West Coast Fertility Centers Science . Solutions . Success!

(714) 513-1399 INFERTILITY CAUSES AND DIAGNOSES Infertility is defined as the inability to achieve pregnancy after 12 months of unprotected intercourse when the woman is less than 35 years of ageor after 6 months if the women is more than 35 years old. It is generally accepted that after this time a couple should consult a fertility specialist to undertake Level 1 of pretesting. The basic testing can be completed in one month and consists of: Taking a medical history A physical examination Hormonal blood tests for the woman A hysterosalpingogram (HSG) x-ray to check the fallopian tubes A semen analysis for the male Depending on the results, additional tests may be recommended. More advanced testing includes an outpatient surgical procedure called laparoscopy to evaluate the womans internal pelvic organs or an ultrasound to evaluate the male. See Causes of Male Infertility below for more details. THE NATURAL DECLINE IN FEMALE FERTILITY A frequently ignored or misunderstood factor is the natural decline in fecundity (fertility rate per month) which occurs in women. This is primarily attributed to the ongoing attrition or programmed cell death of human eggs. In fact, women are born with a fixed number of eggs after which there is no new egg formation. Thus it can be said there are sufficient favorable eggs for about 20 years of active reproductive life suggesting a woman will ovulate about 300 times per lifetime. After age 35, each passing month without pregnancy therefore diminishes the reproductive potential. With physiologic aging, declining egg quality makes it more difficult for a normal embryo development to occur, accounting for abnormalities, decreased implantation and increased miscarriage rates. This age related infertility makes it imperative that prospective parents not wait past age 38 to begin trying to conceive. Graph 1 depicts the natural decline in female fertility. POTENTIAL CAUSES OF INFERTILITY To understand the causes of infertility, it is important to note that fertility in humans is not a very efficient process. Even among fertile couples, the likelihood of achieving pregnancy is only about 15% per month. This is important because it is the basis of comparison with the success rate of fertility treatments offered at most clinics. After Level One Testing is completed, female factors are found in 40%, male factors in 40%, combined female and male factors are found in 15% and unexplained factors are found in the final 5%. See Graph 2. Graph 2: Causes of Infertility in Humans

CAUSES OF FEMALE INFERTILITY

There are multiple causes of female infertility including structural factors such as adhesions or fibroids, infectious causes such as Chlamydia resulting in PID and tubal blockage, hormonal reasons such as polycystic ovaries and ovulatory problems, genetic factors causing premature menopause or embryo defects, and declining egg quality due to advancing age. The most likely causes for female infertility are: Pelvic Inflammatory Disease (PID) - PID is the most common cause of infertility worldwide. It's an infection of the pelvis involving one or more reproductive organs, including the ovaries, the fallopian tubes, the cul-de-sac, the cervix or the uterus. Sometimes PID spreads to the appendix or to the entire pelvic area. Polycystic ovary syndrome (PCO) - This condition affects 5 million American women and is another major cause of infertility. In PCO, the ovaries produce high amounts of male hormones, especially testosterone. LH levels may be abnormally high while FSH levels are abnormally low; thus, normal follicle grow and ovulation do not produce occur. Instead they form fluid-filled cysts that eventually cover the ovaries. Other hormonal problems may be linked to PCO like elevated testosterone which can contribute to medical problems like obesity, diabetes and Metabolic Syndrome. Endometriosis - This disease is another common cause of female infertility. Endometriosis refers to a condition in which sections of the uterine lining implant inside the pelvis. These implants eventually form cysts that grow with each menstrual cycle and may eventually create inflammation and scarring that can affect the egg capture by the fallopian tubes . The scars can then block the passage of the egg, the fertilization of the egg, and possibly the implantation of the embryo. Fibroids - Fibroids, are usually benign growths that may form in the uterine muscle near the fallopian tubes, in the cavity of the uterus or cervix. As a result, the sperm or fertilized egg may not be able to reach the uterus or implant there. Fibroids in the uterus are very common in women over age 35. Premature Menopause - Some women may experience premature menopause, when their ovaries stop producing estrogen and progesterone and eggs. Often the cause is unknown or may be due to a lower number of eggs a woman has in her life time. If this occurs, donor egg may be the best option for a successful pregnancy. A few cases may be due to genetic conditions in the female. What is Male Infertility? As many as 40 percent of couples experience infertility associated with the male partner. Usually, a man must produce healthy, actively moving sperm cells. These specialized cells must pass freely from the testes, through the penis, and be capable of traveling through the uterus into the fallopian tubes. Male infertility may be associated with several conditions such as low sperm count or low motility of the sperm cells. Causes of Male Infertility The etiology of male infertility can be classified into structural, infectious, congenital, anatomic and hormonal and more rarely, genetic causes. Listed below are among the most common problems. Vas deferens obstruction - The vas deferens that carries sperm from the testicles to the penis can be blocked for a variety of reasons including prior vasectomy, injury, infection or physical anomaly.

