Infertility is defined as the inability to conceive a child. Patients struggling with infertility will be unable to get pregnant, even after having carefully timed unprotected sex multiple times. Though there are safe and effective methods that can significantly improve one’s chances of getting pregnant, there are, sadly, many cases of women still struggling to conceive.
What is Recurrent Pregnancy Loss (RPL)?
Recurrent Pregnancy Loss (RPL) is defined by the American Society of Reproductive Medicine as the loss of two or more pregnancies. RPL at an abnormal age can be thought of as a way of determining if a patient is experiencing infertility, as well as the degree of their condition depending on the number of losses.
How common is Infertility in Women?
According to the Center for Disease Control and Prevention, 12% of females 15-44 years of age struggle with infertility in the United States. This includes both getting pregnant and being able to carry a pregnancy.
Why is fertility as common as it is?
The female reproductive system can be thought of as a highly developed network with multiple steps coordinated together in order to ensure a woman can conceive a child. For a woman to be fertile, the ovaries must release healthy eggs. Following suit, the reproductive tract must then pass that egg through the fallopian tubes, where it will join with a sperm cell and develop into a healthy zygote. Even after the zygote is formed, a woman’s reproductive system must provide and maintain a healthy environment in which the fetus can grow and develop. The complexity of such an evolved organ system leaves many areas for complications to arise. Thus it is not as surprising to hear that over one in every ten women will struggle in conceiving a child before the age of 44.
Causes of Infertility
A woman’s reproductive system and ovulation cycle is a very complex and carefully tuned network. Because of this complexity, infertility in women can result from a number of reasons:
Reproductive Organ Abnormalities
Reproductive Organ Damage or Blockage
All of the above possible causes for infertility are also subject to worsen, arise, or be caused by the following disorders:
Age: The older a woman gets, the more her egg quality declines. This drop in quantity of healthy eggs produced is most noticed in one’s mid-30s. Though it is normal for infertility to arise at this age, if a patient is having trouble conceiving a child before their mid-30s, they should certainly seek to meet with a reproductive specialist, as they may be affected by any of the conditions listed above.
Smoking/Tobacco: Like with any health issue, smoking never helps. Cigarettes can have detrimental effects, and it can physically damage your cervix, fallopian tubes, and ovaries. It has also been shown to increase one’s chances of poor egg quality and quantity, as well as increase one’s risk for ectopic pregnancy. Though there is currently a lack of evidence to support that smoking can cause such conditions as endometriosis, it has clearly been shown to be harmful in the case of a woman’s fertility.
Alcohol usage: Many studies have advised patients, both men, and women, to avoid drinking alcohol while attempting to conceive. Women who consume an excessive amount of alcohol have been found to take longer to get pregnant, have lower fertility rates and a higher chance of pregnancy complications. Finally, alcohol has also been shown to aggravate endometriosis for a number of reasons, including liver dysfunctionality and increased levels of estrogen.
Abnormal weight: Both being underweight and overweight have been shown to cause a decrease in ovulation frequency and the likelihood of bearing a child.
Endometriosis is closely linked to infertility. Nearly half of all patients with Endometriosis may experience infertility. Thus, it is important that you follow up with an infertility specialist or with your OB/GYN even after you have been treated for endometriosis. Endometriosis has been shown to cause infertility through several possible causes:
Alterations in prostaglandin secretion (a hormone-like enzyme which can cause inflammation).
Inability of the ovaries to function normally, resulting in a decrease in ovarian reserve and lack of quality egg production.
The body's own impaired immune response (which can result in rejection of the early implanted embryo and miscarriages).
Anatomic distortions due to inflammation, adhesions and/or scar tissue that prevent the proper passage needed for a sperm and egg to interact.
Improper, or a lack of implantation, of the fertilized egg itself due to diffuse inflammation of the peritoneum.
Significant number of cytokines (over 40 different types found) that are detected in the serum of infertile women.
How can endometriosis affect Egg Quality in endometriosis?
Recent studies have found that women who did not have endometriosis but used donor eggs from women with endometriosis, had a much lower rate of achieving a healthy pregnancy. This study thus suggests that women with endometriosis have a lower egg quality. This has been attributed to a detection of cytokines in the peritoneal fluid of patients with endometriosis, which is in fact caused by inflammation. The fluid will encase the healthy eggs and can affect them in such a way that they lose their function.
