What is Infertility?
Infertility is the inability of a person, animal or plant to reproduce by natural means. It is usually not the natural state of a healthy adult organism, except notably among certain eusocial species (mostly haplodiploid insects).
In humans, infertility may describe a woman who is unable to conceive as well as being unable to carry a pregnancy to full term. There are many biological and other causes of infertility, including some that medical intervention can treat. Estimates from 1997 suggest that worldwide "between three and seven per cent of all couples or women have an unresolved problem of infertility. Many more couples, however, experience involuntary childlessness for at least one year: estimates range from 12% to 28%." 20-30% of infertility cases are due to male infertility, 20-35% are due to female infertility, and 25-40% are due to combined problems in both parts. In 10-20% of cases, no cause is found.[3] The most common cause of female infertility is ovulatory problems which generally manifest themselves by sparse or absent menstrual periods. Male infertility is most commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure of male fecundity.
Most people will have the strong desire to conceive a child at some point during their lifetime. Understanding what defines normal fertility is crucial to helping a person, or couple, know when it is time to seek help. Most couples (approximately 85%) will achieve pregnancy within one year of trying, with the greatest likelihood of conception occurring during the earlier months. Only an additional 7% of couples will conceive in the second year. As a result, infertility has come to be defined as the inability to conceive within 12 months. This diagnosis is therefore shared by 15% of couples attempting to conceive. We generally recommend seeking the help of a reproductive endocrinologist if conception has not occurred within 12 months. However, there are various scenarios where one may be advised to seek help earlier. These include:
Infrequent menstrual periods: When a woman has regular menstrual periods, defined as regular cycles occurring every 21 to 35 days, this almost always indicates that she ovulates regularly. Ovulation of the egg occurs approximately 2 weeks before the start of the next period. If a woman has cycles at intervals of greater than 35 days, it may indicate that she is not ovulating an egg predictably, or even at all. Ovulation of the egg is essential for pregnancy. Therefore, we recommend an evaluation if menstrual cycles are infrequent or irregular in a couple attempting pregnancy.
Female age of 35 years or older: For unclear reasons, egg numbers decrease at a rapid rate as women age. Furthermore, as aging occurs, egg quality, or the likelihood of an egg being genetically normal, decreases. Therefore we recommend a fertility evaluation if a couple has been attempting pregnancy for 6 months or more when the woman is 35 years of age or older.
A history of pelvic infections or sexually transmitted diseases: Sexually transmitted infections, such as chlamydia or gonorrhea, can cause inflammation and permanent scarring of the fallopian tubes. The presence of open tubes is essential for natural conception, as sperm must traverse the tubes in order to reach and fertilize the ovulated egg. We recommend immediate evaluation for a couple attempting pregnancy when the woman has a prior history of pelvic infection. As part of the fertility evaluation, we will perform an HSG, a test designed to evaluate if the fallopian tubes are open.
Known uterine fibroids or endometrial polyps: Uterine abnormalities, such as fibroids that indent the endometrial cavity and endometrial polyps, can impair how the endometrium (the lining of the uterus) and embryo interact to lower implantation and pregnancy rates. These abnormalities can also cause irregular bleeding between menstrual cycles. Evaluation should be pursued by 6 months of attempted pregnancy in women with a known history of these abnormalities or a history of bleeding between menstrual cycles. The main approach to correcting or removing these uterine abnormalities is by hysteroscopy, a surgical method by which a narrow scope with a camera is placed within the uterine cavity. Instruments can be introduced through the hysteroscope, allowing the surgeon to remove or correct any anatomic abnormalities.
Known male factor semen abnormalities: If a male partner has a history of infertility with a prior partner, or if there are abnormalities on his semen analysis, then we advise earlier fertility evaluation, ideally within 6 months of attempting pregnancy.
What are the Common Causes of Infertility?
