I had an HSG (x-ray dye study of the tubes) performed, and they didn’t see one tube. Does that mean I don’t have a tube? Why wasn’t I told this before?
Wait just a minute before panicking. I need to help explain some things. When you had the HSG performed, if the radiologist or doctor didn’t see your one fallopian tube, that does not necessarily mean that it is absent or not working at all. If a uterus is normal, then it would be extraordinarily rare for one or both tubes to be absent. When one tube doesn’t show up on the HSG, it is usually has a simple explanation. There is a small muscle at the opening (the ostia) that leads from the uterus into the tube. This is a round sphincter muscle, just like the anal sphincter. When dye is injected into the uterus, these muscles often spasm, closing down tightly. Once they do this, they do not relax easily. So if the dye goes out one tube, and the other tubal openins is having a spasm, the dye just follows the path of least resistance and continues to go out the open tube. With this happening, pressure cannot be built up inside of the uterus to overcome the spasm of the other tube opening.
If the fallopian tube filled with dye and was blocked at the end, then that is a different story. But of the tubes that don’t even fill up, well over 90% of them are normal. The tubal spasm is a side effect of the HSG and is sometimes more commonly found if the HSG is not carefully performed. There can be scar tissue at the opening causing it to be scarred shut, but that is not commonly seen. Tubal scar tissue usually affects the end of the tube and only rarely at the point where the tube joins the uterus. Occasionally there can be a polyp, or endometrial overgrowth, that is right in front of this opening and could serve to block the ostia. We used to take all of these patients to laparoscopy to investigate this, and after doing this time and time again, what we realized was that nearly all of them were normal at the time of surgery. Going to surgery is still a reasonable option for some patients, though, depending on the situation. If one tube appears to be working normally, then more conservative therapy could be used.
Approximately 12% of women in the United States have had difficulty conceiving. The causes are vast and in approximately 10% of couples, the causative factor is not clearly found despite a thorough evaluation. How much of infertility issues are in control of the patient? What can a couple do to ensure themselves the best possible outcome? Below is a brief summary of important modifiable lifestyle factors that can be altered to ensure a couple’s best chance to retain/maintain their fertility.
Maintain a healthy weight.
By just taking a look around, it is obvious that Kentuckians (and Floridians) have problems with weight. As of 2008, KY led the nation with 67% of the population being overweight, and 28% of the population classified as obese. Obesity is known to be a significant risk for both infertility and poor pregnancy outcomes, with increases seen in anovulation, poor sperm function, early miscarriage, stillbirth, gestational diabetes, pre-eclampsia, cesarean delivery rate, and other delivery complications. Though weight loss is not easy for anyone, even a modest loss of 10% body weight has been found to have significant improvement in some of the above outcomes. Exercise, independent of weight loss, can also provide better overall health as well as improved reproductive outcomes. For those persons who are very obese (>100lbs above ideal weight), long-term success of maintaining weight loss is very low. These patients should consider surgical (bariatric) intervention. Though there are significant risks associated with bariatric surgery, current minimally invasive methods have improved outcomes significantly, and this type of procedure been found to be the only significantly successful method of maintaining long term weight loss for the morbidly obese. This leads significant improvement in long-term health. Patients who have undergone bariatric surgery should plan on delaying conception for at least 12 months and possibly longer based upon the recommendations of her physicians.
Limit exposure to substances that may contribute to infertility.
Smoking can have a significant impact on fertility, being associated with impaired ovulation, tubal function, miscarriage, as well as adverse pregnancy outcomes such as low birth weight infants, and sudden infant death syndrome (SIDS). Marijuana use can have severe toxic effects on sperm, and likely has other similar associations within the female as smoking. Steroid use, either prescribed or otherwise, has severe effects on the male reproductive system that limit sperm production. Alcohol is known to have dose related toxic effects on a pregnancy and is related to reduced conception rates even at low to modest intake levels before conception. Caffeine has weakly been linked to decreased conception rates, however the direct causal relationship has not clearly been established. Certain medications can also affect conception as well as be toxic in pregnancy. A thorough discussion with an obstetrician is encouraged for anyone regularly taking medications.
Limit stressors.
Stress is often in the eye of the beholder. The stress that we commonly refer to, emotional stress, can affect us all at some point. Stress can also lead to physical effects in the body as well. Infertility has been linked to stress primarily through pathways that interfere with the body’s natural hormones that induce ovulation. It possibly can affect other aspects as well such as the ability of an embryo to implant in the uterus or the production of normal sperm in a man. Many techniques of stress reduction are available such as meditation, yoga, hypnosis, massage, acupuncture, or just a vacation. No one method has been shown to be superior to another. Any technique that reduces perceived stress is likely to be effective in minimizing these effects on the body.
Stress can be physical as well, such as in those persons who exercise vigorously, have physically demanding work, or may have inadequate calorie intake from aggressive dieting. This can interfere with normal body functions just as any of the above can. Often just cutting back on this behavior can show significant improvement in outcome.
Maintain proper nutrition.
We all know that we should eat healthy and take our vitamins. This is just as true for adults as for children. The diets of most adults provide them with all of the necessary essentials needed for daily living. However, in planning for pregnancy, it is a good idea to build up the body’s stores ahead of time. Folic acid is the most important nutrient needed prior to conception. Adequate body stores of folic acid assist in the proper early development of the brain and spinal column in the early embryo. This occurs prior to many women realizing that they may be pregnant, thus the need for adequate folic acid prior before conceiving. The recommended daily dosage is 400 mcg (micrograms), which is commonly found in most prenatal vitamins. However, many prenatal vitamins have recently increased their dosage to 800 mcg or more to ensure proper body stores. There is no harm in taking more than the recommended amount. Women who have or have had a child with spina bifida (a spinal cord development problem) are recommended to take 4 milligrams (4,000 micrograms) per day. Women with specific diets devoid of certain foods, such as a strict vegetarian or vegan diet should also take a daily vitamin and may want to discuss other dietary needs during pregnancy with a nutritionist.
In conclusion, the protection of a couple’s fertility includes having an awareness of their current position in their reproductive lives, future conception plans, as well as an appreciation of the health and lifestyle issues that may impact their fertility.
Approximately 12% of women (over 7 million) in the United States have had difficulty conceiving. The causes are vast and in approximately 10% of couples, the causative factor is not clearly found despite a thorough evaluation. Though modern advanced reproductive techniques such as in vitro fertilization (IVF) can allow over 90% of suitable previously “infertile” women to conceive, this comes with added levels of invasiveness, time involvement, stress, and cost. Though IVF is the best choice for many couples and the fastest route to pregnancy for most, most women consider it as a last resort and try to exhaust other routes before proceeding to IVF.
How much of infertility issues are in control of the patient? What can a couple do to ensure themselves the best possible outcome? What can be done to protect themselves from possible future contributors to infertility? I hope to briefly address these questions, discussing the most common causes of infertility, and how the woman (and the man!) can help themselves during the quest to start or enlarge their family.
Anovulation
One of the most frequent issues surrounding conception is anovulation, or the lack of regular ovulating cycles which produce fertilizable eggs. Menstrual cycles occurring less than 24 or more than 35 days after the previous menses is most likely not associated ovulation. It is not uncommon for a woman to have 1-2 irregular periods each year, but having less regular cycles than this is considered abnormal. This abnormal condition occurs in 4-6% of all women and comprises approximately 40% of female fertility issues.
The heart of the matter in anovulation is an interference with the production or the effect of the brain’s chemical signaling to the ovaries. This can be due to medical problems such as thyroid dysfunction, overproduction of certain hormones such as prolactin (normally involved with breast milk production), or androgens (the male sex hormones), or a lack of insufficient signaling from the brain to the ovary (termed Hypothalamic Anovulation). The latter of these can be due to excessive stress, including physical stress (extreme over-exercising), lack of adequate caloric intake, and even common emotional stress, though there are serious medical causes that must be ruled out before heading off to that extra yoga class.
