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Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing. Fortunately, there are many safe and effective therapies for overcoming infertility. These treatments significantly improve the chances of becoming pregnant.
SYMPTOMS
Most couples achieve pregnancy within the first six months of trying. Overall, after 12 months of frequent unprotected intercourse, about 90 percent of couples will become pregnant. The majority of couples will eventually conceive, with or without treatment.
The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms.
In some cases, an infertile woman may have irregular or absent menstrual periods. An infertile man may have signs of hormonal problems, such as changes in hair growth, sexual function, reduced sexual desire, or problems with ejaculation. He may also have small testicles or a swelling in the scrotum.
In general, you may consider seeing a doctor about infertility if you and your partner have been trying regularly to conceive for at least one year. You may consider being seen earlier if you're a woman and:
You're age 35 to 40 and have been trying to conceive for six months or longerYou're over age 40You menstruate irregularly or not at allYou have known fertility problemsYou've been diagnosed with endometriosis or pelvic inflammatory diseaseYou've had more than one miscarriageYou've had prior cancer treatment
If you're a man, you may wish to be evaluated sooner if you have:
A low sperm count or other problems with spermSwelling in the scrotum (see 'varicocele' below)You have had a previous vasectomyUndergone prior scrotal or inguinal surgerySmall testicles or problems with sexual function or desireHad prior cancer cancer treatmentDesire to know your fertility status
CAUSES
To become pregnant, the complex processes of ovulation and fertilization need to work just right. For some couples, infertility problems can be present from birth (congenital) or something can go wrong along the way that results in infertility.
The reasons for infertility can involve one or both partners. In general:
In about one-third of cases, the cause of infertility involves only the male.In about one-third of cases, the cause of infertility involves only the female.In the remaining cases, the cause of infertility involves both the male and female, or no cause can be identified.
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Causes of male infertility
Causes of male infertility may include:
Abnormal sperm production or function due to various problems, such as undescended testicles, genetic defects, health problems including diabetes, prior infections such as mumps, trauma or prior surgeries on the testicles or inguinal region. Enlarged veins in the testes can increase blood flow and heat, affecting the number and shape of sperm.Problems with the delivery of sperm due to sexual problems, such as premature ejaculation, semen entering the bladder instead of emerging through the penis during orgasm (retrograde ejaculation), certain genetic diseases, such as cystic fibrosis, structural problems, such as blockage of the part of the testicle that contains sperm (epididymis), or damage or injury to the reproductive organs. Men who have previously undergone a vasectomy and desire a return of fertility will also need to either have the vasectomy reversed (see 'vasectomy reversal' below) or have sperm retrieved through a surgical procedure for use in assisted reproductive techniques.Overexposure to certain chemicals and toxins, such as pesticides, radiation, tobacco smoke, alcohol, marijuana, and steroids (including testosterone). In addition, frequent exposure to heat, such as in saunas or hot tubs, can elevate the testicular temperature, impairing sperm production.Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely. Removal of one testicle due to cancer also may affect male fertility.
Causes of female infertility
Causes of female infertility may include:
Ovulation disorders, which hinder or prevent the ovaries from releasing eggs. Examples include hormonal disorders such as polycystic ovary syndrome, a condition that might relate to your ovaries producing too much of the male hormone testosterone, and hyperprolactinemia, when you have too much prolactin — the hormone that stimulates breast milk production. Other underlying causes may include excessive exercise, eating disorders, injury or tumors.Uterine or cervical abnormalities, including problems with the opening of the cervix or cervical mucus, or abnormalities in the shape or cavity of the uterus. Benign tumors in the wall of the uterus that are common in women (uterine fibroids) may rarely cause infertility by blocking the fallopian tubes. More often, fibroids may distort the uterine cavity interfering with implantation of the fertilized egg.Fallopian tube damage or blockage, which usually results from inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, usually caused by sexually transmitted infection, endometriosis or adhesions.Endometriosis, which occurs when endometrial tissue implants and grows outside of the uterus — often affecting the function of the ovaries, uterus and fallopian tubes.Primary ovarian insufficiency, also called early menopause, when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.Pelvic adhesions, bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery.
Other causes in women include:
Thyroid problems. Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle or cause infertility.Cancer and its treatment. Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman's ability to reproduce.Other conditions. Medical conditions associated with delayed puberty or the absence of menstruation (amenorrhea), such as celiac disease, Cushing's disease, sickle cell disease, kidney disease or diabetes, can affect a woman's fertility. Also genetic abnormalities can make conception and pregnancy less likely.Certain medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
COMPLICATIONS
If getting pregnant has been a challenge for you and your partner, you're not alone. Ten to 15 percent of couples in the United States are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most people and six months in certain circumstances.
Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing. Fortunately, there are many safe and effective therapies for overcoming infertility. These treatments significantly improve the chances of becoming pregnant.
DIAGNOSIS
Before having infertility testing, be aware of the commitment that's required. Your doctor or clinic will need to determine what your sexual habits are and may make recommendations about changing them. Tests and treatment trial periods may extend over several months. In some infertile couples, no specific cause is found (unexplained infertility).