1) Advancing maternal age: Historically before the latter 20th century, women were conceiving in their teens and twenties, when age-related abnormalities with the egg were not evident. However, in our modern era, women are delaying child birth until their thirties and forties, which has lead to the discovery of the adverse effect of advanced maternal age on egg function. In fact, female age-related infertility is the most common cause of infertility today. For unknown reasons, as women age, egg numbers decrease at a rapid rate. And as aging occurs, egg quality, or the likelihood of an egg being genetically normal, decreases as well. Hence the ability to conceive a normal pregnancy decreases from when a woman is in her early 30s into her 40s. A woman is rarely fertile beyond the age of 45. This applies to the ability to conceive with her eggs, but not with donor eggs.
2) Ovulation disorders: Normal and regular ovulation, or release of a mature egg, is essential for women to conceive naturally. Ovulation often can be detected by keeping a menstrual calendar or using an ovulation predictor kit. There are many disorders that may impact the ability for a woman to ovulate normally. The most common disorders impacting ovulation include polycystic ovary syndrome (PCOS), hypogonadotropic hypogonadism (from signaling problems in the brain), and ovarian insufficiency (from problems of the ovary). If your cycles are infrequent or irregular, your doctor will examine you and perform the appropriate testing to discover which problem you may have and present the appropriate treatment options.
3) Tubal occlusion (blockage): As discussed previously, a history of sexually transmitted infections including chlamydia, gonorrhea, or pelvic inflammatory disease can predispose a woman to having blocked fallopian tubes. Tubal occlusion is a cause of infertility because an ovulated egg is unable to be fertilized by sperm or to reach the endometrial cavity. If both tubes are blocked, then in vitro fertilization (IVF) is required. If a tube is blocked and filled with fluid (called a hydrosalpinx), then minimally invasive surgery (laparoscopy or hysteroscopy) to either remove the tube or block/separate it from the uterus prior to any fertility treatments is recommended.
4) Uterine fibroids: Fibroids are very common (approximately 40% of women may have them) and the mere presence alone does not necessarily cause infertility. There are three types of fibroids: 1) subserosal, or fibroids that extend more than 50% outside of the uterus; 2) intramural, where the majority of the fibroid is within the muscle of the uterus without any indentation of the uterine cavity; and 3) submucosal, or fibroids the project into the uterine cavity. Submucosal fibroids are the type if fibroid that has clearly been demonstrated to reduce pregnancy rate, roughly by 50%, and removal of which will double pregnancy rate. In some cases, simply removing the submucosal fibroid solves infertility. Often, but not always, submucosal fibroids can cause heavy periods, or bleeding between periods. There is more controversy regarding intramural fibroids, where larger ones may have an impact and may necessitate removal. Subserosal fibroids do not affect pregnancy. Your physician will examine you carefully to determine if you have fibroids and if removal is necessary.
5) Endometrial polyps: Endometrial polyps are finger-like growths in the uterine cavity arising from the lining of the uterus, called the endometrium, These abnormalities are rarely associated with cancer (<1% in a woman before menopause), but polyps are can decrease fertility by up to 50% according to some studies. Removal of polyps by the minimally invasive procedure hysteroscopy is associated with a doubling of pregnancy rate. In some cases, simply removing the polyp solves infertility.
6) Male factors affecting sperm function: Male factor infertility has been associated as a contributing factor causing infertility in 40-50% percent of cases, and as the sole cause for infertility in 15-20% percent of cases. If a semen analysis is found to be abnormal, generally it is first repeated to confirm the abnormality. Once confirmed, the male partner is referred to a reproductive urologist, especially if the abnormality is severe. In some cases, the reproductive urologist can improve semen function by recommending certain lifestyle changes, by hormonal treatments, or by surgery. In most cases however, sperm function may not improve and therefore any attempts at pregnancy may require additional treatments or procedures performed by our clinic. Options include intrauterine insemination (also known as IUI) or IVF with intracytoplasmic sperm injection (also known as ICSI).
