Diagnosis FAQs

What is Infertility?

Infertility is defined according to a woman’s age, as the female reproductive system changes rapidly with time. The classic definition of infertility is the inability to conceive, or to carry a pregnancy to term within one year of unprotected intercourse. For women over the age of 35, this timeframe is shortened to 6 months. This age adjustment enables the fertility treatment process to begin sooner to accommodate natural changes in egg production and viability. 

Those who have known health conditions that may impact fertility, such as irregular periods (anovulation), PCOS, endometriosis or male factor infertility, should seek a fertility specialist as soon as they are ready to start a family. 

Pregnancy is the result of a multi-stage process:

  • A woman's body must release an egg from one of her ovaries (ovulation).
  • The egg must go through a fallopian tube toward the uterus.
  • A man's sperm must join with (fertilize) the egg along the way.
  • The fertilized egg must attach to the inside of the uterus (implantation).

Infertility can result from a problem with any one of these steps. 

Can infertility be due to a condition in the male partner?

Yes. Infertility is just as likely to be due to a condition in the male partner as the female partner: a third of the time, infertility is attributed to the male partner, a third of the time to the female and a third of the time to unexplained factors. Male infertility is most commonly caused by such factors as low sperm count or poor sperm quality, a blockage in the male reproductive system.

What happens during an initial fertility evaluation?

For men and women, this process involves a complete medical history and at a minimum, female examination and a series of tests that assess the primary fertility functions: 

For a woman

Evaluation focuses on ovarian function and fallopian tube health as well as a thorough examination of the reproductive anatomy. Ovarian function is a key indicator of egg quality as well as female hormone production. The fallopian tubes are where egg and sperm meet and fertilization occurs. A number of tests can evaluate the health of these reproductive systems. In addition, a complete medical history and examination will take into account menstrual history, previous surgery, health conditions, physical activity level, stress level and thyroid health (responsible for reproductive hormone output).

For a man

Evaluation assesses the status of male sperm (shape, volume and mobility) as well as the health of the urinary tract and male reproductive organs. If the semen analysis indicates a male problem, an examination by a urologist/andrologist will be recommended.

Is it possible to have a period, but not ovulate?

A period is not necessarily an indication that you are ovulating. The monthly cycle is a careful balancing act, during which the brain releases the hormones estrogen and progesterone. These hormones work in tandem to coordinate reproductive function and help the body prepare for pregnancy. Under normal circumstances, each month the ovaries prepare an egg for fertilization, and also release estrogen. The estrogen serves to build the uterine lining in the event of pregnancy. During ovulation, the ovary releases the egg and progesterone is activated. Progesterone will prepare the uterine lining for conception; or if pregnancy does not occur, signal the lining to be sloughed off and shed (menstruation).

If hormone production is impaired, ovulation may not actually take place, thus progesterone may not be released. Without progesterone, the uterine lining continues to build unchecked, eventually becoming so thick that it spontaneously bleeds. This often resembles a menstrual period.

What is meant by Decreased Ovarian Reserve?

Decreased Ovarian Reserve (DOR) means that egg supply is lower than optimal. Those eggs that do exist may be perfectly healthy – but there are fewer of them. If the decreased reserve is severe, egg quality may also be affected, with more eggs having abnormalities in chromosome numbers. This leads to lower embryo implantation and pregnancy rates as well as a higher risk of first trimester miscarriage. DOR may be present in younger as well as older women (in older women, this condition is often a sign of approaching menopause). Pregnancy is possible with this condition, and younger women with DOR may have relatively higher success with IVF treatment. However, DOR can make it challenging for woman of any age to become pregnant using her own eggs. Women with DOR do have high success rates when using donor eggs, and this option is often recommended.

How do I know whether my eggs are healthy?

There are a number of relatively simple ways to assess egg quality:

Age.  As part of the aging process, egg quality and quantity naturally decline, leading to more problematic pregnancies and lower pregnancy rates. A woman’s age is a primary factor when evaluating egg health and of all factors, age is the most important in predicting delivered pregnancy rates.

FSH and Estradiol blood test. Given on day 2 or 3 of the menstrual cycle, this routine evaluation measures FSH, the primary hormone responsible for prompting egg production, and also estradiol, the most important estrogen hormone, responsible for reproductive anatomy health and function. An increase in these hormones signals that the body is having difficulty making eggs and is working harder to ‘make up’ for this shortfall. In most clinics, an FSH level of around 10 mIU/ml or higher and Estradiol of 70 pg/ml or higher indicates low ovarian reserve. (While it is helpful to have these numbers as a guide, our nurses and physicians will always walk you through your test results and explain these measurements as they apply to your situation.)

Anti-Mullerian Hormone (AMH). A newer test is the Anti-Mullerian Hormone test. This hormone is directly produced by developing follicles in the ovary and is less dependent on where a woman is in her cycle. The ideal level is 1.0 or higher. Higher levels are better.

CCCT (Clomid citrate challenge) blood test. This is a more sensitive assessment of a woman’s egg supply, in which FSH and Estradiol hormone levels are measured before and after taking the fertility drug Clomid. About 5% of women will have normal day 3 FSH and Estradiol levels but have abnormal levels on Day 10, indicating they do have decreased ovarian reserve. This test is often recommended for those who have not responded to fertility medication, for those above the age of 37 and those who have symptoms of decreased fertility due to surgical complications or other conditions. A level of 10 mIU/mL for FSH on either cycle day 3 or day 10 indicates low ovarian reserve.

Shorter menstrual cycle. A shorter cycle may signal a change or imbalance in the hormone production that drives egg production and quality, and thus is often an indication of decreased fertility.  Higher basal FSH levels drive the egg selected for ovulation that month to mature faster, leading to a short follicular phase (that part of the cycle starting with the onset of menstruation until ovulation).  If a woman has had 28-30 day menstrual cycles, from the start of one menstrual period until the next, but in later years the cycle shortens to 24-26 days this may be the only clinical sign of decreased ovarian reserve. 

Response to treatment with fertility medication. Sometimes ovarian function is so compromised that the body simply does not respond adequately, even to ‘superovulation’ with fertility medication. 

Response to IVF. Sometimes poor egg function during IVF treatment is the first indication that there is a problem with ovarian function or egg quality. While a woman’s eggs may initially appear to be adequate for an IVF cycle, they prove to be incapable of fertilizing or producing a healthy embryo.

Prior ovarian surgery. Surgery to address such conditions as cancer, ovarian cysts, polycystic ovaries or endometriosis may result in scar tissue or other conditions that interfere with hormone or egg production.

I have been diagnosed with having blocked tubes. Can I still get pregnant?

The fallopian tubes are the ‘meeting place’ for egg and sperm, and provide a pathway for the fertilized egg to travel to the uterus. In some cases, blocked fallopian tubes may be cleared. There are surgical and non-surgical techniques to address this condition, depending on the nature of the blockage. After such procedures, pregnancy is often possible.

When a blockage cannot be repaired, pregnancy can often be achieved through IVF. This treatment involves a course of fertility enhancing medication to produce multiple eggs in the ovaries. Eggs are then ‘harvested,’ or removed from the ovaries and combined with the male sperm in the laboratory. The newly fertilized egg is then transferred back into the woman’s uterus via a small tube called a catheter. This procedure thus enables conception to take place outside of the fallopian tubes.

Is pregnancy possible after tubal ligation?

Yes. There are two potential options for women who have had a tubal ligation:

Tubal ligation reversal. This is a surgical procedure wherein the fallopian tubes are reconnected using a mini-laparotomy or small abdominal incision. In some cases, a reversal surgery can cause scarring, which may in turn interfere with a future pregnancy. If a woman is still young (generally less than 35 years of age) and would like to have several more children, tubal ligation reversal is an option. However, birth control after delivery will have to be undertaken in some form again.

IVF (In Vitro Fertilization). IVF enables the fallopian tubes to be bypassed altogether. This treatment involves a course of fertility enhancing medication to produce multiple eggs in the ovaries. Eggs are then ‘harvested,’ or removed from the ovaries and combined with the male sperm in the laboratory. The newly fertilized egg is then transferred back into the woman’s uterus via a small tube called a catheter. 

For those who have had tubal ligation and wish to get pregnant, IVF is often as, or more, successful than surgery. It also enables you to leave the ligation in place, serving as a contraception method in the future. 

Your doctor can discuss with you the benefits and risks of each option according to your particular situation.

Is it true that if you ‘just relax and stop trying’ you will increase your chances of conception?

We have all heard the stories of couples that tried to get pregnant for a long time and may have even failed fertility treatments, and then conceive on their own on vacation. This definitely happens. As long as sperm is present and the fallopian tubes are not blocked, most couples trying to conceive have some finite underlying chance of conception every month. This may happen to coincide with a vacation, or a month taken off from treatment. It can happen at any time which is why we encourage our patients that have a realistic chance to never give up.

What is meant by ‘unexplained infertility’?

For 10-15 percent of patients, the source of infertility simply cannot be determined, even after comprehensive evaluation and diagnostic testing. This frustrating situation is essentially a diagnosis based on exclusion. In these cases, we carefully analyze the infertility evaluation, review each test and how it was administered, re-examine test results and repeat tests and procedures as necessary. Most patients with unexplained infertility can still be successfully treated and achieve pregnancy.