Lifestyle Choices & Fertility

Polycystic ovarian syndrome (PCOS) is an endocrine disorder that affects 10% of women in childbearing age. In PCOS, the ovaries produce excessive amounts of male hormones and develop many small cysts. PCOS is a common cause of infertility, menstrual irregularity and excessive hair growth.

How Does PCOS Cause Infertility?

PCOS is caused by hormonal imbalances that prevent ovulation. A woman with PCOS will not produce enough FSH (follicle stimulating hormone) to make the ovary mature and release eggs during a menstrual cycle. Instead, the ovary will make immature follicles that will develop into small cysts. Since no follicle becomes large enough and no egg matures or is released, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman’s menstrual cycle is irregular or absent, resulting in infertility.

At the same time, women with PCOS will produce too much LH (luteinizing hormone), which tells the body to produce too much estrogen and androgens (male hormones). High levels of estrogen can cause a thickening of the uterine lining which in turn leads to heavy and irregular periods. High levels of androgens can lead the body to develop acne and excessive hair growth and these male hormones also prevent ovulation.

What Are PCOS Symptoms?

Not all women with PCOS share the same symptoms. Some of the common symptoms include: infertility, infrequent or no menstrual periods, irregular bleeding, increased hair growth, acne, weight gain/obesity, diabetes, high cholesterol, high blood pressure, thinning hair and pelvic pain.

How is PCOS Diagnosed?

To diagnose PCOS, Advanced Fertility Care Physicians normally uses the following tests in addition to the presence of PCOS symptoms:

• Transvaginal Ultrasound – this is performed at the onset of a menstrual cycle (days 2 to 4) and gives the doctor the ability to evaluate the ovaries and see how many follicles are present and if they have a characteristic appearance of polycystic ovaries (many small cysts along the edge of the ovary in the “string of pearls” configuration). For a diagnosis of PCOS to be made, a woman MUST have polycystic appearing ovaries.
• Hormonal Blood Tests – to measure the levels and ratios of your key reproductive hormones.
• FSH (follicle stimulating hormone), LH (luteinizing hormone), E2 (estradiol) – normal ratios of FSH:LH are 2:1 and reversal of this ratio with higher levels of LH suggests PCOS.
• Androgens (testosterone and DHEAS) – male hormones are produced both by the ovaries and adrenal gland; excess amounts can be a contributor or result of PCOS like symptoms.
• 17 Hydroxyprogesterone – a hormone level that serves as a screening test for congenital adrenal hyperplasia, a condition of the adrenal gland that can have other more severe consequences on health as well as contributing to PCOS like symptoms. If abnormal, further testing and treatment would be required by a medical endocrinologist.
• Glucose and Insulin Testing – In most cases, patients who are suspected to have PCOS will be required to undergo a 2 hour glucose tolerance test with insulin levels in order to determine if there is a problem with insulin absorption in the body. Abnormal insulin metabolism can lead to ovulatory issues, weight gain, and potential pre-diabetic conditions.

How is PCOS Treated?

If you are trying to get pregnant and you have PCOS, Advanced Fertility Care Physicians have many options available for you. Treatment plans will be based on your specific findings and needs, the severity of your PCOS, and any other infertility issues that you may face.

Common treatments for PCOS include fertility medications to help induce ovulation. These medications can be either oral medications or injectable medications. For women with documented insulin insensitivity, insulin sensitizing medication such as metformin (Glucophage) may be prescribed as well in hopes of resulting in more regular ovulation. If obesity is part of the PCOS, losing weight will also likely improve your symptoms, spontaneous ovulation, and overall chances for pregnancy. Take a few minutes to read more about weight & fertility.

What Are The Causes of Tubal Disease?

• One main cause of tubal disease is scar tissue (adhesions), resulting from endometriosis, gynecological surgery, bowel surgery, Cesarean section, ruptured appendix or other internal trauma.
• Sexually Transmitted Diseases, which go undetected or untreated, such as chlamydia or gonorrhea, can damage the fallopian tubes irreparably.
• Tubal ligation (having your tubes tied to prevent pregnancy) and/or subsequent reversal of tubal ligation can also leave your fallopian tubes damaged.

