By. Dr. Kristi Maas, MD, FACOG
I’ve been reading the recent articles about a mother orca whose baby died shortly after birth. She has been caring this baby for days, unwilling to let go and move on. As a society we are tracking her movements and united in understanding her grief and unwillingness to let go. Oddly, though, this doesn’t seem to translate to care for ourselves and others when a miscarriage happens. Well intentioned people say hurtful things without even thinking about how these words come across. Individuals and couples who have suffered a loss often won’t tell their friends or family for fear of judgement.
Unfortunately, miscarriage happens. It’s certainly not normal, but it’s also not rare. Up to 1/5 pregnancies result in miscarriage. The majority of these are early pregnancies and are due to chromosomal abnormalities. In fact, the more miscarriages an individual has, the more likely these are to be genetically normal as some other factor is contributing to the loss.
Adding confusion to an already painful and stressful situation, there are many different definitions of recurrent pregnancy loss. Some sources state it is 2 or more losses and some state it is 3 or more. Some sources include biochemical pregnancies while others only include losses only after an ultrasound has demonstrated a pregnancy within the uterus. This certainly doesn’t help allay concerns after a loss. The good news is, the majority of individuals or couples who experience loss will eventually go on to have a liveborn child. This is true even for individuals with recurrent pregnancy loss.
When someone has experienced a loss it is important to allow yourself room and time to grieve. Be kind to yourself and reach out for help. Many individuals and couples benefit from counseling and/or support groups. Additionally, discuss these losses with your doctor so she can order the appropriate testing. This generally includes assessment of the anatomy via hysterosalpingogram, sonohysterogram, or hysteroscopy. Additionally hormonal/metabolic causes are evaluated by checking blood levels of TSH, hemoglobin A1C, and prolactin. Anti-cardiolipin antibodies are also checked as are karyotypes (or chromosomal analysis) for both the egg and sperm sources. Despite a long list of labs and tests to evaluate for the cause of recurrent pregnancy loss, 50-75% of individuals with recurrent pregnancy loss have no identifiable cause. Even with unexplained pregnancy loss, 50-60% of individuals and/or couples achieve a liveborn child.
By. Dr. Kristi Maas, MD, FACOG
PCOS stands for polycystic ovarian syndrome. This is a disease that contributes to infertility from multiple factors. Women with PCOS have infrequent or absent periods because they are not releasing an egg or ovulating. This means that sperm and egg do not have a chance to meet so pregnancy doesn’t occur. Additionally, women with PCOS are more likely to have obesity and an elevated BMI has been associated with reduced chances of achieving and/or maintaining a pregnancy.
PCOS is technically a “diagnosis of exclusion” meaning that other conditions that can mimic PCOS must be ruled out. These include abnormalities of the pituitary gland, thyroid, adrenal glands, or ovaries. Additionally, to be diagnosed with PCOS patients must exhibit two of the following:
1) Irregular periods or no periods
2) Clinical signs/symptoms of elevated androgens (excessive hair, male patterned balding, acne) or elevated androgens on laboratory testing
3) Polycystic appearing ovaries on ultrasound
If someone meets two of these criteria and other causes have been ruled out then she has a diagnosis of PCOS. Women with PCOS are often able to get pregnant with ovulation induction. This is generally a process where a woman takes a pill for 5 days to stimulate the ovaries to select and grow an egg for the month. These medications are generally Letrozole or Clomid and recent research demonstrates that Letrozole is favorable in women with PCOS. Some women with PCOS require the use of injectable medications (gonadotropins) to select and grow an egg.
Get the facts on IVF vs. IUI
By. Dr. Kristi Maas, MD, FACOG
Male fertility should be evaluated in any couple who has a diagnosis of infertility (no pregnancy after timed intercourse for 1 year in women under age 35 or 6 months in women over age 35). Men who have significant risk factors for infertility such as testicular surgery, severe trauma, chemotherapy, radiation, known genetic risks for infertility, or any other risks should be evaluated earlier.
The initial step in an evaluation is a comprehensive history and semen analysis. The reproductive history includes prior pregnancies, timing and frequency of sex, duration of infertility, medical history, surgical history, family history, and history of exposure to toxins or radiation. When conducting a semen analysis, semen is generally collected by masturbation 2-5 days after the last ejaculation. Analysis includes evaluation of the semen volume, sperm concentration (how many million sperm per milliliter), motility (what percent are moving), and morphology (shape). Sperm parameters that predict male fertility are concentrations >48 million/ml, >63% motility, and >12% normally shaped sperm. Sperm parameters that predict subfertility are concentrations <13.5 million/ml, <32% motility, and <9% normally shaped sperm. Semen parameters fluctuate so a second semen analysis allows for assessment of variability. Abnormalities on semen analysis may prompt further evaluation and/or referral to a Urologist for further assessment and treatment.
