Questions about Infertility
- What is infertility?
- What causes infertility?
- How is infertility diagnosed?
- How is infertility treated?
- What is in vitro fertilization?
- Is in vitro fertilization expensive?
- Does in vitro fertilization work?
- Do insurance plans cover infertility treatment?
Questions about Reproductive or Menopausal Issues
- What is a reproductive endocrinologist?
- What tests should I ask my doctor for if I think I am going through early menopause?
- What about getting an ultrasound of my ovaries?
- I am still getting periods, but I have a lot of symptoms like hot flashes and night sweats. Is this normal?
- How long will my symptoms last?
- Does going through menopause early mean I am aging more quickly?
Questions about Endometriosis
- What is endometriosis?
- What causes endometriosis?
- Does endometriosis cause infertility?
- Will any medical or surgical treatment cure endometriosis?
- I have been diagnosed as having endometriosis. Do I have a greater chance of developing ovarian cancer?
- I have been diagnosed as having advanced endometriosis. Will I need hysterectomy?
- I am 32 years old and have been trying to conceive for two years. I have been diagnosed as having advanced endometriosis. I have never been pregnant, and my partner's sperm count is excellent. Should I be optimistic that I will conceive?
- I have advanced pelvic endometriosis and severe pelvic pain. What chance do I have of pain relief after resection of endometriosis?
- What about holistic treatments?
Questions about PCOS
- How common is polycystic ovary syndrome (PCOS)?
- What are the symptoms of PCOS?
- Are there other names for PCOS?
- What causes PCOS?
- Is there a cure for PCOS?
- Why do some people call it polycystic ovarian disease and others call it polycystic ovarian syndrome?
- How do you make the diagnosis of polycystic ovarian syndrome?
- People have told me that PCOS is only a problem to worry about when I want to get pregnant. Is this true?
- I have heard about a medication called Glucophage®. How does it work, and is it safe?
- My doctor told me I have to take birth control pills to have a period. Why do I have to have a period?
- I have noticed a discoloration around my neck. Is this anything to be concerned about?
- I have been told I have PCOS. Will I be able to get pregnant?
- I think I have PCOS. What kind of doctor should I see to confirm that I have PCOS and to get the correct treatment?
- Is PCOS related to diabetes?
What is infertility?
Infertility is a disease of the reproductive system that impairs one of the body's most basic functions - the conception of children. Conception is a complicated process that depends upon many factors, including the production of healthy sperm by the man and healthy eggs by the woman, unblocked fallopian tubes that allow the sperm to reach the egg, the sperm's ability to fertilize the egg, the ability of the fertilized egg (embryo) to become implanted in the woman's uterus and sufficient embryo quality. Finally, for the pregnancy to continue to full term, the embryo must be healthy, and the woman's hormonal environment adequate for its development. When just one of these factors is impaired, infertility can result.
What causes infertility?
No one can be blamed for infertility any more than anyone is to blame for diabetes or leukemia. In rough terms, about one-third of infertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners or (in about 20 percent of cases) is unexplained.
The most common male infertility factors include azoospermia (no sperm cells are produced) and oligospermia (few sperm cells are produced). Sometimes, sperm cells are malformed or they die before they can reach the egg. In rare cases, infertility in men is caused by a genetic disease, such as cystic fibrosis or a chromosomal abnormality. The most common female infertility factor is an ovulation disorder. Other causes of female infertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). Congenital anomalies (birth defects) involving the structure of the uterus and uterine fibroids are associated with repeated miscarriages.
How is infertility diagnosed?
Couples are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. A patient over the age of 35 is encouraged to seek medical help after six months of unprotected intercourse. The doctor will conduct a physical examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility. Usually both partners are interviewed about their sexual habits in order to determine whether intercourse is taking place properly for conception. If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of body temperature and ovulation, X-ray of the fallopian tubes and uterus, and laparoscopy. For men, initial tests focus on semen analysis.
How is infertility treated?
Most infertility cases are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs.
What is in vitro fertilization?
