Infertility 101
What is infertility?
Textbook infertility is trying to get pregnant for 12 months without success if you are under 35 and six months if you are 35 or older. It is different so we can get women who are running out of eggs or losing egg quality into an evaluation sooner. Also, if you have no or irregular periods, have trouble with intercourse such as pain or your partner is unable to achieve an erection or ejaculation, you need to see an REI or OBGYN no matter what age you are. Women who are 40 and older should see an REI right away if you are trying to conceive. As you can see there are many factors that go into infertility and when you should see a specialist.
Natural Fertility
Your fertility starts to decrease at age 32 with a more dramatic decline at age 37. These numbers are important to factor in when you are planning to have children. Especially if you want more than one child. The rate of infertility is about 15% or 1 out of 8. This number also depends on when you begin trying to conceive. Your chances decrease the older you get, and it is important to think about how you want to have children. Do you want to do it solo or with your partner? Do you want to freeze your eggs? Also, as the rate of infertility rises, so does the rate of genetic abnormalities and miscarriage.
Understanding your Menstrual Cycle
Before we go into the causes, it is important for you to understand the menstrual cycle. There is a podcast and blog post discussing the menstrual cycle in-depth. Like I mentioned before, regular cycles are key and if your cycles are predictable you can time the fertile window. You can do this with apps or you can use methods like an ovulation prediction kit, cervix mucus monitoring, or basal body temperature monitoring. Many people ask when the best time to have sex is and the answer is the day of ovulation and the several days leading up to it.
What causes infertility?
Are you ovulating?
The first thing I say to my patients when they come to see me is, “Tell me about your periods.” How many days between each cycle? Are they regular? How long do they last? Do you have spotting? Do you have pain? Your periods give me a lot of data. There can be different reasons why you are not ovulating. It can be a brain function problem which means your brain is not sending out hormones such as LH and FSH that cause you to ovulate. This can be due to stress, exercise, thyroid or pituitary gland abnormalities, not eating enough, and exercise. It can also be ovarian dysfunction such as PCOS. The brain is sending out a normal amount of FSH, but it is getting dispersed between all of the follicles and it’s not a strong enough signal to get one to ovulate. It can sometimes be overcome with lifestyle and dietary changes or medications for ovulation induction. Another reason you may not be ovulating is you may be in ovarian failure. You may be out of eggs. We call this menopause when this happens around age 50. When it happens early, it’s called premature ovarian insufficiency or POI. If this is happening to you or you are not having a period, you need to see a doctor. Even if you are not trying to conceive, your body needs an estrogen replacement. The female body is not meant to be without estrogen.
Ovarian Aging
As you get older you have a decrease in the number and quality of your eggs. The quality is typically associated with age and we have no way of measuring or evaluating this. Studies suggest that the majority of eggs from women over the age of 40 are chromosomally abnormal which means a lower chance of success and a higher chance of miscarriage. However, lifestyle factors such as what you eat and environmental toxins likely play a role in your egg quality. Egg quantity or your ovarian reserve decreases with age but everyone trying to conceive has their own rate of decline. This can be evaluated in two different ways. One is with an antral follicle count which counts the small follicles or eggs at the start of a menstrual cycle. The other is an AMH (anti-Müllerian hormone) blood test which tests your egg count. Importantly, a low AMH value is not associated with infertility or fecundability. The numbers can also change month to month depending on how many eggs are released from the vault. I use it to categorize you above average, average, below average, and critical.
Tubal Factor
The fallopian tubes are crucial when it comes to you being able to get pregnant. When an egg is released from your ovary it has to be picked up by your fallopian tube. The end of the fallopian tube is called the Fimbriae. So the egg moves into the Fimbriae then further into the fallopian tube. Sperm is in the vagina with intercourse, and it has to swim out of the ejaculate through the narrow cervix, into the uterus, and into the fallopian tube. This is where fertilization happens. An embryo is then formed in the tube and for the next five to six days it grows until it advances into the uterus. So, if your tubes are blocked, you will not be able to get pregnant naturally, but you can get pregnant through IVF. Your fallopian tubes are very sensitive. If you’ve had chlamydia, it can cause infertility. Endometriosis can cause damage to your fallopian tubes. Sometimes the only symptom of endometriosis is painful periods, and you may have it for years and just think those painful periods are normal. Other symptoms include pain with intercourse or having GI symptoms when you are on your period. I always say that if your period is interfering with your life such as canceling plans or missing work you need to be evaluated for endometriosis. Unfortunately, this is a disease that can only be diagnosed with surgery. We treat it differently based on where you are in your life. Removing the disease can lower inflammation levels and be helpful for trying to conceive or we move to a more aggressive treatment plan depending on your goals.
