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About Infertility & Treatment
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Extensive tubal disease |
Major Causes
Infertility is caused by female-factors in about 50% of couples, male-factors in about 40%, and both male/female-factors in about 10%. Female-factors include problems of ovulation, inadequate hormone production, and abnormal embryo implantation. Tubal and uterine abnormalities may also cause infertility. Conditions such as endometriosis, uterine fibroids, or pelvic adhesions interfere with fertility, frequently through more than one mechanism. Male-factors are associated with oligospermia, decreased sperm motility (asthenospermia), lack of sperm production (azoospermia), or production of abnormal sperm (teratospermia). Combined male/female-factors may be caused by anatomical, immunological, or psychological incompatibility. Systemic diseases in both men and women may also impair fertility, either directly through the effect on the reproductive function or as a result of the treatment used.
What Are the Mechanisms?
It should now be readily apparent that even a minor alteration in the sequence of events outlined in the discussion "about fertility" can lead to infertility. If there are not enough sperm in the fallopian tube when the egg gets there, there will be no fertilization; or if the sperm arrives late, the egg may be post-mature and the embryo will not develop. If the follicle is too small or the LH surge inadequate, the egg may not be released and the so-called luteinized unruptured follicle (LUF) may be detected by ultrasound. The woman will have all signs of ovulation including an increase in progesterone but the egg will be retained in the ovary and, of course, there will be no conception. If preovulatory estrogen is low, decreased endometrial thickness may prevent embryo implantation. Alternatively, low progesterone after ovulation may result in a poor embryo implantation and either an early implantation failure or miscarriage.
Early Pregnancy Losses
The most common cause of early implantation failures and miscarriages is an abnormal number of chromosomes in the developing embryo. Both egg and sperm development involves reduction in the number of chromosomes from 46 to 23. This process (referred to as meiosis) frequently becomes impaired with age, resulting in an abnormal chromosome number in the egg or sperm and in the embryo conceived. Such an embryo does not develop normally and is typically miscarried. The risk of a miscarriage in a 20 year old woman is about 10%; it is 40% at the age of 40. Abnormal chromosomes have been identified in about 70-80% of miscarriages. Age-related changes in meiosis are the major factor responsible for the decline in fertility in women over 35 and the major cause of fetal malformations.
Sub-fertility
Some couples may conceive without treatment after more than one year of attempting pregnancy. They are considered sub-fertile. There are many causes of sub-fertility. Some women may ovulate infrequently (2-3 times a year) or may have abnormal (dysfunctional) ovulation during most of the cycles. Similarly, a man may have variable sperm counts, occasionally normal but most often in the infertile range (oligospermia). Chances for an egg to be fertilized and to develop into a normal embryo are decreased in such couples.
Medical Help - When and Where
If the couple has not conceived after one year of exposure (six months if the woman is older than 35), they should consult an infertility specialist. Traditionally, infertility diagnosis and treatment was in the domain of gynecologists. However, during the past three decades, development of new complex treatment methods and advances in the science of Reproductive Endocrinology (RE) prompted the establishment of the new subspecialty of Reproductive Endocrinology/Infertility (RE/I). Basic infertility evaluation and treatment may be performed by gynecologists with expertise in the field. However, if there is no pregnancy in 4-6 months and especially if the wife is over 35, the couple should seek help from a Board Certified Reproductive Endocrinologist.
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Laparoscopy |
Diagnostic Work-Up
Medical history and physical exam may provide clues as to the cause of infertility. Basic evaluation should include tests to detect uterine anomalies and tubal pathology, the presence of eggs in the ovaries, ovulatory problems, and sperm abnormalities. Other causes of infertility, such as peritubal or periovarian scar tissue (adhesions), endometriosis, or uterine fibroids, may require laparoscopic surgery to diagnose and at the same time correct these conditions. Less common causes of infertility may be associated with gamete abnormalities, abnormal antibody production, immunological incompatibility, and congenital or acquired deficiencies - all of which require more specialized testing.
Unexplained Infertility
Unfortunately, many aspects of the reproductive function in both men and women cannot be tested. There are no tests, for instance, to determine egg release from the ovary (ovulation) or to evaluate tubal function (we can only test tubal patency). There are no tests to determine the fertilizing potential of eggs and sperm, the adequacy of early embryonic development, or embryo implantation potential. As a result, infertility is frequently labeled as 'unexplained'.
Old Treatment Methods
Treatment of infertility in the past was frequently empirical (based on trial and error). For instance, the wife or sometimes the husband was placed on the fertility drug called Clomid which stimulates gonadal function in both men and women; or the wife would be given estrogens to improve the quality of the cervical mucous; or the couple would be told to 'relax'.
Modern Management
Modern management of infertility relies on Assisted Reproductive Techniques (ART) and requires extensive laboratory support. There are essentially two types of ART approaches: controlled ovarian hyperstimulation/artificial insemination (COH/AIH) and in vitro fertilization/embryo transfer (IVF/ET).
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Approach One - (COH/AIH) Approach Two - (IVF/ET) 
Symptoms/Diagnosis Management of Infertility Management of Chronic Pelvic Pain 
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