Diagnosing Infertility

Medical Contribution By Dr. Arthur Sagoskin
So you thought getting pregnant would come easily? You probably even spent time and money on preventing pregnancy, possibly for years, and now the irony stings.
It’s time for a Fertility Primer.

What You Thought You Already Knew

Most of us enter the “trying-to-conceive” arena armed with whatever we learned as teenagers about getting pregnant. Our educators may have been so focused on lessons about avoiding pregnancy that some of the informational details about how pregnancy occurs were passed over as not important at the time. We all start off knowing the basics about sexual intimacy and its possible results.

For most people, that’s all that’s required.

In fact, the average couple has about a 1 in 4 chance of conception, per menstrual cycle. Statistically, 80 percent of couples (with both partners in good health and having what’s considered an average amount of unprotected intercourse) will get pregnant within a year’s time.

For millions, though, a little more knowledge can go a long, long way toward making a baby.

First Things First

One of the easiest clues that someone will have fertility problems is irregular menstrual periods, according to Dr. Arthur Sagoskin. “That’s a pretty obvious indicator that a woman needs to see a physician, starting with her regular OB/Gyn.”

While absent or infrequent periods may seem like a bonus to some women, it can also be an indication of several health conditions, including infertility.

A woman’s menstrual and ovulation cycles are interwoven. It’s all based on a hormonal relay system that involves not only the ovaries, but also the hypothalamus and the pituitary glands. The hormones involved are follicle stimulating hormone (FSH), an estrogen called estradiol (E), luteinizing hormone (LH), and progesterone (P). The graph demonstrates how the ebb and flow of the hormones, just the right amounts of the right ones at the right time, result in both the maturing and then releasing of egg cells (ovulation) plus the building up and eventual sloughing off of the uterine lining (menstruation).

For conception to occur, a healthy supply of well-formed, properly moving sperm cells need to be ready and waiting, already in the woman’s reproductive tract just prior to the actual point of ovulation, around the middle of her cycle.

A glitch in any of the above details, whether it’s a malfunctioning gland, immature egg cells, problems with sperm, or others, can make getting pregnant difficult at best.

In addition to irregular periods, some other factors that may point to possible infertility are :

• History of pelvic infection
• Prior abdominal or pelvic surgery
• Endometriosis, sometimes indicated by extremely painful and heavy periods

Men, too, have their share of fertility-impacting issues to consider, for example :

• History of testicular trauma or infection
• Prostate surgery
• Diabetes

Both men and women should know that commonly transmitted infections like Chlamydia are a frequent cause of infertility in women and sometimes in men. So if you were using condoms during those years before you tried to conceive, that was indeed one of the best things you could’ve done to protect your future fertility.

How Do You Find Out?

A woman‘s age impacts her fertility so it has bearing on when experts recommend she seek assistance from a fertility specialist. But they don’t suggest every woman who wants to get pregnant needs to see an expert.

Dr. Sagoskin explains, “For women younger than 35, if they haven’t been trying for at least a year and there are no other obvious infertility causes, they may want to try for another few months before seeing a specialist. Insurance often won’t cover diagnostics or even consultation with a reproductive endocrinologist until the patient has been trying to conceive for at least a year.”

Fertility experts at Shady Grove Fertility and elsewhere do occasionally have consultation appointments with the “worried well” – young people who’ve read a lot in advance about getting pregnant and all the things that can go wrong.

With the increased availability of health information on the Internet, some people start off down the family-building road too ready to jump into the specialist’s office.

“We don’t always evaluate patients at that point,” says Dr. Sagoskin, “but we’ll talk with them about predicting ovulation and timing intercourse. We may perform a semen analysis, because it’s relatively inexpensive and the only way to determine some male-factor infertility issues.” Sagoskin and his colleagues will also suggest that patients read about treatment basics on the Shady Grove Fertility website.

A number of tests can be run through the patient’s OB/Gyn or even Family Practitioner’s clinic, and as Dr. Sagoskin said, will sometimes only be covered by insurance when ordered by the Primary Care doctor. Once the determination is made that either more complicated diagnostics should be performed, such as hysterosalpingogram (HSG), or if the initial tests indicate an infertility condition exists, many insurance policies will cover the initial consultation with a fertility specialist.

What if Fertility Treatment is the Answer?

The types of treatment that can be conducted through a non-specialist’s clinic are rather limited, primarily to artificial insemination like intrauterine insemination (IUI). However, says Dr. Sagoskin, “Not all OB/Gyns are comfortable performing even basic inseminations.”

In addition to physician experience and skill, Sagoskin says other factors that vary between a non-specialist and a reproductive specialist’s offices are their hours of availability and medication limitations. “Few OB/Gyns will have 24/7 availability (necessary for some types of infertility treatment), and most aren’t prepared to manage patient cases when injectable fertility medications are prescribed.”

Because there are so many variables that can cause a couple or individual’s infertility, treatments also vary from the most basic oral medication to IUI to in vitro fertilization (IVF) and preimplantation genetic testing (PGT).

How Do you Pay for it?

Unfortunately, insurance coverage for further diagnosis and especially treatment of infertility is not a given in all of the United States. Knowing this, centers like Shady Grove Fertility maintain expert financial services staff who are specially trained in guiding patients toward affordable use of the world’s most state-of-the-art assisted reproduction techniques.

