Fertility Problems

Topic Overview

What are fertility problems?

You may have fertility problems if you have not been able to get pregnant after trying for at least 1 year. Another word for this is infertility. Infertility may not mean that it is impossible to get pregnant. Often, couples conceive without help in their second year of trying. Some do not succeed, but medical treatments help many couples.

Age is an important factor if you are trying to decide whether to get testing and treatment for fertility problems. A woman is most fertile in her late 20s. After age 35, fertility decreases and the risk of miscarriage goes up.

• If you are younger than 35, you may want to give yourself more time to get pregnant.
• If you are 35 or older, you may want to get help soon.

What causes fertility problems?

Fertility problems can have many causes. In cases of infertility:¹

• About 50 out of 100 are caused by a problem with the woman’s reproductive system. These may be problems with her fallopian tubes or uterus or her ability to release an egg (ovulate).
• About 35 out of 100 are caused by a problem with the man's reproductive system. The most common is low sperm count.
• About 5 out of 100 are caused by an uncommon problem, such as the man or woman having been exposed to a medicine called DES before birth.
• In about 10 out of 100, no cause can be found in spite of testing.

Should you be tested for fertility problems?

Before you have fertility tests, try fertility awareness. A woman can learn when she is likely to ovulate and be fertile by charting her basal body temperature and using home tests. Some couples find that they simply have been missing their most fertile days when trying to conceive.

If you are not sure when you ovulate, try this Interactive Tool: When Are You Most Fertile?.

If these methods don't help, the first step is for both partners to have some simple tests. A doctor can:

• Do a physical exam of both of you.
• Ask questions about your past health to look for clues, such as a history of miscarriages or pelvic inflammatory disease.
• Ask about your lifestyle habits, such as how often you exercise and whether you drink alcohol or use drugs.
• Do tests that check semen quality and both partners' hormone levels in the blood. Hormone imbalances can be a sign of ovulation problems or sperm problems that can be treated.

Your family doctor can do these tests. For more complete testing, you may need to see a fertility specialist.

How are fertility problems treated?

A wide range of treatments is available. Depending on what is causing the problem, you may be able to:

• Take a medicine that helps the woman ovulate.
• Have a procedure that puts sperm directly inside the woman (insemination).
• Have a surgery that corrects a problem caused by endometriosis or blocked fallopian tubes.
• Have a procedure that might increase the man’s sperm count.

If these options are not possible or don't work for you, you may want to consider in vitro fertilization (IVF). During an IVF, eggs and sperm are mixed in a lab so the sperm can fertilize the eggs. Then the doctor puts one or more fertilized eggs into the woman’s uterus. Many couples try IVF more than once.

Treatment for fertility problems can be stressful, costly, and hard on your body. Before you start testing, make some decisions about what you want to do. You may change your mind later, but it’s a good idea to start with a plan.

• Learn all you can about the tests and treatments, and decide which you want to try. For example, some couples agree to try medicines but don't want surgery or other treatments.
• Find out how much treatments cost and whether your insurance will cover them. If you don't have insurance coverage, decide what you can afford.

Treatments for infertility can increase your chances of getting pregnant. But they also increase your chance of having more than one baby at a time (multiple pregnancy). Be sure to discuss the risks with your doctor.

Fertility problems can put a lot of strain on a couple. It may help to see a counselor with experience in infertility. Think about joining an infertility support group. Talking with other people with the same issue can help you feel less alone.

Health Tools 

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Fertility problems: Should I be tested?
	Fertility problems: Should I have a tubal procedure or in vitro fertilization?
	Infertility: Should I have treatment?
	Multiple pregnancy: Should I consider a multifetal pregnancy reduction?
	Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.
	Interactive Tool: When Are You Most Fertile?

Cause

Infertility has many causes that involve either the woman's, the man's, or both partners' reproductive systems. Some causes include:

• Problems with the man's reproductive system.
• Problems with the woman's fallopian tubes.
• Problems with the woman's uterus and/or cervix.
• Problems with ovulation.
• Uncommon problems such as the man or woman having been exposed before birth to DES, a medicine that was used to prevent miscarriage.

