Infertility Possible Causes of Infertility and Basic Treatment Options Infertility is defined as failure to conceive after one year of intercourse without using contraception. Since approximately 15 to 20 percent of all couples experience some form of infertility, it is important to consider all potential causes when we do an evaluation. If you want to learn more about possible causes for infertility, follow these links: Female factors Menstrual Cycle Cervical Factors Uterine Factors Tubal Factors Peritoneal Factors Male factors Sperm Production Couple factors Diagnosing Infertility Diagnosis begins with a full review of the patient's medical history and a complete physical examination. It is best if both partners attend the initial visit, as testing may be required for both. Testing Detailed instructions for tests that may be used to determine the cause of your infertility: Endometrial biopsy Hysterosalpingogram (HSG) Ovarian reserve testing Post coital test Semen analysis Sonohysterography Treatment Options Treatment for infertility ranges from the use of medications to induce ovulation in the woman to a variety of assisted reproductive technologies (ART), which may also involve treating male partners. Female Factors Menstrual cycle factors Normal menstrual cycle – In the absence of pregnancy or the use of hormonal contraception, a single egg is released approximately once a month during the reproductive life of a woman. The length of the menstrual cycle is calculated by counting the number of days from day one of menses (period) until day one of the next menses. Although a 28-day cycle is considered normal, cycle intervals of 21 to 35 days may also be normal. The menstrual cycle is the result of a carefully coordinated interaction between the brain, the pituitary gland, the ovary, and the uterus. An area in the brain called the hypothalamus tells the pituitary what to do with the hormone, gonadotropin releasing hormone (GnRH). The pituitary tells the ovary what to do with the two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH). The ovary produces hormones (estrogen and progesterone) and proteins that send information back to the hypothalamus and pituitary as well as directing normal development of the uterine lining. When all of the hormonal signals interact normally, ovulation occurs. The normal menstrual cycle can be considered as consisting of three parts: Follicular phase – When the egg is developing, the egg plus the surrounding cells and fluid make up a cyst, known as a follicle. The dominant hormone is estrogen and causes the lining of the uterus (the endometrium) to thicken. The length of the follicular phase can vary. Ovulation – The follicle ruptures and the egg is released. Luteal phase – After the follicle ruptures, the cells that originally surrounded the egg undergo changes and form a structure called the corpus luteum. The corpus luteum may exist as a cystic structure of varying sizes and primarily secretes the hormone progesterone, which causes the endometrium to change in preparation for implantation of the fertilized egg. The length of the luteal phase is usually 12-14 days. Abnormal menstrual cycle – Absence of periods (called amenorrhea) or periods occurring at irregular intervals implies absent or infrequent ovulation. Lack of ovulation can occur even when the menstrual cycle is fairly regular. Other abnormalities of ovulation associated with regular menstrual intervals include the luteal phase defect, which occurs when a woman’s body produces too little progesterone, causing the lining of the uterus to be under-developed. Also, the age of the woman impacts her fertility. A woman is born with a fixed number of eggs, and there is a progressive loss of eggs throughout her reproductive years, even if she is pregnant or on oral contraceptives. A shortage of responsive eggs has been called decreased ovarian reserve. The eggs that remain may be more resistant to stimulation and may be more likely to carry genetic abnormalities, which can result in: a diminished chance for achieving pregnancy in a given cycle, which begins to become noticeable in a woman’s mid-30s an increased risk of miscarriage The premature loss of functional eggs is known as premature ovarian failure. Tests for defects of ovulation The patient can perform basal body temperatures or home monitoring with ovulation predictor kits. Ultrasound monitoring, measuring hormones, and biopsies of the lining of the uterus can also be used to assess whether ovulation is normal. Decreased ovarian reserve can be assessed by ovarian reserve testing, which involves the measurement of specific hormones at certain times in the cycle. Treatment The initial consideration for treating ovulation defects is to use medications or surgery to restore a normal hormonal environment that will result in spontaneous ovulation. When that goal cannot be achieved, medications are used to: replace, increase, or decrease the release of gonadotropin releasing hormone (GnRH) replace or increase the release of follicle stimulating hormone and luteinizing hormone (FSH and LH) replace or increase the mid-cycle surge of LH replace or increase progesterone during the luteal phase Diminished ovarian reserve or premature ovarian