Infertility Evaluation and Treatment
What is Infertility?
Infertility has many causes. It can be traced to specific problems with the man or woman’s reproductive organs, the hormones that regulate the sex drive and fertility, or environmental factors that make pregnancy difficult or impossible. However, infertility also can result from multiple factors and, in some cases, the cause is never known.
What causes Infertility?
Infertility can be caused by any interruption in the usual process of fertilization, pregnancy, and birth, which includes ejaculation of normal amounts of healthy sperm, passage of the sperm through the cervix and into the fallopian tube of the female, passage of an ovum (egg) down the fallopian tube from an ovary, fertilization in the fallopian tube, implantation of the fertilized egg in a receptive uterus, and the ability to carry the fetus to term. In women, the most common problems are failure to ovulate and blockage of the fallopian tubes. In men, low sperm count is the most common problem.
Underlying problems include disease, such as diabetes or mumps in adult men, hormonal imbalances, endometriosis, pelvic inflammatory disease (often caused by sexually transmitted diseases, such as chlamydia), the abuse of alcohol and other drugs, and exposure to workplace hazards or environmental toxins. Uterine irritation or infection that sometimes accompanies IUD use can also reduce fertility. Occasionally there is a chemical or immunological incompatibility between male and female. Psychological factors are difficult to evaluate because of the stressful nature of infertility itself.
How common is Infertility?
More than 15% of couples in this country have difficulty conceiving a child. Delayed childbearing has resulted in more women in their late 30s and early 40s attempting conception than ever before. In fact, 20% of women in the United States now have their first child after age 35.
Many women seeking to conceive after age 40 have no difficulty in achieving a pregnancy. For those who do, however, prompt and thorough evaluation and aggressive treatment are crucial. The probability of having a baby decreases 3-5 % per year after the age of 30, and at a faster rate after 40. Unfortunately, as women age they also have a higher chance of miscarrying.
What does the evaluation entail?
Treatment for infertility is tailored to meet the needs of each couple. Therefore, a comprehensive medical history, a thorough examination, diagnostic tests and other procedures are required to help your physician develop an effective treatment plan. The initial work-up begins with a personal and clinical history, including illnesses and medical conditions, sexual history and genetic predispositions that may contribute to infertility.
In addition, each partner undergoes a series of basic tests. These tests include examination of a semen sample, an x-ray test of the uterus and fallopian tubes (an HSG), and lab work. A few cycles of temperature charting may be required to determine when and if ovulation is occurring. Additional procedures may be required if more information is needed as a result of the initial screening and/or your history. For example, if there is evidence of heredity disease - sickle cell anemia, Tay-Sachs, Canavan’s or Gaucher disease - your physician may order genetic testing and chromosomal analysis. Psychological screening also may be required to determine whether you fully understand and are prepared to deal with the physical, emotional and legal ramifications of fertility treatment, and particularly, in vitro fertilization (IVF).
Based on all of this information, your CHCW physician will determine whether conception and pregnancy are likely as a result of treatment, as well as which therapies provide the best chance for success. Even in cases where the cause of infertility is not clearly identifiable, there may be treatment available to help you conceive.
What treatments are available?
The first step may be treatment of underlying disease and, in men, avoidance of substances that might affect sperm count. Fertility drugs, some of which increase the likelihood of multiple births, are often prescribed. If necessary, procedural correction of blocked tubes can be attempted.
Artificial insemination, in which the man's sperm or donor sperm from a sperm bank is inserted directly into the woman. Another method is in vitro fertilization (IVF), in which an egg is taken from the mother or an egg donor and fertilized outside the body by the father's sperm. The resulting embryo is then inserted into the mother's uterus. Gamete intrafallopian transfer (GIFT) mixes the egg and sperm outside the body, then, using laparoscopic procedures introduces them into the fallopian tube. For men with low sperm count or sperm of low quality, a procedure called intracytoplasmic sperm injection can help by inserting a single sperm directly into an egg. These latter procedures are often performed by an infertility specialist. Your CHCW physician will determine when referral to such a specialist may be appropriate. If none of these measures succeeds, adoption is sometimes considered.