Infertility

Infertility primarily refers to the biological inability of a person to contribute to

conception. Infertility may also refer to the state of a woman who is unable to carry a
pregnancy to full term. There are many biological causes of infertility, some which may
be bypassed with medical intervention.[1]

Women who are fertile experience a natural period of fertility before and during
ovulation, and they are naturally infertile during the rest of the menstrual cycle. Fertility
awareness methods are used to discern when these changes occur by tracking
changes in cervical mucus or basal body temperature.

Definition

There are strict definitions of infertility used by many doctors. However, there are also
similar terms, e.g. subfertility for a more benign condition and fecundity for the natural
improbability to conceive. Infertility in a couple can be due to either the woman or the
man, not necessarily both.

Infertility

Reproductive endocrinologists, the doctors specializing in infertility, consider a couple to

be infertile if:

• the couple has not conceived after 12 months of contraceptive-free intercourse if

the female is under the age of 34.
• the couple has not conceived after 6 months of contraceptive-free intercourse if
the female is over the age of 35 (declining egg quality of females over the age of
35 account for the age-based discrepancy as when to seek medical intervention).
• the female is incapable of carrying a pregnancy to term.

Subfertility
A couple that has tried unsuccessfully to have a child for a year or more is said to be
subfertile meaning less fertile than a typical couple. The couple's fecundability rate is
approximately 3-5%. Many of its causes are the same as those of infertility. Such
causes could be endometriosis, or polycystic ovarian syndrome.

Primary vs. secondary infertility

Couples with primary infertility have never been able to conceive,[2] while, on the other
hand, secondary infertility is difficulty conceiving after already having conceived (and
either carried the pregnancy to term, or had a miscarriage). Technically, secondary
infertility is not present if there has been a change of partners.

Prevalence

• Generally, worldwide it is estimated that one in seven couples have problems

conceiving, with the incidence similar in most countries independent of the level
of the country's development.

• Fertility problems affect one in seven couples in the UK. Most couples (about 84
out of every 100) who have regular sexual intercourse (that is, every 2 to 3 days)
and who do not use contraception will get pregnant within a year. About 92 out of
100 couples who are trying to get pregnant do so within 2 years. [3]

• Women become less fertile as they get older. For women aged 35, about 94 out
of every 100 who have regular unprotected sexual intercourse will get pregnant
after 3 years of trying. For women aged 38, however, only 77 out of every 100
will do so. The effect of age upon men’s fertility is less clear.[3]

• In people going forward for IVF in the UK, roughly half of fertility problems with a
diagnosed cause are due to problems with the man, and about half due to
problems with the woman. However, about one in five cases of infertility have no
clear diagnosed cause [4]
 • In Britain, male factor infertility accounts for 25% of infertile couples, while 25%
remain unexplained. 50% are female causes with 25% being due to anovulation
and 25% tubal problems/other [5]

• In Sweden, approximately 10% of couples are infertile.[6] In approximately one

third of these cases the man is the factor, in one third the woman is the factor
and in the remaining third the infertility is a product of factors on both parts.

Causes

This section deals with unintentional causes of sterility. For more information about
surgical techniques for preventing procreation, see sterilization.

Common causes of infertility:

• Ovulation problems
• tubal blockage
• male associated infertility
• age-related factors
• uterine problems
• previous tubal ligation
• previous vasectomy
• unexplained infertility
• Tuberculosis (TB)
• Male Hypospadias

Virus/Mutation

German scientists have reported that a virus called Adeno-associated virus might have
a role in male infertility[7], though it is otherwise not harmful[8]. Mutation that alters human
DNA adversely can cause infertility, the human body thus preventing the tainted DNA
from being passed on. This could explain why some radiation victims from Chernobyl
incident could not produce children.

Causes in either sex

For a woman to conceive, certain things have to happen: intercourse must take place
around the time when an egg is released from her ovary; the systems that produce eggs
and sperm have to be working at optimum levels; and her hormones must be balanced.
[9]

There are several possible reasons why it may not be happening naturally. In one-third
of cases, it can be because of male problems such as low sperm count. Some women
are infertile because their ovaries do not mature and release eggs. In this case synthetic
FSH by injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate
follicles to mature in the ovaries.

