Infertility Causes & Workups

Here at the Center For Reproductive Health & Gynecology, we believe that discovering the cause of your infertility is the first step to helping you on your way to a new family. There are several things that can cause infertility, including ovulation problems, such as polycystic ovarian syndrome (PCOS), tubal disease, sperm problems, unexplained infertility, and endometriosis. If you want to learn more about the following causes of infertility, including PCOS and endometriosis, contact our Beverly Hills, Valencia, or Burbank office. We look forward to hearing from you!

Infertility Causes

Ovulation Problems

Problems with the ovaries can be caused by several things, including stress, eating habits, nutritional supplements, thyroid disease, other medical conditions, or tumors or growths in the brain. One of the most common causes of ovarian problems is polycystic ovarian syndrome (PCOS).

Polycystic Ovarian Syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) is one of the most common problems affecting women and is one of the leading causes of infertility. PCOS is a syndrome in which the ovaries are enlarged and have several small, painless cysts. PCOS can affect fertility, menstrual cycles, and hormone levels, as well as appearance, including acne, growth of facial hair, and hair loss.

PCOS Symptoms

Symptoms of PCOS can vary widely from woman to woman and can be mild or severe. A woman with PCOS may experience one or more of the following symptoms:

• Infertility
• Irregular or absent periods
• Ovarian cysts
• Excess facial and/or body hair (hirsutism)
• Alopecia (male-pattern hair loss)
• Obesity
• Acne
• Skin tags
• High cholesterol levels or high blood pressure

If you are experiencing these symptoms of PCOS, don’t hesitate to contact us in Beverly Hills, Valencia, or Burbank right away.

PCOS Treatments

There is no cure for PCOS, but it does need to be managed to prevent further problems. There are several medications you can take to control the symptoms of PCOS, including birth control pills, progestins, and blood pressure or cholesterol pills. A balanced diet, exercise, and maintaining a healthy weight can also lessen the symptoms of PCOS.

There is a surgical procedure available to treat PCOS, but it is not recommended as the first course of treatment. Ovarian drilling is a surgical procedure in which a small incision is made above or below the navel, and an instrument is inserted into the abdomen. Punctures are made in the ovary and a small portion is destroyed with an electric current. There is a risk of developing adhesions or scar tissue on the ovary, so it is important that you discuss this procedure with one of our board certified fertility specialists before making a decision.

If you are experiencing symptoms of PCOS, contact our Beverly Hills, Valencia, or Burbank office to schedule an appointment.

Tubal Disease

When the fallopian tubes are blocked or damaged, it can prevent the eggs from getting to the uterus or the sperm from getting to the egg. Common causes of tubal disease include Infection, prior pelvic surgery, or endometriosis.

If you would like to learn more about tubal disease, contact the Center For Reproductive Health & Gynecology in Beverly Hills, Valencia, or Burbank today.

Sperm Problems

Sperm problems, or male infertility, can be the result of several things, including problems with the brain or pituitary gland, systemic disease or other medical conditions, and congenital abnormalities resulting in abnormal count, motility, and morphology. There are some patients who have no sperm (azoospermia), which could be due to a mechanical blockage in the tubes that store and transport sperm from the testes (vas deferens).

If you would like to learn more about male infertility, contact the Center For Reproductive Health & Gynecology in Beverly Hills, Valencia, or Burbank today.

Unexplained Infertility

Unexplained infertility is the failure to conceive after one year of unprotected intercourse with no apparent cause for the infertility, i.e. open fallopian tubes and normal sperm and ovulation.

Unexplained infertility may be due to inefficient fertilization of eggs or lack of fertilization, slow division or stopped division of embryos, thick outer shell (zona pellucida) of the egg, or implantation failure. For more information about thickened outer shell (zona pellucida) and treatment, please visit the assisted hatching section of our website.

If you would like to learn more about unexplained infertility, contact the Center For Reproductive Health & Gynecology in Beverly Hills, Valencia, or Burbank today.

Click here to view Dr. Najmabadi's article on unexplained infertility

Endometriosis

Endometriosis is one of the major causes of female infertility. Endometriosis is a disease that can progressively get worse over time and can reoccur after treatment.

