Infertility

Overview

What Is It?

Ovulation and sperm deficiencies are the most common infertility problems, accounting for two-thirds of all cases.

Infertility is far more common than most people think. According to Resolve, The National Infertility Association, approximately one in eight couples in the United States—about 12 percent of the reproductive-age population—experience fertility problems and have difficulty achieving pregnancy.

The truth is that hundreds of variables must coincide precisely for conception to occur and for a woman's body to successfully maintain a pregnancy for nine months. A healthy, fertile 30-year-old woman who has regular unprotected intercourse has about a 20 percent chance of conception during each menstrual cycle. Once she reaches age 40, the odds drop to about 5 percent each cycle.

There is no "typical" infertile patient. Lack of ovulation and sperm deficiencies are the most common infertility problems.

Ovulation is a complicated communication process between the hormones in a woman's brain and the eggs and hormones in her ovaries. To understand ovulation problems related to infertility, you must first understand ovulation. As your menstrual cycle begins (day one of your period), your estrogen levels are low. Your hypothalamus (the area of your brain responsible for maintaining hormone levels) tells your pituitary gland to start producing a hormone called follicle stimulating hormone (FSH). The FSH triggers eggs that are ready to start developing to grow. One of these egg follicles will develop into the dominant mature egg destined to ovulate, and the others degenerate.

Follicles produce estrogen, and when the estrogen levels reach a certain threshold, the egg is mature and ready to be released. The pituitary gland then releases a hormone called luteinizing hormone (LH) that causes the egg to mature and be released from the ovary wall and begin its 48- to 72-hour or so journey through the fallopian tube.

Ovulation problems can occur due to a number of factors:

• The ovaries may no longer contain eggs
• Eggs are present in the ovary but ovulation is disrupted because of a breakdown in the hormonal communication cycle

Age is also a major factor in a woman's fertility. After age 35, a woman's fertility rapidly declines. By age 43, there are fewer normal eggs remaining in her ovary, and she is less likely to conceive.

The quality of a woman's eggs is critical to her chances of becoming pregnant. If a woman is having trouble conceiving, she may have an ovarian reserve test. If it indicates few high-quality eggs or a very low probability of conception, her physician may recommend using donor eggs.

While an older woman is more likely to have poor egg quality than a younger one, the condition can also affect younger women. Each year, about 20,000 in vitro fertilization (IVF) cycles include the use of donor eggs. Less common identifiable fertility problems for women include structural problems or scarring of the fallopian tubes and/or uterus caused by pelvic inflammatory disease (PID) or endometriosis (a condition causing adhesions and cysts), uterine fibroids or, very rarely, birth defects.

Sperm deficiencies can include low sperm production (oligospermia) or lack of sperm (azoospermia). Sperm may also have poor motility—they don't move properly once inside the female reproductive tract to achieve fertilization. Additionally, sperm cells may be malformed or may not survive long enough to reach the egg.

About one-third of identifiable causes of infertility are due to male factors and about one-third are caused by female factors. Roughly one-third of infertility is couple-related, with a combination of problems in both partners preventing conception

An estimated 20 percent of infertility cases are unexplained; the source of the problem cannot be identified.

The majority of infertility cases are treated with medication or surgery. In vitro fertilization (IVF) and other types of assisted reproductive technologies (ART)—in which barriers to successful conception are overcome in the laboratory—account for a much smaller percentage of infertility treatments.

Diagnosis

Most specialists recommend that couples with no known reproductive health problems try to get pregnant through intercourse for 12 months before seeking medical advice.

However, if a woman is 35 or older, has menstrual or ovulatory irregularities, known tubal problems, a history of miscarriages or thyroid conditions, she should consult a specialist much earlier in the process, usually at six months or sooner.

Men with known sperm deficiencies or a history of infections, cancer treatment or scrotal surgery should also consult a specialist early in the process.

If you are worried about fertility, you and your partner should:

• Consult a specialist early on.
• Educate yourself as much as possible about all aspects of infertility.
• Ask questions.
• Know your treatment options and what is financially and emotionally possible.

Some obstetricians/gynecologists may have gained significant on-the-job experience in treating infertility, combined with specialized coursework to enhance their knowledge. There are many fertility tests and treatments a competent ob/gyn can perform.

