Conditions That Affect Fertility
There are many reasons why a couple may have difficulty in conceiving a child. Disease, drugs, heredity, lifestyle habits or even exposure to certain toxins can affect fertility. Reasons for diminished reproductive capacity include:
- Endometriosis — This condition affects a woman's pelvic cavity, where tissue fragments from the innermost lining of the uterus (the endometrium) grow and function outside the uterus. They are one of the causes of painful menstruation and infertility. These displaced pieces of tissue are not shed vaginally with normal menstrual blood but instead accumulate inside the pelvis on the surface of pelvic organs. If they cause scar tissue on the ovaries or at the ends of the fallopian tubes, the scar tissue can block the tubes and prevent the egg and sperm from meeting inside the tubes for fertilization. In some instances, endometriosis can be surgically removed. Drugs can reduce discomfort related to endometriosis but are less successful at improving fertility.
- Reproductive tract infections — A leading cause of infertility in both men and women is sexually transmitted diseases (STDs) — particularly chlamydia and gonorrhea. If untreated — and many infected women have no symptoms — scarring or damage of the fallopian tubes may cause infertility. In men, an STD can lead to scarring and blockage of the ejaculatory ducts and other reproductive structures, thereby causing infertility.
- Pelvic inflammatory disease (PID) — This infection of a woman's upper reproductive system involves the fallopian tubes, uterus and ovaries. The most common cause of PID is an STD, but it may also occur after complications from an abortion, dilatation and curettage (D&C) surgery, childbirth or even use an intrauterine device (IUD). A single episode of PID is associated with approximately a 15 percent risk of infertility. A second episode doubles infertility risk to about 30%. For three or more episodes, the risk rises to more than 50%.
- Female hormonal imbalances — If your female hormones fail to transmit their chemical signals at precisely the right time, ovulation may be irregular, infrequent or fail to occur. Periods will likely be erratic and unpredictable. Female hormonal imbalances can often be treated with fertility drugs.
- DES exposure. — Men and women exposed in the womb to diethylstilbestrol (DES), a drug used in the past to prevent miscarriages, may find that their fertility is compromised. DES daughters may have reproductive system abnormalities — including an unusually shaped uterus or vagina or abnormal fallopian tubes. These abnormalities can cause ovulation problems in some women, as well as an increased risk of miscarriage, premature delivery and ectopic pregnancy. The data related to sons with DES exposure are not conclusive. Some studies suggest an association with low sperm counts or abnormal sperm, undescended testicles or abnormal openings of the urethra.
- Varicocele — This condition of dilated scrotal veins affects one or both testicles. These dilated, varicose veins are quite common in fertile as well as infertile men. This condition can raise the temperature in the testicles and alter sperm production, causing low sperm counts. Because varicoceles do not always explain a couple's infertility, a urologist will consider all the possible causes of infertility to evaluate whether corrective surgery has a reasonable chance of success.
- Prostatitis — Another potential cause of male infertility is untreated infectious, prostatitis. Symptoms range from none to urgency, painful urination, and pain during or after ejaculation, with or without pain in the prostate. Prostatitis can usually be diagnosed though a physical examination and lab tests. When caused by an infection, it requires treatment with antibiotics.
- Caffeine — Some women who consume an excessive amount of caffeine — equivalent to five cups of coffee per day — take longer to get pregnant.
- Alcohol — For the mother-to-be, alcohol decreases conception rates and increases the risk of miscarriage.
- Smoking — Chemicals in cigarette smoke may reduce a man's ability to conceive. Women who smoke also may have trouble getting pregnant and experience higher rates of miscarriage compared to women who don't smoke.
- Social drugs — Marijuana and cocaine may reduce sperm count and motion, and increase the percentage of defective sperm.
- Heat — There's also evidence that prolonged exposure to heat in hot tubs, saunas or steam rooms produces high scrotal temperatures, which may decrease the number and function of a man's sperm.
