Qus & Ans: Unexplained Infertility

Qus & Ans: Unexplained Infertility

I have been trying to conceive for two years now and recently I read an article about dysmenorrhea. I feel that I have some signs of this, like painful periods that bring me to tears. I also read that it can cause infertility. How true is this? Should I discuss this with my doctor before getting fertility tests done?

The two common signs/symptoms of endometriosis are menstrual pain and inability to conceive. You seem to have both. Menses associated with changes in bowel pattern/intestinal pain and/or painful intercourse are two more symptoms of endometriosis. Individuals who have endometriosis more often have had family members with endometriosis, have longer heavier menses with shorter menstrual cycles, and have not used oral contraceptives. About 30 percent of infertile women have endometriosis. Endometriosis may be suspected by history and further supported by pelvic exam and/or ultrasound showing an endometriotic cyst. The diagnosis can be made only by surgical evaluation. This is most often at the time of a laparoscopy.

A laparoscopy may be indicated solely on the basis of pain. If a laparoscopy is performed, I suggest choosing a surgeon experienced in the diagnosis and treatment of endometriosis and prepared to treat the abnormal findings at the time of surgery. The vast majority of the cases of endometriosis can be treated by laparoscopy. A video or detailed photographic record should be made for further reference. It is also useful to have a hysteroscopy at the same time to exclude uterine problems as a cause of infertility an pain. In women of childbearing age, I always suggest that the tubes should be tested to ensure that they are open (chromotubation). Whether to have a laparoscopy in your particular case requires a detailed discussion between you and your physician.

Sam Thatcher, M.D., Ph.D., FACOG, Director
Center for Applied Reproductive Science, Johnson City, Tennessee, USA

I am 28 and married. We have gone through two unsuccessful IVF cycles, with no explanation. We are about to do a third IVF, and I have been researching on the web and have found a lot of information on taking baby aspirin during the cycle to help blood flow to the uterus. Is it a good thing to try? This is our last chance and we are willing to try anything.

It is unclear to me why you have not become pregnant. Certainly, it can take more than two tries, and, thus far, your lack of success might be only chance. Still, a "sit down" with your doctor is in order to review your case with possible therapy modification and estimation of success for a repeat attempt.

Use of aspirin is controversial. There is one very good and well-publicized study that reports increased success in IVF after aspirin use. Most of even the most successful programs do not routinely use aspirin. The beneficial effect of aspirin has not been unequivocally proven and use needs further validation. We know that large amounts of non-steroidal anti-inflammatory agents such as aspirin, ibuprofen and naprosyn can block ovulation and implantation. Probably small doses have no negative effects. I do not stop patients from using low-dose aspirin, if they wish.

Sam Thatcher, M.D., Ph.D., FACOG, Director
Center for Applied Reproductive Science, Johnson City, Tennessee, USA

It took two and a half years to conceive my first child, with no medical intervention. I have now been trying to conceive baby #2 for nine months. My question is should I wait until after a full year of trying to go get an infertility work-up? Or should I go sooner because of the length of ttc the first time? Also, I was wondering if Clomid is ever used in women that can ovulate on their own, just to "boost" things? Any suggestions would help, and thank you for your time!

To answer your last question first, yes, Clomid is often used as "empiric" therapy for unexplained infertility. By inducing superovulation (i.e., helping you to grow more eggs), it increases your chances of conceiving by increasing the chances of the eggs and sperm meeting. However, it is often misused for this purpose as well, so don't use it for more than three cycles! How soon to go for treatment really depends upon how much of a hurry you are in, which depends upon your age - if you are young and are content to let nature take its own course, then wait for a year. However, if you are older or in a hurry, medical assistance will increase your probability of conceiving sooner.

Dr. Malpani
Malpani Infertility Clinic, Bombay, India

I'm 35 years old, husband is 33 years old. This is cycle 18 of trying for our first child. I'm in excellent health, never sick, normal weight, professional working woman, no history of infertility on either side, exercise three times a week. I have had all the blood tests come out normal, Basal Body temps normal, HSG, normal, post-coital, normal, semen analysis, normal. I grow follicles on my own and ovulate on my own. Everything is normal and they say I have a perfect textbook lining. Yipee for me, so why am I not pg?

My RE said Clomid would boost my chances coupled with IUI. First cycle of IUI/serophene 100mgs, one normal follicle, IUI failed/didn't work.

