What's New in Infertility, a three part series

In the United States 1 in 8 couples has difficulty when they wish to start a family.

***What's new?  The birth rate in the US reached an all time low of 63.2 per 1000 in the US in 2011.

The majority of couples who visited their doctor for infertility issues wish they had visited sooner.

When should couples visit the doctor?

Most experts advise couples to begin with a visit to her doctor (ob/gynor family doctor)  if the couple has been trying unsuccessfully to conceive for over a year. If his age is over 55 or hers is over 35 the visit should happen sooner--after 6 months without success. Of course, same sex couples will need to begin with a visit to the doctor right away.

Causes of infertility are divided approximately equally between the sexes, with female factor infertility accounting for approximately one third of cases, male factor infertility accounting for approximately one third, and the final one third is composed of couples with both male and female factors.  For a significant percentage of couples, no obvious problem is found.  Those couples have traditionally been given the diagnosis of "unexplained infertility".

What are the causes of infertility in women?

In women, causes of infertility can be divided into two very broad catagories:
1) Hormonal problems such as abnormalities of the thyroid or pituitary gland, or problems with ovulation (releasing an egg from the ovary).
2) Physical problems such as blockage of the fallopian tubes, problems with the uterine lining (polyps or fibroids), and problems with the cervical
mucus.

***What's new? Many infertility doctors now believe that many of the cases of "unexplained infertility"  in women are actually cases of very early, mild, or atypical endometriosis
                                                                                                    
What are causes of infertility in men?

As in women, causes of infertility in men can be divided into two broad catagories
1) Hormonal problems such as abnormalities of the thyroid or pituitary, or problems with sperm production caused by low testosterone levels.
2) Physical problems such as blockage of the seminal vessicles, retrograde ejaculation, or failure to achieve or maintain an erection.

***What's new?  Recent studies suggest that a significant number of cases of  unexplained infertility in men are actually cases of excessive DNA fragmentation in the sperm. (DNA is the genetic material  carried by sperm.)  Excessive breakage of DNA strands has been linked to many factors, such as excessive exposure to stress, heat or environmental toxins.

***What else is new? Fertility specialists are investigating a third, controversial category known as Immunologic infertility.   A Malfunction in the body's immune system, which  normally protects against invasion by foreign agents, causes the body to attack itself interfering with  normal mechanisms of fertility.

How is infertility diagnosed?

Traditionally the infertility evaluation begins with the female partner.  An ob/gyn physician or general practitioner can perform the basic work up.  Most physicians will begin the evaluation by determining whether the female partner is ovulating regularly.  A progesterone level at the right time in the cycle(cycle day 21) can confirm ovulation.  Ovulation predictor test strips (which are similar to home pregnancy tests) and  Basal body temperature charting is also useful.

***What's new?  There are some convenient new apps for your laptop or cell phone that can be downloaded to help a woman monitor her cycle and determine her fertile days. Medhelp.org offers a nice tracker for signs and symptoms of ovulation.  http://www.medhelp.org/user_trackers/list/603463  New digital technology such as the The Clear Blue digital fertility monitor, can be used in conjunction with this app to determine the maximum number of fertile days and the optimum timing of intercourse.
  
If the woman is NOT ovulating regularly, the clinician will often evaluate thyroid hormone levels, prolactin levels, and FSH levels.Treatment of thryoid or pituitary abnormalities with appropriate medications can often help to re-establish regular menstrual cycles, and improve fertility.If the FSH level is elevated, this may mean that the ovarian reserve(the number of eggs remaining in the ovaries) is diminished.Older age (35 and up) is the most common reason for an elevated FSH.  Premature ovarian failure is a rare condition in which eggs are depleted before age 40.

***What's new?  Antimullerian hormone level(AMH) is a new blood test that is believed by many doctors to more accurately reflect the number of follicles or eggs remaining in the woman's ovaries than the traditional FSH test. The AMH level can help to estimate the chances that a woman can conceive with her own eggs versus the need for donor eggs.

If it seems that the mom-to-be IS consistently ovulating each month, the problem may lie with a blockage of the fallopian tubes. A hysterosalpingogram (hsg) can be performed. A traditional HSG is an x ray procedure during which dye is injected into the uterus and spills out into the abdomen through the fallopian tubes.  If the dye fails to spill from one or other of the tubes, a blockage is diagnosed.

***What's New?  Selective salpingography is a cutting edge technique in which a tiny cather(tube) is placed inside the hsg catheter and directed into the opening of the tube itself. In this way it is possible to determine whether a tube which might appear blocked on hsg is actually open, but might have spasmed due to the dye.
It is also possible to measure the pressure inside the fallopian tube.  In some cases of endometriosis, the pressure can be elevated causing reduced pregnancy rates.

If the female partner is BOTH ovulating regularly AND her tubes are not blocked, the next step is to investigate the uterus. Ultrasound can be used to evaluate the patient for problems such as cysts or fibroids. Historically, the next step was surgery in which either one of two or both a laparoscopy and hysteroscopy were performed  A hysteroscopy is an evaluation of the lining of the uterus, in which a scope is placed into the uterus through the cervix. Laparoscopy, a minor surgical procedure in which a small scope is placed into the abdominal cavity  is employed at times to evaluate the patient for evidence of endometriosis or other abnormalities of the pelvis such as adhesions which may not be detectable with ultrasound.

***What's new?  Recently, the trend has been toward a less invasive office procedure known as Saline Sonogram--Sterile saline solution is injected into the uterus while the doctor watches with transvaginal ultrasound.  Less expensive, less invasive and less painful, the saline sonogram can disclose a lot about the lining of the uterus, as well as having all of the advantages of traditional transvaginal ultrasound.

The least common abnormality, and usually the last to be investigated,  is a problem with the amount or quality of the cervical mucus.  The sperm must swim through the mucus to reach the egg. Normal mucus is nourishing to the sperm, allowing them to survive for 3-6 days.  Cervical conization or LEEP procedure can cause scarring of the cervix which can contribute to problems with the scanty or hostile cervical mucous.

If the evaluation of the female partner is normal, attention is then focused on the male.

Part two in this three part series will be devoted to diagnosis of fertility problems in the male partner, and treatment of infertility.

Part three will go into more depth on some of today's most relevant topics such as Polycystic Ovary Syndrome and new technologies which are making the biological clock obsolete.