How Does Tubal Disease Cause Infertility?

If the fallopian tubes have adhesions or scar tissue around them, it can block an egg and subsequent embryo from reaching the uterus, causing infertility. If the tubes are partially blocked by adhesions, sperm may meet the egg in the fallopian tube instead of in the uterus, and an ectopic pregnancy may occur.

How is Tubal Disease Diagnosed?

Advanced Fertility Care Physicians may be able to diagnose tubal disease through diagnostic testing:

• Sonohysterogram
• a procedure that uses ultrasound to detect masses in your uterus that may be blocking your fallopian tubes.
• HSG (Hysterosalpingogram)
• an X-ray procedure that uses a special contrast dye injected into your fallopian tubes to see if they are open or blocked.
• Diagnostic Laparoscopy
• a procedure in which a thin lighted telescope, called a laparoscope, is inserted into the abdominal cavity through a small incision in or near the belly button. Through the laparoscope, the doctor can visualize the area around the fallopian tubes and ovaries to visually confirm the presence and extent of any adhesions. During this same procedure, the doctor is frequently able to remove the scar tissue attached to other organs and may be able .

How is Tubal Disease Treated?

There may be a number of options for treating your tubal disease. Laparoscopic surgical removal of the scar tissue may be appropriate for some cases. However, in many cases, if the fallopian tubes are severely damaged, it is often safer and more successful to bypass the fallopian tubes and use in vitro fertilization (IVF) to achieve pregnancy.

Tubal Reversal or Reversing a Tubal Ligation

At Advanced Fertility Care, we speak to a lot of patients that have had their tubes tied and now want to get pregnant. While there are surgical options to reverse a tubal ligation, it can be more costly and risky to perform the surgery with lower chances of conceiving than using in-vitro fertilization (IVF) to achieve pregnancy.

Sperm production takes approximately 10-12 weeks to occur and once sperm mature, they leave the testes and enter the epididymis where they are stored and nourished for approximately 14 days. They then move into the vas deferens until ejaculation. At the time of ejaculation, they leave the vas deferens and combine with fluid from the seminal vesicles and prostate gland to create semen which is expelled from the penis.

During intercourse, normally millions of sperm are deposited into the vagina. As they make their way through the female reproductive tract (vagina / cervix / uterus / fallopian tubes) their numbers drop drastically until only a few hundred sperm get close to the egg; although several sperm try, only one sperm will, on occasion, successfully fertilize the egg within the fallopian tube. Sperm can survive in the female reproductive tract for 2 to 3 days and the time that the egg is within the fallopian tube ranges from 12 to 24 hours.

Just like in women, the main pituitary hormones that regulate the reproductive process are FSH (follicle stimulating hormone) which stimulates production of sperm in the testicles, and LH (luteinizing hormone) which stimulates the production of testosterone.

Factors Influencing Male Infertility

• Behavioral Factors: Nutrition, exercise, smoking, drug, and alcohol intake can influence overall health and fertility.
• Medications: Several medications, including those used to treat high blood pressure or ulcers, can influence a man’s sperm count and libido and should be discussed with the prescribing primary care physician. The use of testosterone injections or gels will cause severe effects on sperm production and should be discontinued when attempting to achieve pregnancy.
• Drugs: The use of cigarettes, marijuana, anabolic steroids, and cocaine may have profound effects on sperm counts. At times, in the case of steroids, this effect may be irreversible.

What Causes Male Factor Infertility?