What is the immune component to infertility due to endometriosis?
Endometriosis has been found to have an immune component that can lead to miscarriages due to excessive inflammation. This can cause the body’s own immune system to reject the early implantation of the embryo. Therefore, it can be very beneficial for a patient to seek an expert in reproductive immunology following any infertility surgical treatment, as they can help correct or strengthen a woman’s immune system in order to increase their chances of having a healthy pregnancy.
How does endometriosis lead to anatomical distortions that cause infertility?
The anatomical distortions that can arise from endometriosis can often lead to many pregnancy complications. For example, scar tissue and adhesions that form on the fallopian tubes can lead to an ectopic pregnancy (when the egg implants outside the uterus). In these cases, it is very important to terminate the pregnancy before the tubes rupture. Another example comes in the form of misshaping of the uterus due to associated adenomyosis scar tissue buildup and inflammation within the uterus. When this happens, patients often will have trouble maintaining a pregnancy. These are just a few of the ways that the reproductive anatomical changes experienced from endometriosis can lead to infertility. Therefore, it is important to consult a gynecological surgeon who can remove any of the scar tissue that causes these distortions in order to reduce inflammation and increase one’s chances of pregnancy.
What is meant by the term "Silent Endometriosis?"
Silent Endometriosis refers to cases where patients with endometriosis are unsuccessful after multiple IVF treatments but show no signs of endometriosis. Many of these endometriosis patients do not receive the treatment they deserve, as they show no signs of endometriosis and are thus not believed to have the disease. Nevertheless, they continuously have multiple failed attempts with IVF treatments and are left undiagnosed for the cause of their infertility. This is why it is important to note that one of the symptoms of endometriosis is having no symptoms at all. It is advised in cases of infertility where there are no signs of endometriosis, that patients should receive a laparoscopic evaluation of the pelvic peritoneum and eliminate inflammation in order to ensure that they are not suffering from “silent endometriosis.”
How can patients overcome infertility due to endometriosis?
Because endometriosis can harm egg quality, young patients with early endometriosis, or a strong history of endometriosis, are often advised to freeze their eggs. It is also advised to conduct in-vitro fertilization (IVF) and preimplantation in order to help achieve a healthy pregnancy. This also allows doctors to see the genetic makeup of the embryo and whether it is genetically sound. Only through transferring healthy embryos will patients gain a better chance of overcoming pregnancy loss. Studies have also shown that women with endometriosis have a higher success rate using frozen embryos for transfer as opposed to fresh eggs.
Because underlying causes of infertility can arise from such reproductive conditions as endometriosis, adenomyosis, etc., the symptoms for infertility are often very similar to that of said disorders. Symptoms can include:
Because infertility is simply defined as an inability to conceive children, as opposed to a visualizable disease, there is no way to concretely diagnose infertility without several failed attempts at pregnancy. Nevertheless, there are many diagnostic tools and methods that can be useful in diagnosing the underlying cause of the condition.
Blood tests: A simple blood test can test whether or not a patient is ovulating properly by checking hormone levels.
Hormone tests: There are many hormones that can be tested to assess a patient’s fertility chances, such as checking levels of ovulatory hormones, early levels of menstrual cycle hormones to assess ovarian reserve (quality and quantity of eggs), and pituitary hormones that control reproductive processes. Any abnormal hormonal values can be a possible sign of infertility.
Sonohysterography: This imaging technique uses an intravaginal ultrasound to produce images that evaluate the uterus and fallopian tubes. It can be used to find blockages, abnormal uterine bleeding or any other symptomatic causes of infertility.
Hysteroscopy: During this inpatient exam, a thinly lighted device is inserted through the vagina in order to examine the cervix, inner uterus, and fallopian tubes. This can help determine if there are any causal diseases of infertility, such as endometriosis, adenomyosis, etc.
Laparoscopy: A minimally invasive surgical technique that makes several small incisions into the abdomen, followed by inserting a small camera to visualize the fallopian tubes, uterus, ovaries and surrounding organs. In addition, the ability to visualize such causal diseases as endometriosis, adhesions, blockages, etc., one of the advantages to laparoscopy is that a surgeon will be able to remove any scar tissue if found. This allows laparoscopy to not only be used as a diagnostic tool for infertility, but also as a form of treatment.
