Surgery (usually laparoscopic) to remove the endometrial lesions.DID YOU ALWAYS SORT OF ASSUME that getting pregnant was going be as easy as chucking the birth control and getting busy? Sometimes it is, but often it isn’t. Making a baby can take more time than you’d expect—even when everything’s in working order on both sides of the bed, but especially when something (or someone) needs a reproductive tune-up, or more. For 1 in 6 couples, it’s not just a matter of time, it’s a matter of fertility challenges. A number of bumps along the road to baby can slow the way, or even make a detour or two necessary. Fortunately, in most cases fertility challenges don’t have to signal the end of your hopes of starting (or adding to) a family. The right treatment for these conditions can get you right back on the baby-making path and pave the way for conception.
Often, overcoming infertility is as easy as finding out what’s blocking your path to pregnancy, and clearing it up. Sometimes, it’s a condition you already knew about—but maybe didn’t realize would affect your fertility. Other times, it’s a condition that you didn’t have a clue about until a fertility workup uncovered it. Either way, treatment is almost always possible, and usually successful. Here are some of the more common fertility challenges and what can be done to overcome them.
What is it? Uterine fibroids are almost always benign (in other words, noncancerous) tumors that grow inside or around the wall of the uterus. Fibroids can grow individually or in clusters and each can be as small as a grain of sand or as large as a melon.
As many as 80 percent of women in the United States have fibroids, and nearly a quarter of these women have symptoms ranging from painful, extremely heavy, longer-than-normal periods and pressure in the pelvic area, to constipation, urinary incontinence, and backache. Some women don’t have any symptoms at all.
Though it is not completely clear what causes them, fibroids are more common among overweight women (it’s believed that high levels of fat-derived estrogen contribute to the growth of fibroids). African American women are three times more likely than Caucasian women to develop fibroids. There’s also a genetic component: If your mother had fibroids, you may be at higher risk for getting them.
How is fertility affected? Most fibroids do not affect fertility and can safely be left alone. Some, however, can interfere with conception by causing blockages in the reproductive tract and by changing the shape of the uterus, making it harder for an egg to be fertilized or for a fertilized egg to implant. Fibroids can also cause inflammation of the blood vessels of the uterus, which in turn can complicate implantation.
What are the treatment options? A number of treatment options for fibroids are available, but only one is appropriate for women who’d like to conceive. That treatment is a surgical procedure called a myomectomy, during which numerous or large fibroids are removed from the uterus. A myomectomy is generally done laparoscopically in an outpatient setting.
What is it? Any time an infection causes inflammation in your pelvic organs, the condition is known in medical-speak as pelvic inflammatory disease (PID). PID can result from a wide range of pelvic infections, including an infection of the uterus (endometritis), of the fallopian tubes (salpingitis), or of the ovaries (oophoritis). PID can occasionally be caused by a ruptured appendix, but most often it’s triggered by untreated sexually transmitted diseases (STDs) such as chlamydia or gonorrhea. In fact, up to 40 percent of women with untreated chlamydia or gonorrhea develop PID.
The symptoms of PID include pelvic pain (which can come on suddenly or build up over time), smelly vaginal discharge, excessive bleeding during your period, fever, chills, painful urination, backache, nausea, and/or vomiting.
How is fertility affected? Twenty percent of women with PID become infertile. That’s because if PID is left untreated, the inflammation can cause scar tissue to form in the fallopian tubes, making it difficult both for an egg to travel through them after ovulation and for the sperm to reach the egg. If fertilization does occur, the scar tissue in the fallopian tube can stop the fertilized egg from reaching the uterus, increasing the risk for an ectopic pregnancy (when a fertilized egg remains in the fallopian tube and grows there instead of implanting in the uterus). If the uterine lining is affected by PID, it could be difficult for a fertilized egg to implant normally.
