Infertility is much more common than previously supposed.  In fact, the American Society for Reproductive Medicine (ASRM) reports that approximately 12 percent of all reproductive age couples experience infertility. The ASRM defines infertility as the absence of pregnancy after one year of regular intercourse.  The time frame is often shortened to six months in women aged 35 or older.

Infertility is often thought of as a female problem; however, we now know that almost half of all infertile couples have a male component. Therefore, we evaluate both partners at the outset. Male infertility can range from slight declines in sperm quality or quantity to complete absence of viable sperm.  For this reason, an infertility work-up involves testing both partners, if appropriate.

Certainly, awareness of infertility has increased as the media focuses on high technology procedures such as in vitro fertilization. However, the majority of couples will become pregnant using lower tech options and will not require advanced technologies such as IVF.  In most practices less than 30 percent of couples will eventually require IVF.

Societal changes over the last twenty years have contributed to the number of women seeking infertility care. Women are most fertile in their teens and twenties and fertility begins to decline, sometimes rapidly, in the thirties ultimately leading to the menopause, and most women are infertile by the forties. Women are choosing to start families later in life, after their careers are established, and are also waiting much later to get married. In the United States, two income families are the norm.

As women age, so do their eggs by losing their ability to fertilize and develop normally. The female reproductive system is definitely not in sync with our societal changes. Once the woman stops producing health eggs, the only means to achieve pregnancy is to use donor egg IVF.  Donor egg success rates are typically high since we use the eggs of young healthy females.

Egg freezing is also generating a lot of media attention.  With egg freezing, a woman's eggs are frozen while she is fertile for use later in life.  Unfortunately, egg freezing is in its infancy and one should not count on the procedure as a means to insure children.  The frozen/thawed eggs are used in an IVF cycle and the success rates are lower than with fresh eggs.  Baystate Reproductive medicine does not currently offer egg freezing.

The number of board certified reproductive endocrinologists/infertility specialists has increased dramatically since the early 1990's.  These are Ob/Gyn physicians who have completed fellowship training in the subspecialty of reproductive endocrinology.  Reproductive endocrinologists help increase public awareness by conducting public educational seminars, providing radio and television interviews and most infertility specialists have Web sites focused on infertility education. Board certified infertility specialists are available in virtually all metropolitan areas throughout the United States.  Baystate Reproductive Medicine has five board certified reproductive endocrinologists.

In the past, many Ob/Gyns offered infertility services such as oral medications (Clomid), fertility surgery, and stimulated IUI.  Stimulated IUI involves the use of follicle stimulating hormone (FSH), which is commercially available as Gonal-F, Follistim, Menopur, and others. FSH causes the ovaries to recruit and mature multiple eggs and is normally produced by the pituitary under the influence of the hypothalamus. The hypothalamus is a small endocrine gland located at base of the brain, which coordinates the production of my reproductive hormones.

Most Ob/Gyns no longer offer stimulated IUI because of potential side effects such as hyperstimulation syndrome (a very serious condition usually requiring hospitalization). There is also the increased potential for high order (>2) multiple births. The vast majority of Ob/Gyns quickly refer infertile women to a reproductive endocrinologist/infertility specialist.

FSH should only be administered by a reproductive endocrinologist/infertility specialist thoroughly trained in its use.  Specialists undergo intense training in many areas including administering and monitoring ovarian stimulation.  We discuss FSH stimulated cycles in depth in the IVF section of this Web site.

Sometimes women will receive a trial of oral Clomid for three months by their Ob/Gyn.  Clomid is most likely to work in the first three ovulatory cycles and therapy beyond this time is rarely effective. Older women, in their thirties or forties, should be referred to a specialist immediately as fertility can decline very rapidly in these age groups.

Unfortunately, we still see women who have been taking Clomid for a year or longer.  Clomid will usually work in the first three cycles, and extended therapy is not recommended.  It is unlikely to produce pregnancy and can increase negative drug side effects.

In general the following processes must occur for a couple to achieve pregnancy:

1. The male must be capable of producing enough sperm of good quality to cause fertilization.
2. These sperm must travel unimpeded through the vas deferens and be ejaculated into the vagina or frozen as donor sperm.
3. The sperm must be motile, or capable of swimming to the egg.
4. One sperm must attach to and penetrate the egg membrane, injecting its genetic material into the egg, producing a fertilized egg or pre-embryo.
5. The female’s ovaries must contain a supply of eggs. All eggs needed for a lifetime are in the ovaries at birth.
6. Ovarian follicles, each containing an egg, must be recruited, grow, and mature under the influence of follicle stimulation hormone (FSH).
7. The hypothalamus must produce gonadotropin releasing hormone (GnRH) which stimulates the pituitary to produce FSH and LH. Levels of FSH and LH are regulated by feedback from the hypothalamus. Healthy developing follicles produce estrogen, which through the hypothalamic feedback mechanism begins to lower FSH production.
8. Once the eggs reach maturity, the pituitary releases a surge of LH which finally prepares the eggs for ovulation and initiates the process 36 hours later.
9. Once mature, the eggs must pass unimpeded through the fallopian tubes to the site of fertilization.  Tubal disease infertility, often caused by endometriosis, can interfere with egg transport.
10. Once fertilized, the pre-embryo enters the uterus and attaches to the endometrium.  The endometrium is the lining of the uterus that has become “thicker' and more vascular during the ovulatory cycle. The endometrium provides support and nutrition to the embryo.  After ovulation, the follicular structure remaining is termed the corpus luteum, which begins to produce progesterone thus stimulating endometrial thickening. After implantation, the placenta continues to produce progesterone. The embryo will continue to divide and grow in the uterus until delivery.

Disruption of any of the processes above can lead to infertility and are discussed on the “infertility causes” page. Fortunately, with the advance of diagnostic technologies and new infertility treatments, over 80 percent of women who seek infertility specialist care will achieve pregnancy.  The most important step is to seek the care of a fertility specialist as soon as possible.

Learn about the causes of infertility.