The History of Infertility
For as long as men and women have been practicing the procreation dance there have been those that have suffered with infertility. Though infertility is a very individual and personal struggle, it is important for couples to know that they are not alone. Over 4.5 million couples experience infertility each year. There have been millions upon millions of couples that have had to cope with infertility throughout the ages. Many of these couples are famous, historical figures.
But she remained childless:
The Book of Genesis speaks of two sisters: Rachel and Leah. Rachel was beautiful and desired. Leah was plain and unloved. God made it possible for Leah to bear children while her sister remained childless. Despite all of her best efforts Rachel did not become pregnant for many, many years. When she finally did give birth Rachel cried out, "God has taken away my disgrace by giving me a son." Rachel’s belief, that her infertility was disgraceful, is a belief that has persisted among infertile woman for centuries. Even today, in modern times of advanced medicine, higher learning, and deeper social awareness, women still feel disgraced and humiliated when they confess they have fertility issues.
From Hanging to Humiliation:
If suffering from humiliation is painful, it is not nearly as painful as some of the punishments netted to woman through history for their inability to conceive. In some ancient cultures it was an acceptable practice for men to hang their wives if they failed to produce an offspring with in the agreed upon time. In Regency England a man could publicly denounce his union and "set aside his wife" if she failed to produce an heir. In more recent times, women have been forced to endure "kitchen burnings." This Indian practice calls for the disgruntled spouse to tie his wife to a chair and set her afire in their kitchen. The only explanation he need give is that he was not satisfied with her this could be for any number of reasons like being a lousy cook, a poor lover, or even an infertile spouse.
Knowledge is power:
Queen Mary of England, daughter of Henry VIII and Katherine of Aragon, said, "Knowledge is foremost to power." This was a personal philosophy that would see her through many trials and tribulations including infertility. Mary inherited the throne despite furious opposition to the notion of a female ruler. One of her most important goals was to have a child to secure her line. The years tricked by slowly and agonizingly for Mary "the Barren Queen" of England. Though she would convince herself she was pregnant, once suffering from a phantom pregnancy wherein she gained the requisite weight, stopped menstruating, and suffered with morning sickness, she never truly obtained her goal. Mary knew, however, that there was more than one way for her to be fruitful in life. She filled her time reading and learning all she could about medical treatments and her religion. Mary set an example that all infertility patients could learn from: though your body may be barren your mind is not!
OVERVIEW
You and your partner have tried for months, perhaps for even more than a year. But despite sexual intercourse without birth control, you've been unable to conceive a child.
If you've been trying to conceive for more than a year, there's a good chance that something may be interfering with your reproductive function. Infertility, also known as subfertility, is the inability to conceive a child within one year. Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing.
Infertility differs from sterility. Being sterile means you're unable to conceive a child. With sterility, you or your partner has a physical problem that precludes the ability to conceive. A diagnosis of infertility simply means that becoming pregnant may be a challenge rather than an impossibility.
The human reproductive process is complex. To accomplish a pregnancy, the intricate processes of ovulation and fertilization need to work just right. For many couples attempting pregnancy, something goes wrong in one or both of these complex processes and causes infertility.
Infertility affects more than 6 million American couples, with the male partner being either the sole or a contributing cause in approximately 40 percent of infertile couples. Problems with female fertility are present about one-half to two-thirds of the time. In both men and women, multiple factors can account for difficulty with fertility.
OVERCOMING INFERTILITY
"Fertility problems are a huge psychological stressor, a huge relationship stressor," says Lisa Rarick, M.D., director of the Food and Drug Administration's division of reproductive and urologic drug products.
So, while going on a relaxing vacation may temporarily relieve the stress that comes with fertility problems, a solution may require treatment by a health-care professional. Treatment with drugs such as Clomid or Serophene (both clomiphene citrate) or Pergonal, Humegon, Metrodin, or Fertinex (all menotropins) are used in some cases to correct a woman's hormone imbalance.Surgery is sometimes used to repair damaged reproductive organs. And in about 10 percent of cases, less conventional, high-tech options like in vitro fertilization are used.
Will the therapies work? "Talking about the success rate for fertility treatments is like saying, 'What's the chance of curing a headache?'" according to Benjamin Younger, M.D., executive director of the American Society for Reproductive Medicine. "It depends on many things, including the cause of the problem and the severity." Overall, Younger says, about half of couples that seek fertility treatment will be able to have babies.
A Year Without Pregnancy
Infertility is defined as the inability to conceive a child despite trying for one year. The condition affects about 5.3 million Americans, or 9 percent of the reproductive age population, according to the American Society for Reproductive Medicine.
Ironically, the best protection against infertility is to use a condom while you are not trying to get pregnant. Condoms prevent sexually transmitted diseases, a primary cause of infertility.
Even a completely healthy couple can't expect to get pregnant at the drop of a hat. Only 20 percent of women who want to conceive become pregnant in the first ovulation cycle they try, according to Younger.
To become pregnant, a couple must have intercourse during the woman's fertile time of the month, which is right before and during ovulation. Because it's tough to pinpoint the exact day of ovulation, having intercourse often during the approximate time maximizes the chances of conception.
After a year of frequent intercourse without contraception that doesn't result in pregnancy, a couple should go to a health-care professional for an evaluation. In some cases, it makes sense to seek help for fertility problems even before a year is up.
A woman over 30 may wish to get an earlier evaluation. "At age 30, a woman begins a slow decline in her ability to get pregnant," says Younger. "The older she gets, the greater her chance of miscarriage, too." But a woman's fertility doesn't take a big drop until around age 40.
"A man's age affects fertility to a much smaller degree and 20 or 30 years later than in a woman," Younger says. Despite a decrease in sperm production that begins after age 25, some men remain fertile into their 60s and 70s.
A couple may also seek earlier evaluation if:
· The woman isn't menstruating regularly, which may indicate an absence of ovulation that would make it impossible for her to conceive without medical help.
· The woman has had three or more miscarriages (or the man had a previous partner who had had three or more miscarriages).
· The woman or man has had certain infections that sometimes affect fertility (for example, pelvic infection in a woman, or mumps or prostate infection in a man).
· The woman or man suspects there may be a fertility problem (if, for example, attempts at pregnancy failed in a previous relationship).
The Man or the Woman?
Impairment in any step of the intricate process of conception can cause infertility. For a woman to become pregnant, her partner's sperm must be healthy so that at least one can swim into her fallopian tubes. An egg, released by the woman's ovaries, must be in the fallopian tube ready to be fertilized. Next, the fertilized egg, called an embryo, must make its way through an open-ended fallopian tube into the uterus, implant in the uterine lining, and be sustained there while it grows.
It is a myth that infertility is always a "woman's problem." Of the 80 percent of cases with a diagnosed cause, about half are based at least partially on male problems (referred to as male factors)--usually that the man produces no sperm, a condition called azoospermia, or that he produces too few sperm, called oligospermia.
Lifestyle can influence the number and quality of a man's sperm. Alcohol and drugs--including marijuana, nicotine, and certain medications--can temporarily reduce sperm quality. Also, environmental toxins, including pesticides and lead, may be to blame for some cases of infertility.
The causes of sperm production problems can exist from birth or develop later as a result of severe medical illnesses, including mumps and some sexually transmitted diseases, or from a severe testicle injury, tumor, or other problem. Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence.
The other half of explained infertility cases are linked to female problems (called female factors), most commonly ovulation disorders. Without ovulation, eggs are not available for fertilization. Problems with ovulation are signaled by irregular menstrual periods or a lack of periods altogether (called amenorrhea). Simple lifestyle factors--including stress, diet, or athletic training--can affect a woman's hormonal balance. Much less often, a hormonal imbalance can result from a serious medical problem such as a pituitary gland tumor.
Other problems can also lead to female infertility. If the fallopian tubes are blocked at one or both ends, the egg can't travel through the tubes into the uterus. Such blockage may result from pelvic inflammatory disease, surgery for an ectopic pregnancy (when the embryo implants in the fallopian tube rather than in the uterus), or other problems, including endometriosis (the abnormal presence of uterine lining cells in other pelvic organs).
A medical evaluation may determine whether a couple's infertility is due to these or other causes. If a medical and sexual history doesn't reveal an obvious problem, like improperly timed intercourse or absence of ovulation, specific tests may be needed.
Understanding your monthly fertility pattern (days in the month when you are fertile, days when you are infertile, and days when fertility is unlikely, but possible) can help you plan a pregnancy, or avoid pregnancy. But if you already understand your menstrual cycle and fertility pattern, and are having problems getting pregnant, there is help and support available. In 1995, one in 10 U.S. women of reproductive age had a problem with fertility. If you have a problem with fertility, learn all you can about you and your partner's health, and your options for treatments.
FERTILITY AWARENESS
The Menstrual Cycle :
Being aware of your menstrual cycle and the changes in your body that happen during this time can be key to helping you plan a pregnancy, or avoid pregnancy. During the menstrual cycle (a total average of 28 days), there are two parts: before ovulation and after ovulation.
· Day 1 starts with the first day of your period.
· Usually by Day 7, a woman's eggs start to prepare to be fertilized by sperm.
· Between Day 7 and 11, the lining of the uterus (womb) starts to thicken, waiting for a fertilized egg to implant there.
· Around Day 14 (in a 28-day cycle), hormones cause the egg that is most ripe to be released, a process called ovulation. The egg travels down the fallopian tube towards the uterus. If a sperm unites with the egg here, the egg will attach to the lining of the uterus, and pregnancy occurs.
· If the egg is not fertilized, it will break apart.
· Around Day 25 when hormone levels drop, it will be shed from the body with the lining of the uterus as a menstrual period.
The first part of the menstrual cycle is different in every woman, and even can be different from month-to-month in the same woman, varying from 13 to 20 days long. This is the most important part of the cycle to learn about, since this is when ovulation and pregnancy can occur. After ovulation, every woman (unless she has a health problem that affects her periods) will have a period within 14 to 16 days.
Charting Your Fertility Pattern :
If you are aware of when you are most fertile, this will help you plan or prevent a pregnancy. There are three ways that you can keep track of this time each month:
· Basal body temperature method - This involves taking your basal body temperature (your body's temperature when you're at rest) every morning before you get out of bed, and recording it on a chart. You will begin to know your own fertility pattern, and you can see the changes from month to month. During the menstrual cycle, your body temperature remains at a somewhat steady, lower level, and begins to slightly rise with ovulation. The rise can be a sudden jump or a gradual climb over a few days. The rise in temperature can't predict exactly when the egg is released, but your temperature rises between .4 to .8 degrees Fahrenheit on the day of ovulation. You are most fertile, and most likely to get pregnant during the two to three days just before your temperature hits the highest point (ovulation), and for about 12 to 24 hours after ovulation. A man's sperm can live for up to three days in your body and is able to fertilize an egg during that time. So, if you have unprotected sex several days before ovulation, there is a chance of becoming pregnant then. Once your temperature spikes and stays at a higher level for about three days, you can be sure that ovulation has occurred. Your temperature will remain at the higher level until your period starts. Basal body temperature differs slightly from woman to woman, but anywhere from 96 to 98 degrees orally is normal before ovulation, and anywhere from 97 to 99 degrees orally after ovulation. So, any changes that you chart are very small and are in 1/10 degree. You can buy an oral basal body temperature thermometer or an easy-to-read thermometer, which has the degrees marked in these small fractions, at a drug store. If you can't find it easily, ask the pharmacist to help you.
· Calendar method - This involves keeping a written record of each menstrual cycle on a regular calendar. The first day of your period is Day 1, which you can circle on the calendar. Continue doing this for eight to 12 months so you know how many days are in your cycle. The length of your cycle can vary from month to month, so write down the total number of days it lasts each time in a list. To find out the first day when you are most fertile, check your list and find the cycle with the fewest days. Then subtract 18 from that number. Take this new number and count ahead that many days on the calendar. Draw an X through this date. The X marks the first day you're likely to be fertile. To find out the last day when you are fertile, subtract 11 days from your longest cycle and draw an X through this date. This method always should be used with other fertility awareness methods, especially if your cycles are not always the same lengths.
· Cervical mucus method (also known as the ovulation method) - This involves being aware of the changes in your cervical mucus throughout the month. The hormones that control the menstrual cycle also cause changes in the kind and how much mucus you have just before and during ovulation. Right after your period, you usually have a few days when there is no mucus present or "dry days." As the egg starts to mature, mucus increases in the vagina, appears at the vaginal opening, and is usually white or yellow and cloudy and sticky. The greatest amount of mucus appears just before ovulation, during the "wet days," when it becomes clear and slippery, like raw egg whites. Sometimes it can be stretched apart. This is when you are most fertile. About four days after the wet days begin, the mucus changes again. There is now much less and it becomes sticky and cloudy. You might have a few more dry days before your period returns. You can describe changes in your mucus on a calendar. Label the days, "Sticky," "Dry," or "Wet." You are most fertile at the first sign of wetness after your period, but maybe also a day or two before wetness begins. This method is less reliable for women whose mucus pattern is changed because of breastfeeding, use of oral contraceptives or feminine hygiene products, having vaginitis, sexually transmitted diseases (STDs), or surgery on the cervix.
To most accurately track your fertility, it is best to use a combination of all three methods, which is called the symptothermal method.
INFERTILITY
It is not uncommon to have trouble becoming pregnant or experience infertility. Infertility is defined as not being able to become pregnant, despite trying for one year, in women under 35, or after six months in women 35 and over. Pregnancy is the result of a chain of events. As described in the Fertility Awareness section, a woman must release an egg from one of her ovaries (ovulation). The egg must travel through a fallopian tube toward her uterus. A man's sperm must join with (fertilize) the egg along the way. The fertilized egg must then become attached to the inside of the uterus. While this may seem simple, in fact many things can happen to prevent pregnancy.
TYPES
A. Hypofertile couples have trouble conceiving quickly. Their fertility may be less than ideal or they may be having problems with timing, but they can eventually conceive without special treatment. For example, the man might have a low sperm count, or the woman might have endometriosis—roadblocks, but not brick walls.
B. Sterile couples won't be able to conceive without medical or surgical treatment. For example, the man might not create enough sperm to fertilize an egg, or the woman might have blocked fallopian tubes.
SIGNS AND SYMPTOMS:
Most men with fertility problems have no signs or symptoms. Some men with hormonal problems may note a change in their voice or pattern of hair growth, enlargement of their breasts, or difficulty with sexual function. Infertility in women may be signaled by irregular menstrual periods or associated with conditions that cause pain during menstruation or intercourse.
REASONS FOR INFERTILITY :
Because of the intricate series of events required to begin a pregnancy, many factors may cause a delay in starting your family.
Every month the pituitary gland in a woman's brain sends a signal to her ovaries to prepare an egg for ovulation. The pituitary hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are involved in stimulating the ovaries to bring an egg to ovulation. A large boost in LH carries a message to the ovarian follicle to release its egg (ovulate). A woman is most fertile at the time of ovulation — around day 14 of her menstrual cycle — although the exact time of ovulation varies among women due to different lengths of menstrual cycles.
The egg is then captured by a fallopian tube and is viable for about 24 hours, but its best chance of being fertilized is within the first 12 hours following ovulation. For pregnancy to occur, a sperm must unite with the egg in the fallopian tube within this time. Sperm are capable of fertilizing the egg for up to 72 hours and must be present in the fallopian tube at the same time as the egg for conception to occur. If fertilized, the egg moves into the uterus two to four days later. There it attaches to the uterine lining and begins a nine-month process of growth.
In order for sperm to reach the egg, many factors are involved in the male fertility process. There must be enough sperm, they must be of the right shape, and they must move in the right way. There must be enough semen to transport the sperm. The man also needs to be able to have an erection, and must be able to ejaculate the semen and deliver it into the vagina.
The cause of infertility can involve one or both partners. Sometimes the problem isn't really one of infertility, but a more general sexual problem such as erectile dysfunction. Other times, the problem may involve an abnormality in the structure of the reproductive hormones or organs. Certain infections and diseases also can affect fertility.
Male infertility
A number of causes exist for male infertility that may result in impaired sperm count or mobility, or impaired ability to fertilize the egg. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, conditions related to a man's general health and lifestyle, and overexposure to certain environmental elements:
Abnormal sperm production or function. More than 90 percent of male infertility cases are due to sperm abnormalities, such as:
· Impaired shape and movement of sperm. Sperm must be properly shaped and able to move rapidly and accurately toward the egg for fertilization to occur. If the shape and structure (morphology) of the sperm is abnormal or the movement (motility) is impaired, sperm may not be able to reach the egg.
· Absent sperm production in testicles. Complete failure of the testicles to produce sperm is rare, affecting less than 5 percent of infertile men.
· Low sperm concentration. A sperm count of 13.5 million per milliliter of semen or fewer indicates low sperm concentration (subfertility). A count of 48 million per milliliter of semen or higher indicates fertility.
· Varicocele. A varicocele is a varicose vein in the scrotum that may prevent normal cooling of the testicle and raise testicular temperature, preventing sperm from surviving.
· Undescended testicle (cryptorchidism). This occurs when one or both testicles fail to descend from the abdomen into the scrotum during fetal development. Undescended testicles can cause mild to severely impaired sperm production. Because the testicles are exposed to the higher degree of internal body heat, sperm production may be affected.
· Testosterone deficiency (male hypogonadism). Infertility can result from disorders of the testicles themselves, or an abnormality affecting the hypothalamus or pituitary glands in the brain that produce the hormones that control the testicles.
· Klinefelter's syndrome. In this disorder of the sex chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production. Testosterone production also may be lower.
· Infections. Infection may temporarily affect sperm motility. Repeated bouts of sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. Mycoplasma is an organism that may fasten itself to sperm cells, making them less motile. If mumps, a viral infection usually affecting young children, occurs after puberty, inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.
In many instances, no cause for reduced sperm production is found. When sperm concentration is less than 5 million per milliliter of semen, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.
Impaired delivery of sperm. Problems with the delivery of sperm from the penis into the vagina can cause infertility.
These may include:
· Sexual issues. Often treatable, problems with sexual intercourse or technique may affect fertility. Difficulties with erection of the penis (erectile dysfunction), premature ejaculation, painful intercourse (dyspareunia), or psychologic or relationship problems can contribute to infertility. Use of lubricants such as oils or petroleum jelly can be toxic to sperm and impair fertility.
· Retrograde ejaculation. This occurs when semen enters the bladder during orgasm rather than emerging out through the penis. Various conditions can cause retrograde ejaculation including diabetes, bladder, prostate or urethral surgery, and the use of psychiatric or antihypertensive drugs.
· Blockage of epididymis or ejaculatory ducts. Some men are born with blockage of the part of the testicle that contains sperm (epididymis) or ejaculatory ducts. An estimated 2 percent of men who seek treatment for infertility lack the tubes that carry sperm (vas deferens).
· No semen (ejaculate). The absence of ejaculate may occur in men with spinal cord injuries or diseases. This fluid transports sperm through the penis into the vagina.
· Misplaced urinary opening (hypospadias). A birth defect can cause the urinary (urethral) opening to be abnormally located on the underside of the penis. If not surgically corrected, this condition can prevent sperm from reaching the cervix.
· Antisperm antibodies. Antibodies that target sperm and weaken or disable them usually occur after surgical blockage of part of the vas deferens for male sterilization (vasectomy). Presence of these antibodies may complicate the reversal of a vasectomy.
· Cystic fibrosis. Men with cystic fibrosis often have missing or obstructed vas deferens.
General health and lifestyle
A man's general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:
· Emotional stress. Stress may interfere with certain hormones needed to produce sperm. Your sperm count may be affected if you experience excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress. Infertility can affect social relationships and sexual functioning.
· Malnutrition. Deficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.
· Obesity. Increased body mass may be associated with fertility problems in men.
· Cancer and its treatment. Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility. You may want to consider freezing (cryopreserving) your sperm before cancer treatment to ensure future fertility.
· Alcohol and drugs. Alcohol or drug dependency can be associated with general ill health and reduced fertility. The use of certain drugs also can contribute to infertility. Anabolic steroids, for example, which are taken to stimulate muscle strength and growth, can cause the testicles to shrink and sperm production to decrease.
· Other medical conditions. A severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, HIV/AIDS, Cushing's syndrome, anemia, heart attack, and liver or kidney failure, may be associated with infertility.
· Age. A gradual decline in fertility is common in men older than 35.
Environmental exposure
Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm count either directly by affecting testicular function or indirectly by altering the male hormonal system. Specific causes include:
· Pesticides and other chemicals. Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production. Exposure to such chemicals also may contribute to testicular cancer. Men exposed to hydrocarbons, such as ethylbenzene, benzene, toluene, xylen and aromatic solvents used in paint, varnishes, glues, metal degreasers and other products, may be at risk of infertility. Men with high exposure to lead also may be more at risk
· Testicular exposure to overheating. Frequent use of saunas or hot tubs can elevate your core body temperature. This may impair your sperm production and lower your sperm count.
· Substance abuse. Cocaine or heavy marijuana use may temporarily reduce the number and quality of your sperm.
· Tobacco smoking. Men who smoke may have a lower sperm count than do those who don't smoke.
Female infertility
The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome, early menopause, benign uterine fibroids, and pelvic adhesions:
a. Fallopian tube damage or blockage.
This condition usually results from inflammation of the fallopian tube (salpingitis). Chlamydia is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever.
Tubal damage with scarring is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.
b. Endometriosis.
Endometriosis occurs when the tissue that makes up the lining of the uterus grows outside of the uterus. This tissue most commonly is implanted on the ovaries or the lining of the abdomen near the uterus, fallopian tubes and ovaries. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.
Infertility in endometriosis also may be due to:
· Ovarian cysts (endometriomas). Ovarian cysts may indicate advanced endometriosis and often are associated with reduced fertility. Endometriomas can be treated with surgery.
· Scar tissue. Endometriosis may cause rigid webs of scar tissue between the uterus, ovaries and fallopian tubes. This may prevent the transfer of the egg to the fallopian tube.
c. Ovulation disorders.
About 25 percent of female infertility is caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation (hypothalamic-pituitary axis) can cause deficiencies in luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation.
Specific causes of hypothalamic-pituitary disorders include:
· Direct injury to the hypothalamus or pituitary gland
· Pituitary tumors
· Excessive exercise
· Anorexia nervosa
d. Elevated prolactin (hyperprolactinemia).
The hormone prolactin stimulates breast milk production. High levels in women who aren't pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. Some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing (galactorrhea) can be a sign of high prolactin.
Polycystic ovary syndrome (PCOS). An increase in androgen hormone production causes PCOS. In women with increased body mass, elevated androgen production may come from stimulation by higher levels of insulin. In lean women, the elevated levels of androgen may be stimulated by a higher ratio of luteinizing hormone (LH). Lack of menstruation (amenorrhea) or infrequent menses (oligomenorrhea) are common symptoms in women with PCOS.
In PCOS, increased androgen production prevents the follicles of the ovaries from producing a mature egg. Small follicles that start to grow but can't mature to ovulation remain within the ovary. A persistent lack of ovulation may lead to mild enlargement of the ovaries.
Without ovulation, the hormone progesterone isn't produced and estrogen levels remain constant. Elevated levels of androgen may cause increased dark or thick hair on the chin, upper lip or lower abdomen as well as acne and oily skin.
e. Early menopause (premature ovarian failure).
Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35. Although the cause is often unknown, certain conditions are associated with early menopause, including:
· Autoimmune disease. The body produces antibodies to attack its own tissue, in this case the ovary. This may be associated with hypothyroidism (too little thyroid hormone).
· Radiation or chemotherapy for the treatment of cancer
· Tobacco smoking
f. Benign uterine fibroids.
Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by interfering with the contour of the uterine cavity, blocking the fallopian tubes.
g. Pelvic adhesions.
Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. They may limit the functioning of the ovaries and fallopian tubes and impair fertility. Scar tissue formation inside the uterine cavity after a surgical procedure may result in a closed uterus and ceased menstruation (Asherman's syndrome). This is most common following surgery to control uterine bleeding after giving birth.
Other causes
A number of other causes can lead to infertility in women:
· Medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
· Thyroid problems. Disorders of the thyroid gland, either too much thyroid- hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
· Cancer and its treatment. Certain cancers particularly female reproductive cancers often severely impair female fertility. Both radiation and chemo therapy may affect a woman's ability to reproduce. Chemotherapy may impair reproductive function and fertility more severely in men than in women.
Other medical conditions. Medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, HIV/AIDS, kidney disease and diabetes, can affect female fertility.
Risk increases with:
· Diabetes mellitus.
· Stress.
· Marital discord and infrequent sexual intercourse.
· Genital disorders.
· Drugs of abuse, such as heroin.
Others Risk factors:
Many of the risk factors for both male and female infertility are the same. These include:
· Age. Age is the strongest predictor of female fertility. After about age 32, a woman's fertility potential declines. A woman does not renew her oocytes (eggs). There is no one special point when fertility declines — it's a gradual transition.
· Chromosomal abnormalities. Infertility in older women may be due to a higher risk of chromosomal abnormalities that occur in the eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. The risk of miscarriage also increases with a woman's age. A gradual decline in fertility is possible in men older than 35.
· Tobacco smoking. Women who smoke tobacco may reduce their chances of becoming pregnant and the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.
· Alcohol. There's no certain level of safe alcohol use during conception or pregnancy.
· Body mass. Extremes in body mass — either too high (body mass index, or BMI, of greater than 25.0) or too low (BMI of lower than 20.0) — may affect ovulation and increase the risk of infertility.
· Being overweight. Among American women, infertility often is due to a sedentary lifestyle and being overweight.
· Being underweight. Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women on a very low-calorie or restrictive diet. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid. Marathon runners, dancers and others who exercise very intensely are more prone to menstrual irregularities and infertility.
INFERTILITY & MISCARRIAGE
Percentage of women with infertility differs with age.
15-24 years old.......... 4.1%
25-34 years old.......... 13.1%
35-44 years old.......... 21.4%
National Center for Health Statistics
Redbook Magazine, August, 1993
The risk of miscarriage differs with age
20-29 years old.......... 10% risk of miscarriage
45 or older ............... 50% risk of miscarriage
Chatelaine Magazine
November 1993, pg. 26
Male infertility increases over past 40 yearsOne-half of 1% of men were functionally sterile in 1938. Today it has reached between 8-12% (an over 15-fold increase). "Functionally sterile" is defined as sperm counts below 20 million per milliliter of semen.
Note: A recent report attaining media attention states sperm count has not declined over the past 4 decades.However, note how the study used the dates of 1951 for the 1st comparison study.1951 was well after the introduction of large amounts of chemicals into society and was a year in which vehicle emissions contained both high levels of lead and large amounts of toxic hydrocarbon/solvent combustion products. Also, by 1951, pesticide use was making its way into consumer use.
Dr. Cecil Jacobson
Reproductive Genetics Center
Vienna, Virginia
Miscarriage more common with low sperm countsWomen experiencing miscarriages typically had husbands with lower sperm counts. On average,48% of husband's sperm appeared "abnormal"(i.e. 2 heads, 2 tails, etc.) under microscopic examination. Men who fathered normal pregnancies had 25% higher sperm counts and only 5% visually abnormal sperm.
Drs. Mirjam Furuhjelm and Birgit Jonson
Dept. of Obst. and Gyn., Sabbatsberg Hospital, Karolinska Institute, Stockholm, Sweden
International J. of Fertility, 7(1):17-21, 1962
40% of couple infertility is due to the male.
Dr. Pat McShane
Department of Obstetrics and Gynecology, Boston Massachusetts
Nationwide infertility ratesA study by the National Center for Health Statistics estimated in 1988 that 8.4% of women 15-44 years had impaired ability to have children and about half of these couples eventually conceive. (These are overall average infertility figures pertaining only to women - statistics will vary greatly depending on the age of the woman.Couple infertility rates are nearly double this percentage since it then takes into account male infertility).
Dr. Howard Jones
New England Journal of Medicine
December 2, 1993 pg. 1710
Article entitled "The Infertile Couple"
Fertility treatments not very effectiveExpensive fertility treatments resulted in only a 6 percentage point improvement in achieving pregnancy over "infertile" couples who just "kept trying." In a study of 1,145 couples who had been diagnosed as infertile, only half of them were treated to help attain pregnancy. After a two to seven-year follow-up, pregnancies occurred in 41% of the treated couples and 35% of the untreated couples.
Dr. John A. Collins
Professor of Obstetrics/Gynecology
McMaster University, Hamilton, Ontario
New England Journal of Medicine
November 17, 1983
More evidence fertility treatments not effectiveAnother study of 2,000 couples found "roughly the same" small improvements in achieving pregnancy when comparing couples who sought infertility treatments and those who kept trying.
Dr. John A. Collins
Professor of Obstetrics/Gynecology
McMaster University, Hamilton, Ontario
Sterility Fertility Journal, Fall of 1993
Infertility treatments are a $1 billion a year industry
HealthFacts
Vol. 19(176), January, 1994
Miscarriage rates higher living near agricultureMothers who lived near crops where certain pesticides were sprayed faced a 40 to 120 percent increase in risk of miscarriage due to birth defects.
Erin Bell (Ph.D.)University of North CarolinaSchool of Public Health
SOURCE: Epidemiology, March 2001
"20% of all cases where the male is the only contributing factor to infertility can be corrected by lifestyle."
Dr. Wolfram Nolten
Division of Endocrinology and Metabolism University of Wisconsin
Lower sperm count increases risk of miscarriageThe odds of having a miscarriage or child with birth defects raises dramatically when fathers have lower sperm counts. When the fathers sperm counts were above 80 million/ml they had only a 1% birth defect rate compared to 6% for the general population. Miscarriages were also lower for the fathers with higher sperm counts - 6% compared to 12% for the general population.
Dr. J. K. Sherman
University of Arkansas study of 1000 children whose mothers were artificially inseminated with sperm from men whose sperm counts were above 80 million per milliliter.
Washington Star Newspaper
January 7, 1979
Smokers have lower sperm countsSmokers sperm counts are on average 13%-17% lower than nonsmokers.
Dr. Marilyn F. Vine
University of North Carolina
Fertility Sterility Journal 6(1):35-43, 1994
Stopping smoking increases sperm countsA study of three smokers who were followed for 5-15 months after stopping smoking reported that their sperm counts rose 50-800%, suggesting that toxic chemicals in the smoke are responsible and any reduction in sperm count is reversible.
(same article as above)
Smokers have more abnormal sperm"Male smokers have an increase in sperm abnormalities, thereby suggesting a mutagenic effect."
Quoted from the American J. of Epidemiology
140(10):921-928, 1994
The original study was reported in the journal Lancet, Volume 1:627-629, 1981
Cigarette consumption increases over 40 years"Cigarette consumption in the U.S. has increased 3-4 fold from 1940 to the beginning of the 1980's."
Dr. R. J. Ravalet
Population Develop. ReviewsVol. 16:213-240, 1990
Smokers face higher infertility38% of female non-smokers conceived in their 1st cycle of attempting pregnancy compared to 28% of smokers. Smokers were also 3-4 times more likely than non-smokers to have taken greater than a year to conceive.
Dr. D. Baird
National Institute of Environmental Health, NC
Journal of American Medical Association
Vol. 253:2979-83, 1985
Abnormally shaped sperm linked to decreased fertilization"A high number of abnormal sperm heads is associated with decreased fertilization. Some drugs such as sulphasalazine, used to treat inflammatory bowel disease can drastically reduce semen quality."
Dr. N. E. Skakkebaek
University Dept. of Growth and Reproduction
Lancet, June 11, 1994, pg. 1474
Pesticides suspected of causing infertilityMen experiencing infertility were found to be employed in agricultural/pesticide related jobs 10 times more often than a study group of men not experiencing infertility. See related articles showing pesticides can damage sperm and testicles.
Dr. Hein Strokum
Institute of Sterility Treatment, Vienna, Austria
American Journal of Industrial Medicine
Vol. 24:587-592, 1983
Common pesticide reduces sperm countLower sperm counts and obvious damage to the quality of the sperm producing part of the testicles (called the seminiferous tubules), were found in test posed to the pesticide chlordane.
Drs. Khawla J. Balash, Muthanna A. Al-Omar
Univ. of Baghdad, Biological Research Center
Scientific Research Council, Baghdad, Iraq
Bulletin of Environmental Contamination Tox.
Vol. 39:434-442, 1987
Infertility caused by pesticide found in the air of most homes built before March 1988Approximately 75% of U.S. homes are being being found to contain the pesticide chlordane in the breathable air. Of significant concern, over 5% of homes built before March of 1988 have been found to have air levels of the pesticide chlordane above the "safe" level of 5 micrograms per cubic meter. (In homes built before 1980 this is over 20%!). If you would like more detailed information on the chlordane problem and how infertility could be caused by living in one of these homes you can visit the chlordane web site at www.chem-tox.com/chlordane
Drs. Samuel S. Epstein, David Ozonoff
School of Public Health, University of Illinois Medical Center, Boston University School of Public Health, Boston, MA
Teratogenesis, Carcinogenesis, & Mutagenesis
Vol. 7:527-540, 1987
Dangerous autoantibodies higher in pesticide exposed peopleThe pesticide Chlorpyrifos (Dursban) was found to cause increases in autoimmune antibodies in people exposed to the pesticide. Autoantibodies are "renegade" immune system components which mistakenly attack the persons own self. (Please see other references in this report which link some cases of male and female infertility to autoimmune disorders in which the immune cells attack either the sperm or egg.
Drs. Jack D. Thrasher, Roberta Madison et. al.
Department of Health Science
California State University
Archives of Environmental Health
Vol. 48(2), 1993 March/April
Car exhaust decreases fertility.The common car exhaust compound benzo(a)pyrene (BaP) causes a significant reduction in fertility in test animals and fertility was further lowered when animals were exposed to both BaP and lead simultaneously. Results showed approximately a 33% reduction in ovarian weight and a "marked reduction in ovarian follicles."
Drs. P. Kristensen, Einar Eilertsen, et al.
National Institute of Occupation Health, Norway
Environmental Health Perspectives
Vol. 103:588-590, 1995
Coffee decreases fertilityA study of 1,909 women in Connecticut found the risk of not conceiving for 12 months (the usual definition of infertility), was 55% higher for women drinking 1 cup of coffee per day - 100% higher for women drinking 1 and one-half to 3 cups and 176% higher for women drinking more than 3 cups of coffee per day.
Hatah (1990)
This study referenced by-
Drs. Larry Dulgosz, Michael B. Brachs
Yale University School of Medicine
Epidemiologic Reviews
Vol. 14, pg. 83, 1992
Coffee increases miscarriage riskCoffee drinking before and during pregnancy was associated with over twice the risk of miscarriage when the mother consumed 2-3 cups of coffee per day.
Dr. Claire Infante-Rivard Department of Occupation Health Faculty of Medicine McGill University, Quebec Canada Journal of the American Medical Association December 22, 1993
Coffee reduces blood to the brainCoffee drinking caused a 20-25% reduction in blood flow to the brains of healthy college volunteers 30 minutes after drinking 250 milligrams of caffeine (about the amount in a freshly brewed cup of coffee).
Dr. Roy J . Mathew
Vanderbilt University, Nashville, Tennessee
British Journal of Psychiatry, December, 1984
Spontaneous abortion after chemical exposureSpontaneous abortion increased over 4-fold for women once they became employed as microelectronics assembly workers. This job was found to subject women to a number of chemical solvents used in cleaning the electronic components including xylene, acetone, trichlorethylene, petroleum distillates and others, as well as solder vapors. Acetone is also used in removing nail polish.
Drs. G. Huel, D. Mergler, R. Bowler
Quebec Institute for Research in Occupational Health and Safety, University of Quebec, Canada
Occupational Medicine Clinic, University of California, San Francisco, California
British Journal of Industrial Medicine
Vol. 47:400-404, 1990
Cocaine and abnormal offspringCocaine exposure to males before conceiving is linked to abnormal development in offspring. The suspected cause is that cocaine binds onto the sperm and therefore, finds its way into the egg at fertilization.
Dr. Ricardo Yazigi
Department of Obstetrics and Gynecology
Washington University School of Medicine
Journal of the American Medical Association
Vol. 66(14), Oct. 9, 1991
MSG greatly reduces pregnancy successMSG (Monosodium Glutamate), a common flavor enhancer added in foods, was found to cause infertility problems in test animals. Male rats fed MSG before mating had less than a 50% success rate (5 of 13 animals), whereas male rats not fed MSG had over a 92% success rate (12 of 13 animals). Also the offspring of the MSG treated males showed shorter body length, reduced testes weights and evidence of overweight at 25 days. MSG is found in ACCENT, flavored potato chips, Doritos, Cheetos, meat seasonings and many packaged soups.
Drs. William J. Pizzi, June E. Barnhart, et. al.
Department of Psychology
Northeaster Illinois University, Chicago, Illinois
Neurobehavioral Toxicology
Vol. 2:1-4, 1979
"20-25% of miscarriages are due to immune system problems."
Dr. Salim Daya
The Fertility Clinic
Chedoke-McMaster Hospital, Ontario
Chatelaine Magazine, November, 1993
Miscarriages higher after chemical solvent exposureTwo solvent chemicals exposed to working pregnant mothers making silicon chips had a 33% miscarriage rate where normally the miscarriage rate is 15%.
Time Magazine
October 22, pg. 27,1992
Male infertility and chemicals in drinking waterDrinking water from the Thames Water Supply in the United Kingdom was pinpointed as the cause of lower sperm counts and increases in abnormally shaped sperm. Common detergents were the chemical suspected as causing the reproductive damage.
Dr. Jean Ginsburg
London Royal Free Hospital
Lancet, Jan. 22
Anesthesia linked to birth defectsBirth defects occurred nearly 3 times more often in a study of 621 Michigan nurse anesthetists (a nurse who helps with anesthesia preparation). A total of 16.4% of the nurses practicing anesthesia during pregnancy had children with birth defects compared to only 5.7% of nurses not practicing anesthesia.
Drs. Thomas H. Corbett and Richard Cornell
Assistant Professor, University of Michigan
Anesthesiology, 41(4), 1974
Malfunctioning immune system causes infertilityThe rate of autoimmune antibodies (antibodies which mistakenly attack the person's own body) was 33% in women unable to deliver a baby to full term and 0% in a control group of women with successful pregnancies.
Dr. Eli Gea
In Vitro Fertilization Unit
Serlin Maternity Hospital
Tel Aviv, Israel
Fertility Sterility Journal, 62(4), October, 1994
Risks from medical fertility treatmentsA common treatment for infertility is administration of follicle stimulating hormones. Regarding this treatment researchers stated, "Persistent stimulation of the ovary by gonadotropins may have a direct carcinogenic effect or an indirect effect attributable to raised concentration of estrogens."
Department of Obstetrics & Gynecology,
Radbond University, Netherlands
Lancet, April 17, 1993, pg. 987
Alcohol reduces fertilization successA large 50% reduction in conception was found in experiments of test animals given "intoxicating" doses of alcohol 24 hours prior to mating.
Dr. Theodore J. Cicero
Washington University School of Medicine
Science News, Vol. 146
In Vitro Fertilization (IVF) success rates depend on the woman's age:
under 35 years....... 45-50% success
35-40 years............ 28-35% success
age 41..................... 20% success
42 and older........... 3% success
The cost of IVF can exceed $8,000- (IVF is fertilization taking place in a "test tube" after removal of a woman's egg).
Dr. Rosenwaks
New York Hospital
Cornell Medical Center
Redbook Magazine, August, 1993
Studies of painters found they are more likely to father children with defects of the central nervous system
Dr. Andrew Olshan
University of North Carolina, Chapel Hill
U.S. News & World Report, December 14, 1992
Dental Workers have over twice the normal number of problems with pregnancyMore spontaneous abortions, stillbirths, and congenital defects occurred in dentists and dental assistants compared with the control group (24% compared to 11%, respectively). Five out of six malformations were spina bifida.
Drs. Birgitte Blatter, Marjolihn van der Star, Nel Roeleveld
Department of Medical Informatics and Epidemiology, University of Nijmegen, Netherlands
International Archives of Occupational & Environmental HealthVol. 59:551-557, 1987
Marijuana use at "moderate" levels was found to stop ovulation in monkeys for 103 to 135 daysResearchers also stated that the THC in marijuana may be directly toxic to the developing egg. Dr. Carol Smith, the main researcher, stated, "There are nervous pathways into the hypothalamus (a gland that regulates the reproductive cycle) that are being suppressed."
Dr. Smith also stressed that women who are attempting to conceive or who are pregnant should not use marijuana.
Dr. Carol Grace Smith
Uniformed Services University of the Health Sciences, Bethesda, Md.
Ricardo Asch, University of Texas, Austin
Science, March 25, 1983
Also reported in Science News, March 26, 1983
Sperm damage was about 50% higher in test posed to the anesthesia enflurane. Anesthesia levels given to the animals was equal to the level that could be given to humans.
Dr. Paul C. Land and E. L. Owen
Department of Anesthesia, Northwestern University Medical School, Chicago, Illinois
Anesthesiology, 54:53-56, 1981
Quotes from the Harvard Health Letter:
"8-10% of sperm from healthy men are abnormal, some carry the wrong chromosome while others have bits and pieces of genetic material out of place."
"Because a child conceived by intoxicated parents was thought to be unhealthy, the ancient cities of Carthage and Sparta had laws prohibiting the use of alcohol by newlyweds."
"The earliest evidence of a link between job occupation and reproductive problems came out in 1860 when a French scientist noted that wives of lead workers were less likely to become pregnant, and if they did were more prone to miscarrying."
"A survey of animal data indicates that paternal (father) exposure to environmental toxins - ranging from recreation drugs to industrial chemicals - apparently contribute to problems ranging from fetal loss and stillbirth to diminished aptitude for learning to perform tasks such as running a maze."
Harvard Health Letter
October, 1992
Other Points from the Harvard Health Letter:
Men who work in aircraft industry or handle paints or chemical solvents have higher risk of producing children with brain tumors.
"Father exposure to paints linked to childhood Leukemias."
Firemen appear to produce an unusually high number of abnormal sperm and be less fertile than other males. (This is believed to be due to the toxic smoke which results when carpets, furniture and paints are burned - of which today are made from synthetic/plastic based compounds).
(page 6 of above reference)
Miscarriages warn of genetic damage90% of fetuses with malformations are spontaneously aborted during early pregnancy. 60% of first trimester spontaneous abortions have chromosome abnormalities.
Dr. Frank M. Sullivan
Department of Pharmacology and Toxicology
University of London
Environmental Health Perspectives
101(Suppl.2):13-18, 1993
Little is known on the reproductive dangers of chemicalsRegarding chemicals in the workplace, the Organization for Economic Cooperation and Development (OECD) and the European Economic Community (EEC) prepared lists of several thousand chemicals produced in amounts of more than 1000 tons per year and many produced at 10,000 tons/year. "Toxicological data of any type exist for a few hundred and reproductive toxicology data exist for probably 100."
Dr. Frank M. Sullivan
Department of Pharmacology and Toxicology
University of London
Environmental Health Perspectives
101(Suppl.2):13-18, 1993
Miscarriage increases from chemical solvents:
The major risk chemicals were:
perchlorethylene (dry cleaning)..... 4.7 times greater risk
trichloroethylene (dry cleaning)..... 3.1 times greater risk
paint thinners ............................... 2.1 times greater risk
paint strippers ............................... 2.1 times greater risk
glycol ethers (found in paints)........ 2.9 times greater risk
Dr. Gayle C. Windham, Ph.D.
Dr. Dennis Shusterman, MD, MPH
School of Public Health
University of California, Berkely
American Journal of Industrial Medicine
Vol. 20:241-259, 1991
Further evidence chemicals damage reproduction.
Quotes from Dr. Baranski, Institute of Occupation Medicine, Denmark:
"Risk of infertility increased in females who reported exposures to textile dyes, dry cleaning chemicals, noise, lead, mercury and cadmium."
"There was a significant risk of increased time to conception among women exposed to anti-rust agents, welding, plastic manufacturing, lead, mercury, cadmium, or anesthetic agents."
"There was also an increased risk of delay to conception following male exposure to textile dyes, plastic manufacturing, and welding. Those who unpacked or handled antibiotics had a significant association with delayed pregnancy of at least 12 months."
Dr. Boguslaw Baranski
Institute of Occupational Medicine, Copenhagen, Denmark
Conference on the Impact of the Environment and Reproductive Health held in Denmark, September 4, 1991
Environmental Health Perspectives
Vol. 101(suppl 2), pg. 85, 1993
Biological reasons for infertility:
Tubal Factors.............................. 36%
Ovulatory Disorders ..................... 33%
Endometriosis.......................... ..... 6%
No known Cause......................... 40%
Dr. David Lindsay
Department of Obstetrics and Gynecology
Monash University, Melbourne, Australia
Lancet, June 18, 1994
Chromosome abnormalities occur in 26% of human oocytes (eggs) and 10% of sperm.
(above reference)
"Recurrent miscarriage is associated with parental chromosome abnormalities, antiphospholipid antibodies and uterine cavity abnormalities. Premature ovarian failure (inability of ovaries to produce eggs) may be genetically determined or associated with autoimmune disease."
Dr. David Lindsay
Department of Obstetrics and Gynecology
Monash University, Melbourne, Australia
Lancet, June 18, 1994
Stillbirth, preterm delivery and small birth weight were higher in certain jobs with chemical exposures in a study of 2,096 mothers and 3,170 fathers.
Women working in rubber, plastics or synthetics industry had an 80% greater chance of stillbirth. Father employment in the textile industry (chemical dyes, plastics, formaldehyde, etc.) resulted in their wives having a 90% greater risk of stillbirth. Exposure of the father to the chemicals polyvinyl alcohol and benzene (found in gasoline, cleaning solvents, adhesives and oil based paints) was associated with a 50% increase in preterm delivery.
Study funded by the March of Dimes
Drs. David A. Savitz, Elizabeth A. Whelan and Robert C. Kleckner
School of Public Health, University of NC
American Journal of Epidemiology
Vol. 129(6):1201-1218, 1989
Chemicals found to mimic human estrogens.
A proper balance of natural estrogens in the body is essential for reproductive success. However, reports have been suggesting that environmental estrogens (chemicals which "mimic" our natural estrogens) are creating infertility problems by confusing the body's estrogen receptors. Some pesticides have already been shown to be environmental estrogens. New research shows that more chemicals are being found to be environmental estrogens including the food additives butylated hydroxyanisole (BHA) Other chemicals found to be somewhat estrogenic include, PVC plastics.
Dr. Susan Jobling, Tracey Reynolds, Roger White, Malcolm G. Parker, and John Sumpter
Department of Biology and Biochemistry
Laboratory of Molecular Endocrinology
Brunel University, London
Environmental Health Perspectives
Vol. 103:582-587, 1995
Environmental Causes of Infertility:
The report is absolutely a "must-have" for every couple having difficulty conceiving. It includes all of the above listed studies as well as additional medical summaries and analysis of the scientific research showing how common chemicals in the home and job can seriously weaken the reproductive processes. Certainly, having this research available together in one easy to read report will greatly increase a couples chance of success (and spouse cooperation...).
Any couple reading this report together will have a completely new outlook regarding the fragility of conception. By laying out the research - study after study - it is sure to encourage modification of lifestyle habits of either spouse. By transferring awareness into real-life changes, couples will greatly improve their odds of conception by removing circumstances found to weaken or damage the reproductive processes. The report exposes the serious lack of testing regarding today's modern chemicals and also discusses the latest research showing how the same chemicals causing infertility and miscarriage can also cause child behavior and learning problems.
Some of the additional research detailed in Environmental Causes of Infertility include - evidence regarding the
1) Reproductive risks of common cosmetic chemicals -
2) Alcohol and marijuana effects -
3) Food additive studies - (specifically MSG) -
4) Pesticides and human hormones -
5) Sperm Damage from a common pesticide found in over 75% of U.S. homes -
6) Relationship between sperm count and fertility -
7) Hazards from anesthesia -
8) Over 20 studies on the infertility effects of coffee and
9) A fascinating1960 study showing how consumption of certain food types is apparently able to damage the sperm development process.
WHEN TO SEEK MEDICAL ADVICE
In general, don't be concerned about infertility unless you and your partner have been trying to conceive regularly for at least one year. However, if you're a woman older than 30 or haven't had a menstrual flow for longer than six months, seek a medical evaluation. If you have a history of irregular or painful menstrual cycles, pelvic pain, endometriosis, pelvic inflammatory disease (PID) or repeated miscarriages, schedule a consultation with your doctor sooner. If you're a man with a low sperm count or a history of testicular, prostate or sexual problems, consider seeking help earlier.
