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Infertility, defined as the failure to achieve pregnancy after 12 months of regular unprotected sexual intercourse, affects 8.8% of US women aged 15 to 49 years, and is often associated with significant physical and emotional stress. Heterosexual women desiring pregnancy who have not conceived after 12 months of unprotected intercourse or donor insemination should undergo an infertility evaluation. Earlier evaluation is recommended for women older than 35 who have not conceived after 6 months, and a more immediate evaluation is warranted in women older than 40.

Infertility is caused by identifiable abnormalities in normal physiology or underlying disease in 85% of infertile couples. The most common causes of infertility are ovulatory dysfunction, male factor infertility, and tubal disease. The remaining 15% of infertile couples have “unexplained infertility”. A history of regular, cyclic menstrual cycles with premenstrual symptoms (e.g., breast tenderness, fluid retention) is sufficient to establish ovulation.

According to the World Health Organization, ovulatory disorders account for 25% of infertility diagnoses. Anovulation should be suspected when periods occur irregularly, in cycles of under 21 days or longer than 35 days, or if the patient reports abnormal uterine bleeding or amenorrhea. Typically, ovulation occurs 14 days before menstruation. The most common cause of anovulation, accounting for 70% of cases, is polycystic ovary syndrome (PCOS). Obesity itself is also associated with anovulation, especially in women with a BMI greater than 27. Eating disorders are another cause of anovulation.

Tubal disorders, where the fallopian tubes are either blocked or incapable of picking up an oocyte from the ovary due to pelvic adhesions (scarring), account for between 11 and 67% of infertility diagnoses. Common causes are a history of sexually transmitted infections (the most common cause), history of abdominal surgery, or a previous abdominal infection (e.g., ruptured appendix). Endometriosis, which is the presence of endometrial tissue outside of the uterine cavity, accounts for 25 to 40% of women with infertility. Another factor is a loss of ovarian reserve, which occurs normally with age. There are also assorted uterine and cervical factors associated with infertility. Last, but not least, are disorders of male physiology, such as low testosterone levels and low sperm counts. Most wives usually blame everything on their husbands but, sorry ladies, male disorders account for only 35% of infertile couples. But, in reality, most infertile couples will have more than one reason for their infertility, which is why evaluation for male factor infertility is performed simultaneously with the woman’s evaluation.

Treatments for infertility include medication to induce ovulation or stimulate the ovaries, the goal being to induce multiple mature ovarian follicles. Timed intercourse or intrauterine insemination (IUI) may be tried to achieve fertilization at the time of ovulation. Alternatively, mature oocytes may be retrieved directly from the ovary for fertilization using an ultrasound guided needle (IVF). Approximately 1 in 8 women aged 15 to 49 receive infertility services. Although success rates differ by age and diagnosis, accurate diagnosis and effective treatment can allow many couples treated for infertility to achieve their goals of becoming pregnant and having a family.

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 By Peter Galvin, MD

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