General
Infertility/Reproductive Endocrinology Q & A
What is a Reproductive
Endocrinology & Infertility Specialist? A Reproductive Endocrinologist
(RE) is first trained in Obstetrics/Gynecology. An additional
fellowship of two to three years follows in the field
of reproductive endocrinology & infertility. An
RE manages problems related to the reproductive system
including hormonal disorders, menstrual problems, infertility,
pregnancy loss and menopause. They are highly trained
in the surgical treatment of the female reproductive
system. They care for patients from birth through death.
Some are also trained in male factor infertility. RE’s
are best known for their work in “test tube babies”
using In Vitro Fertilization (IVF), a small segment
of what they are truly trained to do.
What
is Infertility and What Causes It?
Infertility
occurs when a couple has unprotected intercourse for
one year without conception. Around 15% of all couples
that try to conceive in 12 months will not succeed.
Forty percent of the woman will have problems such as
damaged Fallopian tubes, endometriosis, advanced age,
ovulatory problems and hormone imbalances. Forty percent
of the time it is due to the male caused by hormone
imbalances, a scrotal varicose vein, obstruction, infections,
chronic medical conditions and antibodies. The remaining
20% of the couples will have issues on both sides. Seeing
a Reproductive Endocrinology & Infertility subspecialist
may be an excellent first step.
How Do You Evaluate Infertility?
The evaluation for infertility
can be quite simple. Obtaining a history & physical
exam is crucial. For the woman, checking her Fallopian
tubes with dye and x-rays, checking ovulation via blood
testing and performing a detailed pelvic ultrasound
will diagnose a host of issues. This is a good start
and surgery is often not necessary. The men have it
easy. All they need do is produce an ejaculate after
about two days of abstinence. Having the semen analysis
performed at a reproductive laboratory is very important
so you can be confident of the results. Those are the
basics!
Can
I Choose the Sex of My Baby?
Sexual position, timing, varying
penile penetration depth and insemination procedures
do not increase the chances of having one gender.
There are two techniques, however, that do work. Microsort
helps to separate the sperm carrying the X chromosome
(creates a girl) and the Y chromosome (creates a boy).
The accuracy is 70-80% but the process usually requires
travel to the distant separation facility. Preimplantation
Genetic Diagnosis (PGD) is about 95% accurate and
works by screening a single cell from the developing
embryo. PGD also screens for such problems as Downs
Syndrome. Speak to your Board Certified Reproductive
Endocrinologist for details!
How Do I Choose an Infertility
Specialist?
Your infertility specialist
should be Board Certified in Obstetrics & Gynecology.
They should also be sub-specialty trained and Board
Certified in Reproductive Endocrinology & Infertility.
They need to keep up their yearly board recertification
requirements and have their test scores available
for review. It is ideal that the physician care for
both the man and the woman. Any physician that has
received honors for their work, is published, is involved
in community medical education or currently performs
research should be considered desirable. Their reputation
in the community is very important and their experience
invaluable. Shop well!
How
Often Should We Have Sex to Become Pregnant?
Having sex every 36-48 hours
in the middle part of the women’s menstrual
cycle is ideal. Couples that have sex five times per
week get pregnant faster than those who have sex less
often. Throw away the daily temperature charts and
just have fun! No one has ever shown the charts to
help more than frequent intercourse. Taking a temperature
every morning is also a lousy way to start the day.
Have fun, go on dates, keep it as spontaneous as possible,
remember why the two of you are together and don’t
make creating a baby a second job!
Can
I “Untie” My Tubes?
Fallopian tubes are usually
cut, burned or clipped. There is never a simple bowtie
that could be undone with the pull of a string. Once
sterilized, a woman may undergo surgery to re-attach
the tubes (tubal reanastomosis) or bypass the blockage
via In Vitro Fertilization. Surgery requires recovery
time and the risk for a tubal pregnancy are increased.
Pregnancy often takes longer with surgery and is not
guaranteed. IVF is often quicker but involves injections
for a couple of weeks and the multiple pregnancy rates
are often increased. Speak to your friendly neighborhood
Reproductive Endocrinologist for details!
Does Stress
Cause Infertility?
Stress
itself probably doesn’t cause infertility although
what patients do with their stress certainly can. Smoking
reduces embryo implantation and increases miscarriage
rates. Alcohol can certainly harm the young fetus. Eating
in excess or losing too much weight may cause ovulatory
problems. A few studies have shown that stress may increase
miscarriage rates. Reducing stress through acupuncture
may help but perhaps not any more than exercise, yoga
or mediation. Undue stress may also induce erectile
dysfunction so watch the stress on both sides. Seek
stress reduction when possible if only to enjoy life
more!
How
Does a Woman’s Age Influence Fertility?
At the time that menstruation
starts, women have approximately 300,000 eggs in their
ovaries. About 600 eggs die each month with only one
making it to ovulation. As the number of eggs remaining
falls, the quality of the eggs also diminishes. The
decreased quality of eggs results in a much longer time
to become pregnant, fewer pregnancies overall, higher
miscarriage rates and an increased risk of the delivery
of a Down syndrome child. The pregnancy rates decrease
starting before age 30 and become dramatic near the
age of 37 and beyond. Conception sooner than later is
probably the best option.
What is IVF?
In Vitro Fertilization is the
process wherein women are given medications that induce
the ovaries to produce a number of eggs. These eggs
are removed under anesthesia using a slender needle
placed into the ovaries. The eggs are then combined
with the partner’s sperm to create embryos. After
about five or six days of growth, a small number of
the healthiest appearing embryos are placed back into
the uterus painlessly with a slender catheter. Pregnancy
rates have dramatically improved over the years and
this process is often the only way a couple will be
able to have a child together.
What
is Anonymous Egg Donation?
Some women run out of quality
eggs at an early age. This may occur following cancer
treatment, ovarian surgery or just bad luck. An alternative
is to use a younger woman’s eggs. With anonymous
egg donation, the donor is commonly matched to the
physical characteristics of the wife. The eggs are
removed and combined with the husband’s sperm.
The embryos are grown with one or two transferred
back into the wife’s uterus. The wife carries,
nurtures and protects the pregnancy until delivery.
Pregnancy rates can be amazing. This is a wonderful
option for women who otherwise could not conceive.
What is Anonymous Sperm
Donation?
When the sperm count is abnormal
and can’t be fixed, insemination procedures
and IVF may work well. For men without sperm or women
who do not have male partners, donor sperm may be
the answer. The donated sperm is frozen in liquid
nitrogen at certified facilities and stored for at
least six months. The men undergo comprehensive testing
to assure safety. The sperm is transported to my facility,
thawed and placed inside the uterus near ovulation.
Pregnancy rates are comparable to natural intercourse
so conception often occurs quickly. It is a great
option for some of my patients.
What is Polycystic Ovary
Syndrome?
Polycystic Ovary Syndrome (PCOS)
requires two of three problems to be identified; (1)
ovulation problems, (2) excess male hormone or (3)
multiple small ovarian cysts seen on ultrasound. The
diagnosis is discovered in 6% of women making it the
most common endocrine imbalance in reproductive age
women. These women tend to be heavy and may show some
level of excess facial and body hair growth. About
half will have pre-diabetes with elevations of sugar
and insulin. Treatment commonly includes weight loss,
exercise, medications for the pre-diabetes and medications
used to induce ovulation. Pregnancy may be only an
ovulation away!
What is Recurrent Pregnancy
Loss (RPL) and what causes it?
Recurrent Pregnancy Loss is
the consecutive loss of two or three pregnancies before
the 20th week of gestation. Only 1-5% of all women
will have RPL. Common causes include an abnormally
shaped uterus due to birth defects or acquired damage,
parental chromosomal problems, hormonal imbalances,
lifestyle issues and advanced maternal age. Antibodies
may be produced which attack the placenta resulting
in miscarriage. Treatment plans must be tailored to
the specific problems but often include surgery, hormones,
modification of lifestyle habits as well as medical
treatments. Success rates following treatment are
usually around 70%, so a healthy child is certainly
possible.
What is an Intra-Uterine
Insemination (IUI)?
With infertility treatment,
it is common to induce women to release 1-3 eggs at
a time to improve the chances for pregnancy. On the
same day of induced ovulation, sperm are collected,
purified, concentrated and then placed into the uterine
cavity using a slender catheter inserted through the
cervix. The sperm are then gently injected (Intra-Uterine
Insemination: IUI) placing millions of sperm into
the uterus whereas only hundreds would make it there
during natural intercourse. With the combination of
a few more targets (eggs) and an improved quantity/quality
of sperm, the potential for conception is vastly improved!
What is Embryo Donation?
When embryos are created in
our laboratory, any extra healthy embryos remaining
are frozen in liquid nitrogen for future use. If the
patients don’t want to use these embryos themselves,
they can anonymously donate them to needy individuals/couples.
For example, a breast cancer survivor may become sterile
following treatment. Egg donation is more expensive
and adoption is often not possible because of her
medical history. An excellent option would be the
placement of thawed donated embryos into her hormonally
prepared uterus. Embryo Donation can be a wonderful
and cost effective option for many other types of
patients as well.
What is Endometriosis?
Every month when a woman menstruates,
uterine lining cells flow in a retrograde fashion
back through the Fallopian tubes and into the abdominal
cavity. These “endometrial” cells sometimes
attach to the pelvic structures including the peritoneum
and the ovaries themselves. These islands of tissue
take hold and undergo a type of miniature menstruation
each month releasing substances that are toxic to
eggs, sperm and embryos. Infertility, painful intercourse,
pelvic pain & painful periods are common symptoms
of endometriosis. Surgical therapy often works best,
although In Vitro Fertilization (IVF) can offer superb
success rates for more advanced cases.
Is
There Any Way To Prevent My Child Being Born With A
Genetic Disease We Carry?
Cystic
fibrosis is an example of a genetic mutation that requires
both parents to carry an abnormal gene. When the parents
reproduce, there is a one in four chance the child will
receive both mutations and have the deadly disease.
Commonly, the woman will become pregnant and then check
the child during the second trimester to see if it has
the disease. With Preimplantation Genetic Diagnosis
(PGD), we can screen the embryos for the disease and
only transfer those embryos that that are healthy. The
accuracy is over 98% and we stop genetic disease in
its tracks.
If
My Eggs Are Too “Old,” What Are My Options?
As women age, the potential
for pregnancy becomes extraordinarily unlikely, regardless
of the technique. For these women, options such as
egg donation, embryo donation and adoption are available.
Using a young woman’s eggs, age 18-31, works
about 60% of the time on the first try in my practice.
Some couples may have excess cryopreserved embryos,
which they choose to donate to needy patients and
couples, offering a less expensive option. Adoption
is also available although some agencies will not
offer adoption to older couples. All in all, however,
fantastic options are still available when the eggs
are running out.
What is
Surrogacy?
There are two types of surrogacy.
The first is called Conventional Surrogacy wherein
the surrogate ovulates and is then inseminated with
the husband’s sperm to create a child. A second
more common form of surrogacy involves obtaining both
eggs & sperm from a couple, creating embryos and
then placing the embryos into a Gestational Surrogate.
Sometimes we actually throw in an egg donor into the
process when the wife’s eggs are not healthy.
Regardless, the Gestational Surrogate doesn’t
have a genetic investment in the pregnancy, so she
can’t change her mind. Speak to your Reproductive
Endocrinologist for details.
Do I Have To Have a Hysterectomy if I Have Fibroids?
If you have completed reproduction,
a hysterectomy can certainly be curative. Other procedures
such as uterine artery embolization (blocks off the
uterine vessels so the uterus and fibroids shrink)
and ultrasound ablation techniques are also excellent
options. If you do plan on reproducing, however, it
is probably best to consider removal of the fibroids
with uterine reconstruction. A Cesarean section for
future deliveries is commonly required and some patients
do grow new fibroids, so this decision must be made
carefully. You may want to speak to your friendly
neighborhood Reproductive Endocrinologist to find
out which procedure is best for you.
What Are
My Risks If I Become Pregnant After 40 Years of Age?
High blood pressure and pre-eclampsia
are more common in the older pregnant patient. Diabetes
is increased as women get older. Maternal death rates
are increased from 1 in 5,000 for the younger patient
to 1 in 1,250 deliveries for the older patients -
still a very rare event. Surgical deliveries are doubled
in pregnant women over 40. Premature delivery rates
are slightly increased from 6% for younger women to
8% for older pregnant patients. The risks for Down
syndrome increase as women age although the actual
incidence is still quite infrequent. Our motto is
healthy at any age!
Does Our Lifestyle Influence
our Fertility Rates?
Men and women who contract
sexually transmitted diseases risk damage to their
reproductive organs so condoms are encouraged. Smoking
reduces pregnancy rates by 30%, double miscarriage
rates, increases pregnancy complications and brings
menopause on earlier by two years. Men who smoke have
reduced sperm counts and motility. Women who are underweight
or overweight have ovulation difficulties. Pre-diabetes
or diabetes in both men and women can severely reduce
fertility rates. Alcohol consumption by women reduces
fertility rates and increases the delivery rates of
fetal-alcohol syndrome children. Men who drink in
excess have higher estrogen levels that interfere
with normal sperm development.
When
is Adoption a Better Idea?
When pregnancy attempts have
gone on for years and failure has occurred in spite
of the best of attempts, adoption may be an excellent
option. For some, this may be the most cost affective
method to have a family. Cancer survivors or those
couples that are older will often have difficulties
adopting both within the U.S. and abroad. Single individuals
often have a challenging time adopting a child, especially
here in Florida. The vast majority of adoptions go
well although one may hear “horror” stories.
Be informed and do your research. Adoption may be
a wonderful option for many couples.
Will My Insurance Cover
Infertility?
There has to be a reason for
infertility. Numerous diseases such as endometriosis,
blocked Fallopian tubes and ovulatory dysfunction
can cause infertility. Pre-diabetes and diabetes are
common causes of infertility in both partners. It
is important to carefully and methodically diagnose
and treat these medical conditions. It is also very
important to document and code for these medical problems
in an ethical and imaginative way to maximize insurance
coverage. By simply treating the medical problems,
often a covered service, conception will often occur
on its own!
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