By Dr. Kristi Maas, MD, FACOG
Clomiphene Citrate (Clomid) and Letroozle (Femara) are two medications that can be taken by mouth for infertility treatment. In women who are not having regular menstrual cycles these agents are used for ovulation (releasing an egg) induction. For women having regular menstrual cycles these medications are used for superovulation (releasing more than one egg).
Both Clomiphene Citrate and Letrozole block the feedback from the ovary (Estrogen) to the brain that normally reduces the brain’s release of FSH (follicle stimulating hormone). FSH normally grows eggs and, in a natural cycle, it should be at its highest levels at the beginning of a menstrual cycle. Throughout the menstrual cycle the FSH level drops down and this is one of multiple mechanisms that result in selection of the single egg that is ovulated each month. By blocking the ovary’s feedback to the brain, the brain releases more FSH resulting in ovulation for women who are not doing so or superovulation in women who are having regular menstrual cycles.
Letrozole is an aromatase inhibitor. This means it blocks the production of estrogen and therefore blocks the ovary’s signal to the brain. It is generally well tolerated and comes in 2.5mg tablets. Standard doses range between 2.5-7.5mg daily for 5-7 days.
Clomiphene Citrate is a selective estrogen receptor modulator or SERM. It blocks estrogen from binding to the receptors at the brain (and other sites) and therefore the brain releases more FSH to stimulate the ovary. Clomiphene Citrate comes in 50mg tablets and standard doses are 50-150mg daily for 5-7 days.
Both Letrozole and Clomiphene are taken at the beginning of a menstrual cycle for women having regular cycles, to mimic the natural FSH rise and help select the eggs. Certain patient populations may respond better to Clomiphene or Letrozole. Your doctor will determine if you need one of these medication and recommend one based upon your specific situation.
By. Dr. Kristi Maas, MD, FACOG
Smoking is one of the modifiable factors that impacts fertility. Studies have demonstrated that women who smoke are 1.6 times are likely to be infertile than women who don’t. Additionally, women who smoke go through menopause 1-4 years earlier than non-smokers.
The increased risk of infertility and earlier menopause suggest that smoking likely impacts egg supply. Our current understanding is that women are born with all of the eggs they will have. At 20 weeks in-utero the ovaries have 6-7 million eggs. This drops to 1-2 million at birth and around 0.5 million by puberty. The egg supply continues to decline until menopause, average age of 51 years. Generally, only one egg is used, or ovulated, each month, but the ovary goes through hundreds to thousands of eggs to select and ovulate a single egg. The remaining unused eggs for that month die off. Smoking likely decreases the total number of eggs and, as a result of the decreased egg supply, menopause comes early.
Smoking is also associated with pregnancy and neonatal complications including increased risk of ectopic pregnancy (pregnancy outside of the uterus), miscarriage, intrauterine growth restriction (small babies), placenta previa (placenta placement over the cervix), abruption (tearing of the placenta away from the uterus), preterm premature rupture of membranes (breaking your water early), and low birth weight babies. According to the American College of Obstetricians and Gynecologists “An estimated 5-8% of preterm deliveries, 13-19% of term deliveries of infants with low birth weight, 23-34% of cases of sudden infant death syndrome (SIDS), and 5-7% of preterm-related infant deaths can be attributed to prenatal maternal smoking.” Even after pregnancy is achieved, children born to women who smoke are at in increased risk of health concerns including asthma, colic, and obesity.
Tobacco use among men does not impact fertility as significantly as it does in women. Some studies have demonstrated lower sperm parameters (concentration, movement, and shape) on semen analysis among men who smoke, but studies have not conclusively demonstrated reduced fertility. However, second hand smoke has been shown to increase the risk of low birth weight babies.
Men and women should stop smoking as soon as possible for overall health benefits. This is especially important for those trying to create a pregnancy due to the infertility, pregnancy, and neonatal risks.
1. Augood C, Duckitt K, Templeton AA. Smoking and female infertility: a systematic review and meta-analysis. Hum Reprod 1998;13:1532–9.
2. Baron JA, La Vecchia C, Levi F. The antioestrogenic effect of cigarette smoking in women. Am J Obstet Gynecol 1990;162:502–14.
3. Adena MA, Gallagher HG. Cigarette smoking and the age at menopause. Ann Hum Biol 1982;9:121–30
4. Optimizing natural fertility: a committee opinion. Ferti Steril. 2017 Jan;107(1):52-58.
5. Committee Opinion No. 721: Smoking Cessation During Pregnancy. Obstet Gynecol. 2017 Oct;130(4):e200-e204.
6. Dietze et al. Infant morbidity and mortality attributable to prenatal smoking in the US. Am J Prev Med 2010; 35:45-52.
By. Dr. Kristi Maas, MD, FACOG
Diet and weight can be a sensitive topic, but when it comes to fertility, weight plays an important role. Individuals who are underweight or overweight had decreased fertility. Weight can be classified by a measurement called body mass index or BMI. This looks at your weight compared to your height where you divide your weight in kilograms by your height in meters. A BMI of less than 19 is considered underweight and BMI over 25 is considered overweight. BMI greater than 30 is considered obesity.
