Infertility

Having trouble getting pregnant can be one of the most frustrating problems for couples. It can be a challenge to keep a positive attitude when people all around you seem to be getting pregnant. You are not alone! It is estimated that about 15% of couples have trouble with infertility.

Classically, infertility is defined as an inability to achieve pregnancy after one year of regular, unprotected intercourse. It is at this point that we recommend couples be evaluated. However, if you are 35 years of age or older, we recommend evaluation after 6 months. We also recommend earlier evaluation for:

  • Women who have very irregular periods (suggesting the absence of ovulation)
  • If there is a known fertility problem with you or your partner

If you would like to discuss infertility with your provider, it is best to schedule your visit as a CONSULT visit. This allows you to be booked into the last slot in the morning or afternoon, which affords you the most time with your provider. Discussion of infertility at your annual exam may be less comprehensive given time constraints.

At your initial visit, a thorough medical and pregnancy history will be taken about you and your partner. Be prepared to answer questions about your periods, any abnormal bleeding or discharge you have, pelvic pain, frequency of sexual intercourse, etc. If your periods are irregular and you have a “menstrual calendar” indicating the days of your cycle over the last few months, this could be very helpful. These questions allow us to gain insight into some of the possible reasons of your infertility. If you have records from previous infertility evaluation, it is very helpful if you have those available at this visit. After a thorough history is taken, you may undergo a physical exam. This depends on when the last one was performed by our office and if you have any concerns at the time of that visit.

Infertility can result from a breakdown along any point of the conception cycle. In order to achieve conception, the first step is that the ovary must release an egg, also called ovulation. This egg must be swept up into the fallopian tube. Then the sperm must swim from the vagina, through the cervix and uterus, and into the fallopian tube, where fertilization takes place. The embryo (fertilized egg) then moves to the uterus where it implants into the uterine lining.

It is very important to realize that the cause of infertility is just as likely to be male-factor (meaning something wrong with the sperm) as it is to be female-factor. This is why we like your partner to be an active participant in this evaluation. Here is a quick overview of the different causes of infertility:

Ovulation Factor

  • Irregular or absent ovulation accounts for about 25% of all infertility
  • If you have regular monthly menses every 24-34 days, then you are likely ovulating
  • There are two at-home methods you can use to help evaluate if you are ovulating
    • Body temperature
      • Take your temperature FIRST thing in the morning for a month. This may be charted online or recorded in your menstrual diary. The progesterone that increases after ovulation causes your body temperature to rise 0.5-1 degree Fahrenheit.
      • Not everyone who ovulates gets an increase in body temperature.
    • Ovulation predictor kits (OPKs)
      • These are designed to alert when you ovulate, thus allowing you to have intercourse at the correct time each month.
      • They detect an increase in a hormone called luteinizing hormone, or what we call the “LH surge”. The LH surge is the brain’s way of telling the ovary it is time to ovulate. The LH level starts to rise approximately 36 hours before ovulation and peaks approximately 12 hours before ovulation. The OPKs detect this surge about 1-1.5 days before ovulation, thus a good time to start having unprotected sex. Because a positive OPK result does not indicate where you are in this 36 hour window, we recommend intercourse at least every other day for about 6 days.
      • Not everyone who ovulates will have a detectable LH surge on OPKs. OPKs are notoriously difficult to read and evaluate. If you have difficulty interpreting your OPK results, please schedule an appointment for consultation.
  • The best test to determine ovulation is a laboratory test to check the progesterone level in your blood during the second half of the menstrual cycle. This is usually done around day 21 of your cycle, if you have 28-day cycles (day #1 is the first day of bleeding). However, if your cycle length is typically longer or shorter than 28 days, your provider may recommend checking a progesterone level on another day.

Tubal Factor

  • Abnormal fallopian tubes or inflammation in the abdomen around the fallopian tubes accounts for 35% of infertility.
  • Risk factors for tubal factor infertility include:
    • Gonorrhea or Chlamydia or pelvic inflammatory disease
    • Severe endometriosis
    • Prior ectopic pregnancy in the fallopian tube
    • Multiple pelvic surgeries
    • Prior tubal surgery
  • To assess if the tubes are open and if the uterine cavity is of normal shape, we refer you to get a special x-ray called a hysterosalpingogram (HSG). This can be done in most radiology offices, or sometimes we send you to one of the infertility specialty clinics as they have the equipment to perform this x-ray as well.
    • Expect this test to be scheduled during the first half of your cycle (before expected ovulation as we would not want there to be a chance of you being pregnant).
    • When you get to the exam room, there will some sort of set up with stirrups to allow a pelvic examination. A physician will do a speculum exam and then place a small instrument through your cervix. They will then inject a special radiology dye through this device into your uterus and hopefully out of your fallopian tubes. Several x-ray images will be taken.
    • If there is dilation and blockage of one or both tubes, the doctor at your HSG may prescribe you an antibiotic to prevent the dilated tube from becoming infected.