In addition to being well-versed in both insurance plans and the variety of options for affording treatment, such as loans or other assistance programs, the staff of Shady Grove Fertility was the first in the world to develop a Shared Risk plan. Shared Risk allows couples who need to use IVF for conception to pay a fixed fee for up to six chances at getting pregnant with IVF. If treatment isn’t successful, 100 percent of the fee is refunded, leaving their family-building resources intact for other options such as adoption.

The Best Time to Have a Baby

Nobody likes learning about getting pregnant after it’s become an apparent struggle. Just visiting a website about infertility can make you feel like you’ve lost something. The truth is that infertility has always been around, that millions are affected by it, and the good news is that for those who need help getting pregnant, there has never been a better time.

Most people who seek treatment do not have to use IVF, often considered the most extreme and technical form of assisted reproduction. For those who need IVF, they can take comfort in knowing that after several decades of its use to create successful pregnancies; the techniques are well-honed and proven.

Medical Contribution By Dr. Naveed Khan

Approximately 1 million women in the United States undergo an elective tubal sterilization procedure each year. Some of them change their minds a few years down the road.

“We get calls all the time,” says Dr. Naveed Khan from Shady Grove Fertility’s Leesburg office, “from women who want to have another child but had their fallopian tubes ‘tied’ for contraception. They thought they were done with pregnancy.”

Most of these women have a new partner in their life, someone with whom they want to have a child. Others may be seeking emotional healing after the loss of a child, or even in some cases have a rekindled long-standing marriage. Typically, regrets about a previous choice of tubal ligation are expressed by women younger than 30, women whose decision was influenced by a third party, and those who underwent sterilization immediately postpartum or after an induced abortion.

After that first big decision to have another child, the next question is how best to go about it. In choosing the best treatment option, tubal reversal surgery versus in-vitro fertilization (IVF), there are several important factors to consider. These include tubal factors, semen parameters, female age, and egg quality.

Fertility Treatment? Me?

Dr. Khan says that some women come to Shady Grove Fertility seeking IVF right away to work around a previous tubal contraception. For others, the idea of using “fertility treatment” is a little difficult to grasp, especially when they had no problem conceiving in the past.

“Regardless of which direction a patient is leaning,” Dr. Khan explains, “we’ll recommend the same tests to determine a woman’s current level of fertility. With the results, she can make the best choice of treatment option. Many don’t realize that even just a few years [since a woman’s last pregnancy] can result in a decline of their fertility factors.”

Besides naturally-occurring changes in fertility, women who’ve had tubal ligation have additional factors to consider.

Dr. Khan provides the surgery-specific details. “Whether or not fallopian tubes can be reconnected depend upon the length of remaining tube, the specific procedure used for tubal ligation, and the location of the segment of fallopian tube removed. The longer the length of remaining fallopian tube, the better the chance of a successful pregnancy after a tubal reversal surgery. At a minimum, 4 cm of healthy tube is desired post-surgery.”

A diagnostic laparoscopy can sometimes be helpful in determining if the fallopian tubes can be reconnected by directly visualizing the tubal length. A mini-laparotomy is then performed through a horizontal incision above the pubic bone. Using magnification and very fine suture, the various layers of the fallopian tube are meticulously brought back together.

In general, tubal ligations performed using falope rings, silastic bands, or clips tend to have higher success rates than those performed with electrocautery. The use of electrocautery can result in extensive thermal damage to the tube. Patients are advised to obtain their old medical records when available to determine which technique was utilized.

The Time that has Passed

For all women, fertility naturally declines beginning around the age of 35. So, regardless of how fertile a woman was when she last conceived, the time that has passed since then will be a factor in her fertility level today.

Dr. Khan adds, “Tubal reversal surgery is a good option for young women who have the time to undergo the surgery and then have the needed time to conceive on their own. Women who are older may benefit from IVF due to time constraints imposed by the aging ovary.”

If a woman’s ovarian reserve is compromised as evidenced by a rising follicle stimulating hormone (FSH) value, an elevated baseline estradiol, or a reduced antral follicle count (all simple non-surgical tests that are part of the workup), it becomes more urgent to move towards more efficient and effective therapy quickly.

The Partner’s Role

Another crucial part of the getting-pregnant-again equation, and one that many women (and their partners) don’t consider at first is testing the male’s fertility.

“I wouldn’t recommend that a woman move forward with any surgical procedure before we determine, in fact, whether or not her male partner is fertile,” Dr. Khan advises. Simple semen analysis is considered an expected part of the fertility workup, for any couple trying to decide between tubal reversal or IVF.

“If there are abnormal semen parameters such as reduced count, low motility, or severe morphologic abnormalities, then IVF is the better treatment option. For male factor issues, intracytoplasmic sperm injection (ICSI) can be performed during the IVF cycle to optimize egg fertilization.”

Other Considerations for Comparison

Some additional points to think about in weighing the factors of reversing or not reversing.
Tubal surgery reversal:

• is considered a major surgery
• allows for the possibility to conceive more pregnancies in the future
• is a better option for couples that have ethical or religious objections that preclude IVF
• may require the need for future contraception after pregnancy is attained
• if surgery is not successful then one may need to pursue IVF regardless
• any post-surgery pregnancy needs to be monitored closely due to increased risk for ectopic pregnancy

Dr. Khan says that many women who initially inquire about tubal reversal decide, after considering all the points, that IVF is their preferred route to pregnancy.

