Infertility 101
So first of all, what is Infertility?
The World Health Organization, physicians and insurance companies all have a different definition for infertility, but the most broadly accepted definition is, "the inability to achieve a pregnancy within 1 (or 2) years." This sounds basic, but it's really important, because your definition of infertility might be very different based on your age, medical history, and personal situation. The 20-year-old newlywed who didn't get pregnant this year has more options than the 40-year-old with an autoimmune disorder and a partner with poor semen analysis. The biggest sin we see with healthcare practioners is wasting time. Maybe you go to your gynecologist seeking help for infertility. They take you off contraceptives, make you wait a requisite amount of time (6 months-1 yr.), maybe they give you some medication (all the while not checking with regular ultrasounds to see if you are ovulating). It doesn't work, you get frustrated and lose hope, and worse, you've lost TIME. By the time a woman is 38-40 years old, fertility is declining RAPIDLY. For me, I was barely 30 years old, but my PCOS was causing my eggs to age prematurely; my eggs looked like those of a women ten years my senior! Even the loss of a few months can be detrimental to success with conception. If you take anything away from this book, DON'T WAIT for your doctor to get serious.
Ok, so I've been diagnosed as "infertile." Now what?
Well, the first step is an evaluation. Recall from your high school biology class that in its most basic form, we need sperm, an egg, and a way for them to come together to create an embryo. Your healthcare practitioner will run bloodwork on you to test ovarian function & reserve, check for any issues in the fallopian tubes and likely do a semen analysis on your partner.
When you meet with your physician, get ready to give them the date of the first day of your last period, the last time you were intimate with your partner, what methods of contraception you've used in the past, your full medical history and what you had for breakfast on Tuesday (ok just kidding about the last one. Kinda). You'll need to quickly get comfortable giving your RE as much information as you have (and again, if you have copies of your medical records, it’s always good to bring those to reference). Your RE needs to understand first and foremost, if you are having regular menstrual cycles. If so, are you actually ovulating during those cycles? If not, you need to figure out why. If you ARE ovulating, then we need to look at things like sperm quality, egg quality and your uterus. Maybe your uterine lining is not thick enough to "hold" onto a fertilized egg. Maybe you have another abnormality in your uterus, or a clotting disorder that could cause issues. All of this needs to be considered to obtain a diagnosis to work against. Your goal right now should be to get a diagnosis. Without that, you can't move forward. "I'm just not pregnant" is no longer good enough- let's get serious!
Part of the basic workup also typically includes a Hysterosalpingogram (HSG). This procedure looks at the basic shape of the inside of your uterus- maybe you have a tilted uterus or some other uncommon condition that's not been previously identified. In HSG, a thin tube is threaded through the vagina and cervix. A substance known as contrast material is injected into the uterus. A series of X-rays, or fluoroscopy, follows the dye, which appears white on X-ray, as it moves into the uterus and then into the tubes. If there is an abnormality in the shape of the uterus, it will be outlined. If the tube is open, the dye gradually fills it. The dye spills into the pelvic cavity, where the body reabsorbs it. I will also add that while uncomfortable, this procedure is not painful for most people.
Next, you will need to understand if your ovaries are functioning appropriately. Some doctors will test your estradiol, but you have to take this test on a specific day in your cycle, which can be difficult, if like me, you don't know what cycle day you are on because your cycles are erratic. Another way to test for this is by looking at your AMH (anti-Mullerian hormone) levels, and this blood test can be drawn at any time. Think of this as your "egg count" test- within a week, your physician will have a highly predictive marker for your ovarian function. Higher AMH values (greater than 1 ng/mL) usually signify that a woman has a normal ovarian reserve and lower numbers (less than 1 ng/mL) may indicate a woman with a low or diminished ovarian reserve (known as DOR). We know that a woman’s fertility declines as she ages so typically, we see AMH values also start to decline as women age. The value of this test is that a woman with a low AMH can choose to do something about her fertility now if she desires a family for the future. Again, this will vary by center and physician; some doctors will say that if you have an AMH of less than 2 you have a problem, while other physicians maintain that 2-4 is a healthy & acceptable range. If your RE clinic is one of the ones that use tried and true protocols, and they aren't open to innovative technologies & procedures, many won’t take on a patient with an AMH of less than 2. But don't despair if you get turned down by a clinic due to a low AMH number- you can change it through medications and changes in lifestyle. For me with my PCOS, my AMH was off the charts (30)- meaning I had a ton of eggs but given PCOS none of them could grow into a mature follicle. With a combination of taking the testosterone (DHEA) and diet augmentation (insulin resistance plays a role) I was able to bring my AMH down enough to conceive. In short, AMH is a hugely important number. Know yours and keep getting it retested as it changes with your diet and lifestyle.
What are the causes of fertility?
The causes of infertility are different for males than females, and it's important to understand your specific issues so that you can develop a personalized care plan to combat them. In women, the most common causes of infertility include:
Endometriosis
PCOS
Fallopian Tube Failures
Premature Ovarian Aging
Hormonal Issues
Autoimmune disease
Ovulatory dysfunction
Fibroids
Medications
Sexually Transmitted Diseases
Genetics
Age
In males, common causes of infertility include:
Structural abnormalities or damage to reproductive organs
Abnormal or low sperm production
Varicoceles
Sexually transmitted diseases
Environmental exposures
Autoimmune disease
Age