For women 35 and under, infertility is defined as not having achieved a pregnancy after one year of unprotected intercourse, or having experienced multiple miscarriages. For women over 35, or for those who have previously conceived, it is appropriate to seek evaluation and treatment after six months of trying.
Approximately 35% of infertility is due to a female factor and 35% is due to a male factor. In the remainder of cases, infertility is either a result of problems with both partners (if applicable), or the cause cannot be explained.
According to The Centers for Disease Control and Prevention (CDC), more than 7.3 million Americans, or one in eight couples of childbearing age, are infertile. Several risk factors can contribute to problems with fertility, including age, irregular periods, prior surgeries, extreme weight gain or loss, sexually transmitted infections (STIs), smoking, and/or alcohol use.
At RMA of Philadelphia, we take a personalized, comprehensive approach to diagnosing and treating infertility. Following a medical evaluation, we tailor a fertility plan of care to address the specific needs of each patient. Check out our success ratesand patient testimonials to learn more.
Causes of Infertility
Many factors can cause infertility, affecting either females, males, or both. It is very important for all involved parties to be thoroughly evaluated to determine the cause of infertility. In some cases, however, the reason for infertility cannot be determined.
Most women’s cycles vary between 21 and 35 days. Women with cycles greater than 35 days are considered to have oligo-ovulation. Those who do not ovulate at all have anovulation.
There are a number of reasons why women do not have regular cycles. These include polycystic ovarian syndrome (PCOS), thyroid disorder, and adrenal gland problems. Excessive exercise or weight loss can also cause problems with ovulation. To determine the cause of irregular cycles, we perform an evaluation that includes hormone and other blood testing, as well as a vaginal ultrasound.
Treatment options for ovulation disorders include the use of fertility medications (oral and/or injectable) to help encourage the maturation of eggs within the ovaries.
Tubal disease is a disorder in which the fallopian tubes are blocked or damaged. Scar tissue from endometriosis, surgery, or infection is often the cause of tubal disease.
A number of treatment options are available to overcome infertility caused by tubal disease; these include surgical removal of scar tissue, surgical repair of damaged tubes, and in vitro fertilization (IVF). IVF offers the greatest likelihood of success.
Endometriosis is defined as the presence of endometrial tissue (the normal lining of the uterus) outside the uterine cavity. An estimated three to five million American women of reproductive age suffer from endometriosis, which is more likely to occur in women with infertility.
Many women with endometriosis complain of painful periods (dysmenorrhea), pain with intercourse (dyspareunia), and premenstrual spotting, while others have no symptoms.
Approximately 15% of women suffering from endometriosis have a moderate or severe form, which may be detected by pelvic examination and/or ultrasound. In these cases, pelvic adhesions are frequently found, making it difficult for eggs to travel down the fallopian tubes. Lesser amounts of endometriosis can also interfere with conception.
There is no known cure for endometriosis, but there are treatment options available for women who suffer from the disease and are trying to conceive. Surgical treatment to remove as much endometriosis as possible may improve fertility. In vitro fertilization (IVF) is effective in overcoming infertility due to endometriosis.
Diminished Ovarian Reserve
Diminished ovarian reserve is characterized by a low number of eggs in a woman’s ovaries and/or impaired egg development or recruitment. Research has demonstrated that the likelihood of becoming pregnant begins to decline minimally when a woman reaches age 25. Between the ages of 35 and 40, fertility rates fall significantly, and further accelerate after the age of 40.
Diminished ovarian reserve can be diagnosed with a simple blood test that measures follicle stimulating hormone (FSH) levels on the second, third, or fourth day of a woman’s menstrual cycle. FSH is a hormone that stimulates ovarian follicles (each follicle has the potential to release an egg) and is highly predictive of fertility. While elevated FSH levels mostly affect women in their late thirties and early forties, a younger woman with an elevated FSH level also has a reduced likelihood of establishing a pregnancy without the use of donor eggs.
