“Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow.” ~ Mary Anne Radmacher
Fertility Concerns: What is the delay?
When you are trying to conceive without success, it is easy to become frustrated and need help: both medical and emotional.
This is often a trying time for a couple. We are sensitive to this, and want to reassure you that we will do everything in our power to make this chapter in your life as easy as possible.
Infertility is typically defined as the inability of a couple to conceive after one year of unprotected intercourse.
Infertility or fertility delay is a common condition:
In any given year, about 15% of the couples in the U.S. who are trying to conceive are not able to do so. The ability of a couple to become pregnant depends on several factors in both the male and female partners.
Basic Causes of Infertility
- male factor: 20%
- ovulation dysfunction: 20%
- blocked fallopian tubes: 15%,
- endometriosis: 10%
- uterine abnormalities:? 5%,
- hormonal conditions: < 5%
- unexplained: 25%
Multiple pieces to the puzzle: Often there is more than one contributing factor. If we cannot uncover and address your specific cause within a short period of time, we will refer you to a specialist in reproductive medicine for more advanced investigation and options.
The good news: most couples who present to us with fertility difficulties ultimately become parents, with or without our help, or with the assistance of our specialist colleagues.
Our Consult and Evaluation
Our first discussion is best with both partners to investigate possible historical barriers to pregnancy. These might include not having sex during the fertile time of the month, ejaculatory problems, previously undisclosed medical conditions that could delay fertility.
Both partner's past health and medical history are important in the process of evaluation.
We will ask about childhood growth and development; sexual development during puberty; sexual history; illnesses, infections, surgeries, medications, exposure to certain environmental agents, (alcohol, radiation, steroids, chemotherapy, and toxic chemicals), and any previous fertility testing.
If genetic or chromosomal abnormalities are suspected, specialized blood tests may be needed to check for absent or abnormal regions of the male chromosomes (Y chromosome).
Physical examination — This is usually includes a general examination, with special attention to any signs of hormone deficiency or signs of other conditions that might impair fertility. We will also perform a pelvic examination, which can identify abnormalities of the reproductive tract and signs of low hormone levels.
Blood tests — Blood tests can provide information about the levels of several hormones that play a role in female fertility; in women, key hormones are produced by the hypothalamus, the pituitary gland, and the ovaries. These hormones include follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin.
Ovulation Prediction: Ovulation (the release of an egg from an ovary) is essential for fertility. Abnormalities of ovulation can often be determined from a woman's menstrual history or hormone levels such as the pre-ovulatory LH surge or luteal phase progesterone.
Menstrual history
- Amenorrhea (absent menstrual periods) usually signals an absence of ovulation, which can cause infertility.
- Oligomenorrhea (irregular menstrual cycles) can be a sign of irregular ovulation; although oligomenorrhea does not make pregnancy impossible, it can make it harder, delay the ability to time to conceive.
Hormone levels — Levels of luteinizing hormone (LH) rise abruptly about 36 hours before ovulation. This hormone surge can be detected using an over-the-counter urine test.
However, this kit fails to detect the hormone surge about 15 % of the time. Therefore, we may recommend a blood test to confirm ovulation, at a specific time in your time.
Blood levels of the hormone progesterone are a more accurate indicator of ovulation. Normally, levels of progesterone rise after ovulation. A test to measure the progesterone level is usually performed 18 to 24 days after the first day of a period.
Fallopian tube testing: HSG = Hysterosalpingogram
Hysterosalpingography ("HSG"): should be performed during days 5-10 or so in your menstrual cycle. The period between the cessation of menses and ovulation, to minimize the chance of interfering with a possible early pregnancy.
The HSG procedure: involves having a speculum placed in your vagina, a slim cannula is placed intracervically and radio-opaque medium is instilled slowly through the cervix under fluoroscopic guidance to observe the dye as it moves through your cervix, uterus and fallopian tubes.