The most common cause of anovulation is Polycystic Ovarian Syndrome (PCOS) which affects approximately 10% of all women, and is thought to likely involve a genetic component. Many people associate PCOS with obesity, however only about 50% of PCOS patients are obese. The most current theory implies that most patients with PCOS suffer from some amount of resistance to the effects of their body’s produced insulin. When secreted from the pancreas, insulin allows the cells in the body to utilize glucose as an energy source. In the most severe cases, this is the cause of adult-onset (Type II) diabetes. In essence, the patient is in an early pre-diabetic state. This leads to elevated levels of insulin and overproduction of androgens from the ovaries and adrenal glands. These effects, as well as irregular signaling of the ovary by the brain prohibit ovulation. In addition, the excessively produced androgens can worsen the insulin resistance, thus feeding a vicious cycle.
Long term consequences of unregulated PCOS can include an increased risk of endometrial cancer, an elevated risk of early development of diabetes and cardiovascular disease, and sometimes excessive hair growth and acne. For those not trying to conceive, the mainstay of treatment is oral contraceptive pills, with other treatments tailored to a patient’s clinical scenario. Overweight patients with PCOS can often improve their insulin resistance with modest weight loss (5-10% of body weight) which can re-establish ovulation in some. Though many patients with irregular cycles will have PCOS, a full investigation into other causes is warranted, and only after meeting certain criteria and ruling out all other causes can PCOS be diagnosed.
Continued research developments in understanding the cause, treatment of, and long term effects of PCOS makes the proper treatment a continually evolving concept.
Tubal Problems
Another common cause of infertility, equally as common as anovulation, is fallopian tube damage. This may be damage which is induced (as in sterilization procedures) or acquired in other ways. As many as one third of all patients undergoing a tubal ligation for sterilization will have regrets at some point in their future. In some cases, reversal of a tubal sterilization can be performed. In women with a good prognosis, microscopic tubal surgery to reattach the divided tubes can be very successful. Conventional options for this include using a microscope to allow for an accurate tubal reconstruction. A newer option is the use of the da Vinci Robotic Surgical System, which allows for a microsurgical repair using the minimally invasive laparoscopic surgery route, as opposed to the conventional method requiring an open incision. However, for many women, having a tubal reversal is not the best route to conception. This includes women over 37 years of age, those who had certain types of sterilization, and those who may have other contributing fertility issues. These patients will be better served by proceeding directly to IVF, as their chance of benefiting from a surgical tubal repair is low and not cost effective. It is best to seek the opinion of a reproductive endocrinologist to explore all of the procreative options and for a full discussion of all possible contributing factors prior to proceeding to surgical reversal.
The fallopian tubes can also be damaged in other ways, the most common of which is the prior exposure to an infectious organism. As many as 40% of the general population, both male and female, has been exposed to Chlamydia in the past, though only approximately 6% report such a case. This is due to many infections being “silent” and asymptomatic, being cleared by the body before a more serious pelvic infection sets in, but not before inflicting damage to the delicate tubes through scarring and inflammation. In some cases, skilled reproductive surgeons can correct these damaged tubes through laparoscopic surgery, but in some cases, the tubes will not regain function, leaving IVF as the only realistic reproductive option.
Fallopian tubes can also be damaged by other inciting factors like a ruptured appendix, other extensive pelvic surgery, or a previous ectopic pregnancy. Having tubal damage increases the risk of infertility and ectopic (tubal) pregnancies should one conceive. Prevention is the best practice here, with condom use to protect against sexually transmitted infections being the most protective intervention.
