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Infertility

Overview

If you and your partner are struggling to have a baby, you're not alone. Ten to 15 percent of couples in the United States are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most couples.

Infertility may result from an issue with either you or your partner, or a combination of factors that interfere with pregnancy. Fortunately, there are many safe and effective therapies that significantly improve your chances of getting pregnant.

Symptoms

The main symptom of infertility is not getting pregnant. There may be no other obvious symptoms. Sometimes, an infertile woman may have irregular or absent menstrual periods. Rarely, an infertile man may have some signs of hormonal problems, such as changes in hair growth or sexual function.

Most couples will eventually conceive, with or without treatment.

When to see a doctor

You probably don't need to see a doctor about infertility unless you have been trying regularly to conceive for at least one year. Talk with your doctor earlier, however, if you're a woman and:

  • You're age 35 to 40 and have been trying to conceive for six months or longer
  • You're over age 40
  • You menstruate irregularly or not at all
  • Your periods are very painful
  • You have known fertility problems
  • You've been diagnosed with endometriosis or pelvic inflammatory disease
  • You've had multiple miscarriages
  • You've undergone treatment for cancer

Talk with your doctor if you're a man and:

  • You have a low sperm count or other problems with sperm
  • You have a history of testicular, prostate or sexual problems
  • You've undergone treatment for cancer
  • You have testicles that are small in size or swelling in the scrotum known as a varicocele
  • You have others in your family with infertility problems

Causes

All of the steps during ovulation and fertilization need to happen correctly in order to get pregnant. Sometimes the issues that cause infertility in couples are present at birth, and sometimes they develop later in life.

Infertility causes can affect one or both partners. In general:

  • In about one-third of cases, there is an issue with the male.
  • In about one-third of cases, there is an issue with the female.
  • In the remaining cases, there are issues with both the male and female, or no cause can be identified.

Causes of male infertility

These may include:

  • Abnormal sperm production or function due to undescended testicles, genetic defects, health problems such as diabetes or infections such as chlamydia, gonorrhea, mumps or HIV. Enlarged veins in the testes (varicocele) can also affect the quality of sperm.
  • Problems with the delivery of sperm due to sexual problems, such as premature ejaculation; certain genetic diseases, such as cystic fibrosis; structural problems, such as a blockage in the testicle; or damage or injury to the reproductive organs.
  • Overexposure to certain environmental factors, such as pesticides and other chemicals, and radiation. Cigarette smoking, alcohol, marijuana or taking certain medications, such as select antibiotics, antihypertensives, anabolic steroids or others, can also affect fertility. Frequent exposure to heat, such as in saunas or hot tubs, can raise the core body temperature and may affect sperm production.
  • Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely.

Causes of female infertility

Causes of female infertility may include:

  • Ovulation disorders, which affect the release of eggs from the ovaries. These include hormonal disorders such as polycystic ovary syndrome. Hyperprolactinemia, a condition in which you have too much prolactin — the hormone that stimulates breast milk production — may also interfere with ovulation. Either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism) can affect the menstrual cycle or cause infertility. Other underlying causes may include excessive exercise, eating disorders, injury or tumors.
  • Uterine or cervical abnormalities, including abnormalities with the opening of the cervix, polyps in the uterus or the shape of the uterus. Noncancerous (benign) tumors in the uterine wall (uterine fibroids) may rarely cause infertility by blocking the fallopian tubes. More often, fibroids interfere with implantation of the fertilized egg.
  • Fallopian tube damage or blockage, often caused by inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, which is usually caused by a sexually transmitted infection, endometriosis or adhesions.
  • Endometriosis, which occurs when endometrial tissue grows outside of the uterus, may affect the function of the ovaries, uterus and fallopian tubes.
  • Primary ovarian insufficiency (early menopause), when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain factors are associated with early menopause, including immune system diseases, certain genetic conditions such as Turner syndrome or carriers of Fragile X syndrome, radiation or chemotherapy treatment, and smoking.
  • Pelvic adhesions, bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery.

