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Most couples achieve pregnancy within the first six months of trying. Overall, after 12 months of unprotected intercourse, approximately 85 percent of couples will become pregnant. Over the next 36 months, about 50 percent of the remaining couples will go on to conceive spontaneously.

The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms.

In some cases, an infertile woman may have abnormal menstrual periods. An infertile man may have some signs of hormonal problems, such as changes in hair growth or sexual function.

When to see a doctor
In general, don't be too concerned about infertility unless you and your partner have been trying regularly to conceive for at least one year. Talk with your doctor earlier, however, if:

• You plan to conceive and you're a woman older than 30 or haven't menstruated in six months
• You're a woman who has a history of irregular or painful menstrual cycles, pelvic pain, endometriosis, pelvic inflammatory disease (PID) or repeated miscarriages
• You're a man with a low sperm count or a history of testicular, prostate or sexual problems

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

The human reproductive process is complex. To become pregnant, the intricate processes of ovulation and fertilization need to work just right.

• Each month the pituitary gland in a woman's brain sends a signal to her ovaries to prepare an egg for ovulation.
• The pituitary hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — stimulate the ovaries to release an egg. This is called ovulation. It is during this time that a woman is fertile (usually about day 14 of a 28-day menstrual cycle).
• The egg travels through the fallopian tube and can be fertilized within about 24 hours after its release. Conception is more likely to occur when intercourse takes place one to two days prior to ovulation.
• For pregnancy to occur, a sperm must unite with the egg in the fallopian tube during this time. Sperm are capable of fertilizing the egg for up to 72 hours and must be present in the fallopian tube at the same time as the egg for conception to occur. In order for a sperm to reach an egg, the man must have an erection and ejaculate enough semen to deliver the sperm into the vagina. There must be enough sperm, and it must be the right shape and move in the right way. In addition, the woman must have a healthy vaginal and uterine environment so that the sperm can travel to the egg.
• If fertilized, the egg moves into the uterus where it attaches to the uterine lining and begins a nine-month process of growth.

For some couples attempting pregnancy, something goes wrong in this complex process, resulting in infertility. The cause or causes of infertility can involve one or both partners:

• In about 20 percent of cases, infertility is due to a cause involving only the male partner.
• In about 30 to 40 percent of cases, infertility is due to causes involving both the male and female.
• In the remaining 40 to 50 percent of cases, infertility is due entirely to a cause involving the female.

Causes of male infertility
A number of things can cause impaired sperm count or mobility, or impaired ability to fertilize the egg. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, general health and lifestyle issues, and overexposure to certain environmental elements.

Impaired production or function of sperm. Most cases of male infertility are due to problems with the sperm, such as:

• Impaired shape and movement of sperm. Sperm must be properly shaped and able to move rapidly and accurately toward the egg for fertilization to occur. If the shape and structure (morphology) of the sperm are abnormal or the movement (motility) is impaired, sperm may not be able to reach or penetrate the egg.
• Low sperm concentration. A normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of 10 million or fewer sperm per milliliter of semen indicates low sperm concentration (subfertility). A count of 40 million sperm or higher per milliliter of semen indicates increased fertility. Complete failure of the testicles to produce sperm is rare.
• Varicocele. A varicocele is a varicose vein in the scrotum that may prevent normal cooling of the testicle, leading to reduced sperm count and motility.
• Undescended testicle. Undescended testicle occurs when one or both testicles fail to descend from the abdomen into the scrotum during fetal development. Because the testicles are exposed to the higher internal body temperature, compared with the temperature in the scrotum, sperm production may be affected.
• Testosterone deficiency (male hypogonadism). Infertility can result from disorders of the testicles themselves or from an abnormality affecting the hypothalamus or pituitary gland in the brain that produces the hormones that control the testicles.
• Genetic defects. In the genetic defect Klinefelter's syndrome, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production and possibly low testosterone.
• Infections. Infection may temporarily affect sperm motility. Repeated bouts of sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. If mumps, a viral infection usually affecting young children, occurs after puberty, inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.

In many instances, no cause for reduced sperm production is found. When sperm concentration is less than 5 million per milliliter of semen, genetic causes could be involved. Genetic testing can reveal whether there are subtle changes in the Y chromosome.

