infertility

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Infertility
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Causes and symptoms
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Definition

Infertility is the failure of a couple to conceive a pregnancy after trying to do so for at

least one full year. In primary infertility, pregnancy has never occurred. In secondary
infertility, one or both members of the couple have previously conceived, but are unable
to conceive again after a full year of trying.

Description

Currently, in the United States, about 20% of couples struggle with infertility at any
given time. Infertility has increased as a problem over the last 30 years. Some studies pin
the blame for this increase on social phenomena, including the tendency for marriage to
occur at a later age, which means that couples are trying to start families at a later age. It
is well known that fertility in women decreases with increasing age, as illustrated by the
following statistics:

• infertility in married women ages 16–20 = 4.5%

• infertility in married women ages 35–40 = 31.8%
• infertility in married women over the age of 40 = 70%.

Nowadays, individuals often have multiple sexual partners before they marry and try to
have children. This increase in numbers of sexual partners has led to an increase in
sexually transmitted diseases. Scarring from these infections, especially from pelvic
inflammatory disease (a serious infection of the female reproductive organs, most
commonly caused by gonorrhea) seems to be in part responsible for the increase in
infertility noted. Furthermore, the use of some forms of the contraceptive called the
intrauterine device (IUD) contributed to an increased rate of pelvic inflammatory disease,
with subsequent scarring. However, newer IUDs do not lead to this increased rate of
infection.
To understand issues of infertility, it is first necessary to understand the basics of human
reproduction. Fertilization occurs when a sperm from the male merges with an egg
(ovum) from the female, creating a zygote that contains genetic material (DNA) from
both the father and the mother. If pregnancy is then established, the zygote will develop
into an embryo, then a fetus, and ultimately a baby will be born.

The male contribution to fertilization and the establishment of pregnancy is the sperm.
Sperm are small cells that carry the father's genetic material. This genetic material is
contained within the oval head of the sperm. The sperm are mixed into a fluid called
semen, which is discharged from the penis during sexual intercourse. The

whip-like tail of the sperm allows the sperm to swim up the female reproductive tract, in
search of the egg it will try to fertilize.

The female makes many contributions to fertilization and the establishment of pregnancy.
The ovum is the cell that carries the mother's genetic material. These ova develop within
the ovaries. Once a month, a single mature ovum is produced, and leaves the ovary in a
process called ovulation. This ovum enters a tube leading to the uterus (the fallopian
tube). The ovum needs to meet up with the sperm in the fallopian tube if fertilization is to
occur.

When fertilization occurs, the resulting cell (which now contains genetic material from
both the mother and the father) is called the zygote. This single cell will divide into many
other cells within the fallopian tube, and the resulting cluster of cells (called a blastocyst)
will then move into the womb (uterus). The uterine lining (endometrium) has been
preparing itself to receive a pregnancy by growing thicker. If the blastocyst successfully
reaches the inside of the uterus and attaches itself to the wall of the uterus, then
implantation and pregnancy have been achieved.

— Rosalyn Carson-DeWitt, MD

Infertility: Causes and symptoms

Medical Encyclopedia:

Infertility: Causes and symptoms

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 Definition
Causes and symptoms
Treatment
Prognosis
Resources

Unlike most medical problems, infertility is an issue requiring the careful evaluation of
two separate individuals, as well as an evaluation of their interactions with each other. In
about 3–4% of couples, no cause for their infertility will be discovered. About 40% of the
time, the root of the couple's infertility is due to a problem with the male partner; about
40% of the time, the root of the infertility is due to the female partner; and about 20% of
the time, there are fertility problems with both the man and the woman.

The main factors involved in causing infertility, listing from the most to the least
common, include:

• male problems: 35%

• ovulation problems: 20%
• tubal problems: 20%
• endometriosis: 10%
• cervical factors: 5%

Male factors

Male infertility can be caused by a number of different characteristics of the sperm. To

check for these characteristics, a sample of semen is obtained and examined under the
microscope (semen analysis). Four basic characteristics are usually evaluated:

• Sperm count refers to the number of sperm present in a semen sample. The
normal number of sperm present in just one milliliter (ml) of semen is over 20
million. An individual with only 5–20 million sperm per ml of semen is
considered subfertile; an individual with less than 5 million sperm per ml of
semen is considered infertile.
• Sperm are also examined to see how well they swim (sperm motility) and to be
sure that most have normal structure.
• Not all sperm within a specimen of semen will be perfectly normal. Some may be
immature, and some may have abnormalities of the head or tail. A normal semen
sample will contain no more than 25% abnormal forms of sperm.
• Volume of the semen sample is important. An abnormal amount of semen could
affect the ability of the sperm to successfully fertilize an ovum.

