Hyperprolactinemia is a condition caused by too much prolactin — the hormone that stimulates breast milk production. Because prolactin can interfere with ovulation, hyperprolactinemia can cause irregular periods. As a result, ovulation doesn’t occur every cycle, or the menstrual cycle becomes irregular.
Hyperprolactinemia can also cause headaches because it’s most often caused by a benign tumor in the pituitary gland, which is located just beneath the base of the brain. Some people with the condition also have nipple discharge.
If a patient comes in with those types of symptoms, then the first step is a blood test to see what their prolactin level is. It’s best to do this test first thing in the morning because they need to fast beforehand. It’s also important to avoid nipple stimulation prior to the test, because it can falsely signal elevated prolactin.
If hyperprolactinemia is confirmed, we check to make sure the test was 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, so the recommendation is oral medications that help decrease the prolactin to restore ovulation.
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 two months.
So this was great because fertility treatments can be very expensive. Just correcting the underlying problem was enough for her to get pregnant naturally.
The main contributors to infertility are gonorrhea and chlamydia, both of which can cause damage to the uterine tubes, and that damage can continue even after treatment. When an issue with the uterine tubes is causing infertility, it’s called tubal factor infertility.
The uterine tubes are necessary for natural conception because the egg passes through them to get from the ovaries to the uterus. If the uterine tubes are damaged to the point where an egg cannot get into the uterus, then the only path to pregnancy is usually IVF.
If the tubes become swollen with water, a condition called hydrosalpinx, they might need to be removed. This is another situation when a patient would need IVF to get pregnant. And sometimes the tubes are damaged but still open, and that can lead to the fertilized egg implanting into the tube. This is an ectopic pregnancy, which is a life-threatening condition.
Not all people who get gonorrhea and chlamydia have tubal factor infertility, but it does increase the risk.
Sexually transmitted infections (STIs) are suspected when people come in with burning or abnormal discharge. But STIs don’t always cause symptoms — sometimes people are asymptomatic and the infection is only picked up with screening.
That’s why it’s important to get screenings if you’re sexually active and for doctors to ask your medical history if you have infertility to see if that’s something that should be looked into further.
I had a patient who had a lot of pelvic pain, which can also be a big symptom. She hadn’t told me about a previous infection, and when we did her surgery to see what was causing her pain, we found a lot of adhesive disease in her abdomen and her pelvis. Seeing it prompted me to again ask if she’d had an infection before. This time, I asked privately, not in front of her partner. She then told me this was something in her history, so we moved forward with IVF, and she was able to conceive that way.
Her tubes seemed to be open, so if that hadn’t been diagnosed, she could have conceived naturally and potentially had an ectopic pregnancy because of it.
For most people who have it, endometriosis causes severe pelvic pain, but not everyone has symptoms. But generally speaking, pain is the principal reason it’s suspected. Often, endometriosis is diagnosed by performing surgery. Samples are collected so a pathologist can make the final diagnosis. But not everyone gets surgery for diagnosis — it’s just presumed. This is especially true if they have a history of cyclical pain that occurs right around the time they get their period. That’s a pretty telltale sign of endometriosis. As far as treatment goes, removing the lesions is the preferred method — the inflammation that endometriosis causes can make it more difficult for an embryo to implant or for a pregnancy to be successful.
I had a patient who’d had three surgeries for endometriosis. The pain she was experiencing was life-altering and debilitating. She’d had a very large surgery to deal with the pain, so when she decided she wanted to get pregnant, she came to me.
People with endometriosis usually don’t experience any pain during pregnancy, so the best time to get pregnant is generally within the first 12 months after a surgery to remove it. This patient was still in that window. She was ovulatory, meaning that her cycles were pretty regular. And she wanted to kind of help expedite the timeline for getting pregnant because it had almost been a year since her surgery, after which her probable success rate would start decreasing. Plus, she didn’t want to stop taking her medication for a long time, which might have been the case if she tried to conceive naturally.
