Women's Health | Fertility | Infertility in Women

A woman's age is probably the most significant factor related to her ability to conceive. While many women today are waiting until later in life to attempt pregnancy, the ovary's ability to produce normal, healthy eggs declines with age, increasing the risk of chromosomal abnormalities and unsuccessful implantation.

The likelihood for successful pregnancy generally begins to decrease in women in their early 30s or possibly in their late 20s. A recent European study found that fertility begins to wane as early as age 27. While this decline is initially quite minimal, it begins to accelerate at about age 38 and fall even more rapidly at age 42 and beyond. Many doctors recommend that women over 35 have a fertility evaluation after attempting pregnancy for six months. Couples under age 35 should consider evaluation if conception does not occur after trying for a year. A woman using donor insemination should ask her physician about an infertility evaluation after six months.

Other conditions that can interfere with a woman's ability to conceive and carry a child to term include:

The basic infertility evaluation for women includes a history and a physical examination. Additional testing to further refine the diagnosis is often completed as well. The evaluation typically starts with a careful history of each woman's symptoms and previous experiences. This can include:

Next a physical examination is performed to evaluate the pelvic organs and assess potential hormonal problems.

Finally, additional hormonal testing or ultrasounds may be required to evaluate ovulation. An X-ray of the uterus and tubes, called a hysterosalpingogram or HSG test, may be completed to assess uterine or tubal status. Surgical procedures such as a laparoscopy that uses tiny incisions and a scope to view the interior organs or hysteroscopy, an endoscopic inspection of the uterus, may be indicated to evaluate the structure of the uterus or fallopian tubes in more detail.

Treating specific illnesses such as endometriosis may or may not treat the fertility problem. At least 10 percent of infertility problems are due to unknown causes and another 30 percent are due to problems in both the male and female partners. In addition to medication and surgical infertility treatments to treat specific health conditions in men and women, a new class of treatments that is called assisted reproductive technologies, or ART, has been developed. The most common ART is in vitro fertilization, or IVF, but new procedures can enhance the IVF process or address other infertility conditions. These procedures include:

In vitro fertilization, or IVF, involves fertilization in a laboratory and then the transfer of embryos into the uterus. This procedure was first used for humans in 1977 at Bourne Hall in Cambridge, England and tens of thousands of babies have been delivered worldwide as a result of IVF treatment.

Over the years, IVF procedures have become increasingly simple, safe and more successful.

To accomplish pregnancy as a result of IVF, several steps are involved:

Some types of fertility that might be helped with IVF include:

Assisted hatching involves mechanical or chemical thinning of the outer shell, called the zona pellucida, of the fertilized egg prior to transfer into the uterus. The technique is used to enhance the embryo's ability to hatch or break out of its protective shell and implant in the uterus.

The procedure involves measuring the thickness of the outer shell of embryos. If an embryo has not initiated the thinning process naturally, a small "window" or hole is created chemically using a dilute acidic solution on the embryo surface. The embryos are then implanted normally into the uterus.

The most extensive experience with assisted hatching has been reported from Cornell University where implantation rates are 25 percent per embryo, as compared to 18 percent per embryo with regular IVF in non-assisted cycles.

You may be a candidate for assisted hatching if you are 38 years of age or older, or if you have previously had one or more IVF cycles with failure of your embryos to implant despite otherwise good results.

Blastocyst culturing is a technique to grow embryos beyond the third day of culture. Typically, we transfer embryos into the uterus about three days after the egg retrieval, which is several days earlier than would occur in nature. On the third day, embryos generally are between six to eight cells. We now have the ability to keep the embryos two additional days in a culturing material before implanting in the uterus. During this additional culture period, the embryos continue to grow to become "blastocysts."

The natural process of embryo development begins with fertilization of the egg in the outer part of the fallopian tube. As the newly formed embryo develops, it moves slowly toward the uterine cavity where it will ultimately implant. This process takes about six to seven days. When the embryo reaches the "blastocyst" stage, it is ready to implant.

In certain patients, blastocyst culturing allows optimal selection of embryos for transfer and an increased implant rate. However, this technology may not necessarily increase your chance for pregnancy. The main advantage is that fewer embryos may be transferred to eliminate the possibility of triplet and quadruplet pregnancies, while maintaining a high pregnancy rate.

Please read FAQ: Blastocyst Culturing for more information about this procedure.

Embryo co-culturing was initiated in the IVF lab at UCSF Medical Center in 1999 to improve the quality of embryos prior to transfer into the womb. This technique has been used since 1996 in other centers. It involves using a buffalo rat liver cell line to secrete nutritional products that help growing embryos improve their chances for survival. This technique is only recommended to patients who have had unsuccessful IVF cycles with poor embryo quality.

Please read FAQ: Embryo Co-Culturing for more information about this technique.

Intracytoplasmic sperm injection, or ICSI, is the direct microinjection of a single sperm into a single egg to achieve fertilization. It was originally developed in 1992 to assist fertilization in couples with severe male factor infertility or couples who failed to fertilize in a previous IVF attempt.

The procedure overcomes many barriers to fertilization and allows couples with little hope of pregnancy to obtain fertilized embryos. The procedure was first used at UCSF Medical Center in 1994 and the first successful birth with ICSI assistance was in February 1995. UCSF Medical Center was the first San Francisco Bay Area program to achieve a pregnancy and birth with this procedure.

The technique involves very precise maneuvers to pick a single live sperm and inject it directly into the center of a human egg. The procedure requires that the female partner undergo ovarian stimulation with fertility medications so several mature eggs develop. These eggs are suctioned through the vagina, using vaginal ultrasound, and incubated under precise conditions in the embryology lab.

The semen sample is prepared by spinning the sperm cells through a special medium. This solution separates live sperm from debris and most of the dead sperm. The specialist picks up the single live sperm in a glass needle and injects it directly into the egg.

The current fertilization rate of eggs injected is 70 to 80 percent, and pregnancy rates are comparable to those seen with IVF in couples with no male factor infertility.

Please read FAQ: Intracytoplasmic Sperm Injection (ICSI) for more information about this procedure.

Intra-uterine insemination (IUI), also known as artificial insemination, is the process of preparing and delivering sperm so that a highly concentrated amount of active motile sperm is placed directly through the cervix into the uterus. The current IUI pregnancy rate per treatment at UCSF Medical Center is 14 to 15 percent. It can be performed with or without fertility drugs for the female patient.

The pregnancy rate is double that from using timed intercourse. IUI is commonly performed as a low-tech, cost-effective approach to enhancing fertility.

Please read FAQ: Intra-Uterine Insemination for more information about this procedure.

Historically, oral drugs containing hormones were designed to induce ovulation in women with irregular menstrual cycles who didn't ovulate. The goal was to stimulate the body to produce and release an egg ready to be fertilized.

Later, injected hormones were developed to increase the number of eggs reaching maturity in a single cycle, increasing chances for conception. These drugs increase the risk of multiple conceptions, are more expensive, require more time and may cause ovarian over stimulation.

In the mid-90s, oral drugs were used in women with regular menstrual cycles who ovulate but who have "unexplained infertility." The drugs may treat subtle unidentified defects in ovulation and induce the maturity of two to three eggs, instead of just one, to improve both the quality and quantity of ovulation and enhance pregnancy rates.

Ovulation induction is always combined with intrauterine insemination, and it should only be considered after a complete and thorough evaluation. All underlying hormonal disorders such as thyroid dysfunction should be treated prior to resorting to using fertility drugs.

The following common fertility drugs are used for ovulation induction:

Please read Fertility Drugs Used to Induce Ovulation to learn more about these drugs and the possible side effects associated with taking them.