SCREENING AND DIAGNOSIS:
If you and your partner are unable to achieve conception within a reasonable time and would like to do so, seek help. The woman's gynecologist, the man's urologist or your family physician can determine whether there's a problem that requires a specialist or clinic that treats infertility problems.
One-fourth of infertile couples have more than one cause of their infertility. Thus, your physician will usually begin a comprehensive infertility examination of both you and your partner.
Before undergoing infertility testing, be aware that a certain amount of commitment is required. Your physician or clinic will need to determine what your sexual habits are and may make recommendations about how you may need to change those habits. The tests and periods of trial and error may extend over several months.
Evaluation is expensive and in some cases involves operations and uncomfortable procedures, and the expenses may not be reimbursed by many medical plans. Finally, there's no guarantee, even after all testing and counseling, that conception will occur. However, for couples who are eager to have their own child, such an evaluation is best. It may result in a successful pregnancy.
Tests for Both
The man's evaluation focuses on the number and health of his sperm. The laboratory first examines a sperm sample under a microscope to check sperm number, shape and movement. Further tests may be needed to look for infection, hormonal imbalance, or other problems.The first step to treat infertility is to see a health care provider for a fertility evaluation. He or she will test both the woman and the man, to find out where the problem is. Testing on the man focuses on the number and health of his sperm. The lab will look at a sample of his sperm under a microscope to check sperm number, shape, and movement. Blood tests also can be done to check hormone levels. More tests might be needed to look for infection, or problems with hormones.
Male tests include:
· X-ray: If damage to one or both of the vas deferens (the ducts in the male that transport the sperm to the penis) is known or suspected, an x-ray is taken to examine the organs.
· Mucus penetrance test: Test of whether the man's sperm are able to swim through a drop of the woman's fertile vaginal mucus on a slide (also used to test the quality of the woman's mucus).
· Hamster-egg penetrance assay: Test of whether the man's sperm will penetrate hamster egg cells with their outer cells removed, indicating somewhat their ability to fertilize human eggs.
For the woman, the first step in testing is to determine if she is ovulating each month. This can be done by charting changes in morning body temperature, by using an FDA-approved home ovulation test kit (which is available over the counter), or by examining cervical mucus, which undergoes a series of hormone-induced changes throughout the menstrual cycle.
Checks of ovulation can also be done in the physician's office with simple blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, further testing will need to be done.
Testing for the woman first looks at whether she is ovulating each month. This can be done by having her chart changes in her morning body temperature, by using an FDA-approved home ovulation test kit (which she can buy at a drug store), or by looking at her cervical mucus, which changes throughout her menstrual cycle. Ovulation also can be checked in her health care provider's office with an ultrasound test of the ovaries, or simple blood tests that check hormone levels, like the follicle-stimulating hormone (FSH) test. FSH is produced by the pituitary gland. In women, it helps control the menstrual cycle and the production of eggs by the ovaries. The amount of FSH varies throughout the menstrual cycle and is highest just before an egg is released. The amounts of FSH and other hormones (luteinizing hormone, estrogen, and progesterone) are measured in both a man and a woman to determine why the couple cannot achieve pregnancy. If the woman is ovulating, more testing will need to be done.
Common female tests include:
· Hysterosalpingogram: An x-ray of the fallopian tubes and uterus after they are injected with dye, to show if the tubes are open and to show the shape of the uterus.
· Laparoscopy: An examination of the tubes and other female organs for disease, using a miniature light-transmitting tube called a laparoscope. The tube is inserted into the abdomen through a one-inch incision below the navel, usually while the woman is under general anesthesia.
· Endometrial biopsy: An examination of a small shred of uterine lining to see if the monthly changes in the lining are normal.
· Urinary luteinizing hormone (LH) detector kits. A number of at-home kits are available to test your LH level. Although these kits may be helpful, they also can be inaccurate and misleading. Consult your doctor before using one.
Not everyone needs to undergo all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.
Some tests require participation of both partners. Samples of cervical mucus taken after intercourse can show whether sperm and mucus have properly interacted. Also, a variety of tests can show if the man or woman is forming antibodies that are attacking the sperm.
DIAGNOSTIC METHODS IN FEMALE INFERTILITY
Introduction
Any case of female infertility requires a careful and systematic anamnesis, which includes several questions that are generally not asked in the interview of most patients seen in a gynecological practice. It is after this important step that the necessary clinical investigations for the work-up of each given case can be selected in an appropriate manner in order to establish the correct diagnosis as precisely as possible and in the shortest length of time.
The three main questions to be answered are:
1. Is the patient ovulating ?
2. Are the conditions for implantation adequate ?
3. Is the morphology of the uterus and the tubes normal ?
The answers are provided by the following methods:
Clinical evidence of ovulation:
a. Basal body temperature.
b. Observation of the cervical mucus.
c. Exfoliative vaginal cytology.
d. Transvaginal sonography (ovarian follicles).
e. Pituitary and ovarian hormones assays.
f. Laparoscopy and direct observation of the ovaries.
Clinical evidence of readiness for uterine implantation:
a. Basal body temperature.
b. Transvaginal sonography (thickness of the endometrium).
c. Plasma progesterone assay.
d. Endometrial biopsy.
e. Hysteroscopy.
Clinical evidence of normality of the internal genital tract:
a. Hysterosalpingography.
b. Transvaginal sonography.
c. Hysteroscopy.
d. Laparoscopy.
CLINICAL EVIDENCE OF OVULATION
Basal body temperature (BBT)
The early morning rectal temperature will rise approximately 0.5 to 0.7°C after ovulation and stay in a "plateau" for 12 to 14 days. This rise in BBT is due to a central effect of progesterone secretion. A slight drop of BBT might be observed 24 to 48 hours before ovulation, related to the estrogen peak secreted by the mature follicle.
Observation of the cervical mucus
Under the influence of the highest level of estrogen secretion from the dominant ovarian follicle, which precedes the ovulation, one can observe an abundant, clear and fluid secretion of mucus from the cervical canal. This transient secretion slightly but obviously dilates the external cervical os. It precedes ovulation by 4 to 2 days and is greatest on the day before ovulation. This mucus is highly receptive for the sperm penetration during sexual intercourse. The cervical mucus disappears promptly after ovulation under the influence of progesterone secretion.
Exfoliative vaginal cytology
A vaginal smear, scraped from a lateral vaginal wall with an Ayres spatula or a wet cotton swab, provides a typical result at the time of ovulation, when examined under light microscope observation, after it has been stained with Papanicolaou or Schorr staining, or with any quick dye. The superficial cells of the vaginal mucosa are flat, well scattered, with pyknotic nuclei and highly eosinophilic. As soon as ovulation has taken place, the cells become coiled, packed together and mostly basophilic.
Transvaginal sonography
The sonographic picture of a preovulatory follicle is well documented and typical. The mature follicle measures from 18 to 23 mm in average inner dimension.
After ovulation, the follicular wall becomes irregular and the fresh corpus luteum usually appears as a hypoechogenic structure and may contain some echoes corresponding to internal bleeding. The wall of the corpus luteum becomes thickened as the luteinization progresses.
Pituitary and ovarian hormone assays
The secretion of LH can be detected daily in urine samples by radioimmunoassay. The LH peak usually precedes ovulation by 48 to 24 hours. At the same time, the secretion of estrogen produced by the dominant follicle, reaches a maximum in the peripheral venous blood. Soon after ovulation, the level of progesterone in the peripheral blood rises from 2.5 to 4.0 ng/ml and reaches its maximum from day 5 to day 10 after the LH peak, with a variation from 7 to 12 ng/ml. This intermediate luteal phase is the physiological time for uterine nidation. A schematic representation of the hormonal secretory patterns throughout the menstrual cycle.
Laparoscopy
A mature follicle increases ovarian size considerably and looks like a round bluish cyst with one or two capillaries seen on its surface.
After ovulation, the stigma of the follicular rupture can be easily recognized as a small hole surrounded by an hemorrhagic structure on the surface of the ovary. Scars of previous ovulations can also be recognized on the surface of both ovaries. Clear yellowish follicular fluid can be found in the pouch of Douglas.
CLINICAL EVIDENCE OF READINESS FOR UTERINE IMPLANTATION
Basal body temperature
A sustained "plateau" of 12 to 14 days following ovulation, is indicative of a good progesterone secretion from the corpus luteum, at least of 4 ng/ml in the peripheral blood.
Transvaginal sonography
The thickness of the secretory endometrium can be precisely measured. At its thickest, it reaches 8 to 14 mm, including both layers, and should be echogenic in a regular manner.
Plasma progesterone assays
In order to have a good evaluation of the secretion of the corpus luteum, one should obtain at least three to four blood samples, for instance every other day, starting from the third postovulatory day.
Endometrial biopsy
The tissue sample should be aspired either with a Novak cannula or with a plastic Cornier’s Pipelle around the time when nidation normally takes place, which means between day 20 to 22 of the cycle. Dating of the endometrial biopsy requires strict histological criteria.
Hysteroscopy
Using a small hysteroscope of 5 mm or 3 mm of diameter, an hysteroscopic examination of the uterine cavity can be easily performed on an out-patient basis in a clinic or in the office, with or without anesthesia. The examination can rule out the presence of uterine polyps, synechiae, or endometritis, all of which could interfere with nidation.
CLINICAL EVIDENCE OF NORMALITY OF THE INTERNAL GENITAL TRACT
Hysterosalpingography
As in the case of other medical methods of investigation, strict technique is necessary in order to obtain precise information. A perfectly frontal view and also a good lateral view of the uterus, with a position of the uterus body being strictly parallel to the radiological film, is necessary to appreciate the size, the morphology and the outline of the uterine cavity.
A lateral view of a correct exposure of both tubes gives more information on their morphology than the frontal view. Also, the lateral view gives a better picture of the isthmic segment of the uterus and of its width in case of a suspected incompetence of the internal cervical os.
Until fibroscopic tools have been utilized enough and a sufficient optical knowledge on the inside morphology of the fallopian tubes has been accumulated, hysterosalpingography remains the only way to investigate the intramural segment and the isthmic segment of the fallopian tubes.
Pelvic adhesions can only be demonstrated by this radiological method, if a sufficient amount of opaque medium has been spread into the pelvis or, better, if a complementary hydrotubation with sterile saline is used at the end of the procedure, and if the last picture is taken after the patient has been leaned alternately on each side for a few minutes ("brassage").
Transvaginal sonography
With the use of a vaginal sound, we can now easily measure the size of the uterus, and observe the structure of the endometrium and of the myometrium. Polyps, myomas, internal synechiae and congenital malformations are well documented in specialized text books. Ovarian cysts and sactosalpinx can also be easily recognized with transvaginal sonography.
Hysteroscopy
With this method, using either CO2 gas or saline solution as a dilatation medium, the entire uterine cavity can be explored, and pathological findings detected, even those which can be sometimes missed with the hysterosalpingography. The openings of the fallopian tubes in the uterine cavity can also be observed and demonstrated to be free of any obstacle as polyp or fibrotic tissue.
Laparoscopy
Trans- or paraumbilical laparoscopy remains the most complete method to explore the anatomical situation of both fallopian tubes and their relation with the adjacent ovaries. By means of direct optical observation, one can detect unsuspected peritubal and periovarian adhesions, or asymptomatic endometriosis, or agglutination of the fimbriae of the distal portion of the tubes.
With the advent of fine fibrotic catheters, introduced into the open fallopian tubes under laparoscopic control, we should be able to examine the internal appearance of the ampullary segments and detect small internal adhesions or post-inflammatory atrophy of the tubal epithelia.
UNEXPLAINED INFERTILITY
In about one-fifth of infertile couples, no specific cause is found (unexplained infertility). Couples receiving the diagnosis of unexplained infertility are more likely to seek multiplehealth care providers and be influenced by the experiences of family and friends or literature that promises new hope. Although infertility is unexplained, the pregnancy rate for these couples is among the highest.
POSSIBLE COMPLICATIONS
These includes:
· Psychological distress caused by feelings of guilt, inadequacy, and loss of self-esteem.
· Treatment costs are high and often not covered by insurance.
· The unknown and possible long-term effects of medications used to increase fertility.
Other possible complications of being infertile often involve strong emotions and may trigger negative feelings between you and your partner.
These may include:
•Depression
•Guilt
•Anger
•Disappointment
•Resentment
•Blame
•Fear of losing partner because of infertility
•Diminished confidence and self-esteem
WHEN TO CALL A DOCTOR
Consult with your health professional if:
•You want children but have been unable to become pregnant after 1 year of having sex without using birth control.
•You are a woman over age 35 who has been unable to become pregnant after about 6 months of sex without using birth control.
•You have had several miscarriages in a row.
Watchful Waiting:
Before seeking medical help with conception, try to increase your chances of becoming pregnant by practicing fertility awareness and following the suggestions in the Home Treatment section of this topic.
Who To See:
The following health professionals can help you evaluate whether a fertility problem is present, provide some preliminary guidance, and discuss general testing and treatment options. You can also use this appointment to provide a sperm sample for evaluation, one of the first tests in a routine infertility workup.
•Family practitioner
•Internist
•Nurse practitioner
Health tools help you make wise health decisions or take action to improve your health.
Help and Decision Points
Within the course of every illness or health problem, you have to make decisions—little decisions about whether to call a doctor and what self-care is best, and big
decisions about medications, tests, and surgeries. Decision Point topics focus on medical care decisions you may face.
Decision Point topics help you understand the key information and important issues related to your decision. Before you can make an informed decision it's important that you:
•Fully understand the medical problem and testing or treatment options.
•Consider your personal values and preferences.
This information will help you work in partnership with your doctor. When both you and your doctor participate in the decision-making process, you'll reach the decision that best fits your needs and concerns.
This image identifies links to Decision Points, which generally appear in the Treatment Overview or the Exams and Tests section of selected topics. Decision Points can also be found in the Health Tools section of a topic.
Information included in Decision Points
Introduction and key points
Key points are the core of a decision. They capture the most important information in the Decision Point and present it in an easy-to-understand format. Often, key points summarize compelling medical information, offer a concise look at risk versus benefit, illustrate a desirable outcome (either short term or long term), cite a professional recommendation, or even offer commonsense advice. The remaining sections in the
Decision Point support the statements made in the key points.
Medical Information
The “Medical Information” section presents medical information in question-and-answer format. This section includes:
•Medical information about the decision.
•Medical information about the effectiveness of a test or treatment.
Your Information
The “Your Information” section helps you decide about your personal comfort level and preferences about the decision. This section has a table that lists the pros and cons of the decision. Personal stories about people who chose the treatment option and those who did not choose it are included.
Wise Health Decision
The “Wise Health Decision” section includes a worksheet with statements about your options. Choosing “yes” or “no” for each statement helps you understand how you are feeling about the decision.
Should You consider adoption as an alternative to infertility treatment? Introduction
This information will help you understand your choices as you consider adoption.
Key points in making your decision
If you have had infertility problems and are thinking of adopting a child, consider the following while making your decision:
•Successful adoption and long-term parenting requires the commitment of both partners and a dependable support system. The need for a solid support system is even more important for a single adoptive parent.
•There are many adoption options available to Americans, both domestically and abroad. The Internet can be an efficient and useful tool for researching adoption information.
•The adoption application and placement process can be as time-consuming and
-expensive as infertility treatment. While a U.S. or international infant adoption can take a year or longer, a U.S. minority adoption can take less than a year.
•Some adoption agencies have parental age and other restrictions for infant adoption. If you are in your mid-30s and are considering infant adoption, you may have to weigh agency requirements against your own timeline for starting an adoption process.
If you need more information about infertility treatment for comparison with adoption options.
Should You have a tubal procedure or in vitro fertilization for tubal infertility? Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
If you have a fallopian tube problem and are unable to become pregnant, you may be considering a fallopian tube procedure, in vitro fertilization (IVF), or both. When making your decision, consider the following:
•A fallopian tube procedure can reverse the cause of infertility. If a tubal problem is the only cause of your infertility and surgery is successful (you conceive a healthy pregnancy), you shouldn't need further infertility treatment.
•In vitro fertilization (IVF) does not reverse infertility. You need to undergo an IVF cycle for each pregnancy attempt.
•If a tubal procedure is unsuccessful (you conceive an ectopic pregnancy or not at all), you may need IVF to become pregnant.
•Tubal disease that causes a hydrosalpinx requires a fallopian tubal procedure. Fluid that drains from a hydrosalpinx into the uterus greatly reduces your chances of becoming pregnant, either naturally or with IVF.
•IVF is used to bypass a fallopian tube problem (non-hydrosalpinx) and may result in a shorter conception time than would surgery.
•Your likelihood of successful tubal infertility treatment is unique to your situation and therefore difficult to predict. Your chances of conceiving and carrying a healthy pregnancy to term are influenced by how severe your tubal problem is, your age, and any other fertility problems you or your partner might have.
Should You have infertility testing? Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
If you and your partner have been having trouble getting pregnant, it's possible that one or both of you has a medically treatable fertility problem. As you decide whether to look for a cause, you will have various medical and personal questions to consider. Together, you can use this Decision Point to guide your thinking. It offers basic facts about infertility, testing, and when testing is appropriate. You can also use it to define your personal goals, feelings, and values about infertility testing and treatment.
Consider the following when making your decision:
•If you are younger than 30 and trying to conceive, most doctors recommend well-timed intercourse for at least a year before considering testing and treatment.
•If you (woman) are closer to 35, it's reasonable for both you and your partner to consider testing for treatable causes of infertility sooner, before age-related factors make it too difficult to conceive.
•Infertility testing and treatment can be difficult, sometimes traumatic, and expensive. Before starting infertility testing together, discuss how far you would be willing to go with testing and treatment. Only have testing for conditions that you are willing and financially able to have treated or that would help you move on to other options such as adoption.
•Prolonged infertility testing and treatment can intensify the stress of infertility. If you are becoming overly stressed or your relationship is suffering, ask your doctor to recommend a professional counselor who can help you get through this crisis together.
As a couple, you have the final word on how to use your infertility test results based on your medical information, goals, and values.
Should You have infertility treatment? Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
After having testing for a cause of infertility, your next step is considering your doctor's recommendations about what to do next. Perhaps your tests have identified a problem, and a potentially effective treatment is available. Or, your test results are normal, finding no obvious reason why you shouldn't be able to conceive. In this case, you may be deciding whether to have more testing, try a treatment for "unexplained infertility," or continue trying to conceive naturally. In any case, you may also be considering adoption as a family planning alternative.
This decision module can help you consider the various medical and personal questions that are related to infertility. It offers you information about infertility, treatment options according to condition, risks of those options, and general outcome information. After reviewing this information, you and your partner can use the worksheet to guide your thinking as you decide what to do next.
Consider the following when making your decision:
•A man's fertility is not known to be severely affected by age. A woman's fertility gradually drops from her mid-30s into her 40s, due in great part to the natural aging of the egg supply.
•In 10% to 15% of couples, no cause of infertility is found (unexplained infertility).1 Of all couples with unexplained infertility who do not seek treatment, about 35% will naturally become pregnant within 3 years, and 45% do so within 7 years.2
•The crisis of infertility can be intensified by its treatment, which can be difficult, expensive, and sometimes traumatic. Make a point of:
•Defining your limits for infertility treatment in advance. During infertility treatment, regularly evaluate your emotional, financial, and physical well-being.
•Considering professional counseling. Prolonged infertility testing and treatment can intensify the stress of infertility itself. If you are becoming depressed or overly stressed, or your relationship is suffering, seek professional counseling to help you get through this crisis together.
•Fertility clinic success rates vary. When considering treatment success rates, be aware that many are given in terms of pregnancies conceived. Pregnancy rates do
-not reflect the fact that some pregnancies miscarry. In any group of women, live birth rates are lower than early pregnancy rates.
Treating infertility :
You should talk to your health care provider about your fertility if you:
•are under 35 and, after a year of frequent sex without birth control, you are having problems getting pregnant, or
•are 35 or over and, after six months of frequent sex without birth control, you are having problems getting pregnant, or
•believe you or your partner might have fertility problems in the future (even before you begin trying to get pregnant).
General measures:
•Diagnostic tests may include laboratory studies, such as blood studies of hormones; pelvic examination; hysterosalpinogram (x-ray study of the genital tract); postcoital test (PCT), which is a study of the cervical mucus performed 2 to 12 hours after intercourse; endometrial biopsy to rule out luteal phase defect (a defect in hormone production) and possibly others.
•Surgical diagnostic procedures, such as laparoscopy (use of a small lighted telescope) to examine reproductive organs.
•Keep a basal body-temperature chart to become familiar with your ovulation pattern. Have intercourse just before ovulation, which can be determined from the chart.
•Psychotherapy or counseling, if marital problems exist.
•Don't use a lubricant during sexual relations. Lubricants may interfere with sperm mobility.
•Your partner should withdraw his penis quickly from your vagina after ejaculation. If left in, it reduces the number of sperm that can swim toward the egg.
•After your partner's ejaculation, place pillows under your buttocks to provide an easier downhill swim for the sperm.
•Maintain a positive attitude. Worry and tension may contribute to infertility.
•Alternate pregnancy methods include in-vitro fertilization (IVF) in which eggs from the female are harvested, impregnated with sperm from the male, and implanted in the uterus; GIFT or ZIFT (gamete or zygote intrafallopian transfer) which are implant procedures involving female egg and male sperm; intracytoplasmic sperm injection (ICSI) whereby a single sperm is injected into a single egg and the resulting zygote is transferred to the uterus.
Medication :
•Hormones for a hormone imbalance.
•Gonad stimulants such as clomiphene, menotropins (Pergonal), human chorion gonadotropin (hCG), leuprolide (Lupron) or urofollitropin. Recognize that fertility drugs may cause multiple births.
Activity:
•Work and exercise moderately. Overexercising may contribute to infertility. Rest when you tire.
Diet :
•Eat a normal, well-balanced diet. If you are overweight, try to achieve your ideal weight.
Notify your Midwife or Health care provider if...
•You or a family member has symptoms of infertility and wants help.
•Conception doesn't occur within 6 months, despite recommendations and treatment.
•New, unexplained symptoms develop. Hormones used in treatment may produce side effects.
Drugs and Surgery :
Different treatments for infertility are recommended depending on what the problem is. About 90 percent of cases are treated with drugs or surgery. Various fertility drugs may be used for women with ovulation problems. It is important to talk with your health care provider about the drug to be used. You should understand the drug's benefits and side effects. Depending on the type of fertility drug and the dosage of the drug used, multiple births (such as twins) can occur in some women. If needed, surgery can be done to repair damage to a woman's ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery.
Management of Male Infertility:
Some 15 to 20 percent of couples are still trying to conceive a baby after a year of unprotected intercourse. While many people put most of the blame on women, statistics show that this is a shared problem with male factors involved in more than 50 percent of these infertility cases.
The reassuring news for men is that urologists have a variety of tools and techniques to correct many infertility problems including: hormone manipulation to raise testicular testosterone levels, artificial insemination, medications to counter retrograde ejaculation and microsurgical techniques to undo damage caused by blockages in the epididymis or vas deferens — not to mention correction of swollen veins in the scrotum called varicoceles.
But which problem affects you? More importantly, which treatment will work? The information below should help you discuss male infertility with your urologist and partner.
What occurs under normal conditions?
The male reproductive system is designed to manufacture, store and transport sperm — the microscopic genetic cells that fertilize a woman's ovum. A number of hormones, the most important of which are testosterone and follicle-stimulating hormone (FSH), regulate that process. Like sperm, testosterone is produced in both testicles, organs suspended in a pouch-like skin sac — the scrotum — below the penis.
Sperm production begins when immature cells grow and develop within a network of delicate ducts — microscopic seminiferous tubules — inside the testicles. Because these new sperm cannot move initially on their own, they are dependent on adjacent organs to become functional. They mature while traveling through the epididymis, a coiled channel located behind each testicle.
When climax, or orgasm, occurs, sperm are carried out of the body via semen, a fluid composed of secretions from various male reproductive glands, most notably the prostate and paired seminal vesicles.
What are the causes of male infertility?
Developing and transporting mature, healthy, functional sperm depends on a specific sequence of events occurring in the male reproductive tract. Many disturbances can occur along that path, preventing cells from maturing into sperm production or reaching the woman's fallopian tube where fertilization occurs.
For starters, your infertility may be caused by a diminished output of sperm by your testicles. Abnormal sperm production can also be triggered by genetic factors and a number of lifestyle choices (e.g., smoking, alcohol, and certain medications), all of which impair the normal production of sperm cells, which, in turn, decreases their number.Long-term illnesses (e.g., kidney failure), childhood infections (e.g., mumps), and hormonal or chromosomal deficiencies (e.g., insufficient testosterone) can also account for abnormal sperm numbers.
Perhaps the most prevalent sperm production problem, however, is linked to structural abnormalities, most notably varicoceles. A snake-like bundle of enlarged or dilated varicose veins around the testicles; varicoceles are the most common identifiable cause of male infertility. They are found in about 15 percent of normal males and in approximately 40 percent of infertile men, most often on the left side or simultaneously on
-both sides. A single, right-sided varicocele is rare. Evidence suggests that by creating an abnormal backflow of blood from the abdomen into the scrotum, triggering a rise in testicular temperature, varicoceles hinder sperm production and cause oligospermia.
Your chances of fathering a child are non-existent if your semen has no sperm to transport. Azoospermia, which accounts for 10 to 15 percent of all male infertility, refers to a complete absence of such sperm cells in your ejaculate. In its "non-obstructive" form, azoospermia can be triggered by various hormonal or chromosomal deficiencies often linked to testicular failure. But just as likely, it is the result of damage to some portion — the epididymis, vas deferens, or ejaculatory duct — of the reproductive delivery system. In fact, 40 percent of azoospermia sufferers are diagnosed with an "obstructive" form, caused by either congenital or acquired problems like infections. Vasectomy, the chief contraceptive method available to men today, is a primary example of
-an acquired factor. By cutting and sealing the vas deferens to stop sperm from moving through the reproductive tract, pregnancy is prevented. Vasectomies can often be reversed by use of a vasovasotomy in the hands of an experienced urologic microsurgeon. The blockage may be permanent, however, if the extent of the damage is great and the doctor is unskilled. While vasectomies are a formidable factor, there are other potential disturbances within the reproductive tract that can impede sperm.Because a proper erection is essential in impregnating any partner, it is not surprising that impotence or erectile dysfunction (ED), the inability to sustain an erection, is the most easily identified sexual problem linked to male infertility. Retrograde ejaculation, a lesser known issue, involves the improper deposit of sperm and semen. In this case, your ejaculate content may be normal, but instead of leaving the penis for the vagina, it flows backwards into the bladder due to an improperly functioning bladder neck.
How is male infertility diagnosed?
Unlike female infertility, the cause of which is often easily identified, diagnosing male factors can be difficult. The problems, however, usually fall in one of two areas — sperm production and/or delivery.
Because male infertility results from such varied factors, you will need to see your physician to sort out the possibilities. A primary care doctor can often locate the problem, correctable or not, by completing an initial evaluation. You will probably need further evaluation by a urologist or reproductive specialist if you and your partner have been trying unsuccessfully for a year to get pregnant or if you have a known male factor, such as an undescended testicle.
In any case, the evaluation usually includes medical and surgical histories. The doctor will want to know about childhood diseases (e.g., mumps), current health problems (e.g., diabetes), or even medications (e.g., anabolic steroids) that might interfere with the formation of sperm. He or she will also ask about your use of alcohol, marijuana and other recreational drugs, as well as your exposure to the occupational hazards of ionizing radiation, heavy metals and pesticides. All of these factors can affect fertility.
Every evaluation will also include an assessment of your sexual performance, along with you and your partner's joint efforts to achieve pregnancy. For instance, your doctor will investigate whether you have had difficulty with erections and if your ejaculate has sufficient quality and volume. Such factors can adversely affect your sperm's effectiveness for pregnancy.
In addition to conducting a general exam, your doctor will look for any abnormalities of the penis, epididymis, vas deferens, and testicles. He or she will focus specifically on varicoceles, which can be identified easily in the scrotum when the patient is standing because they feel like a "bag of worms."
Semen analysis is a routine test that is the single most important lab indicator for male infertility. Completed twice, it helps urologists define each factor and its severity. Performed by examining ejaculate within a few hours of masturbation, a semen analysis provides important information about semen volume and content. It also measures the amount, motility (movement) and appearance (shape) of individual sperm. Each factor tells you and your doctor much about your ability to conceive. Your semen is normal, for instance, if it liquefies from a pearly gel into a liquid within 20 minutes. A breakdown in this sequence may indicate a problem with your seminal vesicles. Likewise, a lack of fructose (sugar) in a sperm-free specimen may indicate a congenital absence of the seminal vesicles or your ejaculatory duct may be entirely blocked.
In addition to the above screens, your doctor may order other tools to assess fertility, including transurethral ultrasonography, which detects ejaculatory duct obstructions, and testicular biopsies, which confirm any reproductive blockages. Getting a complete evaluation should help you and your partner understand your infertility issues, not to mention make better decisions about treatment.
What are some treatment options?
Your treatment options will depend entirely on the factors causing your infertility. The good news is that few medical fields have changed as dramatically during the past decades as reproductive medicine, particularly as it pertains to men.
Today, many conditions can be corrected with drugs or surgery thus enabling conception to occur through normal intercourse.
Surgical Therapies for Male Infertility
Among the most exciting treatment developments are microsurgical approaches to repair dilated varicose scrotal veins to improve semen quality. You should consider treatment if you meet the following criteria:
you and your partner are trying to conceive a child, but thus far have been unsuccessful
you have been diagnosed with a varicocele that can be felt
your semen analysis or sperm function tests are abnormal
your partner has normal fertility or treatable infertility
you are contending with a varicocele and abnormal semen
you are an adolescent male with a varicocele and reduced testicle size
If you fit the profile, your doctor can correct your varicocele with any number of surgical options, all of which can be performed in an outpatient center under anesthesia. Some of these approaches include:
Retroperitoneal (or abdominal) approach:
This conventional "open" varicocelectomy is best suited to men whose previously attempted varicocele or hernia repair resulted in significant groin scarring. Complications, which occur at a rate of 5 to 30 percent, include hydroceles, testicular atrophy and injury to the vas deferens.
Laparoscopic varicocelectomy:
While this minimally invasive technique can be used successfully to isolate and repair vessels, it is accompanied by a 6 to 15 percent recurrence rate due, in part, to the preservation of a series of fine veins that may dilate with time and cause recurrence. Also, events such as intestinal injuries or infection give it an 8 to 12 percent complication rate. In addition, laparoscopy must be performed by a urologist experienced in the procedure, which is a limitation.
Microsurgical varicocelectomy:
Cited by many specialists as their preferred approach, this operation uses the optical magnification of a high-powered microscope to provide direct visual access to veins and arteries. Through a mini-incision in the groin, the doctor can reliably separate and preserve testicular arteries, while identifying and ligating both large and small veins that could dilate in the future. Also, while technically demanding, microsurgical varicocelectomy virtually eliminates hydroceles, the most common surgical complications. In fact, microsurgical techniques have significantly reduced recurrence rates to less than 2 percent and complications rates to less than 5 percent while increasing fertility. The effectiveness of this procedure has been reported in the scientific literature to be as high as a 43 percent pregnancy rate for couples after one year and 69 percent after two years.
Percutaneous embolization:
This non-surgical approach is aimed at occluding the varicocele after it is viewed with a specialized X-ray technique. The procedure itself uses a flexible tube inserted into the groin to place a blocking agent that helps obstruct the center of the vessel. This minimally invasive technique is often less painful than surgery, but it requires a physician with experience in interventional radiologic techniques. As such, it is performed in the radiology department.
There is no evidence to suggest that any approach is the best for correcting varicoceles.While surgery removes more than 90 percent of the swollen vein, percutaneous embolization gets rid of 80 to 85 percent. After repair, about 60 percent of men show
-improved sperm counts and/or motility. The effects of either treatment on fertility, however, are much less clear. While some studies show improvement, others suggest no significant change. Regardless, many infertile couples still choose varicocele repair because it improves semen in many men and may improve fertility, both at little risk.
If your semen lacks sperm (azoospermia) as a result of blockage: there are several surgical treatment options at your disposal:
Microsurgical vasovasostomy:
Is designed to restore fertility by reconnecting the severed vas deferens in each testicle. The procedure, which should clear the way for sperm to leave the body, can be accomplished through various approaches, all performed in outpatient hospital or ambulatory surgical settings under general anesthesia, spinal epidurals or sometimes with localized numbing and sedation.In more than 90 percent of patients, sperm returns in the semen, yielding pregnancy in more than 50 percent of cases.
Transurethral resection of the ejaculatory duct (TURED):
When properly diagnosed, ejaculatory duct obstructions can be managed surgically by passing a cystoscope into the urethra and opening the offending blockages. Resecting the duct triggers release of sperm into the ejaculate in about 50 to 75 percent of men. But there can be complications — recurrent blockages, incontinence and even retrograde ejaculation due to bladder injuries. Also, pregnancy rates are only about 25 percent.
Vasoepididymostomy:
The most common microsurgical procedure for treating epididymal obstructions, vasoepididymostomy is also one of the most difficult of all treatments for male infertility. Surgeons must have excellent skills and extensive experience to perform this procedure, a surgical joining of the vas deferens and epididymis to facilitate the transport of fluid. The approach relies on the precise positioning and tying of sutures to secure tissue layers between the structures. When successful, however, an opened channel is restored in 50 to 70 percent of cases; pregnancy rates vary from 25 to 57 percent.
What can I expect after treatment?
Male infertility factors can usually be corrected in an outpatient procedure using general anesthesia or intravenous sedation. While postoperative pain is usually mild, postoperative recovery and follow up varies.
After varicocele repair, your doctor should perform a physical examination to see if the vein is completely gone. Semen should be tested about every three months for at least one year or until pregnancy. If your varicocele returns, or you remain infertile after
the repair, ask your doctor about assisted reproductive techniques (ART). These high-tech procedures are often successful in circumventing the same problem to produce a pregnancy.
While vasectomy reversals cause only mild postoperative pain, expect an out-of-work recovery of four to seven days. The chance for pregnancy depends on many factors, most importantly, the age and fertility status of your female partner and the number of years between your original vasectomy and this procedure. The longer you wait, the less likely you will have a successful reversal.
How are specific male infertility conditions treated without surgery?
Anejaculation: A relatively uncommon disorder, anejaculation — or the absence of any semen — can occur as a result of spinal cord injury, previous surgery, diabetes, or multiple sclerosis. It may also be caused by abnormalities present at birth as well as other mental, emotional or unknown problems. Medical therapy with drugs is usually the first line of treatment, but if that fails, the next step is either rectal probe electroejaculation (RPE) or penile vibratory stimulation (PVS). PVS consists of rhythmic vibratory stimulation of the tip and shaft of the penis to encourage a natural climax. While relatively non-invasive, it is less successful than RPE, particularly in severe cases. RPE, except in the spinal cord injured patient, is usually performed under anesthesia and retrieves sperm in 90 percent of patients. While cell density with this procedure is excellent, sperm movement and shape are still limiting fertility factors. Assisted reproductive techniques, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), have become increasingly important to patients with anejaculation.
Congenital adrenal hyperplasia (CAH): A rare cause of male factor infertility, CAH involves congenital deficiencies in certain enzymes, resulting in abnormal hormone production. CAH is usually diagnosed by demonstrating excess steroids in the blood and urine. When treated successfully with hormone replacement, sperm production increases.
Genital tract infection: It is rare that acute genital tract infections can be linked to infertility, but it does happen in approximately 2 percent of men suffering from reproduction problems. The problem is usually picked up following a simple semen analysis where white blood cells are found. White blood cells generate excess oxidants — reactive oxygen species (ROS) — known to harm the fertilizing potential of sperm. But an infection need not be acute to cause reproductive problems. For instance, testicular atrophy, along with epididymal duct obstruction, may occur following severe infection of the epididymis and testes. Chronic prostatitis, on rare occasions, may also cause obstruction by occluding the ejaculatory ducts. While antibiotics are generally prescribed for full-blown infections, they are not warranted for lesser inflammations since they can be occasionally harmful to sperm production.In those cases, non-steroidal anti-inflammatories are usually recommended.
Hyperprolactinemia: This condition of excessive production of the hormone prolactin by the pituitary gland, has been implicated in both infertility and erectile dysfunction. Treatment of hyperprolactinemia is based on the cause of the increased secretion. If medications are the root, they should be discontinued immediately. Medical therapy may consist of medications to bring prolactin levels to normal.
Hypogonadotropic hypogonadism: Hypogonadotropic hypogonadism refers to the failure of the testicles to produce sperm due to a hypothalamic or pituitary disorder. It is the cause of infertility in a small percentage of patients and can exist at birth or be acquired. Known also as Kallmann's syndrome, the congenital form results from an abnormal production of gonadotropin-releasing hormone (GnRH), a hormone produced by the hypothalamus. Acquired hypogonadotropic hypogonadism can be triggered by a variety of other conditions, including pituitary tumors, head trauma and anabolic steroid use.
When hypogonadotropic hypogonadism is suspected, doctors usually order an MRI along with serum prolactin concentrations to rule out pituitary tumors. If levels of the prolactin are excessive but there is no mass, treatment will consist of lowering prolactin concentrations before proceeding with gonadotropin replacement therapy. During treatment, blood testosterone levels and semen analyses are obtained.Chances for pregnancy are excellent, since resultant sperm are essentially normal.
Immunologic Infertility: Since the early 1950s, when scientists first demonstrated that some cases of infertility were linked to immunologic causes, much research has focused on this area. While oral steroids to decrease significant antisperm antibody have been advocated, this treatment is rarely successful. In vitro fertilization with ICSI is now the treatment of choice for immunological male factor problems.
Reactive Oxygen Species (ROS): A relatively new interest area in male infertility, ROS refers to small molecules present in many bodily fluids, such as seminal white blood and sperm cells. When in appropriate concentrations, ROS can help prepare the sperm for fertilization. However, if in excess, ROS can be harmful to other cells.Because of their already high polyunsaturated fatty acid content, human sperm membranes are particularly sensitive to ROS-related damage. Recent studies have demonstrated an increase in presence of these molecules in the semen of infertile men. Several compounds have been used to detoxify or "scavenge" ROS. The most effective of these, vitamin E (400 IU twice daily) is a very effective antioxidant.Pentoxifylline, a medication employed occasionally to decrease the thickness of blood, has also been shown to decrease sperm oxidant production, but is used much less frequently than vitamin E.
Retrograde ejaculation: Defined as an abnormal backward flow of semen into the bladder with ejaculation, it can be caused by problems that are: anatomic (e.g., previous prostate or bladder neck surgeries); neurogenic (e.g., diabetes, spinal cord injury, and previous surgery); pharmacologic (e.g., anti-depressants, certain anti-hypertensives, and medication
used to treat BPH, prostate enlargement); and idiopathic (other unknown problems). Retrograde ejaculation is diagnosed by the patient urinating immediately following ejaculation to produce a sample that is evaluated microscopically for sperm. Initial treatment for retrograde ejaculation consists of commonly used medications (e.g., Sudafed). If medical therapy should fail, however, doctors may try to recover sperm from the bladder after ejaculation in conjunction with intrauterine insemination.
How are non-specific (idiopathic) male infertility conditions treated without surgery?
Non-specific male infertility factors are often unexplained or ill-defined unlike specific conditions such as retrograde ejaculation or genital tract infection. However, because these procedures often involve the body's hormonal activities, they are just as troublesome to both the treating physician and the patient. In many cases, empiric therapy — designed to address hormonal imbalances — is used.
Empiric therapies generally involve hormonal manipulation. Assessing the impact of empiric treatments is very difficult, given variations in patients as well as dosing regimens, treatment durations and outcome definitions. As such, treatment decisions chosen by individual physicians are often based on their own personal philosophies.
Management of Female Inferility
Home Treatment
To decrease your risk of infertility and increase your chances of becoming pregnant, use the following guidelines.
Track ovulation at home
•Estimate when you are ovulating by practicing fertility awareness, including monitoring your cervical mucus changes, basal body temperature, and luteinizing hormone (LH) levels with a home ovulation predictor test.
•If you know when you will be ovulating, do no have sex during the 5 days before your 6-day "fertile window," which is ovulation day and the 5 days leading up to it. (Not ejaculating for a few days helps build up a man's sperm count.) Then have sex once each day of your fertile window, including ovulation day. If your partner has a low sperm count, have sex every other day, since frequent ejaculation does temporarily lower sperm count.
•If you don't know when you will next be ovulating, have sex two or three times each week.12
•If you exercise strenuously most days of the week, reduce your level of activity. Strenuous exercise can cause women to ovulate less often.
OVULATION DRUGS
INTRODUCTION:
Approximately one-third to one-half of all infertile women have problems with ovulation. This can include the ovaries’ inability to produce mature eggs or “ovulate” (release) an egg. If no eggs are released, this is called anovulation. Infertility specialists rely on a certain group of ovulation drugs, often called “fertility drugs,” to temporarily correct ovulatory problems and to increase a woman’s pregnancy potential. Contrary to popular belief, these drugs do not make all women more fertile and in fact only work during the month in which the medications are taken. The drugs allow ovulation to occur more regularly in some women with ovulatory problems who may otherwise remain anovulatory and therefore infertile. Ovulation drugs can control the time of ovulation and stimulate eggs to mature and be released. These drugs may be used to correct other infertility problems such as improving hormone production to favorably affect the lining of the uterus called the endometrium. These medications also can be used to stimulate the development of multiple eggs during the treatment cycle.
NORMAL OVULATION:
The Process
The ovaries are two small glands, each about one-and-one-half to two inches long and three-fourths to one inch wide, located in a woman’s pelvic cavity. They are attached to the uterus (womb), one on each side, near the fimbriated (finger-like) openings of the fallopian tubes. About once a month, a mature egg is released by one of the ovaries. The fimbriae of the fallopian tubes sweep over the ovary and pick up the egg after it has been released from the follicle (the fluid-filled ovarian cyst containing the egg). If the egg is fertilized, which usually occurs in the tube, the resulting embryo (fertilized egg) continues to mature and increase its number of cells as it travels to the uterus and implants in the endometrium (uterine lining). The embryo’s full journey through the tube takes four to five days. Fallopian, Ovary Uterus, Sperm, Cervical, Mucus, Egg Released (Ovulated), Cervix Fertilization, Usually Tube, Vagina Occurs Here.
Hormone Production
In addition to producing eggs, the ovaries also secrete hormones. Hormones are substances secreted from organs of the body, such as the pituitary gland, adrenal gland, or ovaries, which are carried by a bodily fluid such as blood to other organs or tissues where the substances exert a specific action. The cycle of ovarian hormone production has two main phases. In the first phase, known as the follicular phase, an egg matures inside the ovary. The egg is surrounded by a layer of hormone-producing cells and fluid. The maturing egg, the surrounding cells, and the fluid are collectively known as a follicle. The follicle grows to a diameter of about an inch, forming a cyst-like sac on the surface of the ovary, before the fluid and the egg are released at ovulation. In natural cycles, an ovary contains several developing follicles, but usually only one follicle reaches maturity each month and releases an egg. This follicle, known as the dominant follicle, secretes a generous amount of the female hormone estradiol (estrogen) into the bloodstream during the first phase of the cycle. The estrogen circulates to the uterus where it stimulates the endometrial cells to reproduce rapidly and repeatedly, causing the uterine lining to thicken as ovulation approaches. The physician can usually see this thickening on an ultrasound exam. The second phase of ovarian hormone production begins with ovulation. The dominant follicle ruptures, usually around day 14 in a 28-day cycle, and releases a mature egg onto the surface of the ovary near the fallopian tube. The empty follicle collapses and the remaining follicle cells develop a yellow color. Collectively these cells are known as the corpus luteum, literally a “yellow body.” The corpus luteum secretes estrogen and large quantities of progesterone throughout the second half of the cycle, known as the luteal phase, which lasts approximately two weeks. Traveling through the bloodstream to the uterus, the combination of progesterone and estrogen causes the uterine lining to further mature and produce nourishment for an embryo. About a week after ovulation, the endometrium is in prime condition for an embryo to implant. An experienced physician can tell approximately how many days have passed since ovulation by examining a sample of the endometrium taken in a biopsy. If no embryo implants, the secretion of estrogen and progesterone declines about two weeks after ovulation and, as a result, the endometrium is shed. This shedding of the endometrium is called menstruation. The first day of menstruation is known as “cycle day one.” The length of the menstrual cycle is determined by counting the number of days from cycle day one until the start of the next menstrual period. Although variability in cycle length is usually due to variability in the follicular phase, the luteal phase can also be variable in length. The luteal phase should last 11 to 16 days. If it is not sufficient in length because of inadequate progesterone production, fertility problems may result. Since ovulation usually precedes menstruation by two weeks, a woman with a 28-day menstrual cycle is most likely to ovulate on day 14. Similarly, a woman with a 32-day cycle is most likely to ovulate on day 18.
Directives From the Brain
The hypothalamus and pituitary gland orchestrate the events leading to ovulation. These organs communicate with the ovaries via hormonal messengers traveling in the bloodstream. The hypothalamus is a thumb-sized structure in the base of the brain that controls many bodily functions and regulates the pituitary gland. The pituitary gland, about the size of a finger tip, is located just beneath the hypothalamus. The hypothalamus releases the hormone gonadotropin releasing hormone (GnRH), a messenger that tells the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH are both involved in maturing the follicle, but FSH primarily makes the follicle grow and produce increasing amounts of estrogen. As the follicle grows, the increasing estrogen in the bloodstream signals the pituitary to shut down FSH production. A surge of LH triggers ovulation. After ovulation, the corpus luteum primarily produces progesterone, which prepares the endometrium for the implantation of a fertilized egg.
DIAGNOSIS:
Detecting Ovulation
The key to diagnosing ovulatory problems is to detect and confirm ovulation. This can be done in several ways. An evaluation of the menstrual pattern provides some clues. A woman who menstruates every 25 to 35 days is probably ovulating regularly. She can also assume that ovulation occurs about 14 days before day one of each period. It is important to remember, however, that a woman can have randomly occurring uterine bleeding even though she never ovulates. Moreover, she can also have fairly regular cycles and not ovulate. There are several ways to detect ovulation, including commercially available ovulation prediction kits and basal body temperature charts. For more information on ways to detect ovulation, consult the ASRM patient information booklet titled Ovulation Detection.
TREATMENT:OVULATION MEDICATION
Who Needs Ovulation Medication?
Ovulation drugs are used to either control the time of ovulation or regulate erratic ovulation patterns. These medications, when administered appropriately, can stimulate ovulation in most individuals and can also correct post-ovulatory problems by encouraging more than one egg per cycle to reach maturity. If the time of ovulation is known, the doctor can schedule an insemination, for example, during the woman’s “fertile days” to maximize the chance of pregnancy.
Hormonal Chain of Command
1 Hypothalamus Estrogen Progesterone Uterus GnRH FSH LH 2 3 4 Pituitary Ovary Directives from the Brain. Ovulation drugs also may be prescribed to increase the reliability of monthly ovulation in oligo-ovulatory women (women who ovulate infrequently) or to encourage ovulation in anovulatory women. Women may not ovulate because of high ovarian production of male-type hormones (polycystic ovarian syndrome [PCOS]), insufficient production of LH and FSH by the pituitary, or ovaries that do not respond well to normal levels of LH and FSH. Ovulation drugs may be indicated in the treatment of women with amenorrhea (absence of menstruation) and may be used to temporarily correct a luteal phase defect. A luteal phase defect occurs when progesterone production from the corpus luteum shuts down prematurely, produces an inadequate amount of progesterone to mature the uterine lining, or if the ovary did not actually release an egg at the normal time of ovulation. The interval of time between ovulation and the beginning of the next menstrual period is usually 11 to 16 days. If a luteal phase defect occurs, this time may be shortened and the endometrium won’t be in the proper condition to receive and nourish an embryo; therefore implantation cannot occur. Ovulation drugs are used to correct a luteal phase defect by enhancing the production of progesterone from the corpus luteum after ovulation, thereby making the endometrium more optimal for embryo implantation. The endometrium also can be supported by the use of natural progesterone. Ovulation drugs also can be used to encourage the ovaries to produce more than one egg per cycle. This is done in preparation for various forms of assisted reproduction such as intrauterine insemination or in vitro fertilization (IVF). The intent is to develop several mature eggs in hopes that at least one egg will be fertilized and result in pregnancy. For more information on IVF, consult the ASRM patient information booklet entitled IVF and GIFT: A Guide to Assisted Reproductive Technologies. An evaluation should be performed to look for hormonal imbalances before medication is administered to stimulate ovulation. Abnormal (inadequate) ovulation is sometimes caused by a hormonal imbalance resulting from other conditions, such as thyroid disease. Correction of imbalance may allow ovulation to resume spontaneously without the use of fertility drugs.
