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Infertility: 5 Popular Causes and 5 Stories (with a Happy Ending)

If you and your partner are struggling to have a baby, you’re not alone. Every 7th couple in the USA is infertile. Infertility may arise from a one issue or a combination of factors. Today, Reproductive Endocrinologist & Infertility Specialist, Tiffanny Jones from Dallas IVF clinic tells Flo about the most common infertility causes and shares real cases from her practice.

#1 Hyperprolactinemia 

Hyperprolactinemia is the condition in which a woman has too much prolactin – the hormone that stimulates breast milk production. As a result, a woman will have irregular periods because the prolactin can interfere with ovulation, and so ovulation doesn't occur every cycle, or menstrual cycle will not be regular. 

Other signs of hyperprolactinemia can be headaches because generally it comes from a large tumor in the pituitary, and some women have nipple discharge. 

If I suspect that because someone comes in with those type of symptoms, then the first step is a blood test to see what their prolactin is. Generally, it should be done first thing in the morning. It should be fasting and women should avoid nipple stimulation because those things can lead to a false positive elevated prolactin.   

Treatment

If it’s confirmed that someone has hyperprolactinemia, we are making sure that the test is done appropriately and then I also screen them with an MRI to see if there is a tumor and if there is one to see how big it is.

Most of the time if a tumor is found it's very small, the recommendation is just oral medications to help decrease the prolactin to restore ovulation.   

Success story 

I did have a patient with an elevated prolactin level. She had a very small tumor. And once we started the oral medication, she didn't have to do anything. She was pregnant in 2 months. 

So, it was very good because generally, fertility treatments can be very expensive. So just correcting the underlying problem was enough for her to get pregnant naturally.

#2 Infections

The main contributors to infertility are gonorrhea and chlamydia, both of which can cause damage to the fallopian tubes and that damage could be ongoing even after they're adequately treated. 

The fallopian tubes are necessary for natural fertility because that's how the egg gets into the uterus. If the fallopian tubes are damaged to the point where an egg cannot get into the uterus then the only treatment usually is IVF. 

If the tubes become swollen with water, which is called hydrosalpinx, sometimes they have to be removed and then again, a patient would need IVF. And sometimes the tubes are damaged but still open and that can lead to the fertilized egg implanting into the tube and causing an ectopic pregnancy which is life-threatening. 

Not all people who get gonorrhea and chlamydia have a tubal factor but they are high risk for it.

I suspect those kinds of diseases when people come in with burning, with abnormal discharge. Sometimes it's only picked up with screening, and people are asymptomatic.

So, it's important to screen women who are sexually active for these kinds of diseases and also to get a thorough history for women who have infertility to see if that's something that should be looked into further.   

Success story

There's one woman that had a lot of pelvic pain which can also be a big symptom. She had not told me that she had past infection and when we did her surgery to see why she was having pelvic pain, and she had a lot of adhesive disease in her abdomen and her pelvis, which then prompted me to ask again “Is this something that you've had?” I had to ask it privately, not in front of her partner. Then she did say that this was something in her history and so that prompted us to move forward with doing IVF and she was able to conceive that way.

Have that not been diagnosed, because her tubes were seem to be open, she might have continued to go down the road of trying to get pregnant in a more natural way and potentially would have had an ectopic pregnancy because of it. 

#3 Endometriosis 

With endometriosis generally women have severe pelvic pain, but some women don't have any symptoms. Sometimes it's diagnosed after doing a surgery or it's always diagnosed after doing a surgery. But most of the time it's suspected in people who have pain. 

You do a surgery and send those specimens that look like endometriosis to a pathologist to have a final diagnosis. 

Not everyone gets a surgery so sometimes it's presumed, especially if the history is a cyclical pain that comes right around the time of periods. Generally, that's a pretty telltale of a sign of endometriosis. Removing the lesions is the preferred method of treatment because the inflammation that endometriosis cause can lead to less embryos being able to implant or pregnancies being able to be successful.  

Success story

I had a patient who has had 3 surgeries for endometriosis. She has had really life-altering debilitating pain. She was seeking treatment for her pain before and had a very large surgery and then came to me because she had decided it was time for her to get pregnant.

Actually, people usually don't experience any pain with pregnancy when they have endometriosis. So, the best time to get pregnant is generally within the first 12 months after a surgery to remove it. And so, she was still in that window. She was ovulatory, meaning that her cycles are pretty regular. And she wanted to kind of help expedite the timeline for getting pregnant because she was coming up to after a year of her surgery which would decrease her success rate. And she didn't want to be off of her oral therapies for a very long time trying to get pregnant. 

So, we did ovulation induction, what we call superovulation, to help her release more eggs than she would typically on her own. And she got pregnant the very first cycle. So that was very good for her. Hopefully, she'll have no pain or no problems during pregnancy but that was a very nice story for her and we were all very surprised because a lot of the times even people who have an excellent ovarian reserve and everything looks fine, they don't get pregnant after the first cycle. I was very excited for her.   