“For most women, when one weighs all the advantages and disadvantages of tubal reversal surgery compared to IVF, in-vitro is usually the most efficient and effective therapy leading to pregnancy,” explains Dr. Khan.

For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.

Krista Hayes finally got tired of being told she was too young to worry. Now, she takes every opportunity she can to let other young women in on what was news to her: sometimes, even 20-somethings need fertility treatment to have a baby.

“I had no idea there was anything wrong,” Krista, who is now 30, reflects on the struggles of her teens and early 20’s. “I had a lot of menstrual pain as a teenager and was always told it was expected.”

But We’re Too Young

Living in upstate New York and newly married, a then 24-year-old Krista started trying to conceive. After a year without conceiving on her own, she turned to her OB/Gyn, who performed three intrauterine inseminations (IUI). When all three were unsuccessful, Krista underwent ahysterosalpingogram (HSG) – or dye test – to see if there were any uterine or tubal problems. While the HSG reading indicated that Krista’s right tube was blocked, her OB/Gyn made the decision to continue with three more IUI’s over the next year, none of which resulted in pregnancy.

“That’s the point when I thought ‘I’m too young to be taking two years to get pregnant’ – even though everyone else was telling me ‘Just relax, you’re still young…’” Krista recalls.
But instead of relaxing, Krista took the next step in her fertility journey by deciding to seek out a fertility specialist on her own.

“This was back when there wasn’t as much on the Internet about when you should seek fertility treatment. Most of my information was coming from pregnancy books, and nowhere did I see mentioned that we should’ve sought help after a year of trying,” Krista said.

Already apprehensive about seeing a fertility specialist, a now 26-year-old Krista received the news that made her begin to panic. Without undergoing any ultrasounds, blood work or other tests, the fertility specialist whom she consulted with took one look at her HSG report and told Krista and her husband that IVF was their only option.

“It just didn’t seem possible that we actually needed fertility treatment,” she said. “We were so young.”

Moving In The Right Direction

Before she and her husband could resolve their hesitation about moving forward with IVF, he was transferred to Baltimore. This move turned out to be a very important part of their baby-making journey.

Krista’s cousin had a friend in Baltimore who had nothing but positive things to say about Shady Grove Fertility. Upon hearing that, Krista decided to schedule an appointment with Dr. Ricardo Yazigi at SGF’s Baltimore-GBMC office.

After he reviewed her previous medical history and conducted some additional blood work and a semen analysis, it was determined that Krista quite likely had endometriosis. The recommended laparoscopic surgery to both confirm and treat the common, often painful condition was carried out in a day.

Dr. Yazigi found that Krista’s endometriosis was quite extensive. It was during that surgery that Krista and her new treatment team also learned that the earlier HSG tests run by her old OB/Gyn were inaccurate, and she didn’t have a blocked fallopian tube.

Seeing as she had good tubal function, Dr. Yazigi decided to try two more cycles of IUI with clomiphene citrate. When those didn’t work he tried one cycles of IUI with injectable medications, but that wasn’t successful either. Krista was ready to head for IVF.

Prepared For Taking The Next Step

She cites two things as helping ease her toward that big step. First, she talked to her Episcopal priest because she was worried about how to discuss with loved ones her choice to use fertility treatment. He advised her to explain to others that infertility is a disease, and that she would seek treatment for any other medical condition.

“My priest explained to me that infertility is a disease,” Krista said. “He asked me whether I would wait to seek out treatment if I was diagnosed with cancer. He said I should do the same for my infertility.”

The second was the attention and support she felt from the entire GBMC office.
“I just felt so comfortable with Dr. Yazigi and Dr. Katz and their nursing staff,” she remarks.
Happily, Krista conceived on two separate IVF cycles. She now has two daughters, 5 and a half and 11 weeks old. She is ecstatic to have the family she always wanted and relieved to have found answers to her concerns.

“When I started out I knew nothing,” Krista says. “I had heard of endometriosis, and found out that my grandmother had it — but nobody learned about it until she had a hysterectomy. Now, I know tons of people who are going through infertility. We’ve been very vocal about the fact that this is what we had to do. So many won’t talk about it and will stay silent and frustrated, so we’ve shared our journey with a lot of people.”

Krista hopes that her story will encourage young women to be pro-active with their reproductive health, to not simply dismiss their pain or any other signs of possible fertility trouble, and to seek expert advice after a year of unsuccessful attempts to get pregnant.

“Had I known that after a year of trying that I should have gone to see a fertility specialist, I would have. No one ever told me about my options. So I hope people read this and know that there are options out there for them.”

To learn more about how Shady Grove Fertility can help you if you have endometriosis or toschedule an appointment with one of our physicians, please call 888-761-1967 to speak with one of our patient liaisons.

Medical Contribution By Dr. Eugene Katz

The words “infertility treatment” can conjure up tremendous anxiety in people having trouble getting pregnant. Many people immediately worry that seeing a fertility specialist will equal having to use high-tech assisted reproductive therapies like IVF, and all that means in terms of time, money, and effort.