COMMONLY PRESCRIBED DRUGS:
The most commonly prescribed ovulation drugs are clomiphene citrate, follicle stimulating hormone (FSH), human chorionic gonadotropin (hCG), and human menopausal gonadotropin (hMG). These and four others, bromocriptine, cabergoline, gonadotropin releasing hormone (GnRH), and GnRH analogs, which have very specialized applications, are described below. A chart is provided listing these ovulation drugs and their side-effects .
Drugs Used for Ovulation Induction
Generic Name Brand Name(s) Form Most Common Side Effects Clomiphene citrate Clomid® Serophene®
Clomid Use and AbuseClomiphene Citrate (Clomid, Serophene)
Some women can't get pregnant because they don't secrete enough LH and FSH at the right time during the cycle and, as a result, they don't ovulate. For these women, the first drug doctors often prescribe is clomiphene citrate (Clomid, Serophene). This synthetic drug stimulates the hypothalamus to release more GnRH, which then prompts the pituitary to release more LH and FSH, and thus increases the stimulation of the ovary to begin to produce a mature egg.
Clomiphene is a good first choice drug when a woman's ovaries are capable of functioning normally and when her hypothalamus and pituitary are also capable of producing their hormones. In short, the woman's reproductive engine is in working order, but needs some revving up.
Structurally like estrogen, clomiphene binds to the sites in the brain where estrogen normally attaches, called estrogen receptors. Once these receptor sites are filled up with clomiphene, they can't bind with natural estrogen circulating in the blood and they are fooled into thinking that the amount of estrogen in the blood is too low. In response, the hypothalamus releases more GnRH, causing the pituitary to pump out more FSH, which then causes a follicle to grow to produce more estrogen and start maturing an egg to prepare for ovulation. Typically, a woman taking clomiphene produces double or triple the amount of estrogen in that cycle compared to pretreatment cycles
If a woman is menstruating, even if irregularly, clomiphene is usually effective, particularly if she develops follicles that aren't reaching normal size. Usually, a mature follicle is about 20 millimeters in diameter, or about the size of a small grape, just before it ruptures and releases its egg. Clomiphene may help small, immature follicles grow to maturity.
A low estradiol level in a woman's blood correlates with an inadequately stimulated, small follicle. A woman having a spontaneous ovulation cycle (that is, ovulating without the aid of fertility drugs) generally has peak estradiol levels ranging from 100 to 300 picograms (one trillionth of a gram)/ml. A woman may have enough hormones to produce an egg, but if her estradiol production by the follicles is low (less than 100 pg/ml),
she may not adequately stimulate her cervix to produce fertile mucus or stimulate her endometrium to get ready to accept a fertilized egg for implantation. Clomiphene could boost the weak signals from the hypothalamus to the pituitary to the ovaries.
"A woman who ovulates infrequently, say at six-week intervals or less often, is also a good candidate for clomiphene therapy, since clomiphene will induce ovulation more frequently. The more a woman ovulates, the more opportunities her mature eggs have to be exposed to her husband's sperm and, therefore, the greater her chance to become pregnant.
Clomiphene is also often effective for a woman with luteal phase defect (LPD). A woman with LPD may begin the ovulation process properly, but her ovarian function becomes disrupted, resulting in low production of the hormone progesterone in the luteal phase of the menstrual cycle. Following ovulation, the ovary produces progesterone, the hormone needed to prepare the uterine lining for implantation of the fertilized egg, which has divided and entered the uterine cavity. A fall in progesterone levels in the blood during this critical time can interfere with early embryo implantation or, even if a fertilized egg has already implanted, cause a woman to menstruate too early and end a pregnancy within a few days after implantation.
Using an LH-urine detector kit or keeping a basal body temperature (BBT) chart can help a woman taking clomiphene determine whether the luteal phase of her cycle is shorter than the normal fourteen days. The luteal phase of the cycle, the length of time from ovulation until she menstruates, has a normal range of thirteen to fifteen days. Clomiphene can often "tune up" the hypothalamus and pituitary so they keep producing the hormones the ovary needs to manufacture progesterone throughout the luteal phase.
"Of women whose only fertility problem is irregular or no ovulation at all, about 80 percent will ovulate and about 50 percent will become pregnant within six months of clomiphene treatments. About three percent of women on clomiphene have a multiple pregnancy, usually twins, compared with about one percent in the general population.
If a woman responds to clomiphene and develops a mature follicle (determined by adequate estrogen production and ultrasound examination), but has no LH surge by cycle day 15, then injection of the hormone human chorionic gonadotropin (HCG), which actslike LH, can be given to stimulate final egg maturation and follicle rupture, releasing the egg. The woman tends to ovulate about 36 hours after the LH surge or HCG injection, which can be confirmed by further ultrasound scans.
"Clomiphene is a relatively inexpensive drug, and is taken orally for only five days each month. The doctor attempts to initiate clomiphene therapy so that the woman ovulates on or around day 14 of a regular 28-day cycle. The simplest, most widely used dose starts with one daily 50 mg. tablet for five days starting on cycle day three or five. If a woman ovulates at this dose, there is no advantage to her increasing the dosage. In other words, more of the drug isn't necessarily better. In fact, more may be worse, producing
-multiple ovulation, causing side effects such as an ovarian cyst or hot flashes, and most commonly, interfering with her fertile mucus production (Emphasis is Theresa Venet Grant's.)
If a woman doesn't ovulate after taking one clomiphene tablet for five days, then her doctor will usually double the daily dose to two tablets (100 mg) in her next cycle, and if she still doesn't respond, then triple the daily dose to 150 mg, or add another fertility medication such as human menopausal gonadotropin (Pergonal) in the next cycle. Some doctors increase the dose up to 250 mg. a day, but this is NOT recommended by either of the drug's two manufacturers. Women tend to have side effects much more frequently at higher doses.
If the dose of clomiphene is too high, the uterine lining may not respond completely to estrogen and progesterone stimulation, and may not develop properly. As a result, a woman's fertilized egg may not be able to implant in her uterus.
Side Effects
Because Clomiphene binds to estrogen receptors, including the estrogen receptors in the cervix, it can interfere with the ability of the cervical mucus glands to be stimulated by estrogen to produce fertile mucus. Only "hostile" or dry cervical mucus may develop in the days preceding ovulation. If this occurs, adding a small amount of estrogen beginning on cycle day 10 and continuing until the LH surge may enhance cervical mucus production.
Some women taking clomiphene experience hot flashes and premenstrual-type symptoms, such as migraines and breast discomfort (particularly if they have fibrocystic disease of the breasts). Visual symptoms such as spots, flashes or blurry vision are less common and indicate that treatment should stop.
Clomiphene is a very safe medication with relatively few contraindications. Preexisting liver disease is one contraindication since clomiphene is metabolized by the liver. Enlarged ovaries are also a contraindication since clomiphene may occasionally produce hyperstimulation of the ovaries.
The hot flashes are just like the hot flashes women experience at menopause when the level of estrogen circulating in the blood is low. The clomiphene fools the brain into thinking that blood estrogen levels are low.
Clomiphene Abuse
Too often, doctors give clomiphene to women with unexplained infertility before the couple has a fertility workup, or even after they have a workup, but there is no evidence of an ovulation disorder. This empiric therapy may create new problems, such as interfering with fertile mucus production, and often delays further evaluation that can lead to a specific diagnosis and proper treatment.
For a woman who has normal, spontaneous ovulation, driving the pituitary harder with clomiphene won't make ovulation any more normal. If a woman has taken clomiphene for several cycles without becoming pregnant, then she and her fertility specialist should investigate other conditions that may be preventing her pregnancy.
After noting a good postcoital test (PCT) during a fertility workup, some doctors fail to repeat the test after placing a woman on clomiphene. A PCT needs to be repeated to check the quality of the woman's cervical mucus while she is on clomiphene, since 25 percent or more of women who take the drug develop cervical mucus problems. It's important for a woman to monitor her cervical mucus production during every cycle while trying to become pregnant, including her cycles while taking clomiphene.
MENOTROPIN THERAPY
Overview:
Menotropins are a powerful group of medications in which the most active ingredient in terms of ovulation induction or enhancement is follicle stimulating hormone (FSH). The unit of measurement for FSH is the International Unit (IU) which is based on an international reference preparation (IRP). One ampule of lyophilized (freeze dried) FSH generally has 75 IU of FSH (some have 150 IU of FSH so you should read the label).
Some menotropins, such as Pergonal, Humegon and Repronex, also contain 75 IU (or 150 IU if there is 150 IU of FSH) of Luteinizing Hormone (LH). LH stimulates the production of estrogen's precursor hormones, androstenedione and testosterone) in the ovary. Many women secrete adequate LH, making the addition of LH in these medications unnecessary. If the anticipated estrogen production is quite large, such as when heavily pushed to maximally produce mature eggs in IVF cycles, then many infertility specialists prefer to have additional LH available. Also, there are some women who do not produce LH in adequate amounts and these women benefit from the additional LH.
The basic infertility evaluation should be completed prior to the use of menotropins.
Contraindications:
Menotropins are contraindicated in women with no ovarian reserve (menopause). A woman with early ovarian failure will occasionally have a spontaneous recovery of ovulation (for unknown reasons) but attempts at ovulation induction or enhancement in these women are usually unrewarding. Ovulation induction can be considered if the FSH concentration is less than the LH concentration and/or the estradiol concentration is greater than 40 pg/ml (the amount required for a withdrawal flow). There should always be documentation of tubal patency and availability of sperm prior to initiating treatment with menotropins. I often recommend a laparoscopy to assess and optimize the pelvis prior to menotropin therapy. An exception is when the only finding on evaluation is a clear-cut ovulation disorder. The appropriateness of laparoscopy should be individually discussed with each couple considering menotropins.
Improving Ovulation
Menotropins can be used for either ovulation induction, ovulation enhancement in a process referred to as "controlled ovarian hyperstimulation" (COH) or "assisted reproductive technology" (ART, including IVF).
Menotropins are injectable medications. Most of these have considerable contamination with other proteins and are given as intramuscular injections deep into the upper outer quadrant of the gluteus maximus muscle (rear end). Fertinex is an exception in that it has been highly purified through affinity chromatography so that it can be self administered subcutaneously (under the skin) in the upper thigh. Recombinant forms of menotropins are also highly purified and can be administered subcutaneously.
In my experience, the partner of the woman being treated is the most reliable and caring person to give the intramuscular injections once taught the proper technique (to prepare and administer the medication). The shot is given at night (occasionally twice a day) in a dosage that may change from day to day.
Menotropin Treatment Protocols
There are several protocols commonly used for ovulation induction and enhancement with menotropins. The physician in charge of your Controlled Ovarian
Hyperstimulation (COH) or IVF cycle should be experienced in the use of these medications to optimize your response and limit complications. Common features of appropriate protocols include:
•Perform an ultrasound exam prior to initiating a cycle There should be no large cysts within the ovary at the onset of a stimulation cycle. Cysts greater than 2 cm (and possibly 1.5 cm) are relative contraindications for starting the medication. Larger cysts may interfere with optimal stimulation either by producing hormones locally to disrupt the surrounding follicular development or by mechanically interfering with follicular development due to their size. I will generally advise that the patient with a large ovarian cyst return the following month for an ultrasound and may start stimulation if the cyst has gone away. Most of these cysts seem to be residual (corpus luteum) cysts from the prior cycle and are removed by the body within days to weeks. Selected patients will be allowed to initiate a cycle despite a large ovarian cyst if the circulating estrogen concentration is found to be low (indicating that the cyst is not functioning hormonally). If a larger cyst in the ovary persists over several months, then further evaluation and probably removal would be recommended. Removal of persistent nonfunctional large cysts of the ovary is primarily to rule out serious pathology (such as cancer).
•Menotropins are started in the early part of the cycle A "standard" protocol for COH is two ampules of menotropin per day starting on cycle day two, three or four. The first day of heavy flow is cycle day one. Medications are usually given in the evening at about the same time each day. Monitoring blood work for estradiol concentration is initiated after three days of medication. This estrogen level allows adjustment of the medication dosage and determination of when to return to the office for additional blood work (and possibly an ultrasound). Once additional testing with ultrasounds is begun, monitoring is usually more frequent and may even be required each day. On average, a "typical stimulation" may take seven to 12 days of medication and the patient will have returned to the office on three to five occasions for monitoring.
•Dosing of menotropins may be changed from cycle to cycle Some patient's ovaries are difficult to stimulate with menotropins. If two ampules per day result in a poor response, then increasing the dosage of medication is considered. Increasing from two to four ampules per day is common. Generally I do no use greater than six ampules per day since I have not seen reasonable success in achieving a pregnancy with greater doses. Some patient's ovaries will respond by maturing too many follicles at once. If there is a larger than desired response to two ampules per day, then decreasing the amount of medication to one ampule or half an ampule is considered.
•GnRH agonists may be used for ovarian suppression or "a flare" GnRH agonists are a type of medication often used with menotropins in stimulated cycles. Their most common indications are when more even development of
follicles is desired. If a prior stimulated cycle resulted in maturation of only one or two mature eggs despite the presence of multiple other follicles, then use of a GnRH agonist may be helpful. In these situations, the GnRH agonist is started about a week prior to the expected menses to suppress any early development of follicles (the follicles are at a common baseline of development when the menotropins are started). Also, use of agonists allows for greater control and the ability to push follicles to larger sizes at the end of the stimulation cycle.
The GnRH agonists may be administered in a variety of ways, including as injectable medications or taken as an intranasal spray. There are many different GnRH agonists available and each has a different half life (duration of effectiveness). Thus, these medications may need to be taken either once or twice a day depending on the particular product chosen. GnRH agonists will initially result in the release of stored FSH and LH from the pituitary gland. This stimulatory response to these medicines lasts for the first few days. GnRH agonists also suppress the production of new FSH and LH so that once the stored hormones have been released the circulating FSH and LH is very low. Therefore, following the initial few days of stimulation there is a suppression of the ovary for the duration of administration of the medication. Since these medications deplete stored LH the brain is also incapable of triggering ovulation via an LH surge. A "flare" protocol exists, for which the GnRH agonist is started at (about) the same time as the menotropins. This flare protocol takes advantage of the initial release of pituitary FSH and LH, which may further enhance egg development. With the flare protocol there will be pituitary and ovarian suppression by the time of ovulation so there is an inability to mount the LH surge (signal to ovulate).
•Menotropins are commonly used during IVF Higher doses of menotropins along with a relatively strong GnRH agonist (such as lupron) are generally used for In Vitro Fertilization (IVF). A standard IVF protocol would consist of lupron (initiated on idealized cycle day 21 of the prior cycle) and 4 ampules of menotropins per day (initiated early in the next cycle). Both GnRH agonist and menotropins are continued until ovulation is desired, then the LH surge is simulated with hCG (profasi).
•Polycystic ovaries often are difficult to stimulate Polycystic ovaries are characterized by a large number of follicles arrested in early to mid development. When stimulating polycystic ovaries, the goal is to avoid excessive numbers of small follicles with very high circulating estradiol concentrations since this can result in severe forms of ovarian hyperstimulation syndrome. Protocols to avoid excessive development differ dramatically from one another. Some start with a high dose of menotropins and cut back once a few follicles have begun to develop. Others start with a low dose of menotropins, hoping that only a small number of follicles will respond. Still others administer one to three months of birth control pills to suppress follicular development and then
use a GnRH agonist to continue to suppress abundant follicular development until menotropins are started. There is usually a considerable learning curve (trial and error period) to customize the menotropin strategy for patients with PCOS since the ovaries generally respond uniquely and unpredictably. Trying several different menotropin protocols might be required before settling on an ideal protocol for a particular patient's ovaries.
•Giving steroids may suppress excessive androgenic hormone production If a woman has abundant circulating androgenic hormones they can interfere with follicular development. Androgenic hormones are associated with male pattern hair growth and occasionally dark irregular discoloration of the skin usually in areas of creases (such as arm pits, neck, under breasts). Blood hormone studies can usually (but not always) confirm high circulating levels of these hormones. If the androgens are elevated or if there are clear-cut signs of excess androgens then consideration of concurrent low dose glucocorticoid steroid medication (such as dexamethasone or prednisone) is considered.
•GnRH pumps are available As an alternative to menotropin therapy these pumps will infuse the releasing hormone, GnRH, in preset amounts and time intervals. GnRH will directly stimulate release of FSH and LH from the pituitary gland. In my experience, patients do not like the concept of an indwelling catheter either placed under the skin or into a blood vessel. The catheter stays in place for weeks to months and works by means of a small pump (about the size of a transistor radio) that the patient carries.
Monitoring Menotropin Treatment
Intensive monitoring is required to maximize appropriate egg development and minimize exposure to complications. This monitoring includes transvaginal ultrasounds and blood work for hormone (especially estradiol) levels. Usually, I will perform a baseline ultrasound exam to rule out large ovarian cysts and then obtain blood work and ultrasounds every one to four days until there is full maturation. A typical cycle might involve seven-12 days of medication. At the end of the stimulation process, human chorionic gonadotropin (hCG, such as Profasi) is given into the intramuscular region to simulate the LH surge and trigger both the final maturational step in egg development and the release of the mature egg(s).
Menotropin Costs
Human menopausal gonadotropins are expensive. For controlled ovarian hyperstimulation (COH) with intrauterine inseminations (IUIs) two to three (but up to six) ampules per day are taken for about 10 +/- 3 days, for a normal total of 20-30 ampules. For In Vitro Fertilization, about twice as much medication may be normal. Since each ampule costs about 50 dollars the total for the medication is easily 1-2 thousand dollars per attempted cycle. In addition, the professional and other fees for monitoring can be expensive.
Obtaining menotropin medication can be difficult. Menotropins are not carried as routine stock in many pharmacies. Therefore, you should confirm that your pharmacy has actually received a supply for you prior to attempting to fill your prescription. If you are unable to identify a pharmacy that will order this medication for you, a local infertility center (such as my office) should be able to direct you. Menotropins are stable if stored at room temperature up until their stated expiration date.
There are few side effects to the human menopausal gonadotropins (menotropins). Stress associated with a cycle of IVF or COH can be intense and a free flow of communication between partners can be very effective at reducing this stress. Organization is important for working couples since monitoring may take 30-60 minutes in the morning, exclusive of travel time.
USE OF HERBS FOR INFERTILITY
The use of herbs as a source of medical treatment has been going on since the beginning of time. Allah has put cures in this world which we are to seek, and some of these cures do come in the form of herbs. It was not until recently that herbal remedies have been replaced by synthetic medication. And most doctors do not believe in this "unconventional" medicine and are more inclined towards the modern means of medication. However, many couples do use herbs as one helpful use in the treatment of infertility.
It should be no surprise that Muhammad pbuh himself used herbal remedies in his time. While scholars generally disclude any medically related ahadith as a part of the Sunnah, it is quite interesting to learn the culturally influenced herbal remedies that were used. Some of these remedies are still used today in treatment of certain conditions.
Black Seed
Black Seed is a widely used herb by Muslims, and one of the favorites of Muhammad pbuh.
Abu Hurayra reported Muhammad pbuh as saying: Use the Black Seed as it is the panacea that heals all harms except death.
According to Ibn Qayyim al Jawiziyya the Black Seed was in several forms to treat the following ailments:
Eliminates flatulence, extracts the helmnths, palliates leprosy, provokes menstrual flow and increases milk production
Fenugreek-
Fenugreek was also widely used during the time of Muhammad pbuh and is an herb that he preferred.
Al Qassem ibn Abdur Rahman Muhammad pbuh said: Resort to the cure of the Fenugreek
Muhammad pbuh was also reported to have been present when Al Harth ibn Kalda used it to treat Sa'd Ibn Waqqas as a cure for his ailment.
According Ibn Qayyim al Jawiziyya Fenugreek was used in several forms to treat the following ailments:
Soothes coughs, increase semen, soothes asthma, provokes menstruation, decomposes the tumor in the spleen. Also recommended to women to soak in a bath with to soothe aches related to a tumid womb
The use of herbs is not to be taken as the be all to end all for infertility treatment. There are many causes for infertility that should be medically treated, such as PCOS, Endometriosis, blocked tubes, and uterine fibroids. Herbs as well as vitamins, proper diet and exercise along with conventional medical treatment can all be used. As with any other forms of medication you should consult professional advice and guidance, herbs should not be taken blindly. Many have very powerful affects and can do more harm than good if not taken properly or at the wrong time. You must also be sure to inform your doctors of any herbs that you take to make sure there is no reaction with any medication or procedure that you will undergo.
In order to be safe I recommend an herbalist who has some form of certification, and this does not include the sales girl at your local health food store. They should be well educated and trained in their field. As you do with your own doctor you should have them checked out, ask about them, find out if there are any complaints against them and as always educate yourself before blindly following recommendations of the specialist.
Many incorrectly assume that because herbs are a natural product than a Muslim can take any of them. But just like other medication put in a capsule there is the question of haram ingredients, specifically gelatin.
Gelatin comes from three main sources, pig, cow and vegetable. Pig of course would be prohibited for Muslims to take. The only known exception to this case is in medical necessity. The use of cow as the gelatin source is argued among Muslims, while some feel that a beef source is permissible others believe that if it is a Non Muslim source than it is not permissible. A vegetable base would not be a problem for Muslims.
Before taking a herb with a capsule with gelatin do research to determine the source, willing ignorance is not an excuse. It is easy to call the manufacturer who will inform you of the source if it is known. There maybe other sources of the same herb by a different manufacturer or you may be able to use the same herb in a different form rather than a capsule.
Depending on the herbal product that you are looking for, it is not difficult to buy them. Your local health food stores are a good source for those not so common herbs, but are generally more expensive than you local pharmacy or Wal Mart.
Recommendations for herbal us in fertility and infertility treatments. Please note I do not take any of the below herbs, nor have I tried any for a remedy for my infertility conditions. I can recommend Fenugreek and Blessed Thistle to increase milk supply, but nothing related to infertility. I must stress again that you research and contact a herbalist in your area.
FOR WOMEN-
Promotes Ovulation
Chaste Tree Berry, Black Cohosh, Dong Quai.
To Bring Menstruation
Chaste Tree Berry, Parsley, Ginger, Yarrow, Rosemary, Fenugreek.
Uterine Fibroids and Ovarian Cysts
Combination: PCOS- Licorice.
Preventing Miscarriage
Wild Yam, Sqau Vine, Vitex, Unicorn Root.
Cervical Mucus
Red Clover Blossoms.
Hypothyroidism
Evening Promise Oil.
Endometriosis
False Unicorn Root.
Herbs to Avoid while Pregnant
Angelicia, Black Cohosh, Blue Cohosh, Barberry, Bloodroot, Borage Oil, calamus, Cascara Sagrada, Cayenne, Celandine, Cypress, Ephedra, Fennel, Fenugreek, Flaxseed, Goldenseal, Juniper, Lavender, Licorice Root, Male Fem, Mayapple, Mistletoe, Passion Flower, Pennyroyal, Periwinkle, Poke Root, Rhubarb, Sage, St. St. John's Wort, Tansy, Thyme, Wild Cherry, Wormwood, Yarrow.
FOR MEN
To Increase Sex drive
Humulus, Scutellaria.
Sperm Motility
Avena, Capsicum, Humulus, Cimicifuga, Salix, Thuja.
PREVENTIVE MEASURES
•Obtain treatment for any treatable disorder that causes infertility.
•Avoid preventable causes of infertility.
Most types of male infertility aren't preventable. However, avoid drug use and excessive alcohol consumption, which may contribute to male infertility. Also, high temperatures can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.
If you're a man who's uncertain about whether you would eventually like to become a father, don't undergo permanent sterilization, such as a vasectomy. Although surgery to reverse this condition is possible, risks are involved that could affect fertility in other ways.
A woman can increase her chances of becoming pregnant in a number of ways:
•Exercise moderately. Regular exercise is important, but if you're exercising so- intensely that your periods are infrequent or absent, your fertility is likely to be impaired.
•Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
•Avoid alcohol, tobacco and street drugs. These substances may impair your ability to conceive or produce a healthy child. Don't smoke, limit your caffeine intake to one soda or cup of coffee a day, and avoid illegal drugs such as marijuana and cocaine.
•Limit medications. The use of both prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly.
EXPECTED OUTCOME
•Some fertility problems are minor and reversible. Often, no clear cause for infertility is found. Approach treatment with optimism.
•Research into this area is offering new options to couples.
COUNSELING AND SUPPORT GROUPS
If you've been having problems getting pregnant, you know how frustrating it can feel. Not being able to get pregnant can be one of the most stressful experiences a couple has. Both counseling and support groups can help you and your partner talk about your feelings, and to help you meet other couples like you in the same situation. You will learn that anger, grief, blame, guilt, and depression are all normal. Couples do survive infertility, and can become closer and stronger in the process. Ask your health care provider for the names of counselors or therapists with an interest in fertility.
COPING WITH INFERTILITY
Coping with infertility can be difficult. It's an issue of the unknown — you can't predict how long it will last or what the outcome will be. Infertility isn't necessarily solved with hard work. The emotional burden on a couple is considerable, and plans for coping can help.
EDUCATION
One of the most important things that I have found that works is learning about my condition, as well as my options. This started with reading, alot, visit the library,
-there are many books on infertility in general as well as one that is more in line with your condition. Search the web, it is a great source of information that will make you better informed to your treatment options, your condition, as well as what to expect.
NETWORKING
While it may seem that the last thing you want to do is talk to other people about your problems. It helps to communicate with other women who may be going through the same issues as you are. While the muslim community in general lacks any formal groups, we can take it upon ourselves to find other muslim women that are in the same situation as we are in. We can also find non muslim women who are dealing with fertility issues like we are, while many times the "spiritual" communication is not there networking with non muslim women can lead you to information that you didn't know of. The best doctors, where to get your subscription filled cheaper, some group sessions, books to buy that will be of help and many other positive aspects of such networking, not to mention the opportunity for Dawah.
TALK WITH SPOUSE
While this may appear as being a "given" sometimes it is not easy to open up to your spouse and tell them how you are really feeling. We may have the tendency to keep everything inside, and want to deal with the problem on our own. Perhaps not wanting to burden our spouse. However this can be very harmful for our health and our relationships in the long run. Infertility has many emotional side affects, we go through bouts of depression, feeling of helplessness, blaming ourselves ect ect. Opening up to our partners will help us realize that we are not in it alone, and that he/she maybe feeling the same things that we are. As Allah says we are "garments for each other" this means we are to find protection, comfort, warmth, and security with each other. We must keep this in mind while we do battle with infertility.
DON'T BLAME YOURSELF
While this may appear easier said than done, it is a very important issue. Self blame is not uncommon, and something that most couples facing infertility go through. We must come to terms that this is all Qadr of Allah, and while we may not understanding the reasons behind it all, this is a test, and after hardships comes ease. Although not everyone will be blessed with children, we as Muslims must learn to come to terms with what Allah has decreed for us -vs- what we want for ourselves.
LEARNING TO SAY NO TO BABY RELATED EVENTS
We may feel obligated to go to our friends baby shower, or walk down the baby isle of a store, to goo and ahh over the little newborn clothes. This may not be the best things for us to do at this time. We have to learn that saying no to social events is not always wrong, depending on how you feel. If you notice that you have hard feelings when going to a baby shower than do not go. If you notice going towards a section of a store brings you to tears and bouts of sadness in the baby section, stay clear of that part of the store or ask your spouse to get what you need. It is important to consistently ask for strength from Allah to face these times, we must learn that there are times when we are not strong enough. And in order to protect ourselves during this time, it is ok to avoid such instances.
REDIRECTING FRUSTRATIONS
We are human and there will be days that we want to totally vent all of our feelings. This is not a bad thing, however we should be careful of how we release these frustrations. While some of us may be talkers, easy to get it all out. Some of us tend to be more physical, perhaps a good work out will help, hitting the pillow a few dozen times, or using things such as a darn-it doll. Whatever works for you, do it, as long as it does not hurt others, or is harmful to your own soul.
PRAYER
AND LOTS OF IT!! As believers we must learn to rely on Allah to support us, guide us, and help us through the hard times. Even though it may not be prayer time, make wudu and pray two sunnah rakat glorify Allah through these hard times. Submit yourself to him through these tests and pray that Allah gives you what is best for you for nothing happens but by Allah's will.
Planning for emotional turmoil
•Set limits. Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and attempt to determine a final limit. Fertility treatments may be expensive and often not covered by insurance companies, and a successful pregnancy often depends on repeated attempts. Some couples become so focused on treatment that they continue with-
-fertility procedures until they are emotionally and financially drained.
•Consider other options. Determine alternatives — adoption, donor sperm or egg, having no children — as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
•Talk about your feelings. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.
Managing emotional stress during treatment
•Practice relaxation. Cognitive behavior therapy, which uses methods that include relaxation training and stress management, has been associated with higher pregnancy rates.
•Express yourself. Reach out to others rather than repressing guilt or anger.
•Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.
Managing emotional effects of the outcome
•Failure. The emotional stress of failure can be devastating even on the most loving and affectionate relationships and for people who've prepared well for the possibility of failure. Don't hesitate to seek professional help if the emotional burdens become too heavy for you or your partner.
•Success. Some studies have indicated that even if fertility treatment is successful, -women experience increased stress and fear of failure during pregnancy. Other research suggests that women who achieved pregnancy using fertility treatments felt increasingly better and had higher self-esteem and less anxiety as the pregnancy progressed than did women whose pregnancies didn't involve medical intervention.
•Multiple births. A successful pregnancy that results in multiple births introduces new complexities and emotional problems. The risk of depression is higher in women who have multiple births.
•Parenting. Once a child arrives, parents are more likely to be more anxious and have less confidence and self-esteem. Discuss becoming parents with your partner and plan for the many changes — challenging and rewarding — that a child will bring to your lives.
LIFESTYLE CHOICES AND FEMALE INFERTILITY
About 14% of couples in industrialized countries report infertility problems. There is suspicion that the incidence of infertility is increasing. Since there are many things that can affect fertility that we have control over -- lifestyle choices of smoking, drinking alcohol or caffeine, food ingestion and weight, sexual practices and so forth -- it is important to examine how much effect these things can have on future fertility. Many women are unaware as to how important these lifestyle choices can be with regard to future attempts to conceive.
An article by Silva PD, Cool JL, Olson KL: Impact of lifestyle choices on female infertility. J Reprod Med 1999;44:288-296, helps us to put some of these lifestyle habits in perspective as to how they affect fertility. These authors did an extensive review of the literature to determine how much different life choices affect a woman's ability to later conceive.
Does being overweight affect fertility and if so, how?
Obesity has a strong association with infertility and menstrual irregularities. While some of the ovulation problems and menstrual changes are explainable by women with Polycystic Ovarian Syndrome (PCOS) who are also obese, women who do not have PCOS but are overweight also have the same problems. Group treatment programs that assist obese
-women with diet and exercise plans have shown return of fertility in many patients. Weight loss of 15 lbs (6.5 kg) has been shown to restore ovulation. It is thought that the improvement in insulin resistance has more to do with restoring ovulation than the actual amount of weight or weight loss itself. For most studies, 20% over ideal weight is considered obese. Officially, a BMI (body mass index) of 25-30 is considered overweight and a BMI of over 30 is considered obese.
Can weighing too little lower my chances of getting pregnant?
Low weight and weight loss is also associated with ovulatory dysfunction and thus infertility. Even a moderate weight loss of 10-15% under ideal body weight can result in menstrual irregularity. It does not need to be the weight alteration of 30% or more as seen in women with anorexia nervosa or bulimia. Weight gain programs in these underweight women have been shown to restore ovulation and pregnancy in up to 73% of women who were able to achieve 95% of their ideal body weight. For many studies affecting eating disorders, a BMI (body mass index) of 17.5 - 20 is underweight and under 17.5 (90 lbs at 5 feet 0 inches) is considered very underweight.
I want to put off having children until our careers provide more opportunity. Will delaying childbearing affect my ability to get pregnant?
It is quite common for women to pursue educational and career opportunities and put off childbearing into the late 30's and early 40's. Aging, however, brings with it many effects that will decrease fertility.
•Depletion over time of ovarian follicles affects menstrual regularity.
•Endometriosis has more time to produce scarring of the ovary and tubes so they cannot move freely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows.
•Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding that disrupts implantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the very early stages.
•Abdominal adhesions from other intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility needed to sweep the ovary and gather an ovulated follicle (egg).
Does smoking affect my ability to conceive?
Almost all studies show that smoking decreases fertility. Smoking causes decreased estrogens with breakthrough bleeding and shortened luteal phases. Smokers have an earlier than normal (by about 1.5-3 years) menopause which suggests that there is some toxic affect of smoking on the follicles directly. Chemically, nicotine has been shown to concentrate in cervical mucous and metabolites have been found in follicular fluid and been associated with delayed follicular growth and maturation. Finally, there is some affect on tubal motility because smoking is associated with an increased incidence of ectopic pregnancy as well as an increased spontaneous abortion rate.
I know alcohol is not good during pregnancy, but what about its use while trying to conceive?
The total effect of alcohol on fertility is not as well established as with cigarettes and other substance abuse. In one survey, women with high alcohol use reported more menstrual problems and gynecologic surgery. It has been shown to alter estrogen and progesterone levels as well as cause anovulation. Most chronic alcoholics become amenorrheic. While the effects of alcohol on fertility are real, it is not clear how much must be consumed to affect fertility, or conversely, how much consumption is safe. In pregnancy, we know that an average of 2 drinks per day or more, or binge drinking of 5 or more drinks at a time can produce fetal alcohol syndrome birth defects. As far as fertility, one study found that there was a 60% increase (risk ratio 1.6) in ovulation difficulties with the consumption of more than 100 grams of alcohol a week (about one drink a day). There was no increase with less than 100 grams consumption a week.
Some people say caffeine is bad for trying to conceive but I cannot believe two or three cups of coffee a day could really affect conception -- can it?
Not all reports, but many, show that increased caffeine consumption affects the ability to become pregnant and carry the pregnancy. Caffeine clearance from the body is decreased during the luteal phase. Animal and human data suggest an increased rate of spontaneous abortions with increased caffeine use and most human studies show a decreased fetal growth during pregnancy with increased caffeine intake. How much is too much? Consumption of 3 or more cups of coffee per day (greater than 300 mg caffeine) leads to fertility problems in 4 studies.
Does catching a sexually transmitted disease (STD) always cause infertility?
Tubal factor infertility accounts for about 15% of infertility and pelvic inflammatory disease from gonorrhea or chlamydia infections produce most of this. As many as 40% of untreated chlamydia cervical infections ascend into the tubes and pelvis causing PID (pelvic inflammatory disease). If a woman has PID, she has a 20% chance of being infertile. The biggest problem with the affect of PID on fertility is that it is most often contracted at a time when very little thought is being given to the future ability to become pregnant. Birth control pills and other hormonal methods of contraception do not protect against STDs. Only the barrier methods and especially the use of condoms and spermicidal foam decrease the chances of acquiring an STD.
ASPIRIN AND INFERTILITY
Aspirin is a commonly used over the counter medication which has traditionally been used as an analgesic and fever reducer. In recent years, however, more attention has been paid to its anticoagulative properties. People with a history of heart problems often take a precautionary aspirin per day; individuals experiencing suspected myocardial infarction are also frequently given aspirin in the prehospital care environment..
Why is aspirin used in infertility treatment?
The anticoagulative properties of aspirin have also been studied in the field of reproductive endocrinology. Low dosage aspirin is a common treatment component for women who are positive for antiphospholipid antibodies. Recently, its use in a more general infertility population has also been studied.
Antiphospholipid antibodies (APA) are a class of proteins which appear to be related to coagulation problems. The presence of APA is formally diagnosed through a series of blood tests; however, one of the hallmarks of APA is recurrent fetal loss, often through disruption of placental blood flow due to clotting.
Because of its anticoagulative properties, aspirin reduces the risk of clotting; consequently, the blood supply between an APA patient and her fetus is more likely to remain intact. Most frequently, aspirin is given in conjunction with heparin, a powerful anticoagulant that works at another phase of the coagulation process.
The success of low dose aspirin in the management of APA-related disorders has led to a more general study of its effects on the reproductive system. The focus of this research is upon whether or not the anticoagulative properties of aspirin will lead to increased blood supply to the ovaries and uterus. If there is an increased blood supply to these areas, the reasoning goes, these area will receive a higher dosage of serum-carried hormones. As a result, the ovaries may be more productive, and the uterine lining thicker and more well-developed.
The research on this aspect of aspirin and infertility has yielded positive to mixed results. Several studies have shown improved results for pregnancy rates, endometrial thickness, and follicle development. However, in most studies, patients were not classified in terms of APA status, which leaves the effect of aspirin on the general population less clear. Thus, at this point, the results have been promising, but are not as definitive as those associated with APA.
I'm wondering if I should take aspirin. What should I do?
Despite the fact that it is an over-the-counter drug, aspirin should not be used lightly. Many doctors are fond of saying that, if aspirin were to be discovered today, it would only be available by prescription. Additionally, there are certain members of the population that should generally avoid aspirin. These include individuals allergic to aspirin, a history of gastric irritation or bleeding, and clotting problems.
What should a patient do? First and foremost, the bottom line is that YOU SHOULD NEVER TAKE ANY TYPE OF DRUG (not even over-the-counter) without the ADVICE AND CONSENT of your treating physician. In some cases, doctors may feel comfortable prescribing aspirin in an empiric or prophylactic manner, especially in women who have had multiple unexplained miscarriages. However, the applicability of this strategy will vary from doctor to doctor and patient to patient - it is not a decision that should be made unilaterally by the patient.
But I think my doctor isn't taking my concerns about aspirin seriously.
What if you think that you fit the profile of someone who would be helped by aspirin, but your doctor will not listen? It's important to ask him or her about their reasoning. He or she may have extremely valid reasons for not wanting you to take aspirin. On the other hand, if you as a patient feel that your doctor is dismissive of your questions about any type of treatment, including aspirin, the best solution is to seek a second opinion - not self medicate.
IN VITRO FERTILIZATION (IVF)
In infertile couples where women have blocked or absent fallopian tubes, or where men have low sperm counts, in vitro fertilization (IVF) offers a chance at parenthood to couples who until recently would have had no hope of having a "biologically related" child.
In IVF, eggs are surgically removed from the ovary and mixed with sperm outside the body in a Petri dish ("in vitro" is Latin for "in glass"). After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into
-cells. These fertilized eggs (embryos) are then placed in the women's uterus, thus bypassing the fallopian tubes.
IVF has received a great deal of media attention since it was first introduced in 1978, but it actually accounts for less than five percent of all infertility treatment in the United States.
In vitro fertilization (IVF) and other "high tech" procedures are now referred to as the assisted reproductive technologies (ART). These procedures all involve collecting the oocytes (eggs) and placing them in direct contact with sperm. Together they form an alphabet soup of techniques including: IVF, GIFT, ZIFT, ICSI, and FET.
In its simplest term, IVF is simply the uniting of egg and sperm in vitro (in the lab). Subsequently the embryos are transferred into the uterus through the cervix and pregnancy is allowed to begin. IVF was the first of the ART techniques to be developed. The first birth was in 1978 in England. The procedure was pioneered by a Gynecologist and a Ph.D. (Drs. Steptoe and Edwards). Next came GIFT, which stands for gamete (egg and sperm) intrafallopian transfer. This procedure requires laparoscopy, which is a small incision surgery and requires a general anesthetic. With existing technology, pregnancy rates are similar with IVF and GIFT. Since IVF does not require surgery, it has supplanted GIFT.
ZIFT involves IVF and then a laparoscopic surgical procedure to transfer the embryos into the fallopian tube. Since transferring embryos through the cervix with IVF gives the same pregnancy rate as ZIFT, and is nonsurgical, IVF has also supplanted GIFT.
As the years have passed, IVF has become the dominant ART technology due to its simplicity, efficacy and lack of invasiveness. A typical IVF cycle begins with shutting down the ovaries. This is done with a medication known as a GnRH agonist. The most common drug such used is Lupron. Lupron is given for approximately two weeks after which the ovaries are shut down temporarily. The next phase involves stimulation of the ovaries with potent ovulation medications such as Pergonal. For a full description of these agents go to the page on ovulation medication. These injections are given for approximately 10 days. When the eggs are ready for harvesting, a final step is to give hCG to induce final maturation. The eggs are then harvested by a process called ultrasound guided vaginal retrieval. Under heavy sedation, and with ultrasound guidance, a thin needle is passed a short distance into the ovaries and the eggs are suctioned from the follicles. Typically 5-15 eggs are collected. Typically the eggs are fertilized by adding approximately 100,000 motile sperm to each egg. If the sperm will not fertilize the eggs naturally we can perform intracytoplasmic sperm injection (ICSI). This procedure involves puncturing the egg directly under a microscope and injecting one sperm in the egg.
Figure-1.1
The day following retrieval, we can document fertilization under the microscope. We then observe the embryos for 3-6 days. The current trend is to observe longer. Typically 3-4 embryos are then placed in a catheter and transferred through the cervix into the uterus. This is a simple procedure much like a Pap smear. At the present time, embryos can be transferred either 3 or six days following retrieval. A 3-day embryo is usually at the 6-8-cell stage:
Figure-1.2
It is also possible now to perform advanced stage or blastocyst embryo transfers. These embryos are further along and usually fewer of them need to be transferred:
Figure-1.3
Two weeks later a pregnancy test can be obtained. Two weeks after the pregnancy test, an ultrasound can be performed and the fetal hear beat can be seen. If more embryos were generated than can be replaced, freezing (cryopreservation) can save these additional embryos. Frozen embryos can be stored for future replacement at much lower cost than the original IVF cycle.
As the years have passed, IVF has improved greatly. Today it is arguably the most effective technique to treat infertility when compared with others on a month by month basis. IVF has created a lot of controversy also. First, it is expensive. An IVF cycle can cost $6,000 to $7,000. It may not work on the first cycle. Multiple pregnancies can result. The truth is that it is a powerful technology and must be used carefully. Some patients may have very high odds of success: 45 - 60% chance per attempt. Others may due to their situation have only a 20% chance of success.
The multiple pregnancy risk varies with age. Younger patients need fewer embryos to be replaced, and older patients need more. The worst thing that has happened with IVF is the various centers entering into a race to see who can get "the best statistics". This has encouraged centers to transfer high numbers of embryos to get the statistics while accepting too high a risk of multiple pregnancy.
Also in order to get the best statistics, some patients will be refused care in order to "protect the statistics".f) cells, trigger a local or widespread inflammatory response, and retain the memory of the offending organism to repel it again if it should ever return. Like any finely-tuned machine, however, the system can break down and leave us open to the threat of infection, or, conversely, turn against our own healthy tissues, as occurs in such diseases as rheumatoid arthritis or lupus. The immune system also plays an important role in human reproduction. Inflammatory cells and their secretory products are involved in the processes of ovulation and preparation of the endometrium for implantation of a fertilized egg. Dysfunction of the immune system can interfere with the normal reproductive processes and result in infertility. It has been estimated that an immune factor may be involved in up to 20% of couples with otherwise unexplained infertility. Although many of these associations with infertility remain unproven, there is solid scientific evidence to implicate the formation of
-antibodies against sperm as an important infertility factor.
Antisperm Antibodies: How common are they?
Sperm are relatively protected from the immune system by a natural protective mechanism called the blood-testes barrier. Tight connections between the cells lining the male reproductive tract keep immune cells from gaining entry to the sperm within. If an injury breaches this barrier, then the immune system has access to sperm and antibodies are formed. Antisperm antibodies have been reported in approximately 10% of infertile men, compared to less than 1% of fertile men. The prevalence of antibodies jumps dramatically in men who have had surgery on their reproductive tract: nearly 70% of men who have undergone a vasectomy reversal will have antibodies present on their sperm. Women have a much lower chance for developing antibodies to sperm: less than 5% of infertile women can be shown to have antisperm antibodies, and it is unclear who is at risk for their formation.
Who is at risk for antisperm antibodies?
Anything that disrupts the normal blood-testes barrier can result in the formation of antisperm antibodies. This may include any of the following conditions: Vasectomy reversal Varicocele (dilation of the veins surrounding the spermatic cord) Testicular torsion (twisting of the testicle) Congenital absence of the vas deferens Testicular biopsy Cryptorchidism (failure of testicular descent) Testicular cancer Infection (orchitis, prostatitis) Inguinal hernia repair prior to puberty Fortunately, intrauterine insemination (the placement of washed sperm into the uterine cavity - a common fertility treatment) has not been shown to cause antisperm antibody formation. Despite the long list of risk factors, most men with antisperm antibodies have not had any of the conditions listed above. Therefore all infertile men are potentially at risk, and consideration should be given to testing infertile men for antisperm antibodies, especially if no other reasons for the infertility have been detected by the diagnostic workup.
How do antisperm antibodies cause infertility?
Antibodies that attach to the sperm may impair motility and make it harder for them to penetrate the cervical mucus and gain entrance to the egg; they may also cause the sperm to clump together, which is occasionally noted on a routine semen analysis. Antibodies may also interfere with the ability of the sperm to fertilize the egg.
What is the best way to detect antisperm antibodies?
Over the years, many tests have been developed to detect antisperm antibodies. In women, blood tests for antisperm antibodies in women may be more practical than trying to measure antibodies in the cervical mucus, which is the primary site where her immune system interacts with sperm. The postcoital test, which has been a standard part of the infertility evaluation, may suggest the presence of antisperm antibodies. By examining the cervical mucus following intercourse near the time of ovulation, antisperm antibodies may result in either a lack of sperm or in the presence of sperm, which are shaking in place rather than actively swimming through the mucus. In men, a direct examination of their sperm for attached antibodies is more reliable than testing blood for the presence of antibodies. Two commonly used tests are the immunobead assay and the mixed agglutination reaction (MAR). Both tests use antibodies bound to a small marker, such as plastic beads or red blood cells, which will attach to sperm that have antibodies on their surface. The results are read as a percentage of sperm bound by antibodies.
What treatments are available for antisperm antibodies?
Suppressing the immune system with corticosteroids may decrease the production of antibodies but can result in serious side effects, including severe damage to the hipbone. Intrauterine insemination, with or without the use of fertility medications, has been used for the treatment of antisperm antibodies. It is believed to work by delivering the sperm directly into the uterus and fallopian tubes, thus bypassing the cervical mucus. In vitro fertilization appears to be the most effective treatment for antisperm antibodies, especially when there are very high levels of antibodies (near 100% of sperm are bound by antibodies). There is no clear guidance on whether intracytoplasmic sperm injection (ICSI), the direct fertilization of an egg with a single sperm, is required for the treatment of antisperm antibodies, unless there had been a complete absence of fertilization on a prior attempt at in vitro fertilization
Are there other antibodies that affect fertility? For women with recurrent miscarriage, there are a group of antibodies that appear to attack an early developing pregnancy, resulting in either a miscarriage or severe preeclampsia with risk of intrauterine growth retardation or even fetal death. Collectively these belong to a class of antibodies known as antiphospholipid antibodies, which include the lupus anticoagulant and the anticardiolipin antibody. Testing for these antibodies are an integral part of the workup for recurrent pregnancy loss. However, it is unclear whether these antibodies play any role in the ability to conceive. Some physicians believe that the presence of antiphospholipid antibodies may decrease the chance for pregnancy through in vitro fertilization. Although this is a controversial subject, one of the largest studies that looked for these antibodies in women undergoing in vitro fertilization found that these antibodies were no more likely to be detected in those who did not become pregnant as in women who did conceive.
Is In Vitro Fertilization Expensive?
The average cost of an IVF cycle in the United States is $12,400. Like other extremely delicate medical procedures, IVF involves highly trained professionals with sophisticated laboratories and equipment, and the cycle may need to be repeated to be successful. While IVF and other assisted reproductive technologies are not inexpensive, they account for only three hundredths of one percent (0.03%) of U.S. health care costs.
Work of In Vitro Fertilization :
Yes. IVF was introduced in the United States in 1981 and from 1985 through 1998 ASRM and its affiliate, the Society for Assisted Reproductive Technology (SART), have counted more than 91,000 births of babies conceived through IVF. Through the end of 2000, more than 212,000 babies have been born in the US as a result of reported ART procedures. IVF currently accounts for about 98% of procedures with GIFT, ZIFT and combination procedures making up the remainder. The average live delivery rate for IVF in 1998 was 29.1 per cent per retrieval--a little better than the 20 per cent chance in any given month that a reproductively healthy couple has of achieving a pregnancy and carrying it to termm.
