FAQ: Infertility and Reproductive Endocrinology

Infertility is a condition that makes natural conception difficult. The diagnosis of infertility is usually given to couples who have been attempting to conceive for at least one year (or six months if the woman is 35 or older) without success. Women who can get pregnant, but are unable to stay pregnant, may also be infertile.

Conception and pregnancy are complicated processes that depend upon a number of factors, including:

• Healthy sperm production by the man
• Healthy egg production by the woman
• A woman’s fallopian tubes must be open to allow sperm to reach the egg
• Sperm must be able to fertilize the egg
• The fertilized egg (the embryo) must be able to implant in the woman's uterus
• The quality of the embryo must be sufficient

Infertility may result if there is a problem with any of these steps.

Infertility may result from one or multiple causes. Some of the most common causes include:

• Ovulation disorders, such as polycystic ovarian syndrome (PCOS)
• Damaged or blocked fallopian tubes
• Endometriosis
• Uterine problems, such as fibroids
• Age (the number of healthy eggs a woman has decreases with age)
• Smoking (it can also reduce the number of eggs a woman has)
• Problems with the quantity or quality of the man’s sperm

Yes. According to the Centers for Disease Control and Prevention (CDC), more than 7.3 million Americans, or 1 in 8 couples of childbearing age, have problems conceiving.

Infertility is not only a woman’s problem — many men have fertility problems, too. For women, smoking, increased age, pelvic infections, endometriosis, thyroid disease, stress and some cancer treatments can make conceiving more difficult.

Many women are waiting until their thirties and forties to have children, which makes it more likely that they will have problems conceiving. A woman’s fertility decreases with age, especially after about 35 years of age. This decrease in fertility is largely due to reduced quality of the woman’s eggs.

A man’s sperm can be affected by his overall health and lifestyle. Some things that may reduce the health or number of a man’s sperm include heavy alcohol consumption, drug use, smoking cigarettes, and exposure to environmental toxins, such as pesticides and lead.

The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms. In some cases, an infertile woman may have irregular or absent menstrual periods, which suggests problems with releasing eggs, known as ovulation. A man experiencing infertility may have no noticeable symptoms.

For most people, it is recommended that you visit your primary doctor, which could be either your gynecologist or primary care physician, if you are unable to become pregnant after one year of trying. But for anyone already concerned about fertility, especially women over the age of 35, it is usually a good idea to see a doctor earlier, after about six months of trying. Your primary doctor can offer advice and perform some initial assessments. If necessary, they may refer you to a reproductive endocrinologist.

According to the American Society for Reproductive Medicine, you should seek the care of a specialist if you are unable to achieve pregnancy after 12 months of unprotected intercourse if the woman is under the age of 35, or after six months if the woman is 35 years of age or older.

You should see your doctor sooner if:

• Your periods are irregular, absent or painful
• You have endometriosis or pelvic inflammatory disease (PID)
• You’ve had more than one miscarriage

Men should speak with their doctors if they have a low sperm count or history of testicular, prostate or sexual problems.

In some cases, the difficulty in becoming pregnant can be resolved by your doctor without having to see a specialist. Your doctor can conduct a basic infertility evaluation. If a problem is found during the evaluation, you will most likely be referred to a specialist.

A reproductive endocrinologist (RE) is an obstetrician/gynecologist with specialized training and experience in diagnosing and treating infertility. Urologists, who specialize in the health and functioning of the urinary tract and male reproductive organs, can evaluate and treat infertility in men.

To find an infertility specialist, call 858-657-8745. Patients with infertility concerns are seen daily at Perlman Medical Offices, adjacent to Jacobs Medical Center. Appointments are available for consultation, diagnosis and treatment. For each couple, we develop a carefully individualized treatment protocol.

The process for women usually begins with a discussion of your medical history and any relevant lifestyle factors. For example, things your doctor may ask about could include menstruation, pregnancy, surgical history, birth control usage, current sexual patterns, medications, other health problems, lifestyle factors and your work environment.

An ultrasound is usually then done to examine your uterus and ovaries. Other tests may be necessary and could include hormone testing and a more thorough evaluation of your reproductive organs through a hysterosalpingogram (HSG).

