Treatment for Infertility

What is this condition?

Infertility refers to the inability to conceive a child after regular intercourse without contraception for at least 1 year. It affects approximately 10% to 15% of all couples in North America. About 40% to 50% of infertility is attributed to the female partner.

After extensive evaluation and treatment, about half of these infertile couples achieve pregnancy. In about 10% of the half who don't, doctors can't find a specific cause for infertility; in this group, the prognosis is poor if pregnancy isn't achieved after 3 years.

What causes it?

The causes of female infertility may be functional (lacking a physical or structural origin), anatomic, or psychological. Psychological problems probably account for relatively few cases of infertility. Occasionally, a woman who's under stress may stop ovulating; marital discord may also affect the frequency of sexual intercourse. However, psychological problems usually are a result, rather than a cause, of infertility.

What are its symptoms?

Inability to achieve pregnancy after having regular intercourse without contraception for at least 1 year suggests infertility.

How is it diagnosed?

The woman undergoes a complete physical exam and health history, which includes specific questions about her reproductive and sexual function, past diseases, mental state, previous surgery, types of contraception used in the past, and family history. For instance, if her history reveals irregular, painless menstrual periods, this may indicate that she's not ovulating. A history of pelvic inflammatory disease may suggest a blocked fallopian tube.

The doctor will order the following tests to assess ovulation:

. Basal body temperature graph shows a sustained rise in body temperature after ovulation until just before the menstrual period starts, showing the approximate time of ovulation.

. Endometrial biopsy (removal of tissue from the surface lining of the uterus), done on or about day 5 after the basal body temperature rises, provides evidence that ovulation has occurred.

. Progesterone blood levels, measured when they should be highest, can show inadequate progesterone production.

To assess the structure of the fallopian tubes, ovaries, and uterus. the doctor may perform the following procedures:

. Hysterosalpingography (an X-ray study of the uterus and fallopian tubes in which a radiopaque dye is injected through the cervix) may reveal a blocked fallopian tube or abnormalities of the uterine cavity.

. Endoscopy (visual inspection using an illuminated tube) confirms the results of hysterosalpingography and allows the doctor to examine the endometrial cavity and explore the front surface of the uterus. fallopian tubes, and ovaries. The doctor also may make a small incision in the abdominal wall (laparoscopy) to visualize the abdominal and pelvic areas.

The doctor may also order male-female interaction studies, including the following:

. Postcoital tests (Sims and Huhner's tests) examine the cervical mucus for motile sperm cells after intercourse that has occurred at the middle of the woman's reproductive cycle (as dose to ovulation as possible) .

. Immunologic or antibody testing detects sperm-killing antibodies in the woman's blood. Further research is being conducted in this area.

How is it treated?

Treatment depends on the underlying problem. If an overactive or underactive adrenal or thyroid gland is the cause of infertility, hormone therapy is necessary. For a progesterone deficiency, the woman receives progesterone replacement. A woman who's not ovulating is given the drug Clomid, human menopausal gonadotropins, or human chorionic gonadotropin; typically, she ovulates several days after such treatment.

Surgery may correct certain anatomic causes of infertility, such as a blocked fallopian tube. It may also be done to remove tumors located within or near the hypothalamus or pituitary gland (structures in the brain). To treat endometriosis (abnormal tissue growth on the surface lining of the uterus), the woman receives drug therapy (Danocrine or Depo-Provera or noncyclic oral contraceptives), has surgery to remove the abnormal tissue, or undergoes a combination of both.

Other treatment options for infertility include use of a surrogate, frozen embryos, or in vitro fertilization. However, these options can be controversial and involve emotional and financial cost.