Rates of infertility and miscarriage increase with age. A woman's fertility peaks in her late 20s and gradually begins to decline in her early 30s. A more pronounced drop in fertility and increase in miscarriage risk begins around her mid-30s, primarily due to the aging egg supply. Male fertility also decreases with age but it is a more gradual decline than in women.

Symptoms

Infertility does not cause physical symptoms. Infertility is a general term for a couple's inability to get pregnant after 1 year of having sex 2 to 3 times a week without using birth control methods.

For women younger than age 30 with unexplained fertility problems, some doctors will diagnose infertility and offer treatment to a couple only after 3 years of their trying to become pregnant.

For women over 35, some doctors will offer testing and treatment after 6 months of trying to become pregnant.

What Happens

You can be considered infertile if you have not been able to conceive after 1 year of sex without using birth control. But some people who have an infertility diagnosis do go on to become pregnant.

• In couples who conceive a pregnancy without treatment, 85% will conceive during the first year of trying to become pregnant. Up to 93% of couples will become pregnant without treatment during 2 years of trying.¹
• Infertile couples whose fertility test results are normal are diagnosed with "unexplained infertility." Of all couples with unexplained infertility who do not seek treatment, about 35% will naturally become pregnant within 3 years, and 45% do so within 7 years.²

Major factors that affect your chances of conceiving with or without treatment include age, how long you have been trying to conceive, and the cause of infertility.

• Female fertility normally decreases with age. The older a woman is (particularly over age 35), the less likely she is to become pregnant and the more likely she is to miscarry. This is primarily due to the aging of her egg supply. A woman who is over 40 and fails to ovulate despite medicine, or who does not respond to in vitro fertilization therapy, is encouraged to use donor eggs.
• A couple's chances of conceiving are greatest within their first 3 years of trying. After 3 years of sex without birth control, pregnancy is considered unlikely without treatment.¹
• If a clear cause of infertility can be determined and if there is a promising treatment for that cause, pregnancy is more likely. Treatment for unexplained infertility is less likely to be successful. But medicines or assisted reproductive techniques may still be effective.

Some couples who have tried infertility treatment without success become pregnant later without more treatment.

Personal concerns related to infertility include:

• Emotional and social impact of infertility, testing, and treatment on you and your partner.
• Ethical and legal issues related to assisted reproductive technology, such as how many embryos to transfer to the uterus and what to do with unused embryos.
• Considering adoption instead of, or after trying, infertility treatment.
• Setting limits on testing to avoid overextending yourselves emotionally, physically, and financially.
• Setting limits on treatment, considering your age-related fertility and financial resources.

For more information, see:

Should I have infertility testing?

Should I have infertility treatment?

What Increases Your Risk

Infertility has many causes that involve either the woman's, the man's, or both partners' reproductive systems. Some factors that increase your risk of infertility are within your control; others are not.

Risk factors you cannot control include:

• Age. Rates of infertility (not due to surgical sterilization) in women increase with age and are about:²
  • 7% in women ages 20 to 24.
  • 9% in women ages 25 to 29.
  • 15% in women ages 30 to 34.
  • 22% in women ages 35 to 39.
  • 29% in women ages 40 to 44.
• Problems with the male or female reproductive system that were present at birth (congenital birth defects).
• Exposure to DES (diethylstilbestrol) before birth.
• Moderate or severe endometriosis, the growth of uterine lining (endometrial) cells in other parts of the abdominal cavity (such as the ovaries or fallopian tubes, the outer surface of the uterus, the bowels, or other abdominal organs).
• Past exposure to very high levels of environmental toxins, certain drugs, or high doses of radiation (including cancer chemotherapy or radiation).
• Past infection with a sexually transmitted disease (such as gonorrhea or chlamydia) that has since damaged the reproductive system.

