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Common Causes of Infertility

Considering the complexity of both the male and female reproductive systems, one can view conception as nothing less than miraculous. Any change in the complicated sequence of events can disrupt ovulation, conception or pregnancy. Some of the most common conditions that can contribute to infertility are described below.  Some, but not all, may apply to you.

Abnormal Ovulation

Abnormal ovulation results in irregular or absent periods. Most of the time, this is caused by a hormonal imbalance due to inefficient communication between the hypothalamus and the pituitary gland, which together, causes the release of hormones into the bloodstream. 

Blocked Fallopian Tubes

Blocked or damaged fallopian tubes may interfere with the egg and sperm uniting. Blockages may also cause problems with embryo development and implantation in the uterus.

Endometriosis

Endometriosis occurs when uterine tissue, called the endometrium, also grows in areas outside of the uterus. Although technically benign, the tissue growing in the wrong place can cause fertility problems.

There are numerous reasons as to why endometriosis develops, but it is most likely that multiple causes can contribute to the problem. This is why patients frequently have different symptoms of endometriosis, ranging from pain with menstruation or irregular cycles to almost no pain, even with advanced stages of endometriosis.

The bottom line is that endometriosis affects fertility because it can cause anatomic changes, such as pelvic adhesions and ovarian cysts/pseudo cysts, as well as altering the hormonal environment in which the egg matures and becomes fertilized. Further immunologic irregularities of endometriosis may interfere with the complex process of embryo implantation within the uterus. 

Age

Fertility levels decrease with age, especially in women. Maximum fertility for women occurs between the ages of 15 and 24. Many couples today delay starting a family until they are in their 30’s or 40’s. About one third of women who defer pregnancy until their mid-30’s may have difficulty becoming pregnant, and at least half of all women over the age of 40 may have difficulties as well.

BMI

Body Mass Index can also interfere with getting pregnant.  A healthy BMI is critical to getting pregnant.  We encourage our patients to be in a healthy BMI range.  If you are struggling with weight loss, we can offer you resources.

Recurrent Pregnancy Loss

Treatment for the inability to sustain a successful pregnancy is based on the cause of the loss, if it can be determined.  Sometimes the cause can be determined through testing such as thrombophilia work-ups for blotting clotting issues, uterine cavity diagnostic testing which checks for normal anatomic structure and sperm quality analysis.

Male Factor

Problems may be related to inadequate sperm count or abnormalities relating to volume, shape, and movement of sperm. Male infertility is commonly related to the presence of a varicocele, which are varicose veins in the scrotum that affect sperm quality and quantity. Testicular injury, undescended testicles, and hormonal imbalances may also cause problems with infertility.


Artificial Insemination

AI refers to the process of placing sperm directly into the woman’s uterus via a long sterile catheter. It is a relatively simple and painless procedure that is performed in the office.

Intrauterine Insemination

The most common type of Artificial Insemination is intrauterine insemination (IUI).

An intrauterine insemination is scheduled the day after a positive color change with the ovulation predictor kit or by a confirming ultrasound.  On the morning of the insemination, a fresh semen sample is collected by the male and then prepared by the andrology technician.  The insemination begins with an ultrasound to determine which ovary is ovulating.  Sperm is directly inserted into the uterus via a catheter directing the sample towards the ovary that is ovulating.  If there is clear evidence of ovulation, we do a single insemination.  If ovulation has not yet fully occurred, we will schedule a second insemination the next day.  After your insemination, there are no specific restrictions regarding activity or intercourse.

The goal of IUI is to increase the number of quality sperm at the fertilization site, at the optimal time.

Intrauterine Insemination w/ Gonadotropin Stimulation

Gonadotropins are used to stimulate the growth of follicles.  At our office, we use Follistim.  Follistim contains the active ingredient follitropin beta made using recombinant DNA technology.  This hormone is the same as the follicle-stimulating hormone (FSH) produced by the pituitary gland, which plays an important role in human fertility and reproduction.  It is administered as a subcutaneous injection starting typically on day 8 of menstrual cycle, and continuing approximately 5-7 days, until the follicles reach their target size.  Ovulation is then initiated with hCG 10,000 units or Ovidrel.  An intrauterine insemination is scheduled the day following the hCG injection.

On the morning of the insemination, a fresh semen sample is collected by the male and prepared by the andrology technician.  The insemination begins with an ultrasound to determine which ovary is ovulating.  Sperm is directly inserted into the uterus via a catheter directing the sample towards the ovary that is ovulating.  If there is clear evidence of ovulation, we do a single insemination.  If ovulation has not yet fully occurred, we will schedule a second insemination the next day.  After your insemination, there are no specific restrictions regarding activity or intercourse. The goal of IUI is to increase the number of sperm at the fertilization site, at the optimal time.

Intrauterine Insemination w/ Donor Sperm

Using an outside donor sperm bank, the patient selects their donor sperm and the sample is sent to our office.  The sample is thawed and prepared for your insemination.


Assisted Reproductive Technology

ART refers to the process of surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s uterus.

