Infertility refers to the inability to get pregnant after ≥1 year of trying (or six months in case the woman is ≥35 years), or women who get pregnant but are unable to stay pregnant. According to the Centers for Disease Control and Prevention (CDC), about 10% of women (6.1 million) in the United States (US) aged 15 to 44 years face infertility issues.
Pregnancy is a process that involves multiple steps viz. (i) release of an egg from the woman’s ovaries (referred to as ovulation); (ii) the egg must travel through the fallopian tube toward the uterus; (iii) a man’s sperm must fertilize the egg along the way and (iv) the fertilized egg must get attached to the inside of the uterus (referred to as implantation). An issue in any of the steps could lead to infertility.
Causes and risk factors of Infertility
The majority of female infertility cases are caused due to ovulation problems. Common signs of the lack of ovulation in women include missing or irregular menstrual periods. Ovulation issues are often observed among women with the polycystic ovarian syndrome (PCOS), a hormone imbalance issue Apart from PCOS, other causes for infertility include Primary Ovarian Insufficiency (POI) which occurs due to ovarian dysfunction in <40 years of age. Importantly, POI is not the same and should not be confused with early menopause. Less common causes of infertility include blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy, physical uterus problems and uterine fibroids.
Many things can change a woman’s ability to have a baby and risk factors for infertility include age, stress, lack of balanced diet and exercise, smoking habits, excessive alcohol consumption, weight [body mass index (BMI)], sexually transmitted infections (STIs) and health issues causing hormonal imbalances such as primary ovarian insufficiency and polycystic ovarian syndrome.
Aging increases the chances of infertility in the following ways: (i) reduced ability of ovaries to release eggs; (ii) fewer eggs; (iii) the eggs may not be as healthy; (iv) increased susceptibility to health disorders which could cause infertility and; (v) increased likelihood of miscarriage.
Diagnosis and treatment of infertility
Doctors will do a physical examination and ask for both partners’ health history and sexual history. The first step is usually to find out if the woman is ovulating every month which can be checked by noting down changes in her morning body temperatures for several months, noting down how cervical mucus looks for several months and a home ovulation test can also be used.
Ovulation can be checked with blood tests and imaging modalities such as an ultrasound of the ovaries. If ovulation is normal, other fertility tests are usually prescribed, including hysterosalpingography (x-ray of the fallopian tubes and uterus) and laparoscopy.
Infertility can be treated with medicine, surgery, artificial insemination, or assisted reproductive technology (ART). The treatments may be used independently or in combination. Infertility is usually treated with medications or surgery.
Some commonly prescribed medications administered orally or as injections to treat female infertility include Clomiphene citrate (Clomid), human menopausal gonadotropin or hMG (Repronex, Pergonal), follicle-stimulating hormone or FSH (Gonal-F, Follistim): Gonadotropin-releasing hormone (Gn-RH) analogs, metformin (Glucophage) and Bromocriptine (Parlodel). At times, clomiphene citrate or FSH is combined with metformin.
Intrauterine insemination (IUI) or artificial insemination is an infertility treatment in which, the woman is injected with specially prepared sperm with or without medicines that stimulate ovulation prior to IUI. IUI is indicated in cases of mild male factor infertility, women with cervical mucus problems and couples with unexplained infertility.
Assisted reproductive technology (ART) is a group of techniques used to help infertile couples and works by removing eggs from the woman’s body. Subsequently, the eggs are mixed with sperm to create an embryo. The embryo is then inserted back into the woman’s body.
ART can be expensive and time-consuming but has allowed several couples to have children that otherwise would not have been conceived. Common ART techniques include In Vitro Fertilization (IVF), Zygote Intrafallopian Transfer (ZIFT) or Tubal Embryo Transfer, Gamete Intrafallopian Transfer (GIFT) and Intracytoplasmic Sperm Injections (ICSI).ART procedures may involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos. Donor eggs may be used for women who cannot produce eggs.
Donor eggs or donor sperm may also be used if the woman or man has a genetic disease that can be passed on to the baby. An infertile woman or couple may also use donor embryos; however, the child will not be genetically related to either of the parents.
Women with no eggs or unhealthy eggs could consider surrogacy and women with ovaries but no uterus may consider gestational carriers, which also may be considered for women who shouldn’t become pregnant due to the presence of serious health problems.