Infertility and Reproductive Technologies

What is infertility?

Classic definition: Inability to conceive after one year of exposure.

Realistic definition: Inability to conceive, regardless of period of time, due to one or multiple factors that decrease the likelihood of conception; as such, many couples are "subfertile" rather than "infertile"

Infertility Work Up

Couple should be seen together

History (how long have been trying to get pregnant, previous reproductive history, previous infertility work up)

Sexual History (frequency and timing of intercourse, make sure couple isn’t using lubricants)

Evaluate four "classic factors" that may compromise fertility:

Factor	Options for Evaluation	Treatment Options
Male Factor	History of previous conception(s) Semen Analysis	Surgical and/or hormonal therapy "Sperm Washing" combined with intrauterine insemination In Vitro Fertilization Donor insemination
Ovulation	Menstrual history Basal body temperatures Endometrial biopsy Selective hormonal assessment	Medication to induce ovulation - clomiphene, clompihene citrate, and/or gonadotropins
Tubal/Uterine Factor	Hysterosalpingogram (HSG) Laparoscopy/hysteroscopy	Surgical Repair In Vitro Fertilization
Cervical Factor	Post coital test	Estrogen to enhance cervical mucus Intrauterine insemination to bypass the cervical mucus

Note: most of these can be done within 1-2 menstrual periods. Don’t over-diagnose and under-treat!

Influence of Age on Fertility

The age of the woman is a very significant determination of fertility; specifically, fertility declines with age

Excellent article in lay press describing/explaining this: Maranto G. How Long Can Women Put Off Bearing Children? Atlantic Monthly June 1995.

New Reproductive Technologies – all involve in vitro fertilization (IVF)

In Vitro Fertilization (IVF) – procedure:

(1) Meds given to allow development of many mature oocytes
(2) Oocytes are removed from ovary surgically, before ovulation would occur
(3) Oocytes fertilized in petri dish
(4) Resulting embryos are placed in uterus

Embryo cryopreservation – following IVF, embryos in excess of the number that the couple wants can be frozen

when the couple decides to have more children, the embryos are thawed and placed into the uterus

Surrogate carriers – IVF using couple’s gametes and a donor uterus

allows a woman with no uterus or a non-functioning uterus to have a baby that is genetically her own

Indications for Use of Surrogate Carrier: absent uterus (congenital, surgical), abnormal uterus, medical disease

Diseases of pregnancy: anemia, pulmonary hypertension, etc.

Chronic diseases: cystic fibrosis, diabetes, etc.

Oocyte Donors – IVF using the man’s sperm and an egg donated by someone else, implanted into the woman’s uterus

allows a woman who cannot produce eggs to carry a pregnancy (the fetus will be genetically unrelated to her)

Indications for use of Oocyte Donation: premature ovarian failure; "poor stimulators" (i.e. eggs don’t develop, maternal genetic disease)

Source of Oocytes: usually anonymous donors (it is illegal to pay for gametes, so pay "for her time"); can be known source; "split" (women trying to get pregnant via IVF may donate some of their extra oocytes)

Intracytoplasmic Sperm Injection (ICSI) – IVF in which a single sperm is physically injected into the egg

allows fertilization even in men with severe infertility

Embryo Biopsy ("Pre-implantation genetics") – following IVF but prior to implantation, one cell of embryo is removed and assessed for genetic characteristics; this is used to determine which embryos to place in uterus