Other causes in women include:

  • Cancer and its treatment. Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect fertility.
  • Other conditions. Medical conditions associated with delayed puberty or the absence of menstruation (amenorrhea), such as celiac disease, poorly controlled diabetes and some autoimmune diseases such as lupus, can affect a woman's fertility. Genetic abnormalities also can make conception and pregnancy less likely.
Fertilization and implantation

During fertilization, the sperm and egg unite in one of the fallopian tubes to form a zygote. Then the zygote travels down the fallopian tube, where it becomes a morula. Once it reaches the uterus, the morula becomes a blastocyst. The blastocyst then burrows into the uterine lining — a process called implantation.

Fertilization and implantation

During fertilization, the sperm and egg unite in one of the fallopian tubes to form a zygote. Then the zygote travels down the fallopian tube, where it becomes a morula. Once it reaches the uterus, the morula becomes a blastocyst. The blastocyst then burrows into the uterine lining — a process called implantation.

Female reproductive system

The ovaries, fallopian tubes, uterus, cervix and vagina (vaginal canal) make up the female reproductive system.

Male reproductive system

The male reproductive system makes, stores and moves sperm. The testicles produce sperm. Fluid from the seminal vesicles and prostate gland combines with sperm to make semen. The penis ejaculates semen during sexual intercourse.

Risk factors

Many of the risk factors for both male and female infertility are the same. They include:

  • Age. A woman's fertility gradually declines with age, especially in her mid-30s, and it drops rapidly after age 37. Infertility in older women may be due to the number and quality of eggs, or to health problems that affect fertility. Men over age 40 may be less fertile than younger men are and may have higher rates of certain medical conditions in offspring, such as psychiatric disorders or certain cancers.
  • Tobacco use. Smoking tobacco or marijuana by either partner reduces the likelihood of pregnancy. Smoking also reduces the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can increase the risk of erectile dysfunction and a low sperm count in men.
  • Alcohol use. For women, there's no safe level of alcohol use during conception or pregnancy. Avoid alcohol if you're planning to become pregnant. Alcohol use increases the risk of birth defects, and may contribute to infertility. For men, heavy alcohol use can decrease sperm count and motility.
  • Being overweight. Among American women, an inactive lifestyle and being overweight may increase the risk of infertility. A man's sperm count may also be affected if he is overweight.
  • Being underweight. Women at risk of fertility problems include those with eating disorders, such as anorexia or bulimia, and women who follow a very low calorie or restrictive diet.
  • Exercise issues. Insufficient exercise contributes to obesity, which increases the risk of infertility. Less often, ovulation problems may be associated with frequent strenuous, intense exercise in women who are not overweight.

Diagnosis

Before infertility testing, your doctor or clinic works to understand your sexual habits and may make recommendations based on these. In some infertile couples, no specific cause is found (unexplained infertility).

Infertility evaluation can be expensive, and sometimes involves uncomfortable procedures. Many medical plans may not reimburse the cost of fertility treatment. Finally, there's no guarantee — even after all the testing and counseling — that you'll get pregnant.

Tests for men

Male fertility requires that the testicles produce enough healthy sperm, and that the sperm is ejaculated effectively into the woman's vagina and travels to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.

You may have a general physical exam, including examination of your genitals. Specific fertility tests may include:

  • Semen analysis. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A lab analyzes your semen specimen. In some cases, sperm may be tested for in the urine.
  • Hormone testing. You may have a blood test to determine the level of testosterone and other male hormones.
  • Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing infertility.
  • Testicular biopsy. In select cases, a testicular biopsy may be performed to identify abnormalities contributing to infertility and to retrieve sperm to use with assisted reproductive techniques, such as IVF.
  • Imaging. In certain situations, imaging studies such as a brain MRI, bone mineral density scan, transrectal or scrotal ultrasound, or a test of the vas deferens (vasography) may be performed.
  • Other specialty testing. In rare cases, other tests to evaluate the quality of the sperm may be performed, such as evaluating a semen specimen for DNA abnormalities.