Risk factors you may be able to control include:

• Tobacco or marijuana use, which reduces sperm counts and female fertility.
• Drinking more than 2 to 4 alcoholic beverages daily for several months, which decreases male fertility and causes injury to sperm.
• Timing and frequency of intercourse—some experts say that the ideal frequency is every day for 3 days during the midpoint in the woman's cycle, ending the day before ovulation.² Others say that given a normal sperm count, daily sex during the fertile period may lower sperm count, but it does increase the overall chance of pregnancy.³
• Frequent (daily) or infrequent (every 10 to 14 days) ejaculation, either of which can temporarily lower sperm count.
• Eating a healthy diet, getting enough exercise, and maintaining a reasonable body weight. Being overweight or obese reduces fertility in both men and women.
• Exercising intensely for months or years, which may affect a man's sperm count and prevent a woman's ovulation.
• Increased temperature in a man's scrotal area, which can damage sperm (common causes are hot tub use and high fever).
• Prior surgical sterilization, such as vasectomy or tubal ligation. Surgical sterilization reversal may be successful, depending on the procedure used and how much time has passed since the original surgery.
• Symptoms related to polycystic ovary syndrome, a hormone imbalance that interferes with normal ovulation. If a woman is overweight, sometimes even a small weight loss may stimulate ovulation. If not, medicine may help.

When To Call a Doctor

Consult with your doctor about infertility concerns if you:

• Want children but have been unable to become pregnant after 1 year of having sex without using birth control.
• Are a woman older than 35 who has been unable to become pregnant after about 6 months of sex without using birth control.
• Have had three or more miscarriages in a row.

Watchful Waiting

Before seeking medical help with conception, increase your chances of becoming pregnant by practicing fertility awareness. For more information, see the suggestions in the Home Treatment section of this topic.

Who To See

Your doctor can help you evaluate a possible fertility problem, provide some preliminary guidance, and discuss general testing and treatment options. You can also use this appointment to provide a sperm sample for evaluation, one of the first tests in a routine infertility workup. For this type of help, you can consult:

• A family medicine doctor.
• An internist.
• A nurse practitioner.

For complete infertility testing, see an obstetrician/gynecologist with specialized training and experience in infertility. This doctor may be called a reproductive endocrinologist or fertility specialist. When looking for a specialist, ask what percentage of a doctor's practice is infertility treatment, and whether he or she has training in reproductive endocrinology.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Testing for a cause of infertility usually starts with simple tests for both partners. In addition to an interview and physical examinations, your initial tests will check semen quality and both partners' hormone levels in the blood. Hormone imbalances can be a sign of ovulation or sperm production problems that can be treated.

If your initial test results show no cause of infertility, your doctor may recommend checking fallopian tube function. Depending on your age and other risk factors, you may then be offered further testing or you may begin treatment with superovulation, intrauterine insemination, or both.

Should I have infertility testing?

If the above tests are normal (sperm is within normal ranges and ovulation is regular), one of the following tests is often done next.

If initial testing reveals no cause of infertility or if infertility treatment has been unsuccessful, one or more of the following tests are sometimes used.

If initial testing reveals no cause of infertility or if infertility treatment has been unsuccessful, one or more of the following tests are occasionally used.

What to Think About

Should I have infertility testing?

If you have had three or more miscarriages or repeated in vitro fertilization (IVF) failures with no known cause, talk to your doctor about whether genetic testing might help identify a cause. In about 4% of couples who have had two or more pregnancy losses, one partner has a chromosomal defect that is responsible.⁴

Treatment Overview

Before you and your partner start treatment for infertility, talk about how far you want to go. For example, you may want to try medicine but do not want to have surgery. While you may rethink this end point during your treatment, it’s a good idea to have an idea where you want to draw the line. Many couples do not think about this in the beginning and become emotionally and financially drained from trying a series of treatments.

Treatment for fertility can also be quite expensive, and insurance often does not cover these expenses. If cost is a concern for you, find out how much medicines and procedures cost and if your insurance covers any costs. Talk with your partner about what you can afford.

Keep in mind that some infertility problems are more easily treated than others. In general, as a women ages, especially after 35, her chances of getting pregnant decrease and her risk of miscarriage markedly increases.

If you are 35 or older, your doctor may recommend that you skip some of the steps younger couples usually take because your chances of having a baby decrease with each passing year.

Also, understand that even if you are able to get pregnant, no treatment can guarantee a healthy baby. On the other hand, scientists in this field have made many advances that have helped millions of couples have babies.

Your doctor will first try to find why you have not been able to get pregnant. He or she will do tests to look for a cause. Sometimes doctors do not find a problem with either the man or the woman and don't know why a woman cannot get pregnant.

