Infertility

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What is infertility?

Infertility is a problem of the reproductive system. It affects the body's ability to reproduce. It could be caused by a problem with the man’s system, the woman’s system, or both. For a pregnancy, these must happen:

The man must make healthy sperm.
The woman must make healthy eggs.
The fallopian tubes must be open to let the sperm reach the egg.
The sperm must be able to fertilize the egg.
The fertilized egg must implant in the uterus.
The embryo must be healthy.

Infertility is not just a woman's concern. Half the time, a male factor causes or plays a part in the problem. Many couples have more than 1 factor that plays a role.

In a few cases, a cause for infertility can’t be found.

If you think you're not able to get pregnant, see your healthcare provider soon. Your age and how long you've been trying to get pregnant may affect treatment.

We understand that gender is a spectrum. We may use gendered terms to talk about anatomy and health risk. Please use this information in a way that works best for you and your provider as you talk about your care.

What causes infertility?

Many things can cause infertility. It can be a problem in the female reproductive system. It can be a problem in the male reproductive system. Or it may be both. Below are things that can affect fertility.

Female factors

Ovulation problems. The woman doesn’t make enough hormones to develop, mature, and release a healthy egg.
Anatomical problems. A problem with the woman’s anatomy can prevent the egg and the sperm from meeting. The most common problem is blocked fallopian tubes. Other problems may include scar tissue in the pelvis from past surgeries or infections.
Endometriosis.The tissue that lines the uterus implants outside the uterus in this condition. It usually implants on other reproductive organs or in the belly. Each month, this misplaced tissue reacts to the hormone changes of the menstrual cycle. This means it builds up, breaks down, and bleeds. This can cause scar tissue to form and affect fertility.
Birth defects. Certain birth defects can affect fertility. One of the most common problems happens when a female baby is exposed to DES (diethylstilbestrol) in the birth parent's uterus. Pregnant people in the 1940s and 1950s took this medicine to prevent pregnancy loss. But it was found to cause problems with the development in the uterus and cervix in the baby. This would later hurt their ability to get pregnant.
Infection.Pelvic inflammatory disease (PID) is caused by a type of bacteria, such as gonorrhea and chlamydia. PID can affect the uterus, fallopian tubes, the ovaries, or all of these. It causes scar tissue to grow between organs. This leads to ongoing pelvic pain and raises the risk for an ectopic pregnancy. This is when the fertilized egg implants outside the uterus.
Immune system problems. A problem with a pregnant person's immune system can lead to pregnancy loss. Antibodies can fail to recognize a pregnancy. Or there may be an abnormal immune response to the pregnancy. Women can also develop antisperm antibodies, which attack and destroy sperm.

Male factors

Low or no sperm production. Without enough healthy sperm, the chance of fertilization is decreased.
Abnormal sperm function. Sperm must be able to swim and penetrate the egg.
Varicocele.This is a condition in which varicose veins develop around the testes. It’s a very common cause of infertility in men. It’s treated with surgery.
Hormone disorders. Hormone problems can affect sperm production and fertility.
Chromosome defects.Some defects are linked to male infertility.
Birth defects. Problems in a man's reproductive system can happen in the womb. Some birth defects are due to a man's exposure to DES (diethylstilbestrol) taken by his mother during pregnancy.
Immune system problems. A man may have antisperm antibodies. These attack and destroy sperm.

These lifestyle habits can also affect sperm quality and function:

Use of recreational drugs, such as marijuana or cocaine
Heavy alcohol use
Smoking
Taking certain medicines
Too much heat to the genital area, such as using a hot tub

What are the symptoms of infertility?

A couple is defined as infertile if conception does not happen in these cases:

After 1 year of unprotected sex
After 6 months in women over age 35
If there are known problems causing infertility

How is infertility diagnosed?

To diagnose infertility, both the man and the woman are tested.

Some healthcare providers can do a basic infertility evaluation. But many causes of infertility are best treated by a reproductive endocrinologist. This is an OB/GYN who has had education and training in infertility. They should be certified with the American Board of Obstetrics and Gynecology.

The healthcare provider will test both partners to find the cause of infertility. The healthcare provider is looking for answers to these questions:

Is the woman ovulating regularly?
Is the man making healthy sperm?
Are the woman's egg and the man's sperm able to unite and grow normally?
Are there any problems with implantation?
Is the woman able to maintain the pregnancy?

The below tests are often part of the basic testing for infertility.

Both partners

Female

Physical exam. You will have a full physical exam. This includes a Pap test and testing for infections.
Ovulation evaluation. You can check to see if you are ovulating by keeping a basal body temperature chart. This is your morning body temperature. Other ovulation prediction methods use urine samples.
Hormone testing. Hormone testing may be advised. Some hormones increase and decrease at various times in the monthly cycle.
Ultrasound.This can show the follicles on the ovaries. These are the sacs that contain the developing eggs. It can also show the thickness of the uterine tissues. Your healthcare provider can also check for problems, such as ovarian cysts or fibroids.
X-rays. A hysterosalpingogram may be advised. For this test, a dye is injected into the cervical opening to see inside the uterus. This lets the radiologist see if the fallopian tubes are open.

