Infertility Education
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Definition of infertility:

Infertility is the failure to achieve pregnancy after 12 months or more of regular unprotected intercourse. Earlier treatment may be justified based on medical history and physical findings.
But if the woman is above 35, she should seek treatment by a specialist after 6 months of regular unprotected intercourse.
15 % of couples are infertile. 40% is due to female factor, 40% is due to male factor, and 10% is due to mixed male and female factors and 10% is of unknown reason.

Infertility is 2 types:

1) Primary infertility:
When a woman is unable to ever bear a child, either due to the inability to become pregnant or the inability to carry a pregnancy to a live birth she would be classified as having primary infertility. Women who spontaneously miscarries, or if their pregnancy results in a still born child, without ever having had a live birth are diagnosed as primary infertility.
2) Secondary infertility:
Is when a woman who already delivered a live birth previously and now is unable anymore to bear a child, or unable to become pregnant or unable to carry a pregnancy to a live birth. Thus women who repeatedly miscarry spontaneously or their pregnancy results in a stillbirth, or cannot get pregnant anymore, are diagnosed as secondary infertility.

When to seek help by a fertility doctor?
You have to find a fertility Dr. in the following cases:
After 12 months of unprotected intercourse with no pregnancy, women under 35 have to find a doctor.
After 6 months of unprotected intercourse with no pregnancy, women above 35 have to find a doctor.
Nowadays, the rate of infertility is increasing due to women age factor. Women are getting married older and older. The age factor of the woman is crucial in determining the rates of fertility.
If a woman reaches 35 years and is not married yet, it’s better for her to freeze her eggs to keep her chances in getting healthy kids in the future when she can use them whenever she wants.
Fertility Basics:
Conditions to get pregnant; 
There are several complicated steps that must occur for a pregnancy to take place:
- The woman has to ovulate a healthy and mature egg.
- The man has to produce enough healthy, and mobile sperm.
- The sperm must reach the egg.
- The egg must change its structure to become a fertilized embryo.
- The genetic material of the embryo must be correct.
- The embryo must divide correctly until it forms a blastocyst.
- The blastocyst must implant in the womb without being rejected.
 
I) Your Monthly Cycle:

A regular menstrual cycle is an important element of successful conception. The menstrual cycle refers to the maturation and release of an egg as well as the preparation of the uterus to receive the fertilized egg (embryo).

The hormones released during the menstrual cycle will control the events that lead to pregnancy.

On the first day of the cycle (1st day of the menstrual period), the uterus sheds it's lining from the previous cycle.

The typical menstrual cycle lasts for about 28 days and consists of three phases.

Follicular Phase - Days 1 to 13 during this phase, the hypothalamus and pituitary glands in the brain release a hormone known as follicle stimulating hormone (FSH). FSH stimulates the development of a follicle, which is a tiny fluid-filled sac in each ovary containing a maturing egg. The follicle also secretes estrogen, which produces mid-cycle changes in the cervical mucus. These changes help prepare the cervical mucus to receive and nourish the sperm.

Ovulatory Phase - Approximately 14 Days before Your Next Cycle Starts the ovulatory phase begins when the level of luteinizing hormone (LH), also released by the pituitary gland, dramatically increases or surges. LH causes the follicle to break open and release the mature egg into the fallopian tube. During the reproductive years, a woman usually releases a single mature egg each month. This process is known as ovulation. Cervical mucus is most receptive to sperm around this time and a woman has the best chances to become pregnant right before and during ovulation. It is a common misconception that the ovulatory phase begins around day 14 of your cycle; in fact, it can more easily be determined by 14 days prior to the start of your next cycle, which may not be an exact 28 days. Your cycle begins in the first day that you experience regular flow. Once you determine how long your personal cycle lasts, subtract 14 days from the predicted end of the cycle to determine the time of ovulation.

Luteal Phase - Days 15 to 28: During this phase, the follicle that produces the egg becomes a functioning gland called the corpus luteum. The corpus luteum produces progesterone, which prepares the endometrium (lining of the uterus) for the implantation of the fertilized egg.

Fertilization: The ovulatory phase of the menstrual cycle is the best time for fertilization. When a couple has intercourse during this time, sperm swim through the cervical mucus, into the uterus and along the fallopian tube, where they meet the egg. 

Although millions of sperm are released, only one sperm can fertilize an egg. The egg has the capacity to be fertilized for about 24 hours after it is released from the follicle. (If fertilization does not occur, the egg passes through the uterus and the corpus luteum stops functioning on about day 26. The uterine lining then breaks down and is shed several days later as the next menstrual cycle begins.

Implantation: After fertilization, the embryo goes through the fallopian tube towards the uterus. Inside the uterus, the embryo implants itself into the lining (endometrium) on about the 20th day of the cycle and continues to grow into an embryo and eventually a fetus. The corpus luteum continues to produce progesterone to preserve the uterine lining and help maintain pregnancy.

