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Infertility is the inability to conceive after 12 months of unprotected intercourse.  Basic fertility testing should begin no later than 12 months of trying for young women, and no later than 6 months of trying in women who are over 35 years old.  Women over 35 have a more rapid decline in their egg supply and quality, so testing should begin earlier to avoid losing precious time.  Fertility testing should begin even earlier if there is an obvious problem, such as irregular periods, ovulation problems, or uterine problems such as fibroid tumors.

The following medical conditions often contribute to difficulties conceiving:

Fallopian tube damage, blockage or pelvic adhesions (scar tissue)

The fallopian tubes are very delicate structures and are easily damaged when there is inflammation within the pelvis.  The most common causes of tubal damage include prior pelvic surgery, endometriosis, or a sexually transmitted infection such as chlamydia or gonorrhea.  Blocked fallopian tubes can cause infertility because the sperm will not be able to reach and fertilize the egg.  Damaged fallopian tubes are also a risk factor for an ectopic pregnancy.  In most cases the diagnosis of a tubal problem is made through a hysterosalpingogram (HSG).

Ovulation disorders and polycystic ovary syndrome (PCOS)

Problems with ovulation often result in irregular and unpredictable menstrual cycles.  Women with irregular menses do not need to wait for a fertility evaluation and should proceed with hormone testing to identify the root cause of the irregular cycles.  Irregular periods indicates that ovulation is not predictable or is not occurring at all.  Common hormonal problems that cause ovulation problems include thyroid disorders, hyperprolactinemia, and polycystic ovary syndrome (PCOS). Almost 10% of reproductive age women have PCOS, which is characterized by ovulation problems, irregular cycles, and manifestations of high male hormone (androgen) levels.  The high androgens often cause oily skin, acne, and facial hair.  Most women with PCOS also have insulin resistance, which causes difficulty maintaining a healthy body weight.

Endometriosis

This condition occurs when the endometrial tissue that lines the interior of the uterine cavity spreads outside of the uterus and starts growing in an abnormal location.  Endometriosis commonly occurs on the ovaries, behind the uterus and cervix, or in front of the uterus.  Over time, the tissue proliferates and behaves as if it were in the uterus, bleeding during each menses.  This causes inflammation in the pelvis, leading to adhesion (scar tissue) formation and pelvic pain.  Endometriosis can distort the normal anatomy of the pelvis and create a hostile environment for eggs and sperm.  Unfortunately there are no good tests for endometriosis and it usually cannot be seen by X-ray or ultrasound.  Only surgery with laparoscopy can be done to make a definitive diagnosis.

Decreased ovarian reserve

As women age, there is a decrease in the supply of eggs in the ovaries.  Women are born with a finite supply of eggs and those eggs do not replicate to make new eggs.  As time goes on, eggs are continuously dying and we have no way to stop or reverse the process.  Not only does the supply decline over time, but the quality of the remaining eggs declines as well.  Older eggs are less likely to fertilize normally and produce a normal embryo.  The decline in egg quality and quantity results in lower fertility, higher miscarriage rates, and higher rates of chromosomal abnormalities.

Uterine abnormalities

Some problems with the uterus can cause infertility or increase the chance of adverse pregnancy outcomes.  Common uterine abnormalities include fibroids, polyps and scar tissue within the uterine cavity.  Fibroids are benign tumors originating from the muscle cells within the walls of the uterus.  If they grow and protrude into the cavity of the uterus, there is a clear reduction in fertility and increase in miscarriage rates.  These fibroids require surgical removal via hysteroscopy.  Endometrial polyps are benign growths that originate from the endometrium, which lines the uterine cavity.  Large polyps will also reduce fertility and require removal by hysteroscopy.  Intrauterine adhesions (Ashermans syndrome) or scar tissue, signifies damage to the endometrial tissue, usually as a result of a prior surgery within the uterus or infection.  Scar tissue can be removed by hysteroscopy but some severe cases cannot be repaired and a surrogate, or gestational carrier may be needed.

Male factor infertility

The male infertility evaluation starts with a semen analysis and a medical history.  A second semen analysis is usually requested if the first one is abnormal.  Those with consistent abnormal results are referred to a urologist who specializes in male fertility.  We refer to Dr. Stephen  Shaban at Associated Urologists of North Carolina.   Mild abnormalities can often be treated with medications and intrauterine insemination (IUI).  More severe sperm abnormalities often require in vitro fertilization (IVF).