Understanding Infertility

85% of all couples trying to conceive will become pregnant within one year. Approximately 7 million or 1 in 6 couples will have difficulty conceiving and may need medical help to identify and treat the possible causes of infertility. The good news is that there are treatments available to help almost everyone.

Infertility is a disease of the reproductive system that inhibits a couple’s ability to have a baby. Infertility affects men and women equally, without discrimination, and for this reason both partners should actively participate in the diagnosis and treatment process. 40% of all infertility cases may be attributed to the woman, 40% to the man, in 10% of cases both partners contribute to the problem, and 10% of the time the cause cannot be identified and it is considered unexplained. Bottom line, infertility is not uncommon, and you are not alone.

Defining Infertility
The standard definition of infertility is the inability to achieve a pregnancy after one year of unprotected intercourse in couples where the woman is under age 35. Because a woman’s fertility declines naturally as she gets older, couples should consider seeking medical help after six months of trying when the female partner is over age 35.

Why is age so important?
A woman’s fertility peaks in her mid-20’s, begins to decline around 27 and drops off more steeply after age 35. A woman’s fertility is measured by her ability to achieve a pregnancy on a given month. For women, the ability to conceive is tied to the quality of her eggs. As women age, hormonal changes begin to take place. There is a lot going on, but of particular interest are the two main hormones controlling the development and release of the egg each month. These hormones are FSH (follicle stimulating hormone) and LH (lutenizing hormone). A rising FSH level is linked to a decreasing egg quality. Decreased egg quality means it becomes more difficult for the sperm to fertilize the egg naturally. There may even be chromosomal abnormalities occurring within the egg itself, which is why amniocentesis is recommended for pregnant women over 35. To illustrate this point, the natural pregnancy rate for women >30 is 20-30% per month, but by age 40, the likelihood of conception occurring drops to > 5% per month.

Infertility Topics

Increasing Your Chance of Pregnancy

If you are healthy, have no fertility problems, and want to conceive a baby, you can dramatically improve your chances of becoming pregnant by tracking when you ovulate and having sex near that time. There are several tools available to help you determine the appropriate time to have sex each month.

The first and easiest step to improving your chances of getting pregnant is to chart your menstrual cycle so that you can have sexual intercourse as close as possible to ovulation. Begin by keeping track of the intervals between day one of your period and day one of your next period. The number of days between the first days of your periods is known as your cycle interval.

Once you know your cycle interval, subtract 14 from that number to determine when in your cycle you will likely ovulate. For example, if you have a typical 28-day cycle, by subtracting 14 from 28 you can feel confident that you ovulate around the 14th day of each cycle.

To increase your chances of getting pregnant, have sex every other day around the day you ovulate. For example, if you are on a 28-day cycle, you should have sex on days 10, 12, 14, 16, and 18 of your cycle to maximize your chance of pregnancy. Because sperm can live two to three days, this every other day approach helps to ensure that sperm will be available when eggs are released at ovulation.

There are web sites such as www.webmd.com and www.BabyCenter.com that will help you calculate the day within your cycle when ovulation occurs. According to the National Center for Health Statistics, you have a 96% chance of conceiving within one year if you’re under 25; an 86% chance if you’re between 25 and 34; and a 78% chance if you’re between the ages of 35 and 44.

Using Your Basal Body Temperature
If you are not sure if you are ovulating, charting your morning temperature can help you determine if and when ovulation occurs. Simply take your temperature before you get out of bed each morning and plot it on a chart. When you see a shift of at least 0.4 degrees Fahrenheit, you know that ovulation occurred. Most women have a lower body temperature right before ovulation and a higher body temperature right after ovulation. Because the basal body temperature method can only tell you after the fact that ovulation occurred, it is not an optimum way to maximize your chances of pregnancy. It is, however, useful over the long-term for understanding when you ovulate so you can determine the optimum time for having intercourse.

Ovulation Predictor Kits
Ovulation predictor kits test your urine for signs of those hormones that indicate that ovulation is about to occur. These kits usually detect levels of lutenizing hormone (LH), which triggers ovulation and generally rises 12 to 36 hours before you ovulate. To increase your chances of pregnancy, have sex every other day around the day you ovulate.

