- What is infertility?
Infertility means not being able to get pregnant after one year of trying. Or, six months, if a woman is 35 years of age or older. Women who can get pregnant but are unable to stay pregnant(eg, repetitive pregnancy loss) 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).
- Infertility can happen if there are problems with any of these steps.
- Is infertility a common problem?
Yes. About 10 % of women (6.1 million) in the United States ages 15–44 years have difficulty getting pregnant or staying pregnant.
- Is infertility just a woman's problem?
No, infertility is not always a woman's problem. Both women and men can have problems that cause infertility. About one-third of infertility cases are caused by women's problems. Another one third of fertility problems are due to the man. The other cases are caused by a mixture of male and female problems or by unknown problems.
- What causes infertility in men?
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.
- Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. For example, cystic fibrosis often causes infertility in men.
- What increases a man's risk of infertility?
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
- Smoking cigarettes
- Advancing Age
- Environmental toxins, including pesticides and lead
- Health problems such as mumps, serious conditions like kidney disease, or hormone problems
- Radiation treatment and chemotherapy for cancer
- What causes infertility in women?
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 or other causes.
Ovulation problems are often caused by polycystic ovarian syndrome (PCOS). PCOS is a hormone imbalance problem which can interfere with normal ovulation. 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
- Men Seek Infertility Services
Many couples struggle with infertility and seek help to become pregnant; however, it is often thought of as only a women's condition. But a CDC study analyzed data from the 2002 National Survey of Family Growth, and found that 7.5% of all sexually experienced men reported a visit for help with having a child at some time during their lifetime—this equates to 3.3–4.7 million men. Of men who sought help, 18.1% were diagnosed with a male-related infertility problem, including sperm or semen problems (13.7%) and varicocele (5.9%).
Anderson JE, Farr SL, Jamieson DJ, Warner L, and Macaluso M. Infertility services reported by men in the United States: national survey data. Fertility and Sterility 2009; (6):2466–2470.
- What things increase a woman's risk of infertility?
Many things can change a woman's ability to have a baby. These include—
- Advancing Age
- Excess alcohol use
- Poor diet
- Athletic training
- Being overweight or underweight
- Sexually transmitted infections (STIs)
- Health problems that cause hormonal changes, such as polycystic ovarian syndrome and primary ovarian insufficiency
- How does age affect a woman's ability to have children?
Many women are waiting until their 30s and 40s to have children. In fact, about 20% of women in the United States now have their first child after age 35. So age is a growing cause of fertility problems. About one-third of couples in which the woman is older than 35 years have fertility problems.
Aging decreases a woman's chances of having a baby in the following ways—
- She has a smaller number of eggs remaining
- Her ovaries become less able to release eggs
- Risk of Chromosomal Abnormalities
- 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 miscarriage
- How long should women try to get pregnant before calling their doctors?
Most experts suggest at least one year. Women aged 35 years or older should see their doctors after six months of trying. A woman's chances of having a baby decrease rapidly every year after the age of 30.
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
- Pelvic inflammatory disease
- More than one miscarriage
It is a good idea for any woman to talk to a doctor before trying to get pregnant. Doctors can help you get your body ready for a healthy baby. They can also answer questions on fertility and give tips on conceiving.
- How will doctors find out if a woman and her partner have fertility problems?
Doctors will do an infertility workup. This involves a physical exam. The doctor will also ask for both partners' health and sexual histories. Sometimes this can find the problem. 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 morning 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)
Doctors can also check ovulation with blood tests. Or they can do an ultrasound of the ovaries. If ovulation is normal, there are other fertility tests available.
Some common tests of fertility in women include—
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.
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 laparoscope. With the laparoscope, the doctor can check the ovaries, fallopian tubes, and uterus for disease and physical problems. Doctors can usually find scarring and endometriosis by laparoscopy.
Finding the cause of infertility can be a long and emotional process. It may take time to complete all the needed tests. So don't worry if the problem is not found right away.
- How do doctors treat infertility?
Infertility can be treated with medicine, surgery, artificial insemination, or assisted reproductive technology. 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 can help men deal with impotence or premature ejaculation. Behavioral therapy and/or medicines can be used in these cases.Too few sperm:
Sometimes surgery 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.
- What medicines are used to treat infertility in women?
A number of fertility medicines are used to treat women with ovulation problems. It is important to talk with your doctor about the pros and cons of these medicines. You should understand the possible dangers, benefits, and side effects.
Some 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 gonadotropin or hMG (Menopur, 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 hormone (Gn-RH) analog (Lupron, Antigon, Centrotide, Synarel):
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 hormone that causes milk production.
Many fertility drugs increase a woman's chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems.
- What is intrauterine insemination (IUI)?
Intrauterine insemination (IUI) is an infertility treatment that 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—
- Mild male factor infertility
- Women who have problems with their cervical mucus
- Couples with unexplained infertility
- What is assisted reproductive technology (ART)?
Assisted reproductive technology (ART) is a group of different methods used to help infertile couples. ART works by removing eggs from a woman's body. The eggs are then mixed with sperm to make embryos. The embryos are then put back in the woman's uterus.
- How often is assisted reproductive technology (ART) successful?
Success rates vary and depend on many factors.
