This came out a few months ago, but I just came across it now.

There is a double-headed fertility problem in the UK. The great fertility of the teenage population produces 50,000 pregnancies each year to mothers under age 18, more than any other European country. On the other hand, the spread of STD’s among teens leads to infertility problems in the future. By no coincidence, the UK is the epitome of nanny-state government where policies are in place that lead people to be more dependent on big government for everything (now including the teaching of relationship values) and less dependent on parents, traditional extended families and friends for this. So what is their proposed solution? Give government even MORE control, starting in 2010, to force sex education to kids even as young as age five. Yes, FORCE. There is no freedom for parents to opt out. So whom do you trust to make the best decisions about teaching your kids the facts of life? Some school board administrator or yourself?

The laughable thing is this pertains not only to lessons about anatomy, but also to lessons about relationships. I’m sure the school board is furiously working on the teachers’ manuals for that right now to make sure that no child is left behind on learning how to have healthy relationships with the opposite gender. =)

Entrusting more and more to the government and taking away control from parents may or may not be the cause of Britain’s teen pregnancy problem, but I personally don’t think it is a coincidence at all. The problem results in more unplanned pregnancies AND to infertility later in life, due to the spread of STD’s. But the UK has a solution for that — government-funded IVF.

Just when we get concerned that government has grown out of control in the US, we are reminded to count our blessings because it could be worse elsewhere. Isn’t it time now to halt the growing overreach of big government and get back to more traditional individual freedom? God save us.

A lot of people ask me about unexplained infertility. Well, allow me to explain the unexplainable in very practical terms. If you have gotten pregnant and now have a baby, you are obviously not infertile, so this would not pertain to you. On the other hand, if you’ve been trying for some time, but are still not pregnant, then obviously you are not happy about the situation. I don’t want to restrict the definition of the word infertility with a set time frame, because it differs for each individual. Some people are sad and miserable if they are not pregnant after four months. Others will patiently keep trying beyond three years without any intention of asking for help. So, let’s just say if you are not pregnant yet and you want to be and you have been having unprotected sex for at least six months, then this will be of interest to you.

Prior to any sort of investigation, all infertility is unexplained. After a proper infertility workup, MOST infertility is still unexplained. I will repeat this, modifying it a bit because it goes against what you may have read elsewhere. Repeat. After a proper infertility workup, MOST infertility is still somewhat technically unexplained. Why? It’s like this. When you have finished doing testing for infertility, there are three basic scenarios you could reach. One is the OBVIOUS PROBLEM SCENARIO. This means our testing has unearthed an obvious red-flag big problem. Under these circumstances, couples have essentially zero chance of getting pregnant without medical help. Examples of this include someone whose tubes are both blocked, or who has a husband with zero sperm or someone whose ovaries have completely shut down into premature menopause. If any of these conditions are found, then your search is over and you will have to directly address these issues, because you’re not going to have a baby without medical help.

The second scenario is the EVERYTHING NORMAL SCENARIO. In this case, everything that you have tested, and I’m talking about the basics of a semen analysis, HSG and documentation of ovulation, comes back normal, or even above-average. This is what is classically referred to an unexplained infertility. It means everything looks fine on paper, but yet you are still not getting pregnant. Very frustrating.

The third scenario that is found in reality every day, but is not classically defined by medical textbooks is the SUBOPTIMAL FINDINGS SCENARIO. In these cases, there are found to be one or more things that are not quite perfect, but yet are not bad enough to sentence you to zero chance of conception. These include things like a low (but not zero) sperm count, one-sided tubal blockage with the other side open, surgically-documented scar tissue or endometriosis or evidence of inconsistent, but not absolutely absent, ovulation, or just advanced ovarian age whether chronologically (you really ARE 36) or biologically (you are 26 but your ovaries act 36).

