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American Society of
Reproductive Medicine
INTRODUCTION

Infertility is typically defined as the inability to achieve pregnancy after one year
of unprotected intercourse. If you have been trying to conceive for  six months
or more, you may need to have an infertility evaluation. However, if you are in
your 30s or older, you should begin the infertility evaluation after about six
months of unprotected intercourse rather than a year, so as not to delay
treatment in this age group. Also, if you have very irregular menstrual cycles
(suggesting that you are not ovulating), or if you or your partner has a known
fertility problem, you probably should not wait an entire year before seeking
treatment. If you and your partner have been unable to have a baby, you’re not
alone. One out of seven couples has trouble conceiving. During this time, it is
normal to experience feelings of frustration, jealousy and anger. However, once
you begin to explore your medical options, you’ll find that fertility treatments
offer more hope for a successful pregnancy than ever before.

THE INITIAL VISIT
It is important to find a doctor who you trust and with whom you feel
comfortable. Some general obstetricians/gynecologists (ob/gyns) have a special
interest in the treatment of infertility. Reproductive endocrinologists are
specialized ob/gyns who, after completing the full ob/gyn residency, complete at
least two additional years of specialized training in reproductive endocrinology
and infertility at an approved fellowship program. Some urologists also
specialize in the area of male infertility. Once you decide upon a qualified
physician, you and your partner will undergo a series of tests requiring
significant time, money, and physical and emotional energy. Before these tests
are performed, your physician will ask questions and review any records that
you and your partner may have from a previous infertility evaluation. Ensuring
that your physician has access to previous medical records is critical in
minimizing wasted time and money for repeated diagnostic evaluation and
therapy. Both you and your partner should attend the first meeting since
infertility is a shared experience and is best dealt with as a couple. During this
visit, you’ll begin to understand the degree of commitment and cooperation that
an infertility investigation requires. Your physician will review your history and
ask you and your partner questions that will help clarify or explain potential
causes for your difficulty in conceiving. In a typical initial visit, the physician will
ask about the frequency and regularity of your menstrual period, pelvic pain,
abnormal vaginal bleeding or discharge, history of pelvic infection, and medical
illnesses. Expect questions concerning prior conceptions, miscarriages,
operations, and methods of contraception. Your partner will be asked questions
concerning prior genital injury, operations, infections, drug and/or medication
usage, history of prior paternity, and medical illnesses. You’ll be asked how long
you’ve been trying to conceive, how often you have sexual intercourse, if you
use lubricants during intercourse, and if anyone in either family has birth
defects. Your physician will need to know the complete sexual and reproductive
histories of you and your partner, including any former relationships. Since at
least 25% of infertile couples have more than one factor causing infertility, it is
very important to evaluate all factors that may affect both you and your partner.
During the first visit, you may discuss the emotional stress of infertility, a
subject that is often difficult for you to share with family and friends. Physicians
know that the procedures and intimate questions involved in an infertility
workup can be difficult. You should always feel free to make your physician
aware of your concerns and frustrations. A complete physical examination of
you and your partner usually follows the initial review. The extent of the
examinations will depend upon whether or not any factors impacting your
fertility are found early in the evaluation.

THE PROCESS OF CONCEPTION
In order to understand the fertility tests and treatments you may be offered, it is
important to understand how conception naturally occurs. First, your ovary must
release (ovulate) an egg, which must be picked up by the fallopian tube. Sperm
must travel through the vagina, into the uterus, and up into the fallopian tube in
order to fertilize the egg. Fertilization usually takes place in the fallopian tube.
Then, the fertilized egg, or embryo, travels down to the uterus, where it implants
in the uterine lining and develops. Infertility results when a problem
develops in any part of this process.

