Infertility
Infertility is defined as the inability of a couple to become pregnant after one year of unprotected intercourse. By “unprotected” we mean: without any contraception. Infertility is a common condition: about 10-15% of the couples who are trying to conceive (that is, become pregnant) are not able to do so.
The ability of a couple to become pregnant depends on several factors in both the male and female partners. In general, the male needs to produce normal, motile sperm cells, which have to be present in the ejaculate in adequate numbers. The female needs to ovulate (produce eggs) regularly and have normal reproductive organs (uterus and tubes), which allow (or even facilitate) the passage of sperm cells. Statistics show that of all infertile couples: in about 25% there are male problems, in 40% there are female problems, and in 20% there are combined problems (in both the male and female). In the remaining 15%, the cause of the infertility cannot be traced to specific factors in either partner and it is called “unexplained”. This is why both partners need to have the evaluation, but even if one partner is “responsible”, infertility treatments require close cooperation of both.
The production of sperm cells in the male requires normal testes (or testicles) and it is regulated by hormones which are produced by the reproductive brain centers (hypothalamus and pituitary gland). Therefore, a variety of different conditions can lead to infertility: hormonal, genetic, anatomical and environmental. However, in many cases, this evaluation does not point to a specific reason or condition. But one should not be discouraged as the treatment of male infertility can be as successful, even if we do not find the exact underlying problem. Finally, infertility can result from male sexual dysfunction (Impotence, premature ejaculation etc.), which is most often diagnosed by detailed sexual history.
History & Physical examination — may sometimes give us a hint or a clue to an underlying abnormality. Information about past (sexually transmitted) infections, testicular trauma or surgery, sexual activity, the use of medications and exposure to certain environmental agents (smoking, alcohol, radiation, steroids, chemotherapy, and toxic chemicals) – maybe helpful. The size of the testicles, associated anatomical abnormalities (like varicose vein of the testes, Varicocele) and signs of sexual development (like hair distribution, breasts, etc.,) are also important findings.
Semen analysis — A semen analysis (sperm count by a microscope) is the major part of the infertility evaluation in the male. This test provides information about the amount of semen and the number, motility, and shape of the sperm cells.
A man should avoid sex and masturbation for 2-5 days before providing the semen sample. Ideally, a sample should be produced by masturbation in the clinic or laboratory; but if this is not possible, it may be produced at home into a sterile laboratory container. The sample should be delivered to the lab within one hour of collection.
If the initial semen analysis is abnormal, the doctor will often request an additional sample; this is best done 3-4 weeks later.
Blood tests — are sometimes performed if a hormonal problem is suspected.
Genetic tests — If genetic or chromosomal abnormalities are suspected, specialized genetic studies are required. Klinefelter syndrome is a condition in which the male has an extra X chromosome (XXY instead of XY) and is associated with infertility. Male infertility may be sometimes associated with absent or abnormal regions of the male chromosome (Y). A gene mutation (abnormal DNA information) which causes Cystic Fibrosis may also result in male infertility with low sperm count. In such cases we need also to consider the possibility and consequences of transferring the abnormality to the child.
Other tests — If blockage of the ducts which transfer the sperm from the testicles (epididymis or vas deferens) is suspected a transrectal ultrasound examination may be required. Such blockade can be a congenital malformation or secondary to an infection.
A testicular biopsy (collection of a small tissue sample) may be required in men with low or no sperm on the semen analysis. The biopsy can be done by surgically opening the testis or by fine-needle aspiration (inserting a small needle into the testis and withdrawing a sample of tissue). Biopsy is usually done in the operating room under general anesthesia. The biopsy allows to study the microscopic structure of the testes, determine if sperm is present and even to freeze sperm cells for later IVF, with or without micromanipulation (ICSI).
A variety of conditions may lead to female infertility, but the most common is absent or infrequent ovulation (Anovulation or Oligo-ovulation). This may occur as a result of hormonal problems, but age, environmental factors and stress can play a critical role. The second most common cause of female infertility is “mechanical” or “anatomical” and refers to conditions affecting the fallopian tubes and uterus. These conditions typically interfere with the passage of gametes (egg and sperm) in the tract or the implantation of the embryo in the uterus. Blockage and scarring (adhesions) of the Fallopian tubes may be caused by infection (like Gonorrhea) and pelvic surgery (like Appendectomy). Conditions which affect the uterus can be malformations, polyps, fibroids (myomas) and scar tissue formation after abortions or infections. Another common cause of female infertility is Endometriosis which interferes with normal reproduction by several mechanisms. It is characterized by the presence of uterine lining tissue (Endometrium) in the pelvic cavity (on the tubes, uterus and ovaries). Doctors usually begin the evaluation with medical history, physical examination, and some preliminary tests to determine if the woman ovulates spontaneously.