What You Can Do
Obviously, some cases of infertility — such as those caused by disease and heredity — can't be controlled without a physician's assistance, if at all. But in "borderline" cases of not being able to conceive, there are certain measures that can be tried. Besides giving up drugs, including smoking and alcohol, and altering other potentially negative lifestyle habits that may decrease fertility, some experts suggest that you and/or your partners try these self-help treatments:
Get new underwear
Hot water isn't the only way to produce high scrotal temperatures, which may decrease sperm production. When having trouble fathering a child the male partner may want to switch to boxer shorts, since briefs keep the testicles closer to the body. Having testicles "hang" can keep them cooler.
Try a new lubricant
You might be hurting your chances to conceive by using over-the-counter lubricating products. These products may interfere with sperm mobility, slowing the sperm so they have a tougher time reaching the egg.
Sexual position usually has no bearing on conception, but the missionary position tends to bring the semen into closer contact with the cervix. This won't cure infertility, but it can make a difference in some borderline cases.
Finding An Infertility Specialist
Experts generally advise a couple try to conceive on their own for at least one year before seeking help. But if home ovulation tests or your basal body temperature indicate you're not ovulating, or you or your partner have any medical conditions that impair your fertility — such as irregular periods, a history of sexually transmitted infections, cancer treatment, exposure to environmental toxins, an undescended testicle, or maternal age 35 or over-consider seeing a fertility specialist without delaying one year.
A good place to start is with your own family practitioner or gynecologist and or for men, your urologist. They will encourage both partners to be evaluated for common causes of infertility and may arrange initial testing and intervention. Alternatively, they may recommend a referral to an infertility specialist, a subspecialty of obstetrics and gynecology or a urologist whose subspeciality is treatment of male infertility. There are three types of specialists to consider, depending on your specific type of infertility problem. Both you and your partner will need evaluation because infertility may be due to a male factor, a female factor or some combination.
For female hormonal disorders, look for a reproductive endocrinologist who is board-certified in reproductive endocrinology by the American Board of Obstetrics and Gynecology. This certification means that the doctor has had additional years of training beyond the standard OB/GYN residency; has passed rigorous exams; and demonstrated competency in treating reproductive disorders.
If either you or your partner has a fertility problem that may require surgery, consider a reproductive surgeon, who is either an OB/GYN or urologist with specialized training in repairing anatomical disorders that impair reproduction. These could include scarring from pelvic infection or endometriosis, and varicoceles or other male anatomical problems.
A third type of specialist in the field is an andrologist, who may be a specially trained urologist who specializes in disorders of male reproductive functioning.
To find the right specialist for you:
- Start by discussing your situation with your primary health care professional. He or she may provide you with one or more specialists to consider.
- Contact the local medical society, medical schools and university medical centers for a list of fertility specialists in your area.
After you've found potential specialists, contact their offices, and inquire about their credentials, facilities and success rates.
Testing and Treatment
The first few days of your monthly cycle is the best time to schedule your first visit to a fertility doctor, so you can start trying to get pregnant right away. Bring along all your medical records, or ask your previous doctor to send them directly to the reproductive endocrinologist. Also, you should make a list of any questions that you'd like to discuss during this initial consultation — such as the doctor's success rate in inducing pregnancy. Be sure to also bring basal temperature or other ovulation charts you've been recording at home.
You will also want to ask about the cost of fertility treatment, which can be very expensive. You will need to determine which of them, if any, is covered by your insurance plan. Coverage varies widely, and the degree to which you are reimbursed may depend on exactly what condition the doctor diagnoses as the reason for your or your partner's infertility.
Some of the tests the doctor may want include:
- A sperm count and analysis to evaluate whether your partner is releasing enough live, normally shaped, fast-moving sperm to make fatherhood possible.
- Complete blood count and screening of both partners for blood type, HIV and hepatitis viruses, as well as immunity to German measles, and to assess functioning of organs, such as the thyroid gland.