failure may require assisted reproductive technologies, including donor eggs. Female Factors Cervical factors Normal – During a normal ovulation cycle, the estrogen that is produced by the cells surrounding the egg causes an increase in the amount of cervical mucus and causes the mucus to become thin and watery. These changes allow the sperm to more easily penetrate and move within the mucus. Abnormal – Birth defects involving the cervix, prior treatment of abnormal pap smears (cryotherapy, laser therapy, cone biopsies), or exposure to specific medications can have an adverse impact upon the cervical mucus. Tests The post-coital test is intended to evaluate the interaction between the cervical mucus and the semen. After the couple has intercourse, the patient comes to the clinic where mucus is removed from the cervix and observed under a microscope. Another test called the sperm-mucus interface test involves placing a drop of sperm and a drop of mucus on a slide and observing their interaction. Treatment Various hormonal and non-hormonal therapies have been suggested, such as: discontinuing problem medications or adding other medications bypassing the cervix via intra-uterine insemination Female Factors Uterine factors Normal – A normal uterine cavity is essential for implantation of the fertilized egg. The lining of the uterus (endometrium) must be exposed to appropriate levels of estrogen and progesterone in order to adequately develop. Abnormal – Defects of ovulation or exposure to certain medications may interfere with normal uterine lining (endometrium) development. Anatomical problems with the uterine wall or the endometrial cavity may also prevent normal implantation. Such abnormalities include birth defects, intrauterine scarring from prior surgical procedures, or tumors of the uterine lining or uterine wall. Tests An X-ray study called a hysterosalpingogram (HSG), in which dye is injected through the cervical canal into the uterus and tubes, is used to detect any abnormalities. Sonohysterography is a procedure in which fluid is injected into the uterus, and ultrasound is used to look at the shape of the uterine cavity. Hysteroscopy is a procedure where the uterine cavity is directly observed with a scope. The choice of evaluation will be determined by you and your provider. Treatment Changing the type of medications used to treat ovulation abnormalities or using additional hormonal therapy can treat inadequate endometrial (uterine lining) development. Surgical therapy is required for treating anatomical abnormalities. The surgery may be able to be performed during diagnostic hysteroscopy, but sometimes the abdomen will need to be opened in order to perform the appropriate procedure. Male Factors Sperm Production Normal Sperm Production – Sperm production is a complex series of events that requires approximately 74 days to complete. Just as with ovulation in the female, the hormonal component of sperm production requires a coordinated effort between the brain, the pituitary gland, and the testes. The hypothalamus communicates with the pituitary by way of the gonadotropin releasing hormone (GnRH) The pituitary communicates with the testes via the follicle stimulating hormone (FSH) and luteinizing hormone (LH) The testes are stimulated to produce sperm and the male hormone testosterone as well as other proteins and hormones that are needed for normal sperm development and function. Abnormal Sperm Production – Several conditions may affect a man’s ability to produce sperm, including: Chronic medical conditions and the medications used to treat them Infections Exposure to environmental toxins (heavy metals or other industrial exposures) Conditions that interfere with normal sperm transport from the testes to the penis or normal ejaculation Anatomical problems, such as obstruction or abnormal external genitals Neurological problems, such as nerve injuries or conditions like diabetes Antibodies or abnormalities of sperm function that might prevent the sperm from penetrating the egg Conditions that affect glands other than the testes, such as the thyroid, pituitary, or adrenal gland, may lead to abnormal sperm production. Tests Basic semen analysis – measures the quantity and quality of the sperm. If an abnormality is found, the following may be done: a complete history and physical examination, hormonal studies, and more advanced evaluation of sperm and sperm function may be required. Treatment Treatment of other medical conditions, use of antibiotics for infections, or elimination of toxic exposures may resolve the problem. Abnormalities of sperm number and motility are sometimes responsive to hormonal or surgical therapies. Assisted reproductive technologies provide the opportunity for a couple to conceive when other forms of therapy are not appropriate or have been unsuccessful. When no sperm is available or if the couple does not want to use advanced assisted reproductive technologies (ARTs), then donor insemination is an option. Couple Factors Normal – Fertilization occurs when a single sperm penetrates the egg. In order for this to occur, the sperm is deposited in the vagina, makes its way through the cervix and uterus into the fallopian tubes, and comes in contact