Infertility

Infertility is the inability of a couple to become pregnant (regardless of cause) after 1 year of unprotected sexual intercourse (using no birth control methods).  

• Infertility affects about 6.1 million people in the United States, about 10% of men and women of reproductive age.   
  
  
• Infertility affects men and women equally. 
  
  
• Most infertility cases (85-90%) are treated with medication or surgery. Improvements in fertility treatment have made it possible for many women whose male partner is infertile to become pregnant. These new and advanced technologies include in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and other similar procedures. 

The normal reproduction process requires interaction between the female and male reproductive tracts. The woman ovulates and releases an egg from her ovaries to travel through the fallopian tube to her uterus (womb). The male produces sperm. Both egg and sperm normally meet in the woman’s fallopian tube, where fertilization occurs. The embryo then implants in the uterus for further development.

Infertility occurs when something in this pattern does not happen. The problem could be with the woman, with the man, or with both. Unknown factors cause infertility 10% of the time.  For infertility with an unknown cause, all findings from standard tests may be normal. The actual cause of infertility may not be detected because the problem may be with the egg or sperm itself or with the embryo and its inability to implant.

Pelvic inflammatory disease (PID)

Sexually transmitted diseases, namely, gonorrhea and chlamydia, may be associated with pelvic inflammatory disease (PID) and damage a woman’s fallopian tubes. Your health care provider can detect PID with a Pap smear and blood testing for sexually transmitted diseases. 

If you don’t recall ever having PID, your doctor may be able to see scarring or blockage of the tubes during a surgical procedure called laparoscopy. Tiny cameras and instruments are inserted through small cuts in your abdomen to allow the doctor to view your reproductive organs.

Endometriosis

Endometriosis affects women during their reproductive years. It can cause pelvic pain and infertility. You may be at risk for developing it if you have a family history of the disease. With endometriosis, uterine lining tissue grows outside the uterus and may damage the ovaries and fallopian tubes. You may not know you have a mild form of this condition. Sometimes your doctor finds it during laparoscopy.

Environmental and occupational factors

Certain environmental factors may cause men to produce a less concentrated sperm, according to a government report. Exposure to lead, other heavy metals, and pesticides has also been associated with male infertility. Many other factors, such as excessive heat exposure, microwave radiation, ultrasound, and other health hazards, are more controversial as to whether they induce infertility. 

Toxic effects related to tobacco, marijuana, and other drugs

Smoking may cause infertility in both men and women. In experimental animals, nicotine has been shown to block the production of sperm and decrease the size of a man’s testicles. In women, tobacco changes the cervical mucus, thus affecting the way sperm reach the egg.

Marijuana may disrupt a woman’s ovulation cycle (release of the egg). Marijuana use affects men by decreasing the sperm count and the quality of the sperm.

Heroin, cocaine, and crack cocaine use induces similar effects but places the user at increased risk for PID and HIV infection associated with risky sexual behavior.

In women, the effects of alcohol are related more to severe consequences for the fetus. Nevertheless, chronic alcoholism is related to disorders in ovulation and, therefore, interferes with fertility. Alcohol use by men interferes with the synthesis of testosterone and has an impact on sperm concentration. Alcoholism may delay a man’s sexual response and may cause impotence (unable to have an erection). 

Exercise

Exercise should be encouraged as part of normal activities. However, too much exercise is dangerous, especially for long-distance runners. For women, it may result in disruption of the ovulation cycle, cause no menstrual periods, or result in miscarriages (loss of pregnancy). In men, overexercise may cause a low sperm count.

Inadequate diet associated with extreme weight loss or gain

Obesity is becoming a major health issue in the United States. Obesity has an impact on infertility only when a woman’s weight reaches extremes.

Weight loss with anorexia or bulimia can create problems with menstrual periods (no periods) and thyroid levels, thus disrupting normal ovulation.

Age

A woman becomes less fertile as she ages into her fifth decade of life (age 40-49 years). Among men, as they age, levels of testosterone fall, and the volume and concentration of sperm change.

Healthy couples younger than 30 years who have regular sexual intercourse and use no birth control methods have a 25-30% chance of achieving pregnancy each month. A woman's peak fertility is early in the third decade of life. As a woman ages beyond 35 years (and particularly after age 40 years), the likelihood of becoming pregnant is less than 10% per month.

A fertility specialist is usually an obstetrician-gynecologist (specialist in women’s reproductive health) with advanced education, research, and professional skills in reproductive endocrinology. These highly trained and qualified doctors are the specialists to see about infertility. 

You may want to talk to your health care provider for a referral to a clinic where doctors and staff have this special training. In addition, fertility clinics often have specialized equipment and imaging technology needed to make a diagnosis and to do semen testing and other specialized tests right at the office.

Check the InterNational Council on Infertility Information Dissemination Web site directory of professional members or the American Society for Reproductive Medicine for a specialist and clinic in your area.

Infertility is a problem that involves both partners. Therefore, the infertility specialist evaluates both the woman and the man. Testing for infertility is usually not done until after the couple has tried to become pregnant for at least 1 year if the woman is younger than 35 years or for 6 months if she is older than 35 years.

