FERTILITY

What is an infertility evaluation?

During an infertility evaluation, exams and tests are done to try to find the cause of infertility. If a cause is found, treatment may be possible. Infertility often can be successfully treated even if no cause is found.

When should I consider having an infertility evaluation?

You should consider having an infertility evaluation if any of the following apply to you:

  • You have not become pregnant after 1 year of having regular sexual intercourse without the use of birth control.
  • You are older than 35 years and have not become pregnant after 6 months of having regular sexual intercourse without the use of birth control.
  • Your menstrual cycle is not regular.
  • You or your partner have a known fertility problem.

What causes infertility?

Infertility can be caused by a number of factors. Both male and female factors can contribute to infertility. Female factors may involve problems with ovulation, the reproductive organs, or hormones. Male factors often involve problems with the amount or health of sperm.

Does age affect fertility?

Yes. A woman begins life with a fixed number of eggs. This number decreases as she grows older. For healthy, young couples, the chance that a woman will become pregnant is about 20% in any single menstrual cycle. This percentage starts to decline in a woman’s early 30s. It declines more rapidly after age 37 years. A man’s fertility also declines with age, but not as predictably.

Can lifestyle affect fertility?

Lifestyle factors can play a role in infertility. For women, being underweight, being overweight, or excessive exercise may be associated with infertility. Drinking alcohol at moderate or heavy levels and smoking may make it difficult for a woman to get pregnant. For men, smoking, heavy drinking, marijuana use, and anabolic steroid use can reduce sperm count and movement. Smoking also can lead to erectile dysfunction.

How long does an infertility evaluation take?

The infertility evaluation can be finished within a few menstrual cycles in most cases.

What should I expect during my first visit for infertility?

The first visit usually involves a detailed medical history and a physical exam. During the medical history, you will be asked questions about your menstrual period, abnormal vaginal bleeding or discharge, pelvic pain, and disorders that can affect reproduction, such as thyroid disease.

If you have a male partner, both of you will be asked about the following health issues:                                                 

Medications (both prescription and over-the-counter) and herbal remedies
Illnesses, including sexually transmitted diseases, and past surgery
Birth defects in your family
Past pregnancies and their outcomes
Use of tobacco, alcohol, and illegal drugs
Occupation

You and your partner also will be asked questions about your sexual history:

Methods of birth control
How long you have been trying to become pregnant?
How often you have sex and whether or not you have difficulties?
If you use lubricants during sex
Prior sexual relationships
What tests are done for infertility?
Tests for infertility include laboratory tests, imaging tests, and certain procedures.

What consists in basic testing?

Laboratory tests include tracking basal body temperature, a urine test, a progesterone test, thyroid function tests, prolactin level test, and tests of ovarian reserve. Imaging tests and procedures include an ultrasound exam, hysterosalpingography, sonohysterography, hysteroscopy, and laparoscopy. You may not have all of these tests and procedures. Some are done based on results of previous tests and procedures.

What is the purpose of tracking basal body temperature?

Tracking basal body temperature is a way to tell whether ovulation has occurred. After a woman ovulates, her body temperature increases slightly.

How do I track my basal body temperature?

To perform this test, you will need to take your temperature by mouth every morning before you get out of bed. You record it on a chart for two or three menstrual cycles.

What do results from a urine test determine?

Urine test results determine when and if you ovulate. The test detects luteinizing hormone (LH) in the urine. LH triggers the release of an egg.

How is a progesterone test done?

A sample of blood is taken on a given day in the menstrual cycle. The level of the hormone progesterone is measured. An increased level shows that you have ovulated.

When would a thyroid function test be done?

Thyroid function problems can affect fertility. If a problem is suspected with your thyroid gland, levels of hormones that control the thyroid gland are measured to see if it is working normally.

What is a prolactin level test?

This blood test measures the level of the hormone prolactin. High prolactin levels can disrupt ovulation.

What are tests of ovarian reserve?

These tests measure the levels of certain hormones in the blood that are involved in ovulation. They may be recommended if you are older than 35 years or if you have known fertility problems. Results of these tests can give an idea of the number of eggs the ovaries have and whether they are still healthy.

Why are imaging tests and procedures done?

