There are many potential causes of infertility that need to be considered in women having difficulty becoming pregnant. These causes can generally be lumped into problems with egg production, tubal problems, and uterine problems. Each of these potential problems are evaluated before initiating fertility treatment.
Normal ovulation is essential for producing a mature egg that can be fertilized. Disorders in ovulation can impair conception and cause infertility. Women having problems with ovulation will not generally have menses at regular intervals. Keeping a journal of menses can be a very helpful tool to evaluate ovulation. Regular menses is very predictive
of regular ovulation. Many women use menstrual calendars or smart phone apps in combination with basal body temperature charts and ovulation predictor kits. While these can be useful aids in evaluating potential causes of infertility, they can easily become cumbersome and costly. We do not advise you purchase ovulation monitoring devices with regular and predictable menstrual cycles. Well-spaced intercourse during the middle of a menstrual cycle can be just as effective. Ovulation occurs 14 days before the first day of menses. Women can predict their fertile window by taking the number of days between the start of menses and the start of the next menses and subtract 14. For example, a woman with 32 days between menses would be most fertile on day 16 (counting the first day of flow as day 1). Women not having regular menses will most likely experience difficulty getting pregnant. The lack of menses usually indicates a lack of ovulation. This makes timing intercourse difficult or impossible. The most common cause of an ovulation (absence of menses) or oligoovulation (infrequent ovulation) is polycystic ovarian syndrome (PCOS). Other causes include premature ovarian failure (POF), age related fertility, and endocrine abnormalities such as elevated prolactin or thyroid levels.
Endometriosis is a chronic condition where endometrial tissue (the cells that line the inside of the uterus) implants outside of the uterus. This can be associated with chronic pelvic pain and infertility. There are many theories as to why endometriosis causes infertility problems. One of the more current theories is the displaced tissue causes an inflammatory reaction that kills sperm and eggs. Stopping menses is an effective method of controlling endometriosis though this is not a cure. Laparoscopy and ablating (destroying) the endometriosis is another therapeutic option though it too is not a cure. In Vitro Fertilization offers a very effective way of “bypassing” endometriosis. Women often experience several years of relief from the discomforts of endometriosis following pregnancy.
Endometriosis is found in as many as 35% of women having laparoscopy for evaluation of their infertility. It can be a cause for pelvic pain as well as infertility. Other locations include incisions from previous surgeries, the vagina and cervix, as well as the bowel and bladder. Very unusual locations are also possible but not as common. Specialist vary tremendously on their opinions as to what should be done for the infertile couple with endometriosis. There is supportive evidence for most of the different treatment types which makes things even more confusing for patients seeking “the right thing”. Our program has very good success achieving pregnancy in patients with endometriosis without subjecting patients to extensive and invasive procedures. We also feel strongly that a hysterectomy for endometriosis should be a last resort option when other conservative options have failed.
Structural abnormalities of the uterus can result in decreased pregnancy rates and increased miscarriage rates. In addition to causing infertility, uterine abnormalities may also cause pregnancy losses. Fortunately, many of these abnormalities can be corrected.
Uterine fibroids are muscle tumors of the uterus that can interfere with pregnancy when they lie within the cavity of the uterus. Fibroids can also cause pelvic pain and irregular bleeding. In the absence of infertility or other problems, fibroids can usually be left alone. The surgeons at Family Clinic have extensive experience performing surgeries to remove uterine fibroids, or myomectomies.
Several developmental abnormalities of the uterus can be discovered during an infertility evaluation. A unicornuate uterus, septum or septate uterus, and a bicornuate uterus are among the numerous structural anomalies. These problems arise when the uterus is being formed. A unicornuate uterus is when only one side of the uterus is formed normally. A bicornuate uterus is a uterus that has two sides of the uterus that are attached at the cervix but not at the top of the uterus. A septum is a normal shaped uterus that has a dividing membrane on the inside of the uterus. Hysteroscopy is useful in evaluating and treating these abnormalities. Other effective means of evaluating the uterus include saline contrast ultrasound and hysterosalpingogram (HSG).
Fallopian tubes can become blocked by several different mechanisms. Some of the more common reasons include infections (pelvic inflammatory disease, or PID), surgery, and endometriosis. Blockage of the fallopian tubes can prevent the sperm and egg from uniting and forming a pregnancy. This blockage can also prevent the normal transport of an embryo and increase the likelihood of an ectopic pregnancy (pregnancy inside the tube). Microsurgery is a type of surgery that uses an operative microscope or magnifying lenses to help amplify the surgical field. Microsurgery may be able to repair damaged fallopian tubes and IVF offers a way to bypass fallopian tubes.
