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The causes of sperm production problems can exist from birth or develop later as a result of severe medical illnesses, including mumps and some sexually transmitted diseases, or from a severe testicle injury, tumor, or other problem. Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence.

The other half of explained infertility cases are linked to female problems (called female factors), most commonly ovulation disorders. Without ovulation, eggs are not available for fertilization. Problems with ovulation are signaled by irregular menstrual periods or a lack of periods altogether (called amenorrhea). Simple lifestyle factors — including stress, diet, or athletic training — can affect a woman's hormonal balance. Much less often, a hormonal imbalance can result from a serious medical problem such as a pituitary gland tumor.

Other problems can also lead to female infertility. If the fallopian tubes are blocked at one or both ends, the egg can't travel through the tubes into the uterus. Such blockage may result from pelvic inflammatory disease, surgery for an ectopic pregnancy (when the embryo implants in the fallopian tube rather than in the uterus), or other problems, including endometriosis (the abnormal presence of uterine lining cells in other pelvic organs).

A medical evaluation may determine whether a couple's infertility is due to these or other causes. If a medical and sexual history doesn't reveal an obvious problem, like improperly timed intercourse or absence of ovulation, specific tests may be needed.

Tests for Both

The man's evaluation focuses on the number and health of his sperm. The laboratory first examines a sperm sample under a microscope to check sperm number, shape and movement. Further tests may be needed to look for infection, hormonal imbalance, or other problems.

Male tests include:

X-ray: If damage to one or both of the vas deferens (the ducts in the male that transport the sperm to the penis) is known or suspected, an x-ray is taken to examine the organs.

Mucus penetrance test: Test of whether the man's sperm are able to swim through a drop of the woman's fertile vaginal mucus on a slide (also used to test the quality of the woman's mucus).

Hamster-egg penetrance assay: Test of whether the man's sperm will penetrate hamster egg cells with their outer cells removed, indicating somewhat their ability to fertilize human eggs.

For the woman, the first step in testing is to determine if she is ovulating each month. This can be done by charting changes in morning body temperature, by using an FDA-approved home ovulation test kit (which is available over the counter), or by examining cervical mucus, which undergoes a series of hormone-induced changes throughout the menstrual cycle.

Checks of ovulation can also be done in the physician's office with simple blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, further testing will need to be done.

Common female tests include:

Hysterosalpingogram: An x-ray of the fallopian tubes and uterus after they are injected with dye, to show if the tubes are open and to show the shape of the uterus.

Laparoscopy: An examination of the tubes and other female organs for disease, using a miniature light-transmitting tube called a laparoscope. The tube is inserted into the abdomen through a one-inch incision below the navel, usually while the woman is under general anesthesia.

Endometrial biopsy: An examination of a small shred of uterine lining to see if the monthly changes in the lining are normal.

Some tests require participation of both partners. Samples of cervical mucus taken after intercourse can show whether sperm and mucus have properly interacted. Also, a variety of tests can show if the man or woman is forming antibodies that are attacking the sperm.

Drugs and Surgery

Depending on what the tests turn up, different treatments are recommended. Eighty to 90 percent of infertility cases are treated with drugs or surgery.

Therapy with the fertility drug Clomid or with a more potent hormone stimulator — Pergonal, Metrodin, Humegon, or Fertinex — is often recommended for women with ovulation problems. The benefits of each drug and the side effects, which can be minor or serious but rare, should be discussed with the doctor. Multiple births occur in 10 to 20 percent of births resulting from fertility drug use.

Other drugs, used under very limited circumstances, include Parlodel (bromocriptine mesylate), for women with elevated levels of a hormone called prolactin, and a hormone pump that releases gonadotropins necessary for ovulation.

If drugs aren't the answer, surgery may be. Because major surgery is involved, operations to repair damage to the woman's ovaries, fallopian tubes, or uterus are recommended only if there is a good chance of restoring fertility.

In the man, one infertility problem often treated surgically is damage to the vas deferens, commonly caused by a sexually transmitted disease, other infection, or vasectomy (male sterilization).

Other important tools in the battle against infertility include artificial insemination and the so-called assisted reproductive technologies. (See "Science and Art.")

Tags: Fertility

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