Taking the first step in your infertility journey is overwhelming. Here at Reproductive Health Center, we hope to ease new patient fears by laying out what our initial appointments look like. Whether you have Endometriosis, PCOS, Male Factor, are looking to use Donor Gametes, or have another fertility concern, our main goal is make sure you feel comfortable throughout your entire journey. Dr. Scot Hutchison took to Facebook to share our evaluation and testing process, as well as answering some questions about semen analysis, nutrition, and pregnancy after tubal sterilization.
If you’re interested in becoming a patient here at RHC, read on to learn all about our process or listen to the entire video on Facebook Live.
We’re here to answer your questions. Give us a call at (520)733-0083 or schedule your initial consultation.
Hello, it’s Dr. Scot Hutchison here at Reproductive Health Center in Tucson, Arizona. And it’s our first Hutchison’s Huddle for the new year. So we moved it up a little bit because we see that most of you watch these later in time anyway, on your own time, so that kept me from having to keep my co-workers here super late. And I thank Karina Bacame today who is here helping facilitate this live streaming.
So today’s topic is about what to expect as you start fertility evaluation. And so I won’t speak for all other fertility practices, but I’m just going to tell you kind of what you would expect as far as evaluation, and let’s first start with when you should actually be evaluated–and that’s after you have been trying to get pregnant for about a year, if you are under age 35, and if you are over age 35, after about six months of attempts, or with either one of those if there’s some problem that you know has probably a pretty good possibility of interfering with conception, like, no periods at all or very irregular periods or a male partner with a history of a testicular injury, or if you have, you know, if you’re a lesbian couple, gay couple and there is no chance of getting pregnant on your own, then come and make your appointment sooner.
So, typically for both the male and the female partners, if they’re in a heterosexual relationship, we want them both to be toeing the line as far as no alcohol, no recreational drugs. Again, just because it’s legal doesn’t mean you should do it because marijuana has been shown to be fairly corrosive for fertility. Likewise, I don’t like people to have CBD oil on board because we just–a lot of the CBD products were contaminated with THC. So I would avoid all that. We like you to be taking vitamins like a men’s multi if you’re a guy, a prenatal if you’re a woman, for at least three to six months before even attempting conception, if possible. Extra folic acid if you are wanting to get pregnant you right away and you haven’t been taking the prenatals for at least three months to really help decrease the risk of birth defects in the brain spinal cord. And then for women who are either single and going to be doing donor insemination or a lesbian couple that are going to be going to route where one is going to be trying to get pregnant with the other one’s eggs or just with donor sperm, we really like to, again, follow those rules. For gay male couples who are going to be using egg donation and gestational carriers, we also like whoever is going to be providing the sperm to also toe the line with that. And I think that it’s probably easiest if both partners do that, because it’s pretty difficult, I think to abstain from things like really nice wine if your partner’s sitting across the table from you saying, “Oh, this is so good with this dinner!” So anyway that’s the timeline of like when you should call on things.
Typically when people call here, we set up for at least a 45 minute appointment. Most of the time, it’s going to go beyond that, sometimes it’ll go under. A few people this week, actually, we were able to wrap things up in about 40 minutes, because they had sent in their history forms beforehand and we were able to take a look at that and do all the data entry for that and streamline taking their history and they were very uncomplicated, so they didn’t have lots of issues for us to have to cover after the physical exam. But typically, we take about 10 to 15 minutes to complete the whole history and figure out what’s really going on. And then we take about 10 or 15 minutes to do a physical exam and a pelvic ultrasound, and that is usually a pretty quick deal and not too uncomfortable, but kind of like having a pap smear. We usually will do gonorrhea and chlamydia cultures, or DNA probes. And then a manual exam to see if anything–if we can feel any modularity from endometriosis or fibroids and see if things feel like they’re stuck together in the pelvis suggesting that there’s adhesive disease. And then transvaginal ultrasound, but that all goes pretty fast. And it doesn’t really matter if you’re actually menstruating or not with that. We don’t care. I mean everybody always feels self conscious themselves if they’re bleeding, but again, we here don’t care about that at all. And sometimes that’s a good time to do a physical exam because it’s sort of a clean slate, so to speak, in the pelvis with regard to ovarian cysts and and things like that.
