A 2016 Guide to Understanding Infertility Risks, Causes and Treatment
Anyone who has faced an infertility diagnosis has a unique story to tell, but many are too embarrassed to speak up. Across the United States, many communities still treat infertility as taboo. This is despite the recognition of infertility as a disease that requires evaluation and treatment by the World Health Organization, the American Society for Reproductive Medicine, and the American College of Obstetricians and Gynecologists.
Infertility treatment today is not what it was even five years ago. Technologies are advancing at a rapid pace, with better evaluation techniques, increased success rates without the fear of ending up with multiple babies after in vitro fertilization (IVF), and safer minimally invasive GYN procedures to treat existing conditions. Raising awareness, and knowing the steps to take to start overcoming infertility can help many women and men start or continue to build their families.
INFERTILITY FAST FACTS (From Resolve.org)
- 7.4 million women, or 11.9% of women, have ever received any infertility services in their lifetime. (2006-2010 National Survey of Family Growth, CDC)
- Approximately one-third of infertility is attributed to the female partner, one-third attributed to the male partner and one-third is caused by a combination of problems in both partners or, is unexplained. (www.asrm.org)
- The most recently available statistics indicate the live birth rate per fresh non-donor embryo transfer is 47.7% if the woman is under 35 years of age and 39.2% if the woman is age 35-37. (Society for Assisted Reproductive Technology, 2013)
- Approximately 85-90% of infertility cases are treated with drug therapy or surgical procedures. Fewer than 3% need advanced reproductive technologies like IVF. (www.asrm.org)
NATIONAL INFERTILITY AWARENESS WEEK
The goal of NIAW is to raise awareness about the disease of infertility and encourage the public to understand their reproductive health.
“This year’s theme, #StartAsking, calls on the infertility community to ask the tough questions about infertility, not only to raise awareness about this disease, but also to motivate all who are touched by infertility to commit to the cause,” said Andy Schwartz, CAE, Public Relations Director at Resolve, The National Infertility Association. “Over the course of the week, we want people to #StartAsking:
- Employers for insurance coverage.
- Your lawmakers and legislators to support issues important to the infertility community.
- Friends and family to support you.
- The media to cover infertility and the real challenges we all face.
- Your network to make a donation to the cause.
- Your reproductive endocrinologist (RE), clinics, OB/GYN, or adoption agency to support RESOLVE.
- Your partner to get involved.
- Those who have resolved their infertility to stay involved.
- OB/GYN or healthcare provider to talk about YOUR reproductive health.
- For affordable care for treatment of a disease.
- Legal access to all family building options nationwide.
- About men’s reproductive health.
The biggest challenges for those facing infertility? Accessing medical care due to high out-of-pocket costs.
“Our constituents have told us that the number one improvement that would make the biggest difference in their lives is if an infertility diagnosis and treatment was covered by all insurance plans. The second challenge that needs to be addressed is the emotional toll that infertility takes and how little public awareness and support there is, so people end up feeling isolated and alone.”
Find out more about infertility awareness events and efforts at Resolve.org.
WHERE TO BEGIN & WHEN TO TALK TO THE EXPERTS
SHOULD I HAVE A FERTILITY EVALUATION WITH A REPRODUCTIVE ENDOCRINOLOGIST?
“Much of it comes down to how long a woman or couple has been trying to get pregnant and the woman’s age,” said Stephen Greenhouse, M.D., a reproductive endocrinologist at Shady Grove Fertility. “For women younger than 35, infertility is defined as 12 months of unprotected intercourse without conception occurring. For women 35 to 39, it is defined as 6 months of unprotected intercourse without conception. For women 40 and older, we recommend seeing a specialist after 3 months of trying to conceive, as age is a factor and time is of the essence.”
Dr. Greenhouse continues “One of the first things we ask a couple is ‘When did you stop using birth control?’ This is really when infertility begins. If a couple has been together for 4 years, and they say that they have been trying for 6 months to get pregnant, but have never used birth control, then infertility has actually been present for 4 years.”
It’s important to note Dr. Greenhouse adds, “About half of our patients have been pregnant before and they are now having trouble. Secondary infertility can occur with women or men who had no problems getting pregnant before. It can be baffling, as there may be problems now that didn’t exist before, and now an infertility workup is warranted. Secondary infertility factors may be related to their current age, the age when they were previously pregnant, and the duration between children. We see women who have had a tubal ligation 7 years ago, and now are in a new relationship hoping to get pregnant right away. Those 7 years can make a big difference.”