Male factor infertility as the sole cause of infertility accounts for 40% of infertility cases. Causes of male infertility are somewhat limited. This diagnosis can be seen in men who are diagnosed with a varicocele, which is an enlarged vein within one or both of the testicles. However, in many cases, urologists may determine that it is of no clinical significance. Male infertility can also occur as a result of trauma or surgery to the testicles. In addition, scientific studies have also shown that in some cases of male infertility, there may be a significant genetic component which may be heritable. Men with an otherwise undiagnosed mutation in the cystic fibrosis gene may also suffer from congenital absence of a portion of the reproductive tract called the vas deferens. In some cases, known or unknown environmental exposures may contribute to decrease sperm counts or viability. Primary testicular failure can also be a cause of infertility, however, this is rare and diagnosed by checking blood hormone levels. Despite the above causes, a significant portion of male infertility remains unexplained.

How Is Male Factor Infertility Diagnosed?

Semen Analysis: this test is performed by one of our highly skilled andrologists who perform microscopic evaluation of the sperm and evaluate key parameters such as:

• Volume – The amount of semen produced in a single ejaculate
• Concentration – The number of sperm seen per milliliter of seminal fluid
• Motility – The percentage of sperm that are moving in the sample
• Progression – A measure of how well the moving sperm are moving
• Kruger Strict Morphology – This is the percentage of normally shaped sperm present; this impacts sperm’s ability to fertilize an egg on its own
• Presence of white blood cells and viscosity – Presence of white blood cells may indicate an infection or inflammatory process in the male reproductive tract. This usually requires referral to an urologist and possibly treatment with antibiotics for 30 days prior to repeat testing.

Since only highly trained andrologists can perform this test, we will ask that this test be performed within our Center. Crucial information obtained from the semen analysis for characteristics such as sperm count and shape helps us determine what technique to use to facilitate the sperm fertilizing the egg. These options include timed intercourse, intrauterine insemination, conventional IVF, or IVF with ICSI (intracytoplasmic sperm injection).

• Endocrine Blood Tests: For men who have abnormal semen analysis results, blood tests to measure hormones can uncover potential causes of infertility. The main hormones that usually are tested include FSH, LH, estrogen, prolactin, thyroid, and testosterone. These results along with the semen analysis and physical exam may aid the urologist and determine the cause of the abnormality.
• Infectious Screening: all males who seek care within our facility will undergo HIV, Hepatitis B, Hepatitis C, and Syphilis blood screening. Since these organisms may be passed through the semen, this is a requirement by the State of Arizona prior to using sperm for insemination or cryopreservation.
• Karyotype (Chromosome analysis): Usually recommended based on medical history or previous pregnancy attempts, this is a chromosome analysis which may identify potentially significant abnormalities which prevent fertilization and pregnancy. In addition, chromosome abnormalities may also be responsible for increased miscarriage rates. Subsequent treatment options may include Preimplantation Genetic Screening or Diagnosis with IVF or the use of donor sperm.
• Y Chromosome Deletion Testing: This test is ordered when sperm concentrations on semen analysis are below a threshold value. In some cases of very low sperm concentrations, structural abnormalities in a portion of the Y chromosome that controls development of sperm in the testicles lead to decreased natural pregnancy rate. Using the reproductive technique of ICSI along with IVF, fertilization can usually be achieved; however these abnormalities may be passed on to any male offspring.
• Sperm Chromatin Structure Assay (SCSA): This is a relatively new testing procedure which is implemented in cases of recurrent pregnancy loss and failed fertilization possibly related to male factor infertility. This test looks for defects in DNA fragmentation in the sperm. Studies have shown that significant abnormalities predict reduced probability for natural conception. Fortunately, Fertility Care’s procedures like IVF with ICSI compensate for these decreased statistics. However, even with these techniques, the scientific data to date suggests a pregnancy rate reduced by 66% and a doubling of the spontaneous pregnancy loss rate. Therefore, this test is reserved for certain of our patients suffering from recurrent pregnancy loss or unexpected and otherwise unexplained repeated unsuccessful IVF cycles.
• Cystic Fibrosis Genetic Screening: has been associated with congenital absence of the vas deferens (a key element of the male reproductive tract).
• Urologist Consultation: Men who have severe abnormalities in their semen analysis will be referred to a urologist for a complete physical evaluation to rule out the presence of testicular masses or anatomic abnormalities. The urologist may also recommend hormonal testing and subsequent treatments to improve sperm parameters. In certain circumstances, the urologist may work with Advanced Fertility Care Physicians to perform surgical procedures to access sperm from the male reproductive tract for the use in more fertility treatment.