Sometimes when we find things, especially on the pelvic ultrasound like fibroids, or ovarian endometriosis, we will take the time to measure those and then catalog them to try to get a record of what is going on right now. And sometimes that can be pretty tedious. So if somebody has multiple uterine fibroids or an endometriosis cyst or two, then that transvaginal ultrasound can kind of stretch into, you know, several minutes rather than being really pretty quick.
Then we usually will regroup in the office and we’ll talk about what we found, what else evaluation we’re going to do. And typically, if you haven’t had a lot of blood testing already, what we do is have you on cycle day two or three of normal period to get anti-mullerian hormone (AMH) testing, follicle stimulating hormone (FSH), luteinizing hormone (LH) to look at the ratio of those two–which can kind of suggest some of ovulatory dysfunction–estrodiol, red cell antibody screen, prolactin, thyroid testing, chem-panel blood counts, and then check for all the serum bad diseases so–HIV, Hep B, Hep C and Syphilis. (Glossary of Fertility Terms)
And then we’ll also do a test of the fallopian tubes in women who are actually going to be trying to get pregnant with the fallopian tubes and that’s called a hysterosalpingogram, and that’s done with a–you know, the ultrasound has no radiation, that’s just soundwaves. The histogram actually uses a little bit of x-ray which is ionizing radiation to see the fallopian tubes, but that’s still is the gold standard for assessing the fallopian tube, short of surgery. So, we will go ahead and do that test as well. That’s done after the menstrual period, but before you ovulate, and the reason for that is that eggs are pretty radio-resistant and so are sperm, but in early embryos that’s a lot of genetic material that’s being unfurled and being used, and so it’s more susceptible to that ionizing radiation. So we don’t like to do that after you may have actually ovulated and conceived. For women where there’s no chance of getting pregnant on that given cycle, we will do those sometimes later that in the cycle if the uterine lining doesn’t look too thick. But if it’s really pretty thick, then the second part of the cycle you can actually cause the fallopian tubes to be artificially kind of obstructed by the lining being really thick or getting debris into the connection parts or proximal ends of the fallopian tube. So that’s the standard fertility evaluation and then we also do a semen analysis.
So semen analysis has been done about the same way for about the last hundred years or so. Interestingly, the average numbers of sperm and semen analysis have fallen by about fivefold over the last hundred years. And it’s hard to know what that is all being caused by, but it’s probably a combination of factors including environmental pollution and then especially some of the agents that can act as hormones in the body–the plasticizers like BPA and its ilk–those up here to do some really bad things for sperm production. Also, people have gotten heavier over time. As men gain more fat mass, they make more estrogen and that will pull sperm counts down and the sperm motility. So, semen analysis though, we typically like the sample to be at the office within about an hour. We prefer that men produce a sample at home, because it’s a little more private and they’re able to usually give a little bit better sample. The volume of the seminal fluid is relatively dependent on length of abstinence time, so the longer, the more volume you have, but also arousal. And so if you’re really nervous and you’re trying to collect in a restroom, then that doesn’t really give you the best volume that you’re typically are going to have. We like guys to get the best sample by ejaculating every day for about three or four days beforehand, and then take a day or two off, and then take your time collecting the sample at home, and then just bring that in. For guys that are farther away then an hour, we typically will provide a place to collect on-site where they can be behind a couple of closed doors. So, that’s the general evaluation.
What we tend to see in terms of what’s keeping people from getting pregnant, at least a third or more folks have some sort of ovulation problem. And those are pretty easily corrected. A lot of people have endometriosis, or some history of pelvic adhesive disease. And then about 40% or 50% have some degree of male partner contribution to that either with lower sperm counts, also guys who are over 40 tend to have sperm that work less well and the risk of having kids with autism and bipolar disorder is a little higher for guys over 40 just because of those genetic problems.
