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Understanding Infertility


 

Medically reviewed by Norbert Gleicher, MD, FACOG, FACS - Written by CHR Staff - Updated on Jan 27, 2021

Since CHR’s founding in 1981, our research and clinical efforts have produced a huge amount of data and knowledge. We’d like to pass this information along to you. You’re making big decisions regarding your health and fertility, and having an in-depth understanding of your personal fertility will be vital in choosing a treatment plan that is right for you.

Guide to the Basics of Diagnosis and Treatment

The Center for Human Reproduction (CHR), one of the most prominent fertility research and treatment centers located in New York City, attracts many fertility patients who have (unfortunately) become "expert patients" through their long journey toward parenthood. As a de facto "fertility center of last resort," we serve many patients from all over the world with long treatment histories and many previous IVF failures. We've realized that, as a result, our website may focus mainly on these "expert patients," perhaps leaving those relatively new to fertility treatments rather in the dark. This page is intended to give such new patients a comprehensive overview of infertility conditions and treatments, with links to pages where you can learn about infertility more in depth.

 

Infertility? When to see a specialist

Affecting about 15% of couples, infertility is defined as the inability to conceive or maintain a pregnancy within a certain period of time. For couples under the age of 35, infertility is diagnosed when they fail to conceive after 1 year of regular unprotected sexual intercourse. In addition, couples who are able to conceive but experience repeat miscarriages may also be considered infertile.

Infertility diagnosis and treatment

Infertility diagnosis and Treatment


 

Watch Dr. Barad explain infertility diagnosis and treatment

 

What are the major causes of infertility?

Reproduction is a complex function involving many factors that can affect a couple's ability to become pregnant. About 15% of couples of reproductive age suffer from infertility. At our center, approximately 60% of infertility cases are due to female factors, although in a general infertility population, that ratio is lower. In 15% or so of cases, both male and female partners have infertility issues. In both men and women, most causes of infertility can generally be attributed to either anatomical, hormonal, environmental, or genetic factors that prevent normal reproductive functions.

Causes of female infertility

Causes of male infertility

  • Structural abnormalities or damage to the reproductive organs
  • Abnormal or low sperm production
  • Varicoceles
  • Sexually transmitted diseases
  • Environmental exposures
  • Autoimmune disease
  • Age
 

How is infertility diagnosed?

Couples under 35 years of age who have been having regular unprotected sexual intercourse for more than 1 year are typically diagnosed with infertility. In older couples, it may take longer to conceive. However, older couples also may not have the luxury to "wait and see," since the female reproductive time frame is limited. Older couples, therefore, should seek professional counsel even before a full year of unsuccessful unprotected sexual intercourse. Further testing is needed to determine the specific underlying cause.

Typical diagnostic tests that are prescribed may include:

 Health, social and sexual history interview

Health, social and sexual history interview

Identifies contributing risk factors such as medications, history of sexually transmitted disease, prior ectopic pregnancies, weight, or other health conditions that may impact fertility. Significant family history of infertility, autoimmune problems, etc. can also be discovered in this process. This is the most basic but possibly the most important diagnostic process for fertility patients. Unfortunately, many IVF centers neglect the importance of this step, delegating the responsibility to non-physician staff members.

 Pelvic examination

Pelvic examination

Both the male and female reproductive structures are evaluated for abnormality.

 Hormone evaluations

Hormone evaluations

Males and females are tested for hormone levels that impact ovulation and sperm production. These may include follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid hormone, progesterone, testosterone, anti-mullerian hormone (AMH) and more.

 Sexually transmitted disease testing

Sexually transmitted disease testing

Infections from sexually transmitted diseases can negatively impact your ability to become pregnant.

 Ovulation testing

Ovulation testing

A blood test can be done to help determine whether or not a woman is ovulating each month. This can also be evaluated through the use of basal body temperature readings.

 Hysterosalpingogram (HSG)

Hysterosalpingogram (HSG)

This type of x-ray evaluation uses contrast dye to visualize the uterus and fallopian tubes for damage or abnormalities. In the hands of an experienced fertility specialist, HSG is a good technique to diagnose subtle tubal infertility that may be overlooked by a radiologist who does not specialize in fertility care.

 Hysterosonogram (HSN)

Hysterosonogram (HSN)

An ultrasound (HSN) can help screen for abnormalities of the reproductive organs.

 Semen analysis

Semen analysis

This is the most commonly ordered and most important test for diagnosing male infertility. Sperm count, concentration, morphology (shape of sperm) and motility (mobility of sperm) are tested. Semen analysis is an indirect way to assess the sperm's ability to fertilize an egg.

 Genetic Testing

Genetic Testing

In rare cases where a genetic causes of infertility is suspected, this testing may be indicated.

 Laparoscopy

Laparoscopy

This procedure used to be common. However, with the development of less invasive and more accurate diagnostic methods, laparoscopy is rarely used for diagnostic purposes only. In most high-quality IVF centers, laparoscopy nowadays is a therapeutic procedure, not a purely diagnostic one.

How is endometriosis infertility treated?

Endometriosis infertility is a problem that affects many women with endometriosis. However, with proper treatment and reproductive technology many women are able to overcome this disease.

What is endometriosis?

Endometriosis is a very common gynecological disease in which cells from the inside lining of the uterus (endometrium) grows outside of the uterus. In a normal menstrual cycle these cells on the inside of the uterus are affected by hormones, first thickening and then shedding through menstrual bleeding. In a women with endometriosis, the endometrial cells that are growing outside of the uterus also thicken and shed during the monthly cycle. However, once they shed, they have no place to go. The body sees this bleeding as "wound" and rushes to heal it. This process creates scar tissue and adhesions.

How does endometriosis cause infertility?