Treatment for female infertility

Problems with ovulating. If your doctor finds that you have a problem with ovulating, he or she may first recommend that you try the medicine clomiphene (Clomid, Serophene, Milophene). This medicine (which you take as a pill) stimulates your ovaries to release eggs, so it improves your chances of getting pregnant. It is often tried first because it is considered safe and effective.

Clomiphene has more side effects than gonadotropins but clomiphene costs less, has a lower risk of ovarian hyperstimulation syndrome, and is less likely to result in a pregnancy with more than one baby.

If you're not ovulating because of a condition called polycystic ovary syndrome (PCOS), your doctor might suggest you take a drug such as metformin in combination with clomiphene. For more information, see treatment of women with polycystic ovary syndrome (PCOS).

Unfortunately, clomiphene does not always work. Typically, hormone shots are the next medication tried. You and your partner can weigh the risks and benefits of proceeding to this next step. You start the first series of daily shots at the beginning of your menstrual cycle. You will probably have mild side effects, such as feeling sick to your stomach and bloating. Some women have more serious side effects due to multiple, large ovarian cysts (ovarian hyperstimulation syndrome). While clomiphene increases your chance of having twins or triplets (especially twins), women who take hormonal injections are even more likely to have twins, triplets, or more babies.

Unexplained infertility. If your doctor cannot find out why you and your partner have not been able to get pregnant, he or she may start out by giving you clomiphene. The steps for treating infertility are essentially the same as for women who have ovulation problems. The next step is to try hormone injections. But at this step your doctor may recommend insemination, putting the sperm directly into the uterus, to improve your chances of getting pregnant. If these treatments don't work, your next step is deciding whether to have IVF (in vitro fertilization).

Blocked or damaged tubes. Your doctor may do tests to check your fallopian tubes. Blocked or damaged tubes can prevent the egg from being fertilized by the sperm. If the blockage of your tubes is slight, your doctor might recommend tubal surgery to try to correct the damage. In these cases, between 20% and 60% of women have successful pregnancies after the surgery, depending on what part of the tube was blocked.⁵ But in many cases, doctors recommend skipping tubal surgery and having IVF for more severe blockages. IVF is also often recommended first for women over 34 (regardless of the type of blockage) because tubal surgery and natural conception may use up precious time if in vitro fertilization might be used later.

Should I have a tubal procedure or in vitro fertilization for tubal infertility?

Endometriosis. If you have mild to moderate endometriosis that seems to be the main reason for your infertility, your doctor may use laparoscopic surgery to remove endometrial tissue growth. If surgery does not work, or if you have severe endometriosis, you will need to decide whether to try in vitro fertilization, commonly called IVF. But understand that IVF doesn't work as well for women with endometriosis as with other causes of infertility.

For more information about endometriosis, see the topic Endometriosis.

In vitro fertilization (IVF). Many couples who have problems getting pregnant arrive at a common point: they must decide whether they want to try IVF. IVF is the most common form of a group of similar procedures called assisted reproductive technology, or ART. If you have not already considered adoption, this might be a time to think about it. Some couples decide at this point to spend their resources on adoption instead of IVF. Other couples see IVF as the best option.

In IVF, the man's sperm is mixed with the woman's eggs in a lab. Sometimes donor sperm or donor eggs may be used. If the egg and sperm join, it is called fertilization. Your doctor then puts one or more fertilized eggs (now called embryos) into your uterus so that they can grow, just as in a normal pregnancy. (Usually, more than one embryo is put in the uterus to increase your chances that one will develop into a baby.)

IVF increases your chance of having more than one baby at a time. Your chance of having twins with IVF is between 1 in 3 to 1 in 4. That means that 1 out of every 3 to 4 women who become pregnant with IVF has twins. The chance of having triplets or more is higher than normal but much less than the chance of having twins. Your chances of multiple births depend on how many embryos are placed in the uterus at one time.

Overall, in vitro fertilization (IVF) is emotionally and physically taxing. You must have regular blood tests, daily hormone injections (some of which are quite painful), and frequent monitoring by your doctor. You will probably have side effects like bloating, weight gain, and nausea, and you risk having serious side effects such as liver and kidney problems. The embryos may not grow into babies and the IVF must be repeated.

The good news about IVF is that about 1 out of 3 women per IVF cycle has a baby (or babies). IVF success depends on your doctor’s skill and experience and your age. For the woman, the older you are, the less likely that IVF will work unless you use donor eggs. Also, the cause of your infertility can affect the success of IVF.