Sometimes, a patient comes to me feeling like they know their diagnosis. “Doctor, we have already been checked out by our OB and we now that the problem is my husband’s sperm”. For example, this might be said to me by a couple for whom the semen analysis shows a 13 million / cc count with 39% motility. This is certainly below average and even in the abnormal range according to set criteria. However, if you went to every first-grade class in the country, hunted down the biological father of every healthy child and subjected these fathers to a semen analysis, I would bet that you would find not one, but many samples which have counts less than 13 million. As an additional example, if you did an HSG on every mother, you would find quite a few who have one blocked tube. So basically, in these situations, you have found something, but it’s not necessarily enough to explain the infertility, because it can’t pass the litmus-test question “Can other people with this condition ever get pregnant?” By the way, having said that, in very rare cases, even couples in the first scenario, the OBVIOUS PROBLEM SCENARIO, have been reported to get pregnant. How can a woman with two blocked tubes get pregnant? One theory is that the test was a false positive, like perhaps her tubes went into spasm at the time of the HSG and showed up blocked when in reality there was still a tiny tiny passageway or perhaps the films were misread by the radiologist or perhaps a clerical error led to the report of someone else’s test under her name. You get the point. These situations are extremely rare, but not entirely impossible.

So as many of you know by now, my way of thinking is always focused on solutions, decisions and actions, so while it’s a fascinating intellectual exercise to discuss these definitions and scenarios, the key question is what do we do about it? In the first scenario, the OBVIOUS PROBLEM SCENARIO, you would directly address the obvious problem. Duh. Depending on which problem, some solutions would include IVF, sperm donation, egg donation or attempted sperm extraction.

For the couples in the SUBOPTIMAL FINDINGS and EVERYTHING NORMAL scenarios, there is overlap in the treatment options. The focus becomes more of a shotgun strategy, meaning we can just try to universally give everything a boost. Get some improved egg quality and quantity (ovulation medications). Send the sperm closer to the egg and with perfect timing (IUI). Minimize uncertainty by physically putting the eggs and sperm together in the laboratory (IVF). We do this even if that’s not the suspected problem. So we give fertility medications to a couple with low sperm, in the hopes that more eggs will make up for fewer sperm. It’s like a football team with a terrible defense signing a top free-agent QB and RB and WR to try and overcompensate for the shortcomings on the other side of the ball.

The choice of which strategy depends on many factors including medical ones (test results, past treatment and response history) and non-medical ones (financial choices, personal attitude towards medical treatment, sense of urgency). We will address the important issue of how to approach unexplained infertility in future posts. But just remember the take-home message. In a strict sense, MOST infertility is unexplained.

Grrr. This type of stunt is just infuriating. First of all, she lied to manipulate her boyfriend, even to the point of elaborately embellishing her story with internet photos. She then subjected everybody to unnecessary worry and had police waste their holiday time and energy on this false alarm. Merry Christmas!

QUESTION:

I am looking for some information on high FSH/high estradiol levels. I am 31 and had blood work done in November 2008 on day 1 of my cycle because my skin keeps breaking out, so my dermatologist was trying to figure out if my hormones were the culprit. Turned out my androgen levels were fine, but my FSH was 17.7. So, I went straight to my OBGYN who tested me on day 3 of the next cycle in December 2008. More bad news. FSH was 11.9 and estradiol was 89. He referred me to an RE and said I probably wouldn’t be able to get pregnant on my own (without drugs). Why is this happening to me at 31 years old? I don’t smoke, drink occasionally, and I work out and eat well. What could have possibly happened to me that, at 31, my hormone levels are indicating that my ovarian reserve is either low or of poor quality (or both)? I was on the pill (on and off, but mostly on) for about 12 years. I had a miscarriage (chemical pregnancy) back in October 2008 (I went off the pill in July 2008). I have a history of endometrial polyps, and had a polypectomy back in October 2006. The polyps have not come back, but despite that, I still have dull aches/cramps in my lower abdomen on a regular basis. However, transvaginal ultrasounds show no more polyps growing. I recently had a CT scan which showed a small cyst (less than 2 cm in size) on my right ovary, but the radiologist didn’t seem to think it looked too alarming. Could any of these things be related to my high FSH/estradiol levels? Is this POF/premature menopause? If so, wouldn’t my estradiol be low, not high? I’ve read that the one thing in my favor is my age. Is that true, or do high FSH/estradiol levels mean bad news, despite being only 31?