II) Understanding Infertility:
Eighty percent of all couples trying to conceive will become pregnant within one year. There are treatments now to help almost everyone. Infertility is a disease of the reproductive system that prevents a couple's ability to have a baby. Infertility affects men and women equally. That’s why both partners should participate in the diagnosis and treatment process. Infertility happens often and you are not alone. 40% of all infertility cases are due to the women, 40% to men, in 10% of cases both partners have a problem, and 10% of the time the cause cannot be identified and without explanation.
III) Why age is so important?

A woman’s fertility peaks in her mid-20’s, and begins to decline around 28 and drops after the age of 35. A woman’s fertility is measured by her ability to achieve a pregnancy on a certain time during the month. For women, the ability to conceive depends on the quality of her eggs. As women age, hormonal changes take place. There are two main hormones controlling the development and release of the egg each month: FSH (follicle stimulating hormone) and LH (luteinizing hormone).

A rising FSH level reflects a decreasing egg quality. Decreased egg quality means it becomes more difficult for the sperm to fertilize the egg naturally. There may even be chromosomal abnormalities occurring within the egg itself. That’s why amniocentesis is recommended for pregnant women over 35.

The ovarian egg reserve is also an important factor of fertility. The ovarian reserve also decreases with age. A blood test called AMH (Anti - Mullerian Hormone) which measures the egg reserve in a woman is a good indicator of fertility.

The natural pregnancy rate for women under 30 years is 20% per month, but by the age of 40, the conception drops to about 5% per month.

IV) Causes of Infertility:
When patients come to Dr. Najib Dagher, they’re looking for answers. From the first physician consultation through the diagnostic work-up, everything is explored to determine a diagnosis. Establishing a diagnosis will allow to create your treatment plan, which is the first step on your way to reproductive success. There are lots of possible diagnoses.

The most common causes of infertility include:

1) Advanced Age:

As a woman advances in age, many biological changes take place and work against conceiving and carrying the pregnancy to term. From age 30 to 35, there is a gradual decline in the ability to become pregnant; after age 40, there is a sharp decline.

With age, the chance of miscarriage and chromosomal abnormalities, such as those that cause Down's syndrome will increase.

Even the success of in vitro fertilization and other similar procedures decreases with advancing age.

As women age, they are less likely to ovulate regularly. In addition, they are more likely to have medical problems that can cause infertility, such as endometriosis.

However, the more important reason relates to the quality and decreasing number of the woman's eggs.

As the eggs age, they become more resistant to fertilization. Also, the eggs will tend to have chromosomal abnormalities which may result often in miscarriage.

Diagnostic Tests for Advanced Age Infertility:

Your evaluation is likely to begin with your medical history and a pelvic exam.

However, other tests are needed to determine whether your age is affecting your fertility. You will need the following tests:

Follicle stimulating hormone (FSH) - A blood test that measures the amount of FSH in your blood; a high level of FSH in your blood in the beginning of your cycle may mean that your infertility is age related. The FSH blood test determines the egg quality.

Estradiol - A blood test that measures the amount of estradiol (estrogen) in your blood; a high level in the beginning of your cycle may mean that your infertility is age related.

AMH – Anti - Müllerian hormone is the blood test that determines the ovarian reserve or egg quantity.

Age Is Crucial in Treatment Plan Recommendations:

Delaying pregnancy is a common choice for women today for social, career and economic reasons. Because of this, age related infertility has increased over the last decade. It is estimated that at least 20% of women will wait until after the age of 35 to have their first child. Women have a false sense of security in their choice to delay childbearing. It is well established that fertility decreases with advancing age, but many women may not be aware of the critical role that age plays on their ability to get pregnant. They think that if they are still having a regular menstrual cycle that means that they can still bear kids easily. This is a wrong way of thinking.

Peak fertility occurs during the early 20's and begins to decline significantly after the age of 35. By the age of 40, pregnancy potential is reduced by about 50%. Several factors may contribute to this change but by far the greatest impact is the change in the quality and quantity of eggs that remain in the ovary. Unlike males, who produce new sperm continuously throughout their lives, each female has her lifetime complement of eggs at birth.

The total number of eggs at birth is between 1-2 million and by puberty this number has decreased to approximately 300,000. Only 1% of these eggs will be ovulated with the vast majority being reabsorbed by the body. The loss of eggs accelerates as a woman enters her mid to late 30's and this coincides with her decreased pregnancy potential.

Egg quality is compromised too as a woman ages and this may impair the eggs ability to be fertilized by a sperm. Additionally, chromosomal problems in the eggs that occur with aging may account for the higher incidence of pregnancy loss and chromosomal abnormalities in children of older woman.