Pelvic Disorders
Certain pelvic disorders can affect fertility. These include uterine fibroids, endometrial polyps (growths of the uterine lining), and endometriosis. Fibroids are very common benign tumors of the uterine muscle wall. In some women, these may grow very large during the reproductive years, causing problems such as irregular bleeding or pain. Fibroids can play a factor in infertility as well, especially if their size distorts the normal anatomy of the uterine cavity. In this case, surgical removal is warranted. This can often be done in a minimally invasive route, often through laparoscopy on an outpatient basis. Other alternative therapies marketed for fibroids such as uterine artery embolization (UAE), MRI-focused Ultrasound, or Cryomyolysis should not be performed on a woman who may desire future fertility. Conceiving after having one of these procedures can impair fertility, as well as increase the risks to the pregnancy as well as the mother.
Endometrial polyps are commonly found in anovulatory and not uncommonly in normal cycling women. Though they are often not the primary cause of infertility, they may be a contributing factor or may increase the chance of early miscarriage and thus should be removed. This is simply done either as outpatient or in-office surgery.
Endometriosis is a disease in which the cells that make up the lining of the uterus (the endometrial cells) are located outside of the uterus. Endometriosis is thought to exist in up to 15% of all women, though it is more commonly found in those with infertility, and appears to have a genetically-linked tendency. The endometrial cells migrate out the fallopian tubes and into the pelvis during a menstrual cycle. Here they skirt the body’s normal immune system, and are able to implant and grow within the pelvis, setting up areas of inflammation which can ultimately lead to distorting scar tissue. This inflammatory state can contributes to significantly impaired fertility, which may be partially improved through surgical destruction of the endometriosis. Though this is a continually progressive disease, the use of hormonal contraception such as oral contraceptive pills are recommended when not trying to conceive, as they provide a protective effect by suppressing the growth and continued development of endometriosis.
Age
One of the biggest contributors to infertility is the age of the woman. Unfortunately, this is the one factor for which there is little treatment, regardless of therapy. On average, normal fertility does not start to decline until around age 35, at which time is seen a slow decline in conception rates. A sharper decline occurs after the age of 37, even more so after 40, realistically approaching zero after age 43. It should be noted that this is an average, and some patients may experience a decline in fertility a few years earlier or later than average. Because of this, it is recommended that any woman who has been unable to conceive for over one year, or any woman over the age of 35 who has been trying to conceive for longer than six months should be referred to a Reproductive Endocrinology & Infertility specialist for consultation and evaluation. To date, there is no test that can give precise information about the state of a woman’s ovarian function, but several tests do exist that can give an estimate of this information. However, many variables are involved and blanket interpretation can be misleading, thus this should be discussed with a Reproductive Endocrinologist prior to using these tests to guide decision-making.
Male Issues
Just as women can be affected with fertility problems, approximately 40% of infertility problems within a couple are due to a male issue. This can include abnormalities with his sperm, including low sperm numbers, poor movement, abnormal sperm, or the absence of sperm. These problems may be congenital or acquired. Modifiable factors that can affect a man’s fertility include smoking (with marijuana being particularly harmful), excessive caffeine or alcohol intake, use of any steroid (prescribed or otherwise), chronic exposure to certain chemicals (such as pesticides or volatile chemicals), or chronic exposure to excessive heat (such as in routine sauna or hot tub usage). It is recommended that any couple considering conceiving should eliminate potential harmful contacts, as production of new sperm after removal of an offending agent takes 2-3 months. Obesity is another common factor which can affect a man’s sperm numbers through alterations in hormone profiles. General evaluation of the man’s fertility can be as simple as obtaining a semen analysis, though laboratories associated with a infertility or urology practice should be utilized due to problems with test standardization. Any abnormality justifies a repeat analysis in one month and a referral for an investigation by a urologist who has an interest in male infertility in conjunction with a Reproductive Endocrinologist. Working together, they can actively make a recommendation and provide treatment that is in the best interest of the couple as a whole. Treatment options range from eliminating offending agents, intrauterine insemination, in vitro fertilization, or the option of using donor sperm in some cases.
In conclusion, the protection of a couple’s fertility includes having an awareness of their current position in their reproductive lives, future conception plans, as well as an appreciation of the health and lifestyle issues that may impact their fertility.
