by Alan Penzias, MD
Infertility is a common but frequently treatable condition. It affects one couple out of six and becomes more common with increasing age. Traditionally, infertility has been defined as one year of unprotected intercourse without conception. However, there are many exceptions to this rule. In order to maximize your chances of becoming pregnant you need to know when it is time to seek help. To be your own best advocate, it is helpful to have a basic knowledge of the comprehensive infertility evaluation before even going to the doctor.
The Basics of Reproduction
The truth about eggs
Every woman is born with all of the eggs that she will ever have. Once the eggs are gone, they can't be replaced. At birth, a girl has approximately one million eggs in her ovaries, but by the time she has her first period only about 400,000 remain. Throughout her reproductive lifetime, a woman will ovulate (release an egg from her ovary) approximately 400 times. This means that roughly 1000 eggs are stimulated to develop each month but only one survives and is released from the ovaries. The other 999 eggs simply wither away.
The hormones that control your ovaries
In order for an egg to be released each month, a woman's body produces and releases the hormones luteinizing hormone (LH) and follicles stimulating hormone (FSH) in a very precise and well-controlled way. Just before the egg is released, the LH rises to a level of three or four times its baseline value. This temporary rise of LH causes the ovary to produce the hormone progesterone. At the same time, the egg, which has grown inside a small pouch of cells on the ovary called a follicle, completes its maturation and is released.
Production of progesterone in the ovary is an important event because progesterone causes a rise in a woman's body temperature. The rise in temperature is small (often less than one degree farenheit) but may be detected using a sensitive thermometer that is available in most pharmacies. This is important because it means that most women have a tool available to help them determine when an egg has been released. It may be helpful to use an online chart such as Pregnancy.org's BBT.
Where do the eggs go?
Once the egg has been released by the ovary it is picked up by the fimbria or "fingers" of the fallopian tube. Although the right fallopian tube commonly picks up an egg from the right ovary and the left fallopian tube commonly picks up an egg from the left ovary, either tube can pick up an egg from either ovary.
The story of fertilization
In order for a woman to become pregnant, the egg must meet sperm inside the fallopian tube. Sperm begin their journey to the fallopian tube in the vagina following ejaculation from sexual intercourse. The sperm are carried into the vagina in a complex liquid called semen. The semen contains proteins and buffers that nourish and protect the sperm.
However, the proteins and buffers present in the semen are not meant to enter a woman's uterus (womb). The cervix (which is the entrance to the uterus) is filled with mucous which acts as a filter. This mucous allows only the sperm to enter and keeps the proteins and buffers of the semen in the vagina. From the cervix, the sperm swim through the uterus and into the fallopian tubes.
When sperm and egg meet in the fallopian tube fertilization occurs. The egg is covered by a protective shell called the zona pellucida. Many thousands of sperm attach to the outside of the zona pellucida but only one ultimately enters. When that single sperm gains access to the egg, the zona pellucida hardens preventing additional sperm from entering. After the sperm and the egg are joined, the new cell is called an embryo.
After fertilization, the embryo begins to divide. It goes from one cell to two cells, then from two cells to four cells, and so on as cell division continues. The embryo also begins to migrate down the fallopian to the uterus. The hormonal changes that occurred prior to the release of the egg from the ovary also affect the lining of the uterus (endometrium). These hormonal changes prepare the uterine lining for the arrival of the embryo.
Once the embryo arrives in the uterus it sheds its shell and implants into the uterine lining. The newly implanted embryo begins producing a hormone called human chorionic gonadotropin (hCG). The hCG produced by the tiny embryo is first detectable in a woman's bloodstream. As the hCG level rises, some of it passes through a woman's kidneys and ends up in her urine. Testing for hCG in the blood or urine is the basis for blood and urine pregnancy tests.
Who Should Have an Infertility Evaluation?
Every couple who has had one year or more of unprotected intercourse without conceiving should seek help. However, if you have one or more of the following symptoms or conditions you should speak with your doctor and not wait for one full year.
If you are a woman...
- Irregular periods or no periods
- Bleeding between periods
- Pain with sexual intercourse
- History of pelvic infection (other than vaginal yeast infections)
- History of a ruptured appendix or other abdominal surgery
- Age is greater than 35 years old
If you are a man...
- Difficulty achieving or maintaining an erection
- Inability to ejaculate during intercourse
- History of injury to the testicles
- History of infection in the prostate gland, epididymus, or testicles
- History of mumps as a teenager
- History of an undescended testicle
Tests That Couples Can Do at Home
You can begin your fertility tests at home before you even see your doctor. One of the most important questions that your doctor will ask is, "Do you produce an egg every month?" There are two simple tests that you can do at home to help answer this question. Each test will require a trip to your local pharmacy and a modest investment of a few dollars.
Basal Body Temperature Chart
First, you need to purchase a basal body temperature thermometer. To determine if you are releasing an egg each month, begin taking your temperature with this special sensitive thermometer before you get out of bed each morning. Start taking your temperature on the first day of your period. Chart the results of your temperature on the special graph paper that accompanies your thermometer. Also mark the chart each time you have intercourse. At the end of he month, examine the pattern of your chart. If you notice that the temperature in the morning is lower in the first 10 to 14 days of the month than in the last 10 to 14 days, then it is likely that you are producing an egg. I recommend to my patients that they keep a basal body temperature chart for approximately three months.
Next, look at the chart and see where you have marked the chart for intercourse. Do the marks correspond to the time around the temperature change? If they do, then you are timing intercourse to the release of the egg in an appropriate manner.
Whether or not your temperature chart matches the above description, the information that you have gathered will be very useful to your doctor.
Ovulation Predictor Kits
Another test for ovulation that you can do at home is generally called an ovulation predictor kit. There are many brands to choose from at your local pharmacy. These kits allow you to test your urine for the presence of the hormone LH. Since LH rises temporarily just before ovulation, the indicator stick in the test kit will change color just before the egg is released. I recommend that you begin testing your urine on cycle day 10 (cycle day 1 is the first day of full menstrual flow). Continue testing your urine daily until you detect a color change on the indicator stick.
When your indicator stick changes color, plan to have intercourse that day and/or the following day. Also, keep a record of the cycle day number when the indicator stick changes color. Whether or not the ovulation predictor kit changes color, the information that you have gathered will be very useful to your doctor.
There are two tests that every infertile couple needs to have.
The first is a semen analysis from the male partner. He should have this test regardless of how many children he has or pregnancies he has caused. This is because sperm counts can change over time and up to 35-40% of all infertility is related to a male factor. The test is performed after 36 to 48 hours of abstinence and is painless. The semen specimen is usually collected by masturbation but sometimes can be collected in a special collection condom during intercourse.
The second test, called a hysterosalpingogram or tubogram, helps determine if the uterine cavity is normal in size and shape, and whether the fallopian tubes are open or closed. This test is an x-ray and uses an iodine-based contrast agent which is injected into the uterus through the cervix. If you are allergic to iodine or shellfish you should speak with your doctor to determine how the important information normally revealed by the hysterosalpingogram should be obtained.
Other Diagnostic Tests
Some doctors recommend a series of hormone tests for their patients who are trying to become pregnant. These tests evaluate the pituitary gland, the thyroid gland, the adrenal gland, and the ovaries. Some of these tests -- including tests for FSH, estradiol, and progesterone -- are drawn at a specific time in menstrual cycle while others -- including tests for prolactin -- need to be drawn early in the morning before woman has eaten.
This test is performed around the time of ovulation. A couple having this test is asked to have intercourse in the evening and the woman to report to her doctor's office for the test the following morning. A small amount of cervical mucous is obtained painlessly in procedure similar to a pap smear. The mucous is then placed on a glass slide. The doctor evaluates the slide to determine the number of sperm present and moving.
An endometrial biopsy is a sample of uterine lining tissue obtained by placing a small straw into a woman's uterus just before she expects her period. The test causes mild to moderate cramping, which lasts about 10 minutes. This test measures ovulation indirectly by evaluating the effect of the monthly hormones on the uterine lining tissue.
Hysteroscopy and Laparoscopy
These surgical tests allow the doctor to look inside the uterus (in the case of hysteroscopy) and at the outside of the uterus, ovaries, and fallopian tubes (in the case of laparoscopy). Conditions including uterine polyps, fibroids, adhesions, and endometriosis can be diagnosed and surgically treated with these techniques.
There is great controversy about the usefulness of immune testing for infertile couples. At the present time and after considering all of the scientific data available, the American Society for Reproductive Medicine does not endorse immune testing of infertile couples.
After you and your doctor have reviewed your comprehensive fertility evaluation, it is time to plan treatment. There is no simple formula to determine which treatment is best for you based solely on your test results. In order to design an ideal treatment plan, your doctor will view your test results in the context of your medical history. Several of the more common treatments available today are outlined below.
This technique, sometimes called artificial insemination, is the placement of sperm into the uterine cavity. The sperm is gathered from a liquid ejaculate and separated from the proteins and buffers normally present in semen. Intrauterine insemination can be performed around the time of ovulation in the normal menstrual cycle or in conjunction with medicines that stimulate the ovary.
When a woman takes fertility medicines, the goal is to cause the release of one or more eggs from her ovaries. One medication available today, clomiphene citrate, can be taken by mouth. Other medications called gonadotropins need to be given by injection just under the skin, much in the way diabetics administer insulin to themselves. Ovulation-inducing medications enhance pregnancy by making more eggs available for fertilization by sperm. These medications have helped millions of women once considered infertile bare children. There are several side effects to these medications including multiple pregnancies, i.e. twins, triplets, or even more. As mentioned above, ovulation inducing medications are often combined with intrauterine insemination therapy.
In vitro fertilization
A woman undergoing in vitro fertilization first takes ovulation-inducing medications to induce the maturation of some of her eggs. These eggs are then gathered from her ovaries by a minor surgical procedure. The eggs are combined with her husband's sperm in a special dish which is then placed in an incubator to enable fertilization. The embryos are allowed to grow for 3 to 5 days and are then painlessly placed in the woman's uterus.
Infertility is a common condition that is highly treatable. Couples can help themselves by first recognizing that they have a problem. Several easy tests can be done at home prior to seeing a doctor. These easy tests help reveal important information. If you believe you may be infertile, I encourage you to speak with you doctor about your fertility problem and take advantage of the marvelous advances in treatment that are presently available.
Dr. Alan Penzias is an Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School. He is the Associate Director of the Division of Reproductive Endocrinology and Infertility at Beth Israel Deaconess Medical Center in Boston, MA and is an active practitioner at Boston IVF in Waltham, MA. He received his undergraduate degree in chemistry from the University of Pennsylvania. He received his M.D. degree from the State University of New York Downstate College of Medicine in 1986. Following a residency in Obstetrics and Gynecology at Beth Israel Hospital and Harvard Medical School in Boston, MA, he completed a fellowship in reproductive endocrinology at Yale University School of Medicine.
Dr. Penzias is board certified in both Reproductive Endocrinology and Obstetrics and Gynecology. He has published more than 50 papers and textbook chapters in the field of infertility and has lectured extensively in the United States and abroad. Dr. Penzias is the President-Elect of the Boston Fertility Society and is a member of the American Society for Reproductive Medicine, the Society of Reproductive Endocrinology and Infertility, and the American College of Obstetricians and Gynecologists.
Copyright © Alan Penzias. Permission to republish granted to Pregnancy.org, LLC.