To properly use ovulation predictor kits, you should start testing your urine three days before you think you ovulate. For example, if you think you have a 28-day cycle, you ovulate on day 14 so you should begin testing your urine on day 11 of your cycle. This approach allows you to clearly see a negative result, indicating the lack of LH, and then clearly see a positive result, indicating the presence of LH. You should ovulate about 36 hours after a positive test result. To improve your chance of getting pregnant, you should have intercourse the day that you see a positive result, as well as the day after a positive result.

There are also ovulation predictor kits that test saliva rather than urine. These kits include a glass slide and a microscope that allow you to look for a certain visible pattern in your saliva sample that indicates you will ovulate within the next several days. While these tests are not as accurate as those ovulation predictor kits that test urine, they are less costly and reusable.

Do-It-Yourself Semen Analysis
Many drugstores now sell male infertility tests that help measure sperm concentration. While the test does not provide the same specific information indicated by a medical semen analysis, it can tell if the minimum number of motile sperm is present. These tests are useful for helping couples identify if there are problems with the male partner’s fertility so that they can seek professional treatment early in their quest to become pregnant.

Infertility Testing Basics

Infertility occurs when a couple is unable to conceive after 12 months of having intercourse without the use of birth control. The male partner, the female partner, or both partners may have a problem with their fertility.

In men, the most common reasons for infertility are sperm disorders, such as low sperm count, low sperm motility, malformed sperm, and blocked sperm ducts. The main causes of infertility in women are anovulation, or lack of ovulation, and the inability of the fallopian tubes to carry eggs from the ovary to the uterus. Men and women are equally likely to have fertility problems.

It is generally recommended that you have an infertility evaluation after you have tried unsuccessfully to become pregnant for 12 months or more. In cases, where the female partner is over 35, it is recommended that you have an infertility evaluation after six months of unprotected sex. The infertility evaluation will determine the reasons you have been unable to conceive so that a treatment plan can be developed.

The Basic Infertility Workup
If you have not been able to conceive after 12 months of having sex without the use of birth control, you may want to have an infertility evaluation. The basic infertility workup includes:

  • Physical exam for both partners
  • Medical history of both partners
  • Semen analysis
  • Check for ovulation
  • Tests to check for a normal uterus and open fallopian tubes
  • Discussion of how often and when you have sexual intercourse

Testing for the Male Partner
A semen analysis is a key part of the basic infertility workup. This analysis may need to be conducted more than once. The semen sample is obtained by masturbation. Sometimes the semen sample can be obtained at home, other times it is obtained in a lab. Your doctor will give you instructions and make sure you feel as comfortable as possible about the semen analysis. The semen sample is then sent to a lab, where it is analyzed for:

  • The number of semen present
  • The shape of the semen
  • The movement of the semen
  • Any signs of infection

If any potential problems with the urinary tract are found, the male partner most likely will be referred to a urologist for further testing.

Testing for the Female Partner
For the female partner, the infertility evaluation begins with a physical exam and a comprehensive health history. The health history will focus on four key points:

  • Menstrual function, such as irregular bleeding or pain
  • Pregnancy history
  • Sexually transmitted disease (STD) history
  • Birth control

Another important part of the evaluation is determining whether and when you are ovulating. Here are some of the tests that may be performed:

  • Urine test: This test is performed at home and indicates if ovulation is about to occur.
  • Basal body temperature: You take your temperature every morning before you get out of bed and record it on a chart. Keeping this body temperature chart for two to three menstrual cycles will show whether or not you are ovulating.
  • Blood test: The blood test measures progesterone, which can indicate whether or not you are ovulating.
  • Endometrial biopsy: Because the lining of the uterus changes during ovulation, analyzing sample tissue from the uterus can determine if ovulation occurs.