Different imaging tests and procedures are used to look at your reproductive organs. They check whether your fallopian tubes are healthy and whether there are problems in your uterus. The procedures used depend on your symptoms as well as the results of other tests and procedures.

What does testing of a man involve?

The testing for a man often involves a semen analysis (sperm count). If the result of the semen analysis is abnormal or areas of concern are found in the man’s history, other tests may be considered. For example, an ultrasound exam may be done to find problems in the ducts and tubes that the semen moves through. Ultrasound also may be used to find problems in the scrotum that may be causing infertility.

Glossary

Basal Body Temperature: The temperature of the body at rest.

Erectile Dysfunction: The inability in a man to achieve an erection or to sustain it until ejaculation or until intercourse takes place.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Hormones: Substances produced by the body to control the functions of various organs.

Hysterosalpingography: A special X-ray procedure in which a small amount of fluid is placed into the uterus and fallopian tubes to detect abnormal changes in their size and shape or to determine whether the tubes are blocked.

Hysteroscopy: A procedure in which a slender device, the hysteroscope, is inserted into the uterus through the cervix to view the inside of the uterus or perform surgery.

Laparoscopy: A surgical procedure in which an instrument called a laparoscope is inserted into the pelvic cavity through a small incision. The laparoscope is used to view the pelvic organs. Other instruments can be used with it to perform surgery.

Luteinizing Hormone (LH): A hormone produced by the pituitary gland that helps an egg to mature and be released.
Ovulation: The release of an egg from one of the ovaries.

Progesterone: A female hormone that is produced in the ovaries and that prepares the lining of the uterus for pregnancy.
Scrotum: The external genital sac in the male that contains the testes.

Semen: The fluid made by male sex glands that contains sperm.

Sexual Intercourse: The act of the penis of the male entering the vagina of the female (also called “having sex” or “making love”).

Sexually Transmitted Diseases: Diseases that are spread by sexual contact, including chlamydia, gonorrhea, genital warts, herpes, syphilis, and infection with human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]).

Sonohysterography: A procedure in which sterile fluid is injected into the uterus through the cervix while ultrasound images are taken of the inside of the uterus.

Ultrasound: A test in which sound waves are used to examine internal structures. During pregnancy, it can be used to examine the fetus.

Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy.

What are common signs and symptoms of polycystic ovary syndrome (PCOS)?

Common PCOS signs and symptoms include the following:
Irregular menstrual periods—Menstrual bleeding may be absent, heavy, or unpredictable.
Infertility—PCOS is one of the most common causes of female infertility.
Obesity—Up to 80% of women with PCOS are obese.
Excess hair growth on the face, chest, abdomen, or upper thighs—This condition, called hirsutism, affects more than 70% of women with PCOS.
Severe acne or acne that occurs after adolescence and does not respond to usual treatments
Oily skin
Patches of thickened, velvety, darkened skin called acanthosis nigricans
Multiple small cysts on the ovaries

What causes PCOS?

Although the cause of PCOS is not known, it appears that PCOS may be related to many different factors working together. These factors include insulin resistance, increased levels of androgens, and an irregular menstrual cycle.

What is insulin resistance?

Insulin resistance is a condition in which the body’s cells do not respond to the effects of insulin. When the body does not respond to insulin, the level of glucose in the blood increases. Higher than normal blood glucose levels may eventually lead to diabetes mellitus. Insulin resistance also may cause more insulin to be produced as the body tries to move glucose into cells. High insulin levels may cause the appetite to increase and lead to imbalances in other hormones. Insulin resistance also is associated with acanthosis nigricans.

What can high levels of androgens lead to?

When higher than normal levels of androgens are produced, the ovaries may be prevented from releasing an egg each month (a process called ovulation). High androgen levels also cause the unwanted hair growth and acne seen in many women with PCOS.

What can irregular menstrual periods lead to?

Irregular menstrual periods can lead to infertility and, in some women, the development of numerous small cysts on the ovaries.

What are the health risks for women with PCOS?

PCOS affects all areas of the body, not just the reproductive system. It increases a woman’s risk of serious conditions that may have lifelong consequences.