Your doctor will also want to review your male partner’s medical history. The single most important test of male fertility is the semen analysis, which assesses sperm count, the ability of the sperm to swim (motility) and the total semen volume. If any significant abnormalities are discovered, a consultation with a urologist may be recommended.

Most fertility treatments require the woman to take medication. Some common infertility medications for women include:

• Clomiphene citrate (Clomid) causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. It is taken by mouth.
• Human menopausal gonadotropin or hMG (Repronex, Pergonal) is often used for women who do not ovulate due to problems with their pituitary gland. It is an injected medicine that acts directly on the ovaries to stimulate ovulation.
• Follicle-stimulating hormone or FSH (Gonal-F, Follistim) works much like hMG and stimulates the ovaries to begin the process of ovulation. It is usually an injected medication.
• Metformin (Glucophage) is usually taken by mouth and is used for women who have insulin resistance and/or PCOS. This drug helps lower the elevated levels of male hormones in women with these conditions and helps the body to ovulate. Sometimes clomiphene citrate or follicle-stimulating hormone is used in combination with metformin.
• Bromocriptine (Parlodel) is prescribed for women whose ovulation problems are due to high levels of prolactin, a hormone that causes milk production.

Drugs are not as important in the treatment of male infertility as they are in the treatment of female infertility. Medicines may however, occasionally be prescribed in certain situations, such as antibiotics to treat infections or inflammation.

The potential health risks of taking fertility drugs are not fully understood yet. According to the American Fertility Association, any medication that causes unusual hormone production could potentially cause cancer in the reproductive system. No matter what fertility drug a woman uses, it is recommended that it only be used for a short period of time to avoid an increased risk of cancer. While some studies have linked ovulation-stimulating drugs to an increase in ovarian and breast cancers, others have failed to find any such link.

It should also be noted that all fertility drugs increase a woman's chance of having twins, triplets or other multiples. Because women who are pregnant with multiple fetuses typically have more complications during pregnancy, practitioners generally aim to help their patients achieve single pregnancies.

Reproductive surgery is sometimes performed if there is a structural problem associated with a man or woman’s infertility. The vast majority of surgical procedures used to address infertility in women can now be performed on an outpatient basis, using either a laparoscope inserted through a small incision in the navel or a hysteroscope inserted through the vagina.

For women, surgery can also be done to remove scar tissue from inside the uterus (known as Asherman’s syndrome), treat endometriosis, remove cysts from the ovaries, and remove fibroids or polyps. For men, surgery can be used to attempt to reverse a vasectomy, correct a blockage of the reproductive tract or a varicocele (an enlarged vein in the scrotum).

The services covered by insurance will depend on where you live and the type of insurance plan you have. Some states, including California, currently have laws that require insurers to cover or offer to cover at least a portion of services used to diagnose and treat infertility. However, the existing laws vary greatly in their scope of what may be covered. Check with your insurance company to determine what your coverage includes.

The number one most important factor affecting your chances of conceiving is when and how often you have intercourse within your “fertile window”, which is made up of the days in your menstrual cycle when there is the greatest possibility of pregnancy. The length of this fertile phase is determined by the lifespan of the sperm and egg. Sperm can survive a maximum of five days in fertile cervical fluid and an egg can survive for up to one day. Your theoretical fertile window is thus six days long, including the five days leading up to ovulation and the day of ovulation.

Note that the stress of having strictly scheduled intercourse can decrease fertility. It is recommended that when trying to conceive, you have intercourse on at least a couple different days each week, without worrying about the timing. This will help ensure you have intercourse during your fertile window and will potentially reduce the stress associated with trying to adhere to a strict schedule.

Generally, if a woman has regular periods, it is likely she is ovulating. If she has irregular or absent periods, there may be a problem with ovulation. A woman can confirm she is ovulating by using an over-the-counter urinary ovulation prediction kit (OPK), which detects the increased levels of luteinizing hormone (LH) that trigger ovulation.

It has sometimes been suggested that couples who are trying to conceive should reduce the frequency of sexual intercourse during the fertile window in order to increase sperm supply. This is not true for most couples, however. If a couple has known sperm problems, they should consult their doctor on the best strategies for intercourse, but couples who have no known sperm issues should not reduce the frequency of intercourse during the fertile window. Your odds of conception increase when you have intercourse multiple times within your fertile window. While it is true that sperm concentrations decrease slightly with more frequent intercourse, having intercourse more often is still more likely to result in conception for couples who do not have known male fertility problems.

