Causes of Infertility

What Is Infertility?
According to the National Infertility Association, infertility is a medical condition of the reproductive system that results in the inability to conceive or carry a pregnancy to term. The condition is diagnosed by a physician, usually after a couple has had a year of unprotected, regular intercourse without conceiving, or when pregnancy occurs but does not result in a live birth.

Causes Of Infertility
Infertility can be due to factors in either the female or the male. 35-40% of the time the cause can be traced to the female partner, and 35-40% of the time infertility can be linked to the male partner. Sometimes conditions in both partners play a role. Other times the reason for infertility remains unknown.
Common Causes For Women
  • Impaired ovulation due to disease, infection, birth defects, or abnormal hormone production
  • Blocked fallopian tubes from disease or scar tissue
  • Inability of the uterus to hold the embryo (this may be due to a variety of reasons, including scar tissue on the walls of the uterus)
  • Endometriosis
Common Causes For Men
  • Low sperm count
  • High percent of abnormally shaped sperm
  • High percent of sperm that are not moving forward
  • Ejaculation dysfunction
Sperm production can be affected by blocked passageways, fevers, infections, or birth defects. Both men and women can develop antibodies that attack sperm and prevent fertilization.
Other factors that can contribute to infertility include stress, smoking, alcohol use, excess weight and overall health.

Evaluation & Diagnosis

The causes of infertility are not always easily recognizable. Our specialists may recommend a variety of diagnostic tests that can help determine how to proceed. We begin with a one-on-one consultation, a medical history review, and baseline tests for each partner, to evaluate female hormone levels and egg quality, and male sperm count.

Please bring your medical records to your first appointment. These records contain important information about your personal and family health history, your gynecologic history, and any previous infertility work-ups and treatment. Dr. Miller will reference this important data when planning your treatment.

Given the importance of the ground covered during the work-up stage, we strongly ecnourage both partners to attend. Once your work-up is complete, our physicians will meet with you and your partner to discuss the findings and recommended treatment plan.

WHEN TO SEE A DOCTOR

The National Infertility Association says that most physicians will recommend that couples try to conceive for a year before seeking medical assistance. They also state that if a woman is over 30, has a history of pelvic disease, miscarriage, painful menstruation, irregular cycles, or if her partner has a low sperm count, they may want to seek professional advice sooner.

HOW TO CHOOSE A SPECIALIST

Choosing the right place for infertility treatment is very important. According to the American Society for Reproductive Medicine, there are certain points that need to be considered when making that choice:

  • Qualifications and experience of the people who work in the facility
  • Types of patients being treated (this can have an effect on a program’s pregnancy success rate; e.g., couples over forty are less likely to get pregnant than younger couples)
  • Support services available – some programs may just have IVF or GIFT or they may combine more than one, but you want to be sure they have all services that you may need
  • Cost
  • Convenience
  • Documentation to support their success rates
  • Details about the guidelines they follow, lab accreditations, and statistic reporting

Click here to find the best infertility treatment clinics.

TESTING
Tests may include:

  • Semen analysis to evaluate ejaculate; the specimen is collected after 2 to 3 days of complete abstinence to determine volume and viscosity of semen and sperm count, motility, swimming speed, and shape.
  • Postcoital test (PCT) — to evaluate sperm-cervical mucus interaction through analysis of cervical mucus collected 2 to 8 hours after the couple has intercourse.
  • Measuring serum progesterone (blood test)
  • Endometrial biopsy to determine response of the uterine lining.
  • Testicular biopsy (rarely done)
  • Measuring urinary luteinizing hormone by using kits commercially available for home use to predict ovulation and assist with timing of intercourse.
  • Serum hormonal levels (blood tests) for either or both partners. For women this may include estrogen, TSH, prolactin, inhibin B, antimullerian hormones, LH, and FSH. For men tests may include LH, FSH, TSH, prolactin, and testosterone.
  • Hysterosalpingography (HSG) — X-ray procedure done with contrast dye that enables evaluation of potential transport from the cervix through the uterus and fallopian tubes.
  • Laparoscopy to allow direct visualization of the pelvic cavity.
  • Hysterosonogram – an ultrasound test involving filling the uterine cavity with saline to evaluate for abnormalities.
  • Ultrasound to evaluate uterine health.

Treatment

Your individualized treatment program may include one or more of the following procedures.

