The World Health Organization (WHO) recently published a report that found that infertility affects one in six people globally. Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular, unprotected sexual intercourse. It is an increasingly common occurrence in the United States, affecting millions of couples hoping to start a family. According to the Centers for Disease Control and Prevention, among married women aged 15 to 49 years with no prior births, about one in five (19%) are unable to get pregnant after one year of trying. Within this group, about one in four (26%) women have difficulty getting pregnant or carrying a pregnancy to term.
In recognition of National Infertility Awareness Week, we spoke with infertility expert Jordan Rush, M.D., board-certified OBGYN at Northside Women’s Specialists, part of Pediatrix® Medical Group, in Atlanta, Georgia, to learn more about the basics of the disease.
Causes
Dr. Rush approaches the diagnosis process with a comprehensive look at both partners, including a complete health history. “I try to emphasize to my patients that we should focus on the whole picture,” he said.
While much of the attention is typically on the woman attempting to get pregnant, about 30% to 40% of infertility is caused by the male. “Nearly half of all infertility is due to male factor,” said Dr. Rush. This is a result of low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. “Patients have come to me who are undergoing infertility treatment, and no one has ever evaluated the male,” noted Dr. Rush. “It’s very gender biased.”
Female infertility is typically due to ovulatory disorders (about 15%), which are conditions that affect the normal ovulation process, resulting in failed or irregular ovulation; tubal factor infertility (about 15% to 20%), which occurs when a blockage in the fallopian tubes will not allow the egg and sperm to meet; and endometriosis (30% to 50%), a condition in which the cells lining the uterus start to grow in places they shouldn't, such as the ovaries or fallopian tubes. Dr. Rush notes that tubal factor infertility is often a result of unknown sexually transmitted infections like chlamydia or gonorrhea, which can cause blocked tubes.
Risk Factors
Common risk factors that contribute to male infertility include:
- Past trauma
- Testicular cancer
- Alcohol use
- Drug use
- Use of performance-enhancing drugs
“A lot of men are taking supplemental testosterone now, which decreases sperm production,” said Dr. Rush. However, this can be reversed if use is stopped, and a normal sperm count can typically be achieved within a couple months.
Common risk factors that contribute to female infertility include:
- Age — In women 35 and older, eggs are less fertilizable due to abnormalities in the chromosomes
- History of pelvic inflammatory disease
- History of pelvic infection, including sexually transmitted infections
“Late childbearing continues to be a problem,” said Dr. Rush, noting that the rate of fertility sharply declines in women 35 and older, and conceiving naturally at the age of 40 and older becomes increasingly difficult. At that point, many infertility centers won’t treat a woman with their own eggs and will require a donor.
Evaluation
Dr. Rush opts to start with the least invasive, simplest assessments first, noting that within a month, the cause can typically be identified. “Before going on to invasive testing on the woman, we have to rule out male factor infertility,” said Dr. Rush.
Dr. Rush begins with a semen analysis on the male while at the same time ensuring ovulation in the woman. About 80% of the time, ovulation can be determined by history alone, but an ovulation predictor kit is used as well. Dr. Rush then checks to see if the woman has normal fallopian tubes, where fertilization generally occurs, looking for any tubal factors. This is initially evaluated with a hysterosalpingogram, an X-ray examination in which contrast material (dye) is injected through the cervix to the uterine cavity to see if the tubes are open. A surgical procedure called a laparoscopy may also be performed to better view the tubes and any blockages or other issues, such as adhesions.
If the above factors are ruled out, the cause is then deemed unexplained infertility, at which point treatment is advised.
Treatment
The first line of treatment for unexplained fertility is ovulation induction, which uses fertility medications to stimulate egg development and release, together with intrauterine insemination, which is a type of artificial insemination. For this, the sperm is washed and concentrated and then placed directly in the uterus, bypassing the cervical barrier, around the time the ovary releases one or more eggs to be fertilized.
Dr. Rush notes there is a 15% to 20% success rate per cycle with a one in five chance of becoming pregnant, which is the average rate. If unsuccessful after three cycles, in vitro fertilization is the next step.
Women diagnosed with tubal factor infertility bypass this process entirely and go straight to invitro fertilization.
Tips for Trying to Conceive
Dr. Rush recommends planning three to six months ahead of trying to conceive. During this time, he advises removing any risk factors; optimizing one’s overall health, including body weight; determining any underlying conditions like diabetes or autoimmune diseases; and addressing any history of irregular cycles. Meeting with the woman’s primary OBGYN for preconception counseling is also advised to help guide couples through the planning process.
He also shares that the most common issue he sees in couples who are having difficulty conceiving is that the timing of intercourse is off. Dr. Rush emphasizes how important it is for couples to educate themselves on how to properly time intercourse each month, noting that the egg is only fertilizable for about 24 hours and sperm typically live for about 72 hours. The ideal time for intercourse is one to two days before and the day of ovulation.
Additional resources are available through the American Society for Reproductive Medicine.
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