Female Fertility Problems: Clues From Your Past

"Doctor, I can't get pregnant!" Kathy's voice belied her controlled exterior.

"We want a baby so badly. You're our last hope."

"Kathy," I said, glancing at her history form, "tell me when your periods stopped."

She sat straight and squared her shoulders. "Two years ago."

I scanned the page. "You're a runner. Do you enter the Peachtree Roadrace?"

Her face brightened. "I wouldn't miss it. Last year I came in twelfth."

"That's very good. How long have you been running?"

"I really started training two years ago. Up to then I wasn't so serious about competing."

Two years ago, I thought. And two years ago her periods stopped. Now I had the first important clue to Kathy's fertility problem.

I knew she wouldn't like what I was about to suggest. "Kathy, we know that women athletes often complain that their periods stop. Of course, I need to know a lot more about you, but I wouldn't be surprised if your training regimen is contributing to your fertility problem."

Her smile faded. "You mean I'll have to stop running?"

"Not at all," I assured her. "Many women athletes keep in shape even while they are pregnant. But first, let's figure out how to help you get you pregnant."

She smiled. "Sounds good to me."

Physical exertion is only one of many factors that may affect your fertility. Critical points about your development, medical history, and lifestyle all give me vital clues to solving your fertility problem. In this chapter you'll learn what your doctors investigations into your past can reveal, and gain insight into what may be causing your fertility problem.

Excessive or Rigorous Exercise
This cause of infertility may be grounded in our ancestral heritage. If food supplies were low, we followed herds of migrating animals or ranged far and wide to gather fruits and grain. A pregnancy would impair the woman's ability to keep up with the group. To improve her odds for survival during famine, nature decreased her fertility so that she stopped ovulating and her periods ceased (amenorrhea). This is probably the same protective mechanism that caused Kathy S.'s problem.

Fortunately, resolving Kathy's hormonal imbalance was easy once I identified the cause. I'll tell you how we treat amenorrhea in a later chapter.

Emotional Stress
Most women with fertility problems appear to be under a great deal of stress. But we don't know for any one person whether the stress contributed to the fertility problem, or whether the fertility problem brought on the stress. Many women in high stress situations become pregnant, so we can't say conclusively that stress will disrupt your hormonal balance.

We do know, however, that stress can affect your hypothalamus, the part of your brain that controls sex hormones. And we know that some women who have no apparent reason for being infertile except stress will often respond to a medication that improves hypothalamic function.

I'm not saying that the old wives' tale "Just relax and you'll get pregnant" will work. However, there's a great deal about the link between fertility and stress that we don't understand.

Dieting and Nutrition
Low calorie diets, special athletic diets, eating disorders, and other restrictive eating practices may impair your fertility. A number of factors may cause this problem:

• Losing the weight itself

   

• Reaching a low percentage of body fat

   

• Reaching an absolute minimum weight

   

• Stressing the body

   

• Suffering from a nutritional imbalance.

The mechanism for reducing your fertility isn't clear and it may vary from one individual to another. Like Kathy S., however, the most common complaint is amenorrhea, lack of menstrual periods. (I frequently find that teenagers who have been on crash diets stop having periods.)

Fortunately this is one of the easiest fertility problems to correct. When you change your diet and gain weight, you usually start ovulating and menstruation resumes.

Strangely enough, I've also seen ovulation stop in women who follow strict vegetarian diets. I remember one woman who ate so many carrots that her genitals turned bright orange. The stress of her diet and high blood levels of carotene (from eating carrots) may have caused her anovulation. Rather than taking medication to induce ovulation, she chose to cut down on her vegetables and add fish and eggs (protein) to her diet. Having thus increased her caloric and protein intake, she began ovulating and soon became pregnant.

Women weighing two hundred pounds or more may also have fertility problems. This may also be one of nature's protective mechanisms, since obesity does not provide the best environment for fetal development and birth. In fact, before the age of modern medicine, many obese women and their babies died in childbirth. Nature apparently prefers to reduce your fertility and wait for you to lose weight.

I remember one woman who, at five foot four and 188 pounds, complained of irregular periods with heavy flow. The reasons for her fertility problem are interesting. It seems that fat cells themselves can convert androgens (male hormones produced by the ovaries and adrenal gland) into estrogen (female hormone). Assessing all her symptoms, I suspected that her fat cells were producing enough estrogen to confuse her brain. Her brain, thinking that the ovaries were producing the estrogen, lowered her pituitary gland hormone production, which in turn led to anovulation. (You'll learn more about how these complex hormonal systems control your monthly cycles and fertility in the next chapter.) Once I explained how this woman's obesity affected her fertility and general health, she was more than willing to start a diet. A well-planned weight-reduction diet and exercise program eventually restored her fertility. And since her "reduced" fat cells no longer produced excess estrogen, she got a bonus: her risk of developing endometrial cancer diminished, too.

Pelvic and Reproductive Tract Surgery
Adhesions (scar tissue) inside the abdominal cavity caused by pelvic infections or abdominal surgery can impair fertility. I commonly find scar tissue in women who have had surgery for ruptured appendix, bowel repair, cesarean section, ectopic pregnancy, or the removal of an ovarian cyst. Twisting around the ovaries, fallopian tubes, and even the uterus, these inflexible webs of scar tissue restrict the natural mobility of these delicate organs.

Margaret B., for example, had a ruptured appendix when she was twenty-three. When I looked at her reproductive organs through the laparoscope (telescope), I found that her pelvic adhesions were so extensive they prevented her eggs from entering her fallopian tubes. I clipped and removed the tissue from around the organs so that Margaret's tubes could once again gently flex and coax the ova down the narrow passage toward the waiting sperm.

Scarring may also occur inside the uterus. Debbie W., for example, came to me about a year after having a D & C, saying, "Ever since my gynecologist scraped out my uterus, instead of having a period I just spot each month." When I looked into her uterus with a hysteroscope (small telescope), I found her uterine walls stuck to one another. I used a rather simple yet effective procedure to separate her uterine walls so they could heal and begin functioning normally. I'll discuss more about this procedure in a later chapter.

Frequent Vaginitis
If you suffer from frequent yeast or trichomonas infections, you may also have chlamydia, which can cause tubal damage. Because of increased exposure, women with a number of different sexual partners have a much greater chance of contracting these infections. A history of frequent vaginitis will alert me to the possibility that you have pelvic adhesions and tubal blockage. Once diagnosed, these abnormalities may respond to corrective surgery.

Illnesses May Impair Fertility
A number of illnesses can lead to impaired fertility. The most obvious ones are the venereal or sexually transmitted diseases such as gonorrhea, chlamydia, ureaplasma infection, and pelvic inflammatory disease (PID). These diseases can scar your uterus, block your tubes, and cause the formation of pelvic adhesions. I remember one woman who said that four years ago her doctor thought she had a gallbladder problem. "I had a pain right here," she said, holding her hand over the lower right half of her rib cage. "I guess it just went away, because I haven't had any more trouble."

After asking her several questions about her symptoms I suspected that instead of having a gallbladder problem, she had probably contracted PID. After further tests, I discovered that PID had caused her liver to adhere to the inside of her abdominal wall, a condition called Fitzhugh-Curtis syndrome. Once I surgically removed the adhesions and repaired her scarred fallopian tubes, she soon became pregnant.

Other diseases such as hepatitis fever disease and kidney disease can cause fertility problems. Both your liver and kidneys filter and remove waste products, toxic substances, and impurities from your blood. A buildup of wastes and unmetabolized (not chemically broken down) hormones may interfere with your menstrual cycle. When these diseases are brought under control, fertility usually returns.

Thyroid gland disorders may also interfere with fertility. Increased metabolism from an overproduction of thyroid hormone (hyperthyroidism) will burn up your estrogen supply faster than your body can make it. Without estrogen you cannot ovulate. In contrast, if your thyroid gland produces insufficient thyroid hormone (hypothyroidism), you will stockpile too much estrogen and you may have an elevated prolactin level. If you have an excess of these two hormones, your ovaries cannot function normally. Regulating your thyroid production through surgery or thyroid supplements usually restores fertility.

Adult onset diabetes or insulin resistance may interfere with normal menstrual cycles. High levels of insulin abnormally stimulate the ovary to make high levels of male hormones which block normal ovulation.

Hypertension (high blood pressure) may be associated with an adrenal gland disorder that causes excessive production of male hormones (androgens). Increased androgens can disrupt normal ovarian function as well as disturb your female secondary sex characteristics.

