Approximately 1 in 6 couples will have trouble getting pregnant and need medical help to discover the cause of their infertility. By undergoing a complete infertility workup, couples can quickly get a diagnosis and then pursue a treatment plan to help them on the road to parenthood. Some causes of infertility are more common than others. Learn about various common and uncommon causes of fertility and treatment options for each.
Many couples believe that infertility is caused most often by problems with the female reproductive system. In fact, the causes are equally split among male and female factors. There are also many couples that have infertility issues in both partners.
Dr. Jason Bromer of Shady Grove Fertility’s Frederick office says that for many couples, there is more than one cause found during infertility testing. “We often see couples who have not had a complete infertility workup done or who have only had the female partner tested. This can lead to the couple becoming frustrated and disappointed with treatments that aren’t successful because they overlook one of their infertility factors.”
Finding out the causes of your infertility can be difficult emotionally and, if there are multiple factors, it can also be confusing. Developing a treatment plan with a fertility specialist can give couples a sense of control and provide concrete reasons for them to be hopeful about having a family.
Male factors account for 40% of infertility and are present in an additional 10% of couples that have infertility in both partners. Male factor infertility occurs if sperm are produced in low numbers, are abnormal in shape or are not able to move well. There can also be structural problems within the male anatomy that block the pathways of the sperm. Finally, men can develop antibodies to their own sperm, which may attack and weaken the sperm.
“The good news is that there are several effective ways to treat male factor infertility,” notes Dr. Bromer. In mild cases, sperm “washing” is used to isolate the healthiest sperm in a sample for use with Intrauterine Insemination or IUI. When couples with a male factor diagnosis do In Vitro Fertilization, a procedure called Intracytoplasmic Sperm Injection or ICSI can be used. With ICSI, a single healthy sperm is injected into the center of each egg making fertilization possible with even severe male factor infertility. In some cases, medications may also be part of the treatment plan.
For those with no ejaculated sperm, there are several procedures that can attempt to recover healthy sperm. One procedure is called Percutaneous Epidydimal Sperm Aspiration (PESA ). In this procedure, a needle is inserted into the epididymis and fluid is withdrawn. The fluid is then inspected under a microscope and healthy sperm are extracted from it. If PESA is unsuccessful in retrieving sperm, a second option may be to do a Testicular Biopsy. In this procedure, a small sample of tissue is removed from the testes. The tissue is then inspected under a microscope and any healthy sperm found are extracted.
While these procedures sound uncomfortable, none of them are painful and all of them are effective. “Patients with male factor infertility can be very hopeful about their chances of getting pregnant,” states Dr. Bromer. “In fact, patients at Shady Grove Fertility with a male factor diagnosis have a clinical pregnancy rate of 62% per cycle.”
Female factors account for another 40% of infertility and are present in an additional 10% of couples who have infertility factors in both partners. While the causes of female infertility are more numerous and can be more complicated to diagnose, there are effective treatments available for an overwhelming majority of them. Dr. Bromer adds that it’s common for women to have more than one factor affecting their fertility. “I frequently see patients with multiple issues. For example, a woman who has fibroids may also have endometriosis. That’s why it’s important to do a thorough diagnostic workup, so you can create a treatment plan that takes all the factors into account.”
Common and Uncommon Causes of Infertility
Ovulation is the process by which the ovary releases an egg each month. Disorders that cause a woman not to ovulate or to ovulate infrequently or irregularly are called Ovulatory Disorders. By far the most common diagnosis in this category, PCOS accounts for about 85% of ovulatory disorders. PCOS is caused by hormonal imbalances that prevent ovulation. The woman’s body produces too much of some hormones and not enough of others. Women who are diagnosed with PCOS usually have low levels of follicle stimulating hormone (FSH), yet have high levels of luteinizing hormone (LH). FSH is the hormone that’s responsible for stimulating the growth of follicles in the ovaries that contain maturing eggs. If a woman lacks FSH for a long time, her follicles will not mature and release their eggs, resulting in infertility.