Medical history

Your health care provider will take a complete medical history. You may be asked to provide the following information:  

• Complete medical history for both the man and the woman
  
  
• Whether you have never had a child (primary infertility) or have a child and want another (secondary infertility)
  
  
• How long you have been trying to become pregnant
  
  
• Your history of previous pregnancies, if any
  
  
• How often you have intercourse
  
  
• A woman’s menstrual history
  
  
• Current medical treatment

Physical examination 

Your health care provider may perform a physical examination on both partners, including the following aspects:

• Routine blood pressure, pulse, and temperature
  
  
• Height and weight
  
  
• Inspection of sexual organs
  
  
• Hormone testing
  
  
• Woman: Pelvic ultrasound scan to look for masses, cervical mucus testing
  
  
• Man: Genital examination, testicle size, hernias

our health care provider will discuss the findings from the medical history and physical examination. Sometimes, a complete infertility evaluation may take up to 2 menstrual cycles before the factors causing the infertility can be found.

Further testing for men

The male partner will be asked to submit a semen sample for a complete semen analysis. Even though a man has fathered a child in the past, he will still be asked to submit a semen sample because his reproductive system may have changed. 

The semen sample may be collected at the laboratory (in a private room through masturbation). If a sample is collected at home, it must be collected in a sterile plastic container and delivered to the lab at a body temperature no more than 60 minutes after ejaculation. 

Some men cannot produce a semen sample through masturbation. Therefore, the sample can be collected through intercourse, using a special nonspermicidal condom provided by the laboratory. For best results, the semen sample should be collected 3-5 days after a period of having no sexual intercourse.

A man may produce no sperm for various reasons. He may produce few sperm or sperm that cannot “swim” to meet the egg.

Further testing for women 

Several conditions may affect a woman’s ability to get pregnant. Your health care provider will evaluate the entire reproductive system.

The cervix plays a key role in the transport of the sperm after intercourse. Cervical mucus production, amount, and characteristics change according to the estrogen concentration depending on the menstrual cycle.

The uterus is the final destination for the embryo and the place where the fetus develops until delivery. Therefore, the uterus may be associated with primary infertility or with pregnancy problems and premature delivery. Other problems affect the development and function of the uterus (specifically the endometrium or inner layer of the uterus).

Ovaries may not release eggs. Fallopian tubes may be blocked. Your doctor will want to evaluate all parts of the reproductive system.

Your health care provider may use any of several procedures to examine your reproductive organs:

• elvic exam: This is a general physical examination in which the doctor feels the uterus for detectable masses and views the cervix.
  
  
• Hysterosalpingogram: This is an imaging study of the uterus and fallopian tubes after contrast dye has been injected through the cervix. It shows the shape of the uterus and if the fallopian tubes are open. The dye appears white on an x-ray. This test is usually performed before ovulation so the dye does not disrupt an egg or developing embryo. You may be given pain medication before the test because some women experience minor pain.
  
  
• Ultrasound: Pelvic ultrasound has become an important tool in the evaluation and monitoring of infertile women. It is a way to detect uterine fibroids, endometrial polyps, ovarian cysts, and other abnormalities in the pelvis from the outside with sound waves.
  
  
• Magnetic resonance imaging (MRI): This is another imaging procedure similar to an x-ray that uses magnetic waves to create images of your internal organs.
  
  
• Hysteroscopy: This is a method of directly seeing the uterus with an instrument.
  
  
• Laparoscopy: This is a surgical procedure that allows the doctor to see directly inside the pelvis with tiny instruments inserted through small cuts in the abdomen.  

Infertility may be caused by so many different problems that it is beyond the scope of this discussion to outline them all. 

Your doctor will meet with you and your partner after the evaluation is completed and outline a treatment plan according to the diagnosis, duration of infertility, and the woman's age. If pregnancy has not been accomplished within a reasonable time, you and your doctor may consider further evaluation or a different treatment plan. Your doctor should be able to counsel you in forming realistic expectations for pregnancy. 

Most infertility can be treated with conventional therapies, such as drug treatment (fertility drugs) to promote ovulation or surgery to repair problems with reproductive organs. 

• For men, the most common cause of infertility in the couple is with the sperm. Either no sperm cells are produced or few are produced. Sperm can be deformed or die before they reach the egg. 
  
  
• For women, the most common cause of infertility factor is an ovulation disorder. Other causes of female infertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). Congenital anomalies involving the structure of the uterus or uterine fibroids may cause repeated miscarriages.

For most couples (up to 90%), a cause for the infertility is found. Pregnancy occurs with the use of fertility drugs or corrective surgery in up to 60% of infertile couples, once they are evaluated and treated. Advanced techniques such as surgery, insemination, or in vitro fertilization can help even more couples achieve pregnancy.

|Web Links|

American Society for Reproductive Medicine 

American College of Obstetricians and Gynecologists (ACOG) Resource Center

American Infertility Association  

American Society for Reproductive Medicine, Frequently Asked Questions about Infertility

InterNational Council on Infertility Information Dissemination, Inc.

MEDLINEplus, Infertility
 
National Women’s Health Information Center, Infertility
 
Resolve: The National Infertility Association

infertility, pregnant, pregnancy, low sperm count, fertility, in vitro fertilization, IVF, intracytoplasmic sperm injection, ICSI, assisted reproductive technologies, ART, pelvic inflammatory disease, PID, endometriosis, sexually transmitted diseases, gonorrhea, chlamydia, STDs, sperm donor, sperm quality, egg evaluation, egg quality, egg donor, sperm donation, conception problems, pregnancy problems, pregnancy complications, sexual history, intrauterine fibroid, recurrent pregnancy loss, normal infertile couple

Author: Jairo E Garcia, MD, Associate Professor, Director, Fertility Center and In Vitro Fertilization, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine.

Editors: Bryan D Cowan, MD, Director, Division of Reproductive Endocrinology, Professor, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.