Treatment options that are not as common include gamete or zygote intrafallopian transfer (GIFT or ZIFT). GIFT is the transfer of eggs and sperm into a fallopian tube through a small abdominal incision. ZIFT is the in vitro fertilization of an egg, which is transferred to a fallopian tube through a small abdominal incision. These procedures are rarely done in the United States. Nearly all couples choose IVF, in which the fertilized egg or eggs are placed in the woman's uterus through the cervix. IVF is less expensive than GIFT or ZIFT. It is also less risky because it is not a surgical procedure.

Treatment for male infertility

A semen analysis will be done to see whether the sperm are healthy and if the sperm count is sufficient. Your doctor might recommend that you try insemination first. The sperm are collected and then concentrated to increase the number of healthy sperm for insemination.

If insemination does not work, your doctor may recommend that you try ICSI (say "ICK-see"). ICSI stands for intracytoplasmic sperm injection. In a lab, your doctor injects one of your sperm into your partner’s egg. If fertilization occurs, the doctor puts the embryo into your partner's uterus, just as in vitro fertilization (IVF).

Your doctor may also recommend ICSI if you have had a vasectomy or you have retrograde ejaculation. In retrograde ejaculation the semen is ejaculated into the bladder instead of out through the penis. In these cases, sperm can be taken from the testicles so that they can be injected into an egg.

Also for retrograde ejaculation, the sperm can be recovered from the bladder, washed, and used for insemination.

In very rare cases, infertility problems are caused by hormonal imbalances. Men are then treated with medicine or hormones, such as GnRH, gonadotropins, and bromocriptine, that help the hypothalamus and pituitary gland start normal sperm production.

When healthy sperm are not available or ICSI does not work, your doctor may recommend you use a donor's sperm. Other couples might choose adoption.

For more information on making the decision about treatment, see:

Should I have infertility treatment?

Should I consider a multifetal pregnancy reduction?

What To Think About

Both medicine and assisted reproductive technology, such as IVF, increase your risk of having twins, triplets, or more babies. Currently, about 20% of multiple pregnancies occur naturally, while the other 80% are the result of using fertility drugs or assisted reproductive technology. The majority of these pregnancies are twins, but there are also more triplets (or more) than in the general population.

Complications of multiple pregnancy become more likely with each additional fetus. For more information, see the topics Multiple Pregnancy: Twins or More, Preterm Labor, and Premature Infant.

Other rare complications—such as ovarian hyperstimulation syndrome—can result from hormone shots used to stimulate ovulation, usually for assisted reproductive technology such as IVF.

Infertility treatment success is influenced by many factors, including your doctor's skill and experience, and the cause or causes of your infertility.

Infertility treatment centers are not widely available in some parts of the country, especially in rural areas. You may need to travel for treatment. See the complete Centers for Disease Control and Prevention (CDC) listing of U.S. infertility clinics online in the latest Assisted Reproductive Technology Success Rates report at http://apps.nccd.cdc.gov/ART2005/clinics05.asp.

When you review clinic success rates, be aware that clinics treating more severe infertility problems may have lower success rates. So, it's possible for a clinic with a lower success rate to have greater overall expertise than clinics with higher success rates.

When you review treatment success rates, remember that live birth rates are always lower than ovulation and pregnancy rates. Miscarriages are common among all women and are more likely in women with risk factors such as older age or a poorly controlled chronic health condition.

Prevention

Some causes of infertility are related to lifestyle or other health conditions. To help protect your fertility:

• Avoid using tobacco (cigarettes) and marijuana, which reduce fertility, especially by reducing sperm counts.
• Avoid exposure to harmful chemicals.
• Avoid excessive alcohol use, which may damage eggs or sperm.
• Limit sex partners and use condoms to reduce the risk of getting a sexually transmitted disease (STD). STDs that go undetected and untreated can damage the reproductive system and cause infertility. If you think you may have an STD, get treatment promptly to reduce the risk of damage to your reproductive system. Make sure you know how to use a male condom and/or how to use a female condom.
• Maintain a body weight close to the ideal for your height to reduce the possibility of hormone imbalances. This is very important for men as well as for women.

