Getting Pregnant and Staying Pregnant: Overcoming Infertility and Managing Your High-Risk Pregnancy

By Diana Raab and Harry Farb

Author is a nursing consultant. Text includes the latest information on fertility tests, treatments ranging from improved in-vitro fertilization to updated drug combinations and dosages, genetic testing, screening for hereditary abnormalities, using the Internet, and more.

• Language: English
• Publisher: Turner Publishing Company
• Release date: Jun 11, 1999
• ISBN: 9781630265212

Book preview

Chapter 1

Causes of Infertility

Infertility is defined as the inability to become pregnant after one year of sexual intercourse with no contraceptive protection. Those couples trying to have children consider it a tragedy unlike any other in their lives. The infertile couple may be laden with fears, stresses, concerns, and questions that often only careful medical evaluation can address. It is normal to feel depressed and discouraged as plans for parenthood seem to drift into the nebulous future.

Nearly 20 percent of all couples trying to become pregnant are affected by infertility. In about 30 to 40 percent of those cases, the cause of infertility is related to the woman; in another 10 to 30 percent it is related to the man; 15 to 30 percent of the time it is related to problems involving both the male and female partners; and in another 10 to 15 percent it is unexplained.

In both men and women, infertility may be caused by a combination of anatomical/physiological problems, hormonal imbalances, genetic alterations, exercise/nutritional habits, certain prescription and illicit drugs, environmental hazards, and emotional factors.

CAUSES OF MALE INFERTILITY

Low Sperm Count

Oligospermia, or low sperm count, is the primary cause of male infertility. Many sperm are killed by normal vaginal secretions or lost during their journey to the fallopian tubes. A man who begins with a lower-than-usual sperm count may find he has an infertility problem. Normally, sixty million or more sperm per cubic centimeter are delivered with each ejaculation in a volume ranging from one to four cubic centimeters of semen.

Actual sperm production may be influenced by anatomical conditions, hormones, nutrition, environmental pollutants, industrial chemicals, marijuana, radiation exposure, or certain illnesses. Certain medications, such as large doses of aspirin, Cimetidine (used to treat duodenal ulcers), and Nitrofurantoin (antibacterial medication), may also affect fertility. Diethylstilbestrol (DES), the synthetic female hormone prescribed for many pregnant women to prevent miscarriage between 1941 and 1971, has been associated with male infertility: sons of women who have taken this drug have been found to have abnormal sperm type and motility in addition to testicle abnormalities. You should alert your specialist if your partner has been exposed to DES. Your partner should also be advised to do monthly testicle examinations and to report any lump, growth, or swelling to a urologist. Researchers report that crash diets also have a tendency to lower sperm count, just as strict diets can lead to irregular menstrual cycles in women.

It is now known that warmer temperatures may also hinder sperm production. Some researchers suggest that taking saunas and hot baths can cause overly high temperatures in the scrotal sac, an effect that may hinder sperm production for months. Men who wear tight clothing may be lowering their sperm count as well. Often, males with infertility problems are advised not to wear tight-fitting pants or underwear.

Oligospermia is sometimes treated with Clomid or Humagon. In the United States, Clomid and Humagon have not been approved by the Food and Drug Administration for treating male infertility, so in many cases the male must sign a special consent form prior to beginning the treatment.

In some cases, steroids, antiprostaglandins, or vitamins C and E are recommended to increase sperm count. A study reported in the Journal of the American Medical Association in 1983 by Dr. Earl Dawson at the University of Texas Medical Center showed that a daily dosage of vitamin C may restore fertility. The men in the study were given a one-month supply of vitamin C in 500 mg gelatin capsules. One tablet was to be taken every twelve hours. It was concluded that the men’s fertility could be restored as early as the third or fourth day of treatment. Other studies have shown that an increased intake of zinc and vitamin E may also increase sperm count. These treatments and similar ones remain controversial and should be undertaken only under careful medical supervision.

Anatomical Changes

The tubes, or ducts, that carry the sperm may have flaws that affect fertility. This is the problem for approximately 10 percent of infertile men. Studies indicate that this flaw—often caused by a blockage—is more evident in men whose mothers took DES and among men who have had genital infections or surgery.