Unfortunately, when endometriosis spreads in a woman's reproductive organs, it often affects the fallopian tubes, ovaries, and pelvic floor, leading to endometriosis infertility. Depending on the extent of the disease, the scar tissue or adhesions can prevent normal egg maturation and release, prevent an egg from passing through the fallopian tubes, or a fertilized egg from implanting inside the woman's uterus. In some cases, endometriosis can also release toxic substances causing harm to eggs or embryos.

How is endometriosis infertility treated?

Depending on the extent of the disease, there are several different ways that endometriosis infertility can be treated. Medications to control hormones along with surgery are two ways that physicians can help reverse the effects of endometriosis in addition to the use of assisted reproductive technology such as IVF. When evaluating the possibility of surgery for endometriosis, however, it is important to discuss with your physician how such a surgery may affect your fertility prospects. Too often, we see patients who, after an endometriosis surgery especially involving the ovaries, experience a sudden drop in their ovarian reserve.

Read more: Endometriosis and Infertility Treatment

Watch Dr. Gleicher explain the unique challenges of fertility treatments for endometriosis patients

Endometriosis and Infertility


 

Dr. Gleicher, is an international expert in providing fertility solutions to endometriosis patients. He is responsible for confirming the important link between endometriosis, autoimmunity and fertility.

 

Infertility? When to see a specialist

Tubal Infertility

The term "tubal infertility" refers to the inability to become pregnant due to a problem in the fallopian tubes.

What are fallopian tubes?

The fallopian tubes are the two long hollow appendages on either side of the uterus that connect the uterus to the ovaries. Each month, the ovaries release a mature egg into the fallopian tubes, where they can be fertilized by sperm. Once fertilized, tiny hairs inside the fallopian tubes move the embryo (fertilized egg) down the tubes and into the uterus for implantation and pregnancy.

What Causes Tubal Infertility?

Tubal infertility is most often caused by either damage or blockage in these tiny tubes. This can be due to past infections, sexually transmitted diseases, pelvic inflammatory disease, history of an ectopic pregnancy or endometriosis. Tubal infertility is a mechanical problem that prevents either the fertilization or implantation.

How Common is Tubal Infertility?

It is estimated that approximately 20-25% of all infertility cases involve tubal infertility. However, damage to the fallopian tubes is often missed due to limitations in diagnostic screenings. This statistic likely under-represents the real prevalence of tubal infertility. At CHR, we often see patients with a dubious diagnosis of "unexplained infertility." Many of them have undiagnosed tubal infertility.

How is Tubal Infertility Diagnosed?

The best way to diagnose tubal infertility is through a procedure known as a hysterosalpingography (HSG), in which contrast dye is inserted through vagina to the uterus and fallopian tubes. X-ray images are then taken while the dye is flowing through the structures in order to illuminate any area that may be blocked or partially occluded. It sometimes takes an experienced physician, preferably a fertility expert (not a regular radiologist) to diagnose subtle cases of tubal infertility.

How is Tubal Infertility Treated?

Treatment for tubal infertility depends on the type of damage that is present. In some cases the dye from a HSG exam is enough to clear a blockage whereas in many other cases IVF offers the best hope for pregnancy.

PCOS and infertility

Polycystic ovarian syndrome (PCOS), also known as polycystic ovary disease (PCOD), is a very common cause of female infertility. PCOS is characterized by many small cysts that develop inside of the ovaries and interfere with normal reproductive function.

What Causes PCOS Infertility?

Approximately 30-40% of women with PCOS will experience difficulty becoming pregnant. Women who have PCOS develop a lot of eggs in the ovaries, but these eggs are not released from the ovaries when time for ovulation comes. This means that sperm cannot "meet" a mature egg. Each month, when the egg matures, it becomes trapped inside the ovaries, forming a cyst.

How is PCOS Infertility Treated?

In many case, PCOS infertility can be treated with medications that regulate hormones. However, in some cases, when the cysts interfere with proper ovulation, assisted reproductive techniques such as in vitro fertilization (IVF) or surgery may be considered. (When considering surgical interventions for PCOS, you should discuss your fertility prospects with your physicians below.) As Dr. Gleicher explains in the video below, ovarian stimulation for IVF in PCOS patients should be handled by an experienced IVF expert to avoid hyperstimulation.

Watch Dr. Gleicher explain why PCOS patients need special expertise in IVF cycles

Polycystic Ovary Syndrome (PCOS)


 

Should I get surgery to treat infertility?

Unfortunately, surgery as an infertility treatment is often over-used and in many cases can actually cause more harm than good. (For example, there is no point in using laparoscopy to open a blocked tube for a patient who is 45. At that age, she would most likely need IVF, which makes her tubal status irrelevant.) In addition, surgical intervention for endometriomas ("chocolate cysts," cysts that develop in the ovary due to endometriosis) and certain other conditions can actually lead to loss of fertility. We believe that it is important to fully consider all other less invasive treatment options available before determining whether or not surgery is truly an appropriate choice.

Read more: Is surgery a good idea for infertility?

Male infertility

Contrary to traditional belief, many cases of infertility (up to 40% of all cases) are due to male factors. These factors may include varicoceles, low sperm count, sexually transmitted diseases, structural anomalies, age, or medications.

Male infertility can be diagnosed through a semen analysis or other diagnostic procedure such as a physical evaluation or ultrasound. The type of treatment needed depends on the exact diagnosis and may include medications, surgery or testicular biopsy. However, in most cases of male infertility, treatment does not restore fertility enough for patients to father children "naturally." The good news, however, is that in most cases of male infertility, we now have assisted reproductive techniques, such as IUI and IVF, to help patients become fathers.

Read more →

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21 E 69th Street
Upper East Side

New York, NY 10021
Phone: 929-841-5668
Fax: 212-994-4499
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