As many as one in five couples in the United States are affected by infertility, which is generally defined as the failure to conceive after 12 months of regular, unprotected sex when the gestational parent is under age 35, and after six months for those age 35 and older.
For most, the chance of getting pregnant through intercourse in any given menstrual cycle is about 20%. This figure starts to decline in a person’s late 20s and early 30s, and decreases even more after the age of 35 because women and other people with ovaries tend to ovulate (release an egg from the ovaries) less frequently with age. Men and other sperm producers also experience some decrease in fertility starting in the late 30s.
Causes of infertility can include lifestyle factors, medications, female factors and male factors. In approximately 25% of cases, there is no known reason for infertility. These cases are known as unexplained infertility.
Some of the lifestyle factors that can contribute to infertility include poor nutrition, smoking, stress, eating disorders, extremes of weight (obesity and underweight) and excessive exercise. All of these conditions can affect ovulation and the menstrual cycle.
Exposure to certain drugs and other treatments, such as chemotherapy or radiation, can affect a person’s chances of becoming pregnant. Exposure to a drug called diethylstilbestrol (DES) can also cause problems with fertility in the female offspring of women who took it. DES was a drug given to pregnant people between 1940 and 1971 to prevent miscarriage. If you believe your mother may have received this medication when she was pregnant with you, discuss this with your provider. (For more information on DES, visit the National Institute of Health.)
Female factors of infertility are most commonly related to ovulatory dysfunction. This means that there is a disruption in how well a person ovulates (releases an egg from the ovary). Ovulation typically happens near the middle of the menstrual cycle, but if someone is anovulatory (doesn’t ovulate) or the luteal phase (the time between ovulation and menstruation) is too short, it can be difficult or impossible to conceive.
Some lifestyle factors and medications can affect ovulation, as can other conditions, such as polycystic ovary syndrome (PCOS), thyroid dysfunction, abnormal milk discharge (galactorrhea) and age.
Other female factors include endometriosis, which is when cells that form the uterine lining grow outside of the uterus in areas, such as the ovaries, fallopian tubes and peritoneum (the lining of the abdomen and pelvis). Endometriosis may be associated with painful periods, pelvic pain and/or pain with intercourse. Diagnosis of endometriosis may require a laparoscopy (exploratory surgery).
Untreated sexually transmitted infections (STIs) can also cause infertility by damaging the fallopian tubes and resulting in partial or compete blockage of the tube. The fallopian tubes are the structures that pick up the egg from the ovaries. The sperm and egg will meet in the tube, fertilize and be transported to the uterus where implantation occurs. Tubal damage may be present even without a known history of an STI. Conditions, such as previous pelvic surgery, a history of a tubal pregnancy, severe endometriosis or adhesions (scar tissue) may also cause damage to the fallopian tubes.
Anatomic conditions, such as fibroids, may also impact fertility. Fibroids may interfere with implantation of the embryo if located in the uterine cavity or on the uterine lining. Your provider can use an ultrasound to determine if you have fibroids, and will use those results to decide if any further testing is warranted. In rare situations, genetic anomalies (where a certain part of the reproductive tract does not form normally) or autoimmune conditions may also cause infertility.
Male factors typically account for approximately 25% of cases of infertility. These include abnormal sperm movement, abnormal sperm count, no sperm count and erectile dysfunction. Lifestyle factors and some genetic conditions can also contribute to abnormal sperm counts.
Evaluation and Testing for Infertility
Eighty to 90 percent of couples will conceive within the first year of attempted conception. This is why most providers will recommend waiting a year before initiating a fertility workup (or six months if the gestational parent is over age 35). If you have concerns about ovulation, you can perform basal body temperature charting or use a urinary ovulation predictor kit to see if you are ovulating regularly.
Before your provider orders any tests for infertility, he or she will obtain a complete medical history from you and your partner. This includes a detailed menstrual history and a physical exam. A referral to a urologist may be recommended if there are any indications for male factor fertility. The following is a list of potential tests that may be ordered in the evaluation of infertility.
- Semen Analysis: This is a sample that is evaluated for sperm count, sperm motility and sperm morphology (the size and shape of sperm). This is typically done at an infertility lab and there are specific instructions that must be followed to insure a proper sample.
- Blood tests: Estradiol and Follicle Stimulating Hormone (FSH) are hormones that are commonly tested to evaluate for ovarian reserve. Ovarian reserve is a term that is used to refer to the capacity of the ovary to provide eggs that are capable of being fertilized resulting in a healthy and successful pregnancy. Tests for these hormones are typically ordered on day three of your menstrual cycle. They may be combined with a Clomid challenge test where estradiol and FSH are tested on day three, Clomid is taken for five days and estradiol and FSH are tested again on day ten. In some cases, thyroid function, prolactin and other labs may be ordered, depending on your medical condition and evaluation.
- Ultrasound: An ultrasound is used in a pelvic exam to evaluate the uterus and ovaries. It can help diagnose any uterine conditions, such as fibroids, and also evaluate the ovaries for any ovarian cysts. Ultrasounds can also be used to see how many follicles (eggs) are present at the beginning of your cycle, which is also an indirect measure of ovarian reserve.
- A Hysterosalpingogram (HSG) evaluates the endometrial cavity (inside of the uterus) and the fallopian tubes for any abnormality. Its main role is to see if your tubes are patent (open). This is typically performed shortly after you have finished your menstrual cycle.
- Laparoscopy: In some circumstances your provider may recommend that you undergo surgery to evaluate any potential causes of infertility. Conditions, such as endometriosis, adhesions and tubal damage may be diagnosed by and treated with surgery.
Most of the initial workup for infertility can be done by your OB/GYN. Depending on the results and your age, they can help you decide if a referral to an infertility specialist is necessary.
If you are concerned about your ability to conceive or are thinking about starting a family, contact Women’s Healthcare Associates for more information on fertility assessments and other pre-pregnancy counseling services.