WVU Home
Search:DepartmentHealth Sciences CenterWVU  Go
West Virginia University, Robert C. Byrd Health Sciences Center A-Z WVU Site Index Campus Map WVU Directory Contact Us WVU Home School of Medicine

Department of Obstetrics and Gynecology -
WVU Center for Reproductive Medicine

Potential Causes of Fertility and Basic Treatment Options

Definition

Infertility is defined as failure to conceive after one year of noncontracepted intercourse. Approximately 15-20% of all couples experiences some form of infertility. When performing an evaluation for infertility, we feel that it is important to consider all potential causes. The causes for infertility can be categorized as female factors, male factors, and couple factors.

Female factors

Disorders of ovulation:

Normal Menstrual Cycle: In the absence of pregnancy or the use of hormonal contraception, a single egg (oocyte) is released approximately once a month during the reproductive life of a woman. The length of the menstrual cycle is calculated by counting the number of days from day one of menses (period) until day one of the next menses. Although a 28-day cycle is considered normal, cycle intervals of 21-35 days may also be normal. The normal menstrual cycle is the result of a carefully coordinated interaction between the brain, the pituitary, the ovary, and the uterus. The simplified explanation for this interplay is as follows:

  1. An area in the brain called the hypothalamus tells the pituitary what to do with the hormone, Gonadotropin Releasing Hormone (GnRH).
  2. The pituitary tells the ovary what to do with the hormones Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH).
  3. The ovary produces hormones (estrogen and progesterone) and proteins that send information back to the hypothalamus and pituitary as well as directing normal development of the uterine lining.

When all of the hormonal signals interact normally, ovulation occurs. The normal menstrual cycle can be considered as consisting of 3 parts:

  1. Follicular Phase: When the egg is developing, the egg plus the surrounding cells and fluid make up a cyst which is known as a follicle. The dominant hormone is estrogen and causes the lining of the uterus (the endometrium) to thicken or proliferate. The length of the follicular phase can vary.
  2. Ovulation: When the follicle ruptures and the egg is released.
  3. Luteal Phase: After the follicle ruptures, the cells that originally surrounded the egg undergo changes and form a structure called the corpus luteum. The corpus luteum may exist as a cystic structure of varying sizes and primarily secretes the hormone, progesterone, which causes the endometrium to change and become secretory. The length of the luteal phase is usually 12-14 days.

A more complete explanation is available in the glossary under ovulation.

Abnormal menses or ovulation:
Absence of menses (amenorrhea) or menses occurring at irregular intervals implies absent or infrequent ovulation. Lack of ovulation can occur even when the menstrual cycle is fairly regular. Other abnormalities of ovulation associated with regular menstrual intervals include and the luteal phase defect. A critical area of concern is that of the impact of age on fertility. Women are born with a fixed number of eggs and there is a progressive loss of eggs throughout her reproductive years, even if she is pregnant or on oral contraceptives. A shortage of responsive eggs has been called decreased ovarian reserve. Thus, the eggs that remain may be more resistant to stimulation and may be more likely to carry genetic abnormalities. This results in:

  • A diminished chance for achieving pregnancy in a given cycle. This decline begins to become noticeable in the mid 30's
  • An increased risk of miscarriage

The premature loss of functional eggs is known as premature ovarian failure.

  • Tests for defects of ovulation: The patient can perform Basal Body Temperatures or home monitoring with ovulation predictor kits. Ultrasound monitoring, measurement of hormones, and biopsies of the lining of the uterus can also be used to assess the normalcy of ovulation. Decreased ovarian reserve can be assessed by ovarian reserve testing which involves the measurement of specific hormones at certain times in the cycle
  • Treatment: The initial consideration for the treatment of defects of ovulation is to utilize medications or surgical procedures that restore a normal hormonal environment that will hopefully result in spontaneous ovulation. When that goal cannot be achieved, then medications are used to:
  • Replace, increase, or decrease the release of Gonadotropin Releasing Hormone (GnRH)
  • Replace or increase the release of Follicle stimulating hormone and luteinizing hormone (FSH and LH)
  • Replace or increase the midcycle surge of LH
  • Replace or increase progesterone during the luteal phase.
  • Diminished ovarian reserve or premature ovarian failure will require Assisted Reproductive Technologies including donor oocytes.

