This is the second in the “What Type of Fertility Patient Are You” series.

Usually, we love it when someone rates us or evaluates us and tells us that everything is all right with us! This is not the case for those afflicted with unexplained infertility. For them, after enduring month after month or even year after year of being infertile, they finally get the courage to go to their OB or family practice physician with their problem. A few tests are run and they are told “Congratulations! Everything came back fine!” The temporary feeling of relief quickly disappears when they go back to their previous routine and find themselves still not pregnant after another year. This makes them want to scream because they would almost rather have heard their doctor say “We found a big problem so now we know exactly why you’re not getting pregnant”, especially if followed by “and this is how we’re going to solve that problem”.

Asking yourself what’s causing your infertility is very tricky because most times, we can’t find just one single concrete reason. The best examples of times when we can is if we find that a husband has absolutely zero sperm, or if we find that the wife’s Fallopian tubes are both blocked or if we find that a woman is now menopausal. Aside from these scenarios, there are rarely any clear cut answers. Why? Because, as I’ve stated many times on this site now, getting pregnant is usually a matter of probability. So many couples out there who aren’t pregnant after a few years are that way not because they have zero % chance of getting pregnant each month, but rather because they have something like a 3% chance per month in contrast to normal couples who have a 20-25% chance each month.

EXAMPLES:
Jed and Dorothy have been married for three years. Despite having regular sex every 2-3 days and not using any contraception for the past two years, they are still not pregnant. The workup reveals Jed’s sperm count slightly below average at 37M / cc. Dorothy’s HSG is clear and both tubes are proven patent, but there is some sequestration of the contrast seen after it emerges from the Fallopian tubes, hinting at the possibility of loculations or adhesions. Dorothy’s monthly periods are extremely painful, hinting at possible endometriosis. They have been labeled with the diagnosis of unexplained infertility.

Eduardo and Joy have been married for five years and actively trying to conceive. Eduardo’s sperm count is 200 M / cc. Joy has undergone laparoscopy and was told that her pelvis was immaculately clean and normal with dye seen freely spilling out of both tubes. Joy has had a period exactly every 28 days since age 14 and for the past three years, she has the charts to prove it. Despite all this, they are not getting pregnant. This couple is the extreme example of unexplained infertility.

SO WHAT SHOULD WE DO?
The frustration of unexplained infertility stems mostly from our innate human psychology and the absolute need for an explanation. Remember back in high school when there was that boy you had a crush on and you were so hopeful that he would someday reciprocate the feeling? However, when things didn’t work out, you weren’t content with the rejection because you wanted to know WHY? WHY didn’t he like you and want to date you? That’s the natural way we think. However, that doesn’t mean it’s the best way for us to think. What if, instead of demanding a reason, we just shifted our minds into ACTION-MODE? This might consist of accepting that person as just a friend and finding ways to interact with him in good, fun, non-threatening ways so as to improve his positive associations with you. This would serve to improve the odds that he might even change his mind about you someday. Or in other cases, the best action would be to focus your attention on someone better (yes you probably thought that he was your perfect soulmate and that there is nobody in the world better), but if your goal was to be in a relationship, then there are other ways and other candidates to explore.

So how does this relate to the approach to infertility? Well sometimes, it’s better to focus on what we can do rather than demand some specific explanation that’s not really there. This brings us to the time-proven correct approach to unexplained infertility. Always be asking “What can we try differently?” A good RE will guide you through your options which may include aggressive techniques like IVF, moderate techniques such as IUI and natural techniques such as weight loss, stress reduction and smoking cessation.

Here are two relevant posts, one reinforcing the concept that in reality, most cases of infertility are somewhat unexplained and another on breaking down the options of the best actions to do next.

Good luck!

By the way, I really enjoyed my four-month break from blogging (more on that later), just as much as I hope to enjoy my return!

This is the first in the “What Type of Fertility Patient Are You” series.

The NON-OVULATOR:

You have to ovulate in order to have a baby.

It’s considered normal to ovulate thirteen times a year, which means thirteen opportunities to potentially get pregnant. Some women ovulate fewer than thirteen times per year. Either their cycles are more days apart from each other or they just skip some cycles completely. This means that while the same twelve months is going by in life and they are getting the same one year older just as everybody else is, they are missing out on chances to get pregnant.

WHAT ARE THE DIFFERENT LEVELS OF NON-OVULATION?
The number of ovulations every woman has per year varies greatly. In a best-case scenario, a woman with regular 26-day cycles could potentially have a perfect year when she ovulates one egg fourteen times, giving her fourteen opportunities to get pregnant. It’s also possible for a women to, every once in a while, have a double ovulation month in which she fires off two eggs. This does not happen often, but in women with a family history of twins on their mother’s side, it happens more than it does in other women. These are the good extremes. In the worst-case scenario, you have women who go through an entire year without ovulating even once. Unless this problem is solved, they are not going to get pregnant. The rest of the population fall somewhere in the middle between zero and fourteen ovulations per year.