Endometriosis is a condition in which the tissue that lines the uterus (endometrium) grows outside the uterus. When the endometrium grows outside of the uterus, it can attach to organs in the abdominal cavity and is usually found on or under the ovaries, on the tissues that hold the uterus in place, or on the bladder or bowels. The endometrial tissue outside of the uterus swells and thickens in response to menstrual cycle hormones. The endometrial tissue in the abdominal cavity sheds blood that has no place to go, resulting in pools of blood that cause inflammation and scar tissue. As the tissue grows, it can develop into growths, also called tumors or implants. This scar tissue can interfere with ovulation or block the fallopian tubes, making it difficult to conceive.

What Are The Symptoms of Endometriosis?

Pain is one of the most common symptoms of endometriosis, especially in the abdomen, lower back, and pelvis. Additional symptoms of endometriosis include, but are not limited to:

• Extremely painful menstrual cramps
• Chronic pelvic pain, including the lower back
• Pain during or after sex
• Intestinal pain
• Painful bowel movements or painful urination during menstrual periods
• Heavy menstrual periods
• Premenstrual spotting or bleeding between periods
• Infertility
• Gastrointestinal symptoms similar to those of a bowel disorder
• Fatigue

If you are suffering from these symptoms of endometriosis, contact our Beverly Hills, Valencia, or Burbank office to schedule a comprehensive endometriosis exam with one of our fertility specialists.

What are the Treatment Options For Endometriosis?

No one knows for sure what causes endometriosis. There is currently no cure, but we offer various treatments at both our Beverly Hills and Valencia offices. The only way to confirm that you have endometriosis is to have a laparoscopy. During laparoscopy, a lighted tube is placed inside your abdomen through a small incision below the naval. This allows the surgeon to view the abdominal cavity and the reproductive organs, and it helps to determine the size and location of the growths. There are three classifications of endometriosis: stage 1 (minimal), stage 2 (mild), stage 3 (moderate) and stage 4 (extensive). These classifications are based on the amount of scarring and can help decide the best treatment option for you. Treatment may include medication, surgery, or both.

Medication for Endometriosis

Women with mild endometriosis symptoms may only require medication for pain as needed. If you have minimal endometriosis and want to become pregnant, it may be recommended that you have unprotected sex for six months to one year. If you do not conceive in that time, you may require more extensive treatment. If you have endometriosis but do not wish to conceive, you may be treated with hormones.

Surgery for Endometriosis

In most cases, surgery is the best option for women who have extensive endometriosis or who have severe pain. The most common surgical treatment for endometriosis is laparoscopy. During the procedure, incisions are made in the lower abdomen. Small surgical tools are inserted through the incisions and are used to remove or destroy the scar tissue and growths.

In cases of severe endometriosis, a laparotomy may need to be performed to remove the uterus, ovaries, or fallopian tubes. This is a major surgery and is usually considered the last resort for women who are suffering from extensive endometriosis.

Endometriosis is a common and often painful disorder. If you are experiencing symptoms of endometriosis, don’t wait to contact our Beverly Hills, Valencia, or Burbank office.

Fertility Work-ups

In order to discover what is causing your infertility, we need to perform a fertility work-up. If your attempts at pregnancy have failed for a full year, you should contact the Center for Reproductive Health & Gynecology, located in Beverly Hills, Valencia, and Burbank, to schedule a fertility work-up with one of our board certified infertility specialists. Earlier intervention should be sought if any of the following conditions apply to you:

• Elevated FSH value
• Abnormal Semen Analysis
• Abnormal HSG (showing blocked tubes or damage to the fallopian tubes
• Irregular or missed menstrual periods
• Two or more miscarriages
• Prior history of tubal disease or pelvic infection
• Previous or current prostate infection
• Previous or current sexually transmitted disease of either partner
• Reversal of surgical sterilization of either partner
• Endometriosis
• Breast discharge
• Excessive acne or hirsutism (a heavy growth of hair, often in abnormal distribution)
• If you are about to start cancer treatment and wish to preserve fertility (freeze eggs, embryos, or sperm)

During your fertility work-up, three essential questions will be answered:

• Is there a problem with the sperm?
• Is there a problem with ovulation, egg quality, or ovarian reserve?
• Is there a problem with the fallopian tubes?

We assess the male and female partners by hormonal assays (blood tests), semen analysis, evaluation of ovarian reserve, and evaluation of the uterus (uterine cavity and tubes).

Female Hormonal Assays

Hormonal testing is recommended when irregularities are identified in your menstrual cycle or physical examination. We offer various hormonal tests at our Beverly Hills, Valencia, and Burbank offices, including estrogen and progesterone levels, FSH and LH levels, testosterone and other androgens, thyroid tests, and prolactin levels. The results of these hormonal tests help determine the best course of treatment for each individual patient.

