Human reproduction requires healthy gametes (sperm and eggs) as well as a healthy uterus to nurture the fetus until it is born. 6-7% of heterosexual couples will experience infertility, defined as the inability to achieve pregnancy after 12 months of trying. Since our reproductive systems age as we age, women over the age of 35 are considered infertile after six months of trying and not getting pregnant.
In the natural system, ejaculated semen deposits in the vagina during intercourse. Motile sperm swim out of the semen and travel through the female reproductive tract from the vagina, through the cervix, through the uterus and finally into the fallopian tube(s). If this happens during or just after ovulation (the release of an egg from the ovary), the egg and sperm meet inside the fallopian tube. The sperm then interact with the eggshell (zona pellucida), and one sperm is allowed inside to fertilize the egg. The newly fertilized embryo (zygote) then travels towards the uterus as it develops. First, the one cell divides into two cells, then four, then 8, then 16. Around the 16 cell stage (Day 3 of development), the embryo begins to morulate, and the cells talk to each other and decide which part of the embryo they will become. After morulation, the embryo must blastulate (form a fluid-filled cavity and two distinct tissue masses, the inner cell mass and the trophectoderm). The embryo must reach the blastocyst stage before it is ready to implant into the uterine lining and form a placenta.
The human female reproductive system includes a vagina, cervix (opening between the vagina and uterus), a uterus with two fallopian tubes on either side, two ovaries as well as breast tissue and external genitalia. The reproductive organs are controlled by the reproductive hormones, which are secreted by the pituitary gland in response to hormones released by the hypothalamus in the brain.
Hormones are inter-organ communication messages. They allow the organs to "talk" to each other. In the human female, the hypothalamus releases gonadotropin-releasing hormone (GnRH) to "tell" the pituitary gland to release the gonadotropins. The gonadotropins include follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH "tells" the ovaries to recruit and nurture follicles (small sacs filled with nurturing cells that help an egg develop). In response to this message, follicular cells nurture the egg and make estrogen. LH "tells" the follicle it is time to rupture and release the egg (ovulation). It also "tells" the follicular cells to luteinize (stop making estrogen and start making progesterone) as well as tell the egg that it is time to complete development. This progesterone is vital if an egg fertilizes as it keeps the uterine lining (endometrium) thick and vascularized and ready to form a placenta for the growing embryo.
The male reproductive system includes the testes (where sperm is produced), vas deferens (the tube that sperm travel to exit the body), Cowper's gland, the seminal vesicles, prostate and external genitalia (penis and testicles which house the testes). Sperm precursor cells inside the testes are continually cycling through sperm production in the adult male. It takes about three months from the time a precursor cell begins its development to the time that it is ready to be ejaculated as a mature sperm.
The same hormones control the testes as the female reproductive system. Gonadotropin-releasing hormone is released by the hypothalamus, which then released the gonadotropins (FSH and LH) in response to this signal. These hormones stimulate sperm production in the testes as well as the production of the sex hormone testosterone.
Infertility can be a devastating blow to men and women who are ready to start their family. Often, patients have worked hard to build careers and homes to bring a child into their lives, and facing the inability to conceive is very difficult. It is normal to feel alone, normal to feel depressed, and normal to feel lost. We can help. Our team members have dedicated their lives to helping people just like you, and there are so many people just like you. The problem is that in our society, people still tend not to discuss their issues getting pregnant with others and so there is a vacuum of support in the community. Likewise, celebrities with excellent access to healthcare often deliver healthy babies at any age, defying the odds, making many of us feel hopeless. We promise you that many more people are suffering just like you, and many of the people in your life and on tv who deliver healthy babies did so after using fertility treatments.
There is hope.
Many of us grew up watching the old pregnancy test commercials where the woman surprises their partner with a bright solid line. Well, for some of us, it just isn't going to be that simple. That does not mean that you will not take home a healthy baby. It just means that it may not happen the way you initially thought it was going to happen. Like most situations in life, we need to switch to plan B.
Our team is experts in helping patients along their journey to parenthood, no matter how long, how far, or in what direction that journey takes you. We will be there with you every step of the way, encouraging and supporting you. We will make sure you have a clear understanding of everything you are facing and all of your treatment options. We fell it is our job to make you as comfortable as possible during this challenging period in your life.
Lifestyle Changes to Make
Healthy bodies are simply better at establishing and maintaining healthy pregnancies, and it is in your best interest to work creating that healthy body and healthy reproductive system as soon as you decide to get pregnant. Our team is prepared to help you along the way. Some patients have a medical diagnosis that requires medication or hormonal support before they are ready to begin treatment. Some patients have difficulty maintaining a healthy diet or healthy weight. Some patients are struggling to cope psychologically with the painful experience of infertility. Some patients need to quit bad habits like smoking, excessive drinking or recreational drug use prior to conceiving. Our team of experts is here to help you, no matter what your lifestyle issues are. We will make sure your body is as healthy as possible and ready for conception and pregnancy.
When to Try
Once you have decided you are ready to raise a child, the time of conception becomes crucial to promote success. Women are most fertile before the age of 26. After this age, their reproductive system begins a steady decline in fertility through menopause (the cessation of ovulation and menstruation). Some men maintain their fertility throughout their lives, but many experience an age-related decline after 45 years of age. Because women over the age of 35 are approaching menopause, it is important that they seek out a fertility specialist early in their journey to parenthood.
Over the counter ovulation kits are a great way to start your journey to conceiving on your own. They are available in any drug store and can help you determine if you are timing intercourse properly. They cannot, however, guarantee that you are ovulating. Our office can run testing and cycle monitoring to ensure that you are ovulating.
