What is infertility?

Infertility is defined as the inability to conceive after one year of regular sexual intercourse. About 60 to 70 percent of all couples who try to conceive will succeed within six months. Another 20 percent will conceive within a year. While there is not always a medical condition that interferes with becoming pregnant, the remaining 10 to 20 percent of couples not conceiving after a year will have a higher risk of having a medical condition that interferes with conception.

Infertility is an increasing problem in the United States. Approximately one quarter of all women can expect to have at least one episode of infertility during their childbearing years. Statistics show that in about 40 percent of cases, the cause of infertility lies in the female. In another 40 percent of cases, the cause lies with the male. Of the remaining number, either both partners have a fertility problem or no cause is ever found, although the number of undiagnosed cases is decreasing as better diagnostic methods are introduced.

In order for pregnancy to occur, a man must produce sperm in sufficient quantity and quality and a woman must produce a healthy egg, or ovum. The sperm must travel through the vagina and up through the uterus to meet the ovum while it is in one of the fallopian tubes. The timing of sexual intercourse is important. While sperm usually live for a few days, an ovum can be fertilized only during a 12- to 24-hour period. After the egg is fertilized, it must travel down to the uterus and successfully implant in the uterine lining.

Many theories have been proposed to explain an increasing number of infertile couples. More women are postponing pregnancy until they are in their thirties, a time when fertility begins to decline. Age also increases the possibility of multiple sexual partners, which increases the risk of sexually transmitted diseases that could lead to pelvic inflammatory disease and infertility. Age increases exposure to environmental and industrial toxins which may affect fertility. Unhealthy lifestyle choices, such as smoking, alcohol and drugs, also may affect fertility. Poor dietary choices are possibly contributing to a decline in fertility as well. Focusing on improving overall health and well-being is an important part of improving a woman’s chances of becoming pregnant.

Female infertility
Infertility in a woman can be caused by a variety of medical conditions. Problems include failure to ovulate – including polycystic ovarian syndrome, or PCOS, advancing age which can significantly affect the genetic health of eggs, abnormalities of the uterus, scar tissue from infections in the fallopian tubes, on the ovaries or in the uterus, production of antisperm antibodies, or habitual miscarriage. Endometriosis, uterine fibroids, or uterine polyps in a woman also can inhibit conception and implantation.

Male infertility
Infertility in a man can be traced to inadequate sperm production or function from a variety of causes: anatomical defects, chromosomal abnormalities, hormonal deficiencies, or sexual dysfunction. Antisperm antibodies and physical abnormalities of the male anatomy may also contribute to infertility.

 

How is infertility diagnosed?

An initial evaluation can be performed by a primary care physician. The doctor will check for obvious hormonal or reproductive tract disorders that could explain infertility, such as an excess or deficiency of thyroid hormone, an excess of prolactin (a hormone involved in regulating menses), or an excess of androgens (hormones that stimulate male sexual characteristics). The physician will look for excessive facial or body hair and other symptoms of hyperandrogenism, such as obesity, acne and menstrual irregularities. A pelvic exam will check for signs of endometriosis, uterine fibroids, inflammation of the mucus membrane or other cervical abnormalities, cysts or other growths, and congenital abnormalities.

After an initial evaluation, the couple will be referred to a reproductive endocrinologist, an infertility specialist. Both partners will be evaluated by a specialized medical team that includes the physician, scientists, nurses, technicians and other staff members.

Specialists use a variety of tests to diagnose the cause of infertility. In some cases, a correctable cause may be found that will avoid the use of more expensive infertility treatments. 
 
Hormone testing
Hormonal imbalances can lead to inadequate sperm production or function and problems in ovulation. However, a targeted evaluation is preferred over a “test everything” approach. When indicated, the physician will order necessary hormone tests to evaluate abnormalities that can interfere with the reproductive system.  Hormones are often misunderstood by patients and many physicians. Some hormone tests that may be ordered include the following:

  • Luteinizing Hormone
  • Follicle Stimulating Hormone
  • Estradiol
  • Progesterone
  • Prolactin
  • Free T3
  • Total Testosterone
  • Free Testosterone
  • DHEAS
  • Androstenedione

 
Sperm testing
UC Davis investigators are among the world's experts in semen analysis. Our team is backed by researchers who are currently leading the way in the evaluation and development of sperm assays.  Our lab hosts a team of andrology experts that have years of experience assessing semen parameters as well as serving as instructors in andrology training programs.  By contributing the field of andrology, UC Davis and California IVF are doing much more than simply performing sperm testing.  The California IVF Andrology Laboratory meets the highest quality assurance standards, and it is registered through the State of California Department of Health and Human Services and the Centers for Medicare and Medicaid Services CLIA program.
Semen analysis is one of the first tests performed because any problem would preclude additional and more invasive tests on the woman. A low sperm count, unusual shape and structure, and slow movement can inhibit fertilization. The semen evaluation measures various parameters of the semen sample to determine male fertility. Basic parameters include semen volume, sperm count, motility percentage and sperm morphology. Along with other parameters, the complete semen evaluation will help the physician determine if male factor infertility is present and suggest proper treatment for the couple.

