Primary infertility describes couples who have never been able to become pregnant after at least 1 year of unprotected

sex (intercourse). Or six months, if a woman is 35 or older. Secondary infertility describes couples who have been pregnant at least once, but have not been able to become pregnant again. Women who can get pregnant but are unable to stay pregnant may also be infertile. Pregnancy is the result of a process that has many steps. To get pregnant: y A woman must release an egg from one of her ovaries (ovulation). y The egg must go through a Fallopian tube toward the uterus (womb). y A man's sperm must join with (fertilize) the egg along the way. y The fertilized egg must attach to the inside of the uterus (implantation). Infertility can happen if there are problems with any of these steps. Infertility is not always a woman's problem. Both women and men can have problems that cause infertility. About one-third of infertility cases are caused by women's problems. Another one third of fertility problems are due to the man. The other cases are caused by a mixture of male and female problems or by unknown problems. Infertility in men is most often caused by: A problem called varicocele (VAIR-ih-koh-seel). This happens when the veins on a man's testicle(s) are too large. This heats the testicles. The heat can affect the number or shape of the sperm. y Movement of the sperm. This may be caused by the shape of the sperm. Sometimes injuries or other damage to the reproductive system block the sperm. y Low sperm count; normally, men produce at least 20 million sperms per milliliter of semen (that's around one sixth of the total ejaculate); fewer is judged to be subfertile. y Poor sperm motility; sperms will then be unable to swim through the cervix to meet the egg in the fallopian tube. y Poor shape (known as 'morphology'), so that an individual sperm is unable to penetrate the outer layer of an egg. y Non-production of sperm. (because of testicular failure) or complete absence of sperm (perhaps because of an obstruction)
y

Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. For example, cystic fibrosis ( hereditary disease starting in infancy that affects various glands and results in secretion of thick mucus that blocks internal passages, including those of the lungs, causing respiratory infections. The pancreas is also affected, resulting in a deficiency of digestive enzymes and impaired nutrition) often causes infertility in men. Risk factors of infertility in men A man's sperm can be changed by his overall health and lifestyle. Some things that may reduce the health or number of sperm include: y heavy alcohol use

y y y y y y y

drugs environmental toxins, including pesticides and lead smoking cigarettes health problems such as mumps, serious conditions like kidney disease, or hormone problems medicines radiation treatment and chemotherapyfor cancer age

Most cases of female infertility are caused by problems with ovulation. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods. Ovulation problems are often caused bypolycystic ovarian syndrome (PCOS). PCOS is a hormone imbalance problem which can interfere with normal ovulation. PCOS is the most common cause of female infertility. Primary ovarian insufficiency (POI) is another cause of ovulation problems. POI occurs when a woman's ovaries stop working normally before she is 40. POI is not the same as early menopause. Less common causes of fertility problems in women include: y blocked Fallopian tubes due to pelvic inflammatory disease,endometriosis, or surgery for an ectopic pregnancy y physical problems with the uterus y uterine fibroids, which are non-cancerous clumps of tissue and muscle on the walls of the uterus. y Hormonal disorders; as a result, egg follicles might not grow within the ovary, or an egg might not be released (ovulation). y Damaged or blocked fallopian tubes, which will prevent an egg and sperm meeting. y Endometriosis, in which womb tissue invades and damages neighbouring reproductive tissue. y Excessively thick cervical mucus, which prevents sperm passing through. Many things can change a woman's ability to have a baby. These include: y age y stress y poor diet y athletic training y being overweight or underweight y smoking y excess alcohol use y sexually transmitted infections (STIs) y health problems that cause hormonal changes, such as polycystic ovarian syndrome and primary ovarian insufficiency Many women are waiting until their 30s and 40s to have children. In fact, about 20 percent of women in the United States now have their first child after age 35. So age is a growing cause of

