Infertility

Waiting for a baby

After years of diligently trying not to conceive, some couples find themselves frustrated by how hard it is to actually get pregnant once they decide to start a family. The good news is, 85% of couples conceive within 12 months of stopping birth control use. And up to 60% of those who couldn't conceive in the first year of trying will eventually also get pregnant. But dealing with infertility can challenge your patience, your budget, even your marriage, so it's important to know what to expect.

According to the American College of Obstetricians and Gynecologists (ACOG), in 40% of infertility cases, the man's health problems lead to infertility, in 50% of the cases, it's because of the woman's health problem. Approximately 25% of the time, infertility is caused by more than one factor. And 10% of the time, couples who've had trouble getting pregnant are diagnosed with unexplained fertility, but even that can be treated.

In fact, even as infertility is on the rise -- most notably because we are trying to become parents at later and later ages -- reproductive science has risen to the challenge. Sophisticated tests and procedures result in pregnancies that would not have been possible just a few years ago. Thorough testing (called a fertility workup), drug therapy, surgery, and assisted reproductive technologies, such as in vitro fertilization (IVF), may very well help you conceive the child you've been waiting for. About 50% of couples who complete an infertility evaluation will respond to treatment with a successful pregnancy. And of those couples who don't receive treatment, about 5% have a "spontaneous cure rate" (a cure without any treatment whatsoever).

Detailed Description

Many couples are surprised to learn what a small window of opportunity there is for getting pregnant each month. In order for you to get pregnant, the following have to happen:

    • Ovulation: the release of an egg from one of your ovaries at mid-cycle
    • Fertilization: the joining of your egg with the man's sperm
    • Migration: the transfer of the fertilized ovum through the fallopian tube into the uterus
    • Implantation: the attachment of the fertilized egg to the lining of your uterus (endometrium), about a week after fertilization

Conception can only occur when you have sex during or near the time when you ovulated, since sperm can only live inside a woman's body for two or three days, and an egg must be fertilized within 24 hours. But just because an egg is fertilized, does not mean you'll have a positive pregnancy test. About 40% are defective.

After being fertilized by a sperm in the fallopian tube, the egg slowly travels into the uterus and implants itself in the uterine lining (endometrium), where it will grow into a fetus.

Although it sounds simple enough, many different things can go wrong along the way. A man may be infertile because he doesn't have enough sperm, because his sperm doesn't swim well (low motility), or because the tubal passage through which the sperm moves (vas deferens) is blocked. Or, he could have problems with ejaculation (contractions that squirt the semen through the penis). A woman may be infertile because of a hormonal imbalance causing a lack of, or defective, ovulation; structural problems in her reproductive tract; or obstructions that are from scars produced by healing after infections.

There are two types of infertility: primary infertility is the inability to conceive if you have never carried a baby to delivery; secondary infertility is the inability to conceive after having had at least one baby. It is important to remember that infertility, which means that you are having difficulty conceiving, is not the same as sterility, which means that -- even with treatment -- you have no chance of conceiving.

How Common Is Infertility?

Infertility affects about 15% of U.S. couples. The longer you wait to have children, the more likely you are to be infertile. An estimated 8% of married women between the ages of 20 to 29 are infertile; 15% of women 30 to 34; 22% of women 35 to 39; and 29% of women 40 to 44. A man's fertility also declines as he ages, but not as dramatically.

Researchers find that women's reproductive health problems are responsible for about 50% of infertility cases, while men's problems are responsible for 40%.

What You Can Expect

If your doctor suspects infertility, he will evaluate your medical history and do a series of tests called a fertility workup, or recommend you to a doctor who will perform the evaluation and tests (probably to an infertility specialist, called a reproductive endocrinologist). You and your partner will be evaluated for contributing causes of infertility and treated together.

Since infertility has many causes, your success in conceiving depends on what's causing your difficulty.

