Infertility and Pre-Pregnancy Counseling

Understanding Infertility

By Desireé M. McCarthy-Keith, M.D., M.P.H

Are you having trouble getting pregnant?  Are you preparing for pregnancy down the road?  No matter where you fall on the fertility spectrum, you should be armed with information about your reproductive health.  First, understand that infertility is defined as the inability to conceive after one year of unprotected intercourse, or after 6 months when a woman is 35 years old or older.  At any time, about 10% of couples have trouble getting pregnant, which translates into approximately 7 million women and their partners.  The cause of infertility can be due to female factors, male factors or both.

 A common misconception is that black women don’t struggle with infertility, partly due to unbalanced stereotypes of black women as super-fertile and more in need of birth control than infertility treatment.  You may be surprised to know that while infertility rates for white women are falling, rates have increased for black women over the past several years.  Although black women are more likely to have infertility issues, we are less likely to ever receive infertility treatment.  When we do seek treatment for infertility, we have usually waited longer before seeing a fertility specialist, have more fibroids and are more likely to be overweight than women from other ethnic groups.

The most common causes of infertility for black women are advanced age, uterine fibroids, and damaged fallopian tubes. All women have a natural decline in egg supply over time.  This process beings at birth, with about one million eggs in the ovaries, and completes at menopause when the egg supply is exhausted.  The loss of eggs from the ovaries is gradual through teen and young adult life, but the process speeds up after the mid-thirties.  The loss of eggs is compounded by a decline in the quality of remaining eggs, which are aging as the woman ages.  This natural change in the ovaries results in lower chance of pregnancy and higher chance of miscarriage as we get older.  There are no medical treatments that can slow down normal ovarian aging.  The process is not affected by pregnancy, use of birth control or fertility treatment.  Women must recognize that if they put off having children, it may be more difficult to get pregnant once they are ready and that they should see a fertility specialist sooner as they get older.

By age 50, about 80% of black women will be diagnosed with fibroids, so chances are good that either you, a relative or friend will be treated for fibroids in your lifetime.  Fibroids are benign (non-cancer) tumors of the uterus and are the most common gynecologic problem for women.  Fibroids can range from the size of a pea to the size of a football.  They can cause infertility by blocking sperm from entering the uterus or tubes, or by making the uterus an unhealthy place for a baby to develop.  If fibroids are the cause of infertility, myomectomy (surgical removal of fibroids) can remove this obstacle and improve the chance for pregnancy.  Pelvic infections like gonorrhea and chlamydia, endometriosis and tubal ligation can damage the fallopian tubes and cause infertility as well.  If the tubes are blocked or damaged, in vitro fertilization (IVF) can be an effective treatment with a good chance of pregnancy.

The basic female infertility evaluation should include a test of ovarian reserve, a screen for blocked tubes and an evaluation for uterine fibroids.  A simple blood test to check the Anti-Mullerian Hormone (AMH) level can provide information about a women’s current egg reserve.  As the egg supply declines, so does the AMH level.  The hysterosalpingogram (HSG) is an outpatient x-ray exam which flushes dye into the uterus and fallopian tubes to determine if the tubes are open.  Very large fibroids can be detected on a routine pelvic exam and smaller fibroids can be seen by ultrasound.  

Many couples believe infertility is mostly a female problem, and evaluation of a male partner is usually an afterthought.  But we have to keep our brothers in mind when we’re talking about infertility because in 20-30% of infertile couples, a problem with sperm production or function is the sole infertility factor.   For men, hormonal, physical or genetic conditions can be the cause.  Medical conditions like diabetes and treatment for low testosterone can also have a negative impact on sperm.  Semen analysis should be one of the first tests performed when a couple is having trouble conceiving.

Preparing for Pregnancy

So now you know that the biological clock is real, and that there are other factors that can be a challenge to your fertility.  This may lead you to ask, “What can I do to improve my chances of getting pregnant?”  And “Are there things that I should be working on now in preparation for pregnancy in the future?”  Although you can’t stop the clock, you should be aware of the great impact of your age on your fertility and seek evaluation and treatment sooner if you are having trouble conceiving. 

The obesity epidemic, stemming from poor diet and lack of exercise, is affecting the black community at a high rate.  Being overweight or obese increases a person’s risk of developing diabetes, heart disease and certain cancers.  Ovulation problems are a common cause of infertility in overweight women.  The body mass index (BMI) can be calculated from the height and weight, to determine if a woman’s weight is within the “healthy” range.  Women should aim for a BMI less than 30 to reduce the chance of developing weight related diseases and to avoid any negative impact of weight on fertility.  Regular exercise and healthy diet are the foundation for maintaining a healthy pre-pregnancy weight.  The diet should be low in processed foods, carbohydrates and fat and rich in plant-based sources of protein.

Cigarette smoking and exposure to second hand smoke can lower female fertility.  The toxins produced by cigarette smoke can damage eggs developing in the ovaries, speed up the loss of eggs and lead to premature aging of the ovaries.  Heavy alcohol consumption (14 or more drinks per week) can also lead to longer time to pregnancy and infertility.  Women should abstain from drinking alcohol from conception until the end of pregnancy to avoid any risks of fetal alcohol exposure.  It is generally considered safe for women to consume 200-300 mg of caffeine daily, without any harm to their fertility.

 Some studies suggest that stress can cause female infertility, although it is difficult measure a direct effect.  Planning for pregnancy can be very stressful and dealing with infertility can add to that stress.  Relaxation techniques, acupuncture, stress management and group therapy can be useful in reducing stress and may improve fertility.

Male fertility can be challenged by infections, chemicals, genital trauma and high heat exposure to the testicles.  Contagious diseases like mumps and tuberculosis, and STD’s like gonorrhea and chlamydia can also affect sperm.  Men should avoid exposure to radiation, chemicals and pesticides and avoid hot baths, saunas, tight fitting underwear and prolonged sitting while working or driving.

 When preparing for pregnancy, your best bet is to get healthy before you start trying to conceive and to maintain healthy behaviors for life.  You should get annual gynecologic exams and practice safe-sex techniques to prevent STDs.  Don’t smoke cigarettes, avoid second hand smoke and make healthy diet and exercise part of your daily routine.  Maintaining a healthy weight and keeping an eye on that biological clock are the two best things you can do for your fertility.  To your health!