If you have been diagnosed with cancer and hope to have children in the future, talk to your doctor about preventing cancer treatment–related infertility.

Home Treatment

To decrease your risk of infertility and increase your chances of becoming pregnant, use the following guidelines.

Track ovulation at home

• Estimate when you are ovulating by practicing fertility awareness, including:
  • Tracking your cervical mucus changes.
  • Tracking your basal body temperature on a monthly Fahrenheit temperature chart (What is a PDF document?) or Celsius temperature chart (What is a PDF document?).
  • Tracking your luteinizing hormone (LH) levels with a home ovulation predictor test. Many doctors now recommend home ovulation tests as the best method to track ovulation at home.
• Try this interactive tool to calculate your peak fertility.
• If you know when you will be ovulating, do not have sex during the 5 days before your 6-day "fertile window," which is ovulation day and the 5 days leading up to it. (Not ejaculating for a few days helps build up a man's sperm count.) Then have sex one time each day of your fertile window, including ovulation day. If your partner has a low sperm count, have sex every other day, since frequent ejaculation does temporarily lower sperm count.
• If you don't know when you will next be ovulating, have sex two or three times each week.⁶
• If you exercise strenuously most days of the week, reduce your level of activity. Very strenuous exercise can cause women to ovulate less often.

Protect sperm count and quality

• Avoid alcohol, smoking, marijuana, and other illegal drugs. Any one of these may affect fertility.
• If you use a vaginal lubricant during sexual intercourse, select one that does not kill or damage sperm.
• Stay at a reasonablebody mass index (BMI). This will increase the health of your reproductive system. A high BMI has been linked to reduced semen quality and changes in a man's hormones that may reduce fertility.
• If you exercise strenuously most days of the week, reduce your level of activity. Very strenuous exercise may be a cause of lower sperm counts in some men.
• High scrotal temperatures decrease sperm count and quality⁷, so avoid hot tubs and saunas.
• Try to control fever when you are ill. High fever has been known to have an adverse effect on sperm for 2 to 3 months afterward (sperm take this long to grow from germ cells to mature spermatozoa).

General measures

Now more than ever, it's smart to get regular exercise, eat a healthy diet, reduce or stop caffeine intake, and drink plenty of water. Women who are trying to get pregnant should avoid using alcohol and medicines (including nonsteroidal anti-inflammatory drugs [NSAIDs], such as ibuprofen or aspirin).

Start taking a vitamin-mineral supplement. For women, taking a daily vitamin supplement with 0.4 mg (400 mcg) of folic acid before becoming pregnant reduces the chance of having a baby with a birth defect.

For more information, see the Planning for a Healthy Pregnancy section of the topic Pregnancy.

Medications

Medication or hormone treatments are often the first steps in infertility treatment. They are also used for in vitro fertilization and other assisted reproductive technologies.

Medication Choices

Medications to stimulate ovulation

• Clomiphene citrate (Clomid) stimulates the release of hormones that trigger ovulation. Clomiphene is typically the first choice of treatment for unexplained lack of ovulation because of how easy it is to use—it's taken orally rather than injected, doesn't usually cause severe side effects, and doesn't usually require daily monitoring.
• If clomiphene does not work, your doctor might try hormone shots. These shots, called gonadotropins, directly stimulate the ovaries to produce mature eggs.
• If you have polycystic ovary syndrome, your doctor may suggest a medicine to help start ovulation and restore regular menstrual cycles by correcting insulin resistance.

Medications used for in vitro fertilization

• First, a hormone is used to "shut down" the pituitary, which puts the ovaries in a menopause-like state (menopausal symptoms are common). This is generally done using a gonadotropin-releasing hormone (GnRH) analogue.
• Then ovulation-stimulating gonadotropins are used to trigger ovulation on a schedule. This process is also used before some insemination procedures.

Other medications

• Gonadotropin-releasing hormone (GnRH) (for women and men with low levels of naturally produced gonadotropins) increases the body's production of hormones needed for egg and sperm production. A small pump worn by the user injects a tiny amount of this drug into the body. The drug stimulates the pituitary gland to produce hormones that trigger ovulation in women and sperm production in men.
• Bromocriptine and cabergoline (for women and men) reduces high prolactin levels. High prolactin levels can prevent ovulation in women and can prevent the release of testosterone and production of sperm in men.

