- Click here for the ACOG Pamphlet on Evaluating Female Infertility
- Click here for the ACOG Pamphlet on Treating Female Infertility
Infertility is the lack of ability to achieve pregnancy after 1 year of unprotected sex (regardless of whether or not you were "trying to" become pregnant or not).
Problems achieving pregnancy are caused by female problems about 40% of the time and by male problems 40% of the time. About 10% of the time there is a problem both a male and a female problem contributing, and about 10% of the time, there is no obvious cause.
Male Problems
Of course, since we treat females as gynecologists, that's where our focus is. But one of the first tests that we suggest is a semen analysis for the male partner, regardless of whether or not he has had children in the past, since male problems contribute about 50% toward infertility. Sometimes sperm production is temporarily low because of a fever in the last 3 months, an infection of the testes of prostate, or because of smoking or marijuana use. Sometimes sperm production is chronically low because of an anatomic or congenital problem, which doesn't make achieving pregnancy impossible, but does make it difficult. Sometimes there is no or barely any detectable sperm at all. A normal sperm count is more than 20 million per milliliter, and we look at other factors as well, such as the shape, the motility, the presence of pus cells, etc. More on Male Factor Infertility, written by Dr. Debra Ravasia as a lay press article for Northwest Woman, in 2006...
Female Problems
Female causes of infertility fit into three categories: (1) Problems with ovulation (egg production); (2) Problems with the tubes either being closed or damaged (ie the egg can't get from the ovary to the uterus; and (3) Problems with an inhospitable environment for the sperm, egg or developing fetus - endometriosis plays a role here, as does chronic low grade uterine infection (called "endometritis"), or intrauterine pathology, such as polyps and sometimes fibroids that dangle into the uterus.
1. Problems with Ovulation
You won't be able to achieve pregnancy if you are not producing an egg, and your chances of achieving pregnancy are dramatically decreased if you are only producing one a few times a year instead of every month. The most common reason, by far, ie more than 95% of the time, is a condition called polycystic ovarian syndrome. It's a bit of a misnomer, because only about 3/4 of women with this condition actually have classic polycystic ovaries on ultrasound. This condition would better be called, "lack of ovulation because of insulin resistance". Insulin resistance is a decreased responsiveness of cells all over your body, to the hormone "insulin". Some people are born with a genetic tendency toward it (check if anyone in your family has adult onset diabetes, even in old age, or gestational diabetes when they were pregnant - insulin resistance runs in families). Nearly everyone become insulin resistant with weight gain and as a society we are gaining weight rapidly.
The ovaries need your body to be exquisitely insulin sensitive in order to have an ovulation each month. As your body becomes insulin resistant, you stop ovulating regularly, and your ovaries go into a "steady state" instead of an "cycling" state. When they are in a steady state, they produce high levels of the hormone "estrogen" and very little of its balancing hormone "progesterone". Estrogen acts like fertilizer on the endometrial lining making it thick and plush, while progesterone ("Pro" - gestation) trims the lining down and functions as a "lawn mower" on the lining of the uterus. So as your ovaries go into a steady state, your periods spread out and happen less and less often.
In the meantime, the ovaries continue to try to make eggs. They produce the usually wave of small follicles (simple cysts), each containing an egg. Under normal circumstances, a wave of follicles is produced in the first few days of each month, and one of them gets bigger than all the rest, destroys the others, and is releases its egg into the tube each month at midcycle. Following ovulation, the ovary produces large amounts of progesterone to counteract the effects of the estrogen exposure in the first half of the cycle.
But in the steady state, none of the wave of small follicles ever get to be the big dominant follicle that releases the egg and destroys the other follicles. Instead hundreds of them stay at the surface as small follicles, which often gives the impression on ultrasound of large "polycystic" ovaries. In fact they are normal ovaries, responding as any ovaries would, in an adverse metabolic environment. These small follicles, if not destroyed by the big dominant ovulatory follicle (because it doesn't get to that stage), produce testosterone. Testosterone causes skin changes such as acne, big skin pores, unwanted dark facial hair and body hair growth and male pattern balding. The insulin resistance can cause a brownish discoloration of the skin under the arms and in the groin area and cause skin tags.
Polycystic ovarian syndrome is a symptom of serious underlying metabolic problems, that in the long term increase your risk of heart disease, stroke, diabetes, sleep apnea, reflux, and a variety of estrogen related cancers, to name just a few. It always needs addressing, even if you decide not to pursue fertility treatment.