Second attempt at 150mgs of clomid: Bad reaction. I gained 8 lbs in one cycle, distended stomach, bloated overall yucky feeling, they scanned me and said the eggs were too small and I was going to be annovulatory. RE did a blood test and determined I actually did ovulate but late in the cycle, day 22 or more. Also that cycle I had really bad PMS symptoms. No IUI that cycle. FYI: The weight gain was water weight since I lost 6 lbs of it by day 8 into the cycle. Then I lost the other two pounds by the end of the cycle.

I threw away the pills and tried it natural this cycle and lo and behold I grew two eggs to maturity. One in the left ovary and one in the right ovary, but no fertilization, I got my period last week.

Any suggestions as to why I'm not getting pg? Why am I having bad reactions to the drugs? Are there any other tests that are suggested? RE says I'm not a candidate for a laporoscopy. I'm stumped as to what would be my next step since I have wierd reactions to drugs I have to believe that the stronger drugs will make me have really bad reactions. I have an appointment for a second opinion.

FYI: We are living our lives, go on vacations, I take yoga and I'm a runner. We know how to relax. I feel that relaxation is not our problem, but I do admit that the bad reactions to drugs stress me out.

Thank you!

If you have any pain, you would be a candidate for a laparoscopy to rule out endometriosis, or peritubal adhesions, which would not necessarily show on an HSG. In our program, our next step would be to recommend three cycles of COH with IUI, using an injectable fertility medication. We always prefer to antedate this treatment with a laparoscopy to rule out any other pelvic factors.

Very little infertility in our experience is "unexplained". If you do enough investigations, then a cause turns up most of the time. IVF often gives us the ultimate answer. In addition to being highly successful, it also gives us info regarding the number of eggs per follicle, fertilization rates, and quality of embryos, as well as embryo growth. However, you need other investigations and treatment before getting to that level of treatment.

N. Assad, M.D.

Dear Doc,
I have been trying to concieve for a year, about a year and a half ago I had one side of my thyroid remove because of a benign lump. Before and after the surgery I have been told after blood tests that my thyroid hormone levels were normal. Although I've always felt something was wrong. I had put on wieght unexplainably and have not really been feeling my self. My periods although I still have them come very late in the cycle and this month for the first time I have missed cycle. My doctor just tested my prolactin and it was slightly elevated, I am now scheduled for an MRI. What are my chances after this of having a successful conception and pregnancy barring no other complications? and what possible treatments are availiable? will any medications I will possible be prescribed hurt a subsequent pregnancy? and should I see a specialist for high risk pregnancies? Does it sound like I have problems that need to be taken care of by an endochrinologist?

Did you have TSH tested? That is the most important test of thyroid function.

As far as prolactin goes, you do not need MRI unless your PRL level is >100

Whatever the PRL level is (30, or 60 or 100, or even 150) the treatment is the same - place the patient on Parlodel and watch the PRL fall until it is in the normal range, which it almost always will. It is only when the PRL levels do not fall that one needs to resort to surgery, and I have never seen that.

You do not need a high risk pregnancy doctor (that's after you are pregnant, and have problems like diabetes, or hypertension, etc.). These doctors usually are not familiar with infertility. PRL will normalize with treatment, and pregnancy will not affect it; in fact during pregnancy the PRL is supposed to go up.

You do not need an endocrinologist, because he likewise is not familiar with infertility.

What you need is an intelligent doctor (gynecologist or a reproductive endocrinologist) who does things having thought them through, not because of some protocol he ehard about at a lecture. Ask your doctor what are the chances that the MRI will CHANGE his treatment? Will he not start Parlodel, and monitor the PRL?

There should be an explainable reason for what and why we do things. The outcome of testing should impact on the treatment, if it does not, then it is of no use.

And any treatment should be monitored for the desired effect - it makes no sense to start treatment then not bother to see what that treatment has achieved.

Rafael Haciski, MD FACOG
Gynecology & Infertility Assoc.
Baltimore MD

I am 38, have unexplained infertility- 2nd round of ivf - 8 eggs were retrieved- 3 fertilized - but none divided enough after five days to be implanted. What could be he causes of the failure? Does it likely mean my eggs are of poor quality. Last year we did IVF and 4 of 8 fertlized and were viable (But implantation failed).

I am doing IVF because I live in Europe and the clinic only does ivf not insemination or any other procedure. Periods are normal, sperm count high, lap indicated no prob hormone level.

Thanks- it is hard to get inform here.


