Infertility is the inability of a couple to become pregnant with regular intercourse for a year. Approximately 14% of all couples are unable to conceive in one year. In some cases, diagnosis and treatment of the cause for the infertility is simple. Other cases are complex and more difficult to diagnose and treat. It should be reassuring that modern technology can help most couples to achieve a pregnancy. There are many causes in both women and their partners that can make it difficult to become pregnant. An over-simplification of what is needed to achieve pregnancy is:

• A healthy egg
• Many healthy sperm
• The ability of the egg and sperm to join together
• A fertile field for implantation and growth of the baby

If there is a problem with any of the above, successful pregnancy may not occur.
It is important for both the treating physician and couple who are having difficulty becoming pregnant to recognize that infertility causes anxiety and stress. Except in unusual cases, anxiety and stress do not cause infertility – but is a normal result. Well-meaning relatives and friends frequently add to the anxiety and stress with comments about having a baby. Couples should discuss their concerns with each other and with their physician. 

I want to thank you for all of your attention and help last year when I was experiencing problems with infertility. Our daughter is proof that you all really do make dreams come true. I especially want to tell you that your prompt action in diagnosing me with endometriosis and removing it made my pregnancy possible. Not knowing what was wrong was one of the most difficult experiences I have ever had, but you and your staff were so reassuring and positive that it truly eased my concerns." L.W. 

Causes of Infertility
Male factor is responsible for approximately 35% of infertility in couples. Large numbers of normal sperm with good, forward movement are necessary for normal conception. Previous surgery or infection involving the testicles can affect fertility. Another common cause for decreased sperm count is the varicocele, or dilation of the veins around the testicles. To minimize the risk of male-factor infertility, minimize exposure to:

• Excessive heat to the testicles such as in hot tubs and saunas
• Toxic chemicals or pesticides
• Nicotine and marijuana (and other street drugs)
• Excessive alcohol consumption.

In 25% of infertility cases, there is a problem in the female organs. Common reasons include:

• Adhesions or scar tissue
• Endometriosis
• Leiomyomas (uterine fibroids)
• Congenital abnormalities of the reproductive organs in the female.

Adhesions or scar tissue are most commonly caused by infection or endometriosis. Infection may be a result of pelvic inflammatory disease ("PID"), abortion or other female surgery, ruptured appendix, use of the intrauterine device (IUD), or pelvic tuberculosis. The adhesions may block the uterine cavity, block the fallopian tubes, or prevent the fallopian tubes from picking up the egg from the ovary.

Endometriosis may affect fertility by causing adhesions or scar tissue, affecting release of an egg, or destroying sperm. Endometriosis irritates the tissues in the pelvis. This irritation results in production of cells called macrophages that destroy sperm.

Leiomyomas (uterine fibroids) are benign muscle growths in the uterus which affect large numbers of women. Less than 1 in 2000 fibroids are felt to be malignant. Most women have no symptoms or problems from these fibroids. Most women who have fibroids do have not difficulty becoming pregnant. Occasionally the fibroids can block the fallopian tubes as they come into the cavity of the uterus. If the fibroids are located in the uterine cavity, this does not provide a fertile field for implantation and growth of the baby.

Congenital abnormalities are problems that are present at birth. They can range from complete absence of the vagina with an underdeveloped uterus to slight variations in shape of the uterus (such as the septate or bicornuate uterus in which the cavity is heart-shaped instead of pear-shaped).

Problems releasing an egg (ovulation) account for approximately 20% of cases of infertility. Frequently, but not always, irregular menses indicate an ovulation problem. The problem may be no ovulation, irregular ovulation, ovulation without release of the egg, or inadequate hormone production to support a normal pregnancy. Conditions and symptoms that may be  associated with ovulation problems include:

• Abnormalities of thyroid function
• Milky discharge from the breasts
• Excess hair growth
• Hot flushes
• Weight loss or significant underweight
• Obesity
• Significant psychological stress

A cervical factor is present in approximately 10% of infertility cases. There may be lack of good cervical mucus that is necessary to allow the sperm to travel through the cervix into the uterus and subsequently into the fallopian tubes. There may be infection and inflammation or antibodies that do not allow the sperm through the cervix.