Male Factor

  • Abnormal sperm accounts for 40% of infertility and thus a semen analysis is a very important part of the work-up
  • Your partner will be given a referral to a physician that does this test. This is usually a urology office or an infertility specialty clinic.
  • He will be asked to refrain from ejaculating for 48 hours prior to his appointment.
  • He will then collect a semen sample in a cup by masturbating at home or their office. There are instances, if necessary, where your partner can obtain a sample during sexual intercourse using a special condom provided by the doctor doing the analysis.
  • The semen analysis looks at the amount of sperm, the movement of the sperm, and the shape of the sperm.
  • It is sometimes necessary to repeat a sample 2-3 months later as quality and quantity of sperm can be variable.

Age Factor

  • Fertility begins to decline more rapidly in your late 30’s because fewer eggs remain in the ovaries. Of the eggs that remain, fewer are of the same quality as they were when you were younger.
  • There are blood tests that help us determine your fertility potential by examining the amount of ovarian function you have remaining.
    • Follicle stimulating hormone (FSH) and estradiol drawn on cycle day #2, 3, or 4.
    • Anti-mullerian hormone (AMH)

Uterine Factor

  • This is rarely the sole cause of infertility.
  • The uterine cavity will be assessed at the time of the HSG but can also be assessed with a special ultrasound called a saline-infusion sonogram or sonohysterogram.

Unexplained infertility

  • 5-10% of infertile couples who undergo the full evaluation have all normal results.

To summarize, the evaluation of infertility may include some or all of the following:

  • Cycle day #2,3 or 4 follicle stimulating hormone (FSH) and estradiol to assess ovarian function
  • Thyroid stimulating hormone (TSH) and prolactin levels are often checked as abnormal levels can affect ovulation
  • Anti-mullerian hormone
  • Progesterone level around cycle day 21
  • Hysterosalpingogram
  • Semen analysis

If you are having bloodwork (either day #3 or day#21) performed in the office and this day will fall over a weekend or holiday, please schedule to have your bloodwork performed on the next closest day when the office is open.

Your provider will want to meet with you after all the testing is done to review the results in their entirety and to establish the appropriate treatment plan or referrals.

Treatment of any of the above infertility causes can vary according to each couple’s circumstance and also provider preference. Briefly, below are some of the possible options:

Ovulation Factor

  • Ovulatory assistance can be achieved with medication. Our practice provides this using clomiphene (Clomid) or letrozole (Femara). These medications help your ovaries produce one or more-than-one quality egg each month. It is important to note that Femara is not FDA approved for this use; however, it is commonly used in the OBGYN community for this reason and is considered safe. These medications do increase your twin rate to about 5%. We start with the lowest dose of either medication and have you take the medicine on cycle days 3 through 7 or 5 through 9. Your provider will give you instructions. For the first month at a particular dose, we will have you get your progesterone level checked on or about cycle day #21 in order to confirm whether or not you ovulated. Once we have you on a dose with confirmed ovulation, we encourage you try for 3-6 months. If you do not conceive or if we cannot achieve ovulation with the maximum dose of the medications, we would refer you to an infertility specialist. Once there, the specialists have stronger (injectable) medications to assist with ovulation.

Tubal factor

  • If after your HSG, we suspect scar tissue around the tubes to be the culprit for a blockage, then we may offer you a laparoscopy to surgically evaluate the tubes and possible correct any blockage. Otherwise, tubal factor infertility warrants a referral to an infertility specialist where in vitro fertilization (IVF) is the most common therapy.

Male Factor

  • If there is an abnormal semen analysis on more than one test, then you will need a referral. If there is suspicion for a medical problem that is leading to abnormal sperm, then a urology referral may be given. Otherwise, most of the time we refer to an infertility specialist. Depending on the severity of the abnormal sperm you will likely get offered one of two treatments. With mild to moderate abnormalities, you will likely get offered intrauterine insemination (IUI). For IUI, your partner provides a fresh semen sample on your ovulation day. This sample is cleaned and the healthy sperm are then injected directly into the uterus, increasing the chance that a quality sperm finds the egg. For severely abnormal semen, trying donor sperm with IUI or trying IVF is sometimes the more effective choice.

Age Factor

  • Infertility medications are less effective with decreased ovarian function and miscarriage rates are also higher. We thus tend to refer to an infertility specialist early if we suspect this to be the cause of infertility. Treatment usually starts with ovarian stimulation plus IUI and eventually to IVF. For women in their early to mid-40s or those with markedly decreased ovarian function, IVF using donor eggs is sometimes the best option.

Uterine factor

  • As mentioned above, we can usually surgically correct uterine cavity problems with a surgery called a hysteroscopy. We put a small camera through a cervix and then use surgical instruments to remove the abnormal pathology. For some more complex problems, we can refer to an infertility specialist.

Unexplained infertility

  • Ovarian stimulation drugs in conjunction with IUI have been shown to improve pregnancy rates in those with unexplained infertility, as has IVF. Clomid or Femara alone have not been proven to increase pregnancy rates in those with unexplained infertility; however, we sometimes offer this as a first step for 3-6 cycles if a patient desires.

We understand that, for many couples, infertility can be emotionally taxing. There are good resources available in our community to help. Please speak with your provider if necessary.

Koop Kam 2

Computer Drive Office
3805 Computer Drive
Raleigh, NC 27609

Durant Medical Center
10880 Durant Road, Suite 224
Raleigh, NC 27614

Office Hours
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Fax: 919-783-1819

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