Wednesday, March 21, 2018

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Being Unpregnant Is Not Unfamiliar

Written by  Diane York

Emily Sills was 29 years old, and she wanted to have a baby. She had tried for more than a year and was frustrated and concerned. Her physician, Corinne Tuckey-Larus, MD, an Ob-Gyn with Virginia Physicians for Women in Richmond, put Sills and her husband through several tests. All the results were negative. So what was wrong?  

If you are having difficulty getting pregnant, you are not alone. According to the Centers for Disease Control and Prevention, about 1 in 8 couples have trouble conceiving, and 7.4 million women (approximately 11 percent of women in the U.S.) have received some type of infertility assistance in their lifetime.

When is it time to seek help?

“With most women, I suggest continuing to try for a year,” says Keith Berkle, MD, an OB-GYN with the Virginia Women’s Center in Midlothian. “However, if a woman is at higher risk because of a medical issue or is over the age of 35, I would say she and her partner should seek help at six months.”

Dr. Berkle adds that some of the increases in fertility problems can be due to women delaying pregnancy to a later age or using certain types of contraception. Age does matter: For women in their 20s and early 30s, the infertility rate is between 7 and 9 percent. After age 35, that rate goes up to 25 percent.

Taking the first baby steps

“There are a number of tests that can be performed to get you started,” says Dr. Berkle. These can include multiple hormone tests, thyroid function, semen analysis and estimation of the number and quality of eggs. One of the most common problems occurs when women are not ovulating normally. “We perform a test that shows how many eggs a woman has at a point in time and tells us about the quality of the eggs,“ he says. “Antral follicle counts by ultrasound are one of the best ovarian reserve tests that we currently have available.”

An OB-GYN can handle the initial work-up for a woman who is having trouble getting pregnant. This would include a careful history and physical exam. Dr. Tuckey-Larus says that some of the important information the doctor needs may include:
• Prior pregnancies of the couple.
• Any history of infections.
• Sexually transmitted diseases.
• Injuries (especially in men).
• Tobacco and drug use.
• Environmental factors (use of lubricants, douches, urination habits).
• Habits and positions related to intercourse.

Exams can often reveal obvious problems related to conception.

“These initial work-ups can work in conjunction with awaiting an appointment with a referring specialist,” says Dr. Tuckey-Larus. “Many gynecologists will refer to an infertility specialist sooner if the reports of trying for pregnancy are at the year mark in the older population and if all obvious parameters (like regular menses) are met.”

Dr. Tuckey-Larus tried putting Sills on Metformin, a drug traditionally used for diabetes control but known to affect ovulation. It had a positive effect for Sills, giving her a regular cycle; however, she was still not producing eggs. Then Dr. Tuckey-Larus started her on Clomid, a fertility drug. After increasing the dose several times, Sills was producing eggs in a regular cycle.

Sixteen months after her first consult with her doctor, Sills was pregnant and later delivered a healthy baby, Mason. For Sills and her husband, it took some time but was a relatively simple process. For others it can be much more complex.

What causes infertility?

“First and foremost, infertility is a couple's disease, with 60 percent of issues attributed to the female partner and 40 percent attributed to the male partner,” says Dr. Tuckey-Larus. Researchers say that the causes of infertility are never discovered in about 25 percent of cases. By using some of the advanced therapies for infertility that are available today, conception can still occur even if the root problem remains unknown.

Many issues can block successful conception:

• Ovulation dysfunction.
• Polycystic ovarian syndrome.
• Uterine fibroids.
• Abnormal hormone levels.
• Endometriosis.
• Pelvic inflammatory disease.
• Irregular menstrual cycles.
• Male tubal blockages.
• Poor sperm quality or quantity.
• Sperm allergy.
• History of cancer and chemotherapy.

If no specific cause is found, an OB-GYN can prescribe Clomide, which induces ovulation. This drug has a 5 percent rate of success by itself.

The next step might be intrauterine insemination, a process in which the sperm is spun down and injected into the uterus and followed up with additional medication. Women have a 10 to 20 percent chance of getting pregnant with just one IUI cycle. The more cycles of IUI undergone, the higher the chance is for a pregnancy. With three to six cycles of IUI, pregnancy rates can be as high as 80 percent.

Steps beyond these would be handled by a fertility specialist who can provide advanced measures. In vitro fertilization would be considered. Dr. Berkle explains that IVF involves several steps: hyperstimulating ovulation to produce multiple eggs, harvesting the eggs, checking them for quality and health, mixing the eggs and sperm in a lab and then the implanting the fertilized egg in the woman’s uterus.

Increasing the odds of getting pregnant

Dr. Tuckey-Larus says, “Most couples can increase their chances of conceiving by taking a few simple steps."

• "If the couple uses a lubricant, they should choose a water-based lubricant and avoid spermicidal lubricants. Commercial lubricants have chemicals and/or spermicides designed to prevent pregnancies," cautions Dr. Tuckey-Larus.

• To find the optimum time to attempt conception, a woman should take the average number of days in her menstrual cycle (from the first day of menstrual flow to the next month’s first day and subtract 14 days; that day should be the day of ovulation). For example, if a woman has a 34-day cycle, she is ovulating on or about day 20. Dr. Tuckey-Larus recommends that couples have intercourse at least daily or every other day during the seven-day period surrounding ovulation. She also suggests lying in bed for approximately 20 minutes following intercourse to promote sperm availability.

