Dr. Jennie Draper, OB/GYN at Virginia Physicians for Women, discusses possible causes of infertility, how it is diagnosed, and the different infertility treatment options that can help you reach your goal of a successful pregnancy.
Pregnancy is such an exciting time; but what happens when conceiving naturally hasn’t happened for you yet? There are so many things that must go exactly right each month to help make pregnancy occur: your brain signaling the right hormones, your ovary releasing an egg, the fallopian tube picking up this egg, having intercourse during the right time to fertilize the egg, the egg and sperm having a certain level of quality in order for fertilization to take place, and, if the egg is fertilized, the ability for the embryo to implant in the uterus. That’s a lot of steps to go right!
There’s good news for the many couples who hit a roadblock somewhere in this complicated process. With many medical advancements over the past few decades, there are several great treatment options for infertility that could help you reach your goal of a successful pregnancy. Let’s take a look at what factors could cause fertility issues and the different fertility treatments that could help you grow your family.
How common is infertility?
Infertility is extremely common in the US, affecting up to 15% of couples. Causes vary with approximately one third involving the female process, one third involving the male process, and one third with no explanation! Twenty-five percent of couples experiencing infertility are affected by more than one cause. Infertility can be a primary diagnosis, meaning someone has never been able to get pregnant, or a secondary diagnosis, meaning a person conceived before but cannot subsequently.
When to see your OB-GYN about fertility and planning
It’s a great idea to start the discussion with your OB-GYN about your plans to conceive early. You can do this during a preconception visit before you even start trying to conceive. This consultation includes reviewing your current medical history and identifying ways to optimize your health, which can increase your chances of conceiving. Important things to consider include healthy lifestyle habits for both partners: eliminating tobacco use, reducing excessive alcohol use, and optimizing a healthy body weight. See Dr. Pound’s blog post, Becoming Pregnant: 4 Keys to Mind and Body Prep for some great tips.
However, sometimes there are fertility issues that lifestyle changes alone can’t fix. If you are not having regular predictable menstrual cycles, it’s important to come in for an evaluation by your OB/GYN right away. In general, cycles should resume normally soon after discontinuing birth control.
Another general guideline we recommend is coming in for evaluation if you are under 35 years old and have been trying to conceive for a full year. If you’re 35 years old or greater, we recommend coming in after only 6 months of trying. If you’re over 40, we may suggest coming in even sooner. These are all general guidelines – we encourage starting the discussion earlier depending on your personal situation!
Possible Causes and Risk Factors for Infertility
Causes of infertility include lots of possibilities. The most common cause of female infertility is a problem with ovulation, while the most common cause of male infertility is a problem with sperm cells and how they function.
Risk factors that increase chances of infertility include being underweight or overweight, tobacco use, excessive alcohol use, prior history of sexually transmitted infections (STIs) or pelvic inflammatory disease (PID) which can cause scarring of the fallopian tubes, genetic factors, and increasing maternal age, particularly after age 35. If you’re approaching 40 when trying to conceive, you may want to check out Dr. Brim’s blog post: Getting Pregnant at 40: FAQs and Tips for Optimizing Your Fertility Health.
Other causes of infertility include unmanaged medical problems like diabetes or thyroid disease, clotting abnormalities (which can also cause recurrent miscarriages), fibroids, and endometriosis. It’s important to talk to your OB/GYN if you suspect any medical conditions might be interfering with your hopes of getting or staying pregnant. Read my patient Brittany’s story about why it’s important to be your own fertility advocate!
Male factors can include chronic exposure to high heat (tight clothing, frequent hot tubs/saunas, laptop use near your testes), congenital abnormalities, sexual dysfunction, low testosterone, and misuse of steroids.
This is not a complete list, but these are some of the more common causes of infertility. We will direct you toward treatment options depending on the factors involved for your and your partner’s individual circumstances. In many cases, infertility can be treated even when no cause has been found!
Fertility Testing and Diagnosis of Infertility
When a patient presents for an infertility evaluation, each part of the conceiving process is looked at to make a diagnosis. Diagnosis can include fertility testing and evaluation for both females and males. Most of the initial workup is usually done with your primary OB/GYN.
A fertility evaluation can include:
1. History and physical
Your OB/GYN will review both partners’ medical history and conduct the female partner’s physical exam. The male partner may also need a physical exam.
2. Female lab evaluation
For the female partner, fertility testing can include urine and blood tests to determine if and when you ovulate as well as tests for indicators of infertility. There will be an assessment of hormones including the thyroid hormone, to see if any thyroid issues may be causing infertility, and the anti-mullerian hormone, which can indicate egg quality and volume (ovarian reserve). Blood testing can also determine if your prolactin levels are high, which can cause issues with ovulation. Prolactin is the hormone responsible for lactation.
3. Semen analysis
Your OB/GYN has the ability to order the male partner’s semen analysis, which ultimately is run at an andrology center, a clinic that specializes in men’s reproductive health. The semen analysis is an assessment of the quality and volume of sperm, which can help your provider see if there are any issues that could cause infertility.
4. Ultrasound assessment of the uterus and ovaries
Your OB/GYN may also order an ultrasound to assess your uterus and ovaries to look for any abnormalities such as fibroids, uterine malformations, hydrosalpinges, and ovarian cysts that could interfere with your fertility.
5. Hysterosalpingogram (HSG)
A hysterosalpingogram (HSG) is an x-ray dye test that your OB/GYN can use to view the inside of your uterus and fallopian tubes to determine if they are fully or partially obstructed.
