Q. What is infertility?

A. Infertility is a disease or condition of the reproductive system that interferes with the ability to conceive. It’s typically defined as not being able to get pregnant after having regular unprotected sex for one year. “Regular” is considered every few days when a woman is ovulating–the time of the month when one or more eggs are released from the ovaries. Couples may want to seek medical treatment sooner than the one-year mark if the woman is over 35 or if there is a history of irregular menstrual cycles or diseases of the reproductive system.Infertility also includes the inability to carry a pregnancy to term, as in the case of someone who’s had multiple miscarriages, says Diane Clapp, director of medical information at RESOLVE, a nonprofit advocacy organization for men and women facing infertility. “Some people think that infertility is all in the head and can be fixed with relaxation or a vacation,” says Clapp, who is a registered nurse. “But infertility is a medical disease that most people can be treated for.” About two-thirds of people who are treated for infertility will become pregnant, according to RESOLVE.

Q. What kinds of doctors evaluate and treat infertility?

A. Obstetrician-gynecologists (OB-GYNs) can evaluate and treat infertility in women. OB-GYNs specialize in general medical care of women, including care related to pregnancy and the reproductive tract. Urologists, who specialize in the urinary tract and the male reproductive organs, can evaluate and treat infertility in men.More resistant and complex problems are typically handled by “fertility specialists,” board-certified reproductive endocrinologists who have completed training in obstetrics and gynecology, followed by specialized training in hormonal problems and infertility. One example of a complex problem is a history of failure to conceive despite regular unprotected intercourse in a woman who has regular menstrual periods and whose male partner has normal sperm. Other examples of complex problems include a woman who has experienced multiple miscarriages or who has severely damaged fallopian tubes requiring the need for treatment with assisted reproductive technologies (ART)–the joining of eggs and sperm in a lab so that fertilization can occur.The decision about when to ask for a referral to a fertility specialist is a personal one. Experts say that couples should consider the age of the woman, the complexity of their problems, and how they are feeling about the progress of their treatment. Consumers should be proactive about asking their doctors for a referral to a specialist and about investigating the qualifications of the specialist. A certificate of special qualification in reproductive endocrinology and infertility from the American Board of Obstetrics and Gynecology ensures that the specialist has completed a rigorous course of training.

Q. What goes into a fertility evaluation?

A. A standard fertility evaluation includes physical exams and medical and sexual histories of both partners. Men undergo a semen analysis that evaluates sperm count and sperm movement. “We look at the percent that are moving and how they are moving–are the sperm sluggish? Are they wandering?” says Robert G. Brzyski, M.D., Ph.D., associate professor of obstetrics and gynecology at the University of Texas Health Science Center at San Antonio. “Often, it’s not possible to identify a specific reason for a sperm disorder,” he says. “But there is new recognition that very low sperm or no sperm may be related to genetics–an abnormality of the Y chromosome.”For women, doctors first check to see whether ovulation is occurring. This can be determined and monitored through blood tests that detect hormones, ultrasound examinations of the ovaries, or an ovulation home test kit. “An irregular menstrual pattern would make us suspicious of an ovulation problem, but it’s also possible for a woman with regular periods to have an ovulation disorder,” Brzyski says.If a woman is ovulating, doctors then move to a standard test called the hysterosalpingogram, a type of X-ray of the fallopian tubes and uterus. This test involves placing a radiographic dye solution into the uterine cavity. Multiple X-rays are taken. If the fallopian tubes are open, the dye will flow through the tubes and be visible in the abdominal cavity. If the fallopian tubes are blocked, the dye will be retained in the uterus or fallopian tubes, depending on the location of the blockage.

Doctors have begun to assess the ovarian reserve by measuring hormone levels and seeing how the ovaries respond to various fertility treatments. This helps evaluate the availability of eggs and the likelihood that a healthy pregnancy will result. “Some women who are 35 are fertile while others are not because their supply of eggs is depleted,” Brzyski says. “In the last decade, we’ve learned this can be investigated through a blood test on the third day of the menstrual cycle. If the numbers are normal, it doesn’t guarantee fertility. But if the numbers are abnormal, it points to a serious problem. Up to 20 percent of women who seek infertility care have an abnormal ovarian reserve test.”There are also tests that evaluate how sperm and eggs interact, as well as whether either party is developing antibodies to the sperm. This occurs when the man’s or the woman’s immune system recognizes the sperm as something foreign and attacks it.