7) Endometriosis: Endometriosis is a condition whereby cells very similar to the ones lining the uterine cavity, or endometrium, are found outside the uterine cavity. It is found in approximately 10-50% of reproductive-aged women and can be associated with infertility as well as pain during intercourse and/or menstrual periods. Endometriosis causes infertility by producing inflammation and scarring, which can result in not only pain but also potentially detrimental effects on egg, sperm or embryo. Endometriosis can only be confirmed by surgery, usually laparoscopy. If endometriosis is found, it can be surgically removed by various methods, and its removal may lead to a decrease in pain as well as improvement in the ability to conceive naturally. Your doctor will determine if you are at risk of having endometriosis based on a careful history, physical exam, and ultrasound.
8) Unexplained/other: Sometimes a full evaluation does not reveal the cause of infertility. This occurs approximately 15% of the time. Thankfully, even when the cause of infertility is not known, various fertility treatments can overcome the unknown road block that was preventing pregnancy and eventually lead to delivery of a healthy baby.
What are the Treatment Options?
1) Education: We strongly believe that educating our patients about the normal process of fertility, problems that affect fertility, and treatment options will empower our patients to make the best choices. Understanding the normal reproductive process is essential in knowing when to seek help. Helping our patients develop a deep understanding of their fertility options will make the process smoother. Our goal is to have each and every patient feel as part of our team, a team that is focused on helping them have a healthy baby. For those interested, we offer a free class entitled, "The Couple's Guide to IVF", that meets twice monthly and is open to the public.
2) Medications to induce egg development and ovulation: The medications that help stimulate the ovary to develop mature eggs for ovulation come in two forms: pills taken by mouth and injections. The most commonly prescribed pill to stimulate ovulation (generally of one mature egg) is clomiphene citrate. This pill generally is taken from menstrual cycle days 3 - 7. It works in the following way: Clomiphene is an anti-estrogen. It binds in a part of the brain called the hypothalamus, which is essential in stimulating the ovary to grow and release an egg. When clomiphene binds to estrogen receptors in the hypothalamus, it leads to an increase release of an important signaling hormone called GnRH (gonadotropin releasing hormone). This hormone then binds to another area of the brain called the pituitary gland and leads to the release of FSH (follicle stimulating hormone), a hormone that directly binds to cells in the ovary, leading to egg growth and maturation.
The most commonly prescribed injections that stimulate the ovary are called gonadotropins. The gonadotropins in these formulations are FSH, and in some cases, a combination of FSH and LH (luteinizing hormone). These injections are taken nightly, typically for 5 - 10 days, and act directly on the cells of the ovary to stimulate egg development. Once a follicle containing an egg reaches a mature size, another hormone injection called HCG is often given to mimic the natural LH surge that occurs at the time of ovulation. This leads to the final maturation and release of the egg.
3) Insemination: Intrauterine insemination, also known as IUI, is a process by which sperm is washed and prepared for placement into the uterine cavity, therefore bypassing the cervix and bringing a higher concentration of motile sperm closer to the tubes and ovulated egg. In order to accomplish this, the semen is washed with a solution safe to sperm and eggs, and then centrifuged to separate motile sperm from immotile sperm and other cells. Those motile and viable sperm are then placed in a very small amount of solution, and then very gently and painlessly injected into the uterine cavity using a very thin, soft, and flexible catheter. At least one open tube is required for IUI, and any sperm abnormality cannot be severe, otherwise the sperm will not be able to swim to and fertilize the egg.
4) In Vitro Fertilization (IVF): In vitro means "outside the body." IVF is a process whereby eggs are collected and then fertilized by sperm outside the body, in an embryology laboratory. The first IVF baby was born in 1978 in England. Not long after, the United States delivered its first IVF baby, and the use of IVF has grown dramatically. IVF was a major breakthrough because it allowed for successful pregnancies in women that were previous deemed permanently infertile, such as when the fallopian tubes are both markedly damaged. IVF involves removal of eggs directly from the ovary, fertilization with sperm in the laboratory, followed by transfer of the embryos directly into the uterus, thereby bypassing the tubes. Although tubal disease was the original indication for IVF, many more indications have developed over the years. These include advancing maternal age, severe male factor infertility (whereby ICSI can be used to fertilize the egg), and endometriosis, amongst many others.
