Infertility

Condition Basics

What is infertility?

Infertility means not being able to get pregnant. You may have fertility problems if you couldn't get pregnant after trying for at least 1 year (or 6 months if you're over 35). It doesn't mean you'll never get pregnant. Some people conceive without help in their second year of trying. Treatments help many people.

What causes it?

Most cases of infertility are caused by a problem with the female or male reproductive system. This can include a problem with the eggs, with the uterus or fallopian tubes, or with sperm. But sometimes no cause can be found.

What are the symptoms?

The main symptom of infertility is being unable to get pregnant after 6 to 12 months of trying, depending on your age.

How is it diagnosed?

Doctors can do tests and ask you questions about your past health to check for infertility. Tests may check hormone levels, semen quality, or the uterus, fallopian tubes, and ovaries.

How is infertility treated?

A wide range of treatments may be used for infertility. Depending on the cause, they include:

• Medicine that helps with releasing an egg (ovulating).
• A procedure that puts sperm directly inside the uterus (insemination).
• Surgery for a problem caused by endometriosis or blocked fallopian tubes.
• A procedure to concentrate sperm count for insemination.

You may also consider in vitro fertilization (IVF). During IVF, eggs and sperm are mixed in a lab to fertilize the eggs. Then the doctor puts one or more fertilized eggs into the uterus.

Treatment for fertility problems can be stressful and costly. Before you start, think about how far you're willing to go with treatment. You may change your mind later, but it's a good idea to start with a plan.

Cause

Infertility may be caused by:

• Problems with the eggs or releasing an egg (ovulating).
• Problems with the uterus or the fallopian tubes. This may result from things like endometriosis or pelvic inflammatory disease.
• Problems with the sperm. These problems may include how sperm is made, how it functions, or how it moves.
• An unknown issue. Sometimes the cause of infertility is not known.

Rates of infertility and miscarriage increase with age. Female fertility peaks in the late 20s. It slowly starts to decline in the early 30s. A larger drop in fertility and increase in miscarriage risk begins around the mid-30s. This is mainly because of the aging egg supply. Male fertility also decreases with age. But it's a more gradual decline.

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What Increases Your Risk

Things that increase your risk for infertility include:

• Age. Eggs and sperm can decrease in number or quality with age.
• Birth defects. Some people were born with problems in their reproductive systems.
• Moderate or severe endometriosis.
• Past exposure to very high levels of environmental toxins, certain drugs, or high doses of radiation. This includes cancer chemotherapy or radiation.
• Past infection with a sexually transmitted infection (STI) that has since damaged the reproductive system. This includes gonorrhea or chlamydia.
• Polycystic ovary syndrome. This is a hormone imbalance that can affect ovulation. This can make it harder to get pregnant.

Prevention

Sometimes infertility is related to lifestyle or other health conditions. To help protect your fertility:

• Avoid using tobacco (cigarettes) and marijuana.
• Avoid exposure to harmful chemicals.
• Avoid excessive alcohol use.
• Limit sex partners and use condoms to reduce the risk of getting a sexually transmitted infection (STI). Untreated STIs can damage the reproductive system and cause infertility. If you think you may have an STI, get treatment right away to reduce the risk of damage.
• Stay at a body weight that's close to the ideal for your height. It will reduce the chance of hormone imbalances.

If you have been diagnosed with cancer and hope to have children in the future, talk to your doctor about your options to help preserve fertility.

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When to Call a Doctor

Consult with your doctor if you:

• Want children but have been unable to become pregnant after 1 year of having sex without using birth control.
• Are older than 35 and have been unable to become pregnant after about 6 months of sex without using birth control.
• Have had two or more miscarriages in a row.

Watchful waiting

Before seeking medical help with conception, you can increase your chances of becoming pregnant by practicing fertility awareness. This means charting your basal body temperature and using home tests to let you know when you are likely to ovulate and be fertile.

Who to see

For your first fertility questions and testing, you can see:

For complete fertility testing, see an obstetrician/gynecologist with special training and experience in fertility problems. This doctor may be called a reproductive endocrinologist or fertility specialist. When looking for a specialist, ask what percentage of a doctor's practice is fertility treatment. Also ask if the doctor has training in reproductive endocrinology.

