Infertility: Causes and Treatments
Many couples who want a child face the problem of infertility – they have tried to conceive but have not been able to do so. Couples are considered infertile if they have not been able to conceive after 12 months of regular sexual intercourse without the use of any form of birth control. About 15% of all married couples are infertile.
Infertility may be due to many different problems – in the man, in the woman, or in both. Also, more than one problem may be present in a couple:
If a couple is infertile and wants to conceive a child, they should think about having a complete infertility evaluation. This is done by a doctor to find out what is causing their infertility and whether it can be corrected.
- In 15% - 20% of all couples who are infertile, both the man and the woman have problems that cause the infertility.
- In 35% - 40%, problems occur in the man.
- In another 35% - 40%, problems occur in the woman.
- The remaining cases have no known cause.
How Reproduction Occurs
To understand the factors that can interfere with fertility, it is important to know how reproduction occurs.
Almost all of a woman’s sexual and reproductive system is inside her abdomen. The uterus, which is in the lower abdomen, opens into the vagina. A fallopian tube extends outward from each side of the uterus. An ovary, containing eggs (called ova), is located on each side of the uterus, near the fallopian tubes. About every 28 days an egg is released from one of the ovaries into the nearby fallopian tube. In a woman with a “regular” (28-day) menstrual cycle, ovulation – the release of an egg from an ovary – occurs about 12-14 days before the menstrual period. An increased amount of clear, watery vaginal fluid can usually be noticed before or during the time of ovulation.
Once the egg is in the tube, it moves slowly towards the uterus. The egg remains able to be fertilized for about 12-24 hours after ovulation. If the egg is not fertilized while it is in the tube, it is absorbed in the body. Then there is a drop in hormone levels, causing the uterus to shed its lining. This shedding is the menstrual period.
The male’s role in the reproduction is to provide the sperm that fertilizes the female egg. Sperm are made in the testes. When the sperm mature, they leave the testes through small tubes called the vas deferens, or vas. These tubes carry the sperm to a larger tube in the penis called the urethra. As sperm travel from the testes, they mix with fluid from the seminal vesicles and prostate gland. This mixture of sperm and fluid is called semen. When the man ejaculates or “climaxes” during intercourse, semen travels through the urethra in the penis into the vagina.
Pregnancy can occur if you have sexual intercourse during or near the time of ovulation. When the man ejaculates during sex, his sperm are released into the vagina. They then travel up through the cervix, or opening of the uterus, and out into the tube. It takes about 15 minutes after ejaculation for the sperm to travel to the end of the fallopian tube. The sperm can live for several days in the woman’s reproductive system. If the sperm and egg unite, fertilization can occur. The fertilized egg then moves through the tube into the uterus and becomes attached there to grow and develop into a fetus.
Conditions Needed for Conception
For a couple to conceive, several basic physical conditions must be met. If there is a problem anywhere in this chain of events, infertility can result:
- The man must produce enough normal, live sperm that are healthy and motile – actively moving.
- The woman must produce a healthy egg (ovum) and must ovulate – release the egg from an ovary – into the fallopian tubes.
- The woman’s tubes must be open, so that the egg can move into the uterus.
- The sperm must have open pathways so that they can pass from the testes, where they are formed, out through the penis at the time of ejaculation.
- The male must be able to ejaculate and deposit the sperm in the vagina.
- The sperm must travel up through the cervix into the uterus and into the fallopian tubes.
- If ovulation has occurred and an egg is present, the sperm must be able to fertilize the egg.
- The woman’s reproductive organs must be healthy and able to nourish the sperm in its passage to the egg. They must also be able to protect and nourish the fertilized egg as it grows.
Causes of Infertility
Infertility in the Man
A man may be infertile because he does not have enough sperm, because the sperm are not active enough, or because the passage, or vas, is blocked. A number of causes can contribute to these problems:
Injury to the testicles, such as that resulting from trauma or exposure to radiation, can also cause infertility in the man.
- Sexually transmitted disease, such as gonorrhea or Chlamydia
- Fevers and infections, such as mumps occurring after puberty
- Previous surgery, such as that for undescended testes or hernia repair
- Excess fluid or swollen veins around the testes
Infertility in the Woman
In general, the principal problems leading to infertility in the woman are related to disturbances in the functions of the various parts of the reproductive tract:
- Does ovulation occur? Irregular menstrual periods or problems with hormone production can prevent the release of an egg from an ovary.
- Is the lining of the uterus prepared to receive the fertilized egg? A luteal phase defect, in which the body’s hormones do not properly prepare the lining of the uterus, can interfere with implantation of the fertilized egg.