CLONING
There are groups who are working to be the first ones to clone a human, so the question arises, is this an option for infertile couples. In this article I don't claim to come with concrete answers for there are just to many unknowns. However it is something that we should understand and evaluate in order to make a balanced Islamic decision.
HOW IS CLONING PERFORMED
Cloning is done by the use of the nucleus of an egg and selected DNA from the one being cloned. These two are than fused together with the use of an electrical current. This cell than grows into a genetic duplicate and placed into the womb until full term into a normal human being. At least this is the theory.
So a clone is not an identical person to the one being cloned in all respects. Just as an identical twin is not the twin in all respects. They are two distinct human beings, if one dies the other lives on. Cloning should not be mistaken with the ability to live forever. It is just a genetic duplicate, the two would look the same, have some of the same likes and dislikes but would be two separate distinct human beings.
ARE THEIR HUMAN CLONES NOW
No one can say for sure at this point if there are or not. Dolly was seven months old before we knew that she existed so we can't expect that those who clone a human may rush out and let the world know. Considering that many are against such procedures as being morally wrong those who undertake such medical experiments would have to do so very quietly. There are groups such as the Relians who say they have a lab and scientists working to make a clone of a 10 month old boy who died and have 50 surrogate women who have volunteered to carry the baby to term. Scientists in Japan have claimed to already cloned a human but destroyed the embryo rather than implanting it. Human clones may very well be a present day reality.
IS THIS REALLY A SENSIBLE OPTION FOR INFERTILITY
Many who desire a child but have no other means to conceive would of course say yes. But at what cost are we going to pay in order to produce children? This is something that needs to be evaluated and seriously considered before anyone takes it as a viable option for infertile couples. There is not an issue of will it work, for it can for
couples who may be going through early menopause or the husband lacks viable sperm. The question for such couples who would be the one to clone? Remember a clone is an identical twin to the one being cloned. So if one were to clone their husband a woman would be literally giving birth to her husbands genetic twin. So such a child would be a son to the father as well as his brother and a son to his mother but also a brother in law by marriage. How odd is this picture?
We also have to consider the downfall of cloning, considering that it took 277 tries in order to clone Dolly. The risks of having a deformed child are very great. And it may not be until the mother carries the child full term before the deformities are realized. The emotional trauma that most couples go through in battling infertility are great there is no need to add such an experience on top of it.
THE ISLAMIC POSITION
There seems to be no concrete Islamic stance on this issue. It has been discussed between many scholars and some have declared it out rightly haram. Others have declared it haram on a societal level but hold a wait and see attitude when it comes to personal situations that may arise.
What is at question among Muslims is keeping the lineage established rather than how the procedure is performed. When it comes to treating infertility there are agreed upon basic Islamic principles which we can go by. All agree that an egg, sperm and womb must be used by the wife and the husband. And at the time of the implantation there is a valid marriage, this in order to maintain a proper lineage. So by this we do know that no donor eggs can be used in order to retrieve the nuclei, nor can a surrogate mother be used in order to bring the child to term. The only issue that remains is the use of DNA.
We would now need to ask, can a woman use the DNA of her legal husband?
Can a woman use her own DNA?
Can a couple use the DNA of a child already born?
Can a couple use the DNA of a deceased child?
These questions alone bring many thoughts. If a woman can use her own DNA than what use is the man? Considering that many Muslim women can support themselves would this lesson the reasons for marriage? Add in the fact that most Muslims portray the major reasons for marrying is to reproduce. If one can actually reproduce without the need of a man would they then need to marry or even desire to? Besides the present need for Muslims to reevaluate their understanding of marriage and the importance placed on ones ability to reproduce, one would also have to evaluate the role of men in
-raising children.
We would also need to ask ourselves what rights we have to our own DNA. Can a couple decide to clone a child without their consent? Or can one parent decide to clone while the other one disagrees? One also needs to ask if a valid marriage is needed in such an instance as well, for it is not the sperm which is used by the outcome of the sperm and egg union.
We must keep in mind that in Islam the lineage is closely guarded. We are not to call adopted children other than by their fathers name, we are to remain far from zina, we are to not hide what is in our wombs. All this, and more, is in order to protect the lineage of a child to avoid any types of confusions. In many instances with cloning, confusion is the only outcome. This is against the spirit of Islam and should be avoided, because it does nothing more then harm the society as a whole.
This does remind me of a saying attributed to Muhammad pbuh in which one of the signs of the last day are when the slave girl gives birth to her master In the instance of cloning this hadith will come to a literal reality. We would totally confuse the lineage of people and this is not a good thing for society. If the lineage of a child can be maintained than this is something that needs further study.
ACTING AS GOD
One of the most voiced concerns among Muslims and Non Muslims alike is the feeling that such science wishes to "act as God". I have listened to many Muslims who suggest that infertile couples should just accept the will of Allah and not act as God in order to reproduce. But how far are we to take such an approach to scientific advance? If one argues completely on the basis that cloning is acting like God in order to create another human being, well then isn't IVF treatment the same thing? Isn't one taking the raw components in order to reproduce? So if we follow this line of thinking before we know it all medical advances will be eliminated just on this position. I would find it hard to believe that those who protest on such a basis would be inclined to take such a stance if they or a loved one had a need for a transplant or any other medical treatment.
Inshallah in the future cloning and issues related to it will be rationally discussed by our Muslim scholars. Where the benefits and the harms of society will be weighed and a balanced outcome will be found. On the surface there doesn't appear to be that much of an issue when it comes to human cloning. Considering the basic Islamic guidelines on lineage and halal relationships there doesn't appear to be much room for debate. However there may be circumstances where cloning can be performed in an halal way and we must not shut the door in a heated reaction without discovering all possibilities and judging with all criteria.
STRESS & INFERTILITY
Stress is defined as any event that a person perceives as threatening or harmful. Stress can result in the heightened activity of many body organs. This increased activity is offset by hormones secreted by the adrenal glands and through the nervous system. Acute stress can result in increased heart rate, blood pressure, and respiration, as well as sweaty palms and cool, clammy skin. Chronic stress can also cause depression and result in changes in the immune system and sleep patterns.
STRESS CAUSING INFERTILITY
Although infertility is a highly stressful experience, there is very little evidence that infertility can be caused by stress. In rare cases, high levels of stress in women can change hormone levels and cause irregular ovulation. Some studies have sown that high stress levels may also cause fallopian tube spasm in woman and decreased sperm production in men.
INFERTILITY CAUSING STRESS
Research has shown that women undergoing treatment for infertility have a similar, and often higher, level of "stress" as women dealing with life-threatening illnesses such as cancer and heart disease. Infertile couples experience chronic stress each month, first hoping that they will conceive and then dealing with the disappointment if they do not.
WHY INFERTILITY IS STRESSFUL
When diagnosed with infertility, many couples no longer feel in control of their bodies or their life plan. Infertility can be a major crisis because the important life goal of parenthood is threatened. Most couples are accustomed to planning their lives. Experience has shown that if they work hard at something, they can achieve it. With infertility, this may not be the case. Infertility testing and treatments can be physically, emotionally, and financially stressful. A couple’s intimacy is often reduced by the infertility experience, which further contributes to increased stress levels. Trying to coordinate medical appointments with career responsibilities can also increase pressures on infertile couples.
TIPS FOR STRESS REDUCTION
•Keep the lines of communication open with your partner.
•Get emotional support so you don’t feel isolated. Individual or couple counseling, support groups, and books on infertility can validate your feelings and help you cope.
•Learn stress reduction techniques such as meditation or yoga.
•Avoid excessive intake of caffeine and other stimulants.
•Exercise regularly to release physical and emotional tension.
•Have a medical treatment plan your and your partner are comfortable with.
•Learn as much as you can about the cause of your infertility and the treatment options available.
EXERCISE, WEIGHT, AND FERTILITY
Couples with infertility often wonder if lifestyle habits might compromise their fertility. Two important lifestyle factors, weight and exercise, can affect fertility.
Low weight or weight loss
can lead to a decrease in an important hormonal "message" that the brain sends to the ovaries in women and testes in men. This hormone, gonadotropin releasing hormone (GnRH), is produced in the part of the brain called the hypothalamus. The release of GnRH leads to the release of the hormonal messengers LH and FSH (the gonadotropins) by the pituitary gland. LH and FSH are critical for the development of eggs in the ovaries and sperm in the testes. The degree to which weight loss affects fertility will vary. In mild cases, the ovaries may still produce and release eggs, but the lining of the uterus may not be ready to receive a fertilized egg because of inadequate ovarian hormone production. In more severe cases, ovulation does not occur, and menstrual cycles are irregular or absent. In men, low weight or weight loss may lead to decreased sperm function or sperm count. If low weight or weight loss has been identified as the cause of one’s infertility, the preferred treatment would be to stop losing weight or even to gain weight if needed. An alternative treatment is the use of medications. Drugs such as GnRH (Lutrepulse (R)) or gonadotropins (Pergonal (R), Fertinex (R), Humegon (TM)) replace or eliminate the need for the missing message from the hypothalamus or pituitary and may restore fertility. However, the use of these drugs can be complicated, expensive, and can cause multiple pregnancies.
Being overweight or obese
an affect the hormonal signals to the ovaries or testes. Increased weight can also increase insulin levels in women, which may cause the ovaries to overproduce male hormones and stop releasing eggs. Weight loss is the best plan of action, but drugs such as clomiphene citrate or gonadotropins can be used in overweight patients. It is important to make sure that glucose (blood sugar) levels in overweight patients are normal prior to attempting pregnancy and that specific metabolic causes of obesity are not present.
Proper exercise
And diet are important for maintaining good health and proper weight. Extreme exercise can, however, lead to reduced sperm production in men and the cessation of ovulation in women by decreasing the brain message to the ovaries and testes. However, the amount of exercise must be very extensive; normal exercise will not affect fertility in most couples. It is impossible to know how much exercise for any one person is too much. Generally, running more than 10 miles per week is considered too much when trying to conceive. The most effective way to treat reproductive problems associated with excessive exercise is to decrease or modify the amount of exercise.
INFERTILITY AND NUTRITION
The inability to become pregnant after a long period of regular sexual activity usually signals hormonal problems. Some of the more frequent causes in women include pelvic disease, chlamydia infection (untreated), and allergic reactions to their partner's sperm. Since there are so many possible causes, it is wise to seek the advice of a qualified physician. If all the physical causes have been eliminated, the following program will support the woman's body nutritionally and put her in the best possible hormonal position to conceive.
Full Spectrum Nutrition
•Folic acid - 400 mcg extra
•Vitamin B6 - 50 mg extra
•Zinc - 50 to 100 mg per day
•Vitamin E - 400 to 800 IU extra
•Ovarian Glandular Extract - 4 to 8 tablets per day
•L-Arginine - 4 grams per day
•Iron - 10 to 20 mg per day
•Vitamin B12 - 100 to 300 mcg per day
Some stress is often involved in hormone imbalance, a high potency Stress-B complex formula, taken two or three times per day is often helpful..
PSYCHOLOGICAL COMPONENT OF INFERTILITY
What impact does infertility have on psychological well being?
Infertility often creates one of the most distressing life crises that a couple has ever experienced together. The long term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples. If you find yourself feeling anxious, depressed, out of control, or isolated, you are not alone.
How do You know if You could benefit from psychological counseling?
Everyone has feelings and emotional ups and downs as they pursue infertility treatment. Feeling overwhelmed at times is a perfectly normal response. However, if you experience any of the following symptoms over a prolonged period of time, you may benefit a great deal from working with a mental health professional:
•loss of interest in usual activities
•depression that doesn't lift
•strained interpersonal relationships (with partner, family, friends and/or colleagues)
•difficulty thinking of anything other than your infertility
•high levels of anxiety.
•diminished ability to accomplish tasks
•difficulty with concentration
•change in your sleep patterns (difficulty falling asleep or staying asleep, early morning awakening, sleeping more than usual for you)
•change in your appetite or weight (increase or decrease)
•increased use of drugs or alcohol
•thoughts about death or suicide
•social isolation
•persistent feelings of pessimism, guilt, or worthlessness
•persistent feelings of bitterness or anger
In addition, there are certain points during infertility treatment when discussion with a mental health professional of various options and exploration of your feelings about these options can help facilitate clarification of your thinking and help with your decision making. For example, consultation with a mental health professional may be helpful to you and your partner if you are:
•at a treatment crossroad
•deciding between alternative treatment possibilities
•exploring other family building options
•considering third party assistance (gamete donation, surrogacy)
•having difficulty communicating or if you have different ideas about what direction to take.
How can psychological treatment help you cope with infertility?
Mental health professionals with experience in infertility treatment can help a great deal. Their primary goal is to help individuals and couples learn how to cope with the physical and emotional changes associated with infertility, as well as with the medical treatments that can be painful and intrusive. For some, the focus may be on how to deal with a partner's response. For others, it may be on how to choose the right medical treatment or how to begin exploring other family building options. For still others, it may be on how to control stress, anxiety, or depression. By teaching patients problem- solving strategies in a supportive environment, mental health professionals help people work through their grief, fear, and other emotions so that they can find resolution of their infertility. A good therapist can help you sort out feelings, strengthen already present coping skills and develop new ones, and communicate with others more clearly. For many, the life crisis of infertility eventually proves to be an opportunity for life-enhancing personal growth.
How can You find a mental health professional experienced in working with infertility?
Make sure you choose a mental health professional who is familiar with the emotional experience of infertility. It is recommended that they have:
•a graduate degree in a mental health profession
•a license to practice and/or state registration
•clinical training in the psychological aspects of infertility
•experience in the medical and psychological aspects of reproductive medicine
Interview more than one person. Ask them for their credentials as well as their experience with infertility issues and treatments. Ask if they are currently seeing other people with infertility.
SECONDARY INFERTILITY
Although over three million Americans are affected by the painful experience of secondary infertility, it generally remains an unacknowledged and invisible condition. Secondary infertility is defined as the inability to become pregnant, or to carry a pregnancy to term, following the birth of one or more biological children. Even though the couple already has a child, the couple experiences secondary infertility as the loss of a child, the loss of pregnancy, and the loss of childbirth.
Even though secondary infertility has a higher prevalence rate than primary infertility, couples are far less apt to seek treatment for this condition. When their first child is conceived with ease, many couples are caught completely off guard by the difficulty of having a second child because they hold the belief that past fertility insures future fertility. Physicians, too, may downplay the possibility of secondary infertility in their previously fertile patients and encourage the couple to "keep on trying." These couples are vulnerable to feelings of self-blame, particularly if they seek treatment at a later time and the interventions are unsuccessful. Often they feel regretful at not having taken a more aggressive approach to treatment when they were younger, as advancing age is often an issue in secondary infertility.
The emotional experience of secondary infertility often is a compilation of the distressing feelings of anger, grief, depression, isolation, guilt, jealousy, self-blame, and being out of control. Couples may feel guilty for experiencing normal grief and worry about how their anguish will affect their existing child. The powerlessness to produce a sibling for the existing child often produces feelings of sorrow, as does the inability to perpetuate the parenting role. Many feel distant from their friends as those who were a great source of support when parenting the first child are now linked to sensations of pain and jealously.
Sadly, couples with secondary infertility tend to receive less social support from others than couples who have primary infertility because the infertility is unacknowledged, the pain associated with infertility is invisible as the couple has a child, and there is no concrete loss in the family. In addition, couples experiencing secondary infertility may be recipients of criticism by others who think they should be grateful for one child and that it is foolish to go to extremes to increase family size. Of course, a couple can be extraordinarily thankful for their existing child and still long for more children.
To avoid the sense of isolation that often accompanies secondary infertility, and to maintain necessary social support, it is important to educate friends and family members about the common feelings associated with secondary infertility. For example, with some guidance by the couple, friends may understand that declining an invitation to a baby shower relates to pain and grief, rather than a lack of interest in another's family.
The emergence of secondary infertility can challenge even the strongest of marriages. Partners may have different coping styles that can lead to distancing and alienation within the relationship. For instance, it is quite difficult when one partner seeks information and intervention to relieve anxiety and a sense of helplessness, and the other copes with stress by feeling the matter will resolve itself with time and believes that taking action is unnecessary. In addition it is not unusual for partners to vary in their ability and comfort level in discussing feelings. It is not uncommon for one partner to feel overwhelmed by the other's emotions and the other, alternatively, to experience being shut out by their partner's refusal to discuss the situation.
When partners are out of sync, they often become the targets of reciprocal anger. Although not intentional or conscious, emotional pain can cause partners to blame one another for the infertility or for not commencing with treatment expediently. In addition, couples often have different feelings about family size, the amount of financial resources to invest in treatment, the use of third parties to achieve a pregnancy, the exploration of adoption, whom to tell, and when to terminate treatment. It is crucial that couples strive to understand their partner's experience and to be empathic. It is impossible for a couple to reach conflict resolution without positive communication. Sexuality frequently is affected by secondary infertility. Partners may report decreased sex drive and diminished sense of enjoyment. Couples with secondary infertility often are required to have "sex on demand." Instead of being associated with intimacy, sex becomes associated with procreation, pain, and failure. It is important for couples to take time off from
infertility and to reconnect their sexuality to affection and emotional closeness.
Not only can secondary infertility generate marital problems, it is best understood as a time of family crisis. Until some resolution is achieved, the entire family remains in a state of stress because there is ambiguity about whether there will be more children. The couple must confront the idea that the ideal family size they once envisioned may never become a reality. It is not possible for anyone to give up on their ideal without the experience of loss, grief, and distress.
Unlike in primary infertility, couples who experience secondary infertility already have a child's needs and welfare to consider. It is important for parents to demonstrate to their child that problems are dealt with and not buried. It is naïve to think that a child will remain unaware of her parents' grief just because the parents do not talk about it or address it directly. In fact, if there is an absence of information, children resort to egocentricism and magical thinking to interpret events. For example, the child may be worried seeing the mother go to the doctor, getting shots etc. or the child may think her parents are dissatisfied with her if they are upset and anxious. The young child does not have the cognitive capability to understand her parents' actions and feelings as separate from herself, and, therefore, needs an explanation for her parents' melancholy. In addition to helping the existing child appreciate the parents' emotions, parents must help the child identify his own experiences and feelings.
Guilt about not providing the existing child with a sibling is a common experience of couples suffering from secondary infertility, as they feel they are failing their child. Many couples idealize the sibling relationship by believing the siblings would be emotionally close. Of course, there is no guarantee about any sibling relationship, and the existing child should not be burdened by the loss of this idealized relationship. It is crucial for parents to acknowledge and mourn the loss and then to legitimize the existing family. Families come in all shapes and sizes, even size three.
It is a cruel irony that the more positively parents feel about parenting, the more painful is their experience of secondary infertility. Many parents have expressed ambivalent feelings about their child growing up because they fear they will never re-experience the pleasure of the early years. In addition, parents may become overly protective and attentive to their existing child. In the face of loss, parents want to hang on to what they have and love. Of course, these parental feelings must be kept in balance with the growing child's needs for separation and independence.
The resolution of secondary infertility brings many variables into the decision making process. The couple must focus on the desire to parent a second child and the time, energy, and finances involved in pursuing medical treatment or alternatives such as adoption. These conditions must be weighed with the needs of the existing child in mind. Couples often are concerned whether or not they will continue to be good parents in light
-of the emotional and financial stresses associated with treatment. Sometimes, in grieving the loss, couples find there are advantages, such as more time and more resources, associated with having one child.
Couples often need assistance from professionals and/or support groups as they struggle with the turmoil of secondary infertility. Grieving what might have been is not an easy task, and couples often benefit from the contributions and support of others grappling with the same circumstances. If the grieving process extends for a long period of time, and symptoms of depression exist for more than six months, the help of a mental health professional with experience in reproductive medicine should be sought. With respect to secondary infertility the ultimate goal is to grieve the loss of a child, decide to pursue medical treatment or alternative family building options, or to embrace the established family as it exists. With resolution comes the reclamation of life.
INFERTILITY AND ISLAM
In the Name of ALLAH Most Gracious Most Merciful
Every month a couple has basically 1 in 4 chance of conceiving where no infertility factors exist. In a womans' lifetime she will normally produce 4 to 5 thousand eggs. Eight of these eggs are recruited each month, and only one is brought to maturity and relased into the fallopian tube, the other seven eggs deteriorate and die. The egg only lives from 24-36 hours after it is released and if it is not fertilized by the sperm (which can live up to 72 hours inside a woman) the egg will then deteriorate and die. Within two weeks the uterine lining will shed and a woman will have a menstrual cycle.
There are other factors in the whole fertilization process, such as the opening of a womans cervix, cervical mucus that helps the sperm reach the egg. Not to mention healthy non deformed sperm that can survive and fertilize the egg. Although seemingly an easy process there are many factors that can decrease the chances of fertilization from occurring. These can include blocked fallopian tubes, which can be caused by PID,ENDOMETRIOSIS, Scar tissue from miscarriages or surgical proceedings. There is also the factor of PCOS, which affects the womans ability to normally produce and release an egg each month. These being only female factors of infertility, it is false to assume that infertility is only a womans problem Male factors also make up for about 40% of inferility problems, which include blocked ducts, low amount of sperm, and deformed sperm.
Normally when couples have unprotected sex for a year, a pregnancy will occur. If a woman does not become pregnant within a year (6 months for women over 35)the couple should have a fertility work-up to find out what is going on. Most couples that seek a fertility work-up by a Reproductive Endocronologist (differing from a regular GYN), should know within a month, or shortly thereafter,why pregnancy has not been succesful. Such a work-up includes, but is not limited to: medical history, blood tests, pap smear, vaginal examination,HSG,a semen analysis, cervical cultures and Laparoscopy.
Having infertility problems, in most cases, does not mean the end of conceiving. There are many options open to couples that will help them to concieve children. Some of these options include, but are not limited to, IVF, IUI,GIFT,ZIFT, Ovulation drugs such as Clomid, and tubal surgery.There are also options for male factor infertility such as treatment with fertility drugs, surgery and ART procedures
What concerns us most, as Muslims, is what options are Islamically permissible for us. Are ART procedures permissible, what is not permissible, why are certain things not permissible, are just some of the questions we would like to address. Keep in mind that none of the sisters who add to this web page are scholars, and there may be variant opinions as to what is acceptable and what is not. And due to the fact that an "In Depth" look at fertility options have yet to be addressed by "scholars" some questions will be left unanswered on this web site. We encourage all to seek proper islamic means to deal with your infertility for Allah places things in our lives for a reason. We will all be tested, and as Muslims we should persevere in the way which is right in order to seek any rewards.
INFERTILITY IN THE QUR'AN
The Qur'an is true guidance for all mankind, complete and not lacking anything. It touches on every aspect of life, so it should come as no suprise that infertility is on the vast array of subjects. The Qur'an teaches in many ways, showing us a glimpse of the lives of others before us is one way. There are two stories of infertility in Qur'an which we should draw and learn from. The first story is that of Ibrahim s.a.w. and his wife Sara r.a. The two main accounts of this story, given as follows.
And his wife was standing (there) and she laughed: But we gave her glad tidings of Isaac and after him, of Jacob. She said "Alas for me! Shall I bear a child, seeing I am an old woman, and my husband here, is an old man? That indeed would be a wonderful thing!" They said: "Dost thou wonder at Allah's decree? The grace of Allah and His blessings on
-you, O ye people of the house! For He is indeed worthy of all praise, full of Glory!" 11:71-73
...And they (angels) gave him (Ibrahim) glad tidings of a son endowed with knowledge. But his wife came forward clamoring, she smote her forehead and said: "A barren old woman!" They said "Even so has thy Lord spoken and He is full of wisdom and knowledge."
Not much detail is given in the Qur'an concerning the lives of Sara or Hagar. But some of the details we recieve with ahadith. Islamic exegesis also rely on heavily upon biblical (OT) information about Sara as well as Hagar. What we do know from the Qur'an was that Sara was old and barren when Allah blessed her with a child. Exegesis place her age at about ninety and Ibrahim was over 100 yrs old. It was several years before this that Sara gave her hand maiden, Hagar, to Ibrahim in marriage so that he may have children.
Many women going through infertility can relate to the sense of guilt for "denying" their husbands children. This is a common feeling that is present, as we see with Sarah. As we see in this story polygyny is an option for couple who can not have children due to the illness with the wife.
Accroding to exigisis after Hagar conceived she became "haughty" in her ability to have children. From this rose a jealousy in Sara in which she threatened to do harm to Hagar. Nothing came of this threat and evidently the waters were calmed in Ibrahim's household. The family continued to remain together until Ibrahim's command to take Hagar and Ishmael to the valley of Mecca and leave them there.
We have reference in the Qur'an of Sara striking her face and laughing in the astonishment of being blessed with a pregnancy at 90 yrs of age. It appears Sarah, naturally, had long since given up hopes of conceiving. She had given Hagar to Ibrahim as a way not to deny him and accepting the Qadar (fate) that Allah had set for her.
Here we can take a lesson from Sara, at some point we must learn to just accept what has been written for us and go on. All too often couples become obsessed with having a child to where it is harmful for themselves. We as Muslims must learn to seek a healthy balance in striving for pregnancy. We must learn at what point to stop medical procedures and accept what Allah has planne for us. A woman's (or man's) life does not end because they have no children. Sarah, although barren, remained firm in her faith, true to her husband, and a full woman in every sense of the word.
Sarah was ultimately blessed with a child, Ishaq pbuh. Angels came to her as they were on their way to the people of Lot pbuh and informed her. Not only was she told of a son but she was also informed that she would live to see her grandchildren. Considering her age it could have been the total shock that lead her to smite her face. I'm sure after so many years of giving up on having children a slap on the face is what she needed to reassure herself she wasn't dreaming.
It is important at this point to take notice of the example set by Ibrahim in relation to his barren wife. He was never harsh to his wife in words or deeds even though she was unable to conceive. Nor did he abandon her he chose to stand by his wife as she stood by him. He did not seek out another wife or "right hand possession" to have children, it was Sara who suggested Hagar to him. This bond of marriage, faith, love, and tenderness kept this couple together even in infertile times. Working together in cooperation something we all should take notice of. And men, or cultures for that matter, who blame women for not conceiving and down them as if they were no longer a complete woman should take heed in this example set by Ibrahim.
Ibrahim was indeed a model... 16:120
Another Qur'anic example of infertility is that of Zakariya pbuh and his wife Ishba. The Qur'anic story focuses more on Zakariya than Ishba herself. In fact very little is said about her in the Qur'an, hadith, and exegesis.
There did Zakariya pray to his Lord, saying: "O my Lord! Grant unto me from Thee a progeny that is pure: for Thou art He that heareth prayer! While he was standing in prayer in the chamber, the angels called unto him: "Allah doth give thee glad tidings of Yahya, witnessing the truth of a Word from Allah, and (be besides) noble, chaste, and a prophet,- of the (goodly) company of the righteous." He said: "O my Lord! How shall I have son, seeing I am very old, and my wife is barren?" "Thus," was the answer, "Doth Allah accomplish what He willeth."
(This is) a recital of the Mercy of thy Lord to His servant Zakariya.Behold! he cried to his Lord in secret, Praying: "O my Lord! infirm indeed are my bones, and the hair of my head doth glisten with grey: but never am I unblest, O my Lord, in my prayer to Thee! 1
And (remember) Zakariya, when he cried to his Lord: "O my Lord! leave me not without offspring, though thou art the best of inheritors." So We listened to him: and We granted him Yahya: We cured his wife's (Barrenness) for him. These (three)were ever quick in emulation in good works; they used to call on Us with love and reverence, and humble themselves before Us.
Mary r.a. was placed in the care of Zakariya pbh and her aunt Ishba. Ishba was barren, so the caring of a child was a blessing in her family. Zakariya pbuh at times marveled at how well Mary had grown and it instilled the urge in him to have a son. One who would not only inherit the family lineage, but one who would carry on the teachings of Allah, something which he did himself. Perhaps Mary r.a. fulfilled the natural urge in Zakariya pbuh to have children for a limited time, but when she had matured and no longer a child, the desire seems to have rekindled. Whatever the exact emotions that Zakariya pbuh had, it brought him to a point where he prayed in secret to have a son.
Zakariya pbuh beseeched Allah for this blessing, perhaps not expecting the answer, he appears surprised with it. It was not so much the answer of "yes" but rather the means in which the child would come to him. His old barren wife, cured by Allah, was to conceive. Zakariya responded in natural amazement that his wife would conceive. He was told by Allah that such a thing was easy for Allah.. and it is. His son would be given the name of Yahya pbuh a name not before given who would carry on Zakariya's pbuh work.
We also learn that Ishba and Mary were pregnant around the same time. Yahya's pbuh work with Isa pbuh being something planned by Allah surrounded by many miraculous events.
As with the story of Ibrahim pbuh we have the example of a husband who remains with his barren wife. She is not shunned, shammed, divorced, or looked down upon as an incomplete woman as many men and cultures do to women. This is a lesson that all of our ummah must learn, as Allah says "...He leaves barren whom He wills" (42:50) It is a decree from Allah. This does not make one less of a woman (or man) and one should not be treated as such. We are to remain firm in our faith in Allah, knowing that He brings about things that we may not like and things we are tested with. And the stigma placed on couples who do not have children we are failing our test.
I know many women are thinking, that these two stories have such happy endings (babies) and yet it does not happen with all of us. Why does not Allah bestow on all of us pregnancies.. why must "I" be barren.. why me? As I sit here and write this my mind searches for an example of a woman with no children, suddenly I remembered one so full of faith, and one mentioned in the Qur'an as an example for all those who believe.
And Allah sets forth, as an example to those who believe the wife of Pharaoh: Behold she said: "O my Lord! Build for me, in nearness to Thee, a mansion in the Garden, and save me from Pharaoh and his doings, and save me from those that do wrong"; 66:11
Her name was Asya, and she never conceived a child. It is said that her marriage was one of sacrifice she made for the safety of her people. But the marriage was never consumated, for Allah had stricken Pharaoh with impotence. Whatever the case may have been, here was a childless woman, who is set forth as an example for all believers. She nurtured a Prophet from infancy even though he was not her own, and she was a martyr.
It is said that Pharoah had killed several believers in the palace, among them a maid, her children and her husband. Asya picked up an iron stake to kill Pharaoh, she failed, and Pharaoh had her tortured by piercing iron stakes through her breast. The same childless woman sought Allah to build mansions in the Garden, and to save her from those that do wrong. Do we dare to say that such an example as stated by Allah is incomplete or less of a woman because she bore no children? Do we not take heed in the examples given to us? So anytime one attempts to make you feel low, or less of a woman (or man) think of these
-examples, draw guidance and strength from them. Rely on Allah, and seek Him to give you strength.
May Allah give us All that is good for us, make it easy for us to obtain it and keep us on the straight path when we do.
POLYGYNY: An Option For Infertile Couples
There comes a time in the process of curing infertility when a couple decides that they have availed all options and they must move on with their lives. Many husbands see divorce and then remarriage as the only alternative to have children. Islamically though he has an option that could be far more beneficial to his first wife, himself, and his marriage to follow. The option of polygyny is one that is looked down upon in western society, but one that is permissible and in some cases encouraged in Islam.
Allah(swt) says (what could be translated as):
"And if you fear that you shall not be able to deal justly with the orphan-girls, then marry (other) women of your choice, two or three, or four but if you fear that you shall not be able to deal justly (with them), then only one or (the captives and the slaves) that your right hands possess. That is nearer to prevent you from doing injustice." (An-Nisa 4:3)
From this ayat it is clear that Islam has allowed men to marry up to four wives. He does not need any specific reason to have multiple wives, but he can do so for whatever reason he may wish as long as he is just with them. Most wives though would detest the idea of sharing their husband with another wife. What is said in Islamic sources about marrying for reasons of fertility?
The Prophet Muhammad (saw) said:
"Marry the loving and the fertile because through you, I will compete with the nations for superiority in numbers." (Abu Dawud and others)
The Prophet of Allah has encouraged Muslim men in this hadith to marry those who are fertile, he did NOT say not to marry the infertile amongst you. If for some reason the first wife is infertile then the option to avail the choice of polygyny is one that is encouraged islamically.
It is important to note that only two wives of the Prophet Muhammad(saw) gave birth to his children. Ayesha(rad), one of his most beloved wives, never had any children. Although others of his wives never conceived he treated all his wives justly and in a kind manner. He never raised the status of a fertile wife over an infertile one. His(saw) example is the best example. Men who wish to take on more then one wife should study his(saw) seerah and try to implement his(saw) treatment towards his(saw) wives in their own lives.
What are the benefits for the first wife, wives to follow, and any children from those wives? Oftentimes women who cannot conceive wish more then anything to rear a child or help in rearing a child. They often envy women who have children and wish that for even a day they could take care of a child as their own. I have seen several instance where a brother has taken on another wife as a result of his first wife being infertile. The first wife has almost always been extremely happy to be able to help the second wife in rearing her children. This creates an ideal situation for everyone in the household. The first wife is happy to be able to get a chance to raise children. The second wife receives extra help from the first wife and this strengthens the bond and relationship between the wives. The children have the attention of "two mothers." I am not saying that this happy-go-lucky relationship exists in every polyganous household, but rather I am suggesting that this may be a positive alternative for a husband who would like to have children.
There could also be problems as well. Jealousy is a common problem that arises amongst wives. Infertile women often feel that they were not good enough for their husbands and this was the reason for their remarriage. Husbands usually do not feel this way towards their wives. In fact if they are willing to keep their first wife then obviously the love and honor they feel towards them is what is keeping them together. Husbands should take this into account and make the change as painless as possible for their first wives.
The situation of every couple is different. Each couple knows how much they can take, and what options are best for them. As a couple it is important to sit down and discuss the pros and cons of going into a polygynous relationship. May Allah make it easy on everyone and relieve our hardships (Ameen).
"...Our Lord! Condemn us not
If we forget or fall
Into error; our Lord!
Lay not on us a burden
Like that which Thou
Didst lay on those before us;
Our Lord! lay not on us
A burden greater than we
Have strength to bear.
Blot out our sins,
And grant us forgiveness.
Have mercy on us.
Thou art our Protector..."
-The Meaning of the Qur'an (2:286)
CANCER AND FERTILITY PRESERVATION
In the United States there are approximately 800,000 reproductive-aged men and women who have cancer, many of whom have concerns about their fertility. Lifesaving cancer treatments may reduce fertility by destroying eggs and sperm. The likelihood of reproductive damage depends on the age and sex of the patient and the type and duration of treatment. The most severe damage comes from radiation to the ovaries or testicles and cancer drugs in the “alkylating agent” category such as cyclophosphamide ,mechlorethamine, chlorambucil, and melphalan. Although sperm production may recover, eggs do not regenerate; their loss is permanent and premature menopause may occur as a result. The risk of developing premature menopause is lower for younger women than for older women. The first goal is to cure the cancer, even if the treatment causes sterility. However, there are several options that may help preserve fertility before and after cancer treatments.
Preserving fertility before cancer treatment:
• Men
Semen samples may be frozen at a sperm bank or fertility center before starting chemotherapy or radiation therapy. Samples can be stored for years and used later for insemination. Sperm counts may be low or absent as a result of the underlying cancer. If sperm counts are low and/or the supply is limited from the frozen sample, the sperm can be used for in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).
• Women
If time and circumstances allow, women may be treated with IVF. Embryos created by IVF are then frozen and may be stored for years. Limiting factors for this approach include time, expense, availability of sperm, and possible delay of cancer therapy. If radiation will be administered to the pelvis, the ovaries may be repositioned surgically out of the radiation field. This will reduce the risk that radiation will damage the eggs.
• Areas of research
Ovarian suppression before cancer therapy: In theory, suppressing ovarian function may protect the eggs against the adverse effects of cancer treatment. There is little evidence to support suppression of the ovaries before cancer therapy with birth control pills, GnRH
agonists, or other means of hormonal suppression. Freeze eggs. This technology is investigational, expensive, invasive, and may delay cancer treatment. If used,eggs are collected as for IVF but are frozen before they are fertilized. Theoretically, frozen eggs may be Stored, thawed, fertilized, and used for embryo transfer. Actual success with this method is very limited, and few babies have been born with this technique.
Freeze ovarian tissue: This experimental technique requires surgery to remove ovarian tissue. Once frozen, tissue may be stored for years. Preliminary studies have shown that reimplanted ovarian tissue may survive and function for a limited time, but no babies have been born using this technique as of 2003.
Fertility after cancer treatment
• Men
It may take up to several years for sperm production to recover after cancer treatment. If sperm counts are consistently low, insemination, IVF, and ICSI may be effective measures for achieving pregnancy. Testicular biopsy may be a way to obtain sperm if sperm are not found in a semen analysis. If sperm cannot be obtained, pregnancy may be possible by using frozen donor sperm. The physician may want to wait up to six months before attempting conception. Some couples may choose to pursue adoption.
• Women
After the physician has advised that attempting pregnancy is safe, women may want to consult a fertility specialist to check for damage to reproductive organs. Many women will be able to conceive naturally or with fertility treatments. If significant damage has occurred to the ovaries or uterus, couples may wish to consider egg or
embryo donation, a gestational carrier, or adoption to create a family.
AGING AND INFERTILITY
Background
Female age is very important in consideration of probability for conception. The real issue is egg quantity and quality - which translates over to embryo quality after fertilization.
The age of the male partner does not appear to matter nearly as much. Sperm from older men does not usually have a substantially reduced fertilizing potential as compared to sperm from younger men. However, older men often have less interest in frequent intercourse, which can be a factor in chances for conception.
Many people are not aware of the decline in fertility as the age of the female partner increases:
There is a slow decline in pregnancy rates in the early 30's. This decline is more substantial in the late 30's and early 40's. Few women over 45 are still fertile.
Miscarriage rates also increase substantially as the mother ages (more on miscarriage below).
One important caveat is that the above numbers apply to populations, not individuals. A given woman can have rapid decline in egg quantity and quality at an early age - even in her teens or twenties in rare cases.
A study published in 1957 examined the relationship between the age of the female partner and fertility. This study found that:
By age 30, 7% of couples were infertile
By age 35, 11% of couples were infertile
By age 40, 33% of couples were infertile
At age 45, 87% of couples were infertile
For several reasons, infertility rates are even higher in the general population in the U.S. today than for the population studied by Tietze in the 1950s.
Tests to determine whether "age" is a significant factor in an individual couple
"Age" is in quotes here because the real issue is oocyte (egg) quality and not the number in a woman's age.
A woman can be 45 with exceptionally good quality eggs and still be fertile, or, she can be 25 with very poor quality eggs and be infertile. These are extreme examples, but the point is that egg quantity and quality tends to decline significantly in the late 30s and faster in the early 40s, but egg quantity and quality in an individual woman can be average for her age, better than average, or worse than average.
It would be nice to have a reliable test to determine how good the eggs are in an individual woman at a point in time. We do have some screening tests for ovarian reserve, however, they are far from perfect. Day 3 FSH testing and antral follicles counts are tests used by infertility specialists to help predict ovarian reserve.
Many infertility specialists recommend that women over about 38 that are infertile should have aggressive treatment and proceed to in vitro fertilization relatively quickly - before all fertility potential is lost.
Ten to 15 % of all reproductive age couples suffer from infertility. As a board certified reproductive endocrinologist I spend most of my time treating both men and women, who contribute equally to this insidious disease that afflicts millions. Infertility is defined as one year of unprotected sexual relations without conception. The probability of achieving a pregnancy within one menstrual cycle, ideally each month, is on the average only 25% for normal, young, and healthy couples; thus, these couples have approximately an 85% chance of conceiving with in one year and 93% in two years. Unfortunately, this probability decreases dramatically by one third to one half as women approach their mid 30's and early 40's.
Every time we watch a TV news magazine or open a print magazine we are entertained and enlightened by exposure to the latest advances in reproductive medicine, famous people revealing their difficulties, pursuits, failures and successes in having a baby, and the exceedingly rare, and thus always news-worthy occurrence of, high order multiple gestations, the "X-tuplets". Due to our present day frequent exposure and since years ago we rarely spoke or heard about people who were suffering in silence from this devastating disease, we tend to think that the rate of infertility is increasing exponentially. This is not necessarily true.
There have been a number of significant developments that have changed the practice of reproductive medicine and the public's awareness over the past quarter century. One of the most significant events was the introduction of the assisted reproductive technologies based on in vitro fertilization where eggs are removed from a woman, fertilized with sperm from a man in glassware, in vitro, and then the resultant fertilized egg (embryo) is transferred to a hormonally prepared uterus. The process is sometimes called making "test tube babies". With the birth of Louise Brown on July 25, 1978 and with assistance from the mass media, the medical community and the entire world became aware of novel and promising treatments for those suffering from the once considered shameful disease of infertility.
This publicity generated new hope for many where there was once only despair and emptiness. It also resulted in a domino effect increasing the number of researchers investigating novel diagnostic and treatment regimens, making reproductive services more widely available, successful, and affordable, and making infertility a more socially acceptable disease. This culminated in generating an immense increase in patient consults seeking fertility related care.
Another significant change that the fertility specialists have witnessed over the last 10 years was the dramatic increase in the number of women over age 35 requesting medical intervention for infertility. Approximately 20% of women in United States are having a first child after age 35. This is most likely due to a combination of older age at the time of first marriage and more significantly due to the delay of childbearing in marriage. Other attributable causes resulting in older women seeking fertility care and shortening the time interval in which they desire to reproduce genetically related children are a reflection of the current socio-economic times and morays.
Two income households are more the rule than the exception, even with dual incomes there is still financial instability and uncertainty, liberalization of abortion, effects of sexually transmitted diseases, increased worry and panic about being infertile, and increased use of various contraception options. It has become clear that what modern society is experiencing and fertility specialists are seeing is a dramatic increase in age related infertility in the baby boomer generation since they were the first group of women who could easily exercise control over their fertility.
Countless clinical trials have revealed that a woman's fertility declines significantly with increasing age, yet aging only minimally effects male fertility. Another gender difference is that a man continuously produces sperm throughout his adult life, in contrast to a woman who is born with her unique life time supply of eggs. This number continually decreases until she stops ovulating at menopause. In addition, research supports that this decline in female fertility is more likely related to the aging egg and less likely due to an aging uterus. The healthiest, most fertile eggs are ovulated when a woman is in her teens through her late 20's, a woman's time of peak fertility. When a woman reaches her mid to late 30's, the remaining eggs have substantially less potential for fertilizing and establishing a healthy pregnancy. This is mostly due to chromosomal injuries that normally occur as eggs age within the ovaries.
Advanced egg age probably accounts for the increased risk of both miscarriage and infertility in women over the age of 35 and especially by the age of 40. Because this is primarily a problem related to the chromosomes and cellular machinery of the eggs, there is little that can be done to correct or reverse this biological trend. This knowledge and clinical trials lead to the very successful treatment that employs egg donors where the entire egg cells are obtained from women usually in their 20's and fertilized with the infertile woman's husband's sperm. Nuclear transfer, where the nucleus of an infertile woman's adult cell is replaced for the nucleus in a younger woman's donor egg cell, and cytoplasmic transfer, where the cytoplasm of a fertile woman's egg is injected into the
-infertile woman's egg cell, have both been experimented with and pending FDA approval. The goal of both techniques is to maintain the older woman's genetics housed in the nucleus, but utilize the healthy cell replicating machinery located in the cytoplasm of the younger donor egg cell. Unfortunately, some genetic material is also found in the cytoplasm, so new questions have been raised and must be answered before these techniques become standard of care.
In women less than 35 years of age, the vast majority of eggs ovulated have a normal chromosomal composition. As the woman progresses beyond 35 years of age, an increasing number of her eggs are likely to be genetically abnormal, aneuploid. This is a natural process of aging. Egg quantity and quality declines at an exponential rate. Chromosomally abnormal eggs may fertilize, but will infrequently establish a healthy pregnancy. When defective genetic embryos inadvertently implant into the uterine lining, the resultant pregnancies often result in spontaneous first trimester miscarriages. This has been evidenced by an overall miscarriage rate as high as 75% in women 40 years and older. If this were not the case, there would be many more genetically defective babies born. This is also the reason why women who use their own eggs and who are 35 years or older are encouraged to undergo amniocentesis or chorionic villus sampling (CVS) to evaluate the fetus for chromosomal abnormalities. Consequently, in women of advancing age, not only is the pregnancy rate markedly lower and the miscarriage rate significantly higher, but the overall risk of chromosomal anomalies in the few babies born is also dramatically increased. After considering the above realities, you can see why there is a dismally low probability of delivering a healthy child, the ultimate goal, when using eggs from older women in natural or assisted reproduction cycles. To improve the odds, some reproductive endocrinologist advocate older patients undergoing IVF with preimplantation genetic diagnosis, PGD, where some genetic abnormalities may be identified prior to embryo transfer and thus only the "normal" embryos may be selected for transfer. Unfortunately, sampling one cell from a multi-celled embryo may not always reflect the genetics found in all the other cells and this technique does not correct for non-genetic age related defects in the egg such as defects in the meiotic spindle fibers that result in chromosomal misalignment or problems with microtubular matrix composition.
The problems of advancing age on eggs and subsequently on embryo quality occur independently of a woman's proximity to the menopause. The eggs of a younger woman who is destined to undergo premature ovarian failure, let's say in her late 20's, are just as capable of producing a healthy baby as the eggs of a woman of the same age who will enter the menopause in her late 50's. The converse is also true, that a woman in her 40's who has entered the peri-menopause, a time period of 5-10 years prior to menopause and marks the advent of the accelerated decline in ovarian function, will have a relatively high percentage of chromosomally defective eggs. Thus, growing older has a unique, irreversible, and devastatingly negative effect on female fertility.
I always remind younger patients suffering from infertility that there is no abrupt change in fertility for any given women at age 40, and therefore, this decline in fertility may occur in younger women, although much less often, even those in their late teens. This rate of decline is on a continuum, from early and subtle changes of hormone markers (FSH or inhibin B) to noticeable impaired fertility to menopause, complete depletion of eggs. Other factors that contribute to age related female infertility are the total number of eggs that a woman is born with and her rate of loss of these eggs. Both are genetically and uniquely predetermined. The rate off egg loss can not be slowed or stopped; but, smoking, medications, and surgery can accelerate it. In another words, the number of eggs available for possible ovulation or medical intervention per menstrual cycle is directly proportional to the unique number a woman is born with, her age, and her proximity to menopause. Although uterine pathology also increases with age, it has little impact in comparison to the effect of aging eggs.
Over the last 15 years reproductive endocrinologists have gained experience using various dynamic tests in order to predict a woman's potential for pregnancy in both natural and assisted reproduction. Qualitative "guestimations" of fertility potential at a specific time in a woman's life can be estimated through the performance of the clomiphene citrate challenge test. This test of "ovarian reserve" and possibly egg quality consists of simple blood tests measuring a woman's blood levels of follicle stimulating hormone (FSH) produced in the pituitary and estrogen, produced in the ovaries from the developing eggs before and after taking oral fertility medication, clomiphene citrate. The clomiphene citrate challenge test (CCCT) is performed by measuring day 3 FSH and estradiol, administering clomiphene citrate 100mgs daily from cycle days 5-9, and then measuring FSH on cycle day 10. The test is considered abnormal if either FSH value is above the laboratory's upper limit for the follicular phase or the cycle day 3 estradiol is greater than 80 pg/ml.
The literature strongly suggests that women who have an abnormal clomiphene citrate challenge test, regardless of their chronological age, experience decreased response to higher doses of gonadotropins, have higher cycle cancellation rates, and suffer from poor reproductive performance when using their own eggs, i.e., have a poor probability of conception and delivery of a live born baby with or without fertility treatments, around 5% per cycle. Thus, this provocative test predicts the lack of success. A single elevated cycle day 3 FSH value predicts a poor prognosis, even when normal values are obtained during future cycle. However, if the test is normal, it does not guarantee a woman's certainty of conceiving or delivering a healthy baby, especially in older women. The likelihood of an abnormal result increases with increasing age. Patients are always cautioned that no one test in medicine is 100% predictive of any outcome, positive or negative. The rule of thumb is that age is a better predictor of egg quality, and FSH level is a better predictor of egg number. I also stress to patients there is little if any literature related to an abnormal clomiphene challenge test and the age of onset of the menopause. Women still worry. The CCCT is recommended for all unexplained infertile couples,
-women > 34 years of age, and women < 35 with one ovary, history of ovarian surgery, and exposure to chemotherapy or radiation therapy.
Other tests of ovarian reserve under investigation that are not the standard of care due to conflicting data regarding prognostic value include inhibin B levels, gonadotropin-releasing hormone agonist test, and small antral follicle count by transvaginal ultrasound.