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Exams and Tests

To check for infertility, a doctor can:

• Do a physical exam.
• Ask questions about your past health. This may help your doctor find clues, such as a history of miscarriages or pelvic inflammatory disease.
• Ask about your lifestyle habits. This includes how often you exercise and whether you drink alcohol or use drugs.
• Do tests that check semen quality. Other tests can measure hormone levels. Hormone imbalances can be a sign of ovulation problems or sperm problems that can be treated.
• Check the uterus, fallopian tubes, and ovaries.

Before you have fertility tests, it may help to try fertility awareness. Chart basal body temperature and use home tests to learn when you are likely to ovulate and be fertile. Some people find that they have been missing the most fertile days when trying to conceive.

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Treatment Overview

A wide range of treatments may be used for infertility. Treatment depends on the cause of fertility problems. They can include:

• Problems with releasing an egg (ovulating). Treatment may include taking medicine, such as:
  • Clomiphene or letrozole. These stimulate your ovaries to release eggs.
  • Metformin. It's used to treat polycystic ovary syndrome.
• Blocked or damaged tubes. If your fallopian tubes are blocked, treatment may include tubal surgery.
• Endometriosis. If mild to moderate endometriosis seems to be the main reason for your infertility, treatment may include laparoscopic surgery to remove endometrial tissue growth. This treatment may not be an option if you have severe endometriosis.
• Problems with sperm. Depending on the cause of the problem, treatment may include medicines, surgery, or insemination. If your doctor recommends insemination, the sperm are collected. Then an increased number of healthy sperm are placed inside the uterus.
• Unexplained infertility. If your doctor can't find out why you haven't been able to get pregnant, treatment may include:
  • Clomiphene.
  • Hormone injections.
  • Insemination.

Assisted reproductive technology

Many people who have problems getting pregnant consider assisted reproductive technology (ART). The most common type of ART is in vitro fertilization (IVF). During IVF, eggs are fertilized by sperm in a lab. The fertilized egg or eggs are then placed in the uterus through the cervix. Sometimes a technique called intracytoplasmic sperm injection, or ICSI (say "ICK-see"), is used during IVF. With ICSI, each egg is injected with one sperm in the lab. This can help fertilize the eggs.

Taking time to plan

Before you start treatment, talk with your doctor about treatment success rates and risks. And think about how far you want to go with treatment. For example, you may want to try medicine but don't want to have surgery. You may change your mind during your treatment. But it's good to start with an idea of what you want your limits to be.

Treatment for fertility can also cost a lot. And insurance often doesn't cover these expenses. If cost is a concern for you, ask how much the medicines and procedures cost. Then find out if your insurance covers any costs.

What affects the success of treatment?

Infertility treatment is a success if it results in the birth of a healthy baby. Many things affect your chances of conceiving and carrying a healthy pregnancy. These include:

Your age and how long you've been trying to conceive.

Your age (and the age of your egg supply) has a big impact on your chances of getting pregnant and having a healthy baby. From your mid-30s into your 40s, your chance of pregnancy with your own eggs decreases. And your risk of miscarriage increases.

The cause of infertility.

Ovulation problems (except those related to age) are the most successfully treated cause of infertility. But problems with the fallopian tubes can be harder to treat. The success of treating other causes depends on the type of problem and how severe it is.

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Self-Care

• Take a multivitamin with folic acid. This helps to prevent birth defects if you do become pregnant.
• Get regular exercise. But do not overdo it. Excessive exercise can cause eggs to release less often or sperm count to lower.
• Avoid excessive alcohol and caffeine use.
• Avoid smoking, marijuana, and illegal drugs.
• Stay at a healthy weight. This will increase your chances of getting pregnant. Being overweight or weighing too little can affect fertility.
• Talk to your doctor about all medicines you are taking or may take. This includes over-the-counter and prescribed medicines and herbal remedies. Some medicines interfere with pregnancy.
• Write down when your period starts and stops for a few months. Bring that information to your doctor. Your doctor can help you figure out when you ovulate and are most likely to get pregnant if you have sex. Or you may prefer to use a home ovulation test.
• If you know when you will ovulate, try to have sex once a day for the 4 days before ovulation and on the day of ovulation.
• If you don't know when you will ovulate, have sex 2 or 3 times each week.
• Don't use lubricants during sex. They may affect how well sperm can travel to meet an egg.

