Infertility

Definition

Primary infertility describes couples who have never been able to become pregnant after at least 1 year of unprotected sex (intercourse).

Secondary infertility describes couples who have been pregnant at least once, but have not been able to become pregnant again.

Alternative Names

Inability to conceive; Unable to get pregnant

Causes, incidence, and risk factors

Causes of infertility include a wide range of both physical and emotional factors. A couple's infertility may be due to female factors, male factors, or both:

FEMALE INFERTILITY:

Female infertility may be due to:

• Problems with a fertilized egg or embryo being able to survive once it is attached to the lining of the uterus
• Problems with the eggs being able to attach to the lining of the uterus
• Problems with the eggs being able to move from the ovary to the uterus
• Problems with the ovaries producing eggs

Female infertility may be caused by:

• Autoimmune disorders, such as antiphospholipid syndrome (APS)
• Clotting disorders
• Defects of the uterus and cervix (myomas or fibroids, polyps, birth defects)
• Excessive exercising, eating disorders, or poor nutrition
• Exposure to certain medications or toxins
• Heavy use of alcohol
• Hormone imbalance or deficiencies
• Long-term (chronic) disease, such as diabetes
• Obesity
• Ovarian cysts and polycystic ovary syndrome (PCOS)
• Pelvic infection or pelvic inflammatory disease (PID)
• Scarring from sexually transmitted disease or endometriosis
• Tumor

MALE INFERTILITY:

Male infertility may be due to:

• A decrease in the number of sperm
• Sperm being blocked from being released
• Sperm that do not work properly

Male infertility can be caused by:

• Environmental pollutants
• Exposure to high heat for prolonged periods
• Genetic abnormalities
• Heavy use of alcohol, marijuana, or cocaine
• Hormone deficiency or taking too much of a hormone
• Impotence
• Infections of the testes or epididymis
• Older age
• Previous chemotherapy
• Previous scarring due to infection (including sexually transmitted diseases), trauma, or surgery
• Radiation exposure
• Retrograde ejaculation
• Smoking
• Surgery or trauma
• Use of prescription drugs, such as cimetidine, spironolactone, and nitrofurantoin

In healthy couples both under age 30, having sex regularly, the chance of getting pregnant is only 25 - 30% per month. A woman's peak fertility occurs in her early 20s. As a woman ages beyond 35 (and especially after age 40), the likelihood of getting pregnant drops to less than 10% per month.

When to seek help for infertility depends on your age. For women under age 30, it is generally recommended to try to conceive for at least a year before seeking testing.

Symptoms

The physical symptom of infertility is the inability to become pregnant.

Experiencing infertility can bring on a range of painful emotions in one or both members of the couple. In general, having at least one child already tends to soften these painful emotions.

Signs and tests

A complete medical history and physical examination of both partners is essential.

Tests may include:

For women:

• Blood hormone levels
• Cervical mucus to detect ovulation
• Hysterosalpingography (HSG)
• Pelvic ultrasound
• Laparoscopy (especially if endometriosis is suspected)
• Luteinizing hormone urine test (ovulation predictor kit)
• Pelvic exam
• Progestin challenge
• Serum progesterone
• Temperature first thing in the morning to check for ovulation (basal body temperature charting)

For men:

• Semen analysis
• Testicular biopsy (rarely done)

Treatment

Increase your chance of becoming pregnant each month by having sexual intercourse at least every 3 days in the weeks leading up to and through the expected time of ovulation. Ovulation occurs about 2 weeks before the next period starts. So, if you get your period every 28 days, you should have sexual intercourse at least every 3 days between the 7th and 18th day after you get your period.

Treatment depends on the cause of infertility. It may involve:

• Education and counseling
• Medical procedures such as intrauterine insemination (IUI) and in vitro fertilization (IVF)
• Medicines to treat infections and clotting disorders, or promote ovulation

It is important to recognize and discuss the emotional impact that infertility has on you and your partner, and to seek medical advice from your health care provider.

Support Groups

Many organizations provide informal support and referrals for professional counseling. See infertility - support group.

Expectations (prognosis)

A cause can be determined for about 80 - 85% of infertile couples.

Getting the right therapy (not including advanced techniques such as in vitro fertilization) allows pregnancy to occur in 50 - 60% of couples who were infertile.

Without any treatment, 15 - 20% of couples diagnosed as infertile will eventually become pregnant.

Complications

Although infertility itself does not cause physical illness, it can have a major emotional impact on the couples and individuals it affects.

Couples may have problems with their marriage. Individuals may experience depression and anxiety.

Calling your health care provider

Call for an appointment with your health care provider if you are unable to get pregnant.

Prevention

Because sexually transmitted diseases (STDs) often cause infertility, practicing safer sex behaviors may minimize the risk. Gonorrhea and chlamydia are the two most common causes of STD-related infertility.

STDs often don't have symptoms at first, until PID or salpingitis develops. These conditions scar the fallopian tubes and lead to decreased fertility, infertility, or an increased risk of ectopic pregnancy.

Getting a mumps vaccine in men has been shown to prevent mumps and its complication, orchitis. The vaccine prevents mumps-related sterility.

Some forms of birth control, such as the intrauterine device (IUD), carry a risk for pelvic infection, especially in women with more than one sex partner and when sexually transmitted diseases occur.

Maintain a healthy diet, weight, and lifestyle to optimize your chances for getting pregnant and having a healthy pregnancy.

Remember to take either prenatal or multivitamins containing folate while you are trying to become pregnant to decrease your risk for miscarriage and fetal abnormalities.

References

Jose-Miller AB, Boyden JW, Frey KA. Infertility. Am Fam Physician. 2007;75(6):894-856.

Lobo RA. Infertility: etiology, diagnostic evaluation, management, prognosis. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: chap 41.

Speroff L, Fitz M, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa; Lippincott Williams & Wilkins; 2005.