To protect your eggs and to keep them from aging and to get more information about Egg Freezing or Egg Vitrification, contact Dr. Najib Dagher on 0096170906427 or email: info@drnajibdagher.com. 

 

Egg donation:

An option for older women is the use of eggs donated by a young woman who is in her 20s -28s. The eggs are fertilized by her partner's sperm and transferred to her uterus. Younger eggs are more likely to result in pregnancy and less likely to end in miscarriage. Egg donation has very high success rates.

For more information on Advanced Age and egg donation, please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

2) Ectopic Pregnancy:

An ectopic pregnancy is any pregnancy that implants in a site other than the uterine cavity. In most cases, ectopic pregnancy occurs in a fallopian tube – a fertilized egg becomes trapped there and implants.

During a normal pregnancy, an egg becomes fertilized by a sperm inside the fallopian tube. The fertilized egg travels down through the fallopian tube, and into the uterus, where it implants on the inside wall.

An ectopic pregnancy occurs when the embryo implants outside the uterus. In most cases, ectopic pregnancy occurs in a fallopian tube - a fertilized egg becomes trapped there and implants. Ectopic pregnancy can also occur in other places such as on an ovary, within the cervix, or in the abdomen.

Symptoms of ectopic pregnancy: Symptoms of ectopic pregnancy may include irregular bleeding after a missed period, lower abdominal pain, and lower back pain, and maybe hypotension. If you have these symptoms, call your doctor right away - an ectopic pregnancy can become a serious, life-threatening medical emergency if it is not diagnosed and treated early. Your fallopian tube can rupture from the growing embryo, resulting in severe pain, uncontrolled internal bleeding, and shock.

Diagnosis of ectopic pregnancy: The medical history and a pelvic exam are helpful in diagnosing ectopic pregnancy. However, other tests are needed to confirm the diagnosis. You may need one or more of the following tests:

• ẞHCG (human chorionic gonadotropin) test - a blood test that confirms pregnancy by measuring the amount of βHCG (a hormone produced by the pregnancy) in your blood; often, this test is repeated every 2 days. Usually it has to double each 2 days.

• Trans vaginal Ultrasound - a scan that uses high frequency sound waves to determine where the pregnancy has implanted.

Causes of ectopic pregnancy: The cause is often unknown. However, ectopic pregnancy tends to occur when the fallopian tube has become damaged in some way - from a previous infection, endometriosis, tubal surgery, or even a previous ectopic pregnancy. Scar tissue that is partially blocking the inside of the fallopian tube can trap the fertilized egg, resulting in an ectopic pregnancy.

Treatment of ectopic pregnancy: Treatment will depend on how early the ectopic pregnancy is discovered. If you are in a lot of pain and have heavy internal bleeding, you will likely need emergency surgery to stop the bleeding by laparoscopy. The surgery may involve either removing the embryo from your tube or removing the segment of the tube containing the embryo. If the ectopic pregnancy is discovered early, before the embryo has grown large enough to rupture your fallopian tube, an injection of a medication, methotrexate, may be an option. Methotrexate prevents the rapid division of cells in early pregnancy thereby ending the pregnancy.

Ectopic pregnancy can damage your fallopian tube, which may reduce your chances for future normal pregnancies. In addition, women who have had an ectopic pregnancy are at increased risk for a future ectopic pregnancy. Your doctor will discuss treatment options that may increase your chance for pregnancy.

An Ectopic Pregnancy may also be a complication of IVF. 

For more information about ectopic pregnancy and how it affects fertility, please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

3) Endometriosis:

Endometriosis is a condition in which endometrial tissue (the tissue that lines the inside of the uterus) grows outside of the uterus. This tissue will respond to your menstrual cycle hormones by swelling and thickening. But since it’s growing outside of the uterus, the swelled tissue does not shed like menstrual blood and becomes inflamed, forming scar tissue.

Endometriosis may be a cause of infertility.

Endometrial tissue grows outside the uterus and attaches to other organs in your abdominal cavity such as the ovaries and fallopian tubes. The endometrial tissue inside and outside of your uterus responds to your menstrual cycle hormones in a similar way - it swells and thickens, then sheds to mark the beginning of the next cycle. Unlike the menstrual blood from your uterus that is discharged through your vagina, the blood from the endometrial tissue in your abdominal cavity has no place to go. Inflammation occurs in the areas where the blood pools, forming scar tissue. Scar tissue can block the fallopian tubes or interfere with ovulation. In addition, endometrial tissue growing inside the ovaries may form a type of ovarian cyst (chocolate cyst) called an "endometrioma", which may interfere with ovulation.

Endometriosis is a progressive disease. It tends to get worse over time and can come back after treatment.

Endometriosis usually improves after menopause.

Diagnosis of endometriosis:

The medical history and a pelvic exam may suggest the diagnosis of endometriosis. However, only a laparoscopy can confirm this diagnosis.

