What are the causes of anovulation (failure to ovulate)?
Anovulation may be caused by several endocrinologic disorders. Screening for abnormal thyroid function or elevations in the hormone prolactin is typically required. In these cases, specific treatment of those disorders is necessary. Many women who are anovulatory have polycystic ovarian syndrome (PCOS) which is diagnosed when there is evidence for elevations in androgen levels (like testosterone) and ultrasound findings of many small immature follicles in the ovaries. These women may be benefit from clomid treatment, or in some cases with insulin sensitizing medications.
Women who don’t menstruate at all (amenorrhea) require investigation to assess the cause of the problem which may relate to abnormalities of the brain (hypothalamus and pituitary gland) or the ovaries. These women may require more involved treatments, like injectable fertility agents medications.
What is unexplained infertility and how is it treated?
After the initial infertility evaluation, if nothing specific cause is found, “unexplained infertility” is diagnosed. Approximately 20% of fertility patients are diagnosed with unexplained infertility. Treatments for unexplained infertility include intrauterine insemination (IUI) with either oral or injectable medications clomiphene stimulation (oral medication) or with (injectable) FSH stimulation, or in vitro fertilization (IVF).
With unexplained infertility, the monthly conception rate without clinical treatment, monthly conception for patients with unexplained infertility is low (under 5%). Thus, fertility treatments that improve upon that are utilized. The chance of becoming pregnant and can increase to 20%-25% after 3 or 4 treatment cycles of IUI with clomiphene is about 20 to 25%, with IUI with injectable FSH is about or 30 to 35% with IUI using injectible medications. Pregnancy success rates can increase to 75-85% in young women with several IVF treatments, and with IVF is as high as 75 to 85% in young women.
Age is important with regard to success rates. Women over 35 may choose to move to more aggressive treatments like IVF sooner than later. Usually, treatment begins with IUI with clomiphene for 3 to 4 cycles. If that is unsuccessful, either IUI with FSH or IVF is considered. This choice is made after weighing the costs, success rates, and especially multiple pregnancy rates, given the high risk involved. IVF may be chosen because of the its higher success and lower risk for triplets. In addition, there is more control over multiple pregnancy risk since one may choose to transfer fewer embryos. With more liberal use of elective single embryo transfer, the multiple pregnancy rate with IVF will continue to diminish. The goal should be to arrive at a singleton pregnancy in the safest way possible and as quickly as is appropriate for that couple.
What is ovarian reserve and how is it evaluated?
The term ovarian reserve describes a woman’s reproductive potential with respect to the number of ovarian follicles and egg quality. A blood test measurement of the levels of FSH and estradiol on day 2 or 3 of the menstrual cycle is often used to test for ovarian reserve. Elevations in FSH or estradiol may indicate decreased ovarian reserve and may predict a poorer prognosis in women of older reproductive age. More recent ovarian reserve tests are being evaluated for clinical use including ultrasound evaluation of the number of visible follicles (antral follicle count) and measurement of a substance called anti-Mullerian hormone (AMH).
How does age relate to infertility?
Fertility declines with increasing female age, beginning as early as the late 20’s and early 30’s, and is most pronounced in women over 35. This is believed to be related to decline in ovarian reserve and a higher incidence of oocyte (egg) abnormalities. The decline in fertility is accompanied by an increase in the rate of miscarriage. Evaluation and treatment of infertility should not be delayed in women over 35 who have attempted conception for over 6 months.
Before getting pregnant, how can you optimize the chances of a healthy, safe pregnancy?
Getting yourself into optimum condition prior to pregnancy involves the establishment of a healthy lifestyle and screening for disorders or genetic carrier state. Healthy lifestyle requires eliminating habits that may be detrimental such as cigarette smoking or excessive alcohol or caffeine intake. Proper diet and exercise are recommended as well. Women with diabetes or hypertension should see their medical doctors about getting these diseases in the best under control possible before conceiving. Women who are obese should strongly consider weight loss prior to getting pregnant.
Folic acid intake has been shown to reduce the risk of certain birth defects (neural tube defects). This may be accomplished by the daily intake of at least 400 micrograms of folic acid. Genetic screening is recommended based on ethnicity. We recommend screening for cystic fibrosis, spinal muscular atropy, and fragile X. Additional testing is recommended for specific ethnic groups.
How is recurrent pregnancy loss evaluated?
Evaluations are completed within the office and may include blood tests, uterine exams, and genetic screening. The important purpose of the evaluation of recurrent pregnancy loss is to identify causes that may be able to be treated prior to achieving another pregnancy. SA specific causes are is identified in approximately 50% of the patients who can later achieve full term pregnancies. The investigation usually includes several blood tests and an examination of the uterus.
Genetic testing evaluation of both the male and female is performed in order to identify the presence of a chromosomal translocation. In such cases, a small piece of the chromosome in one of the parents is “broken off” and located on another chromosome. That parent is normal, however, when an egg or sperm is made it may contain the extra piece, which upon fertilization may result in an embryo with an abnormal chromosome content. This can resulting in recurrent miscarriages. Future fertility treatment is possible with IVF and PGD.
Evaluation for the antiphospholipid syndrome or for thrombophilia requires several blood tests. If any of these are abnormal, treatment may be necessary during pregnancy which may prevent further miscarriages.
Testing of the uterine cavity is typically accomplished by a hysterosonogram (HSN) which is a simple office procedure requiring the installation of saline into the uterus with a catheter and an ultrasound. If a fibroid, polyp, or uterine anomaly is discovered, these may be surgically treated prior to further pregnancies.
What is recurrent pregnancy loss?
Recurrent pregnancy loss is a disease distinct from infertility defined by 2 or more failed pregnancies.
If a semen analysis is required, can it be completed at home or at your office? Do we have to be a patient of the Greenwich Fertility Center and when will we get the results back?
We prefer that all specimens for analyses be collected on-site in our private, comfortable, collection room. All specimens need to be collected after an abstention from ejaculation for two to five days prior to providing the sample. Shorter or longer periods of abstinence may yield suboptimal semen specimens. Complete semen collection instructions will be supplied to you in writing when you schedule your appointment. A physician order is required for this test to be completed by our andrology laboratory.
How long should a woman wait before seeking advice from a fertility specialist?
Couples are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. If the woman is over the age of 35, a medical evaluation of both the male and female may be recommended after six months of trying to get pregnant.
How long is the wait for a consultation appointment?
New patient consults can generally be offered to patients within one-week time. If you are a cancer patient in need of a fertility preservation consultation, we will accommodate you with a consultation within 48 business hours.