Cervical factors:
Normal: During a normal ovulatory cycle, the estrogen that is produced by the cells surrounding the egg causes an increase in the amount of cervical mucus and causes the mucus to become thin and watery. These changes allow the sperm to more easily penetrate and move within the mucus.

Abnormal: Birth defects involving the cervix, prior treatment of abnormal pap smears (cryotherapy, laser therapy, cone biopsies), or exposure to specific medications can have an adverse impact upon the cervical mucus.

  • Tests: The postcoital test is intended to evaluate the interaction between the cervical mucus and the semen. After the couple has intercourse, the patient comes to the clinic where mucus is removed from the cervix and observed under a microscope. Another test called the sperm-mucus interface test involves placing a drop of sperm and a drop of mucus on a slide and observing their interaction.
  • Treatment: Various hormonal and non-hormonal therapies have been suggested.
  • Discontinuation of offending medications or adding other medications.
  • Bypassing the cervix by performing intrauterine insemination.


Uterine factors:
Normal: A normal uterine cavity is essential to allow implantation of the fertilized egg. The lining of the uterus (endometrium) must be exposed to appropriate levels of estrogen and progesterone in order to adequately development.

Abnormal: Defects of ovulation or exposure to certain medications may interfere with this normal endometrial development. Anatomic problems with the uterine wall or the endometrial cavity may also prevent normal implantation. Such abnormalities include birth defects, intrauterine scarring from prior surgical procedures, or tumors of the uterine lining or uterine wall.

  • Tests: The Hysterosalpingogram (HSG) is an X-ray study in which dye is injected through the cervical canal into the uterus and tubes in order to detect any abnormalities. Sonohysterography is a procedure in which fluid is injected into the uterus and ultrasound is used to look at the shape of the uterine cavity. Hysteroscopy is a procedure where the uterine cavity is directly observed with a scope. The choice of evaluation will be determined along with you by your provider.
  • Treatment:
  • Changing the type of medications used to treat abnormalities of ovulation or using additional hormonal therapy can treat inadequate endometrial development.
  • Surgical therapy is required for treating anatomic abnormalities. The surgery may be able to be performed while performing diagnostic hysteroscopy, but sometimes will require the abdomen to be opened in order to perform the appropriate procedure.

Tubal factor:
Normal: The fallopian tubes are more than just pipes that carry the egg to the uterus.

  • The ends of the tubes, the fimbria are delicate structures that must be able to sweep over the surface of the ovary in order to pick up the newly released egg.
  • Each subsequent portion of the tube has different appearances and functions. Fertilization takes place within the tube and early development occurs within the tubal environment.

Abnormal: Any condition that prevents the tube from picking up the egg, prevents the sperm from reaching the egg, or prevents the fertilized egg from reaching the uterine cavity will result in infertility.

  • Tests: The Hysterosalpingogram (HSG) is an X-ray study in which dye is injected through the cervical canal into the uterus and tubes in order to detect any abnormalities. Laparoscopy is a surgical procedure that allows direct visualization of the tube. Other surgical procedures have been developed to view the tube through an incision in the vagina or for viewing the inside of the tubes through a scope passed up through the cervix and uterus.
  • Treatment: Surgical therapy or procedures performed under X-ray guidance may be able to reopen blocked tubes and restore normal pelvic anatomy. When such procedures are unsuccessful or are felt to have poor potential for success, then Assisted Reproductive Technologies are required.


Peritoneal factors:

Normal: The peritoneal cavity is the area in your body that contains the intestines and reproductive organs. The role of the cells that line this cavity in normal reproduction are uncertain; but can be considered to provide an environment where normal development of the egg can occur, where the tube and ovary can interact to allow the egg to be picked up, and the sperm and egg can interact within the fallopian tube.

