Trouble with Baby-Making: Understanding Infertility

by Marissa Camilon, MD 2011 | camilon@myhousecallmd.com

What is infertility? When should you see a doctor?

In a world where one woman can become famous for having eight children and celebrities can have children at practically any age, some people lose sight of why this aspect of medicine even exists. Despite the media’s glamorization of the subject, infertility is not a condition taken lightly by the medical community. Infertility is a serious condition, just like diabetes, asthma or cancer, with proven medical treatments available. Many of us take the ability to become pregnant for granted; something we think happens with the blink of an eye. We have to remember that the chance of becoming pregnant is 20% per month of unprotected intercourse (not 100%). As physicians, we begin to investigate infertility after a couple tries a year of regular, unprotected intercourse that does not lead to a pregnancy. We pick one year as the cutoff because 85% of couples will conceive within that time frame. If you and your partner have been trying for that long, or even longer in some cases, it may be time to see a Reproductive Endocrinologist and Infertility specialist.

Causes of Infertility

Infertility can be caused by any number of factors that can interfere with fertilization and subsequent implantation. In order for a woman to become pregnant, three key factors need to be present:

  1. An egg, provided by the women via ovulation
  2. Sperm, provided by the male during ejaculation
  3. A clear pathway between the two (i.e. healthy and clear uterus and fallopian tubes)

When we look at the causes of infertility as a population, we find the following breakdown:


When a woman is unable to become pregnant, we investigate three main factors which relate to the three essential components when trying to become pregnant:

  1. The female factor
  2. The male factor
  3. The tubal or uterine factor

The first step in successful fertilization, called ovulation, is the release of an egg from a woman’s ovary which usually occurs on day 14 of a cycle (learn how to count your cycle days in the section “What you can do at home”). When your physician investigates the “female factor,” this is the part of the equation they are looking into. Ovulation is controlled by the hormone cycles in a woman’s body thus any imbalance of hormones can prevent ovulation from occurring on a regular basis and, without ovulation, it is impossible for the egg to be fertilized. Ovulation issues can also present as irregularity in a woman’s periods (though this may not always be the case). Common conditions that cause hormonal imbalances are hyper- or hypothyroidism, hyperprolactinemia, Polycystic Ovarian Syndrome, eating disorders, extreme weight loss and obesity.

The second factor physicians investigate is the “male factor.” This investigation consists of a thorough history (Ever conceived a pregnancy before? Sexual practices? etc.) and examination of the male’s sperm. Luckily, this step is almost always non-invasive (although it may be a bit embarrassing depending on the circumstances of specimen collection). The sperm sample is sent to a lab ASAP to evaluate the volume of the ejaculate and sperm concentration, motility and morphology. If any of these factors are abnormal, the sperm may not be able to enter the uterus during intercourse and will thus be unable to fertilize the egg during ovulation. A number of factors can cause abnormal sperm including hormones (low testosterone), excessive heat (think tighty white-ies) or a history of testicular trauma.

Think of the first two factors as being stood up on a date. Only on individual is showing up to the party. The last factor, the “tubal factor,” is more like getting lost on your way to the party. Everyone is on their way but you can’t quite get everyone together. The tubal or uterine factor refers to the anatomy of a woman’s reproductive organs. Once fertilized, the sperm and egg (called a zygote at this stage), travels down the fallopian tube and into the uterus to implant for the duration of the pregnancy. A previous history of a pelvic infection (usually Pelvic Inflammatory Disease) or any type of previous vaginal surgery can lead to abnormal scarring in the uterus, preventing sperm from reaching the egg or the zygote from properly implanting. Additionally, a woman may be born with a septum or other abnormal uterine anatomy (which often does not cause any symptoms prior to trying to become pregnant…see examples at left.). This abnormal anatomy can prevent the zygote from implanting in the uterus, halting an otherwise a viable pregnancy.

What can we do for you?

While infertility is commonly associated with advanced (and expensive) In Vitro Fertilization technology, there are other treatments that much cheaper and less invasive. If a hormone imbalance is suspected, such as hyperprolactinemia or hyperthyroidism, treating the underlying imbalance can significantly increase your chance of becoming pregnant. For women with ovulation problems, Clomiphene Citrate, or Clomid is often used. Clomid, which acts in a round about way to hyperstimulate ovulation, has been shown to increase a woman’s chance of becoming pregnant. It is used to either

  1. Stimulate ovulation in women with trouble ovulating due to hormonal imbalances OR
  2. Cause a “superovulation” to occur in women who already ovulate

After receiving a prescription for your doctor, you can take Clomid for 5 days during a particular phase of your cycle. That particular cycle will then either end with a pregnancy or your regular period. If you have your period, you would then return to the clinic for another trial of Clomid the next month since you just entered a new cycle and thus have another chance to use the medication.

If the results of a sperm analysis are abnormal, the couple can try intrauterine insemination (IUI). During this procedure, sperm is collected in the clinic and concentrated in the lab into a small pellet. This pellet of concentrated sperm is then directly inserted into a woman’s uterus through a small tube, decreasing the number of obstacles the sperm would have to overcome in making its way to the awaiting egg. Finally, if the problem stems from abnormal anatomy, surgery designed to correct the anatomical abnormality and create an “implant-friendly” environment is an option.

What is In Vitro Fertilization?

In some cases, in vitro fertilization may be the best treatment option. In vitro fertilization (IVF) is an infertility treatment in which hormones are strictly regulated and ovulation closely watched by physicians. Here’s how the process works:

  • Step 1: The ovaries are hyperstimulated with hormones leading to the development of multiple follicles contained eggs that are ready for fertilization
  • Step 2: Multiple eggs are surgically collected using a long needle with ultrasound guidance.
  • Step 3: These eggs are fertilized with collected sperm in the lab.
  • Step 4: Fertilized embryos are allowed to mature for a short period of time in the lab to ensure the embryo is viable before placing it into the uterus.
  • Step 5: Multiple embryos (usually 2-3 although the exact number depends on the individual) are then placed into the uterus for implantation.
  • Step 6: Ultrasound and increasing levels of beta-HCG (the hormone that pregnancy tests detect) confirm pregnancy.

A number of variations of this process are available with IVF, whether it’s the use of donor sperm/eggs or a surrogate for the pregnancy. While IVF is notorious for being costly, the amount of time spent in an IVF clinic is often a significantly higher than the time spent in your primary physician’s office and the entire process requires a great deal of expensive medications, tests, technology and procedures. Basically, you’re getting what you’re paying for which, in this case, is high quality, personalized medical care.

What you can do at home?

You’ve been trying to get pregnant for at least a year without much success. Now what? There are a number of things you can do at home that may help increase your chances even before you set foot in a doctor’s office:

  • Keep track of your cycle days: Cycles days are numbered from the beginning of a woman’s period, starting with day 1 on the first day of menstruation and usually lasting to day 28, with the last day preceding the start of the next period. Ovulation occurs in most women in the middle of the cycle (which would be day 14 in a standard 28 day cycle). Because most of our work as physicians will be in the context of cycle days, it may be helpful to become familiar with this method of counting days as well.
  • Lose weight: You’ve heard it a million times before but its hard to go wrong when you maintain a healthy weight. Weight loss in heavier patients has been shown to increase fertility rates in women with ovulatory dysfunction. Not only is weight loss good for your general health, it can also help you get pregnant and decrease your chances of other complications once you do become pregnant.
  • Have intercourse regularly: Ovulation is not easy to detect in some women. As such, if you want to become pregnant, you need to employ the shotgun approach. The more shots you take, the more likely you are to score a goal. It seems simple but you’d be surprised how many patients show up in clinic wondering why they can’t become pregnant despite having sex once a month. We recommend intercourse 3-4 times per week. No need to worry about sperm quality with frequent intercourse either; it’s been shown that all the factors measured in a sperm analysis are normal, if not improved, with daily ejaculation. On the flip side, the quality of the sperm can actually decrease with abstinence greater than 5 days. Hey, we never said there was no work involved.
  • Plan ahead: One of the biggest factors affecting a woman’s ability to conceive is her age. It’s a big deal. While relationship articles offer a number of theories and philosophies about when your relationship is healthy enough to have a baby, the medical data is a little more black and white. Studies have shown decreased fertility rates with age in both men and women. So as much as possible, planning to have a family may be more successful if done earlier rather than later. No way around it…the biological clock is ticking.
  • Ovulation kits and timed intercourse: For those who can afford it, there are more scientific means of monitoring ovulation that can be bought at your local pharmacy. Ovulation urine kits can be used in the middle of a woman’s cycle to more precisely monitor ovulation, allowing couples to plan to have intercourse immediately after a positive result and optimize their natural family planning. The probability of becoming pregnant on a day near ovulation is 10% but if you time it just right and have intercourse on the exact day of ovulation, your probability of becoming pregnant jumps up to 33%. We like those odds.

Questions? E-mail the Author: camilon@myhousecallmd.com

References

1. The Male Infertility Best Practice Policy Committee of the American Urological Association and the Practice Committee of the American Society for Reproductive Medicine. “Report on optimal evaluation of the infertile male.” Fertility and Sterility Nov 2006: 86(4): S202-209.

2. Practice Committee of the American Society for Reproductive Medicine and Society for Reproductive Endocrinology and Infertility. “Optimizing Natural Fertility.” Fertility and Sterility Nov 2008: 90: S1-6.

3. Practice Committee of the American Society for Reproductive Medicine. “Optimal Evaluation of the Infertile Female.” Fertility and Sterility Nov 2006: 86(4): S264-266.

4. Practice Committee of the American Society for Reproductive Medicine. “Use of Clomiphene Citrate in Women.” Fertility and Sterility Nov 2006: 86(4): S187-193.

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07 2010

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