What is infertility?
In women younger than 35 years of age: failure to conceive following one year of unprotected intercourse.
In women older than 35 years of age: failure to conceive following six months of unprotected intercourse.
Why am I not getting pregnant?
There may be one or more factors explaining why a couple can’t get pregnant. Frustratingly, in approximately 20% of couples, no known reason may be discovered. Problems that are identifiable may generally be categorized as follows:
- Ovarian factor: ovulation problems and/or poor ovarian function (few eggs and/or poor quality eggs)
- Male factor: poor quality, low count, no sperm, ejaculatory problems, or vasectomy
- Uterine factor: polyps, fibroids, or abnormally shaped uterus
- Tubal factor: blocked fallopian tubes, endometriosis, or tubal ligation
In some cases, couples don’t have trouble getting pregnant, but instead, they have trouble staying pregnant – referred to as recurrent pregnancy loss or recurrent miscarriages. These couples are evaluated in a similarly systematic way.
Tests can be done to evaluate the potential causes of a couple’s infertility. It is usually possible to complete the evaluation within a single menstrual cycle (i.e., one month).
Do I really need to see a fertility doctor?
There are two important factors to consider when judging a couple’s fertility: the age of the female partner AND the length of time a couple has been sexually active without using an effective form of contraception.
The monthly chance of pregnancy (called fecundity) depends on the age of the female partner and decreases as a woman ages (read more below). For instance, a woman in her twenties has 25 percent fecundity, but as she approaches her 40s fecundity is approximately 5 percent.
Furthermore, the chances of getting pregnant are highest during the first 3-6 months after discontinuing contraception (i.e. stopping the birth control pill). After one unsuccessful year, irrespective of female age, remaining couples have a much smaller chance of pregnancy without treatment, less than 3 percent per cycle (assuming the woman ovulates, sperm are present, and at least one fallopian tube is open).
The cause of infertility may be identified, but remains “unexplained” in approximately 20 percent of couples, meaning that a specific cause for their infertility is unknown. However, many successfully achieve pregnancy with treatment – often with simple interventions.
What is a Reproductive Endocrinologist and Infertility (REI) Specialist?
REI specialists treat problems related to the female reproductive tract, such as infertility, endometriosis, recurrent pregnancy loss, and polycystic ovary syndrome (PCOS). These doctors receive many years of training following medical school – four years of residency in Obstetrics and Gynecology, followed by two-three years of subspecialty Fellowship training in Reproductive Endocrinology and Infertility (REI).
Such experts specialize in treatments including intrauterine insemination (IUI), in vitro fertilization (IVF), third party reproduction (such as egg donor or gestational carrier/surrogacy), and minimally invasive surgeries (e.g., hysteroscopy and laparoscopy).
Does a woman’s age affect fertility?
Yes. Women are born with all their eggs; they do not produce new eggs in their lifetime. Each month (assuming that a woman is ovulating) one egg matures giving it the potential to be fertilized by sperm. Meanwhile, during each cycle hundreds of eggs are lost without ever achieving such an opportunity. By the time a woman reaches her late thirties, only a small fraction of her eggs remain fewer than 10 percent.
In addition to the problem of decreasing egg number, a woman’s age also affects egg quality. Eggs from older women harden and stiffen, which makes it more difficult for the sperm to enter the egg and also results in more errors as the egg passes down its’ chromosomes. Not only is fertilization is less likely to occur, but those eggs that fertilize are more likely to result in embryos with abnormal chromosome numbers, thereby increasing the risk of genetic problems, such as Down’s syndrome (trisomy 21, having three copies of chromosome 21 instead of the normal two). The frequency and complexity of these errors increase with age.
Consequently, the potential for a woman to produce normally fertilized eggs and resultant embryos drops dramatically as she ages. Given that naturally she only has one opportunity each month to mature an egg (i.e., ovulate), a woman at 40 years of age may have only one chance per year of producing a normal egg!
Is infertility primarily a woman’s problem?
While it is true that women receive most of the assessments and treatments, fertility affects both men and women. Men are the main cause of a couple’s infertility approximately 20% of the time and contribute to a combined cause nearly 50% of the time. Additionally, men are often unknowingly affected by the process, they can feel isolated, out of control, and guilty.
Why do fertility treatments work?
There are several ways to increase a couple’s fertility, and the specific treatment depends on the cause of infertility. Sometimes surgery is needed to correct a specific problem, such as removing endometriosis, fibroids or polyps [Link to Surgery Page].
Often times, however, fertility medications are used with methods of sperm washing and sperm transport to increase a couple’s fertility. Some women never ovulate and require medications to induce ovulation. For other women, the fertility medications (i.e., Clomid® or FSH shots) may lead to more than one egg maturing each cycle, which creates more “targets” for the sperm to reach, and, incidentally, leads to a risk of multiple gestation pregnancies (e.g., twins or triplets). This treatment is referred to as superovulation or controlled ovarian stimulation (COS).
Fertility treatments can also assist the sperm and egg to meet and fertilize by placing the sperm closer to the egg at the time of ovulation – using either, intrauterine insemination (IUI) or in vitro fertilization (IVF). More advanced reproductive technologies can be used during IVF to help improve fertilization and pregnancy rates. For instance, a common technique, intracytoplasmic sperm injection (ICSI), places one sperm inside the egg to facilitate fertilization.
Other treatments aid implantation by opening the outer shell of the embryo before transfer, called assisted hatching (AH). More recently, comprehensive chromosome screening (CCS)/ preimplantation genetic screening (PGS), which involves embryo biopsy of cells to provide DNA for chromosome testing to gather information about an embryo BEFORE a woman conceives. This gives the opportunity to select more viable embryos to transfer. As with any technique, CCS/PGS has both risks and benefits that are important to consider before committing to this treatment.
Why do I need to be evaluated at the start of each treatment?
It is important to be evaluated at the start of each treatment cycle with a pelvic ultrasound and/or blood tests. Before starting fertility medications, we need to be sure that there are no problems, such as ovarian cysts or abnormal hormone levels. Also, evaluating your ovaries at the start of the cycle helps determine the most appropriate protocol and medication dosage.
Do I really need so many office visits and blood tests during my fertility treatments?
Yes. Each patient responds differently to fertility medications, and it is necessary to follow your cycle closely by monitoring with pelvic ultrasound and/or hormone blood tests. This ensures that medication changes and treatment decisions can be made at the appropriate time in your cycle in order to maximize your chances for success.
Once I’m pregnant, what are my restrictions?
Restrictions in pregnancy vary by trimester and may be modified depending on whether or not you are having problems. Once you are pregnant, please review your “Now that you are pregnant…” handout that summarizes important “dos and don’ts” in pregnancy, as well as a list of medications that are considered safe. Please feel free to ask questions if you are unsure.
Who will take care of me in my pregnancy?
Once you are pregnant, you will continue your care with CCRM OC Fertility until 12 weeks, which coincides with the end of your 1st trimester. At that point, you will “graduate” to your general Obstetrician or Perinatologist/High-Risk Obstetrician for the remainder of your pregnancy.