In fertility: a condition shared by millions
The definition of infertility is that a couple cannot get pregnant after one year of trying or after six months if a woman is 35 or older. Women who can get pregnant but are unable to stay pregnant may also be infertile.Pregnancy is the result of a process that has many steps. To get pregnant:
- A woman’s body must release an egg from one of her ovaries ( ovulation).
- The egg must go through a fallopian tube toward the uterus (womb).
- A man's sperm must join with (fertilize) the egg along the way.
- The fertilized egg must attach to the inside of the uterus (implantation).
About 10 percent of women (6.1 million) in the United States ages 15 to 44 have difficulty getting pregnant or staying pregnant, according to the Centers for Disease Control and Prevention (CDC). But contrary to common belief, infertility is not always a woman's problem.
Both women and men can have problems that cause infertility. About 40 percent of infertility cases are caused by women’s problems. Another 40 percent of fertility problems are due to the man. The other cases are caused by a mixture of male and female problems or cannot be diagnosed.
Male infertility & causes
Infertility in men is most often caused by:- A problem called varicocele (VAIR- ih-koh-seel). This happens when the veins on a man’s testicle(s) are too large. This heats the testicles. The heat can affect the number or shape of the sperm.
- Other factors that cause a man to make too few sperm or none at all.
- Movement of the sperm. This may be caused by the shape of the sperm. Sometimes injuries or other damage to the reproductive system block the sperm.
A man's sperm can be changed by his overall health and lifestyle. Some things that may reduce the health or number of sperm include:
- Heavy alcohol use
- Drugs
- Smoking cigarettes
- Age
- Environmental toxins, including pesticides and lead
- Health problems such as mumps, serious conditions like kidney dis- ease, or hormone problems
- Medicines
- Radiation treatment and chemotherapy treatments for cancer
Female infertility & causes
Most cases of female infertility are caused by problems with ovulation. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.Ovulation problems are often caused by polycystic ovarian syndrome (PCOS). PCOS is a hormone imbalance problem which can interfere with normal ovula- tion. PCOS is the most common cause of female infertility. Primary ovarian insufficiency (POI) is another cause of ovulation problems. POI occurs when a woman’s ovaries stop working normally before she is 40. POI is not the same as early menopause.
Less common causes of fertility problems in women include:
- Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy
- Physical problems with the uterus
- Uterine fibroids, which are non-cancerous clumps of tissue and muscle on the walls of the uterus
- Age
- Smoking
- Excess alcohol use
- Stress
- Poor diet
- Athletic training
- Being overweight or underweight
- Sexually transmitted infections (STIs)
- Health problems that cause hormonl changes, such as polycystic ovarian syndrome and primary ovarian insufficiency
Aging decreases a woman's chances of having a baby in the following ways:
- Her ovaries become less able to release eggs.
- She has a smaller number of eggs left.
- Her eggs are not as healthy.
- She is more likely to have health conditions that can cause fertility problems.
- She is more likely to have a miscar- riage.
Some health problems also increase the risk of infertility. So, women should talk to their doctors if they have:
- Irregular periods or no menstrual periods
- Very painful periods
- Endometriosis
- Pelvic inflammatory disease
- More than one miscarriage
Zeroing in on the causes of infertility
A reproductive endocrinologist can do a thorough infertility checkup. This involves a physical exam and an interview in which the fertility physician asks for both partners’ health and sexual histories. Sometimes these two steps can find the cause of infertiliy.However, most of the time, the doctor will need to do more tests. In men, doctors usually begin by testing the semen. They look at the number, shape, and movement of the sperm. Sometimes doctors also suggest testing the level of a man's hormones.
In women, the first step is to find out if she is ovulating each month. There are a few ways to do this. A woman can track her ovulation at home by:
- Writing down changes in her morn- ing body temperature for several months
- Writing down how her cervical mucus looks for several months
- Using a home ovulation test kit (available at drug or grocery stores)
Some common tests of fertility in women include:
- Hysterosalpingography (HIS- tur-oh-sal-ping-GOGH-ru-fee): This is an x-ray of the uterus and fallopian tubes. Doctors inject a special dye into the uterus through the vagina. This dye shows up in the x-ray. Doctors can then watch to see if the dye moves freely through the uterus and fallopian tubes. This can help them find physical blocks that may be causing infertility. Blocks in the system can keep the egg from moving from the fallopian tube to the uterus. A block could also keep the sperm from reaching the egg.