When should you consider having an infertility evaluation?
You should consider having an infertility evaluation if any of the following apply to you:
What is the treatment of female infertility?
Fertility drugs generally work like the natural hormones - follicle-stimulating hormone ( FSH ) and luteinizing hormone ( LH ) - to trigger ovulation. They're also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs. Fertility drugs may include: Clomiphene citrate.
What is a fertility evaluation?
A standard fertility evaluation includes physical exams and medical and sexual histories of both partners. ... This can be determined and monitored through blood tests that detect hormones, ultrasound exams of the ovaries, or an ovulationhome test kit.
How can I solve my infertility problem?
However, there are several things that women can do to decrease the possibility of infertility:
How can I increase my fertility?
How to Improve Female Fertility
Can Gynecologists test for fertility?
Here are the basic steps in a typical fertility evaluation, which may be used by an ob/gyn or reproductive endocrinologist (fertility specialist) to determine your level of fertility and to detect potential problems. Remember that your doctor will schedule tests based on your own situation and medical history.
What are the initial tests for infertility?
Following a history and physical examination, the initial tests used to assess the major causes of infertility are: Day 2 or 3 FSH (Follicle Stimulating Hormone) and estradiol (estrogen) Hysterosalpinogram (tubal dye test) and/or Sonohysterogram (ultrasound) Ultrasound to document the time of ovulation.
Ovalation Induction
Ovulation induction is a treatment for anovulation (irregular ovulation), an infertility condition in which follicles in a woman's ovary do not mature and release eggs (ovulate).
What is the success rate of ovulation induction?
Ovulation induction usually produces pregnancy rates of 10% to 20% per cycle, depending on a woman's age, diagnosis, and duration of infertility. Among women with certain ovulatory disorders, ovulation induction treatment may even restore normal fertility rates of 20% to 25% per month.
When should I take an ovulation injection?
It takes just over 38 hours for ovulation to occur after an injection of hCG (Pregnyl). Eggs are mature and can float free from about 34 hours after hCG, giving a four-hour window for egg retrieval, which is scheduled 36 hours after the hCG injection.
How is ovulation induction done?
Ovulation induction involves taking medication to induce ovulation by encouraging eggs to develop in the ovaries and be released, increasing the chance of conception through timed intercourse or artificial insemination. ... Medications used in ovulation induction can include: Clomiphene Citrate (Clomid)
Is ovulation induction safe?
Ovulation induction circumvents this problem by artificially inducing ovulation. The process is safe, generally does not require any invasive procedures or tests, and often works wonders even for couples who have unsuccessfully tried for years to get pregnant.
How can I ovulate naturally?
Hence some simple changes to improve your body's healthy ability to ovulate include:
Can sperm make you ovulate?
Semen May Trigger Ovulation. A semen protein dubbed ovulation-inducing factor (shown here as crystals) may affect the female brain and trigger ovulation. A recently discovered protein in semen can cause female mammals to ovulate, new research finds.
How long does egg live after ovulation?
about 12-24 hours
How long do the sperm and egg live? An egg lives for about 12-24 hours after you ovulate, and sperm can live for five to seven days. Ideally, you need a lot of sperm on stand-by to 'pounce' on that egg when it's released, so have sex in the days leading up to when you ovulate and a day after.
IUI
Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman's uterus to facilitate fertilization. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization.
How successful is IUI?
As with most fertility procedures, IUI success is higher for younger women. Here are the chances of pregnancy after one IUI cycle, by age: Under 35: 10 to 20 percent chance of pregnancy. Between 35 and 40: 10 percent chance.
