Infertility is typically defined as the inability to achieve pregnancy after one year of unprotected intercourse. However women who are 30 years or older should begin their infertility evaluation after about six months of unprotected intercourse rather than a year, so as not to delay treatment. Also, in women with very irregular menstrual cycles (suggesting anovulation), or if the partner has a known fertility problem, one should not wait for an entire year before seeking treatment. One out of seven couples, have trouble conceiving. During this time, it is normal to experience feelings of frustration, jealousy and anger. However, once one begin to explore the medical options, one will find that fertility treatments offer more hope for a successful pregnancy than ever before.
The Process of Conception
In order to understand the fertility tests and treatments, it is important to understand how conception naturally occurs. First, the ovary must release an egg (ovulation), which must be picked up by the fallopian tube. The egg must be fertilized within 24 hours after its release. The man must have an erection and ejaculate enough semen to deliver the sperm into the vagina. There must be enough sperm, and it must be the right shape and move in the right way. Sperm must travel through the vagina, into the uterus, and up into the fallopian tube in order to fertilize the egg. The woman must have a healthy vaginal and uterine environment to encourage the transport of sperms to the egg. Sperm are capable of fertilizing the egg for up to 72 hours. Fertilization usually takes place in the fallopian tube. The fertilized egg, or embryo, travels down to the uterus, where it implants in the uterine lining. The uterus and its lining must be normal enough to be able to implant the embryo. Infertility results when a problem develops in any part of this process.
There are many causes of infertility. The main causes are as follows:
- The Ovulation Factor
Problems with ovulation are common causes of infertility, accounting for approximately 25% of all infertility cases. Women with regular menstrual cycles, are probably ovulating. Cycle lengths of approximately 24 to 34 days are usually ovulatory. Women with periods every few months or not at all, are probably not ovulating or are ovulating infrequently. The commonest cause on anovulation is polycystic ovarian syndrome.
- The Tubal Factor
Open and functional fallopian tubes are necessary for conception. Tubal factors, as well as factors affecting the peritoneum (lining of the pelvis and abdomen), account for about 35% of all infertility problems. The common causes of tubal block include infection and endometriosis. Chlamydia, a sexually transmitted disease, is the most frequent cause of tubal infection. Tubal inflammation may go unnoticed or may cause pain and fever.
- The Male Factor
In approximately 40% of infertile couples, the male partner is either the sole or a contributing cause of infertility.
- The Cervical/Uterine Factor
Conditions within the cervix, may impact fertility, but they are rarely the sole cause of infertility. Any treatment of the cervix including prior biopsies, surgery, freezing and/or laser treatment of the cervix, may affect the chances of pregnancy. Uterine factors include uterine scar tissue, endometrial polyps, fibroids, or an abnormally shaped uterine cavity. Problems within the uterine cavity may interfere with implantation of the embryo or may increase the incidence of miscarriage.
- Peritoneal Factor Infertility
Peritoneal factor infertility refers to abnormalities involving the peritoneum such as scar tissue (adhesions) or endometriosis. Endometriosis is found in about 35% of infertile women who have no other diagnosable infertility problem. Endometriosis is found more commonly in women with infertility. Laparoscopy is a surgical procedure which is performed to diagnosis and treat adhesions or endometriosis.
- Unexplained Infertility
In approximately 5% to 10% of couples trying to conceive, all of the above tests are normal and there is no apparent cause for infertility. In a much higher percentage of couples, only minor abnormalities are found that are not severe enough to result in infertility. In these cases, the infertility is referred to as unexplained. Couples with unexplained infertility may have problems with egg quality, tubal function, or sperm function that are difficult to diagnose and/or treat.
Many of the risk factors for both male and female infertility are the same. They include:
Delaying pregnancy is a common choice for women in today’s society. The number of women in their late 30s and 40s attempting pregnancy and having babies has increased in recent years. Fertility begins to decline significantly in the mid 30s and accelerates to late 30s. Some women even begin to experience a decline in their fertility in their late 20s and early 30s. Fertility declines with age because fewer eggs remain in the ovaries, and the quality of the eggs remaining is lower than younger women. Blood tests can help determine the ovarian reserve, which reflects the age- related fertility potential. In the simplest of these tests, the hormones FSH and estradiol are tested in the blood on the second, third, or fourth day of the menstrual period. An elevated FSH level indicates the chances for pregnancy may be slim, especially in women age 35 or older, but does not mean that there is no chance of successful conception. Older women tend to have a lower response to fertility medications and a higher miscarriage rate than younger women. The chance of having a chromosomally deformed embryo, such as one with Down syndrome, also increases with age. Because of the marked effect of age on pregnancy and birth rates, it is common for older couples to begin fertility treatment sooner and, in some cases, to consider more aggressive treatment than younger couples.
