Infertility is a sign of an underlying disease and not a diagnosis in itself. With restorative reproductive approaches such as NaProTechnology, underlying diseases are targeted and then corrected to restore optimal health. Healthy parents are more likely to conceive and have healthy pregnancies and children.
Targeting the underlying disease also applies to general health as reflected in signs of fertility, such as young men with sexual dysfunction or young women with cycle disorders. These underlying diseases should be identified and corrected not only for family planning but for overall health.
In working with couples challenged with fertility concerns, think about 2 broad categories: Lifestyle Choices and Medical/Surgical. Let us continue with medical/surgical approaches.
◻️Fertility care/fertility awareness charting. Fertility care/fertility awareness charting can reflect accurately a woman’s physiology especially when taught by a trained, certified teacher. It is a vital medical record and it will help enormously in directing & interpreting lab tests, imaging studies, procedures, and timing of treatment. The chart also becomes a guide for couples helping them focus intercourse during times of fertility and help to accurately date conception.
History, physical, and fertility care chart review: Blood pressure, weight, and PAP smear. Any sleep dysfunction (snoring, restless legs, irregular breathing, morning depression) can be a sign of sleep apnea which negatively affects pregnancy outcomes.
Labs: Targeted hormone profile (LH, FSH, progesterone, estradiol): Many reproductive hormones vary through the cycle and getting certain labs based on the fertility care chart (her physiology) verses the calendar is much more precise. Because of their highly irregular cycles, some women will be directed to get labs on a modified schedule. Other hormones such as testosterone, prolactin (elevated levels from benign brain tumors can affect cycles), thyroid (at least TSH and fT4 with the TSH ideally between 1-2 and the fT4 in the upper third of the range), and DHEA-S for possible adrenal causes.
Glucose/Insulin: Fasting glucose levels can be deceiving and many times women are suffering from insulin resistance. Higher levels of insulin are toxic to the follicle as well as other organs. A Hemoglobin A1C can assess average glucose levels over the past 90 days. Even better is an oral glucose tolerance test with insulin response. Excellent research has shown that much tighter standards are superior in discovering glucose/insulin impairment. Improving nutrition is fundamental but the supplement myo-inositol (2-4 grams daily) helps with insulin resistance. Metformin, a prescription medication, may still be indicated.
General Labs: CBC (complete blood count) checks for anemia especially when a woman has heavy menstrual flow but also other parameters of her blood which can affect fertility. Comprehensive metabolic is a general chemistry lab that screens kidney and liver function as well as protein and electrolytes and glucose. Although fatty liver is the most common form of elevated liver function tests, levels above 20 in women should be assessed further for hepatitis infections. The ranges on most labs are higher only because there is so much fatty liver in the western world and blood centers would be able to accept fewer donations if the range was more physiologic. Cholesterol is the building block of hormones and should be checked. Additionally, many women have high cholesterol from genetics and nutrition and the high levels may be revealing associated diseases such as polycystic ovarian syndrome. Bleeding/Clotting tests may be indicated if there have been blood clots, excessive/prolonged bleeding, and multiple miscarriages.
Imaging: Pelvic Ultrasound: This ultrasound can help to evaluate the structure of the ovaries, uterus, and cervix. There maybe congenital defects, presence of uterine fibroids, ovarian cysts, etc. that may need to be corrected to improve pregnancy outcomes. The ultrasound is not used to diagnose endometriosis. Hysterosalpingogram (HSG): This is when an X ray is taken after dye is squirted into the uterus which then travels through the tubes. This is to assess if the tubes are open. Hysteroscopy: This is usually done by a gynecologist who views the uterus and the first part of the tubes with a very small scope put into the cervix. The gynecologist can view the tissue, take samples, and test if there is back pressure in the tubes. Additionally, dye is used to get an X ray.
Surgery: Laparoscopy: A gynecologist looks into the pelvis with a scope through the abdominal wall and can perform surgery through that scope. Most gynecologists are now being trained in robotic microsurgery. Highly trained NaProTechnology gynecologists are trained in “near-contact” surgery, evaluating very closely any and all possible endometrial blebs and remove them. Ovaries can be treated with ovarian wedge resection or drilling for polycystic ovarian disease. “Napro” gynecologist are also trained in microsurgery tube repair in addition to all standard gynecologist procedures. Additionally, these gynecologists are trained in special techniques to reduce or eliminate post-surgical adhesions.
