What Causes Infertility in Women and Men? (podcast)

Dr. Nelson: Endometriosis occurs when the lining of the uterus grows outside of the uterus, in the pelvis or on the ovaries. It can cause scar tissue that can prevent conception from occurring. Also, it can block the fallopian tubes so the egg and sperm can’t meet.

There are also many different types of hormone imbalances that can cause a woman not to ovulate on time or not to ovulate at all, which can lead to infertility as well.

Dr. Friedman: Fibroids are basically a smooth muscle ball. It’s a benign tumor in the uterus. If a fibroid is small and not close to where a pregnancy needs to grow, it’s not going to cause a problem with fertility. But if fibroids get quite large or if they’re impacting the cavity of the uterus where a pregnancy needs to grow, then that can cause a challenge as far as fertility.

Dr. Nelson: A lot of women initially blame themselves, but at least 25 percent of the time or more it’s the man. They often have no idea. They have no reason to suspect it. But they can have a shortage of sperm, where they don’t make enough.The sperm can be abnormal in shape and that causes them not to move as well. The sperm can be too slow to make it to the ovary or the egg on time. Some men don’t have any sperm at all.

Dr. Friedman: Our fertility as women is a little bit unfair. We’re born with all of our eggs and we lose them over time. Because of that, there is a decline in egg quality as we age. Men get to make new sperm every 70 days. It’s not fair. But that’s really the fundamental biologic difference that accounts for why women have a harder time reproducing later in life and men have an easier time reproducing as they get older. There still is a small impact of paternal age on fertility, but it’s nowhere near to the degree that age impacts women and fertility.

The egg is a single cell that we’re born with. Over time those eggs accumulate genetic mutations, missing or extra chromosomes. Therefore, it will be harder for that embryo to be a healthy embryo and have the correct number of chromosomes to implant in the uterus successfully and develop. In addition to a decline in fertility, there is an increased risk of miscarriage.

When it comes to men, there tends to be a decline in motility and in the shape of the sperm. The sperm quality can decline as well as men age.

Dr. Nelson: The age at which we’re best to reproduce is not really the age at which most of us are ready financially, mentally and psychologically. In the ideal world, we would all have our children when we were 22 or 23 years old, but for most of us that’s not the right time.

I know putting it off until you’re over 35 is a gamble for many people and definitely not recommended. If your lifestyle enables you to have children sooner, I would recommend trying a little earlier than that if you can.

Dr. Friedman: It also depends a little bit on your family building goals. Sometimes I’ll see couples that conceived really easily when they were 35, but are now coming back to see me and she may be 39. As the years advance and we get closer to 40, it can become that much harder. So, it depends a little bit on your family building goals too.

Dr. Nelson: In your 20s you’ve got at least a 90 to 95 percent chance that you’re going to conceive, especially within a year. As long as you’re less than 35, you're still 75, 80 percent. It starts going down from there, especially after the age of 40.

Dr. Nelson: You have to look at if the woman is having regular menstrual cycles or not. I always tell my patients if they are not having regular cycles then they need to come in a lot sooner.

Generally, if a woman is under the age of 35, it’s recommended to try for about a year if their cycles are regular. If over the age of 35, typically we recommend starting to do tests after six months of trying.

Dr. Friedman: We have to gather the puzzle pieces. There’s a lot of different moving parts. We have to look at egg supply. We can do that in a couple different ways. A blood test can be very helpful. Checking to make sure the fallopian tubes are open is typically done with a test in radiology where they put dye in the uterus to make sure the tubes are open. It’s very important that the fallopian tube is open, otherwise the sperm and egg are not going to have an opportunity to meet.

Dr. Nelson: We definitely need to check out the male partner and do an analysis of the sperm or semen analysis.

Also, an ultrasound is usually performed on the woman’s uterus and ovaries to make sure they look normal as well as checking hormones.

Dr. Friedman: If you are struggling with infertility, you’re not alone. There are wonderful fertility options, depending on what the cause of infertility is. If a woman is not ovulating, sometimes there are medications to help her ovulate or the ovary to release an egg. There is IUI or intrauterine insemination. There is also IVF or in vitro fertilization.

Many of my patients refer to IUI as the turkey baster approach. That’s when a man provides a sample of sperm. We process that sperm in the lab, concentrate the sperm into a tiny catheter and that catheter goes inside the uterus closer to where it needs to go. Typically this is done in conjunction with the woman taking medication to have the ovary release more than one egg. That’s what we’d consider our low-tech approach of IUI or intrauterine insemination. IVF, or in vitro fertilization, is more of our high-tech approach.

Dr. Friedman: IVF is when a woman takes medication to encourage the ovaries to make multiple eggs. Those eggs are taken out with a surgical procedure and then the eggs are fertilized with sperm in the lab. That fertilized egg or embryo then goes back into the uterus.

As fertility treatment has gotten more and more effective and successful, we are really advocating transferring just one single embryo. Our goal is one healthy baby at a time.

Dr. Nelson: It depends on what the problem is. But one of the medications that OB-GYNs often prescribe is called Clomid. It’s an oral medication that is used to help a woman who is not ovulating or maybe not ovulating early enough in her cycle. It kind of tricks her body into thinking that she needs more stimulating hormone. That’s something that is successful in certain types of hormone imbalances where they can just take a pill at home for five days in the cycle and that can sometimes work to help a patient to ovulate. Sometimes with other hormone imbalances, or for the process of initiating in vitro fertilization, they actually have to use injections of hormones to stimulate the ovaries, which is something that you have to see a fertility specialist for.