Infertile couples in which women have blocked or absent fallopian tubes or in which men have low sperm counts, in vitro fertilization (IVF) offers a chance at parenthood to couples who until recently would have had no hope of having a biologically related child. In IVF, eggs are surgically removed from the ovary and mixed with sperm outside the body in a petri dish (in vitro is Latin for "in glass"). After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into cells. These fertilized eggs (embryos) are then placed in the women's uterus, thus bypassing the fallopian tubes. IVF has received a great deal of media attention since it was first introduced in 1978, but it actually accounts for less than five percent of all infertility treatments in the United States.
Is in vitro fertilization expensive?
The average cost of an IVF cycle in the United States is $12,400. Like other extremely delicate medical procedures, IVF involves highly trained professionals with sophisticated laboratories and equipment, and the cycle may need to be repeated to be successful. While IVF and other assisted reproductive technologies are not inexpensive, they account for only three hundredths of one percent (0.03%) of U.S. healthcare costs.
Does in vitro fertilization work?
Yes. IVF was introduced in the United States in 1981. Since 1985, when we began counting, through the end of 2006, almost 500,000 babies have been born in the United States as a result of reported Assisted Reproductive Technology procedures (IVF, GIFT, ZIFT, and combination procedures). IVF currently accounts for more than 99% of ART procedures with GIFT, ZIFT and combination procedures making up the remainder. The average live delivery rate for IVF in 2005 was 40.6 percent per retrieval for women 35 years old or younger -- a little better than the 20 per cent chance in any given month that a reproductively healthy couple has of achieving a pregnancy and carrying it to term.
Do insurance plans cover infertility treatment?
The degree of services covered depends on where you live and the type of insurance plan you have. Fourteen states currently have laws that require insurers to either cover or offer to cover some form of infertility diagnosis and treatment. Those states are Arkansas, California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia. HOWEVER, the laws vary greatly in their scope of what is and is not required to be covered. For more information about the specific laws for each of those states, please call your state's Insurance Commissioner's office or to learn about pending insurance legislation in your state, please contact your State Representatives.
Whether or not you live in a state with an infertility insurance law, you may want to consult with your employer's director of human resources to determine the exact coverage your plan provides. Another good source of assistance is RESOLVE, an infertility patient advocacy and information organization.
Whether or not you live in a state with an infertility insurance law, you may want to consult with your employer's director of human resources to determine the exact coverage your plan provides. If that is not an option, an excellent resource for determining coverage is the booklet Infertility Insurance Advisor: An Insurance Counseling Program for Infertile Couples. This booklet is available for a small fee from RESOLVE, an infertility patient advocacy and information organization.
What is a reproductive endocrinologist?
A reproductive endocrinologist is a doctor who specializes in infertility and hormonal disorders. Many women with premature ovarian failure prefer seeing these doctors because they are specialists who are particularly helpful for patients hoping to pursue a pregnancy.
What tests should I ask my doctor for if I think I am going through early menopause?
The key test to determine whether or not you are in menopause is a FSH test, which measures the blood levels of your follicle-stimulating hormone (FSH). Your FSH levels rise when your ovaries stop producing enough estrogen, so high FSH levels can signal that your body is entering menopause. The best time to get an FSH test for the most accurate reading is on the third day of your menstrual cycle, if you are still getting periods. Another test you might want to consider is a blood test of your estradiol levels. Estradiol is a form of estrogen in your body, and the levels of it drop when your ovaries start to fail. Low estradiol levels, therefore, may indicate that you are entering an early menopause. A thyroid test may also be a wise option. Many of the symptoms of premature and early menopause are the same as those for thyroid disease, so it's a good idea to determine whether your symptoms are due to thyroid problems or menopause.
What about getting an ultrasound of my ovaries?
In some cases, your doctor may perform high-resolution ovarian ultrasound to view your ovaries. This procedure determines whether you still have eggs and follicles, but this information does not help that much. The problem is that even when eggs are detected, attempts to stimulate ovulation through hormones have been relatively unsuccessful. However, ultrasound may make sense if you are in the early stages of premature menopause and are intending to pursue an aggressive fertility program.