In vitro Fertilization (IVF)

The most common type of ART is In vitro Fertilization (IVF).  There are 4 Stages of IVF:

1: Follicular Stimulation This is the process of developing eggs, which are formed in follicles on your ovaries and takes about ten days.  Having a greater number of mature eggs available for retrieval increases the chances for achieving pregnancy.  Since a woman’s body normally releases only one mature egg every month, gonadotropins such as Follistim and Menopur, are used to stimulate the ovaries to develop more follicles.

2: Egg Retrieval/Aspiration Once ovarian stimulation is complete and follicles have matured, as many eggs as possible will be retrieved, although all eggs may not be used in the current IVF cycle. The vaginal egg retrieval is performed under IV sedation.  A needle guide is placed alongside the ultrasound probe which is then inserted into the vagina.  A long, skinny needle is then inserted through the needle guide, penetrating the vaginal wall and directed into the ovary(ies) to withdraw the fluid from the mature follicle with gentle suction. The fluid is immediately examined under a microscope to see if an egg has been retrieved. The process is repeated for each visible follicle in both ovaries. All retrieved eggs are removed from the follicular fluid and placed in an incubator to await fertilization. On day of aspiration, a fresh semen sample is collected from the male partner and processed to select the strongest, most active sperm.

3: Fertilization Intracytoplasmic Sperm Injection (ICSI) Each egg is placed under a microscope and held in place by a gentle vacuum with a small glass tube called a micropipette.  A single sperm is then drawn up and quickly passed through the zone pellucida (the gel-like egg shell) and the inner cell membrane, directly into the center of the egg, anticipating fertilization.  When the egg is fertilized with the sperm, embryos are now created.  The embryologist will monitor and incubate the embryos until transfer time. Assisted Hatching In order for implantation to occur, the embryo must hatch out of its outer layer and implant in the lining of the uterus.  Just prior to the transfer, the embryologist makes a small opening in the outer layer of the embryo with a tiny needle to facilitate this process.

4: Embryo Transfer The embryo transfer itself is not a complicated procedure and is performed in our office. The embryos are placed in a catheter which is inserted through the cervix into the uterine cavity, by visualization from an abdominal ultrasound. The number of embryos transferred depends, but is not limited to, a woman’s age, cause of infertility, pregnancy history, and other factors.   If there are additional embryos that are of exceptional quality, they may meet the guidelines for freezing (cryopreservation) for later use.  Approximately two weeks after the day of egg retrieval, a pregnancy test is performed.  

Frozen Embryo Transfer (FET)

Sometimes there may be extra embryos created in the process of IVF which are not transferred to the uterus.  They can be frozen for future cycles.  When you are ready to use these embryos, the thawing and transferring of these embryos is known as a Frozen Embryo Transfer (FET).

Uterine preparation begins with the use of the birth control pill and then overlaps with the start of daily Lupron injections to suppress ovulation and keep your ovaries quiet.  You will have an assigned date to stop the pill which will bring on a period, but you will continue the Lupron.  This period is referred to as a Lupron bleed.  The use of Estrace then begins for approximately 3 weeks.  This helps to thicken your uterine lining for the transfer.  When the endometrial lining is sufficient in thickness, progesterone in oil injections will begin to help to continue to enrich the lining to accept the embryos for implantation.


Surgical Procedures

When infertility is caused by anatomical problems, all but the most severe cases can usually be corrected surgically. The cause of infertility can sometimes be traced to previous infections or inflammation that left scarring. Endometriosis, fibroids, and other uterine abnormalities can also be treated with surgical techniques.

An Operative Hysteroscopy is a visual examination of the interior of the uterus to look for tumors, scars, or abnormalities. This procedure is performed on an outpatient basis under general anesthesia.  The cervix will be dilated to allow the hysteroscope to be inserted through the vagina and cervix into the uterus. To make viewing easier, the cavity is inflated with a small amount of carbon dioxide. If needed, small sterile instruments are then inserted into the uterus through the hysteroscope to perform any corrections.  Some common findings may be polyps, fibroids, adhesions or uterine septums.

In addition to the Operative Hysteroscopy, a Laparoscopy may also performed. This procedure is also performed on an outpatient basis with the use of general anesthesia. An instrument is passed into the abdomen through a tiny incision below the navel. A second instrument is inserted through an incision at the pubic hairline. The cavity is inflated with a small amount of carbon dioxide to make viewing easier. This procedure gives a direct view of the uterus, ovaries, fallopian tubes and pelvic cavity, allowing for detection of any scar tissue. It may help to identify endometriosis, which is the presence of normal uterine tissue in abnormal places outside the uterus.

A Laparotomy/Myomectomy is performed for the removal of large fibroids. During a laparotomy, an incision is made in the abdomen for removal of the fibroid(s). The uterine wall is then repaired to help prevent pelvic adhesions or scarring, while the uterus is left alone, for future fertility. This procedure is major abdominal surgery and is done as an inpatient surgery in the hospital. One can expect to be in the hospital for 2-3 days, with a total recovery time of 4-6 weeks.