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Infertility may be defined as lack of conception when a couple has been having regular sexual intercourse for one year. It is usually suggested that a couple wait one year before seeking an infertility evaluation because on average a couple only has about a 20 percent chance of conception during any given menstrual cycle. After a year, about 90 percent of couples who are going to conceive will have conceived. If there are any obvious infertility problems, such as lack of menstrual periods, or amenorrhea, it is not necessary to wait a year and the evaluation and treatment can begin immediately. Also, if the female partner of the couple is 30 years or older treatment may begin before allowing a year to see if conception occurs. This is because the fertility rate in females begins to decline after age 30.
What are the causes of infertility?
Click on the links below to read about the factors leading to infertility and the frequency of occurrence.
Ovulatory factors are involved in 10-20 percent in infertility. This is quite a treatable cause of infertility and pregnancy can usually be achieved in the couple who have an ovulatory factor. The first line of treatment is clomiphene therapy. This type of treatment is relatively inexpensive and usually successful. This type of treatment is often given when the patient has polycystic ovaries. Polycystic Ovaries is a condition where the ovaries have multiple small follicles (a small fluid filled area where an egg develops) but maturation of one of the eggs to maturity and ovulation don’t occur. Polycystic ovaries are sometimes associated with obesity and excessive hair growth of the face (hirsutism), and with irregular periods.
Evaluation includes checking prolactin hormone (a hormone secreted by the pituitary gland) which, if elevated cause lack of menstrual periods and lack of ovulation. Medication may be given to decrease prolactin hormone which will result in regular menstrual periods and ovulation.
Finally gonadotrophin therapy is sometimes given for ovulatory dysfunction. This involves multiple injections of the gonadotrophin hormones which induces ovulation. This type of therapy is expensive and requires intensive monitoring.
Tubal factors are responsible for 15 to 20 percent of infertility. Fallopian tube occlusion may result from infection of the fallopian tubes. Infertility from this cause is very difficult to treat and is usually not successful, unless in-vitro fertilization is done. An exception is reversal of tubal ligation which, under certain circumstances carries about an 80 percent success rate.
Endometriosis is a condition where the lining of the uterus is normally outside of the uterus. It may be on the ovaries, fallopian tubes, or elsewhere in the pelvis. When menstruation occurs, bleeding in the pelvis is irritating and may cause adhesions and scar tissue giving rise to infertility. Different treatments are available for this including drugs, surgery to remove endometriosis and adhesions, and in-vitro fertilization.
Male factors count for 20 to 40 percent of infertility. The more factors involved, the more difficult the infertility is to treat.
After a through evaluation including documentation of ovulation, assessment of fallopian tube patency, and a semen analysis, 10 to 15 percent of patients have unexplained infertility. Empiric treatment may be offered to these patients including clomaphene therapy combined with washed intrauterine insemination, gonadotrophin therapy combined with washed intrauterine insemination and in-vitro fertilization.
Primary Amenorrhea may be defined as no menstrual periods by age 15 without secondary sexual characteristics, such as breast development, or by age 17 with secondary sexual characteristics. Secondary amenorrhea is lack of menstrual periods for a period of time equivalent to three previous menstrual cycles. The incidence of amenorrhea is about 6 percent of reproductive age women. In primary amenorrhea, gonadotrophins, FSH and LH (hormones secreted by the pituitary gland that are responsible for ovarian hormone synthesis and oocyte (egg) development and maturation are checked. If gonadotropin hormones are elevated, the ovaries have failed to develop, and more than likely the female hormones (estrogens) will never be secreted and pregnancy will never occur. A chromosome analysis or karyotype is done and if there is a Y or male chromosome present in these individuals the gonads are removed because of the propensity for malignant transformation.
If the gonadotrophins are normal, the ovaries are also probably normal and pregnancy can usually be achieved.
The incidence of secondary amenorhhea is about 4 percent of reproductive age women. Here again gonadotrophins can be measured to see weather ovarian failure has occurred.
Also usually a progestin hormone challenge is given. A progestin hormone is taken, and if there is vaginal bleeding then all of the machinery to produce female hormones and eggs are present and usually medications can be given to induce menstrual periods and to cause ovulation which will facilitate pregnancy.
In-vitro Fertilization was first successful in 1978. The procedure involves stimulation of the mother’s ovaries with the gonadotrophin hormones to cause numerous oocytes to develop, capture of the oocytes by inserting a needle through the vagina in the follicles in the ovaries, mixing the eggs with sperm in the laboratory, and insertion of the resulting embryo back into the mother’s uterus. The success of the procedure is most directly related to the patients’ age. According to the Center for Disease Control the percentage of transfers resulting in live birth are about 22% if the mother is less than 35 years of age, 20% age 35-37, 17% age 38-40 and 15% for ages 41-42. In this office, the procedure is done in collaboration with Medical College of Georgia. The price per cycle is about $8,000.00.