INFERTILITY: Causes & Treatments

Many couples who want a child face the problem of infertility - they have tried to conceive but have not been able to do so. Couples are considered infertile if they have not been able to conceive after 12 months of having sex without the use of any form of birth control. About 14% of couples in the United States are infertile.
Infertility may be due to many problems. More than one factor may be causing the infertility. Some causes are easily diagnosed and treated, while others are not. In some cases, no cause can be found in either partner.
If you and your partner are infertile and you want to have a child, you should think about having an infertility evaluation. This is done by a doctor to find out what is causing the infertility and what can be done to correct it.

CONDITIONS FOR CONCEPTION

At the peak of a woman's fertility - around her early to mid-20s - the odds are only 20% that she will conceive during any one menstrual cycle. This figure starts to decline in her late 20s and early 30s and drops even further around 35. A man's fertility also declines with age, but not as quickly.
Certain events must take place in order for conception to occur:
  • Ovulation - the release of an egg from one of the woman's ovaries
  • Fertilization - the uniting of the woman's egg and the man's sperm
  • Implantation - the attaching of the fertilized egg to the lining of the uterus
Conception can occur if you have sexual intercourse during or near the time of ovulation. Ovulation occurs about 14 days before the start of the next menstrual period. Once an egg is released, it remains able to be fertilized for 12-24 hours. When the man ejaculates during sex, his sperm are released into the vagina. Sperm can live in the woman's reproductive tract for 2-3 days or longer. They travel up through the cervix, or opening of the uterus, and out into the tube. If the sperm and egg unite, fertilization can occur. The fertilized egg then moves through the tube into the uterus and becomes implanted to grow and develop into a fetus. If there is a problem anywhere in this chain of events, infertility can occur.

CAUSES OF INFERTILITY

There are many possible causes of infertility. A single cause may not be linked to either the man or the woman. Often the problem stems from a combination of factors in either or both partners. You and your partner will be diagnosed as a couple to determine the best treatment for you.

Infertility in the Man

A man may be infertile because he does not have enough sperm; because the sperm are not active enough; because the passage, or vas deferens, is blocked; or because of problems with ejaculation. A number of factors can cause or contribute to male infertility:
  • Sexually transmitted diseases, such as gonorrhea or chlamydia
  • Fevers and infections, such as mumps occurring after puberty
  • Surgery of the reproductive tract, such as that for undescended testes, hernia repair, disorders of the prostate gland, or cancer
  • Damage to the vas deferens, most often by vasectomy
  • Varicose veins in the scrotum (varicocele)
  • Use of certain drugs, such as those for depression or high blood pressure
  • Exposure of the testes to high temperatures, such as those that result from the wearing of tight, unventilated clothing; excessive use of hot tubs; or conditions in the workplace
  • Use of tobacco, marijuana, or alcohol
  • Medical conditions, such as diabetes
  • Genetic or hormonal problems
Injury to the testes, such as that resulting from physical trauma or exposure to radiation, can also cause infertility in the man.


Infertility in the Woman

A woman may be infertile because of hormone imbalances or problems in the reproductive tract. Factors that can cause or add to female infertility include:
  • Hormone levels that prevent the release of an egg from an ovary or the implantation of a fertilized egg in the lining of the uterus
  • Extra weight (more than 30% over her ideal body weight), which may cause problems with ovulation
  • Scarring or tumors of the uterus or defects of the uterus present from birth
  • Too little or poor-quality cervical mucus, sometimes due to surgery or other treatment
  • Endometriosis - a condition in which tissue like that normally lining the uterus (the endometrium) is found outside the uterus
  • Adhesions - bands of scar tissue from previous surgery, endometriosis, or infections that bind together tissues inside the abdomen
  • Infections such as pelvic inflammatory disease (PID), a severe infection of the female reproductive organs that may be caused by sexually transmitted diseases such as gonorrhea or chlamydia; or appendicitis, which can result in scarring of the internal pelvic organs
  • Production of antibodies that attack her partner's sperm
  • Medical conditions, such as thyroid disease or diabetes
  • Genetic conditions such as Turner's syndrome, in which a woman has only one X chromosome and may not completely develop breasts or pubic hair
  • Use of tobacco, marijuana or alcohol

In the female reproductive system, the egg is released from the ovary at ovulation (1), is fertilized by sperm in the fallopian tube (2), and moves through the tube to the lining of the uterus (3) where it become implanted and grows.

