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Infertility
Infertility is a common problem in partners. Fortunately, major advances have been made in recent decades, and the problem of infertility can be solved in many cases. Problems of infertility can include problems with the sperm, problems with the egg, or difficulties encountered in their union. lnfertility problems also can result from sexual dysfunction. To physicians, the term infertility usually means the inability to become pregnant after 1 year of frequent sexual intercourse without using any contraception. Three out of four fertile couples will become pregnant within this time. For many couples, "under-fertility" is often a better term-that is, despite the absence of pregnancy, fertility is still possible, but the odds are not as good as they might be, for example, more than a year might be required before pregnancy occurs. If you and your partner are unable to achieve conception within a reasonable time and would like to do so, seek help. The woman’s gynecologist, the man’s urologist, or the family physician can determine whether there is a fertility problem that requires a specialist or clinic that treats infertility problems. Although either partner or both partners can be infertile, physicians usually begin evaluation with the man because it is much easier to perform the tests necessary to evaluate male infertility. The woman’s tests not only are more complex but also entail more risk. If tests for the man do not find a source of the infertility, then the woman can be evaluated. Before embarking on infertility tests, a couple should be aware that a certain amount of commitment is required. The physician or clinic will need to determine exactly what your sexual habits are and, moreover, may make recommendations about how you should change those habits. The tests and periods of trial and error may extend over several months. Evaluation is expensive and in some cases entails operations and uncomfortable procedures, and the expenses may not be reimbursable by many medical plans. Depending on the cause, there is no guarantee, even after all the tests and counseling, that conception will occur. However, for couples eager to have their own child, such evaluation is the route to take. It may result in a successful pregnancy. Infertility tests for men: For a man to be fertile, his testicles must produce enough sperm, the sperm must be able to pass unobstructed through his body, and the sperm must be ejaculated effectively into the woman’s vagina. Tests for the man attempt to determine whether any of these steps are impeded. The first step is a general physical examination. This includes examination of the genitals and questions concerning your medical history, illnesses or disabilities, medications, and sexual habits. Your physician probably will require a specimen of ejaculated semen. This is generally obtained by masturbating, or interrupting intercourse, and ejaculating the semen into a clean container. Your physician will provide instructions. Such a specimen may be required more than once. The semen is then analyzed by a laboratory, and the quantity, color, and presence of infections or blood are noted. Principally, however, the analysis is of the sperm themselves. The laboratory will determine whether the number of sperm present in the ejaculate is enough for fertility and whether the shape, appearance, and motility (activity) of the sperm indicate that they are healthy enough for fertility. A needle biopsy of the testicle is often the most definitive way to identify the cause of an abnormal result of semen examination. This usually can be performed in a urologist’s office. Other tests also are required sometimes, such as a blood test to determine the level of testosterone or other hormones. Infertility Tests for the Woman: If tests for the man do not reveal the cause of infertility, testing for the woman is the next step. For a woman to be fertile, her ovaries must release healthy eggs regularly and her reproductive tract must allow the eggs and sperm unobstructed passage for a possible union in the fallopian tubes. A general physical examination is the first step. Your physician will ask many questions concerning your health history, illnesses, medications, menstrual cycle, and sexual habits. Specific fertility tests follow. The first thing that your physician must establish is that healthy eggs are released. There are different methods of making this determination. In a common method, temperature charting, you take your temperature each morning before rising and record the temperature on a chart during one complete menstrual cycle. The temperature normally rises slightly when ovulation—the release of an egg—occurs. Another test you can do is a home LH monitoring test. LH refers to luteinizing hormone, which affects ovulation and the preparation of the uterus for receiving a fertilized egg. This simple urine test makes it possible for you to monitor the hormone yourself. Another useful test is the cervical mucus test. This test is performed at about the time when ovulation should occur, and at a time between 2 and 16 hours after intercourse. The physician takes a tiny sample of the mucus lining your cervix, which is the lower portion of the uterus where it meets the vagina. The procedure is painless. The sample is examined under a microscope to determine how well sperm penetrate and survive. Endometrial biopsy, another test, can help to determine whether and when ovulation is occurring and whether the lining of the uterus is hormonally prepared. In this test, the physician takes a small sample of tissue from the uterine lining shortly before the beginning of the menstrual period. Once one or more of these tests has been performed, your physician will know whether ovulation occurs and whether sperm can survive in the reproductive tract. If no problems have been uncovered, additional information may be needed. Hysteroscopy is a procedure in which a small instrument is used to examine the interior of the cervix and uterus for irregularities that might lead to