Evaluating, testing, and treating infertility can be very expensive and most insurance companies don't cover many of the procedures involved. Be sure to report symptoms of irregular bleeding, cramping, pain, etc., that often accompany infertility, rather than focusing on infertility alone. Your physician will be an advocate for you. Speak with your insurance company before undergoing treatment so you can appropriately plan for medical expenses.

Established Causes

For men

    • Low sperm count (defined as fewer than 20 million per milliliter after a 72-hour abstinence from ejaculation)
    • Sperm that are unable to swim (also called immotile sperm)
    • Blocked passageways in the reproductive tract due to a vasectomy, previous infections (including sexually transmitted diseases), or varicose veins (varicoceles) in the scrotum
    • Insufficient ejaculation, usually because the man is impotent, because of backward (or retrograde) ejaculation, or some sort of obstruction
    • Sperm allergy (although this is most common after a vasectomy, 10% of infertile men and women have immune reactions to sperm)

For women

    • Ovulation problems (conditions that prevent the regular release of an egg from the ovary during each menstrual cycle)
    • Blocked, diseased, or scarred fallopian tubes, which may be the result of pelvic inflammatory disease (PID), endometriosis (the growth of uterine tissue outside of the uterus), surgery, a condition present at birth (congenital defect), previous infections, or appendicitis
    • Uterine abnormalities such as fibroid tumors, polyps, or infections inside the uterine cavity
    • Cervical problems, such as poor mucus production, tumors, fibroids, or obstructions

Theoretical Causes

Although stress has, in some cases, been shown to contribute to infertility, it cannot cause infertility.

Risk Factors

The risk of infertility may increase with the following factors:

For men

    • History of sexually transmitted diseases (STDs), such as gonorrhea or chlamydia
    • History of fevers and infections, such as mumps, after puberty
    • Chronic conditions, such as cancer, asthma, or depression
    • Undescended testicles
    • Surgery of the reproductive tract
    • Damage to the passage through which sperm travels (vas deferens)
    • Varicose veins (varicoceles) in the scrotum
    • Some drugs, including steroids and antidepressants
    • Exposing the testes to high temperatures (saunas, hot tubs, sitting on vinyl seats for long periods of time, etc.)
    • Use of alcohol, tobacco, or marijuana
    • Frequent, long-distance bike rides
    • Regular hot tub or sauna use
    • History of testicular cancer, tumor, or cysts
    • Your mother's use of diethylstilbestrol (DES) while she was pregnant with you (this drug was thought to prevent miscarriage)

For women

    • Endometriosis (the growth of uterine tissue outside of the uterus)
    • Infections such as pelvic inflammatory disease (PID), a severe infection of the female reproductive organs, often associated with sexually transmitted diseases such as chlamydia or gonorrhea
    • Fibroid tumors
    • Pelvic or abdominal surgery
    • Irregular menstrual periods
    • Chronic conditions, such as cancer, depression, or thyroid disease
    • Your mother's use of diethylstilbestrol (DES) while she was pregnant with you (this drug was thought to prevent miscarriage)
    • Overweight (more than 30% above ideal body weight)
    • Some drugs, including steroids and antidepressants
    • Extreme exercise, such as marathon or endurance-race training, which can suppress ovulation
    • Use of alcohol, tobacco, or marijuana
    • Too little or poor-quality cervical mucus, sometimes after treatment for an abnormal Pap smear
    • Previous ectopic pregnancy
    • Ruptured appendix

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

If you've had frequent (two to three times a week), unprotected sex for 12 months without getting pregnant, you or your partner would be diagnosed as infertile.

How Infertility Is Diagnosed

Most doctors delay fertility testing (also called a fertility workup) until you've tried to conceive for 12 months. Your doctor may, however, agree to begin testing earlier if you are more than 35 years old or under other special circumstances.

The doctor will begin by reviewing your medical history and that of your partner. He or she will also ask about when and how often you have sexual intercourse to determine whether the timing or frequency are causing the infertility. Inquiring about pain during sex is usual, too. Most likely, he will then perform at least one of the following tests to determine the cause (or causes) of your infertility.

