When you want to conceive, but it's not happening

When you are trying to conceive for months without success it is easy to become frustrated and need help: both medical and emotional.  This can be a trying time for any couple.  We are sensitive to this, and want to reassure you that we will do everything in our power to make this chapter in your life as easy as possible. 
 
Infertility is typically defined as the inability of a couple to conceive after one year of unprotected intercourse.  If you are 35 or over, we begin the evaluation sooner than one year, as maternal age can independently affect your ability to conceive.
 
Infertility or fertility delay is a common condition: In any given year, about 15% of the couples in the U.S. who are trying to conceive are not able to do so. The ability of a couple to become pregnant depends on several factors in both the male and female partners.
 
Basic Causes of Infertility

1. male factor: 20%
2. ovulation dysfunction: 20%
3. blocked fallopian tubes: 15%,
4. endometriosis: 10%
5. uterine abnormalities: 5%,
6. hormonal conditions: < 5%
7. unexplained: 25%

 
Multiple pieces to the puzzle: 

Often there is more than one contributing factor.  If we cannot uncover and address your specific cause within a short period of time, we will refer you to a specialist in reproductive medicine for more advanced investigation and options.  The good news: most couples who present to us with fertility difficulties ultimately become parents, with or without our help, or with the assistance of our specialist colleagues.
 
Your Consult and Evaluation

Our first discussion is best with both partners to investigate possible historical barriers to pregnancy. These might include not having sex during the fertile time of the month, ejaculatory problems, previously undisclosed medical conditions that could delay fertility.   Both partner's past health and medical history are important in the process of evaluation. 
 
We will ask about childhood growth and development; sexual development during puberty; sexual history; illnesses, infections, surgeries, medications, exposure to certain environmental agents, (alcohol, radiation, steroids, chemotherapy, and toxic chemicals), and any previous fertility testing. If genetic or chromosomal abnormalities are suspected, specialized blood tests may be needed to check for absent or abnormal regions of the male chromosomes (Y chromosome).
 
Physical examination

This is usually includes a general examination, with special attention to any signs of hormone deficiency/excess or signs of other conditions that might affect fertility. We will also perform a pelvic examination, which can identify abnormalities of the reproductive tract and signs of low hormone levels. 
 
Blood tests 

Blood tests can provide information about the levels of several hormones that play a role in female fertility; in women, key hormones are produced by the hypothalamus, the pituitary gland, and the ovaries. These hormones include follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin.
 
Ovulation Prediction 

Ovulation (the release of an egg from an ovary) is essential for fertility. Abnormalities of ovulation can often be determined from a woman's menstrual history or hormone levels such as the pre-ovulatory LH surge or luteal phase progesterone.
 
Menstrual history 

• Amenorrhea (absent menstrual periods) usually signals an absence of ovulation, which can cause infertility.

• Oligomenorrhea (irregular menstrual cycles) can be a sign of irregular ovulation; although oligomenorrhea does not make pregnancy impossible, it can make it harder, delay the ability to time to conceive.

 
Hormone levels 
Levels of luteinizing hormone (LH) rise abruptly about 36 hours before ovulation. This hormone surge can be detected using an over-the-counter urine test.
However, this kit fails to detect the hormone surge about 15 % of the time. Therefore, we may recommend a blood test to confirm ovulation, at a specific time in your time.

Blood levels of the hormone progesterone are a more accurate indicator of ovulation. Normally, levels of progesterone rise after ovulation. A test to measure the progesterone level is usually performed 18 to 24 days after the first day of a period.
 
Fallopian tube testing: HSG = Hysterosalpingogram
Hysterosalpingography (HSG): should be scheduled during days 6-10 or so in your menstrual cycle.  This is the period between the cessation of menses and ovulation, to minimize the chance of interfering with a possible early pregnancy. 

The HSG procedure: involves having a speculum placed in your vagina, a slim cannula is placed intracervically and radio-opaque medium is instilled slowly through the cervix under fluoroscopic guidance to observe the dye as it moves through your cervix, uterus and fallopian tubes.   In general, radiographs are taken in sequence: at the beginning of uterine cavity filling, when the cavity is filled, during tubal filling to evaluate the tubal mucosa, and later to document whether there is spillage of contrast into the peritoneal cavity. Fluoroscopy can detect small lesions or abnormalities that might be missed without real-time imaging. 
 
This test requires radiographic equipment.  HSGs can be done locally at Northeast Radiology or WP Hospital, for NERad, call 914.666.6692 , to schedule at White Plains Hospital, call:914.681.1260.  If you are seeing a specialist in IVF, they often want to do the procedures themselves.
 
Because the procedure can cause uterine cramping, we advise you to take ibuprofen 600 mg one hour before procedure. In addition to diagnostic information gained about your anatomy, HSG also has a therapeutic benefit for some patients: increased pregnancy rate after the procedure. This is believed to be due to opening the tubes up by the pushing of fluid through them for the test.  
                                                                            
Tubal Disease. 

The major cause of tubal infertility is pelvic inflammatory disease. Other conditions, such as endometriosis or pelvic adhesions from an intraabdominal infection or surgery, may also interfere with egg pick-up by the fallopian tube.
 
Uterine Abnormalities

A wide variety of uterine abnormalities have been linked to infertility and miscarriage, including congenital uterine anomalies (eg. uterine septum), abnormalities associated with in utero exposure to DES (eg, a T-shaped uterus), fibroids (depending on location), polyps, and scarring from prior uterine procedures.  These can be identified by HSG and hysteroscopy (intra-uterine “scope”) can be used to evaluate further and to surgically treat scarring, submucous fibroids, polyps, or a septum.   

Testing: Semen Analysis 

Semen analysis is performed to determine if there are any sperm abnormalities. The test provides an evaluation of the count, motility and structure of the sperm. Collection of the semen specimen should be done within one hour of dropping of the specimen at the lab. 

The impact of psychological distress/stress on infertility:
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• The process of trying to become pregnant and the difficulty doing so can lead to a variety of emotions, including anxiety, depression, anger, shame, and guilt.
• In one study, 40% of infertility patients suffered with some type of psychiatric disorder; the most common diagnosis was an anxiety disorder (23 %), followed by major depressive disorder (17%.) Both men and women can suffer from these problems, which can further hinder a couple's ability to become pregnant.
• Psychological distress is associated with infertility treatment failure and interventions to relieve stress are associated with increased pregnancy rates. The best approach for treatment of psychological distress related to infertility treatment has not been determined.

 
Relaxation techniques

• Most experts support relaxation techniques to help patients working toward their fertility: including: stress-management, coping skills training, and group support. Consider world expert, Alice Domar, PhD’s, book: "Conquering Infertility: Dr. Alice Domar's Mind/Body Guide to Enhancing Fertility and Coping with Infertility." She is on faculty at Harvard and has done much research into methods to improve results of fertility therapy by reducing stress during the process.
• Several studies have looked at the impact of acupuncture in men who had low sperm counts, and there appears to be improvement (and subsequent pregnancies) in many, but there have not yet been any controlled studies, so the evidence is not clear.
• In women, studies have shown increased pregnancy rates in those who received acupuncture compared to women who lay quietly. However, it is not known if this effect is from the acupuncture or from a placebo effect.
• We know that most people who receive acupuncture report feeling an increased sense of well-being, less anxiety, and less depression, and since there is an association with increased pregnancy rates, it is worth pursuing acupuncture treatment.