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What is infertility?
Infertility is defined as one year of unprotected intercourse without conceiving a desired pregnancy. Women over 35 should consult their doctor if not pregnant after six months of trying because of age related decline in pregnancy rates.
What causes infertility?
How is infertility diagnosed?
Semen analysis - Is the sperm count normal or are there low numbers? A low sperm count is associated with a lower monthly pregnancy rate. The morphology is important also. If the sperm count is high but all the sperm are abnormal then pregnancy rates are also low.
Ovulation evaluation – Cycles longer than 35 days indicate an ovulation problem and a lower chance of pregnancy. Low progesterone production by the ovary after ovulation is called a luteal phase defect and is associated with lower pregnancy rates. Ovulation predictor kits are used to tell the woman she is about to ovulate. We make sure she ovulates with ultrasound and then schedule serum progesterone levels to see if she has a luteal phase defect.
Postcoital test – After making love close to the time of ovulation there should be a lot of sperm moving around in the cervical mucus. Dead sperm or very few motile sperm indicates this may be the reason for not conceiving.
Tubal evaluation - There are several techniques to evaluate the fallopian tubes. The hysterosalpingogram (HSG) is an indirect x-ray test where a fluid that is visible on x-ray is injected through the cervix. If the tubes are open, the fluid will be seen to spill from the fallopian tubes on x-ray.
Multiple authors have compared HSG to laparoscopy. HSG is a good way to assess tubal patency. It is not good for diagnosing scar tissue or endometriosis. Laparoscopy is considered the gold standard for pelvic evaluation. But it is expensive because it requires hospitalization. It is also more painful because of the need for incisions.
Two other modalities are available for tubal assessment, sonohysterography(SHG) and transvaginal hydroLaparoscopy(THL).
SHG - In this procedure, a small balloon tip catheter is placed in the uterus. Under ultrasound visualization, fluid is inserted into the uterine cavity. Ultrasound can detect the spillage of fluid in the pelvis. SHG can be performed in an office. It is no more painful than an HSG and does not expose the woman to x-rays.
THL - Transvaginal hydrolaparoscopy is close in accuracy to standard abdominal laparoscopy and more accurate than HSG. THL can be performed in the office with oral pain meds(no IV is necessary). Pelvic anatomic problems can be diagnosed more accurately than with HSG. The Advanced Women's Health Institute feels that office THL is the most cost-effective approach to evaluate pelvic problems that cause anatomic infertility.
How many women have infertility problems?
Infertility affects approximately 15% of reproductive age couples in U.S. The likelihood of infertility increases with age. The number of couples experiencing this problem continues to grow over the years as more women delay their decision to start a family.
What are the treatment options?
Male factor infertility
IUI(intrauterine insemination)– At the time of ovulation, the semen is collected by masturbation like for a sperm count. In the lab, the semen is added to physiologic wash solution and the sperm are separated from the rest of the semen. Pure sperm are inserted by catheter through the cervical canal and into the uterine cavity. Far more sperm get out to the tubes than would with intercourse.
IVF(In-vitro fertilization)– When the sperm count is extremely low it is possible to fertilize an egg with a single sperm. The process is called intracytoplasmic sperm injection.
Donor insemination – A couple goes to the doctor to find out they cannot become pregnant, the sperm count is extremely low. The options are: do IVF, do not conceive or select a suitable sperm donor. In a step family a man marries a woman with a child. With donor the outcome is similar but a bit different. Women without a male partner who want a family choose donor.
Clomiphene and Letrozole are oral medications used to improve ovarian function. There are different causes of ovarian dysfunction including luteal phase defect, stress and polycystic ovarian syndrome. Oral meds and IUI are also used to treat unexplained infertility.
Gonadotropins are injection medications that stimulate the ovaries when oral meds are not indicated.
Tubal/Peritoneal factor - Minimally invasive laparoscopic procedures can free up the fallopian tubes in cases of adhesions. Ovarian cysts can be removed laparoscopically almost all the time. Treatment of endometriosis improved pregnancy rates by 75% after 9 months in a Canadian multi-center study.
Cervical factor– IUI bypasses a cervical mucus problem.
Immunologic problems – A woman may have antibodies against sperm. This is not common and is generally treated with IUI for a few cycles. After vasectomy reversal anti-sperm antibodies may be present. IUI may be helpful. IVF is sometimes the necessary procedure.
Anti-phospholipid immunologic problems interfere with implantation and can cause miscarriage. Low-dose aspirin, and heparin may help improve pregnancy rates.
Infections - Low-grade infections are thought to sometimes interfere with implantation and pregnancy.
Unexplained infertility - Intrauterine insemination and ovulation induction are the first steps in the treatment of unexplained infertility. The success rate is usually high. IVF also has a high rate of success when conservative measures have not worked. There are causes we have yet to discover.