Answer: Unexplained infertility is frustrating for both the couple and the physician. It is estimated that up to 10% of couples with infertility will have no explanation. Our group at Fertility Centers of the Carolinas has a special interest in this type of couple and has ongoing research that suggests implantation failure may be part of this scenario. When the male has normal sperm and the female has open tubes, ovulatory cycles, and normal hormone profile, we have to look beyond the usual causes. The good news for these couples is that this often represents a form of inflammation that can be diagnosed and treated effectively. We usually recommend that women with unexplained infertility have a careful evaluation for endometriosis. In an ongoing study of couples with unexplained infertility, we find that the vast majority have stage I or II (minimal or mild) stages of the disease. Once diagnosed, most of these couples conceive on their own without further treatment. Unfortunately, many couples do not get early diagnosis and therefore may have problems even during in-vitro fertilization (IVF). Our philosophy is to diagnose our patients first and then start treatment. We believe this has made big difference in our high success rates in couples with unexplained infertility.
Polycystic Ovary Syndrome Question: I have been trying to get pregnant for the past two years. The hysterosalpingogram showed that my fallopian tubes were open and my husband was told he is okay. I don’t get my periods very often but when I do, they are very heavy and painful. What should I do next?
Answer: The most common cause of irregular menstrual cycles is polycystic ovary syndrome or PCOS. This is the most common endocrine disorder affecting reproductive-age women and is often associated with irregular cycles, polycystic-appearing ovaries on ultrasound, and frequently signs or symptoms of excessive male hormone, testosterone. This can include acne or excessive hair growth, although this does not have to be present to make the diagnosis. Importantly, we like to exclude other conditions that could cause the irregular cycles including thyroid disease, high levels of prolactin, or disorders of the adrenal glands. PCOS has a genetic component and can lead to insulin resistance and diabetes if left untreated. There is also a risk for endometrial disease including endometrial polyps or even hyperplasia or cancer if left untreated for many years. The good news is that this is a recognized cause for infertility and can be adequately treated with diet and exercise, although medications are often helpful as well. It is surprising how many women have PCOS, perhaps reflecting changes in our society regarding weight, exercise and eating patterns.
Male Factor Infertility Question: My wife and I have been trying to get pregnant for over a year. My doctor tells me that my sperm are moving very fast and that they have a “morphology” problem. So far my wife has been told she was normal on all her testing. What can we do for my problem and can we still have children using my sperm?
Answer: Morphology refers to the size and shape of the sperm and is an area that is commonly abnormal in infertile couples. Normally, sperm have an oval-shaped head, a thickened midpiece, and a long, thin tail that beats back and forth. Sperm with abnormal morphology may have heads that are too large or too small, two heads, two tails, long tapered heads, or broken midpieces and tails. The abnormal sperm do not lead to abnormal children, they simply do not seem to fertilize eggs normally. Investigators have looked for causes for morphology defects such as infection, environmental toxins, and exposure to high heat, but no consistent connections have been proven. Still, there is no absolute level of normal morphology below which pregnancy does not occur.
According to the World Health Organization’s criteria for judging sperm shape, only 30% of sperm need to be normal for a semen analysis to be considered normal. Most fertility centers use a stricter set of criteria called the Kruger criteria by which only 15% of sperm need to be normal. Despite this 15% cut off level, many men with lower morphology scores may still be fertile, albeit, subfertile.
Many dietary supplements and medications have been prescribed for men with low sperm morphology, but none have made significant differences for all patients. Still, it makes sense to practice a few preventive measures and healthier lifestyle choices. Avoiding exposure to high heat and chemical solvents, eating a balanced diet, and supplementing with a good multivitamin are reasonable, low cost ideas.
While intrauterine insemination (IUI) is considered to be a first line treatment for male factor infertility, it really does not compensate for fertilization problems associated with low morphology. Modest decreases in morphology may still be treated with IUI, but more profound abnormalities are usually treated with in-vitro fertilization (IVF) combined with intracytoplasmic sperm injection (ICSI). ICSI involves selecting the most normal looking sperm under a microscope and injecting them into eggs in a laboratory. The embryos that develop after ICSI are perfectly normal and lead to normal IVF pregnancy rates.
Endometriosis Question: We have been trying to get pregnant and no one seems to know what’s wrong with us. My husband’s sperm count was normal and I have a normal uterus and tubes. I do notice spotting for several days before my period starts and have always had very painful periods, especially on the first day. What can we do?
