What Causes Infertility?

The rate of conception for a couple at age 30 is approximately 25% per cycle. However, due to many factors which may impair fertility, one out of every six couples attempting to achieve a pregnancy will experience difficulty. Our objective is to provide the best medical evaluation and therapy available in order to achieve pregnancy in a minimal amount of time and expenses.

Causes of Infertility:

Ovulation Disorders:
Ovulation disorders may be broken down into three distinct categories. The first, anovulation, is when a woman does not ovulate at all. Ovulation inducing drugs, (also known as "fertility drugs") are used to correct anovulation. The most commonly prescribed are Clomid (clomiphene citrate) or Serophone, an orally administered compound used to stimulate the release of pituitary gonadotropins to mediate ovulation. We also use injectable medications comprised of luteinizing hormone (LH) and follicle stimulating hormone (FSH), also known as human menopausal gonadotropins (hMG), prescribed as Menopur. A similar injectable drug, Follistim, and Bravelle, which is pure FSH minus the LH, is used in similar circumstances in conjunction with hMG. Its clinical application is to stimulate ovarian follicle growth and maturation. The third fertility drug which would be prescribed, in cases where the serum prolactin level is elevated, would be Dostinex or Bromocriptine.

The second type of ovulation disorder is a luteal phase defect. There are two kinds of luteal phase defects, the first, referred to as a pure luteal phase defect, in which there is insufficient production of the hormone progesterone, but the follicle (the sac containing the egg) is mature. Progesterone is needed to build up the uterine lining, to enable the embryo to implant. To determine a progesterone deficiency an endometrial biopsy is performed, a simple procedure done in the office where a small sample of endometrial (uterine) tissue is obtained with a plastic pipette. Supplementation of progesterone during the luteal phase of the menstrual cycle (after ovulation) may be given. Information regarding the benefits of progesterone and the options for treatment will be provided to patients in order that they may select the treatment option that best suits their physical comfort and financial affordability.

Another type of luteal phase defect is known as immature follicles. This is determined by inadequate serum estradiol levels, less than 200 pg/mL, and or follicles size less than 18mm on ultrasound, both studies being performed at mid-cycle when follicular maturation occurs. Ovulation inducing drugs, as previously described, are used to correct these defects. The medication used is chosen after careful monitoring with blood levels and ultrasound. Each drug has its advantages and disadvantages. Clomiphene citrate is a less expensive ovulation inducing drug, but may sometimes interfere with the production of cervical mucus (causing what is known as cervical factor-for a more detailed description see cervical factor below). Although more costly, hMG in some cases is more effective in promoting follicular maturation. The decision of which drug to employ is made after careful evaluation and consultation with your physician.

The third type of ovulation disorder is known as premature luteinization, when the production of progesterone occurs prematurely, that is before ovulation has taken place. Referred to medically as the follicle undergoing "atresia", it causes the egg to die and destroys the cervical mucus needed to aid in transporting the sperm through the cervix. Once again, an ovulation inducing drug may be used to insure ovulation has taken place before the rise in progesterone. Frequently, this may be corrected by first blocking the woman's LH through the use of high-dose estrogen or a drug known as a gonadotropin releasing hormone agents (GnRHa) which suppresses LH and FSH. An example is leuprolide acetate (Lupron). This drug would be followed by either Follistim and/or Menopur.

Cervical factor:
Inadequate quality or quantity of cervical mucus is determined by performing a simple test known as the post-coital test (PCT). This is done by aspirating some of the mucus with a small syringe and microscopically examining it for the presence of sperm. The couple would have been requested to have intercourse 8-12 hours (up to 24 hrs) prior to the PCT. The optimal quality mucus should be present immediately preceding ovulation. This test is also performed in conjunction with blood and ultrasound monitoring of follicular maturation. In treating mucus problems, the simplest approaches would be taken initially, such as the use of guaifenesin (or a pill form of the same), an expectorant which stimulates your mucus glands to help make thinner more abundant cervical mucus. If that alone is ineffective, a short course of estrogen may be given, in addition to the Robitussin, once the follicle is mature. Although this would provide maximal stimulation of the mucus glands, the estrogen at the same time may suppress the ovaries, in which case the following cycle it may be necessary to move on to hMG which would allow the estrogen to work on the cervical mucus while the hMG acts to stimulate ovulation. The sperm itself and/or the mucus should be also checked for antisperm antibodies.

