Symptoms

Most couples achieve pregnancy within the first six months of trying. Overall, after 12 months of unprotected intercourse, approximately 90 percent of couples will become pregnant. The majority of the remaining couples will eventually conceive, with or without treatment.

The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms.

In some cases, an infertile woman may have abnormal menstrual periods. An infertile man may have some signs of hormonal problems, such as changes in hair growth or sexual function.

When to see a doctor In general, don't be too concerned about infertility unless you and your partner have been trying regularly to conceive for at least one year. Talk with your doctor earlier, however, if you're a woman and:

• You're age 34 or older and have been trying to conceive for six months or longer
• You menstruate irregularly or not at all
• Your periods are very painful
• You have been diagnosed with endometriosis or pelvic inflammatory disease (PID)
• You've had more than one miscarriage

If you're a man, talk with your doctor if you have:

• Low sperm count
• A history of testicular, prostate or sexual problems

Causes

To become pregnant, the complex processes of ovulation and fertilization need to work just right. For some couples attempting pregnancy, something goes wrong along the way, resulting in infertility.

The cause or causes of infertility can involve one or both partners. In general:

• In about one-third of cases, infertility is due to a cause involving only the male partner.
• In another one-third of cases, infertility is due to causes involving both the male and female.
• In the remaining one-third of cases, infertility is due to a cause involving only the female.

Causes of male infertility A number of things can affect sperm count, ability to move (motility) or ability to fertilize the egg. The most common causes of male infertility include:

• Abnormal sperm production or function due to various problems, such as undescended testicles, genetic defects or repeated infections.
• Problems with the delivery of sperm due to sexual problems, such as premature ejaculation or painful intercourse (dyspareunia); health issues, such as retrograde ejaculation; certain genetic diseases, such as cystic fibrosis; or structural problems, such as blockage of the part of the testicle that contains sperm (epididymis).
• General health and lifestyle issues, such as poor nutrition, obesity, or use of alcohol, tobacco and drugs.
• Overexposure to certain environmental factors, such as pesticides and other chemicals. In addition, frequent exposure to heat, such as in saunas or hot tubs, can elevate your core body temperature. This may impair your sperm production and lower your sperm count.
• Damage related to cancer and its treatment. Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility.
• Age. Men older than age 40 may be less fertile than younger men.

Causes of female infertility The most common causes of female infertility include:

• Fallopian tube damage or blockage, which usually results from inflammation of the fallopian tube (salpingitis). Chlamydia, a sexually transmitted infection, is the most frequent cause.
• Endometriosis, which occurs when the uterine tissue implants and grows outside of the uterus — often affecting the function of the sperm, egg and ovaries, uterus, and fallopian tubes.
• Ovulation disorders, which can prevent the ovaries from releasing eggs (anovulation). Underlying causes may include injury, tumors, excessive exercise and starvation. In addition, some medications can be associated with ovulation disorders.
• Elevated prolactin (hyperprolactinemia), the hormone that stimulates breast milk production. High levels in women who aren't pregnant or nursing may affect ovulation.
• Polycystic ovary syndrome (PCOS), a condition in which your body produces too much of the hormone androgen causing ovulation problems. PCOS is also associated with insulin resistance and obesity.
• Early menopause, which is the absence of menstruation and the early depletion of ovarian follicles before age 40. Although the cause is often unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.
• Uterine fibroids, which are benign tumors in the wall of the uterus and are common in women in their 30s and 40s. Rarely, they may cause infertility by blocking the fallopian tubes. More often, fibroids interfere with proper implantation of the fertilized egg.
• Pelvic adhesions, bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. This scar tissue formation may impair fertility.

Other causes in women

• Medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
• Thyroid problems. Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
• Cancer and its treatment. Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman's ability to reproduce. Chemotherapy may impair reproductive function and fertility in men and women.
• Other medical conditions. Medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, kidney disease and diabetes, can affect a woman's fertility.

