The impairment of any of these functions can cause infertility. They can be impaired for many reasons, which are described below.

Abnormal Ovulation (or Hypothalamic Pituitary Dysfunction)
Abnormal ovulation occurs most often when there are irregularities in the hormones needed to produce and release healthy eggs. It may also be associated with weight, if a woman is significantly underweight, overweight, or experiences significant changes in weight. Abnormal ovulation results in irregular or absent menstrual periods, and can usually be treated successfully with hormone therapy.

Male Factor
Infertility may be related to low sperm count, abnormal size, shape or movement (motility) of the sperm, or the absence of sperm. This is commonly caused by the presence of a varicocele, which is a varicose vein in the scrotum. It can also be caused by injury to the testicles, undescended testicles, hormonal imbalance, or the presence of infection or diseases (such as diabetes mellitus, central nervous system dysfunction or pituitary tumors), past illnesses or medications.

Blocked Fallopian Tubes
If the fallopian tubes are damaged or blocked, the sperm and the egg may not be able to unite. Blockages may also prevent an embryo from developing or implanting in the uterus. Damage to the fallopian tubes can be caused by conditions such as pelvic inflammatory disease (PID) or endometriosis. Often, there are no symptoms. Treatment may require specialized surgery.

Cervical Problems
When the body is not ovulating, mucous in the cervix helps prevent infection by killing bacteria. However, during normal ovulation, the consistency of the mucous changes to allow sperm to enter the uterus. If the mucous does not change properly, couples may have problems getting pregnant. Other problems occur when an abnormally shaped cervix prevents sperm from entering the uterus. Cervical problems are often treated using artificial insemination.

Endometriosis
Every month the lining of the uterus (called the endometrium) thickens in preparation for the implantation of an embryo. If a pregnancy does not occur, the body sheds this lining and menstruation takes place. Endometriosis occurs when the endometrial cells get off course and attach to the ovaries and other pelvic organs, causing them to become inflamed. Sometimes there are no symptoms, but other times it causes long and painful menstrual periods. Endometriosis can be treated with medications or surgery, depending on the situation.

Age
Fertility levels decrease with age, especially in women. A woman is in her fertile prime between the ages of 15 and 24. About one third of women who wait until they are mid 30s will have problems getting pregnant. At least half of women who wait until their 40s will have trouble.

Unexplained
In some cases infertility cannot be explained.

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The reproductive specialists at Minnesota Gynecology and Surgery follow a careful process to help couples learn why they are having trouble getting pregnant.

Consultation
Before any testing is done, our reproductive specialist will schedule a consultation with you and your partner to get to know you and your reproductive history. You should be prepared to discuss your medical history, including your current health status, diet and lifestyle, past medical and surgical events, occupational risks, sexual development, use of birth control and any previous pregnancies. You will also need to discuss you current sexual activity. It may be uncomfortable, but it is important in successfully identifying and treating any problems.

Physical Exam
If you haven't already done so, both you and your partner should undergo a physical exam to determine your general state of health and to evaluate physical disorders that may be affecting your ability to conceive. If no cause for infertility can be found, more specific tests may be recommended.

Testing
If further testing is necessary, we'll always start with the simplest appropriate test, and include the more complex tests only as they become necessary. With these tests, we are trying to answer the following questions:

- Is there a problem with ovulation?
- Is there a problem with sperm?
- Is there a hormonal problem?
- Is there a problem with fertilization?
- Can implantation occur and be maintained?

TESTS TO DETERMINE IF THERE IS A PROBLEM WITH OVULATION.

Basal Body Temperature (BBT) Charting
During normal ovulation most women experience a slight rise in temperature due to the production of the hormone progesterone. Charting your temperature can provide us with valuable information about your menstrual cycle.

Ovulation Test Kits
There is a natural surge in luteinizing hormone (LH) just before ovulation. These kits help pinpoint when ovulation is occurring by detecting the level of LH in the urine. This can help you plan intercourse around your most fertile days, and can also be helpful in scheduling other tests and procedures that must be performed within a certain time of ovulation.

TESTS TO DETERMINE IF THERE IS A PROBLEM WITH SPERM.

