Before we speak about infertility, it is important to define the word. Many of my patients believe that if they do not conceive on their first try, they will never get pregnant. This is so untrue. Infertility is defined as a lack of conception after 12 months of trying without birth control and with frequent intercourse in a woman under the age of 35, and after 6 months in a woman over age 35. Eighty to 90 percent of couples will conceive within 12 months of trying to get pregnant.
Unfortunately, fertility peaks at 24 years of age and decreases as we age. It is difficult for a woman to conceive after 40, so I would waste little time working up a patient for infertility if she was over 40. I would give her only 3 months to try, and then start a workup.
Infertility can be due to either of the partners (or both), so both need to be evaluated. We propose an infertility work up by 12 months of not conceiving or earlier depending on the patient’s history, physical exam, and age.
The man is examined first and is sent for a sperm analysis. If it comes back normal, we turn to the female partner. If the analysis comes back abnormal, it should be repeated. If it is still abnormal, then I refer the man to a male infertility specialist. There, he is given a thorough workup, including a medical history, physical exam, and bloodwork. After that, treatment options can be discussed.
The female partner now needs to be worked up as well. She needs a history and physical, a menstrual history, lab testing, and an assessment of the Fallopian tubes and uterus. Is she ovulating? This means that every month she is releasing an egg from her ovary to be fertilized by a sperm. If she is not ovulating, clearly there will be no conception. Taking your Basal body temperature (BBT) daily, first thing in the morning, and charting it throughout an entire menstrual cycle helps show that a woman is ovulating. Ovulation kits are available at drug stores over the counter but are sometimes hard to interpret, so I prefer the BBT. Polycystic ovarian disease (PCOS) is a very common reason why a woman may not be ovulating. Also, a patient’s BMI will affect fertility.
Determination of open Fallopian tubes and a normal uterine cavity are important in an infertility work up. A hysterosalpingogram (HSG) is a test that will show these characteristics. Dye is put through the cervix into the uterus and X-rays are taken to see the dye in the uterus and then if it passes through the tubes.
If a woman is over 35, I encourage her to undergo second- or third-day bloods. This is an examination of the ovaries and the quality of the eggs. If the FSH is over 12, this could be a poor predictor of ovarian reserve. As we age, it seems that fertility goes down because of our egg quality.
If a woman presents with severe menstrual cramps, back pain, pain on intercourse, abnormal bleeding, and infertility she may have endometriosis, in which case I would recommend a diagnostic laparoscopy to diagnose her disease.
Once the cause of the infertility has been established, therapy can start. I always talk to my patients about lifestyle modifications. If they are a smoker, I tell them this is the time to stop. I allow my patients one cup of caffeine a day, whether coffee or tea or soda or chocolate. I talk with my patients about how much they exercise and I only allow the patient and her partner one glass of alcohol a week while trying to conceive. Also, please no lubricants or jellies while having intercourse. They can kill sperm. The only lubricant I recommend is preseed. It can be obtained on the Internet.
If there is no ovulation, medication such as Clomid may be necessary to help a woman ovulate. If a woman is heavy (BMI greater than 25), she may need to lose some weight to help her ovulate and respond to the Clomid. If a woman is too thin (BMI under 19), she may need injections of medications to help her conceive. If her tubes are abnormal, she may need tubal surgery or possibly IVF. If her uterine cavity shows submucous fibroids, polyps, or scarring, she needs to have a surgical procedure called a hysterscopic resection of the abnormality, D&C. This will allow the embryo to implant in her uterus. And if there is a mucus problem at the level of the cervix, the patient may need to undergo IUI (intrauterine insemination).
I know that many infertility physicians push in vitro fertilization (IVF). This is because they feel they get their best results with this procedure. It is expensive and intense, and couples really feel they have been put through the ringer. But when I deliver those babies, I can only tell you the satisfaction the couples have when they hold their baby in their arms. There is nothing like it in the world.
When I first started in practice, I use to advise patients to try to have their first baby by age 35. Now I am asking them when they plan to start trying to conceive. Infertility will increase with age. The fact that you look young and are in good health can be misleading. If I can give one piece of important advice after everything I have said about infertility, PLEASE do not wait too long to try to get pregnant. My patients come back to me after they have had their first child and say they wished they’d started earlier. Now they want a second child and it is not happening. Why? Because she is now 43 or 44.
Last words to be said: a woman can now freeze her eggs up to the age of 39. It gives women some control over their fertility and it allows them some time. So, if it seems like children are important in your life but the man of your future has not shown up yet, this very straightforward procedure is something to consider.
I hope I have helped you understand a little more about infertility and eased some fears, if it’s been taking you a little while to conceive. If you feel it has been too long, though, then it is time to move on to an infertility workup.
Stay tune to my next blog “J” is for “Joints.”