EXAMPLES:

• Jamie’s periods come like clockwork every 29 days. In the past year, she tried ovulation testing three times and each time, her sticks eventually turned positive. In one month, she even had her RE do serial ultrasound monitoring. With that, she saw her follicle grow bigger and bigger before finally disappearing on day #15. CONCLUSION: The best estimate is that Jamie is a normal ovulator with 12 to 13 chances per year to get pregnant. If she’s still not getting pregnant, it’s best to look for other factors, such as tubal or sperm problems.
• Heather has very irregular periods. In the past three years, she estimates having about 3 periods per year. CONCLUSION: If each of Heather’s periods is an indication of ovulation, she is having, at most, three chances to get pregnant per year. However, it’s also possible that her three periods per year are not all ovulatory cycles, in which case, she might be having zero, one or two ovulations per year. Yes, it’s possible to have bleeding without actual ovulation that month. Attempts to help her conceive should focus on getting her to ovulate more frequently.
• Leslie has regular cycles which consistently come every 36 days. Her ovulation testing lately has shown that she is consistently ovulating around day 21. CONCLUSION: She is likely ovulating. Buyt, because it takes longer than average for each ovulation, she is ovulating at most, 10 times per year. She is missing out on about three chances per year to get pregnant, compared to Jamie.
• Anne used to have regular periods in the past, but her very last period came when she was 38. After she turned 39, she did not have any more periods and she is now 41. Her random FSH value is 39 IU/L. CONCLUSION: Anne is most probably a non-ovulator due to menopause. Her condition is permanent.

HOW DOES OVULATION TRANSLATE TO CHANCE OF GETTING PREGNANT?
The focus, so far, has been on the number of times of ovulation. The number of eggs you ovulate per year is your QUANTITY of ovulation. But often, we hear talk about the QUALITY of ovulation. First of all, there is no universally-accepted definition of what egg quality means. In fact, we use the word quality, in everyday language to generally mean something that is “good”. But just ask people and you’ll get differing views on what constitutes a quality friendship or a quality tomato. So I will define for myself that when I use the term “egg quality” here, I’m referring to the percentage chance of making a baby with that egg. Someone who is ovulating a high quality egg might have a 30% chance to have a baby with that egg. On the other hand, someone with poor quality ovulations might only have a 1% to conceive a baby with each egg. So our wish list should include not just egg number but also egg quality. After all, would you rather have a single “30% egg”? Or would you rather have a dozen “1% eggs”?

WHAT ARE THE DIFFERENT CAUSES OF NON-OVULATION?
There are many different reasons for ovulation problems, but they can be broken up into two main categories. One is actual problems with the eggs themselves and the other is problems with the hormonal system that is supposed to mature and develop the eggs. Think of it as a hardware issue vs a software issue. Some women fail to ovulate because their remaining eggs are poor quality and resistant to growing well despite sincere efforts by her hormonal system to nudge them along. This is most often due to age and can be detected by checking FSH levels. Other women fail to ovulate even though they have lots of fantastic eggs. However, their problem is that their brain is not programming the eggs to mature and develop correctly. This is a much easier problem to solve. Again, just as with the computer analogy, a software problem can be fixed by changing the programming while a hardware problem cannot be fixed by anything other than replacing the components.

WHAT ARE SOME CLUES THAT YOU ARE A NON-OVULATOR?
You may be a non-ovulator if you have irregular or absent periods (anything other than a standard regular 11-13 cycles per year) or if you have consistent failure to have positive ovulation testing.

WHAT IS THE BEST APPROACH TO HELPING A NON-OVULATOR?
Find out the cause of her non-ovulation. Fix it if possible. If ovulation is restored and pregnancy still does not occur, then it’s time to look for other problems.

SUMMARY:
Some non-ovulators can be helped to ovulate quite easily. If so, and if that’s their only problem, meaning no coexisting sperm or tubal problems, they can get pregnant fast. Other non-ovulators have coexisting problems, so that resolving the ovulation issue is only part of the game. Still other non-ovulators are in a sadder state because it is nearly impossible to help them achieve a good ovulation. If you suspect that you are a non-ovulator, please consider getting help right away.

Anybody who is a regular visitor on Facebook is all too familiar with the epidemic of cute little quizzes revealing “Which Disney character are you?” or “What kind of dinosaur are you?”. That’s how I got the inspiration to start a new series of blog posts on “What type of fertility patient are you?”

It’s true that everyone is different and no two fertility patients are exactly alike. However, RE’s very naturally speak of categories, such as tubal factor, unexplained, diminished ovarian reserve or male factor, for example. Labeling patients with these labels can generally help guide our treatment. However, we sometimes have to be careful not to let labels make us too narrow minded. There is going to be a lot of overlap between the different types, especially when many couples have more than one factor.

Anyway, starting later this week, I’ll begin posting on different “types” of fertility patients. If you have any suggestions on what “types” you’d like to see profiled, let me know.

As I complete each post, I’ll put a link at the end of this post, so if you would like, you can bookmark this page now and come back later to check for updates. This should be fun for me and informative for you!

What kind of fertility patient are you?

1. The NON-OVULATOR
2. The UNEXPLAINED-INFERTILITY SUFFERER
3. ????????