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What is infertility?
Infertility is the inability to conceive after a year of unprotected
intercourse. Infertility affects 15 percent of the population, or about one of
every six or seven couples.
What causes infertility?
Infertility can be caused by many different factors, including:
- Blocked or scarred fallopian tubes
- Ovulatory problems
- Endometriosis (growth of endometrial tissue outside of the
uterus)
- Male factor infertility (abnormal semen analysis; low sperm
count or motility)
- Unexplained infertility (in 10 to 15% of infertile couples, the
cause of infertility cannot be detected.)
How is the cause of infertility determined?
A brief infertility evaluation is performed to identify any treatable
causes. Your physician may order a semen analysis, hysterosalpingography (an
X-ray dye test to check the uterus and fallopian tubes), and hormone levels to
evaluate ovulation. Your physician may also recommend laparoscopy (using an
endoscope, a slender fiberoptic scope attached to a video camera, to view the
pelvic organs).
What are the treatments for infertility?
Treatment options include medical therapy, reproductive surgery,
intrauterine insemination, and assisted reproductive technologies.
Medical therapy
Medical therapy is a treatment option for correcting ovulation dysfunction
(irregular or infrequent periods). If there are no underlying causes of
ovulation problems (such as a thyroid disease), the first line of treatment is
an oral medication such as Clomid, Femara, or Glucophage. They induce normal
ovulatory function in more than 80 percent of patients. Unfortunately, only
about half of these women conceive. Patients may experience mild side effects
and there is a slightly increased incidence of twins. If oral medication fails
to correct the problem, or conception does not occur within six good ovulatory
cycles, the couple should consider other treatment options.
Gonadotropin therapy (Follistim, Gonal-F, Bravelle, and Menopure) is the next
line of medical therapy. It is very effective in inducing ovulation when oral
agents do not work. It can also enhance fertility by causing multiple eggs to
ovulate during the cycle. (Normally, only one egg is released each month.) This
therapy may also be offered for unexplained infertility or when other factors
have been corrected but pregnancy has not occurred. It is given as a daily
injection, like an insulin shot, for approximately 1 week. During this time, the
patient is monitored with blood tests and ultrasound to optimize timing and
reduce the risk of multiple pregnancy and to prevent overstimulating the
ovaries.
Reproductive surgery
The vast majority of reproductive surgery can be performed endoscopically on
an outpatient basis. Using a laparoscope (a type of endoscope) inserted through
the naval, the surgeon can remove scar tissue, treat endometriosis, remove cysts
on the ovaries, and unblock the fallopian tubes. A hysteroscope placed into the
uterus through the cervix can be used to remove polyps and fibroid tumors,
divide scar tissue, and open blocked tubes.
The advantages of these endoscopic procedures include reduced cost, quicker
recovery, fewer complications, less pain, better cosmetic results, and success
rates as good as if not better than those performed by laparotomy (open
surgery). Laparotomy may still be required for reversing tubal ligations and
removing large fibroid tumors, but even those procedures can usually be
performed through a small incision as an outpatient.
Intrauterine insemination
Intrauterine insemination refers to an office procedure in which semen
undergoes a "washing" process and the sperm are then placed into the
uterus using a slender plastic catheter inserted through the cervix.
Intrauterine insemination is performed in couples with mildly abnormal semen
analyses. Intrauterine insemination is also used for couples being treated with
gonadotropins because pregnancy rates are higher with combined treatment. In
cases when the male partner has no sperm at all, or the numbers are severely
low, the procedure can also be performed using anonymous donor sperm.
Assisted reproductive technology
In vitro fertilization (IVF)
In vitro fertilization refers to a procedure in which oocytes (eggs) are
fertilized in a culture dish and placed into the uterus. First, the woman takes
gonadotropins to stimulate multiple eggs to mature. When monitoring shows that
the eggs are mature, they are collected nonsurgically using a vaginal ultrasound
probe with a needle guide. This is performed in an office setting under deep
sedation.
The sperm are collected, washed, and added to the eggs in a culture dish.
Several days later, two to three embryos (fertilized eggs) are returned to the
uterus using an intrauterine insemination catheter. Any extra embryos may be
cryopreserved (frozen) for later use.
In vitro fertilization is reserved for couples with uncorrectable tubal
disease, severe male factor infertility, and when all other treatment options
have failed. It also serves as a diagnostic test in that the fertilization of
the eggs with sperm can be observed. Success rates among couples vary depending
on the age of the patient, the duration of infertility, and the severity of the
infertility factor(s). Overall, more than one-third of patients conceive per
attempt. (The normal monthly pregnancy rate in the general fertile population is
only about 20%.) In vitro fertilization increases a woman's risk of having a
multiple pregnancy, but does not change the risk for miscarriage and birth
defects.
Freezing the extra embryos increases the cumulative pregnancy rates, since
the patient may have multiple attempts to conceive with fresh and frozen embryos
from a single egg collection procedure. The cost is also reduced since the
frozen embryos can be transferred during a natural menstrual cycle, thereby
avoiding the need for fertility drugs and another egg recovery procedure.
Intracytoplasmic sperm injection
For couples with abnormal semen analysis, as well as couples whose eggs did
not fertilize well during a previous IVF cycle, intracytoplasmic sperm injection
(ICSI) may be an option. This procedure involves injecting a single sperm
directly into each mature egg using a micro-needle.
Pre-implantation genetic testing
Pre-implantation genetic testing (PGD) is performed on a single cell taken from
3-day old embryos produced by IVF. It is an option for patients who are at
increased risk for having miscarriages or a child with a genetic problem. These
risks include the following:
- advanced maternal age
- recurrent miscarriage
- one or both partners carry a genetic disease, or
- couples who have failed to conceive after several IVF attempts.
Only genetically normal embryos are then placed into the uterus.
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