Other tests may be used to examine your reproductive organs. These tests check the appearance of your uterus and determine if your fallopian tubes are open. Your individual circumstances and symptoms determine which of these tests are performed:

  • Hysterosalpingography (HSG): This test is an x-ray that shows the inside of your uterus and fallopian tubes. A small amount if dye is placed in the uterus through a thin tube inserted through the cervix. An x-ray is then taken.
  • Transvaginal Ultrasound: A device is inserted in the vagina that uses ultrasound waves to produce images of your ovaries and uterus.
  • Hysteroscopy: A thin telescope-like device is placed through the cervix. The inside of your uterus may be filled with a harmless gas or liquid so that the doctor can correct any problems and obtain a tissue sample if needed.
  • Laparoscopy: A small telescope-like device is inserted through a small cut at the lower edge of the navel. The doctor looks for pelvic problems in the fallopian tubes, ovaries, and uterus.
Treatment Options

Infertility may be caused by a problem with the woman, the man, both, or your lifestyle. Infertility can be caused by more than one factor or, in some cases, the cause of infertility cannot be identified.

To treat infertility, your doctor may recommend lifestyle changes, medication, surgery, or assisted reproductive technologies. In some cases, treatments may be combined to improve results. For example, medication and insemination may be used at the same time.

Whether infertility lies with one or both partners, a number of treatment options can be considered. Before you begin treatment for infertility, talk with your doctor about the expected success rates for each treatment and how success is defined. Also talk with your doctor about the cost of each treatment and whether or not it is covered by insurance. The Centers for Disease Control and Prevention (CDC) lists the success rates for most fertility clinics in the United States on their web site: www.cdc.gov.

Ovulation Induction
If your infertility evaluation determines that you have a problem with ovulation, you may be given medication to cause ovulation or to cause more eggs to be released at ovulation. Most women who take ovulation induction medication begin to ovulate regularly. If there are no other problems, more than half of these women become pregnant within six treatment cycles. In some cases, the ovulation medication results in a multiple pregnancy.

Sometimes, surgery can correct the problem that has been causing infertility. If your fallopian tubes are blocked, surgery may be done to open the tubes. Surgery may also be performed to:

  • Remove growths, such as uterine fibroids or polyps
  • Remove scarring from a previous surgery, infection, or endometriosis
  • Treat endometriosis

Surgery can also sometimes be used to correct a problem with the male partner’s sperm. The success of this kind of surgery depends on the type and extent of the problem. Lifestyle changes such as losing or gaining weight, increasing or decreasing exercise, stopping smoking, or changing when and how often you have sex may help increase your chances of becoming pregnant.

Assisted Reproductive Technologies
Assisted reproductive technologies (ART) involve medically processing human eggs or sperm or both to help an infertile couple conceive a child. This process is done in a laboratory. Sometimes ART treatment uses donor eggs or donor sperm. The sperm may also be obtained through masturbation or with a special condom that is used during intercourse. In some cases, sperm may be obtained surgically. Here are some of the assisted reproductive technologies that can be used by couples trying to conceive:

  • Insemination: sperm are placed in your uterus by means other than sexual intercourse around your time of ovulation. In most cases, the sperm are treated in a lab to decrease the risk of infections and to increase the chance of fertilization. The sperm can be supplied by your partner or by a donor, whose sperm is frozen and checked for certain genetic disorders and sexually transmitted diseases.
  • In Vitro Fertilization (IVF): sperm from the male partner are used to fertilize your eggs in a lab. The eggs are removed from your ovary using a needle inserted through your vagina just before ovulation. In most cases, medication is given to cause more than one egg to mature. The eggs are combined with healthy sperm from a partner or donor and watched in the lab to see if they become fertilized. One or more of the fertilized eggs (embryos) are placed in your uterus. This process is called embryo transfer. Your unused fertilized eggs can be frozen and stored for later use. The success rate of IVF depends on the woman’s age and the reason for the infertility. Multiple pregnancy is possible with this method, so many fertility centers are opting for single embryo transfer. This isn’t an option for every couple, so we encourage you to discuss this with your physician.

If there is a problem with the male partner’s sperm, a procedure known as Intracytoplasmic Sperm Injection (ICSI) is performed. Healthy sperm are removed from the man’s semen and your eggs are retrieved. In the lab, one sperm is injected into each egg’s center. The eggs are later checked to see if they have fertilized and fertilized eggs (embryos) are placed in your uterus to grow. Any unused fertilized eggs can be frozen for later use. Pregnancy rates with ICSI are about the same as with IVF.

