MEDICAL MONDAYS NEWS NOTES
Kelly Williams, MD, Obstetrics and Gynecology
TOPIC: Difficulty Getting Pregnant?
Monday, August 11, 2008
Understanding Infertility - the Basics
A person who is infertile has a reduced ability to have a child. It usually doesn't mean a person is sterile -- that is, physically unable ever to have a child.
For many couples, infertility is a crisis. Fertility problems often come with feelings of guilt or inadequacy. But a diagnosis of infertility is not necessarily a verdict of sterility. Up to 15% of all couples are infertile, but only 1% to 2% are sterile. Half of couples who seek help can eventually bear a child, either on their own or with medical assistance.
Men and women are equally likely to have a fertility problem. In about 1 in 5 infertile couples, both partners have contributing problems, and in about 15% of couples, no cause is found after all tests have been done, called "unexplained infertility."
What Causes Fertility Problems in Men?
In men, the most common reasons for infertility are sperm disorders. These problems include:
Another common problem is a temporary drop in sperm production. This happens when the testicles have been injured, such as when the testicles have been too hot for too long or the man has been exposed to chemicals or medications that affect sperm production.
Spending a long time in a hot tub, for example, or wearing underwear that holds the testicles too close to the body can increase the testicular temperatures and impair sperm production. Sometimes there is a physical reason. In the relatively common condition called varicocele, veins around the vas deferens (the duct that carries sperm from testicle to urethra) becomes dilated -- similar to a varicose vein in the leg. The pooling of blood in these veins keeps the temperature inside the scrotum too high.
Certain lifestyles, like increased alcohol intake and smoking, can also have a negative effect on sperm count. Men who are 40 or older often have decreased fertility.
What Causes Fertility Problems in Women?
The primary reason for infertility in women is anovulation, or lack of ovulation (release of eggs from the ovary). The major cause of anovulation is a condition called polycystic ovary disease, or PCOS.
Rarely, in the uterus, fibroid growths, endometriosis, tumors, cervical problems, or irregular uterine shape can keep the egg from implanting in the uterus. Fertilization may not happen if the cervical mucus damages sperm or impedes their progress.
Age is a major factor of female infertility. In women, fertility declines with age, and even more so after the age of 35. Conception after age 45 is rare. Being overweight or underweight can also play a role in having trouble getting pregnant.
Evidence suggests that couples trying to get pregnant should see a doctor for a periconception visit as soon as they start trying to conceive. This is especially important for couples with medical issues. During the periconception visit, they can explore whether there are any problems that should be treated to improve fertility and increase their chances of getting pregnant and having a healthy baby.
Women trying to conceive should add a supplement of at least 600 mcg folic acid, either alone or as part of their prenatal vitamins, to decrease the risk of fetal malformations. Folic acid may also decrease the risk of a miscarriage. The folic acid supplement should be started at least 1 to 2 months prior to conception to maximize its efficacy.
Boxers or Briefs: Myths and Facts about Men's Infertility
By Deb Levine, MA
When a couple is diagnosed infertile, first thoughts often run to the woman. She's barren. She can't conceive. She's not a "complete" woman because she can't get pregnant. As nature would have it, problems with infertility are equally due to male and female conditions.
Infertility is the inability to get pregnant after one year of unprotected sexual intercourse. Statistics suggest that 35 to 40 percent of the problems are caused by male conditions, another 35 to 40 percent by female conditions, and the last 20 to 30 percent a combination of the two, plus a small percentage of unknown causes.
Men's part in fertilization is quite amazing. About 200 million sperm are mixed with semen to form ejaculate. In most men, 15 to 45 million of these sperm are healthy enough to fertilize an egg, although only 400 survive after a man ejaculates. Only 40 of those 400 reach the vicinity of the egg, surviving the toxic environment of the semen and the hostile environment of the vagina. After another process called capacitation (an explosion that allows the remaining sperm to drill a hole through the tough outer layer of the egg), only one lone sperm reaches the egg for fertilization and conception.