Infections - There are many types of infections that might cause sterility or low sperm counts in men. These can be recent infections or from childhood. Common infections can be mumps or certain types of sexually transmitted infections (STI). Chronic Disease - Diseases that can affect hormonal controls and sperm production, particularly when not controlled are also causes of infertility. Diabetes, hypertension and other problems can all affect the fertility of men. Erectile Dysfunction (ED) - Problems maintaining an erection or ejaculatory difficulties will result in sperm transport problems. This may be caused by chronic illnesses like diabetes, hypertension or heart problems. Some medications used to treat chronic illnesses can contribute to these types of male factor. Spinal cord injuries may damage the nerves which assist in normal sexual function. Failure to Produce Sperm - If the body isn't producing sperm there can be many reasons. Some may be from hormonal dysfunction or testicular failure. Genetic illnesses and certain medications may also impact sperm production. Exposure to Harmful Substances - Environmental or work hazards such as solvents, radiation and high temperatures can affect sperm production. Injury - Traumatic injury to the testicles may lead to destruction of sperm producing cells. Varicocele - This is a varicose vein located in the testes and can interrupt normal blood flow or increase the temperature surrounding the testes. Each male factor patient will receive individual recommendations for treatment options in conjunction with our staff Urologist. Testing for Male Infertility Testing for infertility in the male begins with a complete medical history and physical examination. A complete semen analysis is scheduled for the male following three days of abstinence. Unlike sperm testing performed at a commercial lab, the semen analysis at WCFC is interpreted by a reproductive biologist with advanced expertise in the subtle forms of male infertility. A semen sample is collected and analyzed in our special Andrology laboratories. The sample is checked for sperm count, motility, sperm shape and other factors. A single semen analysis is only a screening test and does not provide a diagnosis, and thus, more advanced testing may be required. It is important to recall that infertility is a couple's condition and at times, both male and female factors may be present. For example, the female partner may develop anti-sperm antibodies or suboptimal cervical mucus against her partner's sperm cells. This underscores the need for both male and female partners to be tested simultaneously when searching for the causes of infertility. Male Fertility Treatment For a long time male infertility was a mystery. Today, however, an accurate diagnosis can be made in about 80 percent of cases, and treatment is successful in more than half of these. Only when the cause of the man's infertility is isolated can effective treatment begin. A low sperm count or low motility may be caused by a hormonal imbalance or by damaged sperm-producing cells due to infection, trauma or a varicocele. Abnormalities associated with varicocele occasionally respond to surgical correction. The ability to deliver the sperm into the woman's vagina may also be a problem. This may be due to obstruction of the man's sperm passages resulting from trauma, surgery or genetic malformation. Micro-surgery may correct these problems. PESA at West Coast Fertility is a highly successful technique used to

collect sperm in cases of obstruction of the ejaculatory duct or after a prior vasectomy. It is performed in our Surgi-suite under anesthesia and involves using a fine aspirating needle to collect sperm directly from the testes. The sperm is frozen and later it is injected directly into the female egg cell using ICSI, thus achieving fertilization.

How Age Affects Fertility

The Impact of Age on Female Fertility

What is the Biologic Clock? The "Biologic Clock" is a collective term that refers to the incessant winding down of the reproductive organs along with the physiologic wear and tear occurring throughout the normal aging process. Few topics related to infertility arouse so much anxiety and confusion as the effect of aging on fertility and ultimately pregnancy. It is a source of internal stress that can be overwhelming as a woman worries about her "biologic clock", which can sometimes lead to additional medical problems like anxiety and depression. During this time it can be helpful to become well informed in order to best understand how the physiologic process of aging affects fertility. What Happens to Reproduction as Women Age? Although it is not frequently discussed, reproduction in humans is very inefficient at best. Even during peak human fertility in the teen years and the 20's, the chance of pregnancy is about 20% per month, assuming a woman has regular ovulation, with open Fallopian tubes and a partner with normal sperm production. Dysfunction in any of these factors can lead to infertility or may prolong the time needed to become pregnant. Additional gynecologic problems such as endometriosis, pelvic scarring and uterine fibroid tumors can occur at any time and may interfere with the normal process of egg entry into the Fallopian tubes or failed implantation of the embryo. How does Aging Affect Human Eggs (Oocytes)? One of life's greatest ironies is that just at the right time when a woman is prepared emotionally and personally to begin her family, she may be confronted by the obstacles associated with infertility (Life is just not fair!) Note that the terms "eggs" and "oocytes " will be used interchangeably in this discussion. At birth, most women (but not all) are born with about 2 million oocytes (eggs) that are stored in their ovaries. Each egg is a microscopic, fluid filled cell lying in a protective capsule called a follicle, which in turn is located within the ovaries. Each oocyte is formed with a pre-determined lifespan that cannot be altered and may be as brief as a few days or up to many years. From the time of birth until menopause, there is a natural, unrelenting loss or attrition of the oocyte number as they are eliminated from the resting pool. The magnitude of egg loss is truly staggering, such that by adolescence, 90% of the eggs available for ovulation has been lost, leaving about 100,000 from the original 2 million at birth (see graph 1). Unlike ongoing fresh sperm production in men, there is no new formation of fresh, healthy eggs in women. (Again, life is not fair). Natural Egg (Oocyte) Decline in Women Age Related Changes in the Internal Structure of Human Eggs The cytoplasmic fluid within the egg contains many tiny organelles along with microtubules collectively known as the cytoskeleton which control critical internal motion and alignment. Certain organelles, like the mitochondria, are the energy powerhouses of the oocyte and are essential for normal egg function.

Disturbances within the structure of microtubules and aging of the maternal mitochondria can interfere with normal fertilization and growth. This may lead to the development of sub optimal embryos that fail to develop normally, leading to implantation failure or loss of the pregnancy (miscarriage) during the first few weeks. Chromosomal and Genetic Abnormalities Associated with Aging Among the most common types of errors related to aging is ANEUPLOIDY, a term given to numerical abnormalities in the number of chromosomes Physiologic aging can disturb the function of a delicate barrel shaped internal organelle called the SPINDLE resulting in uneven distribution of chromosomes as the embryo begins to grow. This can lead to the loss or abnormal duplication of entire chromosomes. This will lead to failed implantation of the embryo or may result in multiple miscarriages. The most well known of these types of chromosomal errors is Down Syndrome where one extra chromosome is seen in the 21st pair of chromosomes (Trisomy21). Chromosomes contain thousands of gene sequences that form the "genetic blueprint" controlling every aspect of human life. Spontaneous errors or genetically linked diseases can be transmitted in some families where the parents are "carriers" of the genetic mutation. This may lead to a birth defect or an early pregnancy loss because vital DNA information necessary for the development of a normal child is abnormal. An example of a genetic mutation is the disease called Cystic Fibrosis. These types of abnormalities can be diagnosed with In-Vitro Fertilization using a specialized technique called Pre-Implantation Genetic Screening (PGS). THE NATURAL PROCESS OF EGG SELECTION Only the Strongest Egg Survives Each month, at the start of a new menstrual cycle, the ovaries initiate recruitment of 40 to 50 eggs from the resting oocyte pool. An elimination process begins such that by ovulation time 14 days later, only the most favorable oocyte is released each month. Even with this rigorous selection, an oocyte can still have undetectable abnormalities, which can slip by nature's protective screening mechanisms. These checks and balances help minimize abnormal pregnancies, insuring that only the healthiest embryos can implant. Unsuitable eggs may fail to become fertilized or not divide properly leading to failed implantation or abortion. Unfortunately, the changes discussed above cannot be reversed and with advancing age, even IVF may not overcome the egg abnormalities. In these cases the physician may recommend the use of donor eggs to bring about a healthy pregnancy and a happy family.