Fertility specialists are subspecialists in the field of obstetrics and gynecology known as reproductive endocrinology. Because the field is so specialized, there are far fewer reproductive endocrinologists in the United States than there are ob/gyns.

Urologists with a subspecialty in andrology are specialists who diagnose and treat male infertility.

Finding board-certified physicians in reproductive endocrinology—which means they completed extensive training and passed both oral and written examinations in the subspecialty—is one way to ensure that your health care professional is truly a specialist.

When looking for a specialist, be sure to ask about his or her training and how long the specialist has been practicing in the field of infertility. As with most medical evaluations, identifying potential fertility problems should begin with the easiest, least expensive and least invasive approach. An initial evaluation should include:

• Medical histories of both partners, including questions about pelvic infections, sexually transmitted diseases (STDs), cycle length, prior obstetric history, surgeries, etc.
• Blood tests to screen for certain hormonal abnormalities in men or women
• An assessment of how often you ovulate
• Semen analysis (the quantity and quality of the man's sperm).
• Hysterosalpingogram (HSG). A special dye is injected into the uterus through the vagina during an X-ray. This helps your health care professional to see both the uterine cavity and the fallopian tubes to see if they are open.
• Transvaginal ultrasound. This examination allows your health care professional to look at the thickness of your endometrium and for any abnormalities such as polyps, fibroids or ovarian cysts to see how well an egg could implant in the uterine lining. Newer tests that infuse a mixture of saline and air (Femvue) can also determine whether the fallopian tubes are functioning properly. Additionally, an antral follicle count can be performed during the ultrasound to determine the quantity of eggs remaining in the ovary. This is one of the ""ovarian reserve tests" commonly performed.
• Laparoscopy. During a laparoscopy, the surgeon inserts a thin telescope through a small incision below the belly button to view the outside of the uterus, ovaries and fallopian tubes. If the surgeon finds endometriosis or adhesions, he or she can remove them during the procedure. Laparoscopy is usually performed under general anesthesia.
• Hysteroscopy. During a hysteroscopy, a small telescope is inserted into the uterus. Small fibroids, polyps or scar tissue that may be preventing implantation can then be removed.

Insurance coverage varies for these diagnostic procedures. While some plans may cover some tests and specialized treatments, most are far from comprehensive. Check your insurance coverage carefully so you understand what tests are covered during the diagnosis and treatment stages.

Treatment

Once you understand what type of infertility problem you have, it's important that you understand your options, including the potential physical, financial and emotional costs. In most cases, there is more than one acceptable option. While you will receive counseling about various options, ultimately it is your choice how to proceed.

The unexpected realization that you have a fertility problem can create a great deal of stress and frustration. Being infertile can make you feel out of control and that the next step in your life is blocked. Faced with the loss of a natural part of life, some people feel grief, loss and guilt.

Many infertile couples aren't prepared for the emotional roller coaster of grief and loss of infertility treatments. The layers of stress are multiple:

• Financial—How will we pay for treatment that may cost thousands of dollars?

• Professional—Will I miss job promotions or will my work suffer because of treatment needs?

• Emotional—How will we cope as a couple if treatment fails?

Facing friends, family members or coworkers who have children is another stress in an infertile couple's life.

Thus, it is important that you:

• Are prepared to experience many unfamiliar and uncomfortable feelings. Understand that there are psychological reactions to infertility that are very real and related to the stress of diagnosis, treatment and lack of pregnancy. Being infertile can be overwhelming. So can treatment.

• Understand that men and women cope with stress and infertility differently. While a woman is physically and emotionally dealing with the effects of treatment, her outlets may involve many people. She may want to talk a lot about her experiences with her partner or anyone else who will listen. Men, however, may be perceived as being emotionally and physically distant because they may be less likely to express their emotions outwardly, despite their deep concern for and commitment to their partner.

• Know that marriages and relationships will either be strengthened or pulled apart by infertility treatment. What happens depends on your relationship prior to treatment. Are you able to discuss intimate feelings? Do you have a good marriage? A good sex life? Are you a cohesive unit as a couple?

• Realize that infertility and its wide range of treatment options can be overwhelming. There are many complicated issues, such as preserving embryos by freezing them for future use, adoption, donor eggs, surrogacy, multiple pregnancy and fetal reduction, in which a woman carrying multiple embryos is induced to miscarry one or more. Educating yourself and your partner as much as possible about treatment options makes it less likely you'll be overwhelmed.