Estrogen

Estrogen is largely responsible for stimulating the development of the endometrium, the blood-rich mucus membrane that lines the uterus. There are three forms of estrogen found in the human body - estrone, estradiol (E2), and estriol. Low levels of estradiol may indicate that the follicles (small sacs in the ovaries) do not contain healthy eggs. Because estrogen levels vary during the menstrual cycle, they are usually measured over several days.

Progesterone

Progesterone is a hormone produced after ovulation that is critical to successful implantation. The progesterone hormone test is performed four to nine days after predicted ovulation or the LH surge to determine if ovulation has occurred. Low findings of progesterone may suggest a lack of ovulation or anovulation (the failure, termination, or suppression of ovulation).

FSH and LH Levels

Follicle Stimulating Hormone (FSH) and Luetinizing Hormone (LH) control ovarian function. These hormone tests are usually recommended for women who have abnormalities in their menstrual cycles or who do not ovulate normally.

Testosterone and Other Androgens

The ovaries and adrenal glands usually produce small amounts of androgens (male hormones), including testosterone. If androgens are overproduced, normal ovulation can be affected. Indications of excess androgen include oily skin, acne, and excessive hair growth.

Thyroid Tests

The thyroid can affect fertility, the ability to become pregnant and maintain a healthy pregnancy, postpartum health, successful breastfeeding, and even the health of your baby.

The thyroid-stimulating hormone (TSH) is tested at both our Valencia and Beverly Hills clinics to detect any problems affecting the thyroid gland. TSH, which is produced by the pituitary gland, is measured first because it is a more sensitive indicator of thyroid function than the thyroid hormone itself.

Prolactin

The prolactin hormone is located at the base of the brain and is responsible for stimulating milk formation during pregnancy. Excess prolactin, a condition known as hyperprolactinemia, can result in an assortment of reproductive dysfunctions, including irregular ovulation and menstruation, absence of menstruation, and galactorrhea (breast milk production by a woman who is not nursing).

Male Hormonal Assays

There is a common misconception that infertility is a “woman’s problem.” That is simply not true. In fact, infertility affects males and females with almost equal frequency. Common factors contributing to male infertility are low sperm count, poor sperm motility, and abnormal semen levels or function. We offer several male hormonal assays at our Beverly Hills, Valencia, and Burbank locations to evaluate hormones essential to sperm production, including the follicle stimulating hormone (FSH), luteinizing hormone (LH), testosterone, and prolactin.

Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH)Tests

Both the luteinizing hormone (LH) and follicle-stimulating hormone (FSH) are essential for reproduction. The FSH stimulates the production of sperm and the LH stimulates the testes to secrete the male sex hormone, testosterone. High levels of FSH and LH can indicate a failure of testicular function that may not respond to hormone therapy. Low levels of FSH and LH may indicate that the testes are not receiving an adequate stimulatory message from the pituitary gland or hypothalamus, which can be improved with hormone therapies.

Testosterone Tests

Testosterone, which is produced by the testes, stimulates sperm production and is required for sperm motility. A low sperm count may indicate a problem with testosterone levels. Thyroid dysfunction may also be present, although it is rarely a cause of male infertility.

Prolactin Tests

A high prolactin level may result in an abnormal semen production. Treatment for elevated prolactin is both available and effective.

Ovarian Reserve Screening

Age has a significant impact on both the quality and quantity of a woman’s eggs. In fact, a female’s fertility begins to decline in her early 30s. Ovarian reserve screening is a method we can use to predict your reproductive potential as well as the potential of a healthy pregnancy. Ovarian reserve screening tests at our Valencia, Beverly Hills, and Burbank clinics include:

1. Estradiol (E2) and Follicle stimulating Hormone (FSH) testing.
2. Inhibin B.
3. Clomid Challenge test.
4. Ultrasound for antral follicle count.
5. Ovarian volume and blood flow evaluation.

Semen Diagnostic Testing

An evaluation of male infertility should be taken early in your infertility assessment so we can determine your options. Semen diagnostic testing at our center in Beverly Hills or Valencia can help you decide which treatment is the best choice for you.

Semen Analysis and Sperm Function Testing

A semen analysis is used to determine whether there is normal sperm production and delivery. If a problem is identified, a more detailed evaluation should be performed.