Tests for women

Fertility for women relies on the ovaries releasing healthy eggs. Her reproductive tract must allow an egg to pass into her fallopian tubes and join with sperm for fertilization. The fertilized egg must travel to the uterus and implant in the lining. Tests for female infertility attempt to determine whether any of these processes are impaired.

You may have a general physical exam, including a regular gynecological exam. Specific fertility tests may include:

  • Ovulation testing. A blood test measures hormone levels to determine whether you're ovulating.
  • Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the condition of your uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid spills out of your fallopian tubes.
  • Ovarian reserve testing. This testing helps determine the quality and quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.
  • Other hormone testing. Other hormone tests check levels of ovulatory hormones, as well as pituitary hormones that control reproductive processes.
  • Imaging tests. Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) is used to see details inside the uterus that are not seen on a regular ultrasound.

Depending on your situation, rarely your testing may include:

  • Hysteroscopy. Based on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease. During hysteroscopy, your doctor inserts a thin, lighted device through your cervix into your uterus to view any potential abnormalities.
  • Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
  • Genetic testing. Genetic testing helps determine whether there's a genetic defect causing infertility.

Not everyone needs to have all, or even many, of these tests before the cause of infertility is found. You and your doctor will decide which tests you will have and when.

Hysteroscopy

During a hysteroscopy, your doctor uses a thin, lighted instrument (hysteroscope) to view the inside of your uterus.

Hysteroscopy

During a hysteroscopy, your doctor uses a thin, lighted instrument (hysteroscope) to view the inside of your uterus.

Sonohysterography

During sonohysterography, your doctor uses a thin, flexible tube (catheter) to inject salt water (saline) into the hollow part of your uterus. With an ultrasound probe, your doctor obtains images of the inside of your uterus and checks for irregularities.

Treatment

Infertility treatment depends on:

  • What's causing the infertility
  • How long you've been infertile
  • Your age and your partner's age
  • Personal preferences

Some causes of infertility can't be corrected.

In cases where spontaneous pregnancy doesn't happen, couples can often still achieve a pregnancy through use of assisted reproductive technology. Infertility treatment may involve significant financial, physical, psychological and time commitments.

Treatment for men

Men's options can include treatment for general sexual problems or lack of healthy sperm. Treatment may include:

  • Altering lifestyle factors. Improving lifestyle and behavioral factors can improve chances for pregnancy, including discontinuing select medications, reducing/eliminating harmful substances, improving frequency and timing of intercourse, establishing regular exercise, and optimizing other factors that may otherwise impair fertility.
  • Medications. Certain medications may improve a man's sperm count and likelihood for achieving a successful pregnancy. These medicines may increase testicular function, including sperm production and quality.
  • Surgery. In select conditions, surgery may be able to reverse a sperm blockage and restore fertility. In other cases, surgically repairing a varicocele may improve overall chances for pregnancy.
  • Sperm retrieval. These techniques obtain sperm when ejaculation is a problem or when no sperm are present in the ejaculated fluid. They may also be used in cases where assisted reproductive techniques are planned and sperm counts are low or otherwise abnormal.

Treatment for women

Although a woman may need just one or two therapies to restore fertility, it's possible that several different types of treatment may be needed before she's able to conceive.

  • Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk with your doctor about fertility drug options — including the benefits and risks of each type.
  • Intrauterine insemination (IUI). During IUI, healthy sperm are placed directly in the uterus around the time the woman's ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
  • Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum or intrauterine scar tissue can be treated with hysteroscopic surgery.

Assisted reproductive technology

Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. An ART health team includes physicians, psychologists, embryologists, lab technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.

In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs from a woman, fertilizing them with a man's sperm in a dish in a lab, and implanting the embryos in the uterus three to five days after fertilization.

