"We do not fear the unknown- we fear what we think we know about the unknown."
There are millions of American women right now wondering why they are not getting pregnant. Out of these millions of women, some have faced the dreaded diagnosis of 'infertile' and for other's, it's simply taking longer than anticipated.
More than 7 million women in the U.S. suffer from infertility (source). Infertility can be tricky because it does not necessarily mean that a couple can not get pregnant on their own. It can mean anything from a fertile couple that is simply taking longer to conceive than the 12-month time frame that declares a couple infertile, to the other extreme, such as having no sperm and being completely sterile.
There are many unknowns and fears, making the process feel out of hand. For some couples, the reason may simply come down to timing intercourse incorrectly, for another it may be to lose 10 pounds and yet for another, it may require a more invasive procedure such surgery to fix a tubal blockage.
People still today tend to believe that women are the main cause of infertility, but the truth is that infertility is equally split between men and women. There are many unknowns and fears when getting pregnant takes longer than anticipated, making the process feel out of hand. Education can help empower you during this time and give you more control. For this week's blog, we will first address female-factor infertility and next week we will take a look at male-factor infertility diseases and conditions.
Ovulatory disorders are the most common cause of infertility in women and account for 40% of cases of female infertility. In some women, ovulation may fail to occur altogether (anovulation) or as in most cases, it may be irregular.
Irregular ovulation during reproductive years is typically due to hormonal imbalances. Once we are in our late 30s or early 40s, irregular ovulation is a natural process that occurs as we age but can happen prematurely.
Sometimes spotting can be confused for a period, but you will not have a regular period if you do not ovulate. You will typically know if you are irregular by your periods being shorter or longer than average or if you skip periods. If your cycle is in the range of 21-35 days this indicates that you are probably ovulating regularly. The biggest concern fertility expert, Dr. Don Aptekar, finds with cycle lengths closer to 21 days or 35 days are couples missing their fertile window.
Hormonal imbalances may be due to diet, weight (either too much or too little), hypothyroidism or hyperprolactinemia or low progesterone. PCOS is one of the most common ovulatory disorder and will be discussed below.
If you are found to have an ovulatory disorder, your doctor should work with you to find out the cause behind the anovulation or irregular ovulation.
Some doctors feel that patients with irregular periods are pushed to medication or IVF too early. For someone that ovulates 6 times a year, it will naturally take them longer than someone that ovulates 12 times a year. If you are ovulating, you may not need to take fertility drugs. Fertility drugs will often shorten the process but the risk is multiple births. Fertility drugs encourage the body to make more eggs. Dr. Aptekar says, "If you don’t want twins or triplets, then wait to find out if you are ovulating first. If you pinpoint your fertile window and when you ovulate, you will increase your chances greatly getting pregnant naturally." Click here for 'Who Needs Fertility Drugs to get Pregnant: Fertility Drugs 101.
If you and your doctor believe your ovulation disorder could be due to too much weight, too little weight, or your weight fluctuates often, you may consider working with a nutritionist that specializes in fertility.
Polycystic Ovarian Syndrome (PCOS)
The name Polycystic Ovary Syndrome (PCOS) is so confusing that the medical community is thinking of changing the name (source). While the name implies that it is a disease of the ovaries, it is actually an endocrine disorder that has multiple side effects. It is also the most common cause of female infertility (source).
Since the symptoms vary significantly in individual women, it is often misdiagnosed or remains undiagnosed. Out of the 5-10% of women who have PCOS, it is thought to be undiagnosed in up to 70% of the women (source). It is also the most common cause in women for infertility. Due to the hormonal imbalances, many women with PCOS do not ovulate regularly, which is why women typically find out that they have PCOS when they are trying to get pregnant.
Common symptoms include irregular menstrual cycle, weight gain, acne and excess facial hair.
To be diagnosed with PCOS women need to meet 2 out of 3 criteria:
- Elevated males sex hormones
- Irregular or absent periods
- Multiple follicular cysts on one or both ovaries.
Doctors, such as Dr. Kyle Willets find that the number one way to treat PCOS is via a healthy diet and exercise (see Dr. Willets personal story on healing from PCOS here). You actually don’t need to lose a lot of weight to improve ovulation and insulin sensitivity.
As far as drugs to help, Metapharm is used for insulin resistance and can be used to correct the hormone imbalance. Often that alone will correct infertility due to PCOS.
There are also other medications to treat the hormonal imbalance such as spironolactone, progesterone and thyroid medication.
Low progesterone can also be classified under ovulatory disorders and may be a symptom of other disorders such as hypothyroidism. If you have low progesterone, it may cause insufficient ability to maintain the endometrium to support a pregnancy (source). Symptoms of low progesterone include a low luteal phase and low energy. If you have been diagnosed with unexplained infertility, you may want to request a progesterone level test via saliva test (source).
There are lifestyle factors that you can change to see if it helps balance your estrogen/progesterone levels for a healthy cycle. These include avoiding products that contain toxins that are endocrine disrupters found in food, plastic, household cleaners and makeup.