Treatment of endometriosis:

- Surgical treatment: A laparoscopy is an outpatient surgical procedure. Your doctor will use a narrow fiber optic telescope inserted through an incision near your navel to look for and coagulate and remove scar tissue and endometrial tissue attached to other organs. Surgery is the best option for treating endometriosis.

- Medical treatment: Medications are mainly used to treat symptoms of endometriosis.

However, if the disease is severe, then IVF will be recommended.

Symptoms of endometriosis:

You may experience painful menstrual periods, the pain persists during all the menstrual period.  

Abnormal menstrual bleeding, or pain during or after sexual relations, infertility, fatigue, painful urination during menstrual periods, painful bowel movements during menstrual periods, and other gastrointestinal problems, such as diarrhea, constipation, and/or nausea may indicate the presence of endometriosis.

However, you may not have any symptoms at all.

Causes of endometriosis:

Cause of endometriosis is still unknown. One theory suggests that during menstruation, some of the menstrual tissue backs up through the fallopian tubes into the abdomen, where it implants and grows. Another theory suggests that endometriosis is a genetic birth abnormality, in which endometrial cells develop outside the uterus during fetal development.

Stages of endometriosis:

Doctors classify endometriosis as minimal (stage 1), mild (stage 2), moderate (stage 3), or extensive (stage 4), based on the amount of scarring and diseased tissue found. Staging is important for determining which treatment will be best for you.

The stage of endometriosis is based on the location, amount, depth, and size of the endometrial implants. Specific criteria include:

• The extent of the spread of the implants

• The involvement of pelvic structures in the disease

• The extent of pelvic adhesions

• The blockage of the fallopian tubes

The stage of the endometriosis does not necessarily reflect the level of pain experienced, risk of infertility, or symptoms present. For example, it is possible for a woman in Stage I to be in tremendous pain, while a woman in Stage IV may be asymptomatic. In addition, women who receive treatment during the first two stages of the disease have the greatest chance of regaining their ability to become pregnant following treatment.

Where Endometriosis is found?

Endometriosis is most often found in the ovaries, but can also be found in other places, including:

• The fallopian tubes

• Ligaments that support the uterus

• The internal area between the vagina and rectum

• Outer surface of the uterus

• In the lining of the pelvic cavity

Occasionally, the implants are found in other places, such as:

• Intestines

• Rectum

• Bladder

• Vagina

• Cervix

• Vulva

• Abdominal surgery scars

How is endometriosis related to infertility?

Endometriosis is considered one of the three major causes of female infertility.

In mild to moderate cases, the infertility may be temporary. In these cases, surgery to remove adhesions, cysts, and scar tissue can restore fertility.

In other cases (a very small percentage), women may remain infertile.

How endometriosis affects fertility is not clearly understood. It is thought that scar tissue from endometriosis can impair release of the egg from the ovary and pickup by the fallopian tube. Other mechanisms thought to affect fertility include changes in the uterine lining that result in impaired implantation of the fertilized egg.

Treatment of endometriosis:

Your doctor may want to treat your endometriosis surgically, with medications, or a combination of both. Surgery involves removing the endometrial tissue from your ovaries or fallopian tubes. It can usually be done during a laparoscopy. They include medications that shrink the endometrial tissue and those that stop or interfere with estrogen production.

A decrease in estrogen production stops the growth of endometrial tissue.

For more information about endometriosis and its treatment options and how it affects fertility, please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

4) Fibroids:
Fibroids are noncancerous growths that develop in or on the uterus.

Fibroids can interfere with pregnancy in many ways. Those that grow on the inside of the uterine wall can cause changes in the endometrial tissue, making it difficult for a fertilized egg to attach to the uterine wall. Fibroids that develop outside of the uterus can interfere with pregnancy by compressing or blocking the fallopian tubes.

Fibroids, also known as leiomyomas are noncancerous growths that develop in or on the uterus.

Location of the fibroids:

Uterine fibroids develop from the smooth muscle cells of the uterus and can grow inside or outside of your uterus.

How do Fibroids interfere with pregnancy?

The ones that grow on the inside wall of your uterus can cause changes in the endometrial tissue, making it difficult for a fertilized egg to attach to the uterine wall. Fibroids that develop outside your uterus can interfere with pregnancy by compressing or blocking the fallopian tubes, thereby preventing the sperm from reaching the egg.

Diagnosis of fibroids: The medical history and a pelvic exam are necessary in diagnosing fibroids.

Here are tests that may also be used to confirm the diagnosis:

• Ultrasound - a scan that uses high frequency sound waves to detect fibroids in and around the uterus and cervix

• Hysterosalpingography - a procedure that uses x-rays and a special dye to detect fibroids on the inside of your uterus and to see if your fallopian tubes are open.