I am still getting periods, but I have a lot of symptoms like hot flashes and night sweats. Is this normal?
Yes, it is. Even though the technical definition of menopause is not having your period for at least six months to a year, it is not uncommon for young women going through early menopause or premature ovarian failure to get periods fairly regularly. Hormones often fluctuate erratically at the beginning stages of early or premature menopause, so you may be producing enough estrogen to get periods even while your FSH levels are high. Many times, your cycles will be "anovulatory" (in other words, you are not producing an egg), but you are producing enough estrogen to build up your uterine lining.
How long will my symptoms last?
Some women get symptoms for only a short time, while others get intense symptoms for years. Most women get symptoms for a few years, and then they fade out. The real key to making your symptoms go away now is by either going on hormone replacement therapy (HRT) or by using alternative treatments, like phytoestrogens, herbs and vitamins.
Does going through menopause early mean I am aging more quickly?
No. Going through menopause years before you expected does not mean you are suddenly older. It does mean that your ovaries are not functioning the same way as those of most women in their 20s and 30s. Early or premature menopause does not mean that you have a shorter life span or that you have fast-forwarded to the body of an older woman. Yes, there are certain health risks that you now face, like the threat of osteoporosis. You might also notice your skin getting drier or a change in your body shape, but if you go on HRT, you can minimize those risks, reverse those symptoms and feel like yourself again!
What is endometriosis?
The endometrium is the tissue that lines the uterus. Endometriosis is the presence of endometrial tissue in places where it is not normally found. Common sites of involvement are the ovaries, space behind the uterus (cul-de-sac, rectum, uterosacral ligaments) and urinary bladder. Endometriosis is usually confined to the pelvis.
What causes endometriosis?
Research has shown that many women with endometriosis appear to have a defect in their immune system. Other causative factors may be: spillage of menstrual blood into the pelvis through open fallopian tubes; movement of endometrial cells throughout the pelvis (and even outside of the pelvis) through blood and lymphatic systems; and the ability of certain cells to change into endometrial cells, hence endometriosis.
Does endometriosis cause infertility?
Endometriosis has been identified as a major cause of infertility. However, having endometriosis does not mean that a woman will have trouble conceiving. Some women with endometriosis conceive without trouble.
Will any medical or surgical treatment cure endometriosis?
There is no known cure for endometriosis. Hormonal and other medical treatments can be useful in most situations, such as controlling pain, but as with surgical therapies, it does not eradicate the disease. In general, endometriosis is managed most effectively with a combination of properly performed surgery and the use of appropriate medical therapies.
I have been diagnosed as having endometriosis. Do I have a greater chance of developing ovarian cancer?
No. Endometriosis is not thought to be associated with increased risk of ovarian cancer.
I have been diagnosed as having advanced endometriosis. Will I need hysterectomy?
Usually not. A maximal surgical effort in conjunction with medical and other treatments will often prevent the need for hysterectomy. Whereas the disease may not be curable, it is usually controllable.
I am 32 years old and have been trying to conceive for two years. I have been diagnosed as having advanced endometriosis. I have never been pregnant, and my partner's sperm count is excellent. Should I be optimistic that I will conceive?
Absolutely! Studies have shown that properly performed surgery can improve the chance of pregnancy in women with endometriosis. You should seek the medical support of a reproductive endocrinologist so that you can benefit from having a specialist treat your endometriosis and your fertility concerns.
I have advanced pelvic endometriosis and severe pelvic pain. What chance do I have of pain relief after resection of endometriosis?
Approximately 50% of patients experience major pain relief, a further 30% have adequate improvement and the final 20% are not improved. Often the latter group has additional problems.
What about holistic treatments?
Diet, massage therapy, acupuncture and other holistic approaches have been used in endometriosis patients with varying degrees of success.
How common is polycystic ovary syndrome (PCOS)?
Polycystic ovary syndrome affects approximately five percent of women of childbearing age, and it is a leading cause of infertility. Many more women may exhibit one or more characteristics of the syndrome.
What are the symptoms of PCOS?
Women with PCOS may have some of the following symptoms:
- Abnormal lipid levels
- Acne/oily skin/seborrhea
- Baldness or thinning hair
- Chronic pelvic pain
- Cystic ovaries
- Enlarged ovaries
- Excess body hair
- High blood pressure
- Increased levels of male hormones
- Infrequent or absent ovulation
- Insulin resistance, overproduction of insulin and diabetes
- No menstrual period, infrequent menses and/or irregular bleeding
- Obesity or weight gain
Are there other names for PCOS?
This syndrome is also known as Stein-Leventhal Syndrome, hyperandrogenic chronic anovulation, functional ovarian hyperandrogenism and polycystic ovary disease.
What causes PCOS?
The exact cause of PCOS is unknown. Some studies are looking at the possibility of a genetic link. Just as one might have a genetic predisposition to diabetes, one might also have a disposition to PCOS.
Is there a cure for PCOS?
No. PCOS is a condition that can be managed, but currently no cure exists. Treatment of the symptoms can help reduce risks of future health problems.
Why do some people call it polycystic ovarian disease and others call it polycystic ovarian syndrome?
The terms polycystic ovary syndrome (PCOS) and polycystic ovarian disease (PCOD) are commonly used interchangeably. We prefer to use the term polycystic ovary syndrome because it more accurately reflects the complex signs, symptoms and nature of this condition, namely that of a syndrome. Syndrome is the favored term because it alludes to the varied signs and symptoms but does not imply a precise cause of the condition, as for PCOS the exact cause has yet to be determined. This definition is in contrast to that of a disease, which commonly implies a specific cause for the condition. An old term for PCOS that is not used currently is the Stein-Leventhal syndrome.
How do you make the diagnosis of polycystic ovarian syndrome?
In order for your doctor to make the diagnosis of PCOS he/she will have to obtain a detailed medical and gynecological history. In addition, your physician will need to perform a physical examination, which will include blood testing and in some cases an ultrasound. The current criteria for the diagnosis of PCOS include the following three items:
- Irregular or absent periods
- Signs of excess androgens (male hormones) in the form of excess hair growth or blood tests that show elevated levels of androgen
- Lack of any other conditions that would explain the above two conditions, such as problems with the pituitary, thyroid or adrenal glands
Through the history, physical exam and blood testing your physician will have enough information to diagnose PCOS or determine another cause for your symptoms.
People have told me that PCOS is only a problem to worry about when I want to get pregnant. Is this true?
No, this could not be further from the truth. Although it is true that PCOS can cause difficulty getting pregnant, its' effects go far beyond fertility. A few good examples of these far reaching effects include hirsutism (hair growth), insulin resistance, heart disease risk factors and even uterine cancer. This list is far from complete, but we can review these few examples here in order to give you some idea of the importance of seeking treatment for PCOS long before you desire pregnancy.
Hirsutism is the excess growth of coarse dark hair in a predominantly male pattern. Women affected by PCOS commonly experience hirsutism due to increased levels of the male hormones called androgens. The longer a women with PCOS goes untreated the more severe her hirsutism will become.
Insulin resistance is a condition common to PCOS in which the tissues of the body become less responsive to the hormone insulin. If left untreated, the body may become so unresponsive to insulin as to develop a type of diabetes. If diagnosed appropriately, there are treatments available that can prevent the progression to diabetes.
Heart disease risk factors are more common in women with PCOS. Women affected by PCOS are frequently overweight, have increased levels of androgens and may have insulin resistance, elevated cholesterol and high blood pressure. With proper attention these risk factors can be treated, but if left untreated they can increase the woman's risk of heart disease.
One final example of the far-reaching effects of PCOS, beyond that of fertility, is the rare complication of uterine cancer. Women with PCOS can often go great lengths of time without a menstrual period. When this occurs the inside lining of their uterus, called the endometrium, is exposed to the hormone estrogen for long periods of time without a break. This can lead to a condition of disorganized cell growth within the endometrium. If left untreated this disorganized cell growth can develop into cancer of the uterus. With appropriate medical treatment this can be prevented in almost all cases. Having said this, it is very important that we stress that it is not the period itself that prevents endometrial cancer. Rather, it is exposure of the uterine lining to the hormone progesterone, which is commonly lacking in women with PCOS. Appropriate treatment to prevent uterine cancer will include a progesterone-like medication.
I have heard about a medication called Glucophage®. How does it work, and is it safe?
Glucophage®, the brand name for metformin, is a medication that is designed to treat people with type 2 diabetes. Metformin works in two ways. Firstly, it decreases glucose (sugar) production in the liver, and secondly, it increases the sensitivity of body tissues to the hormone insulin. Thus, the body is able to maintain a more normal sugar level with lower insulin levels. For the woman with PCOS who also has insulin resistance, metformin can help maintain a lower blood sugar level with less insulin. By reducing the insulin level required to maintain blood sugar levels, there is less insulin available to induce the negative effects of elevated insulin levels. This has been shown to translate into weight loss, lower androgen levels, and even increased ovulation in some women.
Metformin is generally a safe medication, although some side effects may occur. The majorities of these side effects are minor and improve with continued use of the medication. The most common side effects are nausea, diarrhea, and stomach upset. This can be improved by taking metformin with meals. Metformin has been associated with one very rare and possibly serious side effect called lactic acidosis. This condition occurs most commonly in people with kidney problems and has been seen in approximately one in 33,000 people. If you know you have kidney or liver problems, make sure your doctor is aware of this before you begin taking metformin.
Metformin has been taken in pregnancy without an increased risk to the fetus, although long-term information is not yet available. If you should become pregnant while taking metformin, stop the medication and see your physician. However, available data would suggest that using the medication in early pregnancy should not be expected to cause problems for the baby.
My doctor told me I have to take birth control pills to have a period. Why do I have to have a period?
Women with PCOS are commonly bothered by very irregular menstrual periods. Often women report they would rather have regular and predictable cycles rather than the random episodes of heavy bleeding they are experiencing. On the other hand, we frequently hear women say they prefer not having a period every month, and would rather not be bothered by regular cyclic bleeding. Whatever your preference, this is a personal choice for each woman to make, and your physician can help you obtain your goals.
What is more important than the actual act of bleeding is the abnormal hormone levels that lead to irregular periods in women with PCOS. Women affected by PCOS do not ovulate on a regular basis. As a result, the inside lining of the uterus - called the endometrium - is exposed to the hormone estrogen for great lengths of time without being exposed to the hormone progesterone. It is the cyclic rise and fall in both estrogen and progesterone that cause menstrual bleeding. In the case of PCOS, there can be prolonged lengths of time without the production of progesterone. During this time the endometrium is continuously exposed to estrogen. The result of this prolonged estrogen exposure is the buildup of the endometrium. When the endometrium becomes too thick, heavy and irregular bleeding can occur. Also when the endometrium is exposed to estrogen for prolonged periods of time, cell changes can occur in which the cells of the endometrium become abnormal and, if not treated appropriately, can develop into cancer of the uterus. Progesterone prevents the build-up of the endometrium.
Thus, in order to protect the endometrium from the effects of prolonged estrogen exposure we need to provide progesterone in some way. For most women, this is easily done using the oral contraceptive birth control pill. The pill, when used in this way, can provide several benefits at the same time. First, the pill contains a progesterone-like compound that will protect the endometrium from the cell changes mentioned earlier. Second, the pill will provide women with a regular and predictable menstrual cycle. Third, for women who do not want to become pregnant, the pill provides reliable contraception.