infertility. Hysterosalpingography is a test that also is used to evaluate the condition of the uterus as well as the fallopian tubes. This test sometimes is done under general anesthesia. A fluid is injected into the uterus and an x-ray is obtained to determine whether the fluid progresses out of the uterus and up the fallopian tubes. Blockages or problems often can be located, and these can be corrected with medications or operation. Another test is laparoscopy; it involves a brief operation, with either local or general anesthesia, to insert a thin viewing device to examine the fallopian tubes, ovaries, and uterus. In up to 20 percent of infertile women, regardless of which tests are used, no cause can be found. The numerous treatments for infertility depend on the cause. Recent developments in therapy have increased the number of once infertile couples who can have their own child. Some causes of infertility cannot be corrected. However, even then, various means of insemination or embryo transfer may be possible so that the woman can still become pregnant. Infertility therapy is divided into two categories; restoring or bringing about fertility, and artificial fertilization. Therapy To Achieve Fertility: One of the easiest means of treating infertility for many couples is advice on when and how often to have intercourse to improve the chances of achieving fertility. This means is particularly effective in couples with impaired fertility rather than infertility for example, when the man has oligospermia. In addition to giving suggestions on the frequency of intercourse, and how to time it to best match the ovulatory cycle, your physician can give other advice, such as recommending that the woman remain supine (on her back) and with her knees bent for some minutes after intercourse to keep her organs in the best position for the further movement of the sperm toward the egg. General sexual problems, such as impotence or premature ejaculation, also can be treated to improve fertility. When the source of infertility lies in the man’s sperm (or lack of it), restoring or initiating fertility is sometimes possible. For example, varicocele, a common source of problems with the sperm, can be corrected surgically, and in some instances this also will restore fertility. Problems with the testicles, prostate gland, seminal vesicles, and urethra also can be treated. When sperm production is impaired because of damage to the sperm-producing areas of the testicle, drug treatment has been of little use. In extremely rare instances when sperm production is impaired because of a pituitary gland problem, the use of human chorionic gonadotropin or human pituitary gonadotropin has been helpful. When infections hamper sperm production, block the transport of sperm, or damage or kill the sperm, treatment of the infection often restores fertility. This is particularly true of sexually transmitted diseases, and both partners must be treated. In the woman, treatment also depends on the results of the examination and tests. Treating any infection or underlying illness is, as usual, the first step. If the fertility problem is related to anovulation (failure to release an egg), your physician can attempt to bring about ovulation. Generally, clomiphene citrate, human menopausal gonadotropins, or gonadotropin-releasing hormones with or without human chorionic gonadotropin are administered. Occasionally, an ovarian operation is necessary to bring about ovulation. Blockages, tumors, or other problems in the fallopian tubes usually are repaired surgically. Microsurgical techniques permit delicate operations on the fallopian tubes. Not all fallopian tube damage can be repaired surgically, however. Endometriosis can be treated with medications, including oral contraceptives taken in low doses. Sometimes surgical removal of the endometrial tissue is necessary. Correction of endometriosis can improve fertility. Artificial Fertilization: When a couple remains infertile despite treatment of the cause, when the cause is determined but cannot be treated, or when the cause cannot be determined, pregnancy is often still possible. The techniques used involve artificially fertilizing an egg from the woman with sperm from the partner or from another man. The fertilization can take place inside the woman’s body or outside the body, in which case the fertilized egg is then transferred to inside the body (embryo transfers). The term test—tube babies actually is inaccurate because the baby is developed within the mother; only fertilization and the very earliest development of the fertilized egg (embryo) take place in a test tube. The correct term is in vitro fertilization. It does, however, require a surgical procedure, and it is costly and difficult. With in vitro fertilization, eggs are removed from the woman’s ovary—with laparoscopy or with ultrasonography to locate the follicle in the ovary so that a needle can be inserted into the follicle for retrieval of the eggs. Semen is obtained from the male partner or from a donor. Attempts are then made to fertilize an egg with a sperm in a laboratory under optimal conditions. If fertilization occurs, the embryo is transferred to the uterus of the woman (embryo transfer). The technique achieves pregnancy in about one of five or six cases. The partner’s semen is used for artificial insemination if it contains healthy sperm. The semen is collected, and the physician places it directly into the woman’s uterus at the time of ovulation. In other words, the more variable transit of the semen after sexual intercourse is not relied on; instead, to reduce the element of chance, it is placed where fertilization is most likely to occur. With a slightly different technique, called gamete intrafallopian transfer, sperms taken from the partner and eggs from the woman are placed directly in the fallopian tube. This also is done with laparoscopy. The intent is to encourage fertilization to occur "naturally" within the woman. As with in vitro fertilization, the success of this procedure is by no means ensured.
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