Uterine Factor
This is another cause of infertility. Fascinatingly, your uterus has two different forms. Uterine buds form and they grow and elongate next to each other like two little tubes. Then they connect together, and the inside is divided by a septum that has to reabsorb before you get that empty triangle like form that you’re used to seeing. These are called Müllerian anomalies. You can have a failure of any different part of this process. The most common is having a uterine septum which means you had a failure of reabsorption and leaves you with a small septum in the uterus. The septum is avascular so it doesn’t have that muscular myometrial component to the uterus that contracts and has lots of good blood supply. Therefore if a pregnancy comes and tries to implant there you have an 80% chance of miscarriage. This number is extremely high, so if you have a uterine septum we are going to go ahead and take it out through surgery. We take a camera and put it through the vagina, cervix, and uterus. We use small micro-instruments through the camera, fill the uterus with water, and cut the septum out. It’s a super easy surgery that is also fascinating. Another uterine abnormality is called uterine fibroids. It is a benign muscle mass inside the uterus. Depending on where these fibroids are, they can prevent implantation which can be associated with miscarriage.
How can we monitor these factors?
Both tubal and uterine factors are best evaluated with a test called HSG also known as the x-ray dye test. During this test, a speculum is placed in the vagina, a small catheter goes to the cervix, and dye is injected into the uterus while we take x-rays. The x-ray allows us to see the inside of the uterine contour, and the dye can move through the fallopian tube. The combination of the HSG test and a transvaginal ultrasound gives us all the information we need to know about your anatomy.
Male Factor
Our male partners can also play a role in infertility. The easiest way to test males is through a semen analysis. This is a sample of sperm that gets evaluated under a microscope. We are looking for volume, the concentration of sperm, motility (how they move), and the shape of the sperm. I believe that structure equals function. Even if the body is making enough sperm, the environment in which the sperm grow is really important. Diets and toxins can play a huge role in sperm function. Sperm changes every three months, which is very different from women. Therefore, if your partner has had a child previously, it does not mean he is still fertile. Therefore, I will do a semen analysis no matter what.
What is the evaluation like?
So when you come into my office for infertility, we are going to have a chat about your history. We’ll talk about your menstrual cycle, some other medical history such as medications, surgeries, abnormal pap smears, and your lifestyle. Then we will do a pelvic ultrasound to look at your uterus and ovaries. We will order some blood tests such as AMH and preconception bloodwork. We will also do genetic carrier screening to see if you and your partner are silent carriers of the same disease. I’m talking about life-altering diseases. In this case, we would do IVF which allows genetic testing of embryos. This gives us the greatest chance of reaching your goal of having a live-born healthy baby. Depending on your history, we may order other tests such as thyroid, prolactin, Vitamin D, or hemoglobin A1C. Next, you will get the HSG test we talked about earlier. This will need to be done when your uterine lining is its thickest to get the best results. Lastly, we will do the semen analysis. Once I have all of your data, I will come up with a treatment plan that is best for your individual case.
What are my treatment options?
