Most people will have the strong desire to conceive a child at some point during their lifetime. Understanding what defines normal fertility is crucial to helping a person, or couple, know when it is time to seek help. Most couples (approximately 85%) will achieve pregnancy within one year of trying, with the greatest likelihood of conception occurring during the earlier months. Only an additional 7% of couples will conceive in the second year. As a result, infertility has come to be defined as the inability to conceive within 12 months. This diagnosis is therefore shared by 15% of couples attempting to conceive. We generally recommend seeking the help of a reproductive endocrinologist if conception has not occurred within 12 months.
There are various scenarios where one may be advised to seek help earlier. These include:
- Infrequent menstrual periods: When a woman has regular menstrual periods, defined as regular cycles occurring every 21 to 35 days, this almost always indicates that she ovulates regularly. Ovulation of the egg occurs approximately 2 weeks before the start of the next period. If a woman has cycles at intervals of greater than 35 days, it may indicate that she is not ovulating an egg predictably, or even at all. Ovulation of the egg is essential for pregnancy. Therefore, we recommend an evaluation if menstrual cycles are infrequent or irregular in a couple attempting pregnancy.
- Female age of 35 years or older: For unclear reasons, egg numbers decrease at a rapid rate as women age. Furthermore, as aging occurs, egg quality, or the likelihood of an egg being genetically normal, decreases. Therefore we recommend a fertility evaluation if a couple has been attempting pregnancy for 6 months or more when the woman is 35 years of age or older.
- A history of pelvic infections or sexually transmitted diseases: Sexually transmitted infections, such as chlamydia or gonorrhea, can cause inflammation and permanent scarring of the fallopian tubes. The presence of open tubes is essential for natural conception, as sperm must traverse the tubes in order to reach and fertilize the ovulated egg. We recommend immediate evaluation for a couple attempting pregnancy when the woman has a prior history of pelvic infection. As part of the fertility evaluation, we will perform an HSG, a test designed to evaluate if the fallopian tubes are open.
- Known uterine fibroids or endometrial polyps: Uterine abnormalities, such as fibroids that indent the endometrial cavity and endometrial polyps, can impair how the endometrium (the lining of the uterus) and embryo interact to lower implantation and pregnancy rates. These abnormalities can also cause irregular bleeding between menstrual cycles. Evaluation should be pursued by 6 months of attempted pregnancy in women with a known history of these abnormalities or a history of bleeding between menstrual cycles. The main approach to correcting or removing these uterine abnormalities is by hysteroscopy, a surgical method by which a narrow scope with a camera is placed within the uterine cavity. Instruments can be introduced through the hysteroscope, allowing the surgeon to remove or correct any anatomic abnormalities.
- Known male factor semen abnormalities: If a male partner has a history of infertility with a prior partner, or if there are abnormalities on his semen analysis, then we advise earlier fertility evaluation, ideally within 6 months of attempting pregnancy.
- History and physical examination – First and foremost, your fertility physician will take a very thorough medical and fertility history. Your doctor may ask you many of the following questions: How long have you been trying to get pregnant? How often are you having intercourse? Do you have pain with menstrual periods or intercourse? Have you been pregnant before? What happened with your prior pregnancies? Have you had any sexually transmitted infections or abnormal pap smears? How often do you have menstrual cycles? Do you have any medical problems or prior surgeries? Do you have a family history of medical problems? These and many other questions will help your physician design a specific evaluation and potential treatment for you. In addition to a careful history, a physical evaluation may also be performed.
- Transvaginal ultrasound – Ultrasound is an important tool in evaluating the structure of the uterus, tubes, and ovaries. Ultrasound can detect uterine abnormalities such as fibroids and polyps, distal fallopian tube occlusion, and ovarian abnormalities including ovarian cysts. Additionally, transvaginal ultrasound affords the opportunity for your physician to assess the relative number of available eggs. This measurement is called the antral follicle count and may correlate with fertility potential.
- Laboratory testing – Depending on the results of the evaluation discussed above, your physician may request specific blood tests. The most common of these tests include measurements of blood levels of certain hormones such as estradiol and FSH, which are related to ovarian function and overall egg numbers; TSH, which assesses thyroid function; and prolactin, a hormone that can affect menstrual function if elevated.
- Hysterosalpingogram (HSG) – This test is essential for evaluating fallopian tubal patency, uterine filling defects such as fibroids and polyps, and scarring of the uterine cavity (Asherman syndrome). Many uterine and tubal abnormalities detected by the HSG can be surgically corrected.
- Semen analysis – The semen analysis is the main test to evaluate the male partner. There are four parameters analyzed: 1) semen volume – should be at least 1.5 to 2 ml. A smaller amount may suggest a structural or hormonal problem leading to deficient semen production; 2) sperm concentration – normal concentration should be at least 20 million sperm per 1 ml of semen. A lower concentration may lead to a lower chance for conception without treatment; 3) sperm motility or movement – a normal motility should be at least 50%. Less than 50% motility may significantly affect the ability for sperm to fertilize the egg without therapy; and (4) morphology, or shape – there are three parts of the sperm that are analyzed for morphology: the head, midpeice, and tail. Abnormality in any of those regions may indicate abnormal sperm function and compromise the ability of sperm to fertilize the egg. Ideally, using strict morphology criteria, a minimum of 5 – 15% normal forms leads to a better ability for sperm to fertilize the egg. An abnormal semen analysis warrants a further evaluation usually by a reproductive urologist. Your physician will refer you to a reproductive urologist if appropriate.
The most commonly prescribed injections that stimulate the ovary are called gonadotropins. The gonadotropins in these formulations are FSH, and in some cases, a combination of FSH and LH (luteinizing hormone). These injections are taken nightly, typically for 5 – 10 days, and act directly on the cells of the ovary to stimulate egg development. Once a follicle containing an egg reaches a mature size, another hormone injection called HCG is often given to mimic the natural LH surge that occurs at the time of ovulation. This leads to the final maturation and release of the egg.