Answer: The approach to couples with infertility includes assessment of the male (semen analysis), the fallopian tubes (HSG) and some assessment of ovulatory status. In women with painful periods, inclusion of a laparoscopy is also warranted, since up to 40% of couples we see have endometriosis diagnosed. This is a condition that is common and often overlooked. Spotting or bleeding at times other than your period is sometimes a sign of endometriosis. The presence of endometrium (lining of the womb) outside of the uterus is associated with painful menses but also infertility. Interestingly, even mild forms of this disease can cause profound infertility. The good news is that endometriosis is very treatable and most women conceive after it is diagnosed.
Cervical Factor Infertility Question: When I was younger, I had an abnormal pap smear and was told that my cervix needed to be treated. The doctor performed “cryotherapy” and since then my pap smears have been normal. Now that we are trying to get pregnant, I wonder if there is reason for concern related to having my cervix frozen.
Answer: Having cryosurgery, “freezing” your cervix, rarely causes a complication preventing pregnancy. The cervix functions by making watery mucus around the time of ovulation that makes it easy for the sperm to swim to the egg. After surgery on their cervix, some women have a decrease in mucus production. When there is a decrease in mucus, sperm might have trouble getting to the egg for fertilization. This can easily be treated with intrauterine inseminations (IUI). IUI is a common fertility procedure that improves fertility in most couples. There is no more discomfort with an IUI than a woman encounters with a pap smear. A small catheter is placed through the cervix and into the woman and the sperm are injected there. This places the sperm beyond the damaged cervical glands. There is one other thing to think about for women with a history of cryosurgery of the cervix. They are at a slightly increased risk of having tubal damage for a number of reasons. If pregnancy does not occur soon, even with IUI, a test of the fallopian tubes would also be helpful.
One other concern about more advanced treatments for cervical dysplasia, including removing some of the cervix (cold knife cone or LEEP procedures) is that scarring might occur that could limit the outflow of menstrual blood. Women with this problem often notice an increase in pelvic discomfort during their menses. In addition to causing infertility, cervical stenosis could also increase the development of endometriosis.
Answer: Both human and animal studies have demonstrated a negative effect of both acute and chronic stress on hormone production and fertility. Animal studies are much more convincing, given our ability to perform experiments in a very controlled environment. The difficulty with interpreting such studies is that stress is difficult to measure and what may be stressful to some is just a mere annoyance to others. Likewise, different individuals will experience varying degrees of their own innate stress response (e.g., rapid heart rate, shallow breathing, stomach upset) when faced with the same unpleasant circumstances. What seems clear is that removing the stress, or learning to better cope with it, has a positive impact on fertility. For example, recent reports on the efficacy of teaching women how to elicit a relaxation response to previously upsetting situations using mind/body techniques supports the notion that thoughts influence the body’s physiology. Is stress typically the sole cause of infertility? No. But it is an irrefutable contributor to fertility problems in many cases.
Answer: Infertility after a previous successful pregnancy is called secondary infertility. Even though you may be in great health, subtle anatomic and hormonal issues, as well as age factors could be contributing to your difficulty. For example, up to 40% of women in their reproductive years develop fibroid tumors in their uterus. Fibroids are benign muscle tumors that can distort the shape of the uterus and prevent embryos from implanting. Others may have hormone issues, like an underactive thyroid gland (hypothyroidism), that can affect the ovaries’ ability to release eggs and make hormones.
One of the most subtle causes of secondary infertility is reproductive aging. As women get older, their ovaries contain fewer eggs that require stronger signals from the pituitary gland to ovulate. When the eggs are released, they tend to not fertilize as easily and may produce embryos that stop growing. Outwardly, this may be show up as infertility. Aging factors seem to become more important as women approach the age of 40 and beyond.
Weight & Infertility Question: My husband and I are both overweight. Is this a cause for infertility?A. Women and men who are overweight or obese have significantly lower pregnancy rates when compared to their normal-weight peers. Fat cells are hormonally active, making weak hormones on their own, converting some weak hormones in the blood to stronger ones, and acting as storage depots for many other hormones. In addition, women who are obese have much higher rates of ovulation problems, irregular periods, and miscarriage. Even the most potent fertility treatment options, such as in-vitro fertilization, are less successful for women who are obese.
