Women's Health Specialists of St. Louis
Obstetrics and Gynecology

Articles - Infertility

Difficulty conceiving a child can be psychologically and economically demanding. Infertility is defined as the inability to conceive after one year of intercourse without contraception. Infertility affects approximately 15% of couples in the United States. Evaluation for infertility can be complex because there are many possible causes of infertility. For example, male factor infertility or abnormal semen is the cause for infertility in 20-30% of couples trying to conceive. Lack of regular ovulation may also be the cause for infertility in approximately 20% of couples. Abnormal Fallopian tubes can cause infertility by preventing the egg and sperm from meeting. Endometriosis can cause infertility by causing damage to the tubes and or ovaries and also by the hormonal imbalance that it can create. Unfortunately, as many as one third of couples with infertility have no identifiable cause of infertility. This is often referred to as unexplained fertility.

Evaluation for infertile couples begins with a thorough history and physical as well as laboratory evaluation. Most evaluations will begin with a semen analysis as this is the least invasive test and generally will eliminate most of the causes of male infertility. Though irregular menstrual cycles are often a sign of irregular ovulation, determining whether a woman is ovulating is much more complex. Basal body temperature charts may be used to help confirm ovulation but charting requires the diligent recording of temperatures in order to detect changes in body temperature by a tenth of a degree. The charting can be frustrating because it requires the temperature to be taken at the same time daily and temperature changes can be affected by illness, stress, etc. Ovulation predictor kits are available over the counter but they can be costly and just as frustrating. The kits can detect the surge of hormone that causes ovulation to occur with 95% accuracy. However, the accuracy is reliant on the skill of the patient to perform the test at the time of the hormonal surge. Since this test can be falsely negative because of timing, the surge predictor kits are in reality only 85% accurate. In general, most physicians will use a combination of history, home testing, and laboratory testing to help determine if a patient is ovulating.

Assessment of the uterus and tubes is the next step in evaluation if ovulation and semen quality are normal. A wide variety of uterine abnormalities may be associated with infertility including fibroids, congenital anomalies, and scarring from prior procedures or infections. Evaluation of the inside of the uterus and tubes may be performed by hysterosalpingogram and or hysteroscopy. A hysterosalpingogram or HSG is when dye is placed through the cervix into the uterus and tubes while an x-ray is performed. This is a procedure that is performed without anesthesia. It is a useful tool to determine if there is an abnormality of the shape of the uterine cavity or if the Fallopian tubes are blocked. A hysteroscopy involves placement of a camera inside the uterus. Use of the camera allows the physician to take biopsies and to remove abnormal growths if they are present. Conversely, laparoscopy is the use of a camera to look at the outside of the uterus and tubes and to look at the ovaries. Laparoscopy is the standard of care for the diagnosis and treatment of endometriosis.

Evaluation for infertility can be a long and emotional process. Thankfully, with thorough evaluation and treatment, most couples will successfully conceive spontaneously. For those couples who are unable to conceive or who have unexplained infertility, assisted reproduction with in-vitro fertilization and other technologies can still offer the opportunity to conceive.