In our first post for National Infertility Awareness Week 2012, Dr. Kerri Luzzo of Reproductive Science Center of New England shares her expertise with a general overview of infertility. Tune in each day this week for a new post from each of our Circle of Support sponsors.
If you’re looking for more information about managing your infertility, come to our free program on Tuesday, April 24th – Coping with Infertility: Managing Stress, Friends, Family & Life. And make sure to check out our jam-packed calendar of free events, programs and fundraisers for National Infertility Awareness Week 2012!
What is Infertility?
Infertility, defined as the failure to achieve a successful pregnancy after 12 months of regular unprotected intercourse in women under age 35 years, or after 6 months in women over age 35 years, affects approximately 10-15 % of couples. About 85-90% of couples will conceive after one year of attempting pregnancy, the majority will conceive in the first 6 months of trying.
Couples that have never been pregnant have primary infertility, while couples that have achieved pregnancy in the past have secondary infertility. Couples with secondary infertility may have problems conceiving with a subsequent pregnancy due to advancing maternal age, increasing weight, change in medical conditions that may affect fertility, or pregnancy complications that affect future pregnancies.
Overall infertility rates in the US are not rising, however clinicians are more informed, the number of infertility treatment centers has increased, and public awareness of infertility has grown.
With regards to the normal human reproductive process, each month the ovary usually ovulates a mature egg, sperm must ascend the fallopian tubes and fertilize the oocyte which typically occurs 12-24 hours after ovulation. The fallopian tubes must capture the oocyte, transport the sperm, and then transport the embryo to the uterus. The uterus plays a role in both implantation and growth of the embryo. Problems with any of these components can affect fertility.
Common Causes of Infertility
With regards to etiology of infertility, approximately 20-40% of couples have ovulatory dysfunction, where regular release of a mature egg does not occur. A portion of these women have polycystic ovary syndrome (PCOS), defined as oligomenorrhea (< 8 menstrual cycles/year) clinical or lab signs of elevated male hormone levels (increased hair growth/acne, or findings of polycystic ovaries on ultrasound. Approximately 30-40% of couples have tubal/pelvic disease, which may cause blocked fallopian tubes, or adhesions that distort normal anatomy thereby affecting ovum pick up and oocyte/embryo transport. A history of pelvic infections or prior surgeries can lead to scarring or blockage of fallopian tubes. Endometriosis, a disease where endometrial glands and stroma are found outside of the uterus can cause both pelvic pain and infertility. Endometriosis may affect fertility by distorting adnexal anatomy, which interferes with the fallopian tube capturing the oocyte or by causing and environment of chronic inflammation that affects the ovaries, fallopian tubes, and endometrium. One third of infertility is male factor due to abnormalities in semen parameters. Depending on the severity of abnormalities in the semen analysis, a repeat semen analysis and urology referral may be recommended. Approximately 10-15% of couples have unexplained infertility, which is a diagnosis of exclusion, and implies evidence of normal semen analysis, uterine cavity and fallopian tubes, and ovulation. Unexplained infertility is more common in women over age 35 years, and therefore frequently related to an age related decline in fertility.
Other Factors Influencing Your Fertility
Other elements that can affect fertility include lifestyle factors. Smoking may lead to earlier menopause, increases time to conception (even in those patient undergoing in vitro fertilization), and increases in both miscarriage and ectopic pregnancy rates. Abnormalities in sperm morphology, motility and density are also associated with smoking. Marijuana, cocaine, and alcohol have all been linked to decreased fertility. Women attempting pregnancy should avoid tobacco and other drugs, and limit alcohol and caffeine intake.
Obesity also plays a major role in the ability to achieve pregnancy. Women that are obese (body mass index or BMI >30) have increased rates of anovulation, longer times to conception, and are more likely to need fertility treatments. In treatment cycles, obese women often require higher doses of medications, have lower estrogen levels, and in some studies have poorer embryo quality compared to non-obese women. When obese women do achieve pregnancy, they have higher rates of pregnancy complications including miscarriage, gestational diabetes, hypertension, cesarean delivery, and congenital anomalies.
