Washington Center for Reproductive Medicine

Infertility Overview

Infertility is a common condition affecting approximately 11% of couples at some point in their reproductive lives. A reproductively healthy fertile couple generally has about a 25 percent chance of conceiving during any one month of unprotected intercourse. In females, the incidence of infertility increases with advancing age.  As more and more women delay child bearing, this life altering condition has become more prevalent.

In females less than 35 years of age, infertility is defined as the inability to conceive after 12 months of unprotected intercourse. For women over 35, the definition changes to the inability to conceive after six months of unprotected intercourse.

Infertility is defined as either primary or secondary. The term "primary infertility" is used when no previous successful pregnancy has occurred. The term "secondary infertility" is when a first conception and delivery was successful but difficulty is encountered when trying to become pregnant again.

It is always best to consult a reproductive endocrinologist, like Dr. Kustin, early in the fertility evaluation. Obstetricians and gynecologists, although dedicated and well meaning, may not have the expertise and experience to deal with fertility issues, especially as time is of the essence for many patients.  Treatment requires constant diligent review of progress and alterations in treatment strategies that are best managed by a specialist.

In women there are many conditions that warrant immediate consultation with a specialist and include:

  • Advanced age
  • Long history of infertility despite unprotected intercourse
  • History of sexually transmitted disease
  • Ruptured appendix, ovarian cyst, or other pelvic surgery
  • History of pelvic inflammatory disease (PID) 
  • Polycystic Ovarian Syndrome (PCOS)
  • Three to six months of unsuccessful Clomid therapy with or IUI
  • Reduced ovarian reserve
  • Persistent anovulation (no ovulation) 

Some conditions in the male that warrant immediate consultation with a specialist include:

  • A history of undescended testicles 
  • A history of sexually transmitted disease 
  • Hernia repair
  • Vasectomy reversal
  • A known poor semen analysis
  • A history of trauma to the testicles

Infertility affects men and women almost equally and is always a "couples" problem. It is important to realize that infertility can be treated and that greater than 80% of infertile couples succeed in having a baby. Consultation with an infertility specialist, such as Dr. Kustin, early in the evaluation often expedites a successful pregnancy. Often simple measures prescribed by an expert will result in excellent outcomes.

Treatment from a fertility specialist does not typically warrant advanced, expensive procedures such as IVF. Less than 10% of women receiving treatment for infertility require these advanced procedures. It is imperative that couples undergo a tailored fertility investigation in order to identify the deficiencies in the reproductive process resulting in infertility. Costly treatments without a plan rarely succeed and cause unwarranted anxiety and delay.

Oftentimes, women receive treatment with drugs such as clomiphene citrate (Clomid)before seeking specialized care, including a thorough infertility evaluation. Studies have shown that there is little advantage to administering Clomid for more than three ovulatory cycles and that continued use may be detrimental. Increasing the dose of clomiphene in a woman who is ovulating does not increase her chances of conception. Also, a woman who ovulates regularly (normal periods) is not a candidate for clomiphene. (Be sure and review the sections on male and female reproductive physiology)

Major Causes of Female Infertility

In general, there are five basic causes of female infertility:

  • Tubal disease can be caused by previous surgery, pelvic inflammatory disease, endometriosis, or it can be congenital. Depending upon where the tube is damaged (blocked) IVF is often the treatment of choice.
  • Ovarian disease is a common cause of infertility especially in the older patient. Ovulation is controlled by a complex interaction between numerous endocrine hormones (see section on physiology). Imbalance in this "feedback" mechanism can prevent ovulation or cause it to be irregular. Clomid is often used to treat anovulation (lack of ovulation). If clomiphene does not produce regular ovulation, injectable drugs such as gonadotropins (FSH, Follistim and Repronex) are often indicated. A specialist thoroughly trained in their use should administer these products.
  • Another condition, which can cause anovulation, is hyperprolactinemia. This condition is caused by a tumor (usually benign) located on the pituitary gland. Treatment with the drug Parlodel is often very effective in treating this condition.
  • Uterine factor  disease is a cause of infertility in a small number of cases. The uterus can be damaged by pelvic inflammatory disease; previous surgery,endometriosis, or some women are born with a malformed uterus. In cases of severe uterine damage, surrogacy (another female who can carry the pregnancy) is the only treatment.
  • Cervical disease occurs when the cervical mucus is insufficient, too thick, or hostile to sperm.  When antisperm antibodies are present in the cervical mucus, they can incapacitate or destroy sperm. Antisperm antibodies can also rarely be produced by a male to his own sperm. IUI is usually the treatment of choice for female antisperm antibodies.

Numerous treatment options are available based upon each couple's diagnosis.


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