In general, radiographs are taken in sequence: at the beginning of uterine cavity filling, when the cavity is filled, during tubal filling to evaluate the tubal mucosa, and later to document whether there is spillage of contrast into the peritoneal cavity. Fluoroscopy can detect small lesions or abnormalities that might be missed without real-time imaging.
To schedule an HSG: we do not do these at our offices as they require radiographic equipment. HSGs can be done locally at NWH Women’s Imaging Center, or Northeast Radiology. For appointment with NWH, call: 914.666.1371, for NERad, call 914.666.6692 to schedule during the first part of your cycle, days 6-10. To schedule at White Plains Hospital, call: 914.681.1260.
Because the procedure can cause uterine cramping, we advise you to take ibuprofen 600 mg one hour before procedure.
In addition to diagnostic information gained about your anatomy, HSG also has a therapeutic benefit for some patients: increased pregnancy rate after the procedure. This is believed to be due to opening the tubes up by the pushing of fluid through them for the test.
Tubal Disease. The major cause of tubal infertility is pelvic inflammatory disease. Other conditions, such as endometriosis or pelvic adhesions from an intraabdominal infection or surgery, may also interfere with egg pick-up by the fallopian tube.
Uterine Abnormalities. A wide variety of uterine abnormalities have been linked to infertility and miscarriage, including congenital uterine anomalies (eg. uterine septum), abnormalities associated with in utero exposure to DES (eg, a T-shaped uterus), fibroids (depending on location), polyps, and scarring from prior uterine procedures. These can be identified by HSG and hysteroscopy (intra-uterine “scope”) can be used to evaluate further and to surgically treat scarring, submucous fibroids, polyps, or a septum.
Testing: Laparoscopy (see our section on "Minimally Invasive Surgery") Testing: Semen Analysis
Semen analysis is performed to determine if there are any sperm abnormalities. The test provides an evaluation of the count, motility and structure of the sperm. Collection of the semen specimen should be done within one hour of dropping of the specimen at the lab. While no appointment is needed, it is important to confirm staff is present at drop-off, please call lab at 914.666.1690.
The NWH lab is open Monday through Friday and specimens are asked to be dropped off before 8:00 am. It is located on the 2 floor of Northern Westchester Hospital, 400 East Main Street, Mt Kisco. First, stop at registration, as you enter through ER entrance; make first right, it is immediately on your left, across from the security guard station. Follow sign on 2 floor for “Lab/Blood Bank”. Please remember to bring a copy of your referral or prescription with you.
Collection of the Sperm Specimen: "Semen Analysis"
Your partner is advised to abstain from ejaculation for 2 to 4 days prior to producing the semen specimen by masturbation. Although you may assist, avoid oral and vaginal stimulation. Also avoid soaps, detergents, creams, or lubricants to aid in specimen collection because these can negatively affect the results of the test.
Sterile Container
The specimen should be collected in a sterile container that can be obtained from one of the laboratory staff or nurses. If collecting at home, the sterile container must be obtained from us prior to collection. After careful cleaning of the genital area, the entire specimen should be collected in the sterile container. Complete the identification label provided and attach it to the specimen container.
Spillage
If there is any spillage, please note that on separate paper, and which portion (first or towards the end) was not collected. This is very important because it can affect the results of your analysis.
Keeping Specimen Body Temp En Route
The semen specimen must be delivered to the lab for evaluation within one hour of production. It is important that the specimen be kept as close to body temperature as possible. Therefore, we suggest transporting it close to the body, such as in inside pocket.
Results: Follow-up Appointment
Review of testing is done with you and your partner at your follow-up appointment scheduled with Dr. Malley or Dr. McGroary.
This follow-up appointment is usually 30 minutes and encompasses all the results, a list of possible diagnoses and options for the next step. It helps to have both partners present, but is understandable if only one can attend. We have Saturday and evening hours if this long consult will add stress to your workday.
