Female Fertility Problems: Clues From Your Past

I use a number of methods to determine the time of peak fertility, but many women, however, can do so by increasing their awareness about their bodies. Around the time of ovulation many women sense a discomfort on one side of their lower abdomen. The feeling associated with ovulation, called mittleschmerz, does not occur in women who do not ovulate_for example, in women taking birth control pills. Also at the fertile time of the month women often notice a clear stringy mucus discharge from their vagina. When your mucus thins out, it allows sperm to swim through the cervical canal. This definitely signals the right time to have sex. I'll discuss other methods you can use to pinpoint your peak fertility in a later chapter.

Cramps and Pelvic Heaviness
If you have cramps or take medication for cramps, your doctor needs to know how severe they are. Severe pain at the onset of your period may indicate the presence of endometriosis. If you do not become bloated, do not cramp, and develop only a scanty flow, you may not be ovulating. That's why women who take birth control pills often have less discomfort during their periods. Fortunately ovulation induction treatment is successful for most women.

If you experience pelvic heaviness, you may have large fibroids (non-cancerous growths) in your pelvis. Fibroids may also interfere with your ability to conceive and with the ability of your uterus to support an early pregnancy. When necessary, the offending fibroids can be surgically removed and fertility restored.

Menstrual Flow
A heavy monthly flow may indicate that too-persistent estrogen production is overstimulating the growth of your uterine lining. A scanty flow may indicate that your body produces too little estrogen to prepare the uterine lining for implantation, or that you have intrauterine adhesions. When estrogen levels are controlled, normal menstrual flow resumes and the quality of the uterine lining improves. When indicated, intrauterine adhesions can be surgically removed.

Spotting during the middle of your cycle may indicate a hormonal imbalance or abnormalities inside your uterus for example, the presence of scar tissue or an IUD you forgot about. Don't laugh. I once removed an IUD from a patient who had tried to get pregnant for two years. When I extracted the coil she'd received some four years earlier, she was shocked, saying, "But my doctor said I'd passed it!" When the string disappeared, her doctor assumed her uterus had expelled the IUD. In fact, her uterus had "swallowed" the string and concealed its presence for two years. Never assume.

Amenorrhea
"Doctor, I'm not having monthly periods. My husband and I want a baby. What should I do?"

When I hear this complaint, I first establish whether the woman has ever had a period. If she has, then her reproductive tract is patent (intact and open to the outside). If she has never menstruated (primary amenorrhea), I examine her to determine if she has a uterus, if her uterus opens into a vagina, and if the vagina opens to the outside. If the vaginal tract is closed, I can open it surgically and restore fertility. However, if her reproductive organs are missing or severely deformed, not much can be done to correct the abnormalities. If her ovaries are intact, new technologies provide hope that her eggs can be fertilized and nurtured in another woman's uterus. (See Hysterectomy below.) If I've established that she is not pregnant and has no physical abnormalities, I begin to look for signs of hormonal deficiencies.

Secondary amenorrhea, or the cessation of periods after they've been initiated, is a much more common finding. Secondary amenorrhea may be caused by pregnancy, damaged uterine lining, ovulatory failure, ovarian failure, hypothalamic failure, or pituitary failure. First I determine if your hormonal systems are functioning properly. For example, if your breasts are underdeveloped, if your pubic hair is absent or scanty, or if you have signs of virilization such as a mustache (hirsutism) or masculinized genitalia, I'll suspect a hormone imbalance. If I find elevated FSH(pituitary hormone) levels, I'll suspect ovarian failure. (Remember, this is also the sign for testicular failure in men.) Only by performing a complete fertility workup can I identify the reason for your failure to menstruate. Hormone stimulation and replacement therapies are successful in most of these cases.

Because amenorrhea is the most common complaint of women with fertility problems, I've devoted chapters 12, 13, and 14 to discussing ovulatory failure and treatment.

D&C
If you've had a D&C (dilation and curettage) to scrape out the contents of your uterus, the doctor treating your fertility problem needs to know why. Sometimes a doctor performs a D&C to remove unwanted scar tissue or the remains of an incomplete abortion. Instead of the D&C improving the uterine environment as expected, however, sometimes the procedure will cause the inflamed uterine walls to stick (adhere) together. People with Asherman's syndrome, as this condition is known, usually have regularly occurring, scanty periods. I can correct this condition with a rather simple procedure described in chapter 19.