Fertility and Age
Age also plays a major role in fertility. Fertility peaks between age 20-24 and then starts to decline progressively around age 32. As women age, becoming pregnant becomes more difficult, live birth rates decrease, and miscarriage rates increase, as do rates of pregnancy complications including gestational diabetes, hypertension, and fetal chromosomal abnormalities.
The age related decline in fertility is due to a decrease in both oocyte quality and quantity. A woman has the maximum number of oocytes as a fetus at 20 weeks gestation (6-7 million); this number progressively declines from that point to 1-2 million at birth, 300,000-500,000 at puberty, and 25, 000 at age 40 years. With age, aneuploidy rates also increase leading to higher rates of miscarriage.
What to Expect When Seeing a Reproductive Endocrinologist
When couples seek treatment from a fertility specialist, the physician usually orders tests to further evaluate a potential cause for infertility. This may include a semen analysis, a hysterosalpingogram to evaluate the uterine cavity and patency of fallopian tubes, bloodwork to evaluate hormones that may affect menstrual cycles and fertility including thyroid function and prolactin, and ovarian reserve testing.
Uterine cavity imaging is important to evaluate for congenital anomalies, fibroids, polyps, or adhesions; all of which may affect fertility. Ovulation is assessed by menstrual history, basal body temperature, serum progesterone levels, and urine luteinizing hormone (LH). Home ovulation predictor kits measure the urinary LH, which is important in terms of timing intercourse or insemination. The day of the LH surge and the 2 following days are the most fertile days in the cycle. After the initial evaluation, couples often meet their physician to determine a treatment plan.
Understanding Your Treatment Options
Treatment options are individualized based on the patient’s history, lab results, and age. Some of these treatment options may include medications to induce ovulation such as clomiphene citrate with intrauterine insemination, injectable medications such as follicle stimulation hormone (FSH) with intrauterine insemination, or in vitro fertilization (IVF).
Success rates with any type of treatment vary based on diagnosis and patient age. Overall maternal age is one of the most important prognostic indicators for success with IVF. For fertile couples, per cycle live birth rate is only 20-35% in humans, which is a good number to keep in perspective when comparing the efficacy for different treatment options. IVF is indicated with severe tubal disease, severe male factor infertility, when there are multiple factors involved with infertility, with advanced maternal age, or when other treatments have not been successful.
Some couples choose to proceed with IVF to prevent a genetic disorder from being passed down to their children. Preimplantation genetic diagnosis (PGD) is a process where one cell is removed from a cleavage stage embryo and tested for a specific genetic disorder to try to reduce the risk of having a child affected with that disorder.
With any fertility treatment there is a risk of multiples (twins, triplets, and higher), and with a multiple gestation pregnancy there is increased health risk in for both Mom and Baby. As technology improves, and more fertility centers promote single embryo transfer in the appropriate patients, we will hopefully continue to minimize rates of multiples while not compromising overall pregnancy rates for our patients with infertility.
About the Author
Dr. Luzzo earned her medical degree at the Medical College of Wisconsin and completed her residency in Obstetrics and Gynecology at Tufts New England Medical Center in Boston, where she served as administrative chief resident. Board certified in Ob/Gyn, Dr. Luzzo’s sub-specialist fellowship training in Reproductive Endocrinology and Infertility was earned at Washington University School of Medicine in St Louis. Dr. Luzzo currently acts as an ad hoc reviewer for articles submitted to ‘Fertility and sterility’, a journal read worldwide by reproductive endocrinologists.
Dr. Luzzo is a member of the American Society for Reproductive Medicine (ASRM), the New England Fertility Society (NEFS), the American Congress of Obstetricians and Gynecologists (ACOG) , the Society for Gynecologic Investigation (SGI), and is an associate member of the Society for Reproductive Endocrinology and Infertility (SREI).
Dr. Luzzo is helping patients find solutions to their fertility challenges at the RSC New England Center in Providence, Rhode Island. (134 Thurbers Avenue, Suite 207).