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Overview of Infertility

by Robert W. Rebar, MD

Infertility is the inability of a couple to achieve a pregnancy after repeated intercourse without contraception for 1 year.

Frequent intercourse without birth control usually results in pregnancy:

  • For 50% of couples within 3 months

  • For 75% within 6 months

  • For 90% within 1 year

To maximize the chance of pregnancy, couples should have frequent intercourse for the few days when egg release (ovulation) is most likely—the time when women are most likely to become pregnant. Ovulation usually occurs in the middle of the menstrual cycle, which is about halfway between the first day of two periods. There are two methods women can use to estimate when ovulation occurs:

  • Measurement of body temperature at rest (basal body temperature)

  • Home ovulation predictor kits

If women have regular periods, they can estimate when ovulation occurs by measuring their temperature each day before they get out of bed. A decrease suggests that ovulation is about to occur. An increase of 0.9° F (0.5° C) or more suggests ovulation has just occurred. However, this method is inconvenient for many women and is not reliable or precise. At best, it predicts ovulation only within 2 days.

Home ovulation prediction kits are more accurate. These kits are used to detect an increase in luteinizing hormone in the urine. (This hormone stimulates the ovaries to trigger ovulation.) Usually, this increase occurs 24 to 36 hours before ovulation. Women usually need to repeat the test for several consecutive days, so kits typically include five to seven sticks. The sticks can be held under a stream of urine or dipped into urine that is collected in a sterile container.

Whether excessive consumption of caffeine impairs fertility in women is unclear.

About one in five couples in the United States do not conceive for at least a year and are thus considered infertile.

The cause of infertility may be due to problems in the man, the woman, or both:

  • Problems with sperm (in 35% or more of couples)

  • Problems with ovulation (in 20%)

  • Problems with the fallopian tubes in the pelvis (in 30%)

  • Problems with mucus in the cervix (in 5% or fewer)

  • Unidentified factors (in 10%)

Thus, the diagnosis of infertility problems requires a thorough assessment of both partners. Usually, the assessment is done after at least 1 year of trying to achieve a pregnancy. However, it is done sooner if

  • The woman is over 35.

  • The woman's menstrual periods occur infrequently.

  • The woman has an abnormality of the uterus, fallopian tubes, or ovaries.

  • Doctors have identified or suspect problems with sperm in the man.

Age is a factor, especially for women. As women age, becoming pregnant becomes more difficult, and the risk of complications during pregnancy increases. Also, women, particularly after age 35, have a limited time to resolve infertility problems before menopause.

Of the couples who have not conceived after a year of trying, more than 60% conceive eventually, with or without treatment. The goals of treatment are to treat the cause of infertility if possible, to make conception more likely, and to reduce the time needed to conceive.

Even when no cause of infertility can be identified, the couple may still be treated. In such cases, the woman may be given drugs that stimulate several eggs to mature and be released—so-called fertility drugs (see Problems With Ovulation : Treatment). Examples are clomiphene and human gonadotropins. A woman’s chances of becoming pregnant are about 10 to 15% with each month of such treatment. Alternatively, an artificial insemination technique that selects only the most active sperm may be tried.

While a couple is being treated for infertility, one or both partners may experience frustration, emotional stress, feelings of inadequacy, and guilt. They may alternate between hope and despair. Feeling isolated and unable to communicate, they may become angry at or resentful toward each other, family members, friends, or the doctor. The emotional stress can lead to fatigue, anxiety, sleep or eating disturbances, and an inability to concentrate. In addition, the financial burden and time commitment involved in diagnosis and treatment can cause marital strife.

These problems can be lessened if both partners are involved in and are given information about the treatment process (including how long it takes), regardless of which one has the diagnosed problem. Knowing what the chances of success are, as well as realizing that treatment may not be successful and cannot continue indefinitely, can help a couple cope with the stress. Information about when to end treatment, when to seek a second opinion, and when to consider adoption is also helpful. For example, if pregnancy has not occurred after 3 years of attempting it or after 2 years of being treated for infertility, the chance of pregnancy is low and adoption can be considered. Ideally, couples should ask for this information before treatment is begun. Counseling and psychologic support, including support groups such as RESOLVE and the American Fertility Association, can help.

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