What is Infertility?
Infertility is a medical condition characterized by the inability to conceive after 1 year of regular unprotected intercourse in women age < 35. The diagnosis is made after 6 months of unprotected intercourse in women age > 35. It can be caused by male factors, female factors, or both. It is most frequently due to female factors such as ovulatory dysfunction, fallopian tube dysfunction, or endometriosis. Male factors include hypogonadism, medical side effect (e.g., finasteride), or testicular varicoceles (dilated veins).
Male or female patients can also develop infertility due to pituitary adenoma. This is a pituitary tumor that results in hypogonadism and breast enlargement in men and menstrual irregularities in women. Hypogonadism in men can cause symptoms such as breast enlargement, lower energy levels, loss of libido, and erectile dysfunction.
What Causes Infertility?
Infertility is caused by male factors, female factors, or both. The most common male factors associated with infertility include:
- Low testosterone - hypogonadism
- Post-testicular defects
- Abnormalities of the seminiferous tubules
Low androgen (testosterone) levels may be due to use of medications such as Propecia (finasteride) or Aldactone (spironolactone). Patients with scrotal varicoceles may also develop infertility – varicoceles are dilated veins in the scrotum that could potentially lead to impaired semen production. Prior testicular trauma is also a risk factor. Infectious diseases such as mumps (orchitis) can also lead to testicular failure in some cases.
The most common female factors associated with infertility include:
- Ovulatory dysfunction
- Fallopian tube dysfunction
- Cervical abnormalities
Both men and women can potentially develop infertility from thyroid dysfunction (e.g., hypothyroidism) or pituitary tumors (prolactinomas). Occasionally, no cause of infertility is identified in a couple.
How Common is Infertility?
Infertility is common in the United States and often initially evaluated in the primary care clinic. It is most often related to female fertility factors, although male fertility factors occasionally contribute. The condition often requires referral to a fertility specialist.
A large study found that between the years 2006-2010, about 6% of American women age 15-44 had infertility. Other estimates suggest that the prevalence of infertility is approximately 12%-18%. A study in developed countries demonstrated that female infertility occurs in 37% of cases, male infertility occurs in 8% of cases, and infertility in both occurs in 3% of cases. An estimated 5% of infertility cases go unexplained.
Signs and Symptoms
Males with hypogonadism may have low energy, decreased libido, ejaculatory problems, and erectile dysfunction. They can also have signs of testicular atrophy or loss of pubic hair on physical examination. There may be presence of scrotal varicoceles, often describing as having a “bag of worms” feeling on palpation of the scrotum.
Women may have irregular menses, pelvic pain, excessive vaginal bleeding during menses (menorrhagia), and pain with sexual intercourse (dyspareunia) – these are the cardinal features of endometriosis.
Rarely, male or female infertility is caused by a prolactinoma, a type of pituitary tumor. This can result in reduced LH and FSH levels, leading to decreased testosterone production by the testes in men, and reduced estrogen production by the ovaries in women. The mass effect of the tumor in the brain may cause headache, nausea, and loss of peripheral vision. Additionally, men can develop gynecomastia (breast enlargement).
Infertility is generally workup up by your doctor if you and your partner have not been able to conceive after 12 months of unprotected and frequent sexual intercourse. Occasionally, a diagnostic evaluation will be undertaken sooner in women age >35.
Your doctor will commonly order blood tests including a CMP (comprehensive metabolic panel), CBC (complete blood cell count), and thyroid function studies (TSH, free T4). They will also usually obtain testosterone levels and a semen analysis in men. Women usually undergo an assessment of the uterus and fallopian tubes with hysterosalpingography, hysteroscopy, or ultrasound. Less commonly, women undergo diagnostic laparoscopy.
Fertility Medications and Treatment
The treatment of infertility initially aims to reverse any known underlying causes. Patients are often provided with general lifestyle measures that can be useful such as quitting smoking, decreasing caffeine intake, and reducing alcohol consumption.
Ovarian induction is often used in women with infrequent ovulation (oligoovulation) not caused by ovarian failure. The most common ovulation induction agents include:
- Clomid (clomiphene)
- Aromatase inhibitors such as Femara (letrozole)
- Pulsatile GnRH or gonadotropin therapy (LH and FSH)
Individuals with fallopian tube obstruction can benefit from tubal reconstruction surgery. This method can be associated with a higher risk of ectopic pregnancy. In vitro fertilization is another option that is usually preferred in older women or those with significant fallopian tube disease.
Women with infertility due to endometriosis may benefit from surgical resection of the endometriosis, ovulation induction, and intrauterine insemination. Other conditions that can be surgically corrected include submucous fibroids, endometrial polyps, and septate uterus. Infertility related to cervical factors can be treated by bypassing the cervix with intrauterine insemination. This is often done in concert with ovulation induction agents.
- Practice Committee of American Society for Reproductive Medicine. Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril 2012; 98:302. - https://www.ncbi.nlm.nih.gov/pubmed/25936238
- Dancet EA, D'Hooghe TM, van der Veen F, et al. "Patient-centered fertility treatment": what is required? Fertil Steril 2014; 101:924. - https://www.fertstert.org/article/S0015-0282(14)00302-1/pdf
- ESHRE Task Force on Ethics and Law, including, Dondorp W, de Wert G, et al. Lifestyle-related factors and access to medically assisted reproduction. Hum Reprod 2010; 25:578. - https://www.ncbi.nlm.nih.gov/pubmed/20085914
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.