Medical history — A woman's past health and medical history may provide some clues about the cause of infertility. The doctor will ask about sexual development during puberty; sexual history; sexually transmitted infections; surgeries; medications used; exposure to certain environmental agents (alcohol, radiation, steroids, chemotherapy, and toxic chemicals); and any previous fertility problems.
Physical examination — A general physical examination may suggest hormonal imbalance (for instance: abnormal hair growth or sexual development) and pelvic examination may find anatomical abnormalities of the reproductive organs.
Blood tests — The levels of some key hormones which are produced by the brain centers which regulate ovulation (the hypothalamus and the pituitary gland) and the ovaries can be determined by blood tests. . These hormones include follicle-stimulating hormone (FSH) to assess how well the ovaries are functioning, TSH to test thyroid function, and prolactin to rule out the presence of a benign pituitary tumor.
Tests of ovulation — Ovulation (the release of an egg from an ovary) is essential for female fertility. Abnormalities of ovulation can often be suspected from a woman's menstrual history or hormone levels (LH surge before ovulation or progesterone levels in the luteal phase).
Menstrual history — Amenorrhea (absent menstrual periods) usually signals an absence of ovulation, which can cause infertility. Irregular menstrual cycles can be a sign of irregular ovulation; although this does not make pregnancy impossible, it can interfere with the ability to become pregnant.
Basal body temperature (BBT) — In the past monitoring of BBT (measured before getting out of bed in the morning) was recommended to determine if ovulation occurred, as the BBT usually rises by 0.5ºF to 1.0ºF after ovulation. However, BBT patterns can be difficult to interpret and are not recommended anymore in the evaluation of infertility.Hormone levels — The levels of the luteinizing hormone (LH) rise abruptly approximately 38 hours before ovulation. This hormone rise can be detected by an over-the-counter home urine test. However, this method fails to detect the rise in about 15% of the cases and another blood test may be needed d to confirm ovulation. Normally, the blood levels of the hormone progesterone rise after ovulation and it is a more accurate indicator of ovulation.
Tests to evaluate the uterus and fallopian tubes — Uterine problems that can contribute to infertility include congenital anatomical abnormalities (a septum or malformation of the uterine cavity), fibroids, polyps, and abnormalities that can result from gynecologic procedures (i.e., scarring and adhesions after abortions).
Scarring and obstruction of the fallopian tubes can occur as a result of pelvic inflammatory disease, endometriosis, or pelvic adhesions (scar tissue) from abdominal infection or surgery.
Pelvic ultrasound — Transvaginal ultrasound, which involves the insertion of a small ultrasound probe into the vagina, allows detailed anatomical evaluation of the female reproductive organs. It is used to evaluate and measure the size and shape of the uterus and ovaries and to determine if there are structural abnormalities (such as fibroids or ovarian cysts).
Hysterosalpingogram (HSG) — Hysterosalpingogram is used to help identify anatomical abnormalities of the uterus and fallopian tubes. It involves injecting a liquid which can be seen on x-ray through the cervix and into the uterus An x-ray (Roentgen) picture is taken after the liquid is injected, which shows the outline of the uterus and the fallopian tubes. An abnormally shaped uterus or blocked fallopian tubes can be diagnosed by this test. Most women experience moderate to severe pelvic cramps when the liquid is injected, but this usually improves after 5 to 10 minutes. This examination is usually performed 5-7 days after the menstrual period (before ovulation has occurred).