- Are the tubes blocked, diseased, or bound by scar tissue? There are a number of causes of tubal blockage or scarring:
- Sexually transmitted diseases such as gonorrhea and Chlamydia
- Endometriosis – a condition in which tissue like that normally lining the uterus is found outside the uterus
- Adhesions – bands of scar tissue that bind together affected surfaces of the tissues inside the abdomen
- Infections such as pelvic inflammatory disease (PID), a severe infection of the female reproductive organs, or appendicitis, which can result in scarring of the internal pelvic organs
- Does the cervix produce an adequate amount of mucus for the sperm to survive? Surgery or other treatment of the cervix may have interfered with mucus production.
General health problems may also add to problems leading to infertility in both the man and the woman. For instance, being more than 30% of her ideal body weight may cause problems with ovulation in the woman. Also, factors such as too much stress, smoking, or alcohol can make infertility problems worse for both the man and the woman.
Through the examination process, the doctor attempts to find out the causes of infertility. A detailed evaluation of the couple is needed. This will probably require many office visits as well as procedures that may be uncomfortable and expensive. It is easy to become discouraged, but the process must be thorough. After it is completed, the doctor will discuss the results and what, if anything, can be done about them.
Usually, medical exams for infertility begin with a medical history, a general physical exam of the woman, and a semen analysis or physical exam of the man. A medical history of the woman lets the doctor know if she has had any past illnesses such as appendicitis or pelvic infections that might have scarred her reproductive organs. The couple will also be asked about their sexual relations to find out if their infertility may be linked to the timing or frequency of intercourse.
Testing the Man
The first test for male infertility is a semen analysis. Usually the man is asked to bring a sample of his semen into a lab for examination. Sometimes he is asked to produce the semen sample at the lab, since sperm have a fairly short life span and rapidly lose their ability to fertilize.
The semen sample will be analyzed in the lab to determine the number of sperm present, as well as their movement, their structure, and other factors such as the presence of pus cells. If there is any question about the findings, a repeat semen analysis may be performed, or the man may be referred to a urologist (a doctor who specializes in matters involving the urinary tract). The urologist may perform a more thorough physical exam, giving special attention to the functions and structure of the testes and other reproductive organs.
Testing the Woman
A woman’s reproductive system requires more testing to adequately evaluate her problem.
Ovulation Tests. To become pregnant, a woman must be ovulating; that is, producing an egg. The simplest method to detect whether ovulation has occurred is by evaluating a record of the woman’s basal body temperature. For this study, the woman takes her temperature every morning when she wakes up, before she gets out of bed. She records the temperature on a graph sheet. Each month when a woman ovulates, there is usually a slight but detectable rise in body temperature that will be shown in the record. This record usually has to be kept for 2-3 months. The temperature rise helps the doctor find out whether ovulation has already occurred, and so this method is not helpful in planning the time of intercourse for that cycle.
Sometimes if the results of the basal body temperature record are uncertain, and endometrial biopsy is performed to determine if and when ovulation has occurred. This procedure is done in the doctor’s office. A thin tube is inserted into the vagina and through the cervix to remove a small piece of the tissue lining the uterus (called the endometrium). This sample is later examined under a microscope to find out how the lining of the uterus is responding to the hormones produced during the menstrual cycle.
Another test to indicate whether ovulation has occurred is a blood test. A sample of blood is taken and sent to the lab for a test that measures a hormone produced by the ovary after ovulation has taken place.
Cervical Mucus Test. Examination of the cervical mucus is done because the mucus plays a role in the movement of the sperm out of the vagina and up into the uterus and tubes. The postcoital (after sex) test (PCT) is the usual method of examining the cervical mucus. It can be carried out in the doctor’s office. In this test, the couple has intercourse (coitus) close to the time of ovulation, and the cervical mucus is examined some hours later. This demonstrates the ability of sperm to enter and move into the cervical mucus at the time of ovulation. Since the test involves timing intercourse in relation to the visit to the doctor, the couple may find the procedure inconvenient. Because the test is best performed at the time of ovulation, which is difficult to predict, it may need to be repeated.
Tubal Patency Tests. There are two methods commonly used for determining whether at lease one of the fallopian tubes is open. The method used will depend on the individual case.
The method called hysterosalpingography (HSG) uses X-ray and is usually done in a radiologist’s office or in the X-ray department of a hospital. A dye is placed into the uterus through a thin tube inserted through the cervix, and an X-ray is taken. This not only tells whether the tubes are open but also outlines the inside of the uterus.
The other method used to assess tubal patency is performed at the time of laparoscopy. This surgical procedure permits the doctor to look into the abdomen and inspect the female organs with a slender, light-transmitting instrument called a laparoscope. The procedure is usually done under general anesthesia and does not require being admitted to a hospital overnight. The laparoscope is inserted through a small incision (1/2 inch or less) at the lower edge of the navel. With laparoscopy, the doctor can look for pelvic disease, such as endometriosis, that may interfere with conception. The fallopian tubes are also examined and tested to determine whether they are open. During the procedure, the doctor can correct minor problems or determine whether another operation is needed.