Insulin resistance increases the risk of type 2 diabetes mellitus and cardiovascular disease. Another condition that is associated with PCOS is metabolic syndrome. This syndrome contributes to both diabetes and heart disease.

Women with PCOS tend to have a condition called endometrial hyperplasia, in which the lining of the uterus (the endometrium) becomes too thick. This condition increases the risk of endometrial cancer.

Are treatments available for women with PCOS?

A variety of treatments are available to address the problems of PCOS. Treatment is tailored to each woman according to symptoms, other health problems, and whether she wants to become pregnant.

How can combination birth control pills be used to treat women with PCOS?

Combination birth control pills can be used for long-term treatment in women with PCOS who do not wish to become pregnant. Combination pills contain both estrogen and progestin. Birth control pills regulate the menstrual cycle and reduce hirsutism and acne by decreasing androgen levels. They also decrease the risk of endometrial cancer.

What effect can weight loss have on women with PCOS?

For overweight women, weight loss alone often regulates the menstrual cycle. Even a small weight loss of 10–15 pounds can be helpful in making menstrual periods more regular. Weight loss also has been found to improve cholesterol and insulin levels and relieve symptoms such as excess hair growth and acne.

How can insulin-sensitizing drugs help treat women with PCOS?

Insulin-sensitizing drugs used to treat diabetes frequently are used in the treatment of PCOS. These drugs help the body respond to insulin. In women with PCOS, they can help decrease androgen levels and improve ovulation. Restoring ovulation helps make menstrual periods regular and more predictable.

What can be done to increase the chances of pregnancy for women with PCOS?

Successful ovulation is the first step toward pregnancy. For overweight women, weight loss often accomplishes this goal. Medications also may be used to cause ovulation. Surgery on the ovaries has been used when other treatments do not work. However, the long-term effects of these procedures are not clear.

Glossary

Acanthosis Nigricans: Patches of thickened, velvety, darkened skin that is sometimes associated with insulin resistance.

Androgens: Steroid hormones produced by the adrenal glands or by the ovaries that promote male characteristics, such as a beard and deepening voice.

Cardiovascular Disease: Disease of the heart and blood vessels.

Cells: The smallest units of a structure in the body; the building blocks for all parts of the body.

Cholesterol: A natural substance that serves as a building block for cells and hormones and helps to carry fat through the blood vessels for use or storage in other parts of the body.

Cysts: Sacs or pouches filled with fluid or other material.

Diabetes Mellitus: A condition in which the levels of sugar in the blood are too high.

Endometrial Hyperplasia: A condition in which the lining of the uterus grows too thick; if left untreated for a long time, it may lead to cancer.

Endometrium: The lining of the uterus.

Estrogen: A female hormone produced in the ovaries.

Glucose: A sugar that is present in the blood and is the body’s main source of fuel.

Hirsutism: Excessive hair on the face, abdomen, and chest.

Hormones: Substances produced by the body to control the functions of various organs.

Infertility: A condition in which a couple has been unable to get pregnant after 12 months without the use of any form of birth control.

Insulin: A hormone that lowers the levels of glucose (sugar) in the blood.

Metabolic Syndrome: Combination of factors that contribute to both diabetes and heart disease.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Ovulation: The release of an egg from one of the ovaries.

Progestin: A synthetic form of progesterone that is similar to the hormone produced naturally by the body.

What is infertility?

Infertility is defined as not having become pregnant after 1 year of having regular sexual intercourse without the use of birth control. Infertility can be caused by a number of factors. Both male and female factors can contribute to infertility.

What treatment options are available for infertility?

Treatment options depend on the cause of your infertility. Lifestyle changes, medication, surgery, or assisted reproductive technology (ART) may be recommended. Several different treatments may be combined to improve results. Infertility often can be successfully treated even if no cause is found.

What lifestyle changes may help improve my chances for pregnancy?

If lifestyle factors are identified, you may need to lose or gain weight or do more or less exercise. You or your male partner may need to reduce your intake of alcohol, quit smoking, or stop using illegal drugs.

How is surgery used to treat infertility in women?

In women, surgery may be able to repair blocked or damaged fallopian tubes. Surgery is used to treat endometriosis, which is commonly associated with infertility.

How is surgery used to treat infertility in men?

