Infertility & Recurrent Pregnancy Loss

Infertility:  defined as the woman's inability to achieve a pregnancy after 12 months of regular, unprotected sexual intercourse. NaPro defines Infertility as the inability to achieve a pregnancy after 6 months of timed intercourse using the Creighton Model System of charting (CrMS). 

Primary Infertility: the woman has never achieved a pregnancy. 

Secondary Infertility: the woman has achieved a pregnancy in the past, but she is unable to achieve a pregnancy now. 

Recurrent Pregnancy Loss (RPL) (recurrent miscarriage) is defined as two or more pregnancy losses at less than 20 weeks gestation. 

Chemical Pregnancy: the woman achieved a pregnancy, but the baby was lost (miscarriage) very early, typically at less than 4-6 wks.   

There are many causes of infertility and RPL. NaPro providers will do a thorough work up to look for all of them. 

Uterine Structural Causes: 

• Congenital uterine anomalies, eg unicornuate, bicornuate, sepate uteri
• Endometriosis
• Adenomyosis 
• Chronic endometritis (subclinical infection of endometrium) 
• Leiomyoma (fibroids)  
• Polyps 
• Intrauterine adhesions (scar tissue)
• Cervical insufficiency 
• Defective endometrial receptivity, eg: chronic endometritis

Thrombophilias: (thrombo = clot; philia = favor) 

• Factor VII Deficiency 
• Protein S & C Deficiencies
• Factor V Leiden mutation 
• Prothrombin mutation 
• MTHFR mutation 

Immunological Diseases: (Auto-Immune Disorders)

• Antiphospholipid syndrome (APS)
• Systemic Lupus Erythematosous (SLE) 
• Celiac Disease (even mild)
• Myasthenia Gravis  

Endocrine Diseases: 

• Diabetes Mellitus
• Thyroid Disease
• Hyperprolactinemia
• Polycystic Ovarian Syndrome
• Luteal Phase deficiency 

Genetic factors: 

• Aneuploidy- conditions with abnormal # of chromosomes, eg: Down Syndrome (Trisomy 21).
• Other chromosomal abnormalities, eg: Turner’s Syndrome (45X).

Male Infertility 

• Male infertility is believed to be solely responsible for approximately  20-30% of the infertility experienced by couples in the US. 
• Oftentimes I will recommend your husband has a semen analysis and a physical exam for the spouses. 
• Did you know that varicoceles (enlarged veins present in the scrotal sac) are present in 4.4% to 22.6% of the general male population, in 21% to 41% in men with primary infertility, and found in as many as 75% to 80% in men with secondary infertility? Varicoceles can also be easily treated by a urologist. 
• Learn more about Male Infertility here.

For patients who have a diagnosis of Infertility or Recurrent Pregnancy Loss, we will pay attention to two very specific biomarkers: a) TEBB "Tail End Brown Bleeding (brown spotting at the end of your period) and b) a persistent "2W" mucus pattern in the post-Peak phase. Either biomarker may indicate a condition called Chronic Endometritis (C.E.) If you have either biomarker, we would discuss an option to schedule an endometrial biopsy, which can done in a local GYN office or preferably with a NaPro surgeon trained to recognize subtle signs of CE in the endometrium. The endometrial tissue should be sent for examination to look for signs of inflammation. A specific stain called a "CD138" must be ordered with this biopsy to correctly make the diagnosis of CE. About 78% of women treated for for CE with the appropriate antibiotic for 14-21 days are able to achieve a healthy pregnancy. 

On occasion, if the woman's TEBB does not abate with progesterone replacement and she has had RPL, we could have a discussion about "empiric treatment for CE".  This means, I will offer a course of doxycycline or clarithromycin be taken for 14 days to both the woman, which can sometimes resolve the chronic endometritis and allow the woman to achieve a pregnancy. Empiric Treatment will be done on a case by case basis. We do have data to show efficacy. 

 If you are interested in reading a few research articles discussing Chronic Endometritis click hereand here.