Hysteroscopy — Hysteroscopy involves the insertion of a small tube with a light source through the cervix and into the uterine cavity.It allows direct inspection of the lining of the uterus and the sites where the fallopian tubes enter the uterus. This examination is very useful in diagnosing polyps, adhesions or fibroids (myomas) which protrude into the cavity.Hysteroscopy is usually recommended after transvaginal ultrasound and/or hysterosalpingogram suggest an abnormal uterine cavity. Diagnostic hysteroscopy can be performed in the doctor's office without anesthesia or sedation. Hysteroscopy can also offer treatment for some of these abnormalities, like removal of septum, polyp or adhesions. If hysteroscopic surgery is necessary, it is usually performed in an operating room under local, regional or general anesthesia.
Laparoscopy — Laparoscopy involves the insertion of a thin optic tube with a light source through a small incision into the abdomen, allowing the doctor to view the organs in the abdominal cavity (specifically the uterus, ovaries, and fallopian tubes). It is performed under general anesthesia in the operating room and also allows treatment of some of the abnormalities without the need “to open the abdomen” (i.e., use the small entry points and avoid the wide incision in the abdominal wall).
Laparoscopy can detect disease conditions and blockage of the fallopian tubes, endometriosis, and other abnormalities of the pelvic organs. It is the best method to diagnose endometriosis or pelvic adhesions (scarring). However, laparoscopy is not routinely done during an evaluation of infertility.
Genetic tests — Genetic testing is rarely recommended for female infertility as genetic and chromosomal abnormalities are less common than in the infertile male. However, absence of an X chromosome (Turner syndrome) and some gene mutations are associated with female infertility. Like in the male, the presence of genetic abnormality requires discussion of the possibility of transmission to the child.
The process of trying to become pregnant and the inability to do so can lead to a variety of emotions, including stress, anxiety, depression, anger, shame, and guilt. In one study, about 40% of infertility patients suffered from a psychological problem.
Both men and women can suffer from these problems, which can further interfere with their ability to get pregnant. Psychological distress is associated with infertility treatment failure, and interventions to relieve stress are associated with increased pregnancy rates.
The best approach for treatment of the psychological distress which is related to infertility has not been determined. However, some experts suggest relaxation techniques, stress management, coping skills training, and group support. Evaluation by a psychiatrist may be needed for those with significant symptoms of anxiety or depression.
There are a number of options for the treatment of both male and female infertility. These include surgery (usually for anatomical abnormalities) ovulation inducing drugs (clomiphene, gonadotropins), Intrauterine insemination (IUI), In-vitro fertilization (IVF) and other options, including sperm/egg donations.
The ability of a couple to become pregnant depends on several factors in both the male and female partners. In general, the male needs to produce normal, motile sperm cells, which have to be present in the ejaculate in adequate numbers. The female needs to ovulate (produce eggs) regularly and have normal reproductive organs (uterus and tubes), which allow (or even facilitate) the passage of sperm cells. Statistics show that of all infertile couples: in about 25% there are male problems, in 40% there are female problems, and in 20% there are combined problems (in both the male and female). In the remaining 15%, the cause of the infertility cannot be traced to specific factors in either partner and it is called “unexplained”. This is why both partners need to have the evaluation, but even if one partner is “responsible”, infertility treatments require close cooperation of both.
The production of sperm cells in the male requires normal testes (or testicles) and it is regulated by hormones which are produced by the reproductive brain centers (hypothalamus and pituitary gland). Therefore, a variety of different conditions can lead to infertility: hormonal, genetic, anatomical and environmental. However, in many cases, this evaluation does not point to a specific reason or condition. But one should not be discouraged as the treatment of male infertility can be as successful, even if we do not find the exact underlying problem. Finally, infertility can result from male sexual dysfunction (Impotence, premature ejaculation etc.), which is most often diagnosed by detailed sexual history.
History & Physical examination — may sometimes give us a hint or a clue to an underlying abnormality. Information about past (sexually transmitted) infections, testicular trauma or surgery, sexual activity, the use of medications and exposure to certain environmental agents (smoking, alcohol, radiation, steroids, chemotherapy, and toxic chemicals) – maybe helpful. The size of the testicles, associated anatomical abnormalities (like varicose vein of the testes, Varicocele) and signs of sexual development (like hair distribution, breasts, etc.,) are also important findings.
Semen analysis — A semen analysis (sperm count by a microscope) is the major part of the infertility evaluation in the male. This test provides information about the amount of semen and the number, motility, and shape of the sperm cells.
