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What is it?
Often, 'infertility' is the word used to describe a decreased ability to produce children. The word 'infertile' sometimes means sterile (not being able to have children at all) while the term 'subfertility' is used to describe a lower-than-normal ability to reproduce. A more detailed definition of infertility from Resolve: the National Infertility Foundation follows:

Infertility is defined as the inability to conceive after one year of unprotected intercourse (six months if the woman is over age 35) or the inability to carry a pregnancy to live birth.
Women who have stopped taking oral contraceptives (birth control pills) may not regain fertility for up to 15 months, and those who have stopped using injectable methods of contraception may not regain fertility for up to 18 months. Additionally, women over the age of 35 may have more trouble than younger women conceiving a child because female fertility declines with age.
 

What causes it?
Most couples who are trying actively to have a child experience successful conception rates of about 20%-25% per month. Conception means becoming pregnant. It is the fertilization of a woman's egg by a man's sperm. Surprisingly, though, the biological process of having a child is not always simple. Both the male and female reproductive systems are quite complicated. For successful conception and pregnancy, a series of complex and interconnected hormonal events must take place with relatively precise timing. Even a small disturbance in any one of these processes can result in infertility. Although infertility is not a life-threatening condition, it can be both emotionally and financially difficult.

Either or both members of the couple may have health issues contributing to infertility. The National Women's Health Information Center estimates that about one-third of infertility cases have causes relating to the man (male factors). Roughly another third of cases have causes related to the woman (female factors), and the remaining cases have multiple or unknown causes. Although abnormalities in the reproductive system account for most cases of infertility, other physical factors that can affect fertility include extreme exercise activity, injuries, and being overweight or underweight. In addition, being exposed to certain chemicals, taking certain prescription medications, using illegal drugs, smoking cigarettes, drinking alcohol, or consuming high amounts of caffeine can also decrease fertility. Along with physical causes, fertility can be affected by other factors such as anxiety and stress.

While most infertility results from long-term conditions, some causes of infertility may be temporary. For example, a man who uses a sauna or holds a portable computer on his lap for an extended length of time may be less fertile than usual for several hours or days afterward because heat decreases sperm production and functioning. Also, an active infection of the reproductive tract may interfere with either male or female fertility until the infection is cured.

Who has it?
In the United States, the number of individuals treated for infertility problems is on the rise. One reason may be that many individuals are marrying later and couples are waiting to start their families. The chance of infertility is higher in women who are in their late 30s and 40s. Another reason may be that infertile couples are more open about asking for medical help than they might have been a few years ago. Changing sexual practices may also contribute. Having an untreated sexually-transmitted disease (STD), such as chlamydia or syphilis, often leads to scarring in the reproductive tract which results in infertility.

According to a survey conducted in 2002 by the National Center for Health Statistics, approximately 12% of women between 15 and 44 years of age in the United States (over 7 million women) reported fertility problems. About a million of these women reported seeing a doctor specifically to be counseled or treated for infertility. Over their reproductive years, about one-quarter of American women who want to have a child will have some difficulty getting pregnant. In addition, nearly 2 million American men are estimated to have some degree of infertility.

What are the risk factors?
Certain risk factors (traits or actions that contribute to having certain conditions) are associated with infertility. Early detection and treatment of infertility may help to prevent problems that are more serious later, so couples having difficulty conceiving should consult a doctor if any of the following risk factors for infertility are present.

Risk Factors for Men

• Chronic conditions such as diabetes, hypertension, psoriasis, or ulcers (and some of the medications used to treat them)
• Exposure to hazardous chemicals (such as lead, mercury, or pesticides) or other toxins (such as radioactivity or x-rays)
• Having the mumps after puberty (the age when sexual organs mature)
• Heavy alcohol consumption
• Hernia surgery
• Obesity
• Prostate gland infection
• Sexually transmitted diseases (STDs) such as chlamydia, gonorrhea, or syphilis
• Smoking cigarettes or marijuana
• Stress or anxiety
• Traumatic injury
• Undescended testicles (the testicles remain in the abdomen rather than moving into the scrotum before birth; also called cryptorchidism or empty testicles)
• Use of diethylstilbestrol (DES) by the man's mother during her pregnancy
• Use of hot baths, saunas, steam rooms, or whirlpools