- Hormone screening tests to find out if your body is producing normal levels of the various fertility hormones at the right time in your cycle; your partner may also be tested to see if he has normal levels of male hormones.
- Bacterial cultures of your cervix to check for gonorrhea, chlamydia and other infections that could impair fertility.
- Cervical mucus tests, which are done on the day you're most likely to have "fertile mucus," and a postcoital test (conducted after you and your partner have had sex) to see if the sperm are alive and can swim freely in your cervical mucus.
- Ultrasound exams, also done in mid-cycle, to evaluate your uterus (and its lining) and the ovaries, check for fibroid tumors and monitor egg development.
- X-ray studies of your uterus and tubes to determine whether there is an anatomical impairment is preventing you from conceiving.
- Laparoscopy, a surgical procedure in which a small fiberoptic telescope is inserted into the pelvic cavity through very small incisions, may be recommended if less invasive tests do not determine the cause of infertility.
If these or other tests indicate one or both of you has a fertility problem, there are many treatments that might make pregnancy possible. Here's a brief guide to some of the more common ones:
- Fertility drugs There are several medications that can help stimulate ovulation in women. Clomiphene citrate (Clomid, Serophene) has been used since the 1960s. There is a 75% to 80% success rate for stimulating ovulation in women who never or seldom ovulate, and 30% to 40% of them will conceive. Clomid is sometimes combined with other drugs to improve chances for ovulation. Another approach to achieving ovulation is by using human menopausal gonadotropin, a more potent treatment with an 80% to 90% ovulation rate, and 40% to 50% pregnancy rate. Unfortunately, these drugs have more side effects, including a 20% rate of multiple birth. For women who fail to ovulate on these drugs, another treatment, synthetic gonadotropin-releasing hormone (GnRH), can be given by a portable infusion pump over several days. Some of these medications are also used for men, but in different doses.
- Microsurgery — Using needles as thin as a human hair, and suture material invisible to the naked eye, surgeons can make extremely precise repairs to blocked fallopian tubes (or in some case, reverse prior tubal sterilization), blocked ducts in the male reproductive system or varicose veins in the testicles. Laparoscopic surgery can be used to remove adhesions caused by endometriosis or to widen fallopian tube openings.
- Intrauterine insemination — To increase the odds of pregnancy, fertility drugs are used first to stimulate release of several eggs at once; concentrated, moving sperm are then placed directly into the uterus with a syringe or thin tube. This treatment is most helpful for couples with unexplained infertility, and for women with ovulation problems or antibodies that attack their partners' sperm in the vagina.
- Donor sperm banks — For males who suffer from zero sperm or extremely low sperm count.
- Assisted reproductive technologies — There are several variations of these high-tech methods in which sperm and egg are combined to maximize the chances of achieving a successful pregnancy. All of the variations involve two steps — beginning with the woman taking fertility drugs to stimulate the ovaries to produce several eggs (superovulation); followed by the use of procedures to retrieve them, while she is under anesthesia.
The best known of these methods is in-vitro fertilization (IVF), which was responsible for the birth of many "test-tube babies." The eggs obtained through the vaginal canal using ultrasound guidance are fertilized with the partner's sperm outside the woman's body, not in a test tube, but in a culture dish. A few days later, the eggs, now called zygotes, are placed in the woman's uterus. If one or more of the zygotes implants successfully, pregnancy results.
Two variations of this technique are gamete intra-fallopian transfer (GIFT), and zygote intra-fallopian transfer (ZIFT). Using GIFT, the harvested eggs are mixed with the man's sperm and then inserted directly into the fallopian tubes, which allows fertilization (if it occurs) to take place in the natural way. In ZIFT, the harvested eggs are fertilized in a culture dish and then placed in the fallopian tubes during laparoscopic surgery. Both of these methods are only suitable for women who have functional fallopian tubes. The national rate for successful deliveries for one pregnancy attempt using these methods are 27% for GIFT and 23% for ZIFT. When selecting a clinic, you should check on its success rate.