Female Fertility Unraveling Your Fertility Mystery

When an Agatha Christie mystery begins to unfold, at first the investigator suspects every character of having committed the crime. As the plot unwinds, however, our hero gradually pieces together one shred of evidence after another, until, in the final climactic scene, the master investigator pinpoints the culprit.

There's little difference between conducting this kind of investigation and doing a fertility evaluation. When a woman first comes to my office, I suspect a broad range of causes: tubal blockage, endometriosis, pelvic adhesions, uterine abnormalities, anovulation, and so forth. As I review her history, I search for clues that will help me narrow my list of suspects. Repeated pelvic infections, for example, lead me to suspect tubal blockage or pelvic adhesions. If she tells me she's not menstruating, I'll focus my investigation on hormonal problems or uterine abnormalities. If she complains of extreme discomfort when her period starts, endometriosis will be uppermost in my thoughts.

Just as the master detective can be thrown off by misleading evidence, I must also be cautious not to jump to conclusions. It's all too easy to say, "Pain at menstrual onset? You have endometriosis." Although this may be correct, endometriosis may not be the only offender. Intrauterine adhesions or hormonal imbalances may also play a part.

The challenge presented by contradictory clues can seem overwhelming Just as I think I'm about to close in on one suspect, I uncover evidence that doesn't seem to fit the pattern. With my theory blown out of the water, I must formulate a new strategy for tracking down the culprit. By analyzing the clues and continually searching for additional ones, I draw closer and closer to the solution until I reach the climactic day when I tell you that you are pregnant.

Lucy H., for example, had infrequent periods and pain with intercourse. Ovulation induction therapy had regulated her periods but she'd failed to get pregnant. When her doctor referred her to me, I performed a laparoscopy (telescopic examination of the inside of her pelvis) and discovered that she had endometriosis and that adhesions (scar tissue) encased her ovaries. Even if she had ovulated, her eggs could not have reached her fallopian tubes.

The five key elements of female fertility are:

• Ovulation

   

• Sperm-mucus interaction

   

• Fertilization

   

• Tubal transport

   

• Embryo implantation

During the physical examination and fertility workup, I attempt to confirm or eliminate each of these candidates as hindrances to your fertility. Your history may point strongly to some of them. The clues I gather during the physical examination will offer additional evidence. Once I've pinpointed the areas of greatest concern, I can recommend specific tests and procedures to confirm my diagnosis. For now, though, I'd like to discuss what clues I can gather from the physical examination.

During the physical examination I look for evidence that you are ovulating, that your mucus allows sperm to reach the egg in good shape, and that the fertilized egg can successfully implant and grow in your uterus. A number of things may go wrong during this process. The sperm may not be able to journey through inhospitable cervical mucus or, having reached the egg, they may be unable to penetrate its surface. The egg may get lost in the body cavity and never find its way into the fallopian tube. Fallopian tubes, damaged by infection or trapped in adhesions, may not be capable of moving the egg toward the uterus. The growing, fertilized egg may become entangled in webs of intratubal adhesions caused by infection and develop into an ectopic pregnancy. Or the uterine lining may fail to nourish the early embryo. Once I determine where these processes are breaking down, I have a good chance of restoring your fertility.

Fertility Factor #1: Ovulation
Any woman who comes to me complaining of very heavy menstrual flow, very light menstrual flow, no menstrual flow, irregular cycles, breast discharge, or scanty or overabundant body hair growth is telling me that she may not be ovulating. This may be due to an intrinsic malfunction of her reproductive organs or hormones, or to a systemic disease causing other body chemistry problems.

During the physical examination I look for evidence of systemic disease: jaundiced (yellow) skin and eyes are indicative of liver disease; tenderness in the middle of the back and water retention (edema) may indicate kidney malfunction.

Nancy F., for example, had been trying to get pregnant for six months. When I examined her, I found that her ankles and fingers were swollen. Further tests indicated that her kidneys were not functioning well. I referred her to a kidney specialist, since once her kidney function improved, her periods would probably return to normal.

Since your liver and kidneys filter impurities from your blood (including "old" hormones), their function is vital for maintaining hormonal balance. If I find high blood pressure together with excessive body hair, I may suspect - adrenal gland abnormalities, which can affect ovarian function. (I discuss more about how we diagnose and correct these problems in the chapters on - ovulation.) I also look for other clues pointing to ovulation problems. For example, if you weigh over two hundred pounds, if you're severely underweight, or if; you have a highly developed athletic build, I may suspect a hormonal imbalance. Kathy S., who ran fifteen to twenty miles a week, had leg muscles; a man would be proud of. It didn't take much imagination to know that she was exercising to the point that she would cause ovulatory failure. (Chapter 9 explains the mechanisms for these disorders.)

When I examined Dorothy L., I found that her thyroid gland was swollen, and she appeared lethargic. Suspecting a thyroid deficiency, I ordered a thyroid hormone blood test. After she began taking a thyroid supplement, she became more energetic, had much more interest in having sex with her husband, and her periods returned to normal. Five months later she called to tell me she was pregnant.

Both hyperthyroidism (overproduction of thyroid hormone) and hypothyroidism (underproduction) may interfere with your menstrual cycle by disturbing estrogen supplies. I'll discuss more about how your hormonal system works in chapters 11, 12, and 13.

When I examined Gale P., I found that she had a translucent, white discharge from her breasts. She said that she'd had a milky discharge ever since she'd stopped nursing her toddler. I suspected she was producing excess prolactin, a hormone usually associated with nursing mothers. This hormone prevents ovulation and pregnancy so that you can give your baby the best nutrition possible. When you're trying to get pregnant, however, you don't need prolactin's birth control protection. With treatment, Gale's fertility quickly returned.

Your body build and secondary sex characteristics may provide additional clues to hormonal imbalance. Undersized breasts, scanty pubic hair, and underdeveloped hips all suggest a female hormone deficiency. An enlarged clitoris and abnormal hair growth such as a mustache may suggest excess male hormones. Rarer conditions such as ambiguous genitalia (not clearly male or female) and duplicate reproductive organs may point to genetic or enzyme defects that can interfere with ovulation. Although breast size, body conformation, and hair distribution are not conclusive evidence, they may corroborate suspicions created by other clues.

If your menstrual history and evidence from your physical examination point to ovulatory problems, I will recommend a number of tests to confirm this diagnosis. Like the detective, I need corroborative evidence to prove my case. Chapters 11 through 14 describe in detail what can cause ovulatory problems and how, with treatment, most women with ovulatory disorders can get their miracle babies.