Possible Causes of Infertility and Basic Treatment Options
Infertility is defined as failure to conceive after one year of intercourse without using contraception. Since approximately 15 to 20 percent of all couples experience some form of infertility, it is important to consider all potential causes when we do an evaluation.
If you want to learn more about possible causes for infertility, follow these links:
- Sperm Production
Diagnosis begins with a full review of the patient’s medical history and a complete physical examination. It is best if both partners attend the initial visit, as testing may be required for both.
- Endometrial biopsy
- Hysterosalpingogram (HSG)
- Ovarian reserve testing
- Semen analysis
Menstrual cycle factors
Normal menstrual cycle – In the absence of pregnancy or the use of hormonal contraception, a single egg is released approximately once a month during the reproductive life of a woman. The length of the menstrual cycle is calculated by counting the number of days from day one of menses (period) until day one of the next menses. Although a 28-day cycle is considered normal, cycle intervals of 21 to 35 days may also be normal. The menstrual cycle is the result of a carefully coordinated interaction between the brain, the pituitary gland, the ovary, and the uterus.
When all of the hormonal signals interact normally, ovulation occurs. The normal menstrual cycle can be considered as consisting of three parts:
- Follicular phase -“ When the egg is developing, the egg plus the surrounding cells and fluid make up a cyst, known as a follicle. The dominant hormone is estrogen and causes the lining of the uterus (the endometrium) to thicken. The length of the follicular phase can vary.
- Ovulation – The follicle ruptures and the egg is released.
- Luteal phase – After the follicle ruptures, the cells that originally surrounded the egg undergo changes and form a structure called the corpus luteum. The corpus luteum may exist as a cystic structure of varying sizes and primarily secretes the hormone progesterone, which causes the endometrium to change in preparation for implantation of the fertilized egg. The length of the luteal phase is usually 12-14 days.
Abnormal menstrual cycle – Absence of periods (called amenorrhea) or periods occurring at irregular intervals implies absent or infrequent ovulation. Lack of ovulation can occur even when the menstrual cycle is fairly regular. Other abnormalities of ovulation associated with regular menstrual intervals include the luteal phase defect, which occurs when a woman’s body produces too little progesterone, causing the lining of the uterus to be under-developed. Also, the age of the woman impacts her fertility. A woman is born with a fixed number of eggs, and there is a progressive loss of eggs throughout her reproductive years, even if she is pregnant or on oral contraceptives.
Tests for defects of ovulation
The patient can perform basal body temperatures or home monitoring with ovulation predictor kits. Ultrasound monitoring, measuring hormones, and biopsies of the lining of the uterus can also be used to assess whether ovulation is normal.
The initial consideration for treating ovulation defects is to use medications to restore a normal hormonal environment that will result in spontaneous ovulation by:
- replacing or increasing the mid-cycle surge of LH
- replacing or increasing progesterone during the luteal phase
Normal – During a normal ovulation cycle, the estrogen that is produced by the cells surrounding the egg causes an increase in the amount of cervical mucus and causes the mucus to become thin and watery. These changes allow the sperm to more easily penetrate and move within the mucus.
Abnormal – Birth defects involving the cervix, prior treatment of abnormal pap smears (cryotherapy, laser therapy, cone biopsies), or exposure to specific medications can have an adverse impact upon the cervical mucus.
Various hormonal and non-hormonal therapies have been suggested, such as:
- discontinuing problem medications or adding other medications
- bypassing the cervix via intra-uterine insemination
Normal – A normal uterine cavity is essential for implantation of the fertilized egg. The lining of the uterus (endometrium) must be exposed to appropriate levels of estrogen and progesterone in order to adequately develop.
Abnormal – Defects of ovulation or exposure to certain medications may interfere with normal uterine lining (endometrium) development. Anatomical problems with the uterine wall or the endometrial cavity may also prevent normal implantation. Such abnormalities include birth defects, intrauterine scarring from prior surgical procedures, or tumors of the uterine lining or uterine wall.
An X-ray study called a hysterosalpingogram (HSG), in which dye is injected through the cervical canal into the uterus and tubes, is used to detect any abnormalities. Sonohysterography is a procedure in which fluid is injected into the uterus, and ultrasound is used to look at the shape of the uterine cavity. Hysteroscopy is a procedure where the uterine cavity is directly observed with a scope. The choice of evaluation will be determined by you and your provider.
Changing the type of medications used to treat ovulation abnormalities or using additional hormonal therapy can treat inadequate endometrial (uterine lining) development.