Top Causes of Male Infertility
Even though specialists know the causes of male infertility, what's not always known is the cause behind the cause. There are many factors -- lifestyle, genetics, physiology -- that might explain low sperm count, slow sperm mobility, abnormal sperm shape, and so on.
Recent developments in treatment have made fertility possible for many men. But before undergoing any complicated procedures, there are some simple lifestyle changes that can better the odds of a successful conception. (These tips are helpful for any couple trying to conceive, whether or not infertility has been diagnosed.)
Have you ever heard the debate about whether men should wear boxers or briefs? It goes something like this: Briefs are tighter, so it's possible that they can raise your body temperature above the norm for sperm to survive. So if a guy wants to be really fertile, boxers are the way to go. Truth is, this has yet to be scientifically proven. But if you're trying to get pregnant, there's no harm in wearing loose clothing and staying out of hot tubs and saunas.
Since infertility affects one in 25 men these days, maintaining a healthy lifestyle and a positive attitude is the way to go if you're considering becoming a father.
Additional Factors That May Inhibit Men's Fertility
Understanding Infertility - Symptoms
You should see a doctor if you have not become pregnant after 1 to 2 years of trying. Here, "trying" means having unprotected intercourse an average of 3 times a week, but not more often than every 36 hours.
The best place to start is at your primary care or ob-gyn's office, not at a specialized fertility clinic. The fertility problem may turn out to be quite simple, such as not having intercourse near the time of ovulation.
Superovulation is the production of many mature eggs in one menstrual cycle, usually triggered by a medication that stimulates the ovaries. Such medications include clomiphene, follicle-stimulating hormone (FSH), and gonadotropins.
Superovulation with gonadotropins or FSH is monitored closely to prevent severe ovarian hyperstimulation, a potentially life-threatening condition.
While superovulation increases the likelihood of conception, it also increases the risk of becoming pregnant with more than one fetus, such as twins or triplets.
Understanding Infertility - Treatment
How Do I Know If I Am Infertile?
In tracing the cause of infertility, a doctor usually begins by asking both partners about their health histories, their use of medications, their sexual histories, and their sexual practices. The man often undergoes a physical examination first. Male infertility is usually related to sperm health or function, which is usually tested with a spermanalysis.
For the woman, testing generally begins with a full physical exam and cervical smear. The doctor then makes sure that she ovulates regularly and assesses whether her ovaries are doing their job of releasing eggs. Having regular menstrual cycles and a biphasic basal body temperature curve usually confirms that ovulation is regular. Blood tests can measure hormone levels.
The ovaries and uterus may be examined by ultrasound, and a specific test can check for tubal blockage or abnormality in the uterus. In about 80% of couples, the cause of infertility is either a sperm problem, irregular or no ovulation, or blockage of the fallopian tubes. In 15% of couples all tests are normal, and the diagnosis of "unexplained infertility" is made.
What Are the Treatments for Infertility?
Many couples once pronounced "barren" can now produce their own child. Common-sense steps that raise the chances of conception may help.
Couples who want children should have intercourse during the 5 to 6 fertile days of her cycle, which means the 4 to 5 days before she ovulates plus the 1 day of ovulation.
A tip-off to ovulation is that there is a sustained rise in basal body temperature about 1 to 2 days after ovulation. A home testing kit can also be used to detect chemical changes in the urine. A newer device is able to detect ovulation from a single drop of saliva.
If the cause of infertility is that the man doesn't have enough sperm, then attempts should be made to find and treat the sperm problem. If, for example, he has a varicocele, then surgery can sometimes improve the sperm count.
The small percentage of couples whose infertility cannot be corrected can try artificial fertilization. In intrauterine insemination or artificial insemination, the woman is injected with carefully prepared sperm from the husband, partner, or a donor. This is the easiest and usually least costly method. In the procedure known as IVF (in vitro fertilization), the egg is fertilized outside the woman's body and then placed in the womb or fallopian tube. In another procedure, called GIFT (gamete intrafallopian transfer), egg and sperm are brought together in a fallopian tube. Both methods are difficult and seldom succeed on the first attempt. They are also costly.