FERTILITY FACTORS
The Ovulation Factor
Problems with ovulation are common causes of infertility, accounting for
approximately 25% of all infertility cases. Ovulation involves the release of a
mature egg from one of your ovaries. After ovulation, the ovary produces the
hormone progesterone. During the 12 to 16 days before the onset of
menstruation, progesterone transforms the lining of your uterus into a receptive
environment for implantation and nurturing of the fertilized egg. If you have
regular menstrual cycles, you are probably ovulating. Cycle lengths of
approximately 24 to 34 days are usually ovulatory. If you only have a period
every few months or not at all, you are probably not ovulating or are ovulating
infrequently. Charting your basal body temperature (BBT) is a simple,
inexpensive way to see if you are ovulating. To complete a BBT chart , you must
take your temperature orally each morning the moment you awaken for at least
one month and record the temperature daily under the appropriate date.
Normally, the release of progesterone due to ovulation causes a mid-cycle
temperature rise of 0.5 to 1.0 degrees Fahrenheit, indicating that ovulation has
occurred. However, some women who ovulate normally may not have a rise in
temperature, and many factors unrelated to the reproductive cycle, such as a
cold or fatigue, can affect the BBT. At best, the BBT chart helps determine when
and if ovulation is taking place, but only after it has happened. To predict
ovulation before it takes place, in order to schedule intercourse or
insemination for example, you may use an ovulation prediction kit.
These urine test kits are designed to detect the surge of luteinizing hormone
(LH) that occurs just before you ovulate. The LH surge stimulates one of the
ovaries to release an egg and produce progesterone. Ovulation prediction kits
usually detect the LH surge about a day or a day and a half before ovulation,
giving you and your partner advance notice of impending ovulation. However,
not all women who ovulate will have an LH surge that will be detected using
these kits. In a normal cycle, progesterone levels peak about seven days after
ovulation. Your physician may perform a blood test to measure the level of
progesterone in your blood at this time. Generally, blood progesterone is tested
on day 19 to 23 of a 28-day menstrual cycle. An elevated progesterone level
helps to confirm ovulation and the adequacy of ovarian hormone production.
Your physician may perform a pelvic ultrasound examination to evaluate
ovulation, but this is not done routinely. This examination may indicate whether
your ovaries are producing follicles. These follicles are fluid filled sacs (cysts)
located just beneath the ovary’s surface that contain the immature eggs.
Ultrasound may also help to document the follicle’s collapse, implying release of
the egg. Another procedure, the endometrial biopsy, may be advised in a few
cases to evaluate the uterine lining. Just before your period begins, your
physician takes a small sample of tissue from your endometrium, which is the
inner lining of your uterus. This test may produce painful cramping and your
physician may prescribe medication for pain relief prior to the procedure. A
pregnancy test may be performed prior to the biopsy to make sure that you are
not pregnant. The removed tissue is specially prepared by a pathologist and
examined under a microscope to  determine the effect of your hormones on your
endometrium. The endometrial biopsy is usually obtained one to three days
before menstruation is expected, typically day 26 of a 28-day cycle, which is
when progesterone-induced changes in the endometrium are at their maximum.
The endometrial biopsy can also be scheduled 12 to 13 days after the LH surge.
Your physician must know the ovulation date or the starting date of your next
period to interpret the biopsy. The biopsied tissue’s appearance under the
microscope may indicate a luteal phase defect, which means that it has not
responded properly to the progesterone secreted by the ovary after ovulation.
Treatment may consist of administering progesterone or ovulation drugs.
If you are not ovulating, your physician may prescribe ovulation drugs to induce
ovulation as well as order special tests to determine the reason. Your medical
history and physical exam will help determine which tests are appropriate. More
potent fertility drugs given by injection may be prescribed if oral therapy fails.
The Tubal Factor
Because open and functional fallopian tubes are necessary for conception, tests
to determine tubal openness (patency) are important. Tubal factors, as well as
factors affecting the peritoneum (lining of the pelvis and abdomen), account for
about 35% of all infertility problems. Aspecial x-ray called a
hysterosalpingogram (HSG) (Figure 4) can be performed to evaluate the fallopian
tubes and uterus. During an HSG, a special fluid (dye) is injected through your
cervix, fills your uterus, and travels into your fallopian tubes. If the fluid spills out
the ends of the tubes, they are open. If the fluid does not spill out the ends, then
the tubes are blocked. If the HSG shows blocked fallopian tubes, your physician
may perform a laparoscopy to assess the degree of tubal damage. If the tubes
are found to be blocked, scarred, or damaged, surgery can sometimes correct
the problem. Although some tubal problems are correctable by surgery, women
with severely damaged tubes are so unlikely to become pregnant that in vitro
fertilization (IVF) offers them the best hope for a successful pregnancy. Because
very badly damaged tubes may fill with fluid and lower IVF success rates, your
physician may recommend removal of the tubes prior to IVF.
The Male Factor
In approximately 40% of infertile couples, the male partner is either the sole or a
contributing cause of infertility. Therefore, a semen analysis is important in the
initial evaluation. To prepare for a semen analysis, your partner will be asked to
abstain from ejaculating for at least 48 hours. He then will collect a semen
sample in a cup by masturbating at home or in the physician’s office. In some
instances, a semen sample may be obtained during sexual intercourse using a
special condom provided by the physician. The semen specimen is examined
under a microscope to determine the volume (amount), motility (movement), and
morphology (appearance and shape) of the sperm. In general, two or three
semen analyses are recommended over two to six months, since sperm quality
can vary over time. Other tests may be recommended as well.
If your partner’s semen analysis reveals abnormalities, he may need to
consult a urologist or other physician who specializes in male infertility.
Treatment for male factor infertility may include antibiotic therapy for infection,
surgical correction of varicocele (dilated or varicose veins in the scrotum) or
duct obstruction, or medications to improve sperm production. In some cases, no
obvious cause of poor sperm quality can be found. Intrauterine insemination
(IUI) or IVF may then be recommended. Direct injection of a single sperm into
an egg (intracytoplasmic sperm injection [ICSI]) may be recommended as well.
If no sperm are present, your physician may discuss using a sperm donor.
Insemination with donor sperm may also be considered if IUI is not successful
or if you and your partner do not choose to undergo IVF.