fertility problems. About one-third of couples in which the woman is over 35 have fertility problems. Aging decreases a woman's chances of having a baby in the following ways: y Her ovaries become less able to release eggs. y She has a smaller number of eggs left. y Her eggs are not as healthy. y She is more likely to have health conditions that can cause fertility problems. y She is more likely to have a miscarriage. Most experts suggest at least one year trying and getting pregnant before calling a doctor. Women 35 or older should see their doctors after six months of trying. A woman's chances of having a baby decrease rapidly every year after the age of 30. Some health problems also increase the risk of infertility. So, women should talk to their doctors if they have: y Irregular periods or no menstrual periods y Very painful periods y Endometriosis y Pelvic inflammatory disease y More than one miscarriage It is a good idea for any woman to talk to a doctor before trying to get pregnant. Doctors can help you get your body ready for a healthy baby. They can also answer questions on fertility and give tips on conceiving. Medical diagnosis Doctors will do an infertility checkup. This involves a physical exam. The doctor will also ask for both partners' health and sexual histories. Sometimes this can find the problem. However, most of the time, the doctor will need to do more tests. In men, doctors usually begin by testing the semen. They look at the number, shape, and movement of the sperm. Sometimes doctors also suggest testing the level of a man's hormones. In women, the first step is to find out if she is ovulating each month. There are a few ways to do this. A woman can track her ovulation at home by: y Writing down changes in her morning body temperature for several months y Writing down how her cervical mucus looks for several months y Using a home ovulation test kit (available at drug or grocery stores) Doctors can also check ovulation with blood tests. Or they can do an ultrasound of the ovaries. If ovulation is normal, there are other fertility tests available. Some common tests of fertility in women include:

Hysterosalpingography (HIS-tur-oh-sal-ping-GOGH-ru-fee): This is an X-ray of the uterus and Fallopian tubes. Doctors inject a special dye into the uterus through the vagina. This dye shows up in the X-ray. Doctors can then watch to see if the dye moves freely through the uterus and Fallopian tubes. This can help them find physical blocks that may be causing infertility. Blocks in the system can keep the egg from moving from the Fallopian tube to the uterus. A block could also keep the sperm from reaching the egg. Laparoscopy (lap-uh-ROS-kuh-pee): A minor surgery to see inside the abdomen. The doctor does this with a small tool with a light called a laparoscope (LAP-uh-roh-skohp). She or he makes a small cut in the lower abdomen and inserts the laparoscope. With the laparoscope, the doctor can check the ovaries, Fallopian tubes, and uterus for disease and physical problems. Doctors can usually find scarring and endometriosis by laparoscopy. During this surgery doctors use a tool called a laparoscope to see inside the abdomen. The doctor makes a small cut in the lower abdomen and inserts the laparoscope. Using the laparoscope, doctors check the ovaries, Fallopian tubes, and uterus for disease and physical problems. Doctors can usually find scarring and endometriosis by laparoscopy.

Finding the cause of infertility can be a long and emotional process. It may take time to complete all the needed tests. So don't worry if the problem is not found right away. Infertility can be treated with medicine, surgery, artificial insemination, or assisted reproductive technology. Many times these treatments are combined. In most cases infertility is treated with drugs or surgery. Doctors recommend specific treatments for infertility based on: test results how long the couple has been trying to get pregnant the age of both the man and woman the overall health of the partners preference of the partners

y y y y y

Doctors often treat infertility in men in the following ways: y Sexual problems: Doctors can help men deal with impotence or premature ejaculation. Behavioral therapy and/or medicines can be used in these cases. y Too few sperm: Sometimes surgery can correct the cause of the problem. In other cases, doctors surgically remove sperm directly from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count. y Sperm movement: Sometimes semen has no sperm because of a block in the man's system. In some cases, surgery can correct the problem. In women, some physical problems can also be corrected with surgery.

A number of fertility medicines are used to treat women with ovulation problems. It is important to talk with your doctor about the pros and cons of these medicines. You should understand the possible dangers, benefits, and side effects. Some common medicines used to treat infertility in women include: Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth. y Human menopausal gonadotropin or hMG (Repronex, Pergonal):This medicine is often used for women who don't ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine. y Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected. y Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray. y Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined withmetformin. This medicine is usually taken by mouth. y Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production.
y

Many fertility drugs increase a woman's chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems. Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, the woman is injected with specially prepared sperm. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI. IUI is often used to treat: y Mild male factor infertility y Women who have problems with their cervical mucus y Couples with unexplained infertility Assisted reproductive technology (ART) is a group of different methods used to help infertile couples. ART works by removing eggs from a woman's body. The eggs are then mixed with sperm to make embryos. The embryos are then put back in the woman's body. Success rates vary and depend on many factors. Some things that affect the success rate of ART include: y age of the partners

y y y y y

reason for infertility clinic type of ART if the egg is fresh or frozen if the embryo is fresh or frozen

