Infertility Basics

Amber and Paul (Cancer Survivor) IVF Scholarship Recipients
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Amber and Paul (Cancer Survivor) IVF Scholarship RecipientsWhat is the accepted definition for Infertility?

Infertility is means not being able to become pregnant after a year of trying. If a woman can get pregnant but keeps having miscarriages or stillbirths are also classified as infertility.

Infertility is fairly common. After one year of having unprotected sex, about 15 percent of couples are unable to get pregnant. About a third of the time, infertility can be traced to the female. In another third of cases, it is because of the male. The rest of the time, the cause is both partners or unexplained.

There are treatments that are specifically for men or for women. Some involve both partners. Drugs or surgery are common treatments. Be sure the invasive procedures are done be sure there is more basic testing of the man's sperm. Happily, many couples treated for infertility go on to have babies.

In general, infertility is defined as not being able to get pregnant (conceive) after one year of unprotected sex. Women who do not have regular menstrual cycles, or are 35 years and older and have not conceived during a 6-month period of trying, should consider making an appointment with a reproductive endocrinologist—an infertility specialist. These doctors may also be able to help women with recurrent pregnancy loss—2 or more spontaneous miscarriages. Infertility takes a first big decline in the late twenties. INCIID stresses if you haven't conceived within a 6 month period of trying and you are 30 years old or older - go directly to a reproductive endocrinologist not an OB/GYN dabbling with infertility patients. You want a practice dedicated to infertility.

Pregnancy is the result of a process that has many steps.

To get pregnant—

  • A woman’s body must ovulate - that is release an egg from one of her ovaries
  • A man's sperm must join with the egg along the way (fertilize).
  • The fertilized egg must go through the fallopian toward toward the uterus
  • The fertilized egg must attach to the inside of the uterus (implantation).

Infertility may result from a problem at any of these points along the way.

Impaired fecundity is a condition related to infertility and refers to women who have difficulty getting pregnant or carrying a pregnancy to term.

 

How common a problem is infertility?

Yes. About 6% of married women 15–44 years of age in the United States are unable to get pregnant after one year of unprotected sex (infertility).

Also, about 11% of women 15–44 years of age in the United States have difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status (impaired fecundity).

 

Infertility - NOT just a woman's problem?

 Both men and women contribute to infertility.

Many couples struggle with infertility and seek help to become pregnant; however, it is often thought of as only a women’s condition. A CDC study analyzed data from the 2002 National Survey of Family Growth and found that 7.5% of all sexually experienced men younger than age 45 reported seeing a fertility doctor during their lifetime—this equals 3.3–4.7 million men. Of men who sought help, 18% were diagnosed with a male-related infertility problem, including sperm or semen problems (14%) and varicocele (6%).

 

What causes infertility in men?

Infertility in men can be caused by different factors and is typically evaluated by a semen analysis. A specialist will evaluate the number of sperm (concentration), motility (movement), and morphology (shape). A slightly abnormal semen analysis does not mean that a man is necessarily infertile. Instead, a semen analysis helps determine if and how male factors are contributing to infertility.

Conditions that can contribute to abnormal semen analyses include—

 

  • Varicoceles, a condition in which the veins on a man’s testicles are large and cause them to overheat. The heat may affect the number or shape of the sperm.
  • Medical conditions or exposures such as diabetes, cystic fibrosis, trauma, infection, testicular failure, or treatment with chemotherapy or radiation.
  • Heavy alcohol use, testosterone supplementation, smoking, anabolic steroid use, and illicit drug use contribute to a poor sperm analysis.
  • Environmental toxins including exposure to pesticides and lead. - If you have questions about environmental cause - Ask Dr. Robert Greene

 

What causes infertility in women?

Women need functioning ovaries, fallopian tubes and a uterus to get pregnant without help from a reproductive endocrinologist. Conditions affecting any one of these organs can contribute to female infertility. Some of these conditions are listed below and can be evaluated using a number of different tests.

Ovarian Function (presence or absence of ovulation and effects of ovarian “age”):

Ovulation: Regular predictable periods that occur every 24–32 days likely reflect ovulation. Ovulation can be predicted by using an ovulation predictor kit and can be confirmed by a blood test to see the woman’s progesterone level. A woman’s mentrual cylce, on average, is 28 days long.

