By Rachel Gelman
The older I get, the more I realize that there is another ‘F-word.’ For many people it is a harmless word, but for others it carries the same weight as any other profanity. I am talking about fertility. For a portion of people who are sexually active, fertility is a scary word. For some, fertility can mean a pregnancy that they are not ready for, but for many it may remind them of a pregnancy they are desperately hoping for. At The Pelvic Health and Rehabilitation Center, I treat many patients who are struggling to conceive. I get asked many questions regarding fertility and decided to better educate myself on the topic. Since sharing is caring, I decided to turn my knowledge into a blog post, not only to provide you with some information, but hopefully to shed light on a common problem that is often swept under the rug.
According to the Center for Disease Control, 6-12% of women in the United States struggle with infertility, but this is not a single gender issue. In 8% of couples dealing with infertility, a male factor was the only identified cause, while in 35% of couples, both partners presented with factors contributing to infertility. The American Society for Reproductive Medicine (ASRM) recommends a person consult with a fertility specialist if after 12 months of having unprotected intercourse a person has been unable to conceive. Many women consult with a reproductive endocrinologist or other fertility specialist after experiencing two or more miscarriages. It is important to note, however, that early pregnancy loss is common: according to the American College of Obstetrics and Gynecology, miscarriage occurs in 10% of all clinically recognized pregnancies. This number may be higher as many women may not realize they are pregnant when they miscarry. It is important to know that having a miscarriage does not necessarily mean that a person will be unable to conceive and carry a full-term pregnancy. In fact, the ASRM reports that a woman has a 60-80% chance of a successful pregnancy without medical intervention, even after three miscarriages.
If you think about the process of getting pregnant — and I am for once not even talking about the fun part– but the actual physiological process whereby the sperm and egg unite and settle in the uterus — a lot needs to happen. To understand this process, you need to understand hormones. For the man, testosterone is key to produce enough quality sperm. Quantity is key because only 10% of sperm will survive to try and make it past the cervix en route to the egg. (Shout out to the strong swimmer that got each of us here today and RIP to all those that didn’t make it.) Once that one sperm makes it past the cervix, it needs to meet up with the egg in the fallopian tube, and like most dates, this needs to be timed and well-planned. If the woman isn’t ovulating and no egg is in sight, then the sperm made the trip for nothing. Ovulation occurs when several hormones (estrogen, FSH and LH) increase, telling the ovary to release an egg. An imbalance in any of those hormones could cause a woman to not ovulate, which is a common cause of infertility. But if a sperm is able to join forces with the egg at the right time, fertilization occurs. The fertilized egg begins to divide and starts to implant into the lining of the uterus. This is where progesterone, the pregnancy hormone, is a big player. Progesterone helps make the uterus a happy home for a fetus to grow and develop. If, for whatever reason, the progesterone is off or the uterine lining doesn’t respond, then the whole operation stops.
During pregnancy, the growing embryo produces Human Chorionic Gonadotropin (HcG) which tells the body that it is pregnant and to keep producing the necessary hormones. If there is a genetic abnormality or a certain number of chromosomes weren’t produced, then fetal development may stop, which will halt HcG production and cause the body to believe it is no longer pregnant, which is a common cause of miscarriage.
Now that we have completed a crash course in conception, let’s talk specifics.
In men, fertility issues can be caused by different factors such as trauma to the testes, anabolic steroid use, smoking or excessive alcohol consumption. Obesity can increase a man’s risk for infertility. Some men can develop varicoceles, where the veins on a man’s testicles become enlarged and can cause overheating, thereby affecting the number or shape of the sperm. Other medical conditions such as diabetes, certain endocrine or autoimmune disorders, and cancer or cancer treatment (chemotherapy, radiation or surgery) may contribute to testicular or ejaculatory dysfunction. Hormonal disorders, an impairment in the hypothalamus or pituitary glands may compromise testicular function or decrease sperm production.