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, and we were all very surprised because even people who have an excellent ovarian reserve don’t get pregnant after the first cycle. I was very excited for her.
As I mentioned earlier, a big risk factor for tubal factor infertility is STIs like chlamydia and gonorrhea. Inflammatory bowel disease, previous surgery, and previous ectopic pregnancy also increase the risk. Those are all red flags that indicate the tubes should be very thoroughly investigated as a potential cause of infertility. But tubal factor infertility can also be idiopathic, meaning we don’t know why it’s happened.
To diagnose tubal factor infertility, generally, we do a hysterosalpingogram, or HSG. This is a procedure where we put contrast into the uterus to see if it goes out of the uterine tubes and check that the tubes look normal in size. If the contrast can go through, generally, the tubes are open.
Microscopic studies of the uterus sometimes will show that tubes are dilated, which means that they’re much bigger in diameter than normal. Sometimes you can see a structure next to the uterus that doesn’t look like a bulk or cyst — it’s a tube filled with water. Reviewing their medical history can sometimes indicate if a patient 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 is a contributing factor to at least one third of cases of infertility.
Should the tubes be removed if there’s tubal factor infertility, or is there another treatment?
There are definitely times when the tubes can be saved.
Some tubal blockages are on the connection point between the tube and the uterus, which is called a proximal tubal occlusion. Sometimes those can be opened just on an HSG — the pressure needed to perform the procedure sometimes opens the tubes.
In other cases, laparoscopic surgery can facilitate that connection if there are some adhesions from something like endometriosis. This involves using a little tube with a camera to go inside the uterus, and sometimes the adhesions that are there can be removed.
But if the tube is filled with water and severely dilated, it really needs to be removed or at least clipped where it meets the uterus to prevent that fluid from getting back in, because that fluid can be very toxic to embryos and prevent implantation.
And if the tubes are severely damaged, it could lead to ectopic pregnancy. If this is the case, I recommend removing the tube. If someone has had ectopic pregnancies and the tube looks as though it can’t be saved, then removing it at least prevents another ectopic pregnancy in that tube. But the risk would still be high for the other tube, even if it appears normal.
I do have a story of a couple trying to get pregnant, and the woman trying to get pregnant had pelvic pain. Another surgeon had previously operated on her and said that her tubes were blocked and she was high risk for an ectopic pregnancy. So the couple came to me for a second opinion because they were ready to start trying. And we did surgery and found that one of the tubes was blocked and one was open. After that surgery, she got pregnant on her own. So again, you know, not everyone needs to have rigorous treatment. Sometimes correcting the underlying problem or just evaluating things further to confirm is all that people need.
Male infertility is a contributing factor to at least one 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 very strongly suspect a male factor infertility if they use any hormones like testosterone because that can definitely lead to very low sperm levels.
Actually, some men who have been on hormone therapy like that for a long time don’t have any sperm. So, that’s something I always try to ask to make sure that it’s not a contributing factor. Sometimes we don’t do a lot of exams, but if I find his testicles are smaller than usual during an exam, 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, sometimes history and exams are enough to say if the risk would be higher, but no matter what, everyone should have a semen analysis.
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. Cystic fibrosis is (sometimes, not always) associated with an absence of vas deferens, which is the tube that carries the sperm out of the testicle. But that doesn’t mean they don’t have sperm.
There are procedures to use that sperm to create an embryo so they can have a biological child. So I was able to tell them that they could get pregnant without using donor sperm, which some couples with male factor fertility need to do. And with the help of assisted reproductive technologies, they got pregnant!
When should a TTC couple see a doctor?
If someone is younger than 35 and they haven’t been able to conceive within a year, they should talk to their OB-GYN or be referred to a specialist.
We run routine tests to check ovarian reserve and uterine anatomy. And it can provide them peace of mind to know their tubal status, like, if the tubes are open, the uterus looks normal, and the ovarian reserve is normal.
If applicable, it’s also very important to do a semen analysis to make sure that nothing is in the way of their making a baby.