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!


updated 1/12/10

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