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Fertility Basics

Fertility Basics (From

Facing infertility can be a difficult and emotional time for many couples. It is normal to have feelings of guilt, anger or sadness during these trying times. Fortunately, there is a happy ending for many couples going through this challenge.

Fertility specialist Mark Kan, MD, explains.

A difficult time
Today, more couples are able to become pregnant than ever before. Advances in reproductive science and technology have given new hope to couples who were previously unable to conceive.

Infertility affects 15 percent of couples in the United States. The average time to conception in young, healthy couples is roughly five months. Infertility is defined as the inability to conceive after one year of unprotected intercourse. Approximately 5 million American couples are affected, with 1.3 million of those receiving medical advice or treatment per year.

How natural conception occurs
For natural conception to occur, the sperm must fertilize the egg (oocyte), and the resulting embryo must implant into the lining of the uterus. The process of fertilization normally takes place in the fallopian tube, and the fertilized oocyte travels slowly down the length of the tube over several days before resting in the uterus and implanting in the endometrial lining. Once implanted, the embryo continues to develop and grow. Any condition that affects this natural process can lead to difficulty in conception and pregnancy.

Problems leading to infertility
If a woman does not release an egg regularly (normally once a month), she is said to have an ovulation disorder (or ovulatory dysfunction). If there is scarring or blockage of the fallopian tubes, it may not be possible for the sperm to meet the egg. This is considered an anatomical problem and can occur from a prior pelvic infection or endometriosis, among other conditions. These are common reasons for female infertility, however there can be many reasons a couple can have a difficult time achieving pregnancy.

Infertility is not only a female condition. Male-factor infertility is associated with 30 percent to 40 percent of infertile couples. Some men may have low or abnormal sperm counts which preclude normal fertilization.

One of the sentinel advances in the treatment of male-factor infertility was the development of intracytoplasmic sperm injection (ICSI). Originally pioneered in Belgium by Dr Gianpiero Palermo, ICSI involves the injection of a single sperm cell directly into the oocyte. Using this technique, men with extremely poor sperm quality can father pregnancies using in-vitro fertilization (IVF).

In-vitro fertilization
With the advent of IVF, infertility patients are able to bypass the tubal fertilization process. IVF is a procedure that involves ovarian stimulation with medications over a one to two week period with subsequent egg retrieval. The medication is given to produce the development of multiple follicles (follicles are structures that contain eggs).

After multiple eggs are retrieved, they are inseminated and the resulting embryos are cultured for three to five days in the laboratory (hence the term “in vitro” fertilization, which is Latin for “outside the living body”).

The last step in the process involves the transfer of the developing embryos to the mother’s uterus with a thin flexible catheter. Two weeks after fertilization, pregnancy can be documented using a blood test.

Who should see a fertility specialist?
There are many reasons couples seek the advice and treatment of fertility specialists. The most common reason is that couples have tried on their own after an extended period of time (generally one year) and are not able to conceive. Some couples are able to repeatedly become pregnant but are unable to maintain the pregnancy (a condition called recurrent pregnancy loss). For others, there is a diagnosed medical condition where only IVF or ICSI can facilitate pregnancy (for example in severe male-factor patients with low sperm counts, or in women who do not have fallopian tubes due to previous surgery).

Treatment is available
Some patients have genetic predispositions, which can be diagnosed in the embryo before transfer to the uterus (preimplantation genetic diagnosis), thus decreasing the chance of the baby being affected with a disease such as Tay-Sachs or Cystic Fibrosis.

Still others may have decreased ovarian reserve due to advancing age or premature ovarian failure. Despite the causes, there are many treatment options for patients dealing with these difficult problems. In addition to fertility concerns, Reproductive Endocrinologists also diagnose and treat patients with endocrine disorders like polycystic ovarian syndrome (PCOS) or precocious puberty. Currently, the training regimen for a Reproductive Endocrinology and Infertility specialist entails three years of sub-specialty fellowship preceded by four years of residency in Obstetrics and Gynecology.

Remarkable achievements have been made in the field of infertility since the first IVF baby was born in 1978. Assisted reproductive techniques and advances in related scientific areas have given many infertile couples the ability to achieve pregnancy and start a family. Although it can be a challenging time for many of these couples, there are more options for successful treatment today than there have ever been in the past.