Infertility

A woman’s age can affect her ability to conceive, especially as she enters her 30s and 40s. For a healthy woman in her 20s or early 30s, the chances of conception each month are 25%-30%. But by the time a woman is 40 years old, the chances are 10% or less.

Fertility declines with age because fewer eggs remain in the 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, a term that reflects your age-related fertility potential. The hormones follicle-stimulating hormone (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 lower than routinely expected for your age, especially if you are age 35 or older. In addition, an AMH level (anti-müllerian hormone level) is also ordered to provide additional information about your ovarian reserve. A lower AMH level indicates decreased ovarian reserve. Abnormally high FSH or low AMH levels do not mean that you have no chance of successful conception. However, they may indicate that success rates may be lower, that more aggressive treatment may be warranted, and/or that higher medication doses may be needed. Another option to detect ovarian reserve is the use of transvaginal ultrasound to determine antral follicle count (AFC), which is when each follicle in both ovaries are counted. An AFC is performed during the first 3-4 days of the menstrual cycle.

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 abnormal 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 patients to begin fertility treatment sooner and, in some cases, to consider more aggressive treatment than younger patients.

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. Embryo donation has also become a viable option for many patients.

OVULATION DYSFUNCTION

Women who don’t have regular menstrual periods often don’t ovulate. If a woman doesn’t ovulate about once a month, she may have trouble getting pregnant. Problems like polycystic ovary syndrome (PCOS), thyroid disease, and other hormonal disorders can affect ovulation and lead to infertility. Women who are overweight or underweight are more likely to have problems with ovulation than women of normal body weight.

TUBAL DISEASE

Fallopian tubes are attached to the uterus and are where
the sperm and egg usually meet. Blocked or damaged tubes can cause infertility or ectopic pregnancy. Tubal factors, as well as factors affecting the peritoneum (lining of the pelvis and abdomen), account for about 35% of all infertility problems. The chances of having blocked tubes are higher
in women who have or have had endometriosis, surgery in
the pelvis, or sexually transmitted infections (like gonorrhea or chlamydia).

A special x-ray called a hysterosalpingogram (HSG) can be performed to evaluate the fallopian tubes and uterus. During an HSG dye is injected through the 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, a laparoscopy may be recommended to further assess the degree of tubal damage.

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 (hydrosalpinx) and lower IVF success rates, removal of the damaged tubes prior to IVF may be recommended.

MALE FACTOR

A third of all cases of infertility is because of a problem in the male partner. In the male partner, infertility can be caused by not being able to make or ejaculate sperm. Sperm quality is also important and
is measured by the amount, the movement, and the shape of sperm. Sometimes other medical problems can affect a man’s ability to make normal amounts or normal quality sperm.

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 men, surgery to obtain sperm from the testis can be performed. 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 a part of the IVF process.

THE CERVICAL/UTERINE FACTOR

Conditions within the cervix may impact your fertility, but they are rarely the sole cause of infertility. It is important for the physician to know if you have had prior biopsies such as a cone biopsy, surgery, “freezing” and/or laser treatment of the cervix (LEEP), 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. Cervical problems are generally treated with antibiotics, hormones, or IUI.

The HSG test often 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 typically done. Possible uterine abnormalities that may be identified include scar tissue, polyps (bunched-up pieces of the endometrial lining), fibroids, or an abnormally- shaped uterine cavity.

Problems within your uterus may interfere with the implantation of the embryo or may increase the incidence of miscarriage. Hysteroscopy, a minor and minimally invasive, incision-free surgical procedure, may be required to further evaluate and possibly correct uterine structural problems.

Uterine abnormalities can also be seen with a saline sonohysterogram (SHG). An SHG is a pelvic ultrasound performed while sterile fluid 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 that may be helpful in many cases.

THE PERITONEAL FACTOR

Peritoneal factor infertility refers to abnormalities involving the peritoneum (lining of the surfaces of your internal organs) 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, pelvic pain, and painful intercourse. Endometriosis may affect the function of the ovaries, your ovarian reserve, the function of the fallopian tubes, as well as implantation.

Laparoscopy is minimally invasive surgical procedure is performed to diagnose and treat adhesions or endometriosis.

UNEXPLAINED INFERTILITY

In approximately 10% of patients trying to conceive, all of the above tests are normal and there is no easily identifiable cause for infertility. In a much higher percentage of patients, only minor abnormalities are found that should not be severe enough to result in infertility. In these cases, infertility is referred to as “unexplained”. patients with unexplained infertility may have problems with egg quality, fertilization, genetics, tubal function, or sperm function that are difficult to diagnose and/or treat. Fertility drugs and IUI have been used in patients with unexplained infertility with limited success. If no pregnancy occurs within three to six treatment cycles, IVF may be recommended and has been shown to be the most effective treatment for unexplained infertility.