Patience really is a virtue when it comes to diagnosing and treating infertility: A complete fertility workup and diagnosis can take as many as four or five menstrual cycles because many of these tests have to be performed at certain stages in your cycle and can't be combined.

Tests for men

    • Semen test. The doctor will probably ask you not to ejaculate for two or three days before this test. Your semen sample, collected in a special cup or condom, will be analyzed in the lab within two hours after collection, to determine its quality, quantity, and ability to swim (motility).
    • Urological exam. Your doctor may refer you to a specialist physician in urinary tract conditions (urologist), who will perform a physical exam, including a rectal exam for the prostate gland, and may conduct a sperm test as well as a blood test to check the level of the hormones that affect fertility. In some cases, a biopsy of the testes is also required.

Tests for women

    • Pelvic exam. This internal exam may help your doctor detect scarring, cysts, signs of sexually transmitted diseases, etc., that may interfere with conception. Cultures of cervical secretions may be done, and a Pap smear may be advised as well.
    • Urine test. Your doctor may perform a urine test in order to predict ovulation. The presence of large amounts of luteinizing hormone (LH), which is released by the pituitary gland to cause ovulation, indicates that ovulation is about to occur. Your doctor may ask you to perform this test at home for several months to determine your ovulation pattern. There are several do-it-yourself tests on the market, including First Response's 3-Minute Ovulation Kit and Clearplan's Easy 1-Step Ovulation Kit, which work the same way. Your doctor may perform urine tests, or ask you to perform them in conjunction with tracking your basal body temperature.
    • Basal body temperature tracking. You can also pinpoint ovulation by tracking your basal body temperature, your temperature first thing in the morning -- before you even get out of bed. You'll need to buy a special basal thermometer, which shows minute changes in temperature, to do this. This test will help your doctor determine whether you ovulate regularly and when.
    • Progesterone test. A blood test taken five to 10 days before your period is due tests for progesterone, a hormone produced after ovulation by the ovaries that prepares the lining of the uterus to nourish a fertilized egg.
    • Endometrial biopsy. Your doctor can also assess the quality of your uterine lining and determine whether you're ovulating by removing a small piece of the lining. This quick procedure with a thin plastic tube can be done right in your doctor's office.
    • Postcoital test (PCT). This test is performed within a couple of hours after you and your partner have sex near the time of expected ovulation. Your doctor will examine your cervical mucus to evaluate its interaction with sperm. He'll look for a lack of mobility that could be causing infertility and also estimate the number and quality of sperm.
    • Hysterosalpinography (HSG). This special X-ray allows your doctor to visualize physical abnormalities or obstructions in the uterus and fallopian tubes or around them. The doctor injects a dye into the cervix that travels through the uterus and the fallopian tubes.
    • Ultrasound. This painless procedure allows your doctor to take pictures of your ovaries and uterus using high-frequency sound waves. The doctor presses a small probe against your abdomen, or in the vagina, and moves the probe to produce sound waves in areas he or she wants to view. The images are displayed on a video screen during the exam and recorded on film. This test also allows your doctor to determine the thickness of the lining of the uterus and the development of eggs in the ovary. An ultrasound procedure may also be used to diagnose varicose veins (varicoceles) in the man's scrotum.
    • Laparoscopy. During this procedure, the doctor inserts a fiber-optic viewing tube (a laparoscope) into your abdomen through a small incision just below your navel so he or she can see into your abdomen to look for signs of scarring, endometriosis, or other blockage. A colored solution is likely to be injected through the uterus and fallopian tubes during the procedure, allowing the direct observation of unobstructed flow (or open tubes). This outpatient procedure is mostly performed under general anesthesia, which means you'll be asleep the whole time, but local anesthesia and sedation is another option.
    • Hysteroscopy. During this procedure the doctor inserts a fiber-optic viewing tube instrument (hysteroscope) through the cervix to view the inside of the uterus. During this procedure, he or she can also view the openings of the fallopian tubes into the uterus, take a biopsy, and correct minor problems. Hysteroscopy is performed under local or general anesthesia.

 

Goals of Treatment

The goal of infertility treatment is to eliminate the cause of infertility and promote successful conception. According to Resolve, an organization that provides support for people undergoing fertility treatment, about 50% of couples who complete an infertility evaluation will respond to treatment with a successful pregnancy. Of those couples who don't receive treatment, about 5% have a "spontaneous cure rate" (a cure without any treatment whatsoever) Of course, it depends on the cause of your infertility: some problems respond with higher rates, others lower.

Once a diagnosis is complete, one or both partners may be advised to make lifestyle changes or undergo drug therapy, surgery, assisted reproductive technology (such as in vitro fertilization), or a combination of treatments.

Treatment Options

 

Drug Therapy

Drugs most commonly prescribed

In many cases, the main focus of fertility treatment is to stimulate ovulation, but drug therapy may be used for other purposes, too. The following drugs are commonly prescribed when treating infertility:

    • Clomid and Serophene (Clomiphene citrate): This drug stimulates the release of eggs by the ovaries (ovulation) in women and the production of sperm in men. Chorionic gonadotropin may be used following these drugs.
    • Gonadotropin-releasing hormones (GnRH): These hormones, which you take as injections, reduce secretion of ovarian hormones, and prepare the ovaries for a strong simulation with other drugs that trigger the release of several eggs per cycle by improving your body's response to ovulation stimulators. Some of the most commonly prescribed brands of GnRH are Lupron or Synarel, given by injection or intranasally, respectively.
    • Humegon, Pergonal, and Repronex (Menotropins): These newer drugs provide the strong stimulus to mature several eggs simultaneously for harvesting. Sometimes chorionic gonadotropin (HCG) is used in tandem with menotropins to initiate ovulation.

Surgery

Surgery can improve fertility in many instances, such as those of congenital defects, obstructions due to adhesions (fibrous bands), fibroids, etc.

Surgical treatment for men

    • Varicocelectomy: This procedure removes varicose veins (varicoceles) in the scrotum, which inhibit sperm production
    • Vasovasostomy: removes obstruction from a prior vasectomy
    • Testicular biopsy: for obtaining sperm

Surgical treatment for women

Some of the surgical techniques used to diagnose infertility can also treat it.

    • Laparoscopy. This procedure is usually used to treat endometriosis-- the growth of uterine tissue outside of the uterus-- which causes adhesions and other structural distortions. After making a tiny abdominal incision, the doctor uses a small instrument called a laparoscope to view the uterus, fallopian tubes, ovaries, and upper abdominal organs. He or she can also remove misplaced endometrial tissue.
    • Laparotomy. If there is too much distortion of the uterus or tubes to be removed in a laparoscopic procedure, your doctor may suggest a laparotomy or referral to an advanced laparoscopic surgeon. A laparotomy is a more extensive procedure with a full incision and longer recovery period. Repair of damaged fallopian tubes, removal of ovarian cysts, or correction of congenital defects can all be done at the same time.
    • Hysteroscopy. During this procedure, the doctor passes a fiber-optic viewing instrument called a hysteroscope through the vagina, cervix, and into the uterus. Looking through the device, he can remove uterine polyps and small fibroid tumors.

Assisted reproductive technology (ART)

These expensive techniques have varying success rates and carry the risk of multiple pregnancy, but have allowed many couples to become parents. All of these techniques involve stimulating the ovary to produce an excess number of eggs, and removing (harvesting) the eggs from the woman.

    • In vitro fertilization (IVF). In vitro fertilization bypasses most of the things that can go wrong in the process of getting a healthy egg out of the ovary, into and through the fallopian tube, and fertilized, by accomplishing those things outside the body. After the ovaries are stimulated with hormonal drugs, your doctor will collect the cultivated eggs from your ovaries with a laparoscope or a needle directed by ultrasound. Eggs and sperm (either from your partner or a donor) are then combined in a lab dish. Between two and five days later, your doctor will transplant one or more of the fertilized eggs, or embryos, into your uterus, with the hope that it will implant itself in the uterine lining, thus establishing pregnancy.
    • Gamete intrafallopian transfer (GIFT). Also known as in vivo fertilization, GIFT generally follows the same procedure as IVF. A woman must have at least one healthy fallopian tube to use this technology. Rather than combining the egg and sperm in a lab dish as is done with IVF, during GIFT the egg and sperm are placed in the fallopian tube so fertilization can take place there.
    • Zygote intrafallopian transfer (ZIFT). This procedure is another variation of IVF and GIFT. ZIFT involves transplanting an already fertilized egg (zygote) into a fallopian tube.
    • Intracytoplasmic sperm injection (ICSI). ICSI involves injecting a single sperm into a single egg, then transplanting the embryo in the uterus. This procedure permits men with only a few sperm to be fertile.

Other treatment

    • Intra-uterine insemination This technique may work if the female's cervical mucus seems to reject or immobilize her partner's sperm, a condition known as hostile cervical mucus. In this outpatient procedure, washed sperm from a male partner is implanted in the woman's uterine cavity as close as possible to the time of ovulation.
    • Artificial insemination. This is most commonly used in cases of infertility where the male partner produces no sperm and when he is unresponsive to medical or surgical remedies. Even if the male partner has low sperm count, unhealthy sperm, or sperm with poor swimming ability (motility), artificial insemination using sperm from a selected donor may be a good choice. When the woman has no fertility problems, success rates for artificial insemination, which simply means insemination by means other than sexual intercourse, are quite high.
    • Egg or embryo donation. This is a choice for the woman whose ovaries don't work properly or whose eggs aren't healthy or are absent but whose uterus is able to sustain a pregnancy. Donor eggs can be fertilized with the infertile woman's partner's sperm or that of a sperm donor. Your doctor will then transplant a couple of the fertilized eggs, or blastocysts (mature embryos), into your uterus, with the hope that one or at the most two will implant themselves in the uterine lining, establishing pregnancy.

Appropriate Healthcare Setting

Inpatient care may be necessary for surgery and some of the diagnostic tests, but the vast majority of infertility treatments can be performed on an outpatient basis.

Healthcare Professionals Who May Be Involved in Treatment

The following healthcare professionals may be involved in your fertility treatment:

    • Obstetrician/gynecologists (OB/GYNs)
    • Urologists
    • Reproductive endocrinologists

Most couples turn to a fertility specialist, called a reproductive endocrinologist, for treatment. To find one in your area, contact Resolve (719-623-0744 or www.resolve.org), an organization that provides support for people undergoing fertility treatment, or the American Society for Reproductive Medicine (205-978-5000 or www.asrm.org). You can also ask your OB/GYN for a referral.

Activity & Diet Recommendations

Both men and women should avoid alcohol, tobacco, and other drug use when they're trying to get pregnant since these substances hinder estrogen and sperm production. Of course, women should also avoid these substances once they conceive.

While no specific diet can increase fertility, your good health depends on good nutrition. You may also want to ask your doctor about taking specially formulated prenatal vitamins, including folic acid, while you are trying to conceive.

Men with a low sperm counts should avoid activities and clothing that will raise scrotal temperatures (which reduces sperm production). Some culprits are tight-fitting underwear and clothing (particularly those made of synthetic fabrics), hot baths, hot tubs, and saunas. Long-distance cycling may also cause pressure on the scrotum and testes and should be avoided while you're trying to conceive.

Women experiencing fertility difficulties should avoid strenuous dieting and extreme exercise (such as marathon or endurance-race training), which may lead to excessive loss of body fat, menstrual irregularity, and cessation of ovulation.

Possible Complications

Some drugs and assisted reproductive technologies used to treat infertility may result in multiple births (twins, triplets, etc.). While this aspect of fertility treatment is very controversial, some couples view it as a blessing, not a complication. This risk has recently been greatly reduced by allowing the fertilized eggs to develop into blastocysts before selection for transfer into the uterus.

Quality of Life

For many men and women, learning that they have fertility problems is shattering. An infertility diagnosis can distort our basic definitions of womanhood and manhood, however temporarily. Shame, anger, guilt, denial, and blame are just some of the emotions you and your partner may be dealing with.

As if the intrusion and shock of diagnosis weren't enough, few medical interventions are as expensive or invade our privacy quite so much as fertility treatments. After all, who wants to discuss his or her sex life in detail with a doctor or be compelled to masturbate on demand and have intercourse on a prescribed schedule-- and pay for it?

The good news is, you're not alone. According to Resolve, an organization that provides support for couples undergoing fertility treatment, more than 5 million people of childbearing age in the United States experience infertility. Talking to others who are going through the same treatment as you may help. To locate a local support group, ask your doctor or contact Resolve (719-623-0744 or www.resolve.org). See Resources for more information.

However thrilling the eventual outcome may be, fertility is a rough and rocky road for many couples, one they may travel on for years. Fertility treatment involves emotional, ethical, moral, even religious dilemmas. Only you and your partner can decide how, or if, you want to make the journey.

And, only the two of you know how much medical assistance you want, can tolerate, or afford in your goal to achieve pregnancy. An open and ongoing discussion among you, your partner, and your doctor(s) can help you at each juncture of your treatment. Your family may also benefit from counseling to understand your experience and reactions.

Should you decide against aggressive fertility treatments, or should your efforts prove unsuccessful, talk to your doctor about bringing a child into your family through surrogacy or adoption.

Supplements

    • Multivitamins: Women should make sure theirs contain folic acid (800 mcg/day), which helps prevent spinal birth defects. Men should make sure theirs contain zinc (30 mg to 50 mg), which is crucial to the male reproductive system.
    • Antioxidants: Many studies show that antioxidant nutrients improve both male and female fertility. [1] Try a daily dose of 2,000 mg of vitamin C, 25,000 IU of mixed carotenoids (the vitamin A family of nutrients, including beta-carotene), 400 IU to 800 IU of vitamin E, and 200 mcg of selenium.

Herbs

    • Ginseng may help to increase sperm counts. Italian researchers gave ginseng (4 g/day) to 46 men with low sperm counts and 20 men with normal counts. After three months, both groups showed significantly higher sperm counts, though the infertile men's counts were still low. [2]
    • Herbs to avoid: Just as many drugs can depress fertility, recent research suggests that some herbs might inhibit conception. Studies have been conducted in the laboratory by bathing sperm and egg cells in herb extracts. Herbs may not have the same effect in humans, but until scientists learn more, it would be prudent for infertile couples to avoid echinacea, ginkgo, and St. John's Wort.

1 Andrew Weil's Self-Healing newsletter, 12-97.

 2 Salvati, G., et al. "Effects of Panax Ginseng Saponins on Male Infertility," Panmineva Med. (1996) 38:249.

Preventing Infertility

The following self-care steps may help increase fertility in both men and women:

    • Practice safer sex. This helps avoid sexually transmitted diseases and the infertility problems that may result from them.
    • If you smoke, quit. If you don't smoke, don't start. Smoking interferes with fertility in both sexes.
    • Follow a diet rich in whole foods such vegetables, fruits, whole grains, and legumes. Protein is important, but make sure it comes from the least fatty sources of meat or fish. Good choices are chicken, turkey, and lean cuts of beef.

Additionally, these self-care measures are available to each sex to help promote conception:

Women

    • Avoid strenuous dieting and workouts. These may lead to excessive loss of body fat, menstrual irregularity, and cessation of ovulation.
    • Avoid recreational drug and alcohol abuse -- they diminish the production of estrogen.
    • Avoid caffeine.

Men

    • Stay away from lead, cadmium, arsenic, and mercury.
    • Men with low sperm counts should avoid activities and clothing that will raise scrotal temperatures (thus reducing sperm production), including tight-fitting underwear and clothing (particularly those made of synthetic fabrics), hot baths and lengthy hot showers, hot tubs, saunas, rowing machines, cross-country skiing machines, and treadmills. Bicycling may also cause pressure on the scrotum and testes and should be avoided.
    • Avoid recreational drug and alcohol abuse -- they reduce sperm count.
    •  


Websites & Organizations

American College of Obstetricians & Gynecologists
409 12th Street, SW
Washington, DC 20024-2188
Phone: 800-762-ACOG (2264)

American Fertility Society
2140 11th Avenue, South, Suite 200
Birmingham, AL 35205
Phone: 205-933-8494

Child of My Dreams Resource Center

Fertility Research Foundation
1430 Second Avenue, Suite 103
New York, NY l0021
Phone: 212-744-5500

Health Resource Center at the McKinley Health Center
Room 222, East Building 1109
S. Lincoln Avenue
Urbana, IL 61801

International Council on Infertility
Information Dissemination
P.O. Box 6836
Arlington, VA 22206
Voicemail: 520-544-9548
Fax: 703-379-1593
Email: INCIIDinfo@inciid.org

National Women's Health Resource Center, Inc.
120 Albany Street, Suite 820
New Brunswick, NJ 08901
Phone: 877-98-NWHRC (877-986-9472)
Email: NatlWHRC@aol.com

Organization of Parents Through Surrogacy
Surrogacy referrals, reading material, and support
P.O. Box 213
Wheeling, IL 60090
Phone: 847-394-4116

RESOLVE, Inc.
1310 Broadway
Somerville, MA 02144-1779
Phone: 627-623-1156
Email: info@resolve.org

Society for Assisted Reproductive Technology (SART)
1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000

Sources for This Article

Books

Balch, James F. and Balch, Phyllis A. Prescription for Nutritional Healing. Garden City Park, NY: Avery Publishing, 1997.

Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W. B. Saunders, 1996.

Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.


Articles

Bahamondes, L, Bueno, JG, Hardy, E, Vera, S, Pimentel, E, Ramos, M. "Identification of Main Risk Factors for Tubal Infertility." Fertil Steril. 61(3):478-82. Mar 1994.

Campana, A, de Agostini, A, Bischof, P, Tawfik, E, Mastrorilli, A. "Evaluation of Infertility." Hum Reprod Update. 1(6):586-606. Nov 1995.

Gant, NF. "Infertility and Endometriosis: Comparison of Pregnancy Outcomes with Laparotomy versus Laparoscopic Techniques." Am J Obstet Gynecol. 166(4):1072-81. Apr 1992.

Irvine, DS. "Epidemiology and Aetiology of Male Infertility." Hum Reprod. 13 Suppl 1():33-44. Apr 1998.

Moskowitz, MO, Mellinger, BC. "Sexually Transmitted Diseases and their Relation to Male Infertility." Urol Clin North Am. 19(1):35-45. Feb 1992.

Ouahes, N, Qureshi, TA, Ahmed, AR. "Infertility in Women with Pemphigus Vulgaris and Other Autoimmune Diseases." J Am Acad Dermatol. 36(3 Pt 1):383-7. Mar 1997.

Ru'iz-Velasco, V, Gonz'alez, Alfani G, Pliego, S'anchez, L, Alamillo, Vera, M. "Endometrial Pathology and Infertility." Fertil Steril. 67(4):687-92. Apr 1997.

Salvati, G. et al. "Effects of Panax Ginseng Saponins on Male Infertility," Panmineva Med. (1996) 38:249.

Saulsbery, SB, Pohlhaus, MF. "Assessment and Initial Management of Infertility." J Am Acad Nurse Pract. 4(2):53-7. Apr-Jun 1992.

Schlegel, PN, Girardi, SK. "Clinical Review 87: In vitro Fertilization for Male Factor Infertility." J Clin Endocrinol Metab. 82(3):709-16. Mar 1997.

Weil, Andrew Self-Healing newsletter 12-97.

Yoshida, A, Miura, K, Nagao, K, Hara, H, Ishii, N, Shirai, M. "Sexual Function and Clinical Features of Patients with Klinefelter's Syndrome with the Chief Complaint of Male Infertility." Int J Androl. 20(2):80-5. Apr 1997.


 

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