In men, surgery can be used to treat some infertility problems. A common problem that leads to male infertility, varicocele, sometimes can be treated with surgery.

How are hormonal problems treated in women?

Abnormal levels of hormones can cause irregular ovulation or lack of ovulation. For example, polycystic ovary syndrome is a condition in which the levels of certain hormones are abnormal and menstrual periods are irregular or absent. It is a common cause of infertility. This condition often is treated with lifestyle changes or medication. Progesterone may be used to treat some ovulation problems. Other hormonal conditions that affect fertility in women, such as thyroid disease, should be ruled out.

What is ovulation induction?

Ovulation induction is the use of drugs to induce a woman’s ovaries to release an egg. This treatment is used when ovulation is irregular or does not occur at all and other causes have been ruled out.

How is ovulation induction done?

The drug most commonly used for ovulation induction is clomiphene citrate. About 40% of women achieve pregnancy with the use of this drug within six menstrual cycles. Side effects usually are mild and include hot flashes, breast tenderness, nausea, and mood swings.

What drugs other than clomiphene citrate are used for ovulation induction?

If clomiphene citrate is not successful, drugs called gonadotropins may be tried to induce ovulation. Gonadotropins also are used when many eggs are needed for ART or other infertility treatments. This is called super ovulation.

How are gonadotropins used?

Gonadotropins are given in a series of shots early in the menstrual cycle. Blood tests and ultrasound exams are used to track the maturation of the follicles (small sacs in which eggs develop). When test results show that the follicles have reached a certain size, another drug called human chorionic gonadotropin (hCG) may be given. This drug triggers ovulation.

What risks are associated with ovulation induction?

Twins occur in about 10% of women treated with clomiphene citrate. Triplets or more are rare. The risk of multiple pregnancy is higher when gonadotropins are used. Up to 30% of pregnancies conceived with gonadotropins are multiple. About two thirds of these pregnancies are twins and one third are triplets or more.

Ovulation induction can lead to ovarian hyperstimulation syndrome. Most cases of this condition are mild. In severe cases, hospitalization may be needed.

What is intrauterine insemination?

In intrauterine insemination, a large amount of healthy sperm is placed in the uterus as close to the time of ovulation as possible. It often is used with ovulation induction or super ovulation. The woman’s partner or a donor may provide the sperm. Sperm that has been retrieved earlier and frozen also can be used.

What are the risks of intrauterine insemination?

If ovulation drugs are used with intrauterine insemination, multiple pregnancy can occur. If too many eggs are developing at the time of insemination, the insemination may be canceled.

What is assisted reproductive technology (ART)?

ART includes all fertility treatments in which both eggs and sperm are handled. ART usually involves in vitro fertilization (IVF). In IVF, sperm is combined with the egg in a lab, and the embryo is transferred to the uterus. IVF is done for the following causes of infertility:

  • Damaged or blocked fallopian tubes that cannot be treated with surgery
  • Some male infertility factors
  • Severe endometriosis
  • Premature ovarian failure
  • Unexplained infertility

How can I find out ART success rates?

The Centers for Disease Control and Prevention reports this information on its web site (www.cdc.gov/reproductivehealth/ index.htm). Success rates also are listed on the web site of the Society for Assisted Reproductive Technology (SART) (www.sart.org).

How is in vitro fertilization (IVF) done?

IVF is done in cycles. It can take more than one cycle to succeed. The sperm may come from your partner or from a donor. Sperm can be retrieved and then frozen for later use in IVF. Ovulation usually is induced with gonadotropins so that many eggs are produced. The egg also may come from a donor. Eggs that have been previously frozen can be used.

Eggs are removed from the ovaries when they are mature. Healthy sperm then are added to the eggs in the lab. The eggs are checked the following day to see if they have been fertilized. A few days later, one or more embryos are placed in your uterus. The embryo may come from a donor. Healthy embryos that are not transferred can be frozen and stored for later use.

What is intracytoplasmic sperm injection (ICSI)?

Sometimes, a single sperm may be injected into each egg. This is called ICSI. ICSI may be recommended if there is a problem with your partner’s sperm. In ICSI, only a single healthy sperm is needed for each egg. A few days later, one or more embryos are placed in the uterus through the vagina.