A hydrosalpinx is a blocked fallopian tube that has filled with fluid. The fluid in the tube indicates the fallopian tube is blocked. There are many causes of damage to fallopian tubes that can result in a hydrosalpinx. Pelvic infections, endometriosis, or surgery around the fallopian tubes are common causes. When the ends of the tubes become blocked, the fallopian tube becomes filled with fluid. There can be a small amount of leakage at the end of the tube attached to the uterus. The fluid trapped in the fallopian tube is thought to be harmful to a pregnancy in the uterus. Microsurgical repair called a neosalpingostomy, or tuboplasty, can be an effective way to open the blockage and allow for pregnancy. There is an increased risk of ectopic pregnancies, and a risk of the tube scarring shut after the surgery. If the tube has swollen from a large amount of fluid, the lining of the tube can be damaged. Once the lining of the tube becomes damaged, it will usually not allow for the normal passage of the sperm and embryo. Our surgeons are experienced with microsurgical repair of fallopian tubes. In many cases, the fallopian tubes can be repaired, but this doesn’t mean the function of the fallopian tube will be restored. Patients should understand all of the potential risks and alternatives to tuboplasty, or repair of a fallopian tube before having surgery.
IVF offers an excellent alternative to surgical repair of the fallopian tubes and the associated risk of ectopic pregnancy. When IVF is selected and hydrosalpinges are present, removal of the tubes is recommended in order to improve pregnancy rates. In cases where the scar tissue around the tubes is bad, disconnecting the tubes from the uterus can improve IVF pregnancy rates. The fluid from the tubes is thought to impact pregnancy rates even with IVF. In most cases, the fluid filled tubes can be removed by laparoscopy surgery. The ovaries are left in place so a woman can still produce eggs that can be collected by the IVF process.
Tubal ligations cause interruptions in the fallopian tube that prevent sperm and egg from meeting. These procedures can be reversed and offer couples a “more natural” means of conception. There are many considerations when deciding between IVF and tubal reversal. Dr. Kavita Mantry has extensive experience performing the surgery known as bilateral tubal anastomosis (BTA) and can provide you more information about your options.
Unexplained infertility is a diagnosis of exclusion. This means that all other causes of infertility within reason have been ruled out. Many times a presumptive diagnosis of unexplained infertility is given when the evaluation is not completed due to a low likelihood that further testing will find an abnormality. Examples of tests often deferred are laparoscopy and endometrial biopsies in women without symptoms. Unexplained infertility can be very frustrating because people want answers. Fortunately, treatment options offer significant improvements in couples with unexplained infertility.
The most important thing to understand about unexplained infertility is that testing has not found a cause for infertility, but this doesn’t mean there isn’t a cause of infertility. There are many natural barriers to pregnancy. The natural process of reproduction is not highly efficient in humans. Sperm must pass the cervix and enter the uterus and fallopian tubes. The egg must enter the fallopian tube and end up fertilized by the sperm. The majority of eggs that are fertilized will be chromosomally abnormal. Once fertilized, the egg forms an embryo that has to travel back to the uterus and implant. The embryo then has to develop into a complex set of organ structures and grow into a baby. Each step along the way can interfere with pregnancy or lead to a miscarriage. Testing cannot evaluate what is happening on a microscopic level inside the body. Testing can identify the most common things that can prevent pregnancy, however problems with sperm and egg quality are usually not readily detectable unless ovulation or an abnormal semen analysis is the source of the problem. When patients use donor sperm and donor eggs in a donor embryo program like Family Clinic Conceptions, pregnancy rates are extremely high. This tells us there are a lot of cases of unexplained infertility related to sperm and egg quality. While these factors may be present and may affect fertility, patients with unexplained infertility can still have good rates of success with treatment. Age is another important factor that affects fertility and this effect may not always be obvious during testing.
Age Related Infertility
Many women are not aware of the extreme effect that age can have on fertility. Women are born with all the eggs they will ever have in their lifetime. This pool of eggs declines continuously throughout a woman’s life. The effects can be seen in a woman’s early 30’s and becomes a common problem in women 35 and over. By the time a woman reaches 40 she will have a drastic reduction in her chances of becoming pregnant. This reduction in pregnancy is due to fewer available eggs and a reduction in egg quality. As the eggs age, the biologic process used to divide the cell becomes less efficient. This leads to non-viable eggs and an increase in chromosomal abnormalities. While there are tests to estimate a woman’s potential to produce eggs, there is not a very effective treatment to overcome this decline in egg function. Collecting eggs over multiple IVF cycles will improve the odds of finding a normal egg that can be used to make a successful pregnancy.