The most realistic options for women with an abnormal result, especially women greater than 34 years of age, are in vitro fertilization and embryo transfer using donor egg, IVF with their own eggs possibly with assisted hatching and PGD, controlled ovulation with gonadotropins and IUI, (in decreasing order of success), adoption, or to not expand their family. Of course most couples are dismayed with these choices at first. Eventually some couples take comfort in the fact that their prior diagnosis of "unexplained infertility" has been given a more definitive and impressive name, that of diminished ovarian reserve, with an evolutionary and biological explanation. Others are angered and frustrated by yet another effect of time, the limitations of reproductive science, and the misinformation preached to them by the preceding generation.
The baby boomer generation took their lead from their parents, older friends and colleagues, and worldly teachers who advised them to be responsible and learn from their years of wisdom. This meant completing at least a college education, obtaining a financially rewarding career, finding a soul-mate to make and share a life, and once thought to be emotionally and financially secure, to embark on having children, their own genetic offspring, in order to continue the life cycle of another generation. Unfortunately, these well meaning mentors, trying to better our lives from their hard-learned lessons never carefully thought about evolution in regards to reproduction and tested the female biological clock. Now it is our responsibility to bestow on to the next generation conceived in the laboratory with love our newfound enlightenment.
For as long as men and women have been practicing the procreation dance there have been those that have suffered with infertility. Though infertility is a very individual and personal struggle, it is important for couples to know that they are not alone. Over 4.5 million couples experience infertility each year. There have been millions upon millions of couples that have had to cope with infertility throughout the ages. Many of these couples are famous, historical figures.
But she remained childless:
The Book of Genesis speaks of two sisters: Rachel and Leah. Rachel was beautiful and desired. Leah was plain and unloved. God made it possible for Leah to bear children while her sister remained childless. Despite all of her best efforts Rachel did not become pregnant for many, many years. When she finally did give birth Rachel cried out, "God has taken away my disgrace by giving me a son." Rachel’s belief, that her infertility was disgraceful, is a belief that has persisted among infertile woman for centuries. Even today, in modern times of advanced medicine, higher learning, and deeper social awareness, women still feel disgraced and humiliated when they confess they have fertility issues.
From Hanging to Humiliation:
If suffering from humiliation is painful, it is not nearly as painful as some of the punishments netted to woman through history for their inability to conceive. In some ancient cultures it was an acceptable practice for men to hang their wives if they failed to produce an offspring with in the agreed upon time. In Regency England a man could publicly denounce his union and "set aside his wife" if she failed to produce an heir. In more recent times, women have been forced to endure "kitchen burnings." This Indian practice calls for the disgruntled spouse to tie his wife to a chair and set her afire in their kitchen. The only explanation he need give is that he was not satisfied with her this could be for any number of reasons like being a lousy cook, a poor lover, or even an infertile spouse.
Knowledge is power:
Queen Mary of England, daughter of Henry VIII and Katherine of Aragon, said, "Knowledge is foremost to power." This was a personal philosophy that would see her through many trials and tribulations including infertility. Mary inherited the throne despite furious opposition to the notion of a female ruler. One of her most important goals was to have a child to secure her line. The years tricked by slowly and agonizingly for Mary "the Barren Queen" of England. Though she would convince herself she was pregnant, once suffering from a phantom pregnancy wherein she gained the requisite weight, stopped menstruating, and suffered with morning sickness, she never truly obtained her goal. Mary knew, however, that there was more than one way for her to be fruitful in life. She filled her time reading and learning all she could about medical treatments and her religion. Mary set an example that all infertility patients could learn from: though your body may be barren your mind is not!
You and your partner have tried for months, perhaps for even more than a year. But despite sexual intercourse without birth control, you've been unable to conceive a child.
If you've been trying to conceive for more than a year, there's a good chance that something may be interfering with your reproductive function. Infertility, also known as subfertility, is the inability to conceive a child within one year. Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing.
Infertility differs from sterility. Being sterile means you're unable to conceive a child. With sterility, you or your partner has a physical problem that precludes the ability to conceive. A diagnosis of infertility simply means that becoming pregnant may be a challenge rather than an impossibility.
The human reproductive process is complex. To accomplish a pregnancy, the intricate processes of ovulation and fertilization need to work just right. For many couples attempting pregnancy, something goes wrong in one or both of these complex processes and causes infertility.
Infertility affects more than 6 million American couples, with the male partner being either the sole or a contributing cause in approximately 40 percent of infertile couples. Problems with female fertility are present about one-half to two-thirds of the time. In both men and women, multiple factors can account for difficulty with fertility.
OVERCOMING INFERTILITY
"Fertility problems are a huge psychological stressor, a huge relationship stressor," says Lisa Rarick, M.D., director of the Food and Drug Administration's division of reproductive and urologic drug products.
So, while going on a relaxing vacation may temporarily relieve the stress that comes with fertility problems, a solution may require treatment by a health-care professional. Treatment with drugs such as Clomid or Serophene (both clomiphene citrate) or Pergonal, Humegon, Metrodin, or Fertinex (all menotropins) are used in some cases to correct a woman's hormone imbalance.Surgery is sometimes used to repair damaged reproductive organs. And in about 10 percent of cases, less conventional, high-tech options like in vitro fertilization are used.
Will the therapies work? "Talking about the success rate for fertility treatments is like saying, 'What's the chance of curing a headache?'" according to Benjamin Younger, M.D., executive director of the American Society for Reproductive Medicine. "It depends on many things, including the cause of the problem and the severity." Overall, Younger says, about half of couples that seek fertility treatment will be able to have babies.
A Year Without Pregnancy
Infertility is defined as the inability to conceive a child despite trying for one year. The condition affects about 5.3 million Americans, or 9 percent of the reproductive age population, according to the American Society for Reproductive Medicine.
Ironically, the best protection against infertility is to use a condom while you are not trying to get pregnant. Condoms prevent sexually transmitted diseases, a primary cause of infertility.
Even a completely healthy couple can't expect to get pregnant at the drop of a hat. Only 20 percent of women who want to conceive become pregnant in the first ovulation cycle they try, according to Younger.
To become pregnant, a couple must have intercourse during the woman's fertile time of the month, which is right before and during ovulation. Because it's tough to pinpoint the exact day of ovulation, having intercourse often during the approximate time maximizes the chances of conception.
After a year of frequent intercourse without contraception that doesn't result in pregnancy, a couple should go to a health-care professional for an evaluation. In some cases, it makes sense to seek help for fertility problems even before a year is up.
A woman over 30 may wish to get an earlier evaluation. "At age 30, a woman begins a slow decline in her ability to get pregnant," says Younger. "The older she gets, the greater her chance of miscarriage, too." But a woman's fertility doesn't take a big drop until around age 40.
"A man's age affects fertility to a much smaller degree and 20 or 30 years later than in a woman," Younger says. Despite a decrease in sperm production that begins after age 25, some men remain fertile into their 60s and 70s.
A couple may also seek earlier evaluation if:
· The woman isn't menstruating regularly, which may indicate an absence of ovulation that would make it impossible for her to conceive without medical help.
· The woman has had three or more miscarriages (or the man had a previous partner who had had three or more miscarriages).
· The woman or man has had certain infections that sometimes affect fertility (for example, pelvic infection in a woman, or mumps or prostate infection in a man).
· The woman or man suspects there may be a fertility problem (if, for example, attempts at pregnancy failed in a previous relationship).
Impairment in any step of the intricate process of conception can cause infertility. For a woman to become pregnant, her partner's sperm must be healthy so that at least one can swim into her fallopian tubes. An egg, released by the woman's ovaries, must be in the fallopian tube ready to be fertilized. Next, the fertilized egg, called an embryo, must make its way through an open-ended fallopian tube into the uterus, implant in the uterine lining, and be sustained there while it grows.
It is a myth that infertility is always a "woman's problem." Of the 80 percent of cases with a diagnosed cause, about half are based at least partially on male problems (referred to as male factors)--usually that the man produces no sperm, a condition called azoospermia, or that he produces too few sperm, called oligospermia.
Lifestyle can influence the number and quality of a man's sperm. Alcohol and drugs--including marijuana, nicotine, and certain medications--can temporarily reduce sperm quality. Also, environmental toxins, including pesticides and lead, may be to blame for some cases of infertility.
The causes of sperm production problems can exist from birth or develop later as a result of severe medical illnesses, including mumps and some sexually transmitted diseases, or from a severe testicle injury, tumor, or other problem. Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence.
The other half of explained infertility cases are linked to female problems (called female factors), most commonly ovulation disorders. Without ovulation, eggs are not available for fertilization. Problems with ovulation are signaled by irregular menstrual periods or a lack of periods altogether (called amenorrhea). Simple lifestyle factors--including stress, diet, or athletic training--can affect a woman's hormonal balance. Much less often, a hormonal imbalance can result from a serious medical problem such as a pituitary gland tumor.
Other problems can also lead to female infertility. If the fallopian tubes are blocked at one or both ends, the egg can't travel through the tubes into the uterus. Such blockage may result from pelvic inflammatory disease, surgery for an ectopic pregnancy (when the embryo implants in the fallopian tube rather than in the uterus), or other problems, including endometriosis (the abnormal presence of uterine lining cells in other pelvic organs).
A medical evaluation may determine whether a couple's infertility is due to these or other causes. If a medical and sexual history doesn't reveal an obvious problem, like improperly timed intercourse or absence of ovulation, specific tests may be needed.
Understanding your monthly fertility pattern (days in the month when you are fertile, days when you are infertile, and days when fertility is unlikely, but possible) can help you plan a pregnancy, or avoid pregnancy. But if you already understand your menstrual cycle and fertility pattern, and are having problems getting pregnant, there is help and support available. In 1995, one in 10 U.S. women of reproductive age had a problem with fertility. If you have a problem with fertility, learn all you can about you and your partner's health, and your options for treatments.
FERTILITY AWARENESS
The Menstrual Cycle :
Being aware of your menstrual cycle and the changes in your body that happen during this time can be key to helping you plan a pregnancy, or avoid pregnancy. During the menstrual cycle (a total average of 28 days), there are two parts: before ovulation and after ovulation.
· Day 1 starts with the first day of your period.
· Usually by Day 7, a woman's eggs start to prepare to be fertilized by sperm.
· Between Day 7 and 11, the lining of the uterus (womb) starts to thicken, waiting for a fertilized egg to implant there.
· Around Day 14 (in a 28-day cycle), hormones cause the egg that is most ripe to be released, a process called ovulation. The egg travels down the fallopian tube towards the uterus. If a sperm unites with the egg here, the egg will attach to the lining of the uterus, and pregnancy occurs.
· If the egg is not fertilized, it will break apart.
· Around Day 25 when hormone levels drop, it will be shed from the body with the lining of the uterus as a menstrual period.
The first part of the menstrual cycle is different in every woman, and even can be different from month-to-month in the same woman, varying from 13 to 20 days long. This is the most important part of the cycle to learn about, since this is when ovulation and pregnancy can occur. After ovulation, every woman (unless she has a health problem that affects her periods) will have a period within 14 to 16 days.
Charting Your Fertility Pattern :
If you are aware of when you are most fertile, this will help you plan or prevent a pregnancy. There are three ways that you can keep track of this time each month:
· Basal body temperature method - This involves taking your basal body temperature (your body's temperature when you're at rest) every morning before you get out of bed, and recording it on a chart. You will begin to know your own fertility pattern, and you can see the changes from month to month. During the menstrual cycle, your body temperature remains at a somewhat steady, lower level, and begins to slightly rise with ovulation. The rise can be a sudden jump or a gradual climb over a few days. The rise in temperature can't predict exactly when the egg is released, but your temperature rises between .4 to .8 degrees Fahrenheit on the day of ovulation. You are most fertile, and most likely to get pregnant during the two to three days just before your temperature hits the highest point (ovulation), and for about 12 to 24 hours after ovulation. A man's sperm can live for up to three days in your body and is able to fertilize an egg during that time. So, if you have unprotected sex several days before ovulation, there is a chance of becoming pregnant then. Once your temperature spikes and stays at a higher level for about three days, you can be sure that ovulation has occurred. Your temperature will remain at the higher level until your period starts. Basal body temperature differs slightly from woman to woman, but anywhere from 96 to 98 degrees orally is normal before ovulation, and anywhere from 97 to 99 degrees orally after ovulation. So, any changes that you chart are very small and are in 1/10 degree. You can buy an oral basal body temperature thermometer or an easy-to-read thermometer, which has the degrees marked in these small fractions, at a drug store. If you can't find it easily, ask the pharmacist to help you.
· Calendar method - This involves keeping a written record of each menstrual cycle on a regular calendar. The first day of your period is Day 1, which you can circle on the calendar. Continue doing this for eight to 12 months so you know how many days are in your cycle. The length of your cycle can vary from month to month, so write down the total number of days it lasts each time in a list. To find out the first day when you are most fertile, check your list and find the cycle with the fewest days. Then subtract 18 from that number. Take this new number and count ahead that many days on the calendar. Draw an X through this date. The X marks the first day you're likely to be fertile. To find out the last day when you are fertile, subtract 11 days from your longest cycle and draw an X through this date. This method always should be used with other fertility awareness methods, especially if your cycles are not always the same lengths.
· Cervical mucus method (also known as the ovulation method) - This involves being aware of the changes in your cervical mucus throughout the month. The hormones that control the menstrual cycle also cause changes in the kind and how much mucus you have just before and during ovulation. Right after your period, you usually have a few days when there is no mucus present or "dry days." As the egg starts to mature, mucus increases in the vagina, appears at the vaginal opening, and is usually white or yellow and cloudy and sticky. The greatest amount of mucus appears just before ovulation, during the "wet days," when it becomes clear and slippery, like raw egg whites. Sometimes it can be stretched apart. This is when you are most fertile. About four days after the wet days begin, the mucus changes again. There is now much less and it becomes sticky and cloudy. You might have a few more dry days before your period returns. You can describe changes in your mucus on a calendar. Label the days, "Sticky," "Dry," or "Wet." You are most fertile at the first sign of wetness after your period, but maybe also a day or two before wetness begins. This method is less reliable for women whose mucus pattern is changed because of breastfeeding, use of oral contraceptives or feminine hygiene products, having vaginitis, sexually transmitted diseases (STDs), or surgery on the cervix.
To most accurately track your fertility, it is best to use a combination of all three methods, which is called the symptothermal method.
INFERTILITY
It is not uncommon to have trouble becoming pregnant or experience infertility. Infertility is defined as not being able to become pregnant, despite trying for one year, in women under 35, or after six months in women 35 and over. Pregnancy is the result of a chain of events. As described in the Fertility Awareness section, a woman must release an egg from one of her ovaries (ovulation). The egg must travel through a fallopian tube toward her uterus. A man's sperm must join with (fertilize) the egg along the way. The fertilized egg must then become attached to the inside of the uterus. While this may seem simple, in fact many things can happen to prevent pregnancy.
TYPES
A. Hypofertile couples have trouble conceiving quickly. Their fertility may be less than ideal or they may be having problems with timing, but they can eventually conceive without special treatment. For example, the man might have a low sperm count, or the woman might have endometriosis—roadblocks, but not brick walls.
B. Sterile couples won't be able to conceive without medical or surgical treatment. For example, the man might not create enough sperm to fertilize an egg, or the woman might have blocked fallopian tubes.
SIGNS AND SYMPTOMS:
Most men with fertility problems have no signs or symptoms. Some men with hormonal problems may note a change in their voice or pattern of hair growth, enlargement of their breasts, or difficulty with sexual function. Infertility in women may be signaled by irregular menstrual periods or associated with conditions that cause pain during menstruation or intercourse.
REASONS FOR INFERTILITY :
Because of the intricate series of events required to begin a pregnancy, many factors may cause a delay in starting your family.
Every month the pituitary gland in a woman's brain sends a signal to her ovaries to prepare an egg for ovulation. The pituitary hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are involved in stimulating the ovaries to bring an egg to ovulation. A large boost in LH carries a message to the ovarian follicle to release its egg (ovulate). A woman is most fertile at the time of ovulation — around day 14 of her menstrual cycle — although the exact time of ovulation varies among women due to different lengths of menstrual cycles.
The egg is then captured by a fallopian tube and is viable for about 24 hours, but its best chance of being fertilized is within the first 12 hours following ovulation. For pregnancy to occur, a sperm must unite with the egg in the fallopian tube within this time. Sperm are capable of fertilizing the egg for up to 72 hours and must be present in the fallopian tube at the same time as the egg for conception to occur. If fertilized, the egg moves into the uterus two to four days later. There it attaches to the uterine lining and begins a nine-month process of growth.
In order for sperm to reach the egg, many factors are involved in the male fertility process. There must be enough sperm, they must be of the right shape, and they must move in the right way. There must be enough semen to transport the sperm. The man also needs to be able to have an erection, and must be able to ejaculate the semen and deliver it into the vagina.
The cause of infertility can involve one or both partners. Sometimes the problem isn't really one of infertility, but a more general sexual problem such as erectile dysfunction. Other times, the problem may involve an abnormality in the structure of the reproductive hormones or organs. Certain infections and diseases also can affect fertility.
A number of causes exist for male infertility that may result in impaired sperm count or mobility, or impaired ability to fertilize the egg. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, conditions related to a man's general health and lifestyle, and overexposure to certain environmental elements:
Abnormal sperm production or function. More than 90 percent of male infertility cases are due to sperm abnormalities, such as:
· Impaired shape and movement of sperm. Sperm must be properly shaped and able to move rapidly and accurately toward the egg for fertilization to occur. If the shape and structure (morphology) of the sperm is abnormal or the movement (motility) is impaired, sperm may not be able to reach the egg.
· Absent sperm production in testicles. Complete failure of the testicles to produce sperm is rare, affecting less than 5 percent of infertile men.
· Low sperm concentration. A sperm count of 13.5 million per milliliter of semen or fewer indicates low sperm concentration (subfertility). A count of 48 million per milliliter of semen or higher indicates fertility.
· Varicocele. A varicocele is a varicose vein in the scrotum that may prevent normal cooling of the testicle and raise testicular temperature, preventing sperm from surviving.
· Undescended testicle (cryptorchidism). This occurs when one or both testicles fail to descend from the abdomen into the scrotum during fetal development. Undescended testicles can cause mild to severely impaired sperm production. Because the testicles are exposed to the higher degree of internal body heat, sperm production may be affected.
· Testosterone deficiency (male hypogonadism). Infertility can result from disorders of the testicles themselves, or an abnormality affecting the hypothalamus or pituitary glands in the brain that produce the hormones that control the testicles.
· Klinefelter's syndrome. In this disorder of the sex chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production. Testosterone production also may be lower.
· Infections. Infection may temporarily affect sperm motility. Repeated bouts of sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. Mycoplasma is an organism that may fasten itself to sperm cells, making them less motile. If mumps, a viral infection usually affecting young children, occurs after puberty, inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.
In many instances, no cause for reduced sperm production is found. When sperm concentration is less than 5 million per milliliter of semen, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.
Impaired delivery of sperm. Problems with the delivery of sperm from the penis into the vagina can cause infertility.
These may include:
· Sexual issues. Often treatable, problems with sexual intercourse or technique may affect fertility. Difficulties with erection of the penis (erectile dysfunction), premature ejaculation, painful intercourse (dyspareunia), or psychologic or relationship problems can contribute to infertility. Use of lubricants such as oils or petroleum jelly can be toxic to sperm and impair fertility.
· Retrograde ejaculation. This occurs when semen enters the bladder during orgasm rather than emerging out through the penis. Various conditions can cause retrograde ejaculation including diabetes, bladder, prostate or urethral surgery, and the use of psychiatric or antihypertensive drugs.
· Blockage of epididymis or ejaculatory ducts. Some men are born with blockage of the part of the testicle that contains sperm (epididymis) or ejaculatory ducts. An estimated 2 percent of men who seek treatment for infertility lack the tubes that carry sperm (vas deferens).
· No semen (ejaculate). The absence of ejaculate may occur in men with spinal cord injuries or diseases. This fluid transports sperm through the penis into the vagina.
· Misplaced urinary opening (hypospadias). A birth defect can cause the urinary (urethral) opening to be abnormally located on the underside of the penis. If not surgically corrected, this condition can prevent sperm from reaching the cervix.
· Antisperm antibodies. Antibodies that target sperm and weaken or disable them usually occur after surgical blockage of part of the vas deferens for male sterilization (vasectomy). Presence of these antibodies may complicate the reversal of a vasectomy.
· Cystic fibrosis. Men with cystic fibrosis often have missing or obstructed vas deferens.
General health and lifestyle
A man's general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:
· Emotional stress. Stress may interfere with certain hormones needed to produce sperm. Your sperm count may be affected if you experience excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress. Infertility can affect social relationships and sexual functioning.
· Malnutrition. Deficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.
· Obesity. Increased body mass may be associated with fertility problems in men.
· Cancer and its treatment. Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility. You may want to consider freezing (cryopreserving) your sperm before cancer treatment to ensure future fertility.
· Alcohol and drugs. Alcohol or drug dependency can be associated with general ill health and reduced fertility. The use of certain drugs also can contribute to infertility. Anabolic steroids, for example, which are taken to stimulate muscle strength and growth, can cause the testicles to shrink and sperm production to decrease.
· Other medical conditions. A severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, HIV/AIDS, Cushing's syndrome, anemia, heart attack, and liver or kidney failure, may be associated with infertility.
· Age. A gradual decline in fertility is common in men older than 35.
Environmental exposure
Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm count either directly by affecting testicular function or indirectly by altering the male hormonal system. Specific causes include:
· Pesticides and other chemicals. Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production. Exposure to such chemicals also may contribute to testicular cancer. Men exposed to hydrocarbons, such as ethylbenzene, benzene, toluene, xylen and aromatic solvents used in paint, varnishes, glues, metal degreasers and other products, may be at risk of infertility. Men with high exposure to lead also may be more at risk
· Testicular exposure to overheating. Frequent use of saunas or hot tubs can elevate your core body temperature. This may impair your sperm production and lower your sperm count.
· Substance abuse. Cocaine or heavy marijuana use may temporarily reduce the number and quality of your sperm.
· Tobacco smoking. Men who smoke may have a lower sperm count than do those who don't smoke.
Female infertility
The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome, early menopause, benign uterine fibroids, and pelvic adhesions:
a. Fallopian tube damage or blockage.
This condition usually results from inflammation of the fallopian tube (salpingitis). Chlamydia is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever.
Tubal damage with scarring is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.
b. Endometriosis.
Endometriosis occurs when the tissue that makes up the lining of the uterus grows outside of the uterus. This tissue most commonly is implanted on the ovaries or the lining of the abdomen near the uterus, fallopian tubes and ovaries. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.
Infertility in endometriosis also may be due to:
· Ovarian cysts (endometriomas). Ovarian cysts may indicate advanced endometriosis and often are associated with reduced fertility. Endometriomas can be treated with surgery.
· Scar tissue. Endometriosis may cause rigid webs of scar tissue between the uterus, ovaries and fallopian tubes. This may prevent the transfer of the egg to the fallopian tube.
c. Ovulation disorders.
About 25 percent of female infertility is caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation (hypothalamic-pituitary axis) can cause deficiencies in luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation.
Specific causes of hypothalamic-pituitary disorders include:
· Direct injury to the hypothalamus or pituitary gland
· Pituitary tumors
· Excessive exercise
· Anorexia nervosa
d. Elevated prolactin (hyperprolactinemia).
The hormone prolactin stimulates breast milk production. High levels in women who aren't pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. Some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing (galactorrhea) can be a sign of high prolactin.
Polycystic ovary syndrome (PCOS). An increase in androgen hormone production causes PCOS. In women with increased body mass, elevated androgen production may come from stimulation by higher levels of insulin. In lean women, the elevated levels of androgen may be stimulated by a higher ratio of luteinizing hormone (LH). Lack of menstruation (amenorrhea) or infrequent menses (oligomenorrhea) are common symptoms in women with PCOS.
In PCOS, increased androgen production prevents the follicles of the ovaries from producing a mature egg. Small follicles that start to grow but can't mature to ovulation remain within the ovary. A persistent lack of ovulation may lead to mild enlargement of the ovaries.
Without ovulation, the hormone progesterone isn't produced and estrogen levels remain constant. Elevated levels of androgen may cause increased dark or thick hair on the chin, upper lip or lower abdomen as well as acne and oily skin.
e. Early menopause (premature ovarian failure).
Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35. Although the cause is often unknown, certain conditions are associated with early menopause, including:
· Autoimmune disease. The body produces antibodies to attack its own tissue, in this case the ovary. This may be associated with hypothyroidism (too little thyroid hormone).
· Radiation or chemotherapy for the treatment of cancer
· Tobacco smoking
f. Benign uterine fibroids.
Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by interfering with the contour of the uterine cavity, blocking the fallopian tubes.
g. Pelvic adhesions.
Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. They may limit the functioning of the ovaries and fallopian tubes and impair fertility. Scar tissue formation inside the uterine cavity after a surgical procedure may result in a closed uterus and ceased menstruation (Asherman's syndrome). This is most common following surgery to control uterine bleeding after giving birth.
Other causes
A number of other causes can lead to infertility in women:
· Medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
· Thyroid problems. Disorders of the thyroid gland, either too much thyroid- hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
· Cancer and its treatment. Certain cancers particularly female reproductive cancers often severely impair female fertility. Both radiation and chemo therapy may affect a woman's ability to reproduce. Chemotherapy may impair reproductive function and fertility more severely in men than in women.
Other medical conditions. Medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, HIV/AIDS, kidney disease and diabetes, can affect female fertility.
Risk increases with:
· Diabetes mellitus.
· Stress.
· Marital discord and infrequent sexual intercourse.
· Genital disorders.
· Drugs of abuse, such as heroin.
Many of the risk factors for both male and female infertility are the same. These include:
· Age. Age is the strongest predictor of female fertility. After about age 32, a woman's fertility potential declines. A woman does not renew her oocytes (eggs). There is no one special point when fertility declines — it's a gradual transition.
· Chromosomal abnormalities. Infertility in older women may be due to a higher risk of chromosomal abnormalities that occur in the eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. The risk of miscarriage also increases with a woman's age. A gradual decline in fertility is possible in men older than 35.
· Tobacco smoking. Women who smoke tobacco may reduce their chances of becoming pregnant and the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.
· Alcohol. There's no certain level of safe alcohol use during conception or pregnancy.
· Body mass. Extremes in body mass — either too high (body mass index, or BMI, of greater than 25.0) or too low (BMI of lower than 20.0) — may affect ovulation and increase the risk of infertility.
· Being overweight. Among American women, infertility often is due to a sedentary lifestyle and being overweight.
· Being underweight. Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women on a very low-calorie or restrictive diet. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid. Marathon runners, dancers and others who exercise very intensely are more prone to menstrual irregularities and infertility.
Percentage of women with infertility differs with age.
15-24 years old.......... 4.1%
25-34 years old.......... 13.1%
35-44 years old.......... 21.4%
National Center for Health Statistics
Redbook Magazine, August, 1993
The risk of miscarriage differs with age
20-29 years old.......... 10% risk of miscarriage
45 or older ............... 50% risk of miscarriage
Chatelaine Magazine
November 1993, pg. 26
Male infertility increases over past 40 yearsOne-half of 1% of men were functionally sterile in 1938. Today it has reached between 8-12% (an over 15-fold increase). "Functionally sterile" is defined as sperm counts below 20 million per milliliter of semen.
Note: A recent report attaining media attention states sperm count has not declined over the past 4 decades.However, note how the study used the dates of 1951 for the 1st comparison study.1951 was well after the introduction of large amounts of chemicals into society and was a year in which vehicle emissions contained both high levels of lead and large amounts of toxic hydrocarbon/solvent combustion products. Also, by 1951, pesticide use was making its way into consumer use.
Dr. Cecil Jacobson
Reproductive Genetics Center
Vienna, Virginia
Miscarriage more common with low sperm countsWomen experiencing miscarriages typically had husbands with lower sperm counts. On average,48% of husband's sperm appeared "abnormal"(i.e. 2 heads, 2 tails, etc.) under microscopic examination. Men who fathered normal pregnancies had 25% higher sperm counts and only 5% visually abnormal sperm.
Drs. Mirjam Furuhjelm and Birgit Jonson
Dept. of Obst. and Gyn., Sabbatsberg Hospital, Karolinska Institute, Stockholm, Sweden
International J. of Fertility, 7(1):17-21, 1962
40% of couple infertility is due to the male.
Dr. Pat McShane
Department of Obstetrics and Gynecology, Boston Massachusetts
Nationwide infertility ratesA study by the National Center for Health Statistics estimated in 1988 that 8.4% of women 15-44 years had impaired ability to have children and about half of these couples eventually conceive. (These are overall average infertility figures pertaining only to women - statistics will vary greatly depending on the age of the woman.Couple infertility rates are nearly double this percentage since it then takes into account male infertility).
Dr. Howard Jones
New England Journal of Medicine
December 2, 1993 pg. 1710
Article entitled "The Infertile Couple"
Fertility treatments not very effectiveExpensive fertility treatments resulted in only a 6 percentage point improvement in achieving pregnancy over "infertile" couples who just "kept trying." In a study of 1,145 couples who had been diagnosed as infertile, only half of them were treated to help attain pregnancy. After a two to seven-year follow-up, pregnancies occurred in 41% of the treated couples and 35% of the untreated couples.
Dr. John A. Collins
Professor of Obstetrics/Gynecology
McMaster University, Hamilton, Ontario
New England Journal of Medicine
November 17, 1983
More evidence fertility treatments not effectiveAnother study of 2,000 couples found "roughly the same" small improvements in achieving pregnancy when comparing couples who sought infertility treatments and those who kept trying.
Dr. John A. Collins
Professor of Obstetrics/Gynecology
McMaster University, Hamilton, Ontario
Sterility Fertility Journal, Fall of 1993
Infertility treatments are a $1 billion a year industry
HealthFacts
Vol. 19(176), January, 1994
Miscarriage rates higher living near agricultureMothers who lived near crops where certain pesticides were sprayed faced a 40 to 120 percent increase in risk of miscarriage due to birth defects.
Erin Bell (Ph.D.)University of North CarolinaSchool of Public Health
SOURCE: Epidemiology, March 2001
"20% of all cases where the male is the only contributing factor to infertility can be corrected by lifestyle."
Dr. Wolfram Nolten
Division of Endocrinology and Metabolism University of Wisconsin
Lower sperm count increases risk of miscarriageThe odds of having a miscarriage or child with birth defects raises dramatically when fathers have lower sperm counts. When the fathers sperm counts were above 80 million/ml they had only a 1% birth defect rate compared to 6% for the general population. Miscarriages were also lower for the fathers with higher sperm counts - 6% compared to 12% for the general population.
Dr. J. K. Sherman
University of Arkansas study of 1000 children whose mothers were artificially inseminated with sperm from men whose sperm counts were above 80 million per milliliter.
Washington Star Newspaper
January 7, 1979
Smokers have lower sperm countsSmokers sperm counts are on average 13%-17% lower than nonsmokers.
Dr. Marilyn F. Vine
University of North Carolina
Fertility Sterility Journal 6(1):35-43, 1994
Stopping smoking increases sperm countsA study of three smokers who were followed for 5-15 months after stopping smoking reported that their sperm counts rose 50-800%, suggesting that toxic chemicals in the smoke are responsible and any reduction in sperm count is reversible.
(same article as above)
Smokers have more abnormal sperm"Male smokers have an increase in sperm abnormalities, thereby suggesting a mutagenic effect."
Quoted from the American J. of Epidemiology
140(10):921-928, 1994
The original study was reported in the journal Lancet, Volume 1:627-629, 1981
Cigarette consumption increases over 40 years"Cigarette consumption in the U.S. has increased 3-4 fold from 1940 to the beginning of the 1980's."
Dr. R. J. Ravalet
Population Develop. ReviewsVol. 16:213-240, 1990
Smokers face higher infertility38% of female non-smokers conceived in their 1st cycle of attempting pregnancy compared to 28% of smokers. Smokers were also 3-4 times more likely than non-smokers to have taken greater than a year to conceive.
Dr. D. Baird
National Institute of Environmental Health, NC
Journal of American Medical Association
Vol. 253:2979-83, 1985
Abnormally shaped sperm linked to decreased fertilization"A high number of abnormal sperm heads is associated with decreased fertilization. Some drugs such as sulphasalazine, used to treat inflammatory bowel disease can drastically reduce semen quality."
Dr. N. E. Skakkebaek
University Dept. of Growth and Reproduction
Lancet, June 11, 1994, pg. 1474
Pesticides suspected of causing infertilityMen experiencing infertility were found to be employed in agricultural/pesticide related jobs 10 times more often than a study group of men not experiencing infertility. See related articles showing pesticides can damage sperm and testicles.
Institute of Sterility Treatment, Vienna, Austria
American Journal of Industrial Medicine
Vol. 24:587-592, 1983
Common pesticide reduces sperm countLower sperm counts and obvious damage to the quality of the sperm producing part of the testicles (called the seminiferous tubules), were found in test posed to the pesticide chlordane.
Drs. Khawla J. Balash, Muthanna A. Al-Omar
Univ. of Baghdad, Biological Research Center
Scientific Research Council, Baghdad, Iraq
Bulletin of Environmental Contamination Tox.
Vol. 39:434-442, 1987
Infertility caused by pesticide found in the air of most homes built before March 1988Approximately 75% of U.S. homes are being being found to contain the pesticide chlordane in the breathable air. Of significant concern, over 5% of homes built before March of 1988 have been found to have air levels of the pesticide chlordane above the "safe" level of 5 micrograms per cubic meter. (In homes built before 1980 this is over 20%!). If you would like more detailed information on the chlordane problem and how infertility could be caused by living in one of these homes you can visit the chlordane web site at www.chem-tox.com/chlordane
Drs. Samuel S. Epstein, David Ozonoff
School of Public Health, University of Illinois Medical Center, Boston University School of Public Health, Boston, MA
Teratogenesis, Carcinogenesis, & Mutagenesis
Vol. 7:527-540, 1987
Dangerous autoantibodies higher in pesticide exposed peopleThe pesticide Chlorpyrifos (Dursban) was found to cause increases in autoimmune antibodies in people exposed to the pesticide. Autoantibodies are "renegade" immune system components which mistakenly attack the persons own self. (Please see other references in this report which link some cases of male and female infertility to autoimmune disorders in which the immune cells attack either the sperm or egg.
Drs. Jack D. Thrasher, Roberta Madison et. al.
Department of Health Science
California State University
Archives of Environmental Health
Vol. 48(2), 1993 March/April
Car exhaust decreases fertility.The common car exhaust compound benzo(a)pyrene (BaP) causes a significant reduction in fertility in test animals and fertility was further lowered when animals were exposed to both BaP and lead simultaneously. Results showed approximately a 33% reduction in ovarian weight and a "marked reduction in ovarian follicles."
Drs. P. Kristensen, Einar Eilertsen, et al.
National Institute of Occupation Health, Norway
Environmental Health Perspectives
Vol. 103:588-590, 1995
Coffee decreases fertilityA study of 1,909 women in Connecticut found the risk of not conceiving for 12 months (the usual definition of infertility), was 55% higher for women drinking 1 cup of coffee per day - 100% higher for women drinking 1 and one-half to 3 cups and 176% higher for women drinking more than 3 cups of coffee per day.
Hatah (1990)
This study referenced by-
Drs. Larry Dulgosz, Michael B. Brachs
Yale University School of Medicine
Epidemiologic Reviews
Vol. 14, pg. 83, 1992
Coffee increases miscarriage riskCoffee drinking before and during pregnancy was associated with over twice the risk of miscarriage when the mother consumed 2-3 cups of coffee per day.
Dr. Claire Infante-Rivard Department of Occupation Health Faculty of Medicine McGill University, Quebec Canada Journal of the American Medical Association December 22, 1993
Coffee reduces blood to the brainCoffee drinking caused a 20-25% reduction in blood flow to the brains of healthy college volunteers 30 minutes after drinking 250 milligrams of caffeine (about the amount in a freshly brewed cup of coffee).
Dr. Roy J . Mathew
Vanderbilt University, Nashville, Tennessee
British Journal of Psychiatry, December, 1984
Spontaneous abortion after chemical exposureSpontaneous abortion increased over 4-fold for women once they became employed as microelectronics assembly workers. This job was found to subject women to a number of chemical solvents used in cleaning the electronic components including xylene, acetone, trichlorethylene, petroleum distillates and others, as well as solder vapors. Acetone is also used in removing nail polish.
Drs. G. Huel, D. Mergler, R. Bowler
Quebec Institute for Research in Occupational Health and Safety, University of Quebec, Canada
Occupational Medicine Clinic, University of California, San Francisco, California
British Journal of Industrial Medicine
Vol. 47:400-404, 1990
Cocaine and abnormal offspringCocaine exposure to males before conceiving is linked to abnormal development in offspring. The suspected cause is that cocaine binds onto the sperm and therefore, finds its way into the egg at fertilization.
Dr. Ricardo Yazigi
Department of Obstetrics and Gynecology
Washington University School of Medicine
Journal of the American Medical Association
Vol. 66(14), Oct. 9, 1991
MSG greatly reduces pregnancy successMSG (Monosodium Glutamate), a common flavor enhancer added in foods, was found to cause infertility problems in test animals. Male rats fed MSG before mating had less than a 50% success rate (5 of 13 animals), whereas male rats not fed MSG had over a 92% success rate (12 of 13 animals). Also the offspring of the MSG treated males showed shorter body length, reduced testes weights and evidence of overweight at 25 days. MSG is found in ACCENT, flavored potato chips, Doritos, Cheetos, meat seasonings and many packaged soups.
Drs. William J. Pizzi, June E. Barnhart, et. al.
Department of Psychology
Northeaster Illinois University, Chicago, Illinois
Neurobehavioral Toxicology
Vol. 2:1-4, 1979
"20-25% of miscarriages are due to immune system problems."
Dr. Salim Daya
The Fertility Clinic
Chedoke-McMaster Hospital, Ontario
Chatelaine Magazine, November, 1993
Miscarriages higher after chemical solvent exposureTwo solvent chemicals exposed to working pregnant mothers making silicon chips had a 33% miscarriage rate where normally the miscarriage rate is 15%.
Time Magazine
October 22, pg. 27,1992
Male infertility and chemicals in drinking waterDrinking water from the Thames Water Supply in the United Kingdom was pinpointed as the cause of lower sperm counts and increases in abnormally shaped sperm. Common detergents were the chemical suspected as causing the reproductive damage.
Dr. Jean Ginsburg
London Royal Free Hospital
Lancet, Jan. 22
Anesthesia linked to birth defectsBirth defects occurred nearly 3 times more often in a study of 621 Michigan nurse anesthetists (a nurse who helps with anesthesia preparation). A total of 16.4% of the nurses practicing anesthesia during pregnancy had children with birth defects compared to only 5.7% of nurses not practicing anesthesia.
Drs. Thomas H. Corbett and Richard Cornell
Assistant Professor, University of Michigan
Anesthesiology, 41(4), 1974
Dr. Eli Gea
In Vitro Fertilization Unit
Serlin Maternity Hospital
Tel Aviv, Israel
Fertility Sterility Journal, 62(4), October, 1994
Risks from medical fertility treatmentsA common treatment for infertility is administration of follicle stimulating hormones. Regarding this treatment researchers stated, "Persistent stimulation of the ovary by gonadotropins may have a direct carcinogenic effect or an indirect effect attributable to raised concentration of estrogens."
Department of Obstetrics & Gynecology,
Radbond University, Netherlands
Lancet, April 17, 1993, pg. 987
Alcohol reduces fertilization successA large 50% reduction in conception was found in experiments of test animals given "intoxicating" doses of alcohol 24 hours prior to mating.
Dr. Theodore J. Cicero
Washington University School of Medicine
Science News, Vol. 146
In Vitro Fertilization (IVF) success rates depend on the woman's age:
under 35 years....... 45-50% success
35-40 years............ 28-35% success
age 41..................... 20% success
42 and older........... 3% success
The cost of IVF can exceed $8,000- (IVF is fertilization taking place in a "test tube" after removal of a woman's egg).
Dr. Rosenwaks
New York Hospital
Cornell Medical Center
Redbook Magazine, August, 1993
Studies of painters found they are more likely to father children with defects of the central nervous system
Dr. Andrew Olshan
University of North Carolina, Chapel Hill
U.S. News & World Report, December 14, 1992
Dental Workers have over twice the normal number of problems with pregnancyMore spontaneous abortions, stillbirths, and congenital defects occurred in dentists and dental assistants compared with the control group (24% compared to 11%, respectively). Five out of six malformations were spina bifida.
Drs. Birgitte Blatter, Marjolihn van der Star, Nel Roeleveld
Department of Medical Informatics and Epidemiology, University of Nijmegen, Netherlands
International Archives of Occupational & Environmental HealthVol. 59:551-557, 1987
Marijuana use at "moderate" levels was found to stop ovulation in monkeys for 103 to 135 daysResearchers also stated that the THC in marijuana may be directly toxic to the developing egg. Dr. Carol Smith, the main researcher, stated, "There are nervous pathways into the hypothalamus (a gland that regulates the reproductive cycle) that are being suppressed."
Dr. Smith also stressed that women who are attempting to conceive or who are pregnant should not use marijuana.
Dr. Carol Grace Smith
Uniformed Services University of the Health Sciences, Bethesda, Md.
Ricardo Asch, University of Texas, Austin
Science, March 25, 1983
Also reported in Science News, March 26, 1983
Sperm damage was about 50% higher in test posed to the anesthesia enflurane. Anesthesia levels given to the animals was equal to the level that could be given to humans.
Dr. Paul C. Land and E. L. Owen
Department of Anesthesia, Northwestern University Medical School, Chicago, Illinois
Anesthesiology, 54:53-56, 1981
Quotes from the Harvard Health Letter:
"8-10% of sperm from healthy men are abnormal, some carry the wrong chromosome while others have bits and pieces of genetic material out of place."
"Because a child conceived by intoxicated parents was thought to be unhealthy, the ancient cities of Carthage and Sparta had laws prohibiting the use of alcohol by newlyweds."
"The earliest evidence of a link between job occupation and reproductive problems came out in 1860 when a French scientist noted that wives of lead workers were less likely to become pregnant, and if they did were more prone to miscarrying."
"A survey of animal data indicates that paternal (father) exposure to environmental toxins - ranging from recreation drugs to industrial chemicals - apparently contribute to problems ranging from fetal loss and stillbirth to diminished aptitude for learning to perform tasks such as running a maze."
Harvard Health Letter
October, 1992
Other Points from the Harvard Health Letter:
Men who work in aircraft industry or handle paints or chemical solvents have higher risk of producing children with brain tumors.
"Father exposure to paints linked to childhood Leukemias."
Firemen appear to produce an unusually high number of abnormal sperm and be less fertile than other males. (This is believed to be due to the toxic smoke which results when carpets, furniture and paints are burned - of which today are made from synthetic/plastic based compounds).
(page 6 of above reference)
Miscarriages warn of genetic damage90% of fetuses with malformations are spontaneously aborted during early pregnancy. 60% of first trimester spontaneous abortions have chromosome abnormalities.
Dr. Frank M. Sullivan
Department of Pharmacology and Toxicology
University of London
Environmental Health Perspectives
101(Suppl.2):13-18, 1993
Little is known on the reproductive dangers of chemicalsRegarding chemicals in the workplace, the Organization for Economic Cooperation and Development (OECD) and the European Economic Community (EEC) prepared lists of several thousand chemicals produced in amounts of more than 1000 tons per year and many produced at 10,000 tons/year. "Toxicological data of any type exist for a few hundred and reproductive toxicology data exist for probably 100."
Dr. Frank M. Sullivan
Department of Pharmacology and Toxicology
University of London
Environmental Health Perspectives
101(Suppl.2):13-18, 1993
Miscarriage increases from chemical solvents:
The major risk chemicals were:
perchlorethylene (dry cleaning)..... 4.7 times greater risk
trichloroethylene (dry cleaning)..... 3.1 times greater risk
paint thinners ............................... 2.1 times greater risk
paint strippers ............................... 2.1 times greater risk
glycol ethers (found in paints)........ 2.9 times greater risk
Dr. Gayle C. Windham, Ph.D.
Dr. Dennis Shusterman, MD, MPH
School of Public Health
University of California, Berkely
American Journal of Industrial Medicine
Vol. 20:241-259, 1991
Further evidence chemicals damage reproduction.
Quotes from Dr. Baranski, Institute of Occupation Medicine, Denmark:
"Risk of infertility increased in females who reported exposures to textile dyes, dry cleaning chemicals, noise, lead, mercury and cadmium."
"There was a significant risk of increased time to conception among women exposed to anti-rust agents, welding, plastic manufacturing, lead, mercury, cadmium, or anesthetic agents."
"There was also an increased risk of delay to conception following male exposure to textile dyes, plastic manufacturing, and welding. Those who unpacked or handled antibiotics had a significant association with delayed pregnancy of at least 12 months."
Dr. Boguslaw Baranski
Institute of Occupational Medicine, Copenhagen, Denmark
Conference on the Impact of the Environment and Reproductive Health held in Denmark, September 4, 1991
Environmental Health Perspectives
Vol. 101(suppl 2), pg. 85, 1993
Biological reasons for infertility:
Tubal Factors.............................. 36%
Ovulatory Disorders ..................... 33%
Endometriosis.......................... ..... 6%
No known Cause......................... 40%
Dr. David Lindsay
Department of Obstetrics and Gynecology
Monash University, Melbourne, Australia
Lancet, June 18, 1994
Chromosome abnormalities occur in 26% of human oocytes (eggs) and 10% of sperm.
(above reference)
"Recurrent miscarriage is associated with parental chromosome abnormalities, antiphospholipid antibodies and uterine cavity abnormalities. Premature ovarian failure (inability of ovaries to produce eggs) may be genetically determined or associated with autoimmune disease."
Dr. David Lindsay
Department of Obstetrics and Gynecology
Monash University, Melbourne, Australia
Lancet, June 18, 1994
Stillbirth, preterm delivery and small birth weight were higher in certain jobs with chemical exposures in a study of 2,096 mothers and 3,170 fathers.
Women working in rubber, plastics or synthetics industry had an 80% greater chance of stillbirth. Father employment in the textile industry (chemical dyes, plastics, formaldehyde, etc.) resulted in their wives having a 90% greater risk of stillbirth. Exposure of the father to the chemicals polyvinyl alcohol and benzene (found in gasoline, cleaning solvents, adhesives and oil based paints) was associated with a 50% increase in preterm delivery.
Study funded by the March of Dimes
Drs. David A. Savitz, Elizabeth A. Whelan and Robert C. Kleckner
School of Public Health, University of NC
American Journal of Epidemiology
Vol. 129(6):1201-1218, 1989
Chemicals found to mimic human estrogens.
A proper balance of natural estrogens in the body is essential for reproductive success. However, reports have been suggesting that environmental estrogens (chemicals which "mimic" our natural estrogens) are creating infertility problems by confusing the body's estrogen receptors. Some pesticides have already been shown to be environmental estrogens. New research shows that more chemicals are being found to be environmental estrogens including the food additives butylated hydroxyanisole (BHA) Other chemicals found to be somewhat estrogenic include, PVC plastics.
Dr. Susan Jobling, Tracey Reynolds, Roger White, Malcolm G. Parker, and John Sumpter
Department of Biology and Biochemistry
Laboratory of Molecular Endocrinology
Brunel University, London
Environmental Health Perspectives
Vol. 103:582-587, 1995
The report is absolutely a "must-have" for every couple having difficulty conceiving. It includes all of the above listed studies as well as additional medical summaries and analysis of the scientific research showing how common chemicals in the home and job can seriously weaken the reproductive processes. Certainly, having this research available together in one easy to read report will greatly increase a couples chance of success (and spouse cooperation...).
Any couple reading this report together will have a completely new outlook regarding the fragility of conception. By laying out the research - study after study - it is sure to encourage modification of lifestyle habits of either spouse. By transferring awareness into real-life changes, couples will greatly improve their odds of conception by removing circumstances found to weaken or damage the reproductive processes. The report exposes the serious lack of testing regarding today's modern chemicals and also discusses the latest research showing how the same chemicals causing infertility and miscarriage can also cause child behavior and learning problems.
Some of the additional research detailed in Environmental Causes of Infertility include - evidence regarding the
1) Reproductive risks of common cosmetic chemicals -
2) Alcohol and marijuana effects -
3) Food additive studies - (specifically MSG) -
4) Pesticides and human hormones -
5) Sperm Damage from a common pesticide found in over 75% of U.S. homes -
6) Relationship between sperm count and fertility -
7) Hazards from anesthesia -
8) Over 20 studies on the infertility effects of coffee and
9) A fascinating1960 study showing how consumption of certain food types is apparently able to damage the sperm development process.