What are the risks associated with IVF?

There is an increased risk of multiple pregnancy with IVF. IVF also has been linked to an increased risk of birth defects. These defects include cleft palate, heart problems, and problems with the digestive tract. Overall, however, the increase in risk of birth defects is small.

What steps can be taken to help prevent multiple pregnancy with IVF?

Several things can be done to help prevent multiple pregnancy. If test results suggest that too many eggs are developing, the hCG shot that triggers ovulation may be delayed or not given. Your doctor also may limit the number of embryos transferred to your uterus.

Glossary

Assisted Reproductive Technology (ART): A group of infertility treatments in which an egg is fertilized with a sperm outside the body; the fertilized egg then is transferred to the uterus.

Egg: The female reproductive cell produced in and released from the ovaries; also called the ovum.

Embryo: The developing organism from the time it implants in the uterus up to 8 completed weeks of pregnancy.

Endometriosis: A condition in which tissue similar to that normally lining the uterus is found outside of the uterus, usually on the ovaries, fallopian tubes, and other pelvic structures.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Follicles: The sac-like structures in which eggs develop inside the ovary.

Hormones: Substances produced by the body to control the functions of various organs.

Human Chorionic Gonadotropin (hCG): A hormone produced during pregnancy; its detection is the basis for most pregnancy tests.

In Vitro Fertilization (IVF): A procedure in which an egg is removed from a woman’s ovary, fertilized in a dish in a lab with the man’s sperm, and then reintroduced into the woman’s uterus to achieve a pregnancy.

Multiple Pregnancy: A pregnancy in which there are two or more fetuses.

Ovarian Hyperstimulation Syndrome: A condition caused by overstimulation of the ovaries that may cause painful
swelling of the ovaries and fluid in the abdomen and lungs.

Ovaries: Two glands, located on either side of the uterus, that contain the eggs released at ovulation and that produce hormones.

Ovulation: The release of an egg from one of the ovaries.

Polycystic Ovary Syndrome: A condition characterized by two of the following three features: the presence of growths called cysts on the ovaries, irregular menstrual periods, and an increase in the levels of certain hormones.

Premature Ovarian Failure: A condition in which ovulation and the menstrual cycle stop before age 35 years.

Progesterone: A female hormone that is produced in the ovaries and that prepares the lining of the uterus for pregnancy.

Sexual Intercourse: The act of the penis of the male entering the vagina of the female (also called “having sex” or “making love”).

Sperm: A male cell that is produced in the testes and can fertilize a female egg.

Ultrasound: A test in which sound waves are used to examine internal structures.

Uterus: A muscular organ located in the female pelvis that contains and nourishes the developing fetus during pregnancy.

Varicocele: Varicose veins in the scrotum.

 

A diet rich in proteins appears to have a pronounced positive effect on fertility, according to new research presented today at the Annual Clinical Meeting of The American College of Obstetricians and Gynecologists. Women undergoing in vitro fertilization (IVF) treatments who consumed high levels of protein and low levels of carbohydrates had better quality eggs and embryos.

Research led by Jeffrey B. Russell, MD, at the Delaware Institute for Reproductive Medicine (DIRM) in Newark, showed that patients whose daily protein intake was 25% or more of their diet and whose carbohydrate intake was 40% or less of their diet had four times the pregnancy rates of patients who ate less protein and more carbs daily before and during IVF cycles.

“Protein is essential for good quality embryos and better egg quality, it turns out,” said Dr. Russell. Between January 2010 and December 2011, 120 patients participating in an assisted-reproduction therapy program at DIRM completed a three-day nutritional log and had an embryo transfer. The diet diaries revealed that 48 patients had an average daily protein intake greater than 25% vs. 72% who had less than 25%. No differences were found in body mass index (BMI) in either group.

Embryo development was assessed after five days of culture or at the blastocyst stage. An increased blastocyst formation was found in 54.3% of patients whose daily protein intake was greater than 25% vs. 38% blastocyst formation in patients whose daily protein intake was less than 25%. The pregnancy rate was also significantly improved in patients with greater than 25% daily protein intake (66.6 % vs. 31.9%).