Treatment of Infertility
Treatment for the Man
If there is some problem with the man’s sperm – too few sperm being produced, too few motile sperm, or too many abnormal sperm – he may be referred to a urologist. The treatment depends on the specific problem that is found. Medication or surgery may be recommended. The success with these treatments, however, is somewhat limited.
Treatment for the Woman
If the woman is not ovulating or has hormone problems that interfere with the implantation of the fertilized egg, she may be treated by taking certain drugs, either in pill form or by injection. Side effects, such as multiple pregnancy, sometimes occur with the use of these drugs, and they must be taken only under close medical supervision. The risk of multiple pregnancy is higher with the use of some of these drugs than others.
Tubal blockage or the formation of adhesions can be caused by infection, endometriosis, or previous pelvic surgery. Mild adhesions around the tubes can be treated with laparoscopy. If more extensive repair is needed, though, further surgery may have to be performed. You may be referred to a gynecologist with special skills in this area.
If all measures for correcting male infertility have failed, an alternative called artificial insemination is available. For this procedure, semen is obtained from a donor and is frozen while the donor is screened for genetic disorders and certain sexually transmitted diseases. After the donor has been screened, the semen, and the sperm it contains, is inseminated, or introduced, into the woman’s vagina or cervix.
A technique called in vitro fertilization (IVF) is now being used in some places as a treatment for infertility. IVF involves inducing ovulation with drugs that cause multiple eggs to be produced. These eggs can be removed from the ovary during laparoscopy or by inserting a needle into the ovary, either through the abdomen or through the vagina and cervix, and withdrawing the eggs through the needle. In the latter method, the needle is guided by an ultrasound, a technique in which sound waves are used to view the pelvic organs. The eggs are then fertilized with sperm in a dish in the lab. The fertilized eggs are then transferred back into the mother’s uterus through her vagina.
A variation of the IVF procedure is gamete intrafallopian transfer (GIFT). In this technique, as in IVF, drugs are used to produce multiple eggs in the woman’s ovaries. The eggs are then collected, usually by laparoscopy, and two or three eggs are added to the man’s sperm. The eggs and sperm are placed into the woman’s fallopian tube.
The main differences between IVF and GIFT are 1) the way in which the eggs are collected from the woman’s ovary, and 2) the placement of unfertilized eggs with sperm (instead of fertilized eggs) into the fallopian tube (rather than the uterus). Another difference is that in the GIFT procedure, fertilization of the eggs usually takes place inside the fallopian tube, rather than in a dish in the lab. Some centers use a combination of IVF and GIFT to treat infertility.
These methods are new and expensive and are not widely used. They also involve special considerations that must be carefully weighed by a man and woman and their doctor. Such alterations are not for everyone and should be considered only if other methods don’t work. Also, the likelihood of achieving a successful pregnancy is limited in most centers where these techniques are used. You should have a clear understanding about the success rates in the institution where you are being treated. In inquiring about success rates, discuss not just the number of pregnancies that are achieved, but also the number of live infants delivered.
Thinking it Over
It is important for a couple to think very carefully about the decision to go through an infertility workup. It can be an expensive and time-consuming process that requires a big commitment from both partners. There are no guarantees that the cause of infertility will be found or that pregnancy will be achieved.
Before making the decision, a couple should look at their motives for having children. Sometimes a couple may feel pressure – from family, friends, or society in general – to have children. Or they may feel that somehow they are not a real family if they remain childless. Some couples want to have children because they hope that it will help a troubled relationship, while usually the opposite is true. In the past, women were “expected” to get pregnant after they were married. Some women may feel unfulfilled without children, especially as they get older, and want to have a baby while there is still time.
Many couples today find that they can have a satisfying life together without children. Discuss your feelings with your partner. Think about the alternatives, including the possibility of not expanding your family.
Adoption is also a valid alternative to bearing a child. The process of adopting a child can be long and complex and varies from area to area. Check with your local agencies, or call our office about available resources.
By thinking over these questions and issues before making the decision of whether to have an infertility workup, you and your partner will have a more realistic attitude about what to expect. You will also have a clearer idea about your wishes concerning childbearing, including the alternatives to having children of your own.
Counseling and Emotional Factors
Couples who have been infertile may hear advice from friends or family that they should just “relax” and they will be able to conceive a child. Although stress has been shown to contribute to infertility in some cases, emotional problems have real physical causes.
Infertility can lead to severe stress and tension in a relationship. This is particularly true if a couple has learned they have little or no chance of conceiving a child. The couple may have to cope with many emotional problems – feeling of sexual inadequacy, failure, or guilt. It is a time when a couple needs to be especially supportive of each other and may choose to turn to professional counseling.
A couple who suspects they are infertile should talk with their doctor about any questions or concerns they may have. They may wish to have testing done as a first step in dealing with the problem. Testing may be able to find the cause and determine if anything can be done to correct it. If you are interested in adoption, artificial insemination, or IVF or GIFT, call our office for more information.