The American Society of Reproductive Medicine defines infertility as the inability to conceive after one year of unprotected intercourse in women under the age of 35. In women over 35, the time frame is shortened to six months.       

       The incidence of infertility increases as the female ages reflecting the normal decline in egg quality experienced with age. Infertility in men is not age dependent (until after 55 year of age) thus, a child can be fathered until very late in life. On average, a normal fertile couple has a 20% - 25% chance of conceiving during any cycle (month) where regular intercourse occurs.

       Many women are choosing to have children later in life, after they have established their careers and achieved financial security. Unfortunately, the biological time clock does not match these socioeconomic choices as peak fertility usually occurs between the ages of eighteen and twenty-five. Women over the age of thirty five have a much higher incidence of infertility and are more likely to miscarry or have a child with a chromosomal abnormality. Women over forty are unlikely (10-15% chance ) to become pregnant even using assisted reproductive technology such as IVF, unless they use donor eggs from a younger woman (which gives them perhaps as high as 65-70% chance of success).

      Over the last several years, specialists have become much more aware of the role of male infertility. It is estimated that there is a male component is up to 49% of infertility cases. Rarely, should any treatment of the female begin until the male evaluation is complete. Male fertility is evidenced by a low sperm count and/or abnormalities in one or more of many other measured parameters( motility, sperm shape, viability). The male partner must receive a thorough semen analysis at the beginning of the infertility evaluation before treatment of the female begins.

      Infertility is a complex condition with numerous potential causes. Reproductive Endocrinologists are Infertility Specialists who undergo years of advance training, enabling them to diagnose and treat infertility. There is no short cut or "magic treatment". Each couple is different and thorough evaluation of the male and female are always warranted.

Each brief description of the common causes of infertility links to a complete discussion:

      Ovarian- One cause of infertility is failed ovulation, which is termed anovulation (lack of ovulation) or oligoovulation (irregular ovulation). Ovulatory disorders can be caused by many conditions including PCOS, excessive exercise, a small tumor benign tumor on the pituitary gland, ovarian failure due to age, genetics, premature menopause (age less than 40), radiation or chemotherapy.

      Ovulation is controlled by a complex interaction of several hormones including follicle stimulating hormone, leutinizing hormone, and estrogen. The hypothalamus, a small gland at the base of the brain, is responsible for monitoring, or regulating, the levels of these hormones. The action and interaction of these hormones is discussed in detail in the section on ovulatory failure.

      Medications such as Clomid or gonadotropins-FSH or HMG (Gonal-F, Follistim, Menopur, Repronex, Bravelle) are often used to regulate or cause ovulation. Clomid acts at the level of the hypothalamus while FSH and HMG act directly upon the ovaries.

      Tubal Factor- The egg must travel to the end of the fallopian tube where fertilization occurs. If the tube is blocked or damaged, the eggs movement is impeded. Endometriosis can attach to, and penetrate, the tubes causing damage and blockage.

      The tubes can be scarred by previous surgery (tubal ligation, ectopic pregnancy, ruptured appendix), damaged by pelvic inflammatory disease, gonorrhea or chlamydia infections, or the tubes may be deformed or missing at birth (rare). In many cases, women who previously had their tubes "tied", as a means of birth control, seek to have the procedure reversed.

      Endometriosis- Endometriosis is a common cause of infertility and can affect reproductive organs including the tubes, uterus, and ovaries. Endometrial tissue (cells of the uterine lining) can attach to virtually any internal organ where it grows causing damage and inflammation. If some cases, the endometrial tissue can penetrate the organ it is attached to. Therapy consists of medications which lower the level of estrogen and/or surgical removal.

      Uterine Factor- Once fertilization occurs, the embryo travels to the uterus where it implants in the endometrium (lining of the uterus). The endometrium must be thick and vascular to provide an optimal environment for the developing embryo. Estrogen and progesterone stimulate endometrial development and must be present in the correct amounts at the right time in the cycle. The uterine cavity must also be free of fibroids or polyps which could interfere with embryo implantation. Medications can be used to stimulate endometrial development. hysteroscopic surgery (going inside the uterine cavity with telescope, without any external incisions) is usually effective in removing polyps and fibroids.

