Pregnancy – Conditions That Affect Fertility

 

There are many reasons why a couple may have difficulty in conceiving a child. Disease, drugs, heredity, lifestyle habits or even exposure to certain toxins can affect fertility.

Among the most common culprits of diminished reproductive capacity are:

• Endometriosis — This condition affects a woman’s pelvic cavity, where tissue fragments from the innermost lining of the uterus (the endometrium) grow and function outside the uterus. They are one of the causes of painful menstruation and infertility. Endometriosis strikes up to 10 million American women and is a major cause of female infertility. These displaced pieces of tissue are not shed vaginally with normal menstrual blood, but instead accumulate inside the pelvis on the surface of pelvic organs. They grow, causing adhesions (scar tissue) on the ovaries or at the ends of the fallopian tubes. This scar tissue can block the tubes and prevent the egg and sperm from meeting inside the tubes for fertilization. In some instances, endometriosis can be surgically removed, or treated with drugs.

 

• Reproductive-tract infections — A leading cause of infertility in both men and women is sexually transmitted diseases (STDs) — particularly gonorrhea, which strikes about 1 million Americans a year; and chlamydia, which is responsible for 4 million cases a year. If untreated — and many infected women have no symptoms — scarring or damage of the fallopian tubes may cause infertility. In men, an STD can lead to scarring and blockage of the ejaculatory ducts and other reproductive structures, thereby causing infertility.

 

• Pelvic inflammatory disease (PID) — This infection of a woman’s upper reproductive system involves the fallopian tubes, uterus and ovaries. The most common cause of PID is a sexually transmitted disease, but it may also occur after complications from an abortion, dilatation and curettage (D&C) surgery, childbirth or even use an intrauterine device (IUD). More than 8 million women in this country have been diagnosed with PID, with 35 percent becoming infertile after a single episode, 50 percent to 60 percent after two, and 75 percent after three.

 

• Female hormonal imbalances — If your female hormones fail to transmit their chemical signals at precisely the right time, ovulation may be irregular, infrequent or fail to occur. Periods will likely be erratic and unpredictable. Female hormonal imbalances are major causes of infertility but can often be successfully treated with fertility drugs.

 

• DES exposure. — The 8 million men and women exposed in their mothers’ wombs to diethylstilbestrol (DES), a drug used in the past to prevent miscarriages, may find that their fertility is compromised. Some researchers report that 40 percent of DES daughters have reproductive-system abnormalities — including an unusually shaped uterus or vagina or abnormal fallopian tubes. These abnormalities can cause ovulation problems in some women, as well as an increased risk of miscarriage, premature delivery and ectopic pregnancy. DES sons may have low sperm counts or abnormal sperm, undescended testicles or missing ducts in their reproductive systems.

 

• Varicocele — This condition of dilated scrotal veins affects one or both testicles. These dilated, varicose veins of the testicles can be seen in up to 25 percent of infertile men and also can be seen in 10 percent to 15 percent of fertile men. This condition can raise the temperature in the testicles and alter sperm production, causing low sperm counts. A urologist usually evaluates the man to confirm the presence of a varicocele and if it requires corrective surgery, because varicoceles do not always explain a couple’s infertility.

 

• Prostatitis — A frequent cause of male infertility, prostatitis is an infection in the prostate gland. Symptoms range from none to urgency, painful urination, and pain during or after ejaculation, with or without pain in the prostate. Prostatitis can be diagnosed though a physical examination and lab tests, and may be require treatment with antibiotics.

 

• Caffeine — A report published in the American Journal of Epidemiology found that women who consume an excessive amount of caffeine — equivalent to five cups of coffee — take longer to get pregnant. Overall, those who consume the most caffeine had a 45 percent risk of waiting more than nine months before becoming pregnant. Caffeine is also thought to cause defects in male sperm.

 

• Alcohol — For the mother-to-be, alcohol increases the risk of miscarriage and also may damage the ovum before conception.

 

• Smoking — Chemicals in cigarette smoke may kill sperm and reduce a man’s ability to conceive. Women who smoke also may have trouble getting pregnant and experience higher rates of miscarriage compared to women who don’t smoke.

 

• Social drugs — Marijuana and cocaine may dramatically reduce sperm count and motion, and increase the percentage of defective sperm.

 

• Heat — There’s also evidence that prolonged exposure to heat in hot tubs, saunas or steam rooms produces high scrotal temperatures, which may decrease the number and function of a man’s sperm.