Unexplained infertility may result after infertility evaluation in 5-10% of couples. With modern-day technology, this is seen in fewer and fewer couples.

Evaluation of Infertility
The evaluation for infertility may be fairly simple or more complex depending on the suspected cause or causes for the problem.
A basic work-up usually includes the following:

• Medical history and physical examination
• Semen analysis (sperm count)
• Evaluation of ovulation (releasing an egg)
• Postcoital test (test after intercourse)
• Evaluation of tubal patency (whether the tubes are open)

Medical history and physical examination is important in evaluation of any medical problem. The results may suggest a likely cause for the fertility problem.
Since male factor is responsible for 35% of fertility problems, a semen analysis is an important part of any infertility evaluation. When the results of a semen analysis are abnormal, the test is usually simply repeated in 2-4 weeks. The sperm that are ejaculated today were actually produced about 70 days before. A mild viral infection could result in an abnormal test. Many males are reluctant to provide a specimen because of an attitude that "it can’t be me." The possibility of an abnormal semen analysis can be a real threat to the male ego. Fortunately, many of the problems with an abnormal semen analysis can be dealt with, allowing successful pregnancy.

Ovulation evaluation can be done in several ways.

• Basal body temperature (BBT) charts require taking the temperature daily first thing every morning. Drawbacks of the BBT include the fact that it is a nuisance to do, can add to the stress when pregnancy does not occur, and has some inherent error.
• Over-the-counter ovulation kits can be more accurate than the BBT charts and use a mid-day urine specimen.
• Measurement of serum progesterone (a blood test) may be helpful in some cases. Progesterone is produced at the time of ovulation. The disadvantage of this test is that progesterone is produced in a pulsatile fashion (it is not produced in continuous levels, but goes up and down in a 24 hour period)
• Endometrial biopsy is the most reliable test to detect ovulation and to determine if adequate amounts of progesterone are being produced to support a pregnancy. A small biopsy of the lining of the uterus is done in your physician’s office and is usually associated with moderate, menstrual-like cramping that is short-lived.

The postcoital test allows evaluation of the sperm-cervical mucus interaction. You should abstain from intercourse for 48 hours prior to the test. The test is best performed 24-48 hours before ovulation. You are asked to have intercourse and come in for a pelvic examination 2-8 hours later. The test is painless, similar to a PAP smear, and involves microscopic evaluation of the cervical mucus and the sperm in the mucus.

Evaluation of tubal patency is usually accomplished with a hysterosalpingogram (HSG). Usually done in the radiology department, and instrument is attached to the cervix to allow injection of dye into the uterus and fallopian tubes. The internal shape of the uterine cavity is seen as well as the patency of the fallopian tubes (whether or not the tubes are open). The procedure usually causes moderate menstrual-like cramping, although the cramping can sometimes be intense for a short period of time. In some cases, a nerve block is given in the cervix that can significantly reduce the discomfort.

Depending on the findings in the above tests, more advanced evaluation may be indicated.

• Blood tests may be indicated in the woman or her partner. These may be hormonal, antibody, or other tests that can assist in the diagnosis.
• Ultrasound can help evaluate the uterus, the uterine cavity, and the areas next to the uterus.
• Hysteroscopy can be used to further evaluate (and treat) abnormalities within the uterine cavity.
• Laparoscopy is recommended when adhesions or scar tissue or endometriosis are suspected. It is also used in certain instances when fibroids are present.

Treatment of Infertility
Infertility treatment depends on the specific cause or causes of the problem. Patients frequently ask for a fertility drug. Fertility drugs are most commonly used to induce ovulation or to support the growth of the baby once ovulation and conception has occurred. Giving a drug to induce ovulation when the woman is already ovulating will not necessarily improve the chance of pregnancy and may actually decrease the possibility. Specific treatment is given for specific cause.