- Laparoscopy (lap-uh-ROS-kuh- pee): A minor surgery to see inside the abdomen. The doctor does this with a small tool with a light called a laparoscope (LAP-uh-roh-skohp). She or he makes a small cut in the lower abdomen and inserts the lapa- roscope. With the laparoscope, the doctor can check the ovaries, fallopi- an tubes, and uterus for disease and physical problems. Doctors can usu- ally find scarring and endometriosis by laparoscopy.
Treatments for infertility
Fertility physicians can treat infertility with medicine, surgery, artificial insemination, or assisted reproductive technology (see more below on ART). Many times these treatments are combined. In most cases infertility is treated with drugs or surgery.Doctors recommend specific treatments for infertility based on:
- Test results
- How long the couple has been trying to get pregnant
- The age of both the man and woman
- The overall health of the partners
- Preference of the partners
- Doctors often treat infertility in men in the following ways:
- Sexual problems: Doctors can help men deal with impotence or prema- ture ejaculation. Behavioral therapy and/or medicines can be used in these cases.
- Too few sperm: Sometimes sur- gery can correct the cause of the problem. In other cases, doctors surgically remove sperm directly from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.
- Sperm movement: Sometimes semen has no sperm because of a block in the man’s system. In some cases, surgery can correct the problem.
- In women, some physical problems can also be corrected with surgery.
Medications for treating infertility
Common medicines used to treat infertility in women include:- Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
- Human menopausal gonado- tropin or hMG (Repronex, Pergonal): This medicine is often used for women who don't ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
- Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
- Gonadotropin-releasing hor- mone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
- Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
- Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hor- mone that causes milk production.
Assisted reproductive technology
Assisted reproductive technology (ART) is a group of different methods for treating infertile couples, all of which involve removing eggs from a woman's body. Fertility specialists then mix the eggs awith sperm to make embryos, and a fertility physician then places the embryos in the woman's body.ART can be expensive and time-consuming. But it has allowed many couples to have children that otherwise would not have been conceived. The most common complication of ART is multiple fetuses. But this is a problem that can be prevented or minimized in several different ways.
Common methods of ART include:
- In vitro fertilization (IVF) is by far the most popular means of fertilization outside of the body and the most effective ART. It is often useful when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs that can then be removed and fertilized in a laboratory. After three to five days, a fertility doctor implants healthy embryos in the woman's uterus.
- Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer is similar to IVF, although like GIFT (see below), it is an aging and rarely used treatment in the 21st century. Fertilization occurs in the laboratory. Then a doctor transfers the very young embryo to the fallopian tube instead of the uterus.
- Gamete intrafallopian transfer (GIFT) involves transferring eggs and sperm into the woman's fallopian tube, so fertilization occurs in the woman's body. Few fertility clinics offer GIFT as an option.
- Intracytoplasmic sperm injection (ICSI) is often a tool for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a laboratory specialist injects a single sperm into a mature egg. Then a doctor transfers the embryo to the uterus.
ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously fro- zen embryos. Donor eggs are sometimes used for women who can not produce eggs. Also, donor eggs or donor sperm is sometimes used when the woman or man has a genetic disease that can be passed on to the baby.
An infertile woman or couple may also use donor embryos. These are embryos that were either created by cou- ples in infertility treatment or were cre- ated from donor sperm and donor eggs. The donated embryo is transferred to the uterus. The child will not be genetically related to either parent.
Recent research by the Centers for Disease Control showed that ART babies are two to four times more likely to have certain kinds of birth defects. These may include heart and digestive system problems, and cleft (divided into two pieces) lips or palate. Researchers don't know why this happens. The birth defects may not be due to the technology. Other factors, like the age of the parents, may be involved. More research is needed. The risk is relatively low, but parents should consider this when making the decision to use ART.
Intrauterine insemination (IUI)
As a less complex and less costly alternative to ART, intrauterine insemination (IUI) is often called artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.IUI is often used to treat:
- Couples with mild cases of male infertility
- Women who have problems with their cervical mucus
- Couples with unexplained infertility