Problems affecting women include endometriosis or damage to the fallopian tubes

(which may have been caused by infections such as chlamydia).

Other factors that can affect a woman's chances of conceiving include being over- or
underweight for her age - female fertility declines sharply after the age of 35.
Sometimes it can be a combination of factors, and sometimes a clear cause is never
established.

Factors that can cause male as well as female infertility are:

• Genetic Factors
o A Robertsonian translocation in either partner may cause recurrent
spontaneous abortions or complete infertility.
• General factors
o Diabetes mellitus, thyroid disorders, adrenal disease
• Hypothalamic-pituitary factors
o Kallmann syndrome
 o Hyperprolactinemia
o Hypopituitarism
• Environmental Factors
o Toxins such as glues, volatile organic solvents or silicones, physical
agents, chemical dusts, and pesticides.

Combined infertility

In some cases, both the man and woman may be infertile or sub-fertile, and the couple's
infertility arises from the combination of these conditions. In other cases, the cause is
suspected to be immunological or genetic; it may be that each partner is independently
fertile but the couple cannot conceive together without assistance.

Unexplained infertility

In about 15% of cases the infertility investigation will show no abnormalities. In these
cases abnormalities are likely to be present but not detected by current methods.
Possible problems could be that the egg is not released at the optimum time for
fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the
egg, fertilization may fail to occur, transport of the zygote may be disturbed, or
implantation fails. It is increasingly recognized that egg quality is of critical importance
and women of advanced maternal age have eggs of reduced capacity for normal and
successful fertilization.

Assessment

If both partners are young and healthy, and have been trying for a baby for 12 months
to two years without success, a visit to the family doctor could help to highlight potential
medical problems earlier rather than later. The doctor may also be able to suggest
lifestyle changes to increase the chances of conceiving. [12]

Women over the age of 35 should see their family doctor after six months as fertility
tests can take some time to complete, and age may affect the treatment options that are
open in that case.

A family doctor will take a medical history and give a physical examination. They can
also carry out some basic tests on both partners to see if there is an identifiable reason
for not having achieved a pregnancy yet. If necessary, they can refer patients to a
fertility clinic or a local hospital for more specialized tests. The results of these tests will
help determine which is the best fertility treatment.

Treatment

Treatment methods for infertility may be grouped as medical or complementary and

alternative treatments. Some methods may be used in concert with other methods.

At-home conception kit

In 2007 the FDA cleared the first at home tier one medical conception device to aid in
conception. The key to the kit are cervical caps for conception. This at home [cervical
cap] insemination method allows all the semen to be placed up against the cervical os
for six hours allowing all available sperm to be placed directly on the cervical os. For low
sperm count, low sperm motility, or a tilted cervix using a cervical cap will aid in
conception. This is a prescriptive medical device. [13]

At-home assessment

Prior to undergoing expensive fertility procedures, many women and couples will turn to
online sources to determine their estimate chances of success. A take-home baby
assessment can provide a best guess estimate compared with women who have
succeeded with in vitro fertilization, based on variables such as maternal age, duration
of infertility and number of prior pregnancies.[14]

Medical treatments
Medical treatment of infertility generally involves the use of medication, medical device,
surgery, or a combination of the following. If the sperm are of good quality, and the
mechanics of the woman’s reproductive structures are good (patent fallopian tubes, no
adhesions or scarring) physicians may start by prescribing a course of ovarian
stimulating medication. The physician may also suggest using a conception cap cervical
cap which the patient uses at home by placing the sperm inside the cap and putting the
conception device on the cervix, intrauterine insemination (IUI), in which the doctor
introduces sperm into the uterus during ovulation, via a catheter. In these methods,
fertilization occurs inside the body.

If conservative medical treatments fail to achieve a full term pregnancy, the physician
may suggest the patient undergo in vitro fertilization (IVF). IVF and related techniques
(ICSI, ZIFT, GIFT) are called assisted reproductive technology (ART) techniques.

ART techniques generally start with stimulating the ovaries to increase egg production.
After stimulation, the physician surgically extracts one or more eggs from the ovary, and
unites them with sperm in a laboratory setting, with the intent of producing one or more
embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted
into the woman’s reproductive tract, in a procedure called embryo transfer.

