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From The National Women's Health Information Center

There are many reasons why a couple may have difficulty conceiving a child. Disease, drugs, heredity, lifestyle habits or even exposure to certain toxins can affect fertility. Reasons for diminished reproductive capacity include:

• Endometriosis — This condition affects a woman's pelvic cavity, where tissue fragments from the innermost lining of the uterus (the endometrium) grow and function outside the uterus. They are one of the causes of painful menstruation and infertility. These displaced pieces of tissue are not shed vaginally with normal menstrual blood but instead accumulate inside the pelvis on the surface of pelvic organs. If they cause scar tissue on the ovaries or at the ends of the fallopian tubes, the scar tissue can block the tubes and prevent the egg and sperm from meeting inside the tubes for fertilization. In some instances, endometriosis can be surgically removed. Drugs can reduce discomfort related to endometriosis but are less successful at improving fertility.
• Reproductive tract infections — A leading cause of infertility in both men and women is sexually transmitted diseases (STDs) — particularly chlamydia and gonorrhea. If untreated — and many infected women have no symptoms — scarring or damage of the fallopian tubes may cause infertility. In men, an STD can lead to scarring and blockage of the ejaculatory ducts and other reproductive structures, thereby causing infertility.
• Pelvic inflammatory disease (PID) — This infection of a woman's upper reproductive system involves the fallopian tubes, uterus and ovaries. The most common cause of PID is an STD, but it may also occur after complications from an abortion, dilatation and curettage (D&C) surgery, childbirth or even use an intrauterine device (IUD). A single episode of PID is associated with approximately a 15% risk of infertility. A second episode doubles infertility risk to about 30%. For three or more episodes, the risk rises to more than 50%.
• Female hormonal imbalances — If your female hormones fail to transmit their chemical signals at precisely the right time, ovulation may be irregular, infrequent or fail to occur. Periods will likely be erratic and unpredictable. Female hormonal imbalances can often be treated with fertility drugs.
• DES exposure. — Men and women exposed in the womb to diethylstilbestrol (DES), a drug used in the past to prevent miscarriages, may find that their fertility is compromised. DES daughters may have reproductive system abnormalities — including an unusually shaped uterus or vagina or abnormal fallopian tubes. These abnormalities can cause ovulation problems in some women, as well as an increased risk of miscarriage, premature delivery and ectopic pregnancy. The data related to sons with DES exposure are not conclusive. Some studies suggest an association with low sperm counts or abnormal sperm, undescended testicles or abnormal openings of the urethra.
• Varicocele — This condition of dilated scrotal veins affects one or both testicles. These dilated, varicose veins are quite common in fertile as well as infertile men. This condition can raise the temperature in the testicles and alter sperm production, causing low sperm counts. Because varicoceles do not always explain a couple's infertility, a urologist will consider all the possible causes of infertility to evaluate whether corrective surgery has a reasonable chance of success.
• Prostatitis — Another potential cause of male infertility, prostatitis is an infection in the prostate gland. Symptoms range from none to urgency, painful urination, and pain during or after ejaculation, with or without pain in the prostate. Prostatitis can usually be diagnosed though a physical examination and lab tests, and may be require treatment with antibiotics.
• Caffeine — Some women who consume an excessive amount of caffeine — equivalent to five cups of coffee — take longer to get pregnant. In one study, those who consume the most caffeine had a 45% risk of waiting more than nine months before becoming pregnant.
• Alcohol — For the mother-to-be, alcohol decreases conception rates and increases the risk of miscarriage.
• Smoking — Chemicals in cigarette smoke may reduce a man's ability to conceive. Women who smoke also may have trouble getting pregnant and experience higher rates of miscarriage compared to women who don't smoke.
• Social drugs — Marijuana and cocaine may reduce sperm count and motion, and increase the percentage of defective sperm.
• Heat — There's also evidence that prolonged exposure to heat in hot tubs, saunas or steam rooms produces high scrotal temperatures, which may decrease the number and function of a man's sperm.

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• A sperm count and analysis to evaluate whether your partner is releasing enough live, normally shaped, fast-moving sperm to make fatherhood possible.
• Blood screening of both partners for blood type, complete blood count, HIV, and hepatitis viruses, as well as immunity to German measles, and the functioning of such organs as the thyroid gland.
• Bacterial cultures of your cervix to check for gonorrhea, chlamydia and other infections that could impair fertility.
• Cervical mucus tests, which are done on the day you're most likely to have "fertile mucus," and a postcoital test (conducted after you and your partner have had sex) to see if his sperm are alive and can swim freely in your cervical mucus.
• Ultrasound exams, also done in mid-cycle, to evaluate your uterus (and its lining) and the ovaries, check for fibroid tumors and to monitor egg development.
• Hormone screening tests, to find out if your body is producing normal levels of the various fertility hormones at the right time in your cycle. Your partner may also be tested to see if he has normal levels of male hormones.
• X-Ray studies of your uterus and tubes to determine whether there is any anatomical impairment preventing you from conceiving.

• Fertility drugs — There are several medications that can help stimulate ovulation in women. Clomiphene citrate (Clomid, Serophene) has been used since the 1960s. There is a 75% to 80% success rate for stimulating ovulation in women who never or seldom ovulate, and 30% to 40% of them will conceive. Clomid is sometimes combined with other drugs to improve chances for ovulation. Another approach to achieving ovulation is by using human menopausal gonadotropin, a more potent treatment with an 80% to 90% ovulation rate, and 40% to 50% pregnancy rate. Unfortunately, these drugs have more side effects, including a 20% rate of multiple birth. For women who fail to ovulate on these drugs, another treatment, synthetic gonadotropin-releasing hormone (GnRH), can be given by a portable infusion pump over several days. Some of these medications are also used for men, but in different doses.
• Microsurgery — Using needles as thin as a human hair, and suture material invisible to the naked eye, surgeons can make extremely precise repairs to blocked fallopian tubes (or in some case, reverse prior tubal sterilization), blocked ducts in the male reproductive system or varicose veins in the testicles. Laparoscopic surgery (in which a small, thin telescope is inserted through very small incisions in the abdomen) can be used to remove adhesions caused by endometriosis or to widen fallopian tube openings. Laparoscopy is also used to diagnose and treat abnormalities of the uterus and other reproductive structures.
• Intrauterine insemination — To increase the odds of pregnancy, fertility drugs are used first to stimulate release of several eggs at once; concentrated, moving sperm are then placed directly into the uterus with a syringe or thin tube. This treatment is most helpful for couples with unexplained infertility, and for women with ovulation problems or antibodies that attack their partners' sperm in the vagina.
• Donor sperm banks — For males who suffer from zero sperm or extremely low sperm count.
• Assisted reproductive technologies — There are several variations of these high-tech methods in which sperm and egg are combined to maximize the chances of achieving a successful pregnancy. All of the variations involve two steps — beginning with the woman taking fertility drugs to stimulate the ovaries to produce several eggs (superovulation); followed by the use of procedures to retrieve them, while she is under anesthesia. The best known of these methods is in-vitro fertilization (IVF), which was responsible for the birth of many "test-tube babies." The eggs obtained through the vaginal canal using ultrasound guidance are fertilized with the partner's sperm outside the woman's body, not in a test tube, but in a culture dish. A few days later, the eggs, now called zygotes, are placed in the woman's uterus. If one or more of the zygotes implants successfully, pregnancy results. One study reported that 17% of women who have this procedure once go on to deliver a baby. Two variations of this technique are gamete intra-fallopian transfer (GIFT), and zygote intra-fallopian transfer (ZIFT). Using GIFT, the harvested eggs are mixed with the man's sperm and then inserted directly into the fallopian tubes, which allows fertilization (if it occurs) to take place in the natural way. In ZIFT, the harvested eggs are fertilized in a culture dish and then placed in the fallopian tubes during laparoscopic surgery. Both of these methods are only suitable for women who have functional fallopian tubes. The national rate for successful deliveries for one pregnancy attempt using these methods are 27% for GIFT and 23% for ZIFT. When selecting a clinic, you should check on its success rate.

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