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Infertility, is the failure to conceive after one year of regular coitus without contraception. The monthly conception rate of normal couples actively attempting is about 20% to 25%. If you look at conception rates on a monthly basis, after three months a normal couple would have about a 57% chance of conception, after six months 72%, after a year 85%. So even after a year of trying, 15% of normal couples will not have conceived. But then the definition is a year of trying without success, that is considered infertile. After two years that goes up to 93%. But the guidelines by the American Society of Reproductive Medicine is to initiate a workup after one year. If you look at another way of looking at conception, if you look at it based on frequency of coitus, less than one time per week - this is conception over six months - 17%, one to two infertility.
This kind of just goes along with the last definition of infertility. Just a different definition. When you are thinking about infertility, think about primary and secondary infertility. Primary infertility refers to couples who have never established a pregnancy.
The causes for infertility and how it relates to percentage of becoming pregnant includes many factors. Relating from things like endometriosis, male factor, anovulation, tubal factor, and this is just a study showing the numbers that had this.
Some more basic information. Incidence, approximately 10% of couples are infertile. They make the criteria of not being able to conceive within one year. Approximately 15% of infertile couples have no identifiable cause of infertility. Another way of looking at that is there are about four or five million couples every year who have difficulty conceiving. Or another way of looking at it is, one out of every seven. And that number seems to be slowly increasing.
Prevalence in the United States, approximately 10% to 20% of couples are infertile. Popular explanations why there is a declining in the United States: changing roles and aspirations for women, postponement of marriage, delayed age of bearing. These three things all go together along with increased infertility. People are waiting longer to have kids and when you wait longer to have kids - it’s mainly based on the woman’s side of the view - the quality of her eggs diminish and the enhancement of her fertility diminishes. Liberalized abortion, concern over environment, unfavorable economic conditions.
When you are thinking about the workup, first think about the physiology of becoming pregnant and then where those and in any one of those steps there can be a problem and you just basically look at that. In thinking about how to work up the couple, there are four basic areas you want to think about . number one, male factor, and then number two, female factor. Male factor, real easy. You do a semen analysis. We’ll talk in a little greater detail of that. So by simply doing a semen analysis you can get a real good feel for whether or not the guy is the cause of the problem. Again, very often he is forgotten. When you are thinking, or if a couple comes to talk to you about infertility it is a couples thing. It’s not the woman’s problem. I still have a lot of patients who come to me and the woman shows up but the guy’s not there. So you are losing half of your exam right there. Or half of your history by not having the guy there. I will have women that get a million dollar workup and they’ll come to me because they still can’t get pregnant, and I’ll say - might not have the records with me - I’ll say, "What’s your husband’s sperm count?" and they say, "They never did a sperm count." When you are looking at causes for infertility, 40% of the time it is the woman, the other 40% of the time it’s the guy, 20% is just kind of a combo. It’s real easy to find out whether the guy’s got a problem or not by semen analysis. If he’s got a problem, though, it’s real hard to correct. Women on the other hand are a little more complicated, obviously.
So overall then for the evaluation of infertility obviously take a history and physical. If you can, on both the woman and the man. Then you start out with a semen analysis, which is what we will go over first, then assessment of ovulation. If the woman is not ovulating she can’t get pregnant. Assessment of cervical factor and assessment of tubal factor. So that’s how you approach it, those three or four ways: semen analysis, ovulatory mechanisms, cervical factors - which is kind of a combination of male/female - an then tubal factor.
Male factor. It just says that the male gamete can be examined in the seminal fluid as well as in the cervix, the cervical fluid. So that’s the two ways you want to evaluate it. First from a basic semen analysis and then what’s called a post-coital test. Lots of causes for infertility in men. There has been a lot of talk in the literature, particularly in Time. A year ago they were talking about men’s sperm dropping worldwide. Is this real? Is this not real? NIH came out within the last several months saying that it is real. We don’t really know why it is real but it appears to be real. In this country, sperm counts in men are dropping about 1% to 1.5% a year. In Europe it’s a little bit higher. They are dropping about 2% to 3% - the counts are dropping. So we feel that it is a real thing. Male counts are dropping but we really don’t know why. Everyone is fast to jump on environmental factors, farming, pesticides, that type of stuff. But the real thing is, we don’t know. But it does appear that it is dropping.
This is page one of some of the things that we look at when we do a sperm count and this is not unlike many fertility centers. Here you just look up at the gross characteristics of the sperm count and then one of our techs does another gross microscopic, and these are the World Health Organization type of guidelines that are in parenthesis. This is just looking a the specimen itself. Are there white cells and all that in there. Is there an infective process going on. Here’s the guidelines just counting on a hemocytometer. Then what we do is we wash the sperm as if we were to do an insemination. Because from a fertility standpoint, sometimes these characteristics - before you wash the sperm - can be normal but once you wash the sperm and get rid of a lot of the debris and dead sperm, they don’t process well. They clump up and they have antibodies that causes them to clump so they don’t process well. So processing the sperm in anticipation of treatment, artificial insemination, gives me information about how the sperm are functioning and are they functioning normally. We also go on and we do a quantitative morphology on the sperm, where we do a histologic stain and really get a good feel for normals versus abnormals. To back, when we did a morphology here, this is just looking at the sperm on a hemocytometer, which is how most labs look at it.
We also can look at acrocine, which is one of the components, one of the enzymes that plays a role in the fertilization process, looking at well that functions. We look at how the sperm live over 18 hours. If the sperm die within several hours after ejaculation that’s not a good thing also. I just wanted to give you guys a fell for some of the things.
The other thing that you want to look at is you want to look at the sperm-cervical interaction. That’s the post-coital test. And in those circumstances, you ask the couple to have intercourse mid-cycle - and to refresh your memory, the first day of menstrual flow is called day one and that’s when you tell a woman to start timing her cycles. And an idealized cycle, is 28 days, however only about 60% of women have a 28-day cycle. So in the middle of that 28-day cycle you tell them to have intercourse on day 13 or 14 and then you’d like to see them within eight hours of having the intercourse. She comes in, you take a small syringe without the needle on the end, pull out some of the cervical mucus and then look at it under the microscope. What you want to look at is just you want to see, are there sperm? Or no sperm? Are the majority of the sperm moving or nonmotile? What does the mucus itself look like? Is it thick or does it have …is it thin and snotty looking? Called spinnbarkeit.
This is a schematic of the cervix and some sperm trying to get up in there and what you want to do is just take a little syringe and pull some of this mucus out and see if you can find some of these sperm in there. This is what’s called ferning. That’s just salt. If you are looking to see if they are ruptured in labor, trying to see if they have rupture or not, you look for the ferning and the same thing when you are doing a post-coital test. If there is an estrogenic effect. These are just some white blood cells.