The spermatic cord is the cord suspending the testes. It is composed of veins, arteries, lymphatics, nerves, and the vas deferens, which carries the sperm from the epididymis to the ejaculatory duct (see the diagram Male Reproductive Anatomy in Appendix A).

A varicocele is an enlargement of the veins of the spermatic cord. It affects fertility by producing a slightly higher temperature in the testicles, which hinders sperm production. It is present in about 15 percent of all men, usually on the left side, and it accounts for about 40 percent of male infertility problems. As many as 90 percent of the men who have previously fathered a child and are later unable to have this problem.

Varicoceles are treated surgically. The success rate varies; it is estimated that approximately 80 percent of men have an increased sperm count following this surgery. The most common type of procedure is microsurgery, which is done on an outpatient basis under spinal anesthesia. The stitches are self-dissolving, and the man goes home with tiny Steri-Strips or Band-Aids to be removed in ten days. Some specialists prescribe fertility medications such as Clomid to stimulate sperm production following the surgery.

A scrotal injury may also cause male infertility, if the injury affects the blood supply and sperm transportation. Another cause of infertility may be an undescended testicle (corrected or uncorrected). The cool temperatures that allow sperm production are not possible if the testicle is hidden in the abdominal cavity. A male whose testicles descend late in life may also be prone to infertility, and yet an undescended testicle does not necessarily result in infertility problems.

Previous Illness

A history of certain infections, such as mumps, may be another cause of male infertility. If a male gets the mumps during or just after puberty, there is a risk that the virus will attack the testicles. In severe cases, the man will have an increased risk of infertility problems later in life. Sexually transmitted diseases, such as chlamydia, have also been linked to infertility and low sperm count.

Genetics and Hormonal Imbalances

In rare instances, infertility in the male may be inherited. This is usually identified through chromosomal tests. Treatment is often difficult unless the condition is related to a particular problem, such as hormonal deficiency, which can be treated with hormonal replacements. Hormonal problems account for approximately 10 to 15 percent of male infertility. Some imbalances may be due to a poorly functioning pituitary gland. Standard hormone analyses are not often done on the male, mainly because of their cost; an exception is if an abnormality was found in the semen analysis.

CAUSES OF FEMALE INFERTILITY

Ovulation Problems

The most common cause of female infertility is the failure to ovulate regularly or at all, which in turn is usually related to hormonal problems.

Common Reasons for Hormonal Imbalances

Age. The release of reproductive hormones diminishes after a woman’s twenties, and therefore women will ovulate less often.

Pituitary tumor. This may inhibit the release of FSH and LH at the right time during the menstrual cycle, thereby affecting ovulation.

Pituitary gland problems. For example, one such problem is elevated levels of prolactin, the hormone that stimulates breast milk production and blocks ovulation.

Adrenal gland problems. These cause increased levels of androgen, a hormone that interferes with ovulation.

Other causes of ovulation problems include disorders of the ovary, such as an ovarian cyst, overexercising, nutritional deficiencies, and certain medications.

Many practitioners claim that an abnormal menstrual history may be a clue that there is or will be an ovulation problem. By the age of fifteen or sixteen, the menstrual cycle should be more or less regular, with a menstrual period every twenty-eight days or so. If, however, the number of days between periods varies greatly, this may indicate a hormone regulation or timing problem associated with ovulation. This does not mean that if you have irregular periods you will have difficulty becoming pregnant. It means that if you have irregular periods there is a greater chance that you may ovulate late each month or maybe ovulate only every other month. One of my patients ovulated only twice each year.

For the most part, those women who get pregnant very easily are those who have very regular periods. Most women who do not ovulate on a regular basis have a slightly elevated level of male hormone. Signs of increased male hormone include extra facial hair, hair on the lower abdomen, hair on the big toe, and extra hair around the anus. Acne and oily skin may also be associated with excessive male hormone.

Older women who have used the birth control pill for many years may also find that ovulation is temporarily reduced or stopped. In most cases, the Pill does not affect a woman’s fertility if she had normal menstrual cycles prior to starting the Pill. Those who stop taking the Pill and have difficulty getting pregnant may not have been ovulating spontaneously before. A medical investigation may be recommended if you have gone off the Pill and fail to have a normal menstrual cycle within five to six months.

Fertility Drugs

Your specialist will quickly identify ovulation problems through your temperature charts. If your temperature charts indicate that you are not ovulating, the specialist will probably prescribe a fertility drug, such as clomiphene (Clomid). Other fertility drugs include Humagon, GnRH, and Parlodel. These and related drugs are discussed in more detail below.

Clomiphene (Clomid) Clomid is a synthetic drug that signals the pituitary gland to produce hormones that stimulate ovulation. It is used when the woman’s ovaries and hormonal networks are capable of working well but simply need some revving up. Even if the woman is menstruating irregularly, Clomid helps develop follicles that are not reaching their normal size and helps immature follicles grow to maturity. Approximately 75 to 80 percent of women will ovulate using this medication; however, the pregnancy rate is only about 30 to 40 percent. Those women who do not become pregnant usually go on to use Menotropins or ART.

The dosage of Clomid varies, but it usually begins with a 50 mg tablet daily starting on the third day of the menstrual cycle. If the woman does not ovulate during the first cycle, the dose may be doubled or eventually tripled. Women respond differently to Clomid and this is why an initial low dose is used. While taking Clomid, it is recommended that you continue with your temperature charts or ovulator predictor kit. The length of time required to produce results is highly individual, and sometimes it is necessary to have three courses of treatment to achieve results.

There is a risk of multiple births following the use of this drug and all other fertility medications. A twin pregnancy may occur in about one out of fifty women taking Clomid.

One woman shares her experience:

My lifelong desire to have children was fulfilled when I learned in my sixth month of pregnancy that I was having twins. I knew there would be the possibility, because there’s a history of twins in my family, plus I had been on Clomid for four months.

Sometimes it takes longer for fertility medications to work, as this woman describes:

I thought when I popped my first fertility drug I’d be pregnant immediately; however, when four years later I was still not pregnant, it became a real mental strain. I began to think I’d never become pregnant. My treatments seemed to be never-ending. I tried various doses of Clomid, and then finally Humagon was my success drug. This is easy to say now, however, as I sit here with three children under the age of ten.

Some women experience mild side effects from the medication, such as water retention, hot flashes, visual disturbances, abdominal discomfort, and tender breasts. You should notify your physician if you have unusual bloating, stomach or pelvic pain, blurred vision, nausea/vomiting, or any other unusual symptoms.

Menotropins (Humagon, Fertinex) Depending upon your fertility problem, if you fail to ovulate in response to larger doses of clomiphene and have low estrogen levels, your specialist may recommend a stronger medication called human menopausal gonadotropin (hMG), more commonly known as Humagon. Humagon, formerly called Pergonal, belongs to a group of drugs called Menotropins. It contains natural, purified follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and it may also be taken instead of Clomid. Developed in the 1960s, this medication stimulates the ovaries to ovulate and is usually given by injection for several days, beginning on the second or third day of the menstrual cycle. Prior to Humagon treatment you will have an ultrasound to be sure that you have no ovarian cysts; if there are large cysts, they will have to be removed prior to beginning this treatment.

Humagon is generally given under close daily supervision, including watching for cervical mucus changes, ovarian enlargement, and changing estrogen levels. When the eggs are mature, an injection of 10,000 IU of hMG is given and ovulation often occurs within thirty-six hours, at which time intercourse or intrauterine insemination is recommended.

Humagon tends to decrease progesterone levels. For this reason, you may need progesterone injections beginning two to five days after the Humagon. Progesterone is a hormone that is naturally produced by the body to allow the embryo to implant itself in the uterus.

Humagon is very expensive, and it is used only by qualified physicians who have easy access to ultrasound devices. The most significant side effect of this medication is the formation of ovarian cysts, which rarely have to be removed surgically. According to Facts and Comparisons, a drug information and publication service, approximately 80 percent of those taking Humagon will have single births; 15 percent will have twin births, and 5 percent will have three or more fetuses.

GnRH (Gonadotropin-Releasing Hormone) GnRH is produced by the hypothalamus and stimulates the pituitary gland to produce FSH and LH. This medication, sometimes known as Lutrepulse, is used when Clomid is ineffective. Some physicians prescribe it prior to Humagon, while others recommend it after Humagon has failed. Yet other specialists may choose to use these medications in combination.

