Infertility Basics
What is "infertility"?
Infertility, I think we all understand, is decreased ability to achieve conception as compared to the rest of the population. The medical definition happens to be a couple who is trying to get pregnant for a full year with unprotected intercourse; that is to say, without contraception, and still unsuccesful at the end of twelve months. In reality, within that population of those couples who have not conceived at the end of twelve months, is going to be two groups: 1) those who will get pregnant, those who are subfertile if you will, those who have a lower probability of getting pregnant in any one month, and 2) those who are really not going to achieve pregnancy without some kind of intervention. Let's say women with blocked fallopian tubes, men who have no sperm, women who are not ovulating. Any of those groups will need medical intervention, or their chances of getting pregnant is essentially zero. Our job as fertility specialist is to distinguish: is this a subfertile couple?, or is this really a couple that is going to need medical intervention?
What is the average time it takes to conceive?
Human fertility depends to a great extent on the age of the woman, and really, everything is driven by that. When I say young couples what I mean by that is a couple in whom the woman is under the age of 35. What we know is that a young couple have an approximately 20% chance of getting pregnant during any one ovulatory cycle. So, assuming the woman is having normal cycles and the couple is having intercourse at the correct time of month, 20% of those couples will get pregnant in any one month. If you put that onto a mathmatical table you can show that about half of those couples will conceive within 3 months, so 50% will conceive at the end of 3 months, and another 50% of those that are left, will conceive during the next 3 months. By the end of 6 months, 75% of the couples are pregnant, assuming everyone is normal. In other words, if you have not conceived in the end of 6 months, you can be perfectly normal and just be in that one out of four couples who is going to take a little bit longer. That is why we normally say, infertility is after one year.
How long should I wait to see a doctor about whether or not I am fertile?
It really depends on the couple, how long they should wait before they go and seek consultation with a reproductive endocrinologist, and it really depends on the situation at hand. It really depends on, primarily, the age of the woman as well their particular situation. For example, if a couple is beginning to try to get pregnant, and the wife is over the age of forty, I think it's very reasonable to seek consultation even before you try to conceive, or perhaps after a month or two of trying. the probability that something is wrong is quite high, and if treatment is required, you really want as much time on your side as possible. You would not want to wait an entire year to have some simple testing done. If the tests prove to be normal, it may be perfectly acceptable to go back home and try at home for another few months, but at least you are reassured that the testing was normal. In contrast, a young couple, perhaps in their twenties, who are first attempting conception, if the wife has regular periods and everything else seems to be going alright, it's perfectly alright to wait a year before they seek consultation. The key concept is: are you suspicious that something may be wrong? And, how much of a role is the biological clock playing in this particular role? - How old is the female partner, how many children are you thinking of having? Those are the factors that go in there. Remember, it is a bargain to go in and to spend an hour with a fertility specialist just talking about things and discussing whether or not a test is appropriate or not. When in doubt, get some advice.
How common is infertility?
Infertility is far more common than people think. And again, it depends on the age of the woman. We typically think of young couples--that is to say, where the wife is under the age of 35--as having infertility, in perhaps 12-15 percent of couples, maybe one out of six couples. But once you get past 35, and especially as you approach 40, easily 25 or even 35 percent of couples have some degree of infertility. So perhaps one woman in three, at the age of 40.
What factors can prevent me from becoming pregnant?
We think of three basic factors as involved in human fertility which would be: the male factor on the one side, that'd be sperm; and for women there are two separate factors; one of them is ovulation, or the presence of eggs, and then the uterus or the fallopian tubes, that is to say the transport to be able to get the egg and sperm to come together. If you look at the egg or the ovary side of the equation, then, if a woman has irregular menstrual cycles that would be a good indication that she is probably not ovulating. We think of ballerinas, we think of athletes who are runners, perhaps, who don't menstruate regularly - they typically do not ovulate. Women can also have premature ovarian failure or premature menopause, and those women also do not typically have regular menstrual cycles. On the uterus, or the fallopian side of the equation, there can be any number of things that can go wrong: the fallopian tubes can be blocked from prior pelvic surgery, for example, people don't think of appendicitis as being pelvic surgery but the appendix is very close to the fallopian tubes and if it's a complicated appendix case that can cause a blockage of the fallopian tubes. There's a simple x-ray that can be done to check whether the uterus or the fallopian tubes are open.
What are the leading causes of infertility among women?
When we consider the various things that can go wrong on the female side of the fertility equation, of course it depends on what group of women we're talking about as to which cause will play the dominant role. Most women that come to see me are typically in their late 30s. Most of the women that I see tend to have some kind of ovulatory problem, or a problem with egg quality, because they're getting close to menopause. If you look at the population at large, by far and away the most common cause of infertility is some kind of tubal blockage: an infection in the fallopian tubes from a sexually transmitted disease, or from a prior pelvic surgery. This is one of the many reasons that we advocate the practice of safe sex, so that fertility later on in life is preserved. The second leading cause of infertility is lack of ovulation, and there is a condition called polycystic ovary syndrome, or PCOS, in which women do not ovulate and they need fertility medications to help their ovary release the egg. They can get pregnant after that fairly readily. Those are the basic factors: it's the ovulatory factor and the tubal factor, and in our case, sometimes the age factor: the early menopause also being part of the ovulatory side of the fertility equation.
What is "polycystic ovary syndrome" or "PCOS"?