WHEN TO SEEK MEDICAL ADVICE
In general, don't be concerned about infertility unless you and your partner have been trying to conceive regularly for at least one year. However, if you're a woman older than 30 or haven't had a menstrual flow for longer than six months, seek a medical evaluation. If you have a history of irregular or painful menstrual cycles, pelvic pain, endometriosis, pelvic inflammatory disease (PID) or repeated miscarriages, schedule a consultation with your doctor sooner. If you're a man with a low sperm count or a history of testicular, prostate or sexual problems, consider seeking help earlier.
SCREENING AND DIAGNOSIS:
If you and your partner are unable to achieve conception within a reasonable time and would like to do so, seek help. The woman's gynecologist, the man's urologist or your family physician can determine whether there's a problem that requires a specialist or clinic that treats infertility problems.
One-fourth of infertile couples have more than one cause of their infertility. Thus, your physician will usually begin a comprehensive infertility examination of both you and your partner.
Before undergoing infertility testing, be aware that a certain amount of commitment is required. Your physician or clinic will need to determine what your sexual habits are and may make recommendations about how you may need to change those habits. The tests and periods of trial and error may extend over several months.
Evaluation is expensive and in some cases involves operations and uncomfortable procedures, and the expenses may not be reimbursed by many medical plans. Finally, there's no guarantee, even after all testing and counseling, that conception will occur. However, for couples who are eager to have their own child, such an evaluation is best. It may result in a successful pregnancy.
Tests for Both
The man's evaluation focuses on the number and health of his sperm. The laboratory first examines a sperm sample under a microscope to check sperm number, shape and movement. Further tests may be needed to look for infection, hormonal imbalance, or other problems.The first step to treat infertility is to see a health care provider for a fertility evaluation. He or she will test both the woman and the man, to find out where the problem is. Testing on the man focuses on the number and health of his sperm. The lab will look at a sample of his sperm under a microscope to check sperm number, shape, and movement. Blood tests also can be done to check hormone levels. More tests might be needed to look for infection, or problems with hormones.
Male tests include:
· X-ray: If damage to one or both of the vas deferens (the ducts in the male that transport the sperm to the penis) is known or suspected, an x-ray is taken to examine the organs.
· Mucus penetrance test: Test of whether the man's sperm are able to swim through a drop of the woman's fertile vaginal mucus on a slide (also used to test the quality of the woman's mucus).
· Hamster-egg penetrance assay: Test of whether the man's sperm will penetrate hamster egg cells with their outer cells removed, indicating somewhat their ability to fertilize human eggs.
For the woman, the first step in testing is to determine if she is ovulating each month. This can be done by charting changes in morning body temperature, by using an FDA-approved home ovulation test kit (which is available over the counter), or by examining cervical mucus, which undergoes a series of hormone-induced changes throughout the menstrual cycle.
Checks of ovulation can also be done in the physician's office with simple blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, further testing will need to be done.
Testing for the woman first looks at whether she is ovulating each month. This can be done by having her chart changes in her morning body temperature, by using an FDA-approved home ovulation test kit (which she can buy at a drug store), or by looking at her cervical mucus, which changes throughout her menstrual cycle. Ovulation also can be checked in her health care provider's office with an ultrasound test of the ovaries, or simple blood tests that check hormone levels, like the follicle-stimulating hormone (FSH) test. FSH is produced by the pituitary gland. In women, it helps control the menstrual cycle and the production of eggs by the ovaries. The amount of FSH varies throughout the menstrual cycle and is highest just before an egg is released. The amounts of FSH and other hormones (luteinizing hormone, estrogen, and progesterone) are measured in both a man and a woman to determine why the couple cannot achieve pregnancy. If the woman is ovulating, more testing will need to be done.
Common female tests include:
· Hysterosalpingogram: An x-ray of the fallopian tubes and uterus after they are injected with dye, to show if the tubes are open and to show the shape of the uterus.
· Laparoscopy: An examination of the tubes and other female organs for disease, using a miniature light-transmitting tube called a laparoscope. The tube is inserted into the abdomen through a one-inch incision below the navel, usually while the woman is under general anesthesia.
· Endometrial biopsy: An examination of a small shred of uterine lining to see if the monthly changes in the lining are normal.
· Urinary luteinizing hormone (LH) detector kits. A number of at-home kits are available to test your LH level. Although these kits may be helpful, they also can be inaccurate and misleading. Consult your doctor before using one.
Not everyone needs to undergo all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.
Some tests require participation of both partners. Samples of cervical mucus taken after intercourse can show whether sperm and mucus have properly interacted. Also, a variety of tests can show if the man or woman is forming antibodies that are attacking the sperm.
DIAGNOSTIC METHODS IN FEMALE INFERTILITY
Introduction
Any case of female infertility requires a careful and systematic anamnesis, which includes several questions that are generally not asked in the interview of most patients seen in a gynecological practice. It is after this important step that the necessary clinical investigations for the work-up of each given case can be selected in an appropriate manner in order to establish the correct diagnosis as precisely as possible and in the shortest length of time.
The three main questions to be answered are:
1. Is the patient ovulating ?
2. Are the conditions for implantation adequate ?
3. Is the morphology of the uterus and the tubes normal ?
The answers are provided by the following methods:
Clinical evidence of ovulation:
a. Basal body temperature.
b. Observation of the cervical mucus.
c. Exfoliative vaginal cytology.
d. Transvaginal sonography (ovarian follicles).
e. Pituitary and ovarian hormones assays.
f. Laparoscopy and direct observation of the ovaries.
Clinical evidence of readiness for uterine implantation:
a. Basal body temperature.
b. Transvaginal sonography (thickness of the endometrium).
c. Plasma progesterone assay.
d. Endometrial biopsy.
e. Hysteroscopy.
Clinical evidence of normality of the internal genital tract:
a. Hysterosalpingography.
b. Transvaginal sonography.
c. Hysteroscopy.
d. Laparoscopy.
CLINICAL EVIDENCE OF OVULATION
Basal body temperature (BBT)
The early morning rectal temperature will rise approximately 0.5 to 0.7°C after ovulation and stay in a "plateau" for 12 to 14 days. This rise in BBT is due to a central effect of progesterone secretion. A slight drop of BBT might be observed 24 to 48 hours before ovulation, related to the estrogen peak secreted by the mature follicle.
Observation of the cervical mucus
Under the influence of the highest level of estrogen secretion from the dominant ovarian follicle, which precedes the ovulation, one can observe an abundant, clear and fluid secretion of mucus from the cervical canal. This transient secretion slightly but obviously dilates the external cervical os. It precedes ovulation by 4 to 2 days and is greatest on the day before ovulation. This mucus is highly receptive for the sperm penetration during sexual intercourse. The cervical mucus disappears promptly after ovulation under the influence of progesterone secretion.
Exfoliative vaginal cytology
A vaginal smear, scraped from a lateral vaginal wall with an Ayres spatula or a wet cotton swab, provides a typical result at the time of ovulation, when examined under light microscope observation, after it has been stained with Papanicolaou or Schorr staining, or with any quick dye. The superficial cells of the vaginal mucosa are flat, well scattered, with pyknotic nuclei and highly eosinophilic. As soon as ovulation has taken place, the cells become coiled, packed together and mostly basophilic.
Transvaginal sonography
The sonographic picture of a preovulatory follicle is well documented and typical. The mature follicle measures from 18 to 23 mm in average inner dimension.
After ovulation, the follicular wall becomes irregular and the fresh corpus luteum usually appears as a hypoechogenic structure and may contain some echoes corresponding to internal bleeding. The wall of the corpus luteum becomes thickened as the luteinization progresses.
Pituitary and ovarian hormone assays
The secretion of LH can be detected daily in urine samples by radioimmunoassay. The LH peak usually precedes ovulation by 48 to 24 hours. At the same time, the secretion of estrogen produced by the dominant follicle, reaches a maximum in the peripheral venous blood. Soon after ovulation, the level of progesterone in the peripheral blood rises from 2.5 to 4.0 ng/ml and reaches its maximum from day 5 to day 10 after the LH peak, with a variation from 7 to 12 ng/ml. This intermediate luteal phase is the physiological time for uterine nidation. A schematic representation of the hormonal secretory patterns throughout the menstrual cycle.
Laparoscopy
A mature follicle increases ovarian size considerably and looks like a round bluish cyst with one or two capillaries seen on its surface.
After ovulation, the stigma of the follicular rupture can be easily recognized as a small hole surrounded by an hemorrhagic structure on the surface of the ovary. Scars of previous ovulations can also be recognized on the surface of both ovaries. Clear yellowish follicular fluid can be found in the pouch of Douglas.
CLINICAL EVIDENCE OF READINESS FOR UTERINE IMPLANTATION
Basal body temperature
A sustained "plateau" of 12 to 14 days following ovulation, is indicative of a good progesterone secretion from the corpus luteum, at least of 4 ng/ml in the peripheral blood.
Transvaginal sonography
The thickness of the secretory endometrium can be precisely measured. At its thickest, it reaches 8 to 14 mm, including both layers, and should be echogenic in a regular manner.
Plasma progesterone assays
In order to have a good evaluation of the secretion of the corpus luteum, one should obtain at least three to four blood samples, for instance every other day, starting from the third postovulatory day.
Endometrial biopsy
The tissue sample should be aspired either with a Novak cannula or with a plastic Cornier’s Pipelle around the time when nidation normally takes place, which means between day 20 to 22 of the cycle. Dating of the endometrial biopsy requires strict histological criteria.
Hysteroscopy
Using a small hysteroscope of 5 mm or 3 mm of diameter, an hysteroscopic examination of the uterine cavity can be easily performed on an out-patient basis in a clinic or in the office, with or without anesthesia. The examination can rule out the presence of uterine polyps, synechiae, or endometritis, all of which could interfere with nidation.
Hysterosalpingography
As in the case of other medical methods of investigation, strict technique is necessary in order to obtain precise information. A perfectly frontal view and also a good lateral view of the uterus, with a position of the uterus body being strictly parallel to the radiological film, is necessary to appreciate the size, the morphology and the outline of the uterine cavity.
A lateral view of a correct exposure of both tubes gives more information on their morphology than the frontal view. Also, the lateral view gives a better picture of the isthmic segment of the uterus and of its width in case of a suspected incompetence of the internal cervical os.
Until fibroscopic tools have been utilized enough and a sufficient optical knowledge on the inside morphology of the fallopian tubes has been accumulated, hysterosalpingography remains the only way to investigate the intramural segment and the isthmic segment of the fallopian tubes.
Pelvic adhesions can only be demonstrated by this radiological method, if a sufficient amount of opaque medium has been spread into the pelvis or, better, if a complementary hydrotubation with sterile saline is used at the end of the procedure, and if the last picture is taken after the patient has been leaned alternately on each side for a few minutes ("brassage").
Transvaginal sonography
With the use of a vaginal sound, we can now easily measure the size of the uterus, and observe the structure of the endometrium and of the myometrium. Polyps, myomas, internal synechiae and congenital malformations are well documented in specialized text books. Ovarian cysts and sactosalpinx can also be easily recognized with transvaginal sonography.
Hysteroscopy
With this method, using either CO2 gas or saline solution as a dilatation medium, the entire uterine cavity can be explored, and pathological findings detected, even those which can be sometimes missed with the hysterosalpingography. The openings of the fallopian tubes in the uterine cavity can also be observed and demonstrated to be free of any obstacle as polyp or fibrotic tissue.
Laparoscopy
Trans- or paraumbilical laparoscopy remains the most complete method to explore the anatomical situation of both fallopian tubes and their relation with the adjacent ovaries. By means of direct optical observation, one can detect unsuspected peritubal and periovarian adhesions, or asymptomatic endometriosis, or agglutination of the fimbriae of the distal portion of the tubes.
With the advent of fine fibrotic catheters, introduced into the open fallopian tubes under laparoscopic control, we should be able to examine the internal appearance of the ampullary segments and detect small internal adhesions or post-inflammatory atrophy of the tubal epithelia.
In about one-fifth of infertile couples, no specific cause is found (unexplained infertility). Couples receiving the diagnosis of unexplained infertility are more likely to seek multiplehealth care providers and be influenced by the experiences of family and friends or literature that promises new hope. Although infertility is unexplained, the pregnancy rate for these couples is among the highest.
POSSIBLE COMPLICATIONS
These includes:
· Psychological distress caused by feelings of guilt, inadequacy, and loss of self-esteem.
· Treatment costs are high and often not covered by insurance.
· The unknown and possible long-term effects of medications used to increase fertility.
Other possible complications of being infertile often involve strong emotions and may trigger negative feelings between you and your partner.
These may include:
•Depression
•Guilt
•Anger
•Disappointment
•Resentment
•Blame
•Fear of losing partner because of infertility
•Diminished confidence and self-esteem
WHEN TO CALL A DOCTOR
Consult with your health professional if:
•You want children but have been unable to become pregnant after 1 year of having sex without using birth control.
•You are a woman over age 35 who has been unable to become pregnant after about 6 months of sex without using birth control.
•You have had several miscarriages in a row.
Watchful Waiting:
Before seeking medical help with conception, try to increase your chances of becoming pregnant by practicing fertility awareness and following the suggestions in the Home Treatment section of this topic.
Who To See:
The following health professionals can help you evaluate whether a fertility problem is present, provide some preliminary guidance, and discuss general testing and treatment options. You can also use this appointment to provide a sperm sample for evaluation, one of the first tests in a routine infertility workup.
•Family practitioner
•Internist
•Nurse practitioner
MANAGEMENT
Health ToolsHealth tools help you make wise health decisions or take action to improve your health.
Help and Decision Points
Within the course of every illness or health problem, you have to make decisions—little decisions about whether to call a doctor and what self-care is best, and big
decisions about medications, tests, and surgeries. Decision Point topics focus on medical care decisions you may face.
Decision Point topics help you understand the key information and important issues related to your decision. Before you can make an informed decision it's important that you:
•Fully understand the medical problem and testing or treatment options.
•Consider your personal values and preferences.
This information will help you work in partnership with your doctor. When both you and your doctor participate in the decision-making process, you'll reach the decision that best fits your needs and concerns.
This image identifies links to Decision Points, which generally appear in the Treatment Overview or the Exams and Tests section of selected topics. Decision Points can also be found in the Health Tools section of a topic.
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Key points are the core of a decision. They capture the most important information in the Decision Point and present it in an easy-to-understand format. Often, key points summarize compelling medical information, offer a concise look at risk versus benefit, illustrate a desirable outcome (either short term or long term), cite a professional recommendation, or even offer commonsense advice. The remaining sections in the
Decision Point support the statements made in the key points.
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The “Your Information” section helps you decide about your personal comfort level and preferences about the decision. This section has a table that lists the pros and cons of the decision. Personal stories about people who chose the treatment option and those who did not choose it are included.
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The “Wise Health Decision” section includes a worksheet with statements about your options. Choosing “yes” or “no” for each statement helps you understand how you are feeling about the decision.
Should You consider adoption as an alternative to infertility treatment? Introduction
This information will help you understand your choices as you consider adoption.
Key points in making your decision
If you have had infertility problems and are thinking of adopting a child, consider the following while making your decision:
•Successful adoption and long-term parenting requires the commitment of both partners and a dependable support system. The need for a solid support system is even more important for a single adoptive parent.
•There are many adoption options available to Americans, both domestically and abroad. The Internet can be an efficient and useful tool for researching adoption information.
•The adoption application and placement process can be as time-consuming and
-expensive as infertility treatment. While a U.S. or international infant adoption can take a year or longer, a U.S. minority adoption can take less than a year.
•Some adoption agencies have parental age and other restrictions for infant adoption. If you are in your mid-30s and are considering infant adoption, you may have to weigh agency requirements against your own timeline for starting an adoption process.
If you need more information about infertility treatment for comparison with adoption options.
Should You have a tubal procedure or in vitro fertilization for tubal infertility? Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
If you have a fallopian tube problem and are unable to become pregnant, you may be considering a fallopian tube procedure, in vitro fertilization (IVF), or both. When making your decision, consider the following:
•A fallopian tube procedure can reverse the cause of infertility. If a tubal problem is the only cause of your infertility and surgery is successful (you conceive a healthy pregnancy), you shouldn't need further infertility treatment.
•In vitro fertilization (IVF) does not reverse infertility. You need to undergo an IVF cycle for each pregnancy attempt.
•If a tubal procedure is unsuccessful (you conceive an ectopic pregnancy or not at all), you may need IVF to become pregnant.
•Tubal disease that causes a hydrosalpinx requires a fallopian tubal procedure. Fluid that drains from a hydrosalpinx into the uterus greatly reduces your chances of becoming pregnant, either naturally or with IVF.
•IVF is used to bypass a fallopian tube problem (non-hydrosalpinx) and may result in a shorter conception time than would surgery.
•Your likelihood of successful tubal infertility treatment is unique to your situation and therefore difficult to predict. Your chances of conceiving and carrying a healthy pregnancy to term are influenced by how severe your tubal problem is, your age, and any other fertility problems you or your partner might have.
Should You have infertility testing? Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
If you and your partner have been having trouble getting pregnant, it's possible that one or both of you has a medically treatable fertility problem. As you decide whether to look for a cause, you will have various medical and personal questions to consider. Together, you can use this Decision Point to guide your thinking. It offers basic facts about infertility, testing, and when testing is appropriate. You can also use it to define your personal goals, feelings, and values about infertility testing and treatment.
Consider the following when making your decision:
•If you are younger than 30 and trying to conceive, most doctors recommend well-timed intercourse for at least a year before considering testing and treatment.
•If you (woman) are closer to 35, it's reasonable for both you and your partner to consider testing for treatable causes of infertility sooner, before age-related factors make it too difficult to conceive.
•Infertility testing and treatment can be difficult, sometimes traumatic, and expensive. Before starting infertility testing together, discuss how far you would be willing to go with testing and treatment. Only have testing for conditions that you are willing and financially able to have treated or that would help you move on to other options such as adoption.
•Prolonged infertility testing and treatment can intensify the stress of infertility. If you are becoming overly stressed or your relationship is suffering, ask your doctor to recommend a professional counselor who can help you get through this crisis together.
As a couple, you have the final word on how to use your infertility test results based on your medical information, goals, and values.
Should You have infertility treatment? Introduction
This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor's recommendation.
Key points in making your decision
After having testing for a cause of infertility, your next step is considering your doctor's recommendations about what to do next. Perhaps your tests have identified a problem, and a potentially effective treatment is available. Or, your test results are normal, finding no obvious reason why you shouldn't be able to conceive. In this case, you may be deciding whether to have more testing, try a treatment for "unexplained infertility," or continue trying to conceive naturally. In any case, you may also be considering adoption as a family planning alternative.
This decision module can help you consider the various medical and personal questions that are related to infertility. It offers you information about infertility, treatment options according to condition, risks of those options, and general outcome information. After reviewing this information, you and your partner can use the worksheet to guide your thinking as you decide what to do next.
Consider the following when making your decision:
•A man's fertility is not known to be severely affected by age. A woman's fertility gradually drops from her mid-30s into her 40s, due in great part to the natural aging of the egg supply.
•In 10% to 15% of couples, no cause of infertility is found (unexplained infertility).1 Of all couples with unexplained infertility who do not seek treatment, about 35% will naturally become pregnant within 3 years, and 45% do so within 7 years.2
•The crisis of infertility can be intensified by its treatment, which can be difficult, expensive, and sometimes traumatic. Make a point of:
•Defining your limits for infertility treatment in advance. During infertility treatment, regularly evaluate your emotional, financial, and physical well-being.
•Considering professional counseling. Prolonged infertility testing and treatment can intensify the stress of infertility itself. If you are becoming depressed or overly stressed, or your relationship is suffering, seek professional counseling to help you get through this crisis together.
•Fertility clinic success rates vary. When considering treatment success rates, be aware that many are given in terms of pregnancies conceived. Pregnancy rates do
-not reflect the fact that some pregnancies miscarry. In any group of women, live birth rates are lower than early pregnancy rates.
Treating infertility :
You should talk to your health care provider about your fertility if you:
•are under 35 and, after a year of frequent sex without birth control, you are having problems getting pregnant, or
•are 35 or over and, after six months of frequent sex without birth control, you are having problems getting pregnant, or
•believe you or your partner might have fertility problems in the future (even before you begin trying to get pregnant).
General measures:
•Diagnostic tests may include laboratory studies, such as blood studies of hormones; pelvic examination; hysterosalpinogram (x-ray study of the genital tract); postcoital test (PCT), which is a study of the cervical mucus performed 2 to 12 hours after intercourse; endometrial biopsy to rule out luteal phase defect (a defect in hormone production) and possibly others.
•Surgical diagnostic procedures, such as laparoscopy (use of a small lighted telescope) to examine reproductive organs.
•Keep a basal body-temperature chart to become familiar with your ovulation pattern. Have intercourse just before ovulation, which can be determined from the chart.
•Psychotherapy or counseling, if marital problems exist.
•Don't use a lubricant during sexual relations. Lubricants may interfere with sperm mobility.
•Your partner should withdraw his penis quickly from your vagina after ejaculation. If left in, it reduces the number of sperm that can swim toward the egg.
•After your partner's ejaculation, place pillows under your buttocks to provide an easier downhill swim for the sperm.
•Maintain a positive attitude. Worry and tension may contribute to infertility.
•Alternate pregnancy methods include in-vitro fertilization (IVF) in which eggs from the female are harvested, impregnated with sperm from the male, and implanted in the uterus; GIFT or ZIFT (gamete or zygote intrafallopian transfer) which are implant procedures involving female egg and male sperm; intracytoplasmic sperm injection (ICSI) whereby a single sperm is injected into a single egg and the resulting zygote is transferred to the uterus.
Medication :
•Hormones for a hormone imbalance.
•Gonad stimulants such as clomiphene, menotropins (Pergonal), human chorion gonadotropin (hCG), leuprolide (Lupron) or urofollitropin. Recognize that fertility drugs may cause multiple births.
Activity:
•Work and exercise moderately. Overexercising may contribute to infertility. Rest when you tire.
Diet :
•Eat a normal, well-balanced diet. If you are overweight, try to achieve your ideal weight.
Notify your Midwife or Health care provider if...
•You or a family member has symptoms of infertility and wants help.
•Conception doesn't occur within 6 months, despite recommendations and treatment.
•New, unexplained symptoms develop. Hormones used in treatment may produce side effects.
Drugs and Surgery :
Different treatments for infertility are recommended depending on what the problem is. About 90 percent of cases are treated with drugs or surgery. Various fertility drugs may be used for women with ovulation problems. It is important to talk with your health care provider about the drug to be used. You should understand the drug's benefits and side effects. Depending on the type of fertility drug and the dosage of the drug used, multiple births (such as twins) can occur in some women. If needed, surgery can be done to repair damage to a woman's ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery.
Management of Male Infertility:
Some 15 to 20 percent of couples are still trying to conceive a baby after a year of unprotected intercourse. While many people put most of the blame on women, statistics show that this is a shared problem with male factors involved in more than 50 percent of these infertility cases.
The reassuring news for men is that urologists have a variety of tools and techniques to correct many infertility problems including: hormone manipulation to raise testicular testosterone levels, artificial insemination, medications to counter retrograde ejaculation and microsurgical techniques to undo damage caused by blockages in the epididymis or vas deferens — not to mention correction of swollen veins in the scrotum called varicoceles.
But which problem affects you? More importantly, which treatment will work? The information below should help you discuss male infertility with your urologist and partner.
What occurs under normal conditions?
The male reproductive system is designed to manufacture, store and transport sperm — the microscopic genetic cells that fertilize a woman's ovum. A number of hormones, the most important of which are testosterone and follicle-stimulating hormone (FSH), regulate that process. Like sperm, testosterone is produced in both testicles, organs suspended in a pouch-like skin sac — the scrotum — below the penis.
Sperm production begins when immature cells grow and develop within a network of delicate ducts — microscopic seminiferous tubules — inside the testicles. Because these new sperm cannot move initially on their own, they are dependent on adjacent organs to become functional. They mature while traveling through the epididymis, a coiled channel located behind each testicle.
When climax, or orgasm, occurs, sperm are carried out of the body via semen, a fluid composed of secretions from various male reproductive glands, most notably the prostate and paired seminal vesicles.
What are the causes of male infertility?
Developing and transporting mature, healthy, functional sperm depends on a specific sequence of events occurring in the male reproductive tract. Many disturbances can occur along that path, preventing cells from maturing into sperm production or reaching the woman's fallopian tube where fertilization occurs.
For starters, your infertility may be caused by a diminished output of sperm by your testicles. Abnormal sperm production can also be triggered by genetic factors and a number of lifestyle choices (e.g., smoking, alcohol, and certain medications), all of which impair the normal production of sperm cells, which, in turn, decreases their number.Long-term illnesses (e.g., kidney failure), childhood infections (e.g., mumps), and hormonal or chromosomal deficiencies (e.g., insufficient testosterone) can also account for abnormal sperm numbers.
Perhaps the most prevalent sperm production problem, however, is linked to structural abnormalities, most notably varicoceles. A snake-like bundle of enlarged or dilated varicose veins around the testicles; varicoceles are the most common identifiable cause of male infertility. They are found in about 15 percent of normal males and in approximately 40 percent of infertile men, most often on the left side or simultaneously on
-both sides. A single, right-sided varicocele is rare. Evidence suggests that by creating an abnormal backflow of blood from the abdomen into the scrotum, triggering a rise in testicular temperature, varicoceles hinder sperm production and cause oligospermia.
Your chances of fathering a child are non-existent if your semen has no sperm to transport. Azoospermia, which accounts for 10 to 15 percent of all male infertility, refers to a complete absence of such sperm cells in your ejaculate. In its "non-obstructive" form, azoospermia can be triggered by various hormonal or chromosomal deficiencies often linked to testicular failure. But just as likely, it is the result of damage to some portion — the epididymis, vas deferens, or ejaculatory duct — of the reproductive delivery system. In fact, 40 percent of azoospermia sufferers are diagnosed with an "obstructive" form, caused by either congenital or acquired problems like infections. Vasectomy, the chief contraceptive method available to men today, is a primary example of
-an acquired factor. By cutting and sealing the vas deferens to stop sperm from moving through the reproductive tract, pregnancy is prevented. Vasectomies can often be reversed by use of a vasovasotomy in the hands of an experienced urologic microsurgeon. The blockage may be permanent, however, if the extent of the damage is great and the doctor is unskilled. While vasectomies are a formidable factor, there are other potential disturbances within the reproductive tract that can impede sperm.Because a proper erection is essential in impregnating any partner, it is not surprising that impotence or erectile dysfunction (ED), the inability to sustain an erection, is the most easily identified sexual problem linked to male infertility. Retrograde ejaculation, a lesser known issue, involves the improper deposit of sperm and semen. In this case, your ejaculate content may be normal, but instead of leaving the penis for the vagina, it flows backwards into the bladder due to an improperly functioning bladder neck.
How is male infertility diagnosed?
Unlike female infertility, the cause of which is often easily identified, diagnosing male factors can be difficult. The problems, however, usually fall in one of two areas — sperm production and/or delivery.
Because male infertility results from such varied factors, you will need to see your physician to sort out the possibilities. A primary care doctor can often locate the problem, correctable or not, by completing an initial evaluation. You will probably need further evaluation by a urologist or reproductive specialist if you and your partner have been trying unsuccessfully for a year to get pregnant or if you have a known male factor, such as an undescended testicle.
In any case, the evaluation usually includes medical and surgical histories. The doctor will want to know about childhood diseases (e.g., mumps), current health problems (e.g., diabetes), or even medications (e.g., anabolic steroids) that might interfere with the formation of sperm. He or she will also ask about your use of alcohol, marijuana and other recreational drugs, as well as your exposure to the occupational hazards of ionizing radiation, heavy metals and pesticides. All of these factors can affect fertility.
Every evaluation will also include an assessment of your sexual performance, along with you and your partner's joint efforts to achieve pregnancy. For instance, your doctor will investigate whether you have had difficulty with erections and if your ejaculate has sufficient quality and volume. Such factors can adversely affect your sperm's effectiveness for pregnancy.
In addition to conducting a general exam, your doctor will look for any abnormalities of the penis, epididymis, vas deferens, and testicles. He or she will focus specifically on varicoceles, which can be identified easily in the scrotum when the patient is standing because they feel like a "bag of worms."
Semen analysis is a routine test that is the single most important lab indicator for male infertility. Completed twice, it helps urologists define each factor and its severity. Performed by examining ejaculate within a few hours of masturbation, a semen analysis provides important information about semen volume and content. It also measures the amount, motility (movement) and appearance (shape) of individual sperm. Each factor tells you and your doctor much about your ability to conceive. Your semen is normal, for instance, if it liquefies from a pearly gel into a liquid within 20 minutes. A breakdown in this sequence may indicate a problem with your seminal vesicles. Likewise, a lack of fructose (sugar) in a sperm-free specimen may indicate a congenital absence of the seminal vesicles or your ejaculatory duct may be entirely blocked.
In addition to the above screens, your doctor may order other tools to assess fertility, including transurethral ultrasonography, which detects ejaculatory duct obstructions, and testicular biopsies, which confirm any reproductive blockages. Getting a complete evaluation should help you and your partner understand your infertility issues, not to mention make better decisions about treatment.
What are some treatment options?
Your treatment options will depend entirely on the factors causing your infertility. The good news is that few medical fields have changed as dramatically during the past decades as reproductive medicine, particularly as it pertains to men.
Today, many conditions can be corrected with drugs or surgery thus enabling conception to occur through normal intercourse.
Surgical Therapies for Male Infertility
Among the most exciting treatment developments are microsurgical approaches to repair dilated varicose scrotal veins to improve semen quality. You should consider treatment if you meet the following criteria:
you and your partner are trying to conceive a child, but thus far have been unsuccessful
you have been diagnosed with a varicocele that can be felt
your semen analysis or sperm function tests are abnormal
your partner has normal fertility or treatable infertility
you are contending with a varicocele and abnormal semen
you are an adolescent male with a varicocele and reduced testicle size
If you fit the profile, your doctor can correct your varicocele with any number of surgical options, all of which can be performed in an outpatient center under anesthesia. Some of these approaches include:
Retroperitoneal (or abdominal) approach:
This conventional "open" varicocelectomy is best suited to men whose previously attempted varicocele or hernia repair resulted in significant groin scarring. Complications, which occur at a rate of 5 to 30 percent, include hydroceles, testicular atrophy and injury to the vas deferens.
Laparoscopic varicocelectomy:
While this minimally invasive technique can be used successfully to isolate and repair vessels, it is accompanied by a 6 to 15 percent recurrence rate due, in part, to the preservation of a series of fine veins that may dilate with time and cause recurrence. Also, events such as intestinal injuries or infection give it an 8 to 12 percent complication rate. In addition, laparoscopy must be performed by a urologist experienced in the procedure, which is a limitation.
Microsurgical varicocelectomy:
Cited by many specialists as their preferred approach, this operation uses the optical magnification of a high-powered microscope to provide direct visual access to veins and arteries. Through a mini-incision in the groin, the doctor can reliably separate and preserve testicular arteries, while identifying and ligating both large and small veins that could dilate in the future. Also, while technically demanding, microsurgical varicocelectomy virtually eliminates hydroceles, the most common surgical complications. In fact, microsurgical techniques have significantly reduced recurrence rates to less than 2 percent and complications rates to less than 5 percent while increasing fertility. The effectiveness of this procedure has been reported in the scientific literature to be as high as a 43 percent pregnancy rate for couples after one year and 69 percent after two years.
Percutaneous embolization:
This non-surgical approach is aimed at occluding the varicocele after it is viewed with a specialized X-ray technique. The procedure itself uses a flexible tube inserted into the groin to place a blocking agent that helps obstruct the center of the vessel. This minimally invasive technique is often less painful than surgery, but it requires a physician with experience in interventional radiologic techniques. As such, it is performed in the radiology department.
There is no evidence to suggest that any approach is the best for correcting varicoceles.While surgery removes more than 90 percent of the swollen vein, percutaneous embolization gets rid of 80 to 85 percent. After repair, about 60 percent of men show
-improved sperm counts and/or motility. The effects of either treatment on fertility, however, are much less clear. While some studies show improvement, others suggest no significant change. Regardless, many infertile couples still choose varicocele repair because it improves semen in many men and may improve fertility, both at little risk.
If your semen lacks sperm (azoospermia) as a result of blockage: there are several surgical treatment options at your disposal:
Microsurgical vasovasostomy:
Is designed to restore fertility by reconnecting the severed vas deferens in each testicle. The procedure, which should clear the way for sperm to leave the body, can be accomplished through various approaches, all performed in outpatient hospital or ambulatory surgical settings under general anesthesia, spinal epidurals or sometimes with localized numbing and sedation.In more than 90 percent of patients, sperm returns in the semen, yielding pregnancy in more than 50 percent of cases.
Transurethral resection of the ejaculatory duct (TURED):
When properly diagnosed, ejaculatory duct obstructions can be managed surgically by passing a cystoscope into the urethra and opening the offending blockages. Resecting the duct triggers release of sperm into the ejaculate in about 50 to 75 percent of men. But there can be complications — recurrent blockages, incontinence and even retrograde ejaculation due to bladder injuries. Also, pregnancy rates are only about 25 percent.
Vasoepididymostomy:
The most common microsurgical procedure for treating epididymal obstructions, vasoepididymostomy is also one of the most difficult of all treatments for male infertility. Surgeons must have excellent skills and extensive experience to perform this procedure, a surgical joining of the vas deferens and epididymis to facilitate the transport of fluid. The approach relies on the precise positioning and tying of sutures to secure tissue layers between the structures. When successful, however, an opened channel is restored in 50 to 70 percent of cases; pregnancy rates vary from 25 to 57 percent.
What can I expect after treatment?
Male infertility factors can usually be corrected in an outpatient procedure using general anesthesia or intravenous sedation. While postoperative pain is usually mild, postoperative recovery and follow up varies.
After varicocele repair, your doctor should perform a physical examination to see if the vein is completely gone. Semen should be tested about every three months for at least one year or until pregnancy. If your varicocele returns, or you remain infertile after
the repair, ask your doctor about assisted reproductive techniques (ART). These high-tech procedures are often successful in circumventing the same problem to produce a pregnancy.
While vasectomy reversals cause only mild postoperative pain, expect an out-of-work recovery of four to seven days. The chance for pregnancy depends on many factors, most importantly, the age and fertility status of your female partner and the number of years between your original vasectomy and this procedure. The longer you wait, the less likely you will have a successful reversal.
How are specific male infertility conditions treated without surgery?
Anejaculation: A relatively uncommon disorder, anejaculation — or the absence of any semen — can occur as a result of spinal cord injury, previous surgery, diabetes, or multiple sclerosis. It may also be caused by abnormalities present at birth as well as other mental, emotional or unknown problems. Medical therapy with drugs is usually the first line of treatment, but if that fails, the next step is either rectal probe electroejaculation (RPE) or penile vibratory stimulation (PVS). PVS consists of rhythmic vibratory stimulation of the tip and shaft of the penis to encourage a natural climax. While relatively non-invasive, it is less successful than RPE, particularly in severe cases. RPE, except in the spinal cord injured patient, is usually performed under anesthesia and retrieves sperm in 90 percent of patients. While cell density with this procedure is excellent, sperm movement and shape are still limiting fertility factors. Assisted reproductive techniques, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), have become increasingly important to patients with anejaculation.
Congenital adrenal hyperplasia (CAH): A rare cause of male factor infertility, CAH involves congenital deficiencies in certain enzymes, resulting in abnormal hormone production. CAH is usually diagnosed by demonstrating excess steroids in the blood and urine. When treated successfully with hormone replacement, sperm production increases.
Genital tract infection: It is rare that acute genital tract infections can be linked to infertility, but it does happen in approximately 2 percent of men suffering from reproduction problems. The problem is usually picked up following a simple semen analysis where white blood cells are found. White blood cells generate excess oxidants — reactive oxygen species (ROS) — known to harm the fertilizing potential of sperm. But an infection need not be acute to cause reproductive problems. For instance, testicular atrophy, along with epididymal duct obstruction, may occur following severe infection of the epididymis and testes. Chronic prostatitis, on rare occasions, may also cause obstruction by occluding the ejaculatory ducts. While antibiotics are generally prescribed for full-blown infections, they are not warranted for lesser inflammations since they can be occasionally harmful to sperm production.In those cases, non-steroidal anti-inflammatories are usually recommended.
Hyperprolactinemia: This condition of excessive production of the hormone prolactin by the pituitary gland, has been implicated in both infertility and erectile dysfunction. Treatment of hyperprolactinemia is based on the cause of the increased secretion. If medications are the root, they should be discontinued immediately. Medical therapy may consist of medications to bring prolactin levels to normal.
Hypogonadotropic hypogonadism: Hypogonadotropic hypogonadism refers to the failure of the testicles to produce sperm due to a hypothalamic or pituitary disorder. It is the cause of infertility in a small percentage of patients and can exist at birth or be acquired. Known also as Kallmann's syndrome, the congenital form results from an abnormal production of gonadotropin-releasing hormone (GnRH), a hormone produced by the hypothalamus. Acquired hypogonadotropic hypogonadism can be triggered by a variety of other conditions, including pituitary tumors, head trauma and anabolic steroid use.
When hypogonadotropic hypogonadism is suspected, doctors usually order an MRI along with serum prolactin concentrations to rule out pituitary tumors. If levels of the prolactin are excessive but there is no mass, treatment will consist of lowering prolactin concentrations before proceeding with gonadotropin replacement therapy. During treatment, blood testosterone levels and semen analyses are obtained.Chances for pregnancy are excellent, since resultant sperm are essentially normal.
Immunologic Infertility: Since the early 1950s, when scientists first demonstrated that some cases of infertility were linked to immunologic causes, much research has focused on this area. While oral steroids to decrease significant antisperm antibody have been advocated, this treatment is rarely successful. In vitro fertilization with ICSI is now the treatment of choice for immunological male factor problems.
Reactive Oxygen Species (ROS): A relatively new interest area in male infertility, ROS refers to small molecules present in many bodily fluids, such as seminal white blood and sperm cells. When in appropriate concentrations, ROS can help prepare the sperm for fertilization. However, if in excess, ROS can be harmful to other cells.Because of their already high polyunsaturated fatty acid content, human sperm membranes are particularly sensitive to ROS-related damage. Recent studies have demonstrated an increase in presence of these molecules in the semen of infertile men. Several compounds have been used to detoxify or "scavenge" ROS. The most effective of these, vitamin E (400 IU twice daily) is a very effective antioxidant.Pentoxifylline, a medication employed occasionally to decrease the thickness of blood, has also been shown to decrease sperm oxidant production, but is used much less frequently than vitamin E.
Retrograde ejaculation: Defined as an abnormal backward flow of semen into the bladder with ejaculation, it can be caused by problems that are: anatomic (e.g., previous prostate or bladder neck surgeries); neurogenic (e.g., diabetes, spinal cord injury, and previous surgery); pharmacologic (e.g., anti-depressants, certain anti-hypertensives, and medication
used to treat BPH, prostate enlargement); and idiopathic (other unknown problems). Retrograde ejaculation is diagnosed by the patient urinating immediately following ejaculation to produce a sample that is evaluated microscopically for sperm. Initial treatment for retrograde ejaculation consists of commonly used medications (e.g., Sudafed). If medical therapy should fail, however, doctors may try to recover sperm from the bladder after ejaculation in conjunction with intrauterine insemination.
How are non-specific (idiopathic) male infertility conditions treated without surgery?
Non-specific male infertility factors are often unexplained or ill-defined unlike specific conditions such as retrograde ejaculation or genital tract infection. However, because these procedures often involve the body's hormonal activities, they are just as troublesome to both the treating physician and the patient. In many cases, empiric therapy — designed to address hormonal imbalances — is used.
Empiric therapies generally involve hormonal manipulation. Assessing the impact of empiric treatments is very difficult, given variations in patients as well as dosing regimens, treatment durations and outcome definitions. As such, treatment decisions chosen by individual physicians are often based on their own personal philosophies.
Management of Female Inferility
Home Treatment
To decrease your risk of infertility and increase your chances of becoming pregnant, use the following guidelines.
Track ovulation at home
•Estimate when you are ovulating by practicing fertility awareness, including monitoring your cervical mucus changes, basal body temperature, and luteinizing hormone (LH) levels with a home ovulation predictor test.
•If you know when you will be ovulating, do no have sex during the 5 days before your 6-day "fertile window," which is ovulation day and the 5 days leading up to it. (Not ejaculating for a few days helps build up a man's sperm count.) Then have sex once each day of your fertile window, including ovulation day. If your partner has a low sperm count, have sex every other day, since frequent ejaculation does temporarily lower sperm count.
•If you don't know when you will next be ovulating, have sex two or three times each week.12
•If you exercise strenuously most days of the week, reduce your level of activity. Strenuous exercise can cause women to ovulate less often.
INTRODUCTION:
Approximately one-third to one-half of all infertile women have problems with ovulation. This can include the ovaries’ inability to produce mature eggs or “ovulate” (release) an egg. If no eggs are released, this is called anovulation. Infertility specialists rely on a certain group of ovulation drugs, often called “fertility drugs,” to temporarily correct ovulatory problems and to increase a woman’s pregnancy potential. Contrary to popular belief, these drugs do not make all women more fertile and in fact only work during the month in which the medications are taken. The drugs allow ovulation to occur more regularly in some women with ovulatory problems who may otherwise remain anovulatory and therefore infertile. Ovulation drugs can control the time of ovulation and stimulate eggs to mature and be released. These drugs may be used to correct other infertility problems such as improving hormone production to favorably affect the lining of the uterus called the endometrium. These medications also can be used to stimulate the development of multiple eggs during the treatment cycle.
The Process
The ovaries are two small glands, each about one-and-one-half to two inches long and three-fourths to one inch wide, located in a woman’s pelvic cavity. They are attached to the uterus (womb), one on each side, near the fimbriated (finger-like) openings of the fallopian tubes. About once a month, a mature egg is released by one of the ovaries. The fimbriae of the fallopian tubes sweep over the ovary and pick up the egg after it has been released from the follicle (the fluid-filled ovarian cyst containing the egg). If the egg is fertilized, which usually occurs in the tube, the resulting embryo (fertilized egg) continues to mature and increase its number of cells as it travels to the uterus and implants in the endometrium (uterine lining). The embryo’s full journey through the tube takes four to five days. Fallopian, Ovary Uterus, Sperm, Cervical, Mucus, Egg Released (Ovulated), Cervix Fertilization, Usually Tube, Vagina Occurs Here.
Hormone Production
In addition to producing eggs, the ovaries also secrete hormones. Hormones are substances secreted from organs of the body, such as the pituitary gland, adrenal gland, or ovaries, which are carried by a bodily fluid such as blood to other organs or tissues where the substances exert a specific action. The cycle of ovarian hormone production has two main phases. In the first phase, known as the follicular phase, an egg matures inside the ovary. The egg is surrounded by a layer of hormone-producing cells and fluid. The maturing egg, the surrounding cells, and the fluid are collectively known as a follicle. The follicle grows to a diameter of about an inch, forming a cyst-like sac on the surface of the ovary, before the fluid and the egg are released at ovulation. In natural cycles, an ovary contains several developing follicles, but usually only one follicle reaches maturity each month and releases an egg. This follicle, known as the dominant follicle, secretes a generous amount of the female hormone estradiol (estrogen) into the bloodstream during the first phase of the cycle. The estrogen circulates to the uterus where it stimulates the endometrial cells to reproduce rapidly and repeatedly, causing the uterine lining to thicken as ovulation approaches. The physician can usually see this thickening on an ultrasound exam. The second phase of ovarian hormone production begins with ovulation. The dominant follicle ruptures, usually around day 14 in a 28-day cycle, and releases a mature egg onto the surface of the ovary near the fallopian tube. The empty follicle collapses and the remaining follicle cells develop a yellow color. Collectively these cells are known as the corpus luteum, literally a “yellow body.” The corpus luteum secretes estrogen and large quantities of progesterone throughout the second half of the cycle, known as the luteal phase, which lasts approximately two weeks. Traveling through the bloodstream to the uterus, the combination of progesterone and estrogen causes the uterine lining to further mature and produce nourishment for an embryo. About a week after ovulation, the endometrium is in prime condition for an embryo to implant. An experienced physician can tell approximately how many days have passed since ovulation by examining a sample of the endometrium taken in a biopsy. If no embryo implants, the secretion of estrogen and progesterone declines about two weeks after ovulation and, as a result, the endometrium is shed. This shedding of the endometrium is called menstruation. The first day of menstruation is known as “cycle day one.” The length of the menstrual cycle is determined by counting the number of days from cycle day one until the start of the next menstrual period. Although variability in cycle length is usually due to variability in the follicular phase, the luteal phase can also be variable in length. The luteal phase should last 11 to 16 days. If it is not sufficient in length because of inadequate progesterone production, fertility problems may result. Since ovulation usually precedes menstruation by two weeks, a woman with a 28-day menstrual cycle is most likely to ovulate on day 14. Similarly, a woman with a 32-day cycle is most likely to ovulate on day 18.
Directives From the Brain
The hypothalamus and pituitary gland orchestrate the events leading to ovulation. These organs communicate with the ovaries via hormonal messengers traveling in the bloodstream. The hypothalamus is a thumb-sized structure in the base of the brain that controls many bodily functions and regulates the pituitary gland. The pituitary gland, about the size of a finger tip, is located just beneath the hypothalamus. The hypothalamus releases the hormone gonadotropin releasing hormone (GnRH), a messenger that tells the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH are both involved in maturing the follicle, but FSH primarily makes the follicle grow and produce increasing amounts of estrogen. As the follicle grows, the increasing estrogen in the bloodstream signals the pituitary to shut down FSH production. A surge of LH triggers ovulation. After ovulation, the corpus luteum primarily produces progesterone, which prepares the endometrium for the implantation of a fertilized egg.
DIAGNOSIS:
Detecting Ovulation
The key to diagnosing ovulatory problems is to detect and confirm ovulation. This can be done in several ways. An evaluation of the menstrual pattern provides some clues. A woman who menstruates every 25 to 35 days is probably ovulating regularly. She can also assume that ovulation occurs about 14 days before day one of each period. It is important to remember, however, that a woman can have randomly occurring uterine bleeding even though she never ovulates. Moreover, she can also have fairly regular cycles and not ovulate. There are several ways to detect ovulation, including commercially available ovulation prediction kits and basal body temperature charts. For more information on ways to detect ovulation, consult the ASRM patient information booklet titled Ovulation Detection.
Who Needs Ovulation Medication?
Ovulation drugs are used to either control the time of ovulation or regulate erratic ovulation patterns. These medications, when administered appropriately, can stimulate ovulation in most individuals and can also correct post-ovulatory problems by encouraging more than one egg per cycle to reach maturity. If the time of ovulation is known, the doctor can schedule an insemination, for example, during the woman’s “fertile days” to maximize the chance of pregnancy.
Hormonal Chain of Command
1 Hypothalamus Estrogen Progesterone Uterus GnRH FSH LH 2 3 4 Pituitary Ovary Directives from the Brain. Ovulation drugs also may be prescribed to increase the reliability of monthly ovulation in oligo-ovulatory women (women who ovulate infrequently) or to encourage ovulation in anovulatory women. Women may not ovulate because of high ovarian production of male-type hormones (polycystic ovarian syndrome [PCOS]), insufficient production of LH and FSH by the pituitary, or ovaries that do not respond well to normal levels of LH and FSH. Ovulation drugs may be indicated in the treatment of women with amenorrhea (absence of menstruation) and may be used to temporarily correct a luteal phase defect. A luteal phase defect occurs when progesterone production from the corpus luteum shuts down prematurely, produces an inadequate amount of progesterone to mature the uterine lining, or if the ovary did not actually release an egg at the normal time of ovulation. The interval of time between ovulation and the beginning of the next menstrual period is usually 11 to 16 days. If a luteal phase defect occurs, this time may be shortened and the endometrium won’t be in the proper condition to receive and nourish an embryo; therefore implantation cannot occur. Ovulation drugs are used to correct a luteal phase defect by enhancing the production of progesterone from the corpus luteum after ovulation, thereby making the endometrium more optimal for embryo implantation. The endometrium also can be supported by the use of natural progesterone. Ovulation drugs also can be used to encourage the ovaries to produce more than one egg per cycle. This is done in preparation for various forms of assisted reproduction such as intrauterine insemination or in vitro fertilization (IVF). The intent is to develop several mature eggs in hopes that at least one egg will be fertilized and result in pregnancy. For more information on IVF, consult the ASRM patient information booklet entitled IVF and GIFT: A Guide to Assisted Reproductive Technologies. An evaluation should be performed to look for hormonal imbalances before medication is administered to stimulate ovulation. Abnormal (inadequate) ovulation is sometimes caused by a hormonal imbalance resulting from other conditions, such as thyroid disease. Correction of imbalance may allow ovulation to resume spontaneously without the use of fertility drugs.
