Infertility

About 10 percent of U.S. couples are infertile. The length of time that it takes to conceive depends on many factors, including your age, your partner’s age and how long you’ve been trying. If you and your partner have tried to conceive for 6 to 12 months without birth control and you haven’t gotten pregnant, you may want to have an infertility evaluation to find — and treat — the cause of the problem.

The process of becoming pregnant begins with ovulation. Ovulation occurs when a mature egg is released from the woman’s ovary and pushed down the fallopian tube, where it can be fertilized. In an average 28-day menstrual cycle, ovulation occurs about 14 days after the first day of your last period. Once an egg is released, it can be fertilized for about 12 to 24 hours. Fertilization can occur if you have sex during or near the time you ovulate.

When a man ejaculates during intercourse, his semen, the fluid that carries the sperm, is released into the vagina and travels up through the woman’s cervix and into the fallopian tubes, where it can live for 3 days or more. If a sperm penetrates an egg, fertilization occurs. The fertilized egg then moves through the fallopian tube and into the uterus. It attaches itself to the uterine lining and begins to grow. All these events must take place for pregnancy to occur. If there is a problem in this chain of events, infertility may result.

Causes

Infertility may be caused by a number of different factors. Some are easy to find and treat, while others are not. These factors relate to the woman in 65 percent of cases and the man in 20 percent of cases. In 15 percent of cases, no cause can be found in either partner.

Age is one factor. For young, healthy couples, there is a 20 percent chance that a woman will conceive in any one menstrual cycle. This figure starts to decline as a women reaches her late 20s and early 30s, and decreases even more after age 35. A man’s fertility also declines with age, but not as early. For this reason, older couples may not want to wait 6 to 12 months to seek care if they are having problems conceiving.

Male factors most often involve problems with the amount or health of the sperm. Causes may include abnormal hormone levels, infection or scarring from a sexually transmitted disease (STD). Female factors may involve abnormal hormone levels, the ovaries’ inability to produce enough eggs at the right time, or scarring or blockages in the cervix or fallopian tubes.

Lifestyle factors, such as poor nutrition, anorexia and obesity, and health problems can play a part in infertility. Exposure to a drug called diethylstilbestrol (DES) also can cause problems. This might be a concern if you were born in the United States before the late 1970s or in another country before the 1980s.

Testing

The decision to begin infertility testing depends on a number of factors, including your age, your partner’s age and how long you’ve been trying to get pregnant. You and your partner will receive care as a couple. Testing involves the following:

• A physical exam
• A medical history
• A semen analysis
• An ovulation check
• Tests to check for a normal uterus and open fallopian tubes
• A discussion about how often and when you have sex

In most cases, the basic infertility evaluation can be finished within a few menstrual cycles. Ask your doctor about the costs and find out whether they are covered by your insurance.

Basic Man’s Workup

A semen analysis is a key part of a man’s basic workup. It may need to be done more than once. The semen sample is obtained by masturbation, either in a lab or at home. Your doctor will give you instructions. The semen sample then is studied in a lab. The doctor will evaluate the sperm for:

• Number
• Shape
• Movement
• Signs of infection

The man may be referred to a urologist, a doctor who specializes in urinary tract problems and the male reproductive system, for an exam and further testing.

Basic Woman’s Workup

The workup for a woman begins with a physical exam and a health history that focuses on menstrual function (irregular bleeding and pain), pregnancy history, STD history and birth control. It may also include a Pap test, in which cells are taken from the cervix and examined under a microscope, blood tests and tests to determine whether ovulation is occurring. Some are done by the woman, others by the doctor.

• Urine test: This test, done by the woman at home with a kit, predicts ovulation by measuring the luteinizing hormone (LH), which is what makes ovulation occur. If the test result is positive, it means ovulation is about to occur. Sometimes these kits are used with basal body temperature charts.
• Basal body temperature chart: This test, also done by the woman at home, determines whether ovulation has occurred. After a woman ovulates, her body temperature increases a bit. To measure it, a woman takes her temperature by mouth every morning before she gets out of bed and records it on a chart for two or three menstrual cycles.

Procedures

There are a number of procedures used to look at a woman’s reproductive organs and check if the uterus is normal and the fallopian tubes are open. The testing methods used will depend on your factors and symptoms. You may be given pain relief for some of these procedures.

• Hysterosalpingography (HSG): This X-ray, typically taken right after a menstrual period, shows the inside of the uterus and fallopian tubes. A small amount of dye is inserted into the uterus through a thin tube. Once the X-ray is taken, the dye outlines the inside of the uterus and fallopian tubes. If it spills from the tubes, the tubes are open.
• Transvaginal ultrasound: This test uses sound waves to produce pictures of the ovaries and uterus. A wand-shaped device called a transducer is lubricated and inserted into the vagina, and a machine displays an image of the pelvic organs.
• Hysteroscopy: This procedure allows the doctor to look inside the uterus to diagnose or treat a problem. A thin, lighted telescope-like device called a hysteroscope is inserted through your cervix and into your uterus. The hysteroscope transmits the image of your uterus onto a screen, allowing the doctor to see inside. The uterus may be filled with a gas or liquid to reveal more information. During this procedure, the doctor can correct minor problems or collect a tissue sample.
• Laparoscopy: This procedure allows the doctor to view the tubes, ovaries and the outside of the uterus. A laparoscope, a thin telescope-like device with a small camera, is inserted through a small incision at the lower edge of the navel. To determine if the tubes are open or blocked, fluid is placed in the uterus. If it spills from the ends of the tubes, they are open; if not, they are blocked. This technique also can be used to look for pelvic problems, such as endometriosis or scar tissue.

Treatment

Infertility can be treated in many ways — with lifestyle changes, medication, surgery and assisted reproductive technology. The course of treatment will depend on the cause of the infertility. After your evaluation, talk with your doctor about the best treatment options for you and your partner. You may also choose adoption or to live without children.