|
An accepted definition of infertility
is the inability of a couple to conceive after 12 months
of unprotected intercourse appropriately timed with
ovulation. The estimated incidence of infertility is
10-15% of the general population. Interestingly, the
monthly rate of conception for couples without fertility
problems is only 20-25% and after one year approximately
85% of these couples will have conceived.
Infertility is commonly approached as
treatment of a couple and should not be viewed as a
fault of the male or female. During the evaluation,
factors can be identified as potentially contributing
to the cause of infertility. The breakdown is approximately:
Female factors: 40% , Male Factors: 40%,
Unexplained 20%, Tubal blockage, Poorly functioning
sperm, No identifiable cause, Ovulatory dysfunction. In approximately 30-40% of couples, multiple
infertility factors are found together.
The most common fertility medications
are classified as ovulation induction drugs and have
been approved for patients with ovulation disorders.
However, they are also utilized for 'super' ovulation.
These medications by-pass the usual female hormonal
pathways and stimulate the ovary to produce more than
the usual one follicle per month, increasing the number
of eggs exposed to sperm, thereby increasing the chance
for pregnancy.
One type, clomiphene citrate (Clomid, Serophene),
is administered in a tablet form and usually results
in one or two follicles each cycle. The other class
are called gonadotropins (Repronex, Follistim, Gonal-F
) and are currently administered by injection. They
can stimulate the ovary to produce many dominant follicles
each cycle. These medications can be combined with intercourse,
intrauterine insemination, or In-vitro fertilization
(IVF) to enhance one's chance for conception.
Fertility medications carry risks that
can vary depending on the diagnosis and a patient's
response to the medications. In general, the following
are the most common risks with the use of these medications,
usually associated more with gonadotropins.
1) Ovarian hyperstimulation syndrome.
This occurs in about 1-5% of cycles. The ovaries become
enlarged due to overstimulation with fertility medications.
The blood vessels supplying the ovaries become 'leaky'
and results in fluid collecting in the abdomen. In severe
cases (~1%) hospitalization is required for close monitoring.
The problem lasts for 1-2 weeks but can be longer if
pregnancy results.
2) Multiple births. Since more follicles
are being stimulated to grow with fertility medications,
there is a higher rate of multiple births. The multiple
birth rate with clomiphene citrate is 5-10% and with
gonadotropins it is 15-20% per pregnancy. In order to
put this into perspective, the chance for a couple to
have a multiple birth spontaneously is about 1-2%.
3) Ectopic pregnancy is a pregnancy in
another location of the body other than the uterus and
usually is in one of the fallopian tubes. The normal
rate is about 2% in the general population but may be
slightly higher with fertility medications.
4) Twisting of the enlarged, overstimulated
ovary (torsion) can occur in about 1% of cycles. The
ovary is cut off of its blood supply, causing abdominal
pain, and surgery may be required to untwist the ovary
or possibly remove it.
5) The possible risk of ovarian cancer.
There is controversial undetermined data associating
fertility medications and ovarian cancer. The risk is
probably related to continued ovulation in infertility
patients and appears to return to baseline risk with
pregnancy. Unfortunately, the risk may be increased
if no pregnancy occurs. Pregnancy and the use of birth
control pills, which prevent ovulation, decrease the
risk. Certainly, no definitive answer is available and
further research is ongoing.
Each month, hundreds of follicles in the
ovary begin stimulation but only one goes onto full
maturity and ovulation. The other follicles undergo
a natural cell death. Fertility medications stimulate
follicles that would have otherwise not developed to
maturity and does not accelerate the onset of menopause.
Your gynecologist will have you undergo
testing to determine the possible cause of infertility.
Unfortunately, 20% of couples experience unexplained
infertility. This diagnosis can only truly be made after
a laparoscopy which is an outpatient same day operative
procedure. Laparoscopy inserts a telescope through the
belly button into the abdomen to view the internal pelvic
reproductive organs. This procedure will allow a definite
diagnosis of pelvic adhesions, tubal scarring or blockage,
endometriosis, or other abnormalities. These problems
could contribute to infertility and may be treated at
the time of the surgery.
During an evaluation for infertility,
40% of couples are found to have a female factor which
commonly is tubal blockage or ovulation disorder. In
order to assess the fallopian tubes, an HSG is performed.
An HSG is an office procedure in which an X-ray is taken
while contrast dye is instilled through the cervix into
the uterus and tubes. The patient is awake and can often
watch the monitor with the physician to see the results
of the study.