Weight loss can sometimes fix the hormonal problem causing PCOS. More commonly, women with PCOS are treated with a medication called Clomid that induces ovulation. “If PCOS is the only factor affecting a woman’s fertility, then treatment with Clomid is very effective,” says Dr. Bromer. “Over 6 cycles, 70-80% of women will ovulate and 40-50% will get pregnant.”
Another 10% of ovulatory dysfunction is caused by Hypothalamic Amenorrhea. Hypothalamic Amenorrhea is a condition in which ovulation stops due to a problem involving the hypothalamus. The hypothalamus is an area of the brain that produces hormones that control many bodily functions. Its function can be impaired by stress, being underweight or too much exercise.
“Unlike women with PCOS, women with Hypothalamic Amenorrhea will not respond to Clomid,” says Dr. Bromer, “so it is not an appropriate treatment.” One way to treat this condition is to reverse the underlying cause – have the patient gain weight or reduce exercise. She may start ovulating again on her own and become pregnant. Another way to treat this condition is to give the patient the hormones she is missing during a cycle of Intrauterine Insemination (IUI). “For most IUI cycles, the woman takes FSH hormone only,” says Dr. Bromer, “but for women with Hypothalamic Amenorrhea, we also give LH to replace the LH that is not being made in the body.”
Women with Hypothalamic Amenorrhea have a high rate of success using this course of treatment. “The good news is that all we have to do is get these patients to ovulate,” says Dr. Bromer. “They almost always have healthy eggs, and they carry pregnancies normally.”
A subset of hypothalamic amenorrhea is due to hyperprolactinemia. Hyperprolactinemia is a disorder in which the pituitary gland produces excessive amounts of the hormone prolactin. Prolactin normally circulates in the blood in small amounts in women who are not pregnant and in large amounts during pregnancy and right after birth. Hyperprolactinemia can cause irregular or no ovulation, resulting in infertility. One of the most common causes of hyperprolactinemia is a benign tumor growing on the pituitary gland – the gland that produces prolactin. Other causes of excess prolactin production may be an underactive thyroid (hypothyroidism) or certain medications the patient may be taking. Sometimes, the cause is unknown.
“The goal of treatment is to get the woman’s prolactin blood level within the normal range,” says Dr. Bromer. “Once this is achieved, she should start ovulating again and be able to conceive. This condition is similar to Hypothalamic Amenorrhea in that the woman usually has healthy eggs and has a great chance for pregnancy once she ovulates.”
If the patient is diagnosed with an underactive thyroid, her doctor can prescribe a thyroid medication. Once the thyroid problem is corrected, the amount of prolactin in the blood should decline to a normal level. If the patient has a tumor on her pituitary gland, or the cause of the hyperprolactinemia is unknown, treatment with medication can reduce the prolactin levels. This medication usually causes pituitary tumors to shrink as well.
Premature Ovarian Failure
Premature ovarian failure is a relatively rare condition in which menopause occurs before the age of 40. Women who develop early menopause usually have run out of eggs in their ovaries. The cause of premature ovarian failure is generally unknown. However, there are a few reasons why the ovaries may stop producing eggs at an early age. Exposure to certain chemicals or medical treatments, such as chemotherapy, can damage or destroy the ovaries. Autoimmune diseases such as rheumatoid arthritis are also sometimes associated with early menopause because the immune system forms antibodies that attack and damage the ovaries. Heredity can also play a role, as some genetic disorders lead to early menopause.
“Because this condition means that we don’t have healthy eggs to work with, the only option for these patients is to use donor eggs,” says Dr. Bromer. “The good news about donor eggs, though, is that the pregnancy success rates are very high because of the age and health of the eggs being used.”
Tubal Disease or Blocked Tubes
Tubal disease or blocked fallopian tubes account for half of all female infertility. “To understand why this is such a common problem, it helps to think about the woman’s anatomy,” explains Dr. Bromer. “The fallopian tubes and the ovaries are not actually connected to one another. The fallopian tube has to sweep over the ovary to pick up the egg that is released each month. So, this condition is not only caused by a blockage or barrier in the tube but also by anything that prevents the tube from picking up the egg.”
