For many, having children is the adventure of a lifetime. However, for those who struggle to conceive, starting a family can be a long and emotionally draining process, full of unknowns, false hopes, guilt, and even shame.
To reduce the stigma surrounding infertility and educate the public about reproductive health and issues that many families face, April 21-28 is National Infertility Awareness Week, a movement founded by RESOLVE: The National Infertility Association.
According to the U.S. Department of Health & Human Services, infertility is common, as about 12 to 13 out of every 100 couples in the U.S. have trouble becoming pregnant.
Shedding light on the issue with a few fast facts is Mazen Abdallah, MD, assistant professor with McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth); and a certified reproductive endocrinologist and infertility expert affiliated with UT Physicians, Memorial Hermann-Texas Medical Center; and medical director at the Houston Fertility Institute.
- Infertility defined
Couples are considered to be dealing with infertility if they have had unprotected intercourse at least two to three times a week for a year and are not pregnant.
For couples in which the female is 35 or older, an infertility work-up should be done after six months of unsuccessful attempts to conceive.
Most of the time, there is an explanation with one of the partners. About 25% of the time, there is a condition with both partners, and 15% of the time, the infertility work-up is normal for both partners and it’s unknown why the couple can’t conceive.
“The good news is, there is treatment available for almost every couple, no matter what the reason is behind their infertility,” Abdallah said.
- Most common causes behind infertility
“The two most common factors behind infertility are either the female is not ovulating or the male’s sperm count is too low,” Abdallah said. An irregular or absent period can be a sign that a woman is not ovulating.
There are some “home tests” to check whether the woman is ovulating. Basal body temperature charting is a common method, where the woman records her temperature first thing in the morning. When she ovulates, there is a one degree Fahrenheit increase in the basal body temperature, due to the production of progesterone, but only 60% of ovulating women demonstrate the temperature pattern. A more accurate method to document ovulation involves checking the surge in LH, the luteinizing hormone that helps the reproductive system. A woman can use “ovulation predictor kits” that use urine test strips, similar to the urine pregnancy test, to check for LH levels. The test will show positive for about two days before ovulation.
A man’s normal sperm count is at least 15 million sperm per milliliter of semen, with 40 percent of the sperm moving, Abdallah said. Over-the-counter sperm tests are unreliable and Abdallah recommends that a man who receives an abnormal result should repeat the test after two to four weeks. If a man develops an illness, his sperm production could be affected, and repeat analysis may show a recovery in the sperm numbers/motility.
If the repeat semen analysis shows abnormal results, the man should see a specialist for a work-up to identify the cause of the abnormality. Abnormalities include low sperm count, low motility, or low percentage of normally shaped sperm. Causes can include a hormone imbalance, an exposure to an environmental toxin, or an anatomic abnormality like a varicocele, an enlargement of veins within the scrotum. Treatment options include hormone therapy, antioxidants, and surgery.
The absence of sperm may be caused by a lack of production or an obstruction preventing the movement of sperm from the testicles to the ejaculate. Treatments range from hormone therapy to surgical intervention.
The third most common cause of infertility is tubal disease, a disorder that occurs when the fallopian tubes are blocked or damaged. Many cases are caused by pelvic inflammatory disease (PID), which is an infection of a woman’s reproductive organs. Other causes of tubal disease, which often doesn’t have symptoms, include a ruptured appendix, pelvic surgery, and endometriosis.
- Taking testosterone can cause low sperm count
“A man diagnosed with low testosterone is often prescribed testosterone replacement therapy (TRT), either via an injection or a topical gel. But what many don’t know is that TRT can shut down sperm production,” Abdallah said. “I speak with couples almost every month who are struggling to conceive and don’t know why, and it turns out the man has been taking some form of TRT.”
If a man takes testosterone replacement, the brain would sense a high level of testosterone and would decrease a hormone involved in making sperm.
“It’s common for men to have low testosterone in their late 30s and 40s, but what’s needed to achieve “normal” testosterone levels may not be ideal for a patient who is trying to conceive,” Abdallah said.
Sometimes simply halting TRT and continuing efforts to try to conceive is successful within a year of stopping treatment. If sperm production does not recover completely after TRT use, the couple may need fertility treatment ranging from insemination to IVF, depending on the sperm concentration.
- More young professionals are choosing to freeze their eggs
“Voluntary egg freezing for the future is a new trend in our field,” Abdallah said. “Many young professionals and students, as they approach age 30 and beyond, like doctors going through residency, are choosing to freeze their eggs. They know they’ll want to have kids later, and want to go ahead and preserve the quality of their eggs. Sometimes, women do it simply because they haven’t met the person they want to spend the rest of their life with yet.”
Freezing eggs used to be offered as a service to women dealing with cancer or other diseases that require treatment that could negatively impact fertility.
“We figured if we could do it for them, we could broaden out the service,” Abdallah said.
- Past medical procedures could have impacted your fertility without you realizing it
“Sometimes treatments patients have undergone in the past impact their fertility, without them realizing that is a side effect,” Abdallah said.
Surgical treatment for endometriosis can negatively impact fertility, especially if cysts are removed from the ovaries or if the surgery led to scar formation in the pelvis. This can affect one or both fallopian tubes, which can lead to tubal blockage.
Conditions and treatments for other illnesses that could impact reproductive health include ovarian cysts, fibroid surgery, appendix surgery, sexually transmitted diseases like chlamydia and gonorrhea, PID, cancer, and eating disorders like bulimia and anorexia.
“Previous termination could also affect fertility, as the uterus can sometimes be scarred during the procedure,” Abdallah said. “Scar formation inside the uterine cavity may prevent implantation of an embryo.”
- IVF has come a long way
“In the early days of IVF, the success rates were low mainly due to the inability to properly grow embryos in culture. Women used to have four or five embryos transferred at the same time to improve pregnancy and delivery rate. This came with a high risk of having twins, triplets, or even higher-order multiples. As the culture techniques improved and we became more efficient in growing embryos to the implantation stage, the number of transferred embryos gradually decreased. Now, we transfer one embryo at a time. In women age 37 or younger, we can have remarkable success. This cuts down on the number of embryos transferred, decreasing the odds of having multiples. One embryo would have to split for you to end up with twins, which is extremely rare,” Abdallah said.
Women age 35 or younger using IVF now have about a 40 percent chance of having a baby. The average cost for IVF in Houston is about $13,000, depending on a patient’s insurance provider.
- When to see a specialist
“Couples attempting conception need to have intercourse at least two to three times a week, especially during the middle of the woman’s cycle. Frequency matters more than trying to have intercourse while the woman is ovulating. If a year has passed and the couple is not pregnant, they should see a specialist. If the woman is 35 or older, they should seek help after six months of attempting,” Abdallah said.
—Amy Laukka, UTHealth