The U.S. Centers for Disease Prevention (CDC) collects success rates on ART for some fertility clinics. According to the 2006 CDC report on ART, the average percentage of ART cycles that led to a live birth were: y 39% in women under the age of 35 y 30% in women aged 35-37 y 21% in women aged 37-40 y 11% in women aged 41-42 ART can be expensive and time-consuming. But it has allowed many couples to have children that otherwise would not have been conceived. The most common complication of ART is multiple fetuses. But this is a problem that can be prevented or minimized in several different ways. Different types/Common methods of ART include: y In vitro fertilization (IVF) means fertilization outside of the body. IVF is the most effective ART. It is often used when a woman's Fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus. y Zygote intrafallopian transfer (ZIFT)or Tubal Embryo Transfer is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred to the Fallopian tube instead of the uterus. y Gamete intrafallopian transfer (GIFT)involves transferring eggs and sperm into the woman's Fallopian tube. So fertilization occurs in the woman's body. Few practices offer GIFT as an option. y Intracytoplasmic sperm injection(ICSI) is often used for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or Fallopian tube. ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos. Donor eggs are sometimes used for women who can not produce eggs. Also, donor eggs or donor sperm is sometimes used when the woman or man has a genetic disease that can be passed on to the baby. An infertile woman or couple may also use donor embryos. These are embryos that were either created by couples in infertility treatment or were created from donor sperm and donor eggs. The donated embryo is transferred to the uterus. The child will not be genetically related to either parent. Surrogacy

Women with no eggs or unhealthy eggs might also want to consider surrogacy. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child will be genetically related to the surrogate and the male partner. After birth, the surrogate will give up the baby for adoption by the parents. Gestational Carrier Women with ovaries but no uterus may be able to use a gestational carrier. This may also be an option for women who shouldn't become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by the man's sperm and the embryo is placed inside the carrier's uterus. The carrier will not be related to the baby and gives him or her to the parents at birth. Recent research by the Centers for Disease Control showed that ART babies are two to four times more likely to have certain kinds ofbirth defects. These may include heart and digestive system problems, and cleft (divided into two pieces) lips or palate. Researchers don't know why this happens. The birth defects may not be due to the technology. Other factors, like the age of the parents, may be involved. More research is needed. The risk is relatively low, but parents should consider this when making the decision to use ART.

Diagnostic Tests for Infertility Diagnostic Test list for Infertility: The list of diagnostic tests mentioned in various sources as used in the diagnosis of Infertility includes:
y y y y y y y y y y y y

Semen analysis Post-coital cervix test Sperm migration tests Ovulation tests Cervical mucus tests Hormone blood tests Uterus examination tests Fallopian tube examination tests Laparoscopy Laparotomy See also tests for male infertility See also tests for female infertility

Tests and diagnosis discussion for Infertility: 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.1 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, by using an FDA-approved home 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. 1 There are several diagnostic tests physicians can use to see if your reproductive organs are functioning normally. You and your fertility doctor will determine which test is right for you based on your medical history and any symptoms you may be experiencing. Tests to Assess the Fallopian Tubes A blocked fallopian tube could prevent an egg from moving through the tube to the uterus or prevent sperm from reaching the egg. If your uterus has an abnormal shape due to fibroids or

polyps, that abnormality may prevent a fertilized egg from attaching to the uterine wall and cause repeated miscarriages. A hysterosalpingogram (HSG) is an X-ray that shows the inside of your uterus and fallopian tubes. The test is used to see if you have any structural abnormalities. An HSG is usually done two to five days after your menstrual period begins (the test should not be performed if you are pregnant). A thin tube is inserted through the cervix into the uterus. Then a small amount of dye is injected and an X-ray is taken. The dye outlines the inside of the fallopian tubes and uterus so the radiologist can see if there is a blockage and if so, where it is located. The radiologist also watches the dye to see if it moves. If you do not have a blockage, the dye goes through the tubes and into your belly. If you do have a blockage, the dye does not leave the fallopian tubes. A newer test, called a sonohysterosalpingogram, is a non-radiologic method of assessing fallopian tubes and uterine shape with results that are comparable to HSG. This procedure can be done in the fertility doctor's office instead of seeing a radiologist. A sonohysterosalpingogram uses sterile saline and air, which is passed through the cervix into the uterus. Tests to Assess the Uterus The hysterosalpingogram and the sonohysterosalpingogram also assess the uterus, as does a saline sonogram, a test that can show uterine abnormalities such as polyps or cysts. This test is also called a saline sonogram, a sonohysterogram or a water ultrasound. During the test, saline (salt water) is injected through your cervix to outline the inside of the uterus. This test uses ultrasound, not an X-ray, to let the radiologist watch the movement of the saline. The sonogram allows the radiologist to see not only inside the cavity of the uterus, but also the wall of the uterus at the same time to detect polyps or fibroids. Some researchers believe that a saline sonogram is a more accurate test for evaluating the uterine cavity than a hysterosalpingogram or sonohysterosalpingogram. Infertility is often caused by fallopian tube blockages or other problems with the uterus. Hysterosalpingogram (HSG) A hysterosalpingogram is an X-ray test that looks at the inside of the uterus and fallopian tubes, and the area around them. The test is used for several reasons.
y