Assisted Reproductive Technologies
  • In vitro fertilization (IVF)
    A process where egg and sperm are combined in our state-of-the-art IVF laboratory. Once fertilization has occurred, embryos are transferred directly into the uterus..
  • Zygote intrafallopian transfer (ZIFT)
    ZIFT is a method of assisted reproduction that can be used in women with at least one normal fallopian tube. The methods of stimulating the ovaries, egg retrieval, and laboratory fertilization are the same as those used in IVF. In ZIFT, however, once an egg has been fertilized, the embryo is inserted laparoscopically into a fallopian tube.
  • Gamete intrafallopian transfer (GIFT)
    Egg and sperm are placed in a catheter and directly inserted into a fallopian tube. Unlike, IVF or ZIFT, fertilization takes place in the body.
Infertility Treatment
  • Ovulation Induction
    Medication is used to stimulate the ovaries to develop and release more than one egg in a single month.
  • Intrauterine insemination (IUI)
    Sperm is inserted directly into the uterus to enhance the likelihood of fertilization.
  • Micromanipulation Techniques
    • Intracytoplasmic Sperm Injection (ICSI)
      Performing in vitro fertilization requires a significant amount of sperm. In cases where the male partner has a low sperm count or poor sperm mobility, ICSI can be of extreme value, facilitating fertilization with just a few sperm.ICSI utilizes specialized micromanipulation equipment in the Edward lab. An egg is immobilized under the microscope using special glass tubing, and a single sperm is injected into the egg. Sixteen to 24 hours later, the egg can be evaluated to see if fertilization has occurred.
    • Assisted zona hatching (AZH)
      When an embryo is ready to implant in the lining of the uterus, it first must hatch out of its outer layer, called the zona pellucida. There is some evidence that suggests the zona may become abnormally thickened in some individuals as a result of the IVF process, making it more difficult for the embryo to hatch out at the appropriate time.AZH is another micromanipulation technique performed in the lab. Delicate instrumentation is used to stabilize the embryo and create a small slit in the embryo prior to transfer.
 
 
 
Minimally Invasive Gynecologic Surgery (MIGS)
In some cases, surgical procedures may be helpful, and necessary, to resolve conditions that make it difficult to achieve pregnancy. Our surgeons have extensive training in advanced minimally invasive surgical techniques.  The doctor is the Past President of the AAGL, the largest society in the United States devoted to Minimally Invasive Gynecologic Surgery. He is the President Elect to the ISGE (International Society for Gynecologic Endoscopy).   The doctor – Singh completed her fellowship in Minimally Invasive Gynecologic Surgery through Harvard University Medical School.
Laparoscopic Treatment for:
  • Endometriosis
  • Uterine fibroids
  • Pelvic pain
  • Tubal reanastomosis
  • Adhesions
Hysteroscopic Treatment for:
  • Uterine fibroids
  • Adhesions
  • Uterine septum
  • Transvaginal tubal ligations
Additional Services
  • Treatment for recurrent miscarriage
  • Donor oocyte (egg) program
  • Donor sperm program
  • Embryo cryopreservation
  • Gestational carrier (host uterus) program

In Vitro Fertilization

Basic Steps of IVF

  1. Ovarian stimulation and egg development
    Prior to beginning your IVF treatment cycle, you will be started on a medication to suppress the ovaries. Once the ovaries are suppressed, hormones are prescribed to be injected daily or twice daily in order to stimulate the ovaries to develop multiple eggs.
  2. Egg retrieval and evaluation
    After tests indicate that eggs have reached maturity, you’ll be prescribed another hormone, hCG, to finalize the maturation process. Egg retrieval is scheduled for 24 to 36 hours later.Egg retrieval is a brief procedure that is typically performed in the early morning. Guided by the images from a transvaginal ultrasound, the doctor inserts the tip of a small needle through the vaginal wall, into the ovary, and into the egg sac (follicle). The contents of each follicle are evaluated under a microscope by our embryologist.
  3. Egg fertilization and transfer
    Eggs that are determined to be mature thereby having the greatest chance of fertilization or producing a pregnancy are ready to be introduced to sperm four to six hours after egg retrieval. Fertilized eggs are incubated for three to five days, until ready for transfer to the patient.
  4. Pregnancy test
    A pregnancy test is typically performed two weeks after transfer. We’ll provide you with specific instructions as to when to return to the office and what testing will occur.