Not everyone will need every type of fertility testing. Some tests will be ordered based on results of other tests. Your OB/GYN can guide you through this process.
Infertility Treatment Options
Once the initial evaluation has been completed, your OB/GYN can recommend how to proceed, whether recommending lifestyle changes, surgery, medical management, a referral to a urologist for the male partner, or, ultimately, a referral to a reproductive endocrinologist (fertility specialist). We’re happy to help guide you on who to see.
Surgical Treatment
Women affected by blocked fallopian tubes, endometriosis and/or fibroids may benefit from surgical treatment. Your OB/GYN can usually perform this type of surgery. Surgical intervention may also be recommended for the male partner if the workup reveals a blockage to the sperm or history of having a vasectomy.
Ovulation Induction
Many ovulation disorders can be treated via ovulation induction, the use of hormones or fertility medication to help stimulate the female’s ovaries to release one or more eggs. This treatment can be oral or injectable.
There are providers at VPFW who can assist with an initial trial of oral ovulation medication (letrozole or clomiphene) if the cause for infertility is associated with anovulation like polycystic ovarian syndrome (PCOS). Outside of this type of management, treatment for infertility would be managed by a specialist. Ovulation induction may require injectable medications as well, which would be determined by a reproductive specialist.
Assisted Conception
Fertility procedures including intrauterine insemination (IUI) or in vitro fertilization (IVF) are called assisted conception. They help facilitate fertilization, giving the sperm a better chance of fertilizing the egg.
1) Intrauterine Insemination (IUI)
With intrauterine insemination (also called artificial insemination), sperm is inserted directly into the woman’s uterus at the time of ovulation. This is often the first treatment couples start with because it is less expensive and less invasive than IVF. For IUI, a semen sample is collected, then washed in a lab (removing everything but the most mobile sperm), and put into a fluid that is inserted into the uterus with a speculum.
The IUI procedure is carefully timed for the most fertile part of the female partner’s cycle, which means ovulation tracking is necessary. IUI is often done in combination with ovulation-inducing hormones or medication that can increase the number of eggs the female ovulates in a cycle. Thus, couples who combine ovulation induction with IUI have an increased chance of having twins or multiples.
IUI is a great option for many couples and is often recommended by fertility clinics as the first course of action for couples with unexplained infertility. However, IUI depends on the female partner being able to ovulate and implant a fertilized egg, and on a certain level of motility in the male partner’s sperm. If any of these conditions is not met, a couple may be recommended to move straight to IVF.
2) In Vitro Fertilization (IVF)
In vitro fertilization involves removing eggs from the ovary and fertilizing them with sperm in a lab. Later, a fertility specialist will place the embryo into the uterus. A more invasive procedure, IVF is also more expensive than IUI and generally has a higher success rate.
Depending on the cause of infertility, the egg, sperm or embryo used in IVF may be from a donated source. An embryo can also be placed in a gestational carrier (surrogate)’s uterus to carry the pregnancy.
3) Egg Freezing
IVF can also use a female’s eggs that have been retrieved earlier in life and frozen. Because frozen eggs maintain their quality from the time they were frozen, freezing eggs can be a way for women who are not ready to have children to preserve their fertility into the future.
Covering the Costs of Infertility Treatment
Undergoing fertility treatment can be an expensive process, but options do exist.
First, see if your insurance plan (or your partner’s) covers any fertility treatment. If not, you could potentially pay for an additional insurance plan that could help. (You could also look for a job at one of these 57 Companies That Offer Awesome Fertility Benefits.)
You can always ask the fertility clinic about your options when it comes to financing your treatment. A lot of clinics offer their own discount programs and even guarantee programs where you’re only on the hook for the full amount if the treatment is successful. They wouldn’t offer a guarantee if the success rate weren’t optimal!
There are also many grants you can apply for to assist with the cost of fertility treatments. A simple Google search will lead you to these opportunities.
Mental Health and Emotional Support
Having emotional and mental health support through the fertility treatment process is also important. This support can come from your partner, your family, support groups and therapists.
Seven Starling, a group we often refer patients to, offers online therapists that specialize in maternal mental health, including coping with fertility issues. They also have online support groups who meet weekly. There are also numerous Facebook groups for people experiencing infertility that can offer support from a unique community of individuals going through many of the same challenges and asking many of the same questions you and your partner might be asking.
We’re here to help you on your fertility journey
Pregnancy depends on so many different components of both the female and male reproductive systems functioning properly. While conceiving naturally is difficult for a lot of couples, there are a lot of fertility options out there that can provide hope.
Ultimately, one’s fertility journey is not always an easy one, but we are here to help you reach your goal of a successful pregnancy. We love partnering with the reproductive specialists in Richmond, which include The VCU Reproductive Medicine team and Shady Grove Fertility. We have referred many patients to both of these fertility clinics and then welcomed them back to begin their obstetric care!
To schedule an appointment with a VPFW provider, you can call us at 804-897-2100 or set an appointment online.
About Dr. Jennie Draper
Jennie Draper is an OB/GYN at Virginia Physicians for Women who sees patients at VPFW’s Henrico Doctors’, St. Mary’s, and West Creek offices. She delivers babies at Henrico Doctors’ Hospital and St. Mary’s Hospital. When she’s not completing triathlons, marathons, or caring for her patients, you can find her taking advantage of RVA’s food, brewery, and outdoor scene, planning her next international adventure, or spoiling her niece.