What is IUI and how much does it cost?
The average IUI treatment costs $895, with prices varying significantly depending on the clinic you use and whether you need fertility drugs and/or donor sperm. Your insurance coverage as well as the additional costs will determine your final price for IUI, which can be up to $3,000 per cycle for comprehensive care.
What is difference between IUI and IVF?
The main difference between an IUI and IVF treatments are: IVF is a process involving egg stimulation, retrieval, fertilization, and transfer; whereas, an IUI injects sperm into a uterus to decrease the sperm's travel time to the egg. ... transfer of the resulting embryos into the uterus.
How can I increase my chances of getting pregnant with IUI?
Your doctor may recommend that you try 3 to 6 cycles of IUI with injectables before moving on to another fertility treatment option like in vitro fertilization (IVF). To boost your chances of pregnancy with artificial insemination, ask your reproductive endocrinologist about doing two inseminations during your cycle.
How long does it take sperm to reach the egg after IUI?
Most women ovulate about two weeks after their last menstrual period. Before beginning an IUI cycle, a doctor pinpoints the precise moment of ovulation to ensure the sperm has the best possible chances of meeting an egg.
Is IUI safe for baby?
Stimulating ovulation with IUI is not recommended by the NHS, because there is a much greater risk of a multiple pregnancy when taking fertility drugs . However, it may still be offered to you at a private fertility clinic.
What are the chances of getting pregnant with IVF?
Most women typically see success rates of 20-35% per cycle, but the likelihood of getting pregnant decreases with each successive round, while the cost increases. The cumulative effect of three full cycles of IVF increases the chances of a successful pregnancy to 45-53%.
Is IVF procedure painful?
The most potentially painful part of undergoing IVF is the procedure to implant the fertilized eggs back into the uterus. Done a few days after egg retrieval, this feels like a smear test; not pleasant by any means, but nothing to be scared of.
How long does it take for IVF start to finish?
about 6 to 8 weeks
For the woman, however, the IVF process actually starts weeks earlier. IVF is not a single treatment but a series of procedures. An average IVF cycle takes about 6 to 8 weeks from consultation to transfer, but depending on the specific circumstances of each the path is similar for every patient.
How do you know if IVF is successful?
Sensitive breasts, nausea, fatigue, cramping, light spotting-could these be signs the cycle has been successful? Here's the truth: all those symptoms can and do occur even if you're not pregnant. In fact, even if you have no pregnancy symptoms, you may be pregnant. It's really impossible to tell.
What is the best age for IVF?
The good news is that IVF is generally successful, especially for women under age 35 and those using donor eggs. For women of all ages, the odds of a live birth are between 34 and 42 percent over three cycles.
How can I make my IVF more successful?
Here are some improving IVF success tips you need to know before you try out IVF.
Are IVF babies healthy?
Children Born Via IVF May Face Higher Health Risks as They Get Older. In the latest study examining the health of people born through in-vitro fertilization, researchers say there may be an increased risk of high blood pressure. ... People conceived via IVF also seem to be more susceptible to developing insulin resistance.
Is IVF dangerous?
Extended IVF use 'harmful' The experts argue that extended IVF use increases the risk of harm to both the mother and offspring. "Multiple pregnancies are associated with maternal and perinatal complications such as gestational diabetes, fetal growth restriction, and preeclampsia as well as premature birth.
What tests should be done before IVF?
Before beginning IVF, women will first undergo ovarian reserve testing. This involves taking a blood sample and testing it for the level of follicle stimulating hormone (FSH). ... Men will need to have sperm testing. This involves giving a semen sample, which a lab will analyze for the number, size, and shape of the sperm.
Is IVF successful the first time?
To answer your question, chances of success of IVF in the first cycle is not as high as it should be. ... The overall success rate of IVF procedure is 50 percent, but the procedure may not work for you. Few of the women are very lucky to get pregnancy in their first cycle of IVF, but everyone is not so reality.
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