• Understand that treatment may not be successful. It's typical for couples at the beginning of treatment to do whatever it takes to achieve a pregnancy. Eventually, however, some realize that emotionally and financially, there is a limit.

However, before deciding to pursue a different course, like adoption or remaining childless, you must resolve your issues around your infertility. You must explore your options and decide what you are willing to do. This means getting to the point where you both can grieve and put closure to the fact that as a couple you are not going to be able to have a biological child.

Treatments for Infertility

Fertility drugs are typically the first treatment for infertility in women. These drugs are designed to correct specific hormonal imbalances.

The most common fertility drugs—clomiphene citrate (Clomid) and gonadotropins (follicle stimulating hormone, human menopausal gonadotropin and human chorionic gonadotropin)—are used to stimulate the production of mature eggs. Fertility drug treatment can include the following:

• Clomiphene citrate.Clomiphene (Clomid, Serophene) is used to induce ovulation (sometimes called controlled ovarian hyperstimulation). Compared to gonadotropins, this drug is inexpensive and easy to use. Clomiphene is similar in structure to estrogen, which makes it able to bind to estrogen receptors in the brain. In some women who fail to ovulate, inappropriate estrogen secretion is to blame. Inappropriately high estrogen levels suppress follicle stimulating hormone (FSH). As a result, the ovary doesn't get the signal to start maturing an egg. Clomiphene tricks the brain into believing that estrogen is lacking, so the brain asks the pituitary gland to increase its FSH production. This, in turn, calls forth an egg. For women with this form of ovulation dysfunction, about 80 percent will ovulate on clomiphene and about half of those will get pregnant. Clomiphene is taken in pill form and usually given for 5 days at a time for a maximum of six months. Some health care professionals monitor the follicular growth of women taking clomiphene to test the response to the medication and some do not. Possible adverse reactions include swelling of the ovaries, multiple pregnancies, hot flashes, mood swings, depression and irritability. Common side effects include weight gain and water retention.
  
  While clomiphene is generally effective in women who experience abnormal ovulation cycles, it is less likely to cause pregnancy in women who already ovulate.
  
  Letrozole (Femara) is also now commonly used for ovulation induction. While not FDA-approved for this usage, many clinicians believe it is a better choice than clomid for women with polycystic ovary syndrome.

• Gonadotropins. Gonadotropins are hormones (luteinizing hormone, or LH, and follicle stimulating hormone, or FSH) that are given via injection to stimulate ovulation. While clomiphene stimulates the hypothalamus, gonadotropins stimulate the ovaries directly. They include the following:
  • Human menopausal gonadotropin (HMG). HMG (Repronex, Pergonal), an injected medication, is used for women who do not ovulate on their own. Unlike clomiphene, which stimulates the pituitary gland, HMG stimulates the ovaries directly.
  • Follicle stimulating hormone (FSH). FSH (Gonal-F, Follistim, Bravelle), like HMG, directly stimulates the follicles and eggs to grow.
  • Gonadotropin-releasing hormone (Gn-RH) analogs (leuprolide [Lupron], ganirelix [Antagon]) are medications frequently used for women who do not ovulate regularly. Women who ovulate early, before the egg is ready, can also use Gn-RH analogs. These medications work by acting on the pituitary gland to change when the body ovulates. They are usually injected or given with a nasal spray.
    
    Because of their means of action, gonadotropins can be very successful in some patients.

These agents are much more apt to lead to multiple births because they stimulate the release of several eggs. Up to 30 percent of pregnancies that result from gonadotropins are multiples. Additionally, in rare situations, gonadotropins may cause severe and potentially life threatening medical complications, such as ovarian hyperstimulation syndrome (OHSS). Thus, they should only be prescribed by clinicians specifically trained in their use.