Impaired delivery of sperm. Problems with the delivery of sperm from the penis into the vagina can result in infertility. These may include:

• Sexual issues. Often treatable, problems with sexual intercourse or technique may affect fertility. Difficulties with erection of the penis (erectile dysfunction), premature ejaculation, painful intercourse (dyspareunia), or psychological or relationship problems can contribute to infertility. Use of lubricants such as oils or petroleum jelly can be toxic to sperm and impair fertility.
• Retrograde ejaculation. This occurs when semen enters the bladder during orgasm rather than emerging out through the penis. Various conditions can cause retrograde ejaculation, including diabetes, bladder, prostate or urethral surgery, and the use of certain medications.
• Blockage of epididymis or ejaculatory ducts. Some men are born with blockage of the part of the testicle that contains sperm (epididymis) or ejaculatory ducts. Some men lack the tube that carries sperm (vas deferens) from the testicle out to the opening in the penis.
• No semen (ejaculate). The absence of ejaculate may occur in men with spinal cord injuries or diseases. This fluid carries the sperm from the penis into the vagina.
• Misplaced urinary opening (hypospadias). A birth defect can cause the urinary (urethral) opening to be abnormally located on the underside of the penis. If not surgically corrected, this condition can prevent sperm from reaching the woman's cervix.
• Anti-sperm antibodies. Antibodies that target sperm and weaken or disable them usually occur after surgical blockage of part of the vas deferens for male sterilization (vasectomy). Presence of these antibodies may complicate the reversal of a vasectomy.
• Cystic fibrosis. Men with cystic fibrosis often have a missing or obstructed vas deferens.

General health and lifestyle. A man's general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:

• Emotional stress. Stress may interfere with certain hormones needed to produce sperm. Your sperm count may be affected if you experience excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress.
• Malnutrition. Deficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.
• Obesity. Increased body mass may be associated with fertility problems in men.
• Cancer and its treatment. Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility.
• Alcohol and drugs. Alcohol or drug dependency can be associated with poor health and reduced fertility. The use of certain drugs also can contribute to infertility. Anabolic steroids, for example, which are taken to stimulate muscle strength and growth, can cause the testicles to shrink and sperm production to decrease.
• Other medical conditions. A severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, Cushing's syndrome, or anemia may be associated with infertility.
• Age. Men older than age 40 may be less fertile than younger men.

Environmental exposure. Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm count either directly by affecting testicular function or indirectly by altering the male hormonal system. Specific causes include:

• Pesticides and other chemicals. Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production and testicular cancer. Lead exposure may also cause infertility.
• Overheating the testicles. Frequent use of saunas or hot tubs can elevate your core body temperature. This may impair your sperm production and lower your sperm count.
• Substance abuse. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm.
• Tobacco smoking. Men who smoke may have a lower sperm count than do those who don't smoke.

Causes of female infertility
The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome (PCOS), early menopause, benign uterine fibroids and pelvic adhesions.

• Fallopian tube damage or blockage. Fallopian tube damage usually results from inflammation of the fallopian tube (salpingitis). Chlamydia, a sexually transmitted disease, is the most frequent cause. Tubal inflammation may go unnoticed or may cause pain and fever. Tubal damage may result in a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.
• Endometriosis. Endometriosis occurs when the uterine tissue implants and grows outside of the uterus — often affecting the function of the ovaries, uterus and fallopian tubes. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.
• Ovulation disorders. Some cases of female infertility are caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation can cause low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can prevent the ovaries from releasing eggs (anovulation). Specific causes of hypothalamic-pituitary disorders that can result in anovulation include injury, tumors, excessive exercise and starvation. In addition, some medications can be associated with ovulation disorders.
• Elevated prolactin (hyperprolactinemia). The hormone prolactin stimulates breast milk production. High levels in women who aren't pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. In addition, some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing can be a sign of high prolactin.
• Polycystic ovary syndrome (PCOS). In PCOS, your body produces too much androgen hormone, which affects ovulation. PCOS is also associated with insulin resistance and obesity.
• Early menopause (premature ovarian failure). Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 40. Although the cause is often unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.
• Uterine fibroids. Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s and 40s. Rarely, they may cause infertility by blocking the fallopian tubes. More often, fibroids interfere with proper implantation of the fertilized egg.
• Pelvic adhesions. Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. This scar tissue formation may impair fertility.