What To Think About

Ask your doctor questions about medicines you are considering, including whether there are long-term effects, how long the treatment lasts, how often you must be tested while taking it, and whether there are any side effects that will affect your daily life.

Multiple pregnancy risk

If you have irregular or no ovulation, using medicine or hormones to stimulate ovulation will increase your chances of pregnancy. But these treatments increase your risk of multiple pregnancy, which poses health risks to both you and your fetuses. When considering an infertility treatment:

• Ask your doctor about your risk for having a multiple pregnancy and how to minimize the chance of conceiving more than one fetus.
• Think about how a high-risk multiple pregnancy, and the possibility of having multiple disabled children, might affect your life. For more information, see the topics Multiple Pregnancy: Twins or More, Preterm Labor, and Premature Infant.

Other rare complications—such as ovarian hyperstimulation syndrome—can result from hormone shots used to stimulate ovulation, usually for assisted reproductive technology such as IVF.

Surgery

In some cases of infertility, a structural problem can be treated surgically, increasing the chances of natural conception.

For men, surgery can be used to try to reverse a vasectomy, correct blockage of the reproductive tract, or correct a varicocele (an enlarged vein in the scrotum).

For women, surgery can be used to try to correct a fallopian tube blockage, reverse a tubal ligation, or remove growths from the reproductive tract. Often a structural problem or endometriosis growths (implants) found during a diagnostic laparoscopy are surgically repaired during the same procedure.

Surgery Choices

To reverse a vasectomy or repair a varicocele

Vasectomy reversal, reconnecting of the tubes (vas deferens) that were cut during a vasectomy

Varicocele repair, cutting or bypassing of a vein that has expanded into a varicocele

To correct problems with the fallopian tubes

Fallopian tube procedures, including sterilization reversal

Should I have a tubal procedure or in vitro fertilization for tubal infertility?

To correct problems with endometriosis

Laparoscopic surgery for endometriosis

To correct problems with uterine fibroids

Myomectomy for uterine fibroids

To stimulate ovulation in women with polycystic ovary syndrome

Laparoscopic ovarian drilling, when weight loss and medicine have not stimulated ovulation

What To Think About

When considering a surgical infertility treatment, ask your doctor questions about the surgical procedure, including how many times the surgeon has performed the procedure, what your chances of treatment success are, and how long your recovery time will be.

Other Treatment

Some couples have known problems that are preventing the sperm and egg from traveling to the fallopian tubes, fertilizing, and implanting in the uterus where they develop into a fetus. Other couples have unexplained infertility and want to increase their chances of pregnancy. Insemination and assisted reproductive technology (ART) procedures can improve their odds of pregnancy by introducing the sperm to the egg in the woman's reproductive tract (insemination) or the laboratory (ART).

Insemination procedures flush the sperm through a thin, flexible tube directly into a woman's vagina, cervix, uterus, or fallopian tube. Insemination procedures put sperm closer to the egg, to overcome fertility barriers such as low sperm count and cervical mucus. They are also used with donor sperm and can be combined with other fertility treatments, such as clomiphene or hormone shots.

Assisted reproductive technologies (ART) are procedures to remove eggs from a woman's ovaries (or use donor eggs) and fertilize them with sperm outside the body. One or more fertilized eggs are then transferred to the woman's uterus or fallopian tubes. ART is used to treat infertility caused by problems with fallopian tubes, ovulation, and sperm, as well as endometriosis and unexplained infertility.⁸ These expensive and complex procedures are typically used only after more conservative treatment methods have failed.

In order to closely time and control the success of an ART procedure, doctors commonly control the ovaries with hormone treatment. First, one kind of hormone is used to "shut down" the pituitary gland, which in turn stops the ovaries from making eggs (menopausal symptoms are common). This is called pituitary down-regulation with a GnRH analogue. Then, ovulation-stimulating medicines are used to trigger ovulation on a schedule. This process is also used before some insemination procedures. For more information, see the Medications section of this topic.

Complementary and alternative treatments include the use of acupuncture and dietary changes as well as relaxation techniques and mind-body medicine. Early studies are promising about acupuncture, which may be effective for improving sperm quality and enhancing IVF success rates. It is important to talk with your doctor before you use any complementary or alternative treatments.