The treatment for men may include medications or surgery to remedy an underlying condition. A urologist or a male infertility specialist would most likely be the person to help determine a treatment plan. Physical therapy may be incorporated to aide in the healing process if surgery is required, especially following a varicocele repair. Your healthcare provider may recommend that you incorporate exercise or make dietary changes to address some of the factors listed above. It goes without saying that limiting or ceasing alcohol consumption and smoking may help as well. Other forms of assisted reproduction may be recommended by a clinician, which I will discuss more in-depth shortly.
For women, fertility issues can be linked to certain medical conditions such as Endometriosis or Polycystic Ovarian Syndrome (PCOS). Women with PCOS may ovulate infrequently or not at all, and as we discussed earlier, ovulation is key to fertility. Endometriosis is a condition where the tissue that normally lines the uterus grows outside of that organ. If the endometrial tissue blocks the fallopian tubes, it can contribute to infertility. Uterine fibroids may also disrupt the uterus, creating an environment that is unable to support fetal development.
Like men, improper function of the hypothalamus and pituitary glands can result in hormonal imbalances which can cause fertility issues. Similarly, factors such as being overweight, excessive alcohol use or smoking can contribute to female infertility.
In general, female fertility has a lot to do with eggs. Per Dr. Martha Noel, MD, a reproductive endocrinologist at the University of California-San Francisco, egg count and egg quality do not go hand in hand; “Egg count, or what we call your ovarian reserve, determines the length of your reproductive window, ie, the amount of time in which you have to conceive.” Women with a low ovarian reserve have a shorter window and may go into menopause sooner. However, a low egg count does not mean a person has low quality eggs. Dr. Noel goes to say that “Egg quality refers mainly to whether or not the chromosomes in the egg are normal or abnormal, and that is primarily determined by age. So you can be 30 years old with a low ovarian reserve and still have no difficulty conceiving, because your egg quality is good. Conversely, as we get into our late 30s and early 40s, even women with high ovarian reserve may find it harder to conceive, because the percentage of chromosomally normal eggs that we have is low.”
Treating female infertility may include medications or procedures to address the underlying cause. For example, removing the endometrial tissue that is obstructing the fallopian tube may be the solution. Medications may be prescribed to regulate hormones and promote ovulation. Acupuncture may be an option for women who are having trouble conceiving. Little research is available, but one study’s preliminary data suggests that acupuncture may promote menstrual health and help women to cope with infertility. Dr. Noel agrees that “acupuncture can be helpful, even if just as a way to relieve stress during what can be a difficult process.” Many providers recommend patients undergo acupuncture while doing fertility treatment such as Intrauterine insemination (IUI) or with assisted reproductive technology (ART), the most common being In Vitro Fertilization (IVF).
IUI is also referred to as artificial insemination. This procedure places sperm into a woman’s uterus when she is ovulating. Sperm may be provided by a donor or the male partner. The sperm is washed to remove any toxins that may cause adverse reactions in the uterus and is separated to ensure only motile sperm are selected. A doctor will insert the sperm directly into the uterus at the time of ovulation. Certain medications may be used to stimulate ovulation, especially if the patient is not ovulating.
For the sake of brevity, I will only discuss IVF in this post even though there are other types of ART. However, many of the same medications are used in all ART, as well as IUI. In my opinion IVF demonstrates the true power of science. If you are reading this and have undergone IVF, you may understand why I find it to be an awe inspiring process. IVF involves taking an egg or eggs from a female and fertilizing it with sperm outside of the body and then putting the embryo into a uterus! Move over Jurassic Park! That procedure should be its own blockbuster. IVF usually involves the following steps: Ovulation Induction, Egg Retrieval and Embryo Transfer.
