Infertility

Infertility is a common problem;
it affects up to 10% of couples.

The majority of couples will be able to successfully achieve pregnancy after a thorough evaluation and medical treatment. At the Women’s
Clinic of South Texas we can help with your infertility issues. We are equipped to be able to address 90% of couples with infertility issues.
Most patients can be successfully treated with medications and diagnostic imaging studies. The following information
has been listed below to provide you with some preliminary reading material.

What is Infertility?

Infertility is usually defined as the inability to get pregnant after a year of unprotected sex. According to statistics collected by the Centers for Disease Control (CDC), 6.1 million women between the ages of 15 to 44 have an impaired ability to have children, and 2.1 million married couples are experiencing infertility. The statistical study also found that 9.2 million women had made use of infertility services at some time in their life.

Quite clearly, if you and your partner are experiencing infertility, you are not alone.

Diagnosis of Infertility: Do you have infertility?

The definition of infertility can be further broken down into three groups:

Primary Infertility: Primary infertility refers to women who have never achieved pregnancy in the past.

Secondary Infertility: Secondary infertility refers to women who have achieved pregnancy and given birth in the past, but are now having difficulty conceiving.

Recurrent Miscarriage: Women who experience recurrent miscarriages may also receive a diagnosis of infertility if they experience two or more successive miscarriages. While miscarriage is not uncommon (occurring in up to 25% of recognized pregnancies), less than 5% of women will experience two miscarriages in a row, and less than 1% three or more successive miscarriages.

Infertility Myths

This might be a good time to look at some infertility myths, and consider what infertility is not.

Infertility is not limited to women.
Infertility affects women and men equally. According to the American Society of Reproductive Medicine, one-third of infertility cases are due to female factor infertility, one-third are due to male factor infertility, and the remaining third due to problems from both sides, or unexplained reasons.

Infertility is not all in your head.
Infertility is a disease of the reproductive system, and is not caused by not “wanting” to have a baby enough. Infertility can not be imagined into being. If not wanting a baby was enough to cause infertility, then there would be far fewer unintended pregnancies in the world.

Infertility is not limited to unhealthy people.
While living a healthy lifestyle is a good place to start when trying to achieve pregnancy, it does not cure infertility. Poor diet, smoking, drinking, and STDs can threaten your fertility, but the majority of infertility cases are not the result of lifestyle choices.

Infertility is not limited to older couples.
As we age, our ability to achieve pregnancy lowers. Fertility in women peaks during the late teens and 20s, after which it begins to drop, with age 35 beginning the most rapid decline. (This is why couples age 35 and older are encouraged to seek help for infertility after only 6 months of trying.) However, infertility can and does affect men and women of all ages.

Infertility is not going to go away if you just “relax and go on vacation”.
How many times have couples coping with infertility been told, “If you just stop thinking about it, you’ll have a baby.” Not only is this advice incorrect, it’s also hurtful. Extreme stress can disrupt a woman’s menstrual cycle, but stress alone does not cause infertility.

Ignoring infertility does not help, either. While two-thirds of couples seeking infertility treatments will get pregnant and have a baby eventually, couples with diagnosed infertility who do not receive treatment have a 5% or less chance of having a baby.

Understanding the Symptoms of Infertility

For most couples, the first symptom of infertility is when after a year of unprotected sex, they can not get pregnant. It is possible to have regular cycles, a healthy sex life, not have any of the risk factors, be generally healthy, and still suffer from infertility.

But for some couples, there are early warning signs or risk factors that may hint to a fertility problem, before they try for six months to a year unsuccessfully.

Here are some questions to ask yourself and your partner. If you answer yes to any of these questions, you may want to speak to your doctor before you spend a year trying on your own.

Do you have irregular cycles?
An irregular cycle can be a red flag for infertility problems. If your cycles are unusually short or long (less than 24 days, or more than 35 days), or come unpredictably, you should speak with your doctor. An irregular cycle may be a sign of possible ovulation problems.

Ovulatory Dysfunction and Anovulation
Symptoms, Causes, and Treatments for Anovulation

What is Anovulation?
Anovulation means lack of ovulation, or absent ovulation. Ovulation, which is the release of an egg from the ovary, must happen in order to achieve pregnancy. If ovulation is irregular, but not completely absent, this is called oligovulation. Both anovulation and oligovulation are kinds of ovulatory dysfunction.

Ovulatory dysfunction is a common cause of female infertility, occurring in up to 40% of infertile women.

What are the Symptoms of Anovulation or Ovulatory Dysfunction?
Usually, women with anovulation will have irregular periods. Or, in the worst case, they may not get their cycles at all. If your cycles are shorter than 21 days, or longer than 36 days, you may have ovulatory dysfunction.