Dr. Russell pointed out that although BMI is implicated in reduced fertility, he had been seeing poor quality embryos among thin and healthy women. This made him want to take a closer look. After patients filled out their nutritional logs, Dr. Russell was surprised to see a large percentage of the women eating more than 60% carbs each day and 10% (or less) protein. These diets were associated with poor quality embryos.

Dr. Russell now requires patients to eat 25% to 35% protein and 40% or less carbs for three months before allowing them to begin their IVF cycles. His colleagues have also begun doing the same, he said.

Young women undergoing cancer treatment have an increasing number of options for preserving their fertility, a leading researcher told attendees today at the 58th Annual Clinical Meeting of The American College of Obstetricians and Gynecologists.

Thanks to a new medical discipline known as oncofertility, the reproductive outlook for women cancer patients is becoming as good as for men, who long have had the option of banking their sperm, according to Teresa K. Woodruff, PhD, of Northwestern University Feinberg School of Medicine in Chicago, in her lecture "Oncofertility: The Preservation of Fertility Options for Young People with Cancer." A promising new technique for preserving ovarian tissue has the potential to safeguard the future fertility even of very young girls undergoing cancer treatment, she said.

Dr. Woodruff, the Thomas J. Watkins professor of obstetrics and gynecology at Northwestern, coined the term "oncofertility" to describe oncologists and reproductive specialists working hand-in-hand to preserve patients' fertility while treating their disease. She is the leader of the Oncofertility Consortium, which draws on cutting-edge research to counsel patients on fertility options. Headquartered at Northwestern and supported by the National Institutes of Health, the Consortium operates through more than 50 centers in 29 states.

About 140,000 people under age 45 are diagnosed with cancer each year in the United States, Dr. Woodruff said. "There are no good numbers for how many are threatened with loss of fertility, because it depends on the course of the disease and treatment prescribed," she said.

Chemotherapy affects fertility by attacking follicles in the ovaries that contain a woman's lifetime supply of eggs, Dr. Woodruff explained. Because follicles grow rapidly, they are especially sensitive to cancer drugs, which target fast-growing cancer cells. If drugs damage only mature follicles and the eggs they contain, a woman may stop having periods during treatment but resume menstrual cycles after she completes chemotherapy. But if drugs destroy all the follicles, she will be left sterile.

Radiation treatment to the abdomen can damage the follicles, as well as the uterus. If directed to the head, radiation can impact fertility by blocking production of reproductive hormones in the brain.

Many women with cancer who want to safeguard their fertility opt for egg or embryo banking, which oncofertility specialists are making available to more patients. "Egg banking also is much more effective now than five or ten years ago, because we can freeze the eggs better," Dr. Woodruff said.

However, egg banking is not suitable for girls who have not yet gone through puberty or for women who cannot postpone cancer treatment while they take hormones to stimulate production of mature eggs. A new option called ovarian tissue cryopreservation sidesteps these problems. Doctors remove an ovary via laparoscopy, an outpatient surgery that takes 30 to 45 minutes. The procedure requires no hormones and does not delay cancer treatment for more than a couple of days. Tissue from the removed ovary is sliced into strips, frozen, and stored. Because a girl is born with all the eggs she will ever have, this technique could be used on a child as young as one year of age, Dr. Woodruff said.

Following cancer treatment or whenever a woman is ready to have a child, the ovarian tissue can be thawed and transplanted back into her body. "Worldwide, there have been about 20 live births resulting from this procedure, including those among some cancer patients," Dr. Woodruff said. Because transplantation does carry the potential risk of reintroducing cancer cells back into the body, it is not recommended for women who have had ovarian cancer or blood system cancers, such as leukemia or lymphoma.

Researchers are working hard to perfect a safer use of preserved ovarian tissue called in vitro follicle maturation, which may be available in several years. "Instead of growing follicles in a woman's body, we grow them in a dish," Dr. Woodruff explained. "That would allow us to eliminate the possibility of reintroducing the cancer she's just survived. We've produced live, healthy offspring in mice and have gotten good quality eggs in both baboons and rhesus monkeys. Human follicles also have adapted rapidly to the in vitro system. They grow rapidly and are fairly easy to work with."