INFERTILITY 101 FROM DR. GREENHOUSE
- A woman should start with her general gynecologist to see if she meets the criteria of infertility.
- Women in their mid-30s should be more proactive to see a fertility specialist earlier rather than later, so they don’t miss their fertile window.
- If the gynecologist prescribes clomiphene citrate (Clomid pr Serophene) – an oral hormone stimulation medication designed to support the growth and release of a mature egg – this regimen should be limited to 3 months. If it’s going to work, it would have worked within that time period.
Dr. Greenhouse reminds, “If a woman has irregular menstrual cycles, damage to the pelvis, endometriosis, she should probably see a fertility specialist right away. We do three primary tests: ovarian reserve test, hysterosalpingogram (HSG), and a semen analysis.
OVARIAN RESERVE TEST: To get a sense of a woman’s egg reserve, we order a relatively simple blood test anti-Müllerian hormone (AMH) level, and we look for a level above 1.5. If it’s less than that, that makes us concerned about decreased ovarian reserve. If their hormone level is normal, but a woman is older, she may have a good number of eggs, but age is a more important predictor of egg quality.
HYSTEROSALPINGOGRAM: This test shows whether the Fallopian tubes are open or blocked, and if the uterus is normal.
SEMEN ANALYSYS: Given that 40-50% of infertility male factor, heterosexual couples should always have a semen analysis done early, during the initial diagnostic workup, before the course of treatment is decided upon. There is no risk. If there is an abnormality, then you can address that first. It is important for a semen analysis even if a couple has had a child prior.
“Over the last decade, trends in infertility treatments have changed,” said Dr. Greenhouse. “Many patients today delay childbearing. They are advancing in their careers, may be putting off getting married, or having children. While infertility can happen at any age, infertility risks increase after age 35, so the delay has increased the number of patients we see. But, fertility treatments have also advanced. Infertility is recognized as a medical condition, so the stigma has lessened allowing more people to come to us. The one concern many people voiced was that they were afraid they were going to have more than one child at a time with the treatments. As treatments advanced, we no longer need to place multiple embryos hoping one will attach. We can place one and have higher success rates.”
Dr. Greenhouse works closely with The Center for Innovative GYN Care when helping women with GYN conditions prepare for IVF.
AN INFERTILITY DIAGNOSIS: THE ROLE OF THE MINIMALLY INVASIVE GYN SURGEON
A really good specialty surgeon is vital for an infertility patient to have the greatest degree of success with IVF.
“It’s important for the GYN surgeon working with an infertility patient to have specialty experience in managing these types of conditions, said Dr. Paul MacKoul, MD. “A true partnership with a reproductive endocrinologist means there is a detailed account of the patient’s fertility goals and experience with fertility treatments thus far. As you can imagine, if surgery is performed incorrectly, the tubes, the cavity or the structure of the uterus, especially with fibroids, can be adversely affected. Fibroids can be devastating to the uterus, destroying the architecture of it completely, so that there’s no ability for the uterus to hold a baby at all.”
WHAT WOMEN NEED TO KNOW ABOUT GYN SURGERY FOR INFERTILITY
Having a well-defined partnership between two highly skilled and experienced physicians means the best possible patient care.
“If a woman has hydrosalpinx, pelvic pain, or evidence of endometriosis, we typically refer to a gynecological surgeon, and the reason I recommend a pelvic surgeon, is because of the experience,” said Dr. Greenhouse. “A lot of fertility doctors are not doing advanced laparoscopic surgery, but you want to go to someone who does it all the time. And it’s not just the ability to do it, but you want someone who works with you closely who understands what you are trying to accomplish.”
“A fertility patient who has fibroids that need to be removed, needs to see a specialist who can perform a minimally invasive myomectomy to preserve and repair the uterus,” said Dr. Greenhouse.
“Many women after fibroid removal have to have c-sections, because the uterus has lost its integrity and its strength, so it cannot allow for a vaginal delivery due to potential rupture of the baby out of the uterine wall,” said Dr. MacKoul. “The smaller incisions and their placement are very important for patient recovery after a myomectomy. Larger incisions can take up to 2 months to heal and there is often pain well beyond the projected recovery time. With the CIGC LAAM procedure, patients feel better much faster, with an overall recovery time that is about two weeks, giving them the best possible surgical procedure with the smallest incision. They can often start their IVF cycle sooner, and are back to their normal lives faster, with less of a chance of new adhesions forming.”
Fibroids are very common. It has been a long-held belief that if they aren’t bothersome, they can be left alone (The Watch & Wait Method). However, fibroids can wreak havoc on patients trying to conceive with IUI or IVF.
