INFERTILITY CAUSES AND DIAGNOSES
Infertility is defined as the inability to achieve pregnancy after 12 months of unprotected intercourse when the woman is less than 35 years of ageor after 6 months if the women is more than 35 years old. It is generally accepted that after this time a couple should consult a fertility specialist to undertake Level 1 of pre-testing.
The basic testing can be completed in one month and consists of:
- Taking a medical history
- A physical examination
- Hormonal blood tests for the woman
- A hysterosalpingogram (HSG) x-ray to check the fallopian tubes
- A semen analysis for the male
Depending on the results, additional tests may be recommended. More advanced testing includes an outpatient surgical procedure called laparoscopy to evaluate the woman's internal pelvic organs or an ultrasound to evaluate the male. See Causes of Male Infertility below for more details.
THE NATURAL DECLINE IN FEMALE FERTILITY
A frequently ignored or misunderstood factor is the natural decline in fecundity (fertility rate per month) which occurs in women. This is primarily attributed to the ongoing attrition or programmed cell death of human eggs. In fact, women are born with a fixed number of eggs after which there is no new egg formation. Thus it can be said there are sufficient favorable eggs for about 20 years of active reproductive life suggesting a woman will ovulate about 300 times per lifetime. After age 35, each passing month without pregnancy therefore diminishes the reproductive potential. With physiologic aging, declining egg quality makes it more difficult for a normal embryo development to occur, accounting for abnormalities, decreased implantation and increased miscarriage rates. This age related infertility makes it imperative that prospective parents not wait past age 38 to begin trying to conceive. Graph 1 depicts the natural decline in female fertility.
Graph 1: A woman's Age and Her Fertility Potential
POTENTIAL CAUSES OF INFERTILITY
To understand the causes of infertility, it is important to note that fertility in humans is not a very efficient process. Even among fertile couples, the likelihood of achieving pregnancy is only about 15% per month. This is important because it is the basis of comparison with the success rate of fertility treatments offered at most clinics. After Level One Testing is completed, female factors are found in 40%, male factors in 40%, combined female and male factors are found in 15% and unexplained factors are found in the final 5%. See Graph 2.
Graph 2: Causes of Infertility in Humans
There are multiple causes of female infertility including structural factors such as adhesions or fibroids, infectious causes such as Chlamydia resulting in PID and tubal blockage, hormonal reasons such as polycystic ovaries and ovulatory problems, genetic factors causing premature menopause or embryo defects, and declining egg quality due to advancing age.
The most likely causes for female infertility are:
Pelvic Inflammatory Disease (PID) - PID is the most common cause of infertility worldwide. It's an infection of the pelvis involving one or more reproductive organs, including the ovaries, the fallopian tubes, the cul-de-sac, the cervix or the uterus. Sometimes PID spreads to the appendix or to the entire pelvic area.
Polycystic ovary syndrome (PCO) - This condition affects 5 million American women and is another major cause of infertility. In PCO, the ovaries produce high amounts of male hormones, especially testosterone. LH levels may be abnormally high while FSH levels are abnormally low; thus, normal follicle grow and ovulation do not produce occur. Instead they form fluid-filled cysts that eventually cover the ovaries. Other hormonal problems may be linked to PCO like elevated testosterone which can contribute to medical problems like obesity, diabetes and Metabolic Syndrome.
Endometriosis - This disease is another common cause of female infertility. Endometriosis refers to a condition in which sections of the uterine lining implant inside the pelvis. These implants eventually form cysts that grow with each menstrual cycle and may eventually create inflammation and scarring that can affect the egg capture by the fallopian tubes . The scars can then block the passage of the egg, the fertilization of the egg, and possibly the implantation of the embryo.
Fibroids - Fibroids, are usually benign growths that may form in the uterine muscle near the fallopian tubes, in the cavity of the uterus or cervix. As a result, the sperm or fertilized egg may not be able to reach the uterus or implant there. Fibroids in the uterus are very common in women over age 35.
Premature Menopause - Some women may experience premature menopause, when their ovaries stop producing estrogen and progesterone and eggs. Often the cause is unknown or may be due to a lower number of eggs a woman has in her life time. If this occurs, donor egg may be the best option for a successful pregnancy. A few cases may be due to genetic conditions in the female.
The etiology of male infertility can be classified into structural, infectious, congenital, anatomic and hormonal and more rarely, genetic causes. Listed below are among the most common problems.
Vas deferens obstruction - The vas deferens that carries sperm from the testicles to the penis can be blocked for a variety of reasons including prior vasectomy, injury, infection or physical anomaly.
Infections - There are many types of infections that might cause sterility or low sperm counts in men. These can be recent infections or from childhood. Common infections can be mumps or certain types of sexually transmitted infections (STI).
Chronic Disease - Diseases that can affect hormonal controls and sperm production, particularly when not controlled are also causes of infertility. Diabetes, hypertension and other problems can all affect the fertility of men.
Erectile Dysfunction (ED) - Problems maintaining an erection or ejaculatory difficulties will result in sperm transport problems. This may be caused by chronic illnesses like diabetes, hypertension or heart problems. Some medications used to treat chronic illnesses can contribute to these types of male factor. Spinal cord injuries may damage the nerves which assist in normal sexual function.
Failure to Produce Sperm - If the body isn't producing sperm there can be many reasons. Some may be from hormonal dysfunction or testicular failure. Genetic illnesses and certain medications may also impact sperm production.
Exposure to Harmful Substances - Environmental or work hazards such as solvents, radiation and high temperatures can affect sperm production.
Injury - Traumatic injury to the testicles may lead to destruction of sperm producing cells.
Varicocele - This is a varicose vein located in the testes and can interrupt normal blood flow or increase the temperature surrounding the testes.
Each male factor patient will receive individual recommendations for treatment options in conjunction with our staff Urologist.
At West Coast Fertility Center we perform a systematic, well timed series of diagnostic tests called Level One Testing. The testing sequence begins on the day of the initial consultation.
Step 1. A thorough medical history is taken for the woman and her partner followed by a physical and a gynecologic exam. A gentle pelvic ultrasound is included to obtain an image of the uterus and ovaries.
Step 2. Ovarian Function and Egg Quality Testing can be determined by measuring the blood levels of specific reproductive and metabolic hormones between the 3rd to the 5th day of the woman's menstrual cycle. It is a simple blood test performed and analyzed in our on-site laboratory.
Step 3. The health of the woman's Fallopian tubes is determined by a dye test (HSG) performed in the x-ray department after the woman completes her menstrual period. Special water based dye is rinsed into the uterus to observe the passage of the fluid and confirm that the tubes are open. At the same time, x-rays are taken and given to our patients to be reviewed in our center. Dr. Diaz has performed thousands of HSG x-rays followed by laparoscopy and is therefore an expert in interpreting the appearance of the tubes on film.
Step 4. A complete semen analysis is scheduled for the male following three days of abstinence. Unlike sperm testing performed at a commercial lab, the semen analysis at WCFC is interpreted by a reproductive biologist with advanced expertise in the subtle forms of male infertility.
Our nursing staff assists our patients in scheduling the above tests. Level one is completed within about one month to avoid any delay in your care. After reviewing the results, Dr. Diaz will meet with you to explain the results and make recommendations for treatment.