How Is Male Factor Infertility Treated?

The good news for couples who have male factor infertility is that it is one of the most easily treatable conditions. In severe cases of male factor, treatment begins initially with a visit to a specially trained urologist who is used to assessing and treating male factor infertility. If anatomic issues are present, these may need to be addressed surgically by the urologist. In many cases, however, fertility treatments such as artificial insemination, also known as intrauterine insemination (IUI) may be all that is needed to overcome these minor issues. In slightly more severe cases of male factor, IVF with intracytoplasmic sperm injection (ICSI), in which the sperm are individually chosen and used to fertilize eggs harvested from the female is performed. Only in very specialized situations would more urological procedures such as percutaneous epididymal sperm aspiration (PESA), testicular sperm aspiration (TESA), testicular sperm extraction (TESE), or microsurgical epididymal sperm aspiration (MESA) be required.

Regardless of the treatment needed, the outcome with the appropriate fertility treatment is very positive.

Ovulatory disorders are the most common form of infertility in women. Affecting nearly 40% of women in child-bearing age, ovulatory disorders directly affect the ovaries’ ability to release the egg. Symptoms may include the absence of regular periods, called anovulation, or irregular menses due to a hormonal imbalance, severe stress, high endurance or excessive exercising, extreme weight (both over and under), thyroid dysfunction, insulin resistance and eating disorders.

An ovulation is a condition in which a woman’s eggs fail to develop properly, and/or are not released from the follicles of the ovaries. Women who have this disorder may not menstruate for several months. Others may menstruate, but not ovulate.

How is an Ovulatory Disorder Diagnosed?

To diagnose an ovulatory disorder, Advanced Fertility Care Physicians will start with a full evaluation of your medical and menstrual history. They will also use one or more of the following tests:

• Hormonal Blood Tests – to measure the levels of your key hormones, including FSH (follicle stimulating hormone), LH (luteinizing hormone), E2 (estradiol), and progesterone. Often time male hormone levels (androgens) will also be measured.
• Transvaginal Ultrasound – a scan that uses echoes from high frequency sound waves to see follicles and or cysts in your ovaries. The ultrasound can also be used to evaluate ovarian function.

What Are The Different Types of Ovulatory Disorders?

Ovulation is controlled by complex interactions between numerous endocrine hormones including FSH (follicle stimulating hormone), LH (luteinizing hormone), E2 (estradiol), progesterone and others. The pituitary gland sits at the base of the brain and it produces hormones that control the ovary, the thyroid gland and the adrenal gland. If ovulation is not occurring in a regular, timed fashion, it is likely that the pituitary and the ovary are not communicating correctly.

For women with normal thyroid, prolactin and adrenal hormones that have irregular ovulation may still be diagnosed with polycystic ovary syndrome (PCOS). Read more about polycystic ovary syndrome (PCOS).

A less common ovulatory disorder is hypothalamic amenorrhea. Hypothalamic amenorrhea can develop spontaneously, however, it usually develops when poor nutrition, excessive exercise, or stress alters your signaling to the brain to regulate the menstrual cycle. Read more about hypothalamic amenorrhea.

How are Ovulatory Disorders Treated?

If you are trying to get pregnant and you are having trouble ovulating, Advanced Fertility Care Physicians have many options available for you. Common treatments for ovulatory disorders include fertility medications to help induce ovulation. These medications can be either oral medications or injectable medications. Drs. Zoneraich and Larsen will need to monitor you carefully while you are taking these medications through ultrasound and blood work to see if and when you are ovulating.

What is Secondary Amenorrhea?