Conditions that cause scarring in or around the fallopian tubes can cause tubal disease or blocked tubes. Endometriosis, Fibroids, and Pelvic Adhesive Disease, which are described below, can cause tubal disease in addition to other issues that affect fertility. Also, events such as ectopic pregnancies, c-section or any other abdominal surgery can cause scarring and blockages as well.
“With tubal disease, you can either fix the tubal blockages or go around them by doing IVF,” says Dr. Bromer. “The problem with fixing the blockages is that then the woman may continue to be at risk for ectopic pregnancies, so IVF is really the best solution.”
The only time a blocked fallopian tube must be fixed is in the case of something called a Hydrosalpinx. In this condition, the tube is blocked at the end near the ovary. When the cells lining the tube secrete fluid to facilitate transport of the egg, the fluid collects in the tube and then leaks back into uterus. “This fluid is toxic to embryos,” says Dr. Bromer. “Even if your other tube is open, the hydrosalpinx will prevent you from getting pregnant. So, a fallopian tube with a hydrosalpinx has to be removed even if you’re going to do IVF.”
Pelvic Adhesive Disease
Pelvic Adhesive Disease can be caused by surgical procedures, pelvic inflammatory diseases and infections. The result is scar tissue that binds adjacent organs to each other. If adhesions (scar tissue) form inside or around the ends of the fallopian tubes, they may block an egg and sperm from meeting. If the tubes are partially blocked by adhesions, sperm may meet the egg, but the fertilized embryo may be trapped, resulting in an ectopic pregnancy. Adhesions that develop on or around the ovaries may also disrupt the egg being picked up by the fallopian tube, and those that develop inside the uterus may prevent a fertilized egg from implanting properly.
Treatment for Pelvic Adhesive Disease will depend on how it is affecting a woman’s fertility. Dr. Bromer explains, “If necessary, surgery can be performed to remove the adhesions that are affecting the uterus or ovaries. If the adhesions are only causing blocked fallopian tubes, IVF can be performed to avoid using blocked tubes.”
Fibroids are noncancerous growths that develop in or on the uterus. Forty percent of women have fibroids by the time they are 40 years old and they are 3 times more likely to occur in African American women. However, Dr. Bromer explains, “While fibroids are very common, they don’t always cause infertility. The location of the fibroids is usually the key to whether or not they affect fertility.” Fibroids can grow inside the uterus, in the wall of the uterus or on the outside of the uterus. “The ones that most often have an impact on fertility are those inside the uterus and they can be removed surgically,” says Dr. Bromer.
If the fibroid is in the uterine wall or outside the uterus, the impact on a woman’s fertility is less clear. Dr. Bromer explains, “We will look at whether the shape of the uterus is distorted by the fibroid. If it is, it should probably be taken out. If not, it could be left alone while treatments like IUI or IVF are attempted. The only exception to this is if it is in a location where it might interfere with the interaction between the ovary and the fallopian tube in which case it should be removed.”
The decision about whether to remove a fibroid is a difficult one. Patients have to weigh the risk of abdominal surgery that could cause scarring in the uterus. Dr. Bromer says, “If a patient is not sure about surgery, we can try treatments like IUI and IVF first. They may become pregnant despite the presence of the fibroid. If those treatments are unsuccessful, then we still have surgical removal of the fibroid as an option.”
Endometriosis plays a role in about 10% of female infertility. In this condition, the uterine lining, called endometrium attaches and grows outside the uterus in the abdominal cavity. This endometrial tissue responds to your menstrual cycle hormones – it swells and thickens, then sheds to mark the beginning of the next cycle. Unlike the menstrual blood from your uterus that is discharged through your vagina, the blood from the endometrial tissue in your abdominal cavity has no place to go. Inflammation occurs in the areas where this process occurs, eventually forming scar tissue. Scar tissue can block the fallopian tubes or interfere with their function.