• Hysteroscopy - a procedure in which your doctor uses a narrow fiber optic telescope inserted into the uterine cavity to look for and sometimes remove fibroids.

• Laparoscopy - a procedure in which your doctor uses a narrow fiber optic telescope inserted through an incision near your navel to look for and sometimes remove fibroids.

Symptoms of fibroids:

The severity of your symptoms will depend on the number, size, and location of the fibroids. You may experience severe, painful cramps and abnormal or excessive bleeding, especially during your periods. Also, you may have difficulty with moving your bowels or urinating if you have fibroids that are putting pressure on your rectum or bladder. Hemorrhoids may also develop if you become constipated. However, if your fibroids are small, you may not have any symptoms at all - in fact, you may not know that you have fibroids until you go through infertility testing. Causes of uterine fibroids:

The cause of uterine fibroids is unknown, but they require estrogen to grow. They often shrink after menopause, when estrogen levels decrease.

Treatment of fibroids:

Your doctor may want to treat your fibroids surgically or with medications. Fibroids can be removed during a laparoscopy, hysteroscopy, or through an open incision (myomectomy). Medications that stop or interfere with your body's estrogen production are used to shrink fibroids and prevent them from growing larger. Once the medication is stopped, the fibroids will regrow. Medication is mainly used for treatment prior to surgery. However, you can only use these medications for a few months - long-term use may increase your risk of bone loss. Keep in mind that treatments do not provide a cure - new fibroids can grow after treatment.

For more information about fibroids and treatment options and how they affect fertility, please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

5) Hyperprolactinemia:
Hyperprolactinemia is a disorder in which your pituitary gland produces excessive amounts of the hormone prolactin, a hormone that stimulates milk production in women. It appears in small amounts in women who are not pregnant, but then in large amounts when a woman is pregnant or right after birth. Thus, women who have hyperprolactinemia have bodies that think that they are, or recently were, pregnant, causing irregular or no ovulation, resulting in infertility.

Symptoms of hyperprolactenemia:

Women who have this disorder often have irregular periods, and may also experience galactorrhea, milk production when not pregnant.

Causes of hyperprolactinemia:

- One of the most common causes of hyperprolactinemia is a benign tumor growing on the pituitary gland - the gland that produces prolactin.

The pituitary gland is located in the base of the brain near the vision center.

- Other causes of excess prolactin production may be an underactive thyroid (hypothyroidism), or certain medications you may be taking.

- Sometimes, the cause is unknown.

Diagnosis of hyperprolactinemia:

Your medical history and a physical exam are helpful in diagnosing hyperprolactinemia.

Listed below are tests that may also be used to confirm the diagnosis for high Prolactin:

• Prolactin blood level - a blood test that measures the amount of prolactin in your blood

• Thyroid test - a blood test that diagnoses thyroid disorders; hypothyroidism (underactive thyroid) can cause hyperprolactinemia

• Computerized Tomography (CT) - a 3-dimensional scan that produces an image of the pituitary gland to detect a tumor or other abnormality

• Magnetic Resonance Imaging (MRI) - a scan that uses high frequency radio waves to produce an image of the pituitary gland to detect a tumor or other abnormality.

Treatment of hyperprolactinemia:

The treatment will depend on the cause of your excessive prolactin production.

- If you are diagnosed with an underactive thyroid, your doctor can prescribe a thyroid medication for you. Once your thyroid problem is corrected, the amount of prolactin in your blood should decline to a normal level.

- If you have a tumor on your pituitary gland, or the cause of your hyperprolactinemia is unknown, treatment with medication can reduce your prolactin levels.

Also, the medication usually causes pituitary tumors to shrink. Once your prolactin blood level is within the normal range, your periods should become more regular and you should start ovulating normally again.

Although these medications are very effective in bringing down your prolactin level to a normal range, they cannot cure the disorder. If you stop treatment, your prolactin levels are likely to increase again, and your symptoms will probably return.

Effects of high Prolactin level:

Hyperprolactinemia can cause reduced estrogen production from the ovaries. Estrogen plays an important role in keeping your bones strong and dense, so a lack of estrogen can reduce your bone density and leave you at risk for osteoporosis. Estrogen also helps to protect against heart disease. Treatment to correct hyperprolactinemia can restore your estrogen levels and help protect you from osteoporosis and heart disease later in life.

For more information about high prolactin blood level and the treatment options and how it affects fertility, please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

6) Hypothalamic Amenorrhea:
Hypothalamic amenorrhea is a condition in which menstruation stops for several months due to a problem involving the hypothalamus.

The hypothalamus, located in the brain, controls the reproduction. The hypothalamus produces gonadotropin, a hormone needed for the egg to mature and for ovulation. Hypothalamic amenorrhea occurs when gonadotropin stops being produced, ceasing ovulation and menstruation.