Determining if your fallopian tubes are blocked and see where the blockage is located at the junction of the tube and uterus (proximal) or at the end of the tubes (distal). A blockage could prevent an egg from moving through a fallopian tube to the uterus or prevent sperm from moving into a fallopian tube and fertilizing an egg. Finding problems in the uterus such as an injury, abnormal shape or structure, polyps, fibroids or adhesions. The test may also find problems on the inside of the uterus that prevent an embryo (fertilized egg) from implanting on the uterine wall. Seeing whether surgery to reverse tubal ligation has been successful. A hysterosalpingogram involves the injection of radiographic dye into your uterus, and it must be performed by a radiologist or someone trained in radiographic imaging. The uterus fills with this dye, and if your fallopian tubes are clear, it will spill into your abdominal cavity. Pictures are

taken using a steady beam of X-ray (fluoroscopy) as the dye passes through the uterus into the fallopian tubes. Sonohysterosalpingogram (SSG) A sonohysterosalpingogram is an innovative, non-radiologic method of assessing fallopian tubes and uterine shape with results that are comparable to HSG. Testing with sonohysterosalpingogram is typically less expensive than with hysterosalpingogram with the added benefits of: no exposure to radiation because no X-ray equipment is required, the procedure is usually done in the office, eliminating the need for an oupatient hospital visit. A sonohysterosalpingogram uses sterile saline and air, which is passed through the cervix into the uterus and visualized by transvaginal ultrasound. The test allows the fertility doctor to assess the uterine lining, shape and texture, as well as the fallopian tubes. The test may cause some cramping as it is being performed. Saline Sonogram (SIS) A saline sonogram, also known as a saline infusion sonogram, a sonhysterogram or an SIS is an ultrasound test done after a saline solution has been infused into the uterus. The test is used to detect uterine abnormalities such as polyps or cysts. The saline solution distends the uterus and acts as a contrast to the internal structure, which provides more detail than a conventional ultrasound. A fertility workup will help your doctorand youdetermine the right course of treatment. With the right treatment, almost 90 percent of fertility patients are able to have a baby. Treatment Options When most people hear the term infertility treatment they think of in vitro fertilization (IVF), whereby a fertilized egg (embryo) is transferred to the uterus. In reality, IVF accounts for less than 3 percent of infertility services. Variations on standard IVF include natural cycle IVF, low-stimulation (low-stim) IVF, gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT). IVF can also be performed with donor eggs and/or donor sperm. If more embryos develop than will be implanted during an IVF cycle, those embryos will be frozen, or cryopreserved. Intrauterine insemination (IUI) is procedure that also bypasses the fallopian tubes; sperm are inserted into the uterus at the time of ovulation. This is an appropriate first treatment option for many fertility patients. Women with ovulation disorders are typically given fertility medication in order to induce ovulation. The oral fertility drug Clomid is often the first line of treatment; injectable medications are prescribed to spur follicle growth when oral medications don't work.

