Most couples assume that they will become pregnant when they wish and that once they stop using birth control, pregnancy will happen right away. Although this occurs without too much difficulty for the majority of couples, others soon realize that conceiving is not as easy as they had anticipated. At some point in their lives, at least 15 percent of couples will experience some degree of infertility, along with its many feelings and frustrations.
From a purely medical perspective, infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse or the inability to carry a pregnancy to live birth. However, for most couples, infertility is more than just a physical condition—it represents a seemingly unsolvable problem that affects them physically, financially, and emotionally.
Considering the precision and intricacy with which the human reproductive system functions, it seems a miracle that babies are conceived and born to the majority of couples. However, any change in this complicated sequence of events can result in infertility.
Who Should Evaluate Your Fertility?
Your regular gynecologist may perform the initial fertility evaluation and treatment, or you may choose to be evaluated by a fertility specialist, who has two years additional training in infertility evaluation and treatment. It is important to find a doctor who you trust and with whom you feel comfortable.
If you start treatment with your OB-GYN, it is important to know when to seek care from a fertility expert:
- You are concerned that something is wrong.
- You are 35 years of age or older and have been trying for six months.
- You have irregular periods or don’t have periods at all.
- You have been attempting pregnancy for more than two years.
- You have been undergoing medical treatment for one year and have not conceived.
- You have a history of abdominal or pelvic surgery.
- You have a history of pelvic infections, hormonal problems, endometriosis, fibroids, DES exposure, excessive facial or body hair, or a sperm problem that has been identified.
- You have had several pregnancy losses or a prior ectopic pregnancy.
- You are considering having a laparoscopy or hysteroscopy.
- You have been on clomiphene for more than three months with no success and there is no proposed change for your treatment in the months to come.
- You report pelvic pain, heavy periods, and/or bladder or bowel symptoms around the time of menstruation and the doctor does not suggest having a hysterosalpingogram or laparoscopy to determine the cause of the symptoms.
- A fibroid or tubal damage has been noted on a hysterosalpingogram.
What Does a Fertility Evaluation Entail?
The first step in evaluating infertility is to perform a detailed medical and personal history. This includes information from the couple about past medical and surgical history, current health status, occupational risks, history of sexual development, previous use of birth control, past gynecological and obstetric history, and current sexual practices.
The basic questions that are answered with an infertility evaluation are:
Are there enough high quality sperm? The semen analysis is the single most important test in the evaluation of the male. It provides information about a number of factors related to fertility such as volume of semen, number of live sperm, sperm movement, shape, and structure. In order to perform the test, a semen sample is collected by masturbation into a sterile container provided by the physician.
Is an egg produced each month? Regular menstrual cycles, a biphasic BBT chart, and detection of luteinizing hormone LH in the urine all are reassuring that ovulation is occurring. However, if there is a concern, an ultrasound may be performed to examine the ovary or blood tests may be performed to determine the reason why ovulation is not occurring.
Are there any barriers that prevent the sperm and egg from getting together?Common barriers include blockage of the fallopian tubes, hostile cervical mucus, and the presence of endometriosis or adhesions. The most common tests include a hysterosalpingogram (HSG), which determines if the fallopian tubes are open, and laparoscopy, a procedure performed under general anesthesia to assess the reproductive organs and repair structural infertility problems that may be present.
Is the uterine lining receptive? Factors that interfere with implantation include inadequate production of progesterone (determined by a blood test), lack of proteins (beta 3-integrins) that allow the embryo to stick to the uterine lining, congenital uterine deformities, and irregularities of the uterine lining such as polyps or fibroids.
Sometimes the factors affecting your fertility are easy to detect and treat, but in many cases a specific reason for infertility may be difficult to identify. Forty percent of infertility can be attributed to male factors and the remainder to female or couple factors. There are two different treatment philosophies that are used by physicians who treat infertility: (1) find out what’s wrong and fix it or (2) nonspecifically enhance fertility by increasing the chances that the sperm and egg will get together. Thanks to the many options existing today, including advanced reproductive technologies and adoption, most infertile couples will be able to experience the joy of parenthood.
What Happens Next?
Where there are obstacles to conceiving, there are ways around them. If ovulation is a problem, there are oral and injectable medications that enhance ovulation. Intrauterine insemination can be used to get the sperm closer to the egg. When sperm quantity or quality is an issue, varicoceles (varicose veins of the testicles that cause the sperm to be overheated) can be repaired, intrauterine insemination can be performed, the sperm can be placed inside the egg (intracytoplasmic sperm injection, or ICSI), or donor sperm can be used. Surgery is indicated to remove fibroids, endometrial polyps, endometriosis, and adhesions and to repair tubal damage. When tubes are blocked and cannot be repaired or when other treatments have failed, in vitro fertilization (IVF) allows the sperm and eggs to be fertilized in a dish and placed in the uterus. For women who do not produce eggs because of age or ovarian failure, egg or embryo donation provides an alternative.
Appropriate therapy allows pregnancy to occur in 50 to 60 percent of previously infertile couples. When IVF is used, an additional 35 to 50 percent conceive with each IVF cycle. In contrast, without any treatment intervention, 15 to 20 percent of couples previously diagnosed as infertile will eventually become pregnant.
Although infertility itself does not cause physical illness, it can have a major emotional impact on the couples and individuals it affects. Feelings such as anger, sadness, guilt, and anxiety are common and may affect your self-esteem and self-image. It is important to know that these feelings are normal responses to infertility and are experienced by many couples. Although a physician will describe various treatments and realistic odds of success with treatments, you must decide how far you will go in your attempts to conceive.
For more information:
- American Fertility Association
- American Society for Reproductive Medicine
- RESOLVE: The National Infertility Association