Infertility, or the inability to conceive a child, is unfortunately a common problem affecting one out of seven married couples. Age, biological factors and life-style can all lower the chances of conceiving a child. However, there has been an increased understanding of the physiology and pathophysiology of reproduction, both in the male and female, thereby allowing the medical community to provide medical and surgical therapy in assisting a couple to conceive a child.

The definition of infertility has not been specifically defined. Couples over 30 years of age who have not conceived after six months of frequent intercourse without birth control should be evaluated. Couples under the age of 30 should seek infertility counseling if they have not conceived after one year of unprotected intercourse. If a couple is having such a problem, they should be evaluated by doctors who specialize in infertility. In women, this is generally through an obstetrician/gynecologist, and in men by a urologist. Within both of these fields, there are superspecialists who can further assist in the care of the patient. There are many reasons why couples have difficulty getting pregnant: female factor contributes 40% of the problem, male factor contributes 40%, and a combined male and female factor contributes to 20%.

Common fertility problems in men include low sperm count, poor sperm motility, abnormal appearing sperm, and dilated veins in the scrotum (varicocele). Other problems include obstruction of the tubes that carry sperm from the testicles and out of the penis. A history of urinary tract infections or tobacco/drug/alcohol abuse can also affect fertility in men.

Common causes of infertility in women include an irregular release of eggs due to hormone imbalances, scar tissue that formed in the abdominal cavity around the ovaries or the fallopian tubes after infection or surgery, and endometriosis (overgrowth of uterine tissue). Antisperm antibodies in the cervical mucus of the female, and/or in the male seminal fluid can also contribute to infertility.

In evaluating fertility problems one must first determine if the female has eggs, if these eggs are being released (ovulation) on a regular basis (hormone driven), if there are enough sperm, are the sperm of good quality to inseminate, and finally, once an egg is fertilized, can it be implanted in the uterus.

There are several steps in the fertility process in women. First, hormones are released from the pituitary gland and ovaries throughout the month. The pituitary gland is a small structure in the brain that secretes FSH and LH (hormones), both of which help control ovulation. FSH and LH stimulate the ovary to secrete estrogen and progesterone, hormones that help prepare the cervix and uterus for conception.

Ovulation, which occurs once in each cycle, is when the egg is released from the ovary. A cycle lasts approximately 28 days, and it is midway into this cycle when the egg is released. Soon after ovulation, progesterone is then produced and elevated temperatures may be recorded. The egg passes into the fallopian tube, which is a tube that connects the ovary to the uterus.  It is here that fertilization occurs when one of many sperm penetrate the egg and starts the process of conception. The fertilized egg stays in the fallopian tube for up to three days and then passes into the uterus for implantation. Implantation is the process in which the egg becomes attached to the lining of the uterus. An implanted egg produces a hormone called HCG, which is the substance measured in pregnancy tests.

Males produce sperm in 90 day cycles. When ejaculation occurs, up to 500,000,000 sperm can be released and must swim through the vagina, cervix and uterus to meet the egg in the fallopian tube within hours of ovulation. The pituitary gland secretes FSH and LH, hormones that stimulate the production of sperm in the testicles. Sperm production occurs in the testicles at precisely 94 degrees Fahrenheit. These sperm continually move through a coiled tube called the epididymis, which is located behind the testicle. It is in the epididymis that the sperm mature over a 12-14 day period. From the epididymis, the sperm then move into a long tube called the vas deferens, which carries the sperm to the prostate gland (a structure which lies below the urinary bladder). When patients undergo a vasectomy, it is the vas deferens that is cut, thereby preventing the sperm from being transported out from the testicle. From the prostate and seminal vesicle (a tube located behind the prostate), the majority of the fluid called semen is added to the sperm. Semen contains nutrients that sustain the sperm. Ejaculation propels the sperm out from the vas deferens, through the penis and into the vagina. The sperm may live up to 48 hours swimming to meet the egg. Overall, in both the male and female, the process of conception is so intricate that even the most fertile couple has only a 1:3 chance of conceiving each month.

FEMALE EVALUATION

The obstetrician/gynecologist (OB/GYN) will begin the evaluation by taking a thorough medical, menstrual and sexual history. Questions may cover prior surgeries, pregnancies, and prior vaginal and pelvic infections. A menstrual history will include questions pertaining to when the patient began menstruating, menstrual frequency and discomfort. A sexual history may include questions about frequency and technique of intercourse.