The reality is that most people who seek fertility treatment don’t have to use IVF to get pregnant. In fact, the most common reason for female infertility — ovulation disorders — is very often resolved with the lowest tech treatments available.

Bumps in the Road

If you think of ovulation as a series of events, instead of as a single occurrence in which an egg is dispersed from the ovary, it becomes clear that there are several points in the cycle where something can go wrong.

Dr. Eugene Katz, at the Shady Grove Fertility Center at GBMC in Baltimore, explains how the common diagnosis we call “ovulation disorders” is really a spectrum of infertility causes.
“There are different reasons that cause ovulatory disorders,” Dr. Katz says, “and also different levels of severity.”

Many compartments in the female body need to be working in sync for healthy ovulation to occur.
At the highest level is the hypothalamus in the brain. It sends a signal to start the ovulation cycle rolling. Disorders of the hypothalamus can result in amenorrhea, complete lack of ovulation and menstrual periods. Very serious levels of psychological stress, such as living in constant danger, can cause hypothalamic dysfunction.

Exercise-induced stress and related amenorrhea can also happen to women who are under-weight. A certain percentage of body fat is necessary to promote proper functioning of the brain and endocrine glands. Women with eating disorders may have their fertility disrupted in this way.

In the same region of the brain, the pituitary gland sometimes produces excess prolactin; when this occurs, the brains stops making substances to command the ovaries to work. A common symptom of prolactin disorders is the production of breast milk in a woman who is not pregnant or nursing.
Jumping to the end of ovulatory disorder spectrum, we find ovarian failure and poor ovarian reserve. These are diagnoses given when a woman isn’t yet menopausal, but the ovaries are no longer producing eggs.

“This is the most difficult group of patients to treat,” Dr. Katz says, “because we can’t go back in time. If the ovaries have failed, that’s it. Before her body gets to that point, however, we can try more aggressive treatments.”

Patients with ovulatory disorders fall into a spectrum that ranges from irregular cycles and occasional ovulation to complete absence of ovulation and menses, including some suffering from Polycystic Ovarian Disease (PCOD) or Syndrome (PCOS).
Women with PCOD have:

• Abnormal menses and
• Excess male hormones

Using the criteria listed above, the diagnosis of PCOD is relatively easy to make with an expert professional eye. Dr. Katz explains, “The severity of presentation is very variable. Some people simply don’t ovulate regularly, but they have no signs of excess male hormone. Other groups will have many visible signs of male hormone excess, like hirsutism, acne, and over-weight issues.”

The Issue of Timing in Treatment

Except for cases of ovarian failure, women with ovulation disorders are easily treatable with a high degree of success.

Typical treatments are medications that will induce ovulation. Conception may result following timed intercourse, so long as no male factor infertility is present in the couple. In fact, any couple pursuing fertility therapy should also be sure that the male partner undergoes a semen analysis before the female begins using fertility medications.

It may be more efficient in some cases to also use intrauterine insemination (IUI). If a patient is older than mid 30’s, or if timing is otherwise an issue (say, for a schoolteacher who wants to schedule her treatment around summer break,) IUI may be recommended.

“Not all patients will require sophisticated fertility therapies,” Dr. Katz ventures. “Age is very important — in fact, once you have this diagnosis of ovulatory disorder, age is key to success, the most important factor. We start seeing a minimal decline in fertility at 30, more significant decline at 35, and a dramatic drop in ability to conceive at 38.”

Unfortunately, fertility specialists often see patients who have already spent a lot of time at a primary care practice in fruitless pursuit of pregnancy.

“Most women taking medication to induce ovulation will succeed within two to four months,” Katz says, “After that point, if pregnancy has not occurred, it’s time to see a specialist and explore other possible causes of infertility.”

Examples of other factors that impact fertility include male factor issues and fallopian tube blockages, both of which can be treated, but that need more than just ovulation medication and IUI.
A fertility specialist should be consulted if a woman has :

• Experienced irregular or absent menstrual periods;
• Already tried fertility medication prescribed by a gynecologist and not been successful with getting pregnant;
• Been unable to conceive after three months and is 37 years or older.

People who are having trouble conceiving need not fear the higher-end assisted reproductive technologies, but many no doubt breathe a sigh of relief upon learning that most patients need only low-tech treatment for a successful pregnancy.

For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.

Endometriosis is a condition where cells similar to those that make up the lining of the uterus grow in places where they have no business showing up – like the ovaries, bowel and bladder, and even the muscular tissue of vagina. Like their relatives in the uterus, these rogue upstarts (called implants) respond to the hormonal cues of the menstrual cycle, first getting thicker and then breaking down to “bleed.”

But unlike the endometrial lining of the uterus, the implants have nowhere to flow and as a result may form into painful scar tissue or fluid-filled lesions – ouch!
Pelvic pain (sometimes severe!) at the time of menstruation and/or ovulation is the most common symptom of endometriosis, and secondary symptoms may include abnormally heavy periods and infertility. If you are under the care of a physician for endometriosis, treatment can include birth control pills, other hormonal medications and in advanced cases, laparoscopy to remove scar tissue and implants.