Semen analysis
A routine semen analysis allows us to evaluate the quantity and quality of sperm. If necessary, a more extensive test can be performed to detect other problems.

Blood Tests
A blood test is performed to look at the levels of certain hormones including follicle stimulating hormone (FSH), leutinizing hormone (LH) and testosterone, all of which are important in the proper development of the sperm.

TESTS TO DETERMINE IF THERE IS A HORMONAL PROBLEM.

Blood Test to Check FSH and Estradiol Levels
The level of follicle stimulating hormone (FSH) in your bloodstream gives us information about your ovarian reserves (number of eggs) and checks your body's resistance to ovulation. The level of estradiol helps us determine your estrogen level. Women with high levels of FSH and/or estradiol usually have lower pregnancy rates.

Blood Test to Check TSH Levels
The level of thyroid stimulating hormone (TSH) in your bloodstream gives us information about your pituitary activity, which controls the release of hormones needed to produce eggs. It also provides information about the levels of prolactin , which is the hormone that stimulates the production of breast milk. High levels of prolactin cause a condition called hyperprolactinemia, which can interfere with ovulation.

TESTS TO DETERMINE IF THERE IS A PROBLEM WITH FERTILIZATION.

Cervical Mucous Testing
A sample of cervical mucous is taken at the time of ovulation to determine if its quality and consistency is adequate to allow sperm to enter the uterus.

Hysterosalpingogram (HSG)
For this test, dye is injected into the uterus and fallopian tubes through a tube inserted into the cervix. On x-ray, the dye enables us to see abnormalities in the size or shape of the uterus, pelvic abnormalities and blockages in the fallopian tubes.

Diagnostic Laparoscopy
For this test, an instrument that works like a camera is passed into the abdomen through a tiny incision below the navel. This camera allows us to look directly at the reproductive organs to detect abnormalities, scar tissue or other blockage of the fallopian tubes. This is usually an outpatient procedure performed under general anesthesia.

Hysteroscopy
During a laparoscopy, the doctor may use a different instrument to look more closely at the uterus to determine if there are tumors, scars or other abnormalities.

TESTS TO DETERMINE IF THERE IS A PROBLEM WITH IMPLANTATION.

Serum Progesterone Testing
Progesterone is the hormone responsible for preparing the lining of the uterus for implantation. If the body does not produce enough progesterone, implantation cannot be maintained. A blood test measures the function of the corpus luteum, which produces progesterone.

Endometrial biopsy
The lining of the uterus (endometrium) must thicken in order for a fertilized egg to implant and grow. In this test, a sample of tissue is taken from the endometrium and viewed under a microscope to allow us to determine if it has developed properly.

Ultrasound
An intra-vaginal ultrasound helps us determine the thickness of the endometrium and if the uterus is responding appropriately to hormone production.

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Once we've determined the cause of infertility, we'll create a treatment plan for you and your partner. Minnesota Gynecology and Surgery offers the majority of services available to help couples conceive. However, Assisted Reproductive Technologies (ART), such as in-vitro fertilization (IVF) will be referred to an infertility clinic that specializes in these procedures, and we can continue to provide all your support services.

Induced Ovulation
Ovulation inducing drugs are presently the most widely prescribed treatment for infertile couples. These medications regulate levels of hormones needed by the ovaries to produce and release healthy eggs for fertilization.

CLOMIPHENE CITRATE (USUALLY CLOMID©)
Administered orally, this drug signals the pituitary gland to produce higher levels of hormones that stimulate the production of eggs.

FOLLICLE-STIMULATING HORMONE (FSH) (USUALLY REPRONEX©)
Administered as an injection under the skin, FSH generates a higher hormonal response and is usually prescribed for patients who do not respond to clomiphene citrate.

HUMAN CHORIONIC GONADOTROPIN (HCG)
Once clomiphene citrate or FSH has been administered and an ultrasound confirms that the reproductive system is ready, this drug is injected into the muscle to cause the release of mature eggs from the ovaries (ovulation).