“How you treat endometriosis depends on how it is affecting the woman’s fertility,” says Dr. Bromer. There are surgical options to remove the endometriosis tissue from the ovaries or fallopian tubes and there are medications that shrink endometrial tissue. Dr. Bromer adds, “In most cases, women with endometriosis are more likely to be successful with IUI or IVF.”
Recurrent miscarriage or recurrent pregnancy loss (RPL) is characterized by having 2 or more miscarriages. There are several different possible causes. A common cause of RPL is “aneuploidy” or an abnormal number of chromosomes. When fertilization occurs, an embryo receives one copy of its chromosomes from the female and one from the male. These chromosomes line up in pairs that are matched to one another precisely. In some patients, especially older patients, the copying mechanism fails and the chromosomes are wrongly paired. A rare but well established cause of aneuploidy is a condition called a “translocation.” A simple blood test can show a couple’s risk for translocation during conception.
Other potential causes are problems within the uterus, such as congenital abnormalities in the shape of the uterus or scarring, that can prevent the embryo from implanting properly. Certain autoimmune diseases in the female also can lead to RPL. Autoimmunity means that the body is making antibodies that work against it, in other words, attacking itself instead of invaders. This can result in conditions like lupus. Dr. Bromer adds that “conditions like diabetes or thyroid disease can also cause miscarriage, so normally these types of causes would be ruled out as well.”
Treatment depends on finding the cause of the miscarriage. If the couple is at risk for translocation, they can do IVF with pre-implantation genetic screening. This is a process in which the embryos created during IVF are screened for genetic conditions so that only healthy embryos can be chosen for transfer. Problems with the shape of the uterus or fibroids can be corrected with surgery. Some immune problems or hormone imbalances can be corrected with medication. “Sometimes we don’t find a cause for the miscarriage,” says Dr. Bromer. “But even in these cases, there is still a very high chance that eventually you will deliver a healthy baby.”
As women approach age 40, the quality and number of their eggs tends to decline, ovulation may become irregular, and the ovaries may produce less estrogen and progesterone. In addition, women this age are more likely to have medical problems that can cause infertility, such as fibroids. Also, more of a woman’s eggs will have chromosomal abnormalities, which can result in miscarriage.
IVF can be successful for women 38 and older, but the success rates decline as the age of the woman goes up, especially as women reach their 40’s. “Women with significant age-related infertility may need to consider using donor eggs,” says Dr. Bromer. “Because the eggs are donated by a woman between the ages of 21 and 32, the chances for pregnancy are the same as if she were that age. The success rates for women using donor eggs are very high, so it’s a great option for women of advanced age.”
Approximately 10% of infertility cases are unexplained. The evaluation of such a couple begins with a comprehensive review of all testing and treatment performed to date. It is not uncommon to uncover evidence within this past evaluation which may in fact document the cause of infertility.
True unexplained infertility may be related to egg and sperm dysfunction, among other causes. These conditions are difficult to establish through conventional testing. However, many such conditions can be successfully and safely treated through in vitro fertilization or related techniques. Treatment decisions are based on a number of factors. These include the age of the female partner, the duration of infertility, a working diagnosis of the problem and the desires of the couple.
Treatment options may include, controlled ovarian hyperstimulation and a processed sperm specimen for intrauterine insemination, or in vitro fertilization. The important difference being that through in vitro fertilization egg and sperm interaction can be maximized in order to promote fertilization and establish a successful pregnancy.
Don’t Delay Diagnosis
Many infertile couples try to get pregnant on their own for far too long before seeking help. Because age is such an important factor to fertility, waiting too long may reduce the likelihood that fertility treatment will work. The best thing is to follow the accepted guidelines about when to see a fertility specialist.
Women under 35 should seek medical help after one year of unprotected sex without conceiving. If the woman is over 35, she should only wait 6 months. Women who are 40 years old or older and are trying to get pregnant may consider seeing a fertility specialist right away.
Though it may be scary to be diagnosed with infertility, this diagnosis can start you on the path to pregnancy. Once the causes of infertility are known, a treatment plan can be created that gives you options and clearly states your chances for success. With the caring guidance of a fertility specialist, you can be on your way to joining the thousands of couples who have successfully overcome infertility.