Risk factors

Many of the risk factors for both male and female infertility are the same. They include:

• Age. After about age 30, a woman's fertility potential gradually declines. Infertility in older women may be due to a higher rate of chromosomal abnormalities that occur in the eggs as they age or to health problems that may interfere with fertility. Men older than age 40 may be less fertile than are younger men.
• Tobacco smoking. A couple’s chance of achieving a pregnancy is reduced if either partner smokes tobacco. Smoking also reduces the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.
• Alcohol use. For women, there's no safe level of alcohol use during conception or pregnancy. Alcohol use increases the risk of birth defects, and it may also — at moderate to heavy levels — make it more difficult to become pregnant. Moderate alcohol use does not appear to decrease male fertility.
• Being overweight. Among American women, infertility often is due to a sedentary lifestyle and being overweight. In addition, a man's sperm count may be affected if he is overweight.
• Being underweight. Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women following a very low calorie or restrictive diet.
• Too much exercise. In some studies, exercising more than seven hours a week has been associated with ovulation problems. On the other hand, not enough exercise can contribute to obesity, which also increases infertility.

Appointment

If you and your partner have been trying to get pregnant for six months or longer, call your doctor. Depending on your age and personal health history, your doctor may recommend a medical evaluation.

A woman's gynecologist or a man's urologist or a family doctor can help determine whether there's a problem that requires a specialist or clinic that treats infertility problems. Both you and your partner will likely undergo a comprehensive infertility examination.

Here's some information to help you get ready for your first appointment, and know what to expect from your doctor.

What you can do

• Write down details about your attempts to get pregnant. Your doctor will need information such as when you started trying to conceive and how often you have had intercourse, especially around the midpoint of your cycle.
• Write down your key medical information, including any other conditions with which you or your partner has been diagnosed and any medications you're currently taking.
• Write down questions to ask your doctor.

Prepare a list of questions so that you can make the most of your time with your doctor. For infertility, some basic questions to ask your doctor include:

• What are the possible reasons we haven't yet conceived?
• What kinds of tests do we need?
• What treatment do you recommend trying first?
• What side effects are associated with the treatment you're recommending?
• What is the likelihood of conceiving multiple babies with the treatment you're recommending?
• For how many cycles will we try this treatment?
• If the first treatment doesn't work, what will you recommend trying next?
• Are there any long-term complications associated with this or other infertility treatments?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor Your doctor is likely to ask each of you a number of questions. Being ready to answer them will help your doctor quickly determine next steps in making your diagnosis and starting care.

Questions for the couple

• How long have you been having sex without birth control?
• How long have you been actively trying to get pregnant?
• How frequently do you have intercourse?
• Do you use any lubricants during sex?
• Do either of you smoke?
• Have either of you been treated for any other medical conditions, including sexually transmitted infections?
• How much does stress play a role in your lives?
• How satisfied are you with your relationship?

Questions for the woman

• At what age did you start menstruating?
• What are your cycles typically like? How regular, long and heavy?
• Have you ever been pregnant before?
• Have you ever been evaluated for infertility in the past?
• Have you been charting when you ovulate? For how many cycles?
• Have you been treated for any other medical conditions?
• Are you currently taking any medications, including dietary supplements or anabolic steroids?
• Do you use alcohol or recreational drugs? How often?
• What is your typical daily diet? Does it include caffeine?
• Do you exercise regularly? How much?
• Has your body weight recently changed?

Questions for the man

• At what age did you start puberty?
• Have you had any sexual problems in this relationship, including difficulty maintaining an erection, ejaculating too soon or not being able to ejaculate?
• Do you use recreational drugs, including marijuana? How often?
• Are you exposed through your work or lifestyle habits to chemicals, pesticides, radiation or lead?
• Are you currently taking any medications, including dietary supplements or anabolic steroids?
• Do you regularly take hot baths or steam baths?
• Have you conceived a child with any previous partners?

Tests and diagnosis

Before undergoing infertility testing, be aware that a certain amount of commitment is required. Your doctor or clinic will need to determine what your sexual habits are and may make recommendations about how you may need to change those habits. The tests and periods of trial and error may extend over several months. In about one-third of infertile couples, no specific cause is found (unexplained infertility).

Evaluation is expensive and in some cases involves uncomfortable procedures, and the expenses may not be reimbursed by many medical plans. Finally, there's no guarantee — even after all the testing and counseling — that conception will occur.

Tests for men For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman's vagina. Tests for male infertility attempt to determine whether any of these processes are impaired.

• General physical examination. This includes examination of your genitals and questions concerning your medical history, illnesses and disabilities, medications, and sexual habits.
• Semen analysis. This is a very important test for the male partner. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes your semen specimen for quantity, color, and presence of infections or blood.
• Hormone testing. A blood test to determine the level of testosterone and other male hormones is common.
• Transrectal and scrotal ultrasound. Ultrasound can help your doctor look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstruction.