Secondary amenorrhea is when a woman who previously menstruated on a regular basis misses her periods for six months, or when a woman who previously experienced irregular periods skips her periods for 12 months. The most common form of secondary amenorrhea is hypothalamic amenorrhea, where the female body reverts to survival mode because it cannot sustain reproductive mode.

What is Hypothalamic Amenorrhea?

Hypothalamic amenorrhea develops when poor nutrition or stress alters your signaling to the brain to regulate the menstrual cycle. Women with this condition may be severely restricting their caloric intake, exercising more than two to three hours a day, or under major psychological stress. It is a common pattern seen in performance athletes and dancers as well as women with anorexia nervosa, with the common denominator of very low body fat levels and significantly low body mass index (BMI). In this situation your brain doesn’t get adequate energy or macronutrients to pulse the hormones that govern follicle ripening and release of eggs.

What are the Symptoms of Hypothalamic Amenorrhea?

The most common symptom of hypothalamic amenorrhea is missing a period, or extremely light bleeding during menstruation. Others include:

• Low libido
• Feeling cold often
• Depression and anxiety
• Difficulty sleeping
• Increased hunger
• Low energy

How Is Hypothalamic Amenorrhea Diagnosed?

To diagnose hypothalamic amenorrhea, Advanced Fertility Care Physicians first try to eliminate some of the basic possibilities of why your periods have stopped. During diagnostic testing, hey check to ensure that you are not pregnant or that you do not have a pituitary problem that’s causing menstruation to stop. They will typically order the following blood tests:

Hormonal Blood Tests

to measure the levels of your key hormones, including FSH (follicle stimulating hormone), LH (luteinizing hormone), E2 (estradiol), HCG (human chorionic gonadotropin) and prolactin. High levels of HCG indicate a pregnancy. Low levels of FSH, LH and E2 may indicate hypothalamic amenorrhea. High levels of prolactin suggest a tumor on the pituitary gland.

Progesterone Challenge

a test that will induce menstrual bleeding in women with some types of amenorrhea, but not in women who have hypothalamic amenorrhea. In general, these women do not have enough estrogen to thicken the uterine lining, and therefore will only bleed if given both estrogen and progesterone, as in the form of a birth control pill.

Can Hypothalamic Amenorrhea Be Treated?

Reversing hypothalamic amenorrhea is possible by examining your lifestyle for unusual stress factors, including extreme diet and exercise habits. These lifestyle changes can be done in conjunction with fertility medications to help you to start ovulating and menstruating again.

What Happens if Hypothalamic Amenorrhea Is Not Treated?

Can amenorrhea lead to infertility? Untreated, hypothalamic amenorrhea can lead to continued problems with infertility as well as osteoporosis and heart disease. If you feel that you have hypothalamic amenorrhea and do not wish to become pregnant, it is still important to seek out medical treatment for your condition.

A uterine fibroid, also known as a uterine leiomyoma or myoma, is a non-cancerous (benign) tumor that grows in or around the uterus. Uterine fibroids originate from the smooth muscle cells in the wall of the uterus and they are the most common benign tumors in females. It is estimated that 25% of all American women have fibroids, with African American women being 3 times more likely to have fibroids than Caucasian women.

Do Fibroids Affect Fertility?

According to the American Society for Reproductive Medicine, although fibroids are very common, they only cause about 3% of infertility. The fibroids that grow on the inside wall of the uterus can cause changes in the endometrial tissue, making it difficult for a fertilized egg to attach to the uterine wall. Fibroids that develop outside the uterus can interfere with pregnancy by pressing on or blocking the fallopian tubes, reducing the chance for the egg to travel down into the uterus.

How Are Fibroids Diagnosed?

Advanced Fertility Care Physicians use 4 different diagnostic procedures to determine the presence, location and size of fibroids. Each patient does not undergo all 4 procedures.

