Infertility is more common
than people think.
Working With Your Fertility Doctor
A fertility doctor is a reproductive endocrinologist — a physician who practices a subspecialty of obstetrics and gynecology called reproductive endocrinology and infertility (REI).
REI is an area of medicine that addresses hormonal functioning as it pertains to reproduction and infertility in both women and men.
U.S. fertility doctors have four years of OB/GYN training before they undergo a three-year fellowship to become a Reproductive Endocrinologist (RE). The fellowship includes extensive research and clinical experience in diagnosing and designing appropriate treatment for infertility, administering in vitro fertilization (IVF) cycles, laparoscopic surgery and many other areas.
Our fertility specialists are trained to identify and treat a wide range of conditions or complications affecting fertility and reproduction. In women, these may include diseases of the fallopian tube, endometriosis, repeated pregnancy loss, uterine myomas, uterine abnormalities, age-related infertility and reproductive endocrine disorders. Men also face reproductive and fertility complications, which may result from disorders such as erectile dysfunction, abnormal sperm production, genetic defects or health issues.
Today, as many as one in seven couples trying to conceive will experience infertility. Recent studies show that after a year of having unprotected sex, 15 percent of couples are unable to conceive a child and after two years, 10 percent of couples have still not achieved a successful pregnancy. Infertility has traditionally been defined as the inability to conceive after twelve months of regular, unprotected intercourse. According to the guidelines, published by the ASRM in the June 2008 issue of its society journal Fertility and Sterility, women over 35 years of age are now encouraged to seek fertility evaluation if they fail to conceive after only six months of trying.
Boosting Your Fertility
Below are things both women and men can do to boost fertility and help get pregnant faster, whether trying to conceive naturally or undergoing fertility treatments.
- Maintain a healthy body weight
- Avoid smoking, alcohol and drugs, including anabolic steroids, which can decrease sperm count and motility in men
- Know when you ovulate and making sure that you are having sex at the right time in your cycle. If you have regular cycles, you will ovulate around two weeks before your period. Females are most fertile within a day or two of ovulation, which is when the ovaries release an egg. But, it is possible to get pregnant in the days leading up to ovulation, as sperm can survive for several days inside the female body
Even while you may be doing all the right things, you still may require help. If you are under 35 and have been trying to conceive for a year with no pregnancy, or over 35 and have been trying to get pregnant for six months with no pregnancy, contact an Eden physician for a complete evaluation to see whether you need fertility treatment to help.
Fertility drugs, mainly “ovulation-inducing” drugs, are available to treat many of the conditions that cause infertility.
Fertility drugs generally support follicle (egg) growth which leads to ovulation. Some of the most common fertility drugs include:
An oral medication, Clomid is often a first line of treatment for infertility to induce ovulation. If successful, pregnancy usually occurs during the first three months taking Clomid and treatment beyond six months is not recommended.
Among women with polycystic ovary syndrome (PCOS), especially those where obesity is a factor, letrozole has been found to work better than Clomiphene in triggering ovulation.
Women with (PCOS) may be insulin resistant, which can cause problems with ovulation. Metformin can decrease insulin resistance.
Gonadotropins (Follistim, Fertinex, Bravelle, Menopur, and Gonal-F)
This group of hormones stimulates activity in the ovaries, including ovulation. When other treatments do not work, follicle stimulating hormone (FSH) and a luteinizing hormone (LH) may be recommended. This treatment is given through injection.
Lupron (leuprolide acetate) is often prescribed for endometriosis because it dramatically lowers estrogen levels by regulating the body’s production of FSH and luteinizing hormone (LH). Endometriosis occurs when the lining of the uterus, the endometrium, grows in other places, such as the fallopian tubes, ovaries or along the pelvis. The uterine lining is highly dependent upon estrogen for growth. It is also prescribed in IVF cycles to shut down the body’s reproductive hormone system. While shut down, IVF patients use a FSH drug like Gonal-F or Follistim to develop follicles.
Human chorionic gonadotropin – hCG (Novarel, Ovidrel, Pregnyl, Profasi)
hCG can be used to trigger ovulation in women who are undergoing stimulated IUI or IVF. In a normal ovulatory cycle, a surge of luteinizing hormone (LH) triggers ovulation and release of the egg(s). The body responds to hCG in the same manner as it does LH, so a surge of hCG can also initiate ovulation.
Hyperprolactinemia is a condition in which the levels of the hormone prolactin are abnormally elevated, leading to abnormal ovulation and infertility. Prolactin levels normally rise in pregnancy to stimulate the production of breast milk, but high prolactin levels in the absence of pregnancy can stop a woman from ovulating and are often due to a small tumor at the base of the pituitary gland. Treatment sometimes involves removal of the tumor, or the drug Parlodel (bromocriptine) is prescribed to normalize levels.