I remember one woman referred to me for a fertility workup said, "Doctor, I'm growing a mustache!" The hair growth on her upper lip (a condition called hirsutism), very oily skin, and acne told me she was probably producing excessive androgens. As I expected, her blood tests revealed that she had an overactive adrenal gland. When she received medication to slow her androgen production down, her periods resumed, and much to her relief her mustache stopped growing.

Treatment for Abnormal Pap Smears
Cone biopsy, laser surgery, Leep, or cryosurgery may be used to treat a condition detected by an abnormal Pap smear. Any of these procedures can degrade the quality of your cervical mucus to the point that sperm cannot travel into your uterus. I performed a cone biopsy on a twenty-seven-year-old patient of mine who had a precancerous Pap smear result. I hoped I could halt the growth of abnormal tissues and prevent Nancy V. from developing cervical cancer. A year later she married and wanted to have a baby. When I performed a postcoital test, I found that her mucus was too scant and thick for the sperm to pass. So I recommended we wash her husband's sperm and inject them directly into her uterus (intrauterine artificial insemination homologous). After three tries Nancy became pregnant.

A cone biopsy can also weaken the cervix and allow premature pregnancy loss. So during Nancy V.'s pregnancy I watched her cervix to make sure that it stayed shut until delivery. Fortunately all went well and she delivered an eight-pound fourteen-ounce baby boy. I'll discuss more about the procedures I used with Nancy in chapter 19.

Anticancer Agents and Radiation
Anticancer agents such as methotrexate or radiation treatment may also compromise your fertility. Radiation can cause not only pelvic adhesions but also chromosomal damage to your eggs. If you're concerned about the effects of these treatments, talk with your doctor.

Endometriosis
Endometriosis may scar your fallopian tubes, interfere with your ability to ovulate, and prevent embryo implantation. Endometriosis is the presence of endometrial tissue outside the womb. Unfortunately we do not know the exact mechanism by which endometriosis forms. Being sensitive to monthly hormonal changes, this tissue grows and then, as does the endometrium in the uterus, sheds during menstruation. This "bleeding" inside the abdominal cavity is very painful, as Shelley T. testified: "When my period starts, my cramps get so bad I have to go to bed."

When I looked inside Shelley T.'s abdomen with a laparoscope, I found extensive pelvic inflammation and scarring. Since endometriosis can also cause tubal blockage, I injected dye into her uterus and tubes to see if they were open. I was really relieved to see the blue inklike fluid seeping out each fimbria (the opening of the fallopian tube near the ovary).

Fortunately endometriosis frequently responds to hormonal therapy and, when necessary, to surgery. In Shelley's case I decided to use the laparoscope and a small instrument passed through a second small incision to cut her adhesions. Then I used a laser to selectively cauterize and excise the endometrial implants. She received GnRHa (Synarel , Lupron, Zoladex) for three months after her surgery and then attempted pregnancy. A later chapter will explain more about these procedures.

German Measles (Rubella)
German measles (rubella) does not impair fertility. However, if you contract rubella during the first half of your pregnancy, your baby will likely suffer from severe defects, including deafness and mental retardation. It would be tragic to undergo extensive fertility treatment only to achieve a pregnancy blighted by German measles. Therefore, I always do a blood test to determine if my fertility patient is immune to German measles. If the test is negative, I give her a rubella vaccine. I then recommend that the couple use barrier contraception, such as condoms, for three months to avoid the remote possibility that the live virus vaccine could affect their baby.

Tender Breasts and Milky Discharge
If your breasts are tender or if you have a milky discharge, you may have breast tumors. If I cannot detect any abnormal growths, I look for other factors that can cause a hormone imbalance for example, an excess production of prolactin.

Prolactin, one of the primary hormones responsible for milk production (lactation), suppresses ovulation. I remember one patient who came to me because she hadn't responded to the drugs her doctor prescribed to induce her to ovulate. Heather P. complained of milk leaking from her breasts, so I suspected that her pituitary gland was producing excessive amounts of prolactin. When this was confirmed by a blood test, I prescribed Parlodel (bromocriptine, an oral medication. That did the trick and she got pregnant in her very next cycle. I'll discuss this treatment more in chapter 12.

