Infertility

Infertility is the term health care providers use for women who are unable to get pregnant, and for men who are unable to impregnate a woman, after at least one year of trying.

In women, the term is used to describe those who are of normal childbearing age, not those who can’t get pregnant because they are near or past menopause.

Women who are able to get pregnant but who cannot carry a pregnancy to term (birth) may also be considered infertile.

Causes

Infertility does not have a single cause because successful pregnancy is a multi-step chain of events.

Simply described, pregnancy includes the following steps: A woman’s ovaries must be able to release a viable egg, which then must be able to travel down the fallopian tube. The man must be able to ejaculate, and his sperm must be able to travel to the fallopian tube. The sperm and egg must unite to fertilize the egg. The fertilized egg must attach to the inside of a receptive uterus (or implant) and be nurtured by the body to allow the fetus to develop and grow until it is ready for birth.

Problems with any of these steps can lead to infertility.

The cause of infertility can rest in the woman or the man, or can be from unknown factors or a combination of factors. In some cases, environmental factors can contribute to infertility. In other cases, genetic conditions or other health problems are the main cause of infertility.

Female infertility
As explained above, female fertility requires a variety of conditions to be successful. If even one of these conditions is not met, or is not met for the right amount of time, the pregnancy may either not happen or it may end before birth.
Most cases of infertility in women result from problems with ovulation. The most common of these is [/[polycystic ovary syndrome (PCOS)]]. PCOS is characterized by irregular ovulation/menstrual cycles and elevation of androgens (male-type hormones). Insulin resistance probably also plays a role in some cases of PCOS. Premature ovarian failure, in which the ovaries stop functioning before natural menopause, is another ovulation problem. Hypothalamic Amenorrhea is caused by failure of the hypothalamus to produce sufficient quantities of GnRH, which in turn eventually causes ovulation problems. This type of ovulation problem can be caused by Anorexia Nervosa, Kallman's Syndrome or low body weight in association with high-intensity exercise. Malfunction (excess production or insufficient production of hormones) of the pituitary and thyroid glands can also interfere with normal ovulation and menstrual cycles. Among women who have PCOS, even when a healthy egg is released and fertilized, the uterus may not be receptive to implantation of a fertilized egg, which results in infertility.

Other causes of infertility might include:

• Blocked fallopian tubes due to endometriosis, pelvic inflammatory disease, or surgery
• Luteal phase insufficiency (not enough progesterone is produced by the ovaries)
• Physical problems with the uterine wall such as Asherman's syndrome which is scarring of the uterine lining.
• Uterine fibroids can block fallopian tubes, distort the uterine lining, or cause problems with implantation of the fertilized egg.
• Endometriosis can cause infertility even if the fallopian tubes are patent, possibly via an immune mechanism.
• Cervical Factor in which inufficient or poor quality cervical mucous interferes with sperm motility.

A woman’s risk for infertility can also be affected by certain lifestyle and environmental factors, including (but not limited to):

• Age
• Stress
• Poor diet
• Being overweight or underweight
• Smoking, drugs, and alcohol
• Medication
• Environmental toxins
• Genetic conditions, such as being a carrier of Fragile X syndrome or an unbalanced translocation (which is an abnormal chromosome).
• Other health problems, such as sexually transmitted diseases

Male infertility

The male fertility process involves the production of mature sperm and getting the sperm to reach and fertilize the egg. Although it may seem to be a simpler process than female fertility, male fertility also requires many conditions to be met: the ability to have and sustain an erection, having enough sperm, having enough semen to carry the sperm to the egg, and having sperm of the right shape that move in the right way. A problem meeting any of these conditions contributes to infertility.

Like female infertility, male infertility can result from physical problems, such as testes that don’t make enough normal sperm, hormonal problems, and lifestyle or environmental factors, including (but not limited to):

• Age
• Stress
• Exposing the testes to high temperatures, which can affect the ability of the sperm to move and to fertilize an egg. For instance:
  • Cryptorchism is a condition where the testes do not descend into the scrotum. Although it does not usually affect the ability to have and sustain an erection, cryptorchism means that the testes are still inside the body cavity, which has a higher temperature than the external scrotum.
  • Tight underwear—For some men, wearing tight underwear can also increase the temperature of the testes.
• Smoking, drugs, and alcohol
• Medications
• Environmental toxins
• Genetic conditions, such as Klinefelter syndrome
• Other health problems

But, in some cases, health care providers cannot determine a cause for infertility in the man or woman. In addition, some known causes of infertility do not have any treatments. This type of infertility is usually referred to as unexplained infertility.

Diagnosis

Although not getting pregnant is an indication of possible infertility, only a health care provider can provide a diagnosis of infertility. Those who suspect they are infertile should see their health care providers, including:

• Couples who have been trying to conceive for a year without getting pregnant
• Women who have experienced menstrual irregularities or who have had endometriosis or uterine fibroids
• Women who have gotten pregnant but who have had more than one miscarriage or stillbirth
• Men and women with certain genetic conditions

Common diagnostic tests for infertility include:

• Basal Body Temperature Charts in which a woman records her body temperature daily to determine if and when she is ovulating.
• Ovulation predictor kits which are useful in determining if and when a woman is ovulating.
• Thyroid Hormone levels, Prolactin levels, FSH (follicle stimulating hormone), LH (luteinizing hormone), Progesterone levels
• Hysterosalpingogram--an x-ray/dye study used to determine if fallopian tubes are blocked
• Saline Ultrasound which is used to check for abormalities of the uterine cavity
• Post-Coital test which is a test of cervical mucous quality
• Semen Analysis which evaluates a semen sample for sperm numbers, motility, abnormalities, and other parameters

Treatment

There are a variety of ways to treat infertility, including:

Medication

Medications can be used to correct imbalances in prolactin or thyroid hormone levels. Progesterone is commonly used to treat luteal phase insufficiency. Clomiphene Citrate is commonly used to induce ovulation, and can also be used to improve sperm counts in men. Dexmethasone is sometimes used to suppress abnormal androgen levels in women and improve ovulation. Metformin has also shown some promise as a therapy for PCOS.

Surgery

Types of surgery include laser surgery for removal of endometriosis. Tubal surgery to correct blocked fallopian tubes. Myomectomy to remove uterine fibroids, Hysteroscopy to treat abnormalities of the uterine lining.

Intrauterine insemination/artificial insemination

The woman is injected with carefully prepared sperm from the husband, partner, or a donor. This technique can be used to treat cervical mucous problems, or problems with abnormal semen analysis such as low sperm count or poor sperm motility.

Assisted reproductive technology (ART)

Such as in vitro fertilization

Most often, health care providers treat infertility with medication or surgical repair of the reproductive organs. In addition, lifestyle changes may also help alleviate infertility, such as reducing stress, diet modification, stopping use of drugs or alcohol, or reducing the temperature around the testes. Women who are attempting to conceive should consider taking at least 400 mcg of Folate daily, as studies have shown that folate supplementation can reduce the risk of certain types of birth defects.