About Infertility

A young woman looking sadTrying to get pregnant at a specific time or on a certain schedule can be very frustrating. Even when there is no underlying problem, the chance of getting pregnant during a given month is only 20-25%. This is known as the monthly fecundity rate. The chance of a couple getting pregnant over a year of trying is 80%. If a couple has been trying for at least one year and does not achieve a pregnancy, they meet the criteria for infertility and should seek evaluation and treatment. However, this is a general guideline and there are many exceptions. If the couple is young and has no obvious problems, they have a 50% chance of conceiving during their next year even if they don't seek help. Therefore, after two years of trying only 10% of couples will actually have an infertility problem. There are some couples who should not wait one year before seeking help. If the woman is over age thirty-five, she should seek help if she is unable to conceive within a six month period of time. This is because the ability to conceive does decrease with increasing age of the female partner. This decreased fecundity begins around age thirty but increases after age thirty-five and particularly after the age of forty. The primary reason for this is that a woman's eggs are all present at birth and age along with her. By contrast, sperm are produced every 70-90 days and therefore the male partner's age does not directly affect the ability to conceive, although there may be associated genetic problems. Other reasons for seeking help early include a woman with very irregular menses, indicating that she does not ovulate regularly, or any other historical problem such as a ruptured appendix leading to a bad pelvic infection that might have directly compromised the reproductive organs.

A young woman indeep thoughtOnce a couple decides to seek help, the prospect of undergoing an infertility evaluation can be daunting. Certainly, dealing with reproductive issues can be intimidating and/or embarrassing for some, and an infertility workup is commonly thought to be quite expensive. With the modern emphasis on "outcomes based" research for medical testing and treatment, we have been able to simplify the basic evaluation and in many cases control the expense. Many previously commonly used tests, such as the after intercourse test, the basal body temperature chart, and the endometrial biopsy are rarely used today. If a woman has regular menses approximately once a month, that is good evidence that she is ovulating. A semen analysis does need to be performed on the male partner to assess sperm quality. If both normal sperm and ovulation are present, then the assumption must be made that there is a problem within the woman's pelvis that is preventing normal fertilization, embryonic development or implantation. These potential problems include endometriosis and pelvic scar tissue. The evaluation of the woman's reproductive tract requires outpatient surgery via laparoscopy to diagnose and in many cases treat these reproductive problems.

If studies for ovulation, male factor and the reproductive tract are all normal, then the couple has unexplained infertility. Approximately 10-15% of couples with infertility will fall into this category. They require further testing with a blood test done early in the menstrual cycle for follicle stimulating hormone. This is a test of egg quality and an abnormal test indicates a problem with poor ovarian reserve which requires consideration of more advanced therapy. All female partners over the age of thirty-five should also undergo this test, as poor ovarian reserve becomes a more frequent problem as women age.

Couple holding handsNot all couples need to undergo all these tests. If the woman has very irregular periods, this is indicative of an ovulation disorder and she should to be placed on therapy with ovulation induction agents such as clomiphene citrate. Almost half of all couples with an ovulation disorder will conceive with clomiphene and avoid going through any further extensive testing or treatment. If the male factor evaluation shows a very abnormal semen analysis, then standard therapies are not indicated. That couple will need to be evaluated for more advanced reproductive technologies, such as in vitro fertilization with sperm injection.

The most important thing for couples to understand is that there is help available. Although in the past only about half of all couples could be helped, with modern treatment protocols most couples will be able to have a successful pregnancy. Most of the basic evaluation and treatment can be done by a woman's own gynecologist. If he or she is unsuccessful then specialty care is available, particularly for the more advanced therapies such as in vitro fertilization and the use of donor gametes (eggs and sperm). There are many web based resources to get further information. One of the best is www.asrm.org.