Infertility FAQ: Part 2

by Food and Drug Administration (FDA)

(Page 2 of 4)

Q. What kinds of doctors evaluate and treat infertility?

A. Obstetrician-gynecologists (OB-GYNs) can evaluate and treat infertility in women. OB-GYNs specialize in general medical care of women, including care related to pregnancy and the reproductive tract. Urologists, who specialize in the urinary tract and the male reproductive organs, can evaluate and treat infertility in men.

More resistant and complex problems are typically handled by "fertility specialists," board-certified reproductive endocrinologists who have completed training in obstetrics and gynecology, followed by specialized training in hormonal problems and infertility. One example of a complex problem is a history of failure to conceive despite regular unprotected intercourse in a woman who has regular menstrual periods and whose male partner has normal sperm. Other examples of complex problems include a woman who has experienced multiple miscarriages or who has severely damaged fallopian tubes requiring the need for treatment with assisted reproductive technologies (ART) — the joining of eggs and sperm in a lab so that fertilization can occur.

The decision about when to ask for a referral to a fertility specialist is a personal one. Experts say that couples should consider the age of the woman, the complexity of their problems, and how they are feeling about the progress of their treatment. Consumers should be proactive about asking their doctors for a referral to a specialist and about investigating the qualifications of the specialist. A certificate of special qualification in reproductive endocrinology and infertility from the American Board of Obstetrics and Gynecology ensures that the specialist has completed a rigorous course of training.

Q. What goes into a fertility evaluation?

A. A standard fertility evaluation includes physical exams and medical and sexual histories of both partners. Men undergo a semen analysis that evaluates sperm count and sperm movement. "We look at the percent that are moving and how they are moving — are the sperm sluggish? Are they wandering?" says Robert G. Brzyski, M.D., Ph.D., associate professor of obstetrics and gynecology at the University of Texas Health Science Center at San Antonio. "Often, it's not possible to identify a specific reason for a sperm disorder," he says. "But there is new recognition that very low sperm or no sperm may be related to genetics — an abnormality of the Y chromosome."

For women, doctors first check to see whether ovulation is occurring. This can be determined and monitored through blood tests that detect hormones, ultrasound examinations of the ovaries, or an ovulation home test kit. "An irregular menstrual pattern would make us suspicious of an ovulation problem, but it's also possible for a woman with regular periods to have an ovulation disorder," Brzyski says.

If a woman is ovulating, doctors then move to a standard test called the hysterosalpingogram, a type of X-ray of the fallopian tubes and uterus. This test involves placing a radiographic dye solution into the uterine cavity. Multiple X-rays are taken. If the fallopian tubes are open, the dye will flow through the tubes and be visible in the abdominal cavity. If the fallopian tubes are blocked, the dye will be retained in the uterus or fallopian tubes, depending on the location of the blockage.

Other tests give doctors more information. For example, ultrasound can be used to examine the female reproductive structures. Hysterosonography is a more complicated type of ultrasound that involves putting salt water (saline) into the uterus during an ultrasound exam. "This is more likely to reveal structural abnormalities than regular vaginal sonography will show alone," Brzyski says. One such abnormality that hysterosonography may identify is fibroid tumors, which may distort the shape of the uterine cavity.

A surgical procedure called laparoscopy also allows doctors to examine the ovaries, uterus, fallopian tubes, and abdominal cavity. This involves inserting a fiber-optic telescope into the abdomen. One advantage of laparoscopy is that it allows doctors to both diagnose and treat conditions such as endometriosis, when uterine cells attach to tissue outside of the uterus. Adhesions, abnormal attachments between two surfaces inside the body, can also be treated in this way.

Doctors have begun to assess the ovarian reserve by measuring hormone levels and seeing how the ovaries respond to various fertility treatments. This helps evaluate the availability of eggs and the likelihood that a healthy pregnancy will result. "Some women who are 35 are fertile while others are not because their supply of eggs is depleted," Brzyski says. "In the last decade, we've learned this can be investigated through a blood test on the third day of the menstrual cycle. If the numbers are normal, it doesn't guarantee fertility. But if the numbers are abnormal, it points to a serious problem. Up to 20 percent of women who seek infertility care have an abnormal ovarian reserve test."

There are also tests that evaluate how sperm and eggs interact, as well as whether either party is developing antibodies to the sperm. This occurs when the man's or the woman's immune system recognizes the sperm as something foreign and attacks it.

Q. What does it mean when infertility is "unexplained"?

A. Sometimes a couple is told that their infertility is unexplained. This means the reason can't be identified through diagnostic tests. Even in cases of unexplained fertility, it's still possible to be treated successfully.

Researchers continue to look for clues that may shed light on unexplained infertility and improve treatment. In 2003, researchers funded by the National Institutes of Health and private sources reported the discovery that an embryo initially attaches to the uterine wall by using specialized molecules located on the surfaces of the embryo and the uterus. The embryo is able to attach because of a sticky interaction with the uterine wall.

The process is "like a tennis ball rolling over a tabletop covered with syrup," says Susan Fisher, Ph.D., the study's senior author and an anatomy professor at the University of California, San Francisco. "Understanding the molecular underpinnings of the process that initiates pregnancy is the first step in devising therapies that will improve the rate of implantation."

About the Author

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FDA is A United States government body that oversees medical devices, including contact lenses, intraocular lenses, excimer lasers and eyedrops. In the US, these products must be approved by the FDA before they can be marketed.