Your reproductive endocrinologist can also prescribe you progesterone supplements in the form of pills, vaginal suppositories and/or injections. The goal is these medications is to help thicken the uterine lining to allow the embryos to attach.
Endometriosis is a chronic disease that causes the endometrium, or lining of the uterus, to grow outside the uterine cavity. In some cases, this can lead to blocked tubes. Having endometriosis does not necessarily mean that you are infertile. It is estimated that 60-70% of women that have endometriosis will have no problem having children (source). Common symptoms include heavy and painful periods or pain during intercourse, however, not all women experience symptoms or pain.
Endometriosis can only be diagnosed by laparoscopy, a surgical procedure using a lighted tube to check for any visible endo lesions (also called implants) and adhesions (also known as scar tissue). Some endometriosis isn’t visible, yet it responds well to medication. Many doctors recommended a treatment that involves medical and surgical therapy to treat this disease.
Tubal Factor Infertility
Dr. Don Aptekar says that 3 things need to happen for conception: 1) there needs to be sperm, 2) there needs to an egg and 3) the two need to be able to get together. If you find that your partner's sperm is fine and you are ovulating just fine and still not getting pregnant, your doctor may suggest checking that your tubes are open and that your uterus is healthy. Tubes can be blocked due to a history of STDs such as chlamydia, endometriosis, or scar tissue that forms after pelvic surgery.
To find out if your tubes are blocked, your doctor will perform a hysterosalpingogram in which a dye or contrast material is put through a thin tube into the vagina and into the uterus. The fallopian tubes and uterus are connected, so the dye should flow into the fallopian tubes from the uterus. This fluoroscopy or X-ray can show injury and abnormalities of the uterus and fallopian tube. If it shows that there is a blockage, your egg can not travel from the fallopian tube to the uterus. This can lead to an ectopic pregnancy or prevent the sperm from fertilizing the egg. This procedure can also detect if there are any problems in the uterus that would prevent implantation of the fertilized egg.
If there is a blockage or significant damage, treatment typically involves IVF, medication or surgery. For more information on procedures and treatment click here for a chart of the pros and cons of each.
Age (or Egg Factor)
While many women are able to conceive naturally without problems into their late 30s, age is the most important factor for women in regards to being able to conceive and have a healthy child. It is also the one area that to date has no treatment. Fertility starts to decline in our early 30s and then more rapidly declines after 35 years of age. While there are tests to check on your ovarian reserve, there is no test for the quality of the eggs.
You can't stop the continual loss of eggs but you can try to be as healthy as possible. Some examples include losing weight, managing any hormonal or thyroid issues and taking vitamins such as fish oils, Vitamin D and CoQ10, which all help egg quality.
If you have no or little eggs left and the statistical chance of conception is low even using IVF, some women opt to use a donor egg and others opt to adopt.
Dr. Aptekar says the number one reason his patients have a difficult time conceiving is that they 1) have not waited long enough and 2) are timing intercourse wrong. Learning about your ovulation cycle will help you pinpoint your fertile window.
There are typically about 6 days a month you are fertile. Having intercourse two days before you ovulate will significantly increase your chances of getting pregnant (see graph). As you can see in the graph, the day after you ovulate that is a 0% chance of getting pregnant.
There are several techniques to determine your fertile window.
- Use a product to find your fertile days and when you ovulate that uses your own biological clues (such as a temperature sensor, LH-sticks that measure LH-hormone levels from urine or saliva tests that measure your estrogen levels). Vaginal core temperature is the most accurate way to identify when you ovulate.
- Use a calendar or app to track your cycle length in conjunction with using other methods. Since timing is everything, keeping track of when your period will start and the length of your cycle will help to get the timing right.
- Learn about your cervical mucus and watch for when it is clear and slippery which indicates that you are fertile.
- If waking up the same time each morning does not seem too daunting, you may want to track your basal body temperature (BBT) to identify the day you ovulate. A rise in temperature indicates that you ovulated. Internal temperature sensors can predict ovulation by detecting a subtle dip that occurs two days before ovulation.
Other risk factors that are not listed above include smoking, shift work, extreme stress, anatomical abnormalities, not enough sleep and certain medications.
If you are under 35 years of age, your doctor will recommend trying for up to a year before extensive fertility testing and if you are over 35 years of age, doctors recommend waiting only 6 months. While you are trying, you can learn more about your cycle simply by downloading a free app and inputting the start and stop dates. You can also make healthy lifestyle changes that will not only help you conceive but also support a healthy pregnancy.
Anytime you have a question or concern, even it if it is before the recommended wait time, feel free to talk to your doctor.
Good luck on your trying to conceive journey. Here is a chart by Baby Center on the major causes of infertility and the success rates with the treatment given the condition.
If you would like to submit any questions about trying to conceive or pregnancy, please email Jackie at firstname.lastname@example.org