Although the oral contraceptive pill is the most commonly used medication for the reasons mentioned, it is important to understand that it may not be for everyone. Some women can not tolerate the pill and for these women taking a progesterone-like medication for approximately two weeks each month can protect the endometrium. This will produce a regular and predictable menses. However, it will not provide contraception. For the woman who does not want to experience regular cycles, but needs to have her endometrium protected from the continuous estrogen, there are ways to provide the needed progesterone without causing a monthly period. Obviously, for women who desire pregnancy the oral contraceptive pills are not ideal. For these women, medications are available to induce ovulation. With ovulation there is production of the progesterone that is needed to protect the endometrium.
In conclusion, it is not necessary to actually have a period. However, it is necessary for women with PCOS to receive some type of hormone therapy to provide progesterone in order to protect their endometrium. The oral contraceptive pill is the most common means of providing this hormone replacement, however, it is not the only option. Your doctor will be able to provide you with the medication that best fits your personal goals.
I have noticed a discoloration around my neck. Is this anything to be concerned about?
This discoloration my represent a condition called acanthosis. Acanthosis nigricans is a condition in which the skin at specific sites - most commonly the neck, groin region, under the breasts and arms - becomes darker in color and is often said to appear velvety. Acanthosis is an outwardly visible sign of insulin resistance with elevated levels of insulin. The level of insulin resistance determines the severity of acanthosis. Acanthosis can occur in any race. Although acanthosis is a good marker for insulin resistance, not all women with acanthosis will be found to have insulin resistance. The exact mechanism by which insulin resistance causes acanthosis is not known.
I have been told I have PCOS. Will I be able to get pregnant?
Women with PCOS generally have irregular, infrequent, or even absent ovulation. Without ovulation there is no egg or ovum that is available for fertilization. Also, due to the abnormal hormone levels, the endometrium, or inside lining of the uterus, does not develop normally in women with PCOS. Therefore, even if a rare ovulation was to occur and the egg was fertilized, the endometrium may not be properly developed to allow for the attachment and growth of the embryo. This may explain the increased risk of miscarriage in women with PCOS.
Can this problem with ovulation be fixed? The answer is yes. Your doctor can provide you with medications that can help you ovulate, in a process called ovulation induction. Common ovulation induction agents include clomiphene citrate (brand names include Serophene®, Clomid®) and human menotropins or gonadotropins (brand names include Pergonal®, Humegon®, Repronex®, Follistim®, Gonal-F®). Insulin sensitizers can also be used to improve ovulation.
If ovulation induction alone is not successful in producing a normal pregnancy, then the use of the assisted reproductive technologies (ART), such as in vitro fertilization, can be attempted.
In conclusion, a diagnosis of PCOS suggests that you are likely to have some difficulty becoming pregnant. However, with help from you doctor, pregnancy should be an option for almost everyone with PCOS.
I think I have PCOS. What kind of doctor should I see to confirm that I have PCOS and to get the correct treatment?
There is no specific title that guarantees that a doctor is knowledgeable in the diagnosis and treatment of hirsutism and PCOS. Overall, there are less than 50 individuals in United States, and another similar number abroad, that are very knowledgeable about these disorders, both through their research and extensive experience. However, many board-certified reproductive endocrinologists are familiar with these disorders, and these physicians may serve as your first line of consultation. In addition, some board-certified medical and pediatric endocrinologists, and on occasion general gynecologists, internists, or family doctors, may have an interest in PCOS and hyperandrogenism, and may be comfortable treating you. In general, dermatologists are quite knowledgeable about treating the skin manifestations of PCOS, such as the hirsutism, acne or androgenic alopecia, but do not generally feel comfortable dealing with the hormonal and metabolic problems of PCOS. When selecting a physician for diagnosing and treating PCOS or hirsutism it is best for you to do some research by checking with other patients, professional societies or the Internet. You should also discuss these concerns with your doctor in order to get his/her advice.
Is PCOS related to diabetes?
Women with PCOS have an increased risk for "insulin resistance" which is a condition where the body has a reduced response to insulin. Insulin is an important hormone which helps the body to process the food we eat. Insulin resistance can develop into Diabetes.