What You Can Do

Obviously, some cases of infertility — such as those caused by disease and heredity — can’t be controlled. But in “borderline” cases of not being able to conceive, there are certain measures that can be tried. Besides giving up drugs, including smoking and alcohol, and altering other potentially negative lifestyle habits that may decrease fertility, some experts suggest that you and/or your partners try these self-help treatments:

Take More Vitamin C

Some studies show that increased amounts of vitamin C may reverse some cases of male infertility. Increased sperm count, movement and longevity was found in men who consumed 1,000 milligrams a day. Men should consult with their doctors to be sure there is no reason not to take this higher dose of vitamin C every day.

Get new underwear

Hot water isn’t the only way to produce high scrotal temperatures, which can damage sperm. When having trouble fathering a child the male partner may want to switch to boxer shorts, since briefs keep the testicles closer to the body. Having testicles “hang” can keep them cooler.

Try a new lubricant

You might be hurting your chances to conceive by using over-the-counter lubricating products such as K-Y jelly. These products might interfere with sperm mobility, slowing the sperm so they have a tougher time reaching the egg. If you need extra lubrication, egg white might be better. It’s high in protein (like sperm) and makes a better “carrier” than commercial lubricants. Just don’t use egg white if you’re allergic, and remove the yolk before applying egg white to the penis or vagina.

Go missionary

Sexual position usually has no bearing on conception, but the missionary position tends to assure that the semen has better contact with the cervix. This won’t cure infertility, but can make a difference in some borderline cases.

Finding An Infertility Specialist

Experts generally advise a couple try to conceive on their own for at least one year before seeking help. But if home ovulation tests or your basal body temperature indicate you’re not ovulating, or you or your partner have any medical conditions that impair your fertility — such as irregular periods, a history of sexually transmitted infections, cancer treatment, exposure to environmental toxins, an undescended testicle, or maternal age 35 or over-consider seeing a fertility specialist without delaying one year.

A good place to start is with your own family practitioner or gynecologist and or for men, your urologist. They will encourage both partners to be evaluated for common causes of infertility and may arrange initial testing and intervention. Alternatively, they may recommend a referral to an infertility specialist, a subspecialty of obstetrics and gynecology or a urologist whose subspeciality is treatment of male infertility. There are three types of specialists to consider, depending on your specific type of infertility problem. Both you and your partner will need evaluation because infertility may be due to a male factor, a female factor or some combination.

For female hormonal disorders, look for a reproductive endocrinologist who is board-certified in reproductive endocrinology by the American Board of Obstetrics and Gynecology. This certification means that the doctor has had additional years of training beyond the standard OB/GYN residency; has passed rigorous exams; and demonstrated competency in treating reproductive disorders. These specialists may also be members of the Society of Reproductive Endocrinologists, which is open to only board-certified physicians in this field.

If either you or your partner has a fertility problem that may require surgery, consider a reproductive surgeon, who is either an OB/GYN or urologist with specialized training in repairing anatomical disorders that impair reproduction. These could include scarring from pelvic infection or endometriosis, and varicoceles or other male anatomical problems. Since 1989, membership in the Society of Reproductive Surgeons requires completing a fellowship in reproductive endocrinology or surgery, spending at least three years in a reproductive surgery practice, and demonstrating competency by performing fertility surgery with two other reproductive surgeons.

The third type of specialist in the field is an andrologist, who may be a specially trained urologist who specializes in disorders of male reproductive functioning. These doctors belong to the American Society of Andrology, which is now developing a board certification program.

To find the right specialist for you:

• Start by discussing your situation with your primary health-care provider. He or she may provide you with one or more specialists to consider.

 

• Contact the local medical society, medical schools and university medical centers for a list of fertility specialists in your area.

 

• Ask friends who have had successful fertility treatment for the names of their doctors.

 

• Call Resolve, a national self-help group for infertile couples that offers support groups, referrals to specialists and printed material about various aspects of infertility. The number is 617-623-0744, or their Web site: www. www.resolve.org/.

After you’ve found several potential specialists, contact their offices, and inquire about their credentials and facilities. A good fertility center should have a high-tech, certified lab on the premises, preferably one accredited by a national organization, such as the Commission on Laboratory Accreditation or the American College of Pathologists. Additionally, it should have transvaginal ultrasound equipment, which monitors ovulation in women taking fertility drugs. Finally, the center should be open seven days a week, since some tests or treatments must be done at very precise times in your monthly cycle.

Testing and Treatment

The first few days of your monthly cycle is the best time to schedule your first visit to a fertility doctor, so you can start trying to get pregnant right away. Bring along all your medical records, or ask your previous doctor to send them directly to the reproductive endocrinologist. Also, you should make a list of any questions that you’d like to discuss during this initial consultation — such as the doctor’s success rate in inducing pregnancy. Be sure to also bring basal temperature or other ovulation charts you’ve been recording at home.