Also, if your cycles fall within the normal range of 21 to 36 days, but the length of your cycles varies widely from month to month, that may also be a sign of ovulatory dysfunction. (For example, one month your period is 22 days, the next it’s 35.)

It is possible to get your cycles on an almost normal schedule and not ovulate, though this isn’t common. A menstrual cycle where ovulation doesn’t occur is called an anovulatory cycle.

How Does Anovulation and Ovulatory Dysfunction Cause Infertility?
For a couple without infertility, the chances of conception are about 25% each month. So even when ovulation happens, a couple isn’t guaranteed to conceive.

When a woman is anovulatory, she can’t get pregnant because there is no egg to be fertilized. If a woman has irregular ovulation, she has fewer chances to conceive, since she ovulates less frequently. Plus, it seems that late ovulation doesn’t produce the best quality eggs, which may also make fertilization less likely.

Also, it’s important to remember that irregular ovulation means the hormones in the woman’s body aren’t quite right. These hormonal irregularities can sometimes lead to other issues, like lack of fertile cervical mucus, thinner or over thickening of the endometrium (where the fertilized egg needs to implant), abnormally low levels of progesterone, and a shorter luteal phase.

What Causes Anovulation?
Anovulation and ovulatory dysfunction can be caused by a number of factors. The most common cause of ovulatory dysfunction is polycystic ovarian syndrome, PCOS.

Other potential causes of irregular or absent ovulation:

  • Obesity
  • Too low body weight
  • Extreme exercise
  • Hyperprolactinemia
  • Premature ovarian failure
  • “Advanced maternal age”, or low ovarian reserves
  • Thyroid dysfunction (either hyperthyroidism or hypothyroidism)
  • Extremely high levels of stress

How is Anovulation Diagnosed?
Your doctor will ask you about your menstrual cycles, and if you report irregular or absent cycles, ovulatory dysfunction will be suspected. You doctor might also ask you to track your basal body temperature at home for a few months. How To Detect Ovulation With Basal Body Temperature Charting?

Next, your doctor will order blood work to check hormone levels. One of those tests might include a day 21 progesterone blood test. After ovulation, progesterone levels rise. If your progesterone levels do not rise, you are probably not ovulating.

Your doctor may also order an ultrasound. The ultrasound will check out the shape and size of uterus and ovaries, and also look to see if your ovaries are polycystic, a symptom of PCOS.

Ultrasound can also be used to track follicle development and ovulation, though this isn’t commonly done. In this case, you might have several ultrasounds over a one- to two-week period.

What are the Potential Treatments for Anovulation?
Treatment will depend on the cause of the anovulation. Some cases of anovulation can be treated by lifestyle change or diet. If low body weight or extreme exercise is the cause of anovulation, gaining weight or lessening your exercise routine may be enough to restart ovulation.

The same goes for obesity. If you are overweight, losing even 10% of your current weight may be enough to restart ovulation.

The most common treatment for anovulation is fertility drugs. Usually, Clomid is the first fertility drug tried. Clomid can trigger ovulation in 80% of anovulatory women, and help about 45% get pregnant within six months of treatment. If Clomid doesn’t work, there are many other drugs worth trying.

What is Clomid?

Clomid is the brand name for the fertility drug clomiphene citrate. Clomiphene citrate may also be sold under the brand name Serophene. Whether you’re taking the brand name Clomid, Serophene, or a generic version of clomiphene citrate, it’s all the same drug. (Think of Clomid in the same way that we use Kleenex® to refer to facial tissues.)

Clomid is the most well-known fertility drug, probably because it is the most commonly used. And with good reason. About 25% of female factor infertility involves a problem with ovulation, and clomiphene citrate, as a fertility drug, is easy to use (taken as a pill, not an injection), with not too many side effects, is pretty inexpensive compared to other fertility drugs, and is effective in stimulating ovulation 80% of the time.

When is Clomid Used?
Clomid is used when there are problems with ovulation, but no problems with blocked fallopian tubes. (In that case, stimulating ovulation would be pointless — the egg and sperm can’t meet if the tubes are blocked.) If a woman has irregular cycles, or anovulatory cycles (menstruation without ovulation), Clomid may be tried first.

Clomid is often used in the treatment of polycystic ovarian syndrome (PCOS) related infertility. It may also be used in cases of unexplained infertility, or when a couple prefers not to use the more expensive and invasive fertility treatments, like IVF.

Clomid may also be used during an IUI (intrauterine insemination) procedure, but it is rarely used during IVF treatment. With IVF, injectable ovulation meds are more frequently chosen. All About Fertility Drugs

How is Clomid Taken?
You should follow the directions your doctor gives you, as every doctor has a slightly different protocol.

However, the most common dosage of Clomid is 50 mg, taken for five days, on days 3 through 7 of your cycle, or days 5 through 9 of your cycle. (With day one of your cycle being the first day of real menstrual bleeding, and not just spotting.) Ovulation and pregnancy rates have been shown to be similar whether the drug is started on day two, three, four, or five, so don’t feel concerned if your doctor tells you a different protocol to follow than your friend.

If 50 mg doesn’t work, your doctor may increase the medication, according to their judgment, for a successive cycle. Or, they may give it another try at 50 mg. You might think that more is always better, but higher doses, especially at or above 150 mg, can actually make conception more difficult. (See below, under side effects.)

What are Clomid’s Common Side Effects?
Clomid’s side effects aren’t so bad, as far as fertility drugs are concerned. The most common side effects are hot flashes, breast tenderness, mood swings, and nausea. But once the medication is stopped, the side effects will leave, too.

The side effect you’re probably most familiar with is the risk of multiples. You have a 10% chance of having twins when taking Clomid, but triplets or multiples of more are rare, happening less than 1% of the time.

One of the more annoying side effects to comprehend is that Clomid can decrease the quality of your cervical mucus (which sperm need to make their way to the egg), making conception more difficult. Clomid can also make the lining of your uterus thinner and less ideal for implantation. This is why “more” is not necessarily better when it comes to Clomid dosage and use.

How Successful Is Clomid?
Clomid will jumpstart ovulation in 80% of patients, and about 40% to 45% of women using Clomid will get pregnant within six cycles of use.

Using Clomid for more than six cycles is not generally recommended. If six cycles go by, and pregnancy is not achieved, other alternatives may be considered.

When Clomid Does Not Achieve Ovulation
While 75% of women taking Clomid for anovulation will ovulate, 25% will not. Without ovulation, pregnancy achievement is impossible. If you don’t achieve ovulation on Clomid, will you need to move on to stronger drugs or more complex treatments? Not necessarily.

Clomid Resistance
Sometimes, the reason you may not ovulate on Clomid is because the dosage is too low. It’s common to start Clomid treatment at 50 mg, and then increase to 100 mg if you don’t respond to 50 mg. In some cases, doctors will try doses up to 250 mg. However, if you’re still not ovulating, your doctor may say you are Clomid resistant.

Clomid resistance is just a fancy way of saying that your body does not respond the way we’d like to Clomid.

What Causes Clomid Resistance?
Your doctor’s approach to treating Clomid resistance depends partially on why he thinks you are not responding. Here are a few known, possible reasons for Clomid resistance:

PCOS: Women with PCOS commonly have trouble with Clomid resistance, especially those who are diagnosed as insulin resistant or with hyperandrogenic levels (high levels of DHEAs and male hormone levels).

BMI over 25: A body mass index (BMI) over 25 can decrease the chances of Clomid working successfully.

Hyperprolactinemia: Women with hyperprolactinemia may not respond well to Clomid, without also treating the hyperprolactinemia.

Of course, there are times when it’s not clear why Clomid is not helping induce ovulation.

Options in Treating Clomid Resistance
For women with PCOS, treatment with the insulin resistance drug Metformin, also known as Glucophage, may help. Ideally, Metformin would usually be prescribed for a period of three to six months before trying Clomid again. Some studies have shown that besides improving ovulation rates, taking metformin and Clomid together may also increase the pregnancy rate and decrease the risk of miscarriage.

Ovarian drilling is an older method of treating Clomid resistance in women with PCOS, but is not commonly used today because of the risks. If your doctor suggests ovarian drilling, you may want to question the reason for that choice, when there are other options that can and should be tried first.

If your BMI is over 25, your doctor may suggest that you lose some weight before retrying Clomid. Losing just 10% of your current body weight may improve Clomid’s effect. – Could Your Weight Keep You From Getting Pregnant?

For those with hyperprolectinemia, treatment with the drug Bromocriptine, either alone or in combination with Clomid, may improve ovulation rates.

Birth Control Pills for Infertility?
One interesting way of dealing with Clomid resistance is taking birth control pills for one to two months before trying another cycle of Clomid. This is recommended for women with high levels of the hormone DHEAs.

It seems a bit counterintuitive — birth control pills will help you get pregnant? But research studies have shown good results. In one study on the use of birth control pills, just over 65% of Clomid resistant women ovulated, after taking oral birth control pills for two months preceding a cycle of Clomid treatment.

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