Endometriosis is challenging under any circumstances, but managing endometriosis while you’re trying to conceive adds an entirely new level of complexity. Obviously, when you’re trying to conceive, using birth control pills and hormone treatment becomes trickier. Nevertheless, don’t despair. Your OB or Reproductive Endocrinologist will counsel you on how best to treat your endometriosis in preparation for ART (Assisted Reproductive Technology). In addition, the following holistic practices can help you manage pain and stress, as well as support your reproductive system in preparation for a successful pregnancy.

1. Eat an anti-inflammatory/gut-friendly diet

The pain associated with endometriosis is thought to be in part due to inflammation caused by higher levels of “bad prostaglandins.” Prostaglandins are chemical messengers produced in every cell in the body.

These chemicals have some beneficial effects (enhance immune function, increase blood flow, block inflammation) and some problematic effects (promote inflammation, decrease blood flow, contract muscles and produce pain). Unfortunately, research shows that women with endometriosis produce higher than normal levels of the second guys, pro-inflammatory prostaglandins

(1) as well as higher levels of oxidative stress (click here to read more about oxidative stress and fertility)

(2) Certain foods can increase levels of inflammation in the body. For that reason, women with endometriosis can benefit from limiting pro-inflammatory foods like red meat, omega-6 oils and refined sugars. Other foods, including healthy oils and anti-oxidant rich fruits and vegetables can help reduce inflammation.

Promoting good digestion is also key. Endometrial implants can occur in the gut and pelvic pain is often exacerbated by poor digestion. At Pulling Down the Moon we recommend that women with endometriosis adopt an ultra-healing diet like our ART Recovery/Prep Program. This eating program is designed to decrease dietary sources of inflammation and promote gut health.

2. Stress Reduction

Interestingly, studies show that women with endometriosis suffer from depression at a higher rate than their fertile counterparts.

(2). In addition, levels of the stress hormone cortisol are higher in the follicular fluid of women with endometriosis vs. fertile women

(3). Since stress and depression have been shown to negatively impact a woman’s ability to conceive, relaxation training and finding emotional support can play an important of healing endometriosis.

(4) Taking a yoga class, joining a support group or learning basic relaxation techniques are all good strategies for women with endometriosis.

3. Acupuncture/Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) treats endometriosis in much the same way that it treats any disorder – as a symptom of underlying imbalance that can be treated with acupuncture, herbal therapy and lifestyle changes. While no specific studies exist looking at endometriosis, TCM and fertility, there is a growing body of evidence that TCM can help with the pain and dysmenorrheal that many women with endo experience.

(5). In addition, it is well established that TCM helps treat stress and depression.

4. Massage

Many women don’t realize the potential healing benefit of massage for endometriosis. Studies have shown that mechanical manipulation (stretching and pulling) on body tissue can release and potentially break down scar tissue

(7). Touch therapy also helps to elevate mood and reduce stress and release tight musculature that contributes to pelvic pain. A fertility massage like our FEM protocol session “Enhance the Blood” that focuses on deep work in the pelvis and improving blood and fluid flow in lower abdomen can be extremely beneficial for women with endometriosis – even when not trying to conceive.

The take-home message here is if you’re struggling with endometriosis, you can still feel very optimistic about your odds of conceiving. A combination of excellent medical care and lifestyle changes can drastically impact your symptoms and put parenthood in your sights.

For more information or for help building your holistic self-care strategy, contact Pulling Down the Moon at 301-610-7755 or visit our website at www.pullingdownthemoon.com.

<sub>1. Lee J. Selective blockade of prostaglandin E2 receptor EP2 and EP4 signaling inhibits proliferation of human endometriotic epithelial cells and stromal cells through distinct cell cycle arrest. Fertil Steril. 2010 Mar 5. [Epub ahead of print].
2. Ngo C. Reactive oxygen species controls endometriosis progression. Am J Pathol. 2009 Jul;175(1):225-34. Epub 2009 Jun 4.
3. Danielle L. Depression: an emotional obstacle to seeking medical advice for infertility. FertileSteril. 2010 Jan 2. [Epub ahead of print]
4. Oehmke F. Impact of endometriosis on quality of life: a pilot study. Gynecol Endocrinol. 2009 Nov;25(11):722-5
5. Volgsten H. Personality traits associated with depressive and anxiety disorders in infertile women and men undergoing in vitro fertilization treatment. Acta Obstet Gynecol Scand. 2010;89(1):27-34
6. Wayne P. Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial. J Pediatr Adolesc Gynecol. 2008 Oct;21(5):247-57.
7. Langevin H. Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. Am J Physiol Cell Physiol. 2005 Mar;288(3):C747-56. Epub 2004 Oct 20</sub>

Approximately 1 in 8 couples will have trouble getting pregnant and need medical help to discover the cause of their infertility. By undergoing a complete infertility workup, couples can quickly get a diagnosis and then pursue a treatment plan to help them on the road to parenthood. Some causes of infertility are more common than others. Learn about various common and uncommon causes of fertility and treatment options for each.

Many couples believe that infertility is caused most often by problems with the female reproductive system. In fact, the causes are equally split among male and female factors. There are also many couples that have infertility issues in both partners.

Dr. Jason Bromer of Shady Grove Fertility’s Frederick office says that for many couples, there is more than one cause found during infertility testing. “We often see couples who have not had a complete infertility workup done or who have only had the female partner tested. This can lead to the couple becoming frustrated and disappointed with treatments that aren’t successful because they overlook one of their infertility factors.”