Other causes in women

• Medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
• Thyroid problems. Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
• Cancer and its treatment. Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman's ability to reproduce. Chemotherapy may impair reproductive function and fertility in men and women.
• Other medical conditions. Medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, kidney disease and diabetes, can affect a woman's fertility.
• Caffeine intake. Excessive caffeine consumption can reduce fertility in women.

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

Many of the risk factors for both male and female infertility are the same. They include:

• Age. After about age 32, a woman's fertility potential gradually declines Infertility in older women may be due to a higher rate of chromosomal abnormalities that occur in the eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. The risk of miscarriage also increases with a woman's age. Men over age 40 may be less fertile than younger men.
• Tobacco smoking. Men and women who smoke tobacco may reduce their chances of achieving a pregnancy and reduce the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.
• Alcohol use. For women, there's no safe level of alcohol use during conception or pregnancy. Moderate alcohol use does not appear to decrease male fertility.
• Being overweight. Among American women, infertility often is due to a sedentary lifestyle and being overweight. In addition, a man's sperm count may be affected if he is overweight.
• Being underweight. Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women following a very low calorie or restrictive diet. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid.
• Too much exercise. In some studies, exercising more than seven hours a week has been associated with ovulation problems. On the other hand, not enough exercise can contribute to obesity, which also increases infertility.
• Caffeine intake. Studies are mixed on whether consuming too much caffeine may be associated with decreased fertility. Some studies have shown a decrease in fertility with increased caffeine use while others have not shown adverse effects. If there are effects, it's likely that caffeine has a greater impact on a woman's fertility than on a man's. High caffeine intake does appear to increase the risk of miscarriage.

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

If you and your partner have been trying to get pregnant for six months or longer, call your doctor. Depending on your age and personal heath history, your doctor may recommend a medical evaluation.

A woman's gynecologist, a man's urologist or a family doctor can help determine whether there's a problem that requires a specialist or clinic that treats infertility problems. Both you and your partner will likely undergo a comprehensive infertility examination.

Here's some information to help you get ready for your first appointment, and what to expect from your doctor.

What you can do

• Write down details about your attempts to get pregnant. Your doctor will need information such as when you started trying to conceive and how often you have had intercourse, especially around the midpoint of your cycle.
• Write down your key medical information, including any other conditions with which you or your partner has been diagnosed and any medications you're currently taking.
• Write down questions to ask your doctor.

Prepare a list of questions so that you can make the most of your time with your doctor. For infertility, some basic questions to ask your doctor include:

• What are the possible reasons we haven't yet conceived?
• What kinds of tests do we need?
• What treatment do you recommend trying first?
• What side effects are associated with the treatment you're recommending?
• What is the likelihood of conceiving multiple babies with the treatment you're recommending?
• For how many cycles will we try this treatment?
• If the first treatment doesn't work, what will you recommend trying next?
• Are there any long-term complications associated with this or other infertility treatments?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask each of you a number of questions. Being ready to answer them will help your doctor quickly determine next steps in making your diagnosis and starting care.

Questions for the couple

• How long have you been having sex without birth control?
• How long have you been actively trying to get pregnant?
• How frequently do you have intercourse?
• Do you use any lubricants during sex?
• Do either of you smoke?
• Have either of you been treated for any other medical conditions, including STDs?
• How much does stress play a role in your lives?
• How satisfied are you with your relationship?

Questions for the woman

• At what age did you start menstruating?
• What are your cycles typically like? How regular, long and heavy?
• Have you ever been pregnant before?
• Have you ever been evaluated for infertility in the past?
• Have you been charting when you ovulate? For how many cycles?
• Have you been treated for any other medical conditions?
• Are you currently taking any medications, including dietary supplements or anabolic steroids?
• Do you use alcohol or recreational drugs? How often?
• What is your typical daily diet? Does it include caffeine?
• Do you exercise regularly? How much?
• Has your body weight recently changed?

Questions for the man

• At what age did you start puberty?
• Have you had any sexual problems in this relationship, including difficulty maintaining an erection, ejaculating too soon or not being able to ejaculate?
• Do you use recreational drugs, including marijuana? How often?
• Are you exposed through your work or lifestyle habits to chemicals, pesticides, radiation or lead?
• Are you currently taking any medications, including dietary supplements or anabolic steroids?
• Do you regularly take hot baths or steam baths?
• Have you conceived a child with any previous partners?

