Fertility Frequently Asked Questions
At Fertility C.A.R.E. educating our patients is our first priority. We believe that knowledge is empowerment for our patients. Below you will find a list of the most frequently asked questions from our patients and the answers to those questions. We also encourage you to feel free to contact us with any questions or concerns you may have before your first visit.
- What is the definition of infertility?
- What are the most common reasons for infertility?
- What are fertility medications and how do they work?
- What are the risks of fertility medications?
- Will I go into menopause sooner on fertility medications?
- Why would I need a laparoscopy?
- What is a hysterosalpingogram (HSG)?
- How do I know if and when I am ovulating?
- What is intrauterine insemination (IUI)?
- What is the relationship between fertility and age?
- What is the work-up for the male?
- What is In-Vitro Fertilization (IVF)?
- When should I be referred to a fertility specialist?
- What is endometriosis?
1. What is the definition of infertility?
An accepted definition of infertility is the inability of a couple to conceive after 12 months of unprotected intercourse appropriately timed with ovulation. The estimated incidence of infertility is 10-15% of the general population. Interestingly, the monthly rate of conception for couples less than 30 years of age without fertility problems is only 20-25% and after one year approximately 85% of these couples will have conceived.
2. What are the most common reasons for infertility?
Infertility is commonly approached as a treatment of a couple and should not be viewed as a fault of the male or female. During the evaluation, factors can be identified as potentially contributing to the cause of infertility. The breakdown is approximately:
- Female factors: 40%
Causes: Tubal blockage or Ovulatorion dysfunction - Male Factors: 40%
Causes: Poor functioning sperm or Decreases sperm number - Unexplained: 20%
Causes: No identifiable cause
In approximately 30-40% of couples, multiple infertility factors are found together.
3. What are fertility medications and how do they work?
The most common fertility medications are classified as ovulation induction drugs and have been approved for patients with ovulation disorders. However, they are also utilized for 'super' ovulation. These medications by-pass the usual female hormonal pathways and stimulate the ovary to release more than the usual one follicle (egg) per month, increasing the number of eggs exposed to sperm, thereby increasing the chance for pregnancy.
One type, clomiphene citrate (ClomidR, SeropheneR), is administered in a tablet form and usually results several follicles each cycle. The other category is gonadotropins (PergonalR, HumegonR, RepronexR, FollistimR, Gonal-FR) and are currently administered by injection. They can stimulate the ovary to produce many follicles each cycle.
These medications can be combined with intercourse, intrauterine insemination, or In-vitro Fertilization (IVF) to enhance one's chance for conception.
4. What are the risks of fertility medications?
Fertility medications carry risks that can vary depending on a patient's response to the medications. In general, the following are the most common risks, usually more associated with gonadotropins.
- Ovarian hyperstimulation syndrome. This occurs in about 1-5% of cycles. The ovaries become enlarged due to overstimulation by fertility medications. The blood vessels supplying the ovaries become 'leaky' resulting in fluid collecting in the abdomen. In severe cases (~1%) hospitalization is required for close monitoring. The problem lasts for 1-2 weeks but can be longer if pregnancy results.
- Multiple births. Since more follicles are being stimulated to grow with fertility medications, there is a higher rate of multiple births. The multiple birth rate with clomiphene citrate is 5-10% and with gonadotropins it is 15-20% per pregnancy. In order to put this into perspective, the chance for a couple to have a natural twin pregnancy is about 1-2%.
- Ectopic pregnancy is a pregnancy in another location of the body other than the uterus and usually is in one of the fallopian tubes. The normal rate is about 2% in the general population but may be slightly higher with fertility medications.
- Twisting of the enlarged, overstimulated ovary (torsion) can occur in about 1% of cycles. The ovary is cut off of its blood supply, causing abdominal pain, and surgery may be required to untwist the ovary or possibly remove it.
- The possible risk of ovarian cancer. There is controversial undetermined data associating fertility medications and ovarian cancer. The risk is probably related to continued ovulation in infertility patients and appears to return to baseline risk if a pregnancy occurs. Pregnancy and the use of birth control pills, both preventing ovulation, decreases the risk. Fortunately, no definitive evidence.
5. Will I go into menopause sooner on fertility medications?
Each month, hundreds of follicles in the ovary begin stimulation but only one goes onto full maturity and ovulation. The other follicles undergo a natural cell death (apoptosis). Fertility medications stimulate follicles that would have otherwise not developed to maturity and does not accelerate the onset of menopause.
6. Why would I need a laparoscopy?
Your gynecologist will have you undergo testing to determine the possible cause of infertility. While 20% of couples experience unexplained infertility, this diagnosis can only truly be made after a laparoscopy - an outpatient same day operative procedure.
