Infertility

In this condition factsheet:

• The Facts
• Causes
• Symptoms and Complications
• Making the Diagnosis
• Treatment and Prevention

The Facts

Infertility is usually defined as the inability to become pregnant after 1 year of vaginal intercourse without birth control. Without contraception, frequent intercourse results in pregnancy for 50% of couples within 3 months, 75% of couples within 6 months, and 90% of couples within 1 year.

Infertility affects about 1 in 6 Canadian couples. While it was often considered only a woman’s problem, both men and women can contribute to infertility. In about a third of couples with infertility, a male factor is identified along with a female factor.

People shouldn't assume that they or their partners are infertile until they've tried and failed to conceive for at least 6 months if the female partner is 35 years or older, or for at least 1 year if the female partner is less than 35 years of age. If you are still unable to get pregnant after this time, check with your doctor. You may want to see your doctor after 6 months of trying to get pregnant if the female partner has an irregular menstrual cycle or known reproductive abnormalities, or if the male partner is known to have fertility issues. Fortunately, it's not uncommon for couples to suddenly conceive a child after years of trying unsuccessfully without treatment.

Causes

Infertility in both women and men can be caused by a variety of medical conditions and problems.

Causes of infertility in women include:

• age
• chlamydia and other sexually transmitted infections (STIs)
• damaged ovaries
• blocked fallopian tubes
• hypothyroidism (a thyroid disorder)
• endometriosis (a condition where cells from the womb lining are found outside the womb)
• polycystic ovary syndrome
• scarring in the uterus
• fibroids (benign tumours of the uterus)
• congenital diseases like cystic fibrosis
• excessive exercise (leading to missed menstrual periods)
• anorexia or bulimia
• frequent changes in weight
• damage to the cervix (e.g., through an abortion or dilatation and curettage [D&C])
• hyperprolactinemia (higher than normal levels of the hormone prolactin in the blood)
• untreated celiac disease or other autoimmune condition

Infertility may seem more common these days because more people are choosing to have children later in life. But because female fertility decreases with age, women in their late 30s and early 40s naturally have a harder time conceiving, even with treatment. Although 25% to 50% of women dealing with infertility are found to have at least some traces of endometriosis upon examination, it is not known in some cases if this is the cause of the infertility.

Some women suffer repeated miscarriages, which are often due to immune problems, genetic problems, hormonal problems, or occasionally, a uterus that is slightly misshapen. Occasionally, the man's sperm is unable to penetrate the woman's egg, but there is a treatment for this which requires in-vitro fertilization (IVF).

Hyperprolactinemia is another possible cause of infertility in women. This is an excess of the hormone prolactin, which normally stimulates breast milk production in women. High prolactin levels can interfere with ovulation and menstruation. Stress, marijuana, and hypothyroidism are among the factors believed to contribute to high prolactin levels. Certain prescription medications can also cause an elevated prolactin level. Rarely, it may be caused by a very small tumour in the pituitary gland of the brain that is easily treated with medication.

Women may also be concerned that having used birth control pills, vaginal rings, patches, and injections could possibly make them less fertile after they have stopped using them. There is no evidence that using birth control pills, vaginal rings, or patches increases the risk of infertility; however, you may want to delay trying to get pregnant for at least one menstrual cycle after stopping these medications. This is to help you get the cycle restarted even though your periods were regular when you were using these birth control methods. However, if you had irregular or infrequent periods before you began taking birth control pills or any one of these hormonal methods of birth control, your periods are likely to go back to the way they were. That is, if you were having periods every 1 to 2 months or so, the pattern will restart itself and return.

Using intrauterine devices (IUD) has also not been shown to increase the risk of infertility in women. Some women who use injection birth control methods (progesterone injections) may notice that it may take almost a year for their periods to restart and for fertility to return. Talk to your doctor or pharmacist about whether infertility may result from your method of birth control and if so, how long this time may be.

Causes of infertility in men include:

• hormone disturbance
• smoking
• overheating of the testicles caused by exercise, hot water, tight clothing, excessive sitting (truck drivers) and other conditions and situations
• cancer medications and radiation therapy
• mumps after puberty
• STIs
• anatomical abnormalities of the genitals such as undescended testicles
• use of some medications, such as some for high blood pressure, some antidepressants, and male hormones
• genital injury
• prostate surgery
• varicose veins in the testicles
• excessive alcohol
• intercourse problems such as premature withdrawal or poor timing with their partner's menstrual cycle
• spinal cord injury
• genetic abnormalities
• urinary tract infection
• cystic fibrosis
• illicit drug use (e.g., using cocaine, smoking marijuana)
• opiates
• steroids
• pesticide exposure

Some men are more prone than others to infertility problems. These factors contribute to the risk of infertility:

• diabetes
• poor nutrition
• smoking (lowers sperm count and reduces erections)
• hot baths
• being very overweight or underweight

The environment may also affect fertility. Sperm counts are going down in industrialized countries due to unknown environmental factors.