Initial Infertility Work Up
When you work with Eden, our specialists will oversee a thorough examination of you and your partner’s medical history and hormonal health, as well as a physical exam to determine the likely cause of infertility and to create a treatment plan.
Your physician will also run tests to check whether you are ovulating normally, and whether you have any endocrine problems.
The common causes of female infertility include ovarian disease, tubal disease, endometriosis, uterine disease, cervical disease, immune disorders and “unexplained infertility,” which means that a specific cause of infertility cannot be identified.
Fertility tests will be ordered to assess ovarian function including the day 3 hormone evaluation. Elevated levels of FSH on day 3 may indicate diminishing ovarian reserve. Ovulation may also be assessed using urinary LH test kits (ovulation prediction kit), progesterone hormone measurements, ultrasound visualization and others.
An infertility work-up also typically includes:
A saline infusion sonogram (SIS) and hysterosalpingogram (HSG) to diagnosis conditions such as fibroids, polyps or blocked fallopian tubes. A SIS is a noninvasive technique using a slow infusion of sterile saline into the uterine cavity during ultrasound imaging. This procedure allows your physician to evaluate abnormalities of the endometrium cavity. HSG is a procedure that uses an X-ray to look at your fallopian tubes and uterus.
Hysteroscopy – A surgical procedure to exam the endometrial cavity to rule out endometrial polys and fibroids. If polys or fibroids are discovered they can be removed during this procedure or scheduled for removal at a later time.
A transvaginal ultrasound allows the physician to view the ovaries, uterus and many other internal organs. Many times dense structures, such as uterine fibroids, are clearly visible on transvaginal ultrasound. The ultrasound is also able to show the follicles on the ovaries as they develop and are ovulated.
Treatment recommendations will be made once infertility workup is completed. A common misconception is that most infertile couples will require in vitro fertilization (IVF). In fact, according the American Society for Reproductive Medicine, approximately 85-90 percent of infertility cases are treated with drug therapy or surgical procedures. Fewer than 3 percent need advanced reproductive technologies like in vitro fertilization (IVF).
Infertility Evaluation and Testing
While infertility was once considered a “female problem,” we now know that up to half of all couples have a male infertility component. This makes thorough testing of the male a necessity before beginning any female treatments.
Fertility tests evaluate the separate processes that must occur for pregnancy to result. Each Eden physician will oversee a thorough screening of each couple.
How Age Affects Fertility in Women and Men
When trying to get pregnant, age matters. Many women don’t realize their fertility begins to decline as early as their late 20s.
A healthy young woman has a 20% chance per month to get pregnant.
Why does fertility decline with age? Even though women today are healthier and taking better care of themselves than ever before, improved health in later life does not offset the natural age-related decline in fertility.
Women are born will all of the eggs they will ever have in their ovaries – unlike men who continue to produce sperm their entire lives. Women start out with more than a million eggs, but only have about 300,000 left by the time they reach puberty, of which only about 300 are ovulated during the reproductive years. Also, as you age, the quality of eggs reduces, too, meaning that the eggs you ovulate are more likely to have genetic abnormalities. The quantity and quality of your eggs is referred to as the ovarian reserve, a low ovarian reserve may indicate lower quality as well, and an indicator of a woman’s fertility. Young women may also have diminished ovarian reserve due to smoking, family history of premature menopause and prior ovarian surgery, or even if they have no known risk factors.
Unlike the early fertility decline seen in women, a man’s decrease in sperm characteristics occurs much later. Sperm quality deteriorates somewhat as men get older, but it generally does not become a problem before a man is in his 60s.
Causes and Risks of Infertility
Often times, the cause of infertility is unknown, however there are several factors that can put individuals at greater risk for difficulty conceiving.
PCOS is a common endocrine disorder causing infertility in up to 10 percent of reproductive-aged women. PCOS prevents follicles in the ovary from producing and releasing mature eggs. This results in polycystic ovaries (ovaries with many small follicles or cysts), infertility and hormonal imbalances.
Fertility specialists define PCOS as the presence of chronic anovulation (not ovulating) or an excess of male hormones (androgens). Below are common symptoms and health problems associated with PCOS:
- Menstrual irregularities
- Trouble getting pregnant due to lack of ovulation
- Increased hair growth (e.g. face and chest)
- Increased miscarriage rates
The goal of treatment for infertility in PCOS is to cause ovulation to occur predictably. Low-dose oral contraceptives can be used to decrease the amount of androgens in the bloodstream to decrease the effects of androgens on the body. Metformin is most commonly used to improve insulin resistance, lower insulin levels, and improve ovulatory function.
Obesity and Infertility
Obese women have a greater incidence of reproductive-related disorders and high-risk pregnancies, including gestational diabetes. Severely overweight patients also represent a high-risk group for infertility. At Eden, we try to provide a holistic approach to obesity and reproductive health by encouraging a proper diet, exercise, behavior modification and stress reduction in concert with drug treatment when indicated.