Hormones play a crucial role in every step of a successful pregnancy. The hypothalamus in the center of the brain controls reproduction. It produces the hormone, gonadotropin releasing hormone (GnRH). GnRH signals the production of other hormones needed for the egg to mature and for ovulation, such as follicle stimulating hormone (FSH) and after ovulation, the luteinizing hormone (LH). In turn, FSH and LH signal the ovaries to produce estrogen. Estrogen thins the cervical mucus and, along with progesterone, prepares the uterus for a fertilized egg. Sometimes the hypothalamus stops producing GnRH, which in turn, will reduce the amount of other hormones produced (FSH, LH, and estrogen). Ovulation and menstruation stop, resulting in infertility.

Diagnosis of hypothalamic amenorrhea:

Diagnosing hypothalamic amenorrhea involves eliminating some of the other possibilities as to why your periods have stopped. For example, your doctor will want to make sure you're not pregnant or have another disorder that's causing the problem.

Your medical history and a pelvic exam are necessary in diagnosing ovulatory dysfunction, as well as one or more of the following tests:

Hormonal studies - Blood tests that measure the levels of the hormones, follicle stimulating hormone (FSH), luteinizing hormone (LH), human chorionic gonadotropin (HCG), and prolactin. Low levels of FSH and LH may indicate hypothalamic amenorrhea. High levels of prolactin suggest a tumor on the pituitary gland, which can lead to amenorrhea. HCG is a test used to confirm or eliminate the possibility of pregnancy

Progesterone challenge - A test that will induce menstrual bleeding (after taking progesterone) in women with certain types of amenorrhea, but not in women who have hypothalamic amenorrhea

Computerized Tomography (CT) - A 3-dimensional scan that produces an image of the pituitary gland to detect a tumor or other abnormality

Treatment of hypothalamic amenorrhea:

Treatment will vary depending on the cause.

If your doctor suspects your daily routine is the cause of your amenorrhea (very thin), you may be asked to make some changes, such as limiting your exercise or gaining weight.

If this doesn't work, your doctor may prescribe hormone or fertility medications so that you will start ovulating and menstruating again.

Hypothalamic amenorrhea can lead to less estrogen production from the ovaries. Estrogen helps to prevent bone loss, so if you lack estrogen you may be at increased risk for osteoporosis. Estrogen also helps to protect against heart disease. Your doctor may recommend estrogen therapy to reduce these risks if you do not wish to attempt pregnancy.

Ovulation Induction Medications may be recommended.

 For more information about hypothalamic amenorrhea and its treatment options and how it affects fertility, please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

7) Ovulatory Disorder:

Ovulatory disorders are one of the leading causes of infertility. While there are many types of ovulatory disorders, they are all presented by irregular or no ovulation, resulting in infertility. Anovulation (no ovulation) is a disorder in which eggs do not develop properly, or are not released from the follicles of the ovaries.

Women who have this disorder may not menstruate for several months. Others may menstruate even though they are not ovulating. Although anovulation may result from hormonal imbalances, eating disorders, and other medical disorders, the cause is often unknown. Women athletes who exercise excessively may also stop ovulating.

Oligo-ovulation is a disorder in which ovulation doesn't occur on a regular basis, and the menstrual cycle may be longer than the normal cycle of 21 to 35 days.

Diagnosis of ovulatory disorders:

The medical history is useful in diagnosing ovulatory disorders.

However, other tests may be required to confirm the diagnosis. You may need one or more of the following tests:

• FSH blood level - a blood test that measures the amount of follicle stimulating hormone (FSH) in your blood to see if you are approaching menopause

• Progesterone blood level - a blood test that measures the amount of progesterone in your blood to diagnose if ovulation has occurred.

• Ultrasound - a scan that uses high frequency sound waves to see if follicles in your ovaries are developing; also used to evaluate ovarian function - for example, small ovaries with a few small follicles may be a sign of approaching menopause

• Endometrial biopsy - a procedure in which a sample of your endometrial tissue is examined to determine if it is developed enough to support a pregnancy.

. Ovulation prediction kits are helpful for detecting when you are about to ovulate. They measure the luteinizing hormone (LH) in your urine. An LH surge (high level of LH in your urine) means that you will probably ovulate within the next 24 to 36 hours. The test is performed mid-cycle. (For example, it is performed on days 13 and 15 of your menstrual cycle if you usually get your period every 28 days. Day 1 is the first day of your period.) If you do the test every day during your mid-cycle and do not detect an LH surge, you may not be ovulating.

For more information on ovulatory disorders, please call 00961709064 or schedule an appointment for an initial consultation with Dr. Najib Dagher by email: info@drnajibdagher.com

 

8) Pelvic Adhesive Disease:

Pelvic adhesive disease is a condition in which scar tissue binds adjacent organs to each other. If adhesions form inside or around the ends of the fallopian tubes, they may block an egg and sperm from meeting. Adhesions can block the fallopian tubes or develop on the ovaries or even inside the uterus. If adhesions form in reproductive organs, infertility will likely occur.

