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Having children can be one of life's greatest joys, but some couples have difficulty conceiving. Fortunately, most couples - about 85 percent - are able to become pregnant within the first year of trying through unprotected sexual intercourse. An additional 7 percent are able to conceive naturally within the second year.
Medically, a couple is considered infertile if they are unable to become pregnant within one year of having unprotected sex. However, a couple may be considered infertile after just six months of unsuccessfully trying to become pregnant if:
- The female partner is over 35 years old
- The female partner's menstrual cycles are irregular or infrequent
- Either partner has a sexually transmitted disease
- The female partner has suffered from pelvic infections
- The female partner has been diagnosed with endometrial or uterine fibroid growths
- The male partner has been diagnosed with low sperm count, low motility, or abnormally shaped semen
Infertility can involve male factors, female factors, or both, so it is important for both partners to be tested for common causes. If a woman is over 40 years old and trying to become pregnant, her doctor or fertility specialist may immediately run tests to improve her chances of conception.
Being infertile does not necessarily mean a couple is sterile, although some patients confuse the two terms. While as many as 15 percent of people are infertile, meaning they have issues that make conception difficult, only 2 percent of couples are sterile, meaning that they will never be able to become pregnant.
Many couples feel upset, frustrated, or guilty about their inability to become pregnant. While having an emotional response to this condition is normal, it is important to remember that infertility issues are not either partner's fault. In addition, couples seeking help for infertility have ample cause to be optimistic: about half of patients who seek fertility treatment do eventually become pregnant, either with medical assistance or naturally.
Infertility versus Impaired Fecundity
Women who frequently miscarry pregnancies suffer from impaired fecundity, which can involve infertility issues but is not the same condition. Fertility specialists can help with both infertility and impaired fecundity. Women who have suffered two or more unexplained miscarriages should see a doctor about their condition.
Human reproduction is a complex and delicate process. There are many potential causes for infertility, both male and female. Understanding the roots of infertility is one of the most important parts of treatment.
Steps of a Healthy Pregnancy
To understand the causes of infertility, you first need to know the steps involved in a normal conception. These are:
- The female partner releases a mature egg from one of her ovaries. If a woman does not become pregnant, she discards this ovum during menstruation.
- Once semen is ejaculated into the vagina, a sperm combines with the ovum to fertilize it.
- A fertilized egg travels through the fallopian tubes to the womb.
- This fertilized egg implants into the uterus, from which point it can develop into a fetus.
This process means that there only approximately six days per cycle that a woman can become pregnant, before and during ovulation.
Female Infertility Causes
Many of the steps in healthy conception rely on the female body functioning properly. Common sources of female infertility include:
- Endometriosis: The endometrium is a mucus membrane that grows during a woman's cycle, providing important support for an implanted egg and breaking down during menstruation, when it is released. However, if the endometrium develops outside the uterus rather than within it, these cells can create scar tissue, become inflamed, or form blood-filled cysts. These abnormalities can make sex painful or obstruct the fallopian tubes. Up to 50 percent of women struggling with infertility suffer from this condition.
- Uterine fibroids: Fortunately, abnormal growths within the uterine cavity are typically benign. In fact, as many as three quarters of women have fibroids, but never know it because they experience no symptoms. However, uterine fibroids can interfere with fertility when they block the movement of sperm and eggs in the fallopian tubes, cervix, or uterus.
- Tubal blockages or disorders: A fertilized egg must pass through the fallopian tubes to implant in the uterus, so any damage to or blockage of these tubes can cause infertility. Salpingitis, a type of inflammation caused by sexually transmitted infections, adhesions (scar tissue), pelvic inflammatory disease, or endometriosis, most often creates tubal blockages. Previous abdominal surgery can also increase the risk of tubal disorders.
- Abnormal ovulation: Producing healthy, mature eggs is key for conception. Ovulation disorders can create anovulation, when a
woman's ova never develop or release as they should, or oligo-ovulation, when eggs release very inconsistently. Women with improper ovulation may or
may not experience regular menstruation. Typical causes of ovulation problems include:
- Functional hypothalamic amenorrhea (FHA): A woman's hormonal levels are very sensitive to her daily habits. Excessive exercise, increased stress, or dramatic weight loss can interfere with ovulation and menstruation. Patients who suffer from functional hypothalamic amenorrhea can usually reverse this condition by reducing physical activity, decreasing stress, or gaining weight.
- Premature ovarian insufficiency (POI): Some women's ovaries quit producing and releasing eggs properly before age 40. This condition is similar to premature menopause but unlike in the case of premature menopause, some women with POI may still have occasional periods and can sometimes become pregnant with proper treatment.
- Menopause: At around age 50, women gradually stop producing ova. During this process, most women experience irregular periods and hot flashes from hormonal fluctuations. This process is entirely natural and normal, but it can make conception difficult or impossible.
- Diminished ovarian reserve (DOR): Women usually have about 300,000 usable eggs and release about ten percent of these during ovulation before menopause. However, due to surgical, medical, or congenital conditions, some women's eggs deteriorate and decline, causing infertility.
- Polycystic ovary syndrome (PCOS): If a woman's adrenal glands or ovaries become hormonally imbalanced and produce too much testosterone, small ovarian cysts can form. These can interfere with ovulation and cause infertility. Unfortunately, this condition is so common that PCOS is the number one cause of female infertility.
- Luteal phase defects (LPD): The luteal phase of the menstrual cycle falls between ovulation and menstruation. During this stage, a woman's uterus develops a thicker lining to prepare for egg implantation. Patients who suffer from LPD do not develop a thick enough lining, making it more difficult for fertilized eggs to implant in the uterus.
- Irregular uterus shape: Anatomic abnormalities in the shape of a woman's uterus can make it more difficult for fertilized eggs to reach the womb and implant there.
- Pelvic scar tissue: Women who have had pelvic surgery, an appendicitis, abdominal surgery, or a pelvic infection may have developed adhesions around their uterus, ovaries, or fallopian tubes that could make conception more difficult.
- Cancer: Both cancer and the radiation or chemotherapy used to treat it can cause infertility. Chemotherapy in particular can lead to permanent ovarian failure in some patients. Women who have had ovarian or uterine cancer are more likely to have reproductive issues.