with the egg. Sperm are stored in the cervical mucus that then acts like a sperm bank, releasing sperm on a continuous basis, so that the couple does not have to have intercourse right at the moment of ovulation. Data suggests that having intercourse within a short period of time prior to the egg’s release gives a better chance for pregnancy than having intercourse after the egg has been released. Abnormal Timing of intercourse may be off-schedule with ovulation and may be a cause of infertility. The use of douches or lubricants can affect the ability of the sperm to survive within the vagina or the cervix. Abnormalities of the penis or ejaculation may prevent sperm from being deposited in the vagina. Abnormalities of the vagina may prevent sperm from being deposited. Treatment Timing and use of douches or lubricants are handled better by the couple. Anatomical or physiological abnormalities may require intrauterine insemination or assisted reproductive technologies (ARTs). Infertility Testing Endometrial biopsy The ideal time to perform an endometrial biopsy has been debated. WVU's Center for Reproductive Medicine maintains that the biopsy should be performed 10 to 12 days after ovulation or right before the next expected period. The biopsy is performed in the office, and since the procedure causes cramping, you might want to take 400 to 600 mg of ibuprofen before arriving at the office. A pregnancy test is obtained prior to the procedure. A speculum is placed, the cervix cleansed with an antiseptic, and a plastic catheter is passed into the uterine cavity. Suction is applied and a sample of tissue is removed. There are no restrictions on activities for the remainder of the day. Infertility Testing Hysterosalpingogram (HSG) The test is usually scheduled right after your period has stopped and before ovulation occurs. Therefore, you need to call 304-598-3100 when your period starts so that the test can be scheduled. This test is performed in the radiology department, which is on the third floor of Ruby Memorial Hospital. Since the procedure causes cramping, 400 to 600 mg of ibuprofen is suggested prior to arriving at the hospital. Arrive 15 minutes prior to the scheduled test for registration. From the third floor guest elevators, turn right and the registration desk will be on the right side of a large hallway that goes off to your left. After registration, you will be taken to a changing area. After you have changed into a gown, you will be taken back to the X-ray room. A speculum will be placed, and the cervix cleansed with an antiseptic solution. An instrument will be attached to your cervix and a small catheter placed into the cervix. A special dye will be injected and continuous X-rays will be performed to observe the dye as it fills the uterus and goes into the tubes. It is recommended that you bring someone with you to the hospital to drive you home. We recommend that you do not return to work. Infertility Testing Ovarian reserve testing This test usually consists of ultrasound and hormonal testing. On day three of your menstrual cycle, a baseline ultrasound might be obtained. Blood levels of follicle stimulating hormone and the estrogen, estradiol, are obtained. Clomiphene citrate challenge test: clomiphene citrate, 100 mg, is taken on days five through nine of the cycle. Return on day 10 for ultrasound and a serum follicle stimulating hormone level. Different labs and clinics may use different methods to measure these hormones. Therefore, the levels that are considered normal are specific for the clinic that you are attending. Infertility Testing Post coital test The ideal time to perform this test is immediately prior to ovulation. Have intercourse the evening prior to your scheduled test. Do not use lubricants or douche. You will be scheduled to come into the clinic the following morning. A speculum will be placed in the vagina, and a syringe attached to a soft plastic catheter will be used to remove mucus from your cervix. The mucus will then be examined under a microscope. A vaginal ultrasound may be performed at the same time to make sure that the test was scheduled at the appropriate time. There are no restrictions on your activities for the remainder of the day. Infertility Testing Sonohysterography This test is performed in the Center for Reproductive Medicine. The test is usually scheduled right after your period has stopped and before ovulation occurs. Call 304-598-3100 when your period starts so that the test can be scheduled. The procedure is performed in the ultrasound room. A baseline vaginal ultrasound is performed. A speculum is placed, and the vagina and cervix cleansed with an antiseptic solution. A small catheter is inserted into the uterine cavity, and a small balloon is inflated to keep the catheter in place. The speculum is removed, and the vaginal ultrasound is inserted again. Sterile fluid is injected into the uterus while simultaneously performing ultrasound. After satisfactory images are obtained, the procedure is ended. Most women experience little or no discomfort with this examination, but you can choose to use 400-600 mg ibuprofen one hour prior to the procedure. There are no restrictions on your activities for the remainder of the day.