We usually receive the results in 2-3 days after processing, and if you do not wish to wait for the next visit, feel free to call the office to get a verbal report from our nurse.
Abnormal Testing:
Please remember that the test may be abnormal, but almost everything can be overcome with the right help.
- Abnormal semen analysis result will typically be repeated. Your partner will be referred to a urologist for a consult and evaluation for possible therapy. There are many excellent urologists in Westchester; our favorite:
- Sheldon Axelrod, MD, 914.232.3135, world's favorite urologist, http://www.mkmg.com/index.cfm/fuseaction/site.physicians/action/dtl/phys/99803665.cfm with offices in Katonah & Carmel. Dr. Axelrod seamlessly balances the kindness of one's long-time physician with the skill and brilliance of yan amazing physician an surgeon. You and your partner should meet him early in the process for his exam, a semen analysis, and discussion of male treatment options if that is found to be a contributing factor. He will take the fear out of the process, I promise.
- Abnormalities diagnosed by HSG or laparoscopy prompt a referral to a specialist ininfertility, since insurance now covers many of these services, and their experience increases their success rate, see below. They are very experienced in either correcting surgically or circumventing blocked fallopian tubes or other organic variations in the uterus that affect your ability to conceive.
The process of trying to become pregnant and the difficulty doing so can lead to a variety of emotions, including anxiety, depression, anger, shame, and guilt.
In one study, 40% of infertility patients suffered with some type of psychiatric disorder; the most common diagnosis was an anxiety disorder (23 %), followed by major depressive disorder (17%.) Both men and women can suffer from these problems, which can further hinder a couple's ability to become pregnant.
Psychological distress is associated with infertility treatment failure and interventions to relieve stress are associated with increased pregnancy rates. The best approach for treatment of psychological distress related to infertility treatment has not been determined.
Relaxation techniques have been supported by most experts in the field, including: stress-management, coping skills training, and group support.
Consider world expert, Alice Domar, PhD’s, latest book: "Conquering Infertility: Dr. Alice Domar's Mind/Body Guide to Enhancing Fertility and Coping with Infertility."
She is on faculty at Harvard and has done much research into methods to improve results of fertility therapy by reducing stress during the process. (domarcenter.com:"grounded in science, inspired by compassion.")
Several studies have looked at the impact of acupuncture in men who had low sperm counts, and there appears to be improvement (and subsequent pregnancies) in many, but there have not yet been any controlled studies, so the evidence is not clear.
In women, studies have shown increased pregnancy rates in those who received acupuncture compared to women who lay quietly. However, it is not known if this effect is from the acupuncture or from a placebo effect.
We know that most people who receive acupuncture report feeling an increased sense of well-being, less anxiety, and less depression, and since there is an association with increased pregnancy rates, it is worth pursuing acupuncture treatment.
Restorative yoga
In addition, studies show that decreasing stress, may increase your chance for a successful pregnancy. For chronic pain/fatigue disorders such as fibromyalgia, restorative yoga can offer an experience of painless practice while substantially improving digestion and sleep. (from domarcenter.com)
Specialists in Reproductive Medicine & IVF:
(In Vitro Fertilization and more...)
These are well-respected fertility experts in the Westchester area that we know very well, have delivered many of each other's patients and their babies and enjoy working with, including:
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- Drew Tortoriello, MD and Nicole Browne, MD of Purchase, NY and NYC: 914.696.7476.
- Rachel Bennett, MD of Mt Kisco, NY: 914-218-8955
- Rony Elias, MD and Glenn Schattman, MD , of Mt Kisco, NY (NWH) and The NY Presbyterian Hospital - Cornell, NYC: 914.242.3700
- John Stangel, MD of Rye, NY: 914.967.6800
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"There is in every true woman's heart, a spark of heavenly fire, which lies dormant in the broad daylight of prosperity, but which kindles up and beams and blazes in the dark hour of adversity." ~ Washington Irving
