Infertility

Infertility is often defined as the inability of a couple to become pregnant after one year of regular, unprotected sex.  For couples over the age of 35, infertility is often diagnosed and treated if pregnancy does not occur within six months of regular, unprotected sex.  Infertility is actually fairly common, with between 10-15% of couples having difficulty conceiving.  The causes of infertility can be due to the man, the woman, or both individuals.  Overall, infertility is attributed to women in about half of cases and men in one-third of cases.  The remaining cases have no real known cause as to why the couple cannot conceive.  In this section we will discuss male infertility in depth, but we will also discuss female infertility since infertility is something you experience together as a couple – not alone. 

 

MALE INFERTILITY

Male infertility typically consists of four different types of problems.  The first is little to no sperm production in the testicles.  The second is something called sperm morphology.  Basically, a condition where less than 4% of sperm ejaculated are “normal” in shape and appearance and able to fertilize an egg.  The third occurs when sperm is being produced but is unable to move from the testicles to the ejaculatory duct to mix with semen (usually an issue in the epididymis or vas deferens).  The final problem occurs when semen cannot be ejaculated into the vagina. 

Sperm Production Issues

 

For a man to be considered “fertile” there should be more than 40 million sperm per ejaculation and more than 13-15 million sperm per milliliter.  That may sound like a lot of sperm; however, previously we discussed that less than one in 1 million sperm will make it to the fallopian tubes where conception occurs, leaving only a handful of sperm available for fertilization. 

 

Low sperm count (oligospermia) and no sperm count (azoospermia) can be caused by repeated reproductive tract infections, genetic abnormalities, pituitary hormone disorders, environmental issues (like overly warm testicles), and age.  Some infections of the testicles can cause inflammation and decrease the ability of the sertoli cells to produce large numbers of sperm.  Genetic disorders can cause genetic deletions of information on the Y chromosome that can cause low sperm counts in 16% of men. 

 

The testicles are triggered to make sperm by gonadotropins (LH and especially FSH) from the pituitary gland.  Low levels of these, and sometimes other pituitary hormones, can shut down the signal to the testicles to produce sperm.  Sometimes, these disruptions in gonadotropins can be caused by men taking testosterone or pro-hormone therapy.  As testosterone levels rise artificially, the pituitary gland is tricked into thinking the testicles are working efficiently – thereby shutting down production of gonadotropins which can lead to the testicles shrinking in size and in some cases becoming almost permanently non-functional. 

 

Environmental factors like scrotal temperature can cause low sperm counts.  Hot baths, saunas, hot tubs, and a persistently warm scrotal region can lead to low sperm production.  The main reason the testicles are located outside of the body and inside the scrotum is because the body is too warm for sperm to be viable.  If the scrotum is kept too warm, the sperm won’t develop.  The old wives’ tale of “tight underwear causing infertility” can actually be true as tighter underwear can hold the testicles next to the warm body, thus increasing the scrotal temperature and inhibiting sperm formation. 

 

Finally, sperm counts tend to diminish with age.  Beginning around age 40, men often experience a decrease in sperm count.  However, men are able to father children nearly all of their life, even in their 70s and 80s.

Treatment for low sperm count depends on the cause.  Male infertility dealing with sperm count requires a bit of patience since it takes a sperm six months to develop and mature before it can be capable of fertilizing an egg.  In cases where sperm counts are low due to environmental issues, simply showering rather than bathing, wearing looser boxers rather than tighter briefs, and wearing cool breathable clothing can help increase sperm count over a period of about six months.  For men who have a pituitary disorder, they may be given a medication pump that provides pulse doses of FSH and LH every 90-120 minutes over the course of six months or oral drugs called aromatase inhibitors on a daily basis for six months. 

 

Sperm Morphology

 

A second cause of male infertility involves sperm morphology.  Sperm morphology describes the shape and shape of sperm.  Men don’t always make “normal sperm”.  In fact, the vast majority of sperm that men make are abnormal and not able to fertilize and egg.  In fact, “normal” is for at least 4% of sperm to be normally shaped.  In fertility studies men’s sperm morphology is often broken down into three categories – less than 4% normal, 4-14% normal, and more than 14% normal. That means that even on the high end, 86-96% of the sperm men produce is abnormal and unlikely to fertilize an egg.  This is just one more reason why men produce hundreds of millions of sperm for each ejaculation. 