- Surgical therapy is required for treating anatomical abnormalities. The surgery may be able to be performed during diagnostic hysteroscopy, but sometimes the abdomen will need to be opened in order to perform the appropriate procedure.
Normal Sperm Production – Sperm production is a complex series of events that requires approximately 74 days to complete. Just as with ovulation in the female, the hormonal component of sperm production requires a coordinated effort between the brain, the pituitary gland, and the testes.
- The testes are stimulated to produce sperm and the male hormone testosterone as well as other proteins and hormones that are needed for normal sperm development and function.
Abnormal Sperm Production – Several conditions may affect a man’s ability to produce sperm, including:
- Chronic medical conditions and the medications used to treat them
- Exposure to environmental toxins (heavy metals or other industrial exposures)
- Anatomical problems, such as obstruction or abnormal external genitals
- Neurological problems, such as nerve injuries or conditions like diabetes
- Antibodies or abnormalities of sperm function that might prevent the sperm from penetrating the egg
- Conditions that affect glands other than the testes, such as the thyroid, pituitary, or adrenal gland, may lead to abnormal sperm production.
- a complete history and physical examination,
- hormonal studies, and
- more advanced evaluation of sperm and sperm function may be required.
- Treatment of other medical conditions, use of antibiotics for infections, or elimination of toxic exposures may resolve the problem.
- Assisted reproductive technologies provide the opportunity for a couple to conceive when other forms of therapy are not appropriate or have been unsuccessful.
Normal – Fertilization occurs when a single sperm penetrates the egg. In order for this to occur, the sperm is deposited in the vagina, makes its way through the cervix and uterus into the fallopian tubes, and comes in contact with the egg. Sperm are stored in the cervical mucus that then acts like a sperm bank, releasing sperm on a continuous basis, so that the couple does not have to have intercourse right at the moment of ovulation. Data suggests that having intercourse within a short period of time prior to the egg’s release gives a better chance for pregnancy than having intercourse after the egg has been released.
- Timing of intercourse may be off-schedule with ovulation and may be a cause of infertility.
- The use of douches or lubricants can affect the ability of the sperm to survive within the vagina or the cervix.
- Abnormalities of the penis or ejaculation may prevent sperm from being deposited in the vagina.
- Abnormalities of the vagina may prevent sperm from being deposited.
- Timing and use of douches or lubricants are handled better by the couple.
- Anatomical or physiological abnormalities may require intrauterine insemination or assisted reproductive technologies (ARTs).
The ideal time to perform an endometrial biopsy has been debated. WVU’s Center for Reproductive Medicine maintains that the biopsy should be performed 10 to 12 days after ovulation or right before the next expected period. The biopsy is performed in the office.
A pregnancy test is obtained prior to the procedure.
A speculum is placed, the cervix cleansed with an antiseptic, and a plastic catheter is passed into the uterine cavity. Suction is applied and a sample of tissue is removed.
There are no restrictions on activities for the remainder of the day.
The test is usually scheduled right after your period has stopped and before ovulation occurs. Therefore, you need to call 304-598-3100 when your period starts so that the test can be scheduled. This test is performed in the radiology department.
Ovarian reserve testing
This test usually consists of ultrasound and hormonal testing.
- On day three of your menstrual cycle, a baseline ultrasound might be obtained. Blood levels of follicle stimulating hormone and the estrogen, estradiol, are obtained.
- Clomiphene citrate challenge test: clomiphene citrate, 100 mg, is taken on days five through nine of the cycle.
- Return on day 10 for ultrasound and a serum follicle stimulating hormone level.
- Different labs and clinics may use different methods to measure these hormones. Therefore, the levels that are considered normal are specific for the clinic that you are attending.
This test is performed in the Center for Reproductive Medicine. The test is usually scheduled right after your period has stopped and before ovulation occurs. Call 304-598-3100 when your period starts so that the test can be scheduled.
- A speculum is placed, and the vagina and cervix cleansed with an antiseptic solution.
- A small catheter is inserted into the uterine cavity, and a small balloon is inflated to keep the catheter in place.
- Sterile fluid is injected into the uterus while simultaneously performing ultrasound.
- After satisfactory images are obtained, the procedure is ended.
- Most women experience little or no discomfort with this examination, but you can choose to use 400-600 mg ibuprofen one hour prior to the procedure.
- There are no restrictions on your activities for the remainder of the day.