Infertility Overview

Drs. John and LeighAnn Frattarelli established the Oahu infertility clinic in Kailua and Honolulu to treat all patients in Hawaii. The fertility providers at ARMG are some of the most successful and experienced infertility physicians in the United States. Dr. John Frattarelli and Dr. Anatte Karmon are the only infertility specialists who travel to the neighbor islands of Hawaii and Maui, to see and treat patients.

What is Infertility?

Infertility is any medical condition that impairs a couple’s ability to conceive and give birth. If you and your partner are having trouble getting pregnant, the best opportunity for evaluation and successful treatment is from a physician with a special interest in the area of infertility.

When should couples seek infertility treatment?

Couples should seek medical help if the woman has been unable to achieve pregnancy following six months (1 year if the woman is under 35 years old) of regular, unprotected sexual intercourse.   Women with history of pelvic inflammatory disease, endometriosis, miscarriage, irregular or painful menstrual cycles, or men with low sperm count, who are having difficulty having a baby may benefit from consulting with a physician earlier.

Does infertility only happen to women?

While many people associate infertility with women, it actually occurs equally among both women and men. About one third of all cases can be traced to factors involving women and one third are associated with male factors. The remaining cases are caused by a combination of problems involving both partners or cannot be explained.

Understanding the human reproductive process

Conception and pregnancy depend on complicated relationships between many factors in both women and men. A disruption in any of these processes in either or both partners can influence fertility. For this reason, it is important to understand the normal reproductive functions in both partners.

The Female Reproductive System

Women are born with approximately 500,000 eggs, which are stored in two small ovaries. During her reproductive years, a woman usually releases a single mature egg each month as part of her menstrual cycle. In addition to producing a mature egg, the ovaries produce the female hormones, estrogen and progesterone.

The eggs develop and mature inside follicles, which are tiny fluid-filled sacs that exist in each ovary. At mid-cycle, one egg is released from a follicle in a process known as ovulation. After the egg travels along one of the fallopian tubes toward the uterus, it is ready for fertilization by the man’s sperm. If a sperm penetrates the egg, fertilization occurs. The fertilized egg then implants itself into the lining of the uterus, where it will gain nourishment as it grows.

The uterus is the muscular organ where a fertilized egg, or embryo, attaches and develops. It is about the size and shape of a pear and is lined with a rich and nourishing mucous membrane called the endometrium. The vagina is the passage that leads from the outside of the body to the cervix, which is the opening to the uterus.

Normal anatomy and regular menstrual cycles in the female are important factors in establishing fertility. Monthly changes in a woman’s hormone levels control the sequence of events. To help understand the process a little better, it is important to understand the menstrual cycle and the hormones involved.

The Menstrual Cycle

The menstrual cycle refers to the maturing and releasing of an egg and to the preparation of the uterus to receive and nurture the embryo. The typical cycle takes approximately 28-32 days and is divided into three distinct phases. On the first day of the cycle, when menstruation begins, the uterus sheds its lining from the previous cycle.

Follicular Phase- Day 1 to about Day 13

During the follicular phase, the body releases a hormone known as follicle stimulating hormone (FSH). FSH stimulates the development of the follicle, which contains the maturing egg. The follicle also secretes estrogen, which produces mid-cycle changes in the cervical mucus. These changes help prepare the cervical mucus to receive and nourish sperm from the man.

Ovulatory Phase- Around Day 14

The ovulatory cycle phase begins when the level of hormone called luteinizing hormone (LH) dramatically increases, or surges. LH causes the follicle to break open and release its egg into the fallopian tube. This process is known as ovulation and lasts for approximately 24 hours. Most women do not ovulate exactly on “Day 14”. Some women ovulate earlier, some later and some not at all. Also, a woman’s ovulation pattern can vary from month to month. It’s also important to note that a woman may get her period even though she is not ovulating.

Luteal Phase-Day 15 to about Day 28

After ovulation occurs, the luteal phase begins. During the luteal phase, the follicle that produced the egg becomes a functioning gland called the corpus luteum. The corpus luteum produces progesterone, which prepares the uterus with the rich lining needed for implantation of the fertilized egg (embryo).

A women’s fertile time is around midcycle when ovulation occurs, which is on or about the 14th day after the first day of the period. Unlike the rest of the monthly cycle, cervical mucus is receptive to sperm around the time of ovulation. When a couple has intercourse during this time, sperm swim in the cervical mucus. Gradually, sperm swim into the uterus and along the fallopian tube, where the egg and sperm unite. The egg can be fertilized for about 24 to 48 hours after it is released from the follicle.

The fertilized egg, or embryo, travels back through the fallopian tube toward the uterus. Once inside the uterus, the embryo implants itself into the lining on about the 20th day of the cycle. The corpus luteum can sense the pregnancy and will continue to produce progesterone, thus preserving the uterine lining and pregnancy.

If fertilization does not occur, the corpus luteum will cease to function on about day 26. The uterus will then break down and shed its lining several days later, and the next menstrual cycle begins.

How to know when ovulation occurs

There are several ways to determine approximately when a woman ovulates. One way is to use a basal body thermometer (BBT) to take the woman’s basal temperature every morning and chart the temperature.

Another way to determine ovulation is through the use of an ovulation predictor urine test kit. This test measures hormone levels in urine and allows the woman to determine during her cycle when she is ovulating. Intercourse or insemination can then be scheduled to take advantage of this window of fertility.

The Male Reproductive System

The male reproductive system is also under the influence of hormones and is responsible for producing sperm. In fact, the same hormones that regulate female reproductive functions also regulate the production of sperm in the male. FSH stimulates sperm production, and LH stimulates the production of the hormone testosterone. Testosterone helps maintain sperm production, sexual desire, and male characteristics such as hair growth.

Sperm is produced by the testes (or testicles)- glands located in the scrotum, the fleshy pouch at the base of the penis. The scrotum protects the testes and maintains a constant temperature, which is somewhat lower than normal body temperature, to help sperm develop properly. As sperm are produced, they pass from the testes through the coiled channels of the epididymis, which is an organ that stores and nourishes sperm as they mature.

Once sperm are completely mature (spermatozoa), they move into the vas deferens. This tubal structure connects the epididymis with the seminal vesicles, which are two pouch-like glands that store mature sperm. The entire process of sperm formation to maturation takes about 72 days. However, this is an ongoing process, and sperm are being manufactured all the time.

When a man ejaculates (releases fluid from his penis during intercourse), the sperm from the seminal vesicles combine with a thick fluid from the prostate gland to create semen. The fluid (ejaculate) is deposited into the woman’s vagina. Sperm can live 48 – 72 hours within the female reproductive tract, retaining the ability to fertilize an egg. This is why sexual intercourse around the time of ovulation is necessary for conception to occur.

The sperm’s ability to fertilize an egg

Several factors determine whether a man’s sperm can fertilize an egg. Semen quality and quantity may affect the ability of sperm to fertilize the egg successfully. The ability of sperm to move, referred to as motility, appears to be one of the most important factors in determining the fertilizing capability of sperm. Even with a low sperm count, men with highly motile sperm may still be fertile. The shape of the sperm, referred to as morphology, may also affect its ability to fertilize an egg. In addition, the sperm must live long enough to reach the egg, a characteristic known as viability.