The inability to become pregnant or carry a pregnancy to term is caused by a myriad of medical conditions and other contributing factors. Therefore, each case of infertility needs to be uniquely reviewed to identify if there is a single cause, several causes, or no identifiable cause. Both partners should be evaluated, as in the U.S. about 9% of men and 11% of women in their reproductive age experience fertility problems. Evaluating the cause of infertility in only the female partner can waste months of valuable time and result in the use of inappropriate, unnecessary, and often expensive procedures while during this time, the male partner could be identifying and correcting his fertility status as well. Even if there is an identifiable cause in the female, the male partner should still be evaluated.
Infertility Evaluations of Both Partners
The following standard evaluations are performed when infertility concerns arise.
WHO Semen Analysis Reference Ranges
| PARAMETER | NORMAL |
|---|---|
| Semen volume | >1.5 mL |
| pH | 7.2 or more |
| Sperm concentration | 15 million/mL or more |
| Total sperm number | 39 million or more |
| Total motility | >32% progressive motile, >40% progressive and nonprogressive |
| Vitality | 58% or more live spermatozoa |
| Sperm morphology | 4% or more |
Male partner standard evaluations include:
- History: prior paternity; undescended testicles at birth; trauma to testicles; medical and surgical review; sexual dysfunction; medication, alcohol, tobacco, and illicit drug use.
- Examination: testicular abnormalities; varicocele; absences of vas deferens.
- Semen analysis: See chart above.
Female partner standard evaluations include:
- History: prior pregnancies and
outcome; medical and surgical
review; sexual dysfunction; medication, alcohol, tobacco, and illicit drug use; menstrual disturbances. - Ovulation: urine luteinizing
hormone ovulation predictor kits; mid-luteal serum progesterone. - Ovarian reserve: cycle day 3 follicle-stimulation hormone; estradiol levels; clomiphene citrate challenge test; antral follicle count.
- Uterine and fallopian tube:hysterosalpingogram to test tubal
patency and uterine contour; follicular phase transvaginal ultrasound.
Eumenorrhea, or normal menstrual cycles by history, is a highly accurate marker of ovulation, and anovulatory levels of serum progesterone (<3ng/mL) are found in only a very small minority of normal menstrual cycle patients. Therefore, if you do not have normal menstrual cycles and are considering conception, whether in the near or far future, it is advisable to seek out treatment for your abnormal cycles.
The results of ovarian reserve testing are not absolute indicators of infertility, but abnormal levels correlate with decreased response to ovulation induction medication and lower birth rates after IVF, which is of concern when considering advanced reproductive technology treatment options.
Unexplained Infertility
When healthcare providers cannot find a specific or likely cause from the standard testing above, the term “unexplained infertility” is used to describe a couple’s fertility status. Unexplained infertility cases apply to approximately 30% of infertile couples and it has been shown that unexplained infertility couples have a greater rate of spontaneous conception than couples with an identifiable cause for their fertility struggles. According to the Journal of Reproduction and Infertility, spontaneous pregnancies have been reported to be 13–15% in the first year of attempts, increasing to 35% the next two years of attempting to become pregnant, and can reach as high as 80% in younger couples in the following three years of unprotected sex. It is argued that with such a high rate of conception in unexplained infertility, no further fertility treatment is necessary.
The argument to stop here and wait can seem like torture for many eager couples who urgently wish to be pregnant, leading many physicians to refer patients to advanced reproductive technologies (ART) prematurely and unnecessarily. While many unexplained infertility couples will become pregnant without assistance, it is worth taking a look at other reasons for the couple’s inability to conceive. Often these reasons are not identified or addressed by mainstream doctors; therefore, couples will need to make an appointment with a functional medicine practitioner.
Unexplored Categories with Fertility Impacts
- Adrenal Dysfunctions: The glucocorticoid (GC) cortisol has numerous studies showing high levels adversely impact health, including direct inhibition of the brain hormone, GnRH, that regulates FSH and LH release. GC also affects estrogen, progesterone, and ovulation.
- Thyroid Dysfunctions: Autoimmune thyroid conditions, even without elevated TSH, are linked to infertility with increased risk of miscarriage. Most physicians stop at TSH testing and never look at a full thyroid panel.
- Gut Health: Improper bacteria, poor intestinal lining integrity, and dysfunctional digestion and absorption can all indirectly influence fertility health. Your liver’s role in removing hormones is another reason to look at the health of the digestive system.
- Nutritional Deficiencies: Due to genetic variants, some people are unable to create the active form of important fertility nutrients. Folate is one such nutrient and is vital for proper fetal development. Genetic mutations for activating folate into methyl folate are associated with recurrent pregnancy loss. Vitamin A is another commonly overlooked fertility nutrient. Deficiency of vitamin A can cause a genetic mutation wherein the body does not effectively convert food beta-carotene into the active form the body uses, retinol. Women with this mutation can have what is described as “golden ovaries” due to the accumulation of beta-carotene, as well as other menstrual abnormalities.
- Environmental Toxins: Environmental toxins can alter immune cell function, produce inflammatory markers in the body, create progesterone resistance and estrogen dominance, cause oxidative stress, and can result in poor egg quality and reduced sperm motility. One toxin of particular concern in regard to fertility is bisphenol A, found in soft plastics designated with #7 or PC letters, canned foods, receipts at stores, glass jar lids, and more. Another toxin that has not been made since 1977 but is found in umbilical cords of infants born today is PCB (polychlorinated biphenyls), which people are exposed to mostly through eating contaminated fish, meat, and dairy products. Heavy metal toxicity is another environmental factor that impacts time to conception and pregnancy outcomes. Phthalates found in toys, vinyl flooring, medical devices, perfumes, lotions, and cosmetics are of particular concern with male fertility health.
In a recent study, 85% of women in IVF cycles had bisphenol A (BPA) in their urine, which were found to be inversely associated with the number of oocytes (eggs). Urinary BPA was also inversely associated with peak serum estradiol levels, meaning the more BPA in the urine, the lower the estrogen peak was. This equated to the women being “poor responders” to IVF. There have been studies showing implantation failure in women with higher BPA levels undergoing IVF and increased miscarriage with higher serum levels of BPA. As for BPA’s influence on the fertility of the male partner, a five-year study showed higher exposures to BPA, measured in urine, resulted in lower-quality sperm concentration, count, and motility, and decreased sperm vitality. BPA has also been found in the follicular and amniotic fluid.
PCB levels in the general public have been shown to increase the odds of implantation failure and ability to become pregnant from one cycle to the next. Additionally, phthalates in the urine are associated with decreased sperm concentration, motility, and FSH and LH, both hormones involved in sperm formation.
Exploring Your Options
Unexplained infertility can be even further explored through examining diet choices, lifestyle habits, and sleep disturbances/habits, which, once corrected, can improve a couple’s chances of becoming pregnant. These are unexplored reasons for infertility in many cases and they are known to greatly impact your overall health when not balanced. Find a trusted practitioner who will work with you through the extra exploration that may be needed to find the reason behind your infertility struggle.
Dr. Nicole Kerr, ND, LAc is the owner of an all-natural fertility clinic in Wallingford CT, Fertility Oasis. At Fertility Oasis, Dr. Kerr teaches her patients the importance of preconception care and about all treatment options available to couples wanting and/or struggling to conceive. Male and female infertility factors are addressed to offer comprehensive fertility care for her patients.
Fertility Oasis, 857 N Main St Ext Suite 1, Wallingford CT, 203.265.0459
fertilityoasis.com.