“If fibroids involve the cavity itself (submucosal), they can prevent implantation or full-term pregnancies,” said Dr. MacKoul. “If the embryo implants on the fibroid, it will have no blood supply and the pregnancy will abort. Fibroids near the cavity can do the same thing.
Dr. MacKoul continues”When patients have large fibroids, that are not in either location, while these may not prevent pregnancy from happening, as the uterus grows, the fibroids will grow, too, feeding off of the estrogen. Patients can have horrible symptoms, pain to the upper abdomen, to the chest, they can get IUGR (intrauterine growth restriction) because of the inability of the embryo and the placenta to get blood supply from the muscle due to the fibroid. It can prevent or constrict the pregnancy from growing normally. Fibroids can also cause tubal blockage. If you take the fibroids out the tubes open up.”
“Trying to get every bit of endometriosis out can damage ovarian reserve,” said Dr. Greenhouse. “Knowing when to stop is important. We refer patients for uterine septum, or intrauterine scarring, so it’s vital to have someone who is very familiar with pelvic anatomy. About 10% of our patients need surgery – whether that is someone needing a polyp removed or extensive endometriosis excision.”
“If you do too much stripping, or excision of endometriosis, patients can end up with a lot of scar tissue, and nothing will work,” said Dr. MacKoul. “The tubes may scar up, leaving no pathway for the eggs to get to the tubes to get transferred into the uterine cavity. There is also a lot of pain with any kind of aggressive stripping of the disease off of the lining. It’s a combination of knowing when to do the surgery, knowing how much to do, and the complications that can happen with aggressive excision. Endometriosis is an inflammatory process. We don’t know why endometriosis causes infertility, but removing endometriosis does give patients a better ability to get pregnant within the first 6 months of the surgery.”
CIGC surgeons use DualPortGYN to perform endometriosis excision surgery. This technique uses just 2 tiny incisions, one at the belly button, and one at the bikini line. This technique can be conservative or thorough depending on the patient’s desire for fertility and is tailored to each patient.
HYDROSALPINX (FLUID-FILLED FALLOPIAN TUBES), UTERINE SEPTUM, POLYPS & ADHESIONS
Hydrosalpinx is fluid in the tube. If it backs up into the cavity, the toxic fluid can poison the ability of the embryo to implant in the uterine cavity. There is a blockage at the end of the tube that creates water (hydro) in the tube. It flows back in as a toxic fluid, and that can prevent implantation of a very expensive embryo.
Uterine septum is very fibrous tissue with no blood supply. If the embryo attaches to that, it will abort. A uterine septum needs to be removed to prevent that problem.
Polyps are excess growths on the uterine lining that can interfere with an embryo implanting. After removal, pregnancy rates were 63 percent compared to 28 percent of women who did not have them removed. Miscarriages are higher among women with uterine polyps.
Intrauterine Adhesions, uterine cavity adhesions can prevent the embryo from getting to the uterine lining. Many times after a D&C, or an extensive myomectomy there is scarring in the cavity. The lining needs to be regenerated. We take the scar tissue down using very specific set of maneuvers we put a special balloon device in the cavity after the procedure, which is inflated to prevent the edges of the cavity from sticking together again. If a surgeon just takes the scar tissue away, and doesn’t put the balloon in, the procedure can cause further scarring. The balloon keeps the edges of the cavity apart while you give high dose estrogen to regenerate the lining. You end up with a decent cavity which allows for implantation.
Learn more about Shady Grove Fertility and The Center for Innovative GYN Care.
ABOUT THE CENTER FOR INNOVATIVE GYN CARE ADVOCACY EFFORTS
The Center for Innovative GYN Care is dedicated to providing information and materials for women to help navigate the complicated healthcare system. Our minimally invasive surgeons have seen firsthand the pain and anxiety women with infertility face. We have also seen what delaying surgery can do to distort a woman’s uterus. The longer a woman suffers with a GYN condition, the likelihood of extensive damage to her reproductive organs increases.
It is essential that advocacy, legislation and research efforts like those mentioned above are expanded. CIGC works closely with awareness organizations to ensure that our patients have access to the support they need, and have the most up-to-date information about the most effective minimally invasive fibroid removal to manage pain, bleeding and infertility.
CIGC minimally invasive GYN surgical specialists Paul MacKoul MD and Natalya Danilyants MD developed techniques to perform fibroid removal using only two small incisions. Using LAAM, our surgeons can safely and thoroughly remove all fibroids and repair the uterus in an outpatient setting, allowing women to return to their lives faster, with less pain.