Lutrepulse is given with a battery-operated pump held in a pocket with a tube leading to a vein in the arm. The medication is administered every ninety minutes until ovulation occurs, mimicking natural hormonal release. The technique is similar to that for diabetics receiving continuous doses of insulin and may be done in the hospital. Some women are now given the option of home administration by their partners. The dose and number of treatments vary with the individual; however, once the right dose is determined for you, you will probably respond to a similar dose in subsequent cycles.

According to Ortho Pharmaceuticals, the manufacturer of Lutrepulse, the treatment cycle is twenty-one days, and the cost is approximately $1,200 to $1,500. This cost includes the medication and pump, an ultrasound, and physician visits. Approximately 93 percent of those taking this medication will ovulate following the treatment, and about 62 percent will get pregnant. The actual dose is approximately 5 mcg every ninety minutes.

Parlodel (Bromocriptine Mesylate) This is an oral medication given to lower the level of prolactin. It may also be used to decrease the size of a pituitary tumor. This medication may be given to a woman wanting to become pregnant, because prolactin can interfere with the normal production of LH and FSH and therefore hinder ovulation.

Tests for prolactin are usually done in the morning, when raised levels are most noticeable. They should not be done following any breast palpation, including during sexual activity, and/or following a breast examination done by the woman or her physician, as this may result in a false positive result.

The dose of Parlodel is usually 1.25 to 3.75 mg taken daily at bedtime. Side effects during the first few days may include dizziness, nausea, headache, fatigue, and nasal congestion. These side effects may be minimized if the dosage is increased gradually. Ovulation may be expected within six weeks of starting Parlodel. However, it is sometimes necessary for the specialist to prescribe Clomid simultaneously if you have not ovulated after two months on Parlodel.

Lupron (Leuprolide Acetate) This is a newer fertility drug that has been used to treat endometriosis. For endometriosis, it is given in a single intramuscular injection monthly for six months. As of this writing, the drug has not been specifically approved for the treatment of infertility, although some physicians are prescribing it for infertile women. It is often used presurgically, before treating endometriosis, and with in vitro fertilization. Some women claim that side effects from this medication are similar to symptoms experienced during menopause. These include hot flashes, headaches, acne, vaginal dryness, bone pain, reduction of breast size, emotional changes such as depression, and decreased libido. Lupron is usually given for no more than a total of six months due to the possibility of bone loss.

Metrodin (Urofollitropin) Metrodin is a potent gonadotropic substance used to stimulate follicle growth. It is given to women who have polycystic ovaries, have elevated LH/FSH, or do not respond to Clomid. After Metrodin is administered, it must be followed by hCG. Women receiving Metrodin will be examined at least every other day during the treatment and twice weekly after the treatment has ceased. Couples are reminded to have intercourse daily, beginning on the day prior to treatment with hCG until ovulation is apparent from progesterone levels. Approximately 83 percent of women who conceive while taking Metrodin will have single births, and 17 percent will have multiple births.

hCG (Human Chorionic Gonadotropin) When Humagon or Metrodin have stimulated the growth of mature follicles, then the woman will be given an injection of hCG to stimulate the release of the eggs from the follicles. It is usually recommended that the couple have intercourse daily, starting on the day prior to the hCG shot, up until ovulation occurs. Ovulation is confirmed by basal body temperature (BBT) charts, change in cervical mucus, and a positive pregnancy test. When the woman becomes pregnant she produces her own hCG, which stimulates the corpus luteum, a body formed in the ovary that produces progesterone. This is the main hormone of pregnancy and is the stimulus for many of the mother’s physical changes during pregnancy. It is the hormone that home pregnancy tests detect.

Women who have been given hCG occasionally complain of tenderness at the injection site. Some hCG users experience minor side effects such as hot flashes, fluid retention, and headaches.

Luteal-Phase Problems

The luteal phase occurs during the second half of the menstrual cycle. After you ovulate, the part of the ovary that releases the egg becomes the corpus luteum, which produces progesterone, which prepares the uterus for egg implantation. When the luteal phase is shorter than normal, or if the amount of progesterone secreted is less than normal, the woman is considered to have a luteal-phase problem.

