General Information
Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy, after at least 1 year of unprotected intercourse. Secondary infertility describes couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy.
Causes of infertility include a wide range of physical as well as emotional factors. Approximately 30-40% of all infertility is due to a “male” factor such as retrograde ejaculation, impotence, hormone deficiency, environmental pollutants, scarring from sexually transmitted disease, or decreased sperm count. Some factors affecting sperm count are heavy marijuana use or use of prescription drugs such as cimetidine, spironolactone, and nitrofurantoin.
A “female” factor — scarring from sexually transmitted disease or endometriosis, ovulation dysfunction, poor nutrition, hormone imbalance, ovarian cysts, pelvic infection, tumor, or transport system abnormality from the cervix through the fallopian tubes — is responsible for 40-50% of infertility in couples.
The remaining 10-30% of infertility cases may be caused by contributing factors from both partners, or no cause can be identified. It is estimated that 10-20% of couples will be unable to conceive after 1 year of trying to become pregnant. It is important that pregnancy be attempted for at least 1 year. The chances for pregnancy occurring in healthy couples who are both under the age of 30 and having intercourse regularly is only 25-30% per month. A woman’s peak fertility occurs in her early 20s. As a woman ages beyond 35 (and particularly after age 40), the likelihood of getting pregnant drops to less than 10% per month.
Other Risk Factors
In addition to age-related factors, increased risk for infertility is associated with the following:
- Multiple sexual partners (increases risk for sexually transmitted diseases)
- Sexually transmitted diseases
- History of PID (pelvic inflammatory disease)
- History of orchitis or epididymitis in men
- Mumps (men)
- Varicocele (men)
- A past medical history that includes DES exposure (men or women)
- Eating disorders (women)
- Anovulatory menstrual cycles
- Endometriosis
- Defects of the uterus (myomas) or cervical obstruction
- Long-term (chronic) disease such as diabetes
Infertility Testing
A complete history and physical examination of both partners is essential. Tests may include:
- Semen analysis: the specimen is collected after 2 to 3 days of complete abstinence to determine volume and viscosity of semen and sperm count, motility, swimming speed, and shape.
- Measuring basal body temperature: taking the woman’s temperature each morning before arising in an effort to note the 0.4 to 1.0 degree Fahrenheit temperature increase associated with ovulation.
- Monitoring cervical mucus changes throughout the menstrual cycle to note the wet, stretchy, and slippery mucus associated with the ovulatory phase.
- Postcoital testing (PCT) to evaluate sperm-cervical mucus interaction through analysis of cervical mucus collected 2 to 8 hours after the couple has intercourse.
- Measuring serum progesterone (a blood test).
- Biopsying the woman’s uterine lining (endometrium).
- Biopsying the man’s testicles (rarely done).
- Measuring the amount of luteinizing hormone in urine with home-use kits to predict ovulation and assist with timing of intercourse.
- Progestin challenge when the woman has sporadic or absent ovulation.
- Serum hormonal levels (blood tests) for either or both partners.
- Hysterosalpingography (HSG): an x-ray procedure done with contrast dye that looks at the route of sperm from the cervix through the uterus and fallopian tubes.
- Laparoscopy to allow direct visualization of the pelvic cavity.
- Pelvic exam for the woman to determine if there are cysts.