All of the organs in your abdominal cavity are covered with a smooth, slippery tissue. The surface of this tissue is lubricated, allowing adjacent organs to glide easily against each other. However, when the surface becomes damaged or inflamed, scar tissue forms. Scar tissue that develops between 2 organs will cause the surfaces of the organs to stick, or adhere to each other. The bands of scar tissue are called adhesions.

Adhesions are often a cause of infertility. If they form inside or around the ends of the fallopian tubes, they may block an egg and sperm from meeting. If the tubes are partially blocked by adhesions, sperm may meet the egg, but the fertilized embryo may be trapped, resulting in an ectopic pregnancy.

Adhesions that develop on the ovaries may disrupt ovulation, and those that develop inside the uterus may prevent a fertilized egg from implanting properly.

Diagnosis of pelvic adhesive disease:

Medical history and a pelvic exam may suggest the diagnosis of pelvic adhesive disease.

However, only a laparoscopy or hysteroscopy can confirm this diagnosis. A laparoscopy is an outpatient surgical procedure in which your doctor will use a narrow fiber optic telescope inserted through an incision near your navel to look for and sometimes remove adhesions in your pelvic cavity.

A hysteroscopy is an outpatient procedure in which your doctor will use a narrow fiber optic telescope inserted into your uterus through your cervix, to look for and sometimes remove adhesions inside your uterus.

Causes of pelvic adhesive disease:

Anything that causes damage to the peritoneum - the smooth, slippery tissue covering the organs in the abdominal cavity - may result in adhesions. Surgical procedures, infections, and inflammation from endometriosis are the most common causes. It is not uncommon for adhesions to form after bowel surgery or surgery for appendicitis. Surgery on the ovaries, fallopian tubes, uterus, or cervix may also lead to adhesions. Infection and endometriosis are also capable of causing inflammation, which may damage the peritoneum and lead to adhesions.

Symptoms of pelvic adhesive disease:

Many women who have adhesions do not have any symptoms, except for infertility. Other women may feel abdominal or pelvic pain, menstrual cramps, tenderness, pain during intercourse, or pain during bowel movements.

Treatmentof pelvic adhesive disease:

Surgery to remove the adhesions is the primary treatment option. It can usually be performed during a laparoscopy or hysteroscopy. Adhesions do not grow back. However, new adhesions may form in the areas that were treated surgically.

Treatments for pelvic adhesion disease may include IVF or reproductive surgery.

For more information on pelvic adhesion disease, please call 0096170906427 or schedule an appointment for an initial consultation with Dr. Najib Dagher by email: info@drnajibdagher.com

 

9) Polycystic Ovary Syndrome (PCOS):

Polycystic ovary syndrome, or PCOS, is a disorder in which the ovaries produce excessive amounts of male hormones and develop many small cysts. This hormonal imbalance can prevent ovulation. PCOS is caused by hormonal imbalances that prevent ovulation. Your body produces too much of some hormones and not enough of others. Women who are diagnosed with PCOS usually have low levels of follicle stimulating hormone (FSH), yet have high levels of luteinizing hormone (LH). FSH is the hormone that's responsible for stimulating the growth of follicles in the ovaries that contain maturing eggs. If you lack FSH for a long time, your follicles will not mature and release their eggs, resulting in infertility. Instead, the immature follicles in your ovaries develop into small cysts. High levels of LH cause your body to produce too much estrogen and androgens (male hormones) - testosterone and DHEAS (di hydro epi androsterone sulfate). High levels of estrogen can cause the endometrial tissue in your uterus to get very thick, which can lead to heavy and/or irregular periods. If your androgen levels are high for a long time, you may develop acne and hair on your face. Women with PCOS have abnormal insulin metabolism which worsens with anovulation, increases androgens and leads to obesity. Diagnosis of PCOS:

Medical history and a pelvic exam are necessary in diagnosing PCOS.

However, other tests are needed to confirm the diagnosis. You may need one or more of the following tests:

• Blood hormone levels - Blood tests that reveal the levels of certain hormones in your blood, such as follicle stimulating hormone (FSH), luteinizing hormone (LH), estrogen (estradiol), and androgens (testosterone and DHEAS)

• Ultrasound - A scan that uses high frequency sound waves to identify the many small cysts in the ovaries

• Endometrial biopsy - A procedure in which a sample of your endometrial tissue is examined to help explain why your periods are irregular. 

Symptoms of PCOS:

You may have heavy, irregular periods, or you may stop menstruating entirely. You probably won't be able to tell if you are ovulating until your doctor does a few tests. Other symptoms include acne, excessive hair growth on the face, obesity, and infertility.