There is no one-size-fits-all treatment plan. Your goals play a big role in your treatment recommendations. First, you will need to have surgery if we find a septum, polyp, or follicles. Then, if your periods are irregular, we need to make you ovulate. This can be done with oral medication and there are two options that either lower your estrogen levels or block your estrogen receptors. Either way, your brain does not sense that estrogen is there and sends out your signal of FSH. It will send out the signal at a higher level than normal and make you ovulate maybe one or more eggs. However, if your brain is your problem and it struggles to send out FSH or LH, taking medication will not work. We will find this out in the evaluation. In this case, you will take another medication that is essentially FSH and LH in an injectible form instead of coming from your brain. The risk of these medications is multiple pregnancies so we will monitor with ultrasound. I am not trying to get you on a reality TV show. So once you have four follicles, we will cancel the cycle, and tell you not to have sex until the next month. It’s important to know that your chance of having multiples is higher than normal when you are on these medications. If you have a medical condition that would cause problems if you were carrying multiples, we will shy away from these treatments. We would likely move on to IVF which has a lower chance of multiples. Something we often pair with these medications is called an IUI or Intrauterine Insemination. It is often used for mild male factor, unexplained infertility, same-sex couples, or single people using donor sperm. For this process we have a male ejaculate sample during the time of ovulation, we clean off the sample, put it into a small catheter, and inject it into the uterus. This does not ensure fertilization, but what I like to say is that it is getting your best players further down the field. When we combine this with ovulation induction, sometimes our goal for unexplained infertility. This means we are getting your best players further down the field with multiple goals at the end. I cannot make it happen but I can certainly increase your probability by having more opportunities.
IVF
Of course, IVF is going to be the treatment option with the highest success rate and it is something we usually recommend for unexplained infertility. IVF can overcome so many barriers. It doesn’t matter if your tubes are blocked. Eggs are coming out, getting injected with sperm, embryos are growing in a controlled environment and getting transferred back into the uterus at the right time. IVF is the same thing as egg freezing except for what happens to the eggs after they come out of your body. So if you don’t have a partner and just want to freeze your eggs, the process is essentially the same. So our goal is to have the eggs from the vault grow each month by giving you the injectible hormones at higher doses. So for 8-12 days, you will give yourself shots at home, and you are coming into the office every 2-3 days for ultrasound and blood work so we can monitor how the follicles are growing. When you get to the stage where you have the highest number of mature eggs, you will undergo an egg retrieval which is a procedure where you will get an anesthetic in your arm, and we go in vaginally with a needle. The needle is inserted into all the follicles, the fluid is drained, and the eggs are taken out. We immediately get them into test tubes. The eggs are isolated out, cleaned, and cracked open to inject sperm. Sometimes we do something different and put the eggs in a dish, squirt the sperm on top, and put the dish into an incubator and see what happens. The next day is day one. We see how many eggs have fertilized, and they grow out for 5-6 days until they get to the stage of a blastocyst. This process has changed drastically over the past few years. At this stage, we do the implantation also called an embryo transfer. You are fully awake during this process, and it doesn’t feel much different than a pap smear. We can also freeze the embryos and do the transfer the next month when your hormone levels are down in a more natural phase that has been shown to have higher pregnancy rates. The embryos can also be genetically tested to detect the number of chromosomes and genetic abnormalities. We can also test for single-gene disorders or translocation. This allows us to choose the embryo that has the best chance of survival. Your age has a huge impact on your chance of abnormal embryos.
Donor Egg IVF and Egg Freezing
Donor egg IVF is when you receive eggs from someone else. It is necessary when you have either run out of eggs or you have a low ovarian reserve that statistically or financially does not make sense. Egg Freezing is going through this entire process and stopping at the egg stage. It is important to know that embryos freeze better, so if you have a partner that you plan to have children with in the future, fertilizing your eggs makes more sense. Eggs are more fragile so you can expect about an 80-85 percent survival rate. Your doctor should give you a goal of how many eggs you need to freeze to give you the best chance of getting pregnant. Egg freezing is not guaranteed. The reason to do egg freezing is to give yourself the best chance of having a genetic child with a partner that is not yet determined. Thinking about this at a younger age will be the most beneficial to you. I hope that gave you an in-depth overview of infertility and what the process will look like. There are many other reasons for infertility that I did not discuss as well as other treatment options. These are just the most common.
My challenge to you
I want to change the way you think about infertility. Infertility can be isolating and there can be a lot of shame and blame thinking it is your fault you can’t get pregnant. Please stop asking your friends when they are having kids. If someone opens up to you about their struggles, please be supportive and be mindful of what you are saying. No more, “Have you just tried relaxing? or “My cousin did this.” Ask, “What can I do for you?” Ask if they need you to go with them to an appointment or if they need to talk to you alone. Stop telling people they can just do IVF. As you know, it is not an easy process and it is not a guarantee. Stop telling them they can just adopt. This is not helpful. Think before you start asking people questions that may potentially hurt them. Give them a big hug and words of encouragement.