Male factor infertility is usually evaluated and treated by a urologist. The treatment may include medication and/or surgery. If the treatment is not successful, alternative therapies may be available.

• With intrauterine insemination, the semen is washed in a special solution and placed directly into the uterine cavity. Intrauterine insemination may be performed with your partner’s semen or a donor’s. Intrauterine insemination is also used when there is a cervical factor.
• If the male partner has no sperm or a genetically-carried disease, a couple may choose to have donor insemination in which semen from a donor is placed in the cervix or in the uterus just before ovulation. This is a painless office procedure. Donors can usually be selected by general physical characteristics and are screened for diseases such as AIDS and hepatitis.
• When the partner has a very low sperm count, ICSI is sometimes recommended. ICSI involves injection of a single sperm into an egg and is a specialized form of IVF or in vitro fertilization.

The Pelvic Factor is most frequently treated surgically. If surgical treatment is not successful, assisted reproductive technology may be necessary (see below).

• Hysteroscopy is performed to diagnose and treat conditions within the uterus (adhesions or scar tissue, septa or divisions in the cavity, and fibroids). Fallopian tube recanalization can sometimes relieve a blockage of the tube. A small catheter (tube) is carefully guided into the fallopian tube under guidance with a hysteroscope or at the time of a HSG.
• Laparoscopy is most commonly used to diagnose and treat endometriosis and adhesions or scar tissue involving the pelvic organs. Laparoscopy can also be used to remove fibroids of the uterus. Tubal blockage can sometimes be treated successfully at surgery, but if the blockage is severe enough, IVF may be the best way to achieve pregnancy. Occasionally open surgery or laparotomy is necessary for surgical treatment if the procedure cannot be done at laparoscopy. A word about endometriosis – it can be treated either medically or surgically. Current medical treatment of endometriosis is with the use GNRH analogues that suppress the endometriosis but do not eliminate the condition. Most specialists prefer surgical removal of endometriosis. If this does not result in pregnancy, IVF is the treatment of choice.

The ovulatory factor is most frequently treated with medication. Ovulation may be stimulated directly with medication. In other situations, treatment of other conditions such as hypothyroidism (low thyroid hormone) or hyperinsulinism (excessive insulin) may result in spontaneous ovulation. In some instances ovulation may occur, but there may be inadequate progesterone production (luteal phase defect) to support a pregnancy. This is treated with replacement of the progesterone. Many women are choosing to delay childbearing until their 30’s and 40’s. As a result, a condition called diminished ovarian reserve is seen more frequently. As eggs age, their ability to be fertilized and grow into a baby is lessened. If this is present, a donor egg can allow a normal pregnancy.

Cervical factor is treated with medication to improve the cervical mucus, treat inflammation and infection, or to suppress antibodies against the sperm. Intrauterine insemination is also sometimes successful in bypassing cervical factor problems. If these treatments do not work, IVF is the treatment of choice.

Unexplained infertility is most often treated with assisted reproductive technology (ART). ART is also used in many conditions as noted above when other forms of therapy do not work. These include:

• IVF or in vitro fertilization. Eggs from the woman are combined with sperm from her partner, allowed to grow for three days is a "test tube," and then placed in the uterine cavity.
• ICSI involves injection of a single sperm into an egg, allowing the conceptus to grow, and then placing it into the uterine cavity.
• Assisted hatching is similar to IVF except the conceptus is transferred around day 5 instead of day 3. This improves the ability of the conceptus (embryo) to attach to the wall of the uterus.
• Ovum transfer is similar to IVF except the conceptus is placed in the uterus of a surrogate mother (not the woman who produced the egg).
• Egg donor is used when diminished ovarian reserve is present or when the woman has undergone natural or surgical menopause and desires pregnancy.
• GIFT and ZIFT or gamete intrafallopian transfer or zygote intrafallopian transfer are variations of IVF.

Adoption. If treatment of infertility is not successful or if a couple cannot afford or chooses not to participate in assisted reproductive technology, they may choose adoption.