Other medical techniques are e.g. tuboplasty, assisted hatching, and Preimplantation
genetic diagnosis.

Recently, a hormone-antioxidant combination therapy was suggested to improve sperm

count and motility in infertile men, according to an Egyptian study. Ghanem H et al.
Combination clomiphene citrate and antioxidant therapy for idiopathic male infertility: A
randomized controlled trial. Fertil Steril 2009 Mar 5; [e-pub ahead of print]. Published in
Journal Watch General Medicine March 31, 2009 The study included 60 men who were
randomly selected to take either the combination treatment of clomiphene citrate and
vitamin E or a placebo for six months. The pregnancy rate was about 37 percent among
men who had taken the combination therapy, compared with 13 percent for those in the
placebo group. The men in the treatment group also had a greater increase in sperm
concentration and an improvement in sperm progression, the Cairo University
researchers found. Clomiphene citrate is an anti-estrogen drug designed as a fertility
medicine for women but sometimes used to boost sperm production in men with low
sperm counts and poor sperm motility. Vitamin E helps counter oxidative stress, which
is associated with sperm DNA damage and reduced sperm motility. "The results of this
study will be encouraging to male factor patients and their doctors," Dr. R. Dale
McClure, president of the American Society for Reproductive Medicine, said in a society
news release. "However, more research is needed to determine how the components of
the combination therapy affect the different semen parameters observed and the
advantages of using these drugs singly or in combination with other drugs not used in
this study."

Complementary and alternative treatments

Three complementary or alternative female infertility treatments have been scientifically

tested, with results published in peer-reviewed medical journals.

1. Group psychological intervention: A 2000 Harvard Medical School study

examined the effects of group psychological intervention on infertile women
(trying to conceive a duration of one to two years). The two intervention groups—
a support group and a cognitive behavior group—had statistically significant
higher pregnancy rates than the control group. [15]
2. Acupuncture: Acupuncture performed 25 minutes before and after IVF embryo
transfer increased IVF pregnancy rates in a German study published in 2002.[16]
In a 2006 similar study conducted by The University of South Australia, the
acupuncture group’s odds (although not statistically significant) were 1.5 higher
[17]
than the control group. Although definitive results of the effects of acupuncture
on embryo transfer remain a topic of discussion, study authors state that it
appears to be a safe adjunct to IVF.[17][18]
3. Manual physical therapy: The Wurn Technique, a manual manipulative physical
therapy treatment, was shown in peer reviewed publications to improve natural
[19]
and IVF pregnancy rates in infertile women in a 2004 study, and to open and
 [20]
return function to blocked fallopian tubes in a 2008 study. The therapy was
designed to address adhesions restricting function and mobility of the
reproductive organs. [19][20]

Tourism

Main article: Fertility tourism

Fertility tourism is the practice of traveling to another country for fertility treatments. [21] It
may be regarded as a form of medical tourism. The main reasons for fertility tourism are
legal regulation of the sought procedure in the home country, or lower price. In-vitro
fertilization and donor insemination are major procedures involved.

Ethics

There are several ethical issues associated with infertility and its treatment.

• High-cost treatments are out of financial reach for some couples.

• Debate over whether health insurance companies should be forced to cover
infertility treatment.
• Allocation of medical resources that could be used elsewhere
• The legal status of embryos fertilized in vitro and not transferred in vivo. (See
also Beginning of pregnancy controversy).
• Anti-abortion opposition to the destruction of embryos not transferred in vivo.
• IVF and other fertility treatments have resulted in an increase in multiple births,
provoking ethical analysis because of the link between multiple pregnancies,
premature birth, and a host of health problems.
• Religious leaders' opinions on fertility treatments.
• Infertility caused by DNA defects on the Y chromosome is passed on from father
to son. If natural selection is the primary error correction mechanism that
prevents random mutations on the Y chromosome, then fertility treatments for
men with abnormal sperm (in particular ICSI) only defer the underlying problem
to the next male generation.
Many countries have special frameworks for dealing with the ethical and social issues
around fertility treatment.

• One of the best known is the HFEA - The UK's regulator for fertility treatment and
embryo research. This was set up on 1 August 1991 following a detailed
commission of enquiry led by Mary Warnock in the 1980s

• A similar model to the HFEA has been adopted by the rest of the countries in the
European Union. Each country has its own body or bodies responsible for the
inspection and lisencing of fertility treatment under the EU Tissues and Cells
directive [22]

[23]
• Regulatory bodies are also found in Canada and in the state of Victoria in
Australia [24]

Psychological impact

Infertility may have profound psychological effects. Partners may become more anxious
to conceive, ironically increasing sexual dysfunction.[25] Marital discord often develops in
infertile couples, especially when they are under pressure to make medical decisions.
Women trying to conceive often have clinical depression rates similar to women who
have heart disease or cancer[26]. Even couples undertaking IVF face considerable
stress.[27]

Emotional stress and marital difficulties are greater in couples where the infertility lies
with the man.[28]

Social impact

In many cultures, inability to conceive bears a stigma. In closed social groups, a degree
of rejection (or a sense of being rejected by the couple) may cause considerable anxiety
and disappointment. Some respond by actively avoiding the issue altogether; middle-
class men are the most likely to respond in this way [29].
There are legal ramifications as well. Infertility has begun to gain more exposure to legal
domains. An estimated 4 million workers in the U.S. used the Family and Medical Leave
Act (FMLA) in 2004 to care for a child, parent or spouse, or because of their own
personal illness. Many treatments for infertility, including diagnostic tests, surgery and
therapy for depression, can qualify one for FMLA leave.

Fictional representation

Perhaps except for infertility in science fiction, films and other fiction depicting emotional
struggles of assisted reproductive technology have had an upswing first in the latter part
of the 2000s decade, although the techniques have been available for decades. [30] Yet,
the amount of people that can relate to it by personal experience in one way or another
is ever growing, and the variety of trials and struggles is huge.[30]

Any individual examples are referred to individual subarticles of assisted reproductive