What are the treatment options? If you notice any of the symptoms of PID, visit your doctor for a diagnosis. If PID is diagnosed, antibiotics can get rid of the infection and may protect your fertility. Getting treated right away for STDs and following safe sex practices with partners who have STDs will decrease your risk not only for an STD, but also for PID. If the PID leads to scarring, surgery may be recommended (see facing page). Unfortunately, antibiotics can’t reverse damage that is already done, so if PID is not treated, and even in some cases when it is, it’s possible to suffer infertility that can’t be treated with surgery. In such a case, IVF will be necessary in order to conceive.
What is it? Endometriosis, a condition that affects approximately 15 percent of women of reproductive age, occurs when tissue from the uterine lining (the endometrium) gets deposited during menstruation on other parts of the pelvic area (such as the fallopian tubes, ovaries, bladder, appendix, or even intestines) and grows. Because this tissue acts the same way as it does inside the uterus no matter where it ends up, each month when estrogen levels rise as part of a normal menstrual cycle, the endometrial tissue will grow and then bleed if there’s no pregnancy. This results in extreme pelvic pain, severe cramps during your period, painful intercourse, lower back pain, and nausea and vomiting.
Endometriosis is thought to be caused by a combination of factors, including a malfunction of the immune system; a backup of endometrial tissue during menstruation (instead of all the tissue flowing out in the form of a period, some tissue backs up the wrong way and into the abdominal cavity); and genetic factors (if your mom or another close female relative had endometriosis, your chances of developing the condition are increased).
How is fertility affected? Fortunately, endometriosis can be treated. But if left undiagnosed or untreated, the endometrial tissue can continue to grow and block the fallopian tubes, or impede implantation of a fertilized egg in the uterus (if the growths invade uterine muscles, and not just the uterine lining). It is estimated that 30 to 40 percent of women with untreated endometriosis are infertile.
What are the treatment options? Though there is no cure for endometriosis, there are ways to treat the condition and protect (or recover) your fertility. Such therapies include:
Surgery (usually laparoscopic) to remove the endometrial lesions.
Possibly, diet modifications—including avoiding high-fat dairy and stepping up intake of complex carbs, as well as essential fatty acids found in sesame seeds, salmon, flax, walnuts, or walnut oil—may help ease symptoms, though there isn’t any conclusive evidence to support their effectiveness. Since all of these foods are fertility- and baby-friendly anyway, there certainly isn’t any downside to adding them to your eating plan, and there could definitely be some benefits.
Hormonal treatments to reduce the level of estrogen can shrink some of the lesions. Your doctor may suggest a specific course of birth control pills as part of a hormone therapy, though clearly this is not the best treatment if you’re trying to conceive.
What is it? Scar tissues are bands of fibrous material that can develop in and around your uterus as a result of inflammation from PID or endometriosis, or after a gynecological procedure such as a dilation and curettage (D&C). Scar tissue can grow in any part of your body after it’s wounded (like in your finger—the one you sliced along with the tomatoes that time). If your uterus feels wounded because of a D&C or because of PID or other infections, protective layers of tissue (known, not surprisingly, as scar tissue) form in the areas of inflammation as healing takes place. Sometimes, layer upon layer of scar tissue (or adhesions) can grow. An overgrowth of scar tissue in the uterus, called Asherman’s syndrome, may cause symptoms, including pain and light or absent periods.
How is fertility affected? Most scarring in the uterus doesn’t lead to fertility problems, but in some cases it can stop the endometrium (the uterine lining) from forming properly. Without a robust and healthy endometrium, it’s difficult for a fertilized egg to implant and grow properly. Rarely, scar tissue can also form on the cervix, and if it blocks the cervical opening completely, it can impede fertility.
What are the treatment options? If you have lots of adhesions, if you have pain, or if you have trouble conceiving, your doctor may recommend surgery to remove scar tissue. Often, the surgery is performed with a hysteroscope, an instrument inserted through the cervix and into the uterus that is used to visualize the uterine cavity. If any adhesions are found, additional instruments can be inserted through the hysteroscope to remove the scar tissue.