Evaluation can be expensive and in some cases involves uncomfortable procedures. Many medical plans may not reimburse the cost of fertility treatment. Finally, there's no guarantee — even after all the testing and counseling — that conception will occur.
Tests for men
For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman's vagina and be able to travel to and fertilize the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.
You may have a general physical exam. This includes an 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 laboratory analyzes your semen specimen for the health of sperm and the semen fluid.Hormone testing. A blood test to determine the level of testosterone and other male hormones is common.Transrectal and scrotal ultrasound. Ultrasound can help your doctor look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstruction.Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing infertility.Testicular biopsy. This test involves removing samples from the testicle with a needle. The results of the testicular biopsy will tell if sperm production is normal. If it is, your problem is likely caused by a blockage or another problem with sperm transport.Other testing. In some cases, other blood or semen tests may be recommended to try to determine why the sperm may not be able to effectively fertilize the egg.
Tests for women
For a woman to be fertile, her ovaries must release healthy eggs. Her reproductive tract must allow an egg to pass into her fallopian tubes and allow the sperm to join the egg for fertilization. The fertilized egg must travel on to the uterus and implant in the lining. Tests for female infertility attempt to determine whether any of these processes are impaired.
You may have a general physical exam. This includes a regular gynecological exam. Specific fertility tests may include:
Ovulation testing. A blood test is performed to measure hormone levels to determine whether you're ovulating, if you have not had positive home ovulation tests. Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the condition of your uterus and fallopian tubes. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid spills out of your fallopian tubes. Blockage or other problems often can be located.Ovarian reserve testing. This testing helps determine the quality and 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 thyroid and pituitary hormones that control reproductive processes.Imaging tests. Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) 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:
Other imaging tests. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease.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. Laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.Genetic testing. Genetic testing helps determine whether there's a genetic defect causing infertility.
Not everyone needs to have all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.
TREATMENT
Treatment of infertility depends on the cause, how long you've been infertile, your age and your partner's age, and many personal preferences. Some causes of infertility can't be corrected. However, a woman may still become pregnant with assisted reproductive technology. Infertility treatment involves significant financial, physical, psychological and time commitment.
Treatment for men
Approaches that involve the male include treatment for general sexual problems or lack of healthy sperm. Treatment may include:
Treating infections. Antibiotic treatment may cure an infection of the reproductive tract, but doesn't always restore fertility.Treatments for sexual intercourse problems. Medication or counseling can help improve fertility in conditions such as erectile dysfunction or premature ejaculation.Hormone treatments and medications. Your doctor may recommend hormone replacement or medication in cases where infertility is caused by high or low levels of certain hormones or problems with the way the body uses hormones.Surgery. For example, a varicocele can often be surgically corrected or an obstructed vas deferens repaired. See 'vasectomy reversal' and 'varicocele' below. In cases where no sperm are present in the ejaculate, sperm may often be retrieved directly from the testicles.Assisted reproductive technology (ART). ART treatments involve obtaining sperm through normal ejaculation, surgical extraction or from donor individuals, depending on your specific case and wishes. The sperm is then inserted into the female genital tract, or used to perform in vitro fertilization or intracytoplasmic sperm injection.
Treatment for women
Although a woman may need just one or two therapies to restore fertility, it's possible that several different types of treatment may be needed before she's able to conceive.
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 that have been collected and concentrated are placed directly in the uterus around the time the woman's 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 or intrauterine scar tissue can be treated with hysteroscopic surgery.
Assisted reproductive technology
Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. An ART health team includes physicians, psychologists, embryologists, lab technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.
In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs from a woman, fertilizing them with a man's sperm in a dish in a lab, and implanting the embryos in the uterus three to five days after fertilization.
Each year thousands of babies are born in the United States as a result of ART. The success rate of ART is lower after age 35.
Other techniques are sometimes used in an IVF cycle, such as:
Intracytoplasmic sperm injection (ICSI). In ICSI, a single healthy sperm is injected directly into a mature egg. ICSI is often used when semen quality is a problem, there are few sperm, or if fertilization attempts during prior IVF cycles failed. Assisted hatching. This technique attempts to assist 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 the woman's own eggs and her partner's sperm. However, if there are severe problems with either the eggs or 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 female 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. Babies born prematurely are at increased risk of health and developmental problems. The goal of infertility treatment should be a single healthy pregnancy, and preventing multiple pregnancies should be discussed before treatment starts. In some cases, fetal reduction can be used to help a woman deliver fewer babies with lower health risks. Pursuing fetal reduction, however, is a major decision with ethical, emotional and psychological consequences.Ovarian hyperstimulation syndrome (OHSS). Use of injectable fertility drugs to induce ovulation can cause OHSS, 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.Premature delivery or low birth weight. The greatest risk factor for low birth weight is a multiple fetus pregnancy. In single live births, there may be a greater chance of preterm delivery or low birth weight associated with IVF.Birth defects. Some research suggests that babies conceived using IVF might be at increased risk of certain birth defects, such as heart and digestive problems and cleft lip or cleft palate. However, most studies conclude that this appears to be related to why couples need infertility treatment and not the IVF procedures themselves.
Complications of male infertility treatment are rare and may occur following surgery including infection, bruising, or lack of efficacy with the procedure.
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