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FREQUENTLY ASKED QUESTIONS
What are common causes of infertility? Can a basic evaluation be carried out quickly? What is the purpose of a laparoscopy? What is endometriosis? Why is age an important issue for a woman's fertility? Are diet, exercise, and life's stresses important fertility factors? What are the pros and cons of fertility medications? What is polycystic ovarian syndrome (PCOS)? What factors can lead to multiple miscarriages?
Approximately 60-70% of couples who are planning a pregnancy will generally become pregnant within 6 months, whereas 80-85% of couples will conceive within one year. Generally, any couple who has been actively attempting conception for greater than one year should seek consultation with a physician committed to carrying out an efficient evaluation. It may be appropriate to seek consultation prior to one year if there has been a history of prior infertility, miscarriage, or irregular menstrual cycles. What are common causes of infertility? An evaluation by a fertility specialist should focus on common female factors such as blocked or scarred fallopian tubes, problems within the uterine cavity or lining, or ovulation abnormalities (problems with egg production or release). More subtle ovarian disturbances or autoimmune problems can occasionally be uncovered. About one third of couples who seek our help present with a "male factor", meaning that the sperm count or quality is not in the normal range. Often, a combined female and male factor may be found.
Usually, a prompt and efficient evaluation can be completed within 2-3 months. At our Center, a couple's evaluation includes a detailed initial consultation, physical examination, and vaginal ultrasound. If no prior evaluation had been carried out, we will commonly proceed with recommending a semen analysis, hysterosalpingogram (HSG), LH hormone testing, a post-coital test, and a well-timed endometrial biopsy. We will commonly carry out a Clomid challenge test to assess ovarian function, and will commonly recommend a laparoscopy, depending on the results of the prior evaluation. back to top What is the purpose of a laparoscopy? Laparoscopy provides a careful and detailed assessment of a woman's pelvis. In our experience, it is very common during laparoscopy to find a problem related to infertility. Fortunately, many of these problems can be treated at the time of the laparoscopy. For many women, this can dramatically improve their chances of conceiving. Common diagnoses made and corrected at the time of laparoscopy include endometriosis, pelvic scarring (adhesions), and tubal abnormalities such as fimbrial conglutinations ("clumping") and paratubal cysts. Through modern advances in laparoscopic surgery, tiny instruments such as scissors, forceps, and laser instruments can be inserted through 5 millimeter incisions in the lower abdomen. Although general anesthesia is usually offered, there is no overnight hospitalization, and complete recovery usually takes about 1-3 days. Different theories have been proposed over the years to explain the cause of endometriosis. Endometriosis probably starts when cells shed from the uterine lining implant in the deep regions of the pelvis. When these cells implant and grow in response to a woman's estrogen production each month, pelvic pain and/or infertility can result. It is believed that infertility occurs because the abnormal uterine cells secrete inflammatory factors that may prevent egg fertilization or embryo implantation. A great deal of research efforts have tried to explain these links to infertility, but there are no definite answers. The gold standard test for diagnosing endometriosis remains laparoscopy, and recent clinical studies have indicated that aggressive laparoscopic treatment should improve fertility potential. It is possible that medical treatment with GnRH agonists (medications such as Lupron(r) or Zoladex(r)) following laparoscopic treatment can prove helpful in further suppressing endometriosis and enhancing chances of conceiving. Why is age an important issue for a woman's fertility? A woman's ovaries will typically start producing mature eggs in the teen years. When an egg matures each month, it is nourished and protected by a follicle, a round cyst-like "incubator" that grows to about 1 inch in diameter. After 20 to 30 years of this monthly cyclical process, either the follicles and/or the eggs start to show the stresses of aging. When no further follicles are produced by the ovaries, menopause results. Ten to 15 years prior to menopause, it is possible to identify a certain hormone profile that predicts reduced chances of conceiving. This can be due to a suboptimal environment within the follicle, and/or a genetic or maturation problem with the egg. Many patients inquire about this "biological timeclock" issue, and it is a valid and important issue to address with your physician. Recently, many fertility centers have utilized the Clomid challenge test as a method for giving some assessment about prognosis. Whether the ovarian aging process can be slowed or overcome is not well understood. It has been clearly shown by many fertility centers that diminished ovarian reserve is a very negative prognostic indicator for success with in vitro fertilization (IVF).
Normal reproduction requires the careful coordination of various organs, including the brain, pituitary gland, thyroid gland, adrenal gland, the pancreas, the liver, and the ovaries and testes. Every man and woman has thresholds for allowing or inhibiting the normal symphony of events leading to successful reproduction. We have seen in our Center, as have others, the harmful effects of poor nutrition, inactivity, overactivity, and stress. To what extent each of these factors affects a specific woman's ovarian function can sometimes be determined. However, the effects can often be subtle and difficult to diagnose. However, as an example, in some couples we have seen dramatic effects when nutrition is improved. Our goals are to promote positive lifestyle habits that will improve both overall health and reproductive potential. back to top What are the pros and cons of fertility medications? There are two general classes of fertility medications. Clomid® (clomiphene citrate) is an oral medication that helps achieve ovulation in women who don't reliably develop a follicle and egg each month. Clomid can also be used selectively in some women who do ovulate on their own, but the indications for this usage should be carefully evaluated on an individualized basis. Also, Clomid use should usually be monitored by ultrasound and/or hormone levels. Gonadotropins are more potent injectable medications that contain the pituitary hormone FSH (follicle stimulating hormone) as the active ingredient. These medications are commonly known under the following brand names: Pergonal®, Metrodin®, Fertinex®, Humegon®, Repronex®, Follistim®, and Gonal-F®. Follistim and Gonal-F are genetically engineered forms of FSH. There is little evidence that one brand has advantages over the other, but many IVF centers have reported good success with the recombinant forms of FSH. Gonadotropins are used for either 1) ovulation induction, or 2) in vitro fertilization (IVF). During ovulation induction, multiple follicles are stimulated and the eggs are released within the body for eventual fertilization. During IVF, the eggs are removed from the follicles at a specific time. These eggs are fertilized outside the body, and subsequently transferred back to the uterus 3-5 days later. The indications for carrying out ovulation induction versus IVF are complex for each couple, and need to be discussed carefully with your physicians. Fertility treatments with gonadotropins carry a risk of multiple pregnancy (25-30% of all pregnancies that occur), with a risk of higher order multiples such as triplets or quadruplets. This can be a serious problem for certain couples, so all parameters for treatment should be discussed in advance. The physicians at Reproductive Associates of Delaware believe strongly in the concept of informed consent.
Many women present with significant ovulation problems that may indicate an underlying issue with their metabolism and nutrition. The common symptoms that may indicate polycystic ovarian syndrome (PCOS) include very irregular or absent periods (100%), large and cystic ovaries (95%), obesity (75%), problems with excessive body hair growth and/or acne (70%), cholesterol and/or triglyceride abnormalities (70%), and a strong family history of diabetes, hypertension, heart diseases, obesity, and irregular periods (100%). What factors can lead to multiple miscarriages? When couples are presented with the frustrating problem of recurrent pregnancy loss, the approach is straightforward and compassionate. It is important to explore the clinical events surrounding each prior loss, and to try to understand whether there are any features that the miscarriages seem to have in common. Sixty to 70% of pregnancies fail to develop because of a chromosomal disorder, which often can be diagnosed when the tissue is submitted to a cytogenetics laboratory. As such, even a woman with 3 prior losses has a high chance that one or more of the miscarriages was due to a chromosomal abnormality. Abnormalities within the uterus can promote miscarriage, and a detailed evaluation should be carried out for this possibility. Hormonal issues surrounding normal pregnancy implantation can sometimes be found when the lining of the uterus is inspected by a trained pathologist. A certain autoimmune abnormality known as anti-phospholipid antibodies has been linked to recurrent pregnancy loss in 5-10% of cases, and tests for these antibodies should be carried out. Overall, if no abnormality is identified, the chances of a normal pregnancy outcome is 70% or better. If an abnormality is identified and treated, the prognosis for a healthy pregnancy is 80% or better. As such, each couple who has suffered multiple miscarriages should maintain an optimistic viewpoint.
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Can a basic evaluation be carried out quickly? 
Are diet, exercise, and life's stresses important fertility factors?