Another test can be performed to evaluate the ability of the sperm to penetrate the outer
coat of the ovum. This is done by observing whether sperm in a semen sample can
penetrate the outer coat of a guinea pig ovum; fertilization cannot occur, of course, but
this test is useful in predicting the ability of the individual's sperm to penetrate a human
ovum.
Any number of conditions result in abnormal findings in the semen analysis. Men can be
born with testicles that have not descended properly from the abdominal cavity (where
testicles develop originally) into the scrotal sac, or may be born with only one instead of
the normal two testicles. Testicle size can be smaller than normal. Past infection
(including mumps) can affect testicular function, as can a past injury. The presence of

abnormally large veins (varicocele) in the testicles can increase testicular temperature,
which decreases sperm count. History of having been exposed to various toxins, drug use,
excess alcohol use, use of anabolic steroids, certain medications, diabetes, thyroid
problems, or other endocrine disturbances can have direct effects on the formation of
sperm (spermatogenesis). Problems with the male anatomy can cause sperm to be
ejaculated not out of the penis, but into the bladder; and scarring from past infections can
interfere with ejaculation.

Treatment of male infertility includes addressing known reversible factors first; for
example, discontinuing any medication known to have an effect on spermatogenesis or
ejaculation, as well as decreasing alcohol intake, and treating thyroid or other endocrine
disease. Varicoceles can be treated surgically. Testosterone in low doses can improve
sperm motility.

Other treatments of male infertility include collecting semen samples from multiple
ejaculations, after which the semen is put through a process that allows the most motile
sperm to be sorted out. These motile sperm are pooled together to create a concentrate
that can deposited into the female partner's uterus at a time that coincides with ovulation.
In cases in which the male partner's sperm is proven to be absolutely unable to cause
pregnancy in the female partner, and with the consent of both partners, donor sperm may
be used for this process. Depositing the male partner's sperm or donor sperm by
mechanical means into the female partner are both forms of artificial insemination.

Ovulatory problems

The first step in diagnosing ovulatory problems is to make sure that an ovum is being
produced each month. A woman's morning body temperature is slightly higher around the
time of ovulation. A woman can measure and record her temperatures daily, and a chart
can be drawn to show whether or not ovulation has occurred. Luteinizing hormone (LH)
is released just before ovulation. A simple urine test can be done to check if LH has been
released around the time that ovulation is expected.

Treatment of ovulatory problems depends on the cause. If a thyroid or pituitary problem

is responsible, simply treating that problem can restore fertility. (The thyroid and
pituitary glands release hormones that also are involved in regulating a woman's
menstrual cycle.) Medication can also be used to stimulate fertility. The most commonly
used of these are called Clomid and Pergonal. These drugs increase the risk of multiple
births (twins, triplets, etc.).

Pelvic adhesions and endometriosis

Pelvic adhesions and endometriosis can cause infertility by preventing the sperm from
reaching the egg or interfering with fertilization.

Pelvic adhesions are fibrous scars. These scars can be the result of past infections, such as
pelvic inflammatory disease, or infections following abortions or prior births. Previous
surgeries can also leave behind scarring.

Endometriosis may lead to pelvic adhesions. Endometriosis is the abnormal location of

uterine tissue outside of the uterus. When uterine tissue is planted elsewhere in the pelvis,
it still bleeds on a monthly basis with the start of the normal menstrual period. This leads
to irritation within the pelvis around the site of this abnormal tissue and bleeding, and
may cause scarring.

Pelvic adhesions cause infertility by blocking the fallopian tubes. The ovum may be
prevented from traveling down the fallopian tube from the ovary or the sperm may be
prevented from traveling up the fallopian tube from the uterus.

A hysterosalpingogram (HSG) can show if the fallopian tubes are blocked. This is an x-
ray exam that tests whether dye material can travel through the patient's fallopian tubes.
A few women become pregnant following this x-ray exam. It is thought that the dye
material in some way helps flush out the tubes, decreasing any existing obstruction.
Scarring also can be diagnosed by examining the pelvic area through the use of a scope
that can be inserted into the abdomen through a tiny incision made near the naval. This
scoping technique is called laparoscopy.

Pelvic adhesions can be treated during laparoscopy. The adhesions are cut using special
instruments. Endometriosis can be treated with certain medications, but may also require
surgery to repair any obstruction caused by adhesions.

Endometriosis

Definition
Endometriosis is a condition in which bits of the tissue similar to the lining of the uterus
(endometrium) grow in other parts of the body. Like the uterine lining, this tissue builds
up and sheds in response to monthly hormonal cycles. However, there is no natural outlet
for the blood discarded from these implants. Instead, it falls onto surrounding organs,
causing swelling and inflammation. This repeated irritation leads to the development of
scar tissue and adhesions in the area of the endometrial implants.

Description
Endometriosis is estimated to affect 7% of women of childbearing age in the United
States. It most commonly strikes between the ages of 25 and 40. Endometriosis can also
appear in the teen years, but never before the start of menstruation. It is seldom seen in
postmenopausal women.
Endometriosis was once called the "career woman's disease" because it was thought to be
a product of delayed childbearing. The statistics defy such a narrow generalization;
however, pregnancy may slow the progress of the condition. A more important predictor
of a woman's risk is if her female relatives have endometriosis. Another influencing
factor is the length of a woman's menstrual cycle. Women whose periods last longer than
a week with an interval of less than 27 days between them seem to be more prone to the
condition.
Endometrial implants are most often found on the pelvic organs—the ovaries, uterus,
fallopian tubes, and in the cavity behind the uterus. Occasionally, this tissue grows in
such distant parts of the body as the lungs, arms, and kidneys. Newly formed implants
appear as small bumps on the surfaces of the organs and supporting ligaments and are
sometimes said to look like "powder burns." Ovarian cysts may form around endometrial
tissue (endometriomas) and may range from pea to grapefruit size. Endometriosis is a
progressive condition that usually advances slowly, over the course of many years.
Doctors rank cases from minimal to severe based on factors such as the number and size
of the endometrial implants, their appearance and location, and the extent of the scar
tissue and adhesions in the vicinity of the growths.