y y

Canceled Cycles Occasionally fertility treatment cycles may be cancelled. Cancelled cycles may be the result of ovarian hyperstimulation, poor stimulation, or eggs that dont fertilize. Preimplantation Genetic Diagnosis Preimplantation genetic diagnosis (PGD) screens embryos for chromosomal abnormalities, and provides an opportunity for patients to transfer the embryos with the best chance of implantation. (It may also be used for gender selection.) PGD is used with IVF. Alternative Treatments Alternative treatments, such as acupuncture and Chinese herbs are gaining wider acceptance from the Western medical community, are being integrated into treatment plans, and offered at some fertility clinics in the U.S. The Two-Week Wait and Pregnancy Tests With both IUI and IVF, there is what is referred to as a two week wait. This is the amount of time between the procedure and the pregnancy test. Understandably its often a time filled with great anxiety, and the temptation always looms to use a home pregnancy test. For accurate results, a blood pregnancy test done in your physicians office is recommended. Causes of infertility include a wide range of both physical and emotional factors. A couple's infertility may be due to female factors, male factors, or both: FEMALE INFERTILITY: Female infertility may be due to: y Problems with a fertilized egg or embryo being able to survive once it is attached to the lining of the uterus y Problems with the eggs being able to attach to the lining of the uterus y Problems with the eggs being able to move from the ovary to the uterus y Problems with the ovaries producing eggs Female infertility may be caused by: y Autoimmune disorders, such as antiphospholipid syndrome (APS) y Clotting disorders y Defects of the uterus and cervix (myomas or fibroids, polyps, birth defects) y Excessive exercising, eating disorders, or poor nutrition y Exposure to certain medications or toxins y Heavy use of alcohol y Hormone imbalance or deficiencies y Long-term (chronic) disease, such as diabetes y Obesity y Ovarian cysts and polycystic ovary syndrome (PCOS)

y y y

Pelvic infection or pelvic inflammatory disease (PID) Scarring from sexually transmitted disease or endometriosis Tumor

MALE INFERTILITY: Male infertility may be due to: y A decrease in the number of sperm y Sperm being blocked from being released y Sperm that do not work properly Male infertility can be caused by: y Environmental pollutants y Exposure to high heat for prolonged periods y Genetic abnormalities y Heavy use of alcohol, marijuana, or cocaine y Hormone deficiency or taking too much of a hormone y Impotence y Infections of the testes or epididymis y Older age y Previous chemotherapy y Previous scarring due to infection (including sexually transmitted diseases), trauma, or surgery y Radiation exposure y Retrograde ejaculation y Smoking y Surgery or trauma y Use of prescription drugs, such as cimetidine, spironolactone, andnitrofurantoin In healthy couples both under age 30, having sex regularly, the chance of getting pregnant is only 25 - 30% per month. A woman's peak fertility occurs in her early 20s. As a woman ages beyond 35 (and especially after age 40), the likelihood of getting pregnant drops to less than 10% per month. When to seek help for infertility depends on your age. For women under age 30, it is generally recommended to try to conceive for at least a year before seeking testing Signs and tests A complete medical history and physical examination of both partners is essential. Tests may include: For women: y Blood hormone levels y Cervical mucus to detect ovulation y Hysterosalpingography (HSG) y Pelvic ultrasound y Laparoscopy (especially if endometriosis is suspected) y Luteinizing hormone urine test (ovulation predictor kit) y Pelvic exam y Progestin challenge y Serum progesterone

Temperature first thing in the morning to check for ovulation (basal body temperature charting) For men: y Semen analysis y Testicular biopsy (rarely done)
y

Treatment Increase your chance of becoming pregnant each month by having sexual intercourse at least every 3 days in the weeks leading up to and through the expected time of ovulation. Ovulation occurs about 2 weeks before the next period starts. So, if you get your period every 28 days, you should have sexual intercourse at least every 3 days between the 7th and 18th day after you get your period. Treatment depends on the cause of infertility. It may involve: y Education and counseling y Medical procedures such as intrauterine insemination (IUI) and in vitro fertilization (IVF) y Medicines to treat infections and clotting disorders, or promote ovulation It is important to recognize and discuss the emotional impact that infertility has on you and your partner, and to seek medical advice from your health care provider. Support Groups Many organizations provide informal support and referrals for professional counseling. See infertility - support group. Expectations (prognosis) A cause can be determined for about 80 - 85% of infertile couples. Getting the right therapy (not including advanced techniques such as in vitro fertilization) allows pregnancy to occur in 50 - 60% of couples who were infertile. Without any treatment, 15 - 20% of couples diagnosed as infertile will eventually become pregnant. Complications Although infertility itself does not cause physical illness, it can have a major emotional impact on the couples and individuals it affects. Couples may have problems with their marriage. Individuals may experience depression and anxiety.