EVALUATION

• What is an infertility evaluation?

An infertility evaluation includes an exam and tests to try to find the reason why you and your partner have not become pregnant. If a cause is found, treatment may be possible. In many cases, infertility can be successfully treated even if no cause if 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 age 35 years and have not become pregnant after trying for 6 months without using birth control.

* You are older than age 40 years and have not become pregnant within 6 months of trying without using birth control.

* Your menstrual cycle is not regular.

* You or your partner have a known fertility problem.

• What type of doctor does an infertility evaluation?

Your obstetrician–gynecologist (ob-gyn) usually will do the first assessment. You also may choose to see a specialist. Infertility specialists are ob-gyns with special training in evaluating and treating infertility in women and men. These specialists are called reproductive endocrinologists. Men also may be evaluated and treated by a urologist. Some urologists have special training in male infertility.

• What causes infertility?

The most common cause of female infertility is lack of or irregular ovulation. The most common causes of male infertility are problems in the testes that affect how sperm are made or how they function.

Other factors in women include problems with the reproductive organs or hormones. Scarring or blockages of the fallopian tubes may contribute to infertility. This may be the result of past sexually transmitted infections (STIs) or endometriosis. Problems with the thyroid gland or pituitary gland also may contribute to infertility. In men, blockage of the tubes that carry sperm from the testes may be a cause of infertility.

• How does age affect fertility?

For healthy couples in their 20s or early 30s, the chance that a woman will become pregnant is about 25–30% in any single menstrual cycle. This percentage decreases rapidly after age 37 years. By age 40 years, a woman’s chance of getting pregnant drops to less than 10% per menstrual cycle. A man’s fertility also declines with age, but not as predictably.

• Can lifestyle affect fertility?

In women, being underweight, being overweight, or exercising too much may be associated with infertility. In both men and women, drinking alcohol at moderate or heavy levels may be a factor in infertility. In men, smoking cigarettes and marijuana can reduce sperm count and movement.

• What should I expect during my first visit for infertility?

The first visit with a fertility specialist usually involves a detailed medical history and a physical exam. You will be asked questions about your menstrual period, abnormal bleeding or discharge from the vagina, pelvic pain, and disorders that can affect reproduction such as thyroid disease. You and your partner will be asked about the following health issues:

* Medications (both prescription and over-the-counter) and herbal remedies

* Illnesses, including STIs 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 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. Imaging tests and procedures look at the reproductive organs and how they work. Laboratory tests often involve testing samples of blood or semen.

• What does the basic testing for a woman include?

Laboratory tests may include a urine test, a progesterone test, thyroid function tests, a prolactin level test, and tests of ovarian reserve. Imaging tests and procedures may 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. You also may track your basal body temperature (BBT) at home.

• What is the purpose of tracking basal body temperature?

A woman’s temperature increases around the time of ovulation and stays elevated for the rest of her menstrual cycle. To track ovulation, you will need to take your temperature by mouth every morning before you get out of bed. You record your temperature on a chart for two or three menstrual cycles.

Charting monthly temperature changes can confirm ovulation but it cannot predict it. Some women also monitor their cervical mucus while charting BBT. Just before ovulation, a woman’s cervical mucus becomes thin, slippery, and stretchy. Cervical mucus monitoring is a natural way to help a woman identify her most fertile days.

• What do results from a urine test determine?

A urine test determines when and if you ovulate by detecting an increase in the levels of luteinizing hormone (LH) in the urine. A surge in the level of LH triggers the release of an egg. If the test result is positive, it suggests that ovulation will occur in the next 24–48 hours. This gives you an idea of the best time to have sex to try to get pregnant.

• How is a progesterone test done?

For a progesterone test, a sample of blood is taken about 1 week before you expect your menstrual period or day 21 of your cycle. The level of progesterone is measured through labwork. An increased level shows that you have ovulated.

• Why would a thyroid function test be done?

Problems with the thyroid gland may cause infertility problems. If a thyroid problem is suspected, levels of hormones that control the thyroid gland are measured to see if it is working normally.

• What is a prolactin level test?

This test measures the level of the hormone prolactin. A high prolactin level can disrupt ovulation.

• What are tests of ovarian reserve?

The term ovarian reserve refers to a woman’s supply of eggs. Blood tests are used to check the remaining number of eggs. Anti-mullerian hormone is a blood test that directly measures ovarian reserve.

• Why are imaging tests and procedures done?

Different imaging tests and procedures are used to look at the uterus, ovaries, and fallopian tubes to find problems. Some procedures also are used to treat certain problems if they are found. The procedures that you may have depend on your symptoms as well as the results of other tests. Common imaging tests for female infertility include the following:

* Ultrasound exam—This test can predict when ovulation will occur by viewing changes in the follicles.

* Sonohysterography—This special ultrasound exam looks for scarring or other problems inside the uterus.

* Hysterosalpingography—This X-ray procedure shows the inside of the uterus and whether the fallopian tubes are blocked.

* Hysteroscopy—The procedure uses a camera with a thin light source that is inserted through the cervix and into the uterus. This can show problems inside the uterus and help guide minor surgery.

* Laparoscopy—This procedure uses a camera with a thin light source that is inserted through the abdomen. This can show the fallopian tubes, ovaries, and the outside of the uterus.

• What does the basic testing for a man include?

Testing for a man often involves a semen analysis. This analysis is done to assess the amount of sperm, the shape of the sperm, and the way that the sperm move. Blood tests for men measure levels of male reproductive hormones. Too much or too little of these hormones can cause problems with making sperm or with having sex. In some cases, an ultrasound exam of the scrotum may be done to look for problems in the testes.

• How long does it take to complete an infertility evaluation?

An infertility evaluation can be finished within a few menstrual cycles in most cases. Some insurance companies may cover the cost of an infertility evaluation. It is a good idea to call your insurance company to find out before you start your evaluation.

TREATMENT

• 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. If you are older than 35 years, an evaluation and possible treatment are recommended after 6 months. If you are older than 40 years, an evaluation and possible treatment are recommended before you reach the 6-month mark.

• What causes infertility?

The most common cause of female infertility is lack of or irregular ovulation. The most common causes of male infertility are problems in the testes that affect how sperm are made or how they function.

Age is a major factor in infertility. For healthy couples in their 20s or early 30s, the chance that a woman will become pregnant is about 25–30% in any single menstrual cycle. By age 40 years, a woman’s chance of getting pregnant decreases to less than 10% per menstrual cycle. A man’s fertility also declines with age, but not as predictably.

Lifestyle factors also can play a role in infertility. In women, being underweight, being overweight, or exercising too much may be associated with infertility. In both men and women, drinking alcohol at moderate or heavy levels may be a factor in infertility.

• What treatment options are available for infertility?

Your treatment options will depend on the cause of your infertility. Lifestyle changes, medication, surgery, or other approaches may be recommended. Some 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?

Staying at a healthy weight and eating a healthy diet can be helpful for both men and women with infertility. If you and your male partner smoke, use illegal drugs, or drink alcohol, you should stop.

• How is surgery used to treat infertility in women?

In women, surgery may be able to repair blocked or damaged fallopian tubes. Surgery also may be used to treat endometriosis, which is commonly associated with infertility. Women with polyps or fibroids in the uterus also may have surgery.

• How is surgery used to treat infertility in men?

A common problem that leads to male infertility is the enlargement of a vein in the scrotum. It sometimes can be treated with surgery.

• How are hormone problems treated in women?

Abnormal levels of hormones can cause irregular ovulation or lack of ovulation. Your health care professional may check your levels of certain hormones. If a hormone problem is found, treatment often can be given to correct it. This treatment also may improve your chances of becoming pregnant.

• What is ovulation induction?

Ovulation induction is the use of drugs to help your ovaries release an egg. This treatment is used when ovulation is irregular or does not occur at all and other causes have been ruled out. Ovulation induction may be used with other infertility treatments.

• How is ovulation induction done?

Oral drugs used to induce ovulation include clomiphene citrate, aromatase inhibitors, and insulin-lowering drugs. While taking these drugs, you will be monitored to see if and when ovulation occurs. This can be done by tracking your menstrual cycle or with an ovulation-predictor kit (an at-home urine test). You may be asked to visit your doctor for a blood test or ultrasound exam.

• What are gonadotropins?

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

• 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 development of the follicles. When test results show that the follicles have reached a certain size, another drug may be given to signal a follicle to release its matured egg.

• What risks are associated with ovulation induction?

Twins occur in 5–8% of women treated with clomiphene citrate and aromatase inhibitors. Triplets or more are rare. The risk of multiple pregnancy is higher when gonadotropins are used. Up to 30% of pregnancies achieved using gonadotropins are multiple. If too many eggs are developing, your health care professional may postpone the cycle to reduce the possibility of a multiple pregnancy.

Ovulation induction, especially with gonadotropins, can lead to ovarian hyperstimulation syndrome. Women undergoing ovulation induction are monitored for this condition.

Another risk of using gonadotropins is ectopic pregnancy. This is a pregnancy that begins to grow in a place other than the uterus, usually in one of the fallopian tubes. Ectopic pregnancy requires treatment with medication or surgery.

• What is intrauterine insemination?

In intrauterine insemination (IUI), healthy sperm are placed in the uterus as close to the time of ovulation as possible. IUI can be used with ovulation induction. The woman’s partner or a donor may provide the sperm. Sperm that has been collected earlier and frozen also can be used.

• What risks are associated with IUI?

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

• What is assisted reproductive technology?

Assisted reproductive technology includes all fertility treatments in which both eggs and sperm are handled. ART usually involves in vitro fertilization (IVF). In IVF, sperm are combined with the egg in a laboratory, and later 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 is IVF done?

IVF is done in cycles. It may take more than one cycle to succeed. The first step in IVF is obtaining an egg. Ovulation usually is triggered with gonadotropins so that multiple eggs are produced. The egg also may come from a donor. Eggs that have been previously frozen can be used.

When your eggs are ready to be retrieved, a procedure is performed to remove mature eggs from the ovaries. Fertilization of eggs by the sperm can be done in a laboratory in two ways: 1) the sperm can be added to the eggs, or 2) a single sperm can be injected into each egg.

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 the uterus. This step is called embryo transfer. The embryo also may come from a donor. Healthy embryos that are not transferred may be frozen and stored for later use.

• What are the risks associated with IVF?

There is an increased risk of 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 shot that triggers ovulation may be delayed or not given. Your health care professional also may limit the number of embryos transferred to your uterus.

Some studies suggest that IVF may be linked to a slightly increased risk of birth defects. Other studies show that this increase may be related to the underlying cause of infertility or to the older age at which some infertile couples have children. If you are concerned about birth defects, you may have ultrasound monitoring to look for possible problems with your pregnancy.

• What else should I know about infertility treatment?

Infertility treatment takes time, and it can have high costs. It takes a big commitment from both partners. Some treatments are expensive and may not be covered by insurance.