2. Problems with Tubal Scarring and Disease
The most common cause of tubal scarring is a chlamydia infection in the past, often the distant past. One chlamydia infection leaves you with a 10% chance of tubal disease. Two chlamydia infections, 30%. Often chlamydia infections are silent and cause no symptoms, but show up later as tubal disease. That's why we screen for them every year in women under age 25, or in any woman who is in a new relationship, or who has concerns that her long term partner might have been in another relationship recently.
We can often remove much of the scarring and adhesions throughout the pelvis that results from chlamydia. However scarring inside the tubes, that damages the microscopic small "fimbria" (tiny "tentacles" that push the egg along), cannot be removed.
3. Hostile Environment
Endometriosis is the presence of the uterine lining in places that it shouldn't be, such as inside your tubes or on your ovaries or on the lining of your pelvis. It is thought to get there by backflow through the tubes during heavy periods. It often causes pain, particularly low back pain for a few days prior to menses, that can be intense. Sometimes, however, there is no pain at all, and we just happen to find it when we are exploring for causes of infertility. It is thought to cause fertility difficulty in two ways: (1) creating a hostile environment for the sperm and the fertilized egg; (2) by causing anatomical changes, such as tubal damage and adhesions in the pelvis from the inflammation it induces. Click here for ACOG Patient Information on Endometriosis.
We often have a good look inside your uterus when we are exploring infertility, and take a small sample of the lining, a procedure called Hysteroscopy. We are looking for chronic inflammation and infection. We also want to optimize the shape of the inside of the uterus by removing any polyps or dangling fibroids that may be acting as "IUDs" and creating an environment that is not friendly to a achieving a pregnancy.
Diagnosing and Treating Female Infertility
Medical work-up for female infertility begins with a complete history and physical.
Pelvic ultrasound is very useful for detecting anatomical problems, looking at the size and shape of the ovaries, looking for tumors, cysts and fibroids, and looking at the thickness and regularity of the uterine lining and the uterine muscle. It is NOT good, however, at detecting endometriosis or adhesions or tubal disease, and a "normal" ultrasound does not rule out any of these conditions.
If the semen analysis (sperm count) is normal, and you are ovulating regularly, we usually go on to look for other causes such as tubal disease and endometriosis.
Laparoscopy is an outpatient surgical procedure, done in the hospital, at Sacred Heart Medical Center (hyperlink) with general anesthesia. During this procedure, we look around your pelvis, over and under your uterus, over and under your ovaries, on your bladder, on your bowel and on the pelvic sidewalls, for any signs of endometriosis. When we find it we get rid of it by lightly cauterizing it. This has the effect of improving fertility by 3 times, but still not completely back to normal. The effect lasts a year. We also run a dilute dye mixed with sterile saline from your uterus through your tubes and watch to see if it spills into your abdomen to be sure the tubes are patent (open). As well, we often place a small camera through the vagina and cervix and into your uterus (hysteroscopy) and have a good look inside the uterus and take a small sample of the lining, and remove any polyps.
If the semen analysis is normal, and you are NOT ovulating, we explore why not. First we rule out thyroid disease and a few other rare disorders that can cause this, such as tumors and premature ovarian failure and prolactin overproduction. But 95% of the time, this is a problem of insulin resistance (polycystic ovarian syndrome aka "metabolic syndrome"). Treatment is carefully structured lifestyle change, and involves changing body composition such that you have less fat tissue but maintain your lean tissue (our physicians have bariatric medical training and are very good at this - we typically get you there with a low glycemic index diet, (there are a few options, including the plan outlined in "Lifestyle Medicine" or for a faster and more aggressive approach, the plan outlined at www.ajuvamedicalweightloss.com), fitness and exercise, improving insulin resistance with insulin sensitizing medication such as Metformin, using medications such as "Clomid" or "Letrazole" that "trick" your brain into thinking that there is not enough estrogen, which causes it to produce hormones ("FSH" and "LH") that induce an ovulation. Your provider will discuss the pros and cons of these treatments and come up with a plan for you.
Our clinic offers a basic infertility work-up, usually covered by insurance, including laparoscopic surgery where indicated, endometriosis diagnosis and treatment, polycystic ovarian syndrome and simple ovulation induction. We take a holistic approach and look for how these conditions affect your overall health and well-being and try to address all aspects.
If you need to go beyond these to advanced treatments such as ovulation induction with injectible medications, help with male factor infertility, in vitro fertilization, surrogate pregnancies, same sex partner pregnancies and other advanced techniques, we will refer you outside of our clinic and help set that up for you.