Finding out the causes of your infertility can be difficult emotionally and, if there are multiple factors, it can also be confusing. Developing a treatment plan with a fertility specialist can give couples a sense of control and provide concrete reasons for them to be hopeful about having a family.

Male Factor

Male factors account for 40% of infertility and are present in an additional 10% of couples that have infertility in both partners. Male factor infertility occurs if sperm are produced in low numbers, are abnormal in shape or are not able to move well. There can also be structural problems within the male anatomy that block the pathways of the sperm. Finally, men can develop antibodies to their own sperm, which may attack and weaken the sperm.

“The good news is that there are several effective ways to treat male factor infertility,” notes Dr. Bromer. In mild cases, sperm “washing” is used to isolate the healthiest sperm in a sample for use with Intrauterine Insemination or IUI.

When couples with a male factor diagnosis do In Vitro Fertilization, a procedure called Intracytoplasmic Sperm Injection or ICSI can be used. With ICSI, a single healthy sperm is injected into the center of each egg making fertilization possible with even severe male factor infertility. In some cases, medications may also be part of the treatment plan.

For those with no ejaculated sperm, there are several procedures that can attempt to recover healthy sperm. One procedure is called Percutaneous Epidydimal Sperm Aspiration (PESA ). In this procedure, a needle is inserted into the epididymis and fluid is withdrawn. The fluid is then inspected under a microscope and healthy sperm are extracted from it.

If PESA is unsuccessful in retrieving sperm, a second option may be to do a Testicular Biopsy. In this procedure, a small sample of tissue is removed from the testes. The tissue is then inspected under a microscope and any healthy sperm found are extracted.

While these procedures sound uncomfortable, none of them are painful and all of them are effective. “Patients with male factor infertility can be very hopeful about their chances of getting pregnant,” states Dr. Bromer. “In fact, patients at Shady Grove Fertility with a male factor diagnosis have a clinical pregnancy rate of 62% per cycle.”

Female Factor

Female factors account for another 40% of infertility and are present in an additional 10% of couples who have infertility factors in both partners. While the causes of female infertility are more numerous and can be more complicated to diagnose, there are effective treatments available for an overwhelming majority of them.

Dr. Bromer adds that it’s common for women to have more than one factor affecting their fertility. “I frequently see patients with multiple issues. For example, a woman who has fibroids may also have endometriosis. That’s why it’s important to do a thorough diagnostic workup, so you can create a treatment plan that takes all the factors into account.”

Common and Uncommon Causes of Infertility

Polycystic Ovary Syndrome (PCOS)	Tubal Disease or Blocked Tubes	Recurrent Miscarriage
Hypothalamic Amenorrhea	Pelvic Adhesive Disease	Advanced Age
Hyperprolactinemia	Fibroids	Unexplained Infertility
Premature Ovarian Failure	Endometriosis

 Polycystic Ovary Syndrome (PCOS)

Ovulation is the process by which the ovary releases an egg each month. Disorders that cause a woman not to ovulate or to ovulate infrequently or irregularly are called Ovulatory Disorders. By far the most common diagnosis in this category, PCOS accounts for about 85% of ovulatory disorders. PCOS is caused by hormonal imbalances that prevent ovulation.

The woman’s body produces too much of some hormones and not enough of others. Women who are diagnosed with PCOS usually have low levels of follicle stimulating hormone (FSH), yet have high levels of luteinizing hormone (LH). FSH is the hormone that’s responsible for stimulating the growth of follicles in the ovaries that contain maturing eggs. If a woman lacks FSH for a long time, her follicles will not mature and release their eggs, resulting in infertility.

Weight loss can sometimes fix the hormonal problem causing PCOS. More commonly, women with PCOS are treated with a medication called Clomid that induces ovulation. “If PCOS is the only factor affecting a woman’s fertility, then treatment with Clomid is very effective,” says Dr. Bromer. “Over 6 cycles, 70-80% of women will ovulate and 40-50% will get pregnant.”

Hypothalamic Amenorrhea

Another 10% of ovulatory dysfunction is caused by Hypothalamic Amenorrhea. Hypothalamic Amenorrhea is a condition in which ovulation stops due to a problem involving the hypothalamus. The hypothalamus is an area of the brain that produces hormones that control many bodily functions. Its function can be impaired by stress, being underweight or too much exercise.

“Unlike women with PCOS, women with Hypothalamic Amenorrhea will not respond to Clomid,” says Dr. Bromer, “so it is not an appropriate treatment.” One way to treat this condition is to reverse the underlying cause – have the patient gain weight or reduce exercise.

She may start ovulating again on her own and become pregnant. Another way to treat this condition is to give the patient the hormones she is missing during a cycle of Intrauterine Insemination (IUI).

The good news is that all we have to do is get these patients to ovulate,” says Dr. Bromer. “They almost always have healthy eggs, and they carry pregnancies normally.”

Hyperprolactinemia

A subset of hypothalamic amenorrhea is due to hyperprolactinemia. Hyperprolactinemia is a disorder in which the pituitary gland produces excessive amounts of the hormone prolactin.

