Unexplained infertility is by far the most frustrating of all conditions I see. To get this diagnosis, all the testing patients have undergone show that everything is normal. There are adequate sperm for the male, and female patients seem to be ovulating or “making eggs.” The “plumbing” has been checked through an ultrasound and hysterosalpingogram, or “dye test,” and there are no abnormalities. We cannot find a medical reason for failure to conceive. 

I have sat before many patients with this diagnosis, including many that are in the medical profession, and the look of utter frustration is intense. They say “Everything checks out, so why won’t it all work?” The fact is that as many as 20 to 30 percent of all the patients we treat for infertility are not truly explained. The patients look to us for a treatment plan, but what are we treating? Doctors, as a general rule, like to know what and why they are doing things before they do anything. But unexplained infertility defies that rule because the lack of a plan of action is unacceptable. So, we need guidelines.

Clearly, if you do not know what you are treating then anything you do is empiric. In other words, we will rely on observation and experience rather than clear cut science. The general rule is if the woman is 35 or younger, and there is a normal semen analysis, doctors should provide Intrauterine Insemination (IUI) three times. That yields about a 30 to 35 percent overall pregnancy rate after three attempts. 

If IUI fails, you move on to IVF for 3 attempts. The combined IUIx3/IVFx3 yields between 85 and 90 percent success rate. But, if the semen analysis is significantly abnormal, or if the woman is older (or there is evidence of a diminished egg reserve), you should recommend going straight to IVF. 

Obviously, patients have choices. There have been many patients who have insisted on trying IUI first, and some who wanted to skip the IUIs and go straight to the most effective tool we have, In-Vitro Fertilization. Medical ethics dictate that the choice must be made by affirming “patient autonomy” and the “Doctor’s Beneficence.” That means the patient should be involved in making the choice, but the doctor can only do what has a real chance of working.

Before I initiate a treatment plan, I review the history closely, especially the family history. It is my experience that many unexplained infertility patients are in fact getting pregnant, but they are miscarrying and do not know it. Incredibly, a study showed that probably 70 percent of all pregnancies never make it. The woman may get her menstrual cycle on time or may not. It may come a few days late, the patient may feel that the breasts are tender and may think to themselves that it doesn't come tomorrow I will run out and buy a pregnancy test. Then the menstrual cycle starts. 

In other words, I believe that many of these patients are in fact getting pregnant but repeatedly losing pregnancies. Recurrent pregnancy loss, however, is the subject of an entire different blog. Regardless, I very often if not always look at the possibility that the patient is experiencing recurrent pregnancy loss. It’s extremely important - imagine finding out you have a treatable recurrent miscarriage condition after losing viable IVF pregnancies. 

Unfortunately, no doctor can find answers for every patient. Sometimes unexplained infertility, despite our best efforts and the use of the latest technology and tests, stubbornly remains unexplained. For those patients, gestational carriers or adoption may be their best paths to parenthood. As disappointing as this can be, the good news is that more than 50,000 people in the U.S. every year become parents through these methods. The path to parenthood can be a rocky one, and those who battle unexplained infertility certainly have among the rockiest of journeys, but in most cases there can be a happy ending.

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Having just had a number of patients with fibroids as their major cause of infertility, it’s the perfect time to talk about this frustrating and widespread problem.

First, we really do not have an accepted theory as to why or how fibroids come about. We know that they are more common in certain races (for example, as many as 40 percent of African-American women have fibroids) and can run in families, so there is most surely a genetic component. But while the researchers try to figure all that out, we practitioners are stuck with what to do about them. The answer lies in what the person with fibroids is experiencing and what she desires regarding her fertility. 

Fibroids are often present with no obvious symptoms, or the symptoms can be so severe they feel as if they are ruining one's life. They can cause heavy menstrual flow and clots, and consequently severe anemia. They also can put pressure on surrounding organs like the bladder, causing a frequent urge to urinate. A fibroid can grow so big that it outgrows its own blood supply and cause severe pain as ischemia ( lack of oxygen) will do – similar to a heart attack. 

With regards to pregnancy, fibroids can prevent an embryo from attaching and implanting in the wall of the uterus and also be a cause of recurrent miscarriages. As fibroids may grow during pregnancy, they can put a pregnancy at risk in its later stages by causing premature labor or even incompetence of the uterus.

Fibroids are classified by where they are attached to the uterus. From the inside out, they can be: 

• Submucosal - under the endometrium or lining, often extending into the cavity (think of a boulder emerging from your lawn). Submucosal fibroids will cause increased bleeding, a failure to implant or even miscarriages. 

• Intramural - in the wall of the uterus. These fibroids often cause no symptoms but can cause bleeding if close to the cavity/lining and can cause increased menstrual cramping. They also can become quite large and cause pressure or abdominal swelling. I have seen intramural fibroids compress the fallopian tube as it travels through the wall out to the ovary, possibly blocking transport of sperm and embryos.

• Subserosal - these are on the outside of the uterus and are also often without symptoms, but they can cause pressure on the bladder and abdominal swelling. Also if positioned near the side (i.e. the tubes and ovaries), they could interfere with the transport of the egg to the tube by pushing them apart.