Abnormal: These are factors outside of the uterus and tubes that might interfere with fertility.

    • The presence of scar tissue (adhesions) that have developed as a result of prior pelvic surgery
    • The presence of scar tissue as a result of prior pelvic infections
    • Endometriosis (the presence of endometrial tissue outside of its usual location within the uterine cavity) may lead to scar tissue that prevents the normal interaction between the tubes and ovaries. Endometriosis also appears to be able to interfere with fertility even when the tubes are open. This interference would appear to be due to inflammatory chemicals that are secreted by endometriosis and in response to the presence of endometriosis.
  • Tests: Laparoscopy is usually required to diagnose peritoneal factors.
  • Treatment:
    • Surgical therapy is used to treat adhesions.
    • Surgical and hormonal therapy can be used in the treatment of endometriosis.
    • When such procedures are unsuccessful or are felt to have poor potential for success, then Assisted Reproductive Technologies are required.

Male Factors:

Sperm production is a complex series of events that requires approximately 74 days to complete. Just as with ovulation in the female, the hormonal component of sperm production requires a coordinated effort between the brain, the pituitary, and the testes.

Normal

  • The hypothalmus communicates with the pituitary with the hormone Gonadotropin Releasing Hormone (GnRH)
  • The pituitary communicates with the testes the hormones Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH)
  • The testes are being stimulated to produce sperm and the male hormone testosterone as well as other proteins and hormones that are needed for normal sperm development and function.

Abnormal

  • Conditions that affect glands other than the testes such as the thyroid, pituitary, or adrenal may lead to abnormal sperm production.
  • Chronic medical conditions and the medications used to treat these conditions
  • Infections
  • Exposure to environmental toxins (heavy metals or other industrial exposures)
  • Conditions that interfere with normal transport of the sperm from the testes to the penis or normal ejaculation
  • Anatomic (obstruction or abnormal external genitals)
  • neurologic (nerve injuries or conditions such as diabetes)
  • Antibodies or abnormalities of sperm function might prevent the sperm from penetrating the egg and causing fertilization.

Tests: The basic semen analysis measures the quantity and quality of the sperm. If an abnormality is found, the following is usually done:

  • a complete history and physical examination
  • hormonal studies
  • more advanced evaluation of sperm and sperm function may be required

Treatment

  • Treatment of other medical conditions, the use of antibiotics for infections, or elimination of toxic exposures may resolve the problem.
  • Abnormalities of sperm number and motility are sometimes amenable to hormonal or surgical therapies.
  • The development of Assisted Reproductive Technologies provides the opportunity for the couple to conceive when other forms of therapy are not indicated or have been unsuccessful.
  • When no sperm is available or if the couple does not want to use advanced Assisted Reproductive Technologies, then donor insemination is an option.

Couple Factors

Normal

  • Fertilization occurs when a single sperm penetrates the egg. In order for this to occur, the sperm is deposited in the vagina, makes its way through the cervix and uterus into the Fallopian tubes and comes in contact with the egg. Sperm are stored in the cervical mucus that then acts like a sperm bank, releasing sperm on a continuous basis so that the couple does not have to have intercourse right at the moment of ovulation. Data suggests that having intercourse within a short period of time prior to release of the egg give a better chance for pregnancy than having intercourse after the egg has been released.


Abnormal

  • Timing of intercourse remote from ovulation may be a cause of infertility.
  • The use of douches or lubricants can affect the ability of the sperm to survive within the vagina or the cervix.
  • Abnormalities of the penis or ejaculation that prevents sperm from being deposited in the vagina.
  • Abnormalities of the vagina that prevent sperm from being deposited.

Treatment

  • Timing and use of douches or lubricants are handled by the couple
  • Anatomic or physiologic abnormalities may require intrauterine insemination or assisted reproductive technologies