Dr. Nelson: It is a pretty common disorder which we see in a lot of women where there’s a predominance of male hormones, which is typically caused by a resistance to insulin. These imbalances can cause a woman to not ovulate at all or to ovulate extremely late in the cycle where the egg isn’t very good anymore or the lining of the uterus is old and not prepared to receive the egg. It also makes it harder to get pregnant when you don’t know when you might ovulate in the cycle. It is a disorder that can be treated sometimes with Clomid and other medications. We see it often in women who are very overweight. That can play a big role in hormone imbalances.

Dr. Friedman: That’s something that is a big part of our tool box. We’ve helped many, many patients conceive with assisted reproductive technology or what we call third party reproduction, donor eggs, donor sperms, or surrogacy. It can be a really wonderful way for people to build their family.

At the San Diego Fertility Center, we do have our own egg donor database. Patients can look at the egg donor database and select an egg donor that they feel is a good match for them. And then that young woman under the age of 30 is going to go through the process of taking medications. We’d retrieve her eggs with the procedure, typically fertilize her eggs with the intended parent’s sperm, create the embryo and then transfer the embryo to the egg donor recipient.

Dr. Nelson: We see donor sperm involved in many cases, sometimes with same-sex couples, where they need a sperm donor, or if the man’s sperm is so abnormal that even IVF is not going to solve the problem. There are banks where you can pick out sperm based on many characteristics of the man, so that they can look and maybe be as close to the husband as possible.

Dr. Friedman: You also see this with women who are single moms by choice. We’re seeing a lot of women who maybe haven’t found Mr. Right and they’re choosing to then start that process to parenthood.

Dr. Friedman: Infertility can really take a tremendous toll, not just on the individual, but the couple and the relationship of the couple. It’s important to emphasize that infertility affects one out of every eight couples. These patients going through it are not alone. It’s very common and it’s a medical disorder like really any other. So, those patients who are struggling with infertility need that extra emotional support because it is such an emotional journey. But they’re not alone and we do have very effective treatments.

Dr. Nelson: At least 25 percent of all recognized pregnancies will miscarry and that’s from getting your positive pregnancy test to the first three months of the pregnancy. So, that is also very, very common. It’s important to know that just because you have a miscarriage doesn’t mean you won’t be able to have a baby. Many women have a miscarriage and go on to have many healthy babies after that.

Dr. Friedman: Most miscarriages are caused by missing or extra chromosomes in the embryo. We always emphasize to someone who has gone through a miscarriage, that it’s not her fault. It’s very common for women to blame themselves and feel like it’s something I did that caused this. But that’s really not the case.

Dr. Nelson: Typically something isn’t right with the pregnancy, so either the embryo is abnormal or later in the first trimester organ development might not be normal. It’s like Mother Nature knows that this isn’t normal and is taking care of the problem before it gets to the point of where the parents may have to make decisions about, “Is this baby normal or not?” That is taken care of a lot of the time for us. I like to remind people that when they have a miscarriage that of course they should be sad about it, but on the flip side that something wasn’t right with it and so they really want a healthy, normal baby and so they have to kind of move on to the next pregnancy and focus on that rather than focusing on the loss.

Dr. Friedman: As far as outside factors, there are certain environmental exposures. Cigarette smoking does increase the risk of miscarriage. Extreme obesity can also increase the risk of miscarriage. There are certain medical conditions that can increase the risks of miscarriage, such as uncontrolled diabetes. Certainly those are factors that an OB-GYN would go over with a patient and try to reduce or eliminate those risk factors.

Dr. Nelson: Excessive alcohol tends to be a lower cause of miscarriages, at least in our population. But certainly that definitely contributes to abnormal embryos, which would then result in miscarriage.

Dr. Nelson: I think the most important thing is trying to have your babies younger, if you can. And then just being healthy. Not anything too extreme, but eating a healthy diet, not smoking and exercising a realistic amount. We see problems with people who do things to excess, such as excess training for marathons, triathlons. Athletes, dancers can sometimes have difficulty because they’re on the extreme end of fitness.

Dr. Friedman: Ideally, if someone wants a larger family, it’s best to start trying as soon as possible. We’re most fertile in our 20s, but that may not be the right time for some women. From a fertility perspective, we’re at our peak in our 20s. But certainly if someone wants a larger family, starting that journey when under the age of 35 would be important because as we move into our later 30s, or particularly closer to 40, it can become substantially more difficult to get pregnant.

Dr. Nelson: One important thing is letting the patient know that it’s not their fault. They’re not causing this to happen.They didn’t do anything wrong. Most of the time, it isn’t something that they did wrong. Just helping them and supporting them through that is important because blaming themselves or blaming each other can cause more problems in their relationship and turn something that’s supposed to be a healthy, fun activity into something that’s very stressful and can cause lots of problems with the marriage.

Dr. Friedman: Typically, I encourage patients if they’re having a hard time to seek help. See a mental health professional. There are support groups. It’s important just to know that they’re not alone. It’s really important to know that there are options. There is support and there is help.