Prolactin normally circulates in the blood in small amounts in women who are not pregnant and in large amounts during pregnancy and right after birth. Hyperprolactinemia can cause irregular or no ovulation, resulting in infertility. One of the most common causes of hyperprolactinemia is a benign tumor growing on the pituitary gland – the gland that produces prolactin.

Other causes of excess prolactin production may be an underactive thyroid (hypothyroidism) or certain medications the patient may be taking. Sometimes, the cause is unknown.

“The goal of treatment is to get the woman’s prolactin blood level within the normal range,” says Dr. Bromer. “Once this is achieved, she should start ovulating again and be able to conceive. This condition is similar to Hypothalamic Amenorrhea in that the woman usually has healthy eggs and has a great chance for pregnancy once she ovulates.”

If the patient is diagnosed with an underactive thyroid, her doctor can prescribe a thyroid medication. Once the thyroid problem is corrected, the amount of prolactin in the blood should decline to a normal level.

If the patient has a tumor on her pituitary gland, or the cause of the hyperprolactinemia is unknown, treatment with medication can reduce the prolactin levels. This medication usually causes pituitary tumors to shrink as well.

Premature Ovarian Failure 

Premature ovarian failure is a relatively rare condition in which menopause occurs before the age of 40. Women who develop early menopause usually have run out of eggs in their ovaries. The cause of premature ovarian failure is generally unknown.

However, there are a few reasons why the ovaries may stop producing eggs at an early age. Exposure to certain chemicals or medical treatments, such as chemotherapy, can damage or destroy the ovaries.

Autoimmune diseases such as rheumatoid arthritis are also sometimes associated with early menopause because the immune system forms antibodies that attack and damage the ovaries. Heredity can also play a role, as some genetic disorders lead to early menopause.

“Because this condition means that we don’t have healthy eggs to work with, the only option for these patients is to use donor eggs,” says Dr. Bromer. “The good news about donor eggs, though, is that the pregnancy success rates are very high because of the age and health of the eggs being used.”

Tubal Disease or Blocked Tubes 

Tubal disease or blocked fallopian tubes account for half of all female infertility. “To understand why this is such a common problem, it helps to think about the woman’s anatomy,” explains Dr. Bromer.

“The fallopian tubes and the ovaries are not actually connected to one another. The fallopian tube has to sweep over the ovary to pick up the egg that is released each month. So, this condition is not only caused by a blockage or barrier in the tube but also by anything that prevents the tube from picking up the egg.”

Conditions that cause scarring in or around the fallopian tubes can cause tubal disease or blocked tubes. Endometriosis, Fibroids, and Pelvic Adhesive Disease, which are described below, can cause tubal disease in addition to other issues that affect fertility. Also, events such as ectopic pregnancies, c-section or any other abdominal surgery can cause scarring and blockages as well.

“With tubal disease, you can either fix the tubal blockages or go around them by doing IVF,” says Dr. Bromer. “The problem with fixing the blockages is that then the woman may continue to be at risk for ectopic pregnancies, so IVF is really the best solution.”

The only time a blocked fallopian tube must be fixed is in the case of something called a Hydrosalpinx. In this condition, the tube is blocked at the end near the ovary. When the cells lining the tube secrete fluid to facilitate transport of the egg, the fluid collects in the tube and then leaks back into uterus.

“This fluid is toxic to embryos,” says Dr. Bromer. “Even if your other tube is open, the hydrosalpinx will prevent you from getting pregnant. So, a fallopian tube with a hydrosalpinx has to be removed even if you’re going to do IVF.”

Pelvic Adhesive Disease 

Pelvic Adhesive Disease can be caused by surgical procedures, pelvic inflammatory diseases and infections. The result is scar tissue that binds adjacent organs to each other.

If adhesions (scar tissue) form inside or around the ends of the fallopian tubes, they may block an egg and sperm from meeting. If the tubes are partially blocked by adhesions, sperm may meet the egg, but the fertilized embryo may be trapped, resulting in an ectopic pregnancy.

Adhesions that develop on or around the ovaries may also disrupt the egg being picked up by the fallopian tube, and those that develop inside the uterus may prevent a fertilized egg from implanting properly.

Treatment for Pelvic Adhesive Disease will depend on how it is affecting a woman’s fertility. Dr. Bromer explains, “If necessary, surgery can be performed to remove the adhesions that are affecting the uterus or ovaries. If the adhesions are only causing blocked fallopian tubes, IVF can be performed to avoid using blocked tubes.”

Fibroids

Fibroids are noncancerous growths that develop in or on the uterus. Forty percent of women have fibroids by the time they are 40 years old and they are 3 times more likely to occur in African American women. However, Dr. Bromer explains, “While fibroids are very common, they don’t always cause infertility.

The location of the fibroids is usually the key to whether or not they affect fertility.” Fibroids can grow inside the uterus, in the wall of the uterus or on the outside of the uterus. “The ones that most often have an impact on fertility are those inside the uterus and they can be removed surgically,” says Dr. Bromer.

If the fibroid is in the uterine wall or outside the uterus, the impact on a woman’s fertility is less clear. Dr. Bromer explains, “We will look at whether the shape of the uterus is distorted by the fibroid. If it is, it should probably be taken out. If not, it could be left alone while treatments like IUI or IVF are attempted.