INNOVATIVE TREATMENTS

Infertility is complex and different for every couple. Sometimes, the factors causing infertility aren’t solved by following a textbook approach. In these cases, more advanced options need to be considered.
The doctor is committed to taking a closer look at innovations that could help a couple achieve a successful pregnancy. Our physicians believe in exhausting every possible diagnostic and treatment angle for each couple. The doctor and team are trained in the latest innovations to help a couple fulfill their dreams of starting a family. Learn about the newest procedures that have helped our patients become parents.
  • Transvaginal Ultrasound Guided Embryo Transfers
  • Blastocyst Transfers
  • Preimplantation Genetic Diagnosis (PGD)
BLASTOCYST TRANSFER
Infertility patients concerned about their risk of having multiples may benefit from blastocyst transfer. This unique process allows a reproductive endocrinologist to transfer fewer embryos that have the best probability for resulting in a successful pregnancy.
Typically, embryos are transferred on day three. After this point, about half of the embryos stop developing and degenerate, reducing the likelihood of a pregnancy. To have the same chances at attaining a pregnancy, it is necessary to transfer more embryos. This carries an increased risk of having multiples.
In a blastocyst transfer, the embryos are grown to day five or six. This is the stage in which an embryo begins to expand again, and it becomes possible to discern the embryos with the best quality.
However, growing an embryo past day three must be done very carefully. The conditions and nutrients required by embryos change, affecting the enriched fluids that house the embryos. Without proper laboratory conditions, an embryo is less likely to implant and may even die.
Dr has a state-of-the-art lab with precise controls in place to maintain embryos beyond day three.
For couples with a smaller number of healthy embryos, this approach may not be beneficial. Many women have infertility due to aging ovaries, and the blastocyst approach is not ideal for them. The patient that has the most to benefit is a couple where the female is young, especially in her 20s.
During an Embryo Transfer Process, the embryos are placed inside the uterus. The thriving embryos will ultimately implant into the endometrial lining. This step takes only ten minutes, but it can significantly affect a woman’s chances for a successful outcome.
There are many delicate steps in this process. For example, the uterine lining may not be scratched or damaged by the catheter while it is within the uterine canal. The location along the uterine canal where the embryos are placed can also impact the chances of success.
Although some centers utilize nurses for embryo transfer, The doctor completes the embryo transfer process.
During the process, the physician cleans the cervix to remove a thick mucous that is secreted in the cervical canal because of hormones. In order to locate and remove this mucous, the physician uses a powerful lighting system within the opening of the cervical canal. If the mucous isn’t completely removed, the embryos can be caught within the cervix.
While virtually every center performs trans-abdominal ultrasound with a full bladder, The doctor performs Embryo Transfers with trans-vaginal ultrasound. This allows the procedure to be completed without a full uncomfortable bladder. Moreover, visualization is superior.
Our Embryo transfer technique is modified for success. The doctor uses a two-catheter technique. A dummy catheter finds the precise location for placement, then a second catheter is used to actually transfer the embryos. “This allows the embryos to spend less time in the unstable environment of the catheter,” said The doctor, director of in vitro fertilization. “The entire procedure takes less than 10 minutes with embryos transferred in mere seconds, but it’s a critical time for the fragile embryos.”
The increased risks of miscarriage and genetic disorders faced by older women who are trying to have a baby can be avoided by use of an innovative technique available through The doctor.
Preimplantation genetic diagnosis (PGD) is a procedure that tests embryos for genetic disorders before placement in the uterus. It is performed in conjunction with IVF and should be considered for women over the age of 37, women with a history of recurrent miscarriages, and families with a history of genetic diseases.
PGD is conducted by analyzing the DNA within one of the cells of each embryo formed during a routine IVF cycle. (There are eight interchangeable cells in a healthy embryo. Removing one cell is not harmful to the development of the baby.) This DNA analysis helps to identify genetic disorders, such as Down’s syndrome and Turner’s syndrome, and to determine which embryo to implant.
The doctor has created a tightly-controlled environment for the delicate science of IVF. Air purity, temperature, oxygen level and other details are in place for the most “embryo-friendly” atmosphere.

Surgical Options

In some infertility cases, surgical procedures may be helpful – and necessary. Innovative technology has changed the way many gynecologic procedures are performed. In fact, many traditional surgeries are being replaced with minimally invasive techniques.
Below are answers to the most frequent questions we get about surgical procedures.
How does minimally invasive surgery differ from more traditional surgery?
Traditional surgery involves making a much larger incision, usually five inches or more. It leads to a longer recovery time, larger scar, and increases the risk of adhesions or scarring within the abdomen. The hospital stay is usually three days or longer. The patient typically does not return to work for four to six weeks. Minimally invasive surgery allows for a quicker recovery and less pain.
How long does it take to recover?
Most patients go home the same day as the surgery is performed. Patients are able to get up and around that evening. Although removing the entire uterus usually requires an overnight stay in the hospital, most patients are up out of bed the next morning and go home early in the day.
What is hysteroscopy?
Hysteroscopy is minimally invasive surgery for the inside of the uterus. The cervix (the part of the uterus that opens into the vagina and through which a baby passes during delivery) is opened to less than half-inch in order to perform surgery. Through this opening a narrow instrument with a video lens at the end is passed through into the uterus. Other instruments can then be passed through alongside the lens, these instruments are used to grasp, cut or vaporize abnormal tissue. In this way, polyps, fibroids and inborn defects of the uterus can be removed.
What is laparoscopy?
Laparoscopy is minimally invasive abdominal surgery performed through very small incisions in the abdomen, generally a half-inch or less. The lens of a small camera is placed through one incision so that the inside of the abdomen may be seen on a TV screen. Two or three other instruments are then placed through the other incisions. These instruments can hold, cut and suture tissue, allowing the experienced laparoscopic surgeon to perform even complex surgeries. A large fibroid or even a entire uterus can then be removed through these small incisions by cutting the fibroid or other tissue into thin strips while inside the abdomen.
Who can perform gynecologic minimally invasive surgery?
Many physicians trained in gynecology can perform some types of laparoscopy and hysteroscopy. However, the extent and difficulty of the surgery they perform in this way depends on their specific training and comfort levels. Gynecologists who have completed a fellowship in reproductive endocrinology and infertility, such as the physicians at Specialists in Reproductive Health, receive much more extensive training in advanced minimally invasive surgery.