The most commonly prescribed ovulation drugs are clomiphene citrate, follicle stimulating hormone (FSH), human chorionic gonadotropin (hCG), and human menopausal gonadotropin (hMG). These and four others, bromocriptine, cabergoline, gonadotropin releasing hormone (GnRH), and GnRH analogs, which have very specialized applications, are described below. A chart is provided listing these ovulation drugs and their side-effects .
Drugs Used for Ovulation Induction
Generic Name Brand Name(s) Form Most Common Side Effects Clomiphene citrate Clomid® Serophene®
Clomid Use and AbuseClomiphene Citrate (Clomid, Serophene)
Some women can't get pregnant because they don't secrete enough LH and FSH at the right time during the cycle and, as a result, they don't ovulate. For these women, the first drug doctors often prescribe is clomiphene citrate (Clomid, Serophene). This synthetic drug stimulates the hypothalamus to release more GnRH, which then prompts the pituitary to release more LH and FSH, and thus increases the stimulation of the ovary to begin to produce a mature egg.
Clomiphene is a good first choice drug when a woman's ovaries are capable of functioning normally and when her hypothalamus and pituitary are also capable of producing their hormones. In short, the woman's reproductive engine is in working order, but needs some revving up.
Structurally like estrogen, clomiphene binds to the sites in the brain where estrogen normally attaches, called estrogen receptors. Once these receptor sites are filled up with clomiphene, they can't bind with natural estrogen circulating in the blood and they are fooled into thinking that the amount of estrogen in the blood is too low. In response, the hypothalamus releases more GnRH, causing the pituitary to pump out more FSH, which then causes a follicle to grow to produce more estrogen and start maturing an egg to prepare for ovulation. Typically, a woman taking clomiphene produces double or triple the amount of estrogen in that cycle compared to pretreatment cycles
If a woman is menstruating, even if irregularly, clomiphene is usually effective, particularly if she develops follicles that aren't reaching normal size. Usually, a mature follicle is about 20 millimeters in diameter, or about the size of a small grape, just before it ruptures and releases its egg. Clomiphene may help small, immature follicles grow to maturity.
A low estradiol level in a woman's blood correlates with an inadequately stimulated, small follicle. A woman having a spontaneous ovulation cycle (that is, ovulating without the aid of fertility drugs) generally has peak estradiol levels ranging from 100 to 300 picograms (one trillionth of a gram)/ml. A woman may have enough hormones to produce an egg, but if her estradiol production by the follicles is low (less than 100 pg/ml),
she may not adequately stimulate her cervix to produce fertile mucus or stimulate her endometrium to get ready to accept a fertilized egg for implantation. Clomiphene could boost the weak signals from the hypothalamus to the pituitary to the ovaries.
"A woman who ovulates infrequently, say at six-week intervals or less often, is also a good candidate for clomiphene therapy, since clomiphene will induce ovulation more frequently. The more a woman ovulates, the more opportunities her mature eggs have to be exposed to her husband's sperm and, therefore, the greater her chance to become pregnant.
Clomiphene is also often effective for a woman with luteal phase defect (LPD). A woman with LPD may begin the ovulation process properly, but her ovarian function becomes disrupted, resulting in low production of the hormone progesterone in the luteal phase of the menstrual cycle. Following ovulation, the ovary produces progesterone, the hormone needed to prepare the uterine lining for implantation of the fertilized egg, which has divided and entered the uterine cavity. A fall in progesterone levels in the blood during this critical time can interfere with early embryo implantation or, even if a fertilized egg has already implanted, cause a woman to menstruate too early and end a pregnancy within a few days after implantation.
Using an LH-urine detector kit or keeping a basal body temperature (BBT) chart can help a woman taking clomiphene determine whether the luteal phase of her cycle is shorter than the normal fourteen days. The luteal phase of the cycle, the length of time from ovulation until she menstruates, has a normal range of thirteen to fifteen days. Clomiphene can often "tune up" the hypothalamus and pituitary so they keep producing the hormones the ovary needs to manufacture progesterone throughout the luteal phase.
"Of women whose only fertility problem is irregular or no ovulation at all, about 80 percent will ovulate and about 50 percent will become pregnant within six months of clomiphene treatments. About three percent of women on clomiphene have a multiple pregnancy, usually twins, compared with about one percent in the general population.
If a woman responds to clomiphene and develops a mature follicle (determined by adequate estrogen production and ultrasound examination), but has no LH surge by cycle day 15, then injection of the hormone human chorionic gonadotropin (HCG), which actslike LH, can be given to stimulate final egg maturation and follicle rupture, releasing the egg. The woman tends to ovulate about 36 hours after the LH surge or HCG injection, which can be confirmed by further ultrasound scans.
"Clomiphene is a relatively inexpensive drug, and is taken orally for only five days each month. The doctor attempts to initiate clomiphene therapy so that the woman ovulates on or around day 14 of a regular 28-day cycle. The simplest, most widely used dose starts with one daily 50 mg. tablet for five days starting on cycle day three or five. If a woman ovulates at this dose, there is no advantage to her increasing the dosage. In other words, more of the drug isn't necessarily better. In fact, more may be worse, producing
-multiple ovulation, causing side effects such as an ovarian cyst or hot flashes, and most commonly, interfering with her fertile mucus production (Emphasis is Theresa Venet Grant's.)
If a woman doesn't ovulate after taking one clomiphene tablet for five days, then her doctor will usually double the daily dose to two tablets (100 mg) in her next cycle, and if she still doesn't respond, then triple the daily dose to 150 mg, or add another fertility medication such as human menopausal gonadotropin (Pergonal) in the next cycle. Some doctors increase the dose up to 250 mg. a day, but this is NOT recommended by either of the drug's two manufacturers. Women tend to have side effects much more frequently at higher doses.
If the dose of clomiphene is too high, the uterine lining may not respond completely to estrogen and progesterone stimulation, and may not develop properly. As a result, a woman's fertilized egg may not be able to implant in her uterus.
Because Clomiphene binds to estrogen receptors, including the estrogen receptors in the cervix, it can interfere with the ability of the cervical mucus glands to be stimulated by estrogen to produce fertile mucus. Only "hostile" or dry cervical mucus may develop in the days preceding ovulation. If this occurs, adding a small amount of estrogen beginning on cycle day 10 and continuing until the LH surge may enhance cervical mucus production.
Some women taking clomiphene experience hot flashes and premenstrual-type symptoms, such as migraines and breast discomfort (particularly if they have fibrocystic disease of the breasts). Visual symptoms such as spots, flashes or blurry vision are less common and indicate that treatment should stop.
Clomiphene is a very safe medication with relatively few contraindications. Preexisting liver disease is one contraindication since clomiphene is metabolized by the liver. Enlarged ovaries are also a contraindication since clomiphene may occasionally produce hyperstimulation of the ovaries.
The hot flashes are just like the hot flashes women experience at menopause when the level of estrogen circulating in the blood is low. The clomiphene fools the brain into thinking that blood estrogen levels are low.
Clomiphene Abuse
Too often, doctors give clomiphene to women with unexplained infertility before the couple has a fertility workup, or even after they have a workup, but there is no evidence of an ovulation disorder. This empiric therapy may create new problems, such as interfering with fertile mucus production, and often delays further evaluation that can lead to a specific diagnosis and proper treatment.
For a woman who has normal, spontaneous ovulation, driving the pituitary harder with clomiphene won't make ovulation any more normal. If a woman has taken clomiphene for several cycles without becoming pregnant, then she and her fertility specialist should investigate other conditions that may be preventing her pregnancy.
After noting a good postcoital test (PCT) during a fertility workup, some doctors fail to repeat the test after placing a woman on clomiphene. A PCT needs to be repeated to check the quality of the woman's cervical mucus while she is on clomiphene, since 25 percent or more of women who take the drug develop cervical mucus problems. It's important for a woman to monitor her cervical mucus production during every cycle while trying to become pregnant, including her cycles while taking clomiphene.
Overview:
Menotropins are a powerful group of medications in which the most active ingredient in terms of ovulation induction or enhancement is follicle stimulating hormone (FSH). The unit of measurement for FSH is the International Unit (IU) which is based on an international reference preparation (IRP). One ampule of lyophilized (freeze dried) FSH generally has 75 IU of FSH (some have 150 IU of FSH so you should read the label).
Some menotropins, such as Pergonal, Humegon and Repronex, also contain 75 IU (or 150 IU if there is 150 IU of FSH) of Luteinizing Hormone (LH). LH stimulates the production of estrogen's precursor hormones, androstenedione and testosterone) in the ovary. Many women secrete adequate LH, making the addition of LH in these medications unnecessary. If the anticipated estrogen production is quite large, such as when heavily pushed to maximally produce mature eggs in IVF cycles, then many infertility specialists prefer to have additional LH available. Also, there are some women who do not produce LH in adequate amounts and these women benefit from the additional LH.
The basic infertility evaluation should be completed prior to the use of menotropins.
Contraindications:
Menotropins are contraindicated in women with no ovarian reserve (menopause). A woman with early ovarian failure will occasionally have a spontaneous recovery of ovulation (for unknown reasons) but attempts at ovulation induction or enhancement in these women are usually unrewarding. Ovulation induction can be considered if the FSH concentration is less than the LH concentration and/or the estradiol concentration is greater than 40 pg/ml (the amount required for a withdrawal flow). There should always be documentation of tubal patency and availability of sperm prior to initiating treatment with menotropins. I often recommend a laparoscopy to assess and optimize the pelvis prior to menotropin therapy. An exception is when the only finding on evaluation is a clear-cut ovulation disorder. The appropriateness of laparoscopy should be individually discussed with each couple considering menotropins.
Improving Ovulation
Menotropins can be used for either ovulation induction, ovulation enhancement in a process referred to as "controlled ovarian hyperstimulation" (COH) or "assisted reproductive technology" (ART, including IVF).
Menotropins are injectable medications. Most of these have considerable contamination with other proteins and are given as intramuscular injections deep into the upper outer quadrant of the gluteus maximus muscle (rear end). Fertinex is an exception in that it has been highly purified through affinity chromatography so that it can be self administered subcutaneously (under the skin) in the upper thigh. Recombinant forms of menotropins are also highly purified and can be administered subcutaneously.
In my experience, the partner of the woman being treated is the most reliable and caring person to give the intramuscular injections once taught the proper technique (to prepare and administer the medication). The shot is given at night (occasionally twice a day) in a dosage that may change from day to day.
Menotropin Treatment Protocols
There are several protocols commonly used for ovulation induction and enhancement with menotropins. The physician in charge of your Controlled Ovarian
Hyperstimulation (COH) or IVF cycle should be experienced in the use of these medications to optimize your response and limit complications. Common features of appropriate protocols include:
•Perform an ultrasound exam prior to initiating a cycle There should be no large cysts within the ovary at the onset of a stimulation cycle. Cysts greater than 2 cm (and possibly 1.5 cm) are relative contraindications for starting the medication. Larger cysts may interfere with optimal stimulation either by producing hormones locally to disrupt the surrounding follicular development or by mechanically interfering with follicular development due to their size. I will generally advise that the patient with a large ovarian cyst return the following month for an ultrasound and may start stimulation if the cyst has gone away. Most of these cysts seem to be residual (corpus luteum) cysts from the prior cycle and are removed by the body within days to weeks. Selected patients will be allowed to initiate a cycle despite a large ovarian cyst if the circulating estrogen concentration is found to be low (indicating that the cyst is not functioning hormonally). If a larger cyst in the ovary persists over several months, then further evaluation and probably removal would be recommended. Removal of persistent nonfunctional large cysts of the ovary is primarily to rule out serious pathology (such as cancer).
•Menotropins are started in the early part of the cycle A "standard" protocol for COH is two ampules of menotropin per day starting on cycle day two, three or four. The first day of heavy flow is cycle day one. Medications are usually given in the evening at about the same time each day. Monitoring blood work for estradiol concentration is initiated after three days of medication. This estrogen level allows adjustment of the medication dosage and determination of when to return to the office for additional blood work (and possibly an ultrasound). Once additional testing with ultrasounds is begun, monitoring is usually more frequent and may even be required each day. On average, a "typical stimulation" may take seven to 12 days of medication and the patient will have returned to the office on three to five occasions for monitoring.
•Dosing of menotropins may be changed from cycle to cycle Some patient's ovaries are difficult to stimulate with menotropins. If two ampules per day result in a poor response, then increasing the dosage of medication is considered. Increasing from two to four ampules per day is common. Generally I do no use greater than six ampules per day since I have not seen reasonable success in achieving a pregnancy with greater doses. Some patient's ovaries will respond by maturing too many follicles at once. If there is a larger than desired response to two ampules per day, then decreasing the amount of medication to one ampule or half an ampule is considered.
•GnRH agonists may be used for ovarian suppression or "a flare" GnRH agonists are a type of medication often used with menotropins in stimulated cycles. Their most common indications are when more even development of
follicles is desired. If a prior stimulated cycle resulted in maturation of only one or two mature eggs despite the presence of multiple other follicles, then use of a GnRH agonist may be helpful. In these situations, the GnRH agonist is started about a week prior to the expected menses to suppress any early development of follicles (the follicles are at a common baseline of development when the menotropins are started). Also, use of agonists allows for greater control and the ability to push follicles to larger sizes at the end of the stimulation cycle.
The GnRH agonists may be administered in a variety of ways, including as injectable medications or taken as an intranasal spray. There are many different GnRH agonists available and each has a different half life (duration of effectiveness). Thus, these medications may need to be taken either once or twice a day depending on the particular product chosen. GnRH agonists will initially result in the release of stored FSH and LH from the pituitary gland. This stimulatory response to these medicines lasts for the first few days. GnRH agonists also suppress the production of new FSH and LH so that once the stored hormones have been released the circulating FSH and LH is very low. Therefore, following the initial few days of stimulation there is a suppression of the ovary for the duration of administration of the medication. Since these medications deplete stored LH the brain is also incapable of triggering ovulation via an LH surge. A "flare" protocol exists, for which the GnRH agonist is started at (about) the same time as the menotropins. This flare protocol takes advantage of the initial release of pituitary FSH and LH, which may further enhance egg development. With the flare protocol there will be pituitary and ovarian suppression by the time of ovulation so there is an inability to mount the LH surge (signal to ovulate).
•Menotropins are commonly used during IVF Higher doses of menotropins along with a relatively strong GnRH agonist (such as lupron) are generally used for In Vitro Fertilization (IVF). A standard IVF protocol would consist of lupron (initiated on idealized cycle day 21 of the prior cycle) and 4 ampules of menotropins per day (initiated early in the next cycle). Both GnRH agonist and menotropins are continued until ovulation is desired, then the LH surge is simulated with hCG (profasi).
•Polycystic ovaries often are difficult to stimulate Polycystic ovaries are characterized by a large number of follicles arrested in early to mid development. When stimulating polycystic ovaries, the goal is to avoid excessive numbers of small follicles with very high circulating estradiol concentrations since this can result in severe forms of ovarian hyperstimulation syndrome. Protocols to avoid excessive development differ dramatically from one another. Some start with a high dose of menotropins and cut back once a few follicles have begun to develop. Others start with a low dose of menotropins, hoping that only a small number of follicles will respond. Still others administer one to three months of birth control pills to suppress follicular development and then
use a GnRH agonist to continue to suppress abundant follicular development until menotropins are started. There is usually a considerable learning curve (trial and error period) to customize the menotropin strategy for patients with PCOS since the ovaries generally respond uniquely and unpredictably. Trying several different menotropin protocols might be required before settling on an ideal protocol for a particular patient's ovaries.
•Giving steroids may suppress excessive androgenic hormone production If a woman has abundant circulating androgenic hormones they can interfere with follicular development. Androgenic hormones are associated with male pattern hair growth and occasionally dark irregular discoloration of the skin usually in areas of creases (such as arm pits, neck, under breasts). Blood hormone studies can usually (but not always) confirm high circulating levels of these hormones. If the androgens are elevated or if there are clear-cut signs of excess androgens then consideration of concurrent low dose glucocorticoid steroid medication (such as dexamethasone or prednisone) is considered.
•GnRH pumps are available As an alternative to menotropin therapy these pumps will infuse the releasing hormone, GnRH, in preset amounts and time intervals. GnRH will directly stimulate release of FSH and LH from the pituitary gland. In my experience, patients do not like the concept of an indwelling catheter either placed under the skin or into a blood vessel. The catheter stays in place for weeks to months and works by means of a small pump (about the size of a transistor radio) that the patient carries.
Monitoring Menotropin Treatment
Intensive monitoring is required to maximize appropriate egg development and minimize exposure to complications. This monitoring includes transvaginal ultrasounds and blood work for hormone (especially estradiol) levels. Usually, I will perform a baseline ultrasound exam to rule out large ovarian cysts and then obtain blood work and ultrasounds every one to four days until there is full maturation. A typical cycle might involve seven-12 days of medication. At the end of the stimulation process, human chorionic gonadotropin (hCG, such as Profasi) is given into the intramuscular region to simulate the LH surge and trigger both the final maturational step in egg development and the release of the mature egg(s).
Menotropin Costs
Human menopausal gonadotropins are expensive. For controlled ovarian hyperstimulation (COH) with intrauterine inseminations (IUIs) two to three (but up to six) ampules per day are taken for about 10 +/- 3 days, for a normal total of 20-30 ampules. For In Vitro Fertilization, about twice as much medication may be normal. Since each ampule costs about 50 dollars the total for the medication is easily 1-2 thousand dollars per attempted cycle. In addition, the professional and other fees for monitoring can be expensive.
Obtaining menotropin medication can be difficult. Menotropins are not carried as routine stock in many pharmacies. Therefore, you should confirm that your pharmacy has actually received a supply for you prior to attempting to fill your prescription. If you are unable to identify a pharmacy that will order this medication for you, a local infertility center (such as my office) should be able to direct you. Menotropins are stable if stored at room temperature up until their stated expiration date.
There are few side effects to the human menopausal gonadotropins (menotropins). Stress associated with a cycle of IVF or COH can be intense and a free flow of communication between partners can be very effective at reducing this stress. Organization is important for working couples since monitoring may take 30-60 minutes in the morning, exclusive of travel time.
USE OF HERBS FOR INFERTILITY
The use of herbs as a source of medical treatment has been going on since the beginning of time. Allah has put cures in this world which we are to seek, and some of these cures do come in the form of herbs. It was not until recently that herbal remedies have been replaced by synthetic medication. And most doctors do not believe in this "unconventional" medicine and are more inclined towards the modern means of medication. However, many couples do use herbs as one helpful use in the treatment of infertility.
It should be no surprise that Muhammad pbuh himself used herbal remedies in his time. While scholars generally disclude any medically related ahadith as a part of the Sunnah, it is quite interesting to learn the culturally influenced herbal remedies that were used. Some of these remedies are still used today in treatment of certain conditions.
Black Seed
Black Seed is a widely used herb by Muslims, and one of the favorites of Muhammad pbuh.
Abu Hurayra reported Muhammad pbuh as saying: Use the Black Seed as it is the panacea that heals all harms except death.
According to Ibn Qayyim al Jawiziyya the Black Seed was in several forms to treat the following ailments:
Eliminates flatulence, extracts the helmnths, palliates leprosy, provokes menstrual flow and increases milk production
Fenugreek-
Fenugreek was also widely used during the time of Muhammad pbuh and is an herb that he preferred.
Al Qassem ibn Abdur Rahman Muhammad pbuh said: Resort to the cure of the Fenugreek
Muhammad pbuh was also reported to have been present when Al Harth ibn Kalda used it to treat Sa'd Ibn Waqqas as a cure for his ailment.
According Ibn Qayyim al Jawiziyya Fenugreek was used in several forms to treat the following ailments:
Soothes coughs, increase semen, soothes asthma, provokes menstruation, decomposes the tumor in the spleen. Also recommended to women to soak in a bath with to soothe aches related to a tumid womb
The use of herbs is not to be taken as the be all to end all for infertility treatment. There are many causes for infertility that should be medically treated, such as PCOS, Endometriosis, blocked tubes, and uterine fibroids. Herbs as well as vitamins, proper diet and exercise along with conventional medical treatment can all be used. As with any other forms of medication you should consult professional advice and guidance, herbs should not be taken blindly. Many have very powerful affects and can do more harm than good if not taken properly or at the wrong time. You must also be sure to inform your doctors of any herbs that you take to make sure there is no reaction with any medication or procedure that you will undergo.
In order to be safe I recommend an herbalist who has some form of certification, and this does not include the sales girl at your local health food store. They should be well educated and trained in their field. As you do with your own doctor you should have them checked out, ask about them, find out if there are any complaints against them and as always educate yourself before blindly following recommendations of the specialist.
Many incorrectly assume that because herbs are a natural product than a Muslim can take any of them. But just like other medication put in a capsule there is the question of haram ingredients, specifically gelatin.
Gelatin comes from three main sources, pig, cow and vegetable. Pig of course would be prohibited for Muslims to take. The only known exception to this case is in medical necessity. The use of cow as the gelatin source is argued among Muslims, while some feel that a beef source is permissible others believe that if it is a Non Muslim source than it is not permissible. A vegetable base would not be a problem for Muslims.
Before taking a herb with a capsule with gelatin do research to determine the source, willing ignorance is not an excuse. It is easy to call the manufacturer who will inform you of the source if it is known. There maybe other sources of the same herb by a different manufacturer or you may be able to use the same herb in a different form rather than a capsule.
Depending on the herbal product that you are looking for, it is not difficult to buy them. Your local health food stores are a good source for those not so common herbs, but are generally more expensive than you local pharmacy or Wal Mart.
Recommendations for herbal us in fertility and infertility treatments. Please note I do not take any of the below herbs, nor have I tried any for a remedy for my infertility conditions. I can recommend Fenugreek and Blessed Thistle to increase milk supply, but nothing related to infertility. I must stress again that you research and contact a herbalist in your area.
FOR WOMEN-
Promotes Ovulation
Chaste Tree Berry, Black Cohosh, Dong Quai.
To Bring Menstruation
Chaste Tree Berry, Parsley, Ginger, Yarrow, Rosemary, Fenugreek.
Uterine Fibroids and Ovarian Cysts
Combination: PCOS- Licorice.
Preventing Miscarriage
Wild Yam, Sqau Vine, Vitex, Unicorn Root.
Cervical Mucus
Red Clover Blossoms.
Hypothyroidism
Evening Promise Oil.
Endometriosis
False Unicorn Root.
Herbs to Avoid while Pregnant
Angelicia, Black Cohosh, Blue Cohosh, Barberry, Bloodroot, Borage Oil, calamus, Cascara Sagrada, Cayenne, Celandine, Cypress, Ephedra, Fennel, Fenugreek, Flaxseed, Goldenseal, Juniper, Lavender, Licorice Root, Male Fem, Mayapple, Mistletoe, Passion Flower, Pennyroyal, Periwinkle, Poke Root, Rhubarb, Sage, St. St. John's Wort, Tansy, Thyme, Wild Cherry, Wormwood, Yarrow.
FOR MEN
To Increase Sex drive
Humulus, Scutellaria.
Sperm Motility
Avena, Capsicum, Humulus, Cimicifuga, Salix, Thuja.
•Obtain treatment for any treatable disorder that causes infertility.
•Avoid preventable causes of infertility.
Most types of male infertility aren't preventable. However, avoid drug use and excessive alcohol consumption, which may contribute to male infertility. Also, high temperatures can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.
If you're a man who's uncertain about whether you would eventually like to become a father, don't undergo permanent sterilization, such as a vasectomy. Although surgery to reverse this condition is possible, risks are involved that could affect fertility in other ways.
A woman can increase her chances of becoming pregnant in a number of ways:
•Exercise moderately. Regular exercise is important, but if you're exercising so- intensely that your periods are infrequent or absent, your fertility is likely to be impaired.
•Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
•Avoid alcohol, tobacco and street drugs. These substances may impair your ability to conceive or produce a healthy child. Don't smoke, limit your caffeine intake to one soda or cup of coffee a day, and avoid illegal drugs such as marijuana and cocaine.
•Limit medications. The use of both prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly.
EXPECTED OUTCOME
•Some fertility problems are minor and reversible. Often, no clear cause for infertility is found. Approach treatment with optimism.
•Research into this area is offering new options to couples.
COUNSELING AND SUPPORT GROUPS
If you've been having problems getting pregnant, you know how frustrating it can feel. Not being able to get pregnant can be one of the most stressful experiences a couple has. Both counseling and support groups can help you and your partner talk about your feelings, and to help you meet other couples like you in the same situation. You will learn that anger, grief, blame, guilt, and depression are all normal. Couples do survive infertility, and can become closer and stronger in the process. Ask your health care provider for the names of counselors or therapists with an interest in fertility.
COPING WITH INFERTILITY
Coping with infertility can be difficult. It's an issue of the unknown — you can't predict how long it will last or what the outcome will be. Infertility isn't necessarily solved with hard work. The emotional burden on a couple is considerable, and plans for coping can help.
EDUCATION
One of the most important things that I have found that works is learning about my condition, as well as my options. This started with reading, alot, visit the library,
-there are many books on infertility in general as well as one that is more in line with your condition. Search the web, it is a great source of information that will make you better informed to your treatment options, your condition, as well as what to expect.
NETWORKING
While it may seem that the last thing you want to do is talk to other people about your problems. It helps to communicate with other women who may be going through the same issues as you are. While the muslim community in general lacks any formal groups, we can take it upon ourselves to find other muslim women that are in the same situation as we are in. We can also find non muslim women who are dealing with fertility issues like we are, while many times the "spiritual" communication is not there networking with non muslim women can lead you to information that you didn't know of. The best doctors, where to get your subscription filled cheaper, some group sessions, books to buy that will be of help and many other positive aspects of such networking, not to mention the opportunity for Dawah.
TALK WITH SPOUSE
While this may appear as being a "given" sometimes it is not easy to open up to your spouse and tell them how you are really feeling. We may have the tendency to keep everything inside, and want to deal with the problem on our own. Perhaps not wanting to burden our spouse. However this can be very harmful for our health and our relationships in the long run. Infertility has many emotional side affects, we go through bouts of depression, feeling of helplessness, blaming ourselves ect ect. Opening up to our partners will help us realize that we are not in it alone, and that he/she maybe feeling the same things that we are. As Allah says we are "garments for each other" this means we are to find protection, comfort, warmth, and security with each other. We must keep this in mind while we do battle with infertility.
DON'T BLAME YOURSELF
While this may appear easier said than done, it is a very important issue. Self blame is not uncommon, and something that most couples facing infertility go through. We must come to terms that this is all Qadr of Allah, and while we may not understanding the reasons behind it all, this is a test, and after hardships comes ease. Although not everyone will be blessed with children, we as Muslims must learn to come to terms with what Allah has decreed for us -vs- what we want for ourselves.
LEARNING TO SAY NO TO BABY RELATED EVENTS
We may feel obligated to go to our friends baby shower, or walk down the baby isle of a store, to goo and ahh over the little newborn clothes. This may not be the best things for us to do at this time. We have to learn that saying no to social events is not always wrong, depending on how you feel. If you notice that you have hard feelings when going to a baby shower than do not go. If you notice going towards a section of a store brings you to tears and bouts of sadness in the baby section, stay clear of that part of the store or ask your spouse to get what you need. It is important to consistently ask for strength from Allah to face these times, we must learn that there are times when we are not strong enough. And in order to protect ourselves during this time, it is ok to avoid such instances.
REDIRECTING FRUSTRATIONS
We are human and there will be days that we want to totally vent all of our feelings. This is not a bad thing, however we should be careful of how we release these frustrations. While some of us may be talkers, easy to get it all out. Some of us tend to be more physical, perhaps a good work out will help, hitting the pillow a few dozen times, or using things such as a darn-it doll. Whatever works for you, do it, as long as it does not hurt others, or is harmful to your own soul.
PRAYER
AND LOTS OF IT!! As believers we must learn to rely on Allah to support us, guide us, and help us through the hard times. Even though it may not be prayer time, make wudu and pray two sunnah rakat glorify Allah through these hard times. Submit yourself to him through these tests and pray that Allah gives you what is best for you for nothing happens but by Allah's will.
Planning for emotional turmoil
•Set limits. Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and attempt to determine a final limit. Fertility treatments may be expensive and often not covered by insurance companies, and a successful pregnancy often depends on repeated attempts. Some couples become so focused on treatment that they continue with-
-fertility procedures until they are emotionally and financially drained.
•Consider other options. Determine alternatives — adoption, donor sperm or egg, having no children — as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
•Talk about your feelings. Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.
Managing emotional stress during treatment
•Practice relaxation. Cognitive behavior therapy, which uses methods that include relaxation training and stress management, has been associated with higher pregnancy rates.
•Express yourself. Reach out to others rather than repressing guilt or anger.
•Stay in touch with loved ones. Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.
Managing emotional effects of the outcome
•Failure. The emotional stress of failure can be devastating even on the most loving and affectionate relationships and for people who've prepared well for the possibility of failure. Don't hesitate to seek professional help if the emotional burdens become too heavy for you or your partner.
•Success. Some studies have indicated that even if fertility treatment is successful, -women experience increased stress and fear of failure during pregnancy. Other research suggests that women who achieved pregnancy using fertility treatments felt increasingly better and had higher self-esteem and less anxiety as the pregnancy progressed than did women whose pregnancies didn't involve medical intervention.
•Multiple births. A successful pregnancy that results in multiple births introduces new complexities and emotional problems. The risk of depression is higher in women who have multiple births.
•Parenting. Once a child arrives, parents are more likely to be more anxious and have less confidence and self-esteem. Discuss becoming parents with your partner and plan for the many changes — challenging and rewarding — that a child will bring to your lives.
LIFESTYLE CHOICES AND FEMALE INFERTILITY
About 14% of couples in industrialized countries report infertility problems. There is suspicion that the incidence of infertility is increasing. Since there are many things that can affect fertility that we have control over -- lifestyle choices of smoking, drinking alcohol or caffeine, food ingestion and weight, sexual practices and so forth -- it is important to examine how much effect these things can have on future fertility. Many women are unaware as to how important these lifestyle choices can be with regard to future attempts to conceive.
An article by Silva PD, Cool JL, Olson KL: Impact of lifestyle choices on female infertility. J Reprod Med 1999;44:288-296, helps us to put some of these lifestyle habits in perspective as to how they affect fertility. These authors did an extensive review of the literature to determine how much different life choices affect a woman's ability to later conceive.
Does being overweight affect fertility and if so, how?
Obesity has a strong association with infertility and menstrual irregularities. While some of the ovulation problems and menstrual changes are explainable by women with Polycystic Ovarian Syndrome (PCOS) who are also obese, women who do not have PCOS but are overweight also have the same problems. Group treatment programs that assist obese
-women with diet and exercise plans have shown return of fertility in many patients. Weight loss of 15 lbs (6.5 kg) has been shown to restore ovulation. It is thought that the improvement in insulin resistance has more to do with restoring ovulation than the actual amount of weight or weight loss itself. For most studies, 20% over ideal weight is considered obese. Officially, a BMI (body mass index) of 25-30 is considered overweight and a BMI of over 30 is considered obese.
Can weighing too little lower my chances of getting pregnant?
Low weight and weight loss is also associated with ovulatory dysfunction and thus infertility. Even a moderate weight loss of 10-15% under ideal body weight can result in menstrual irregularity. It does not need to be the weight alteration of 30% or more as seen in women with anorexia nervosa or bulimia. Weight gain programs in these underweight women have been shown to restore ovulation and pregnancy in up to 73% of women who were able to achieve 95% of their ideal body weight. For many studies affecting eating disorders, a BMI (body mass index) of 17.5 - 20 is underweight and under 17.5 (90 lbs at 5 feet 0 inches) is considered very underweight.
I want to put off having children until our careers provide more opportunity. Will delaying childbearing affect my ability to get pregnant?
It is quite common for women to pursue educational and career opportunities and put off childbearing into the late 30's and early 40's. Aging, however, brings with it many effects that will decrease fertility.
•Depletion over time of ovarian follicles affects menstrual regularity.
•Endometriosis has more time to produce scarring of the ovary and tubes so they cannot move freely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows.
•Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding that disrupts implantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the very early stages.
•Abdominal adhesions from other intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility needed to sweep the ovary and gather an ovulated follicle (egg).
Does smoking affect my ability to conceive?
Almost all studies show that smoking decreases fertility. Smoking causes decreased estrogens with breakthrough bleeding and shortened luteal phases. Smokers have an earlier than normal (by about 1.5-3 years) menopause which suggests that there is some toxic affect of smoking on the follicles directly. Chemically, nicotine has been shown to concentrate in cervical mucous and metabolites have been found in follicular fluid and been associated with delayed follicular growth and maturation. Finally, there is some affect on tubal motility because smoking is associated with an increased incidence of ectopic pregnancy as well as an increased spontaneous abortion rate.
I know alcohol is not good during pregnancy, but what about its use while trying to conceive?
The total effect of alcohol on fertility is not as well established as with cigarettes and other substance abuse. In one survey, women with high alcohol use reported more menstrual problems and gynecologic surgery. It has been shown to alter estrogen and progesterone levels as well as cause anovulation. Most chronic alcoholics become amenorrheic. While the effects of alcohol on fertility are real, it is not clear how much must be consumed to affect fertility, or conversely, how much consumption is safe. In pregnancy, we know that an average of 2 drinks per day or more, or binge drinking of 5 or more drinks at a time can produce fetal alcohol syndrome birth defects. As far as fertility, one study found that there was a 60% increase (risk ratio 1.6) in ovulation difficulties with the consumption of more than 100 grams of alcohol a week (about one drink a day). There was no increase with less than 100 grams consumption a week.
Some people say caffeine is bad for trying to conceive but I cannot believe two or three cups of coffee a day could really affect conception -- can it?
Not all reports, but many, show that increased caffeine consumption affects the ability to become pregnant and carry the pregnancy. Caffeine clearance from the body is decreased during the luteal phase. Animal and human data suggest an increased rate of spontaneous abortions with increased caffeine use and most human studies show a decreased fetal growth during pregnancy with increased caffeine intake. How much is too much? Consumption of 3 or more cups of coffee per day (greater than 300 mg caffeine) leads to fertility problems in 4 studies.
Does catching a sexually transmitted disease (STD) always cause infertility?
Tubal factor infertility accounts for about 15% of infertility and pelvic inflammatory disease from gonorrhea or chlamydia infections produce most of this. As many as 40% of untreated chlamydia cervical infections ascend into the tubes and pelvis causing PID (pelvic inflammatory disease). If a woman has PID, she has a 20% chance of being infertile. The biggest problem with the affect of PID on fertility is that it is most often contracted at a time when very little thought is being given to the future ability to become pregnant. Birth control pills and other hormonal methods of contraception do not protect against STDs. Only the barrier methods and especially the use of condoms and spermicidal foam decrease the chances of acquiring an STD.
ASPIRIN AND INFERTILITY
Aspirin is a commonly used over the counter medication which has traditionally been used as an analgesic and fever reducer. In recent years, however, more attention has been paid to its anticoagulative properties. People with a history of heart problems often take a precautionary aspirin per day; individuals experiencing suspected myocardial infarction are also frequently given aspirin in the prehospital care environment..
Why is aspirin used in infertility treatment?
The anticoagulative properties of aspirin have also been studied in the field of reproductive endocrinology. Low dosage aspirin is a common treatment component for women who are positive for antiphospholipid antibodies. Recently, its use in a more general infertility population has also been studied.
Antiphospholipid antibodies (APA) are a class of proteins which appear to be related to coagulation problems. The presence of APA is formally diagnosed through a series of blood tests; however, one of the hallmarks of APA is recurrent fetal loss, often through disruption of placental blood flow due to clotting.
Because of its anticoagulative properties, aspirin reduces the risk of clotting; consequently, the blood supply between an APA patient and her fetus is more likely to remain intact. Most frequently, aspirin is given in conjunction with heparin, a powerful anticoagulant that works at another phase of the coagulation process.
The success of low dose aspirin in the management of APA-related disorders has led to a more general study of its effects on the reproductive system. The focus of this research is upon whether or not the anticoagulative properties of aspirin will lead to increased blood supply to the ovaries and uterus. If there is an increased blood supply to these areas, the reasoning goes, these area will receive a higher dosage of serum-carried hormones. As a result, the ovaries may be more productive, and the uterine lining thicker and more well-developed.
The research on this aspect of aspirin and infertility has yielded positive to mixed results. Several studies have shown improved results for pregnancy rates, endometrial thickness, and follicle development. However, in most studies, patients were not classified in terms of APA status, which leaves the effect of aspirin on the general population less clear. Thus, at this point, the results have been promising, but are not as definitive as those associated with APA.
I'm wondering if I should take aspirin. What should I do?
Despite the fact that it is an over-the-counter drug, aspirin should not be used lightly. Many doctors are fond of saying that, if aspirin were to be discovered today, it would only be available by prescription. Additionally, there are certain members of the population that should generally avoid aspirin. These include individuals allergic to aspirin, a history of gastric irritation or bleeding, and clotting problems.
What should a patient do? First and foremost, the bottom line is that YOU SHOULD NEVER TAKE ANY TYPE OF DRUG (not even over-the-counter) without the ADVICE AND CONSENT of your treating physician. In some cases, doctors may feel comfortable prescribing aspirin in an empiric or prophylactic manner, especially in women who have had multiple unexplained miscarriages. However, the applicability of this strategy will vary from doctor to doctor and patient to patient - it is not a decision that should be made unilaterally by the patient.
But I think my doctor isn't taking my concerns about aspirin seriously.
What if you think that you fit the profile of someone who would be helped by aspirin, but your doctor will not listen? It's important to ask him or her about their reasoning. He or she may have extremely valid reasons for not wanting you to take aspirin. On the other hand, if you as a patient feel that your doctor is dismissive of your questions about any type of treatment, including aspirin, the best solution is to seek a second opinion - not self medicate.
In infertile couples where women have blocked or absent fallopian tubes, or where men have low sperm counts, in vitro fertilization (IVF) offers a chance at parenthood to couples who until recently would have had no hope of having a "biologically related" child.
In IVF, eggs are surgically removed from the ovary and mixed with sperm outside the body in a Petri dish ("in vitro" is Latin for "in glass"). After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into
-cells. These fertilized eggs (embryos) are then placed in the women's uterus, thus bypassing the fallopian tubes.
IVF has received a great deal of media attention since it was first introduced in 1978, but it actually accounts for less than five percent of all infertility treatment in the United States.
In vitro fertilization (IVF) and other "high tech" procedures are now referred to as the assisted reproductive technologies (ART). These procedures all involve collecting the oocytes (eggs) and placing them in direct contact with sperm. Together they form an alphabet soup of techniques including: IVF, GIFT, ZIFT, ICSI, and FET.
In its simplest term, IVF is simply the uniting of egg and sperm in vitro (in the lab). Subsequently the embryos are transferred into the uterus through the cervix and pregnancy is allowed to begin. IVF was the first of the ART techniques to be developed. The first birth was in 1978 in England. The procedure was pioneered by a Gynecologist and a Ph.D. (Drs. Steptoe and Edwards). Next came GIFT, which stands for gamete (egg and sperm) intrafallopian transfer. This procedure requires laparoscopy, which is a small incision surgery and requires a general anesthetic. With existing technology, pregnancy rates are similar with IVF and GIFT. Since IVF does not require surgery, it has supplanted GIFT.
ZIFT involves IVF and then a laparoscopic surgical procedure to transfer the embryos into the fallopian tube. Since transferring embryos through the cervix with IVF gives the same pregnancy rate as ZIFT, and is nonsurgical, IVF has also supplanted GIFT.
As the years have passed, IVF has become the dominant ART technology due to its simplicity, efficacy and lack of invasiveness. A typical IVF cycle begins with shutting down the ovaries. This is done with a medication known as a GnRH agonist. The most common drug such used is Lupron. Lupron is given for approximately two weeks after which the ovaries are shut down temporarily. The next phase involves stimulation of the ovaries with potent ovulation medications such as Pergonal. For a full description of these agents go to the page on ovulation medication. These injections are given for approximately 10 days. When the eggs are ready for harvesting, a final step is to give hCG to induce final maturation. The eggs are then harvested by a process called ultrasound guided vaginal retrieval. Under heavy sedation, and with ultrasound guidance, a thin needle is passed a short distance into the ovaries and the eggs are suctioned from the follicles. Typically 5-15 eggs are collected. Typically the eggs are fertilized by adding approximately 100,000 motile sperm to each egg. If the sperm will not fertilize the eggs naturally we can perform intracytoplasmic sperm injection (ICSI). This procedure involves puncturing the egg directly under a microscope and injecting one sperm in the egg.
Figure-1.1
The day following retrieval, we can document fertilization under the microscope. We then observe the embryos for 3-6 days. The current trend is to observe longer. Typically 3-4 embryos are then placed in a catheter and transferred through the cervix into the uterus. This is a simple procedure much like a Pap smear. At the present time, embryos can be transferred either 3 or six days following retrieval. A 3-day embryo is usually at the 6-8-cell stage:
Figure-1.2
It is also possible now to perform advanced stage or blastocyst embryo transfers. These embryos are further along and usually fewer of them need to be transferred:
Figure-1.3
Two weeks later a pregnancy test can be obtained. Two weeks after the pregnancy test, an ultrasound can be performed and the fetal hear beat can be seen. If more embryos were generated than can be replaced, freezing (cryopreservation) can save these additional embryos. Frozen embryos can be stored for future replacement at much lower cost than the original IVF cycle.
As the years have passed, IVF has improved greatly. Today it is arguably the most effective technique to treat infertility when compared with others on a month by month basis. IVF has created a lot of controversy also. First, it is expensive. An IVF cycle can cost $6,000 to $7,000. It may not work on the first cycle. Multiple pregnancies can result. The truth is that it is a powerful technology and must be used carefully. Some patients may have very high odds of success: 45 - 60% chance per attempt. Others may due to their situation have only a 20% chance of success.
The multiple pregnancy risk varies with age. Younger patients need fewer embryos to be replaced, and older patients need more. The worst thing that has happened with IVF is the various centers entering into a race to see who can get "the best statistics". This has encouraged centers to transfer high numbers of embryos to get the statistics while accepting too high a risk of multiple pregnancy.
Also in order to get the best statistics, some patients will be refused care in order to "protect the statistics".f) cells, trigger a local or widespread inflammatory response, and retain the memory of the offending organism to repel it again if it should ever return. Like any finely-tuned machine, however, the system can break down and leave us open to the threat of infection, or, conversely, turn against our own healthy tissues, as occurs in such diseases as rheumatoid arthritis or lupus. The immune system also plays an important role in human reproduction. Inflammatory cells and their secretory products are involved in the processes of ovulation and preparation of the endometrium for implantation of a fertilized egg. Dysfunction of the immune system can interfere with the normal reproductive processes and result in infertility. It has been estimated that an immune factor may be involved in up to 20% of couples with otherwise unexplained infertility. Although many of these associations with infertility remain unproven, there is solid scientific evidence to implicate the formation of
-antibodies against sperm as an important infertility factor.
Antisperm Antibodies: How common are they?
Sperm are relatively protected from the immune system by a natural protective mechanism called the blood-testes barrier. Tight connections between the cells lining the male reproductive tract keep immune cells from gaining entry to the sperm within. If an injury breaches this barrier, then the immune system has access to sperm and antibodies are formed. Antisperm antibodies have been reported in approximately 10% of infertile men, compared to less than 1% of fertile men. The prevalence of antibodies jumps dramatically in men who have had surgery on their reproductive tract: nearly 70% of men who have undergone a vasectomy reversal will have antibodies present on their sperm. Women have a much lower chance for developing antibodies to sperm: less than 5% of infertile women can be shown to have antisperm antibodies, and it is unclear who is at risk for their formation.
Who is at risk for antisperm antibodies?
Anything that disrupts the normal blood-testes barrier can result in the formation of antisperm antibodies. This may include any of the following conditions: Vasectomy reversal Varicocele (dilation of the veins surrounding the spermatic cord) Testicular torsion (twisting of the testicle) Congenital absence of the vas deferens Testicular biopsy Cryptorchidism (failure of testicular descent) Testicular cancer Infection (orchitis, prostatitis) Inguinal hernia repair prior to puberty Fortunately, intrauterine insemination (the placement of washed sperm into the uterine cavity - a common fertility treatment) has not been shown to cause antisperm antibody formation. Despite the long list of risk factors, most men with antisperm antibodies have not had any of the conditions listed above. Therefore all infertile men are potentially at risk, and consideration should be given to testing infertile men for antisperm antibodies, especially if no other reasons for the infertility have been detected by the diagnostic workup.
How do antisperm antibodies cause infertility?
Antibodies that attach to the sperm may impair motility and make it harder for them to penetrate the cervical mucus and gain entrance to the egg; they may also cause the sperm to clump together, which is occasionally noted on a routine semen analysis. Antibodies may also interfere with the ability of the sperm to fertilize the egg.
What is the best way to detect antisperm antibodies?
Over the years, many tests have been developed to detect antisperm antibodies. In women, blood tests for antisperm antibodies in women may be more practical than trying to measure antibodies in the cervical mucus, which is the primary site where her immune system interacts with sperm. The postcoital test, which has been a standard part of the infertility evaluation, may suggest the presence of antisperm antibodies. By examining the cervical mucus following intercourse near the time of ovulation, antisperm antibodies may result in either a lack of sperm or in the presence of sperm, which are shaking in place rather than actively swimming through the mucus. In men, a direct examination of their sperm for attached antibodies is more reliable than testing blood for the presence of antibodies. Two commonly used tests are the immunobead assay and the mixed agglutination reaction (MAR). Both tests use antibodies bound to a small marker, such as plastic beads or red blood cells, which will attach to sperm that have antibodies on their surface. The results are read as a percentage of sperm bound by antibodies.
What treatments are available for antisperm antibodies?
Suppressing the immune system with corticosteroids may decrease the production of antibodies but can result in serious side effects, including severe damage to the hipbone. Intrauterine insemination, with or without the use of fertility medications, has been used for the treatment of antisperm antibodies. It is believed to work by delivering the sperm directly into the uterus and fallopian tubes, thus bypassing the cervical mucus. In vitro fertilization appears to be the most effective treatment for antisperm antibodies, especially when there are very high levels of antibodies (near 100% of sperm are bound by antibodies). There is no clear guidance on whether intracytoplasmic sperm injection (ICSI), the direct fertilization of an egg with a single sperm, is required for the treatment of antisperm antibodies, unless there had been a complete absence of fertilization on a prior attempt at in vitro fertilization
Are there other antibodies that affect fertility? For women with recurrent miscarriage, there are a group of antibodies that appear to attack an early developing pregnancy, resulting in either a miscarriage or severe preeclampsia with risk of intrauterine growth retardation or even fetal death. Collectively these belong to a class of antibodies known as antiphospholipid antibodies, which include the lupus anticoagulant and the anticardiolipin antibody. Testing for these antibodies are an integral part of the workup for recurrent pregnancy loss. However, it is unclear whether these antibodies play any role in the ability to conceive. Some physicians believe that the presence of antiphospholipid antibodies may decrease the chance for pregnancy through in vitro fertilization. Although this is a controversial subject, one of the largest studies that looked for these antibodies in women undergoing in vitro fertilization found that these antibodies were no more likely to be detected in those who did not become pregnant as in women who did conceive.
Is In Vitro Fertilization Expensive?
The average cost of an IVF cycle in the United States is $12,400. Like other extremely delicate medical procedures, IVF involves highly trained professionals with sophisticated laboratories and equipment, and the cycle may need to be repeated to be successful. While IVF and other assisted reproductive technologies are not inexpensive, they account for only three hundredths of one percent (0.03%) of U.S. health care costs.
Work of In Vitro Fertilization :
Yes. IVF was introduced in the United States in 1981 and from 1985 through 1998 ASRM and its affiliate, the Society for Assisted Reproductive Technology (SART), have counted more than 91,000 births of babies conceived through IVF. Through the end of 2000, more than 212,000 babies have been born in the US as a result of reported ART procedures. IVF currently accounts for about 98% of procedures with GIFT, ZIFT and combination procedures making up the remainder. The average live delivery rate for IVF in 1998 was 29.1 per cent per retrieval--a little better than the 20 per cent chance in any given month that a reproductively healthy couple has of achieving a pregnancy and carrying it to termm.
