What is Infertility? OB/GYN Chari S. Cruz, MD Explains

It is a female’s instinct to be able to hold a baby in her arms that she had brought to this world.  If having a baby becomes hard or impossible, it can make women feel incomplete, frustrated and devastated.  Infertility is a very sensitive issue for affected women, but it’s more common than people think.   

When it comes to conception, healthy young couples have a 30% chance of getting pregnant in a single menstrual cycle, if the woman is less than 35 years old.  As we get older, the chances go down significantly. In fact, by age 40, there is a less than 10% chance to get pregnant per menstrual cycle.

What is Infertility?

In general, an OB/GYNs  will look at  infertility if a woman, less than 35 years old,  tries to get pregnant for a year, or if a woman 35 years or older, tried to get pregnant for 6 months , without success.  Infertility can affect as much as 15% of couples. 

What do you do if you are one of those 15%? 

If you find yourself having trouble getting pregnant, there are a few things you can try on your own. First, make sure you are living a healthy lifestyle. 

• Eat a healthy diet and try to exercise every day, or at least 3x/week for 30 minutes.  
• If you are smoking, now is the best time to stop. By the time you realize you are pregnant after you will likely be 5-6 weeks pregnant, and the fetus will have been exposed to smoking already.  
• For men, smoking cigarettes or marijuana can reduce the number and health of their sperm.  If your partner smokes, they should also try to quit to increase chances of a successful conception.   
• Cutting back on alcohol consumption and not using any illicit drugs are also important steps to take when you’re trying to conceive.  
• If you have a medical condition like diabetes, high blood pressure or hypo/hyperthyroidism, speak with your primary care doctor to ensure these conditions are under control before getting pregnant. 
• If you have issues with obesity, BMI >30, losing just 5% of your weight can sometimes trigger ovulation.

One simple thing you can do on your own is to buy an ovulation kit over the counter (OTC).  These kits check for your level of luteinizing hormone (LH) in the urine.  An LH surge predicts ovulation in the next 24-48 hours. If you are having periods monthly, chances are you are ovulating but, it is better to check this with the ovulation test.  Similar to a pregnancy test, you check your urine daily from day 8 of your period until it becomes positive.  Day 1 is the first day of your period, called LMP, last menstrual period.  I know it is weird, we call it LAST menstrual period, when we mean the FIRST day of your period!  It confuses a lot of patients but it is just what it is called since time immemorial.  So imagine, out of a normal 28-day cycle, it is only on this one day of ovulation that you can get pregnant!  Even if you do not have intercourse for the other 27 days, but do on that day, your chances of getting pregnant is much higher.  Gone are the days of daily temperature monitoring to predict ovulation;   it’s now as easy as a daily urine test until it turns positive.  

If you have finished the entire ovulation kit and have not gotten a single positive test or still have not gotten pregnant, then it’s time to see your gynecologist.  Be prepared to answer questions about:

• your period
• past pregnancies including miscarriages and abortions
• sexual practices
• abnormal Pap smears
• medical problems
• surgeries
• medicines you are taking, including OTC ones
• birth defects in you or your partner’s family
• illnesses in the family like diabetes or high blood pressure
• blood clots
• history of smoking, alcohol or drug use 

Your occupation is also important to see if you have been exposed to agents that can cause infertility.  Writing down answers to these questions before the appointment can be helpful to avoid possibly missing an important piece of information.

Your gynecologist will help you find the reason or possibly reasons for the infertility and treat those problems.  About 30% of the time, a cause cannot be found which is called infertility of unknown cause.  You and your doctor will try to find out where the issue is, starting from top to bottom.  Are there enough eggs in the ovaries, are they releasing eggs monthly, are the tubes patent or blocked, is there something in the uterine cavity that is preventing implantation, can the cervix hold the pregnancy to term, is there any infection going on in the vagina that needs to be treated first? 

Your doctor will take blood tests in order to answer some of these questions. These include testing your:

• Progesterone level which is taken a week before your expected period.  This only works for those who have predictable periods.  An increased level of progesterone shows that you have ovulated during your cycle.
• Thyroid function because irregular function can cause infertility. Prolactin levels which is released from the pituitary gland in the brain.  If this is elevated this can interrupt also with ovulation. AMH, anti-mullerian hormone, tells us how much reserve you have of the remaining eggs in your ovaries.

Diagnostic imaging tests also look for problems in the uterus, tubes or ovaries:

• Ultrasound can reveal things like fibroid tumors or polyps in the cavity that deter implantation of the fertilized egg, dilate or block the tubes, or the ovaries to ovulate or not.
• SIS (Saline Infusion Sonogram) or sonohysterogram is an ultrasound that tests where fluid is injected into the cavity to see if there are scars or polyps/fibroids in the uterus.
• HSG (HysteroSalpingoGram) is an x-ray test to check for patency of the tubes while dye is injected into the uterus.
• Laparoscopy is placing a camera inside the abdomen to check the uterus, tubes and ovaries from the top.  If there are cysts or adhesions, then these problems can be addressed at that time.

Many tests can be performed on women, but checking a partner’s sperm is just as important. Best practice is to do a sperm analysis to find out the number, shape, and movement of your partner’s sperm.  If there is a problem, then it can be addressed by referral to an urologist who can do hormone tests or an ultrasound of the scrotum to check for varicosities that can affect sperm production. It’s important to also check with your insurance to see what infertility testing is and treatment is covered.

An infertility work-up can take up 3-6 cycles so patience is very important. Dealing with infertility is an emotional time, but it’s important to note there are many tests and treatment options available and your OB/GYN is here to guide you every step of the way.

Chari S. Cruz, MD, earned her Medical Degree from University of Santo Tomas in Manila, Philippines and completed her Residency in Obstetrics & Gynecology at Stroger Hospital of Cook County in Chicago, IL. Dr. Cruz is Board Certified in Obstetrics & Gynecology and her clinical interests include: normal and high-risk obstetrics, vaginitis, cervicitis, abnormal pap smears, abnormal uterine bleeding, endometriosis, PCOS, PID, infertility, obesity, fibroids/myoma, adolescent and geriatric gynecology, and menopause. She is providing care to patients in Middletown.