technology

References

1. ^ Makar RS, Toth TL (2002). "The evaluation of infertility". Am J Clin Pathol. 117
Suppl: S95–103. PMID 14569805.
2. ^ MedlinePlus Encyclopedia Infertility
a b
3. ^ NICE fertility guidance
4. ^ HFEA Chart on reasons for infertility
5. ^ Khan, Khalid; Janesh K. Gupta; Gary Mires (2005). Core clinical cases in
obstetrics and gynaecology: a problem-solving approach. London: Hodder
Arnold. pp. 152. ISBN 0-340-81672-4.
6. ^ Sahlgrenska University Hospital. (translated from the Swedish sentence: "Cirka
10% av alla par har problem med ofrivillig barnlöshet."
7. ^ http://www.newscientist.com/article.ns?id=dn1483
8. ^ http://news.bbc.co.uk/1/hi/health/1620174.stm
9. ^ About infertility & fertility problems
10. ^ Mendiola J, Torres-Cantero AM, Moreno-Grau JM, et al. (Jun 2008). "Exposure
to environmental toxins in males seeking infertility treatment: a case-controlled
study". Reprod Biomed Online 16 (6): 842–50. PMID 18549695.
http://openurl.ingenta.com/content/nlm?genre=article&issn=1472-
6483&volume=16&issue=6&spage=842&aulast=Mendiola.
11. ^ Smith EM, Hammonds-Ehlers M, Clark MK, Kirchner HL, Fuortes L (Feb 1997).
"Occupational exposures and risk of female infertility". J Occup Environ Med. 39
(2): 138–47. doi:10.1097/00043764-199702000-00011. PMID 9048320.
http://meta.wkhealth.com/pt/pt-core/template-
journal/lwwgateway/media/landingpage.htm?issn=1076-
2752&volume=39&issue=2&spage=138.
12. ^ Infertility Help: When & where to get help for fertility treatment
13. ^ http://www.newsrx.com/pr_details.php?type=1&id=2904
14. ^ http://www.formyodds.com
15. ^ Domar AD, Clapp D, Slawsby EA, Dusek J, Kessel B, Freizinger M (Apr 2000).
"Impact of group psychological interventions on pregnancy rates in infertile
women". Fertil Steril. 73 (4): 805–11. doi:10.1016/S0015-0282(99)00493-8. PMID
10731544. http://linkinghub.elsevier.com/retrieve/pii/S0015-0282(99)00493-8.
16. ^ Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K (Apr 2002).
"Influence of acupuncture on the pregnancy rate in patients who undergo
assisted reproduction therapy". Fertil. Steril. 77 (4): 721–4. doi:10.1016/S0015-
0282(01)03273-3. PMID 11937123.
http://linkinghub.elsevier.com/retrieve/pii/S0015028201032733.
 a b
17. ^ Smith C, Coyle M, Norman RJ (May 2006). "Influence of acupuncture
stimulation on pregnancy rates for women undergoing embryo transfer". Fertil
Steril. 85 (5): 1352–8. doi:10.1016/j.fertnstert.2005.12.015. PMID 16600225.
18. ^ Stener-Victorin E, Humaidan P (Dec 2006). "Use of acupuncture in female
infertility and a summary of recent acupuncture studies related to embryo
transfer" ([dead link]). Acupunct Med 24 (4): 157–63. doi:10.1136/aim.24.4.157. PMID
17264833. http://www.acupunctureinmedicine.org.uk/linkout.php?article=24_157.
a b
19. ^ Wurn BF, Wurn LJ, King CR, et al. (2004). "Treating female infertility and
improving IVF pregnancy rates with a manual physical therapy technique".
MedGenMed 6 (2): 51. PMID 15266276. PMC 1395760.
http://www.medscape.com/viewarticle/480429.
a b
20. ^ Wurn BF, Wurn LJ, King CR, et al. (2008). "Treating fallopian tube occlusion
with a manual pelvic physical therapy". Altern Ther Health Med 14 (1): 18–23.
PMID 18251317.
21. ^ wordspy.com
22. ^ http://europa.eu/scadplus/leg/en/cha/c11573.htm EU Tissues and Cells
directive
23. ^ Assisted Human Reproduction Canada
24. ^ ITA
25. ^ Donor insemination Edited by C.L.R. Barratt and I.D. Cooke. Cambridge
(England): Cambridge University Press, 1993. 231 pages., page 13, citing Berger
(1980)
26. ^ Domar AD, Zuttermeister PC, Friedman R (1993). "The psychological impact of
infertility: a comparison with patients with other medical conditions". J
Psychosom Obstet Gynaecol 14 Suppl: 45–52. PMID 8142988.
27. ^ Beutel M, Kupfer J, Kirchmeyer P, et al. (Jan 1999). "Treatment-related
stresses and depression in couples undergoing assisted reproductive treatment
by IVF or ICSI". Andrologia 31 (1): 27–35. doi:10.1046/j.1439-
0272.1999.00231.x. PMID 9949886. http://www.blackwell-synergy.com/openurl?
genre=article&sid=nlm:pubmed&issn=0303-
4569&date=1999&volume=31&issue=1&spage=27.
 28. ^ Donor insemination Edited by C.L.R. Barratt and I.D. Cooke. Cambridge
(England): Cambridge University Press, 1993. 231 pages., page 13, in turn citing
Connolly, Edelmann & Cooke 1987
29. ^ Schmidt L, Christensen U, Holstein BE (Apr 2005). "The social epidemiology of
coping with infertility". Hum Reprod. 20 (4): 1044–52.
doi:10.1093/humrep/deh687. PMID 15608029.
a b
30. ^ chicagotribune.com --> Heartache of infertility shared on stage, screen By
Colleen Mastony, Tribune reporter. June 21, 2009

ds. LH and FSH are critical for the development of eggs in ovaries and

Possible Causes of infertility

There are numerous causes of infertility. In men, these include environmental and
hormonal factors that affect the production of healthy, motile sperm and normal semen,
as well as blockages that affect the delivery of sperm. In women, the causes are more
varied since she plays a greater role in reproduction. First, one of the organs involved in
reproduction may be absent, mal-formed or non-functional such as damaged fallopian
tubes. Less frequent causes include, for example, endometriosis and
hyperprolactinemia.. Second, the organs may be normal, but the complex hormonal
feedback system that is necessary to support follicular development, ovulation and
implantation of the fertilized egg may be disrupted.
Other causes
Body weight
Women who are significantly overweight or underweight can face difficulties in getting
pregnant. Low weight or excessive weightloss can lead to decrease in important
hormonal "messages" that the brain sends to the ovaries in women and testes in men.
Gonardotropin releasing hormone(GnRH) is produced in the part of the brain called
Hypothalamus. The release of GnRH leads to release of hormonal messangers LH and
FSH by the pitutary glan sperm in the testes.

