified at this time.
The next set of tests evaluate three critical factors: the functioning of sperm, the fallopian tubes, and ovulation. These include:
- Measurements of hormones that regulate ovulation and egg quality
- Imaging tests of the fallopian tubes
- Semen analysis (volume, sperm count, motility and morphology)
Most second-round tests will pinpoint the causes of infertility in either the man or woman, and lead to corrective treatment.
The primary reason for female infertility is a lack of ovulation. Polycystic ovary syndrome, or PCOS, is the primary cause of no ovulation. A transvaginal ultrasound may be performed to determine if there are follicles in the ovaries.
The fallopian tubes are another common cause for infertility in women. The physician may perform a hysterosalpingogram (an X-ray) or sonohystogram (sonogram with saline) of the fallopian tubes in order to pinpoint any malformations or blockages.
A laparoscopy may be performed if the physician suspects endometriosis is the cause of infertility. A small cut is made in the pelvis and a camera is inserted abdomen to evaluate and potentially correct any problems.
The physician will guide the patient through the recommended tests in order to pinpoint the cause of infertility.
About half of all infertile couples suffer from one or more compromised factors in the male partner. For this reason, during the initial evaluation the male partner (if there is one) will be tested for the following:
- Semen analysis for sperm count, motility, volume and viscosity
- Antibody and white blood cell count
- Physical abnormalities (azoospermia, blocked sperm ducts, varicocele)
- Other factors that might affect the sperm's ability to penetrate the egg
In some cases a biopsy of the testicle may be necessary. If a problem is found, treatment may involve sperm retrieval, surgery or donor insemination.
After testing is complete, the doctor will discuss the evaluation results and determine an appropriate treatment. If no conclusive indications are found, additional testing may be performed.
Treatment of Infertility
For most patients, medical or surgical treatment improves fertility enough for conception to be successful. Treatment plans are designed to enhance some fertility factors and bypass others in an attempt to maximize the couple's fertility potential. Three common types of fertility treatment are:
1. Clomiphene citrate and intrauterine insemination, or IUI. Clomiphene citrate, a mild fertility drug, is given for five days to produce one or more mature eggs. One dose of the hormone hCG stimulates the ovaries to release the eggs. Then the male partner's washed and prepared sperm is injected into the uterus via insemination.
2. Gonadotropins and IUI. This is similar to the clomiphene citrate method except gonadotropins stimulate the growth of more follicles and also increase the quality of the eggs, cervical mucus and uterine lining.
3. Ovulation induction and in vitro fertilization, or IVF. Lupron, Synarel or other hormones are administered along with gonadotropins to produce three or more eggs, which are then retrieved from the ovaries before in vitro fertilization. Fewer than 5% of infertile couples need these services.
Considerations of Infertility
For about 10-20% of infertile couples, even with a thorough evaluation, a cause for infertility cannot be determined. Unexplained infertility may be caused by intermittent symptoms such as irregular ovulation or variable sperm count, or other factors that we do not yet understand or cannot test for. Some couples with unexplained infertility successfully conceive after treatment or even without treatment.
Factors that may lessen the chance of success include:
- Older age
- Poor egg quality
- Poor sperm quality
- Duration of infertility
- Severe damage to fallopian tubes, usually due to chronic infection
- Severe endometriosis
- Blockage of fallopian tubes, which may require tubal cannulation
The couple should discuss all fertility treatment options with the physician in order to determine the best approach.