Laparoscopy inserts a telescope through the belly button into the abdomen to view the internal pelvic reproductive organs. This procedure will allow a definite diagnosis of pelvic adhesions, tubal scarring & blockage, endometriosis, or other abnormalities. These problems could contribute to infertility and may be treated at the time of the surgery.
7. What is a hysterosalpingogram (HSG)?
During an evaluation for infertility, 40% of couples are found to have a female factor which commonly is tubal blockage or ovulation disorder. In order to assess the fallopian tubes, an HSG is performed.
An HSG is an office procedure in which an X-ray is taken while contrast dye is instilled through the cervix into the uterus and tubes. The patient is awake and can often watch the monitor along with the physician to see the results of the study.
8. How do I know if and when I am ovulating?
Approximately 25% of couples experience infertility due to an ovulation disorder. The easiest way to determine if and when a woman is ovulating is by a home urine test. This method detects the hormonal surge of ovulation and, when positive, will predict ovulation over the next 24 to 36 hours. Basal body temperature charts can also be used for this purpose but are not as accurate in predicting ensuing ovulation.
9. What is intrauterine insemination (IUI)?
IUI is the use of husband or donor sperm to inseminate the uterus. The semen sample is washed, prepared and then placed into the uterus by passing a small plastic catheter through the cervix. This is an office procedure and is usually associated with no discomfort. The procedure places a large concentration of sperm into the upper uterus so the sperm are closer to the fallopian tubes where they can travel to fertilize an egg.
10. What is the relationship between fertility and age?
A woman is born with all of the eggs she will ovulate in her lifetime. Until puberty, the eggs are resting at a certain stage of development. Beginning with the first menses (menarche), hundreds of eggs are stimulated each month but only egg will complete development and ovulate, the rest will regress.
As a woman ages, the number of years the eggs have been resting increases. This explains the consistent decline in reproductive capacity beginning approximately around ages 32-33years of age. There is a more marked decrease after age 40 due to fewer and lesser quality eggs resulting in an increase in miscarriages and genetic abnormalities of the embryo.
Age can also affect males in terms of sexual function, frequency of sexual relations, and sperm production. However, the semen analysis does not show significant decline generally until after age 60.
11. What is the work-up for the male?
Since 40% of infertile couples will have a male factor, it is imperative to evaluate the male. The initial work-up will include a history to investigate any potential areas that could be contributing to infertility. While there is no definitive fertilization screen (outside of pregnancy), the best definitive test for a male factor is the semen analysis. This examination of the collected sperm evaluates most importantly count (density), motion (motility), and shape (morphology).
Based on these results, a decision may be made to proceed with further investigation by an urologist, preferably one who specializes in male infertility.
12. What is In-Vitro Fertilization (IVF)?
IVF is an assisted reproductive technology procedure whereby fertilization of the egg and sperm occur in the laboratory or 'in-vitro.' The woman receives stimulation with one of the injectable fertility medications (gonadotropins, discussed above). When the ovaries contain multiple mature follicles (eggs), the woman undergoes a minor procedure under sedation to retrieve the eggs by placing a needle through the vagina into the ovary under ultrasound guidance. Sperm are then added to each of the eggs and fertilization is then checked the next day. The embryos are transferred to the uterus 3-5 days after the 'retrieval' procedure and a pregnancy test is taken approximately 2 weeks after egg retrieval.
13. When should I be referred to a fertility specialist?
This is an excellent question but one that is very individualized depending, most importantly, on the diagnosis, female age, patient motivation level and financial resources. In general, after the gynecologist has performed an initial work-up, the patient AND the gynecologist should devise a game plan and time line after which referral should be recommended to a board-certified Reproductive Endocrinologist (Fertility Specialist).
There are some situations where a patient should be referred promptly to a fertility specialist, e.g. advanced reproductive age, severe male factor, and blocked fallopian tubes.
14. What is endometriosis?
Endometriosis is a condition where tissue from the lining of the uterus implants in other places of the body, usually in the abdomen and on the ovaries. The most likely explanation is reverse flow of menses through the tubes into the abdomen. Minimal and mild cases have been shown to correlate with some decline in fertility. More advanced stages worsen the prognosis for pregnancy, presumably due to scarring of the tubes and ovaries. The exact reason for the cause is unknown but an endometrial biopsy for an implantation protein, integrin, may be an important association.
Endometriosis usually has no serious medical consequences although it has been shown to correlate with pain. Interestingly, the degree of pain may be inversely proportional to the extent of endometriosis. Treatment depends on the diagnosis and symptoms of the patient and involves medical or surgical options. Pregnancy may have a temporary beneficial effect.