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

Before undergoing infertility testing, be aware that a certain amount of commitment is required. Your doctor or clinic will need to determine what your sexual habits are and may make recommendations about how you may need to change those habits. The tests and periods of trial and error may extend over several months. In about one-third of infertile couples, no specific cause is found (unexplained infertility).

Evaluation is expensive and in some cases involves uncomfortable procedures, and the expenses may not be reimbursed by many medical plans. Finally, there's no guarantee, even after all testing and counseling, that conception will occur.

Tests for men
For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman's vagina. Tests for male infertility attempt to determine whether any of these processes are impaired.

• General physical examination. This includes examination of your genitals and questions concerning your medical history, illnesses and disabilities, medications and sexual habits.
• Semen analysis. This is the most important test for the male partner. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes your semen specimen for quantity, color, and presence of infections or blood. Detailed analysis of the sperm also is done. The laboratory will determine the number of sperm present and any abnormalities in the shape and movement (motility) of the sperm. Often sperm counts fluctuate from one specimen to the next.
• Hormone testing. A blood test to determine the level of testosterone and other male hormones is common.
• Transrectal and scrotal ultrasound. Ultrasound can help your doctor look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstruction.

Tests for women
For a woman to be fertile, the ovaries must release healthy eggs regularly, and her reproductive tract must allow the eggs and sperm to pass into her fallopian tubes to become fertilized by a sperm. Her reproductive organs must be healthy and functional.

After your doctor asks questions regarding your health history, menstrual cycle and sexual habits, you'll undergo a general physical examination. This includes a regular gynecological examination. Specific fertility tests may include:

• Ovulation testing. A blood test is sometimes performed to measure hormone levels to determine whether you are ovulating.
• Hysterosalpingography. This test evaluates the condition of your uterus and fallopian tubes. Fluid is injected into your uterus, and an X-ray is taken to determine whether the fluid progresses out of the uterus and into your fallopian tubes. Blockage or problems often can be located and may be corrected with surgery.
• Laparoscopy. Performed under general anesthesia, this procedure involves inserting a thin viewing device into your abdomen and pelvis to examine your fallopian tubes, ovaries and uterus. A small incision (8 to 10 millimeters) is made beneath your navel, and a needle is inserted into your abdominal cavity. A small amount of gas (usually carbon dioxide) is injected into the abdominal cavity to create space for entry of the laparoscope — an illuminated, fiber-optic telescope. The most common problems identified by laparoscopy are endometriosis and scarring. Your doctor can also detect blockages or irregularities of the fallopian tubes and uterus. Laparoscopy generally is done on an outpatient basis.
• Hormone testing. Hormone tests may be done to check levels of ovulatory hormones as well as thyroid and pituitary hormones.
• Ovarian reserve testing. Testing may be done to determine the potential effectiveness of the eggs after ovulation. This approach often begins with hormone testing early in a woman's menstrual cycle.
• Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing infertility.
• Pelvic ultrasound. Pelvic ultrasound may be done to look for uterine or fallopian tube disease.

Not everyone needs to undergo all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

Treatment of infertility depends on the cause, how long you've been infertile, the age of the partners and many personal preferences. Some causes of infertility can't be corrected. However, a woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.

Treatment for couples
These approaches can involve steps related to the male or to the female, or both.

Increase frequency of intercourse. Having intercourse two to three times a week may improve fertility. However, too-frequent ejaculation can lessen sperm quality. Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation.

Treatment for men
Approaches that involve the male include treatment for:

• General sexual problems. Addressing impotence or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.
• Lack of sperm. If a lack of sperm is suspected as the cause of a man's infertility, surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible. For example, varicocele can often be surgically corrected. For blockage of the ejaculatory duct or in the case of retrograde ejaculation, sperm can be taken directly from the testicles or recovered from the bladder and injected into an egg in the laboratory setting.