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Normal sperm morphology includes a sperm that has:

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Blockages of the Epididymis/Vas Deferens

A third cause of male infertility is the failure of sperm reaching the ejaculatory duct and mixing with semen.  Causes can vary from blockages or inflammation, genetic disorders, surgical procedures (prior vascectomies), or structural issues.  Blockages in the epididymis or vas deferens can occur from repeated infections or inflammation.  This can be due to prostatitis, epididymitis, and sexually transmitted infections like chlamydia and gonorrhea.  Genetic mutations, like those found in men with cycstic fibrosis, can prevent the vas deferens from forming.  Vasectomies also clearly inhibit sperm from passing through the vas deferens.  Finally, structural issues such as varicoceles (varicose veins in the scrotum) and hernias (abdominal contents pressing into the scrotum) can create pressure in the spermatic cord, thus kinking the vas deferens and preventing sperm from continuing past that point.  Similar blockages have also been noted in some men who have had surgery to repair an inguinal hernia.  

 

Treatment for blockages varies by cause.  Men with varicoceles can typically have the varicocele removed and fertility will resume by allowing sperm to pass through the vas deferens more freely.  Reversals of vasectomies don’t always work and the scarring and inflammation that can occur can be difficult to bypass.  In severe blockage cases, infertility treatment may include removing sperm directly from the epididymis by needle for use in IVF.

 

Issues preventing ejaculation inside the vagina

 

In some cases sperm counts can be normal, but semen cannot be delivered into the female reproductive system.  Causes include ejaculatory issues and structural/functional issues of the penis.  Ejaculatory issues lead to infertility:

  • Retrograde Ejaculation – sperm/semen moves backwards into the bladder rather than forward out of the penis into the vagina during intercourse

  • Premature Ejaculation – sperm/semen is ejaculated before the penis can be inserted into the vagina

  • Anejaculation – inability to ejaculate (seen in men with spinal cord injuries)

 

Correction of these types of ejaculatory disorders can restore fertility.  Retrograde ejaculation (semen ejaculating backwards into the bladder rather than forward) is typically a side effect of certain medications.  Medications can often be changed to remove this side effect.   Premature ejaculation can also often be treated to allow enough time for vaginal penetration before ejaculation.  However, in men with severe premature ejaculation, “catching” the semen in a clinic setting can allow for intrauterine insemination (IUI) therapy.  IUI involves placing semen directly into the uterus by catheter.  Treatment of underlying causes of anejaculation can also be effective.  In some men with spinal cord injuries, certain types of neurostimulation may be required to trigger the reproductive system to ejaculate.  Semen from these ejaculations are almost always collected in a clinic and used for IUI or IVF (in-vitro fertilization) types of therapies.

 

Structural and functional abnormalities that prevent semen from entering the vagina:

  • Erectile Dysfunction (ED) – the penis cannot become rigid enough to insert into the vagina

  • Penile Curvatures – severe curvatures can prevent an erect penis from inserting into the vagina

  • Urethral Abnormalities – placement of the urethra on the lower shaft of the penis or even abdominal wall can prevent semen from being ejaculated deep enough in the vagina for a good chance to cause fertilization

  • Severe Micropenis – an erect penis that is shorter than 5cm (2 inches) may have difficulties delivering semen into the vagina or deep enough into the vagina to increase the chances of fertilization

 

All of these abnormalities can include semen collection in a clinic setting and used in IUI or IVF.  However, treatment for men who have ED can be as simple as treating the ED itself and restoring erectile function.  For severe curvatures and urethra abnormalities, surgical correction of these disorders can result in a penis that can function normally to deliver sperm via intercourse.  Hormone therapy can be administered to some men with micropenis that may help enlarge the penis in some cases.

 

FEMALE INFERTILITY

Infertility in women can be caused by a number of different reasons.  There can either be structural issues or hormonal issues.