TESTING

Testing may be done after a couple has had 12 months of sex without birth control and conception has not occurred. Testing may be begun sooner, though, depending on age and other factors.
An infertility workup involves both the man and the woman. If the couple and the doctor decide to proceed, the basic evaluation usually can be completed within a few menstrual cycles. If testing is needed, several office visits may be required. Ask your doctor about the costs involved. Find out whether they are covered by your insurance. The basic workup includes:

  • A semen analysis
  • Proof that ovulation has occurred
  • A postcoital test to see how the sperm move through the cervical mucus
  • Evaluation of whether the woman's tubes allow passage of the eggs
The couple will also be asked about their sexual relations to find out whether their infertility might be linked to the timing or frequency of intercourse.

BASIC WORKUP

Testing the Man. A semen analysis is an important part of the basic workup. The doctor may tell the man not to ejaculate for 2-3 days before he gives his semen sample. Sometimes he is asked to produce the semen sample at the lab, since sperm have a fairly short life span outside of the body and quickly lose their ability to fertilize.
The semen sample is analyzed in the lab to determine the number of sperm present, as well as to study their movement and their structure. Factors such as the presence of infection can be detected as well. The semen analysis may need to be repeated.
Other tests of the man may also be needed. He may be referred to a urologist (a doctor who specializes in conditions involving the urinary tract). The urologist will perform a physical exam, looking closely at the functions and structure of the testes and other reproductive organs. Special tests of sperm function may be done. A blood sample may be taken to check the level of those hormones that affect fertility. Sometimes a biopsy of the testes may be helpful in finding the cause of infertility.

Testing the Woman. Most tests used to detect infertility in a woman check if and when ovulation has occurred. These tests may be performed before, during, or after ovulation. Others check for any structural abnormalities in her reproductive system.

Urine Test. A way to predict ovulation is by using a urine test kit at home. This test measures luteinizing hormone (LH), which is released by the pituitary gland to cause ovulation. If the test is positive, it indicates that ovulation is about to occur. Sometimes these kits are used to supplement basal body temperature charts.

Basal Body Temperature. After a woman ovulates, there is a rise in body temperature - as much as 1 degree F - that can happen suddenly in one day or slowly over several days. To record her basal body temperature, a woman takes her oral temperature every morning before she gets out of bed and records it on a sheet of graph paper. This record usually has to be kept for 2-3 months. This test may suggest whether ovulation has occurred and whether it occurs on a regular basis. It may be helpful in planning the timing of other tests.

Progesterone Test. After a woman ovulates, the ovaries produce progesterone, a hormone produced in the ovaries that prepares the lining of the uterus to nourish a fertilized egg. A blood test, taken 5-10 days before a woman's period is due, can be used to test for ovulation by measuring progesterone.

Endometrial Biopsy. Sometimes this test is performed to find out whether and when ovulation has occurred and whether there are problems with how the lining of the uterus responds to ovulation. The procedure is done a few days before a woman's period is due. A thin, hollow tube is inserted into the vagina and through the cervix to remove a small piece of the uterine lining. This sample is later examined under a microscope. This procedure is done in the doctor's office.

Postcoital Test (PCT). The postcoital (after sex) test examines the ability of sperm to enter and move into the cervical mucus just before time of ovulation. The couple has intercourse close to the time of ovulation, and the cervical mucus is examined a few hours later. A PCT can also show if there is a reaction between the sperm and cervical mucus that could be causing infertility.

Hysterosalpingography (HSG). This test is an X-ray that examines the inside of the uterus and fallopian tubes. It is usually performed right after the menstrual period in a radiologist' office or the X-ray department of a hospital. A small amount of fluid is placed in the uterus through a thin tube inserted through the cervix, and an X-ray is taken. The fluid outlines the inside of the uterus and shows (by a spill of the fluid out of the tubes) whether they are open.

Ultrasound. Ultrasound uses sound waves to produce images of internal structures. This test can check the ovaries and uterus, as well as the thickness of the uterine lining. It can also be used to show the development of the egg in the ovary.

Hysteroscopy. For this procedure, the doctor places a telescope-like instrument, called a hysteroscope, through the cervix. The inside of the uterus may be filled with a gas or liquid. With the hysteroscope, the doctor can see the contents of the uterine cavity, including the opening of the tubes on the inside of the uterus. During this procedure, the doctor can correct minor problems, get a biopsy sample, or determine whether another operation is needed. Hysteroscopy is performed under local or general anesthesia.

Laparoscopy. A light-transmitting, telescope-like instrument, called a laparoscope, is inserted through a small incision (about 1/2 inch or less) at the lower edge of the naval. The abdominal cavity is filled with gas so the uterus can be seen. With this procedure, the doctor can look for pelvic disease, such as endometriosis, that may interfere with conception. The fallopian tubes can also be examined and tested to determine whether they are open by injecting a fluid into the uterus and tubes. It usually is performed under general anesthesia and does not require an overnight hospital stay.


TREATMENT OF INFERTILITY

Treatment for the Man
Treatment for the man depends on the specific problem that is found. If, for example, the vas or other parts of the reproductive tract are blocked, microsurgery (surgery on very small structures under a microscope) is usually successful in cutting out the blocked area and reconnecting the cut segments. If the man has low levels of certain hormones, an injection can sometimes be given to stimulate the production of sperm. The success of these treatments depends on the nature, severity, and often the duration of the problem.

Treatment for the Woman
If the woman has eggs but they are not being released, she may be given fertility drugs to bring on ovulation. Side effects, such as multiple pregnancy, sometimes occur with the use of these drugs, and they must be taken under close medical supervision. The risk of multiple pregnancy is higher with the use of some drugs than with others.
Problems that can't be treated by drugs may be treated by surgery. Some procedures used for diagnosis may be used for treatment. Sometimes more extensive treatment is needed.

Treatment for the Couple
When each member of the infertile couple has been evaluated, but a problem remains with one or both members, there are several options for treating the couple. If the problem is linked to life style, such as substance abuse or being overweight, you should take steps to address the problem. But medical treatment may be necessary for conception. If so, you should have a clear understanding of the expense and effort involved and of the experience of the team that will be treating you.

Artificial Insemination. Artificial insemination - insemination by means other than intercourse - is one option. Usually the sperm are treated to enhance the chances for successful fertilization. Around the time of ovulation, the sperm are placed in the vagina, cervix, or uterus, or sometimes the tubes or pelvic cavity.
The sperm for artificial insemination may be provided by the woman's partner (may be called artificial insemination-husband, or AIH) or by a donor (artificial insemination-donor, or AID). The choice depends on the nature of the medical problem. Semen from a donor has been frozen while the donor is screened for genetic disorders and some sexually transmitted diseases, including AIDS.
Artificial insemination can be used in certain women along with fertility drugs to mature several eggs (sometimes called superovulation). The sperm are placed into the uterus close to the time of ovulation. There is an increased risk of multiple pregnancy with this method, however.

In Vitro Fertilization (IVF). In vitro fertilization also involves using fertility drugs that cause multiple eggs to mature. These eggs are removed from the ovary just before ovulation is due. The eggs are removed by laparoscopy or by inserting a needle through the abdomen or the vagina, and withdrawing the eggs through the needle. The eggs are fertilized with sperm in a dish in the lab. A fertilized egg is then placed in the woman's uterus through her vagina. The unused fertilized eggs can be frozen and stored for later use.

Gamete Intrafallopian Transfer (GIFT). A variation of the IVF procedure is gamete intrafallopian transfer, or GIFT. A woman must have at least one healthy fallopian tube for this technique to be tried. As in IVF, drugs are used to produce multiple eggs in the woman's ovaries. The eggs are collected, usually by laparoscopy, just before ovulation is to occur. Two or three eggs are mixed with the man's sperm. The eggs and sperm are placed in the woman's fallopian tube for fertilization to take place there. Some fertility centers use a combination of IVF and GIFT.

Zygote Intrafallopian Transfer (ZIFT). Yet another variation of IVF and GIFT is zygote (fertilized egg) intrafallopian transfer, or ZIFT. As in IVF, the egg is fertilized in a dish before placement in the tube.


THINKING IT OVER

It is important for a couple to think very carefully about the decision to go through an infertility workup. It can be an expensive and time-consuming process that requires a big commitment from both partners. There are no guarantees that the cause of the infertility will be found or that pregnancy will be achieved.
Before making the decision, a couple should look at their reasons for wanting a child. A couple may feel pressure - from family, friends, or society in general - to have a child. They may feel that somehow they are not a real family if they remain childless. However, many couples have a satisfying life together without children. Discuss your feelings with your partner. Think about the alternatives, such as adoption or not expanding your family. Sometimes professional counseling can help to sort out these feelings.
Couples who have been infertile may also hear advice from friends or family that they should just "relax" and they will be able to conceive a child. Although stress has been shown to contribute to infertility in some cases, emotional problems are usually not the major cause. Most infertility problems have real physical causes that can be treated.
Once the couple have made the decision to try to have a baby, they should talk with their doctor about any questions or concerns they may have. The doctor can explain in greater detail what may be involved in the workup. After the workup, he or she can also explain the chances for successful treatment.



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