Tests for women For a woman to be fertile, the ovaries must release healthy eggs regularly, and her reproductive tract must allow the eggs and sperm to pass into her fallopian tubes to become fertilized by a sperm. Her reproductive organs must be healthy and functional.

After your doctor asks questions regarding your health history, menstrual cycle and sexual habits, you'll undergo a general physical examination. This includes a regular gynecological examination. Specific fertility tests may include:

• Ovulation testing. A blood test is sometimes performed to measure hormone levels to determine whether you are ovulating.
• Hysterosalpingography. This test evaluates the condition of your uterus and fallopian tubes. Fluid is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid progresses through your fallopian tubes. Blockage or problems often can be located and may be corrected with surgery.

• Laparoscopy. Performed under general anesthesia, this procedure involves making a small incision (8 to 10 millimeters) beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus.

  The most common problems identified by laparoscopy are endometriosis and scarring. Your doctor can also detect blockages or irregularities of the fallopian tubes and uterus. Laparoscopy generally is done on an outpatient basis.

• Hormone testing. Hormone tests may be done to check levels of ovulatory hormones as well as thyroid and pituitary hormones.
• Ovarian reserve testing. Testing may be done to determine the potential effectiveness of the eggs after ovulation. This approach often begins with hormone testing early in a woman's menstrual cycle.
• Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing infertility.
• Pelvic ultrasound. Pelvic ultrasound may be done to look for uterine or fallopian tube disease.

Not everyone needs to undergo all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.

Treatments and drugs

Treatment of infertility depends on the cause, how long you've been infertile, your age and your partner’s age, and many personal preferences. Some causes of infertility can't be corrected. However, a woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.

Treatment for men Approaches that involve the male include treatment for:

• General sexual problems. Addressing impotence or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.
• Lack of sperm. If a lack of sperm is suspected as the cause of a man's infertility, surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible. In some cases, sperm can be taken directly from the testicles or recovered from the bladder and injected into an egg in the laboratory setting.

Treatment for women Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. In general, they work like natural hormones — such as follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. Commonly used fertility drugs include:

• Clomiphene citrate (Clomid, Serophene). This drug is taken orally and stimulates ovulation in women who have polycystic ovary syndrome (PCOS) or other ovulatory disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
• Human menopausal gonadotropin (Repronex, Menopur). This injected medication is for women who don't ovulate on their own due to the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, which stimulates the pituitary gland, human menopausal gonadotropin (hMG) and other gonadotropins directly stimulate the ovaries. This drug contains both FSH and LH.
• Follicle-stimulating hormone (Bravelle). FSH works by stimulating maturation of egg follicles the ovaries.
• Human chorionic gonadotropin (Ovidrel, Pregnyl). Used in combination with clomiphene, hMG and FSH, human chorionic gonadotropin (HCG) stimulates the follicle to release its egg (ovulate).
• Gonadotropin-releasing hormone analogs. This treatment is for women with irregular ovulatory cycles or who ovulate prematurely — before the lead follicle is mature enough — during hMG treatment. Gonadotropin-releasing hormone (Gn-RH) analogs suppress pituitary gland activity, which alters hormone production so that a doctor can induce follicle growth with FSH.
• Aromatase inhibitors. This class of medications, which includes letrozole (Femara) and anastrozole (Arimidex), is approved for treatment of advanced breast cancer. Doctors sometimes prescribe them for women who don't ovulate on their own and who haven't responded to treatment with clomiphene citrate. These drugs are not approved by the Food and Drug Administration for inducing ovulation, and their effect on early pregnancy isn't yet known.
• Metformin (Glucophage). This oral drug is taken to boost ovulation. It's used when insulin resistance is a known or suspected cause of infertility. Insulin resistance may play a role in the development of PCOS.
• Bromocriptine (Parlodel). This medication is for women whose ovulation cycles are irregular due to elevated levels of prolactin, the hormone that stimulates milk production in new mothers. Bromocriptine inhibits prolactin production.

Surgery Depending on the cause, surgery may be a treatment option for infertility. Blockages or other problems in the fallopian tubes can often be surgically repaired. Laparoscopic techniques allow delicate operations on the fallopian tubes.

If you have endometriosis, your doctor may treat you with ovulation therapy, in which medication is used to stimulate or regulate ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.

Assisted reproductive technology (ART) Each year thousands of babies are born in the United States as a result of ART. An ART health team includes physicians, psychologists, embryologists, laboratory technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.