Megan

Dear Megan,

I am sad for you about your news. Your situation points out the fact that a woman’s ovaries could age faster than expected without any obvious signs. It doesn’t happen to many women, but it happens to about 1%. It’s lucky that some random quirk of fate involving your skin led you to get your FSH tested, so you discovered this now rather than waiting until after it gets above 25. Your results predict that you are likely to have a harder time conceiving as compared to other women your age who have normal FSH values. An elevated FSH at 31 years of age still gives you hope for getting pregnant, either naturally or with help. However, the odds of getting pregnant naturally are probably pretty low (less than 2% per month), whereas the odds WITH the help of medications or IVF are likely to be higher. High estradiol levels (greater than 80 pg/ml) througout one’s cycle are good, but on day 3, high values are bad. The reverse is true. Lower E2 levels on day 3 are good, whereas if they stay low throughout one’s cycle, that is bad.

As for factors that are related to this, the polyps that you mentioned are not related to the FSH. The cysts are also unrelated. Your past history of taking birth control pills would probably have been of benefit (or at least neutral), rather than contributing harmfully.

While it is a natural human reaction to want to know WHY something bad has happened, the utility of knowing why is strongest when it can guide us to do something to reverse or halt it. In this case, if your diminished reserve were due to intense smoking, chronic illness, chemotherapy, environmental toxins or surgical damage to the ovarian blood supply, then it would be helpful to think about changing our behavior. However, in many cases, diminished ovarian reserve is due to unknown causes or to factors that exerted their effect before you were even born. So asking why becomes less useful than asking “What can I do now?”

Your doctor’s action of referring you to an RE was wise. It could be very helpful for you to discuss your fertility options promptly. Some options would include injectable gonadotropins or even IVF. If you are currently using contraception to intentionally delay childbearing, you might want to rethink things promptly. There still seems to be hope, but you have been given an indirect warning signal via your dermatologist. Good luck!

OK, so you have decided you want to have a baby. Perhaps this means you are going to stop taking those birth-control pills that you’ve been on since your wedding day. Or perhaps it means you and your husband will simply stop using condoms. Or for some of you, who have been less diligent about birth control, perhaps it simply means no longer “pulling out” or no longer avoiding your supposedly fertile days, whatever you think those days may be. Your mind is innocent and worry-free. You are expecting that you will get pregnant so easily. You had no suspicion that you would ever find yourself hurled one year later into a world of taking your daily temperature and peeing on ovulation sticks. You never expected the day when 90% of your web activity is related to researching infertility. You never imagined a time when your every waking thought centers around why you’re not getting pregnant.

In the very early stages of this transition from happy-go-lucky to the fertility-obsessed, as you first become acutely aware of all your friends and neighbors and every woman at the supermarket being pregnant while you are not, what is the first question that takes shape in your mind? I’ll give you a hint. It is NOT “Why do all their husbands have good sperm and mine doesn’t?” or “Why are their Fallopian tubes so efficient and mine are not?” Nope. The first question that comes to mind for most women is “Why is everyone else having sex at the correct time and we are not?”

As human beings, our brains are quick to attribute a cause, whether real or imagined, to things that we don’t understand. In medicine, you see it all the time. For example, as a medical student, I remember a young man who came to the emergency room with a complaint of feeling sick, bleeding from the nose and having trouble breathing. Eventually, the workup revealed that he had leukemia. After the initial shock, his first question was “You know? Six months ago, I was in Mexico and I got really sick after eating some bad food. Do you think that’s what caused this?”

We see it all the time when counseling patients after a failed IUI or failed IVF cycle. They are quick to come up with a lot of potential explanations. “I was one hour late with my injections one day. Do you think that’s why it didn’t work?” “I noticed you said that my lining was only 8mm. I was talking to your other patient in the waiting room and she got pregnant with a 10mm lining. Do you think my lining is the reason I’m not pregnant?” “I heard that Brand X fertility medicine is better and I took Brand Y. Do you think that’s why the cycle failed?”

As women first begin to suspect they have a fertility problem, often their first inclination is to blame it on their not having sex at the correct time. Witness the booming industry of home ovulation tests, books that teach you to obsess about your mucus or websites with software for tracking your temperature. So, is poor timing truly the culprit for most infertility? No. No. No. With a mixture of common sense and looking at published reports, we can better get at the truth.

The truth is this: If you can have sex at a reasonable frequency (every 2-3 days) then just do it and completely forget about timing it. However, if you can only have sex once or twice a month, due to your schedules or for whatever reasons, then it’s very helpful to time it. A lot of couples make the mistake of obsessing about timing, when they already have sex frequently anyway. By trying to time things, they actually wind up having LESS sex than they normally would, thereby potentially reducing their fertility.

When can a woman get pregnant? In theory, the six-day period prior to ovulation is all a potential time for conception. To fine-tune it further, the two or three-day period prior to ovulation is the window period of highest fertility. Therefore, the BEST STRATEGY is to have sex every day. But doesn’t that result in depleted sperm? No. Contrary to myth, for men with good sperm counts, there is no significant depletion of the sperm parameters of count nor motility, even with daily ejaculation. I know this is counterintuitive, but research confirms it. Furthermore, there is even evidence suggesting that men with BAD sperm counts don’t even suffer a significant drop in these parameters neither. My own personal observations looking at samples from couples who do double IUI’s on back-to-back days confirms these findings. Most of the time, the second sample is better, equal to or just slightly worse than the first. Only rarely is it significantly worse.

OK, so what if daily sex is not practical for you? First of all, don’t feel bad. I can tell you from working with hundreds of married couples that daily sex is not the norm. Fortunately, a strategy of aiming for every 1 to 3 days is more than sufficient. By doing this, you absolutely ensure yourself of getting together during the 3-day window period. With the exception of ultrasound, all methods of trying to predict ovulation (temperature, ovulation kits, mucus checks, calendars) have inherent flaws and are not able to be 100% accurate.

So then you might ask, of what possible value is it to chart temperature, check mucus and do ovulation testing? Well, for most people it is of zero value. There is no research that suggests any benefit of all this diligent tracking over simply having sex every 1-3 days. But again, if you are unable to consistently have sex every 1-3 days, then charting or being aware of mucus can help you focus the general window period during which you should concentrate your frequency of intercourse. Just don’t obsess about predicting the one EXACT day of ovulation.

Having said all this, in my opinion, there are still two more possible ways that charting and timing might be of some benefit.

1. If you find it stress-relieving to be more in-control, then charting and timing might be of help in relaxing you. You are not doing anything to boost your chances of conception by timing things, but you might feel less anxious if you feel more in-control, and that could have positive benefits.
2. If charting and checking for ovulation results in clues telling you that you are NOT ovulating, then you will be alerted to seek medical help sooner than later.

So in conclusion, rather than obsessing about the proper timing of intercourse, just go for a sexual frequency of every 1-3 days and forget about the charting and the fertility awareness. Any questions?

When is a one-pound weight gain a good thing? ANSWER: When you were anticipating a two-pound weight gain.

This week, I saw five patients back for their post-metformin consult. In the course of investigating infertility patients, one common finding is insulin resistance, related to PCOS. One way to try and treat this problem is with a drug called metformin. Typically, I put some patients on metformin after their blood tests come back showing clear insulin-resistance. Other times, busy patients, wishing to skip the tedious three-hour blood test just opt to try the medication empirically, based on the existence of many clues supporting the assertion that she has insulin resistance. Some of these clues include family history of diabetes, weight gain out of proportion to what she eats, fat distribution concentrated around the waist (as opposed to hips and thighs), extreme daytime sleepiness/sluggishness (especially after meals), uncontrolled cravings for carbs and sweets, issues with facial hair, and of course, irregular menses and infertility.

I almost always bring patients back for a discussion after trying them on the medication for three weeks. Approximately 80% of the time, patients describe some success with the metformin. They notice increased energy, decreased cravings for carbs and sweets, weight loss, a noticeable slimming of their waistline, and possibly resumption of normal periods. The other 20% report no benefit and are usually discontinued off the medication.

When I pick up the chart on these patients who are returning after a 3-week trial of metformin, the first thing I glance at is their weight and the comparison to their weight BEFORE starting the medicine. If someone had a 10-pound weight loss during the three weeks, I can usually anticipate a discussion in which they will beam with excitement about the changes in their carbs cravings. If someone gained weight or stayed the same during this time, I can usually anticipate them to report no change in their carbs cravings and possibly just the usual bad side effect, which is bad diarrhea.

This week, something odd was happening. Some patients were coming back with negligible weight loss or even slight weight gain, but they were still raving about how great the metformin was, in helping them avoid cookies and soda. It didn’t make sense, because it stands to reason that if a person who usually eats a lot of carbs and sweets can drastically cut down their intake, then they should expect to lose weight. The mystery was solved after one patient elaborated. She had actually gone up from 149 pounds to 150 pounds in three weeks. But she was raving about how the metformin had wonderfully taken away her previous intense cravings. Whereas she used to absolutely require a cookie or soda 2 hours after lunch each day, she now had no desire for such junk. She reported that the difference was like night and day. When I expressed some surprise that despite this change, she had gained one pound, she explained that near Thanksgiving, she had participated in three big feasts, one with her family, one with her in-laws and one at work. Each year, she said, Thanksgiving would see her with a gain of four to five pounds easily. So the fact that she gained only one pound this year was not a minor setback, but a major victory!

In the future, I will remember to take into account the Thanksgiving Effect when assessing the success or failure of metformin.

Just because something CAN be done through modern medical technology doesn’t necessarily mean it SHOULD be done. Now if this were to happen with a Hollywood celebrity, you might see her going on record lying that it was with her own eggs rather than with the help of donor eggs.

Here’s another example of an uninteresting finding dressed up to make it almost seem newsworthy. In this article, it’s not clear how they are assessing sperm quality. Probably the more relevant measure of quality is the actual function, not just some parameters relating to how the sperm LOOKS. In any case, this is a mildly interesting bit of trivia and nothing that should change anyone’s decisions. Women should seek intelligent mates if that’s what they want, but not if they’re specifically after better sperm. Furthermore, reading, doing puzzles and doing things to stimulate the brain would not be expected to improve sperm parameters. I can think of a few of our patients in which the husband is a super-genius, but yet, the sperm is not too good.

To quote the article:

Dr Allan Pacey, a male fertility expert from Sheffield University, said: ‘The fact that it’s possible to detect a statistical relationship between intelligence and semen quality in adult men probably says more about the co-development of brain and testicles when the man was in his mother’ womb, and therefore how well they both function in adult life, rather than suggesting that playing Sudoku can somehow stimulate more sperm to be produced.

‘The improvement in semen quality with intelligence observed in this paper is small and therefore it is unlikely to have a big impact on the ability of men of different intelligences to conceive.’

Human innovation continues as hospitals respond to an increased number of women with twin and triplet pregnancies by building special units to accommodate them. It can be a quite a transition for an infertile couple to go from having zero babies to suddenly having two or three, and units like this can ease the transition.

A while back, when I was doing my monthly volunteer staffing at the indigent population clinic for the OB/Gyn residents, we came across a patient who came in for an ultrasound. She had delivered a baby seven years ago in her home country, but never got pregnant after that. Despite not getting pregnant naturally, she no longer wanted to get pregnant. In fact, she wanted to make sure of it and desired to get her tubes tied. It’s always a bit of a change of pace for me to see women who WANT to become infertile.

She was referred to us because she had been denied as a candidate for a tubal ligation because an ultrasound had shown her to have an IUD in her uterus. The story didn’t make sense. She fiercely denied ever having an IUD placed. She was from Central American and not from China. In China, there have been patients who have had IUD’s placed against their wishes, although not without their knowledge. We weren’t sure what to make of it, so we went ahead and did our own ultrasound. Sure enough, there were two very bright lines in her uterus, which did not look like anything natural. We did a pelvic exam and looked for the string to remove the IUD, but could not find one. After questioning her some more, I was leaning towards believing her story.

We set her up to get hysteroscopic surgery.

Today, I got an email from the residents. They had completed the surgery and fished out the objects. The pathology report identified them as being BONE, with some cartilage. It is a phenomenon described in the medical literature as heterotopic endometrial calcification. So she was telling the truth after all about never having an IUD placed. Although technically, the bone in her uterus would act as a very effective biological IUD. The source of this bone tissue is still controversial. The theories range from retained fetal bones to embryological development from stem cells after a pregnancy termination. So we still will never know exactly how they got there.

Now I am reminded to add “Bone Fragments in the Uterus” to the long list of thing that cause infertility.