Special Circumstances

Q: What if I have fibroids and/or endometriosis? Does this mean I am likely to have fertility challenges?

Dixon: Fibroids do not necessarily mean fertility problems. The only fibroids that have been shown to have an impact on fertility are the submucosal fibroids, which grow deep in the wall of the uterus (just under the surface of the endometrial lining), and the larger intramural ones (that push into the cavity). Others have no impact.

Endometriosis is associated with a degree of sub-fertility but is not necessarily consistent with the stage of endometriosis. If you have Stage III endometriosis, it doesn't mean you will not get pregnant, although it alters the pelvic/abdominal environment. Conversely, Stage I and II endometriosis do not guarantee pregnancy with ART. We are starting to recommend that women with endometriosis go straight to IVF because the money they spend trying to get pregnant - so much invested in ovulation induction and everything - almost equals the cost of IVF.

Schoolcraft, who explains why removal of submucosal fibroids is necessary, as opposed to removal of intramural (those within the uterine wall) and subserosal (those that bulge outside the wall) fibroids: Fibroids can decrease pregnancy rates if they impinge on the uterine cavity, that is, if they bulge into the interior of the uterus. Besides decreasing fertility, fibroids can increase miscarriage rates and rates of preterm labor.

Licciardi: Most doctors today believe the only way endometriosis causes infertility is by causing scar tissue that interferes with tubal function. Some doctors like to perform a laparoscopy on every infertility patient, using the excuse that 10 percent of women have endometriosis, so we need to find it and annihilate it. This is over-operating and is fruitless. Other tests can be performed to look for endometriosis, including an ultrasound and hysterogram. If these two tests are normal, a laparoscopy may be indicated in only a small percentage of cases.

Q: For the last year or so, I have taken natural progesterone from days 14 through 28 of my cycle to ease my PMS symptoms. Will taking a natural hormone like this interfere with my efforts to get pregnant and if so, how?

Several doctors said yes, the hormone will interfere. The reason, one explained, is that, "If you started the progesterone before you ovulated, the window of implantation is shifted and the uterine lining is less receptive."

Ashby: Yes, it could potentially interfere with ovulation and your chances of conceiving. If you take natural progesterone before you ovulate, it will act like a contraceptive. I would recommend no exogenous hormonal manipulation if you are trying to get pregnant. Women should discuss any hormone supplements they are taking with their physician.

Redmond: Natural progesterone is completely safe in the second half of a woman's cycle. In fact it is commonly used in selected patients to help conception along.

Q: I take antidepressants. Will I need to go off these when I am pregnant and/or should I go off them before I start the process of trying to conceive?

Most doctors recommend that this is something to be discussed with your doctor, to evaluate the risks and the benefits. In 2005, an FDA alert was issued noting that GlaxoSmithKline had changed its warning label on Paxil to include the risk of birth defects. A recent study found an increased risk of cardiovascular defects or congenital malformations, in instances where the mother was taking Paxil during the first trimester of pregnancy.

Singleton: It is very much something you need to discuss with your doctor to weigh the risks versus the benefits. Sometimes the fertility process can be very stressful; we don't want to compromise the patient's well-being. You have to have a well mother before you can have a baby. Studies have found that what we call Category C antidepressants show no demonstrated risk to humans.

Q: Are there ways to increase my fertility or foods I should be eating regularly as I prepare my body for pregnancy?

Most doctors we talked to question any claims of fertility wonder foods, and have more advice about what to refrain from. Many suggested taking a folic acid supplement (800mg per day), not smoking, and losing weight if you are overweight.

Singleton: I have had patients who have read books that say if you eat certain foods it will increase your ovarian reserve. There is absolutely zero evidence to support this conclusion.

Vaughn: It is paramount that women should not be smoking and it is recommended that they avoid second-hand smoke. Women who smoke will decrease their chance of conceiving by at least one-third and will increase their chance of miscarrying. (Smoking is detrimental to sperm as well.) Marijuana can lower the chance of conceiving and increase the chance of miscarriage. Excessive ingestion of caffeine by women is believed to decrease the chance of conceiving and possibly increase the chance of miscarriage. Folic acid supplementation is important for women while they are attempting pregnancy. The supplement does not increase the chance of conceiving but does decrease the chance of the baby having open neural tube defects (spina bifida).

Q: I want to have a girl (or boy). Is there something that can be done to increase my chances? What is the success rate for this?

Due to ethical concerns, many clinics will not do sex selection with IVF embryos except to rule out diseases that are more common in one gender or the other. In this case, it is done by conducting a biopsy of the embryo before implanting it in the uterus.

Wisot: Other than IVF selection, there is only one near-certain method. A patented product called MicroSort(R) is 70 percent effective for boys and 90 percent effective for girls. The process itself costs $3,500 and sometimes increases other fertility-related costs as well. The process uses a fluorescent dye, added to the sperm sample, to bind to chromosomal DNA, according to London's Parliamentary Office of Science and Technology. Because X-bearing sperm contain 2.8 percent more DNA than Y-bearing sperm, they take up more dye and thereby can be sorted. The physician then uses an X- or Y-enriched sperm sample for artificial insemination. I recommend carefully weighing the ethical considerations and increased cost of using a sex-selection process. Sometimes the number of sperm is small so that insemination is not practical and IVF with ICSI is needed.

Schoolcraft: It does decrease significantly the amount of sperm available. If one is already using frozen and thawed sperm and then goes through the MicroSort procedure, pregnancy rates could be diminished. This is not something we generally recommend.

Sims: There are two common methods: swim up methods and flow cytometric methods. We used to perform the Erickson swim up method but abandoned it as unreliable. The flow cytometry method is only useful for fresh sperm. There is only about a 1 to 2 percent recovery after a flow cytometer sorting. My advice is to hope for a happy healthy child.