Tests of ovulation

Irregular or abnormal ovulation accounts for approximately 25 percent of all cases of infertility. Physicians use a variety of tests to evaluate ovulation:

Basal Body Temperature (BBT Charts)

A simple, inexpensive way to see if a woman ovulates is by charting the body's temperature for a month. This daily chart of a woman's morning temperatures, called basal body temperature charting, reveals a 0.5 to 1.0 degree Fahrenheit rise when the hormone progesterone is released after ovulation. If ovulation doesn't occur, body temperature remains relatively unchanged.

Ovulation Predictor Kits (OPK)
Home test kits designed to indicate when a woman is ovulating. This can be used to predict fertile days. Testing is not always accurate and can be difficult to detect for some women. In the setting of irregular menstrual cycles, this is less useful because the fertile window is less predictable. Prolonged use of OPK’s is usually not advised.

Progesterone Hormone
Progesterone is an ovarian hormone that thickens the uterine lining (endometrium) to prepare for implantation. It can be measured in a carefully timed blood sample. The basal body temperature pattern helps plan the progesterone test.

Endometrial Biopsy
The endometrium forms the protective environment where the embryo "nests." When the embryo attaches to the endometrium, the process is termed implantation. Since an abnormal uterine lining may prevent implantation, a sample of the endometrium is collected for microscopic analysis during an office procedure known as an endometrial biopsy.
 
Evaluation of the Uterus and Fallopian Tubes
Saline Contrast Ultrasound (Sonohysterography)

The Sonohysterography is sometimes called a saline contrast hysterography, saline contrast ultrasound or “water ultrasound” is a diagnostic test involving the use of saline as a contrast agent inside the uterine cavity. This contrast is visualized by vaginal ultrasound in the clinic. The contour of the endometrial cavity can be assessed using this technique. Other types of contrast media have been tried in evaluation the fallopian tubes but most of these methods are less reliable than a hysterosalpingogram when the tubes need testing.

Hysterosalpingogram
The hysterosalpingogram (HSG) is a test that can reveal if the fallopian tubes are open and help determine if the shape of the uterus is normal. During this special X-ray procedure, the specialist uses a catheter to pass a radio-opaque contrast agent through the cervix. As the contrast fluid flows up into the uterus and fallopian tubes, any obstruction or other abnormality becomes apparent. A blockage in the fallopian tubes is a common cause of infertility. Benign tumors (fibroids, polyps) or uterine scarring can distort the uterine cavity and interfere with reproduction.  Pelvic surgery, infections, and sexually transmitted diseases can also lead to blockage of the fallopian tubes.

Laparoscopy
Laparoscopy is an outpatient surgical procedure that enables the physician to see the female pelvic organs. A small telescope is inserted through a one-half inch incision below the navel while the patient is asleep under general anesthesia. Laparoscopy can diagnose and treat problems such as endometriosis or scar tissue, which might not be detected with X-rays or blood tests.
Hysteroscopy
Hysteroscopy is an outpatient procedure that enables the physician to look directly into the uterus. A small telescope is inserted through the cervical opening, avoiding surgical incision. Abnormalities of the inside of the uterus (fibroids, polyps, scar tissue) can be confirmed and treated by hysteroscopy

 

Can a hormone imbalance lead to health problems?

An imbalance of female hormones can cause such problems as abnormal menstrual periods, excessive facial and body hair growth, or even inappropriate breast milk.

Abnormal menstrual periods
Most reproductive-aged women, ages 15 to 45, have regular monthly menstrual cycles. The absence of menstrual bleeding (amenorrhea) is normal during pregnancy and after menopause. In a young, healthy woman, amenorrhea may be caused by a wide range of problems including abnormalities of the uterus or the ovaries (lack of ovulation). Some women have irregular, heavy or unusually painful menstrual periods.

There are several tests that physicians can use to evaluate the condition of the uterus and the ovaries, such as measuring hormone levels, charting basal body temperatures, viewing ultrasound and X-ray studies, or looking directly into the abdominal cavity with laparoscopy or into the uterus through hysteroscopy.

Hirsutism
An imbalance between male and female hormones can cause an excessive growth of dark, male-type hair over the face, chest, breasts and lower abdomen of a woman. The condition is called hirsutism. It can be a sign of problems with ovulation (polycystic ovaries, PCOS), and occasionally it indicates the presence of a tumor of the pituitary gland, the ovary, or the adrenal gland. Measuring the hormone level helps the physician determine the cause. Treatments vary, but oral contraceptive pills frequently help women who do not want to become pregnant. Clomid and other oral medications can be used to help restore ovulation when pregnancy is desired.