Dear Marie,

38 year old with unexplained infertility is on the right track with IVF.

However, lack of fertilization, or poor progression of cell division is a bad sign. It signifies either improper ovarian stimulation, or poor inherent egg quality. The first is corrected by changing ovulation induction protocols, the second is not correctable (except through use of donor eggs).

But I am curious why it is hard to get information from your doctors?

Good luck with your endeavors.

Rafael Haciski, MD FACOG
Gynecology & Infertility Assoc.
Baltimore MD

I am a 31 year old female who, in the course of 3 years now, have been unable to become pregnant. My husband and I have gone to an infertility specialist in the area and have both been tested with no problem on either side (with sperm or blocked tubes). I have gone through surgery and extensive tests to back this up, but it seems I may not be ovulating. To this date, I am on clomid 200mg. My progestrone level at this amount was 4.8. I understand it must be 15 or higher. My question is this, is there any way (what with both my husband and I both in good health) to get this show on the road? I realize there are steps that must be taken, but 3 years of steps leads to depression and other problems. I still have hope there is a doctor out there that can and will take my situation serious, but so far I feel I've only been a number who pays big $$$. Please respond as soon as possible as my period should start any day now, and I'd like not waste it.
Thank you for attention.
Desperate Debbie

Dear Desperate Debbie,

Approximately 5% of Patients experience unexplained infertility.

Approximately 15% of couples experience infertility. Approximately 40% of infertility is related to female causes, 40% to male factor, and approximately 20% of couples have more than one factor.

Ovulation disorders account for approximately one third of fertility problems, endometriosis for another third, tubal factor approximately 15% and cervical mucous factors approximately 5%.

Initial investigations should rule out ovulation disorders-Luteal Progesterone levels, BBT, and if necessary endometrial biopsies.

Tubal factors can usually be ruled out with an x-ray called a hysterosalpingogram.

If pain is a big feature, ie pain with periods, intercourse, bowel movements etc. then endometriosis should be considered a factor. Only laparoscopy can rule this diagnosis out with certainty. Certainly, there are a small number of patients who have few to no symptoms with endometriosis, and if conventional treatments are not working, particularly in younger patients, then we recommend a laparoscopy to rule out endometriosis, and pertitubal factors, prior to getting into higher tech treatments. Cervical factors can generally be ruled out with a post-coital test.

For the male, we prefer to do a Kruger Critical Semen Analysis, which looks at morphology in great detail.

If all of that has been done and the patient's don't respond to an outcome based protocol of treatment, then we would recommend going on to In Vitro Fertilization- Embryo transfer. If you call our office at 1-800-577-7133, I will Fax you a copy of a suggested outcome based treatment protocol.

In addition to assisting in conception, IVF also has a large diagnostic component which enables us to assess egg and sperm quality, quality of follicular recruitment, efficacy of fertilization, quality of embryo, growth rates of embryos, etc.

Hope this helps.

N. Assad, M.D.
Southwest Fertility

I am 28 years old, and my husband and I were diagnosed with unexplained infertility. After trying many different things we conceived "naturally" last year. Unfortunately, I ended up in surgery due to my second ectopic pregnancy. I know from our previous infertility work-up that my left tube and ovary are functioning normally. My question is this:
When I had surgery to remove my right tube, why didn't the doctor remove my right ovary as well? I know that if I only had the left ovary, it would be forced to ovulate every month, where now I may be ovulating from the right side, and "wasting" a cycle. IVF is not an option for us and my doctor knew this going into surgery. Thanks in advance for your help.

Dear Karen:

It is not considered good practice to remove an ovary from an infertile patient in spite of your concern about alternating ovulation and wasting 50% of your cycles.

This decision has been reached after many patients with a tubal pregnancy have been shown to have a problem with their remaining tube following their unilateral salpingectomy. These patients have been shown to have had a small chronic infection within the lumen of the fallopian tube. Thus, no ensuing pregnancy was documented in approximately 66% - 70% of the patients who had a unilateral salpingo-ophorectomy. There was no difference in pregnancy rates whether the ovary was removed in conjunction with the fallopian tube or not.

I hope this answers your question.

Jaime Vasquez, M.D.
Voice: (615) 321-8899 ~ FAX: (615) 321-8877

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I am bloated, swollen palms and legs, headache and vomitting effect after taken parlodel for 30days. I did urine test last week for pregnancy but was negative. What can i do because am still feeling pain in my lower abdominal and my whole body is bloated.

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