- Thyroid issues: Since the thyroid is closely tied to hormone production, any conditions involving this organ, such as hyperthyroidism or hypothyroidism, can prevent normal ovulation and menstruation from occurring.
- Medications: Certain types of medication can disrupt your reproductive cycles and make it more difficult to become pregnant. These include antipsychotic drugs; NSAIDs, or non-steroidal anti-inflammatory drugs, like aspirin or ibuprofen, when used over a long period of time; and spironolactone, a medication that helps patients who suffer from oedema, a type of fluid retention.
- Unhealthy lifestyle: To be fertile, a woman needs to lead a healthy lifestyle. Dramatic weight changes, excessive stress,
overindulgence in alcohol, or smoking can contribute to infertility.
Male Infertility Causes
Men can also suffer from conditions that make becoming pregnant difficult. In fact, male factor infertility affects up to half of couples that have difficulty conceiving. Typically, male fertility issues come from sperm with low motility (speed and effectiveness of motion), morphology (shape), or concentration (overall number). Conditions that can precipitate male factor infertility include:
- Trauma to the testicular region
- Chemotherapy and radiation
- Cystic fibrosis
- Environmental toxins, such as lead or pesticides
- Varicoceles, when testicles' veins are enlarged, which causes sperm to overheat
- Taking anabolic steroids
- Heavy drinking
- Using testosterone supplements
- Improper ejaculation, such as retrograde ejaculation, in which the man's semen releases into the bladder rather than through the head of the penis when he ejaculates
In about 15 percent of cases, a fertility specialist is unable to determine the cause of infertility, even after standard exams and tests have been performed. However, many treatment options are still available to couples struggling with unexplained infertility.
Many factors can increase your chances for infertility or worsen an existing condition that impairs your ability to conceive. Generally, heavy drinking, smoking, and consuming an unhealthy diet can predispose you and your partner to more male and female factor infertility issues. Exercising too much or too little can also disrupt proper reproductive function, as can being overweight or underweight.
Female Fertility and Aging
Regardless of a woman's specific conditions, her infertility risks increase as she ages. As a woman ages:
- Fewer healthy eggs remain for release during ovulation
- The ovaries' ability to develop and release eggs diminishes
- The ova are not as healthy, and are more likely to have genetic abnormalities
- Her risk for miscarriage increases
- She is at higher risk for other conditions that precipitate infertility
Evidence has shown that these factors all increase after about age 35. Women over 35 should consult with their doctor or fertility specialist about their reproductive health. Conceiving after age 45 is extremely rare.
Older men are also generally less fertile than younger men, but their decrease in ability to conceive is often much less pronounced and usually begins at age 45 rather than age 35.
The most obvious symptom of infertility is failing to conceive after having unprotected sex for between six and twelve months. Given that infertility can have myriad causes from both male and female conditions, there is no one set list of symptoms. However, identifying common symptoms can help you decide if you and your partner need to see a doctor or specialist.
Female Infertility Symptoms
Some typical symptoms for women experiencing infertility or conditions that can cause difficulty conceiving include:
- Lighter or heavier periods during menstruation
- Anovulation, a lack of menstruation
- Severe back pain, pelvic pain, or cramping during menstruation
- Irregular or variable cycle length
- Dyspareunia, or painful sexual intercourse
- Hair loss or thinning
- White discharge from nipples
- Growing dark hair on the chin, lips, or chest
- Increased acne or changes in skin condition
- Increased or decreased sex drive
Male Infertility Symptoms
Symptoms of male factor infertility are often much subtler than those for women suffering from infertility, so it is important that men who are having difficulty impregnating their partners pay close attention to their condition. Common symptoms for men who are suffering from infertility or conditions that can precipitate infertility include:
- Noticeable differences in sex drive
- Testicular pain
- Swollen testicles
- Ejaculatory issues
- Firmness or lumps in the testicles
- Abnormal hair growth
These lists are by no means exhaustive. See your doctor or fertility specialist if you are having any reproductive issues, even if your symptoms do not align with any of the above. Also, remember that many conditions, such as uterine fibroids, may be asymptomatic while still affecting your ability to conceive. Catching the causes of infertility sooner can help improve your chances of becoming pregnant.
When to Seek Treatment
If you are under 35, most doctors recommend seeking treatment after twelve months of attempting to become pregnant with unprotected sex. If you are over 35, you should see your doctor after six months of trying, and if you are 40 years old, you may need to seek treatment right away.
Some conditions are a serious threat to your health or could impair your fertility further if left untreated
Some conditions are a serious threat to your health or could impair your fertility further if left untreated. You should see your doctor as soon as possible if you:
- Experience anovulation (no menstruation) or oligo-ovulation (occasional, infrequent, or irregular menstruation).
- Have severe pain during your period.
- Have had a prior gynecological or abdominal surgery.
- Suffer from a sexually transmitted disease.
- Have issues with your thyroid, which can affect your hormones.
- Have hyperprolactinemia, meaning that your body overproduces prolactin, an amino acid that encourages breast development and lactation.
- Have tumors in your pituitary gland, which produces hormones for your body.
- Experience any symptoms of endometriosis, which include intestinal discomfort, pain during urination or bowel movements while menstruating, extreme menstrual cramp pain, dyspareunia (painful sexual intercourse), pain following sex, bleeding or spotting between periods, and chronic pelvic or lower back pain.
- Suffer from pelvic inflammatory disease (PID), an infection of female reproductive organs. This can cause the formation of scar tissue that could interfere with your ability to conceive. If treated quickly, your doctor can limit the damaging effects of PID.
If you do not have any of the above symptoms or conditions, you and your partner should begin seeking treatment within six months to a year since you began trying to conceive, based on the woman's age. Before seeking treatment, it is also important that you and your partner discuss your priorities and are emotionally ready to tackle your infertility.
How to Choose a Fertility Specialist
Since infertility issues are often very private and emotional concerns, finding a fertility specialist who has the skills, experience, and compassion to work well with you is very important. You and your partner will likely work with your fertility specialist for at least a few months to complete a cycle of treatment, so it is important you feel comfortable with him or her.
Do Your Research
Your doctor, family, or friends may provide referrals to fertility clinics. While this can be a great place to start your search, it is important to do your own research to make sure the clinic you choose will provide the care you need. First, check out clinics' websites to learn more about their philosophies and treatment options. You can also find reviews on sites like Yelp or Google Plus Local.