Being too thin can impact fertility and impair egg release (ovulation). One of the first signs can be irregular menstrual cycles (periods) or no cycles. Multiple factors signal our body that it is a suitable time and environment to reproduce. If our body perceives it is starving, this is not an optimal time for pregnancy given that calorie requirements increase in pregnancy. Even individuals with a normal weight can signal the body they are starving with restrictive dieting and/or eating disorders. In general, a woman must gain 2 pounds more than the weight at which she stopped having her period to resume menstruation. Individuals looking to gain weight should focus on healthy fats and complex carbohydrates, not high calorie simple carbohydrates. Studies suggest that individuals with a BMI <19 take four times a long to conceive than those with a normal BMI.
Being obese also impacts ovulation. Women with a BMI >30 are at an increased risk of having irregular or absent menstrual cycles. Even modest weight reduction of 5-10% in obese patients can be enough to restore ovulation. Weight reduction should be gradual and consistent at a max of approximately 2 pounds per week. Studies have shown that individuals with a BMI >35 take twice as long to conceive.
Tracking calories consumed and calories burned with a food and activity diary can help patients achieve their goal weight and maintain this weight for optimization of fertility. All individuals should achieve at least 150 minutes of exercise per week. Those looking to lower their BMI should increase this duration and those with a low BMI who already exercise above this may want to reduce their activity in addition to increasing their caloric intake. Working with a nutritionist and/or a personal trainer and discussing your goal weight with your doctor can help you optimize your fertility.
By Dr. Kristi Maas, MD, FACOG
One of the most common questions I’m asked is how to time intercourse. The reality is that if there was a magic pill or potion that we would give it to all patients and 100% of people wanting to get pregnant would do so. That said, there are things that you can control to optimize your fertility.
Timing intercourse appropriately is important to optimize sperm and egg exposure at the peak fertility window. Your most fertile days are the day before your release and egg (ovulate) and the day before that. In men with normal sperm parameters, daily ejaculation usually does not impair sperm function. Abstinence intervals greater than 5 days between ejaculations may impact sperm quality and after 10 days semen parameters are impaired.
The fertile window is the time period where sperm exposure maximizes the chance of pregnancy. This is generally defined as the 6 day time period leading up to the day of egg release, but can vary from woman to woman. Predicting your fertile window can be done with menstrual tracking, ovulation predictor kits, or cervical mucus evaluation. Most applications available for menstrual tracking perform well for women with regular approximately 28 day cycles. They are less reliable for women with longer or shorter menstrual cycles. For women with shorter or longer cycles a good estimate is to subtract 14 from the general cycle length to get the day of ovulation. Daily or every other day intercourse during your fertile window can optimize your attempts of natural conception.
Although there are tales of putting your feet above your head or following a routine after intercourse, there are no validated techniques that enhance your chances. Sperm placed at the top of the vagina can be found in the cervical canal within seconds after ejaculation and will swim to the fallopian tubes within 15 minutes.
One aspect to be cautious regarding is the use of certain lubricants. Water based lubricants can inhibit sperm movement when it is assessed in a lab. Oil or hydroxyethylcellulose based lubricants do not have the same effect and would be recommended for couples trying to conceive.
Submitted by a former patient, 2018
You will ask each other questions you thought you would never have to ask. What will you do if you divorce? What will you do if either of you die? What will you do if it doesn’t work? Can you be happy with or without a child? Can you be strong? Can you be vulnerable? Can you tell each other the truth?
You’ll find yourself in a room with your partner asking each other those questions. You will make choices together that impact the both of you until the day that you take your last breath. There will be anger, sorrow, sadness, and frustration. You will feel all of that for your partner. You will find yourselves frustrated with your doctor. You will question every choice you both made throughout the process.
You will cry and weep because of the pain that may find you.
You will hold onto hope when it feels as if there is none left. You will need to turn to each other every step of the way. The only people that will understand what you are going through are the both of you, and those that have gone through it themselves.
But don’t be afraid to share. Don’t be afraid to tell your friends. Share as much as you can with those closest to you. In your vulnerability you will find your strength. When you encounter defeat, don’t stop. When all hope is lost, don’t stop.
You’ll want to be done, but keep going.
Eventually, you’ll find an answer, and that little boy or girl you’ve been hoping for will be with you. It may not be in the way you expected and the road you took may have required you to stretch yourself in ways you never thought you would have to, but you can get to the place that you wanted to when you first walked through those doors into your doctor’s office.
It will be a long road, but at the end of it you’ll find it was the end of a chapter, not the end of a story. Your story is just beginning, and that’s why you’re here.
You’re here because of the next chapter….poopy diapers, first steps, school, t-ball, training wheels, and a cranky teenager. You will fight for your family in a way that most others never have to. Own your journey here, but don’t let if define you.
You will find a light at the end of your path and years from now you’ll look at your family and know that it was all worth it.