Traumatic Abortion
If a trained physician using sterile procedures performs your abortion, you do not need to worry about compromising your fertility. Illegal, back-alley, and self-induced abortions may lead to life-threatening infection and tubal blockage. Damage to your cervix from a traumatic abortion may also increase your risk for early pregnancy loss. Fortunately these complications occur must less frequently since the Supreme Court legalized abortion.

Spontaneous Abortion and Miscarriage
I need to know if you've ever been pregnant, if you've had an elective abortion, or if you've carried a baby to term. A previous pregnancy demonstrates to me that at some point in your life you were fertile. If your present husband fathered a child with you, I know even more, that together you were fertile. That's a very important piece of information, since there is clear evidence that your fertility potential depends on a unique compatibility between you and your partner.

I also need to know if you lost a baby early in a pregnancy. The positive side of a spontaneous abortion or an ectopic pregnancy is that you can get pregnant. The reactions to early pregnancy loss, however, are anything but positive. The couple suffers shock, disbelief, anger, sadness, and grief. Many women may discard a developing embryo within the first month or so of pregnancy without realizing it. Researchers therefore believe that the spontaneous-abortion rate may be as high as 25 percent. However, if a woman reports repeated abortions, I will want to assess if her uterine lining can support a pregnancy and if her cervix will remain closed throughout the pregnancy. I'll discuss more about correcting these problems in chapter 19.

Ectopic Pregnancy
If scar tissue blocks the pencil-lead-sized fallopian tube passage (lumen), the tiny sperm may be able to get through but the larger, dividing fertilized egg may get stuck. Entrapped by adhesions, the embryo implants in the tube and continues to grow.

Damage to the inside surface of the tube may also interrupt the fertilized egg's journey to your uterus. Waving like blowing grass, the tiny hairlike cells (cilia) lining the inside of a normal fallopian tube stroke the fertilized egg toward your uterus. When infection or surgery strips the cilia from the walls of your tube, the immobilized embryo may attach itself to the smooth tubal wall.

Unfortunately the condition that damaged one of your tubes very likely damaged your other tube. For this reason, if you have one ectopic pregnancy, you have an increased chance for another one on the opposite side. Years ago women suffering from an ectopic pregnancy often lost the affected fallopian tube. The job of creating another pregnancy fell almost exclusively to the remaining ovary and tube. Now, however, with early pregnancy detection and microsurgery, we can often save the affected tube and restore it to a functional state.

In the next few chapters I will reveal many more of nature's fascinating secrets and tell you how you can overcome and cope with pregnancy losses.

Did Your Mother Have a Fertility Problem?
Quite frequently fertility problems run in families. Therefore, clues from your mother's past may help me unravel a complex mystery. I remember a thirty-year-old woman who came to me after she'd had two miscarriages. She told me her mother had also miscarried twice before giving birth to her. I asked my patient to find out if, in order to avoid another miscarriage, her mother had taken a drug called DES when my patient was in utero. We were both greatly relieved to find out that her mother had not taken this insidious drug. Had she been exposed to DES, my patient could have suffered from unexplained infertility and repeated unexplained pregnancy losses, as well as have a deformed cervix and womb.

Congenital Uterine Abnormalities
Congenital abnormalities of the female genital tract range from a simple septum dividing the uterus in half to a complete duplication of all structures - uterus, cervix, vagina, and external genitalia. Some of these abnormalities may interfere with implantation of the embryo or lead to early pregnancy loss. Surgical correction often improves the chances for maintaining a pregnancy to term. Sometimes endometriosis can cause a tipped uterus. The tipped uterus, however, is not causing the fertility problem; the endometriosis is.

Hysterectomy
Today women who had previously given up hope of pregnancy because of a hysterectomy may be able to have their own babies. Using in vitro fertilization techniques, we can surgically retrieve her eggs and fertilize them with her husband's sperm. Since she cannot carry the pregnancy, we deposit the fertilized embryo into a surrogate (substitute) mother's womb. Though born to another woman, the baby will carry its true parents' genes. These exciting prospects are medically possible, and the legal system is grappling with the issues they raise.

Sexual Freedom
Modern contraception, usually regarded as a great success story, may actually be responsible for dramatically increasing fertility problems. The upside of contraception is that women can enjoy sex and still avoid unwanted pregnancies. With the ability to control their fertility and plan their lives, women are making remarkable progress in the educational, artistic, and business worlds. And with the fear of unwanted pregnancy removed, many women enjoy sex with different men. They're glad to see the demise of the double standard.