Women with luteal-phase problems often miscarry because the uterus is not ready for the egg’s implantation. A blood test after ovulation usually detects the low blood progesterone associated with luteal-phase problems. Endometrial biopsies may also be done. Women who become pregnant with luteal-phase problems may have early spotting and, unless treated, may miscarry. Treatment includes progesterone, clomiphene, or hCG. Up to 15 percent of infertile women have luteal-phase problems.

Endometriosis

Endometriosis is another potential cause of infertility, affecting as many as 7 percent of women of childbearing age. It is often detected only after a woman reports that she is unable to conceive. Fragments of the endometrium, the uterine tissue, lodge in areas such as the abdominal cavity, ovaries, fallopian tubes, or bowel. Each month at the time of menses, these growths of tissue bleed in small amounts, stimulating the body to form scar tissue or adhesions.

Endometriosis may be mild, moderate, or severe. Some women with mild to moderate endometriosis have no symptoms, while others may experience very painful periods, painful intercourse, and abnormal bleeding. Pain alone, however, is not indicative of endometriosis, nor is it indicative of the severity of the problem.

The cause of endometriosis remains unclear. One theory is that during a woman’s period, blood carrying tissue from inside the uterus is moved into the fallopian tubes. This tissue then adheres to other organs in the pelvis and peritoneum. Other researchers suspect certain immunological factors, such as the formation of antiendometrial antibodies or alterations in prostaglandin inhibitors. Women with a family history of endometriosis and women who have never had children are generally thought to be at a greater risk. Some researchers claim that most women experience some degree of endometriosis; but for unknown reasons, possibly an altered immune response, not every woman reacts to this condition in the same way.

There are also several theories as to how endometriosis affects fertility. These include ovulatory dysfunction, impaired tubal transport, hormonal and immunological factors, disturbed implantation of the egg, and subsequent spontaneous abortion.

A specialist who suspects endometriosis may recommend a laparoscopy to determine the extent of the problem. During the procedure, he or she may decide to remove the scar tissue. Afterward, oral contraceptives or progestin may be prescribed to suppress the body’s natural hormonal secretions, thus reducing the chance of recurrence.

Treatments for endometriosis vary according to the severity of the problem. The newest medications used are gonadotropin-releasing hormone agonists. Pain is usually relieved within two to three months of treatment. Lupron injections can be given once a month for six months or Nafarelin nasal spray, prescribed at 200 mg twice a day for three to six months. Each of these medications can produce side effects, such as hot flashes, headaches, depression, and bone loss. Sometimes low-dose estrogen and progestin are added to reduce the negative effects. Danazol is a synthetic hormone that shrinks endometrial tissue. It is taken as a pill, prescribed at 200 to 400 mg, twice a day. Like Lupron, Danazol suppresses female hormones, causing artificial menopause. Side effects may include weight gain, water retention, cessation of menses, decreased breast size, acne, oily skin, hot flashes, and mood swings.

Moderate to severe endometriosis may be treated with both surgery and medication. Some physicians use various types of lasers and advanced laparoscopic surgery. The first laser surgery was performed in 1974 by Dr. Joseph Bellina. Today, the technique has been refined and it is no longer a particularly long or delicate surgery. With the help of television cameras, lasers are used through a laparoscope to remove small adhesions in the fallopian tubes. Studies have indicated that pregnancy rates after surgery for women with moderate endometriosis can be as high as 47 percent, rates for those with severe endometriosis as high as 38 percent. However, studies have also shown decreased pregnancy rates when using in vitro fertilization (IVF) following laparoscopic surgery. IVF is often the best treatment option for infertile couples, so some women with mild endometriosis may choose to bypass this surgery in order to better their chances for a successful IVF pregnancy.

One woman shares her experience with endometriosis:

When I was in my early twenties, I was told I had endometriosis and that achieving pregnancy might pose a problem. We were married for a little more than two years when we decided to start a family. I thought that we’d better start trying because I was thirty-four and my husband was forty. Psychologically we prepared ourselves for long months of trying and infertility investigations. We didn’t look forward to it all. Then came the big surprise . . . about six weeks after we began trying to conceive, I got a positive pregnancy test. I was shocked and unprepared at the same time. I quickly adapted to the idea, but really one never knows how long it will take to become pregnant. You should be prepared the moment you start trying.