One of the most important steps in your initial research is using the Centers for Disease Control and Prevention's federal database of statistics. Here, you can find fertility clinics' success rates, which they must submit every few years. A clinic's statistics can give you basic information about their expertise, but the clinic with the highest rates isn't necessarily the best for you.
You should look for statistics that are at or above the national average, but watch out for abnormally high success rates-this may indicate that the specialists there are more aggressive in their treatment and may be more concerned about their numbers than their patients.
Types of Clinics
Some patients don't realize that there are many different types of fertility clinics, each of which offers distinct benefits and disadvantages. Large clinics typically keep all of their laboratory work, testing, nursing, and treatment in-house, but you may see more than one specialist throughout the course of your treatment.
Smaller practices with a sole practitioner or fewer than eight specialists provide more personalized care, but may have less advanced equipment or less resources. These clinics may partner with larger fertility labs for specific treatments. Fertility networks are groups of small or large clinics that use standardized treatments and often provide better financing.
Hospital-based practices often have access to a wide variety of resources, but you may have to deal with bureaucracy. University-based clinics may give you access to the most advanced treatments and be less expensive, but medical students may attend your appointments as part of their education. Determining which type or types of clinic you prefer can help you narrow down your options.
Interview the Specialist
Fertility treatment is often a very physically, emotionally, and financially involved process. Before you decide to invest your time, energy, and money in a clinic, you should ask certain questions, either over the phone or in person. Ask your prospective specialists:
- What procedures do you perform? The clinic should provide a variety of treatment options, which is especially important for couples that have not yet found the cause of their infertility issues. If a doctor has already diagnosed the cause of your infertility, make sure that the specialist is familiar with your condition and offers multiple treatment options for it.
- What type of diagnostic tests do you perform for unexplained infertility?
- What type of technology do you use, and how recently have you updated it? For example, ask them if they perform blastocyst transfer, a fairly advanced but routine procedure often performed during in vitro fertilization (IVF).
- If the clinic offers IVF (most do), has the College of American Pathologists accredited its lab?
- Is your clinic a member of SART, the Society for Assisted Reproductive Technologies?
- Does your clinic meet the standards for ASRM, the American Society of Reproductive Medicine?
- Do you specialize in a particular infertility condition or treatment?
- Are you board-certified in obstetrics, gynecology, infertility, and reproductive endocrinology? Are you a member of the SREI, the Society of Reproductive Endocrinology and Infertility? To effectively treat complex infertility problems, it is important that your fertility specialist is trained in reproductive endocrinology (the study of glands and hormones), not just gynecology or obstetrics.
- How long have you been practicing infertility medicine?
- Do you have an affiliation with a local hospital?
- How long have you worked at this clinic?
- How long have the director and team of technicians been at the clinic? High turnover could be a bad sign.
- How many patients or cycles of treatment do you perform each year? Beware of very high numbers, since these may indicate less personal treatment.
- Who is a candidate for treatment? This will help you determine if you are eligible for the clinic's programs. In addition, clinics that do not have clear age limits or candidacy requirements are suspect, as they may not be operating with proper medical ethics.
- Who makes specific decisions about treatment, such as the number of eggs implanted during IVF? It is important that you as the patient retain at least partial control of these important choices.
- What is the cost of treatment? Obviously, you don't necessarily want to choose the least expensive clinic, but fertility treatment costs can add up, so it is important that you can plan for the expense. Some clinics offer a money-back guarantee, which can be appealing for some patients, but this could also indicate a more aggressive treatment style.
- Do you offer financing for treatment? What kind? Depending on the clinic, you may be able to finance more expensive treatments over six to 24 months. You may also be able to purchase a package of treatments or cycles at once for a reduced price.
- What kind of health insurance do you accept? Your current health insurance may cover a portion of your testing and treatment. Some companies, such as the New Life Agency, also offer short-term fertility insurance to help you cover the costs of treatment.
- Do you have walk-in or call-in hours for patient questions? Ideally, your specialist will set aside a few hours each week for current patients to check in or ask questions about treatment.
Getting the answers to these questions will also give you an opportunity to gauge the style and personality of the doctors. If they take the time to thoughtfully answer your questions, this could be a good sign for their care throughout the treatment process.
The Initial Consultation
Your first appointment at your fertility clinic is an exciting and potentially nerve-wracking experience, especially if you and your partner have been struggling with infertility for some time. Unless you are a single woman using a sperm donor, both you and your partner need to attend the initial consultation. Your doctor will typically meet with you for about an hour to answer your questions and begin planning your treatment. Being sufficiently prepared for this first appointment can help you make the most of your time with your fertility specialist.
Before the Consultation
There are a number of things you can do to prepare for your first appointment. To increase your chances for success, you and your partner should be in the best health possible. Use your fertility treatment as the impetus to begin leading a healthier lifestyle.
You should make sure to:
- Exercise regularly, although the female partner should do only gentle physical activity.
- Begin taking pre-natal vitamins to help your body get ready for pregnancy.
- Eat a healthy, balanced diet.
- Stop smoking.
- Avoid drinking heavily.
- Work to reduce your stress, through either meditation, massage, acupuncture, hobbies, therapy, or fertility support groups.
- Make sure you get enough sleep, ideally at least eight hours per night in total darkness.
- Review fertility brochures, and documents. Most clinics will send you packets of information several weeks before your initial consultation so you know what to expect. Make sure you have read and fully understood these documents. If you have any questions, note them so that you can ask the specialist.
- Fill out forms. Your clinic will need certain forms to begin treatment. You will likely need to fill out paperwork detailing both you and your partner's medical history, especially detailing any previous pregnancies or children. To complete these forms, you may to request information from your primary caregiver, which he or she will then send to the clinic. You will also need to provide health insurance documentation if your insurance is covering a part of your treatment. Ideally, you should have a printed insurance policy or authorization form from your general practitioner. Also, you will typically need to fill out consent forms to protect your privacy and give the clinic access to your information.
- Confirm your appointment. Several days before your consultation, you should call your fertility clinic to confirm your appointment.
