Definition: Inability to get pregnant after one year of attempts (if the woman
partner is under age 35) or after 6 months of attempts (if over age 35).
Incidence: Approximately 10-12% of couples are unable to conceive. The chance
of a fertile couple to conceive is 20-25% each month, or 85% after 12 months
of attempts.
Causes: Roughly one third of infertility is due to male factors, one half
due to female factors, and the remainder either due to combined factors or unexplained
infertility. Among female factors, the most common causes are the peritoneal
factor (tubal damage, scar tissue, and/or endometriosis) and problems with ovulation.
A distant third factor is cervical mucus abnormalities. Infection, mostly sexually
transmitted, causing tubal damage in the female and scarring in the male is a
common cause. Environmental factors such as exposure to toxins are emerging as
an increasingly important factor of infertility, especially in the male.
Diagnosis: In the male, the semen analysis (preferably using strict morphology
criteria) is the mainstay of diagnosis. A urologist specializing in male infertility
is often the preferred physician to refer to for evaluation and treatment. In
the female, testing tubal and uterine integrity via hysterosalpingogram (HSG)
or sonohysterogram (SHSG) is the preliminary basic workup for the peritoneal
factor, followed by a laparoscopy to diagnose and treat pelvic scarring, tubal
blockage, or endometriosis. Ovulation can be determined by the basal body temperature
(BBT) chart, urine ovulation test, and/or a well-timed blood level of progesterone
(luteal progesterone). While the utility of the post-coital test (PCT or PK)
is debated, it may be helpful in directing the physician to additional tests.
Blood tests for hormone levels should be performed only when indicated by certain
signs and symptoms (e.g. irregular periods, breat discharge). Testing of basic
immune functions is only indicated in the case of habitual miscarriages.
Treatment: male factor infertility may be treated by reducing adverse environmental
factors (smoking, alcohol, stress, excess heat, certain offensive medications);
beneficial medications (e.g. antibiotics, clomiphene), inseminations, or in vitro
fertilization (IVF). Female peritoneal factors may be addressed at surgery (usually
at outpatient laparoscopy) or bypassed by performing IVF. Ovulation problems
may be addressed by changing life habits (weight loss, stress reduction); fertility
medications (either pills- clomiphene or letrozole, or injections of gonadotropins).
Metformin, a medication for diabetes, may be used for correction of ovulatory
problems in insulin-resistant patients. Cervical mucus abnormalities may be addressed
by treatment with antibiotics or bypassed by artificial insemination. For long-standing
infertility resistant to conventional treatment, IVF is offered. Generally, treatment
of infertility must take into account the patient's age, anxiety level, financial
ability, length of infertility, and what was already done in the past for this
condition. The principle FIRST DO NO HARM must be kept in mind at all times.
©Copyright Eli Reshef MD
back to Fertility Articles Main Page