When to Seek Help
Women over the age of 35 should wait no longer than six months of trying before discussing their options with a reproductive endocrinologist. Women under 35 can try for one year, or they may elect to speak with a fertility specialist during that year of trying just to make sure they are fertile. Our office provides a full range of testicular and ovarian function testing, and we can help you determine if you are on the right track or not.
Patients who have had any of the following should seek out a reproductive endocrinologist early on:
- Patients with painful and/or irregular periods
- Patients with more than one miscarriage in the past
- Patients who are not in their recommended body mass index (BMI)
- Patients and partners who have a history of sexually transmitted disease
- Patients and partners who have a history of cancer/chemotherapy/radiation or other treatment likely to cause infertility
- Patients and partners who have a history of substance abuse or smoking
- Patient and partners who have certain endocrine disorders
- Patients who are concerned that their future plans may negatively impact their fertility before they are ready to conceive
Female Factor Infertility
Polycystic Ovary Disease (PCOS)
For many years the symptoms and causes of PCOS were poorly understood. It includes a collection of symptoms, some of which may seem unrelated to fertility. These symptoms include excessive follicles visualized on sonogram, hyperandrogenism, anovulation and metabolic irregularities.
Patients with PCOS should only undergo ovulation induction or ovarian stimulation with a board-certified reproductive endocrinologist as they are at an increased risk to over-respond to the medication creating a potentially life-threatening complication called ovarian hyperstimulation syndrome (OHSS).
Anovulation and Ovulatory Disorders
Some patients have a hint to their ovulation disorder by their irregular periods. Some patients, however, may undergo regular periods and still fail to ovulate eggs properly. These disorders are easily diagnosed and usually treatable without in vitro fertilization (IVF) by merely regulating the menstrual cycle with hormones.
Premature Ovarian Failure (maternal age younger than 36 years)
While menopause is a natural process, most women should not expect to undergo menopause until they approach 40 years of age or older. Women under 40, however, can experience a complete cessation of menstruation and ovulation, which is termed premature ovarian failure. The diagnosis is relatively simple with blood work and sonogram. Still, the treatment may require IVF depending on how far advance the decline in ovarian function is when treatment has begun.
Diminished Ovarian Reserve (maternal age 36 years and older)
As you approach menopause, your reproductive system will be in steady decline, and each cycle fewer eggs will be available for recruitment either in the natural menstrual cycle or in a stimulated treatment cycle. For this reason, it is important that women over the age of 35 seek out a fertility specialist early in their journey to parenthood. For these patients, there just simply is not a lot of time to waste.
The uterus is a complex organ that must nurture and protect a pregnancy from the very beginning through birth. Many types of disorders can affect the uterus. In some cases, fertility treatment may allow a patient to carry a pregnancy to term even with uterine factor infertility. In more severe cases, the use of a gestational carrier to carry the pregnancy to term will be required.
Male Factor Infertility
Male factor infertility usually involves a decreased amount of motile sperm in the ejaculate. Still, it can range to patients who do not have any sperm in the ejaculate or who are unable to ejaculate. Having zero sperm in the ejaculate does not mean that you are not making sperm; it just means for some reason; it is not making its way into the ejaculate. A urologist who specializes in fertility can help determine why this is happening and how to retrieve the sperm directly from the testicle. Likewise, patients who have little or no ejaculate may be making plenty of sperm. Still, either their accessory glands are dysfunctional, or the sperm may be passing into the bladder during ejaculation. In either case, our team can help determine the cause and recover sperm to use in infertility treatments. In some cases, fertility hormones are not functioning properly, and medication can be prescribed to help regulate their function and production.
Because the reproductive system of both men and women is so complex and requires so many other systems of the body to function properly, many patients will experience unexplained infertility. Meaning, even with all of our training, expertise, and access to testing, we still cannot clearly define the exact cause of your infertility. This diagnosis is only used when all other diagnoses have been explored and have been determined inadequate in describing your issues. Many patients end up embarking on treatment without a clear, concise cause of their infertility ever becoming known. Treatment options are still available for these patients and they can still conceive healthy pregnancies.
Inherited Diseases and Disorders
Some patients have no trouble conceiving at all but are not able to carry a genetically healthy baby to term. Some patients know or come to know after prenatal genetic testing that they are carrying an inherited gene known to cause disease and wish to not pass along this gene to the next generation. These patients can use IVF to conceive and have the option to test biopsied samples of their embryos for these known gene sequences.
Other patients are not carrying gene sequences that are linked to disease, but rather carry entire chromosomes that are the wrong size, shape or have missing or duplicated information in the wrong places.
For male patients with normal ejaculatory function and normal sperm concentration in their semen sample, preservation is as simple as ejaculating into a specimen cup and delivering the sample to us for cryopreservation. For male patients with less than normal sperm concentrations in their semen sample and/or ejaculatory dysfunction, fine needle biopsy or microsurgical biopsy of the testes may be necessary to obtain sperm for cryopreservation. The frozen sperm can then remain in storage for many years.
For female patients, fertility preservation requires egg retrieval after monitoring for the development of the egg or after stimulation of the ovaries to produce more than one egg and careful monitoring in our office. This process takes about two weeks. The retrieved eggs are then vitrified and may remain in storage for many years.
For patients that have already found the partner they will be starting a family with in the future, they may choose to undergo routine IVF and vitrify embryos for long term storage until they are ready to conceive.