Some things that affect the success rate of ART include—
- Age of the partners
- Reason for infertility
- Type of ART
- If the egg is fresh or frozen
- If the embryo is fresh or frozen
- CDC collects success rates on ART for some fertility clinics.
According to the CDC's 2011 Preliminary ART Success Rates, the average percentage of ART cycles that led to a live birth were—
- 42% in women younger than 35 years of age
- 32% in women aged 35–37 years
- 22% in women aged 38–40 years
- 12% in women aged 41–42 years
- 5% in women aged 43–44 years
ART can be expensive and time-consuming. But it has allowed many couples to have children that otherwise would not have been able to conceive. The most common complication of ART is multiple fetuses. This is a problem that can be prevented or minimized in several different ways.
- What are the different types of assisted reproductive technology (ART)?
Common methods of ART include—
In vitro fertilization (IVF)
means fertilization outside of the body. IVF is the most effective ART. It is often used 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. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer
is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred 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 practices offer GIFT as an option.
Intracytoplasmic sperm injection (ICSI)
is often used 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 single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.
ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen 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 couples in infertility treatment or were created from donor sperm and donor eggs. The donated embryo is transferred to the uterus. The child will not be genetically related to either parent.
- In vitro fertilization (IVF)
- Gestational Carrier
Women with ovaries but no uterus may be able to use a gestational carrier. This may also be an option for women who shouldn't become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by the man's sperm and the embryo is placed inside the gestional carrier's uterus. The carrier will not be related to the baby and gives him or her to the parents at birth.
Courtesy of the National Women's Health Information Center.
- 5 Common Misconceptions About PGS and PGD
By Heather Huhman
Of the widely debated and misunderstood treatment options for infertility, genetic screening is at the top of the list. Preimplantation genetic screening (PGS) and preimplantation genetic diagnosis (PGD) are screening processes designed to increase the chances of a healthy embryo implantation. PGS screens for extra or missing copies of chromosomes, while PGD looks for single-gene defects that may lead to genetic disorders.
To help clear the air surrounding these preventative measures, here are five common misconceptions (and little-known facts) about PGS and PGD testing:
Misconception #1: PGS is designed for women of advanced maternal age.
It’s easy to understand why so many people believe PGS is geared solely toward women of advanced maternal age. While it’s true that an increase in age results in an increased risk for fertility issues, the belief that younger women aren’t at risk just isn’t true.
Fact: Women of all ages are at risk of having chromosomally abnormal embryos — even women under 30 years of age. But, for women in their late 30s, the chances of having abnormal embryos is ~50%.
Misconception #2: PGS is only for identifying chromosome abnormalities.
There’s no denying that PGS can provide infertile couples with valuable genetic insight. By looking for chromosomal abnormalities, couples can identify and prepare for conditions like Down’s syndrome.
Couples who have a family history or are at risk of chromosome abnormality are ideal candidates for PGS, but so are couples that have had multiple failed pregnancies or IVF transfers and simply want to find out why.
Fact: Preimplantation genetic screening can also be used to help infertile couples learn the reasoning behind their infertility. Most people don’t know why their embryos either aren’t implanting or are resulting in early losses until after genetic testing. Especially for couples dealing with unexplained infertility, PGS can supply some much-needed answers.
There are some who believe PGS is used for gender selection, or so-called “family balancing,” but most fertility clinics do not share the gender with patients until they are successfully pregnant following a transfer — and for good reason. I am glad to be under the care of a clinic that operates this way.
Misconception #3: PGD is “like playing God.”
Preimplantation genetic diagnosis is considered by some to be a controversial procedure. PGD is used in conjunction with in vitro fertilization (IVF) to screen for single-cell gene defects that could lead to genetic disorders.
By screening for these genetic conditions, couples affected by an inherited disorder can reduce the risk that their children will also be affected — hence why so many liken the procedure to “playing God.”
Fact: This one isn’t so black and white, as it plays on other factors, such as faith and morals. However, it’s important to remember that so much of what has come about from today’s medical technology can be subjected to the same interpretation, from preventative medications to C-sections to ventilators.
Misconception #4: PGD is recommended for individual carriers of single-gene disorders.
For individuals with a family history of single-gene disorders like cystic fibrosis or sickle cell anemia, PGD might seem like the obvious solution. But you may want to think twice before spending an arm and a leg on PGD to assess embryo risk.
Fact: According to Maisenbacher, most couples are not at risk for single-gene disorders. Most individuals are actually carriers of four to six different genetic diseases, but their partner is not usually a carrier for the same genetic disease. And, in the case of most single-gene disorders that PGD is done for, both parents need to be carriers in order for their to be a risk to the child.
Misconception #5: A low grade embryo results in an unsuccessful pregnancy.
IVF embryos are “graded” to help pick the best for transfer. While it might seem obvious to shoot for mostly grade A embryos, low grade embryos also have the potential to result in a successful pregnancy.
Fact: While there seems to be a relationship between embryo grade and chromosome abnormality, the two don’t necessarily correlate.
“We’ve seen couples transfer really low grade embryos and have a successful pregnancy after knowing that that embryo was chromosomally normal when,” says Maisenbacher, “if they hadn’t gone through the PGS screening, that wouldn’t have been one of the embryos considered for transfer based on the grade.”