Taking Charge of Your Fertility

by Toni Weschler

  Surgery and IVF

  Even though there are many who believe that endometriosis is best treated by surgery, it can be a risky option if you are trying to get pregnant, for the reasons discussed above. Indeed, certain fertility specialists like to say that you need to be “quick but conservative.” In other words, once you have been diagnosed with the condition, you should keep in mind that it tends to get worse with time, so you will want to treat it fairly aggressively. At the same time, you should be extremely cautious with any surgery that could cause excessive scarring, especially on the ovaries.

  Some women will need a combination of both medical and surgical therapy, but in any case, if you want to conceive, you should try to get pregnant within six months of completing treatment. This is because the condition can quickly recur as bad as it was before. And finally, if you don’t respond to any of the above, you may still be able to get pregnant through IVF.

  Weighing the options

  To summarize, if you find a surgeon who is highly experienced with removing endometriosis, that may be your best choice. However, there are many doctors today who believe that if you have endometriosis on the ovaries themselves, you should bypass surgery and go straight to IVF in order to avoid further scarring. Of course, the condition itself can compromise the IVF procedure, so you may require more attempts than average for it to be successful. Alas, and as you can see, there is no ideal or risk-free solution for this condition.

  FALLOPIAN TUBE ISSUES

  If you’re reading this section, it’s likely that you’ve already had an HSG to determine whether or not your tubes are open. And, while you may have been relieved to learn that they are, if you are still dealing with idiopathic infertility, you should know that there is another test that may be able to identify more difficult-to-detect tube-related problems.

  Before discussing that test, though, let’s briefly review what an HSG is. It’s a procedure in which dye fills the uterus and ultimately flows through the fallopian tubes, revealing any abnormalities, such as uterine fibroids or adhesions. If the dye flows through the tubes, most clinicians will declare the test successful, and for most women, it is. However, if you’re still struggling to get pregnant after having undergone only the HSG, you should discuss the utility of the test below with your clinician.

  Tubal Perfusion Measurements and the Broader Tubal Picture

  Just because the dye spills out of the uterus and through the tubes, it only tells you that they are open. However, the more important question is whether they are functioning normally, for an open tube may still have mechanical issues that prevent it from grasping the egg and drawing it inside. Fortunately, the procedure known as Tubal Perfusion Pressures (TPP) tests precisely for this situation.

  If your TPP results are abnormally high, it may signal that your tubes, while open, are too rigid or diseased. Because of this, the fimbria at the end of the tubes may not be able to sweep the released egg into the tubal opening, thereby making an eventual conception impossible. (See picture of fimbria in the color insert.) If this were the case, your most promising option would be IVF.

  There are several causes of blocked or dysfunctional tubes, including pelvic inflammatory disease and even appendicitis, while the most frequent condition affecting the actual fimbria is endometriosis. Regardless, having the proper tests will hopefully reveal not only whether your tubes are open, but whether they’re truly functioning properly, and if they’re not, where to focus next.

  IMMUNOLOGICAL INFERTILITY

  One of the more disputed causes of unexplained infertility is that of immunological conditions such as autoimmune disease, though for the purposes of this discussion, we’ll assume the link. Unlike many other causes of diminished fertility, these conditions may not only make it difficult to get pregnant, but it could also make it difficult to sustain a healthy pregnancy once conception has occurred.

  Autoimmune diseases are serious chronic illnesses that can affect both genders, but they occur more often in women, and most frequently during the childbearing years. Normally, the immune system functions incredibly well to protect various organs in the human body, but occasionally it goes awry and attacks those very organs. There are more than 80 serious, chronic autoimmune illnesses that can impact nerves, muscles, and connective tissues as well as the endocrine and gastrointestinal systems.

  Some of the more common examples of autoimmune diseases are multiple sclerosis, ulcerative colitis, psoriasis, rheumatoid arthritis, and lupus. Although these conditions are still among the most poorly understood illnesses today, it appears that hormones play a role. And while there is a strong hereditary component, the way they cluster in families is not straightforward. For example, a grandmother may have ulcerative colitis, her daughter rheumatoid arthritis, and her granddaughter psoriasis.

  Part of the challenge of diagnosing these types of diseases is that in the early stages, symptoms and lab results can be ambiguous, though in principle they are diagnosed through overt symptoms, a physical exam, and lab tests. Interestingly, infertility itself can be one of the first signs that a woman is in the early stages of such an illness.

  Since the causes of these chronic conditions are not well understood, their treatment can be tricky, especially as it pertains to fertility issues and miscarriages. If you are diagnosed with one, you should ideally find a clinician experienced with the fairly aggressive medical treatment that may be required, and you can take heart from the fact that most patients with autoimmune conditions are still able to conceive and give birth to a healthy baby.

  Moving Past the Mystery

  My hope is that this chapter has given you the basic information and confidence you need to ask for various alternative tests that may ultimately uncover the cause of your fertility issues and, if necessary, to seek out the second and even third opinion of those clinicians who are open to different approaches. I believe that by more thoroughly exploring these common causes of unexplained infertility, women can significantly raise the odds of finding the root causes and necessary treatments to finally give birth, and ideally without having to resort to the invasiveness and expense of IVF.

  CHAPTER 18

  Maintaining Your Gynecological Health

  Sex is a pleasurable exercise in plumbing, but be careful or you’ll get yeast in your drain tap.

  —RITA MAE BROWN

  Have you ever thought about how odd it is that the most intimate details about your body are filed in a medical office across town? Why shouldn’t you have access to such records in your own home? Once women learn to chart, they take control of all facets of their health care—from annual exam results to the symptoms that may prompt them to seek medical care in the first place.

  Most women have fairly common conditions that are considered medically normal but may appear problematic to them simply because they were not taught about the healthy female body. In addition, as mentioned earlier, there are true gynecological conditions that can be more easily identified through charting, including:

  •vaginal infections

  •unusual bleeding

  •premenstrual syndrome

  •breast lumps

  •endometriosis

  •PCOS

  By now, this list should be familiar to you. But I think it’s important to repeat why charting is so beneficial for your gynecological health. One of the points I made in the beginning of this book is that charting enables a woman to understand her body in a practical way. As you’ll recall, I said that a woman who charts every day is so aware of what is normal for her that she can help her clinician determine irregularities based on her symptoms rather than those of the average woman. The remainder of this chapter will discuss both normal and abnormal gynecological conditions and how FAM can be used to distinguish the two.

  NORMAL, HEALTHY CERVICAL FLUID VERSUS REAL VAGINAL INFECTIONS

  Healthy Cervical Fluid

  From a health perspective, the obvious benefit of learning about your own pattern of cervica
l fluid is to be able to determine if and when you have a true vaginal infection.

  Marsha is an American FAM instructor teaching in Israel. While getting her master’s degree in public health in the States, she had an annual Pap test. She was charting her cycles, and planned her appointment for midcycle, knowing it would be more comfortable for her since her cervix would be slightly open. Of course, she also had a lot of stretchy cervical fluid at the time. As the physician removed the speculum, he exclaimed, “My dear, you have an infection,” to which she replied, “Excuse me? I feel fine and don’t have any symptoms.” He replied, “Look at this discharge!” showing her the Pap stick with the obvious cervical fluid on it. “Well, I know I’m in my fertile phase and these are just my fertile secretions.”

  The nurse stood behind him, winking and nodding in agreement with her. He curtly and abruptly responded, “Well, we can’t know for sure. I’m going to prepare these slides for STIs, including gonorrhea, syphilis, and chlamydia,” and then proceeded to prescribe a week’s antibiotics to take until the results came back.

  Needless to say, she didn’t take the drugs. Nor did the results test positive for any infections. As she cynically sighed, “I knew this was normal for me. But what about the average woman who doesn’t know FAM? What kind of message does this send her?”

  Is it any wonder that women grow up believing they are dirty all the time and in need of douching and spraying away the “discharge”? The continual advertising of douches and feminine sprays only reinforces the confusion between healthy cervical fluid and what is in fact a true infection. Millions of dollars a year is spent promoting vaginal douches alone.

  If you think this is harmless, consider a well-known talk show whose topic one day dealt with gynecology. No sooner had the two OB/GYNs finished explaining why douches and sprays were unnecessary and potentially infection-producing, when the show cut to a commercial. And what was the commercial about? You guessed it—vaginal sprays!

  Only a minute earlier, one of the gynecologists had wryly commented that the income he generated treating women who had developed infections from using these products was enough to send all his children to college. And nowadays, with over-the-counter products readily available for yeast infections, how many women buy them to try to eliminate “those annoying infections” that just keep recurring every month?

  Realistically, though, there may be times when you really do have a vaginal infection. Obviously, knowing your own pattern will enable you to detect the onset of an infection almost immediately, and treat it before you’re tempted to shoot yourself. One of the reasons women are often misdiagnosed, as was the FAM instructor above, is that a “symptom” during one time in a woman’s cycle may be nothing more than a fertility sign in another. So, for example, wet secretions midcycle is absolutely normal, but may be an indication of an infection if it occurs in the latter phase. (One exception is explained here.) Of course, the sooner you detect a potential infection, the sooner you can treat and eliminate it.

  Symptoms of Vaginal Infections That Can Be Distinguished from Normal Cervical Fluid

  Fortunately, once you learn your own cervical fluid pattern, you’ll be able to identify true infections, which almost always occur with any number of unpleasant symptoms that distinguish them. Vaginal infections can range from STIs such as chlamydia and herpes to various forms of vaginitis and, of course, the generic yeast infection.

  And women who may be more susceptible to infections are those who have cervical eversion, a benign condition in which the cells that normally line the cervical canal migrate to the outside of the cervix. Since these cells are more delicate, they can become more easily infected. Those who are more prone to cervical eversion are teens, women on the pill, and pregnant women.