Types of male infertility include:

• azoospermia – no sperm in the ejaculate
• oligospermia – low concentrations of sperm in the ejaculate
• asthenospermia – sperm are present but can't swim normally
• teratospermia – high proportion of abnormally-shaped sperm
• retrograde ejaculation – the tube through which sperm normally travel is blocked and sperm may end up in the bladder

Symptoms and Complications

A young, reproductively healthy couple who isn't using contraception has roughly a 20% chance of conceiving in any given month. If someone is young and has no reason to think they might be infertile, they should try for up to a year before considering consulting a physician regarding some kind of infertility treatment. If the female partner is over 35, most fertility specialists recommend seeking treatment after 6 months, so that the chances can be improved while the woman is still young enough to be fairly confident of a problem-free pregnancy.

Making the Diagnosis

There are dozens of possible infertility tests for both men and women. Your doctor will start by getting a detailed history and asking you and your partner to record various information such as the woman's menstrual cycle, timing of intercourse, etc.

The basis of diagnosis for men is the physical examination and semen analysis. For a semen analysis, the man will need to provide a sample of his ejaculate. The sperm sample is studied under the microscope and various chemical tests can be applied to see how many sperm look normal, how many are alive, and how many can swim.  Blood tests may also be done to look at the levels of certain hormones that play a role in male fertility.

In women, the first thing to check is the physical examination of the reproductive tract as well as the level of various hormones. These provide clues not only to the cause of infertility but also to the chances of successfully treating it. An ultrasound is often ordered to look for fibroids, the shape of the uterus, cysts on the ovary, or other abnormalities. An X-ray may also be done in which dye is inserted into the cervix to see if the fallopian tubes are open. Other tests include a laparoscopy or hysteroscopy, where a camera-bearing tube is used to look for endometriosis, blockage of the tubes, and other signs of abnormality.

Treatment and Prevention

While couples shouldn't rush to the nearest infertility clinic after failing to conceive for a month or two, there's no reason to be shy about asking a doctor for advice even before trying to get pregnant. A doctor may know things from a medical perspective that are relevant to your chances of having a healthy baby.

The most important way to prevent infertility is to practice safer sex. Because sexually transmitted infections such as chlamydia and gonorrhea can lead to infertility, it is important to protect yourself against them, and to have them quickly diagnosed and treated if they occur. Excessive amounts of exercise reduce fertility in both men and women. Also, if weight fluctuates a lot, hormones may be thrown out of balance. You should talk to your doctor if you think these factors might be playing a role. Other lifestyle modifications that can help improve fertility include reducing caffeine and alcohol intake, and appropriately timing intercourse.

Sometimes, infertility can be treated in the operating room. A laparoscopy can identify endometriosis, which may be treated at the same operation. Fibroids or scarring inside the uterus may also be treatable with a hysteroscope. In men, surgery may be used to repair varicose veins in the testes and mechanical problems of ejaculation.

Women dealing with infertility, and especially women who have suffered repeated miscarriages, may have an immune reaction to the pregnancy itself. There are many tests and treatments for these problems. Women who have tried in-vitro fertilization (IVF) but have found that apparently healthy embryos fail to implant in the uterine lining should also consider this possibility.

There are several hormone treatments that are sometimes used to treat infertility in women, and these treatments are available as pills and injections. Hormone treatments are typically less expensive than other fertility treatments. However, when you factor in the fees for procedures that enhance fertility, such as a sperm wash and IVF, the cost quickly adds up. Fertility medications may also increase the chance of a multiple pregnancy (twins, triplets, etc.). Careful monitoring will be required by your physician.

There are several techniques to increase the chance for a woman to become pregnant. In IVF, hormones are used to stimulate the production of many eggs, which are then removed from the body. In one technique, the eggs are placed in a dish to which sperm are added. Technicians determine which eggs have become fertilized (embryos), and the fertilized egg(s) are inserted into the uterus. Extra fertilized eggs can be frozen for insertion in a later cycle. This is called an embryo transfer. In another technique, called intracytoplasmic sperm injection (ICSI), the eggs are removed from a women's body and one sperm is injected into one egg. This is done for several eggs in cases of very low sperm counts, or when there has been failure of the sperm to fertilize the egg in IVF.

The costs and potential health coverage of these procedures vary by province in Canada. Some private insurance plans may also pay part of the cost. The chance of a successful pregnancy depends on the age of the woman and whether male causes of infertility are involved. Only the fertility specialist can estimate each individual's chances of success. While IVF has a high success rate, couples who are considering this procedure should realize that it is not 100% successful.

One of the possible outcomes of fertility treatment is a multiple pregnancy. Multiple pregnancy and birth carries a number of risks for the mother and babies including, premature delivery, miscarriage, and a higher risk of birth defects. Therefore, fertility clinics and specialists are extremely careful to reduce this possibility by transplanting the minimum number of embryos necessary to give a reasonable chance of success. You will be involved in the decision-making of how many embryos are transferred. Eggs that are not transferred are often frozen and can be used in another cycle.

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