Other techniques are sometimes used in an IVF cycle, such as:

  • Intracytoplasmic sperm injection (ICSI). A single healthy sperm is injected directly into a mature egg. ICSI is often used when there is poor semen quality or quantity, or if fertilization attempts during prior IVF cycles failed.
  • Assisted hatching. This technique assists the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).
  • Donor eggs or sperm. Most ART is done using the woman's own eggs and her partner's sperm. However, if there are severe problems with either the eggs or sperm, you may choose to use eggs, sperm or embryos from a known or anonymous donor.
  • Gestational carrier. Women who don't have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using a gestational carrier. In this case, the couple's embryo is placed in the uterus of the carrier for pregnancy.

Complications of treatment

Complications of infertility treatment may include:

  • Multiple pregnancy. The most common complication of infertility treatment is a multiple pregnancy — twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery, as well as problems during pregnancy such as gestational diabetes. Babies born prematurely are at increased risk of health and developmental problems. Talk to your doctor about ways to prevent a multiple pregnancy before you begin treatment.
  • Ovarian hyperstimulation syndrome (OHSS). Fertility medications to induce ovulation can cause OHSS, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
  • Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology.
In vitro fertilization

During in vitro fertilization, eggs are removed from mature follicles within an ovary (A). An egg is fertilized by injecting a single sperm into the egg or mixing the egg with sperm in a petri dish (B). The fertilized egg (embryo) is transferred into the uterus (C).

In vitro fertilization

During in vitro fertilization, eggs are removed from mature follicles within an ovary (A). An egg is fertilized by injecting a single sperm into the egg or mixing the egg with sperm in a petri dish (B). The fertilized egg (embryo) is transferred into the uterus (C).

ICSI

In intracytoplasmic sperm injection (ICSI), a single healthy sperm is injected directly into each mature egg. ICSI is often used when semen quality or number is a problem or if fertilization attempts during prior in vitro fertilization cycles failed.

Preparing for an appointment

Depending on your age and personal health history, your doctor may recommend a medical evaluation. A woman's gynecologist or a man's urologist or a family doctor can help determine whether there's a problem that requires a specialist or clinic that treats infertility problems. In some cases, both you and your partner may require a comprehensive infertility evaluation.

What you can do

To get ready for your first appointment:

  • Provide details about your attempts to get pregnant. Write down details about when you started trying to conceive and how often you've had intercourse, especially around the midpoint of your cycle — the time of ovulation.
  • Bring your key medical information. Include any other medical conditions you or your partner has, as well as information about any previous infertility evaluations or treatments.
  • Make a list of any medications, vitamins, herbs or other supplements you take. Include the doses and how often you take them.
  • Make a list of questions to ask your doctor. List the most important questions first in case time runs short.

For infertility, some basic questions to ask your doctor include:

  • What are the possible reasons we haven't yet conceived?
  • What kinds of tests do we need?
  • What treatment do you recommend trying first?
  • What side effects are associated with the treatment you're recommending?
  • What is the likelihood of conceiving multiple babies with the treatment you're recommending?
  • For how many cycles will we try this treatment?
  • If the first treatment doesn't work, what will you recommend trying next?
  • Are there any long-term complications associated with this or other infertility treatments?

Don't hesitate to ask your doctor to repeat information or to ask follow-up questions.

What to expect from your doctor

Be ready to answer questions to help your doctor quickly determine next steps in making a diagnosis and starting care.

Questions for the couple

Possible questions for the couple include:

  • How long have you been actively trying to get pregnant?
  • How frequently do you have intercourse?
  • Do you use any lubricants during sex?
  • Do either of you smoke?
  • Do either of you use alcohol or recreational drugs? How often?
  • Are either of you currently taking any medications, dietary supplements or anabolic steroids?
  • Have either of you been treated for any other medical conditions, including sexually transmitted infections?
  • Are you exposed through your work or lifestyle habits to chemicals, pesticides, radiation or lead?