The general rule of thumb with making an appointment a lot of people feel kind of uncomfortable asking questions. We really want you to ask those questions. We really want to know if you’re really understanding the whole process of what we’re trying to figure out what’s going on. And then if you really understand like, whatever treatment we’re going to have you do, because understanding that biology is really pretty important. And you know, in other places in our neighboring state of New Mexico, they have far better health education in high school years, even in middle school years. Here in Arizona, we haven’t really abysmal health education, part of it is due to an agenda by some legislators up in the Maricopa County or Phoenix area to really restrict the sex education because basically they don’t feel that it’s appropriate for even high school students to have access to that information. But the upshot is that it’s not just about talking about sex education, birth control, but just biology. So many of our patients don’t understand even the basics of ovarian function like how the ovary is recruiting several eggs a month, and then it’ll allow one to go forward and ovulate, and that container for the egg is called a follicle, and that after that follicle releases the egg, it’s going to make progesterone, and then that will continue until the woman gets pregnant or until a couple of weeks go by. And then if she’s not pregnant, then the ovulation cysts will undergo programmed cell death and kind of go away and then the woman will get a menstrual period. So, if you don’t understand all that stuff, please let us know because we really want to bring you up to speed on that so that you can have a pretty good idea about the rationale of what we’re going to try to do to help you conceive.
Karina, anything else you can think of?
So the people where we find things wrong, like even on the initial evaluation, if they’ve got uterine lining polyps, sometimes we will evaluate those further by doing what’s called a sonohysterogram test, or the hysterosalpingogram, where we’re checking the fallopian tubes as well. And a lot of those polyps will go away with proper nutrition. You probably have heard me say before, but there’s a growing body of data that the uterine lining biome or the bacteria that live in the uterine cavity actually have a big impact on our fertility. So to get those really good bacteria into the uterine cavity, what we are recommending is that people eat fermented foods regularly–so foods like kimchi and active culture sauerkraut and active culture pickles, and eat at least two or three bites of those with some other food once a day or even a few times a day. If you’re new to those fermented foods, sometimes they will give you a little bit of diarrhea–I would encourage you to stick with it and continue with those until things straighten out. Certainly our patients who have a history of chronic constipation will do a lot better typically with eating those fermented foods and we really do want people to have regular bowel movements all the way through pregnancy because pregnancy tends to slow down the bowels anyway and it can really put people at risk for things like hemorrhoids which are really uncomfortable later. So then if you do have polyps that don’t go away on their own, we usually will remove those with a tool called the hysteroscope and that’s a telescope that goes in the uterine cavity. And then we can use different tools like the MyoSure device, which is a small suction and cutting device that can then chip those little polyps out of there.
People who have really high sugar diets, high junk food diets tend to have more uterine lining polyps and what we see is that they tend to have a harder time getting pregnant overall. Part of that may be that you know, tha a high junk food diet also puts people at risk for being heavier and if you’re heavier, your fertility is lower, whether you’re male or female.
Typically we’ll have discussions with people about what our findings are down the road or if they’re confused. Those IVF discussions, in particular, we do those without charge because we don’t want people to feel like they have to commit IVF and pay out of pocket to kind of figure out more about that. So if you would like to have one of those discussions, if you’re thinking about IVF, certainly that’s a that’s a really good idea to get that going sooner rather than later.
Anyway, if any of you have any questions right now, feel free to ask, but that’s kind of how we get started here at Reproductive Health Center. But other places may do it a little bit differently. And feel free to send us messages asking questions, if you have any others.
Oh, wait. There’s another question here. What about tubal reversal information?
