What is infertility?

Infertility is defined as the inability to conceive a child despite trying for 1 year. The condition affects about 9% of the reproductive age population.

To become pregnant, a couple must have intercourse during the woman’s fertile time of the month, which is right before and during ovulation. Because it is tough to pinpoint the exact day of ovulation, having intercourse every other day during this time maximizes the chances of conception.

After a year of frequent intercourse without contraception that does not result in pregnancy, a couple should go to a health-care professional for an evaluation. In some cases, it makes sense to seek help for fertility problems even before a year is up.

A woman over age 30 may wish to get an evaluation before 1 year. At age 30, a woman begins a slow decline in her ability to get pregnant. The older she gets, the greater her chance of miscarriage. However, fertility does not take a big drop until around age 40. Despite a decrease in sperm production that begins after age 25, some men remain fertile into their 60s and 70s.

A couple may also seek earlier evaluation if:

  • The woman is not menstruating regularly, which may indicate an absence of ovulation that would make it impossible for her to conceive without medical help.
  • The woman has had three or more miscarriages (or the man had a previous partner who had had three or more miscarriages).
  • The woman or man has had certain infections that sometimes affect fertility (for example, pelvic infection in a woman, or mumps or prostate infection in a man).
  • The woman or man suspects there may be a fertility problem (if, for example, attempts at pregnancy failed in a previous relationship).

Causes of Infertility

Impairment in any step of the intricate process of conception can cause infertility. For a woman to become pregnant, her partner’s sperm must be healthy so that at least one can swim into her fallopian tubes. An egg, released by the woman’s ovaries, must be in the fallopian tube ready to be fertilized. Next, the fertilized egg, called an embryo, must make its way through an open-ended fallopian tube into the uterus, implant in the uterine lining, and be sustained there while it grows.

Of the 80% of cases with a diagnosed cause, about half are based at least partially on male problems (referred to as male factors)–usually that the man produces no sperm, a condition called azoospermia, or that he produces too few sperm, called oligospermia.

Lifestyle can influence the number and quality of a man’s sperm. Alcohol and drugs–including marijuana, nicotine, and certain medications–can temporarily reduce sperm quality. Also, environmental toxins, including pesticides and lead, may be to blame for some cases of infertility.

The causes of sperm production problems can exist from birth or develop later as a result of severe medical illnesses, including mumps and some sexually transmitted diseases, or from a severe testicle injury, tumor, or other problem. Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence.

The other half of explained infertility cases are linked to female problems (called female factors), most commonly ovulation disorders. Without ovulation, eggs are not available for fertilization. Problems with ovulation are signaled by irregular menstrual periods or a lack of periods altogether (called amenorrhea). Simple lifestyle factors–including stress, diet, or athletic training–can affect a woman’s hormonal balance. Much less often, a hormonal imbalance can result from a serious medical problem such as a pituitary gland tumor.

Other problems can also lead to female infertility. If the fallopian tubes are blocked at one or both ends, the egg can’t travel through the tubes into the uterus. Such blockage may result from pelvic inflammatory disease, surgery for an ectopic pregnancy (when the embryo implants in the fallopian tube rather than in the uterus), or other problems, including endometriosis (the abnormal presence of uterine lining cells in other pelvic organs).

A medical evaluation may determine whether a couple’s infertility is due to these or other causes. If a medical and sexual history doesn’t reveal an obvious problem, like improperly timed intercourse or absence of ovulation, specific tests may be needed.

What Tests Are Needed

For the woman, the first step in testing is to determine if she is ovulating each month. This can be done by charting changes in morning body temperature, or use an ovulation test kit (which is available over the counter), or by examining cervical mucus, which undergoes a series of hormone-induced changes throughout the menstrual cycle.

Checks of ovulation can also be done in the physician’s office with simple blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, further testing will need to be done.

Common female tests include:

  • Hysterosalpingogram: An x-ray of the fallopian tubes and uterus after they are injected with dye, to show if the tubes are open and to show the shape of the uterus.
  • Laparoscopy: An examination of the tubes and other female organs for disease, using a miniature light-transmitting tube called a laparoscope. The tube is inserted into the abdomen through a one-inch incision below the navel, usually while the woman is under general anesthesia.
  • Endometrial biopsy: An examination of a small shred of uterine lining to see if the monthly changes in the lining are normal.

Some tests require participation of both partners. Samples of cervical mucus taken after intercourse can show whether sperm and mucus have properly interacted. Also, a variety of tests can show if the man or woman is forming antibodies that are attacking the sperm.