While not all infertility cases can be corrected, it is always worth the effort to try and find a proper treatment option. A big deciding factor on how to treat your infertility is to first determine the cause of the condition.
Medication: Fertility medication is used for women suffering from ovulation disorders. By stimulating ovulation through key hormones, it increases one’s chances of producing a greater quantity and quality of eggs. However, a woman should discuss the risks and benefits of taking this medication with her doctor before use.
Laparoscopic surgery: As noted above, laparoscopy can be used to both diagnose certain causes of infertility, as well as to treat said disorders. By utilizing this technique, a surgeon can remove all believed endometriosis tissue and adhesions in order to reduce inflammation and distortion of the uterus and other reproductive organs. This ultimately increases a patient’s chances of becoming pregnant as a great deal of inflammation is reduced on top of the many possible causes of infertility itself.
Assisted reproductive technology (ART)
Intrauterine insemination (IUI): In this process, a healthy sperm is placed directly into the uterus in order to ensure the optimal time of healthy egg release, and thus fertilization. This process will be properly timed with your menstrual cycle, whether it is normal or assisted by fertility medication.
In Vitro Fertilization (IVF)- This is by far the most common form of ART. In this technique, multiple mature eggs are stimulated and retrieved from inside a woman’s uterus and fertilized in a petri dish with the sperm of interest. After a few days, the newly formed embryo is then implanted back into the uterus where the pregnancy will be carried out.
Third-party assisted ART: There are a number of third-party ARTs that are often used either by themselves or in congruence with any of the above ART techniques. These can include sperm donation, egg donation, surrogate or gestational carrier. A surrogate is used when the female in a couple is incapable of producing healthy eggs, and thus the sperm of the male partner must be used with a third party female. On the other hand, a gestational carrier is used when the female simply cannot carry a pregnancy, in which case IVF is conducted, and the resulting embryo is implanted into a third-party for pregnancy and delivery purposes.
The best approach that we can provide in treating infertility is through laparoscopic deep excision surgery. By using this minimally invasive surgical technique, we are able to completely remove all visible endometriosis scar tissue in the uterus, ovaries and surrounding reproductive organs. After complete excision of endometriosis in the pelvis, all inflammation sources are eliminated. We also will surgically correct any observed uterine defects and free up the fallopian tubes in order to increase the patient's chances of pregnancy. Finally, we work with some of the best reproductive endocrinologists and immunologists so that patients receive the best care that we can provide. We have had a great number of patients go on to have healthy pregnancies, and we pride ourselves on giving patients the highest chance of achieving a healthy pregnancy as we possibly can.
Nevertheless, endometriosis has been found to have an immune component that can lead to miscarriages even after surgical debulking. While our surgery greatly improves the outcome, any patient who has gone on to become pregnant and miscarry, or those who have failed to conceive at all, should arrange for a reproductive immunology profile. This can be done by scheduling a reproductive immunologist follow-up meeting, which we are more than happy to help coordinate. If needed, we also recommend and can provide a referral to a clinic that provides assisted reproductive technology (ART). We strongly believe that in cases of continuous infertility, your best chance of conceiving a child will come by utilizing all forms of infertility treatment to your advantage.
Infertility due to endometriosis is one of the most personable conditions we encounter at our practice. In these instances, we want our patients to feel that they have options. While no one can guarantee a definitive cure for infertility, we do our absolute best in treating what is often the underlying cause of the disorder, ultimately making great improvements in a patient’s chances of bearing children. Patients are often unaware of just how impactful excision surgery can be on their particular case. We work extremely hard to provide the best care possible, while at the same time ensuring patients that they are not alone in this battle. Our door is always open for discussion, and we love to help patients with their family building needs.
When faced with such heartbreaking challenges as overcoming infertility, we believe that it should be a team effort between a woman and her partner. Therefore, we love meeting our patients' partners and hearing what they have to say on such issues. Take a listen to an overjoyed husband from Great Neck who struggled to have a child with his wife for over five years, only to be blessed with a baby girl one year following his wife's surgery.
We are both proud and ecstatic to say, you can read more stories of patients overcoming infertility, at varying stages, in our testimonial section.