Protecting sperm count and quality

Here are some steps you can take to help lower the risk of fertility problems and increase the chances of pregnancy.

• If you use a vaginal lubricant during sex, select one that doesn't kill or damage sperm.
• Reduce your level of activity, if you exercise strenuously most days of the week.

  Very strenuous exercise may be a cause of lower sperm counts.

• Try to reduce your risk from lifestyle factors that affect fertility.

  Smoking, drinking alcohol, using marijuana or other drugs, being very overweight, and psychological stress are some of the lifestyle factors that can affect sperm and sperm production.

• Avoid having increased heat to the scrotum for long periods of time.

  Many things may increase scrotal temperatures, including regular use of hot tubs and saunas. High scrotal temperatures may decrease sperm count and quality.

• Try to reduce your exposure to environmental toxins at work or home.

  These include substances such as pesticides and heavy metals, including lead, cadmium, and mercury.

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Getting Support

When you have infertility, you may feel alone, confused, or scared. Talking with others about your feelings can help. Here are some places you may find support.

• Family and friends. They can help you cope by giving you comfort and encouragement.
• Counseling. Professional counseling can help you understand and deal with your infertility, and the emotions that may come with it.
• Your doctor. Find a doctor you trust and feel comfortable with. Be open and honest about your fears and concerns.
• Spiritual or religious groups. These groups can provide comfort. And they may be able to help you find counseling or other social support services.
• Support groups. In a support group, you can talk to others who have had similar experiences. Your doctor may be able to tell you about groups in your community. You may also be able to find support in online groups, forums, or discussion boards.

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Medicines

Medicine or hormone treatments are often the first steps in fertility treatment. They're also used for in vitro fertilization (IVF) and other assisted reproductive technologies. Medicines include:

• Clomiphene and letrozole. These stimulate the release of hormones that help with ovulation.
• Gonadotropins. These hormone shots stimulate the ovaries to produce mature eggs.
• Treatment for polycystic ovary syndrome (PCOS). If you're not ovulating because of PCOS, your doctor might recommend a drug such as metformin along with clomiphene.
• Gonadotropin-releasing hormone (GnRH). It increases production of hormones needed to produce eggs and sperm.
• Bromocriptine and cabergoline. These lower prolactin levels. High prolactin levels can prevent ovulation and sperm production.
• GnRH analogue. This is used for IVF.

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Surgery

For some people with fertility problems, a structural problem can be treated with surgery. Treatment can increase the chances of natural conception.

When thinking about surgery, ask your doctor questions about the procedure. For example, how many times has the surgeon done the procedure? What are the chances of treatment success? How long will it take to recover?

Surgery may include:

• Fallopian tube procedures. This includes sterilization reversal.
• Laparoscopic surgery. This may help treat endometriosis.
• Myomectomy. This may help treat uterine fibroids.
• Laparoscopic ovarian drilling. This may be used when weight loss and medicine haven't stimulated ovulation in people who have polycystic ovary syndrome (PCOS).
• Varicocele repair. This is used to cut or bypass an enlarged vein in the scrotum.
• Vasectomy reversal. This reconnects the tubes (vas deferens) that were cut during a vasectomy.

If you have severely blocked fallopian tubes, your doctor may recommend that you skip surgery and have in vitro fertilization (IVF). You might also choose IVF first if you are older than 34 (for any type of blockage) or if you want to get pregnant as soon as possible, at any age. You may be able to get pregnant sooner if you choose IVF than if you have surgery.

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Complementary Treatments

Complementary medicine may help you stay well and cope with infertility. Complementary medicine for fertility includes:

• Acupuncture.
• Dietary changes.
• Relaxation techniques.
• Mind-body medicine.

Talk with your doctor about any complementary health practice that you would like to try or are already using. Your doctor can help you manage your health better if they know about all of your health practices.

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