A man should avoid sex and masturbation for 2-5 days before providing the semen sample. Ideally, a sample should be produced by masturbation in the clinic or laboratory; but if this is not possible, it may be produced at home into a sterile laboratory container. The sample should be delivered to the lab within one hour of collection.
If the initial semen analysis is abnormal, the doctor will often request an additional sample; this is best done 3-4 weeks later.
Blood tests — are sometimes performed if a hormonal problem is suspected.
Genetic tests — If genetic or chromosomal abnormalities are suspected, specialized genetic studies are required. Klinefelter syndrome is a condition in which the male has an extra X chromosome (XXY instead of XY) and is associated with infertility. Male infertility may be sometimes associated with absent or abnormal regions of the male chromosome (Y). A gene mutation (abnormal DNA information) which causes Cystic Fibrosis may also result in male infertility with low sperm count. In such cases we need also to consider the possibility and consequences of transferring the abnormality to the child.
Other tests — If blockage of the ducts which transfer the sperm from the testicles (epididymis or vas deferens) is suspected a transrectal ultrasound examination may be required. Such blockade can be a congenital malformation or secondary to an infection.
A testicular biopsy (collection of a small tissue sample) may be required in men with low or no sperm on the semen analysis. The biopsy can be done by surgically opening the testis or by fine-needle aspiration (inserting a small needle into the testis and withdrawing a sample of tissue). Biopsy is usually done in the operating room under general anesthesia. The biopsy allows to study the microscopic structure of the testes, determine if sperm is present and even to freeze sperm cells for later IVF, with or without micromanipulation (ICSI).
A variety of conditions may lead to female infertility, but the most common is absent or infrequent ovulation (Anovulation or Oligo-ovulation). This may occur as a result of hormonal problems, but age, environmental factors and stress can play a critical role. The second most common cause of female infertility is “mechanical” or “anatomical” and refers to conditions affecting the fallopian tubes and uterus. These conditions typically interfere with the passage of gametes (egg and sperm) in the tract or the implantation of the embryo in the uterus. Blockage and scarring (adhesions) of the Fallopian tubes may be caused by infection (like Gonorrhea) and pelvic surgery (like Appendectomy). Conditions which affect the uterus can be malformations, polyps, fibroids (myomas) and scar tissue formation after abortions or infections. Another common cause of female infertility is Endometriosis which interferes with normal reproduction by several mechanisms. It is characterized by the presence of uterine lining tissue (Endometrium) in the pelvic cavity (on the tubes, uterus and ovaries). Doctors usually begin the evaluation with medical history, physical examination, and some preliminary tests to determine if the woman ovulates spontaneously.
Medical history — A woman's past health and medical history may provide some clues about the cause of infertility. The doctor will ask about sexual development during puberty; sexual history; sexually transmitted infections; surgeries; medications used; exposure to certain environmental agents (alcohol, radiation, steroids, chemotherapy, and toxic chemicals); and any previous fertility problems.
Physical examination — A general physical examination may suggest hormonal imbalance (for instance: abnormal hair growth or sexual development) and pelvic examination may find anatomical abnormalities of the reproductive organs.
Blood tests — The levels of some key hormones which are produced by the brain centers which regulate ovulation (the hypothalamus and the pituitary gland) and the ovaries can be determined by blood tests. . These hormones include follicle-stimulating hormone (FSH) to assess how well the ovaries are functioning, TSH to test thyroid function, and prolactin to rule out the presence of a benign pituitary tumor.
Tests of ovulation — Ovulation (the release of an egg from an ovary) is essential for female fertility. Abnormalities of ovulation can often be suspected from a woman's menstrual history or hormone levels (LH surge before ovulation or progesterone levels in the luteal phase).
Menstrual history — Amenorrhea (absent menstrual periods) usually signals an absence of ovulation, which can cause infertility. Irregular menstrual cycles can be a sign of irregular ovulation; although this does not make pregnancy impossible, it can interfere with the ability to become pregnant.
Basal body temperature (BBT) — In the past monitoring of BBT (measured before getting out of bed in the morning) was recommended to determine if ovulation occurred, as the BBT usually rises by 0.5ºF to 1.0ºF after ovulation. However, BBT patterns can be difficult to interpret and are not recommended anymore in the evaluation of infertility.Hormone levels — The levels of the luteinizing hormone (LH) rise abruptly approximately 38 hours before ovulation. This hormone rise can be detected by an over-the-counter home urine test. However, this method fails to detect the rise in about 15% of the cases and another blood test may be needed d to confirm ovulation. Normally, the blood levels of the hormone progesterone rise after ovulation and it is a more accurate indicator of ovulation.
