Infertility

Overview

If you and your partner are struggling to have a baby, you're not alone. In the United States, 10% to 15% of couples are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most couples.

Infertility may result from an issue with either you or your partner, or a combination of factors that prevent pregnancy. Fortunately, there are many safe and effective therapies that significantly improve your chances of getting pregnant.

All of the steps during ovulation and fertilization need to happen correctly in order to get pregnant. Sometimes the issues that cause infertility in couples are present at birth, and sometimes they develop later in life.

Infertility causes can affect one or both partners. Sometimes, no cause can be found.

Causes of male infertility

These may include:

• Abnormal sperm production or function due to undescended testicles, genetic defects, health problems such as diabetes, or infections such as chlamydia, gonorrhea, mumps or HIV. Enlarged veins in the testes (varicocele) also can affect the quality of sperm.
• Problems with the delivery of sperm due to sexual problems, such as premature ejaculation; certain genetic diseases, such as cystic fibrosis; structural problems, such as a blockage in the testicle; or damage or injury to the reproductive organs.
• Overexposure to certain environmental factors, such as pesticides and other chemicals, and radiation. Cigarette smoking, alcohol, marijuana, anabolic steroids, and taking medications to treat bacterial infections, high blood pressure and depression also can affect fertility. Frequent exposure to heat, such as in saunas or hot tubs, can raise body temperature and may affect sperm production.
• Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely.

Causes of female infertility

Causes of female infertility may include:

• Ovulation disorders, which affect the release of eggs from the ovaries. These include hormonal disorders such as polycystic ovary syndrome. Hyperprolactinemia, a condition in which you have too much prolactin — the hormone that stimulates breast milk production — also may interfere with ovulation. Either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism) can affect the menstrual cycle or cause infertility. Other underlying causes may include too much exercise, eating disorders or tumors.
• Uterine or cervical abnormalities, including abnormalities with the cervix, polyps in the uterus or the shape of the uterus. Noncancerous (benign) tumors in the uterine wall (uterine fibroids) may cause infertility by blocking the fallopian tubes or stopping a fertilized egg from implanting in the uterus.
• Fallopian tube damage or blockage, often caused by inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, which is usually caused by a sexually transmitted infection, endometriosis or adhesions.
• Endometriosis, which occurs when endometrial tissue grows outside of the uterus, may affect the function of the ovaries, uterus and fallopian tubes.
• Primary ovarian insufficiency (early menopause), when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain factors are associated with early menopause, including immune system diseases, certain genetic conditions such as Turner syndrome or carriers of Fragile X syndrome, and radiation or chemotherapy treatment.
• Pelvic adhesions, bands of scar tissue that bind organs that can form after pelvic infection, appendicitis, endometriosis or abdominal or pelvic surgery.
• Cancer and its treatment. Certain cancers — particularly reproductive cancers — often impair female fertility. Both radiation and chemotherapy may affect fertility.

Before infertility testing, your doctor or clinic works to understand your sexual habits and may make recommendations to improve your chances of getting pregnant. In some infertile couples, no specific cause is found (unexplained infertility).

Infertility evaluation can be expensive, and sometimes involves uncomfortable procedures. Some medical plans may not cover the cost of fertility treatment. Finally, there's no guarantee — even after all the testing and counseling — that you'll get pregnant.

Tests for men

Male fertility requires that the testicles produce enough healthy sperm, and that the sperm is ejaculated effectively into the vagina and travels to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.

You may have a general physical exam, including examination of your genitals. Specific fertility tests may include:

• Semen analysis. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A lab analyzes your semen specimen. In some cases, urine may be tested for the presence of sperm.
• Hormone testing. You may have a blood test to determine your level of testosterone and other male hormones.
• Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing infertility.
• Testicular biopsy. In select cases, a testicular biopsy may be performed to identify abnormalities contributing to infertility or to retrieve sperm for assisted reproductive techniques, such as IVF.
• Imaging. In certain situations, imaging studies such as a brain MRI, transrectal or scrotal ultrasound, or a test of the vas deferens (vasography) may be performed.
• Other specialty testing. In rare cases, other tests to evaluate the quality of the sperm may be performed, such as evaluating a semen specimen for DNA abnormalities.