• Control your weight. Excess body fat can lead to overproduction of certain hormones that disrupt ovulation, resulting in less regular menstrual cycles with less frequent ovulation, which lowers a woman’s chances of getting pregnant. On the flip side, having too little body fat may mean the body is not able to produce enough hormones for ovulation each month or to sustain a pregnancy if does conception occur.
• Maintain a healthy diet. Staying well-nourished boosts your odds of conceiving. Make sure to take a prenatal vitamin every day. The folic acid in these vitamins is very important for reducing the risk of birth defects.
• Do not smoke. Smoking cigarettes can impair both male and female fertility. Cigarette toxins damage a woman's eggs and cause the ovaries to age. In men, smoking can reduce sperm production and damage DNA.
• Track your cycle. Take advantage of your fertile window and aim to have intercourse during the six days when you are most fertile.
• Limit alcohol and caffeine consumption. It is probably best to limit your caffeine intake to one or two regular-sized cups of coffee a day. Also keep in mind that excessive alcohol consumption can negatively affect reproductive functioning.
• Avoid excessive heat. Men should avoid exposing their testicles to excessive heat, such as in hot tubs or saunas, which can damage sperm. Note that recovery from heat damage can take up to 72 days.
• Avoid exposure to certain chemicals. Pesticides, especially agricultural pesticides, may harm both male and female fertility. Exposure to some solvents and toxins, including those used in printing businesses and dry cleaning establishments, can adversely affect female fertility.

Acupuncture can help you relax and overcome some of the stresses associated with infertility and undergoing infertility treatments. The use of acupuncture during fertility treatment carries minimal risks.

Prenatal vitamins should be started as soon as you start trying to conceive, if not before. The folic acid in these vitamins decreases the risk of birth defects.

Typically, it is not advisable for couples who are trying to become pregnant to use herbs and other dietary supplements that have not been properly tested. Many over the counter preparations tout increased fertility without adequate proof through research. Keep in mind, the Food and Drug Administration (FDA) does not regulate and oversee the manufacture, distribution, usage and label claims of dietary supplements. Therefore, statements of efficacy are generally not supported by rigorous scientific research and clinical testing.

The 1992 Fertility Clinic Success Rate and Certification Act requires that the Centers for Disease Control and Prevention (CDC) publish an annual Assisted Reproductive Technology (ART) Success Rates Report. According to their definition, ART includes all fertility treatments in which both eggs and sperm are handled.

In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. This category of procedures does not include treatments in which only sperm are handled, such as intrauterine insemination or artificial insemination, or procedures in which a woman takes medicine to stimulate egg production without the intention of having eggs retrieved.

The annual ART Success Rate data can be viewed online on the CDC’s website. Data is presented in national summary tables, representing information from fertility clinics that have provided and verified data on the outcomes of all ART cycles started at their clinics. Click here to access this information.

Artificial insemination is a technique that can help treat certain kinds of infertility problems in both men and women. In this procedure, sperm are inserted directly into a woman's cervix or uterus. This makes the trip shorter for the sperm and bypasses any possible obstructions. Intrauterine insemination (IUI), in which the sperm is placed inside the uterus, is the most common form of artificial insemination.

Though the pregnancy rates for women undergoing artificial insemination may not be as high as they are for some more advanced techniques, this technique has a key advantage: it's a simple procedure with few side effects. For those reasons, your doctor may recommend it as an initial form of treatment for infertility.

In vitro fertilization (IVF) is a technique where eggs are surgically removed from the ovaries and are combined with sperm outside the body. After a few days, fertilized eggs (embryos) are placed inside the women's uterus, thus bypassing the fallopian tubes. IVF has received a great deal of media attention since it was first used successfully in Cambridge, England in 1978.

IVF was introduced in the United States in 1981. Like other extremely delicate and sophisticated medical procedures, IVF involves highly trained professionals and the use of advanced laboratories and equipment. The cost of IVF cycles tend range from $14,000 and $20,000.