We can also diagnose diminished ovarian reserve by measuring Anti-Mullerian hormone (AMH). AMH is a protein made by the cells that surround each egg. The more eggs a woman has, the higher her AMH level. A simple blood test can determine AMH levels. AMH levels can be drawn at any point in the menstrual cycle and results generally do not vary cycle-to-cycle. Ideally, AMH levels should be greater than 1.2 ng/ml. Levels less than 1.2 ng/ml are concerning and might lead to earlier or more aggressive fertility treatment to maximize the likelihood of a successful pregnancy. Low AMH levels are associated with a low likelihood of success.
Another method to assess ovarian reserve is by evaluating antral follicles via ultrasound. An antral follicle count is a good predictor of the number of follicles in the ovaries that may produce a mature egg.
Fibroids (myomas) are benign tumors arising from the muscular wall of the uterus. Fibroids are easily visualized by ultrasound. Their presence and location can be further evaluated by the use of hysteroscopy, hysterosalpingogram, or saline infusion sonography.
Common symptoms of fibroids include pelvic pressure and/or pain, heavy, painful, and prolonged periods, pain with intercourse, and bladder pressure with frequent urination. Fibroids located in the uterine cavity can also increase the likelihood of miscarriage, and infertility. Many women with fibroids may not have any symptoms, or even know that they have fibroids.
In women with multiple fibroids, especially fibroids that are large and symptomatic, abdominal or laparoscopic myomectomy (surgical removal of fibroids from the uterus) may be necessary. Even small fibroids located within the uterine cavity should be removed because they can interfere with achieving or maintaining a pregnancy. This procedure is done by inserting a hysteroscope (a thin, lighted tube used to examine the uterine cavity) through the vagina. Pregnancy rates following this surgery are often very high.
A successful pregnancy requires that the embryo attach to the lining of the uterus (endometrium), where it will develop. There is only a narrow window of implantation during the menstrual cycle when the uterus is receptive for an embryo to establish a pregnancy.
To evaluate uterine receptivity, we measure blood levels of progesterone a week after ovulation. Elevated levels of progesterone have been associated with normal corpus luteum function (what remains of a follicle after a woman ovulates).
Women who have poor uterine receptivity or do not ovulate due to polycystic ovarian syndrome (PCOS) or hypothalamic amenorrhea, can be easily treated with medications to create a receptive endometrium.
To evaluate the male partner, a semen sample is analyzed to determine the amount or volume of semen, the concentration of sperm, the percent of actively moving sperm, and the number of normally shaped sperm.
Causes of male infertility include hormonal abnormalities, varicocele (a varicose vein in the testes), a blockage, or absence of the duct that carries the sperm from the testes, and/or difficulty with ejaculation. Often there is no identifiable cause for abnormal sperm production, motility, or appearance.
For hormonal abnormalities, varicocele (a varicose vein in the testes), or a blockage we will work with a urologist if/when appropriate.
Recurrent Pregnancy Loss
Miscarriage, although a traumatic experience, is relatively common. It is estimated that 30% of pregnancies end in miscarriage. Most pregnancy losses occur prior to eight weeks gestational age. Only 3% of pregnant women miscarry after eight weeks.
Recurrent pregnancy loss is defined as having two or more consecutive miscarriages. It is important to recognize that the likelihood of having a successful pregnancy remains high for those who have experienced multiple miscarriages. Women who have had three consecutive, unexplained miscarriages have a 70% chance that the subsequent pregnancy will be entirely normal. This is because the majority of all miscarriages are due to random chromosomal abnormalities of the embryo that typically do not recur.
For women who have had two or more miscarriages, we routinely perform a hysteroscopy to look inside the uterine cavity for the presence of fibroids, polyps, congenital malformations, or scar tissue. Both females and males are tested for chromosomal and other abnormalities. We perform extensive blood testing on the female patient, evaluating for immunologic disorders, abnormalities of blood clotting, and hormonal imbalances. Even with a thorough evaluation, a cause for recurrent pregnancy loss cannot be determined in approximately 50% of patients.
Therapies for treatment of recurrent pregnancy loss are determined by the underlying disorder found through diagnostic testing. One such treatment, in vitro fertilization (IVF) with PGS (preimplantation genetic screening), which tests the embryos for chromosomal abnormalities, is an effective option for many patients.
For more information on female infertility treatment options, please contact us today.