Answer: The good news is that weight loss through diet and exercise can reverse these negative effects. The other bit of good news is that women do not need to lose 10 dress sizes to improve their fertility. Several well-designed studies have documented improved success for infertility treatments with as little as a 5% weight loss. For a woman who weighs 200 pounds, that means losing 10 pounds. The key concept with weight loss to improve fertility is to increase fat metabolism, that is, to burn fat even when weight may be stable. Individuals who exercise regularly quite often lose weight initially, then go through a period of time where their weight loss plateaus. As frustrating as this phenomenon can be, they are still receiving benefit from their work-outs because they are still burning fat; it is just being replaced with muscle that is more dense than fat.
Answer: Virtually all scientific evidence points to the fact that cigarette smoking has negative effects on both female and male fertility.
Smoking appears to accelerate the loss of a woman’s eggs as she ages, and may cause an early menopause. It is also strongly associated with an increased risk for miscarriage. Women who smoke during pregnancy are known to have low birthweight babies and preterm labor and delivery. There is also an increase in sudden infant death syndrome in homes where a smoker lives.
Men who smoke are known to have lower sperm counts and more abnormal sperm than men who do not smoke. The direct effects of this on fertility are less clear, but the second-hand smoke that the female partner will be exposed to can create all of the same problems as if she were smoking herself.
Ultimately, smoking cessation needs to be the goal, but significant reductions in smoking are believed to help fertility, and should be attempted by all couples attempting to conceive who also smoke.
Answer: There are countless articles published in the reproductive medicine literature that show that extremes of body weight—either being too heavy or too thin—diminish pregnancy chances. On the most basic animal level, this makes sense, as you want individuals who are fit and have adequate energy stores to have offspring in order to continue the species. When considered in this light, it is a question of maximum survival. Now, we know that the external pressures that affected our forefathers are not nearly as pressing as they once were—things like food, famine, disease, etc. But the internal bodily adjustments that occur involuntarily are still there and can affect reproduction.
In the case of being overweight, for instance, we know that women may suffer from any of the following:
- altered menstrual cycles
- elevated testosterone (male hormone) levels
- elevated insulin levels
- diminished egg and embryo quality
- increased miscarriage rate
Even high-tech treatments, such as in-vitro fertilization, are less effective when women are overweight. A study that we published in the journal Fertility and Sterility in 2003 showed that women who were moderately overweight or obese had a 33% decline in IVF pregnancy rates compared to normal-weight individuals. This translates into greater expense for fertility therapy–emotionally, physically, and financially.
The good news is that past and present research has shown that modest weight loss (that is, 5-10% of total body weight), can significantly increase pregnancy chances. This means that a woman who weighs 200 pounds should have a weight loss goal of 10 to 20 pounds before beginning any infertility therapy. The reason why modest loss works has to do with the effect of fat on the cellular level. Fat cells are hormonally active, making weak estrogens, driving up insulin levels, and acting as storage depots for most steroid hormones. When we diet or exercise, we mobilize fat stores and lessen the hormonal effects of fat. It is worth mentioning that the combination of diet and exercise seems to work best when it comes to improving pregnancy chances. Even though individuals who exercise may not seem to lose weight as quickly, due to the replacement of fat with more dense muscle tissue, they are losing inches and breaking down fat cells.
The effect of being overweight on male fertility is less clear, but seems to point in the same direction—that fat decreases sperm production and quality. We know, for instance, that men who are obese have higher circulating levels of estrogens in their blood and are more prone to diminished testosterone production by the testes. Although we cannot say how much weight is too much, the same general rules for improved fitness that apply to women also apply to men. Fortunately, studies in which groups, rather than individuals, have worked together to lose weight have shown greater overall success in achieving fitness goals. Couples are encouraged to work together in this regard to improve their chances of success.
Answer: Just as women who are overweight have diminished fertility, evidence exists for a negative impact for thinness. In IVF studies such as the one we published in 2003, women who are underweight for their height may have a 31% reduction in pregnancy rates. Even women who are considered to be normal weight but are in a state of negative energy balance, that is, burning more calories than they are consuming, have significantly lower success rates with various treatment options. This problem can be attacked in one of two ways: either stop exercising vigorously, avoiding things like cardiovascular-type activity, or increase food intake with good nutrition by eating balanced meals from the four basic food groups. In general, women who have adequate caloric intake but are “restrictive eaters” still can have problems with their fertility. Restrictive eating means scrutinizing every morsel of food in your diet and avoiding certain categories of food, throwing off the natural balance that we all need. Of course, none of the physicians at Fertility Center of the Carolinas want you to adopt an unhealthy lifestyle, but we do want you to be more aware of the effect of your eating and exercise behaviors.
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