The most common forms of ART include:

• In vitro fertilization (IVF). IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory, and implanting the embryos in the uterus three to five days after fertilization.
• Electric or vibratory stimulation to achieve ejaculation. Electric or vibratory stimulation brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who can't otherwise achieve ejaculation.
• Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract, such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if the ejaculatory duct is blocked.
• Intracytoplasmic sperm injection (ICSI). This procedure consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure.
• Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).

ART works best when the woman has a healthy uterus, responds well to fertility drugs, and ovulates naturally or uses donor eggs. The man should have healthy sperm, or donor sperm should be available. The success rate of ART is lower after age 35.

Complications of treatment Certain complications exist with the treatment of infertility. These include:

• Multiple pregnancy. The most common complication of ART is a multiple fetus pregnancy. Generally, the greater the number of fetuses, the higher the risk of premature labor. Babies born prematurely are at increased risk of health and developmental problems.

  The number of quality embryos kept and matured to fetuses and birth ultimately is a decision made by the couple. If too many are conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.

• Ovarian hyperstimulation syndrome (OHSS). If overstimulated, a woman's ovaries may enlarge and cause pain and bloating. Mild to moderate symptoms often resolve without treatment, but severe cases — marked by abdominal swelling and shortness of breath — require emergency treatment. Younger women and those who have polycystic ovary syndrome have a higher risk of developing OHSS than do other women.
• Bleeding or infection. As with any invasive procedure, there is a risk of bleeding or infection with assisted reproductive technology.
• Low birth weight. The greatest risk factor for low birth weight is a multiple fetus pregnancy. In single live births, there may be a greater chance of low birth weight associated with ART.
• Birth defects. There is some concern about the possible relationship between ART and birth defects. More research is necessary to confirm this possible connection. Weigh this factor if you're considering whether to take advantage of this treatment. ART is the most successful fertility-enhancing therapy to date.

Coping and support

Coping with infertility can be difficult. It's an issue of the unknown — you can't predict how long it will last or what the outcome will be. Infertility isn't necessarily solved with hard work. The emotional burden on a couple is considerable.

Taking these steps can help with coping:

• Set limits. Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and attempt to determine a final limit. Fertility treatments may be expensive and often are not covered by insurance companies, and a successful pregnancy often depends on repeated attempts.
• Consider other options. Determine alternatives — adoption, donor sperm or egg, surrogacy, or even having no children — as early as possible in the infertility evaluation. This may reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
• Talk about your feelings. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.

Managing emotional stress during treatment

• Acupuncture. This ancient therapy has been shown to reduce anxiety and increase optimism during IVF. While this may not have any effect on your chances of becoming pregnant, it can make the process more tolerable.
• Practice relaxation. Cognitive behavioral therapy, which uses methods that include relaxation training and stress management, has been associated with higher pregnancy rates.
• Express yourself. Reach out to others rather than repressing guilt or anger.
• Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.

Managing emotional effects of the outcome Whatever the result of your fertility treatment, you'll face the possibility of psychological challenges. Seek professional help if the emotional impact of any of these outcomes becomes too heavy for you or your partner:

• Failure. The emotional stress of failure can be devastating even on the most loving and affectionate relationships and for people who've prepared well for the possibility of failure. Common emotional responses include anger, guilt, shock, self-esteem problems, sexual problems and marital problems.
• Success. Even if fertility treatment is successful, it's common to experience stress and fear of failure during pregnancy. If you have a history of depression or anxiety disorder, you're at increased risk of these problems recurring in the months after your child's birth.
• Multiple births. A successful pregnancy that results in multiple births introduces new medical complexities and the likelihood of significant emotional stress both during pregnancy and after delivery.

Prevention

Most types of male infertility aren't preventable. However, avoid drug and tobacco use and excessive alcohol consumption, which may contribute to male infertility. Also, high temperatures can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.

For couples, having intercourse two to three times a week may improve fertility. Too-frequent ejaculation can lessen sperm quality. Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation.

A woman can increase her chances of becoming pregnant in a number of ways:

• Exercise moderately. Regular exercise is important, but if you're exercising so intensely that your periods are infrequent or absent, your fertility may be impaired.
• Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
• Avoid alcohol, tobacco and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don't drink alcohol or smoke tobacco. Avoid illegal drugs such as marijuana and cocaine.
• Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for guidance on safe use of caffeine.
• Limit medications. The use of both prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly.