Infertility

Roughly fifteen to twenty percent of women who are trying to conceive are confronted with the letdown and frustration of a negative pregnancy test month after month.

The current phenomenon of women delaying childbirth until well until their thirties or even forties is a result of longer life expectancy, delayed (or no) marriage, and the personal and societal expectation that a woman can be CEO of her company by age forty and then carry and raise three or four children. Currently, one-third of American women now have their first baby after age thirty-five. We recognize this and appreciate that many of our patients have delayed childbearing and therefore need an early, thorough evaluation to detect potential problems.

Age, of course, is not the only factor that determines if someone is able to conceive. Even young women often find themselves unable to get pregnant due to endometriosis, irregular menstrual cycles, or other factors.

We at Gynecologic Specialists of Northwestern work closely with reproductive endocrinologists (fertility specialists) to offer you state-of-the-art fertility evaluation and treatment, including ovulation induction and artificial insemination, right in our office.

If you do not conceive, we then facilitate the transfer to a fertility specialist for advanced reproductive techniques such as In-Vitro Fertilization. None of the basic evaluation or protocols need be repeated since we follow the recommendations of the experts with every cycle from the beginning.

We start with a detailed history and physical exam, timed hormonal testing, and ultrasound to evaluate ovulatory function.

Hysterosalpingograms and saline-infused ultrasound are performed conveniently in our office for evaluation of the tubes and uterine cavity. 

An early semen analysis is also recommended in order to make sure that a male factor is not the problem.

 

 

 

 

Please read on for more information about what normally occurs to achieve pregnancy. 

Understanding the biology behind what your body does (or doesn't do!) will help you understand the evaluation and treatment that we will recommend.

The uterus, ovaries and millions of eggs are present in every girl at birth. The hormonal changes that initiate the menstrual cycle and allow pregnancy to occur, however, do not occur until puberty. Gonadotropins are hormones that are secreted from the pituitary gland and consist of Follicle Stimulating Hormone (FSH) and Lutenizing Hormone (LH). As early as age nine, FSH and LH stimulate the ovary so that a follicle develops. A follicle is a group of cells that form a small ovarian cyst that surround the egg and produce large amounts of estrogen and small amounts of progesterone. Estrogen causes the endometrial lining to thicken and grow. This occurs during the first part of the menstrual cycle, known as the proliferative phase.

At the time of ovulation, the follicle ruptures and an egg is released. In most women, this occurs mid-cycle, two weeks before menstruation begins. The egg then travels down the fallopian tube where it may or may not meet up with a sperm. If fertilization does occur, the fertilized egg travels down the tube and implants in the wall of the uterus. If fertilization does not occur, the egg is resorbed.

The ruptured follicle is now referred to as a corpus luteum cyst and primarily produces progesterone as opposed to estrogen. The main function of progesterone is to prepare the lining of the uterus to support a pregnancy in the event that fertilization has occurred. This portion of the menstrual cycle is known as the luteal phase and lasts fourteen days.

At the end of the luteal phase, progesterone levels plummet and the lining of the uterus (the endometrium) sloughs off, resulting in menstruation. This cycle normally repeats itself in the absence of pregnancy on a monthly basis during the reproductive years.

 

Menstruation is therefore not only a female rite of passage but also a reassuring indication that everything is working as it should. The sole purpose of the menstrual cycle is to prepare the uterus for pregnancy. Monthly bleeding caused by the shedding of the lining of the uterus heralds an unsuccessful cycle and gives the body another chance to become pregnant.

Unfortunately, it is entirely possible to menstruate without ovulating, producing an appropriate progesterone level, or adequately preparing the lining of the uterus for a potential pregnancy. In other words, just because you are menstruating doesn't mean you can get pregnant.

So even if you get reasonably regular periods, you need to figure out if you are consistently releasing an egg. Ovulation predictor kits (sold over the counter right next to the pregnancy tests) are a useful way to document ovulation by testing your urine mid-cycle. If your cycles are long, you may have to use multiple kits to hit the right day. If an egg is released, your progesterone level will rise. We often do a blood test during the second half of your cycle to confirm that you have in fact ovulated. It is a good idea to check at least a few cycles, since one month may not be representative of what happens every month.

Keep in mind that you cannot check ovulation or hormone levels if you are currently taking the pill or using other forms of hormonal contraception.

A blood test to measure follicle-stimulating hormone (FSH) is the best way to determine age-related ovarian function.

Follicle-stimulating hormone is secreted from the pituitary gland but is regulated by ovarian estrogen production, and is therefore an indirect measurement of ovarian reserve. FSH levels are low in young women, when estrogen levels are high, and rise after menopause. Long before someone stops producing estrogen and is officially menopausal, FSH levels fluctuate and rise slightly. It is at that point that fertility is diminished. For some women, that occurs when they are thirty-five years old. For others, conception is still possible at forty-five. An important caveat to checking the FSH level is that it must be checked at the appropriate time in the cycle. There is an FSH surge mid-cycle and if someone unwittingly checks a level at that time, they may think they have entered menopause, when in fact they may be about to ovulate!

In addition, since FSH tends to fluctuate during the perimenopausal years, an isolated FSH level is only an indication of what is happening that month, not necessarily what happens every month. If you are forty years old and had a low FSH level a year ago, don't assume that is still the case.

Therefore, particularly if you are not ovulating, the best indicator of the impact your age will have on fertility is determined by having your doctor do a blood test to check your FSH level on the third or fourth day of menstrual bleeding. If someone has not had a period for months, a measurement can be done at any time. If the level is unexpectedly high, it should be repeated two weeks later to make sure it is not just a mid-cycle surge.

In general, the lower the FSH, the better. Low FSH levels generally translate to high estrogen levels, and if not the likelihood that you are spontaneously ovulating, at least the likelihood that intervention may induce ovulation. Most fertility clinics have an "FSH cut-off" beyond which they decline to treat a woman unless she is using a donor egg. They generally check an FSH level every single month during treatment since it is inappropriate (and futile) to stimulate women with expensive and potentially dangerous drugs if there is little or no chance of conceiving.

Factors that Contribute to when your Fertility will Diminish

If you are in that lucky low FSH group, is there a way to predict how long that low FSH will stay low? Are you destined to hang on to your fertility for an additional ten years, or are you more likely to become infertile before you hit your fortieth birthday?

There are a number of factors that are predictive of when one's ovaries will start to wind down.

Genetics
Even if you have almost nothing in common with your mother, her hormonal pattern is frequently predictive of when you are genetically destined to enter menopause. While the average age of menopause (when the ovaries stop producing estrogen) in the United States is 51.5, it is likely that you are fated for a later menopause if your mother menstruated until she was in her late fifties. On the other hand, if your mother stopped menstruating in her forties, you may be destined to as well. Fertility diminishes long before menopause, but women with a later menopause can usually conceive at a more advanced age than average. Asking your mother when she went through menopause isn't necessarily helpful since she is likely to say something like "I still am." It is common for women to equate "going through menopause" as having symptoms such as hot flashes, insomnia and mood swings, which may start years before menopause and continue for years after. The question you need to ask is: "When did you stop menstruating?" If your mother was young, say in her forties, it is not a given that you will go through menopause in your forties since many other factors (that may not apply to you) may have contributed to the fact that she stopped on the early side. Still, it may indicate that you are more likely to have an early menopause than if she was in her fifties.

Medical conditions
Some medical conditions are associated with the onset of not only diminished fertility, but an earlier onset menopause as well. If you have one of these conditions, it does not mean that you will definitely have difficulty getting pregnant; it just means that you are more likely to wind down a little sooner. Many kinds of cancer fall into this category. Autoimmune diseases, chronic liver or kidney disease, some thyroid diseases and Cushing's syndrome are also commonly associated with early infertility. In addition, some adrenal and ovarian tumors can instigate an early menopause. Medications used to treat certain illnesses are known to diminish fertility and/or accelerate the onset of menopause. Chemotherapy, antipsychotic drugs, and steroids are the most common examples.

Gynecologic Conditions that May Affect Fertility
Many gynecologic conditions influence fertility that are not specifically age-related but still frequently affect the older woman who is trying to conceive, simply because a forty-year-old has a greater likelihood of developing one of these problems with the passage of time. A twenty-year-old woman might have fibroids, but they will most likely be small and inconsequential. If that same woman waits until she is thirty-five to try and conceive, the additional fifteen years of growth may result in huge fibroids that distort the uterine cavity such that a pregnancy cannot implant. In addition to fibroids, endometriosis, pelvic surgery that has created scar tissue, and pelvic infections can all impair fertility and are more likely to be an issue for a forty-year-old than a twenty-year-old.

What About the Pill?

It is a common misconception that taking birth control pills for an extended time decreases fertility. It is not unusual for a young woman to start the pill at sixteen or seventeen and continue until she is in her late thirties. She then goes off the pill, tries to get pregnant, discovers she is not ovulating, and is convinced she is having problems because she took the pill for so many years. The reality is the fact that she is forty years old, not the exposure to hormones for twenty-four years, has resulted in decreased fertility. Even if she had not taken the pill for 24 years, she would still be infertile at age forty.

In many cases, the pill actually preserves fertility. It is well accepted that women with endometriosis protect their fertility by suppressing periods with the pill. Taking the pill also prevents abnormal cysts that might result in ovary removal. It is also a little-known fact that women who take the pill have a significantly decreased risk of developing ovarian cancer… the ultimate in loss of fertility, not to mention potential loss of life. The bottom line is that taking the pill for a long period of time is good for most women. Waiting until forty is the problem, not the pill.

How long do you need to be off the pill before conception? There are actually two issues: when is the pill out of your system so that it is "safe" to conceive, and when will you have a normal return to fertility?

The pill is essentially out of your system within days of discontinuing them. That's why it is so important to take the pill the same time every day. If you don't, the hormone level drops rapidly and your own hormones kick in. If you were to conceive the day after going off the pill, there is NO increased risk to a developing baby. In fact, even if you conceive while taking the pill (rare, but it happens), there is still no risk to the unborn baby.

As to when your "normal" fertility kicks in, that depends. A twenty-year-old who has normal cycles will usually ovulate and get normal periods within a few weeks of discontinuing the pill. A woman in her thirties or early forties may take a lot longer. In any event, it's a good idea to discontinue the pill three of four months before you want to conceive so that you are able to evaluate your cycles and address ovulatory dysfunction, particularly if you are in your late thirties or older. If you are sexually active, however, and don't want to conceive, you need to use protection one week after discontinuing the pill since you will no be longer protected. Inevitably, the only ones who conceive the minute they go off the pill are the ones who don't want to.

Storing Eggs

If pregnancy is years away, the perfect solution would seem to be simply to store your eggs until you are ready to use them. Many single women inquire about freezing eggs in order to increase the possibility of pregnancy with their own genetic material when her own eggs are no longer usable.

While freezing embryos (an egg that has been fertilized with sperm and is at an early stage of development) is very successful, cryopreservation of unfertilized eggs is still considered to be investigational. 

If you are interested in storing your eggs, we will be happy to refer you to a reproductive endocrinologist.