  While it’s beyond the scope of this book to identify the individual symptoms and treatments for all these conditions, the following symptoms are definitely not part of healthy cervical fluid secretions, and should therefore be seen by a clinician:

  •abnormal discharge

  •unpleasant odor

  •itching, stinging, swelling, and redness

  •blisters, warts, and chancre sores

  Some women may have a gummy or yellow secretion that is usually thick and snaps like old rubber cement. This may actually be normal, although it can also indicate an inflamed cervix (cervicitis). In addition, a clear or whitish constant discharge can be a sign of cervical erosion. So, you will want to have either of these checked to rule out a potential problem.

  Avoiding Infections

  There are certain precautions you should take to avoid contracting infections in the first place. Aside from the obvious consequences of douching, you should be aware that wearing clothing that is either damp or too tight may create an unhealthy vaginal environment. So I’m afraid the camel-toe look, in addition to being a tad tacky, is clearly not an option if you value a healthy vagina. In any case, be sure to always wear cotton underwear, or, at a minimum, underwear with cotton crotches, and lingerie that allows your body to breathe.

  NORMAL NABOTHIAN CYSTS ON THE CERVIX VERSUS ABNORMAL CERVICAL POLYPS

  Nabothian Cysts

  These cysts are a fairly common female condition. They are little bumps that appear on the surface of the cervix and are caused by cervical glands which may become temporarily blocked. Women who haven’t been taught about these cysts may panic the first time they feel one, not realizing they are completely harmless. Women often feel them the first time while checking their cervix or inserting a diaphragm or cervical cap.

  They usually disappear on their own, but if they don’t, you should probably have them checked by a clinician at your next annual exam to rule out anything else. Then simply draw them on your chart in the miscellaneous section and keep track of them. You can chart them as done in the example here.

  Abnormal Cervical Polyps

  Polyps are small, tear-shaped growths that protrude from the mucus membranes of the cervical canal. Unlike nabothian cysts, which are quite firm, these tend to be somewhat spongy. Although they are considered abnormal, they’re almost always benign. You may not even be aware you have one unless you experienced one of their symptoms—unusual bleeding. This is due to their vulnerable position in the vagina, making them susceptible to being tapped, especially during intercourse. They are typically not painful, but may cause excess cervical fluid due to irritation of the mucus glands. If you think you may have one, you should consult a physician.

  NORMAL CYCLE-RELATED PAIN VERSUS ABNORMAL PAIN

  Normal Cycle-Related Pain

  Alas, female pain can be a little tricky. Certain pains during a woman’s cycle can be absolutely normal. For example, midcycle pain, which is often referred to as mittelschmerz, is thought to be caused by a number of factors:

  •the follicles swelling within the ovaries

  •the egg passing through the ovarian wall

  •contraction of the fallopian tubes

  •a small amount of blood being released at ovulation, irritating the pelvic wall

  This is all considered normal, and even constitutes a secondary fertility sign. When you feel mittelschmerz, you can be pretty certain that ovulation is about to take place or just occurred.

  Another example of cyclical pain is headaches, which tend to occur in the postovulatory (luteal) phase. If a woman weren’t charting, she might not realize that they are related to her cycle instead of being a potential problem. If she finds a pattern of headaches on her chart at only certain points in her cycle, she can be more confident that these headaches are probably hormonally based.

  Regardless, you can record them as Maddie did in the chart below.

  Maddie’s chart. Various pains throughout the cycle. Colors can be used to keep track of cyclical pains or other symptoms. Note that Maddie filled in the specific symptoms she wanted to track in the far left column. (Click here to see the page in the color insert for another example.)

  Abnormal Pain

 
; On the other hand, if you notice pelvic pain that is intense or occurs at other times in the cycle, it could be an indication of any number of conditions. If it’s possible you are pregnant and you experience a sharp stabbing pelvic pain, you should see a doctor immediately, since this could be a sign of an ectopic pregnancy. Such pregnancies are life-threatening if they rupture and cause internal bleeding. They occur when a fertilized egg implants outside of the uterus, usually in the fallopian tubes (which is why they are often called tubal pregnancies), and may include the following symptoms beyond the pain itself:

  •an overdue period

  •unusual vaginal bleeding

  •a positive pregnancy test

  •fainting

  •shoulder pain, due to possible internal bleeding

  Another type of pain with potentially serious ramifications is associated with pelvic inflammatory disease (PID), an infection and inflammation of the upper reproductive tract. It’s the leading cause of preventable infertility due to the pervasive scarring it can cause, especially in the fallopian tubes. Although you may not have any symptoms, it’s more likely that you will feel:

  •pain in your lower abdomen

  •fever

  •vaginal discharge

  •painful urination

  •pain during intercourse

  •irregular menstrual bleeding

  Perhaps the most problematic source of pain is endometriosis. As you may remember, this is where cells from the uterine lining (the endometrium) begin to grow outside the uterus, often attaching to other parts of the internal reproductive system. It can result in adhesions and scarring, and potentially impede fertility. One of the classic symptoms of endometriosis is pelvic pain before and during menstruation, as well as during intercourse (click here for a list of other symptoms).