A standard semen analysis usually includes:

• Semen level (normal semen volume is 2-5 mL)
• pH (normal: 7.5-8.5)
• Concentration (20 million/mL is the acceptable lower threshold of normal fertility, but lower numbers do not rule out a fertile male)
• Motility, or the ability of the sperm to swim (normal motility is at least 50 percent)
• Morphology, or appearance of the sperm (normal % morphology by strict criteria is >14 percent)
• Progression (the ability of the sperm to swim in a purposeful manner)
• Viability (the percentage of sperm in a sample that are alive)
• Viscosity (the ability of semen to become thinner by 30 minutes after ejaculation)

There are four categories of semen abnormalities that may be found during the semen analysis: azoospermia (a complete absence of sperm seen in the ejaculate), oligospermia (a low sperm count with concentrations of less than 20 million/mL), asthenospermia (a low motility with less than 40 percent motile sperm/mL), and teratospermia (a low percentage of normal sperm forms).

Uterus and Fallopian Tube Testing

Hysterosalpingogram (HSG)

A hysterosalpingogram (HSG) is an x-ray of the uterus and fallopian tubes that reveals abnormalities in the uterus or blockages in the tubes. During hysterosalpingogram at our Beverly Hills, Valencia, or Burbank office, x-ray sensitive dye is injected into the uterine cavity that reveals the size, shape, and symmetry of the uterus. If there is no blockage present in the tubes, the dye will spill into the abdominal cavity. Dye flowing into the abdominal cavity does not guarantee normal function, but it is a positive sign.

Hysterosalpingograms can also determine where blockages are located. The two most common areas for blockage are where the tube and the uterus meet (proximal) and the end of the fallopian tube (distal). In some cases, pushing dye through the fallopian tube will remove any material that is causing a blockage. In fact, some women have become pregnant following a hysterosalpingogram without the use of further fertility treatments.

Other conditions that can be seen with a hysterosalpingogram include polyps, fibroid tumors, scar tissue, and defects within the fallopian tubes. Hysterosalpingograms can also provide an estimate of the quality of the tubal structure and the condition of the tubal lining.

No special preparation is needed for hysterosalpingogram, but in some cases, antibiotics need to be taken to protect against infection. You may also need to take anti-inflammatory medication, such as Motrin, an hour before your exam to help alleviate cramping. You may also experience a sensation of warmth during the hysterosalpingogram, but many patients report little discomfort.

Saline Infusion Sonography (SIS)

Saline infusion sonography (SIS) can effectively diagnose and evaluate abnormalities within the uterine cavity, including scarring of the uterine lining, uterine fibroids, and endometrial polyps. It can also be a valuable diagnostic tool for evaluating women who have had recurrent miscarriages.

SIS is usually performed at our Valencia, Beverly Hills, or Burbank office just after menstrual flow has stopped but before ovulation has begun. During the procedure, the endometrium is separated to allow visualization of the entire endometrial lining.

Laparoscopy

During laparoscopy, which is usually performed under general anesthesia, a telescope-like instrument is inserted through a small incision at the belly button into the abdomen. The abdomen is then inflated with carbon dioxide to allow full visualization of the pelvic organs. One or two small incisions are made along the lower abdomen where graspers can be inserted to visualize the entire abdominal cavity. Dye is then passed through the cervix and uterus to evaluate function and patency, and the fallopian tubes are inspected to ensure there are no blockages or abnormalities. Video and photographs are taken during the procedure to record findings. Once the procedure is complete, the abdomen is deflated and the incisions are stitched closed. Recovery time for laparoscopy is usually about one hour.

Hysteroscopy

Hysteroscopy is a minimally invasive surgical technique that allows one of our board certified fertility specialists to evaluate the uterine cavity. This is important because abnormalities of the uterine cavity may prevent fertility and can even interfere with pregnancy.

Diagnostic hysteroscopy is performed when:

• The results of a hysterosalpingogram show a uterine abnormality
• Women have repeated miscarriages
• A routine ultrasound shows evidence of a polyp or fibroid

Fertility-related diagnoses that can be made with hysteroscopy include:

• Submucosal myomas
• Uterine polyps
• Adenomyosis (endometrium glands growing into the muscle wall of the uterus)
• Scarring of the uterine lining (Asherman's Syndrome)
• Presence of a uterine septum or bicornuate formation
• Congenital abnormalities of the uterus

If minor abnormalities are detected during the hysteroscopy, they can be treated at the office during the procedure. If more extensive correction is needed, hysteroscopic surgery can be scheduled for a later date.

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