You will also want to ask about the cost of fertility treatment, which can be very expensive. You will need to determine which of them, if any, is covered by your insurance plan. Coverage varies widely, and the degree to which you are reimbursed may depend on exactly what condition the doctor diagnoses as the reason for your or your partner’s infertility.

Some of the tests the doctor may want include:

• A sperm count and analysis to evaluate whether your partner is releasing enough live, normally shaped, fast-moving sperm to make fatherhood possible. His semen should also be cultured for infections.

 

• Blood screening of both partners for blood type, complete blood count, cholesterol levels, AIDS and hepatitis viruses, as well as immunity to German measles, and the functioning of such organs as the thyroid gland.

 

• Bacterial cultures of your cervix to check for gonorrhea, chlamydia and other infections that could impair fertility.

 

• Cervical mucus tests, which are done on the day you’re most likely to have “fertile mucus,” and a postcoital test (conducted after you and your partner have had sex) to see if his sperm are alive and can swim freely in your cervical mucus.

 

• Ultrasound exams, also done in mid-cycle, to evaluate your uterus (and its lining) and the ovaries, check for fibroid tumors and to monitor egg development.

 

• Hormone screening tests, to find out if your body is producing normal levels of the various fertility hormones at the right time in your cycle. Your partner should also be tested to see if he has normal levels of male hormones.

 

• X-Ray studies of your uterus and tubes to determine whether there is any anatomical impairment preventing you from conceiving.

If these or other tests indicate one or both of you has a fertility problem, there are many treatments that might make pregnancy possible. Here’s a brief guide to some of the more common ones:

 

• Fertility drugs — There are several medications that can help stimulate ovulation in women. Clomiphene citrate (Clomid, Serophene) has been used since the 1960s. There is a 75 percent to 80 percent success rate for stimulating ovulation in women who never or seldom ovulate, and 50 percent of them will conceive. Clomid is sometimes combined with other drugs to improve chances for ovulation. Another approach to achieving ovulation is by using human menopausal gonadotropin, a more potent treatment with an 80 percent to 90 percent ovulation rate, and 50 percent to 60 percent pregnancy rate. Unfortunately, these drugs have more side effects — a 20 percent rate of multiple birth. For women who fail to ovulate on these drugs, another treatment, synthetic gonadotropin-releasing hormone (GnRH), can be given by a portable infusion pump over several days. Some of these medications are also used for men, but in different doses.

 

• Microsurgery — Using needles as thin as a human hair, and suture material invisible to the naked eye, surgeons can make extremely precise repairs to blocked fallopian tubes (or in some case, reverse prior tubal sterilization), blocked ducts in the male reproductive system or varicose veins in the testicles. Laparoscopic surgery (in which a small, thin telescope is inserted through very small incisions in the abdomen) can be used to remove adhesions caused by endometriosis or to widen fallopian tube openings. Laparoscopy is also used to diagnose and treat abnormalities of the uterus and other reproductive structures.

 

• Intrauterine insemination — To increase the odds of pregnancy, fertility drugs are used first to stimulate release of several eggs at once; concentrated, moving sperm are then placed directly into the uterus with a syringe or thin tube. This treatment is most helpful for couples with unexplained infertility, and for women with ovulation problems or antibodies that attack their partners’ sperm in the vagina.

 

• Donor sperm banks — For males who suffer from zero sperm or extremely low sperm count.

 

• Assisted reproductive technologies — There are several variations of these high-tech methods in which sperm and egg are combined to maximize the chances of achieving a successful pregnancy. All of the variations involve two steps — beginning with the woman taking fertility drugs to stimulate the ovaries to release several eggs (superovulation); followed by the use of procedures to harvest them, while she is under anesthesia.The best known of these methods is in-vitro fertilization (IVF), which was responsible for the birth of many “test-tube babies.” The eggs obtained through the vaginal canal using ultrasound guidance are fertilized with the partner’s sperm outside the woman’s body, not in a test tube, but in a culture dish. A few days later, the eggs, now called zygotes, are placed in the woman’s uterus. If one or more of the zygotes implants successfully, pregnancy results. One study reported that 17 percent of women who have this procedure once go on to deliver a baby.Two variations of this technique are gamete intra-fallopian transfer (GIFT), and zygote intra-fallopian transfer (ZIFT). Using GIFT, the harvested eggs are mixed with the man’s sperm and then inserted directly into the fallopian tubes, which allows fertilization (if it occurs) to take place in the natural way. In ZIFT, the harvested eggs are fertilized in a culture dish and then placed in the fallopian tubes during laparoscopic surgery. Both of these methods are only suitable for women who have functional fallopian tubes. The national rate for successful deliveries for one pregnancy attempt using these methods are 27 percent for GIFT and 23 percent for ZIFT. When selecting a clinic, you should check on its success rate.

IntelliHealth Online, Oct 8 2004