• Other medications. These drugs include:
  • Leuprolide (Lupron) is a synthetic hormone that mimics gonadotropin releasing hormone (GnRH). Drugs like leuprolide are called GnRH agonists. Though these drugs mimic GnRH in action, their net effect is to suppress the release from the pituitary gland of both FSH and LH and therefore, ovulation. If given early in the cycle these drugs will cause a "flare" of pituitary gonadotropins. Long-term use of an agonist also cuts off estrogen production in the ovaries and prevents a woman from ovulating. These drugs can be used to treat endometriosis and uterine fibroids. In IVF, these drugs are used to prevent a woman from ovulating while she takes gonadotropins to stimulate egg maturation.
  • Ganirelix (Antagon) and cetrorelix (Cetrotide) are GnRH antagonists similar in structure to GNRH. These drugs differ from agonists like leuprolide in that they directly cut off the production of FSH and LH (in contrast to leuprolide, which overstimulates the pituitary gland so it eventually stops producing FSH and LH). Like leuprolide, the GnRH antagonists help prevent premature ovulation during IVF.
  • Metformin (Glucophage) is an insulin-sensitizing drug used to boost ovulation when insulin resistance is a known or suspected cause of infertility. Insulin resistance may contribute to the development of polycystic ovarian syndrome (PCOS). Metformin is sometimes used with clomiphene or FSH.
  • Bromocriptine (Parlodel) is a medicine used for women with ovulation problems resulting from high levels of prolactin, a hormone that causes milk production.

For women receiving donor eggs, a combination of two or three hormonal medications is used to manipulate the menstrual cycle. The goal is to keep the egg recipient on the same cycle as her egg donor so her uterine lining is prepared to support the embryo once it is ready for implantation. Leuprolide is used to suppress the menstrual cycle, and estrogen supplements are used to get the cycle in synch with the donor's cycle. Progesterone is usually used to prepare the uterus for implantation when the donor is ready for retrieval.

Fertility drugs may cause a variety of physical and emotional side effects. There was also some concern that they may increase the risk of ovarian cancer, but the most recent research shows this isn't the case. However, infertility itself is a risk factor for ovarian cancer, while having children and using oral contraceptives protects against ovarian cancer.

Intrauterine Insemination (IUI)

Intrauterine insemination (also called artificial insemination) is a procedure in which the woman is injected with specially prepared sperm. In some cases, the woman takes medications to stimulate ovulation before the IUI procedure. IUI is a treatment option for couples in which the male has mild male factor infertility or the woman has problems with her cervical mucus, or in cases of unexplained infertility.

Assisted Reproductive Technologies (ART)

Assisted reproductive technologies offer another step in infertility treatment. These include:

• In vitro fertilization (IVF). During this procedure, the ovaries are stimulated with one or more fertility drugs so they produce multiple eggs. The developing eggs are then removed in a minor surgical procedure lasting only a few minutes; mild anesthesia is usually given.

• Intracytoplasmic sperm injection (ICSI). ICSI is used when there are problems with sperm function or number or to improve chances of fertilization. With ICSI, an embryologist injects a single sperm directly into each egg. ICSI is a highly specialized procedure performed in conjunction with IVF.
  
  In IVF and ICSI, the eggs and sperm are then combined in a petri dish, which is placed in an incubator in specialized media to promote fertilization. After about 24 hours, the eggs are examined to see if they have been fertilized. If fertilization occurs, one or more embryos are transferred to the uterus during another procedure several days later or frozen for later use. According to the 2012 Assisted Reproductive Technology National Report from the U.S. Centers for Disease Control and Prevention (CDC), the success rate for IVF using fresh non-donor eggs or embryos is 40 percent of cycles for women under ages 35; 31 percent for women ages 35 to 37; 22 percent for women ages 38 to 40; 12 percent for women 41 to 42; 4 percent for women 43 to 44; and 2 percent for women over 44.

• Donor egg. Donor eggs are an option for women who cannot produce eggs or for whom egg quality is an issue. Another woman donates her eggs to be used for an IVF procedure. A woman using a donor egg becomes the biological mother to the offspring, but she doesn't share the child's genetic makeup. However, if the male partner's sperm was used in the fertilization process, the child shares his genetic background. Each year, about 20,000 IVF cycles include the use of donor eggs. This procedure is most often recommended for women over 40 and for younger women with poor quality eggs.

• Donor sperm. Tested, screened and quarantined donated sperm is available with many sperm banks. The sperm can be used for IVF or related procedures.