Tests to evaluate the uterus and fallopian tubes — Uterine problems that can contribute to infertility include congenital anatomical abnormalities (a septum or malformation of the uterine cavity), fibroids, polyps, and abnormalities that can result from gynecologic procedures (i.e., scarring and adhesions after abortions).
Scarring and obstruction of the fallopian tubes can occur as a result of pelvic inflammatory disease, endometriosis, or pelvic adhesions (scar tissue) from abdominal infection or surgery.
Pelvic ultrasound — Transvaginal ultrasound, which involves the insertion of a small ultrasound probe into the vagina, allows detailed anatomical evaluation of the female reproductive organs. It is used to evaluate and measure the size and shape of the uterus and ovaries and to determine if there are structural abnormalities (such as fibroids or ovarian cysts).
Hysterosalpingogram (HSG) — Hysterosalpingogram is used to help identify anatomical abnormalities of the uterus and fallopian tubes. It involves injecting a liquid which can be seen on x-ray through the cervix and into the uterus An x-ray (Roentgen) picture is taken after the liquid is injected, which shows the outline of the uterus and the fallopian tubes. An abnormally shaped uterus or blocked fallopian tubes can be diagnosed by this test. Most women experience moderate to severe pelvic cramps when the liquid is injected, but this usually improves after 5 to 10 minutes. This examination is usually performed 5-7 days after the menstrual period (before ovulation has occurred).
Hysteroscopy — Hysteroscopy involves the insertion of a small tube with a light source through the cervix and into the uterine cavity.It allows direct inspection of the lining of the uterus and the sites where the fallopian tubes enter the uterus. This examination is very useful in diagnosing polyps, adhesions or fibroids (myomas) which protrude into the cavity.Hysteroscopy is usually recommended after transvaginal ultrasound and/or hysterosalpingogram suggest an abnormal uterine cavity. Diagnostic hysteroscopy can be performed in the doctor's office without anesthesia or sedation. Hysteroscopy can also offer treatment for some of these abnormalities, like removal of septum, polyp or adhesions. If hysteroscopic surgery is necessary, it is usually performed in an operating room under local, regional or general anesthesia.
Laparoscopy — Laparoscopy involves the insertion of a thin optic tube with a light source through a small incision into the abdomen, allowing the doctor to view the organs in the abdominal cavity (specifically the uterus, ovaries, and fallopian tubes). It is performed under general anesthesia in the operating room and also allows treatment of some of the abnormalities without the need “to open the abdomen” (i.e., use the small entry points and avoid the wide incision in the abdominal wall).
Laparoscopy can detect disease conditions and blockage of the fallopian tubes, endometriosis, and other abnormalities of the pelvic organs. It is the best method to diagnose endometriosis or pelvic adhesions (scarring). However, laparoscopy is not routinely done during an evaluation of infertility.
Genetic tests — Genetic testing is rarely recommended for female infertility as genetic and chromosomal abnormalities are less common than in the infertile male. However, absence of an X chromosome (Turner syndrome) and some gene mutations are associated with female infertility. Like in the male, the presence of genetic abnormality requires discussion of the possibility of transmission to the child.
The process of trying to become pregnant and the inability to do so can lead to a variety of emotions, including stress, anxiety, depression, anger, shame, and guilt. In one study, about 40% of infertility patients suffered from a psychological problem.
Both men and women can suffer from these problems, which can further interfere with their ability to get pregnant. Psychological distress is associated with infertility treatment failure, and interventions to relieve stress are associated with increased pregnancy rates.
The best approach for treatment of the psychological distress which is related to infertility has not been determined. However, some experts suggest relaxation techniques, stress management, coping skills training, and group support. Evaluation by a psychiatrist may be needed for those with significant symptoms of anxiety or depression.
There are a number of options for the treatment of both male and female infertility. These include surgery (usually for anatomical abnormalities) ovulation inducing drugs (clomiphene, gonadotropins), Intrauterine insemination (IUI), In-vitro fertilization (IVF) and other options, including sperm/egg donations.