Risk Factors for Women

• Abnormal pap smears, especially those that resulted in treatment with cryosurgery (the use of intense cold to destroy abnormal cervical tissue) or a cone biopsy (surgery to remove a small section of abnormal tissue from the cervix)
• Age over 30
• Chronic conditions (such as arthritis, asthma, diabetes, hypertension, systemic lupus erythematosus) and some of the medications used to treat them
• Eating disorders
• Ectopic pregnancy (pregnancy outside the uterus)
• Endometriosis or a family history of endometriosis in close female relatives (mother, sisters)
• Extremely intense regular exercise
• Hair growth on unusual areas such as the face; acne on the face, chest, or abdomen; mannish facial features
• Heavy alcohol consumption
• Irregular menstrual cycles or very heavy menstrual flow
• Multiple miscarriages or abortions
• Obesity
• Ovarian cysts
• Pelvic surgery
• Ruptured appendix
• Sexually transmitted diseases (STDs) such as chlamydia, gonorrhea, or syphilis
• Smoking cigarettes or marijuana
• Stress or anxiety
• Traumatic injury
• Tubal surgery
• Use of an intrauterine device (IUD) for contraception
• Use of diethylstilbestrol (DES) by the woman's mother during her pregnancy
• Very low body fat

What are the symptoms?
Infertility has no easily recognized symptoms. In fact, most individuals do not even realize they are infertile until they try to conceive a child. However, only about 45% of infertile couples seek medical help.

For those undergoing medical evaluation of fertility, the first step is usually complete physical examinations to rule out medical causes, such as sexually transmitted diseases (STDs) for both partners. Each will also be checked for structural abnormalities, such as undescended testicles (for men) and missing or blocked fallopian tubes (for women). Additionally, medical histories will be taken to identify potential contributing factors such as past abdominal infections and previous surgeries. For women, information about menstrual cycles, previous pregnancies, and use of contraceptives will be needed.

Typically, the next steps in evaluating couples for infertility are:

• an analysis of the man's semen
• an evaluation of the woman's ovulation
• Semen Analysis
• Ovulation Detection
• Additional Testing

How is it treated?
Since infertility has multiple causes, treatment options for it are also varied and many are directed at underlying causes. Timing sexual intercourse for probable dates of ovulation is a common first step. Some study evidence suggests that male hormone levels are higher in the morning and that sperm counts are higher in colder weather than in hot weather. Lifestyle changes (for instance, giving up cigarettes, losing or gaining weight, moderating extremely vigorous exercise programs, and reducing or eliminating the intake of alcohol and caffeine) are recommended for both partners. Counseling and/or medications may relieve anxiety, depression, or other psychological factors contributing to infertility. If the cause is a reproductive-tract infection, antibiotics or antiviral drugs may be enough to restore fertility. Treating health conditions such as diabetes and hypertension, or changing the prescription drugs used to treat them may also reduce infertility for some individuals. Occasionally, blocked reproductive structures may be re-opened by surgery.

If male infertility results from a low sperm count, therapy with male hormones may help. When female infertility is caused by decreased ovulation, certain medications and female hormones can be used to induce ovulation (help stimulate the woman's body to produce mature eggs). It is important to know that most drugs and other infertility treatment options increase the chance that a woman has multiple fetuses (twins, triplets, other multiples). In cases of multiple births, there is an greater chance that the babies will be born early and have developmental and/or health problems. This issue should be discussed with a doctor before starting fertility treatment. For more information about medications used in infertility treatment, click the drug classes links below.

Infertility treatment options other than medications include:

• No Treatment
• Intrauterine Insemination (IUI)
• Assisted Reproduction Techniques (ART)

Drug classes used to treat Infertility

• Biguanides
• Dopamine Agonists
• Estrogen Agonist-Antagonists
• Gonadotropin-Releasing Hormone Analogs (GnRHa)
• Gonadotropins
• Thiazolidinediones

Health Conditions

What is on the horizon?
Much of the current research on infertility involves its causes and the conditions that may contribute to it, in addition to new treatments. For example, fertility researchers at the National Institute of Child Health and Human Development (NICHD) have been looking at several general factors involved in human fertility that include:

• Structures of both male and female reproductive tracts
• Actions of the hormones that regulate fertility
• Functions of the ovaries and testicles
• Mutations of genes responsible for reproductive functions

Researchers continue to try to find ways to improve current treatment options such as assisted reproduction techniques. For example, a screening method known as preimplantation genetic diagnosis (PGD) is being developed and tested so that doctors may identify which embryos are the highest quality for transfer to a woman during in-vitro fertilization.