What is it? A cyst is a soft, fluid-filled sac that grows on the ovary or in one (or more) of the egg follicles. For most women who get ovarian cysts, these blister-like growths come and go with a normal menstrual cycle and are completely harmless. But for others, ovarian cysts can linger, grow large, and even cause symptoms, including pain localized on one side of your abdomen when you ovulate (not to be confused with the small normal twinges sometimes felt midcycle). They can also cause irregular periods.
How is fertility affected? If too many cysts cover the ovary, eggs could fail to develop or be released.
What are the treatment options? Often, cysts resolve on their own, but if a cyst persists or gets larger, or if your symptoms get worse, you may need laparoscopic surgery to remove the cyst.
What is it? About 1 in 10 women have polycystic ovarian syndrome (also known as PCOS), and the condition is the most common cause of infertility. PCOS occurs when the body starts producing too much LH and the ovaries start producing too much testosterone (they usually produce only a small amount). Excess amounts of these two hormones disrupt ovarian function and a normal menstrual period (because without ovulation, the body doesn’t produce progesterone, the hormone responsible for normal periods).
PCOS can be marked by irregular periods, extra long menstrual cycles, excess body hair, acne, and obesity. While it’s not known for certain what causes PCOS, experts speculate there is a genetic component (if your mother or a close female relative had it, your risk is higher), and that it might also have something to do with the body’s inability to use insulin properly (not only does insulin control blood sugar, but it also controls ovarian function). Women with PCOS generally have other out-of-sync hormones (including thyroid hormones) as well as elevated levels of other male hormones—and that might also be a contributing factor.
How is fertility affected? When the ovary can’t perform as it should because of the hormone irregularity characteristic of PCOS, the developing follicles (eggs) can’t mature properly, and instead of one egg dominating each month and eventually bursting out in normal ovulation, the developing follicles stay trapped inside. After time, so many follicles collect in the ovary that cysts begin to form. Eventually, a shell also forms around the outside of the ovary, causing further disruptions to ovulation.
What are the treatment options? Weight loss, regular exercise, and medications (such as metformin) may all help the body better use insulin. With less insulin around to stimulate ovarian production of testosterone, the ovaries function more normally. Eating a healthy, well-balanced diet (one that’s rich in complex carbs, such as whole grains and fresh vegetables, and low in refined carbs and sugar), plus ensuring an adequate intake of vitamin D and the B vitamins, may also help. Losing weight is key to restoring normal hormone function and cycles, however, and for some women weight loss alone can regulate ovulation.
What is it? Irregular periods (cycles lasting longer than 35 to 40 days), no periods, or abnormal bleeding are usually signs that you’re not ovulating. Called anovulation, this condition can be caused by many factors, including stress, an eating disorder, too much exercise, illness, and/or hormonal imbalance (such as a thyroid condition or PCOS).
How is fertility affected? Irregular or abnormal ovulation and menstruation is responsible for up to 30 percent of all cases of infertility. If you don’t ovulate, you can’t get pregnant.
What are the treatment options? First, take a good look at your weight and your lifestyle. If you’re overweight or underweight, getting your weight close to where it should be (see Chapter 2) may reregulate your cycles (but don’t do any extreme dieting, which can also throw your cycles off). A regular exercise program can boost your general health—and possibly, your fertility—but overexercising can prevent you from ovulating (and getting pregnant), so try cutting down if you’ve been hitting the gym too hard. Eating disorders (anorexia, bulimia, or even just periodic bingeing) can also throw off your cycles, so if you—or anyone around you—think you might need help overcoming such a problem, don’t hesitate to seek it. Extreme stress can also derail your cycles, so try to relax, too (see page 24 for some tips on how). If none of these tactics seems to work—and screenings for a thyroid condition or PCOS have come up negative—your doctor may prescribe fertility drugs like Clomid to induce ovulation and normal periods.