      Cervical Factor- Once ejaculated the sperm must "swim" from the vagina through the cervix to the end of the fallopian tubes. There must be sufficient "high quality" mucus to provide support for the sperm. The cervical fluid must also be free of antibodies produced by the female that can destroy the sperm. IUI is usually the treatment of first choice for cervical factor infertility.

      PCOS- Polycystic ovarian syndrome is a common cause of infertility in women. PCOS is characterized by ovaries with many small cysts, being overweight, excess body hair, and a "pear shaped" body appearance. Women with PCOS have abnormally high levels of male hormones "androgens". PCOS is treated with Clomid or FSH stimulation and sometimes with surgery (ovarian drilling).

      Unexplained- Sometimes no exact cause for a couple's infertility can be identified and this is termed "unexplained infertility". There is a cause(s) but science has not advanced to the point where it can be identified. These couples may receive up to three cycles of IUI and if this is not successful IVF is usually indicated.

      Male Factor- The importance of male factor cannot be overemphasized      since almost 50% of couples have some degree of male infertility. The semen analysis is the cornerstone test to measure the quantity and quality of sperm.

      Be sure and read the detailed descriptions of each of the potential causes.

      Infertility, which has multiple causes and consequences, is a global public health concern: About 10 percent of all couples worldwide are or have been infertile. Because family planning professionals devote much of their careers to helping clients avoid unintended pregnancies, they may neglect the issue of unintended infertility. But efforts to better prevent, diagnose, and treat the main causes of unintended infertility could help preserve the fertility of millions worldwide. Key points highlighted in this issue of Network are that:

       * infertility often involves both members of the couple;
       * sexually transmitted infections (STIs) are the primary preventable causes of infertility;
       * chlamydial infection and gonorrhea are the two STIs most clearly associated with infertility
       * screening can identify these two often-silent STIs;
       * postpartum and postabortion infections are also associated with infertility; and
       * contraceptive use does not cause infertility. 

      Although infertility is considered by some to be primarily a woman's problem, men often contribute to and are also affected by it. Thus, the issue explores how infertility affects men, the ways in which men can protect themselves and their partners from STIs, and how reproductive health programs and clinics can help men understand and prevent infertility.

In this issue

Defining Infertility

      What does infertility mean for clinicians and clients? This introductory article explores the complex causes and consequences of infertility, which often involves both members of a couple. Although sexually transmitted infections are the primary preventable causes of infertility, postpartum and postabortion infections are also associated with this condition. Other threats to fertility are described in Factors Contributing to Infertility and Harmful Traditional Practices Can Hinder Conception. A common misconception that some contraceptives cause infertility may be a powerful disincentive to contraceptive use, but Contraception and Return to Fertility dispels these misunderstandings. Emphasizing that each case of infertility is unique in its causes, consequences, and outcomes, the article includes One Couple's Story: The Uncertainty of Infertility and a discussion of The Possibility of Assisted Reproduction, with a Web Resource providing an additional source of information on the topic.

Preserving Fertility

      This article by Dr. Willard Cates, Jr., president of FHI's Institute for Family Health, underscores the fact that the main preventable causes of infertility are sexually transmitted infections (STIs), primarily chlamydial infection and gonorrhea. Because these widespread and easily transmitted infections are often "silent" or asymptomatic, Dr. Cates argues, active screening of sexually active persons for these particular STIs is crucial. Otherwise, few women will realize that they have a fertility-threatening infection until they try to become pregnant and are unable to do so. Why chlamydial infection and gonorrhea are so widespread is described in The Most Easily Transmitted STIs and evidence linking them to tubal infertility is reviewed in Global Trends Confirm STI-Tubal Infertility Link. Although diagnosing these two infections may be problematic in many developing-world settings, they are easily treatable (STI Treatment Guidelines) with antimicrobial drugs available throughout the world. Because treating men infected with chlamydia can protect the fertility of their partners, an accompanying article explores the question Should Men Be Screened for Chlamydia? A recommendation to expand the dual protection message to include infertility prevention is presented in Triple Protection Addresses Unplanned Pregnancy, Infections, and Infertility. Finally, Programs Begin to Emphasize STI, Infertility Link explores what programs can do to raise awareness.

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