A complete physical exam including a pelvic exam may reveal signs of prior pelvic infection, pelvic endometriosis, or other clues to fertility problems. The physician may also recommend that the patient obtain her daily basal body temperature (BBT) with a thermometer before getting out of bed each morning. Normally there is little variation in the patient's temperature from day one of the cycle through days 12-18 (midcycle). The BBT rises at midcycle which usually indicates ovulation. Another way of predicting ovulation is through the use of home predictor kits. These tests, in which the woman checks her urine in search for a midcycle LH elevation are performed daily. Ovulation occurs 24-36 hours after the LH surge. Therefore the patient can predict when she is ovulating.

Blood tests performed by the physician include samples to assess hormone levels. Other tests include a hysterosalpingogram, which is performed by injecting dye through the cervix and then x-rays are performed to determine whether the uterine cavity and the fallopian tubes are open and healthy. An endometrial biopsy is a biopsy of the uterine cavity that may be used to assess the lining of the uterus. The evaluation can be taken one step further, by conducting a laparoscopy to directly visualize the uterus and ovaries, and hysteroscopy, to view the cervix, uterus, and fallopian tube openings.

MALE EVALUATION

The urologist is a physician who is knowledgeable in male fertility problems. The evaluation begins with an extensive medical and sexual history followed by a detailed physical exam to detect signs of a fertility problem. Urinalysis and blood tests are frequently obtained as well. The initial laboratory tests include a semen analysis, which is used to evaluate both the quantity and the quality of the sperm.

Regarding the medical history, questions are asked about the patient's childhood illnesses, diabetes, mumps involving the testicles, and previous inguinal or scrotal surgery (i.e. hernia surgery, vasectomy, testicle surgery). Infections along the reproductive tract are an important contributor to male infertility problems and this can be assessed during the history as well. Exposure to toxic chemicals and abuse of drugs, alcohol and tobacco can also contribute to male factor infertility.

A general physical exam is performed, but primarily focuses on the testicles and the prostate. When the urologist examines the testicles, he or she is assessing the location, size and consistency of the testicles, any unusual testicular growths, and the presence or absence of the epididymis, vas deferens, and varicoceles. A varicocele is an enlarged vein in the scrotum, predominantly found on the left side, that may impair sperm quantity and quality. Not all men with varicoceles have difficulty with fertility. However in many instances where men are being evaluated for infertility, a varicocele is found. A history of an undescended testicle is also crucial in evaluating the male. An undescended testicle may be positioned in the body where the temperature is too high for good sperm production.

The semen analysis is the primary test for evaluating sperm production. Generally, 2-3 samples are analyzed to assess the volume of the seminal fluid, and the number, motility, and morphology (how the sperm look) of the sperm. The semen is collected either at home or in the doctor's office after one abstains from sex for 2-3 days. The specimen container should remain close to the patient's body and be delivered to the lab within a very short period of time to keep the sperm active and alive. These details can be discussed with the patient's physician. Other tests, which vary with each individual case, include a cervical mucus penetration test, sperm penetration assay, antisperm antibody testing and a testicular biopsy. The biopsy is a procedure that is performed by the urologist as a day surgery case, in which a small incision is made in the testicle and a sample of the tissue is examined under a microscope. This very brief procedure is done under anesthesia. However, recently there are urologists who may do this in their office.

TREATMENT

The treatment of both male and female infertility may include changing sexual techniques, hormonal or other medical therapy and, in some cases, surgery. In the case of women who have endometriosis, the endometrial "implants" may be removed with electrocautery or laser surgery during laparoscopy. Hormone therapy may also be used to treat this common problem. To treat women who have had previous tubal ligation, there are microsurgical techniques to reverse this procedure, and this should be further discussed with the obstetrician/gynecologist.

Male infertility problems can be treated with hormones, surgical correction of a varicocele and surgical correction of a ductal obstruction (men with a previous vasectomy). With regards to a varicocele, surgical results show that the sperm count and the quality of the sperm may improve in 70-80% of men, and fertility may increase approximately 40-60%. The varicocele repair is performed as day surgery, under general or local anesthesia. The sperm count may rise as soon as three months after surgery, but it may take up to 18 months to notice a significant change.

A common problem in male infertility observed by urologists is men who have had a previous vasectomy. This procedure can be repaired by an operation called a vasovasostomy. This procedure is performed as day surgery under anesthesia, and frequently performed with a special operating microscope. In general, the success rate is dependent upon how many years prior to the reversal the patient had his vasectomy.

In some cases male and female infertility problems may be difficult to treat simply by performing the previously mentioned methods, and for those particular cases, artificial reproductive techniques have been designed to bypass a fertility problem and allow conception to occur. These techniques include artificial insemination, in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) which is a variation of IVF.

The medical community has made tremendous strides in understanding the process of fertility in both the male and female. This has enabled the specialists to design and develop new procedures allowing conception to occur. For the couple, this is an emotional process that requires a large amount of their time and money. However, when a pregnancy is achieved and a healthy baby is delivered, they feel it is time and money well spent.

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