What is it? Premature ovarian failure (POF) occurs when the ovarian follicles are depleted before age 40 or when the ovaries stop working properly long before they should have. POF can be caused by type 1 diabetes; genetic factors such as metabolic disorders, Turner’s syndrome, or fragile X syndrome; autoimmune diseases; or cancer treatments.
How is fertility affected? If the egg reserves are nearly depleted, it becomes extremely difficult to conceive (and if the egg reserves are completely depleted, as is sometimes the case with POF, conception becomes impossible).
What are the treatment options? The most common treatment for women with POF who want to get pregnant is cyclic hormone replacement therapy (HRT) or cyclic progesterone to provide a regular period without suppressing ovarian function. If that doesn’t work to induce ovulation (because there are too few eggs), fertility treatments using egg retrieval or possibly a donor egg would be the next step.
What is it? A surprisingly large number of women—about 1 in 8 women in the United States—develop a thyroid disorder. Thyroid disorder can show up as hyperthyroidism, when too much thyroid hormone is produced, or more commonly, hypothyroidism, when too little thyroid hormone is produced. Signs of an underactive thyroid (hypothyroid) can include a goiter (a ball-like swelling in the neck), unexplained weight gain (or trouble losing weight), thinning hair, dry skin, low energy, depression, constipation, irregular or otherwise abnormal periods, and problems getting pregnant. Those who have an overactive thyroid (hyperthyroid) can have such symptoms as fatigue, hair loss, shortness of breath, constant hunger, weight loss, sweating, weakness, and irregular periods.
Male Infertility
When a couple has difficulty conceiving, approximately 35 to 40 percent of the time the issue can be traced back to the man—usually in the form of a sperm disorder. Low sperm quality (such as sperm with chromosomal defects) can cause fertility problems and/or lead to miscarriage. Any deficiency in sperm count (the number of sperm), sperm motility (ability to move), forward progression (quality of movement), and/or sperm size and shape can also cause fertility difficulties. The ability of sperm to move and the quality of that movement are more important to overall fertility than sperm count. In fact, many men with low sperm count are still fertile.
What are some of the causes of sperm disorders?
Anatomical problems, such as scrotal varicocele (in which varicose veins around a testicle hinder sperm production—about 15 percent of men have varicoceles, and most can be repaired with surgery); retrograde ejaculation (in which the ejaculate flows backward into the bladder instead of out through the penis); undescended testicle (in which the testicle failed to complete its descent into the scrotum by infancy and therefore doesn’t function normally); or erectile dysfunction (ED, the inability to get or maintain an erection, essential for ejaculation). Sometimes medications and/or surgery can correct these problems so that fertility is restored. Assisted reproduction techniques (such as IVF) can also get around these problems.
Age. While men can be fertile well into their 80s, sperm quality and mobility gradually start to decline at age 40. Sometimes this downward trend begins to affect fertility, sometimes it doesn’t.
Immune problems. In rare cases, a man may produce antibodies that treat sperm as foreign invaders. These antibodies attack the sperm, adversely affecting sperm motility and sometimes its ability to fertilize an egg. Corticosteroids can be used to decrease the production of anti-sperm antibodies. If that fails, fertility treatments (such as IVF or ICSI; see pages 169 to 171) can help bypass the antibody problem.
Underweight. Very low weight in men can be linked to lower sperm count and decreased sperm function. Once an underweight man gains weight, this fertility issue can disappear.
Obesity. Men who are obese or even overweight may have infertility problems. That’s because excess fat converts the male hormone testosterone into the female hormone estrogen, possibly suppressing sperm production and lowering overall sperm quality. Weight loss can reverse this type of infertility.
STDs. Untreated sexually transmitted diseases could damage the male reproductive tract, making it hard or impossible for sperm to be transported properly. Treatment of STDs can restore fertility in most cases.
Uncontrolled chronic diseases such as diabetes can cause ED. Some medications can also impact sexual function, as well as affect sperm (see page 10). Getting chronic conditions under control can increase your chances of conception.