1. Ultrasound – a scan that uses echos from high frequency sound waves to create a picture of the pelvic organs
2. Sonohysterography (saline sonography) – sonographic evaluation of the uterine wall and inner uterine cavity performed while filling the uterus with a very small amount of sterile fluid.
3. Diagnostic Hysteroscopy – a procedure in which a narrow fiber-optic telescope (hysteroscope), is inserted into the uterine cavity to identify fibroids or other defects to endometrial lining
4. MRI (Magnetic Resonance Image) – procedure that produces a picture by absorbing energy from specific, high frequency radio waves which can determine the presence and location of fibroids

Can Fibroids Be Treated?

Not all fibroids need to be treated. However, if the doctor determines that you have fibroids and they are interfering with your fertility, there are a number of treatment options. In general, only fibroids which affect or distort the inner lining of the uterus (endometrium) need to be addressed. In most cases, this can be accomplished through a straight-forward outpatient surgery called an operative hysteroscopy in which a telescope is inserted into the uterus through the vagina and cervix and instruments are used to remove the fibroid. In some cases, the problem fibroid may be much larger and mostly contained in the muscle wall of the uterus in which case it needs to be removed through the outside surface of the uterus. In most cases, you will be referred to your Ob/Gyn to undergo an abdominal myomectomy or in special circumstances, laparoscopic (with or without the use of a robot) myomectomy. In some of these cases, your Ob/Gyn may also utilize GnRH medications (lupron) that temporarily reduces the size of your fibroids prior to surgical removal.

In either case, the good news is that fibroids rarely impose more than a temporary speed bump in your path to achieving pregnancy.

Endometriosis is a condition in which tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body. Endometriosis is one of the most common causes of pelvic pain and infertility in women.

Endometriosis lesions can be found anywhere in the body, but are most commonly found in the pelvic cavity: on the ovaries, the fallopian tubes, and on the pelvic sidewall. Other common sites include the uterosacral ligaments, the cul-de-sac, the Pouch of Douglas, and in the rectal-vaginal septum.

The endometrial tissue outside your uterus responds to your menstrual cycle hormones in the same way that your endometrial tissue inside your uterus responds. The tissue swells and thickens and then sheds to mark the beginning of your next cycle. However, blood from endometrial tissue in your pelvic cavity has no place to go. As the blood pools, inflammation occurs and scar tissue is formed. In addition, chemicals released from these tissue implants can be toxic to the eggs that are released from the ovaries prior to entering the fallopian tubes. Furthermore, scar tissue in your pelvic area can block the fallopian tubes from allowing eggs to enter and fertilization to occur.

Does Endometriosis Affect Fertility?

Endometriosis is a common finding in women struggling with infertility. In some cases, it is a known cause with scar tissue blocking the fallopian tubes, but researchers are investigating other links between endometriosis and infertility. Women with endometriosis have been shown to have eggs of poor quality, a lower fertilization rate and a lower implantation rate as compared to women who do not have endometriosis.

How is Endometriosis Diagnosed?

Symptoms of endometriosis can include painful menstrual cramps, abnormal menstrual bleeding, pain during intercourse and infertility. Some patients with endometriosis have no symptoms. Interestingly, the severity of symptoms a woman may exhibit has no relation to how extensive or severe the endometriosis is. In many cases moderate to very severe endometriosis (Stage III-IV) may be incidentally diagnosed at time of laparoscopic surgery on a woman who complains of no pain with periods or intercourse. Likewise, a woman who has excruciating pain and undergoes laparoscopic investigation may be found to have no endometriosis or only a mild case (Stage I-II).

To diagnose endometriosis, Advanced Fertility Care Physicians, or in most cases your Ob/Gyn, would perform a surgical procedure called a laparoscopy. During a laparoscopy, a thin lighted telescope, called a laparoscope, is inserted into the abdominal cavity through a small incision in or near the belly button. Through the laparoscope, the doctor can see the surface of the uterus, fallopian tubes, ovaries and other pelvic organs to visually confirm the presence and extent of endometriosis. During this same procedure, the doctor is frequently able to remove the scar tissue and endometrial tissue attached to other organs.