Approximately 25% of couples experience
infertility due to an ovulation disorder. The easiest
way to determine if and when a woman is ovulating is
by a home urine test. This method detects the hormonal
surge of ovulation and when positive will predict ovulation
over the next 25 to 30 hours.
IUI is the use of husband or donor sperm
to inseminate into the uterus. The semen sample is washed,
prepared and then placed into the uterus by passing
a small plastic catheter through the cervix. This is
an office procedure and is usually associated with no
discomfort. The procedure places a large concentration
of sperm into the upper uterus so they are closer to
the fallopian tubes where they travel to fertilize an
egg.
A woman is born with all of the eggs she
will ovulate in her lifetime. Until puberty, the eggs
are resting at a certain stage of development. Beginning
with the first menses (menarche), hundreds eggs are
stimulated each month but only one egg will complete
development and ovulate, the rest will regress.
As a woman ages, the number of eggs diminish. This explains
the studies of women demonstrating a consistent decline
in reproductive capacity beginning approximately around
ages 33-35. There is a more marked decrease after age
40 due to older and less responsive eggs. In addition
to the monthly decline in pregnancy, there is an increase
in miscarriages and genetic abnormalities of the embryo
with advancing age.
Age can also affect males in terms of
sexual function, frequency of sexual relations, and
sperm production. However, the semen analysis does not
show significant decline generally until after age 60.
Since 40% of infertile couples will have
a male factor, it is imperative to evaluate the male.
The initial work-up will include a history to investigate
any potential areas that could be contributing to infertility.
While there is no definitive screening test (outside
of pregnancy), the best definitive screening test for
a male factor is the semen analysis. This examination
of the collected sperm evaluates most importantly count
(density), motion (motility), and shape (morphology).
Based on these results, a decision may be made to proceed
with further investigation by a urologist, preferably
one who specializes in male infertility.
IVF is an
assisted reproductive technology procedure whereby fertilization
of the egg and sperm occur in the laboratory or 'in-vitro.'
The woman receives stimulation with one of the injectable
fertility medications (gonadotropins, discussed above).
When the ovaries contain multiple mature eggs, she then
undergoes a minor procedure under sedation to retrieve
the eggs by placing a needle through the vagina into
the ovary under ultrasound guidance. Approximately 4
to 6 hours later, sperm are added to each of the eggs
and then checked for fertilization the next day. The
embryos are transferred to the uterus 3-5 days after
the 'retrieval' procedure. A pregnancy test is taken
2 week later.
This is an excellent question but one
that is very individualized depending, most importantly,
on the diagnosis, female age, patient motivation level
and financial resources. In general, after the gynecologist
has performed an initial work-up, the patient AND the
gynecologist should devise a game plan and time line
after which referral should be recommended to a Reproductive
Endocrinologist (Fertility Specialist). There are some
situations where a patient should be referred immediately
to a fertility specialist, e.g. advanced reproductive
age, severe male factor, and blocked fallopian tubes.
Endometriosis is a condition where tissue
from the lining of the uterus implants in other places
of the body, usually in the abdomen and on the ovaries.
The most likely explanation is from reverse flow of
menses of the tubes into the abdomen. Minimal and mild
cases have been shown to correlate with some decline
in fertility. More advanced stages worsen the prognosis
for pregnancy, presumably due to scarring of the tubes
and ovaries. However, the exact reason for the cause
is unknown.
This problem usually has no serious medical consequences
although it has been shown to correlate with pain. Interestingly,
the degree of pain may be inversely proportional to
the extent of endometriosis. Treatment, which depends
on the diagnosis and symptoms of the patient, involves
medical or surgical options. Pregnancy may have a temporary
beneficial effect.
-Mark P. Trolice, MD, FACOG, FACS
Director, Fertility C.A.R.E.
- Infertility-Discussion
- Infertility 101- An Overview, Karen Kaplan, MD Georgia Reproductive Specialists
- Overview by Mark Trolice, MD
- Male Factor Infertility
- Cervical Factor Infertility
- Endometriosis
- PCOS
- Ovulatory Dysfunction
- Tubal Factor Infertility
- Uterine Factor Infertility
- Unexplained Infertility
- Infertility Overview- Samuel Thatcher, MD
- PRESERVING
REPRODUCTIVE OPTIONS IN ONCOLOGY PATIENTS ,
by Bradford Kolb, M.D., F.A.C.O.G.,
Board Certified, Reproductive Endocrinology and Infertility
- THE
CONTEMPORARY FERTILITY EVALUATION, by Daniel Potter, M.D., F.A.C.O.G.,
Board Certified, Reproductive Endocrinology and Infertility,
Huntington Reproductive Center
|