Aging

In addition, investigators are trying to understand why fertility decreases as a woman ages and how to slow or stop this process. There is also the possibility of a woman being able to freeze her eggs for future use if she wishes to delay pregnancy until she is older.

Uterine Transplantation

Another alternative that is currently being studied is uterine transplantation. This treatment would be an alternative to using a surrogate mother (a healthy woman who agrees to have the fertilized egg or eggs implanted in her uterus). However, like other transplant patients, uterine transplant patients would require drugs to prevent the immune system from rejecting the donor organ. These drugs often have unwanted side effects and need to be taken for life. Although some progress has been made with this and other new treatment options, it is unlikely that they will be widely available to women anytime soon. It will take many years to determine whether these new treatment options are safe and effective.

Nutritional Factors

Other research has uncovered possible nutritional factors that may contribute to infertility that is not explained by physical or emotional factors. For example, low levels of folic acid, a type of vitamin B found in fruits, vegetables and other foods, may be associated with infertility in men. Folic acid has long been known to help prevent birth defects of the spine when pregnant women take it, and taking it may improve female infertility, too. Trace elements are chemicals such as aluminum and zinc that the body needs in very small amounts. Shortages of some of these trace elements are also believed to decrease fertility. Zinc deficiencies may contribute to genetic damage that may result in both male and female infertility because zinc is a component of DNA. One study of infertile men has shown a significant increase in sperm production among men who took supplements containing folic acid and zinc. Essential fatty acids (EFAs) are needed by both men and women to make sex hormones and they may have effects on semen and cervical mucus. Other dietary supplements, such as carnitine (found in meat and milk) and melatonin, have been tested for their effects on infertility in men. Results of studies on the role of nutrients and dietary supplements in infertility are not conclusive.

Antioxidants

Frequently called reactive oxygen species (ROS), oxygen free radicals are highly-active molecules that result from normal body processes. Inside the human body, oxygen free radicals may cause damage to other cells including sperm and eggs. They may also contribute to infertility risk factors, such as endometriosis. Antioxidants, for instance beta carotene, selenium, and vitamin C, are substances that help to limit damage from oxygen free radicals. Studies conducted in Australia and India suggest that naturally-occurring antioxidants such as lycopene seem to help improve fertility in men. Research on the effects of oxygen free radicals on fertility in women is less advanced, but studies are underway for both men and women.

Cancer and Infertility

For individuals who may become infertile due to radiation or chemotherapy treatments for cancer or other diseases, sperm or eggs may now be collected before the therapy begins. In a procedure known as cryopreservation, healthy sperm or eggs are taken from the patient and frozen, before therapy begins. After the damaging treatment, the eggs or sperm may be used for ART procedures. More recently, cells from testicles and ovaries have also been cryopreserved and then re-implanted to restore at least partial reproductive function after treatments are ended. Doctors may also use infertility medications to minimize reproductive organ damage during cancer treatment. In a procedure that is beginning to be used more frequently for children, adolescents, and young adults, FSH and LH levels may be suppressed by drugs known as GnRH analogs during the cancer treatment. As a result, the testicles or ovaries become inactive and, therefore, less likely to be damaged by drug or radiation treatments. After the therapy is over, at least partial normal function may be restored.

Long-term Effects of ART

Finally, researchers are focusing on the long-term effects of ART on all members of the family. If ART is not successful, both partners may suffer psychological consequences, such as depression and loss of self-esteem. Procedures that result in live births - especially those producing three, four, or more babies at the same time - often create unexpected physical, financial, and emotional stresses for the family. Frequently, ART procedures produce multiple-infant pregnancies and women pregnant with more than one child are more likely to develop complications during pregnancy. Both multiple and single children born after ART are more often delivered early. They also tend to be lower in birth weight than other babies. Being born early and/or weighing less than five and a half pounds at birth may contribute to breathing, heart, intestinal, and vision problems. In addition, results of a few studies seem to show that some children born as the result of ART may be at a slightly greater risk of having certain birth defects, developmental abnormalities, genetic conditions, or learning disorders than children who are conceived naturally. Whether the tendency to have these conditions is due to ART, to the factors causing the infertility, or to other causes has yet to be determined.

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