• Gestational carrier. This is an option for women who cannot carry a pregnancy. A couple's egg and sperm, or embryo, are placed in another woman's uterus; she is known as the gestational carrier, who will carry the pregnancy and deliver the baby. However, she has no genetic relationship to the baby.

• Assisted hatching. This procedure is sometimes done in addition to IVF. After the embryo forms but prior to its transfer to the uterus, a special solution or laser is used to thin or make a hole in the outer covering of the embryo (called the zona pellucida). This might improve implantation by helping the cells of the embryo emerge from the outer shell, or hatch. This method is usually suggested for women over the age of 40 who have failed one or more IVF attempts or to remove fragments of cells from the embryo, but its use is still considered controversial and benefits have not been proven.

• Preimplantation genetic testing (PGT): With PGT, it's now possible to screen embryos created by IVF for genetic diseases or defects before implantation. The goal is to decrease the chances of miscarriages or births with genetic abnormalities or genetic diseases such as cystic fibrosis or Tay Sachs disease. There are two types of PGT: preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS). PGD is done when parents carry a genetic condition to determine whether that condition has been transmitted to the egg or embryo. PGS is done when parents have no known genetic abnormalities but want to screen for chromosomal abnormalities (aneuploidy) such as Down Syndrome.

• Egg freezing. Another option is to freeze some of your eggs to help preserve your fertility. You may want to consider egg freezing if you will be undergoing radiation or chemotherapy for cancer treatment or if you want to store younger eggs for the future. Many fertility treatment centers now offer egg freezing. Ask your health care provider if egg freezing may be a good option for you.

If you decide to undergo fertility treatments and are choosing a treatment center, here are some questions you may want to ask:

• What is your center's clinical pregnancy rate? You can look this up online at www.sart.org. Keep in mind that the success rates of an IVF center depend on many factors, and a comparison of clinic success rates may not be meaningful because patient characteristics and treatment approaches vary from clinic to clinic.
• What exclusion criteria does your center use to select patients for in vitro fertilization?
• What is the cancellation rate of patients my age? (Most fertility centers have a criteria that determines when they will cancel the IVF process before egg retrieval. For example, a center may cancel a cycle in which a woman produces too few follicles or follicles that are too small). Centers that have a very low cancellation rate may be highly selective in who they accept as patients.
• How many embryos does your center routinely implant for IVF? (Centers that implant more than two or three may have good pregnancy rates, but they will also have more multiple pregnancy rates, which can be risky to mother and babies).
• What are the center's success rates for different types of procedures, particularly those I might face? (Figures should represent live birth rates, not just pregnancies.)
• Is the center still working with the same laboratory and specialists as when the statistics were generated?

To see a summary of ART success rates and reports from fertility clinics around the country, check the statistics reported by the Society for Assisted Reproductive Technologies SART at www.sart.org.

Prevention

There is no way to prevent infertility because there are many factors that contribute to your ability to ovulate, conceive and carry a pregnancy to term. Likewise, your male partner also has numerous factors—natural and environmental—that can contribute to infertility. The condition is not exclusively a woman's problem. About one-third of infertility cases involve male factor problems alone, and approximately one-third involve problems with both partners.

For women, factors that could lead to infertility include:

• Being very overweight or very thin, either of which can affect ovulation and fertility.
• Chronic, debilitating diseases, such as unregulated diabetes, lupus or thyroid problems that can interfere with normal ovarian function. Also, some medications such as high-dose steroids can interrupt ovulation. If you have a chronic health condition, be sure to discuss it with your health care professional. Most women with chronic conditions can become pregnant, have a healthy pregnancy and deliver a healthy baby.
• Polycystic ovarian syndrome (PCOS). Symptoms include irregular or infrequent periods, excessive facial hair and acne.
• Surgeries on the cervix, abnormal Pap smears including cryosurgery or cone biopsy that can affect the function of the cervix.
• Hormonal imbalances that cause abnormalities in your menstrual cycles.
• Multiple miscarriages (two or more early pregnancy losses).
• Environmental factors, such as cigarette smoking, alcohol consumption, illegal drugs and exposure to workplace hazards or toxins.
• Medication including herbal or natural medication.
• Age. Even if your fertility does not seem at risk now, remember that fertility declines with age. A healthy, fertile 30-year-old woman who has regular unprotected intercourse has about a 20 percent chance of conception during each menstrual cycle. Once she reaches age 40, the odds drop to 5 percent each cycle.
• Sexually transmitted diseases (STDs), which occur at a rate of nearly 20 million cases each year in the United States. Some STDs don't cause symptoms at first but, if left untreated, can lead to pelvic inflammatory disease (PID)—an infection of the upper genital tract that may compromise fertility by scarring and blocking the fallopian tubes; it can also lead to an ectopic pregnancy. To reduce your risk of STDs, use latex condoms during sex, avoid having sex with multiple partners and see a health care professional if you have any unusual symptoms such as pain, fever or vaginal discharge. Also make sure your partner is treated if you do have an STD. The best way to avoid STDs is abstinence or monogamy.
• Fallopian tube disease accounts for about 25 percent of infertility cases. If you are having trouble conceiving or are worried about your future fertility, consult with your health care professional. Make sure you disclose if you have ever had pelvic pain, unusual vaginal discharge, bleeding or fever; pelvic surgery for ruptured appendix, ectopic pregnancy or an ovarian cyst.
• Endometriosis, a disease in which endometrial tissue is found outside of the uterus, typically on the ovaries, fallopian tubes bladder and bowel, occurs in reproductive age women. While the connection between endometriosis and infertility is not clearly understood, advanced-stage endometriosis makes it very difficult for the egg and sperm to reach each other. Treatment of early stage endometriosis doesn't seem to make a difference in pregnancy rates, but knowing you have it may influence your choice of reproductive technology. Be sure to report these symptoms to your health care professional: painful menstrual cramps that get worse over time, extremely heavy menstrual flow, diarrhea or painful bowel movements (especially around the time of your period) and painful sexual intercourse.

For men, a variety of factors can lead to infertility. Many researchers believe the causes of declining sperm count during this century are environmental, including pesticide and chemical exposure, drug use, radiation and pollution. Specific risks include:

• Exposure to toxic substances or hazards on the job, such as lead, cadmium, mercury, ethylene oxide, vinyl chloride, radioactivity and X-rays
• Cigarette or marijuana use
• Heavy alcohol consumption
• Prescription drugs for high blood pressure( calcium channel blockers), ulcers and psoriasis
• Chronic exposure of the genitals to elevated temperatures as may occur in some occupations can diminish sperm counts. Occasional visits to the sauna or hot tub will have no effect, however. Though some men may prefer boxers over briefs, boxers aren't any better for sperm production.
• Medical conditions, including hernia repair, undescended testicles, history of prostatitis or genital infection, and mumps after puberty
• Some STDs can lead to epididymitis (inflammation of the duct that carries sperm). Ultimately, infertility can be a consequence of STDs. To decrease this risk, practice safe sex by using latex condoms. Also have any unusual symptoms checked out and treated early—and make sure both partners are treated simultaneously.

Infertility Research

Infertility research is robust. Recent efforts include:

• Oocyte cryopreservation. This is now offered at many fertility centers to preserve a woman's fertility, either for medical or social reasons. Freezing eggs can be performed without having to first fertilize them. This means that patients at risk of becoming infertile from cancer treatments or aging can preserve some eggs to retain the possibility of reproduction even after their eggs would have been either destroyed by chemotherapy or depleted due to aging.
• Ovarian tissue cryopreservation. This can be performed before chemotherapy or radiation treatments for cancer patients who do not have time to undergo an IVF cycle and freeze eggs. While some babies have been born as a result of this tissue being replaced back into the body, it is still considered experimental.
• Genetics and male factor infertility. The more we learn about the origins of male fertility problems, the more we find they have a genetic origin. Understanding the genetic errors that lead to poor semen quality and sperm production can lead to better management of these conditions.
• Embryo selection methods. These have been improving with the goal of being able to one day select the single embryo to transfer that will have the greatest probability of developing, thereby reducing the risk of multiple pregnancy. The latest advancement is development of the Embryoscope, an incubator that maintains the necessary conditions required to support a living embryo in the IVF lab. A special camera captures time-lapse images of an embryo's development and records them in a video.

