Infertility

After a year of attempting conception approximately 85% of women will become pregnant. Somewhat arbitrarily, a couple is diagnosed with infertility if they have not achieved pregnancy after one year. It is estimated that about 6 million American women and their partners are affected by infertility. Infertility may have an identified cause or be unexplained. When a couple is concerned about their inability to become pregnant a careful evaluation of both partners is needed.

An infertility evaluation begins with a careful medical history of both partners. This may point to the cause of infertility and alter the typical infertility evaluation. Sometimes education is all that is needed. Human reproduction is quite remarkable when one realizes that there is only a 24-hour period each month when the female egg can be fertilized by the male’s sperm.

The male partner is a factor in infertility in approximately 40% of infertile couples. Thus a semen analysis should be done early in the evaluation. This involves evaluating the number and mobility of sperm. An abnormal semen analysis should be repeated. If persistent then evaluation by a Urologist is recommended.

In order for a woman to become pregnant, sperm have to pass through cervical mucous, travel to the fallopian tubes and penetrate an egg, the fertilized egg then has to travel down to the uterus and implant into a hormonally prepared endometrium. The ovary has to continue to supply adequate hormones to maintain the pregnancy. Any interruption of this process can result in infertility.

The basic evaluation of infertility in females initially includes an assessment of ovulation. A woman who is having regular menstrual periods and some premenstrual symptoms such as breast tenderness is likely ovulating. However a basal body temperature chart or measurement of hormone levels can confirm ovulation is occurring. A small increase in body temperature first thing in the morning occurs around the time of ovulation. Kits to detect ovulation are commercially available or a physician can measure blood levels of the hormone progesterone to determine if ovulation occurred.

In 35% of infertile women blocked fallopian tubes are the cause of infertility. This may be caused by prior pelvic infections, either recognized or existing without symptoms. Chlamydia is a frequent cause of silent infections that can result in infertility. A Hysterosalpingogram, where dye is injected through the fallopian tubes, is often recommended to evaluate for blocked tubes. Other tests that may be recommended include a postcoital test to assess the adequacy of cervical mucous and an assessment of the endometrium.

Women with significant medical illnesses, who smoke cigarettes or who abuse alcohol or other drugs will also have a more difficult time conceiving. Endometriosis is also more common in infertile women than in fertile women. Treating even mild endometriosis may improve fertility rates.

After a complete evaluation many couples will have no identifiable cause of infertility. This is called unexplained infertility. Some of these couples will become pregnant without any intervention and may be considered "sub-fertile" as opposed to infertile. Others will only achieve pregnancy with assisted reproductive techniques.

For those women who are not ovulating, medications are used to induce ovulation. This may be combined with intrauterine insemination (where the sperm are placed directly into the uterus) to improve pregnancy rates. For couples with blocked fallopian tubes, in vitro fertilization offers the best pregnancy rates. A relatively new procedure called ICSI involves directly injecting a single sperm into an egg. The fertilized egg is then implanted into the uterus. A couple concerned about their inability to become pregnant should consult their physician for a complete evaluation.