Up to 40 percent of women having trouble trying to conceive have endometriosis, a common cause of infertility and pelvic pain in women that occurs when tissue that normally lines the uterus grows outside the uterus. Endometriosis symptoms include pain during menstruation, intercourse, bowel movements, or emptying the bladder.
Endometriosis can affect fertility in many different ways:
- Failed or irregular ovulation
- Failed or impaired fertilization of eggs
- Chronic pelvic inflammation preventing embryos from developing
- Damage to reproductive organs such as the fallopian tubes
Endometriosis is often surgically removed during a laparoscopy. Endometriosis depends on estrogen for growth so drug treatments (e.g. Lupron) aim at reducing estrogen levels. If endometriosis has penetrated the fallopian tubes, in vitro fertilization (IVF) may be the best treatment option.
Cervical Factor Infertility
Sperm must swim in the cervical mucus traveling from the vagina through the cervix and into the uterus. Small glands that line the cervix provide cervical mucus. Cervical factor infertility occurs when the cervical mucus is not the right consistency, does not contain the right nutrients, or contains antisperm antibodies. Any of these cervical abnormalities can prevent the sperm from swimming through and fertilizing the egg.
If the cervical mucus contains antisperm antibodies, the antibodies will attack the sperm as if they were bacteria or viruses and prevent them from swimming through. Usually, these antibodies are produced by the female immune system; rarely, however, a man can produce antibodies to his own sperm. When these antibodies are present, numerous “dead” or immobile sperm are seen in the post coital test.
The first choice of treatment for cervical factor infertility is intrauterine insemination (IUI), which places washed and concentrated sperm directly into the uterus, avoiding exposure to the cervical mucus.
Tubal Factor Infertility
Tubal factor infertility occurs when diseases, damage, scarring or obstructions in the fallopian tubes prevent sperm from reaching the ovary to fertilize an egg, or prevents a fertilized embryo from reaching the uterus for pregnancy. Tubal factor infertility is most commonly caused by pelvic inflammatory diseases, sexually transmitted diseases or other diseases such as endometriosis.
Patients have a high risk of tubal factor infertility if they’ve had a ruptured appendix or previous abdominal surgeries, including surgeries for ectopic pregnancies, a condition in which the embryo grows outside of the uterus. Due to the location of these conditions, tubal issues are more likely to occur.
In vitro fertilization (IVF) is usually recommended as a first line treatment with moderate to severe tubal damage. While surgery may be an option if the tubal blockage is not severe. Tubal surgery is not usually recommended because the risk of increased ectopic pregnancy, IVF produces higher per cycle success rates than tubal reconstruction.
A patient with tubal sterilization may opt for a tubal reversal if she’s young and has no other factors contributing to her infertility. The advantages to tubal reversal is that even though the per cycle success rates are lower than IVF, numerous natural intercourse cycles can be attempted before turning to IVF.
Uterine Factor Infertility
Uterine factor infertility is the general term describing infertility resulting from either an abnormality of the uterus, or a complete lack of uterus.
Uterine factor infertility is relatively uncommon, affecting just three- to five percent of the population. Sometimes a woman is born with a misshapen uterus, such as the bicornuate or horned uterus, which can sometimes be corrected surgically. Large polyps and fibroids, non-cancerous growths that develop in or around the uterus, they can also interfere with fetal growth, and are removed usually via a hysteroscopy.
If the uterus is absent or severely damaged, the only option is to use the services of a surrogate with in vitro fertilization (IVF).
Environmental and Lifestyle Factors Affecting Fertility
Certain industrial chemicals, pesticides, environmental pollutants and radiation are known to contribute to or cause infertility. Lead poisoning, for example, has long been associated with infertility in both men and women. Cigarette smoking, alcohol, marijuana or taking certain medications, such as select antibiotics, Antihypertensives (for blood pressure), anabolic steroids or others, can also affect fertility.
A number of lifestyle factors affect fertility in women, in men, or in both. These include but are not limited to nutrition, weight, and exercise; physical and psychological stress; occupational exposures; substance and drug abuse; and, certain medications.
Specifically, research shows that:
- Obesity is linked to lower sperm count and quality in men.
- Among obese women who have polycystic ovary syndrome (PCOS), losing 5 percent of body weight greatly improves the likelihood of ovulation and pregnancy.
- Being underweight is linked to ovarian dysfunction and infertility in women.
- Strenuous physical labor and taking multiple medications are known to reduce sperm count in males.
- Excessive exercise is known to affect ovulation and fertility in women.
- Body-building medications or androgens can affect sperm formation.
- Substance use, including smoking tobacco, using other tobacco products, marijuana use, heavy drinking, and using illegal drugs such as heroin and cocaine reduce fertility in both men and women.
- Radiation therapy and chemotherapy can cause premature gonadal failure in both females and males.