Infertility Information

This medical condition is defined as the inability of a couple to achieve a pregnancy after one year of properly timed, unprotected intercourse. It has been estimated that about 15-20% of all couples trying to become pregnant are unsuccessful.

A woman is most fertile at middle of the menstrual cycle. Around this window of time, usually lasting about 48 hours, the egg is released and most able to be fertilized by a single sperm. In addition, about 15% of all patients that becomes pregnant experience a spontaneous miscarriage. The maternal age (>35 yrs) is one of the most important contributing factors for poor reproductive performance.

The work up of the infertile couple usually starts by the evaluation of the female partner by the consulting gynecologist. Among the causes for infertility, it has been estimated that about 40% of cases are related to a female problem. About 30% of infertility is related to male conditions.

Furthermore, about 15-20% of the infertility is caused by combined male and female factors. The remainder 15-20% cases are related to unexplained infertility, that is, when no abnormalities in the couple could be detected. Usually unexplained infertility is caused by either fertilization problems in which a sperm is not able to penetrate the egg or implantation failures.

The baseline infertility work up consists of evaluation the ovarian reserve (hormonal blood tests), evaluation of the uterine cavity and patency of the fallopian tubes (hysterosalpingogram) and evaluation of sperm production (semen analysis). Ancillary tests include cervical cultures, blood tests for sexually transmitted diseases, rubella/varicella immunity and detection of mutations in the cystic fibrosis gene/hemoglobin genes, depending on the family ancestry background.

In men, with severe low sperm counts may be screened with hormonal levels as well as mutations in the long arm of the Y chromosome. The long arm of the Y chromosome contains many of the genes responsible for spermatogenesis. In addition, the evaluation of tubo/peritoneal factors may be performed by means of a laparoscopy.

Among the most common causes of female infertility, there are ovulatory disorders (polycystic ovaries, obesity, luteal phase defects), uterine disorders (endometrial polyps, submucosal fibroids, mullerian abnormalities such as uterine septum, unicornuate/didelphic uterus), tubal occlusion caused by previous pelvic adhesions, venereal diseases or endometriosis.

Male conditions that affect the sperm count/motility/morphology include: inflammation of the reproductive structures such as epidydimitis and prostatitis, varicoceles, obstruction of the vas deferens (cystic fibrosis), mutations in the long arm of the Y-chromosome. The combined etiology is the combination of any of the above mentioned factors which are present at the same time in both the male and female component of the couple. Unexplained infertility is usually caused by either fertilization problems in which the sperm is incapable of penetrating the egg or implantation failures of the fertilized egg/developing embryo into the uterus.

There are other factors that contribute to the infertility problem such as the use of tobacco, alcohol and illicit drugs, advanced maternal age (>35 years old), environmental factors such as extreme heat and exposure to pesticides.

It is of outmost importance to have the couple evaluated by a reproductive endocrinologist. A reproductive endocrinologist is an obstetrician/gynecologist with subspecialty training in infertility and reproductive endocrinopathies. The reproductive endocrinologist has extensive expertise in the evaluation and treatment of infertility. This kind of physician is able to deal with complex conditions causing an inability to conceive.

In terms of treatment for infertility, it depends on the abnormalities found in the work up. Usually surgical intervention is coupled with the induction of ovulation using various medications such as clomiphene citrate as well as injectable gonadotropins (FSH, LH, and HCG). These treatments could be coupled to intrauterine inseminations (IUI) or assisted reproductive technologies (such as IVF).