- Compile a list of questions and concerns. Infertility treatment can be physically and emotionally overwhelming, so it's a good idea to write down a list of questions and concerns for your specialist before you come in. You and your partner should work together to create this list and communicate with each other about your confusions and anxieties. In all likelihood, you may answer some of your own questions about the fertility treatment process while conducting research for this list, as well. This also provides you and your partner with an opportunity to discuss how many cycles of treatment you are willing to undergo and which treatments you would consider having. While your expectations and options may change throughout the course of treatment, it is a good idea to come to your initial consultation with some general guidelines about what you and your partner are willing to do.
During Your Consultation
Assuming that you have provided all the correct paperwork and compiled a list of questions, your consultation appointment should go smoothly. You and your partner should make sure to get all of your questions answered so you feel comfortable with the treatment plan your fertility specialist outlines for you. You should also bring a notepad and take notes during this consultation, as your specialist will probably give you a lot of information you don't want to forget.
Also, don't be afraid to speak up if the specialist makes a recommendation or suggestion you don't agree with or don't feel is right for you. It is important that you feel comfortable with the course of treatment prescribed. Since fertility treatment often involves coming in for regular appointments at the clinic, especially during ovulation, you should bring your calendar so you can check for any conflicts in your treatment plan. Missing an important appointment could disrupt or even cancel an entire cycle of treatment, so it is important to plan ahead.
After Your Appointment
Successful fertility treatment is a team effort. After your consultation with the specialist, you will likely discuss the specifics of your procedures with a fertility nurse. If you are using a sperm or egg donor, you will also speak to a coordinator about your treatment plans.
Patients who wish to undergo pre-implantation genetic testing to avoid passing hereditary conditions to their children should meet with a genetic counselor
Patients who wish to undergo pre-implantation genetic testing to avoid passing hereditary conditions to their children should meet with a genetic counselor about this process. If you are using health insurance or financing to pay for your treatment, you will typically talk to the clinic's financial counselor about payment plans. Many clinics also provide a fertility counselor to help you through the psychological side of fertility treatment, so you may meet this person after your initial consultation.
Once you have finished meeting the staff and getting your questions answered, the front office administrator will schedule your next appointment to begin your treatment. He or she may also give you instructions about how to prepare for diagnostic testing or any procedures you've scheduled.
Tests and Diagnosis
Some patients have already had some diagnostic testing for infertility before seeing a fertility specialist. However, fertility clinics can usually perform more comprehensive or advanced testing than your general practitioner or OB/GYN. Your fertility specialist will discuss the types of diagnostic testing you and your partner need to have at your initial consultation. As previously discussed, both men and women's conditions can contribute to infertility, so it is important that both partners get tested.
Female Fertility Tests
Basic diagnosis involves a normal physical and gynecological examination, including a pap smear to verify the condition of your cervix. Depending on your symptoms, your fertility specialist may also perform:
- A hysterosalpingogram. This is an x-ray for your uterus. The doctor or technician will inject a special dyed fluid into your uterus through your cervix. During the x-ray, your fertility specialist will look for proper fluid motion and distribution through your uterus and fallopian tubes. This test can help diagnose a tubal blockage or irregular uterus shape.
- A pelvic ultrasound. Many women know that doctors use ultrasounds to look at a developing fetus, but ultrasound imaging can also help your fertility specialist assess the shape and function of your uterus and fallopian tubes. For more information, your doctor may also perform a hysterosonography, during which he or she will perform an ultrasound while gradually injecting sterile saltwater into your uterus. Your specialist may also perform your ultrasound transvaginally, with a lubricated wand.
- Hormone testing. Your hormone function can impact your ability to conceive, so fertility specialists use blood tests to measure the levels of different hormones to determine if you are ovulating properly, have sufficient reserve ova, or check related hormones, such as those of the pituitary gland or thyroid.
- Urine tests. Two or three days before you ovulate, your body should release a surge of LH, luteinizing hormone. This causes the follicle to develop properly into an egg. Urine tests may be able to determine if your body is properly producing LH.
- A basal body temperature test. During ovulation, your temperature increases slightly. Therefore, if you or your doctor measure your basal body temperature either vaginally or orally every day during your estimated ovulation time, this can help determine if you are ovulating normally. Basal body temperature testing can also help you and your partner better time sex for conception.
- A hysteroscopy. Usually performed when other diagnostic tests have not yielded results, a hysteroscopy is an outpatient minor surgery performed under general anesthesia. If you need a hysteroscopy, your specialist will insert a small, lighted instrument through your cervix into your uterus. Your doctor uses this tool to look for abnormal tissue growth or uterine shape. Your specialist may also recommend a hysteroscopy to confirm your diagnosis before beginning fertility treatment.
- A laparoscopy. Like a hysteroscopy, a laparoscopy is a minor surgical procedure used to examine the uterus, ovaries, and fallopian tubes more closely. During this procedure, your fertility specialist will make tiny incisions at your navel and pubic bone. Then, he or she will insert a probe into one incision and a long, thin tube with special lights and lenses into another. Lit by the tube, the laparoscope, he or she will look for scar tissue in your fallopian tubes, ovaries, or uterus. If your doctor finds scar tissue or abnormalities, he or she may remove them during your laparoscopy.
- An endometrial biopsy. Usually performed as a follow-up to basal body temperature tests, your doctor will take a sample of tissue from your endometrium, the lining of your uterus. He or she can do this either through jet irrigation and a brush, an electronic aspirator, or through a thin pipette. This can help diagnose abnormal uterine bleeding, cancer, or other irregularities with your menstrual cycle.
- A post-coital test. During the five or six fertile days of your cycle (before and during ovulation), you will come into the fertility clinic within twelve hours of unprotected sex. Then, the doctor will swab your vagina for a sample of cervical mucous, which can then be tested to determine if it is hospitable to sperm.
- Genetic tests. If you have a family history of certain genetic conditions or your infertility is still unexplained after regular testing, your fertility specialist may recommend genetic testing. During this process, your doctor will examine your DNA to look for specific sequences that might make it difficult for you to become pregnant.
Male Fertility Tests
Diagnostic exams for male fertility exams can include:
- A general physical. Your fertility specialist or general practitioner can perform a typical physical exam to assess your overall health and look for more visually noticeable conditions such as varicoceles, enlarged veins in the testicles that can cause them to overheat and damage sperm.