Similarly being overweight or obese can affect the hormonal signals to the ovaries and
testes. Increased weight can also increase insulin levels in women which in turn may
cause the ovaries to overproduce the male hormones and stop releasing eggs. Weight
loss is the best plan of action in such cases supported with clomiphene or
gonadotropins. Body fat plays a critical role in human reproduction. Both excess and
deficiency of body fat lead to reproductive failure. Body weight disorders is one of the
first potential causes of reproductive failure in both men and women. This is a problem
that can be corrected by the affected individual and the infertile couple.

Diet & exercise

Foods rich in manganese (oats, wheat germ, rye bread and peas) promote the action of
oestrogen, and vitamin B's (wholegrains such as brown rice, wheat germ, pulses oats
and green vegetables), involved in oestrogen metabolism. Their deficiency can hamper
pursuing pregnancy. Soya beans and wholemeal bread will provide magnesium.

Infertility is associated with low vitamin D, and PMS can be completely reversed by
addition of calcium, magnesium and vitamin D. Vitamin D supports production of
estrogen in men and women. PMS has been completely reversed by addition of
calcium, magnesium and vitamin D. Menstrual migraine is associated with low levels of
vitamin D and calcium. Ten minutes of daily exposure of the arms and legs to sunlight
will supply us with all the vitamin D that we need as humans can manufacture vitamin D
from cholesterol by the action of sunlight on the skin.

Proper diet and exercise is essential to maintain a healthy weight. At the same time
extreme exercise can lead to reduced sperm production in men and lack of ovulation in
women by decreasing the brain message to the testes and ovaries. It is impossible to
know how much exercise for a person is too much. Generally running more than 10
miles a week is considered too much when trying to conceive. Try bringing about
modifications in your exercise routine in order to treat reproductive problems.

Smoking
Smoking is a known contributor to infertility problems in women and can lead to an
increased rate of miscarriage. Women who smoke regularly also may enter menopause
at an earlier age because of the damaging effect of tobacco smoke on ovaries. Men
who smoke may have diminished sperm function.

Drugs and Alcohol

Alcohol is known to cause structural and developmental defects in a fetus. This group of
disorders is termed the "Fetal Alcohol Syndrome." It is best to avoid drinking alcohol
during the course of your infertility treatment or during pregnancy. Marijuana use in men
leads to poor sperm counts that take many weeks to recover after exposure. Other
recreational drugs can lead to other significant problems for pregnancy. At the same
time it is desirable to limit the intake of tea, coffee, soft drinks which contains caffeine.

Vitamins
Women who take folic acid before they conceive reduce their risk of neural tube defects
in the fetus by 50%. It is recommended that all women undergoing infertility treatment
take at least 0.4 mg of folic acid (folate) before they conceive and during the course of
their pregnancy. Some high potency vitamins may have a detrimental effect in
pregnancy (i.e. too high level of vitamin A).

Medication
Regular medications of modern medicine in certain ailments like ulcer, high blood
pressure etc, causes low sperm count & negative side effects that causes infertility
problems in both man & woman.

STDs & PID

Pelvic inflammatory disease (PID) is a major cause of infertility in women. Any sexually
transmitted disease (STD), such as gonorrhea or syphilis, may cause PID, which can
lead to infertility. Prevent STDs by abstaining from sexual intercourse or by using
condoms.

Stress
Does stress cause infertility or does infertility cause stress? Most doctors agree that
reducing stress won't ensure pregnancy, but it may help a couple cope with infertility
and making treatment decisions.

Eating Disorders
The eating disorders anorexia and bulimia can have long lasting impacts (several years)
on fertility. Women with these conditions may not ovulate even if they menstruate. Eggs
may not develop properly. In these cases, treating the disease is essential to restoring
fertility.

Tests of Infertility in female

There are many potentially useful tests that can be obtained as part of the infertility
evaluation for women. However, therapeutic options largely depend on the
results of three fundamental tests:

Uterine Structural Tests

(i.e. for patency of fallopian tubes and anatomy of uterus)

Hysterosalpingography (HSG)
Office Hysteroscopy
Sonohystogram

Ovarian Reserve Testing

This includes a Cycle Day 3 FSH or preferably, a Clomiphene citrate Challenge Test.
There are several additional tests that have been used to evaluate infertility.