#4 Tubal factor

The tubal factor can be idiopathic, meaning we don't know why it's happened. 

A big risk factor is women who have had sexually transmitted diseases like gonorrhea, chlamydia, and some other diseases like inflammatory bowel disease, people who have had surgeries, and then women who have had ectopic pregnancies in the past. Those are all kind of red flags to say that tubes should be very thoroughly investigated as a potential cause of infertility.

To diagnose tubal factor infertility, generally, we do an HSG. It puts contrast into the uterus and if it goes out of the fallopian tubes, and the tubes look normal in size, then we can say that OK, the contrast can go through, then the tubes are generally open. 

Microscopic studies of the uterus sometimes will show that tubes are dilated so that their diameter is a lot bigger than what would be normal. And sometimes you can also see it on an ultrasound, where we see a tubular structure next to the uterus that doesn't look like a bulk or cyst. And it’s a tube filled with water. History can sometimes tell if someone has a risk factor for tubal infertility, and with imaging studies, you can see if there is potential pathology there.   

It is always important to screen both partners because male infertility can be a contributing factor to at least a third of cases of infertility.

Should the tubes be removed if a woman has tubal factor infertility or it can be treated differently?   

Definitely, there are times when the tubes can be saved. 

When some people have a tubal blockage that seems to be on the connection point between the fallopian tube and the uterus, which is called a proximal tubal occlusion. Sometimes those can be opened just on an HSG. With the short sheer pressure needed to perform the study sometimes the tubes will open. 

Sometimes a procedure can be done with a camera going inside the uterus to open up that little area to help facilitate that connection if there are small adhesions from something like endometriosis. Sometimes those can be removed.  

But if the tube is filled with water and severely dilated it really needs to be removed or at least clipped up a point where it does meet the uterus to prevent that fluid from getting back in, because that fluid can be very toxic to embryos and prevent implantation. 

And also, if the tubes are severely damaged, it could lead to ectopic pregnancy so I would recommend it to be removed. And if women have had ectopic pregnancies and the tube looks as though it could not be saved, then removing it at least prevent an ectopic in that tube. But the risk would still be high for the other tube even if it appears normal.   

Success story 

I do have a story of a couple trying to get pregnant. She had pelvic pain. She had an operation with another surgeon. And he said that her tubes were blocked and that she was high risk for an ectopic pregnancy. So, they saw me because they wanted a second opinion because they were ready to start trying. And we did surgery and one of the tubes was blocked and one was open. After doing that surgery to confirm that they looked normal, just one was blocked and couldn't block the other one, she got pregnant on her own. So again, you know, not everyone needs to have rigorous treatment. But if you correct the underlying problem or just evaluate things further to confirm, then sometimes that's all people need.  

#5 Male infertility 

It is always important to screen both partners because male infertility can be a contributing factor to at least a third of cases of infertility. 

Every patient or every couple should have a semen analysis to make sure that that's not a contributing issue. I am very strongly suspecting a male factor if he uses any hormones like testosterone because that can definitely decrease sperm levels to very low. 

Actually, some men who have been on hormone therapy like that for a long time don't have any sperm. So, that is something I always try to ask to make sure that there are no contributing factors there. Sometimes we don't do a lot of exams but if I'll just have an exam and his testicles are smaller, that can be a contributing factor. And you definitely want to get a good history of his family and if potentially he has a genetic disease like cystic fibrosis. So, by history and exams sometimes you can say if the risk would be higher, but no matter what everyone should have a semen analysis.   

Success story

I had a patient with cystic fibrosis and he was told that he could never have children. And, you know, not every doctor is a specialist in everything. Definitely, males who have cystic fibrosis, some of them have an absence of their vas deferens, and that's a tube that carries the sperm out of the testicle. But it doesn't mean they don't have sperm.

There are procedures that even those men can do to help use their sperm to create an embryo so they can have a biological child. Yes, they might not be able to get pregnant a natural way but they definitely can use assisted reproductive technologies to help them. And so that was nice because I was able to tell them that “You know, if you're willing to do this, that it's likely we can help you guys get pregnant together versus using donor sperm, which could also help couples with male factor that can't be corrected”. And they got pregnant!   

When should a TTC couple see a doctor? 

If a couple is less than 35 and they have not been able to conceive within a year, they should see and talk to their OB-GYN or be referred to a specialist. 

We run routine tests to check ovarian reserve and uterine anatomy for the woman. And also, it's nice to know their tubal status, like, if the tubes are open, the uterus looks normal and the ovarian reserve is normal. 

Also, it's very important to know the semen analysis to make sure that everything is in line to be capable to make a baby.

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