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Adam S. Levine, M.D. recently finished his fellowship in reproductive endocrinology and infertility within the department of gynecology and obstetrics at the Johns Hopkins University School of Medicine. His areas of expertise include reproductive endocrinology, infertility, assisted reproductive technology, reproductive surgery, pediatric and adolescent gynecology, and menopause.

 

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fertility

Q:   I am 20 years old and have been trying to conceive for 13 months. I have very regular periods, and I want to try to conceive naturally before I start going to doctors. Do you have any suggestions?	A:   Between 15 and 20 percent of reproductive age couples in the United States have difficulty becoming pregnant. The technical definition of infertility is when a couple is not able to become pregnant after 12 consecutive months of trying. When all couples are considered, approximately 1/3 have a "female" problem, 1/3 have a "male" problem, and 1/3 have a combination "male and female" problem. "Female" problems are usually equally divided among mechanical abnormalities (blocked fallopian tubes) and chemical problems (usually irregular menses). "Male" problems may also result from mechanical abnormalities (blockage of sperm) or chemical problems (abnormal sperm production). The final third of couples usually have minor problems associated with both members of the couple.    The following is one method that may be used to attempt natural conception, provided the woman has regular menstrual cycles. Day one for a woman is defined as the first day that any menstrual blood is noticed. Menstrual cycles normally occur every 28 to 32 days. In these ideal cycles, ovulation generally occurs between days 14 to 16. Sexual intercourse (as frequently or as infrequently as comfortable, usually at least every 2 to 3 days and preferably every day), without any vaginal products, douching, lubricants, etc., should occur between days 12 and 18. Fertilization is more likely to occur when sexual intercourse occurs before ovulation.    Couples that have difficulty becoming pregnant may wish to consult with a reproductive endocrinologist. Reproductive endocrinologists are obstetrician-gynecologists who have undergone specialized training and primarily focus on fertility problems. They may provide the most direct route to becoming pregnant.
Q:   Could you provide me with some information on a female infertility treatment known as Assisted Hatching (AH), which I am told is closely related to a non-surgical procedure known as Embryonic Selective Thinning (NEST)?	A:   Assisted Hatching and Embryonic Selective Thinning are laboratory procedures used during in vitro fertilization (IVF), which is a surgical procedure. Under normal conditions, the sperm and egg fuse, which ultimately results in an embryo. The embryo is actually a collection of cells that are held together and surrounded by the zona pellucida. The zona pellucida will break during embryonic development, thus allowing further growth. The zona pellucida is too thick in some couples undergoing in vitro fertilization. Assisted Hatching or Embryonic Selective Thinning are laboratory procedures that mechanically or chemically open the zona pellucida to allow continued embryonic growth. Assisted Hatching may also be used to help open the zona pellucida after embryo cryopreservation (freezing).
Q:   I was recently diagnosed with an ovarian cyst. What is a sonogram? Who performs them? What effect do cysts have on fertility?	A:   The formation of ovarian cysts is normal in the majority of cases. Cysts or follicles are formed during the menstrual cycle as an oocyte (egg) matures before ovulation. Cysts are usually noticed on pelvic examination. Sonograms (also called ultrasounds) are one method commonly used to evaluate suspected ovarian cysts. Basically, a sonogram uses sound waves that are reflected from the pelvic organs (uterus, ovaries) to determine their size, shape, location and potentially their composition. Pelvic sonograms may be performed by gynecologists, radiologists or specially trained technicians. The effect that an ovarian cyst may have on fertility depends on the cyst. In most cases the cysts are benign and do not effect fertility.
Q:   I am a 25-year-old woman with polycystic ovaries. I have had two miscarriages in the past year (at 12 and five weeks). The pregnancies were achieved with Clomid, which I am taking again this month. Could the miscarriages be related to the polycystic ovaries? Is it time to see a reproductive endocrinologist?	A:   Polycystic ovarian syndrome (also called polycystic ovarian disease) refers to a group of symptoms that include: a higher than normal amount of androgens (or male hormones like testosterone); insulin resistance and a change in carbohydrate (sugar) metabolism; alterations in normal sex hormone production; and multiple follicles or cysts in the ovary that can be seen with ultrasound examination. Women with polycystic ovaries commonly have menstrual disorders and do not ovulate regularly. Clomid is a chemical that is similar to estrogen, and is used in many cases to stimulate ovulation. Unfortunately, humans have a fairly high rate of spontaneous miscarriages. However, depending on a patient's age and preference, I prefer to fully evaluate someone after they have had two losses. There are several potential interactions between pregnancy maintenance, medications used for ovulation induction (Clomid) and the underlying disorder (polycystic ovary syndrome). In this case, because of the complexity of the problem and the many different options that you have, you may benefit from evaluation by a reproductive endocrinologist.
Q:   Do male children of women who took the medication Diethylstilbesterol (DES) to prevent miscarriage develop any health problems related to exposure to that drug?	A:   Diethylstilbesterol (DES) is a synthetic estrogen (female hormone) that was used by 2 to 3 million women in the United States between the late 1940s and the early 1970s in an attempt to prevent pregnancy loss. Unfortunately in 1971, DES was associated with the development of a rare vaginal and cervical cancer in women whose mothers had used it. Since 1971, prenatal DES exposure has been associated with other problems, including male and female infertility, congenital structural abnormalities of the reproductive tract and the development of certain pre-cancerous and cancerous conditions.    Approximately 1 million men in the United States were prenatally exposed to DES. Theoretic and experimental evidence in male animals (rodents) suggests that prenatal exposure to DES could result in structural genital abnormalities, alterations in libido or sexual orientation and infertility. However, there is very little available data. Data from the 1970s support the possibility of a slight increase in structural genital abnormalities. The current data suggest that men with DES exposure are no more likely to have fertility difficulties or alterations in sexual orientation or libido than men who were not exposed.    Men who were prenatally exposed to DES should inform their physicians, and follow the current recommendations for routine health maintenance for all men of their age group. Men with specific genito-urinary or infertility problems may wish to consult with an urologist.
Q:   My 32-year-old husband has high blood pressure and is currently taking Posicor (mibefradil). We want to try to conceive and were wondering if this medication causes impotence, fertility problems or birth defects.	A:   Posicor (mibefradil) is a new drug used to treat hypertension (high blood pressure) and angina (chest pain). There is no data regarding impotence, fertility problems or birth defects. However, Posicor is a vascular-specific calcium channel blocker and can be expected to have similar side-effects as other calcium channel blockers. In some men, these types of medications have been associated with an increased chance of impotence (inability to achieve or maintain a penile erection). In some cases, this impotence is transient and resolves; in other cases, it will require changing the type, timing or dosage of the medication if necessary. Men experiencing impotence while taking this medication should consult with their physicians. Fertility problems are generally associated with impotence. Because sperm production occurs over approximately 3 months, any deleterious effect a medication might have on the number of sperm or activity usually resolves over time.    Finally, unlike in pregnant women, there is no strong data to support an association between a man's exposure to pharmaceuticals and subsequent birth defects. In this case, consultation with the prescribing physician, a urologist specializing in fertility issues, a reproductive endocrinologist or a genetics counselor may be helpful.
Q:    I am a 28 year-old white female, married.  We have been trying to conceive since 1996. I have taken Clomid 50mg and 100mg for about a year and 1/5. I have had two HSG and both show no blockage. I have had an ultrasound showing polycystic ovary disease, but have no follow-up on this. My cycles usually run approximately 80 days (only because I usually end up taking Provera when not on the Clomid.)  When on the Clomid, either 50mg or 100mg,  my cycle usually runs around 38 days. My husband's sperm count has been checked and  the count is high and our post coital test was normal. As of this date, I have not had a laparoscopy (which I was told probably would not show anything for me). My thyroid and pituitary have been checked and all are normal. I am not ovulating obviously, but why? Also, the reproductive endocrinologist said the next step would be injectibles. It seems to me there would be some other alternatives before taking such a large step (not really fond of needles). Any advice? Thank you.	A:     In general terms, approximately 80 - 85 % of women with polycystic ovary disease should begin to ovulate on Clomiphene citrate. The maximum benefit is usually reached after between 6 and 9 months of ovulatory cycles. After this period of time further investigation is necessary sometimes including further blood tests and a laparoscopy. Women who do not ovulate on Clomiphene citrate will usually benefit from injectible medications. In some women who will not ovulate, there are also some surgical options.
Q:    Have you heard any news about Vitamin B6 and a cure for infertility (female/primary)?	A:   To date, I have not seen any recent information published in peer-reviewed medical journals regarding the use of Vitamin B6 as a cure for infertility. I also did perform a brief literature search on Medline from 1964 to the current time and was unable to find any articles to support the use of Vitamin B6 as a cure for infertility. If you would like, I would be happy to evaluate your source for this information and let you know my thoughts.