Cervical factors

The cervix is the opening from the vagina into the uterus through which the sperm must
pass. Mucus produced by the cervix helps to transport the sperm into the uterus. Injury to
the cervix or scarring of the cervix after surgery or infection can result in a smaller than
normal cervical opening, making it difficult for the sperm to enter. Injury or infection can
also decrease the number of glands in the cervix, leading to a smaller amount of cervical
mucus. In other situations, the mucus produced is the wrong consistency (perhaps too
thick) to allow sperm to travel through. In addition, some women produce anti-bodies
(immune cells) that are specifically directed to identify sperm as foreign invaders and to
kill them.

Cervical mucus can be examined under a microscope to diagnose whether cervical factors
are contributing to infertility. The interaction of a live sperm sample from the male
partner and a sample of cervical mucus from the female partner can also be examined.
This procedure is called a postcoital test.

Treatment of cervical factors includes antibiotics in the case of an infection, steroids to

decrease production of anti-sperm antibodies, and artificial insemination techniques to
completely bypass the cervical mucus.

— Rosalyn Carson-DeWitt, MD

Infertility: Treatment
Medical Encyclopedia:

Infertility: Treatment
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Assisted reproductive techniques include in vitro fertilization (IVF), gamete

intrafallopian transfer (GIFT), and zygote intrafallopian tube transfer (ZIFT). These are
usually used after other techniques to treat infertility have failed.

In vitro fertilization involves the use of a drug to induce the simultaneous release of many
eggs from the female's ovaries, which are retrieved surgically. Meanwhile, several semen
samples are obtained from the male partner, and a sperm concentrate is prepared. The ova
and sperm are then combined in a laboratory, where several of the ova may be fertilized.
Cell division is allowed to take place up to the embryo stage. While this takes place, the
female may be given drugs to ensure that her uterus is ready to receive an embryo. Three
or four of the embryos are transferred to the female's uterus, and the wait begins to see if
any or all of them implant and result in an actual pregnancy.

Success rates of IVF are still rather low. Most centers report pregnancy rates between 10–
20%. Since most IVF procedures put more than one embryo into the uterus, the chance
for a multiple birth (twins or more) is greatly increased in couples undergoing IVF.

GIFT involves retrieval of both multiple ova and semen, and the mechanical placement of
both within the female partner's fallopian tubes, where one hopes that fertilization will
occur. ZIFT involves the same retrieval of ova and semen, and fertilization and growth in
the laboratory up to the zygote stage, at which point the zygotes are placed in the
fallopian tubes. Both GIFT and ZIFT seem to have higher success rates than IVF.

— Rosalyn Carson-DeWitt, M

Infertility: Prognosis
Medical Encyclopedia:

Infertility: Prognosis
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It is very hard to obtain statistics regarding the prognosis of infertility because many
different problems may exist within an individual or couple trying to conceive. In
general, it is believed that of all couples who undergo a complete evaluation of infertility
followed by treatment, about half will ultimately have a successful pregnancy. Of those
couples who do not choose to undergo evaluation or treatment, about 5% will go on to
conceive after a year or more of infertility.

— Rosalyn Carson-DeWitt, MD

BOOKS

• Hornstein, Mark D., and Daniel Schust. "Infertility." In Novak's Gynecology. 12th
ed. Ed. Jonathan S. Berek, et al. Baltimore: Lippincott, 1996.
• Martin, Mary C. "Infertility" In Current Obstetric and Gynecologic Diagnosis
and Treatment, ed. Alan H. Decherney and Martin L. Pernoll. Norwalk, CT:
1994.

PERIODICALS

• Intrator, Nancy. "What To Do If You Can't Get Pregnant." Cosmopolitan, Dec.

1995, 154+.
• Mastroianni, Luigi, et al. "Helping Infertile Patients." Patient Care (15 Oct.
1997): 103+.
• Rosenbaum, Joshua. "Beat the Clock: Treatments for Infertility." American
Health (Dec. 1995): 70+.
• Trantham, Patricia. "The Infertile Couple." American Family Physician (1 Sept.
1996), 1001+.
ORGANIZATIONS

• American Society for Reproductive Medicine. 1209 Montgomery Highway,

Birmingham, AL 35216-2809. (205) 978-5000. <http://www.asrm.com>.
• International Center for Infertility Information Dissemination.
<http://www.inciid.org>.
• [Article by: Rosalyn Carson-DeWitt, MD]