The unfortunate downside to freely available contraception is that liberated sex has given rise to a rampant increase in sexually transmitted diseases. Every year over 250,000 college-aged women become infertile from chlamydial infection alone. And many of them won't know it until some years later. Whereas women in the past feared unwanted pregnancy, they should now fear pelvic inflammatory disease. I offer no easy answers for the man or woman who wants a free sex life. We do know that barrier contraceptives such as condoms and diaphragms lower your risk of contracting sexually transmitted infections. My hope is that medical breakthroughs will provide a vaccine or some other means for curbing this epidemic.

The IUD
The IUD, or intrauterine device, particularly exposes the promiscuous woman to an increased risk of pelvic inflammatory disease and tubal damage. Although the exact mechanism of contraception is not well understood, the IUD apparently creates a low level inflammation which prevents the sperm from reaching the egg and an embryo from implanting in the uterus. The IUD string may allow bacteria from your vagina to enter your womb, where they can flourish and invade your delicate reproductive structures. This risk is greatest in the first month following insertion. There's some evidence, though, that copper IUD's and the levonorgestrel containing IUD (Lng-20) may offer some protection against infection.

Since the risk of contracting a sexually transmitted disease and impairing fertility increases with exposure to different partners, the IUD was temporarily removed from the American market. We now know that the IUD is safe and effective contraception for monogamous women and that the new Lng-20 has many medical benefits.

The Pill
Using the Pill won't impair your fertility; however, its use may disguise an underlying fertility problem. I remember when Shelley T. approached me in a panic:

"God's punishing me! I know it!"

"Birth control pills did not cause your fertility problem, Shelley." Once she calmed down a bit I asked, "What were your periods like before you took the Pill?"

"I had terrible cramps," she told me. "But the Pill changed that."

"The Pill may have reduced your cramping, but it did not cure your endometriosis. It's been with you all along," I told her.

The Pill may also artificially regulate women who normally have irregular periods. When their irregular cycle returns after they go off the Pill, these women are often surprised. All the time they took the Pill, they falsely assumed that it had cured their underlying hormone imbalance. It is true that up to 3 percent of women using the Pill will develop menstrual irregularities as a direct result. However, they usually respond very well to ovulation induction therapy. I'll discuss more about the Pill in chapter 12.

Norplant
Norplant contraceptive implants a six small capsules placed into the upper arm. They release a small amount of levonorgestrel, a synthetic progesterone each day. This thickens cervical mucus preventing sperm penetration. Ovulation may also be blocked. And, if all else fails, the normal preparation of the uterine lining so that a pregnancy may attach is prevented. Ovulation generally resumes about 2 weeks after a simple procedure to remove the implants.

Lost Years Lower Your Odds
Couples who use any contraceptive method over a prolonged period of time have only a few remaining fertile years in which to resolve their fertility problem. To compound the difficulty, their fertility naturally declines as they grow older. However, since women can manage a healthy pregnancy through their late thirties, these couples succeed quite frequently. They just need to pursue their fertility treatment more aggressively.

Lubricants and Contraceptive Creams
A lubricant used during sex may contain spermicidal chemicals that attack and kill millions of sperm before they have a chance to enter the protective cervical mucus. Even petroleum jelly may interfere with sperm activity. The easiest and cheapest lubricant is your own saliva, although bacteria in your mouth may degrade the semen. I suggest that if necessary my patients use a water-based lubricant such as Replens, K-Y Jelly or Lubrifax. If you're in doubt about what product to use, ask your doctor.

Douches
If you douche before having sex, you may alter the environment in your vagina and deteriorate the quality of your mucus. Later, when the sperm arrive, your vaginal passage may be hostile and your cervix blocked by mucus that sperm cannot penetrate. If you want to make a baby, I do not recommend douching before sex. Even though most sperm penetrate your mucus within a couple of minutes of ejaculation, I recommend waiting at least thirty minutes after sex before douching. Actually, unless you have some personal preference for douching, you never need to douche regularly. I'm amazed by the ability of commercial advertisers to make money from our fears about smelling bad or being dirty.

Timing
If you don't have sex, you can't get pregnant. You can quote me on that. You'd be surprised at the number of people who do not have sex the national average of two and one-half times a week. You are fertile for about twenty-four hours each menstrual cycle and sperm can survive in your reproductive tract for twenty-four to forty-eight hours. So you can see that if you do not have sex every forty-eight hours around the middle of your cycle (during your fertile days), you probably will not get pregnant. Some couples prefer using a urine LH kit to predict when ovulation is about to occur. When the stick turns blue, ovulation will likely occur the next day. This means only one day of work-sex and the rest of the month can be for lovemaking.