Treatment for women
Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. In general, they work like natural hormones — such as follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. Commonly used fertility drugs include:

• Clomiphene (Clomid, Serophene). This drug is taken orally and stimulates ovulation in women who have polycystic ovary syndrome (PCOS) or other ovulatory disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
• Human menopausal gonadotropin, or hMG, (Repronex). This injected medication is for women who don't ovulate on their own due to the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, which stimulates the pituitary gland, hMG and other gonadotropins directly stimulate the ovaries. This drug contains both FSH and LH.
• Follicle-stimulating hormone, or FSH, (Gonal-F, Bravelle). FSH works by stimulating the ovaries to mature egg follicles.
• Human chorionic gonadotropin, or HCG, (Ovidrel, Pregnyl). Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to release its egg (ovulate).
• Gonadotropin-releasing hormone (Gn-RH) analogs. This treatment is for women with irregular ovulatory cycles or who ovulate prematurely — before the lead follicle is mature enough — during hMG treatment. Gn-RH analogs deliver constant Gn-RH to the pituitary gland, which alters hormone production so that a doctor can induce follicle growth with FSH.
• Aromatase inhibitors. This class of medications, which includes letrozole (Femara) and anastrozole (Arimidex), is approved for treatment of advanced breast cancer. Doctors sometimes prescribe letrozole for women who don't ovulate on their own and who haven't responded to treatment with clomiphene citrate. Letrozole is not approved by the Food and Drug Administration for inducing ovulation. The drug's manufacturer has warned doctors not to use the drug for fertility purposes because of possible adverse health effects. These adverse effects may include birth defects and miscarriage.
• Metformin (Glucophage). This oral drug is taken to boost ovulation. It's used when insulin resistance is a known or suspected cause of infertility. Insulin resistance may play a role in the development of PCOS.
• Bromocriptine (Parlodel). This medication is for women whose ovulation cycles are irregular due to elevated levels of prolactin, the hormone that stimulates milk production in new mothers. Bromocriptine inhibits prolactin production.

Fertility drugs and the risk of multiple pregnancies
Injectable fertility drugs increase the chance of multiple births. Oral fertility drugs such as Clomid increase the chance of multiple births but at a much lower rate. The use of these drugs requires careful monitoring using blood tests, hormone tests and ultrasound measurement of ovarian follicle size. Generally, the greater the number of fetuses, the higher the risk of premature labor. Babies born prematurely are at increased risk of health and developmental problems. These risks are greater for triplets than for twins or single pregnancies.

The risk of multiple pregnancies can be reduced. If a woman requires an HCG injection to trigger ovulation, and ultrasound exams show that too many follicles have developed, she and her doctor can decide to withhold the HCG injection. For many couples, however, the desire to become pregnant overrides concerns about conceiving multiple babies.

When too many babies are conceived, removal of one or more fetuses (multifetal pregnancy reduction) can offer improved survival odds for the surviving fetuses. This presents serious emotional and ethical challenges for many people. If you and your partner are considering fertility drug treatment, discuss this possibility with your doctor before starting treatment.

Surgery
Depending on the cause, surgery may be a treatment option for infertility. Blockages or other problems in the fallopian tubes can often be surgically repaired. Laparoscopic techniques allow delicate operations on the fallopian tubes.

Infertility due to endometriosis often is difficult to treat. Although hormones such as those found in birth control pills are effective for treating endometriosis and relieving pain, they haven't been useful in treating infertility. If you have endometriosis, your doctor may treat you with ovulation therapy, in which medication is used to stimulate or regulate ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.

Assisted reproductive technology (ART)
ART has revolutionized the treatment of infertility. Each year thousands of babies are born in the United States as a result of ART. Medical advances have enabled many couples to have their own biological child. An ART health team includes physicians, psychologists, embryologists, laboratory technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.

The most common forms of ART include:

• In vitro fertilization (IVF). This is the most effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended when both fallopian tubes are blocked. It's also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility, male factor infertility and ovulation disorders. IVF increases your chances of having more than one baby at a time because multiple fertilized eggs are often implanted into your uterus so that there is a greater chance one will develop into a baby. IVF also requires frequent blood tests and daily hormone injections.
• Electric or vibratory stimulation to achieve ejaculation. Electric or vibratory stimulation brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who can't otherwise achieve ejaculation.
• Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract, such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if the ejaculatory duct is blocked.
• Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.
• Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus.