Ovulation induction typically involves several medications to stimulate ovulation. Many of the medications prescribed may be used independently to treat underlying causes of infertility as well. For those pharmacologically inclined, the drug regimen may include clomiphene citrate ( ex: Clomid™), hCG (ex: Pregnyl), Human Menopausal Gonadotropin (ex: Menopur™) or FSH (ex: Follistim™). Additional drugs may be prescribed to prevent a premature surge in the Luteinizing Hormone to avoid an egg being released prematurely. These drugs are typically given subcutaneously. The patient’s estrogen levels will rise and a provider typically wants the woman’s estradiol level to be at least 400 pg/ml for the egg retrieval. In addition to checking her estrogen levels, transvaginal ultrasounds are performed to monitor the growth, size and number of ovarian follicles. When the follicles have reached appropriate size and the estradiol levels are ideal, the provider will instruct the patient to inject hCG — human chorionic gonadotropin often called the trigger shot, — which stimulates the final maturation of the eggs. Within a specific amount of time, typically 34-36 hours, egg retrieval will occur.
Egg retrieval is an ultrasound guided procedure where a needle is inserted through the vagina to collect the follicles. Patients may be given sedatives or anesthesia and experience little to no pain as a result. The eggs are identified and combined with sperm that has been washed and sorted just like in the IUI procedure. After 14-18 hours, the embryos are transferred to a new growth medium and are assessed to determine whether fertilization has occurred. Genetic testing may be used at this stage to test embryos for genetic disorders. After another 38-40 hours, the embryos will be assessed again to confirm that development is proceeding normally before the transfer will occur.
The embryo(s) are transferred into the uterus through a vaginally-inserted catheter. A small amount of fluid is injected into the uterus along with the embryo. Following the transfer, progesterone is typically prescribed to ensure adequate uterine lining for implantation. A pregnancy test is typically done 9-12 days following the transfer. If the test result is positive, the physician will continue to closely monitor the patient and may have the patient continue to take progesterone for several weeks.
The use of ART is becoming a common practice in the United States. Per the CDC, in 2015 1.6% of all infants born in the US every year are conceived using assisted reproductive technology. However, many individuals choose to forgo the needle and stick to less invasive measures such as lifestyle changes, diet, yoga, exercise, acupuncture and visceral mobilization. Many people may use apps such as Glow or Clue or other devices to track ovulation and plan intercourse around the times when they are most fertile. Dr. Noel cautions that some supplements and natural products that claim to boost fertility are not well studied and may be a waste of money; however, pre-natal vitamins are essential and recommended for any woman trying to conceive.
Now let’s talk about the relationship between fertility treatments and patients experiencing pelvic pain. Having pelvic pain or pelvic floor dysfunction (PFD) does not mean that a person will have difficulty conceiving. On the other hand, a number of my patients are dealing with fertility issues while I am treating them for PFD. Many of my patients end up conceiving naturally, a few adopt, and some decide to not have children while others utilize fertility treatments. These patients often ask me: How will fertility treatment impact my symptoms?
It is hard to say. I was unable to find any research regarding fertility treatment and pelvic pain. Per the expert, Dr. Martha Noel:
“I don’t typically see flares in chronic pain as a result of the IVF process. Though often gynecologic issues that cause pain (endometriosis, fibroids) are estrogen-responsive, the amount of time that your estrogen is elevated during an IVF is relatively brief, about 2 weeks. I think the one thing that may limit women with chronic pain who are dependent on medication is that we do recommend avoiding ibuprofen and NSAIDs as you are going through treatment. There are other options for pain control during this time, however…You can also continue physical therapy, acupuncture or other treatment modalities during this time.”
One might be able to argue that since the vulvar tissue is hormonally mediated, the medications used for IVF/IUI could potentially increase a patient’s symptoms, but there is no research to support this idea. Overall, it seems that most patients notice no change in their symptoms. It is important to emphasize that patients with pelvic pain can have successful pregnancies and/or have a family in some way.
Fertility is a daunting subject and this post in no way discusses all the information that exists. If you have questions or concerns, it is important to discuss them with your healthcare provider. Hopefully this post, while dense, helped shed light on a topic that can evoke many different emotions.
Finally, if you are struggling with infertility or a recent miscarriage, there are many resources available to support you. Please check them out below or comment if you have any recommendations.