- Hormone analysis. Similar to female hormone testing, your fertility specialist may perform blood tests to measure your levels of testosterone or other important hormones. Your doctor may also measure hormones produced by your pituitary gland or hypothalamus, since these can affect fertility.
- Semen specimen testing. For this test, you will provide semen for testing so that your fertility specialist can determine if they are moving properly, normally shaped, and in the correct concentration in the ejaculate. Generally, a healthy concentration of sperm is 20 million cells per milliliter of semen. More advanced tests may determine your sperm's ability to attach to or fertilize an egg.
- Ultrasounds. Ultrasound imaging can help your doctor look for obstructions or abnormalities within your reproductive organs. During a scrotal ultrasound, your fertility specialist will examine your testicles and scrotum for any blockages. A transrectal ultrasound is slightly more invasive-your specialist will insert a thin wand into your rectum, which will allow him or her to look for obstructions in your seminal vesicles or ejaculatory ducts, the tubes that transport semen. This procedure can also check your prostate for issues.
- Testicular biopsy. If other semen analysis tests are inconclusive, your specialist may use a small needle to remove tissue from your testicles. From this sample, your specialist will determine if you are producing healthy sperm. In severe cases, your specialist can also use a testicular biopsy to harvest sperm for treatments such as IVF.
- Urinalysis. For this test, you will provide a sample of urine, typically directly after ejaculation. Your fertility specialist will then examine it for white blood cells, which could be a result of infection. He or she will also look for semen in your urine, which could be a sign of retrograde ejaculation.
- Genetic testing. As with female fertility testing, your doctor may recommend examining your DNA to look for hereditary conditions or disease that could be causing infertility. This is usually a last resort effort for couples that have gone through usual testing but have not yet received a clear diagnosis for their infertility.
Types of Infertility
As discussed above, infertility has many potential causes, both male and female. When diagnosing and planning treatment, there are three general types of infertility:
- Primary infertility occurs when a couple that has never had children is unable to conceive after either six months (if under 35) or one year (if over 35) of unprotected sex.
- Secondary infertility is the diagnosis for a couple that is unable to conceive, but either or both of the partners have become pregnant or had a child in the past. While this may seem counterintuitive, secondary infertility is much more common than primary infertility-60 percent of infertile couples experience this type. Some couples suffer from secondary infertility when they decide to have an additional child at an older age. Secondary infertility can also result from sexually transmitted disease or as an effect of an abortion. Couples with secondary infertility typically have different physical and emotional needs than those with primary infertility, since they have already had a child.
- Poor responder infertility is the diagnosis for a couple who is infertile but for whom fertility treatments, such as medications or procedures, have not been effective. Patients with poor responder infertility should discuss other treatment options with their fertility specialist. An egg donor, sperm donor, or gestational carrier (surrogate) may be able to help. Many couples with poor responder infertility also opt for adoption.
Struggling with infertility can be emotionally and physically taxing. Fortunately, modern medicine offers many treatment options. Infertility treatments have already assisted thousands of couples in becoming proud parents. Whether your fertility challenges stem from male or female infertility problems, or both, fertility treatments may be able to help you and your partner conceive. Once your fertility specialist has diagnosed the cause or causes of your infertility, he or she will help you find a treatment that suits your needs and wishes.
IVF (In Vitro Fertilization)
IVF, or in vitro fertilization, is one of the most popular assisted reproductive therapies (ART) performed in the United States. The procedure involves the fertilization of the egg outside of the body, and is done in five separate stages:
- The first step requires the use of fertility drugs, typically in the form of injections, to stimulate the production of eggs.
- Next, the fertility doctor retrieves the eggs using a small needle that penetrates the ovaries and suctions the eggs out of each follicle.
- During the third step of IVF, the highest quality eggs and sperm are inseminated and fertilized.
- Over the next three to five days, the eggs should divide and become a healthy, growing embryo.
- At this time, the final step of the IVF procedure is performed when one or several embryos are implanted in the womb.
IVF can be performed with an egg or sperm donor, as well as a gestational carrier (surrogate).
IVF Procedure Stats
Cost: $10,000-$15,000 per cycle
Success Rates: The Society for Assisted Reproductive Technology has calculated the average IVF success rates for fertility clinics in the United States in 2009 by age group:
Under the age of 35: 47.3 percent live birth rate
35-37 years of age: 37.3 percent live birth rate
38-40 years of age: 28.2 percent live birth rate
41-42 years of age: 16.7 percent live birth rate
Treatment Duration: Six to eight weeks
Side Effects: Headaches, mood swings, cramping, hot flashes, bloating, bleeding, bruising at the injection site, stress, depression
Risks: Ovarian Hyper Stimulation Syndrome (OHSS), during which fertility drugs cause the ovaries to swell and become painful, which can cause abdominal pain, diarrhea, nausea, vomiting, and, in extreme cases, blood clots or kidney failure, ectopic pregnancy, allergic reaction to anesthesia, bleeding, infection, damage to surrounding organs, multiple pregnancies, in which the woman becomes pregnant with more than one baby, which increases the risk for hemorrhage, gestational diabetes, premature delivery, and low birth weight, failed IVF cycle, miscarriage
GIFT and ZIFT
Patients who have had unsuccessful IVF cycles or want their pregnancy to more closely resemble natural conception can use GIFT (gamete intrafallopian transfer) or ZIFT (zygote intrafallopian transfer). These procedures follow the same steps as IVF, with one minor modification: the fertilized eggs grow for less time before being implanted.
In GIFT, a fertility specialist combines the extracted egg and purified sperm, inserting this mixture nearly immediately into the woman's fallopian tubes. With ZIFT, the doctor allows the combination to develop for approximately one day before insertion.
These treatments often allow the egg to become an embryo within the woman's body, which may work better for some patients. Since the gamete or zygote must be surgically inserted in the fallopian tubes, the GIFT or ZIFT process is more complicated. Only two percent of ART patients opt for GIFT or ZIFT over traditional IVF.
