Infertility is a common condition affecting approximately one in 10 couples. It is estimated that millions of couples in the United States alone will face difficulty conceiving each year. While the incidence of infertility has not increased over the past few decades, a greater awareness of both infertility and the technological advances in treatment, as well as the increased baby boom population and the publicity and openness around fertility issues, have led to the impression that it has.
Prior to attempting pregnancy it is important that couples optimize health and adopt lifestyle changes that improve fertility such as taking a multivitamin with a minimum of 400 mcg of folic acid and achieving the ideal BMI (body mass index). Women with a BMI greater than 30-35 ( ex. 175 lbs. and 5”4”) experience difficulty conceiving as well as an increase in birth defects, diabetes of pregnancy, preeclampsia and cesarean sections. Women who have medical conditions such as high blood pressure or diabetes or take prescription medications should consult with their physicians prior to attempting conception to optimize health and decrease risk factors.
Other lifestyle factors that affect pregnancy are smoking, alcohol and caffeine consumption. If you smoke, stop. Smoking is linked to decreased fertility in both men and women and is associated with significant complications during pregnancy. Exposure to caffeine and alcohol should be limited. Heavy alcohol use in women appears to decrease fertility and may affect the developing fetus. It is recommended that no alcohol be consumed during pregnancy as no safe level has been determined. Some studies have shown that a modest amount of caffeine (>300-500 mg) is linked to subfertility and high levels have been linked to miscarriage.
Studies demonstrate that the majority of pregnancies occur within the first six months of trying and that approximately 80-85 percent of couples will have conceived after one year of regular, unprotected intercourse. After that first year another 5-15 percent of couples may be successful, but after two years only about five percent of couples will become pregnant. The majority will achieve pregnancy in the first six to nine months of attempting, and fertility rates begin to decline thereafter. Fertility rates also decline gradually in women as they age with a steeper decline experienced in the late thirties into their forties. Therefore it would be expected to take longer to achieve pregnancy as women age.
It is recommended that infertility evaluation be started in couples who have been attempting pregnancy for over one year. Evaluation is recommended earlier if the woman has known risk factors that such as irregular cycles, suspected uterine or tubal disease such as fibroids, infections, endometriosis or prior ovarian surgery. In women over 35 it is recommended that the evaluation be started after six months because delay may result in a decrease in the success of treatment. Women over 40 may wish to consult a physician sooner. While most men do not experience symptoms related to low sperm counts, there are some risk factors that should prompt an earlier evaluation such as a history of testicular trauma, adult mumps, impotence, chemotherapy, radiation or a history of difficulty conceiving with another partner.
Infertility is a unique medical condition in that it usually involves a couple rather than an individual. The evaluation begins with a careful history and is usually best directed by someone trained in fertility care. The history will direct the specific diagnostic needs of the couple and usually includes: semen analysis to assess male factors, assessment of ovulation, a hysterosalpingogram to make sure that the tubes are open and evaluation of the ovarian reserve and thyroid function. Additional studies may include pelvic ultrasound, genetic studies, and laparoscopy. Infertility may be due to male factor, (two percent) ovulation dysfunction (20 percent), tubal disease (15 percent) or unexplained (25-40 percent). Many couples are identified with multiple factors contributing to subfertility as opposed to one specific diagnosis that would absolutely prevent pregnancy, such as the lack of sperm or blocked tubes.
Once the basic evaluation is complete specific treatment options will be discussed. If reversible factors such as fibroids, blocked tubes or ovulation dysfunction are identified the goal will be to correct these first. The treatment may be as simple as medications aimed at restoring regular ovulation or as complex as surgery to restore normal pelvic anatomy or In Vitro Fertilization (IVF). It is very important to discuss and prioritize all of the findings, the options, the costs and outcomes when counseling couples and planning treatment. It is never an easy journey to undertake, but with the right treatment and support the majority of couples can successfully achieve their goal of a healthy pregnancy.
Judith McBean, MD is board certified in Reproductive Endocrinology and Infertility. She practices at Brattleboro OB/GYN, a department of Brattleboro Memorial Hospital.