ART works best when the woman has a healthy uterus, responds well to fertility drugs, and ovulates naturally or uses donor eggs. The man should have healthy sperm, or donor sperm should be available. The success rate of ART is lower after age 35.

Complications of treatment
Certain complications exist with the treatment of infertility. These include:

• Multiple pregnancy. The most common complication of ART is multiple pregnancy. The number of quality embryos kept and matured to fetuses and birth ultimately is a decision made by the couple. If too many babies are conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.
• Ovarian hyperstimulation syndrome (OHSS). If overstimulated, a woman's ovaries may enlarge and cause pain and bloating. Mild to moderate symptoms often resolve without treatment, although pregnancy may delay recovery. Rarely, fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. This accumulation of fluid can deplete blood volume and lower blood pressure. Severe cases require emergency treatment. Younger women and those who have polycystic ovary syndrome have a higher risk of developing OHSS than do other women.
• Bleeding or infection. As with any invasive procedure, there is a risk of bleeding or infection with assisted reproductive technology.
• Low birth weight. The greatest risk factor for low birth weight is a multiple pregnancy. In single live births, there may be a greater chance of low birth weight associated with ART.
• Birth defects. There is some concern about the possible relationship between ART and birth defects. More research is necessary to confirm this possible connection. Weigh this factor if you're considering whether to take advantage of this treatment. ART is the most successful fertility-enhancing therapy to date.

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

Coping with infertility can be difficult. It's an issue of the unknown — you can't predict how long it will last or what the outcome will be. Infertility isn't necessarily solved with hard work. The emotional burden on a couple is considerable, and plans for coping can help.

Planning for emotional turmoil

• Set limits. Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and attempt to determine a final limit. Fertility treatments may be expensive and often not covered by insurance companies, and a successful pregnancy often depends on repeated attempts. Some couples become so focused on treatment that they continue with fertility procedures until they are emotionally and financially drained.
• Consider other options. Determine alternatives — adoption, donor sperm or egg, surrogacy, or even having no children — as early as possible in the fertility process. This may reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
• Talk about your feelings. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.

Managing emotional stress during treatment

• Acupuncture. This ancient therapy has been shown to reduce anxiety and increase optimism during IVF. While this may not have any effect on your chances of becoming pregnant, it can make the process more enjoyable.
• Practice relaxation. Cognitive behavioral therapy, which uses methods that include relaxation training and stress management, has been associated with higher pregnancy rates.
• Express yourself. Reach out to others rather than repressing guilt or anger.
• Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.

Managing emotional effects of the outcome
Whatever the result of your fertility treatment, you'll face the possibility of psychological challenges. Seek professional help if the emotional impact of any of these outcomes becomes too heavy for you or your partner:

• Failure. The emotional stress of failure can be devastating even on the most loving and affectionate relationships and for people who've prepared well for the possibility of failure. Common emotional responses include anger, guilt, shock, self-esteem problems, sexual problems and marital problems.
• Success. Even if fertility treatment is successful, it's common to experience stress and fear of failure during pregnancy. If you have a history of depression or anxiety disorder, you're at increased risk of these problems recurring in the months after your child's birth.
• Multiple births. A successful pregnancy that results in multiple births introduces new medical complexities and the likelihood of significant emotional stress both during pregnancy and after delivery.

©1998-2009 Mayo Foundation for Medical Education and Research (MFMER). Terms of use.

Most types of male infertility aren't preventable. However, avoid drug and tobacco use and excessive alcohol consumption, which may contribute to male infertility. Also, high temperatures can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.

If you're a man who's uncertain about whether you would eventually like to become a father, don't undergo permanent sterilization, such as a vasectomy. Although surgery to reverse this condition is possible, risks are involved that could affect fertility in other ways.

A woman can increase her chances of becoming pregnant in a number of ways:

• Exercise moderately. Regular exercise is important, but if you're exercising so intensely that your periods are infrequent or absent, your fertility may be impaired.
• Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
• Avoid alcohol, tobacco and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don't drink alcohol or smoke tobacco. Avoid illegal drugs such as marijuana and cocaine.
• Limit caffeine. Women trying to get pregnant may want to limit caffeine intake to no more than 200 milligrams of caffeine a day (one or two cups of coffee).
• Limit medications. The use of both prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly.

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