• Men should wear loose boxer shorts rather than jockey shorts, enabling the testicles to move away from the body. (Sperm require a lower temperature for their production.)

• “The importance of the partners' general health cannot be overemphasized," says Dr. Berkle. "A woman’s weight, for example, can have a significant effect on the ability to conceive because obesity can make ovulation irregular. Have a healthy lifestyle with exercise and no smoking.”

• Stay calm and accept and work through the process and problems as they arise. Anxiety about an inability to get pregnant can become a negative force in people’s lives and relationships. Worrying about it won’t help. Because this process can take anywhere from a few months to years, it’s best not to get into a state of angst about it.

Probably the single most important suggestion here is that the couple should optimize when they have intercourse to coincide with ovulation.

The good news

Sills was so thrilled by her success of her first pregnancy, she is ready to try again. For some time after Mason was born, she had regular cycles with egg production, but it didn't last. So she will soon go back on Clomid to try for a brother or sister for Mason.

Positive news for all want-to-be parents is that the arena of reproductive health is evolving faster than many other areas of medicine. While the cost of these treatments is high, as Dr. Berkle says, “It’s a very successful field.” According to the CDC National Survey of Family Growth, approximately 44 percent of women with infertility have sought medical assistance, and of those who seek medical intervention, approximately 65 percent successfully give birth.

Most Virginia insurers pay for diagnostic testing but not treatment. Some treatments could be covered, depending on the employer.

Eight Ways to Improve the Chances of Conception

Too fat, too thin or just right? Studies at Baylor College of Medicine found that women who had a pre-pregnancy body mass index of 25-39 (considered overweight or obese) took twice as long to get pregnant. For thin women with a BMI of less than 19 (18.5 to 24.9 is considered normal), the results were even worse. Researchers found that time to conception was increased fourfold in women with a BMI below 19. To measure your BMI, see the National Institutes of Health online body mass calculator at .

Save that sperm – Recent studies show that repeated exposure to heat (as in hot tubs or hot baths or using your laptop on your lap for long periods) reduces men’s fertility. One study showed that keeping a cell phone in your pants pocket exposes the scrotum to radiation, which adversely affected the sperm of the men in the study.

You are what you drink – Drinking more than two glasses of alcohol or more than five cups of coffee a day reduced women’s fertility in studies. Moderation is key. The March of Dimes suggests that women who are pregnant or trying to get pregnant should consume fewer than 200 milligrams of caffeine per day. In limited studies, women who drink higher amounts of caffeine had an increased risk for miscarriage.

Smoking isn’t good for anything – In men, smoking can reduce sperm production and damage DNA. Smoking while pregnant boosts the risk of miscarriage.

Timing is everything – Probably the most critical piece of information a woman should know is the days in her menstrual cycle when pregnancy is possible. Technically, these are only the five days before ovulation through the day of ovulation. These six days are the "fertile window" in a woman’s cycle and reflect the lifespan of sperm (five days) and the lifespan of the ovum (one day). If a woman has sex six or more days before she ovulates, the chance she will get pregnant is virtually zero. If she has sex five days before she ovulates, her probability of pregnancy is about 10 percent. The probability of pregnancy rises steadily until the two days before through the day of ovulation. At the end of the fertile window, the probability of pregnancy declines rapidly, and by 12 to 24 hours after ovulation, a woman is no longer able to get pregnant during that cycle. For those women who are not aware of their fertile window or when they ovulate, sexual intercourse is recommended every two to three days to help optimize their chance of conceiving.

Lubricants – Many commercial lubricants have spermicides in them. It’s best to use something natural like organic aloe or organic coconut oil.

Avoid exposures to toxins – Exposures to pesticides, especially agricultural pesticides, can harm both men and women's fertility. And exposure to some solvents and toxins — including those used in printing businesses and dry cleaning establishments — can adversely affect women's fertility.

The vocabulary of fertility

concentration of motile sperm – a measurement of the sperm that can readily swim to fertilize the egg. According to the World Health Organization, there should be a minimum of 10 million motile sperm per milliliter of semen.

endometriosis – a medical condition that involves the presence of tissue similar to the uterine lining in abnormal locations. This condition can affect both fertilization of the egg and embryo implantation.

intrauterine insemination – procedure in which the man’s sperm is cleaned (fast-moving sperm separated from slow-moving sperm) and injected into the woman’s uterus with a catheter. This is generally attempted before in vitro fertilization. If not successful, egg collection is initiated.

in vitro fertilization – the most common type of assisted reproductive treatment. The woman is injected with medications designed to stimulate egg production. If multiple eggs result, they are harvested through OCR. The eggs are then fertilized with sperm in a lab. The resulting eggs with embryos are then transferred to the woman’s uterus.

ovulatory dysfunction – A diagnostic category used when a woman’s ovaries are not producing eggs normally.


Expert Contributers:

~ Keeth Berkle, MD with Virginia Women's Center

~ Corinne Tuckey-Larus, MD with Virginia Physicians for Women