Tests for women

Fertility for women relies on the ovaries releasing healthy eggs. The reproductive tract must allow an egg to pass into the fallopian tubes and join with sperm for fertilization. The fertilized egg must travel to the uterus and implant in the lining. Tests for female infertility try to find out if any of these processes are impaired.

You may have a general physical exam, including a regular gynecological exam. Specific fertility tests may include:

• Ovulation testing. A blood test measures hormone levels to determine whether you're ovulating.
• Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the condition of your uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and to see if the fluid spills out of your fallopian tubes.
• Ovarian reserve testing. This testing helps determine the quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.
• Other hormone testing. Other hormone tests check levels of ovulatory hormones, as well as pituitary hormones that control reproductive processes.
• Imaging tests. Pelvic ultrasound looks for uterine or ovarian disease. Sometimes a sonohysterogram, also called a saline infusion sonogram, is used to see details inside the uterus that are not seen on a regular ultrasound.

Depending on your situation, rarely your testing may include:

• Hysteroscopy. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine disease. During the procedure, your doctor inserts a thin, lighted device through your cervix into your uterus to view any potential abnormalities.
• Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.

Not everyone needs to have all, or even many, of these tests before the cause of infertility is found. You and your doctor will decide which tests you will have and when.

Infertility treatment depends on:

• What's causing the infertility
• How long you've been infertile
• Your age and your partner's age
• Personal preferences

Some causes of infertility can't be corrected.

In cases where spontaneous pregnancy doesn't happen, couples can often still achieve a pregnancy through use of assisted reproductive technology. Infertility treatment may involve significant financial, physical, psychological and time commitments.

Treatment for men

Men's treatment for general sexual problems or lack of healthy sperm may include:

• Changing lifestyle factors. Improving lifestyle and certain behaviors can improve chances for pregnancy, including discontinuing select medications, reducing or eliminating harmful substances, improving frequency and timing of intercourse, exercising regularly, and optimizing other factors that may otherwise impair fertility.
• Medications. Certain medications may improve sperm count and likelihood for achieving a successful pregnancy. These medicines may increase testicular function, including sperm production and quality.
• Surgery. For some conditions, surgery may be able to reverse a sperm blockage and restore fertility. In other cases, surgically repairing a varicocele may improve overall chances for pregnancy.
• Sperm retrieval. These techniques obtain sperm when ejaculation is a problem or when no sperm are present in the ejaculated fluid. They may also be used in cases in which assisted reproductive techniques are planned and sperm counts are low or otherwise abnormal.

Treatment for women

Some women need only one or two therapies to improve fertility. Other women may need several different types of treatment to achieve pregnancy.

• Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk with your doctor about fertility drug options — including the benefits and risks of each type.
• Intrauterine insemination (IUI). During IUI, healthy sperm are placed directly in the uterus around the time the ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
• Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum, intrauterine scar tissue and some fibroids can be treated with hysteroscopic surgery. Endometriosis, pelvic adhesions, and larger fibroids may require laparoscopic surgery or surgery with a larger incision of the abdomen.

Assisted reproductive technology

Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. There are several types of ART.

In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs, fertilizing them with sperm in a dish in a lab, and implanting the embryos in the uterus several days after fertilization.

Other techniques are sometimes used in an IVF cycle, such as:

• Intracytoplasmic sperm injection (ICSI). A single healthy sperm is injected directly into a mature egg. ICSI is often used when there is poor semen quality or quantity, or if fertilization attempts during prior IVF cycles failed.
• Assisted hatching. This technique assists the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).
• Donor eggs or sperm. Most ART is done using a couple's own eggs and sperm. However, if there are severe problems with either the eggs or the sperm, you may choose to use eggs, sperm or embryos from a known or anonymous donor.
• Gestational carrier. Women who don't have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using a gestational carrier. In this case, the couple's embryo is placed in the uterus of the carrier for pregnancy.

Complications of treatment

Complications of infertility treatment may include:

• Multiple pregnancy. The most common complication of infertility treatment is a multiple pregnancy — twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery, as well as problems during pregnancy such as gestational diabetes. Babies born prematurely are at increased risk of health and developmental problems. Talk to your doctor about any concerns you have about a multiple pregnancy before starting treatment.
• Ovarian hyperstimulation syndrome (OHSS). Fertility medications to induce ovulation can cause OHSS, particularly with ART, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating, and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
• Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology or reproductive surgery.