• Pedunculated - (I know what you're thinking...Pe-what?) this means the fibroid is hanging on a stalk – think of a  mushroom. These fibroids are different in that they are at risk for twisting around on their own stalk, cutting off the blood supply and possibly causing acute pain - what I call "a fibroid attack." These fibroids can get quite big and can also displace tubes and ovaries, causing infertility. 

When you are attempting conception, and pregnancy is not happening easily, why not always start by removing fibroids? Fibroid removal is called "myomectomy."  We think carefully before moving forward with myomectomy because the surgery can cause new problems, including scar tissue and new "plumbing issues," so we must be convinced the fibroids are an issue before moving forward to surgery.

So how should you manage fibroids? Part 2 of my blog post, coming Sept. 1, will outline what you and your doctor need to do to manage your fibroids and - if at all possible - preserve your fertility.

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I bet you didn’t know that January is Cervical Health Awareness Month (honestly, I didn’t either until recently, so I'm getting this information to you just under the wire!). You probably don’t spend too much time wondering about the health of your cervix. Let’s face it, other than your annual checkup and how far you’re dilated when you’re in labor, your cervix doesn’t come up for discussion too often. But, if you want to have children someday or you’re actively trying to conceive now, you need to be aware that cervical problems can affect fertility.

For example, did you know that cervical mucus can be “hostile”? Granted, it’s an over-the-top name, but it’s actually pretty accurate. Cervical mucus is vital in helping sperm travel from the vagina into the uterus, and it can be negatively affected by infection or past trauma such as procedures/surgeries to the cervix. Since some infections and most cervical trauma are completely asymptomatic, you may not even know there’s a problem until you have trouble getting pregnant.

You also can run into problems with recurrent miscarriage because of an incompetent cervix. If your cervix is too weak to support your growing uterus, miscarriage or premature labor and delivery can occur – a heartbreaking and frustrating outcome, especially if you’ve already struggled with infertility.

Additionally, your cervix may be compromised because you are a “DES daughter.” What’s that? From 1941 to 1972, many women were prescribed a drug called diethylstilbestrol (DES) to prevent miscarriage. Unfortunately, what the medical establishment realized was that DES was detrimental to both mother and child, increasing the risk of breast cancer in the mom and causing abnormalities in the reproductive systems of the babies. “DES daughters” – offspring of the women who took DES – face an increased risk of clear cell adenocarcinoma (CCA) of the vagina and cervix (although it’s still very rare), as well as reproductive tract structural differences that may cause infertility and/or difficulties with pregnancy. The youngest of the "DES daughters," however, are now 38, so this will eventually become a non-issue as these women move out of their childbearing years.

What can you do to reduce the odds that a cervical issue will cause infertility? Early detection is key, so make sure you have an annual checkup with your OB/GYN, and don’t let embarrassment hold you back from being open with your doctor about your health. Talk about any concerns you have or issues you suspect with your doctor – make sure you give them all the tools they need to help you protect your fertility and be as healthy as possible. If you need more information, check out the National Cervical Cancer public education campaign or the National Cervical Cancer Coalition. Or, I am always available to answer any questions or concerns you may have – email me at esimckes@fertilitypartnership.com or call me at 800.BabyToday.

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After more than 20 years as an obstetrician/gynecologist and fertility specialist, I’ve been honored to be at the births of many healthy babies. But also in those 20+ years, I’ve cared for many women – and their partners - who have had to endure the heartbreaking pain of miscarriage, stillbirth or death of an infant. Some doctors might say that they’ve gotten used to helping women deal with such devastating losses, but I can’t. I don’t think I ever will. I get to know my patients so well that they feel like family to me, and when they go through that kind of agony, I want to be there by their side to support them and help them walk through the pain.

On October 15, we pause to commemorate National Pregnancy and Infant Loss Remembrance Day, and to remember all the babies – all the dreams – lost to mothers and their partners. My message to anyone who has suffered such a loss is a simple one: pregnancy and infant loss is devastating. You will never forget the baby or babies you’ve lost, no matter how many more children you go on to have. But you will go on. You will walk through the pain. You will laugh again. You will be able to look at a pregnant belly or a baby again without crying. But you will never forget, and that’s okay.

Find the support you need when you need it. Cry when you need to. Throw things when you need to. Speak up when you’re not getting what you need from family, friends or your doctor. If your doctor isn’t giving you the information, help or support you need, find another one – remember always that we work for you. Take care of yourself – physically, mentally, emotionally and spiritually.

And if and when you’re ready, give yourself permission to hope again like these strong and brave women did. Today, they pause to remember as well – just as they do every day – but they also commemorate their courage in walking through the pain.

If you’ve ever suffered a pregnancy or infant loss, I hope you give yourself permission to remember and mourn today, but I also hope you come out of this day with a renewed resolve to do whatever you need to do to continue healing – whether it be trying again for another baby or finding peace and contentment with the family you have. No matter what your choice, know that there are medical and counseling professionals ready to help – and while we will remember with you, we also will do all we can to help you continue down the family path you choose.

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Donna Nichols is one of the most courageous and inspiring women you'll ever meet. Here's her story, courtesy of KTVI-TV, about battling the physical and emotional trauma of nine miscarriages before finally giving birth to two beautiful baby boys. Thanks, Donna, for sharing your story and giving hope to many other women dealing with the sorrow of recurrent miscarriage.

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