Questions for the man

If you're a man, you might be asked:

  • Do you have any difficulties putting on muscle or do you take any substances to increase muscle mass?
  • Do you ever notice a fullness in the scrotum, particularly after standing for extended periods of time?
  • Do you experience any testicular or post-ejaculatory pain?
  • Have you had any sexual problems, such as difficulty maintaining an erection, ejaculating too soon, not being able to ejaculate or reduced sexual desire?
  • Have you conceived a child with any previous partners?
  • Do you regularly take hot baths or steam baths?

Questions for the woman

If you're a woman, you might be asked:

  • At what age did you start menstruating?
  • What are your cycles typically like? How regular, long and heavy?
  • Have you ever been pregnant before?
  • Have you been charting your cycles or testing for ovulation? For how many cycles?
  • What is your typical daily diet?
  • Do you exercise regularly? How much?
  • Has your body weight recently changed?

Coping and support

Coping with infertility can be extremely difficult because there are so many unknowns. The emotional burden on a couple is considerable. Taking these steps can help you cope:

  • Be prepared. The uncertainty of infertility testing and treatments can be difficult and stressful. Ask your doctor to explain the steps, and prepare for each one.
  • Set limits. Decide before starting treatment which procedures, and how many, are emotionally and financially acceptable for you and your partner. Fertility treatments may be expensive and often are not covered by insurance companies, and a successful pregnancy often depends on repeated attempts.
  • Consider other options. Determine alternatives — adoption, donor sperm or egg, donor embryo, gestational carrier or adoption, or even having no children — as early as possible in the infertility evaluation. This may reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
  • Seek support. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.

Managing emotional stress during treatment

Try these strategies to help manage emotional stress during treatment:

  • Express yourself. Reach out to others rather than repressing guilt or anger.
  • Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.
  • Reduce stress. Some studies have shown that couples experiencing psychological stress had poorer results with infertility treatment. Try to reduce stress in your life before trying to become pregnant.
  • Exercise and eat a healthy diet. Keeping up a moderate exercise routine and a healthy diet can improve your outlook and keep you focused on living your life.

Managing emotional effects of the outcome

You'll face the possibility of psychological challenges no matter your results:

  • Not achieving pregnancy, or having a miscarriage. The emotional stress of not being able to have a baby can be devastating even on the most loving and affectionate relationships.
  • Success. Even if fertility treatment is successful, it's common to experience stress and fear of failure during pregnancy. If you have a history of depression or anxiety disorder, you're at increased risk of these problems recurring in the months after your child's birth.
  • Multiple births. A successful pregnancy that results in multiple births introduces medical complexities and the likelihood of significant emotional stress both during pregnancy and after delivery.

Seek professional help if the emotional impact of the outcome of your fertility treatments becomes too heavy for you or your partner.

Prevention

Some types of infertility aren't preventable. But several strategies may increase your chances of pregnancy.

Couples

Have regular intercourse several times around the time of ovulation for the highest pregnancy rate. Having intercourse beginning at least 5 days before and until a day after ovulation improves your chances of getting pregnant. Ovulation usually occurs at the middle of the cycle — halfway between menstrual periods — for most women with menstrual cycles about 28 days apart.

Men

For men, although most types of infertility aren't preventable, these strategies may help:

  • Avoid drug and tobacco use and excessive alcohol consumption, which may contribute to male infertility.
  • Avoid high temperatures, as this can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.
  • Avoid exposure to industrial or environmental toxins, which can impact sperm production.
  • Limit medications that may impact fertility, both prescription and nonprescription drugs. Talk with your doctor about any medications you take regularly, but don't stop taking prescription medications without medical advice.
  • Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy.

Women

For women, a number of strategies may increase the chances of becoming pregnant:

  • Quit smoking. Tobacco has multiple negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
  • Avoid alcohol and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don't drink alcohol or use recreational drugs, such as marijuana or cocaine.
  • Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for guidance on the safe use of caffeine.
  • Exercise moderately. Regular exercise is important, but exercising so intensely that your periods are infrequent or absent can affect fertility.
  • Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.

Last updated: August 17th, 2017

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