Facts to Know

1. Infertility affects 6.7 million American women and their partners—about 12 percent of couples of reproductive age.
2. Disorders of both the male and female reproductive systems cause infertility with almost equal frequency.
3. Some infertile couples have more than one factor contributing to their infertility.
4. Recent improvements in medication, microsurgery and in vitro fertilization (IVF) techniques make pregnancy possible for about half of couples pursuing treatment.
5. Fallopian tube blockage or disease accounts for approximately 25 percent of all female infertility problems.
6. Irregular or abnormal ovulation accounts for approximately 25 percent of all female infertility cases.
7. Up to 30 percent of couples who have a complete fertility assessment are diagnosed with unexplained infertility because no specific cause is identified.
8. The number of babies born each year as the result of assisted reproductive technology is growing. The CDC's most recent assisted reproductive technologies (ART) annual report stated that 67,996 babies were born as a result of assisted reproductive technologies in 2013, up 2,836 from 2012.

Questions to Ask

Review the following Questions to Ask about infertility so you're prepared to discuss this important health issue with your health care professional.

1. Are you board certified? Are you an ob/gyn? Are you trained in reproductive endocrinology and infertility?
2. How long should my partner and I try to get pregnant before seeing a specialist?
3. At what time of month am I most fertile?
4. How can I tell when I'm ovulating?
5. Should my partner be evaluated?
6. What kinds of tests will you perform?
7. How much will these tests and treatments cost?
8. What is the likelihood that the treatment you're recommending will result in pregnancy? What is the likelihood that an alternative option will result in pregnancy?
9. What is the next step if the treatment fails?
10. What other treatments should we consider?
11. What are the risks (short and long-term) of the treatment you are prescribing? What is the risk of multiples and how do we limit this risk?
12. I need to talk to someone about my feelings and my partner's feelings about infertility. Is there a support group or a counselor you can refer us to?

Key Q&A

Organizations and Support

For information and support on coping with Infertility, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Website: https://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Society of Andrology
Website: https://www.andrologysociety.com
Address: 1100 E. Woodfield Road, Suite 520
Schaumburg, IL 60173
Phone: 847-619-4909
Email: info@andrologysociety.com

Center for Research on Reproduction and Women's Health
Website: https://www.med.upenn.edu/crrwh
Address: 1355 Biomedical Research Building II/III
University of Pennsylvania Medical Center, 421 Curie Blvd.
Philadelphia, PA 19104
Phone: 215-898-0147

International Council on Infertility Information Dissemination
Website: https://www.inciid.org
Address: P.O. Box 6836
Arlington, VA 22206
Phone: 703-379-9178
Email: INCIIDinfo@inciid.org

EarlyMenopause.org
Website: https://www.earlymenopause.com
Address: P.O. Box 23643
Alexandria, VA 22304
Phone: 703-913-4787

Medivizor
Website: https://medivizor.com

National Family Planning and Reproductive Health Association (NFPRHA)
Website: https://www.nationalfamilyplanning.org/
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

Resolve: The National Infertility Association
Website: https://www.resolve.org
Address: 1760 Old Meadow Rd., Suite 500
McLean, VA 22102
Phone: 703-556-7172

Books

A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker

Complete Fertility Organizer
by Manya DeLeon Miller

Complete Guide to Fertility
by Sandra Ann Carson, Peter R. Casson, Deborah J. Shuman, and American Society for Reproductive Medicine

Expecting Miracles: On the Path of Hope From Infertility to Parenthood
by Christo Zouves

Getting Pregnant and Staying Pregnant: Overcoming Infertility and Managing Your High-Risk Pregnancy
by Diana Raab and M.D. Hal C. Danzer

Getting Pregnant Naturally: Healthy Choices to Boost Your Chances of Conceiving Without Fertility Drugs
by Winifred Conkling

Inconceivable: Winning the Fertility Game
by Julia Indichova

Rewinding Your Biological Clock: Motherhood Late in Life
by Richard J. Paulson and Judith Sachs

The Fertility Guide: A Couples Handbook for When You Want to Have a Baby (More Than Anything Else)
by John C. Jarrett and Deidra T. Rausch

Unofficial Guide to Overcoming Infertility
by Joan Liebmann

Whole Person Fertility Program: A Revolutionary Mind-Body Process to Help You Conceive
by Niravi B. Payne

Spanish-language resources

Medline Plus: Infertility
Website: https://www.nlm.nih.gov/medlineplus/spanish/infertility.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov