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What is infertility?

Infertility is defined as not having become pregnant after 1 year of having regular sexual intercourse without the use of birth control. Infertility can be caused by a number of factors. Both male and female factors can contribute to infertility.

Bleeding in any of the following situations is abnormal:

  • Bleeding between periods
  • Bleeding after sex
  • Spotting anytime in the menstrual cycle
  • Bleeding heavier or for more days than normal
  • Bleeding after menopause

Menstrual cycles that are longer than 35 days or shorter than 21 days are abnormal. The lack of periods for 3 – 6 months (amenorrhea) also is abnormal.

The menstrual cycle begins with the first day of bleeding of one period and ends with the first day of the next. In most women, this cycle lasts about 28 days. Cycles that are shorter or longer by up to 7 days are normal.
Abnormal uterine bleeding can occur at any age. However, at certain times in a woman’s life it is common for periods to be somewhat irregular. They may not occur on schedule in the first few years after a girl has her first period (around age 9–16 years). Cycle length may change as a woman nears menopause (around age 50 years). It also is normal to skip periods or for bleeding to get lighter or heavier at this time.

Abnormal uterine bleeding can have many causes. They include the following:

  • Pregnancy
  • Miscarriage
  • Ectopic pregnancy
  • Adenomyosis
  • Use of some birth control methods, such as an intrauterine device (IUD) or birth control pills
  • Infection of the uterus or cervix
  • Fibroids
  • Problems with blood clotting
  • Polyps
  • Endometrial hyperplasia
  • Certain types of cancer, such as cancer of the uterus, cervix, or vagina
  • Polycystic ovary syndrome
Your health care provider will ask about your personal and family health history as well as your menstrual cycle. It may be helpful to keep track of your menstrual cycle before your visit. Note the dates, length, and type (light, medium, heavy, or spotting) of your bleeding on a calendar. You will have a physical exam. You also may have blood tests. These tests check your blood count and hormone levels and rule out some diseases of the blood. You also may have a test to see if you are pregnant.

Based on your symptoms, other tests may be needed. Some of these tests can be done in your health care provider’s office. Others may be done at a hospital or surgical center:

  • Sonohysterography: Fluid is placed in the uterus through a thin tube, while ultrasound images are made of the uterus.
  • Ultrasound: Sound waves are used to make a picture of the pelvic organs.
  • Magnetic resonance imaging: In this imaging test, powerful magnets are used to create images of internal organs.
  • Hysteroscopy: A thin device is inserted through the vagina and the opening of the cervix. It lets the health care provider view the inside of the uterus.
  • Endometrial biopsy: Using a small or thin catheter (tube), tissue is taken from the lining of the uterus (endometrium). It is looked at under a microscope.
The type of treatment depends on many factors, including the cause of the bleeding, your age, and whether you want to have children. Most women can be treated with medications. Others may need surgery.
Hormonal medications often are used to control abnormal uterine bleeding. The type of hormone you take will depend on whether you want to get pregnant as well as your age. Birth control pills can help make your periods more regular. Hormones also can be given as an injection, as a vaginal cream, or through an IUD that release hormones. An IUD is a birth control device that is inserted in the uterus. The hormones in the IUD are released slowly and may control abnormal bleeding. Other medications given for abnormal uterine bleeding include nonsteroidal anti-inflammatory drugs (such as ibuprofen), tranexamic acid, and antibiotics. Nonsteroidal anti-inflammatory drugs can control bleeding and reduce menstrual cramps. Tranexamic acid is a drug used to treat heavy menstrual bleeding. Infections are treated with antibiotics.
Some women may need to have surgery to remove growths (such as polyps or fibroids) that cause bleeding. Some fibroids can be removed with hysteroscopy. Sometimes other techniques are used. Endometrial ablation may be used to control bleeding. It is intended to stop or reduce bleeding permanently. An endometrial biopsy is needed before ablation is considered. Hysterectomy may be done when other forms of treatment have failed or they are not an option. Hysterectomy is major surgery. Afterward, a woman no longer has periods. She also cannot get pregnant.
A woman’s cervix (the opening of the uterus at the top of the vagina) is covered by a thin layer of tissue made up of cells. Healthy cells grow, divide, and are replaced as needed. Cancer of the cervix occurs when these cells change. Cancer cells divide more rapidly. They may grow into deeper cell layers or spread to other organs. The cancer cells eventually form a mass of tissue called a tumor.
It often takes several years for cervical cancer to develop. During this time, the cells on or around the cervix become abnormal. The cell changes that occur before cancer is present are called dysplasia or cervical intraepithelial neoplasia (CIN).
The main cause of cervical cancer is human papillomavirus (HPV) infection. There are many types of HPV. Some types of HPV, called “high-risk types,” can cause cancer of the anus, cervix, vulva, vagina, and penis. They also can cause cancer of the head and neck. Other types have been linked to genital warts.

The most important risk factor for cervical cancer is infection with the types of HPV linked to cancer. The following factors increase your risk of becoming infected with HPV:

  • Multiple sexual partners
  • Having a male sexual partner who has had multiple sexual partners
  • Early age at which you first had sex (younger than 18 years)
  • A personal history of dysplasia of the cervix, vagina, or vulva
  • A family history of cervical cancer
  • Smoking
  • Certain sexually transmitted diseases, such as chlamydia
  • Problems with the immune system
  • Having a mother who took a drug called diethylstilbestrol (DES) during pregnancy
Yes. The Pap test checks for abnormal cell changes of the cervix. This allows early treatment of the abnormal cells so that they do not become cancer. An HPV test also is available. It is used along with the Pap test to screen for cervical cancer in some women and as a follow-up test when a women has an abnormal Pap test result.
The first signs may be abnormal bleeding, spotting, or watery discharge from the vagina. Menstrual bleeding may be heavier than usual, and bleeding may occur after sex. Signs of advanced cancer can include pelvic pain, problems urinating, and swollen legs. If the cancer has spread to nearby organs or the lymph nodes, the tumors can affect how those organs work. For instance, a tumor might press on your bladder or block blood flow in a vein.

If your health care provider suspects that you have cancer of the cervix, a biopsy may be done. For certain abnormal Pap test results that require treatment, the abnormal cervical tissue may be removed and sent to a lab to be studied. If cervical cancer is diagnosed, your health care provider will assess the size of the cancer and the extent (if any) to which the disease has spread. This process may include the following tests:

  • A pelvic exam (which may include a rectal exam): An examination in which your health care provider checks the uterus, ovaries, and other organs near the cervix
  • Cystoscopy: A test in which the inside of the urethra and bladder are studied with a lighted device
  • Colonoscopy: A test in which the entire colon is examined with a slender, lighted instrument called a colonoscope
“Staging” is the process of finding out how much the cancer has spread. Most types of cancer have stages from I to IV. The lower the number, the less the cancer has spread. Some types of cancer, including cervical cancer, have a stage 0. Stage 0 also is called noninvasive cancer or carcinoma in situ. In stage 0, cancer cells are present on the top layer of the cervix only. They have not gone into deeper layers of the cervical tissue or other organs. The remaining stages are called invasive cancer. In these stages, the cancer has invaded into deeper layers of the cervix.
Invasive cancer of the cervix is treated with surgery (hysterectomy), radiation therapy, and chemotherapy (the use of cancer-killing drugs). The type of treatment chosen depends on the cancer stage. You may receive more than one type of treatment.
Your health care provider may suggest more frequent cervical screening for the first few years after treatment to make sure that all the cancer cells were removed. Even if your cervix has been removed to treat your cancer, you still need cervical cancer screening. Cells are taken from the upper vagina instead of the cervix.
D&C is a surgical procedure in which the cervix is opened (dilated) and a thin instrument is inserted into the uterus. This instrument is used to remove tissue from the inside of the uterus (curettage).
D&C is used to diagnose and treat many conditions that affect the uterus, such as abnormal bleeding. A D&C also may be done after a miscarriage. A sample of tissue from inside the uterus can be viewed under a microscope to tell whether any cells are abnormal. A D&C may be done with other procedures, such as hysteroscopy, in which a slender device is used to view the inside of the uterus.
A D&C can be done in a health care provider’s office, a surgery center, or a hospital.
Your health care provider may want to start dilating your cervix before surgery using laminaria. This is a slender rod of natural or synthetic material that is inserted into the cervix. It is left in place for several hours. The rod absorbs fluid from the cervix and expands. This causes the cervix to open. Medication also may be used to soften the cervix, making it easier to dilate. You also may receive some type of anesthesia before or during your D&C.
During the procedure, you will lie on your back and your legs will be placed in stirrups. A speculum will be inserted into your vagina. The cervix will be held in place with a special instrument. The cervix will then be slowly dilated. This is done by inserting a series of slender rods that become progressively larger through the cervical opening. Usually only a small amount of dilation is needed (less than one half inch in diameter). Tissue lining the uterus will be removed, either with an instrument called a curette or with suction. In most cases, the tissue will be sent to a laboratory for examination.
Complications include bleeding, infection, or perforation of the uterus (when the tip of an instrument passes through the wall of the uterus). Problems related to the anesthesia used also can occur. These complications are rare. In rare cases, after a D&C has been performed after a miscarriage, bands of scar tissue, or adhesions, may form inside the uterus. This is called Asherman syndrome. These adhesions may cause infertility and changes in menstrual flow. Asherman syndrome often can be treated successfully with surgery.
Preterm labor is defined as regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. Changes in the cervix include effacement (the cervix thins out) and dilation (the cervix opens so that the fetus can enter the birth canal).
When birth occurs between 20 weeks of pregnancy and 37 weeks of pregnancy, it is called preterm birth.
After the procedure, you probably will be able to go home within a few hours. You will need someone to take you home. You should be able to resume most of your regular activities in 1 or 2 days. Pain after a D&C usually is mild. You may have spotting or light bleeding.
Preterm birth is a concern because babies who are born too early may not be fully developed. They may be born with serious health problems. Some health problems, like cerebral palsy, can last a lifetime. Other problems, such as learning disabilities, may appear later in childhood or even in adulthood.

You should contact your health care provider if you have any of the following:

  • Heavy bleeding from the vagina
  • Fever
  • Pain in the abdomen
  • Foul-smelling discharge from the vagina

After a D&C, a new lining will build up in the uterus. Your next menstrual period may not occur at the regular time. It may be early or late. Until your cervix returns to its normal size, bacteria from the vagina can enter the uterus and cause infection. It is important not to put anything into your vagina after the procedure. Ask your health care provider when you can have sex or use tampons again.

The risk of health problems is greatest for babies born before 34 weeks of pregnancy. But babies born between 34 weeks and 37 weeks also are at risk.

Factors that increase the risk of preterm birth include the following:

  • Having a previous preterm birth
  • Having a short cervix
  • Short interval between pregnancies
  • History of certain types of surgery on the uterus or cervix
  • Certain pregnancy complications, such as multiple pregnancy and vaginal bleeding
  • Lifestyle factors such as low pregnancy weight, smoking during pregnancy, and substance abuse during pregnancy
If you have had a prior preterm birth and you are planning another pregnancy, a preconception care checkup can help you get in the best possible health before you become pregnant. When you become pregnant, be sure to start prenatal care early. You may be referred to a health care provider who has expertise in managing high-risk pregnancies. In addition, you may be given certain medications or other treatment to help prevent preterm birth if you have risk factors. Treatment is given based on your individual situation and your risk factors for preterm birth.

Call your health care provider right away if you notice any of these signs or symptoms:

  • Change in type of vaginal discharge (watery, mucus, or bloody)
  • Increase in amount of discharge
  • Pelvic or lower abdominal pressure
  • Constant low, dull backache
  • Mild abdominal cramps, with or without diarrhea
  • Regular or frequent contractions or uterine tightening, often painless
  • Ruptured membrane (your water breaks with a gush or trickle of fluid)
Preterm labor can be diagnosed only when changes in the cervix are found. Your health care provider may perform a pelvic exam to see if your cervix has started to change. You may need to be examined several times over a period of a few hours. Your contractions also may be monitored. Your health care provider may do certain tests to determine whether you need to be hospitalized or if you need immediate specialized care. A trans-vaginal ultrasound exam may be done to measure the length of your cervix. The level of a protein called fetal fibronectin in the vaginal discharge may be measured. The presence of this protein is linked to preterm birth.
It is difficult for health care providers to predict which women with preterm labor will go on to have preterm birth. Only about 10% of women with preterm labor will give birth within the next 7 days. For about 30% of women, preterm labor stops on its own.
If your preterm labor continues, how it is managed is based on what is thought to best for your health and your baby’s health. When there is a chance that the baby would benefit from a delay in delivery, certain medications may be given. These medications include corticosteroids, magnesium sulfate, and tocolytics.
Corticosteroids are drugs that cross the placenta and help speed up development of the baby’s lungs, brain, and digestive organs. Corticosteroids are most likely to help your baby when they are given between 24 weeks of pregnancy and 34 weeks of pregnancy.
Magnesium sulfate is a medication that may be given if you are less than 32 weeks pregnant, are in preterm labor, and are at risk of delivery within the next 24 hours. This medication may help reduce the risk of cerebral palsy that is associated with early preterm birth.
Tocolytics are drugs used to delay delivery for a short time (up to 48 hours). They may allow time for corticosteroids or magnesium sulfate to be given or for you to be transferred to a hospital that offers specialized care for preterm infants. In addition to its role in protecting against cerebral palsy, magnesium sulfate also can be used as a tocolytic drug.
If your labor does not stop and it looks like you will give birth to your baby early, you and the baby usually will be cared for by a team of health care providers. The team may include a neonatologist, a doctor who specialized in treating problems in newborns. The care your baby needs depends on how early he or she is born. High-level neonatal intensive care units (NICUs) provide this specialized care for preterm infants.
During an infertility evaluation, exams and tests are done to try to find the cause of infertility. If a cause is found, treatment may be possible. Infertility often can be successfully treated even if no cause is found.
Infertility can be caused by a number of factors. Both male and female factors can contribute to infertility. Female factors may involve problems with ovulation, the reproductive organs, or hormones. Male factors often involve problems with the amount or health of sperm.
Tests for infertility include laboratory tests, imaging tests, and certain procedures.
Laboratory tests include tracking basal body temperature, a urine test, a progesterone test, thyroid function tests, prolactin level test, and tests of ovarian reserve. Imaging tests and procedures include an ultrasound exam, hysterosalpingography, sonohysterography, hysteroscopy and laparoscopy. You may not have all of these tests and procedures. Some are done based on results of previous tests and procedures.
Treatment options depend on the cause of your infertility. Lifestyle changes, medication, surgery or Assisted Reproductive Technology (ART) may be recommended. Several different treatments may be combined to improve results. Infertility often can be successfully treated even if no cause is found.
In women, surgery may be able to repair blocked or damaged fallopian tubes. Surgery is used to treat endometriosis which is commonly associated with infertility.
Abnormal levels of hormones can cause irregular ovulation or lack of ovulation. For example, polycystic ovary syndrome is a condition in which the levels of certain hormones are abnormal and menstrual periods are irregular or absent. It is a common cause of infertility. This condition often is treated with lifestyle changes or medication. Progesterone may be used to treat some ovulation problems. Other hormonal conditions that affect fertility in women, such as thyroid disease, should be ruled out.
Ovulation induction is the use of drugs to induce a women ovary to release an egg. This treatment is used when ovulation is irregular or does not occur at all and other causes have been ruled out.
The drug most commonly used for ovulation induction is clomiphene citrate. About 40 percent of women achieve pregnancy with the use of this drug within six menstrual cycles. Side effects usually are mild and include hot flashes, breast tenderness, nausea and mood swings.
If clomiphene citrate is not successful, drugs called gonadotropins may be tried to induce ovulation. Gonadotropins also are used when many eggs are needed for ART or other infertility treatment. This is called super ovulation.
Twins occur in about 10 percent of women treated with clomiphene citrate. Triple or more are rare. The risk of multiple pregnancies is higher when gonadotropins are used. Up to 30 percent of pregnancies conceived with gonadotropins are multiple. About two thirds of these pregnancies are twins and one third is triplets or more.
In intrauterine insemination, a large amount of healthy sperm is placed in the uterus as close to the time of ovulation as possible. It often is used with ovulation induction or super ovulation. The woman partner or donor may provide the sperm. Sperm that has been retrieved earlier and frozen also can be used.
If ovulation drugs are used with intrauterine insemination, multiple pregnancies can occur. If too many eggs are developing at the time of insemination, the insemination may be canceled.

Art includes all fertility treatments in which both eggs and sperm are handled. ART usually involves In Vitro Fertilization (IVF). In IVF, sperm is combined with the egg in a lab, and the embryo is transferred to the uterus. IVF is done for the following causes of infertility:

  • Damaged or blocked fallopian tubes that cannot be treated with surgery
  • Some male infertility factors
  • Severe endometriosis
  • Premature ovarian failure
  • Unexplained infertility
Sometimes, a single sperm may be injected into each egg. This is called ICSI. ICSI may be recommended if there is a problem with your partner sperm. In ICSI, only a single healthy sperm is needed for each egg. A few days later, one or more embryos are placed in the uterus through the vagina.
There is an increased risk of multiple pregnancy with IVF. IVF also has been linked to an increased risk of birth defects. These defects include cleft palate, heart problems and problems with the digestive tract. Overall, however, the increase in risk of birth defects is small.