Neurological Disorders
Any disturbance in your central nervous system may interrupt the delicate hormonal coordination between your hypothalamus, pituitary gland, and ovaries. If you suffer from seizures, epilepsy, visual disturbances, poor sense of smell, dizziness, loss of balance, or chronic headaches, you may have a neurological disorder. If you take medication to control epilepsy, nervous tension, depression, and so forth, the drugs themselves may interfere with your fertility. I remember one RESOLVE member who reported that when her doctor changed her antidepressant to a different prescription she began ovulating three months later. I may consult with a neurologist if I feel the disorder requires further diagnosis and treatment. Once we correct the neurological abnormality, fertility may return naturally.

Medications That Compromise Fertility
A number of medications may compromise your fertility. If you take hormones, antibiotics, or antihypertensives, they can prevent an embryo from implanting in your uterus. If taken in the middle of your menstrual cycle, Motrin, Anaprox, Indocin, or aspirin usually taken to ease menstrual cramps may prevent your ovary from releasing a ripened egg. Antidepressants, hallucinogens, painkillers, and alcohol may increase your prolactin levels and cause ovulation failure. When you stop these medications (and don't stop taking any medications without consulting your doctor first), fertility usually resumes.

Be sure to tell your doctor about every prescription or over-the-counter drug you take. These drugs may not only play a part in your fertility problem but, should you become pregnant, they may also jeopardize the development of your infant. My general rule of thumb is "When in doubt, do not take it." We honestly do not know the effects of all drugs on a pregnancy, particularly when taken in combination with other medications.

Illicit Drugs
Central nervous system depressants such as heroin or large, frequent doses of marijuana can interfere with your sex drive and with the hormonal balance necessary for ovulation and menstruation. Don't bother to pay for expensive fertility treatment if you plan to continue taking these drugs. Besides, during your pregnancy, a number of these drugs may also threaten your unborn child. Both marijuana and tobacco cigarettes increase the carbon monoxide level in your blood and impair your unborn baby's oxygen supply. Without adequate oxygen, tissues and vital organs may be damaged or killed. Taking hard drugs like cocaine will also reduce the life-sustaining blood supply to your unborn baby. When you stop using these toxic chemicals, your fertility usually returns.

Massive Hemorrhage During Childbirth
At a RESOLVE meeting I met a woman who had nearly died with the birth of her first child. During her delivery she had suffered a massive hemorrhage. "They gave me twelve blood transfusions," she reported. "My baby and I just barely survived." She picked up her infant and held her close. "I tried to nurse Rachael, but she was starving, so I gave it up. After a few weeks it was all I could do to get out of bed, feed her, and change her diapers."

Her husband interrupted. "I knew something had to be wrong, so I put Sarah and Rachael in the car and drove them to the doctor."

"The doctor told us that massive bleeding associated with pregnancy sometimes shocks the pituitary gland to the point that it dies," Sarah said. "He called it Sheehan's syndrome. He didn't know exactly why this happened to me, but my pituitary may have suffered a temporary loss of its blood supply."

Since Sarah's damaged pituitary gland no longer controlled her thyroid hormone production, adrenal hormone production, and blood sugar levels, she experienced a wide range of symptoms including extreme fatigue. In addition, she could not ovulate, she could not have a period, and she could not have another baby. When her doctor put Sarah on pituitary hormone replacement therapy, she eventually regained her fertility and gave birth to a second child.

When Are You Most Fertile?
Day 1 of your menstrual period is the day your period begins. This seems relatively simple, but you wouldn't believe how many people fail to get pregnant because they count the days from the wrong starting point. (Just recently I spoke to a couple who counted from the day her period stopped. They knew she was most fertile around the middle of her cycle, or approximately days 14 to 16, so they timed intercourse two weeks after her period stopped. However, since her period stopped on what they should have counted as day 6, they were having sex a week too late on days 20 to 22.)

Because on the average a woman's cycle varies in length from twenty-six to thirty-five days, you cannot count forward from day I to find your most fertile days. Since you ovulate approximately fourteen days before your next period begins, you count backward fourteen days from the date you expect your next period will start. That means the woman with a thirty-five-day cycle would ovulate on day 20 or 21 and the woman with a twenty-six-day cycle on day 11 or 12. Since you're fertile for only twenty-four hours each month, these calculations become quite critical.

Continued