Infertility: Causes, Diagnosis, and Treatment Options

Generally, if a couple has not conceived within one year of trying, it’s time to consider seeing a fertility specialist.

Some couples should seek help sooner, including:

• Women who have irregular or absent menstrual cycles

• Women age 35 and older who have been trying for 6 months

• Women with a history of endometriosis, pelvic adhesions, or pelvic infections

• Women who need to reverse a tubal ligation or have known tubal diseases

• Men with abnormal semen analysis, or erectile or ejaculatory problems

• Men who need surgery to remove blocked tubes (vas deferens or epididymis)

• Men who need microsurgery to reverse a vasectomy or obtain sperm

• Lesbian or single women requiring donor sperm

What Causes Infertility?

Infertility can be caused by many different factors.

In Women

• Ovulation dysfunction

• Tubal blockage

• Endometriosis

• Structural abnormalities of the uterus such as fibroids

In Men

• Anatomic or hormonal problems that reduce the number and quality of sperm

In many cases, even with the most comprehensive evaluation, no single factor can be identified.
Fortunately, even when the cause of infertility cannot be determined, effective treatments are still available.

How Can Problems Be Diagnosed?

Standard Testing

• Semen analysis – assesses the number and quality of the sperm

• Hysterosalpingogram (HSG) – an X-ray dye test used to evaluate the uterine cavity and fallopian tubes

The HSG is performed by injecting dye through the cervix while observing on a monitor to confirm that the cavity of the uterus is normal and that both tubes are open.

Additional Testing

After reviewing patient history, physical exam, and previous results, fertility specialists may recommend:

• Hormone level tests

• Ultrasound of uterus and ovaries

• Hysteroscopy and/or laparoscopy

Laparoscopy is an outpatient procedure that involves placing a thin scope through the navel to diagnose and treat conditions such as:

• Endometriosis

• Pelvic adhesions (scar tissue)

• Ovarian cysts

• Fibroid tumors

• Tubal disease

What Treatments Are Available for Infertility?

Treatment options include:

• Medical Therapy

• Reproductive Surgery

• Intrauterine Insemination (IUI)

• Assisted Reproductive Technologies (ART) such as In Vitro Fertilization (IVF)

Medical Therapy

Medical therapy is used to correct ovulation dysfunction (irregular or infrequent periods).

• If there are no underlying causes (like thyroid disease), the first step is oral medication to induce regular cycles.

• If oral medication fails after six cycles, other treatments are considered.

Gonadotropin therapy is another option:

• Induces ovulation when oral agents do not work

• Offered for unexplained infertility

• Stimulates more than one egg during a cycle

• Administered as a daily injection for about a week

• Requires monitoring with blood tests and ultrasound to:

  • Optimize timing

  • Reduce risk of multiple pregnancy

  • Prevent ovarian overstimulation

Reproductive Surgery

Surgery may be required to treat infertility-related conditions.

Minimally invasive laparoscopic surgery can:

• Remove scar tissue

• Treat endometriosis

• Remove ovarian cysts or fibroids

• Unblock fallopian tubes

Hysteroscopy can:

• Remove polyps and fibroid tumors

• Divide scar tissue

• Open blocked tubes

Advantages of endoscopic surgery: reduced cost, faster recovery, fewer complications, less pain, better cosmetic results.

Laparotomy (open surgery) may still be needed for reversing tubal ligations or removing large fibroids.

Intrauterine Insemination (IUI)

Intrauterine insemination is an office procedure where:

• Sperm are separated from semen fluid

• Healthy sperm are inserted directly into the uterus

Used for:

• Mildly abnormal semen analyses

• Unexplained infertility (often combined with fertility drugs)

• Single women and lesbian couples using donor sperm

In Vitro Fertilization (IVF)

IVF is a highly successful treatment for many causes of infertility, especially:

• Irreparable tubal disease

• Severe male factor infertility

The IVF Process:

1. Ovarian stimulation using fertility medication

2. Egg retrieval using ultrasound-guided needle (10–15 min procedure under sedation)

3. Fertilization

   • Sperm and egg are placed together in a culture dish

   • Or sperm is directly injected into each egg (ICSI)

4. Embryo culture – embryos grow 5–6 days to reach blastocyst stage

5. Embryo selection and transfer

Elective Single Embryo Transfer (ESET): Most women transfer just one embryo to reduce multiple pregnancies.
Additional healthy embryos can be frozen for future use.

Egg Donation & Surrogacy

• Egg donation is an option for women who cannot produce healthy eggs

• Gestational carriers (surrogacy) are considered for women without a uterus or with health conditions that prevent pregnancy

Egg & Ovarian Tissue Freezing

Ideal for cancer patients wishing to preserve fertility before undergoing treatments like radiation or chemotherapy.

• Ovarian tissue reimplantation can produce new eggs

• Egg freezing is now widely used and no longer considered experimental

Preimplantation Diagnosis & Screening (PGD/PGS)

Used to ensure embryos are genetically normal before pregnancy begins.

• PGD – identifies genetic diseases

• PGS – screens for chromosomal abnormalities

Embryo biopsy removes 5–10 cells from each embryo at blastocyst stage for testing.

Male Fertility Options

A male factor plays a role in at least 40% of infertility cases.
Both partners should be assessed during evaluation.

Male Infertili ty Services Include:

• Microsurgical vasectomy reversal

• Microsurgical correction of epididymal obstruction

• Microsurgical varicocele ligation

• Testicular and epididymal sperm extraction for IVF

Comprehensive semen analysis, antibody testing, oxidative stress tests, and sperm DNA damage assessments are offered.

Additional services:

• Post-vasectomy screening

• Sperm processing for IUI

• Frozen donor semen for insemination

• Sperm and tissue freezing before cancer treatment or vasectomy