GIFT/ZIFT Procedure Stats
Cost: $10,000-$15,000 per cycle
Success Rates: 36 percent of all cycles resulted in pregnancy, according to a 2011 report
Treatment Duration: Six to eight weeks
Side Effects: Headaches, mood swings, cramping, hot flashes, bloating, bleeding, bruising at the injection site, stress, depression, nausea and disorientation associated with anesthesia
Risks: Ovarian Hyper Stimulation Syndrome (OHSS), ectopic pregnancy, infection, damage to surrounding organs, multiple pregnancies, failed GIFT/ZIFT cycle, miscarriage, ectopic pregnancy, typical risks associated with anesthesia and surgery (allergic reaction rare lung infection, stroke, heart attack, or death)
In Vitro Maturation (IVM)
Like GIFT and ZIFT, in vitro maturation (IVM) is a modified form of IVF. It is a very innovative treatment and was first performed in the United States in just 2013. IVM is an excellent option for women who:
- Cannot use fertility drugs
- Suffer from severe PCOS (polycystic ovarian syndrome)
- Are at increased risk for OHSS (ovarian hyperstimulation syndrome)
- Have low egg quality
- Plan to undergo chemotherapy treatment
- Are younger than 35
Unlike traditional IVF, IVM does not require any oral or injected fertility medications to stimulate ovarian production. Instead, the fertility specialist extracts premature eggs and develops them in the laboratory. Once the ova have developed fully, the doctor combines them with "washed" sperm and transfers them to the woman's uterus.
IVM reduces the risks associated with fertility drugs, but doctors often have fewer healthy eggs to use, since they are extracted prematurely and developed in the laboratory. Since a large proportion of the cost of IVF comes from expensive fertility drugs, IVM is also often significantly less expensive. In addition, since IVM uses no fertility drugs, patients do not have to wait to resume treatment after an unsuccessful cycle.
IVM Procedure Stats
Cost: $5,000-$7,000 per cycle
Success Rates: Since this procedure is relatively new, the Centers for Disease Control and Prevention have not collected much information about its success rates yet. Currently, fertility specialists estimate that success rates are roughly equivalent to IVF rates, meaning that they would vary by age:
Under the age of 35: 47.3 percent live birth rate
35-37 years of age: 37.3 percent live birth rate
38-40 years of age: 28.2 percent live birth rate
41-42 years of age: 16.7 percent live birth rate
Treatment Duration: Six to eight weeks
Side Effects: Headaches, mood swings, cramping, bleeding, stress, depression
Risks: Bleeding, infection, damage to surrounding organs, failed IVM cycle, miscarriage, multiple pregnancies,
Artificial insemination, also called IUI or intrauterine insemination, is less invasive and costly than IVF, and is often one of the first fertility treatments that couples try when they are having trouble conceiving.
The treatment process usually starts at the beginning of the female's menstrual cycle, at which time she starts taking fertility drugs to increase the number of eggs that are available for fertilization. When the female partner begins ovulating, the male partner will provide a sperm sample. The fertility specialist then purifies the sperm from the ejaculatory fluid to limit cramping and increase chances of conception. He or she then places the prepared sperm in a catheter that inserts the sperm into the vagina, cervix, or uterus.
Artificial Insemination Procedure Stats
Cost: $300-$700 per cycle
Success Rates: 10-20 percent (younger patients using fertility drugs have higher success rates
Treatment Duration : One to two weeks
Side Effects: Light bleeding, cramping, headaches, mood swings, hot flashes, bloating, bruising at fertility drug injection site, stress, depression
Risks: Ovarian Hyper Stimulation Syndrome (OHSS), bleeding, infection, puncture to the uterus, multiple pregnancies, failed AI cycle, miscarriage
Patients who want to take a more holistic approach to fertility treatment or a helpful supplement to more traditional procedures can use acupuncture. This traditional Chinese medicinal technique involves placing tiny needles at specific points throughout your body to encourage physical, spiritual, and mental energy to flow properly.
Raymond Chang, who is trained as both a medical doctor and acupuncturist, reports seeing the same pregnancy rates in his patients who use acupuncture as those who use Clomid, a popular fertility drug. However, since acupuncture works with the body's natural rhythms, it cannot cause a woman to release multiple eggs at once, as fertility drugs do. It can be a helpful complement to traditional IVF, though. In a 2002 study, 34 of 80 women undergoing IVF along with acupuncture became pregnant, while just 21 women in the control group conceived.
IVM Procedure Stats
Cost: $60-$120 per acupuncture session
Success Rates: Insufficient research has been conducted on acupuncture and fertility to determine average success rates
Treatment Duration: Six to eight weeks (when used along with traditional methods)
Side Effects: Dizziness, nausea, vomiting, fainting, temporary pain or discomfort
Risks: Infection at the points of needle insertion
Ovulation is one of the most important steps in conception-without a healthy, mature egg for fertilization, a woman cannot become pregnant. Fertility drugs such as clomiphene pills and gonadotropin injections are intended to regulate or stimulate the ovulation process. The fertility drugs are prescribed to women that are having trouble getting pregnant due to polycystic ovary syndrome (PCOS) and other ovulation disorders.
Clomiphene causes the pituitary gland to produce additional follicle-stimulating hormone (FSH) and luteinizing hormone (LH) to promote growth of the ovarian follicles that contain an egg. Gonadotropin injections contain FSH and LH and are designed to stimulate the ovaries directly so more eggs are produced in one cycle. Women that take fertility drugs should undergo regular blood, hormone, and ultrasound tests with their fertility specialist in order to achieve the best results.
Fertility Drugs Procedure Stats
Cost: $50-$150 for a one-month supply of clomiphene pills, $2,000-$5,000 for a one-month supply of gonadotropin injections
Success Rates: 80 percent ovulation rate, 20-40 percent pregnancy rate
Treatment Duration: One to several months
Side Effects: Headaches, mood swings, cramping, hot flashes, bloating, bleeding, bruising at the injection site, stress, depression, nausea, swelling of the ovaries, weight gain, fatigue, insomnia, irritability, blurry vision
Risks: Ovarian Hyper Stimulation Syndrome (OHSS), multiple pregnancy, failure to get pregnant, miscarriage
Women may eventually learn that their own eggs are not viable for pregnancy through fertility testing and expert diagnosis or following failed IVF cycles. Egg donors make pregnancy possible for women that cannot get pregnant on their own. Egg donor agencies screen candidates for medical and psychological problems, and include the physical characteristics and ethnic background of each egg donor in their databases so recipients can select the candidate that is right for them.