For patients taking fertility drugs, an ultrasound is performed periodically to ensure the drugs are working properly. A baseline ultrasound is performed on the 1st, 2nd or 3rd day of your menstrual cycle to make sure you have no ovarian cysts before beginning a cycle of clomiphene citrate or FSH. This is done on consecutive cycles for clomiphene citrate and on all cycles for FSH. Once you begin a drug cycle, a second ultrasound is performed to look at your follicles to make sure that eggs were recruited before hCG is given to stimulate ovulation. The mid-cycle ultrasound also measures the uterine lining to determine if it is thick enough for egg implantation.

Artificial Inseminations
This is a simple procedure in which the doctor inserts sperm directly into the woman's vagina or uterus. It is usually performed in couples whose infertility problem is related to low sperm count or poor sperm movement. Placing sperm directly near the cervix increases the number of sperm that can move through the reproductive tract. Artificial insemination is also used when infertility is due to cervical mucous problems. In this case, the doctor may do an intrauterine insemination (IUI) where sperm is inserted directly into the uterus at the time of ovulation. Artificial insemination can take place with the male partner's sperm, or donor sperm. Donor sperm is carefully screened to find an appropriate match and also to protect against transmitting any diseases or genetic disorders.

Laparoscopic Surgery
As a treatment procedure, laparoscopy is performed to remove ovarian cysts.

Other Surgical Procedures
If infertility is caused by physical abnormalities in the reproductive system of either partner (such as scarring, adhesions, endometriosis, fibroids or other uterine or tubal problems), surgery can usually correct all but the most severe cases. If necessary, surgery may be combined with other therapies.

Assisted Reproductive Technologies (ART)
Approximately 5% of couples will require something beyond medical therapy or surgery to help them conceive. More sophisticated techniques, such as in-vitro fertilization (IVF) help to unite sperm and egg, thus bypassing the factors that may be causing infertility. Although Minnesota Gynecology and Surgery does not perform these services, we will refer them to an infertility clinic that specializes in these procedures. We can, however, perform your preliminary and follow-up work.

Multiple Births and Other Risks
According to the Centers for Disease Control, fewer than 6% of births that result from Assisted Reproductive Technologies result in triplets or more. With fertility drugs alone, fewer than 10% of births using medications result in twins, and less than 1% result in three or more babies. Careful monitoring can minimize the risk of multiple births. Fertility drugs may also cause the development of ovarian cysts, and more than twelve cycles of medications may slightly increase the risk of ovarian cancer.

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For most couples trying to get pregnant (with regular sexual intercourse, two or three times a week), the chance of achieving a successful pregnancy is about 25% during the first month of trying. By the end of the first year of trying, about 85% of couples will conceive. Couples should definitely seek help if they are unable to achieve pregnancy after a year of trying, six months if the woman is over 35.

However, the stress of trying to conceive and not being successful can affect you personally, affect your relationship with your partner and further hinder your ability to get pregnant. If your situation is causing anxiety even before a year, we encourage you to at least consult with a fertility specialist to learn more and discuss your options.

Women with a history of pelvic inflammatory disease, endometriosis, miscarriage or irregular or painful menstrual cycles, or men with a known low sperm count should consult with a physician as soon as possible.

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Although Minnesota Gynecology and Surgery specializes in the treatment of infertility, we encourage you to do everything possible to maintain your ability to get pregnant on your own. This includes:

Maintaining a healthy lifestyle: eat a proper diet and exercise regularly. Women who are significantly over or underweight may have difficulty getting pregnant.

Avoiding cigarettes and alcohol: alcohol can affect sperm counts in men, and increase the risk of babies born with birth defects.

Limiting caffeine consumption: although there is no clear understanding of how much caffeine affects fertility, there is a chance that it can. It also increases the risk of miscarriage.

Avoiding lubricants during intercourse: many products have are toxic to sperm. For information about which lubricants can be used safely, consult your doctor.

Being careful with drugs and vitamins: some medications, such as those used to treat ulcers and high blood pressure, can lower a man's sperm count and sex drive. Marijuana and anabolic steroids can also affect sperm counts. Illegal drugs are always harmful and cause additional risks for fertility.

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