- Tobacco smoking
Men and women who smoke tobacco may reduce their chances of achieving a pregnancy and reduce the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.
- Alcohol use
For women, there’s no safe level of alcohol use during conception or pregnancy. Moderate alcohol use does not appear to decrease male fertility.
- Being overweight
Infertility often is due to a sedentary lifestyle and being overweight. In addition, a man’s sperm count may be affected if he is overweight.
- Being underweight
Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women following a very low calorie or restrictive diet. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid.
- Too much exercise
In some studies, exercising more than seven hours a week has been associated with ovulation problems. On the other hand, not enough exercise can contribute to obesity, which also increases infertility.
- Caffeine intake
Studies are mixed on whether consuming too much caffeine may be associated with decreased fertility. Some studies have shown a decrease in fertility with increased caffeine use while others have not shown adverse effects. If there are effects, it’s likely that caffeine has a greater impact on a woman’s fertility than on a man’s. High caffeine intake does appear to increase the risk of miscarriage.
Treatment will depend on the cause of the infertility.
- Ovulation Factor
In women who are not ovulating, ovulation induction can be done. The simplest form of ovulation induction is the use of clomiphene citrate. This drug is usually given for 5 days from the second day of the menses. Other ovulation drugs that can be taken orally are aromatase inhibitors, which include tamoxifen and letrozole (Femara). Ovulation tests may be necessary to ensure ovulation and you will be advised to have sexual intercourse at the time of ovulation. Some women may not ovulate with oral medication and they may require Follicular Stimulating Hormone injections. These injections may be given regularly from the second day of the periods till the follicles reach about 18 mm. When ovulation occurs, timed intercourse can be advised or Intrauterine insemination (IUI) can be done. Patients with PCOS may be given metformin (glucophage) and patients with hyperprolactinemia may be given bromocriptine (parlodel) or carbergoline (dostinex).
- Tubal Factor
If one fallopian tube is patent, then ovulation induction and IUI may be an option. However, if the HSG shows that both fallopian tubes are blocked, laparoscopy may be advised to assess the degree of tubal damage. If the tubes are found to be blocked, scarred, or damaged, surgery can sometimes correct the problem. Although some tubal problems are correctable by surgery, in women with severely damaged tubes pregnancy is so unlikely that in vitro fertilization (IVF) offers them the best hope for a successful pregnancy. Because very badly damaged tubes may fill with fluid and lower IVF success rates, removal of the tubes prior to IVF may be necessary.
- Male Factor
Causes of abnormalities in the semen may include infection, varicocoele (dilated or varicose veins in the scrotum), duct obstruction, or unknown. Infection can be treated by antibiotics. Varicocoele and duct obstruction can be corrected surgically. Medications can be given to improve sperm production but the results are usually poor. Intrauterine insemination (IUI) or IVF may then be recommended. Direct injection of a single sperm into an egg (intracytoplasmic sperm injection [ICSI]) may be recommended as well. If no sperm are present, using a sperm donor is an option.
- The Cervical/Uterine Factor
Cervical problems are generally treated with antibiotics, hormones, or by IUI. If a problem in the uterine cavity is suspected, hysteroscopy may be required to further evaluate and possibly correct uterine structural problems. Endometrial polyps can be removed and uterine septum can be corrected. Fibroids if they are thought to be the cause of the infertility may need to be removed (myomectomy).
- Peritoneal Factor Infertility
Patient with adhesions and endometriosis can be diagnosed and treated by laparoscopy. Patients who could not conceive spontaneously after the surgery may require IUI or IVF.
- Unexplained Infertility
Fertility drugs and IUI have been used in couples with unexplained infertility with some success. If no pregnancy occurs within three to six treatment cycles, IVF may be recommended.