The only exception to this is if it is in a location where it might interfere with the interaction between the ovary and the fallopian tube in which case it should be removed.”

The decision about whether to remove a fibroid is a difficult one. Patients have to weigh the risk of abdominal surgery that could cause scarring in the uterus. Dr. Bromer says, “If a patient is not sure about surgery, we can try treatments like IUI and IVF first. They may become pregnant despite the presence of the fibroid.

If those treatments are unsuccessful, then we still have surgical removal of the fibroid as an option.”

Endometriosis 

This endometrial tissue responds to your menstrual cycle hormones – it swells and thickens, then sheds to mark the beginning of the next cycle. Unlike the menstrual blood from your uterus that is discharged through your vagina, the blood from the endometrial tissue in your abdominal cavity has no place to go.

Inflammation occurs in the areas where this process occurs, eventually forming scar tissue. Scar tissue can block the fallopian tubes or interfere with their function.
“How you treat endometriosis depends on how it is affecting the woman’s fertility,” says Dr. Bromer.

There are surgical options to remove the endometriosis tissue from the ovaries or fallopian tubes and there are medications that shrink endometrial tissue. Dr. Bromer adds, “In most cases, women with endometriosis are more likely to be successful with IUI or IVF.”

Recurrent Miscarriage

Recurrent miscarriage or recurrent pregnancy loss (RPL) is characterized by having 2 or more miscarriages. There are several different possible causes. A common cause of RPL is “aneuploidy” or an abnormal number of chromosomes. When fertilization occurs, an embryo receives one copy of its chromosomes from the female and one from the male.

These chromosomes line up in pairs that are matched to one another precisely. In some patients, especially older patients, the copying mechanism fails and the chromosomes are wrongly paired. A rare but well established cause of aneuploidy is a condition called a “translocation.” A simple blood test can show a couple’s risk for translocation during conception.

Other potential causes are problems within the uterus, such as congenital abnormalities in the shape of the uterus or scarring, that can prevent the embryo from implanting properly. Certain autoimmune diseases in the female also can lead to RPL.

Autoimmunity means that the body is making antibodies that work against it, in other words, attacking itself instead of invaders. This can result in conditions like lupus. Dr. Bromer adds that “conditions like diabetes or thyroid disease can also cause miscarriage, so normally these types of causes would be ruled out as well.”

Treatment depends on finding the cause of the miscarriage. If the couple is at risk for translocation, they can do IVF with pre-implantation genetic screening. This is a process in which the embryos created during IVF are screened for genetic conditions so that only healthy embryos can be chosen for transfer.

Problems with the shape of the uterus or fibroids can be corrected with surgery. Some immune problems or hormone imbalances can be corrected with medication. “Sometimes we don’t find a cause for the miscarriage,” says Dr. Bromer. “But even in these cases, there is still a very high chance that eventually you will deliver a healthy baby.”

Advanced Age

As women approach age 40, the quality and number of their eggs tends to decline, ovulation may become irregular, and the ovaries may produce less estrogen and progesterone. In addition, women this age are more likely to have medical problems that can cause infertility, such as fibroids. Also, more of a woman’s eggs will have chromosomal abnormalities, which can result in miscarriage.

IVF can be successful for women 38 and older, but the success rates decline as the age of the woman goes up, especially as women reach their 40’s. “Women with significant age-related infertility may need to consider using donor eggs,” says Dr.

Bromer. “Because the eggs are donated by a woman between the ages of 21 and 32, the chances for pregnancy are the same as if she were that age. The success rates for women using donor eggs are very high, so it’s a great option for women of advanced age.”

Unexplained Infertility 

Approximately 10% of infertility cases are unexplained. The evaluation of such a couple begins with a comprehensive review of all testing and treatment performed to date. It is not uncommon to uncover evidence within this past evaluation which may in fact document the cause of infertility.

True unexplained infertility may be related to egg and sperm dysfunction, among other causes. These conditions are difficult to establish through conventional testing. However, many such conditions can be successfully and safely treated through in vitro fertilization or related techniques.

Treatment decisions are based on a number of factors. These include the age of the female partner, the duration of infertility, a working diagnosis of the problem and the desires of the couple.

Treatment options may include, controlled ovarian hyperstimulation and a processed sperm specimen for intrauterine insemination, or in vitro fertilization. The important difference being that through in vitro fertilization egg and sperm interaction can be maximized in order to promote fertilization and establish a successful pregnancy.

Don’t Delay Diagnosis

Many infertile couples try to get pregnant on their own for far too long before seeking help. Because age is such an important factor to fertility, waiting too long may reduce the likelihood that fertility treatment will work. The best thing is to follow the accepted guidelines about when to see a fertility specialist.

Women under 35 should seek medical help after one year of unprotected sex without conceiving. If the woman is over 35, she should only wait 6 months. Women who are 40 years old or older and are trying to get pregnant may consider seeing a fertility specialist right away.

Though it may be scary to be diagnosed with infertility, this diagnosis can start you on the path to pregnancy. Once the causes of infertility are known, a treatment plan can be created that gives you options and clearly states your chances for success.

With the caring guidance of a fertility specialist, you can be on your way to joining the thousands of couples who have successfully overcome infertility.