Mumps (if it was contracted after puberty) can sometimes adversely affect testicular function, as can some other childhood infections and diseases.
Cancer treatments. Chemotherapy and radiation targeting certain areas of the body may contribute to fertility issues in men (see box, next page).
Lifestyle and environmental factors can also play a role in male fertility problems—in these cases, eliminating the factor can eliminate the problem:
Prolonged exposure of the testicles to high temperatures (in hot tubs, hot baths, from laptops, or with electric blankets, for instance) can damage sperm.
Extreme bicycling, sports trauma to the penis and/or testicles, or extremely intense exercise routines may lower sperm production.
Exposure to toxic substances (such as pesticides, X-rays, or other environmental or occupational hazards) may affect sperm production and quality.
Use of illegal drugs, including pot, excessive use of alcohol, and smoking can also impact male fertility and sperm production, as can some medications.
Lubricants can affect sperm quality (see page 104 for more on lubes).
Extreme emotional stress can also depress testosterone levels and thus sperm production.
While the jury is still out, there is some preliminary data that excessive cell phone radiation may possibly alter sperm cells (see page 35).
If you have concerns about the quality or health of your sperm or if you suspect any kind of sperm disorder or testicular dysfunction, be sure to schedule an appointment with a doctor to check it out.
Thyroid condition often runs in families (the association between female family members is particularly strong), so if anyone in your family has it, you may want to be tested for it. Even if there’s no one in your family with the condition, some experts recommend you get tested during the preconception period anyway—particularly if you’re having trouble getting pregnant. Testing for abnormal thyroid antibodies may also be recommended. Even women who test normal for thyroid levels sometimes have abnormal thyroid antibody levels, a sign of a related autoimmune dysfunction.
How is fertility affected? Many women with a thyroid condition have no problems getting pregnant, but for some, thyroid dysfunction can prevent ovulation by disrupting the balance of reproductive hormones, leading to irregular periods and problems becoming pregnant.
What are the treatment options? Normalizing thyroid function is usually as easy as popping a daily pill and having regular blood tests to keep an eye on your levels. Once any imbalance is corrected, a thyroid condition shouldn’t interfere with your fertility.
Cancer and Fertility
Each year, 140,000 men and women under the age of 45 in the United States are diagnosed with cancer. Cancer diagnoses are always heartbreaking, but they can be especially devastating to men and women who plan to have children one day. Happily, thanks to advanced treatment options, cancer survival rates for young people are at an all-time high. Though these treatments are life saving, some of them can also lead to infertility. Educating yourself about the fertility risks and options for becoming a parent after cancer is important so you can make the choices that are best for you.
So what are your options for saving your fertility before cancer treatments?
Egg freezing. In this procedure, your eggs are retrieved following hormonal stimulation and then frozen until needed.
Embryo freezing. Once your eggs are retrieved, they are fertilized with sperm (from a donor or your spouse) and the resulting embryos are frozen until needed.
Ovarian tissue freezing. If you don’t want to (or can’t) have hormonal stimulation to retrieve eggs, ovarian tissue freezing is an experimental surgical procedure in which ovarian tissue is removed, frozen, and then reimplanted after treatment with the hope that it will resume normal functioning.
Ovarian shielding, or moving the ovaries outside the radiation field, is a method that minimizes the dangers of radiation to your ovaries and eggs and may be an option depending on the type of cancer you have and the treatments that are necessary.
Sometimes, fertility returns after treatment, making a natural conception possible. If it turns out that your fertility has been permanently affected and you’re unable to conceive naturally, you can use assisted reproductive techniques with the frozen eggs or embryos. Donor eggs can also be considered as an option. You’ll need to talk to your doctor and oncologist to make sure pregnancy will be safe. Most of the time, it will be.
For men, cancer and its treatment can damage fertility, too. Sperm banking before treatment can preserve the ability to father a baby. Testicular tissue freezing is an experimental option that may be available for you, too.
For more information and help for cancer patients regarding fertility, go to fertilehope.org.