Pre-implantation genetic testing (PGT) takes one or more cells from an egg or an embryo (fertilized egg) and performs special tests to learn more about the genetic make-up of the rest of the cells in that embryo.

PGT requires that couples undergo in vitro fertilization (IVF), where the eggs (oocytes) are removed from a woman’s body and mixed with her partner’s sperm in a laboratory. The embryos that are created can be tested on the third day after the eggs have been harvested and then implanted back into the uterus on the fifth day. Alternatively, the embryos can also be frozen after the cells are removed for testing and implanted during a subsequent cycle.

Patients with inherited familial diseases may wish to have their embryos tested to determine the genetic make-up. Specifically, this would include patients with a history of single-gene

disorders, such as cystic fibrosis or sickle cell anemia, and patients with a history of sex-linked disorders, such as Duchenne muscular dystrophy and Fragile X syndrome.

If you are wondering whether you should undergo genetic testing, talk to your doctor about whether pre-implantation genetic testing would be beneficial for you.

The healthiest pregnancies are single pregnancies. Even twin pregnancies are more complex than single pregnancies. Fertility drugs stimulate your ovaries, increasing the odds that you'll release several eggs at the same time.

On average, 20 percent of women taking gonadotropins will become pregnant with more than one baby. Women who get pregnant while taking the drug Clomid have a 5 to 10 percent chance of conceiving twins.

If you undergo in vitro fertilization (IVF), your chances of conceiving more than one child are 20 to 40 percent, depending on how many embryos are placed in your womb.

Yes, pregnancy is possible in some cases following cancer treatment. It does not appear that pregnancy after cancer increases the risk of cancer recurrence, and children born to cancer survivors do not appear to have a higher risk of birth defects. Researchers are actively working to gather more data, but the information currently available is reassuring.

More than ever, cancer patients are surviving their disease and can look forward to the future. Reproductive health issues, including the ability to have children, the need for birth control, retaining sexual function and the possibility of early menopause, are all important to young cancer survivors.

To help young survivors address reproductive health concerns, UC San Diego Moores Cancer Center has a multidisciplinary team of specialists from the fields of reproductive endocrinology, gynecology, oncology, genetics and psychology. For more information, contact Moores Cancer Center’s nurse coordinator at 858-822-2660.

Infertility is a major life crisis for one in eight couples. It may affect self-esteem, body image, sexual identity, life goals and sexual relations. When faced with the possibility or diagnosis of infertility, you may experience a broad range of emotions that could include:

• Initial disbelief and denial, followed by anger and grief
• Loss of control
• Guilt and blame – finding out that one partner is infertile can place strain on a relationship
• Increased stress, particularly if treatment requires frequent testing and intercourse on a specific schedule
• Monthly cycles of hopeful anticipation followed by depression when menstruation begins
• Feelings of isolation – a desire to keep infertility problems a secret can often isolate a couple from important support systems that can be found in friends and family members

Social exchanges and situations may be painful when you see others with babies or are asked about your plans for having children. Having family members who are expecting children may contribute to your feelings of stress, as may your parents’ desires for grandchildren if they are expressed.

Infertility often creates one of the most distressing life crises that a couple has ever experienced together. The long-term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples. If you find yourself feeling anxious, depressed, out of control or isolated, you are not alone. Please let your team of health care providers know what you are struggling with so they can provide you with the right resources to help you cope.

Some people prefer to seek infertility help from a support group or a patient group. While an infertility support group may not be right for everyone, it can be helpful for some. RESOLVE is a national infertility association that has ongoing support groups in the San Diego area. The American Society for Reproductive Medicine is another good resource for information.

In addition, some couples find it beneficial to seek professional relationship counseling, couples counseling or family counseling if the emotions of infertility are affecting other areas of their lives. Some also find sex therapy beneficial when dealing with sexual issues related to infertility.

Make sure you choose a mental health professional who is familiar with the emotional experience of infertility. Ask your reproductive endocrinologist for names of people that he or she would recommend. At UC San Diego Health, the Maternal Mental Health Clinic addresses the mental health needs of women and provides comprehensive care for depression, anxiety, pregnancy loss and infertility. Please call 619-543-6932 to schedule a consultation.