Fertility Resources:

10 Fertility Tips that Make a Difference
  1. Infertility doesn’t discriminate
    Infertility is a disease of the reproductive system and affects both men and women. For this reason, during the initial infertility work-up, it is imperative that both the female & male partner’s fertility is tested. Testing for male fertility is simple and non-invasive; a semen sample is taken to a laboratory and the sperm are observed under microscope. This test is called a semen analysis. Because 40% of fertility problems are attributed to the male, no treatment should be initiated before knowing the results of this test.
  2. Understand you are not alone
    It seems that everyone knows someone who has had trouble conceiving. The fact is that 7 million couples, on average, 1 in 6 couples of reproductive years, will be infertile. The good news is that if they seek treatment, and have the emotional and financial wherewithal, even couples with the most complicated cases can be successful in having a baby. Patient advocacy groups and online patient networks are also great resources for information.
  3. The woman’s age is a key indicator of future success
    The single most common misperception among women is that they can achieve a pregnancy at any age. It is not true. A woman’s fertility naturally decreases with age and fertility treatment results follow the same lines, down over time, beginning in the early 20’s and dropping more rapidly after 35. Even with IVF, pregnancies over the age of 42 are uncommon. But what about those Hollywood stars who are having babies at 45, 48 and even 52? These women are most likely using donor eggs.
  4. Know when to seek help
    For women under 35, infertility is defined as 12 months of unprotected intercourse without conception. For women over 35, it is defined as 6 months of unprotected intercourse without conception. If you stopped taking birth control a few years ago but haven’t been actively trying you should also consider speaking to your doctor just to be sure everything is ok.
  5. Know where to seek medical help
    75% of women begin at their OB/GYN and 15% of women go directly to a reproductive endocrinologist or fertility center. Both doctors will begin the same way, an infertility work-up of the male and female to uncover any potential causes of infertility. The Ob/Gyn may do surgery to improve physical conditions or possibly prescribe Clomid treatment to induce ovulation or to overcome a very mild male factor. For anything more advanced, most will refer out to the specialist.
  6. Do your homework first, especially if you know you need a fertility specialist.
    Infertility impacts couples medically, emotionally, and financially. You want to be sure that you are going to the best place for you and your partner. From a medical perspective, evaluate your doctor’s training, the clinic’s track record of success, and their treatment volume. From the emotional perspective, what kind of resources for support do they offer and is it integrated into the practice or part of an outside service? Are you comfortable with interactions you’ve had with staff? Cost is a big issue, so do you get the sense they are on your team when it comes to insurance and payment options? Most importantly, seek the recommendation from people you trust, your physician, or friends who have gone through this type of treatment.
  7. Insurance often does cover fertility treatment.
    Insurance coverage varies from employer to employer. Typically, insurances will cover the initial work-up and consultation. At Mt. Auburn OBGYN, our insurance coordinators will work with you and your insurance company to determine your benefits. You and your physician will use this information to decide the best treatment options to pursue.
  8. In Vitro Fertilization is often not the first option.
    Many patients will begin with low tech treatment, achieve a pregnancy, and never have a need for In Vitro Fertilization (IVF). Because of their diagnosis, such as: blocked fallopian tubes, advanced age, or male factor infertility, others will have to go straight to IVF or donor egg to help them conceive. Most physicians will take a stepped-care approach to balancing your chances for success and the simplicity of the procedure. While IVF offers outstanding success rates, it may not be necessary.
  9. IVF is not experimental and the incidence of high-order multiple births are decreasing.
    Over the past 25 years, In Vitro Fertilization technology and our knowledge about the reproductive processes have improved, affording many more couples the ability to conceive. Let’s consider the fact that nearly 150,000 babies have been born from IVF since Louis Brown appeared on the scene back in 1978. Pregnancy rates have nearly doubled, Intracytoplasmic Sperm Injection (ICSI) has almost eliminated the need for donor sperm, and high-order multiple births have nearly been eliminated.
  10. More of the same treatment is not always better.
    When you are going through any fertility treatment it is important to understand that your chances for pregnancy are most likely going to be optimized by 3-6 treatment cycles. If pregnancy isn’t happening, and if no new information has been found to help improve the current treatment plan, then it is time to move on to the next option. If you have been taking Clomid for 6 months or more, it may be time to consider your next steps, especially if you are over the age the age of 35.

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