  • A woman with irregular periods is likely not ovulating. This may be because of several conditions and warrants an evaluation by a doctor. Potential causes of anovulation include the following:
  • PCOS is one of the most commonly undiagnosed problems. PCOS creates a hormone imbalance problem that can interfere with normal ovulation. PCOS is the most common cause of female infertility but often goes undiagnosed. See PCOS FAQ
  • Functional hypothalamic amenorrhea (FHA). FHA relates to excessive physical or emotional stress that results in amenorrhea (absent periods)
  • Diminished Ovarian Reserve (DOR). This occurs when the ability of the ovary to produce eggs is reduced because of congenital, medical, surgical, or unexplained causes. Ovarian reserves naturally decline with age. Be sure to have your AMH levels tested and see the AMH Fact Sheet
  • Premature Ovarian Failure or Insufficiency (POF) (POI). POF occurs when a woman’s ovaries fail before she is 40 years of age. It is similar to premature (early) menopause.
  • Ovarian function. Several tests exist to evaluate a woman’s ovarian function.
  • No single test is a perfect predictor of fertility but there is basic testing that should be done when you visit an infertility specialist - a specialist treating infertility is a reproductive endocrinologist.
  • The most commonly used markers of ovarian function include follicle stimulating hormone (FSH) value on day 3–5 of the menstrual cycle, anti-mullerian hormone value (AMH), and antral follicle count (AFC) using a transvaginal ultrasound.

Tubal Patency (whether fallopian tubes are open, blocked, or swollen):

  • Risk factors for blocked fallopian tubes (tubal occlusion) can include a history of pelvic infection, history of ruptured appendicitis, history of STD's and chlamydia, endometriosis or abdominal surgery.
  • Tubal evaluation may be performed using an X-ray which is called a hysterosalpingogram (HSG), or by chromopertubation (CP) in the operating room at time of laparoscopy, a surgical procedure in which a small incision is made and a viewing tube called a laparoscope is inserted.
    • Hysterosalpingogram (HSG) is an X-ray of the uterus and fallopian tubes. A radiologist injects dye into the uterus through the cervix and simultaneously takes X-ray pictures to see if the dye moves freely through fallopian tubes. This helps evaluate tubal caliber (diameter) and patency. An HSG can also be accomplished using a saline procedure and many clinics do them now without use of X-ray and instead do ultrasound using saline. See the INCIID article Sonohysterography Vs, Hysterography

Uterine Contour (physical characteristics of the uterus):

  • Depending on a woman’s symptoms, the uterus may be evaluated by transvaginal ultrasound  and saline or other anatomic abnormalities. If suspicion exists that the fibroids may be entering the endometrial cavity, a sonohystogram (SHG) or hysteroscopy (HSC) may be performed to further evaluate the uterine environment.

What things increase a woman's risk of infertility?

Female fertility is known to decline with—

  • Age. Many women are waiting until their 30s and 40s to have children. In fact, about 20% of women in the United States now have their first child after age 35, and this leads to age becoming a growing cause of fertility problems. (See Egg Freezing article )About one-third of couples in which the woman is older than 35 years have fertility problems. Aging not only decreases a woman's chances of having a baby but also increases her chances of miscarriage (due to poor egg quality) and of having a child with a genetic abnormality. However there are still professionals that overlook abnormal immunological reactions of a womens' bodies to pregnancy. Be sure to read Immunology May be Key to Pregnancy Loss (and implantation failure).

    Aging decreases a woman's chances of having a baby in the following ways—

    • Her ovaries become less able to release eggs.
    • She has a smaller number of eggs left.
    • Her eggs are not as healthy.
    • She is more likely to have health conditions that can cause fertility problems.
    • She is more likely to have a miscarriage.
  • Smoking.
  • Excessive alcohol use.
  • Extreme weight gain or loss.
  • Excessive physical or emotional stress that results in amenorrhea (absent periods).
 

How long should women try to get pregnant before calling their doctors?