Should I have infertility testing?
If you and your partner have been having trouble getting pregnant, it's possible that one or both of you has a medically treatable fertility problem. As you decide whether to look for a cause, you will have various medical and personal questions to consider. Together, you can use this Decision Point to guide your thinking. It offers basic facts about infertility, testing, and when testing is appropriate. You can also use it to define your personal goals, feelings, and values about infertility testing and treatment.
Consider the following when making your decision:
The Fertility Evaluation
Q. What goes into a fertility evaluation?
A. A standard fertility evaluation includes physical exams and medical and sexual histories of both partners. Men undergo a semen analysis that evaluates sperm count and sperm movement. "We look at the percent that are moving and how they are moving--are the sperm sluggish? Are they wandering?" says Robert G. Brzyski, M.D., Ph.D., associate professor of obstetrics and gynecology at the University of Texas Health Science Center at San Antonio. "Often, it's not possible to identify a specific reason for a sperm disorder," he says. "But there is new recognition that very low sperm or no sperm may be related to genetics--an abnormality of the Y chromosome."
For women, doctors first check to see whether ovulation is occurring. This can be determined and monitored through blood tests that detect hormones, ultrasound examinations of the ovaries, or an ovulation home test kit. "An irregular menstrual pattern would make us suspicious of an ovulation problem, but it's also possible for a woman with regular periods to have an ovulation disorder," Brzyski says.
If a woman is ovulating, doctors then move to a standard test called the hysterosalpingogram, a type of X-ray of the fallopian tubes and uterus. This test involves placing a radiographic dye solution into the uterine cavity. Multiple X-rays are taken. If the fallopian tubes are open, the dye will flow through the tubes and be visible in the abdominal cavity. If the fallopian tubes are blocked, the dye will be retained in the uterus or fallopian tubes, depending on the location of the blockage.
Other tests give doctors more information. For example, ultrasound can be used to examine the female reproductive structures. Hysterosonography is a more complicated type of ultrasound that involves putting salt water (saline) into the uterus during an ultrasound exam. "This is more likely to reveal structural abnormalities than regular vaginal sonography will show alone," Brzyski says. One such abnormality that hysterosonography may identify is fibroid tumors, which may distort the shape of the uterine cavity.
A surgical procedure called laparoscopy also allows doctors to examine the ovaries, uterus, fallopian tubes, and abdominal cavity. This involves inserting a fiber-optic telescope into the abdomen. One advantage of laparoscopy is that it allows doctors to both diagnose and treat conditions such as endometriosis, when uterine cells attach to tissue outside of the uterus. Adhesions, abnormal attachments between two surfaces inside the body, can also be treated in this way.
Doctors have begun to assess the ovarian reserve by measuring hormone levels and seeing how the ovaries respond to various fertility treatments. This helps evaluate the availability of eggs and the likelihood that a healthy pregnancy will result. "Some women who are 35 are fertile while others are not because their supply of eggs is depleted," Brzyski says. "In the last decade, we've learned this can be investigated through a blood test on the third day of the menstrual cycle. If the numbers are normal, it doesn't guarantee fertility. But if the numbers are abnormal, it points to a serious problem. Up to 20 percent of women who seek infertility care have an abnormal ovarian reserve test."
There are also tests that evaluate how sperm and eggs interact, as well as whether either party is developing antibodies to the sperm. This occurs when the man's or the woman's immune system recognizes the sperm as something foreign and attacks it.
10 Important Questions to Ask Your Doctor About Infertility & Reproduction
Might my job or my partner's job be contributing to our problems?
Is it important to proceed with an infertility evaluation now, or should we wait a while longer?
What specific tests would you recommend to diagnose our infertility, and what do they cost?
What are the treatment options for our suspected diagnosis, and what do they cost?
How much of the cost of fertility treatments or testing does health insurance typically cover?
What is the national success rate, in terms of live births, for each of these treatments?
How many procedures of the type that you are recommending has this fertility clinic performed, and what is its success rate in terms of live births?
Can you put us in touch with former patients who have undergone similar treatments?