Galactorrhea
After childbirth, the breasts normally produce milk, and many women breast-feed their infants. When the breasts produce milk at times other than childbirth, the condition is called galactorrhea. It is usually a sign of hormonal imbalance. Galactorrhea can be caused by thyroid disease, pituitary gland tumors, or certain prescription drugs. Thyroid hormone tests, prolactin hormone measurements, X-rays of the pituitary, or an MRI of the head can be used to detect the cause. Medications such as bromocriptine, Parlodel, or Cabergoline are frequently successful in treating galactorrhea.

 

What is the treatment for repeat pregnancy loss?

Miscarriages are common. About one of every five or six pregnancies ends in miscarriage, usually in the first few months. Some women experience repeated miscarriages, which can be caused by subtle genetic abnormalities in the couple's chromosomes, problems with the uterine cavity (fibroids, scar tissue, developmental defects), or other disorders. All women who have three or more miscarriages should be tested, especially if the miscarriages are consecutive.

More than half of all miscarriages during the first 13 weeks of pregnancy are caused by problems in the fetus' chromosomes. Chromosomes are tiny structures inside body cells that carry the basic identity of heredity. Each chromosome contains genes that determine a person's appearance, sex, and blood type. Problems in the number or structure of the chromosomes or the genes can lead to miscarriage. Frequently this is nature's way of ending a pregnancy in which the fetus was not developing normally.

Most chromosomal problems occur by chance and are not likely to recur in later pregnancies. But in a small number of cases chromosomal problems can cause repeated miscarriage. A karyotype is a special test to analyze chromosome structure.

Many abnormalities of the uterus, which are linked to miscarriage, can be treated with surgery. A special X-ray (hysterosalpingogram) can detect abnormalities of the uterine cavity, and an endometrial biopsy can provide information about the uterine lining, where implantation occurs.

In some cases the mother's illness has been linked to miscarriage. Systemic lupus erythematosus and other autoimmune disorders, congenital heart disease, severe kidney disease with high blood pressure, uncontrolled diabetes, thyroid disease or an intrauterine infection interferes with pregnancy. When these illnesses are treated, the chances for a successful pregnancy improve. Other illnesses may require close monitoring during pregnancy.

Disorders of the immune system can also lead to miscarriage. The immune system defends the body against disease by recognizing and attacking foreign substances. The mother's body normally protects the fetus from an attack by her own antibodies, but in some cases this protection may be absent in a woman's blood. Problems in the immune system can be diagnosed with a blood test for women with repeated miscarriages. The internet is full of information about these types of disorders, though they are actually very uncommon. Patients should be cautious with information on the internet and rely only on proven tests and treatments.

Low levels of progesterone have been thought to play a role in repeat pregnancy losses. There is a very large amount of data suggesting that low progesterone levels are not a significant cause of pregnancy losses and progesterone supplementation has very little impact on the outcomes of pregnancy.

In some cases environmental and lifestyle factors lead to greater risk of miscarriage. Women who smoke, drink heavily or use illegal drugs, especially cocaine, increase their risk of miscarriage. Exposure to high levels of radiation or toxic substances may also be a factor in repeated miscarriage.

Even if you have had repeated miscarriages, you still have a good chance for a successful pregnancy. Your physician will need to review your health information to determine the cause. You will be asked about your medical history, past pregnancies, lifestyle and work environment.

It's important to have a complete medical workup before you attempt pregnancy again because some of the causes of miscarriage can be treated. If you think you might be pregnant, see your physician right away. You may be referred to a perinatologist (high risk OB doctor) for care.

 

Do I need to replace hormones before or after menopause?

Menopause occurs when the ovaries cease to ovulate (release eggs) and stop making estrogen (the female hormone that controls the menstrual cycle). The average age of menopause is about 50 years old, but it can occur earlier or later. Most menopausal women will benefit from hormone replacement therapy, which can stop or decrease hot flushes, improve sleep, preserve bone strength and decrease the risks of heart disease. Patients differ in their needs for hormone replacement. Treatment is individualized and periodic monitoring is necessary to evaluate side effects and prevent complications. There have been many studies raising questions about the benefits of hormone replacement therapy and this is a very complex topic. Overall a woman may benefit from hormone replacement therapy if she is having significant symptoms such as hot flashes, night sweats, or changes in cognitive function or mood stability.

 

Can contraception programs be designed for women with special medical conditions?

Reproductive aged women, ages 15 through 50, may have special pre-existing medical conditions, such as heart or liver disease, or personal requirements for their contraceptive method. The division specializes in formulating an individual plan for contraceptive services that includes both hormonal and non-hormonal methods.