Structural issues, such as scarring in the fallopian tubes, can decrease fertility.  Scarring can decrease the wafting motions of the fimbrae, thus decreasing the chance of an egg moving down into the fallopian tube to meet up with sperm.  Scarring in the fallopian tubes can also prevent sperm from swimming up high enough to meet up with an egg, or for a fertilized egg (zygote) to make its way down to the uterus for implantation.  Blockages can be caused by genetic problems or from infections such as chlamydia and gonorrhea

Hormonal issues are perhaps the leading cause of infertility overall.  These hormonal issues cause a woman to ovulate irregularly or have menstrual cycles where ovulation doesn’t occur.  Without ovulation, there is no egg to be fertilized by the sperm.  Sometimes menstrual irregularities can be caused by hormone issues, pituitary issues, polycystic ovarian syndrome, or excessive physical activity in some women.  In fact, some female athletes that work out rigorously find they often have fewer periods or they start skipping periods altogether.  These types of female infertility issues will be discussed in the treatment section.

Now let’s jump to discussing the various types of therapy a couple may need to undergo during infertility treatment, including more in-depth discussions on infertility issues that may affect women as well.

 

INITIAL INFERTILITY TESTING

One of the first steps to infertility treatment is to do a little digging to determine the main problem since treatment varies depending on the cause of the infertility. 

Men will be asked about the ability to have intercourse and ejaculate in the vagina, as well as their recent history of hot baths, saunas, type of underwear worn, etc.  They will also be asked about their past medical history that may reveal genetic problems or indicate infections or inflammation that may be causing blockages.  Men will usually have a physical exam, as well as a scrotal exam, to check for varicoceles or other potential causes of infertility.  Men may be asked to provide a semen sample (collected in a clinic via masturbation).  A spermogram will then be done on the semen sample to check the number and quality of sperm to ensure sperm counts are sufficiently high and motile (able to swim). 

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Women are questioned about the frequency of their menstrual cycles to determine if there are irregularities.  They are also asked about their past medical history.  Conditions like endometriosis (growth of the uterine lining outside of the uterus) and sexually transmitted infections like chlamydia and gonorrhea can cause scarring of the fallopian tubes since these are the leading cause of female infertility.  Blood tests can also be used to determine if hormone levels such as thyroid or prolactin could be interfering with fertility.  Finally, ultrasounds and other diagnostic tests can be performed to assess any other issues with the female reproductive system.

TREATMENT OF INFERTILITY

Treatment of infertility can be divided into two main types – coital and non-coital:

  • Coital involves still having intercourse to introduce sperm into the female reproductive tract.  This is most often used first, enhancing or improving the chances for conceiving a child.  It can involve using timing methods to increase the chances of conception or introduce medications that increase sperm counts or egg ovulation.

  • Non-Coital/Assisted Reproductive Technology

    • Semen is collected via masturbation in a clinic setting to be used for fertilization.  There are two main non-coital therapies:

      • Intrauterine insemination (IUI) – sperm/semen is collected then injected through a catheter (tube) directly into the uterus.  This method is used in some types of male infertility where he is able to ejaculate, but not in the vagina (erectile dysfunction, premature ejaculation, etc.).  It also increases the number of sperm that make it to the uterus if he has a low sperm count.  Approximately 49 out of 50 sperm will not make it from the vagina to the uterus, so injecting semen directly into the uterus increases fertility by about 50 times.

      • In vitro fertilization (IVF) – both eggs and sperm are collected and fertilized outside the body in a laboratory.  The fertilized eggs are injected into the uterus to implant and develop.

 

 

Coital Therapy

Sexual Timing (Coital Timing)

For couples not able to conceive during a 1-year period, the first treatment is to ensure sexual intercourse is occurring often enough and during the right times of the month to maximize the chances pregnancy will occur.  An egg can only be fertilized for approximately ten hours and it can take sperm one to two days to reach the fallopian tubes where the egg will be fertilized.  If the woman has one cycle per month, this gives her 12 chances, or 120 hours total, during the entire year to become pregnant.  If she has less frequent cycles, say 9 cycles a year, that’s only 9 chances, or 90 hours total, during the entire year to become pregnant. 

