When Becoming Pregnant is a Problem It is not unusual for couples to have problems when they are trying to have a child. If a woman is unable to become pregnant after a year of unprotected intercourse, it may be necessary for a physician to define the problem and take steps to correct it. Forty percent of the time, the inability to become pregnant can be due to the problems of both partners. In the remaining 60% of the cases, the problems may be evenly divided between men and women. How does pregnacy occur? The female reproductive system involves different organs that are stimulated by chemical messengers called hormones. Glands such as the hypothalamus, the pituitary, the thyroid, and the ovaries produce several different kinds of hormones that prepare the reproductive system for pregnancy each month. Each month, the cycle is started by a series of hormones from the hypothalamus and the pituitary that signal the ovaries to begin ovulation (release an egg). About 20 of the 300,000 egg follicles within the ovaries begin to mature in preparation to release an egg. Usually only one follicle fully matures and releases its egg; the other follicles degenerate. The released egg enters the fallopian tube nearer to the ovary in which the egg was generated and slowly travels toward the uterus. If sperm are present in the fallopian tube, the egg may become fertilized. Once the egg is fertilized, it continues down the fallopian tube into the uterus where it is implanted in the inner wall, called the endometrium, and begins to grow into a fetus. What causes infertility problems in women? Although there can be many reasons why a woman can fail to conceive, three primary causes have been identified:      * failure to ovulate regularly      * structural or mechanical problems      * cervical and/or uterine abnormalities Irregular Ovulation The most common cause of female fertility problems is a failure to ovulate regularly or failure to ovulate at all. This problem can often be traced to a hormonal imbalance. One type of hormonal imbalance occurs naturally. As a woman ages and approaches menopause, her reproductive hormones tend to diminish and she naturally tends to ovulate less often. This makes women in their 30s and 40s less fertile than those in their 20s. Other common hormonal imbalances that disrupt ovulation include: a pituitary gland problem, such as elevated levels of prolactin (a hormone that both stimulates breast milk production and blocks ovulation) a pituitary tumor that inhibits the release of hormones necessary for ovulation problems with the adrenal gland leading to increased levels of androgen, a hormone that interferes with ovulation. In addition, factors such as stress, cigarette smoking, over-exercising, nutritional deficiencies, use of certain medications, or being overweight or underweight can easily alter the delicate hormonal balance needed to ovulate. Finally, disorders of the ovary, such as an ovarian tumor or a cyst, may lead to irregular ovulation or no ovulation. Structural or Mechanical Problems Damage to reproductive organs is responsible for a significant proportion of female fertility problems. Pelvic inflammatory disease, a frequent result of sexually transmitted infections, can cause scar tissue which blocks the fallopian tubes and prevents the sperm from reaching the egg. Structural and mechanical problems may also be caused by endometriosis. This is a common condition in which tissue resembling the interior of the uterus is found on other parts of the body, usually the reproductive organs. This tissue can interfere with the release of the egg or block the egg as it travels through the fallopian tube toward the uterus. Endometriosis is the cause of fertility problems in as many as 40% of women who have the condition. Less common are disorders present at birth, such as a malformed vagina or uterus or the absence of one or both fallopian tubes. A number of women with fertility problems have abnormal reproductive organs because their mothers took a drug called DES (diethylstilbestrol) while pregnant. DES was given to pregnant women between 1940 and 1971 in the belief that it might help prevent miscarriages. Cervical and Uterine Problems Cervical and uterine abnormalities can also responsible for an inability to conceive. These disorders, however, are not as common as hormonal and structural difficulties. A hostile environment in the cervix, such as poor or abnormal mucus production and/or a bacterial infection, can actually kill or immobilize sperm so they cannot fertilize an egg. In rare cases, the female may actually be allergic to her partner’s sperm; her antibodies will attack or immobilize the sperm in the cervix. In the uterus, benign (noncancerous) tumors called fibroids can prevent the fertilized egg from being implanted and interfere with the development of the fetus. In rare cases, the lining of the uterus becomes inflamed and interferes with the growth of the fertilized egg. Can psychological problems prevent pregnancy? Psychological problems play a smaller role in fertility problems than was once believed. The emotional strain of trying to become pregnant can indeed disrupt the delicate hormonal balance needed for ovulation and pregnancy to occur. However, psycho-logical problems are more often a result of the failure to become pregnant than a direct cause. What are the common causes of fertility problems in men? In approximately a third of all couples experiencing fertility problems, the male partner may be the source of the problem. Common causes of male infertility include hormonal, infections, injury to testes, hydrocele (fluid accumulation in the scrotum), undescended testicles, varicocele (a swollen vein in the testicle reducing sperm count), excessive alcohol use or smoking, inflammation of the prostate gland or testicles, poor sperm count, or ejaculation disorders. When is fertility evaluation recommended? One factor is a woman’s age at the time a fertility problem is suspected. Older women should seek help earlier than younger women. Generally, if a woman under the age of 30 has been unsuccessfully trying to conceive for about 2 years, a consultation with a gynecologist or other primary care physician is recommended to determine if the source of the problem lies with the male, the female, or with both partners. Women between 30 and 35, however, should probably wait only 1 year before seeking medical help and those over 35 should visit a physician after 6 months of unprotected intercourse without conception. The problem usually can be resolved by the gynecologist or other primary care physician without an extensive fertility examination. Very often the failure to achieve pregnancy is due to a non-medical problem, such as poor timing of intercourse. If a complete fertility work-up is necessary, the gynecologist or other primary care physician will test both partners or refer the couple to a fertility specialist for this step. The specialist will test both partners and attempt to diagnose and correct their particular fertility problems. Hope for Couples that Desire a Child The cause of a fertility problem can be determined in approximately 90% of couples. In the remaining l0%, the reason underlying the inability to conceive is extremely difficult to explain. Drug or surgical treatments, or a combination of both, and changes in lifestyle (for example, reducing stress or altering dietary patterns) are often effective in helping to achieve pregnancy. Today, in fact, there is more hope for couples to conceive a child than ever before. Adapted from Columbia University college of Physicians and Surgeons Complete Guide to Pregnancy New York, Crown Publishers, 1985, p 69.