There are groups who are working to be the first ones to clone a human, so the question arises, is this an option for infertile couples. In this article I don't claim to come with concrete answers for there are just to many unknowns. However it is something that we should understand and evaluate in order to make a balanced Islamic decision.
HOW IS CLONING PERFORMED
Cloning is done by the use of the nucleus of an egg and selected DNA from the one being cloned. These two are than fused together with the use of an electrical current. This cell than grows into a genetic duplicate and placed into the womb until full term into a normal human being. At least this is the theory.
So a clone is not an identical person to the one being cloned in all respects. Just as an identical twin is not the twin in all respects. They are two distinct human beings, if one dies the other lives on. Cloning should not be mistaken with the ability to live forever. It is just a genetic duplicate, the two would look the same, have some of the same likes and dislikes but would be two separate distinct human beings.
ARE THEIR HUMAN CLONES NOW
No one can say for sure at this point if there are or not. Dolly was seven months old before we knew that she existed so we can't expect that those who clone a human may rush out and let the world know. Considering that many are against such procedures as being morally wrong those who undertake such medical experiments would have to do so very quietly. There are groups such as the Relians who say they have a lab and scientists working to make a clone of a 10 month old boy who died and have 50 surrogate women who have volunteered to carry the baby to term. Scientists in Japan have claimed to already cloned a human but destroyed the embryo rather than implanting it. Human clones may very well be a present day reality.
IS THIS REALLY A SENSIBLE OPTION FOR INFERTILITY
Many who desire a child but have no other means to conceive would of course say yes. But at what cost are we going to pay in order to produce children? This is something that needs to be evaluated and seriously considered before anyone takes it as a viable option for infertile couples. There is not an issue of will it work, for it can for
couples who may be going through early menopause or the husband lacks viable sperm. The question for such couples who would be the one to clone? Remember a clone is an identical twin to the one being cloned. So if one were to clone their husband a woman would be literally giving birth to her husbands genetic twin. So such a child would be a son to the father as well as his brother and a son to his mother but also a brother in law by marriage. How odd is this picture?
We also have to consider the downfall of cloning, considering that it took 277 tries in order to clone Dolly. The risks of having a deformed child are very great. And it may not be until the mother carries the child full term before the deformities are realized. The emotional trauma that most couples go through in battling infertility are great there is no need to add such an experience on top of it.
There seems to be no concrete Islamic stance on this issue. It has been discussed between many scholars and some have declared it out rightly haram. Others have declared it haram on a societal level but hold a wait and see attitude when it comes to personal situations that may arise.
What is at question among Muslims is keeping the lineage established rather than how the procedure is performed. When it comes to treating infertility there are agreed upon basic Islamic principles which we can go by. All agree that an egg, sperm and womb must be used by the wife and the husband. And at the time of the implantation there is a valid marriage, this in order to maintain a proper lineage. So by this we do know that no donor eggs can be used in order to retrieve the nuclei, nor can a surrogate mother be used in order to bring the child to term. The only issue that remains is the use of DNA.
We would now need to ask, can a woman use the DNA of her legal husband?
Can a woman use her own DNA?
Can a couple use the DNA of a child already born?
Can a couple use the DNA of a deceased child?
These questions alone bring many thoughts. If a woman can use her own DNA than what use is the man? Considering that many Muslim women can support themselves would this lesson the reasons for marriage? Add in the fact that most Muslims portray the major reasons for marrying is to reproduce. If one can actually reproduce without the need of a man would they then need to marry or even desire to? Besides the present need for Muslims to reevaluate their understanding of marriage and the importance placed on ones ability to reproduce, one would also have to evaluate the role of men in
-raising children.
We would also need to ask ourselves what rights we have to our own DNA. Can a couple decide to clone a child without their consent? Or can one parent decide to clone while the other one disagrees? One also needs to ask if a valid marriage is needed in such an instance as well, for it is not the sperm which is used by the outcome of the sperm and egg union.
We must keep in mind that in Islam the lineage is closely guarded. We are not to call adopted children other than by their fathers name, we are to remain far from zina, we are to not hide what is in our wombs. All this, and more, is in order to protect the lineage of a child to avoid any types of confusions. In many instances with cloning, confusion is the only outcome. This is against the spirit of Islam and should be avoided, because it does nothing more then harm the society as a whole.
This does remind me of a saying attributed to Muhammad pbuh in which one of the signs of the last day are when the slave girl gives birth to her master
ACTING AS GOD
One of the most voiced concerns among Muslims and Non Muslims alike is the feeling that such science wishes to "act as God". I have listened to many Muslims who suggest that infertile couples should just accept the will of Allah and not act as God in order to reproduce. But how far are we to take such an approach to scientific advance? If one argues completely on the basis that cloning is acting like God in order to create another human being, well then isn't IVF treatment the same thing? Isn't one taking the raw components in order to reproduce? So if we follow this line of thinking before we know it all medical advances will be eliminated just on this position. I would find it hard to believe that those who protest on such a basis would be inclined to take such a stance if they or a loved one had a need for a transplant or any other medical treatment.
Inshallah in the future cloning and issues related to it will be rationally discussed by our Muslim scholars. Where the benefits and the harms of society will be weighed and a balanced outcome will be found. On the surface there doesn't appear to be that much of an issue when it comes to human cloning. Considering the basic Islamic guidelines on lineage and halal relationships there doesn't appear to be much room for debate. However there may be circumstances where cloning can be performed in an halal way and we must not shut the door in a heated reaction without discovering all possibilities and judging with all criteria.
STRESS & INFERTILITY
Stress is defined as any event that a person perceives as threatening or harmful. Stress can result in the heightened activity of many body organs. This increased activity is offset by hormones secreted by the adrenal glands and through the nervous system. Acute stress can result in increased heart rate, blood pressure, and respiration, as well as sweaty palms and cool, clammy skin. Chronic stress can also cause depression and result in changes in the immune system and sleep patterns.
STRESS CAUSING INFERTILITY
Although infertility is a highly stressful experience, there is very little evidence that infertility can be caused by stress. In rare cases, high levels of stress in women can change hormone levels and cause irregular ovulation. Some studies have sown that high stress levels may also cause fallopian tube spasm in woman and decreased sperm production in men.
Research has shown that women undergoing treatment for infertility have a similar, and often higher, level of "stress" as women dealing with life-threatening illnesses such as cancer and heart disease. Infertile couples experience chronic stress each month, first hoping that they will conceive and then dealing with the disappointment if they do not.
WHY INFERTILITY IS STRESSFUL
When diagnosed with infertility, many couples no longer feel in control of their bodies or their life plan. Infertility can be a major crisis because the important life goal of parenthood is threatened. Most couples are accustomed to planning their lives. Experience has shown that if they work hard at something, they can achieve it. With infertility, this may not be the case. Infertility testing and treatments can be physically, emotionally, and financially stressful. A couple’s intimacy is often reduced by the infertility experience, which further contributes to increased stress levels. Trying to coordinate medical appointments with career responsibilities can also increase pressures on infertile couples.
TIPS FOR STRESS REDUCTION
•Keep the lines of communication open with your partner.
•Get emotional support so you don’t feel isolated. Individual or couple counseling, support groups, and books on infertility can validate your feelings and help you cope.
•Learn stress reduction techniques such as meditation or yoga.
•Avoid excessive intake of caffeine and other stimulants.
•Exercise regularly to release physical and emotional tension.
•Have a medical treatment plan your and your partner are comfortable with.
•Learn as much as you can about the cause of your infertility and the treatment options available.
EXERCISE, WEIGHT, AND FERTILITY
Couples with infertility often wonder if lifestyle habits might compromise their fertility. Two important lifestyle factors, weight and exercise, can affect fertility.
Low weight or weight loss
can lead to a decrease in an important hormonal "message" that the brain sends to the ovaries in women and testes in men. This hormone, gonadotropin releasing hormone (GnRH), is produced in the part of the brain called the hypothalamus. The release of GnRH leads to the release of the hormonal messengers LH and FSH (the gonadotropins) by the pituitary gland. LH and FSH are critical for the development of eggs in the ovaries and sperm in the testes. The degree to which weight loss affects fertility will vary. In mild cases, the ovaries may still produce and release eggs, but the lining of the uterus may not be ready to receive a fertilized egg because of inadequate ovarian hormone production. In more severe cases, ovulation does not occur, and menstrual cycles are irregular or absent. In men, low weight or weight loss may lead to decreased sperm function or sperm count. If low weight or weight loss has been identified as the cause of one’s infertility, the preferred treatment would be to stop losing weight or even to gain weight if needed. An alternative treatment is the use of medications. Drugs such as GnRH (Lutrepulse (R)) or gonadotropins (Pergonal (R), Fertinex (R), Humegon (TM)) replace or eliminate the need for the missing message from the hypothalamus or pituitary and may restore fertility. However, the use of these drugs can be complicated, expensive, and can cause multiple pregnancies.
Being overweight or obese
an affect the hormonal signals to the ovaries or testes. Increased weight can also increase insulin levels in women, which may cause the ovaries to overproduce male hormones and stop releasing eggs. Weight loss is the best plan of action, but drugs such as clomiphene citrate or gonadotropins can be used in overweight patients. It is important to make sure that glucose (blood sugar) levels in overweight patients are normal prior to attempting pregnancy and that specific metabolic causes of obesity are not present.
Proper exercise
And diet are important for maintaining good health and proper weight. Extreme exercise can, however, lead to reduced sperm production in men and the cessation of ovulation in women by decreasing the brain message to the ovaries and testes. However, the amount of exercise must be very extensive; normal exercise will not affect fertility in most couples. It is impossible to know how much exercise for any one person is too much. Generally, running more than 10 miles per week is considered too much when trying to conceive. The most effective way to treat reproductive problems associated with excessive exercise is to decrease or modify the amount of exercise.
INFERTILITY AND NUTRITION
The inability to become pregnant after a long period of regular sexual activity usually signals hormonal problems. Some of the more frequent causes in women include pelvic disease, chlamydia infection (untreated), and allergic reactions to their partner's sperm. Since there are so many possible causes, it is wise to seek the advice of a qualified physician. If all the physical causes have been eliminated, the following program will support the woman's body nutritionally and put her in the best possible hormonal position to conceive.
Full Spectrum Nutrition
•Folic acid - 400 mcg extra
•Vitamin B6 - 50 mg extra
•Zinc - 50 to 100 mg per day
•Vitamin E - 400 to 800 IU extra
•Ovarian Glandular Extract - 4 to 8 tablets per day
•L-Arginine - 4 grams per day
•Iron - 10 to 20 mg per day
•Vitamin B12 - 100 to 300 mcg per day
Some stress is often involved in hormone imbalance, a high potency Stress-B complex formula, taken two or three times per day is often helpful..
PSYCHOLOGICAL COMPONENT OF INFERTILITY
What impact does infertility have on psychological well being?
Infertility often creates one of the most distressing life crises that a couple has ever experienced together. The long term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples. If you find yourself feeling anxious, depressed, out of control, or isolated, you are not alone.
How do You know if You could benefit from psychological counseling?
Everyone has feelings and emotional ups and downs as they pursue infertility treatment. Feeling overwhelmed at times is a perfectly normal response. However, if you experience any of the following symptoms over a prolonged period of time, you may benefit a great deal from working with a mental health professional:
•loss of interest in usual activities
•depression that doesn't lift
•strained interpersonal relationships (with partner, family, friends and/or colleagues)
•difficulty thinking of anything other than your infertility
•high levels of anxiety.
•diminished ability to accomplish tasks
•difficulty with concentration
•change in your sleep patterns (difficulty falling asleep or staying asleep, early morning awakening, sleeping more than usual for you)
•change in your appetite or weight (increase or decrease)
•increased use of drugs or alcohol
•thoughts about death or suicide
•social isolation
•persistent feelings of pessimism, guilt, or worthlessness
•persistent feelings of bitterness or anger
In addition, there are certain points during infertility treatment when discussion with a mental health professional of various options and exploration of your feelings about these options can help facilitate clarification of your thinking and help with your decision making. For example, consultation with a mental health professional may be helpful to you and your partner if you are:
•at a treatment crossroad
•deciding between alternative treatment possibilities
•exploring other family building options
•considering third party assistance (gamete donation, surrogacy)
•having difficulty communicating or if you have different ideas about what direction to take.
How can psychological treatment help you cope with infertility?
Mental health professionals with experience in infertility treatment can help a great deal. Their primary goal is to help individuals and couples learn how to cope with the physical and emotional changes associated with infertility, as well as with the medical treatments that can be painful and intrusive. For some, the focus may be on how to deal with a partner's response. For others, it may be on how to choose the right medical treatment or how to begin exploring other family building options. For still others, it may be on how to control stress, anxiety, or depression. By teaching patients problem- solving strategies in a supportive environment, mental health professionals help people work through their grief, fear, and other emotions so that they can find resolution of their infertility. A good therapist can help you sort out feelings, strengthen already present coping skills and develop new ones, and communicate with others more clearly. For many, the life crisis of infertility eventually proves to be an opportunity for life-enhancing personal growth.
How can You find a mental health professional experienced in working with infertility?
Make sure you choose a mental health professional who is familiar with the emotional experience of infertility. It is recommended that they have:
•a graduate degree in a mental health profession
•a license to practice and/or state registration
•clinical training in the psychological aspects of infertility
•experience in the medical and psychological aspects of reproductive medicine
Interview more than one person. Ask them for their credentials as well as their experience with infertility issues and treatments. Ask if they are currently seeing other people with infertility.
Although over three million Americans are affected by the painful experience of secondary infertility, it generally remains an unacknowledged and invisible condition. Secondary infertility is defined as the inability to become pregnant, or to carry a pregnancy to term, following the birth of one or more biological children. Even though the couple already has a child, the couple experiences secondary infertility as the loss of a child, the loss of pregnancy, and the loss of childbirth.
Even though secondary infertility has a higher prevalence rate than primary infertility, couples are far less apt to seek treatment for this condition. When their first child is conceived with ease, many couples are caught completely off guard by the difficulty of having a second child because they hold the belief that past fertility insures future fertility. Physicians, too, may downplay the possibility of secondary infertility in their previously fertile patients and encourage the couple to "keep on trying." These couples are vulnerable to feelings of self-blame, particularly if they seek treatment at a later time and the interventions are unsuccessful. Often they feel regretful at not having taken a more aggressive approach to treatment when they were younger, as advancing age is often an issue in secondary infertility.
The emotional experience of secondary infertility often is a compilation of the distressing feelings of anger, grief, depression, isolation, guilt, jealousy, self-blame, and being out of control. Couples may feel guilty for experiencing normal grief and worry about how their anguish will affect their existing child. The powerlessness to produce a sibling for the existing child often produces feelings of sorrow, as does the inability to perpetuate the parenting role. Many feel distant from their friends as those who were a great source of support when parenting the first child are now linked to sensations of pain and jealously.
Sadly, couples with secondary infertility tend to receive less social support from others than couples who have primary infertility because the infertility is unacknowledged, the pain associated with infertility is invisible as the couple has a child, and there is no concrete loss in the family. In addition, couples experiencing secondary infertility may be recipients of criticism by others who think they should be grateful for one child and that it is foolish to go to extremes to increase family size. Of course, a couple can be extraordinarily thankful for their existing child and still long for more children.
To avoid the sense of isolation that often accompanies secondary infertility, and to maintain necessary social support, it is important to educate friends and family members about the common feelings associated with secondary infertility. For example, with some guidance by the couple, friends may understand that declining an invitation to a baby shower relates to pain and grief, rather than a lack of interest in another's family.
The emergence of secondary infertility can challenge even the strongest of marriages. Partners may have different coping styles that can lead to distancing and alienation within the relationship. For instance, it is quite difficult when one partner seeks information and intervention to relieve anxiety and a sense of helplessness, and the other copes with stress by feeling the matter will resolve itself with time and believes that taking action is unnecessary. In addition it is not unusual for partners to vary in their ability and comfort level in discussing feelings. It is not uncommon for one partner to feel overwhelmed by the other's emotions and the other, alternatively, to experience being shut out by their partner's refusal to discuss the situation.
When partners are out of sync, they often become the targets of reciprocal anger. Although not intentional or conscious, emotional pain can cause partners to blame one another for the infertility or for not commencing with treatment expediently. In addition, couples often have different feelings about family size, the amount of financial resources to invest in treatment, the use of third parties to achieve a pregnancy, the exploration of adoption, whom to tell, and when to terminate treatment. It is crucial that couples strive to understand their partner's experience and to be empathic. It is impossible for a couple to reach conflict resolution without positive communication. Sexuality frequently is affected by secondary infertility. Partners may report decreased sex drive and diminished sense of enjoyment. Couples with secondary infertility often are required to have "sex on demand." Instead of being associated with intimacy, sex becomes associated with procreation, pain, and failure. It is important for couples to take time off from
infertility and to reconnect their sexuality to affection and emotional closeness.
Not only can secondary infertility generate marital problems, it is best understood as a time of family crisis. Until some resolution is achieved, the entire family remains in a state of stress because there is ambiguity about whether there will be more children. The couple must confront the idea that the ideal family size they once envisioned may never become a reality. It is not possible for anyone to give up on their ideal without the experience of loss, grief, and distress.
Unlike in primary infertility, couples who experience secondary infertility already have a child's needs and welfare to consider. It is important for parents to demonstrate to their child that problems are dealt with and not buried. It is naïve to think that a child will remain unaware of her parents' grief just because the parents do not talk about it or address it directly. In fact, if there is an absence of information, children resort to egocentricism and magical thinking to interpret events. For example, the child may be worried seeing the mother go to the doctor, getting shots etc. or the child may think her parents are dissatisfied with her if they are upset and anxious. The young child does not have the cognitive capability to understand her parents' actions and feelings as separate from herself, and, therefore, needs an explanation for her parents' melancholy. In addition to helping the existing child appreciate the parents' emotions, parents must help the child identify his own experiences and feelings.
Guilt about not providing the existing child with a sibling is a common experience of couples suffering from secondary infertility, as they feel they are failing their child. Many couples idealize the sibling relationship by believing the siblings would be emotionally close. Of course, there is no guarantee about any sibling relationship, and the existing child should not be burdened by the loss of this idealized relationship. It is crucial for parents to acknowledge and mourn the loss and then to legitimize the existing family. Families come in all shapes and sizes, even size three.
It is a cruel irony that the more positively parents feel about parenting, the more painful is their experience of secondary infertility. Many parents have expressed ambivalent feelings about their child growing up because they fear they will never re-experience the pleasure of the early years. In addition, parents may become overly protective and attentive to their existing child. In the face of loss, parents want to hang on to what they have and love. Of course, these parental feelings must be kept in balance with the growing child's needs for separation and independence.
The resolution of secondary infertility brings many variables into the decision making process. The couple must focus on the desire to parent a second child and the time, energy, and finances involved in pursuing medical treatment or alternatives such as adoption. These conditions must be weighed with the needs of the existing child in mind. Couples often are concerned whether or not they will continue to be good parents in light
-of the emotional and financial stresses associated with treatment. Sometimes, in grieving the loss, couples find there are advantages, such as more time and more resources, associated with having one child.
Couples often need assistance from professionals and/or support groups as they struggle with the turmoil of secondary infertility. Grieving what might have been is not an easy task, and couples often benefit from the contributions and support of others grappling with the same circumstances. If the grieving process extends for a long period of time, and symptoms of depression exist for more than six months, the help of a mental health professional with experience in reproductive medicine should be sought. With respect to secondary infertility the ultimate goal is to grieve the loss of a child, decide to pursue medical treatment or alternative family building options, or to embrace the established family as it exists. With resolution comes the reclamation of life.
In the Name of ALLAH Most Gracious Most Merciful
Every month a couple has basically 1 in 4 chance of conceiving where no infertility factors exist. In a womans' lifetime she will normally produce 4 to 5 thousand eggs. Eight of these eggs are recruited each month, and only one is brought to maturity and relased into the fallopian tube, the other seven eggs deteriorate and die. The egg only lives from 24-36 hours after it is released and if it is not fertilized by the sperm (which can live up to 72 hours inside a woman) the egg will then deteriorate and die. Within two weeks the uterine lining will shed and a woman will have a menstrual cycle.
There are other factors in the whole fertilization process, such as the opening of a womans cervix, cervical mucus that helps the sperm reach the egg. Not to mention healthy non deformed sperm that can survive and fertilize the egg. Although seemingly an easy process there are many factors that can decrease the chances of fertilization from occurring. These can include blocked fallopian tubes, which can be caused by PID,ENDOMETRIOSIS, Scar tissue from miscarriages or surgical proceedings. There is also the factor of PCOS, which affects the womans ability to normally produce and release an egg each month. These being only female factors of infertility, it is false to assume that infertility is only a womans problem Male factors also make up for about 40% of inferility problems, which include blocked ducts, low amount of sperm, and deformed sperm.
Normally when couples have unprotected sex for a year, a pregnancy will occur. If a woman does not become pregnant within a year (6 months for women over 35)the couple should have a fertility work-up to find out what is going on. Most couples that seek a fertility work-up by a Reproductive Endocronologist (differing from a regular GYN), should know within a month, or shortly thereafter,why pregnancy has not been succesful. Such a work-up includes, but is not limited to: medical history, blood tests, pap smear, vaginal examination,HSG,a semen analysis, cervical cultures and Laparoscopy.
Having infertility problems, in most cases, does not mean the end of conceiving. There are many options open to couples that will help them to concieve children. Some of these options include, but are not limited to, IVF, IUI,GIFT,ZIFT, Ovulation drugs such as Clomid, and tubal surgery.There are also options for male factor infertility such as treatment with fertility drugs, surgery and ART procedures
What concerns us most, as Muslims, is what options are Islamically permissible for us. Are ART procedures permissible, what is not permissible, why are certain things not permissible, are just some of the questions we would like to address. Keep in mind that none of the sisters who add to this web page are scholars, and there may be variant opinions as to what is acceptable and what is not. And due to the fact that an "In Depth" look at fertility options have yet to be addressed by "scholars" some questions will be left unanswered on this web site. We encourage all to seek proper islamic means to deal with your infertility for Allah places things in our lives for a reason. We will all be tested, and as Muslims we should persevere in the way which is right in order to seek any rewards.
INFERTILITY IN THE QUR'AN
The Qur'an is true guidance for all mankind, complete and not lacking anything. It touches on every aspect of life, so it should come as no suprise that infertility is on the vast array of subjects. The Qur'an teaches in many ways, showing us a glimpse of the lives of others before us is one way. There are two stories of infertility in Qur'an which we should draw and learn from. The first story is that of Ibrahim s.a.w. and his wife Sara r.a. The two main accounts of this story, given as follows.
And his wife was standing (there) and she laughed: But we gave her glad tidings of Isaac and after him, of Jacob. She said "Alas for me! Shall I bear a child, seeing I am an old woman, and my husband here, is an old man? That indeed would be a wonderful thing!" They said: "Dost thou wonder at Allah's decree? The grace of Allah and His blessings on
-you, O ye people of the house! For He is indeed worthy of all praise, full of Glory!" 11:71-73
...And they (angels) gave him (Ibrahim) glad tidings of a son endowed with knowledge. But his wife came forward clamoring, she smote her forehead and said: "A barren old woman!" They said "Even so has thy Lord spoken and He is full of wisdom and knowledge."
Not much detail is given in the Qur'an concerning the lives of Sara or Hagar. But some of the details we recieve with ahadith. Islamic exegesis also rely on heavily upon biblical (OT) information about Sara as well as Hagar. What we do know from the Qur'an was that Sara was old and barren when Allah blessed her with a child. Exegesis place her age at about ninety and Ibrahim was over 100 yrs old. It was several years before this that Sara gave her hand maiden, Hagar, to Ibrahim in marriage so that he may have children.
Many women going through infertility can relate to the sense of guilt for "denying" their husbands children. This is a common feeling that is present, as we see with Sarah. As we see in this story polygyny is an option for couple who can not have children due to the illness with the wife.
Accroding to exigisis after Hagar conceived she became "haughty" in her ability to have children. From this rose a jealousy in Sara in which she threatened to do harm to Hagar. Nothing came of this threat and evidently the waters were calmed in Ibrahim's household. The family continued to remain together until Ibrahim's command to take Hagar and Ishmael to the valley of Mecca and leave them there.
We have reference in the Qur'an of Sara striking her face and laughing in the astonishment of being blessed with a pregnancy at 90 yrs of age. It appears Sarah, naturally, had long since given up hopes of conceiving. She had given Hagar to Ibrahim as a way not to deny him and accepting the Qadar (fate) that Allah had set for her.
Here we can take a lesson from Sara, at some point we must learn to just accept what has been written for us and go on. All too often couples become obsessed with having a child to where it is harmful for themselves. We as Muslims must learn to seek a healthy balance in striving for pregnancy. We must learn at what point to stop medical procedures and accept what Allah has planne for us. A woman's (or man's) life does not end because they have no children. Sarah, although barren, remained firm in her faith, true to her husband, and a full woman in every sense of the word.
Sarah was ultimately blessed with a child, Ishaq pbuh. Angels came to her as they were on their way to the people of Lot pbuh and informed her. Not only was she told of a son but she was also informed that she would live to see her grandchildren. Considering her age it could have been the total shock that lead her to smite her face. I'm sure after so many years of giving up on having children a slap on the face is what she needed to reassure herself she wasn't dreaming.
It is important at this point to take notice of the example set by Ibrahim in relation to his barren wife. He was never harsh to his wife in words or deeds even though she was unable to conceive. Nor did he abandon her he chose to stand by his wife as she stood by him. He did not seek out another wife or "right hand possession" to have children, it was Sara who suggested Hagar to him. This bond of marriage, faith, love, and tenderness kept this couple together even in infertile times. Working together in cooperation something we all should take notice of. And men, or cultures for that matter, who blame women for not conceiving and down them as if they were no longer a complete woman should take heed in this example set by Ibrahim.
Ibrahim was indeed a model... 16:120
Another Qur'anic example of infertility is that of Zakariya pbuh and his wife Ishba. The Qur'anic story focuses more on Zakariya than Ishba herself. In fact very little is said about her in the Qur'an, hadith, and exegesis.
There did Zakariya pray to his Lord, saying: "O my Lord! Grant unto me from Thee a progeny that is pure: for Thou art He that heareth prayer! While he was standing in prayer in the chamber, the angels called unto him: "Allah doth give thee glad tidings of Yahya, witnessing the truth of a Word from Allah, and (be besides) noble, chaste, and a prophet,- of the (goodly) company of the righteous." He said: "O my Lord! How shall I have son, seeing I am very old, and my wife is barren?" "Thus," was the answer, "Doth Allah accomplish what He willeth."
(This is) a recital of the Mercy of thy Lord to His servant Zakariya.Behold! he cried to his Lord in secret, Praying: "O my Lord! infirm indeed are my bones, and the hair of my head doth glisten with grey: but never am I unblest, O my Lord, in my prayer to Thee! 1
And (remember) Zakariya, when he cried to his Lord: "O my Lord! leave me not without offspring, though thou art the best of inheritors." So We listened to him: and We granted him Yahya: We cured his wife's (Barrenness) for him. These (three)were ever quick in emulation in good works; they used to call on Us with love and reverence, and humble themselves before Us.
Mary r.a. was placed in the care of Zakariya pbh and her aunt Ishba. Ishba was barren, so the caring of a child was a blessing in her family. Zakariya pbuh at times marveled at how well Mary had grown and it instilled the urge in him to have a son. One who would not only inherit the family lineage, but one who would carry on the teachings of Allah, something which he did himself. Perhaps Mary r.a. fulfilled the natural urge in Zakariya pbuh to have children for a limited time, but when she had matured and no longer a child, the desire seems to have rekindled. Whatever the exact emotions that Zakariya pbuh had, it brought him to a point where he prayed in secret to have a son.
Zakariya pbuh beseeched Allah for this blessing, perhaps not expecting the answer, he appears surprised with it. It was not so much the answer of "yes" but rather the means in which the child would come to him. His old barren wife, cured by Allah, was to conceive. Zakariya responded in natural amazement that his wife would conceive. He was told by Allah that such a thing was easy for Allah.. and it is. His son would be given the name of Yahya pbuh a name not before given who would carry on Zakariya's pbuh work.
We also learn that Ishba and Mary were pregnant around the same time. Yahya's pbuh work with Isa pbuh being something planned by Allah surrounded by many miraculous events.
As with the story of Ibrahim pbuh we have the example of a husband who remains with his barren wife. She is not shunned, shammed, divorced, or looked down upon as an incomplete woman as many men and cultures do to women. This is a lesson that all of our ummah must learn, as Allah says "...He leaves barren whom He wills" (42:50) It is a decree from Allah. This does not make one less of a woman (or man) and one should not be treated as such. We are to remain firm in our faith in Allah, knowing that He brings about things that we may not like and things we are tested with. And the stigma placed on couples who do not have children we are failing our test.
I know many women are thinking, that these two stories have such happy endings (babies) and yet it does not happen with all of us. Why does not Allah bestow on all of us pregnancies.. why must "I" be barren.. why me? As I sit here and write this my mind searches for an example of a woman with no children, suddenly I remembered one so full of faith, and one mentioned in the Qur'an as an example for all those who believe.
And Allah sets forth, as an example to those who believe the wife of Pharaoh: Behold she said: "O my Lord! Build for me, in nearness to Thee, a mansion in the Garden, and save me from Pharaoh and his doings, and save me from those that do wrong"; 66:11
Her name was Asya, and she never conceived a child. It is said that her marriage was one of sacrifice she made for the safety of her people. But the marriage was never consumated, for Allah had stricken Pharaoh with impotence. Whatever the case may have been, here was a childless woman, who is set forth as an example for all believers. She nurtured a Prophet from infancy even though he was not her own, and she was a martyr.
It is said that Pharoah had killed several believers in the palace, among them a maid, her children and her husband. Asya picked up an iron stake to kill Pharaoh, she failed, and Pharaoh had her tortured by piercing iron stakes through her breast. The same childless woman sought Allah to build mansions in the Garden, and to save her from those that do wrong. Do we dare to say that such an example as stated by Allah is incomplete or less of a woman because she bore no children? Do we not take heed in the examples given to us? So anytime one attempts to make you feel low, or less of a woman (or man) think of these
-examples, draw guidance and strength from them. Rely on Allah, and seek Him to give you strength.
May Allah give us All that is good for us, make it easy for us to obtain it and keep us on the straight path when we do.
There comes a time in the process of curing infertility when a couple decides that they have availed all options and they must move on with their lives. Many husbands see divorce and then remarriage as the only alternative to have children. Islamically though he has an option that could be far more beneficial to his first wife, himself, and his marriage to follow. The option of polygyny is one that is looked down upon in western society, but one that is permissible and in some cases encouraged in Islam.
Allah(swt) says (what could be translated as):
"And if you fear that you shall not be able to deal justly with the orphan-girls, then marry (other) women of your choice, two or three, or four but if you fear that you shall not be able to deal justly (with them), then only one or (the captives and the slaves) that your right hands possess. That is nearer to prevent you from doing injustice." (An-Nisa 4:3)
From this ayat it is clear that Islam has allowed men to marry up to four wives. He does not need any specific reason to have multiple wives, but he can do so for whatever reason he may wish as long as he is just with them. Most wives though would detest the idea of sharing their husband with another wife. What is said in Islamic sources about marrying for reasons of fertility?
The Prophet Muhammad (saw) said:
"Marry the loving and the fertile because through you, I will compete with the nations for superiority in numbers." (Abu Dawud and others)
The Prophet of Allah has encouraged Muslim men in this hadith to marry those who are fertile, he did NOT say not to marry the infertile amongst you. If for some reason the first wife is infertile then the option to avail the choice of polygyny is one that is encouraged islamically.
It is important to note that only two wives of the Prophet Muhammad(saw) gave birth to his children. Ayesha(rad), one of his most beloved wives, never had any children. Although others of his wives never conceived he treated all his wives justly and in a kind manner. He never raised the status of a fertile wife over an infertile one. His(saw) example is the best example. Men who wish to take on more then one wife should study his(saw) seerah and try to implement his(saw) treatment towards his(saw) wives in their own lives.
What are the benefits for the first wife, wives to follow, and any children from those wives? Oftentimes women who cannot conceive wish more then anything to rear a child or help in rearing a child. They often envy women who have children and wish that for even a day they could take care of a child as their own. I have seen several instance where a brother has taken on another wife as a result of his first wife being infertile. The first wife has almost always been extremely happy to be able to help the second wife in rearing her children. This creates an ideal situation for everyone in the household. The first wife is happy to be able to get a chance to raise children. The second wife receives extra help from the first wife and this strengthens the bond and relationship between the wives. The children have the attention of "two mothers." I am not saying that this happy-go-lucky relationship exists in every polyganous household, but rather I am suggesting that this may be a positive alternative for a husband who would like to have children.
There could also be problems as well. Jealousy is a common problem that arises amongst wives. Infertile women often feel that they were not good enough for their husbands and this was the reason for their remarriage. Husbands usually do not feel this way towards their wives. In fact if they are willing to keep their first wife then obviously the love and honor they feel towards them is what is keeping them together. Husbands should take this into account and make the change as painless as possible for their first wives.
The situation of every couple is different. Each couple knows how much they can take, and what options are best for them. As a couple it is important to sit down and discuss the pros and cons of going into a polygynous relationship. May Allah make it easy on everyone and relieve our hardships (Ameen).
"...Our Lord! Condemn us not
If we forget or fall
Into error; our Lord!
Lay not on us a burden
Like that which Thou
Didst lay on those before us;
Our Lord! lay not on us
A burden greater than we
Have strength to bear.
Blot out our sins,
And grant us forgiveness.
Have mercy on us.
Thou art our Protector..."
-The Meaning of the Qur'an (2:286)
CANCER AND FERTILITY PRESERVATION
In the United States there are approximately 800,000 reproductive-aged men and women who have cancer, many of whom have concerns about their fertility. Lifesaving cancer treatments may reduce fertility by destroying eggs and sperm. The likelihood of reproductive damage depends on the age and sex of the patient and the type and duration of treatment. The most severe damage comes from radiation to the ovaries or testicles and cancer drugs in the “alkylating agent” category such as cyclophosphamide ,mechlorethamine, chlorambucil, and melphalan. Although sperm production may recover, eggs do not regenerate; their loss is permanent and premature menopause may occur as a result. The risk of developing premature menopause is lower for younger women than for older women. The first goal is to cure the cancer, even if the treatment causes sterility. However, there are several options that may help preserve fertility before and after cancer treatments.
Preserving fertility before cancer treatment:
• Men
Semen samples may be frozen at a sperm bank or fertility center before starting chemotherapy or radiation therapy. Samples can be stored for years and used later for insemination. Sperm counts may be low or absent as a result of the underlying cancer. If sperm counts are low and/or the supply is limited from the frozen sample, the sperm can be used for in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).
• Women
If time and circumstances allow, women may be treated with IVF. Embryos created by IVF are then frozen and may be stored for years. Limiting factors for this approach include time, expense, availability of sperm, and possible delay of cancer therapy. If radiation will be administered to the pelvis, the ovaries may be repositioned surgically out of the radiation field. This will reduce the risk that radiation will damage the eggs.
• Areas of research
Ovarian suppression before cancer therapy: In theory, suppressing ovarian function may protect the eggs against the adverse effects of cancer treatment. There is little evidence to support suppression of the ovaries before cancer therapy with birth control pills, GnRH
agonists, or other means of hormonal suppression. Freeze eggs. This technology is investigational, expensive, invasive, and may delay cancer treatment. If used,eggs are collected as for IVF but are frozen before they are fertilized. Theoretically, frozen eggs may be Stored, thawed, fertilized, and used for embryo transfer. Actual success with this method is very limited, and few babies have been born with this technique.
Freeze ovarian tissue: This experimental technique requires surgery to remove ovarian tissue. Once frozen, tissue may be stored for years. Preliminary studies have shown that reimplanted ovarian tissue may survive and function for a limited time, but no babies have been born using this technique as of 2003.
Fertility after cancer treatment
• Men
It may take up to several years for sperm production to recover after cancer treatment. If sperm counts are consistently low, insemination, IVF, and ICSI may be effective measures for achieving pregnancy. Testicular biopsy may be a way to obtain sperm if sperm are not found in a semen analysis. If sperm cannot be obtained, pregnancy may be possible by using frozen donor sperm. The physician may want to wait up to six months before attempting conception. Some couples may choose to pursue adoption.
• Women
After the physician has advised that attempting pregnancy is safe, women may want to consult a fertility specialist to check for damage to reproductive organs. Many women will be able to conceive naturally or with fertility treatments. If significant damage has occurred to the ovaries or uterus, couples may wish to consider egg or
embryo donation, a gestational carrier, or adoption to create a family.
AGING AND INFERTILITY
Background
Female age is very important in consideration of probability for conception. The real issue is egg quantity and quality - which translates over to embryo quality after fertilization.
The age of the male partner does not appear to matter nearly as much. Sperm from older men does not usually have a substantially reduced fertilizing potential as compared to sperm from younger men. However, older men often have less interest in frequent intercourse, which can be a factor in chances for conception.
Many people are not aware of the decline in fertility as the age of the female partner increases:
There is a slow decline in pregnancy rates in the early 30's. This decline is more substantial in the late 30's and early 40's. Few women over 45 are still fertile.
Miscarriage rates also increase substantially as the mother ages (more on miscarriage below).
One important caveat is that the above numbers apply to populations, not individuals. A given woman can have rapid decline in egg quantity and quality at an early age - even in her teens or twenties in rare cases.
A study published in 1957 examined the relationship between the age of the female partner and fertility. This study found that:
By age 30, 7% of couples were infertile
By age 35, 11% of couples were infertile
By age 40, 33% of couples were infertile
At age 45, 87% of couples were infertile
For several reasons, infertility rates are even higher in the general population in the U.S. today than for the population studied by Tietze in the 1950s.
Tests to determine whether "age" is a significant factor in an individual couple
"Age" is in quotes here because the real issue is oocyte (egg) quality and not the number in a woman's age.
A woman can be 45 with exceptionally good quality eggs and still be fertile, or, she can be 25 with very poor quality eggs and be infertile. These are extreme examples, but the point is that egg quantity and quality tends to decline significantly in the late 30s and faster in the early 40s, but egg quantity and quality in an individual woman can be average for her age, better than average, or worse than average.
It would be nice to have a reliable test to determine how good the eggs are in an individual woman at a point in time. We do have some screening tests for ovarian reserve, however, they are far from perfect. Day 3 FSH testing and antral follicles counts are tests used by infertility specialists to help predict ovarian reserve.
Many infertility specialists recommend that women over about 38 that are infertile should have aggressive treatment and proceed to in vitro fertilization relatively quickly - before all fertility potential is lost.
Ten to 15 % of all reproductive age couples suffer from infertility. As a board certified reproductive endocrinologist I spend most of my time treating both men and women, who contribute equally to this insidious disease that afflicts millions. Infertility is defined as one year of unprotected sexual relations without conception. The probability of achieving a pregnancy within one menstrual cycle, ideally each month, is on the average only 25% for normal, young, and healthy couples; thus, these couples have approximately an 85% chance of conceiving with in one year and 93% in two years. Unfortunately, this probability decreases dramatically by one third to one half as women approach their mid 30's and early 40's.
Every time we watch a TV news magazine or open a print magazine we are entertained and enlightened by exposure to the latest advances in reproductive medicine, famous people revealing their difficulties, pursuits, failures and successes in having a baby, and the exceedingly rare, and thus always news-worthy occurrence of, high order multiple gestations, the "X-tuplets". Due to our present day frequent exposure and since years ago we rarely spoke or heard about people who were suffering in silence from this devastating disease, we tend to think that the rate of infertility is increasing exponentially. This is not necessarily true.
There have been a number of significant developments that have changed the practice of reproductive medicine and the public's awareness over the past quarter century. One of the most significant events was the introduction of the assisted reproductive technologies based on in vitro fertilization where eggs are removed from a woman, fertilized with sperm from a man in glassware, in vitro, and then the resultant fertilized egg (embryo) is transferred to a hormonally prepared uterus. The process is sometimes called making "test tube babies". With the birth of Louise Brown on July 25, 1978 and with assistance from the mass media, the medical community and the entire world became aware of novel and promising treatments for those suffering from the once considered shameful disease of infertility.
This publicity generated new hope for many where there was once only despair and emptiness. It also resulted in a domino effect increasing the number of researchers investigating novel diagnostic and treatment regimens, making reproductive services more widely available, successful, and affordable, and making infertility a more socially acceptable disease. This culminated in generating an immense increase in patient consults seeking fertility related care.
Another significant change that the fertility specialists have witnessed over the last 10 years was the dramatic increase in the number of women over age 35 requesting medical intervention for infertility. Approximately 20% of women in United States are having a first child after age 35. This is most likely due to a combination of older age at the time of first marriage and more significantly due to the delay of childbearing in marriage. Other attributable causes resulting in older women seeking fertility care and shortening the time interval in which they desire to reproduce genetically related children are a reflection of the current socio-economic times and morays.
Two income households are more the rule than the exception, even with dual incomes there is still financial instability and uncertainty, liberalization of abortion, effects of sexually transmitted diseases, increased worry and panic about being infertile, and increased use of various contraception options. It has become clear that what modern society is experiencing and fertility specialists are seeing is a dramatic increase in age related infertility in the baby boomer generation since they were the first group of women who could easily exercise control over their fertility.
Countless clinical trials have revealed that a woman's fertility declines significantly with increasing age, yet aging only minimally effects male fertility. Another gender difference is that a man continuously produces sperm throughout his adult life, in contrast to a woman who is born with her unique life time supply of eggs. This number continually decreases until she stops ovulating at menopause. In addition, research supports that this decline in female fertility is more likely related to the aging egg and less likely due to an aging uterus. The healthiest, most fertile eggs are ovulated when a woman is in her teens through her late 20's, a woman's time of peak fertility. When a woman reaches her mid to late 30's, the remaining eggs have substantially less potential for fertilizing and establishing a healthy pregnancy. This is mostly due to chromosomal injuries that normally occur as eggs age within the ovaries.
Advanced egg age probably accounts for the increased risk of both miscarriage and infertility in women over the age of 35 and especially by the age of 40. Because this is primarily a problem related to the chromosomes and cellular machinery of the eggs, there is little that can be done to correct or reverse this biological trend. This knowledge and clinical trials lead to the very successful treatment that employs egg donors where the entire egg cells are obtained from women usually in their 20's and fertilized with the infertile woman's husband's sperm. Nuclear transfer, where the nucleus of an infertile woman's adult cell is replaced for the nucleus in a younger woman's donor egg cell, and cytoplasmic transfer, where the cytoplasm of a fertile woman's egg is injected into the
-infertile woman's egg cell, have both been experimented with and pending FDA approval. The goal of both techniques is to maintain the older woman's genetics housed in the nucleus, but utilize the healthy cell replicating machinery located in the cytoplasm of the younger donor egg cell. Unfortunately, some genetic material is also found in the cytoplasm, so new questions have been raised and must be answered before these techniques become standard of care.
In women less than 35 years of age, the vast majority of eggs ovulated have a normal chromosomal composition. As the woman progresses beyond 35 years of age, an increasing number of her eggs are likely to be genetically abnormal, aneuploid. This is a natural process of aging. Egg quantity and quality declines at an exponential rate. Chromosomally abnormal eggs may fertilize, but will infrequently establish a healthy pregnancy. When defective genetic embryos inadvertently implant into the uterine lining, the resultant pregnancies often result in spontaneous first trimester miscarriages. This has been evidenced by an overall miscarriage rate as high as 75% in women 40 years and older. If this were not the case, there would be many more genetically defective babies born. This is also the reason why women who use their own eggs and who are 35 years or older are encouraged to undergo amniocentesis or chorionic villus sampling (CVS) to evaluate the fetus for chromosomal abnormalities. Consequently, in women of advancing age, not only is the pregnancy rate markedly lower and the miscarriage rate significantly higher, but the overall risk of chromosomal anomalies in the few babies born is also dramatically increased. After considering the above realities, you can see why there is a dismally low probability of delivering a healthy child, the ultimate goal, when using eggs from older women in natural or assisted reproduction cycles. To improve the odds, some reproductive endocrinologist advocate older patients undergoing IVF with preimplantation genetic diagnosis, PGD, where some genetic abnormalities may be identified prior to embryo transfer and thus only the "normal" embryos may be selected for transfer. Unfortunately, sampling one cell from a multi-celled embryo may not always reflect the genetics found in all the other cells and this technique does not correct for non-genetic age related defects in the egg such as defects in the meiotic spindle fibers that result in chromosomal misalignment or problems with microtubular matrix composition.
The problems of advancing age on eggs and subsequently on embryo quality occur independently of a woman's proximity to the menopause. The eggs of a younger woman who is destined to undergo premature ovarian failure, let's say in her late 20's, are just as capable of producing a healthy baby as the eggs of a woman of the same age who will enter the menopause in her late 50's. The converse is also true, that a woman in her 40's who has entered the peri-menopause, a time period of 5-10 years prior to menopause and marks the advent of the accelerated decline in ovarian function, will have a relatively high percentage of chromosomally defective eggs. Thus, growing older has a unique, irreversible, and devastatingly negative effect on female fertility.
Over the last 15 years reproductive endocrinologists have gained experience using various dynamic tests in order to predict a woman's potential for pregnancy in both natural and assisted reproduction. Qualitative "guestimations" of fertility potential at a specific time in a woman's life can be estimated through the performance of the clomiphene citrate challenge test. This test of "ovarian reserve" and possibly egg quality consists of simple blood tests measuring a woman's blood levels of follicle stimulating hormone (FSH) produced in the pituitary and estrogen, produced in the ovaries from the developing eggs before and after taking oral fertility medication, clomiphene citrate. The clomiphene citrate challenge test (CCCT) is performed by measuring day 3 FSH and estradiol, administering clomiphene citrate 100mgs daily from cycle days 5-9, and then measuring FSH on cycle day 10. The test is considered abnormal if either FSH value is above the laboratory's upper limit for the follicular phase or the cycle day 3 estradiol is greater than 80 pg/ml.
The literature strongly suggests that women who have an abnormal clomiphene citrate challenge test, regardless of their chronological age, experience decreased response to higher doses of gonadotropins, have higher cycle cancellation rates, and suffer from poor reproductive performance when using their own eggs, i.e., have a poor probability of conception and delivery of a live born baby with or without fertility treatments, around 5% per cycle. Thus, this provocative test predicts the lack of success. A single elevated cycle day 3 FSH value predicts a poor prognosis, even when normal values are obtained during future cycle. However, if the test is normal, it does not guarantee a woman's certainty of conceiving or delivering a healthy baby, especially in older women. The likelihood of an abnormal result increases with increasing age. Patients are always cautioned that no one test in medicine is 100% predictive of any outcome, positive or negative. The rule of thumb is that age is a better predictor of egg quality, and FSH level is a better predictor of egg number. I also stress to patients there is little if any literature related to an abnormal clomiphene challenge test and the age of onset of the menopause. Women still worry. The CCCT is recommended for all unexplained infertile couples,
-women > 34 years of age, and women < 35 with one ovary, history of ovarian surgery, and exposure to chemotherapy or radiation therapy.
Other tests of ovarian reserve under investigation that are not the standard of care due to conflicting data regarding prognostic value include inhibin B levels, gonadotropin-releasing hormone agonist test, and small antral follicle count by transvaginal ultrasound.
The most realistic options for women with an abnormal result, especially women greater than 34 years of age, are in vitro fertilization and embryo transfer using donor egg, IVF with their own eggs possibly with assisted hatching and PGD, controlled ovulation with gonadotropins and IUI, (in decreasing order of success), adoption, or to not expand their family. Of course most couples are dismayed with these choices at first. Eventually some couples take comfort in the fact that their prior diagnosis of "unexplained infertility" has been given a more definitive and impressive name, that of diminished ovarian reserve, with an evolutionary and biological explanation. Others are angered and frustrated by yet another effect of time, the limitations of reproductive science, and the misinformation preached to them by the preceding generation.
The baby boomer generation took their lead from their parents, older friends and colleagues, and worldly teachers who advised them to be responsible and learn from their years of wisdom. This meant completing at least a college education, obtaining a financially rewarding career, finding a soul-mate to make and share a life, and once thought to be emotionally and financially secure, to embark on having children, their own genetic offspring, in order to continue the life cycle of another generation. Unfortunately, these well meaning mentors, trying to better our lives from their hard-learned lessons never carefully thought about evolution in regards to reproduction and tested the female biological clock. Now it is our responsibility to bestow on to the next generation conceived in the laboratory with love our newfound enlightenment.
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