Common medications: Prenatal vitamins: It is very important for all women who may become pregnant to take a daily prenatal vitamin because of the folic acid. Taking folic acid at the level in prenatal vitamins significantly reduce neural tube defects (spinal column and cord) in the first 8 weeks of development. Myo-inositol: Over the counter 2-4 grams daily for insulin resistance. Metformin: prescription insulin sensitizer that may be indicated beyond myo-inositol. Cooperative progesterone & progesterone in pregnancy: Progesterone is produced after ovulation by the corpus luteum. Since a woman is charting, she can take progesterone to normalize levels according to her physiology after she ovulates. Getting levels to normal prior to pregnancy is necessary to develop the lining of the uterus and to block progesterone induced blocking factor (PIBF). Progesterone increases steadily in pregnancy until the final couple of weeks but some women need to take progesterone support in pregnancy. This can be injected or taken orally/vaginally and is identical to the progesterone the body makes. Estradiol: Some women may need estradiol support in their cycle and possibly in pregnancy. Human Chorionic Gonadotropin HCG: A subcutaneous injection that is used for post ovulatory support and early pregnancy support. Low dose naltrexone: Helpful in endometriosis, PMS, and autoimmune disorders. Prednisone: Pre-ovulatory for possible sperm antibodies which are usually present in women who have had multiple partners in their life. Clomid or Letrazole: Used in the early part of the cycle to help ovulation. Antibiotics: To increase cervical mucus or to clear any chronic endometritis. Probiotics: Proper intestinal bacterial balance has major impact on health but only work well when eating right.
Common diseases: Endometriosis: Uterine lining that is outside the uterus such as on the bladder, ovaries, tubes, colon and can swell and cause pain and dysfunction. Being considered as to cause autoimmune like disease. Only definitive treatment is removal via laparoscopy. Can be present in teens and usually manifests as painful periods. Highly associated with infertility. Polycystic ovarian syndrome: High testosterone, irregular periods, and ovarian cysts. Associated with insulin resistance, weight gain, depression, acne, and abnormal hair growth. Premenstrual syndrome (PMS): In week prior to menses women will experience food cravings, irritability, sleep problems, depressed mood, breast tenderness, swelling and these symptoms will be relieved within a day or so of the menses. This is a low progesterone state and women are successfully treated with progesterone in the post ovulatory stage. Progesterone is converted to allopregnanolone in the brain which affects the GABA system which has to do with mood and anxiety. Women with PMS are much more likely to suffer with post-partum depression. Post-partum Depression: This is a low progesterone state and is easily treated with progesterone replacement. This will not affect breast feeding.
History and physical: Blood pressure, weight, genital exam especially for varicocele, epididymitis, and prostate. Any sleep dysfunction (snoring, restless legs, irregular breathing) needs to be assessed for sleep apnea. Sleep apnea reduces testosterone and fertility in men while also increases risk for cardiovascular and lung disease.
Labs: Seminal Fluid analysis: Seminal fluid is best collected during a normal act of intercourse for both ethical reasons and for more correct assessment. Size, shape, and activity of the sperm is assessed along with white blood cells. Testosterone: Many men have low testosterone and knowing this level along with the seminal fluid analysis may help to treat poor SFA. General chemistry: Glucose, hemoglobin A1C, kidneys, liver, and proteins. Pre diabetes and diabetes are highly associated with poor fertility in men due to poorer blood flow to testicles. Cholesterol: May indicate cardiovascular disease which reduces blood flow to testicles.
Surgery: Varicocele repair can help improve seminal fluid analysis.
Common medications: Clomid: Prescription low dose daily or every other day helps improve seminal fluid analysis Antioxidant supplements such as Vitamin E, Vitamin C, and glutathione have been demonstrated to improve sperm analysis. Carnitine enhances mitochondrial energy output and selenium helps sperm development, motility, and function.
Author: Dr. Gretchen Marsh, Family Practice Physician and Fertility Provider with MyCatholicDoctor