Once an egg donor is selected, she will begin taking fertility drugs to stimulate the production of eggs. The eggs are then removed from the donor's ovaries, fertilized, and placed in the recipient's uterus via the in vitro fertilization procedure.
Donor Egg Procedure Stats
Cost: $5,000 to $10,000 for the donor egg, plus the cost of IVF
Success Rates: 55.1 percent success rate with an average of two embryos implanted
Treatment Duration: Six to eight weeks
Side Effects for Egg Recipient: Pain, bleeding, stress, depression
Risks for Egg Recipient: Ectopic pregnancy, allergic reaction to anesthesia, bleeding, infection, damage to surrounding organs, multiple pregnancies, failed IVF cycle, miscarriage
Tips for Conception
With or without fertility treatments and procedures, there are many things you and your partner can do to improve your chances of conception. While some age-old techniques are simply old wives' tales, there are some basic methods you can use to conceive more easily.
To Increase Your Chances for Conception
If you want to become pregnant more quickly or make your treatment more successful, you should:
- Know your cycle. You should keep a menstrual calendar whether or not you're trying to become pregnant, but tracking your ovulation is even more important when you're attempting to conceive. Your most fertile time is about five days before ovulation, so it's important your math is accurate. If you're having trouble monitoring your cycle, there's an app for that-Clue can keep track of your menstruation and PMS symptoms, as well as let you know when you're approaching your fertile window.
- Take prenatal supplements. Most doctors recommend starting prenatal supplements like spina bifida and folic acid the cycle before you begin attempting to conceive so your body is primed for pregnancy.
- Relax. Dealing with infertility can be stressful, but becoming too anxious can actually disrupt your ovulation or sperm production and make conceiving that much more difficult. You and your partner should work together to find de-stressing activities, like meditation, listening to music, acupuncture, or taking a walk. In addition, one of the best ways to de-stress is sex.
- Rest after sex. Your impulse may be to go to the bathroom or take a shower right after sex, but it's important to rest for 10 to 15 minutes after coitus. This makes it easier for sperm to travel to your cervix. Also, avoid going to the bathroom too soon after sex, as this could hinder your chances of conception. However, contrary to popular belief, you do not need to lift your feet after sex to encourage conception.
- Improve your lifestyle. If you're trying for a baby, it's important that you and your partner both stop smoking (this can interfere with your hormones, as well as being generally unhealthy), eat a balanced diet, and exercise (gently, if you're a woman) regularly. Improving your overall health can only help your chances for pregnancy.
- Keep sex fun (and frequent). Dealing with infertility can be stressful and emotional, but it's important to keep sex fun rather than making it a chore. Many fertility specialists having sex every other day during ovulation to keep it fresh and fun. It's also important to keep having sex even outside of your fertile window, as this stimulates sperm production and reinforces your relationship.
Things to Avoid
Some of your daily habits might be decreasing your chances of becoming pregnant without you even knowing it! If you want to conceive, don't:
- Worry about your position. Although there are many myths about the best positions for conception, scientific evidence indicates that no one position is any better than another. Generally, sperm can travel more easily if you are lying down rather than sitting or standing.
- Wear tight-fitting clothing. This is especially applicable to men, since wearing constricting pants can lower your sperm count.
- Hop in the Jacuzzi. For men, spending time in a hot tub can negatively affect your sperm concentration, motility, and morphology.
- Keep your cell phone in your pocket. A recent Fertility and Sterility found that men who carried their phones in their pockets had lower average sperm quality.
- Eat soy. Soy naturally produces estrogen, which can interfere with both men and women's hormones. It may also lower sperm concentration.
- Drink caffeine. Research indicates that caffeine can contribute to male and female fertility problems. It's also good to kick the habit since most doctors recommend limiting caffeine intake during pregnancy.
- Use scented tampons, artificial lubricants, or vaginal sprays. When you're trying to improve your fertility, it's best not to interfere with your vagina's natural condition. Scented tampons can imbalance your pH (acidity or alkalinity), artificial lubricants can destroy sperm, and vaginal sprays can affect your vaginal acidity, increase your risk for infection, or wash away important cervical mucus.
- Bike. While exercise is healthy, biking can damage nerves and arteries near male reproductive organs, exacerbating infertility issues. The trauma to and heat in the groin that comes with biking is also not advisable for women who are trying to become pregnant.
- Exercise excessively. Leading a healthy, active lifestyle is important, but overly strenuous exercise can prevent you from ovulating, cause LPD (luteal phase deficiency), or make your menstruation irregular.
If you're looking for more suggestions to improve your chances of pregnancy, talk to your fertility specialist about his or her tips and tricks.
Once you've finally become pregnant after struggling from infertility, you'll want to do everything you can to keep you and your baby healthy. Below are some tips to improve your wellbeing and ensure that you can carry your pregnancy to term:
- Find a good OB/GYN or midwife. Your fertility specialist's job is to help you conceive. While he or she will be usually be available to answer any pertinent questions during your pregnancy, it's important to find a practitioner who can help you through your entire pregnancy. If any fertility condition makes your pregnancy high-risk, make sure you find an OB/GYN who specializes in high-risk pregnancies.
- Don't drink. Alcohol can increase your risk for birth defects. Typically, if you've become pregnant through fertility treatments, you'll have already quit drinking before you conceive.
- Avoid smoke. As with alcohol, if you've pursued fertility treatment, you and your partner will have most likely already quit smoking before you become pregnant. However, make sure you don't expose yourself to secondhand smoke from family or friends, as this could put you and your baby at risk.
- Stay hydrated. Most doctors recommend drinking between eight and ten glasses of water per day during pregnancy. This will give you and your baby the water you need to stay healthy and grow properly.
- Wear comfortable shoes and clothes. Weight gain and hormonal changes during pregnancy can put undue pressure on your legs and feet. To stay comfortable, wear looser shoes and put your feet up a few times per day to reduce swelling.
- Sleep well. Ideally, pregnant women should get at least eight hours of sleep per night.
- Get gentle exercise. While you should avoid strenuous exercise, staying active during pregnancy is important. You can do this by taking exercise classes that are specifically designed for pregnant women, such as prenatal yoga.
- Eat healthy meals. Since you're eating for two, most doctors recommend consuming five or six balanced meals each day.
