There are many potential causes of infertility that need to be considered in women having difficulty becoming pregnant. These causes can generally be lumped into problems with egg production, tubal problems, and uterine problems. Each of these potential problems are evaluated before initiating fertility treatment.
Normal ovulation is essential for producing a mature egg that can be fertilized. Disorders in ovulation can impair conception and cause infertility. Women having problems with ovulation will not generally have menses at regular intervals. Keeping a journal of menses can be a very helpful tool to evaluate ovulation. Regular menses is very predictive of regular ovulation. Many women use menstrual calendars in combination with basal body temperature charts and ovulation predictor kits. While these can be useful aids in evaluating potential causes of infertility, they can easily become cumbersome and costly. This is especially true with the new electronic ovulation "computers" that monitor a woman's fertile window. We do not advise you purchase ovulation monitoring devices. Well spaced intercourse during the middle of a menstrual cycle can be just as effective.
Ovulation occurs 14 days before the first day of menses. Women can predict their fertile window by taking the number of days between the start of menses and the start of the next menses and subtract 14. For example, a woman with 32 days between menses would be most fertile on day 16 (counting the first day of flow as day 1).
Women not having regular menses will most likely experience difficulty getting pregnant. The lack of menses indicates a lack of ovulation. This makes timing ovulation and intercourse practically impossible. The most common cause of anovulation (absence of menses) or oligoovulation (infrequent ovulation) is polycystic ovarian syndrome (PCOS). Other causes include premature ovarian failure (POF), age related fertility, and endocrine abnormalities such as elevated prolactin or thyroid levels.
Endometriosis is a chronic condition where endometrial tissue (the cells that line the inside of the uterus) implants outside of the uterus. This can be associated with chronic pelvic pain and infertility. There are many theories as to why endometriosis causes infertility problems. One of the more current theories is the displaced tissue causes an inflammatory reaction that kills sperm and eggs. Stopping menses is an effective method of controlling endometriosis though this is not a cure. Laparoscopy and ablating (destroying) the endometriosis is another therapeutic option though it too is not a cure. In Vitro Fertilization offers a very effective way of "bypassing" endometriosis. Women often experience several years of relief from the discomforts of endometriosis following pregnancy.
Endometriosis is found in as many as 35% of women having laparoscopy for evaluation of their infertility. It can be a cause for pelvic pain as well as infertility. Other locations include incisions from previous surgeries, the vagina and cervix, as well as the bowel and bladder. Very unusual locations are also possible but not as common. Specialist vary tremendously on their opinions as to what should be done for the infertile couple with endometriosis. There is supportive evidence for most of the different treatment types which makes things even more confusing for patients seeking "the right thing". Our program has very good success achieving pregnancy in patients with endometriosis without subjecting patients to extensive and invasive procedures.
Structural abnormalities of the uterus can result in decreased pregnancy rates and increased miscarriage rates. In addition to causing infertility, uterine abnormalities may also cause pregnancy losses. Fortunately, many of these abnormalities can be corrected.
Uterine fibroids are muscle tumors of the uterus that can interfere with pregnancy when they lie within the cavity of the uterus. Fibroids can also cause pelvic pain and irregular bleeding. In the absence of infertility or other problems, fibroids can usually be left alone. Click for more information.
Several developmental abnormalities of the uterus can be discovered during an infertility evaluation. A unicornuate uterus, septum or septate uterus, and a bicornuate uterus are among the numerous structural anomalies. These problems arise when the uterus is being formed. A unicornuate uterus is when only one side of the uterus is formed normally. A bicornuate uterus is a uterus that has two sides of the uterus that are attached at the cervix but not at the top of the uterus. A septum is a normal shaped uterus that has a dividing membrane on the inside of the uterus. Hysteroscopy is useful in evaluating and treating these abnormalities. Other effective means of evaluating the uterus include saline contrast ultrasound and hysterosalpingogram (HSG).
Fallopian tubes can become blocked by several different mechanisms. Some of the more common reasons include infections (pelvic inflammatory disease, or PID), surgery, and endometriosis. Blockage of the fallopian tubes can prevent the sperm and egg from uniting and forming a pregnancy. This blockage can also prevent the normal transport of an embryo and increase the likelihood of an ectopic pregnancy (pregnancy inside the tube). Microsurgery is a type of surgery that uses an operative microscope or magnifying lenses to help amplify the surgical field. Microsurgery may be able to repair damaged fallopian tubes and IVF offers a way to bypass fallopian tubes. [More Information]
A hydrosalpinx is a blocked fallopian tube that has filled with fluid. Microsurgical repair called a neosalpingostomy can be an effective way to open the blockage and allow for pregnancy. There is an increased risk of ectopic pregnancies and a risk of the tube scarring shut after the surgery. Dr. Zeringue has extensive experience with microsurgical repair of fallopian tubes. IVF offers an excellent alternative to surgical repair of the fallopian tubes and the associated risk of ectopic pregnancy. When IVF is selected and hydrosalpinges are present, removal of the tubes is recommended in order to improve pregnancy rates. The fluid from the tubes is thought to impact pregnancy rates. Tubes can be removed by laparoscopy surgery.
Tubal ligations cause interruptions in the fallopian tube that prevent sperm and egg from meeting. These procedures can be reversed and offer couples a "more natural" means of conception. There are many considerations when deciding between IVF and tubal reversal. Dr. Zeringue has extensive experience performing the surgery known as bilateral tubal anastomosis (BTA) and can provide you more information about your options. More information.
Unexplained infertility is a diagnosis of exclusion. This means that all other causes within reason have been ruled out. Many times a presumptive diagnosis of unexplained infertility is given when the evaluation is not completed due to a low likelihood that further testing will find an abnormality. Examples of tests often deferred are laparoscopy and endometrial biopsies in women without symptoms. Unexplained infertility can be very frustrating because people want answers. Fortunately, treatment options offer significant improvements in couples with unexplained infertility.
Many women are not aware of the extreme effect that age can have on fertility. Women are born with all the eggs they will ever have in their lifetime. This pool of eggs declines continuously throughout a woman's life. The effects can be seen in a woman's early 30's and becomes a common problem in women 35 and over. By the time a woman reaches 40 she will have a drastic reduction in her chances of becoming pregnant. This reduction in pregnancy is due to fewer available eggs and a reduction in egg quality. As the eggs age, the biologic process used to divide the cell becomes less efficient. This leads to non-viable eggs and an increase in chromosomal abnormalities. While there are tests to estimate a woman's potential to produce eggs, there is not a very effective treatment to overcome this decline in egg function. Click here for more information about advanced maternal age (AMA), also known as advanced reproductive age.