Treatment of Endometriosis & Fertility

How endometriosis is treated depends on the severity or stage that has been diagnosed. At one time, fertility experts believed that all endometriosis should be addressed surgically prior to undergoing any treatment. However, over the last several years, an overwhelming amount of research has shown that this is sometimes not the best approach. This section will deal only with those women desiring fertility since the treatment of endometriosis from a purely symptomatic perspective would be different.

For younger patients who have a family history of documented endometriosis, symptoms, and long standing infertility, and absence of any other female or male contributing factors to infertility, a diagnostic evaluation for endometriosis may be warranted. While a surgical laparoscopy to diagnose endometriosis is an outpatient procedure that can usually be performed in under two hours, it is not without its risks. Therefore, you should discuss this option in detail with either your Ob/Gyn or  Dr. Zoneraich, Dr. Larsen or Dr. Troché prior to proceeding. In general, for those women with diagnosed and treated mild endometriosis (stage I-II), initial treatment with superovulation (i.e. clomid) or ovulation induction (i.e. gonadotropins) is recommended.

However, for those patients with documented moderate to severe endometriosis (stage III-IV) with or without the presence of endometriosis (ovarian cysts filled with old blood or endometrial tissue), the most successful treatment has been shown to be in-vitro fertilization (IVF). The current thought is that any surgical intervention that involves the ovary may have a detrimental effect on the ovaries’ blood supply and future stimulation ability. Therefore, undergoing IVF would allow Dr. Zoneraich, Dr. Larsen or Dr. Troché to stimulate the growth of the immature eggs in the ovary and surgically remove these eggs without exposing them to the potential toxic effects of the endometriosis in the pelvis, in the ovaries, or on the surface of the ovaries. Fortunately, this relatively newer approach to treating endometriosis has been shown to greatly improve the overall pregnancy success rates for patients with this diagnosis.

While endometriosis can be a daunting diagnosis, the good news is that advances in fertility treatment have made overcoming this obstacle a likely reality.

A woman’s weight can affect her fertility. There is evidence that the amount of fat stored in a woman’s body can be correlated with the production and distribution of estrogen. Women who are overweight, obese, or even too thin may experience irregular or infrequent menstrual cycles. Anovulation can occur.

To find out if your weight may be a cause of your infertility, we recommend using the Body Mass Index (BMI). A BMI is a statistical measurement which compares a person’s weight and height. Though it does not actually measure the percentage of body fat, it is a useful tool to estimate a healthy body weight based on how tall a person is.

BMI Guidelines:

• A BMI of 19-25 is considered normal or healthy
• A BMI < 19 is considered underweight
• A BMI 26-29 is considered overweight, but not obese
• A BMI over 30 is considered obese

BMI = weight (in kilos) divided by height (in meters) squared

• To convert from pounds to kilos, take pounds divided by 2.2
• To convert from inches to meters, take inches times 0.0254

To calculate your BMI, visit the National Institute of Health at: http://www.nhlbisupport.com/bmi/

To view a BMI Index Table, visit https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_tbl.pdf

Why weight Matters?

While many physicians and health care providers find it difficult to talk to their patients about infertility and weight issues, it is important to understand that obesity does play a significant role in fertility success. While the general consensus is that a BMI >30 has a significantly negative effect on fertility treatment success rates, some studies have shown a 50% decrease in clinical and ongoing pregnancy rates in women undergoing in-vitro fertilization (IVF) with BMI>25 when compared to those with BMI≤25. A high BMI can cause decreased efficacy of fertility medications, safety concerns and increased complication risk during surgical procedures such as egg retrieval, and serious complications during pregnancy and delivery.

At Advanced Fertility Care, our patients’ health and well-being is our first concern, therefore, prior to undergoing any assisted reproductive procedure (IVF or donor egg IVF) we will insist that our patients achieve a BMI≤32 in order to maximize your chance of success and minimize any health risks.

If you have a high BMI and are struggling with infertility, we strongly encourage you to enter a weight loss program. Weight loss of 5% to 10% may dramatically improve ovulation and pregnancy rates. Weight loss of even 15 pounds has been shown to restore ovulation in women who are anovulatory and overweight.