Women typically ovulate 14 days prior to the start of their period.  Many couples often purchase ovulation kits found over-the-counter that identify when a woman is ovulating and have intercourse when the test shows she is ovulating.  This is often not ideal. Knowing that ovulation occurred today doesn’t always allow for a sexual encounter within the next hour to result in sperm being able to swim all the way to the fallopian tubes within the 10-hour window.  Sexual intercourse should begin approximately four days before the “ovulation date” and continue at least every other day for a week.  This increases the number of sperm available to fertilize the egg.  In essence, the sperm need to already be in the fallopian tube “waiting” when an egg is ovulated.  Perhaps the best use of an ovulation kit is to begin tracking when ovulation occurs during a menstrual cycle.  If ovulation occurs on  day 14 one month, day 15 the next month, and day 13 the next month,  a couple can plan to have frequent intercourse starting on day 9 or 10 of the next cycle to ensure sperm are available in the fallopian tubes when the woman actually ovulates.  Intercourse would then continue every other day until day 17 (two days after the last possible day for ovulation).   Ovulation dates can often be calculated by subtracting 14 from the first day of the next menstrual cycle.  A calendar to predict fertility is found below:

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For example,  if a woman had a 26-day cycle as her shortest cycle and a 35-day cycle as her longest cycle, intercourse should occurring at least every other day on days 8 through 22 of her cycle.

For some women, their menstrual cycles can vary widely from one cycle to the next.  Because of this, the day they might ovulate isn’t narrowed down to a handful of days next to each other.  In this case, intercourse every other day should be timed around both the shortest and longest menstrual cycle length and continue for any days in between.  In some cases this may result in a couple having intercourse every other day for a couple of weeks each cycle. 

 

Medications

 

Women who do not ovulate or don’t ovulate on a regular schedule can be given drugs to force ovulation on a specific day.  Creating a specific, known date of ovulation allows the couple an opportunity to time intercourse every other day at the optimal time of the month in order to maximize the chances of pregnancy.  Typically a medication like clomiphene or other estrogen antagonist is given on days 5-9 of the menstrual cycle.  This creates the predicted ovulation day at about day 14.  Couples are advised to have intercourse every other day starting on day 10 and to continue for a full week.  A common concern with this type of drug therapy is an increased the chance of conceiving twins.  However, the chance of twins only goes up slightly with this type of infertility treatment. 

 

There are often underlying reasons women are anolvulatory (don’t ovulate).  A condition called polycystic ovarian syndrome (PCOS) can interfere with ovulation.  Medications such as metformin (a diabetes drug) are often given to reverse some of the symptoms of PCOS, including anovulation.  Ovulation can also cease in women who have hyperprolactinemia – a condition where the pituitary gland secretes too much prolactin.  In women, prolactin is released during breast feeding.  This is one of nature’s birth control methods to attempt to delay another pregnancy until a baby is no longer breastfeeding.  If the pituitary gland releases too much prolactin when a woman isn’t breastfeeding, the ovaries can be tricked into thinking the woman is breastfeeding, and ovulation will not occur regularly.  Medications such as bromocriptine or cabergoline are often given to these women to reduce prolactin levels in an effort to help them ovulate.  In many cases, women who have PCOS or hyperprolactinemia will also be given clomiphene or another estrogen antagonist to trigger ovulation.

 

Women with irregular menstrual cycles may be given birth control pills for a short period of time to help her body get into a regular four week “rhythm”.  Sometimes birth control pills are used for a few months to achieve this rhythm, then the birth control is discontinued and the couple plan on regular intercourse beginning on day 10 in anticipation of the body now being on a 28-day rhythm.  The drawback to this method is that some women may not restart their ovulation cycles in the first month or two.

 

 

Non-Coital Therapy

Intrauterine Insemination (IUI)

This is one of the first treatments for infertility which is caused by the inability of a man to ejaculate vaginally or having lower sperm counts.  Semen is collected in a clinic setting during the most fertile time of a woman’s cycle.  Typically men are asked to refrain from ejaculating for a few days prior to this collection to ensure as much sperm is available in the semen sample as possible.  On the day of the procedure, the man is asked to masturbate in the clinic to collect his semen.  The semen is then introduced into a catheter that is threaded into the vagina and through the cervix into the uterus, thus giving the sperm a head start to the fallopian tubes for fertilization.  IUI can be effective in men with low sperm counts as it artificially increases the chances of conception.  In a man with normal sperm counts, only 5% will reach the uterus.  By depositing the sperm directly into the uterus, it eliminates the 95% “loss” thus increasing his “fertility” 20-50 times.

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In Vitro Fertilization (IVF)

 

IVF is typically used when there are multiple factors for infertility or if coital and IUI therapies have failed.  IVF begins by administering gonadotropins (FSH and LH) to women in order to induce ovulation.  In men that have severe oligospermia (low sperm count) or azoospermia (no sperm count), these same gonadotropins can be administered via pump for approximately six months to increase sperm count.  Once the eggs are collected, a semen sample is provided and an egg is either “washed” in semen or a single sperm cell is injected into the egg to cause conception.  The egg or eggs are then delivered into the uterus where they may attach to the uterine lining and a pregnancy will begin and be maintained.

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OTHER FACTORS TO CONSIDER

One topic rarely discussed in regards to infertility treatment is the “loss of intimacy”.  For many couples, coital therapy is enjoyable the first month or so, but as time goes on and pregnancy doesn’t occur, intercourse begins to be something that is highly scheduled.  For many men they begin to feel like they are showing up for their sperm donation.  In addition, intercourse becomes something that is performed to conceive, and the aspects grow closer together as a couple and showing love oftentimes starts taking a back seat and even breaking down.  In fact, repeated attempts that don’t end in pregnancy can sometimes be perceived by the couple as the failure of intercourse and their sexual relationship.

With couples undergoing non-coital therapy, intercourse must be abstained from during IVF and men experience sexual climax in a reproductive health clinic rather than at home with his partner.  This can be a strain as the other main aspect of sexual relations, namely growing closer together, is placed on the sidelines while fertility takes not only center stage, but becomes the only player on the field so to speak.

It is important for couples undergoing infertility treatment to continue to focus on their relationship and take time to date and express love in both physical and non-physical ways.  Some ideas for couples undergoing coital therapy can be to plan date night around the fertile times of the month where regular sexual activity is required.  Even planning to take baths, snuggling, or simply going out to eat or to a movie beforehand can help introduce the “bonding” aspect of sex rather than having it be something “we have to do tonight”.  Couples undergoing IVF who must abstain from intercourse during the first part of the month can find other ways to fulfill one another’s needs by doing many of the same things.  When sexual fulfillment is needed, couples can find ways to express themselves physically that don’t involve intercourse – holding hands, snuggling, massage, etc.

Another difficulty many infertile couples face are the well-intended, but none-of-your-business comments offered by other people.  Tips on “just relaxing” or “it was easy for us” can become overwhelming.  Keep in mind that most people have good intentions.  For those who haven’t had infertility issues, it can be an experience with which they can’t identify, so they often don’t find the right words to convey their concern.  For many infertile couples, simply putting their infertility out in the open can be liberating.  Oftentimes, the most hurtful comments come from close friends and family that ask when you’re going to “decide” to have children.  They think the couple is just putting it off for now, when in fact they may have “decided” to have a baby years before.  When others know about your infertility issues, it can reduce the number of “stupid” comments.  It’s okay to tell people you’re having issues with infertility and you don’t need them to console you or give advice.  Let them know you may appreciate their thoughts or prayers.  Speaking with another couple that has had infertility issues is often helpful.  They can have a unique perspective and can help you feel less alone and give you both ideas about how to maintain a strong relationship through this trial.

Finally, there is the possibility that infertility treatment will not work and the reality of facing a childless family or adopting is presented.  It’s often a good idea during infertility to discuss “what you will do if you can’t have children.”  This can help prepare couples mentally for the next steps rather than being completely devastated when that news comes.  It can also make the moment if pregnancy does occur all the more sweet.

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