How is "pelvic inflammatory disease" related to infertility?
Pelvic inflammatory disease is a generic term that we use for a condition in which the fallopian tubes become infected. The fallopian tubes and the uterus are in the pelvis, and so pelvic inflammatory disease means that everything basically gets inflamed and that is from an infection. This infection in almost all cases is through a sexually transmitted disease. The common causes are either Chlamydia, or gonorrhea, and what happens is the infection starts as a result of intercourse and the bacteria are deposited in the upper part of the vagina and they then climb through the cervix and up through the uterus and up into the fallopian tubes. The problem with pelvic inflammatory disease is that it can progress to a very severe type of infection and a pelvic abscess can occur. However, from our perspective, we're most worried the pelvic inflammatory disease will damage the fallopian tubes and that patient will have a difficult time getting pregnant in the future. One episode of pelvic inflammatory disease is thought to diminish fertility by about 20%, so it's not by any means an all or nothing, but clearly a significant amount of damage comes from a single episode but that depends how bad the infection is. If someone thinks they are having pelvic inflammatory disease they need to go to the doctor right away and get antibiotics in order to make sure the disease gets cured and, also in an effort to try to preserve fertility for the future.
How can other preexisting health problems affect female infertility?
Most chronic medical conditions do not have a direct effect on fertility. The one notable exception to that is Obesity, which is commonly associated with diabetes. Diabetes actually affects the ovary and causes a condition that looks like polycystic ovary condition, which causes the woman to stop ovulating. Some women will not ovulate if they are too heavy and will only start to ovulate after their weight comes down to a reasonable level. Of course, many other women will ovulate regardless of how heavy they are and subsequently have to deal with the obesity during their pregnancy. In the same way, other medical conditions are primarily a source of problems during the pregnancy itself. For example, high blood pressure, diabetes and kidney disease all have the potential for getting worse during pregnancy and also for making the pregnancy more complicated.
What are my chances of getting pregnant after the age of 30?
Human fertility depends to a great extent on the age of the woman. And we can talk about statistics but of course on an individual level it really depends on when that particular woman is programmed to go through menopause. Some women go through menopause at the age of 50, most of them do, but some can go through menopause at age 45, or 40, or perhaps even 35. Those who go through menopause earlier than the age of 35 are said to have premature ovarian failure, and the incidence of that is about 1%. So women who are in that category of course have limited possibility of getting pregnant even if they are at an age as young as 30. However for most women, fertility does not begin to decline until 30 or perhaps even 35. If you look at population studies fertility seems to decline at 30, and fertility treatment cycles typically not until the age of 35, which means we can probably make up the difference between 30 and 35 with the use of medication. After that however fertility lowers dramatically so that after the age of 45 it's very uncommon to get pregnant with a woman's own eggs. Of course I know there are women out there who do get pregnant on their own but I want to remind you that we do not know what the denominator is in terms of the proportion of women trying to get pregnant at that age. It's very uncommon for a woman to get pregnant with her own eggs after the age of 45 as a result of fertility treatment.
What precautions should I take if I hope to conceive in my thirties or forties?
I would say that women who plan on having children in their early thirties are probably not going to have a problem in general. We don't think of age-related fertility decline as beginning until about the age of 35. But after that there's no question that fertility drops. After 40, it can be a struggle. I mean, it can be quite difficult to get pregnant at that point. So I would say that in the future, or perhaps we are there now, women should look at their life at the age of 30 and say, "am I going to have my children now, in the next 3-5 years?" And if the answer is yes, then that's great. If the answer is no, then I think those are the women who should seriously consider freezing their eggs, because the decline in fertility is so rapid after the age of 35 that, even though you lose some degree of viability in the egg by freezing it, you'll still probably be better off with those frozen eggs than with the woman's own eggs, certainly by the time she's 40.
What causes male infertility?
The causes of male infertility are an alagist to those of female infertility. The sperm are produced in the testicle and that testicle needs to have adequate hormonal stimulation to produce the sperm. Something may have happened to the testicle somewhere along the way. For example, men who are born with undescended testicles commonly have very low sperm production. Men who had mumps or kitis, where the mumps virus actually goes and infects the testicle, commonly have very low sperm counts. There can a blockage of the duct, such as happens intentionally doing a vasectomy, but can happen as a result of an infection in the male reproduction tract. That can cause lack of sperm in the ejaculate. Of course, if the man has a hormonal problem, which he's entitled to have just as women, he may not produce sperm from the testicle. You hope to find this last fertility category because, of course, it's easily treated by giving that man the hormonal stimulation that he needs. Those are the basic causes of male infertility. There's also the issue of heat being delivered to the testicle and something called a varicocele, where there are varicose veins on the outside of the testicle that can cause an increase in the temperature and decrease sperm production in that man.
What are some of the myths about male infertility?
There are many myths about male fertility, and most of them concentrate around various kinds of food that the man is supposed to take. In reality, alterations in lifestyle really play a very minor role, particularly in terms of sperm production. The one very real effect on the testicle is that of heat. Men who spend a lot of time in saunas or in jacuzzis will have a lower sperm count, and it can actually be a major cause of infertility. However, buying boxer shorts instead of jockey shorts does not seem to play a major factor. Although, I see this story in the newspaper at least once a year, about a couple who was infertile, and the husband buys boxer shorts and presto: the wife becomes pregnant. I would classify that one as a myth that is based on some shred of truth.