INCIID suggests if you are 30 years old or older and trying for 6 months see a reproductive endocrinologist (not an OB/GYN delivering babies). than age 35.  A woman's chances of having a baby decrease rapidly every year after the age of 30.

Some health problems also increase the risk of infertility. So, women should talk to a health care provider if they have—

  • Irregular periods or no menstrual periods.
  • Very painful periods.
  • Endometriosis
  • Pelvic Inflammatory Disease (PID) 
  • More than one miscarriage. See articles on immunology and pregnancy (above) or use the search on INCIID

 

 

How will doctors find out if a woman and her partner have fertility problems?

Doctors will begin by collecting a medical and sexual history from both partners. The initial evaluation usually includes a semen analysis and basic testing including a lot of blood work and testing for STD's See the Basic Testing Fact Sheet

How do doctors treat infertility?

There are multiple variables for treating infertility. It is VERY IMPORTANT to go to or be referred to a Fellowship Trained Reproductive Endocrinologist.

What are some of the specific treatments for male infertility?

Male infertility may be treated with medical, surgical, or assisted reproductive therapies depending on the underlying cause. Medical and surgical therapies are usually managed by an urologist who specializes in infertility. A reproductive endocrinologist may offer intrauterine inseminations IUI's or in vitro fertilization IVF to help overcome male factor infertility. See the article on ICSI

 

What medicines are used to treat infertility in women?

Some common medicines used to treat infertility in women include—

  • Clomiphene citrate (Clomid) is a medicine that causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
  • Human menopausal gonadotropin or hMG (Repronex; Pergonal) are medicines often used for women who don't ovulate because of problems with their pituitary gland—hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
  • Follicle-stimulating hormone or FSH (Gonal-F; Follistim) are medicines that work much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
  • Gonadotropin-releasing hormone (Gn-RH) analog are medicines often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
  • Metformin (Glucophage) is a medicine doctors use for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
  • Bromocriptine (Parlodel) is a medicine used for women with ovulation problems because of high levels of prolactin.  Prolactin is a hormone that causes milk production.

 

Fertility drugs increase a woman's chance of having twins, triplets, or other high-order multiples. (See Dr. Angie Beltsos article on multiple pregnancies) Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born prematurely (too early). Premies are at a higher risk of health and developmental problems.

 

What is intrauterine insemination (IUI)?

Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.

 

What is assisted reproductive technology (ART)?

ART includes all fertility treatments in which both eggs and sperm are handled outside of the body. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. The main type of ART is in vitro fertilization (IVF).

How often is assisted reproductive technology (ART) successful?

Success rates vary and depend on many factors, including the clinic performing the procedure, the infertility diagnosis, and the age of the woman undergoing the procedure. This last factor—the woman’s age—is especially important.

There is no oversight for reporting statistics of success rates. Currently all clinics that do report - self-report. Success rates can vary greatly from one clinic to another.Read the article about the importance of "Reading Between the Lines" of the reported statistics. Also a Brief History of IVF Statistics and The History of IVF

 

ART can be expensive and time-consuming, but it has allowed many couples to have children that otherwise would not have been conceived. The most common complication of ART is a multiple fetus pregnancy. This is a problem that can be prevented or minimized by limiting the number of embryos that are transferred back to the uterus. For example, transfer of a single embryo, rather than multiple embryos, greatly reduces the chances of a multiple fetus pregnancy and its risks.

 

 

What are the different types of assisted reproductive technology (ART)?

 

ART procedures sometimes involve the use of donor eggs (eggs donated from another woman), donor sperm, or previously frozen embryos. Donor eggs are sometimes used for women who cannot produce eggs. Also, donor eggs or donor sperm are sometimes used when the woman or man has a genetic disease that can be passed on to the baby. An infertile woman or couple may also use donor embryos. These are embryos that were either created by couples in infertility treatment or were created from donor sperm and donor eggs. The donated embryo is transferred to the uterus. The child will not be genetically related to either parent.

 

Gestational Carrier is Referred to as a Gestational Surrogate - Visit the Center for Surrogate Parenting
Women with ovaries but no uterus may be able to use a gestational carrier. This may also be an option for women who shouldn't become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by her partner’s sperm and the embryo is placed inside the carrier's uterus.

 

 

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