Pelvic Inflammatory Disease (PID)

Certain infections and illnesses may affect fertility. Infections in the pelvic area leave scar tissue behind, which interferes with conception. This condition, called pelvic inflammatory disease, is the cause of about 20 percent of all infertility problems in women, and this number is increasing. The National Institute of Allergy and Infectious Diseases estimates that about one million cases of PID occur annually, and more than one hundred thousand women become infertile each year as a result. The more sexual partners a woman has, the greater is her risk of developing PID. The disease is very difficult to diagnose because it either causes no symptoms or the symptoms it does produce—such as fever, abdominal pain, and vaginal bleeding—are also symptoms of various other disorders. PID may be associated with the use of the IUD and/or a history of sexually transmitted diseases.

Sexually Transmitted Diseases (STDs)

Genital herpes, genital warts, syphilis, gonorrhea, trichomonas, and chlamydia may lead to difficulties in becoming pregnant. A study done in 1985 at the Hutchinson Cancer Research Center in Seattle indicated that women with a history of gonorrhea had twice the chance of having problems conceiving due to fallopian-tube abnormalities, and that a history of trichomonas was also associated with fallopian-tube problems.

Among the one million women who contract STDs each year, as many as 150,000 to 200,000 will have infertility problems. Some classic symptoms of infection include low-grade fever, fatigue, dull pains in the pelvis, sharp sensations in the pelvis or bladder area, and painful intercourse. If you have any of these symptoms, you should see your gynecologist. Tell him or her about your symptoms; they might not be discernible during an examination. A sample should be taken of your vaginal discharge and/or growths and examined under a microscope. The sample will then be sent to a laboratory for a more detailed analysis. A medication may or may not be prescribed at that time.

Polycystic Ovaries (Stein-Leventhal Syndrome)

This is a condition brought on when ovulation has not occurred for an unusually long period of time, causing cysts to be formed on the ovaries. This problem is often associated with abnormal hormonal secretions and may produce symptoms such as irregular periods, excessive hair growth, and a tendency toward obesity.

The problem originates in the pituitary gland, the master gland that triggers the release of hormones in various parts of the body. Blood tests reveal this hormonal imbalance. About 75 percent of women with polycystic ovaries respond well to fertility medications. In some cases, laparoscopic surgery is carried out to remove the ovarian cysts.

One woman shares her experience:

Because I had excessive hair growth even before I decided to start a family, one physician thought that I had this problem. He did many tests and investigations, all of which had normal results. Despite these results, when I was eighteen, he still told me I might have infertility problems one day. I laughed and said that excessive hair growth runs in my family. Ironically, he was right; I did have infertility problems, but for different reasons.

Cervical, Vaginal, and Anatomical Disorders

Disorders such as inadequate cervical mucus, cervical infections, or cauterization (the destruction of tissue with an electrical current, sometimes used to control bleeding after surgery) may affect fertility since mucus interacts in a specific way with sperm.

About the ninth or tenth day of the menstrual cycle, cervical mucus starts to increase and the cervix opens slightly to facilitate sperm entry. A common cause of infertility is the cervical factor, meaning that the woman does not produce an adequate amount or quality (the wrong pH) of cervical mucus to facilitate easy sperm entry into the uterus. Some believe this is caused by a hormonal imbalance. Some physicians prescribe Robitussin cough syrup to loosen up the mucus. Others may recommend intrauterine insemination, in which a small catheter is introduced into the cervix leading into the uterus for implantation.

One woman describes the cause of her infertility problem:

My vaginal mucosa was too acidic and I was producing an environment that killed my husband’s sperm. [Normally the vagina is acidic—the cervical fluid is alkaline, as is the spermatic fluid.] My physician recommended, after many long years of infertility investigations, that I douche with baking soda and water, an alkaline solution, prior to intercourse. I was pregnant with twin boys within four months.

Inadequate cervical mucus (i.e., inadequate in amount or consistency) may be treated by the use of estrogens such as Premarin. The dose of Premarin varies from .625 to 1.25 mg daily prior to ovulation. If after a few months you are still not pregnant, some