Infertility & Problems Getting Pregnant

• In the United States, about 10-15% of women ages 15 to 44, or about 6.1 million women, have problems getting pregnant or carrying a baby to term.

• Major risk factors include:
  • Patient age – fertility decreases with age, especially as patients approach mid- 30s
  • Weight – extremes of weight can impact fertility; the ideal body mass index (weight for height) is 19 to 25
  • Smoking history

• Infertility is generally defined as one year of unprotected intercourse without conception. About 85% of healthy young couples will conceive within one year.

• In general, the probability that a single cycle will result in a pregnancy is 20-25% in normal couples.

• Most “infertile” couples are not truly sterile; most have a simple decrease in fertility.

• The majority of spontaneous pregnancies occur within 3 years; thereafter, the prognosis for success without treatment is relatively poor.

• What influences success?
  • Female partner age
  • Duration of infertility
  • Past conception history
  • Causes of infertility
    • For example, ovulatory dysfunction (as with polycystic ovarian syndrome), male factors (poor semen quantity or quality), fallopian tube disease, abnormalities of the uterus and fallopian tubes and/or endometriosis (poor success if severe endometriosis)

• Indications for evaluation include:
  • Failure to conceive after a year or more of unprotected intercourse
  • Women older than 35
    • Consider testing ovarian reserve
  • Women with irregular or infrequent menses
  • Women with a history of pelvic infection or endometriosis
  • Men with suspected poor semen quality
  • Concerned couple who have not yet tested fertility should consider preliminary evaluation
• What does your doctor need to know? (download Infertility Questionnaire below)

• Laboratory workup will depend on your clinical history.
  • Typical screening includes a semen analysis as part of the initial workup.
  •  Your doctor may want to evaluate ovulation by measuring your serum progesterone level; this is often done on cycle day 21 if you have a 28 day menstrual cycle. However, the best time to test progesterone levels will vary with the overall length of your menstrual cycle.
  • What about home testing with LH Kits?
    • The mid-cycle LH surge is usually a relatively brief event, usually lasting between 48 to 50 hours from start to finish
      • In most tests, the test is positive on only a single day and occasionally on 2 consecutive days
      • Testing is done on a daily basis, usually starting 2 or 3 days before the surge is anticipated based on your menstrual history
      • Test results are sensitive to the volume of fluid intake and the time of day: avoid drinking large volumes of fluid just before you plan to test. LH surges often begin in the morning, so it is often best to test levels in the late afternoon or evening.
      • When are you most fertile? Typically the interval of greatest fertility is the day of LH surge and the following 2 days. If you plan artificial insemination, it is ideal to have this performed the day after your first positive LH test.

• AVOID NSAIDS SUCH AS MOTRIN UNLESS YOU ARE ON YOUR MENSES when you are trying to get pregnant, as these medications can disrupt ovulation

• Serial trans-vaginal ultrasound:
  • This is used to observe your ovaries just before and immediately after ovum release
  • This allows your doctor to determine the size and number of pre-ovulatory follicles. This is used if you are using an ovulation inducing medication such as clomid, and especially if you plan to use medications to trigger ovulation

• What is the post-coital test?
  • Your doctor may want to use this test to try to identify if a cervical factor is a source of infertility.
  • It is performed by collecting a specimen of cervical mucus for microscopic exam shortly before the expected time of ovulation (often based on LH surge or menstrual cycle history from previous cycles) and best no more than 2-12 hours after intercourse
    • Your doctor will look to see how the sperm survives in the mucus and at the quality of your cervical mucus
    • It is best to have your partner abstain from ejaculation for at least 48 hours prior to intercourse for the test
  • What can cause an inaccurate test result? Active vaginal infection leading to inflammation of the cervix. A history of cervical trauma can impact your ability to produce cervical mucus. Furthermore, clomid may affect cervical mucus quality. Lubricants can also interfere with the test result.
  • Why is it used? To determine if the couple may benefit from intrauterine insemination (IUI).
  • Is it necessary to have this test? There is much debate on the utility of this test; some physician use this test and some do not. Often there is more than one cause of infertility; your physician may elect to perform this procedure if it is believed that it will change clinical management (i.e. to inseminate artificially or not). If IVF is planned, this test is unnecessary.

• How will my doctor determine if there are any abnormalities of the structure of my uterus or my fallopian tubes?
  • Anatomic abnormalities that can impact fertility include: congenital malformations, fibroids, scar tissue inside the uterus, and possibly endometrial polyps
  • The anatomy of the uterus can be assessed using a variety of methods including hysterosalpingography (HSG), transvaginal ultrasound and sonohysterography, hysteroscopy, and sometimes laparoscopy. These techniques are best performed in the first half of the menstrual cycle to avoid interruption of pregnancy
    • HSG
      • defines the size and shape of the uterine cavity and to determine if the fallopian tubes are open (tubal patency)
      • Radiopaque dye is injected in the uterus, and an x-ray is performed to evaluate the uterus
      • Sonohysterography
        • Uses fluid and ultrasound to evaluate the uterine cavity and structure and size of the uterus
        • Our office uses a special fluid with doppler imaging to look at the fallopian tubes to determine if they appear open
        • May be better for determining if scar tissue is present inside the uterus, if a uterine septum is present or if the patient has a bicornuate uterus
        • 4 D ultrasound can be used at same time; has a diagnostic accuracy comparable to MRI
        • Can visualize ovaries at the time of the exam
      • Hysteroscopy
        • A camera is used to look inside the uterine cavity
        • The patient is often given conscious sedation for this procedure
        • Provides definitive diagnosis and treatment of intrauterine pathology
      • Laparoscopy
        • Performed under general anesthesia in the hospital or outpatient surgical center
        • A camera is used to look in the abdomen at the uterus, fallopian tubes and ovaries to diagnose and treat conditions that can impact fertility
        • Chromotubation: using a dye to inject in the uterus at the time of surgery to see if the fallopian tubes are open

• ART, assisted reproductive technologies
  • Patients are referred to a Reproductive Endocrinologist. This is a doctor who trained in obstetric s and gynecology and further specialized in management of infertility and treatment of endocrine disorders
  • ART includes vitro fertilization (IVF). Other forms used less often include gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), or embryo transfer via laparoscopy.
  • Indications for IVF:
    • Irreparable fallopian tube damage
    • Severe male factor infertility
    • Couples with multifactor infertility
    • Age-related or unexplained sub-fertility especially when other treatments fail
    • Premature ovarian failure: IVF with donor oocytes is highly successful
    • IVF with gestational surrogate if women with no functional uterus or who have medical disorders for whom pregnancy could cause serious health risk

 *Speroff and Fritz (2005). Clinical Gynecologic Endocrinology and Infertility (7^th Edition). Philadelphia: Lippincott Williams & Wilkins.

 Download Infertility Questionnaire