CONDITIONS WE TREAT

In the United States, among heterosexual women aged 15 to 49 years with no prior births, about 1 in 5 (19%) are unable to get pregnant after one year of trying (infertility).

Both men and women can contribute to infertility.

Disruption of ovarian function (presence or absence of ovulation)

When a woman doesn’t ovulate during a menstrual cycle, it’s called anovulation. Potential causes of anovulation include the following:

• Polycystic ovary syndrome (PCOS). PCOS is a condition that causes women to not ovulate, or to ovulate irregularly. Some women with PCOS have elevated levels of testosterone, which can cause acne and excess hair growth. PCOS is the most common cause of female infertility.

• Diminished ovarian reserve (DOR). Women are born with all of the eggs that they will ever have, and the number of eggs declines naturally over time. DOR is a condition in which there are fewer eggs remaining in the ovaries than expected for a given age. It may occur due to congenital (condition present at birth), medical, surgical, or unexplained causes. Women with DOR may be able to conceive naturally, but will produce fewer eggs in response to fertility treatments.

• Premature ovarian insufficiency (POI). POI, sometimes referred to as premature menopause, occurs when a woman’s ovaries fail before she is 40 years of age. Although certain exposures, such as chemotherapy or pelvic radiation therapy, and certain medical conditions may cause POI, the cause is often unexplained. About 5% to 10% of women with POI conceive naturally and have a normal pregnancy.

• Menopause is a natural decline in ovarian function that usually occurs around age 50. By definition, a woman in menopause has not had a period for at least one year. Many women experience hot flashes, mood changes, difficulty sleeping, and other symptoms as well.

Fallopian tube obstruction (whether fallopian tubes are open, blocked or swollen)

Risk factors for blocked fallopian tubes (Tubal occlusion) can include a history of pelvic infection, rupture appendix, gonorrhea, chlamydia, endometriosis, or prior abdominal surgery.

Physical characteristics of the uterus

Depending on a woman’s symptoms, the uterus may be evaluated by transvaginal ultrasound to look for fibroids or other problems, including intrauterine adhesions, endometrial polyps, adenomyosis, and congenital anomalies of the uterus. A sonohysterogram or hysteroscopy may also be performed to further evaluate the uterine environment.

Disruption of testicular or ejaculatory function

Varicocele, a condition in which the veins within a man’s testicle are enlarged. This can affect the number or shape of the sperm. Trauma to the testes may affect sperm production and result in lower number of sperm. Heavy alcohol use, smoking, anabolic steroid use, and illicit drug use. Cancer treatment involving certain types of chemotherapy, radiation, or surgery to remove one or both testicles. Medical conditions such as diabetes, cystic fibrosis, certain types of autoimmune disorders, and certain types of infections may cause testicular failure.

Hormonal Disorders

Improper function of the hypothalamus or pituitary glands. The hypothalamus and pituitary glands in the brain produce hormones that maintain normal ovulation and testicular function.

Genetic Disorders

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Most experts suggest women younger than age 35 with no apparent health or fertility problems and regular menstrual cycles should try to conceive for at least one year before seeing a doctor. However, for women aged 35 years or older, couples should see a health care provider after 6 months of trying unsuccessfully. Women over 40 years may consider seeking more immediate evaluation and treatment. Some health problems also increase the risk of infertility. So, couples with the following signs or symptoms should not delay seeing their health care provider when they are trying to become pregnant:

For women:

• Irregular periods or no menstrual periods

• Endometriosis

• A history of pelvic inflammatory disease

• Known or suspected uterine or tubal disease

• A history of more than one miscarriage

• Genetic or acquired conditions that predispose to diminished ovarian reserve (chemotherapy, radiation)

For men:

• A history of testicular trauma

• Prior hernia surgery

• Prior use of chemotherapy

• A history of infertility with another partner

• Sexual dysfunction

Doctors will begin by collecting medical and sexual history from both partners. The initial evaluation may include a semen analysis, ovulation testing, and tubal evaluation.

Infertility can be treated with medicine, surgery, intrauterine insemination, or assisted reproductive technology. Often, medication and intrauterine insemination are used at the same time. Doctors recommend specific treatments for infertility on the basis of:

• The factors contributing to infertility.

• The duration of infertility.

• The age of the female.

• The couple’s treatment preference after counseling about success rates, risks, and benefits of each treatment option.

There are two situations in which fertility drugs may be useful. First, these drugs can be used to induce an egg to develop and be released in women who are not ovulating on their own. This is known as ovulation induction. Fertility drugs can also be used to increase the chances of pregnancy in women who are already ovulating. This is known as superovulation. Some common medicines used to treat infertility in women include:

• Clomiphene citrate, sold under the trade name Clomid, is a medicine that causes ovulation by acting on the pituitary gland. This medicine is taken by mouth

• Letrozole, sold under the trade name Femara, is a medication that has been widely used in women with breast cancer. Letrozole belongs to a class of medications known as aromatase inhibitors. Aromatase is an enzyme that is responsible for the production of estrogen in the body. Letrozole works by inhibiting aromatase thereby suppressing estrogen production which causes the brain to naturally make more follicle-stimulating hormone (FSH). This medicine is taken by mouth

• Human menopausal gonadotropin (hMG) is an injectable medication often used for women who don’t ovulate because of problems with their pituitary gland—hMG acts directly on the ovaries to stimulate development of mature eggs.

• Follicle-stimulating hormone or FSH is an injectable medication that works much like hMG. It stimulates development of mature eggs within the ovaries.

• Metformin, sold under the trade name Glucophage, is a medicine doctors use for women who have insulin resistance or diabetes and PCOS. This drug helps lower the high levels of insulin in women with these conditions. This helps the body to ovulate. This medicine is taken by mouth.

• Bromocriptine is a medication used for women with ovulation problems because of high levels of prolactin. These medications are taken by mouth.

Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI. IUI is often used to treat:

• Mild male factor infertility.

• Couples with unexplained infertility.

Assisted Reproductive Technology (ART) includes all fertility treatments in which either eggs or embryos are handled outside of the body. In general, ART procedures involve removing mature eggs from a woman’s ovaries using a needle, combining the eggs with sperm in the laboratory, and returning the embryos to the woman’s body or donating them to another woman. The main type of ART is in vitro fertilization (IVF).

• Bullet ovulation induction

• Tubal surgery:

  • Robotic removal of uterine fibroids (myomectomy)

  • Robotic resection of endometriosis

• IUI with partner sperm

• IUI with donor sperm

• Sperm wash (coming soon)