Male

A semen sample is taken and tested in the lab. The healthcare provider can:

Check the sperm count
Test sperm motility
Check the shape of sperm
Assess the ejaculate liquid

Other tests may be done that test the sperm's ability to penetrate the egg, as well as male hormone testing.

Men may need to see a urologist for more testing.

How is infertility treated?

Once a diagnosis is made, you can work with a fertility expert to find the best treatment. Most people with infertility are treated with medicine or surgery. Depending on the cause, there are many types of treatment.

Types of treatments for women may include:

Intrauterine insemination. This method is done with a small flexible tube called a catheter. The tube is used to place washed and prepared sperm into the uterus. It may be used for low sperm count or cervical mucus problems. This method is often used along with ovulation medicines.
Ovulation medicines. These help regulate the timing of ovulation. They stimulate the growth and release of mature eggs. They can also help correct hormone problems that can affect the lining of the uterus. Ovulation medicines can cause more than 1 egg to be released. This raises the chance of having twins or more. Some of the common medicines include:
- Clomiphene citrate
- Human menopausal gonadotropins
- Medicines with follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
Surgery. Surgery may be used to treat or repair a condition, such as blocked fallopian tubes or endometriosis. This may be done using laparoscopy. In a laparoscopy, a small scope is inserted into the abdominal or pelvic area. This lets the healthcare provider see internal organs. Some methods to treat infertility can be done using small tools put through the laparoscope.
Assisted reproductive technology (ART). For some couples, more extensive treatment is needed. With most forms of ART, the sperm and egg are joined in the lab. The fertilized egg is then returned to the woman's uterus where it can implant and grow. While ART procedures are often costly, many are being used with success.

Types of ART include:

In vitro fertilization (IVF). This is done by removing a woman's eggs and fertilizing them in the lab with sperm. The embryo is then transferred into the woman's uterus through the cervix. Most couples transfer 2 embryos. More may be transferred in certain cases. IVF is the most common form of ART. It's often the treatment of choice for a woman with blocked, severely damaged, or absent fallopian tubes. IVF is also used for infertility caused by endometriosis or male factor infertility. IVF is sometimes used to treat couples with long-term unexplained infertility who have not been able to get pregnant with other treatments.
Intracytoplasmic sperm injection (ICSI). In this procedure, a single sperm is injected directly into an egg. This method is most commonly used to help with male factor infertility problems.
Gamete intrafallopian transfer (GIFT). This is done with a fiber-optic instrument called a laparoscope to guide the transfer of unfertilized eggs and sperm into the woman's fallopian tubes through small incisions in her abdomen. GIFT is only used in women with healthy fallopian tubes.
Zygote intrafallopian transfer (ZIFT). This is done by fertilizing a woman's eggs in the lab. Then the laparoscope guides the transfer of the fertilized eggs (zygotes) into her fallopian tubes. ZIFT is only used in women with healthy fallopian tubes.
Donor eggs. This is done by transferring an embryo from a donor to an infertile woman. The donor gives up all parental rights to any resulting children. ART using donor eggs is more common in older women. The chance of a fertilized egg implanting is related to the age of the woman who produced the egg. Egg donors are typically in their 20s or early 30s.
Embryo cryopreservation. In this method, the embryos are frozen for transfer at a later date. This is often used when an IVF cycle produces more embryos than can be transferred at 1 time. The remaining embryos can be transferred in a future cycle if needed.

Types of treatments for men may include:

Assisted reproductive technologies (ART). This type of treatment may include:
- Artificial insemination.This is done by placing large numbers of healthy sperm either at the opening of the cervix or into the woman’s uterus.
- IVF, GIFT, and other methods. These have been used for the treatment of male infertility. As is the case with artificial insemination, IVF and similar methods offer the chance to prepare sperm in a lab. In the lab, the eggs are exposed to the best concentration of high quality, motile (moving) sperm.
- Microsurgical fertilization.This includes microinjection methods, such as intracytoplasmic sperm injection (ICSI). For this treatment, a single sperm is injected into an egg. Fertilization then takes place under a microscope.
Medicine therapy. A few infertile men have a hormone problem that can be treated with hormone therapy. Hormone imbalances caused by a problem with the hypothalamus, the pituitary gland, and the testes directly affect the development of sperm. Medicine therapy may include gonadotrophin therapy, antibiotics, or another medicine.
Surgery. Surgery for male infertility is done to repair anatomical problems that impede sperm production and maturation or ejaculation. Surgery to remove varicose veins in the scrotum (varicocele) can sometimes improve the quality of sperm.

Key points about infertility

Infertility is a problem of the reproductive system. It impairs the body's ability to reproduce. It could be caused by a problem with the man’s system, the woman’s system, or both.
Infertility is not just a woman's concern. In about half of infertile couples, the male is the sole cause.
The couple are believed infertile if conception does not happen after 1 year of unprotected sex, after 6 months in women over age 35, or if there are known problems causing infertility.
Many causes of infertility are best treated by a board-certified reproductive endocrinologist.
Depending on the cause of infertility, there are many treatment choices for an infertile couple.
Treatment with medicine or surgical repair cure most cases of infertility.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.

Medical Reviewer: Irina Burd MD PhD

Medical Reviewer: Donna Freeborn PhD CNM FNP

Medical Reviewer: Heather M Trevino BSN RNC

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