- Take prenatal vitamins. Taking supplements like folic acid and spina bifida can help you have a healthier pregnancy. Talk to your OB/GYN about which prenatal vitamins are appropriate for you. Often, prenatal vitamins will replace your typical vitamin regime, since some vitamins can actually interfere with pregnancy.
- Discuss new medications or remedies with your doctor. Before beginning any new treatment or taking any new medications, check in with your OB/GYN to make sure this is advisable.
- Wear your seatbelt. As your baby grows, it may become more and more difficult to latch your seatbelt. However, it is extremely important to stay buckled in to protect your and your baby's safety during an accident.
- Reduce your exposure to toxins. If your workplace or residence exposes you to radiation, biological toxins, chemicals, or heavy metals, make sure you stay away from these during your pregnancy. Also, make sure to avoid harmful pesticides, solvents, and cleaning products.
- Maintain your oral health. Changing hormones during pregnancy can increase your risk for gingivitis. Make sure you brush, floss, and rinse with mouthwash, as well as seeing your dentist for regular cleanings.
- Let your partner clean the cat box. A parasite in cat feces can cause toxoplasmosis, a serious condition that can precipitate miscarriage, premature birth, or illness. Have someone else change the cat box for you or purchase an automatic cat box that cleans itself.
- Make plans for labor. Especially if you've dealt with infertility issues, it's important to make plans for labor with your partner and medical professional. In particular, create contingency plans for premature labor so that you are prepared and can keep yourself and your baby safe in case this occurs.
- Stay educated. As someone who has dealt with infertility, you probably already know more about conception and pregnancy than most, but taking classes on childbirth and breastfeeding can help you be even better prepared for your baby.
Make sure to discuss any of your pregnancy concerns of questions with your OB/GYN, midwife, or doula (a practitioner trained to help women through childbirth) to make sure you stay healthy and enjoy this exciting time.
Struggling with infertility can be very hard, especially because many men and women feel embarrassed to openly discuss it. However, it is very important to have emotional support (outside of your partner and physician) during your treatment process. These confidantes can help you vent your frustrations, provide a shoulder to cry on if a cycle of treatment is unsuccessful, or celebrate with you when you are finally able to become pregnant.
Infertility Support Groups
In addition to talking to trustworthy friends and family about your issues and concerns, an infertility support group can help you. Support groups are composed of other men, women, or couples dealing with the same issues, so they understand the particular physical and emotional dynamics of infertility. The people you meet in support groups can become lasting friends who help you maintain your emotional and mental health before, during, and after treatment. Support groups can be so beneficial for patients that some studies have even found higher pregnancy rates among women who attended them.
There are three basic types of infertility support groups:
- Professionally led support groups include a counselor, therapist, or minister who conducts the meetings and provides guidance for attendees. Going to this type of support group meetings can be a lower cost way to get help from a professional while bonding with fellow patients.
- Peer-led support groups have no leader; patients with infertility simply meet to discuss their concerns and share their stories. Some patients feel less pressure when meeting with other patients without a professional present. Peer-led support groups can foster closer bonds between patients.
- Online support groups are an excellent option for patients who lack the time or resources to attend meetings. The Internet allows patients who don't feel comfortable meeting in person or who live in remote areas to receive and provide support with other people who are struggling with infertility. Some online support groups maintain dedicated forums or chat rooms so that members can talk anytime.
Many infertility clinics also provide counselors or therapists who are specially trained in the psychological issues that arise from infertility. These people can help you and your partner keep your relationship intact as you get through this difficult process. In addition, your infertility counselor can be an important liaison if you have any questions, concerns, or issues with your treatment.
Frequently Asked Questions
As you cope with and pursue treatment for infertility, you and your partner will likely have many questions. Some of the most common questions, and their answers, are below:
Can my OB/GYN treat my infertility?
This depends on the severity of your condition. Sometimes, couples that have had difficulty conceiving can become pregnant simply from timing their intercourse more optimally with ovulation. Your OB/GYN can complete basic tests and exams to rule out any major fertility issues. He or she can also recommend ovulation predictor kits, which you can purchase over the counter at your local pharmacy. If your OB/GYN has not been able to diagnose your issue or you have not become pregnant by more accurately tracking your ovulation, you should see a fertility specialist.
Do insurance plans cover infertility treatment?
This depends on your particular insurance provider. Some insurance companies cover fertility tests, but most do not cover treatment. You should call your insurance provider to learn more about your coverage before you begin fertility treatment. It is best to bring documentation of your coverage to your initial consultation with a fertility specialist.
Should my partner and I have pre-implantation diagnosis (PGD)?
This is a very personal decision that you and your partner must make with your fertility specialist's guidance. If you or your partner has a history of serious hereditary diseases, such as sickle cell anemia or cystic fibrosis, PGD could ensure your future baby's long-term health. PGD may also help diagnose the root cause for patients who experience unexplained male factor infertility or recurrent pregnancy loss. Since the risks for genetic defects increase with age, women over 35 may choose to use PGD as a preventive measure.
Should we freeze eggs?
If you use IVF, GIFT, ZIFT, or IVM to treat infertility, you may produce more eggs than you wish to implant. In this case, your fertility specialist can use cryopreservation to save them and store them for future cycles. Frozen eggs have a slightly lower success rate than fresh ova, but using frozen eggs can substantially reduce the cost of additional treatment cycles. Older female patients may also opt for cryopreservation since the quality of their eggs may deteriorate over time. You and your partner should discuss your views on cryopreservation before you begin the treatment process so you will know what to do if you produce enough eggs to freeze some.
I am under 35 years old and my partner and I have been attempting to conceive for less than a year. Can I still seek treatment?
Yes. Acting sooner rather than later could improve your chances of conception if you suspect you may be infertile. If you are concerned about your fertility, ask your general practitioner to complete a basic examination or refer you to a specialist. You can also use at-home fertility tests, which measure the levels of important hormones in your urine during ovulation.
The Answers You Need from Doctors You Can Trust
Fertility specialists urge couples experiencing difficulty conceiving for more than a year and women who are over the age of 35 to see a qualified physician trained in diagnosing and treating infertility problems. To help you find that physician, DocShop provides an online directory of fertility doctors to help you find a specialist in your area. Browse our directory and view the websites of local fertility clinics to find the physician that is right for you and your partner.
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