This is reflected in the decreased ability to become pregnant and the increased rate of miscarriage with age. While we know that infertility increases with age, the precise age when a woman can no longer conceive varies among individuals. However, it is well documented that 30% of couples in which the female partner is age 35 or older will have problems with fertility.

Women are born with their entire supply of eggs. The rest of her life is spent losing the eggs she was born with. A typical woman will have about 3 to 4 million eggs at birth, declining to roughly 500,000 to 700,000 at the start of puberty. Each menstrual cycle will then release a batch of eggs until they are all gone – a time called menopause. This loss occurs monthly regardless of whether a woman is pregnant or is taking hormonal contraceptives such as birth control pills. As a result, experts have shown that female fertility begins to decline many years prior to the onset of menopause despite continued regular ovulatory cycles. As a woman ages, not only does a woman have less eggs, the eggs also have a higher chance of being chromosomally abnormal. Many scientists have shown that by age 40, at least 50% of the remaining eggs in a woman’s ovaries are chromosomally abnormal. Most chromosomally abnormal eggs will never fertilize or implant. When a pregnancy does occur with a chromosomally abnormal egg, the baby could have Down’s syndrome or another chromosomal disorder, and usually results in miscarriage.

Fertility is usually measured by the percentage chance a woman has to get pregnant each month. In women less than 35 years old there is a 20% chance of getting pregnant each month. By the age of 40, this percentage has dropped to only 5%. This is critical information for couples who eventually want to have children, but have delayed childbearing for their careers, economic reasons and the misconception that fertility doesn’t diminish with age. Delaying pregnancy may eventually reduce the chance that the couple will ever successfully conceive and deliver a healthy baby.

Testing For Age Related Infertility

There are several tests that help to predict fertility potential (ovarian reserve) and determine age related infertility in women:

• FSH (Follicle Stimulating Hormone) Blood Test: If you have a high level of FSH (>10 mIU/mL) in your blood at the beginning of your cycle (days 2-4), this may mean that your infertility is age related or you are experiencing premature ovarian dysfunction. In general, women with elevations of FSH have reduced chances of live birth with either ovulation induction or IVF compared to other women of the same age. Many studies have shown that even a single elevated early FSH may indicate a poor prognosis, even when values in subsequent cycles are normal.
• Estradiol Blood Test: If you have a high level of estradiol (>80 pg/mL) in your blood at the beginning of your cycle (days 2-4), this may mean that you are experiencing accelerated follicular development and may be associated with reproductive aging.
• Clomid (Clomiphene Citrate) Challenge Test: The Clomid Challenge Test (CCCT) is a sensitive means to measure ovarian reserve. The test involves an FSH and Estrogen blood test at the beginning of your cycle (days 2-4), followed by taking clomid 100 mg on Days 5-9, with another FSH and Estrogen blood test on Day 10. A high FSH level at the end of the CCCT may indicate age related infertility, and also predicts poor response to the fertility medications used during treatment. In general, an abnormal CCCT predicts that a successful pregnancy will be achieved only about 5% of the time.
• Anti-Mullerian Hormone (AMH): A blood hormone level which may be drawn at any time of month. While still considered investigational, fertility centers around the world are using this test as a marker of declining number of remaining eggs in a woman’s ovaries, and abnormalities may be a reason for concern and a heightened level of aggressiveness with fertility treatment, even prior to seeing elevations in FSH levels.
• Antral Follicle Count: This is the visual measurement performed by transvaginal ultrasound early in the menstrual cycle (days 2-4) which determines how many immature eggs are available per month and reflects the underlying egg supply and future response to ovarian stimulation. This number declines with age. This is also a reflection of the number of eggs that you and your fertility specialist have to work with on any given monthly cycle.

Age is a significant factor in determining how aggressive and how quickly AFC Physicians will start treatment. If you are near or over the age of 40, it is important to schedule your initial consultation as soon as possible to learn about the options that are available to you.