Another therapy to overcome inadequate or "hostile" cervical mucus would be intrauterine insemination (IUI), a procedure which involves placing the sperm (after it has undergone a critical "cleansing" procedure known as sperm washing), directly into the uterus, thus bypassing the cervix altogether. Also, in vitro fertilization (IVF) is another option.

Male Factor:
It is important for couples to realize that fertility potential involves both partners. Therefore, it is beneficial when performing a complete work-up for infertility to evaluate both partners. A semen analysis should be performed, along with some blood hormone levels on the male. Initial work-up of the male includes the following tests on the semen specimen: count-number of sperm per mL of semen, motility-percent of sperm moving, grade of progression-how the sperm are moving, viability-percent of sperm alive, morphology-percent of sperm with acceptable physical characteristics, antisperm antibody (ASA)-percent immunoglobulins attached to sperm, and hypo-osmotic swelling (HOS) test-assess the functional integrity of the sperm membrane.

Other tests performed include the sperm penetration assay (SPA)-percent of sperm that can penetrate a zona free hamster egg and acrosome reaction-measurement of the ability of the sperm to undergo changes necessary for binding and fertilization of an egg.

We also provide services to increase the likelihood of a male or female offspring by selecting out a higher concentration of X and Y sperm and then inseminating. This process does not damage the sperm in any way.

Tubal/Uterine Factor:
To determine whether or not the fallopian tubes are patent (open), one of two procedures is performed. The first, and simpler one, a hysterosalpingogram (HSG) is performed after menses, but before ovulation. This test is done by a physician as an outpatient procedure. Dye is introduced into the uterus and its passage through the uterus and fallopian tubes is visually followed with the use of a fluoroscope to determine whether there is free flow of the dye, or tubal occlusion (blockage).

This procedure may also determine the presence of any uterine anomaly. The HSG is a relatively easy procedure, the only real drawback is that some women may experience cramping, but that can be decreased considerably by taking ibuprofen prior to administering the test. There are times when the test itself seems to help a woman achieve a pregnancy.

A second, more definitive diagnostic procedure is the laparoscopy. This is a surgical procedure performed in the hospital with the use of anesthesia. By inserting a "scope" through the navel, thus gaining full visualization of the pelvis, it allows the physician to see the presence of endometriosis and or adhesions, as well as tubal patency. An advantage of this procedure is that endometriosis and adhesions can be treated through the laparoscope.

If tubal occlusion is determined, in vitro fertilization-embryo transfer (IVF-ET) is usually performed because of its high success rate. Though a surgical procedure known as tubal reanastomosis by microsurgery can also be performed, however, it has not been performed as often as before. It is usually best reserved for certain types of previous tubal ligation. Tubal blockage due to infection has a low success rate following surgery and a high risk of tubal pregnancy.

Endometriosis:
It is a disease in which tissue from the lining of the uterus implants itself on either the ovaries or other pelvic organs. This can only be positively diagnosed laparoscopically. Elevation of serum CA-125 levels has been noted in patients with endometriosis. Routine measurement of CA-125 levels in women with infertility is performed as part of the initial blood screen.

Treatments for endometriosis include laparoscopic laser vaporization or burning of endometriotic implants, or, the use of one of several drugs now available which may help the pain often associated with endometriosis. These drugs include Norlutin, Danazol, Depo-Provera, Ovral or low Ovral, Provera Oral, or estrogen suppression by GNRHa-Depo-leuprolide acetate (1x/month), although there is no strong evidence that the medications improve fertility.

Unexplained Infertility:

Unexplained infertility can be treated in several ways. If a male factor is suspected, either IUI or IVF may be performed. IVF may be effective in the presence of a tubal ovum pick-up problem, despite the appearance of normal fallopian tubes. In vitro fertilization can be used to determine if either the sperm or egg are not able to cause fertilization.

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