The First Steps to Achieving Fertility

by Jacqueline N. Gutmann, MD and Alan Copperman, MD

Difficulty in having children is more common than you may think, affecting one in six couples. If you are one of those couples, you probably have questions about why your reproduction system is not working properly.

Below, two specialists discuss the science and biology of infertility, addressing some of the most common questions. Dr. Jackie Gutmann is an Assistant Clinical Professor at the Thomas Jefferson University School of Medicine in Philadelphia. She also practices at the Women's Institute for Fertility, Endocrinology and Menopause. Dr. Alan Copperman is an Assistant Professor of Obstetrics, Gynecology and Reproductive Medicine at Mount Sinai Medical Center, and is the Director of the Division of Reproductive Endocrinology.

Q: How long must a couple try to conceive naturally before you would suggest they seek professional help?

Generally speaking, if a woman is under the age of 35 and she has been trying to get pregnant for a year, it's time to start taking steps to evaluate why she has not conceived.

If a woman is over 35, or if she has previously gotten pregnant, we shorten that interval to six months. In addition, if somebody has known abnormalities-if they have blocked tubes, if they know they don't have regular cycles or don't ovulate, or if their male partner has had chemotherapy -- then there's no reason to wait for an evaluation and treatment.

Q: So if couples are planning to get pregnant, their entire medical histories need to be examined to determine what factors may be causing problems?

That's right. It is extremely important to really talk to your patients. It's not just a matter of doing this test or that test, but actually finding out what they have been through.

Just by doing some careful questioning and probing into the couple's history, we're able to uncover problems that might have not otherwise been disclosed, and find some keys and clues to why a couple is having trouble conceiving.

Q: What are some of the most common causes of infertility?

One of the most common causes is related to the sperm -- either they are low in number or motility, or they're not normal in appearance. Sometimes, the sperm just simply do not have the capacity to fertilize the egg.

From a female standpoint, the most common things that cause infertility are irregular menstrual cycles and tubal disease -- a condition in which the tubes are blocked, either from previous infection or previous pelvic surgery.

Q: You mention irregular cycles. What are some of the conditions that can cause this problem?

Some women don't have 28-day cycles; they may go six months or a year without their period. This can be because the woman exercises vigorously, and her brain doesn't send the normal sequence of signals to the ovaries to ovulate each month, which is called hypothalamic amenorrhea. Sometimes, regular periods will resume if the woman just gains weight, but other women are born with this condition and need hormonal treatments to help them menstruate.

Other patients have what's called polycystic ovarian syndrome, which is also characterized by a lack of normal sequence of signals from the brain to the ovary. These women are more likely to be overweight. Sometimes, they have evidence of increased male hormones or androgens-like cystic acne, or hair growth on the face. These women require different types of treatments to help them ovulate, usually hormonal modifications, if weight loss and exercise are not enough.

Q: What about thyroid conditions?

Certainly thyroid conditions can play a role in infertility. We often evaluate the thyroid as part of an infertility evaluation. And, on occasion, we do find evidence of an underactive thyroid that a patient would have otherwise not noticed.

Q: What about structural problems, blocked fallopian tubes, for instance?
The most common reason for blocked fallopian tubes is scarring from a prior pelvic infection. Sometimes, women know that they had an infection, but more often than not, they don't. For example, chlamydia, a very common, and often asymptomatic, sexually transmitted disease can cause pelvic infection and subsequent scarring.

Q: In terms of male infertility, you talked about sperm count and sperm mobility. Explain to us why those are so important.

You need a large number of sperm deposited in the vagina in order for conception to take place. It takes more than a single sperm to be able to fertilize the egg; only one sperm actually gets in, but you need a number of sperm clearing the way to allow that single sperm to enter. Also, when the ejaculate is deposited in the vagina, some of it does leak out, and that's perfectly normal.

Q: So basically you need a barrage of sperm?

You need a barrage of sperm, and they need to swim. The sperm have to make their way from the vagina into the cervix, through the cervical mucus, through the uterus and then to the right or the left fallopian tube, where they will ultimately encounter an egg.

What kind of prognostic tests can be done to give an older couple some indication of the likelihood of pregnancy?

One test is called an FSH level, or follicle-stimulating hormone level. It's a blood test that's done on the third day of the cycle, and it gives us a tremendous amount of information about a patient's egg quality.

Based on that blood test alone, we can help give prognostic information, to tell a couple whether they're going to have a hard time conceiving, or perhaps even an easier time conceiving.

Unfortunately, as we age, we do become less fertile, and it's not as simple as, "I'm fit and I'm healthy and I'm sure I'm going to be able to get pregnant."

However, in terms of aging, we all age at our own rates. One 40-year-old woman may be very fertile, one 30-year-old woman may have very unhealthy eggs. That is genetically predetermined and hard to control.

Dr. Gutmann is Assistant Clinical Professor of Obstetrics and Gynecology at the Thomas Jefferson University School of Medicine and an attending physician at Thomas Jefferson University Hospital. She is a graduate of Union College and the Yale University School of Medicine. She is Board Certified in Obstetrics and Gynecology and Reproductive Endocrinology, and is a member of the American Society for Reproductive Medicine, American College of Obstetrics and Gynecology, the North American Menopause Society, and Resolve. She has published numerous articles on infertility, in vitro fertilization, endometriosis, estrogen, and hormonal replacement therapy, and has presented her research in a variety of national and international forums.

Dr. Alan Copperman is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Medicine at the Mount Sinai Medical Center, and is Director of the Division of Reproductive Endocrinology. After earning his degree in medicine, Dr. Copperman performed an internship and residency in Obstetrics and Gynecology at Yale-New Haven Hospital, and then a fellowship in Reproductive Endocrinology at Mount Sinai Medical Center, in New York, where he was the Martin J. Clyman Fellow.

Dr. Copperman is Board Certified in both Obstetrics & Gynecology and Reproductive Endocrinology. He has authored numerous articles and chapters on infertility, endometriosis, polycystic ovarian syndrome, and pelvic surgery.

Copyright © Alan Copperman. Permission to republish granted to Pregnancy.org, LLC.