Approximately 1 in 5 couples will have difficulty conceiving during their reproductive years. If a couple has not conceived within one year, they may have concerns that can be best addressed by a fertility expert. Causes of infertility are numerous and may exist in either male or female. In many cases factors that impact a couple's fertility may exist in both male and female. More common causes for infertility include ovulatory disorders, fallopian tube damage/blockage, uterine abnormalities, peritoneal factors, cervical factors and abnormal semen parameters.

An infertility evaluation is often initiated by a general obstetrician/gynecologist after a couple has been trying to conceive for one year. For women over 35, it may be initiated after a six-month period. Preliminary testing includes testing both female and male partners. After test results are determined, patients may be referred to an infertility specialist (reproductive endocrinologist) for further testing and/or treatment.

Male Factors (common causes that may impact a male's fertility)
Male factors contribute to infertility in approximately 40 percent of couples. A semen analysis may be obtained to evaluate several semen parameters including sperm count, motility (movement) and morphology (shape). Semen parameters can vary over time, therefore, additional semen analyses may be recommended to more thoroughly evaluate a male's infertility. A consultation with a urologist may be recommended for additional evaluation of the male. A history and examination will be performed to determine if infection, obstruction of the ducts, varicoceles (varicose veins in the scrotum) and/or hormonal disorders exist. Treatments will be directed at the cause of the abnormality although in some cases it may be unexplained.

For couples with male factor infertility, intrauterine sperm insemination (washing the sperm and placing it into the uterine cavity at ovulation) may be recommended or in vitro fertilization (IVF). IVF along with an assisted fertilization technique (ICSI) has helped many couples achieve a pregnancy. With ICSI, the woman is medicinally stimulated to increase egg production. The eggs are retrieved in a minor outpatient procedure, and ICSI is then performed by directly injecting a single sperm into an egg in the Reproductive Biology Laboratory. Successfully fertilized eggs, which are now embryos, are then transferred to the woman's uterus in hopes of achieving a pregnancy. Some men have no sperm in their ejaculates. Their reproductive ducts may be absent or blocked (obstructive azoospermia), or others may have no or low sperm production with normal anatomy (non-obstructive azoospermia). Sperm has been successfully obtained from the male reproductive tract of men with obstructive and non-obstructive azoospermia and used as part of IVF since the late 1980s. Your reproductive endocrinology, reproductive urologist, and the reproductive biology laboratory experts work as a team to provide the best possible service and results. For cases where no sperm are present, donor sperm is available through our andrology laboratory.

Female Factors (common causes that may impact a female's fertility)

Tubal Disease
The fallopian tubes are necessary for transporting the fertilized egg to the uterus. Fallopian tube abnormalities are responsible for approximately 35 percent of infertility. Fallopian tube abnormalities include tubal scarring or blockage most commonly from pelvic infections, prior abdominal surgeries and endometriosis. The fallopian tubes are evaluated initially by an hysterosalpingogram (HSG) and can be more thoroughly evaluated if necessary with a laparoscopy. A laparoscopy may correct fallopian tube damage to improve fertility. In cases where the fallopian tubes are severely damaged or surgery does not result in conception, in vitro fertilization (IVF) may be recommended to bypass the fallopian tubes. In cases of blocked and dilated fallopian tubes, patients may consider surgery to open or remove fallopian tubes prior to IVF to improve chances for pregnancy.

Abnormal Ovulation
Ovulation (release of the egg from the ovary) typically occurs between days 12-16 of a menstrual cycle. An abnormal menstrual pattern includes cycles that occur less than every 21 days or more than every 35 days. Abnormal ovulation occurs in approximately 25 percent of patients with infertility. There are several methods to evaluate ovulation including basal body temperature charting (BBT), ovulation predictor kits, endometrial biopsy, ultrasound and blood progesterone testing. BBT charting does not directly detect ovulation but is an indirect way of determining if ovulation has occurred. Ovulation results in the release of progesterone that increases temperature by 0.5 to 1.0 degree Fahrenheit. Ovulation predictor kits detect lutenizing hormone (LH) in the urine. LH is the hormone released by the brain to stimulate the ovary to release the egg. It is another indirect way to evaluate for ovulation. Endometrial biopsy (removing a piece of tissue from the uterus) will determine ovulation but may produce some discomfort, therefore, it is not routinely recommended for evaluation of ovulation. Ultrasound will evaluate if the ovary has produced an egg but blood progesterone testing is the definitive method for determining ovulation. Blood is drawn for progesterone one week after ovulation.

Cervical Factor
The cervix is the lowest portion of the uterus. The cervix produces clear and watery mucus at ovulation allowing sperm to pass into the uterus. Cervical factor infertility is a rare cause of infertility; however, prior cervical surgery (ie cervical biopsy, cone biopsy, LEEP, freezing and/or laser treatments for abnormal pap smears) may contribute to cervical factor. There are no predictive tests for cervical factor. Post coital testing is a test involving taking a sample of mucus during ovulation to evaluate for cervical factor. The results of the test are poor at predicting true cervical abnormalities, therefore, it is not routinely performed. Typically, intrauterine sperm insemination (IUI) is recommended to bypass any potential cervical factors.

Uterine Factor
Uterine factor is another infrequent cause of infertility. It accounts for approximately 5 percent of infertility. Causes of uterine factor include uterine polyps (benign growths of endometrium lining the uterus), uterine scarring from prior infection or surgery, fibroids, or abnormal uterine cavity shape. These are initially evaluated with an hysterosalpingogram (HSG) and/or a hydrosonography. Hysteroscopy may be recommended to further evaluate and treat uterine abnormalities. Uterine fibroids are benign uterine tumors that may interfere with fertility depending on size and location. Surgery may be recommended if indicated, however, fibroids are common and may not necessarily require treatment.

Peritoneal Factor
The peritoneum is the lining of the abdominal cavity and pelvic organs. The peritoneum may be scarred (adhesions) most commonly from infections, prior abdominal surgeries and/or endometriosis. Endometriosis is a condition that results from tissue lining the uterus (endometrium) growing outside the uterus. Endometriosis often results in painful menstrual cycles. The cause is unknown, however, endometriosis is found in approximately 35 percent of infertile women. A laparoscopy may be recommended to evaluate for endometriosis and/or adhesions as a cause for infertility.

Unexplained Infertility
In up to 10 percent of couples, no definitive cause of infertility is determined. Typically, empiric treatment with fertility medications (ovulation induction) is recommended and/or intrauterine insemination for 3 to 6 treatment cycles. Depending on several factors including patient age and duration of infertility, other options may be recommended including in vitro fertilization (IVF), particularly if pregnancy does not occur with ovulation induction. The purpose of IVF is to increase chances for pregnancy, however, in some cases IVF helps determine a cause for infertility by evaluating egg quality, sperm and egg interaction, and embryo development.