Tests for Ovulation

Problems of ovulation (egg release from the ovary) account for approximately 25% of
infertility and may be suggested on the basis of the history and physical
examination.

If your menstrual periods occur at monthly intervals and you also have breast
tenderness, fluid retention, irritability and menstrual cramps, then your cycles are
usually ovulatory, but not necessarily. Therefore some test of ovulation is
necessary:

Urine LH Testing
Blood LH Testing
Basal Body Temperature Graph (BBTG)
Ultrasound Monitoring
MidLuteal Progesterone Testing
Endometrial Biopsy

More Tests in the Female

There are many tests that have been designed to evaluate potential causes of infertility
in women. Very few of these tests, however have been well standardized or even
definitively associated with infertility. Definitive therapy relating to abnormal test
results is also lacking. The following tests although sometimes suggested are
generally no longer recommended as part of the basic infertility evaluation:

Post Coital Test (Sims-Huhner Test, PK)

Cervical Mucus Penetration
Cervical Cultures
Immune Testing
Hormone Testing
Laparoscopy
Diagnostic tests are guided by the history and physical examination and include
simultaneous analysis of both you and your partner. Testing implies that the
knowledge of the result can be used to guide therapy leading to a successful
pregnancy.

There are many tests that have been suggested. However, perhaps the most cost-
effective and arguably the most clinically useful are a semen analysis, an
intrauterine structural study and a test of ovarian age (ovarian reserve) and tubal
patency tests.

Infertility testing in women is designed primarily to determine anatomical factors,

most commonly abnormalities within the uterine cavity, and problems with
ovarian function and tubal patency.

Treatment Options Available

If you think that you are having difficulty becoming pregnant, you should seek the
assistance of your physician. There are several types of treatment. Appropriate
treatment depends on your particular situation or underlying medical or surgical
condition largely depends on the reason thought to be responsible for difficulty in
becoming pregnant.

These treatments may range from the simple like appropriate timing of
intercourse to the complex, high-tech therapies like in vitro fertilization (IVF) in
which medications are given to induce the production of eggs that can be
collected and then put together with sperm in the laboratory so that fertilization
occurs. The fertilized eggs can then be cultured for 3 to 5 days followed by
embryo transfer to the uterus.

IVF (In Vitro Fertilization)

IVF has been used safely and effectively for more than two decades. In a typical IVF
procedure, a woman is treated with fertility drugs to regulate her menstrual cycle
and stimulate the development of higher-quality eggs. This process helps to
ensure that a sufficient number of healthy eggs are available for fertilization.
Eggs are then "retrieved" or collected and prepared for insemination using sperm
from the male partner or a donor. Fertilization occurs in a laboratory dish
specially prepared with a culture medium that supports and nourishes the
fertilized eggs. Within about 72 hours after fertilization, embryos are transferred
into the woman's uterus.

Since the introduction of IVF, there have been many other important
developments that have made infertility treatment even more effective for both
men and women:

In vitro fertilization with endometrial cell co-culture is a special technique for

couples with poor embryo quality where cells from the woman's uterus are used
to enhance development of fertilized eggs. CRMI refined this procedure using the
woman's own endometrial cells rather than cells from animals.

Intracytoplasmic sperm injection (ICSI) is a procedure where a single sperm is

selected and delivered directly into a woman's egg. ICSI is an effective option for
men with low sperm count or sperm that cannot reach the egg successfully.

Cryopreservation is the ability to freeze and store embryos that are not transferred right
away. This process can allow couples to achieve a pregnancy later, either after a
first birth or following medical treatments that might affect fertility such as
chemotherapy for cancer treatment.
Preimplantation genetic diagnosis (PGD) can be used to identify embryos that do not
carry the gene for certain inherited diseases (such as cystic fibrosis and sickle
cell anemia). This capability greatly reduces the risk that these diseases will be
passed on to children.

For male factor infertility, our comprehensive services include microsurgical

repair of obstructions and vasectomy reversals, surgical repair of varicoceles,
and epididymal and testicular sperm retrieval for use with IVF and ICSI.