So for those of you who’ve had a tubal sterilization procedure–and this traditionally has been removing a segment of the fallopian tube and then the tube is tied or just the center part of the tube can be burned–those can be reversed with microsurgery. In general, the pregnancy rates for tubal reversal surgery are less than they are with IVF now because the technology with IVF has gotten so much better that in terms of cost effectiveness, as far as dollar spent for baby got, the IVF is probably more cost effective in most areas of the country. However, there’s still people who want to have tubal reversal surgeries. Those we typically will do–for those patients will typically do that hysterosalpingogram test to see how much remaining tube is left close into the uterus. If there’s not a fairly good amount of that left in there, then trying to do the connection with the other part of the two usually is a dismal failure. And most of those surgeries, we will actually start with doing a laparoscopy if we feel like there’s a good chance of it working. And then if there’s a fair amount of tube left, then we’ll go ahead and put the tubes back together. That procedure we typically will quote people that the tubes will usually stay open, and then about 50% of the time they’ll take home another baby. The disturbing thing about tubal reversals is that about 15% of the patients will have a pregnancy in the fallopian tube down the road and those can be life threatening. So we like to, whenever people can see pretty quick–after a tubal reversal we like to figure out pretty quickly where the pregnancy is and if it’s in the fallopian tube, then it needs to either be removed surgically or we need to give some medicine called methotrexate to remove to have the pregnancy go away, because you can’t open up the tube and transplant the pregnancy into the uterus unfortunately. The same things apply for people who are going to go through a tubal reversal as far as both parties you know, taking their vitamins, eating really healthy food, getting enough sleep, not eating junk food staying out of hot tubs. Certainly, we want to do a semen analysis before we would commit anybody to tubal surgery because we really need to know if there’s going to be enough sperm and you really need to have a pretty normal semen analysis to have the best pregnancy rates with tubal reversal surgery if you’re just going to have intercourse for conception.
So what else about tubal–a lot of patients in the future aren’t going to be eligible for tubal surgery because a few years ago, the gynecologic oncology doctors found out that a lot of what are thought to be ovarian cancers actually originate in the fallopian tubes. So it may be as high as 60% of the ovarian cancers may be from the tube. Certainly, it seems like a pretty solid number is about 40%. So when women are declaring that they’re not going to have any more kids in the future and they want really good contraception, then the surgeons who are doing the tubal sterilizations a lot of the time now we’re removing the the entire fallopian tube, just to decrease that risk of ovarian cancer in the future. And certainly if you remove the whole tube, then there’s not going to be anything to put back together and you’ve got to do IVF for conception. So it’s good to look into both of those options–both IVF and tubal reversal surgery–if you’re willing to have more kids after tubal sterilization.
A phenomenon that we tend to see all the time is that women who have had tubal sterilizations typically did them for a really good reason, like they didn’t tolerate some or many forms of other contraception. So they have gotten pregnant lots of times accidentally on another contraceptive, for example, so they consider themselves to be very, very fertile. But once those tubes have been damaged and then some time has gone on and gone by, then the odds of getting pregnant can really shift into not so good a number. So the kind of the rule of thumb is, if you’ve had a tubal ligation for longer than 10 years, you really need to think twice about doing it just because you probably, you know, you’re 10 years old or older, and if you had it in your 20s, you’re now in your 30s, maybe your late 30s, early 40s, and even though you had great fertility a long time ago, it really may not be all that great now. And with tubal reversal surgery, you cannot test embryos. You’re going to ovulate whatever egg you ovulate and it’s going to roll into the uterine cavity and implant. And we know that that starting at about age, even the late 30s, the risk of miscarriage due to abnormal genetics and embryos tends to go up. By the time you’re 40, it’s about give or take, 20% or more by the time you’re 42, it’s abou 34 to 50%. I mean, it just keeps kind of climbing as time goes by and that’s because most of those embryos were abnormal. So for women in their later 30s or early 40s, who’d had tubal reversals–or have had tubal sterilization surgeries, IVF is really probably a better choice for family building because you can test those embryos before you put them in to decrease the risk of miscarriage and increase the chances of actually taking a baby home.
So anyway, if you have other questions, give us a call here at Tucson (520)733-0083. And even if you’re outside of our area, give us a call! We do these information sessions for a reason, and we want people to be well educated. And especially, do yourself a favor and don’t eat junk food and eat those pickled vegetables, those fermented foods because those are going to do you a good term!