Many factors can interfere with sex - the couple may be too busy, the husband and wife may travel, they may be under too much stress. During fertility treatment you may need to reduce your activities, alter your business schedules, and even cancel vacations. It doesn't make much sense to spend $300 to $500 in a month to become fertile and then blow your chances because of a trip.

Too Much Sex
You know what they say about too much of a good thing.... Seriously, though, extremely frequent sex reduces the amount of sperm available for each ejaculate. We know that it takes about forty-eight hours after sex for a man to build up an adequate supply of sperm. So having sex more frequently than that reduces the man's sperm count so much that pregnancy becomes even less likely. So you'll just have to control yourself - at least until you get pregnant.

Uncomfortable or Painful Sex
Uncomfortable or painful sex may indicate infection or other abnormalities. Sometimes, however, discomfort may only be due to insufficient lubrication. If your vagina is consistently dry during sex, perhaps you and your husband should engage in foreplay longer. Stimulating your nipples, clitoris, and other erogenous areas will make your glands secrete natural juices. If your vagina remains dry after sexual arousal, your lubricant-supplying glands may be infected or your hormones may be deficient. You may require low-dose estrogens to improve your vaginal secretions or you may choose to use a water-soluble lubricant. You need to discuss this problem with your doctor.

Aversion to Sex
Sometimes sex turns a person off. One particularly sad case comes to mind where as a child, my patient had been sexually abused by her uncle. To Donna N. sex was shameful and to be avoided as much as possible, even though she loved her husband.

After she told me about her uncle and her abortion at age thirteen, I referred her for counseling. Although it took some time, her relationship improved to the point where she looked forward to pursuing fertility treatment. If sex turns you off, seek professional advice.

Many couples who come to me already have completed all or part of a fertility workup. They may have been referred to me by their doctor or perhaps they became discouraged and wanted a second opinion. Often they are surprised when I tell them I may need to repeat many of their tests.

However, there are a number of factors I must consider:

Often the reports I receive for previous tests do not contain all the information I need for proper interpretation. For example, only when I know both the test date and the ovulation date can I evaluate your postcoital test and biopsy results.

I know and trust my assistants, technicians, and the outside laboratories I use. Due to the lack of standard methodology, many medical laboratories will report different results on the same blood specimen or do not do a good job of reporting sperm morphology on a semen analysis. I remember one instance where a couple came to me after the wife had undergone fertility treatment for over a year. When I repeated the husband's semen analysis, I found severely abnormal sperm. Four months after I treated them with antibiotics and vitamin C, she became pregnant. Since I'm responsible for my patient's care, I want the best information I know how to get.

While conducting a pelvic exam or ultrasound evaluation, I make many observations that may not be noted on your previous physician's report. I notice, for example, how easily I can manipulate your pelvic organs. If they are stiff and rigid or which area seems to reproduce your pain. I may suspect adhesions. Subtle clues like flinching when I touch your ovary or kicking when I do your rectal exam help me solve the mystery. I'll also find out if your condition has improved or grown worse since your previous doctor examined you.

I may need to perform X rays and/or laparoscopies so I myself can view the dye moving through your tubes. The written results of a previous laparoscopy do not tell the whole story. Watching a videotape and seeing the flow and the response of your reproductive organs to manipulation tells me much more, for example, than knowing that you have a tubal blockage. If necessary, I can even lay out a specific plan for performing corrective surgery. I'll discuss the use of diagnostic laparoscopies and X rays in much more detail in later chapters.

People change with time, for better and for worse. Your fertility potential one year ago is history. I must assess your current condition before I can design a customized treatment plan.

When you change doctors, bring your old records on your first visit and, if possible also bring your hospital records, surgical videotapes, laboratory test results and X ray films. By providing these records you may not totally avoid the need for duplicating tests, but you'll minimize your expense and you'll give your doctor an edge on solving your fertility problem Your doctor should use every available clue from your past because considering every factor will give you the best chance for having your miracle baby.

For more information on your initial visit to your physician read the
INCIID Routine Fertility Workup or IVF.com Homepage.

Miracle Babies and Other Happy Endings
for Couples with Fertility Problems
Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie.