Table of Contents
The Normal Process of Fertilization
For a couple to conceive a number of processes must take place successfully in both the man and the woman; and, at exactly the right time. The following briefly outlines the steps necessary for conception to take place:
- During the menstrual cycle, a woman’s hormones regulate the growth, maturation and release of an egg from her ovary. Each month the pituitary gland located in a woman’s brain sends a hormonal signal to her ovaries to prepare an egg for ovulation. These hormones are known as follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
- The pituitary gland is, in turn, controlled by an area of the woman’s brain known as the hypothalamus, which sends out a hormone known as GnRH, or gonadotropin-releasing hormone. GnRH “tells” the pituitary gland when to release FSH and LH.
- An increase in FSH stimulates the growth of the developing follicles (and eggs) in the ovary.
- A large increase in LH signals the ovary to release an egg—this is known as ovulation. Normally, only one of a woman’s two ovaries produces an egg during the woman’s menstrual cycle.
- The released egg then moves from the ovary into the fallopian tube. The egg remains viable for about 24 hours.
- For fertilization to occur a sperm must locate and penetrate the awaiting egg while it is in the fallopian tube.
- If fertilization occurs, the fertilized egg, or embryo, continues to travel down the fallopian tube into the uterus, where it will attach, or implant, into the lining of the uterus.
In order for a couple to conceive, both the male and female reproductive systems must be functioning properly.
In the female this means:
- Ovulation occurs and leads to the production of a viable egg.
- The fallopian tubes are open and functioning properly to allow the egg and sperm to meet.
- The fertilized egg is able to move into the uterus and is not blocked from implanting in the wall of the uterus.
- The sperm are able to travel through the woman’s vagina, cervix, uterus, and fallopian tubes without being blocked in their attempt to locate the egg.
In the male this means:
- The testes produce viable, or normal sperm, as well as testosterone, the male hormone.
- Ability to achieve an erection and engage in sexual intercourse.
- Normal ejaculation occurs with semen going through the man’s urethra into the vagina.
- The sperm that are produced are properly shaped, able to move rapidly, and can accurately move to the fallopian tubes to locate and fertilize the egg.
What are fertility problems?
You may have fertility problems if you have not been able to get pregnant after trying for at least 1 year. Another word for this is infertility. Infertility may not mean that it is impossible to get pregnant. Often, couples conceive without help in their second year of trying. Some do not succeed, but medical treatments help many couples.
Age is an important factor if you are trying to decide whether to get testing and treatment for fertility problems. A woman is most fertile in her late 20s. After age 35, fertility decreases and the risk of miscarriage goes up.
- If you are younger than 35, you may want to give yourself more time to get pregnant.
- If you are 35 or older, you may want to get help soon.
What causes fertility problems?
Fertility problems can have many causes. In cases of infertility:
- About 50 out of 100 are caused by a problem with the woman’s reproductive system. These may be problems with her fallopian tubes or uterus or her ability to release an egg (ovulate).
- About 35 out of 100 are caused by a problem with the man's reproductive system. The most common is low sperm count.
- About 5 out of 100 are caused by an uncommon problem, such as the man or woman having been exposed to a medicine called DES before birth.
- In about 10 out of 100, no cause can be found in spite of testing
Should you be tested for fertility problems?
Before you have fertility tests, try fertility awareness. A woman can learn when she is likely to ovulate and be fertile by charting her basal body temperature and using home tests. Some couples find that they simply have been missing their most fertile days when trying to conceive.
If you are not sure when you ovulate, try this Interactive Tool: When Are You Most Fertile?.
If these methods don't help, the first step is for both partners to have some simple tests. A doctor can:
- Do a physical exam of both of you.
- Ask questions about your past health to look for clues, such as a history of miscarriages or pelvic inflammatory disease.
- Ask about your lifestyle habits, such as how often you exercise and whether you drink alcohol or use drugs.
- Do tests that check semen quality and both partners' hormone levels in the blood. Hormone imbalances can be a sign of ovulation problems or sperm problems that can be treated.
Your family doctor can do these tests. For more complete testing, you may need to see a fertility specialist
How are fertility problems treated?
A wide range of treatments is available. Depending on what is causing the problem, you may be able to:
- Take a medicine that helps the woman ovulate.
- Have a procedure that puts sperm directly inside the woman (insemination).
- Have a surgery that corrects a problem caused by endometriosis or blocked fallopian tubes.
- Have a procedure that might increase the man’s sperm count.
If these options are not possible or don't work for you, you may want to consider in vitro fertilization (IVF). During an IVF, eggs and sperm are mixed in a lab so the sperm can fertilize the eggs. Then the doctor puts one or more fertilized eggs into the woman’s uterus. Many couples try IVF more than once.
Treatment for fertility problems can be stressful, costly, and hard on your body. Before you start testing, make some decisions about what you want to do. You may change your mind later, but it’s a good idea to start with a plan.
- Learn all you can about the tests and treatments, and decide which you want to try. For example, some couples agree to try medicines but don't want surgery or other treatments.
- Find out how much treatments cost and whether your insurance will cover them. If you don't have insurance coverage, decide what you can afford.
Treatments for infertility can increase your chances of getting pregnant. But they also increase your chance of having more than one baby at a time (multiple pregnancy). Be sure to discuss the risks with your doctor.
Fertility problems can put a lot of strain on a couple. It may help to see a counselor with experience in infertility. Think about joining an infertility support group. Talking with other people with the same issue can help you feel less alone.
In some couples, no obvious cause for their infertility is found. This is called unexplained infertility and may occur in 5 percent or less of couples after the work-up and evaluation are completed. Unexplained infertility simply means that we do not know why the couple is not fertile - essentially, it is a confession of medical ignorance. People with unexplained infertility do have a cause for their infertility, but due to limitations of our current testing, we cannot determine the reason.
Although we have made great strides in understanding human reproduction, there is much more to learn. With time, some causes for what we call unexplained infertility will be better understood.
The diagnosis is one of exclusion-that is, one that is made only after all the tests have been performed and their results found to be normal. Infertility may be labeled as "unexplained" when:
- the woman is ovulating regularly, has open fallopian tubes with no evidence of adhesions or endometriosis;
- the man has normal sperm production;
- sexual intercourse takes place frequently, particularly around the time of ovulation; and,
- the couple has been trying to conceive for at least one year.
Because unexplained infertility carries no specific diagnosis, the treatment recommended by fertility specialists is empiric. This means that the treatment is done to optimize a couple's chance of successful conception but is not used to treat or overcome a specific problem.
In some instances, couples with unexplained infertility will conceive over time. In fact, fifty percent of couples diagnosed with unexplained infertility, who have never had a child before, will conceive within five-and-a-half years. And, if the couple has had a previous child, fifty percent will conceive within two to three years.
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