Infertility is a common problem that affects 15-20% of couples. Every menstrual cycle there is 20% chance of conceiving in women less than age 35 and therefore 50% of couples trying to conceive will become pregnant in 3 months and 85% within 12 months. In women over the age 35, these percentages are lower. Infertility is defined as inability to conceive despite one year of unprotected intercourse in women less than age 35 and 6 months of unprotected intercourse in women over the age of 35.

The main causes of infertility are male factor (35%), tubal or pelvic pathology (35%), ovulation problems (15%), unexplained infertility (10%) and other causes (5%). Many patients classified as having unexplained infertility are likely to have undiagnosed issues relating to egg quality, (such as maternal age >35 and/or increased FSH, Estrogen, AMH levels), or immunologic issues affecting the ability of the embryo(s) to attach to the uterine lining (implantation). A small portion of women will have structural abnormalities of their uterus or conditions in which the brain does not signal the ovaries to produce mature eggs.  Treatment is targeted towards the cause where some patients will only need basic treatments such as (i.e. medication to induce ovulation and/or intrauterine inseminations); others will need more advanced treatments, such as in vitro fertilization (IVF) or advanced reproductive surgery.

Symptoms of cyclic pain are suggestive of endometriosis, but are nonspecific, because majority of women report some pain with their periods. An ultrasound can identify large ovarian cysts, called endometriomas, indicative of advanced disease, but cannot identify early stages of endometriosis. The only way to truly diagnose endometriosis is surgically by laparoscopy. It is recommended that patients be evaluated with laparoscopy when response to medical treatment is suboptimal.

A normal sperm cell has three parts: a head, which contains the genetic material; a tail, which moves the sperm cell forward; and a mid-piece, which provides the energy. Sperm parameters can be assessed by a semen analysis. A sperm sample is produced after 2-3 days of abstinence and analyzed in the laboratory for volume, count, motility (active movement) and morphology (appearance). A normal sample should have a volume of ≥ 1.5 – 2 cc (milliliters), a count of ≥ 20 million sperm/cc, ≥50% motility and ≥ 14% normal morphology (Kruger’s strict criteria).Using the strict criteria, if less than 14% of sperm cells are normal looking, the chance of fertilization is decreased.  If less than 4% of sperm cells are normal, the chance of spontaneous fertilization is very low and treatment with IVF and intra-cytoplasmic sperm injection (ICSI) is recommended. Mild abnormalities of the semen analysis can be successfully treated with intrauterine inseminations (IUI), however, moderate to severe abnormalities should be treated with IVF/ICSI to offer the best chance of success. Semen analysis is a good initial test in evaluating the sperm quantity, but does not provide information about its quality.In order to test the sperm quality, the most practical method today is sperm DNA fragmentation test commonly known as DFI or SCSA. These tests evaluate the sperm for DNA breaks and immaturity. In cases of high percentage of DNA breaks or immaturity, fertility potential is significantly reduced even in the presence of normal semen parameters.

Abnormalities of ovulation account for 10-15% of all infertility and approximately 35% of infertility problems among women. The menstrual cycle has two parts, which are separated by ovulation. In the first half, the proliferative phase, the ovary produces eggs and the estrogen hormone. In the second half, the secretor (or luteal) phase, the ovary produces both estrogen and progesterone following ovulation. The length of the cycle is determined by the first half, which can vary in duration, while the second half is usually constant in most women and typically 13-14 days. The most reliable predictor of ovulation is the occurrence of regular menstrual bleeding accompanied by cramping and breast tenderness. These symptoms are caused by the female hormone progesterone, which is only produced after ovulation. It is also possible to document ovulation by measuring the progesterone level in the second half of the menstrual cycle. Other indicators of probable ovulation include sustained elevation of the basal body temperature (not reliable) or the detection of an LH surge using an ovulation detector kit. Irregular menstrual cycles are often a sign of an abnormality of ovulation and can be caused by a disturbance of thyroid function, increased levels of prolactin hormone or an imbalance of male to female hormone ratios, commonly seen in a condition called polycystic ovary syndrome (PCOS).

Indications for IVF include decreased ovarian reserve, blocked fallopian tubes, moderate or severe male factor infertility, unexplained infertility and endometriosis. Maternal age >40 is a relative indication because of the rapid decline in the egg reserve.Women who do not ovulate due to a condition called polycystic ovary syndrome (PCOS) are at risk for high order multiple gestations (triplets or higher) and IVF can be a good choice because the number of embryos implanted can be controlled with IVF compared to IUI treatments. Endometriosis is another common cause of infertility and a common indication for IVF especially in advanced cases. Patient with mild endometriosis have higher success rates with IVF compared to patients with advanced endometriosis.

ICSI is a procedure that allows treatment of the most severe male factor infertility cases. Using ultra fine instruments, it is possible to select a single sperm and inject it into the egg to accomplish fertilization without damaging the egg. Before ICSI there was no effective treatment for poor sperm other than to use donor sperm. In the era of ICSI, male factor infertility cases have the high success rates with IVF.