Other Treatment Choices

Insemination procedures include artificial insemination (AI) and intrauterine insemination (IUI).

Assisted reproductive technologies include:

• In vitro fertilization (IVF), mixing eggs with sperm outside the body; one or more fertilized eggs are then transferred to the uterus using a thin flexible tube (catheter) inserted through the cervix.
• Intracytoplasmic sperm injection (ICSI), injecting a sperm into an egg and then using a catheter inserted through the cervix to transfer the egg to the uterus.

Gamete or zygote intrafallopian transfer (GIFT or ZIFT) is rarely used because success rates with IVF are as good or better.

For couples with sperm-related infertility, ICSI can be used to achieve the fertilization stage of the in vitro fertilization process.

What To Think About

ART makes it possible to use donor eggs or sperm when it isn't possible to obtain healthy eggs and sperm from one or both partners. Insemination procedures make it possible to use donor sperm.

Overall, IVF-related injections, monitoring, and egg harvesting procedures are emotionally and physically demanding of the female partner. Superovulation with hormones requires regular blood tests, daily injections (some of which are quite painful), and frequent monitoring by your doctor. Other complications, such as ovarian hyperstimulation syndrome, can result (although they are very rare) from hormone shots and assisted reproductive technology such as IVF.

Before deciding on ART treatment, consider the possible emotional and social, financial, religious, ethical and legal questions questions that may come up for you and your partner.

Should I have infertility treatment?

Should I have a tubal procedure or in vitro fertilization for tubal infertility?

For a comparison between ultrasound and laparoscopy for egg collection procedures, see ultrasound in assisted reproductive techniques.

If you have several miscarriages or unsuccessful IVF attempts, talk to your doctor about genetic testing.

Other Places To Get Help

Online Resources

Organizations

Related Information

• Ectopic Pregnancy
• Multiple Pregnancy: Twins or More
• Premature Infant
• Preterm Labor

References

Citations

1. Speroff L, Fritz MA (2005). Female infertility. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 1013–1067. Philadelphia: Lippincott Williams and Wilkins.
2. Lobo RA (2007). Infertility: Etiology, diagnostic evaluation, management, prognosis. In VL Katz et al., eds., Comprehensive Gynecology, 5th ed., pp. 1001–1037. Philadelphia: Mosby.
3. Stanford JB, et al. (2002). Timing intercourse to achieve pregnancy: Current evidence. Obstetrics and Gynecology, 100(6): 1333–1341.
4. American Society for Reproductive Medicine and Society for Reproductive Endocrinology and Infertility (2002). Information on commonly asked questions about genetic evaluation and counseling for infertile couples. Practice Committee Report. Birmingham, AL: American Society for Reproductive Medicine.
5. Al-Inany H (2005). Female infertility, search date April 2004. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.
6. Wilcox AJ, et al. (2000). The timing of the "fertile window" in the menstrual cycle: Day-specific estimates from a prospective study. BMJ, 321(7271): 1259–1262.
7. Speroff L, Fritz MA (2005). Male infertility. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 1135–1173. Philadelphia: Lippincott Williams and Wilkins.
8. Centers for Disease Control and Prevention (2006). Assisted Reproductive Technology (ART) Report: 2005 Preliminary Clinic Data by State and National Summary. Available online: http://apps.nccd.cdc.gov/ART2005/clinics05.asp.

Other Works Consulted

• American College of Obstetricians and Gynecologists (1998, reaffirmed in 2005). Medical management of tubal pregnancy. ACOG Practice Bulletin No. 3. Obstetrics and Gynecology, 92(6): 1–7.
• American Society for Reproductive Medicine (2004). Patient's Fact Sheet: Cancer and Fertility Preservation. Birmingham, AL: Society for Reproductive Medicine.
• American Society for Reproductive Medicine Practice Committee (2006). Multiple pregnancy associated with infertility therapy. Fertility and Sterility, 86(Suppl 4): S106–S110.
• Kumar A, et al. (2007). Infertility. In AH DeCherney et al., eds., Current Diagnosis and Treatment Obstetrics and Gynecology, 10th ed., pp. 917–925. New York: McGraw-Hill.

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