The Age Factor
Delaying pregnancy is a common choice for women in today’s society. The
number of women in their late 30s and 40s attempting pregnancy and having
babies has increased in recent years. If you’ve chosen to delay pregnancy, due
to college or career for example, you may not realize that your fertility begins to
decline significantly in your mid 30s and accelerates in your late 30s. Some
women even begin to experience a decline in their fertility in their late 20s and
early 30s. Fertility declines with age because fewer eggs remain in your ovaries,
and the quality of the eggs remaining is lower than when you were younger.
Blood tests are now available to determine your ovarian reserve, which reflects
your agerelated fertility potential. In the simplest of these tests, the hormones
FSH and estradiol are tested in your blood on the second, third, or fourth day of
your menstrual period. An elevated FSH level indicates that your chances for
pregnancy may be slim, especially if you are age 35 or older, but does not mean
that you have no chance of successful conception. Older women tend to have a
lower response to fertility medications and a higher miscarriage rate than
younger women. The chance of having a chromosomally deformed embryo, such
as one with Down syndrome, also increases with age. Because of the marked
effect of age on pregnancy and birth rates, it is common for older couples to
begin fertility treatment sooner and, in some cases, to consider more aggressive
treatment than younger couples. Possible treatments for age-related infertility in
women include fertility drugs plus IUI or IVF. In cases where the treatments fail
or are predicted to have a low chance of success, egg donation is an option.
Egg donation has a high chance of success, regardless of your FSH level. For
couples who have not succeeded with fertility treatments or who choose to
forgo treatment, adoption is an important option.

The Cervical/Uterine Factor
Conditions within the cervix, which is the lower part of the uterus, may impact
your fertility, but they are rarely the sole cause of infertility. It is important for
your physician to know if you have had prior biopsies, surgery, “freezing”
and/or laser treatment of the cervix, abnormal pap smears, or if your mother
took DES (diethylstilbestrol) while she was pregnant. In order to determine if
there is a problem with your cervix, your physician may recommend a postcoital
test (PCT) which evaluates cervical mucus, sperm, and the interaction between
the two. However, many physicians are not currently recommending this test
because it has not been shown to be of value in increasing pregnancy rates.
Cervical problems are generally treated with antibiotics, hormones, or by IUI.
The HSG test, which is used to investigate the fallopian tubes, can also reveal
defects inside the uterine cavity, which is the hollow space inside your uterus
where an embryo would implant and develop. An HSG is sometimes conducted
after your period stops and before ovulation. Possible uterine abnormalities that
may be identified include uterine scar tissue, polyps (bunched-up pieces of the
endometrial lining), fibroids, or an abnormally shaped uterine cavity. Problems
within your uterus may interfere with implantation of the embryo or may
increase the incidence of miscarriage. Surgery (hysteroscopy) may be required
to further evaluate and possibly correct uterine structural problems.
Uterine abnormalities can also be seen by a saline hysterogram (SHG). This
test may also be called a sono-hysterogram or water ultrasound. An SHG is a
pelvic ultrasound performed while saline is injected through your cervix to
outline the uterine cavity. Unlike the HSG, the SHG allows visualization of the
wall of the uterus as well as the cavity at the same time, a difference which may
be helpful in some cases.

Peritoneal Factor Infertility
Peritoneal factor infertility refers to abnormalities involving the peritoneum
such as scar tissue (adhesions) or endometriosis. Endometriosis is a
condition where tissue that normally lines the uterus begins to grow outside the
uterus. This tissue may grow on any structure within the pelvis including the
ovaries and is found in about 35% of infertile women who have no other
diagnosable infertility problem. Endometriosis is found more commonly in
women with infertility. Laparoscopy is a surgical procedure which is performed
to diagnosis and treat adhesions or endometriosis. Laparoscopy is usually
performed under general anesthesia, often in a hospital’s same-day surgery unit.
During the procedure, a narrow, lighted telescopic instrument called a
laparoscope is inserted through a small incision within or just below your navel.
The physician then looks directly into your abdominal cavity and inspects the
ovaries, fallopian tubes, and uterus. A dye is usually injected through the cervix
to determine if the passage to the uterus and tubes is open. One or more
additional smaller cuts may be made above your pubic area in order for the
physician to insert additional instruments to better examine your pelvic organs
and treat any disease if found. A variety of specialized surgical instruments,
including lasers, may now be used laparoscopically to treat such conditions as
endometriosis, adhesions, and ovarian cysts such as endometiomas (fluid-filled
cysts on the ovaries). In many cases, laparotomy, which involves a larger
abdominal incision than laparoscopy and an approximately six-week recovery, is
rarely necessary since many problems can now be treated laparoscopically.
Although it is reasonable and sometimes advisable to perform laparoscopy to
identify and treat pelvic disease, this procedure is not routinely performed in an
infertility evaluation. Laparoscopy can be expensive and involves some surgical
risk. You and your physician should discuss whether not or laparoscopy is
recommended in your particular case.

Unexplained Infertility
In approximately 5% to 10% of couples trying to conceive, all of the above
tests are normal and there is no apparent cause for infertility. In a much higher
percentage of couples, only minor abnormalities are found that are not severe
enough to result in infertility. In these cases, the infertility is referred to as
unexplained. Couples with unexplained infertility may have problems with egg
quality, tubal function, or sperm function that are difficult to diagnose and/or
treat. Fertility drugs and IUI have been used in couples with unexplained
infertility with some success. If no pregnancy occurs within three to six
treatment cycles, IVF may be recommended.

CHANCES OF SUCCESS WITH IVF
Each couple has a unique set of circumstances, and the chances of treatment
success vary widely. The success of IVF depends on many factors, especially
your age. Your doctor will work with you to refer you to an appropriate IVF
center should that become the best choice for you.

PSYCHOLOGICAL IMPLICATIONS
Infertility is a medical condition that has many emotional aspects. Feelings such
as anger, sadness, guilt, and anxiety are common and may affect your self
esteem and self-image. You may find it difficult to share your feelings with
family and friends, which can lead to isolation. It is important to know that these
feelings are normal responses to infertility and are experienced by many
couples. Although a physician will describe various treatments and realistic odds
of success with treatments, you must decide how far you will go in your attempts
to conceive. Coming to a joint decision with your partner about goals and
acceptable therapies is important. Setting endpoints for therapy may also be
advisable.