Causes of PCOS:

The cause of this disorder is unknown, however, heredity and insulin metabolism play a significant role.

Treatmentof PCOS: Your treatment will depend on your specific needs. Obesity may make the condition worse, so losing weight may help improve the hormonal imbalance. If your goal is to become pregnant, the doctor may prescribe a medication to stimulate ovulation. Other medications such as hormones or insulin metabolism can improve irregular or heavy periods, and other symptoms. Early diagnosis and treatment can reduce the development of acne and facial hair.

Long-term exposure to high levels of estrogen (and not enough progesterone) can lead to an increased risk of uterine cancer. Treatments such as birth control pills are available to reduce this risk. Women who have PCOS may also be at increased risk for diabetes. Your doctor may want you to have a screening test for diabetes.

For more information please call 0096170906427, or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

 

10) Premature Ovarian Failure:

Premature ovarian failure is the medical term used to describe early menopause. Menopause usually occurs in women between the ages of 42 and 56. Premature ovarian failure is a condition in which menopause occurs before the age of 40. Women who develop early menopause usually have run out of eggs in their ovaries.

The cause of premature ovarian failure is generally unknown. However, there are a few reasons why the ovaries may stop producing eggs at an early age. Exposure to certain chemicals or medical treatments can damage or destroy the ovaries. These may include chemotherapy and radiation therapy. Autoimmune diseases such as rheumatoid arthritis are sometimes associated with an early menopause because the immune system forms antibodies that attack and damage the ovaries. Heredity can also play a role - some genetic disorders lead to early menopause. Diagnosis of premature Ovarian Failure:

The medical history is important in diagnosing premature ovarian failure. However, other tests are needed to confirm the diagnosis. You may need one or more of the following blood tests:

• FSH blood level - A high level of follicle stimulating hormone (FSH) in your blood at a specific time in your cycle may indicate menopause

• Immunology testing - Tests that diagnose autoimmune problems of the thyroid, parathyroid, and adrenal gland that may be related to developing early menopause

• Karyotype – A photograph of your chromosomes, used to diagnose genetic causes of early menopause

• AMH – Reflects the egg quantity, or ovarian reserve.

Treatment of premature ovarian failure:

The only option to treat Premature Ovarian Failure is Donor Egg.

Symptoms of premature Ovarian Failure:

You may experience menstrual irregularity, hot flashes, mood changes, loss of libido, and vaginal dryness.

Treatmentof premature Ovarian Failure:

In vitro fertilization (IVF) using donor oocytes (eggs from a fertile young woman) are an option you may want to consider if you wish to become pregnant.

Risks associated with early menopause:

Your ovaries are not producing enough estrogen to protect you from heart disease and osteoporosis (loss of bone density). You can reduce your risks for these diseases with hormone replacement therapy, calcium supplements, and regular exercise.

For more information on premature ovarian failure, please call 0096170906427 or schedule an appointment for an initial consultation with Dr. Najib Dagher on info@drnajibdagher.com

 

11) Recurrent Miscarriage:

Recurrent miscarriage is defined as two or more consecutive, spontaneous pregnancy losses.

Recurrent miscarriages can be due to a variety of factors:

Genetic defect, abnormally shaped uterus, fibroids, scar tissue, hormonal imbalances, and others.

Approximately 20 percent of pregnancies end in miscarriage, which is defined as the loss of a pregnancy before 20 weeks of gestation. Most miscarriages occur within the first 12 weeks of gestation.

Recurrent miscarriage, also known as recurrent pregnancy loss, is commonly defined as 2 or more miscarriages.

Causes of recurrent miscarriages:

When miscarriage occurs this frequently, there may be an underlying cause such as a genetic defect.

Other causes include

- Blood coagulation abnormalities

- An abnormally shaped uterus

- Uterine fibroids

- Scar tissue in the uterus which may hinder implantation or growth of the fetus. 

- Hormonal imbalances of prolactin, thyroid hormone or progesterone can result in miscarriage.

- Diabetes mellitus or immune system abnormalities or blood coagulation abnormalities will increase the chance of miscarriage.

Diagnosis of recurrent miscarriage:

Medical history, a pelvic exam, and one or more of the tests listed below are necessary in diagnosing possible causes of your recurring miscarriages:

• Karyotype - a mapping of your chromosomes, used to diagnose genetic defects

• Hysterosalpingography - a procedure that uses x-rays and a special dye to evaluate the shape of the inside of your uterus

• Hysteroscopy - a procedure in which your doctor uses a narrow fiber optic telescope inserted into the uterus to look inside your uterine cavity

• Vaginal ultrasound - a scan that uses high frequency sound waves to detect abnormalities in and around the uterus, ovaries, and fallopian tubes

• Blood hormone levels - blood tests that reveal the levels of certain hormones in your blood, such as prolactin, thyroid, and progesterone

• Endometrial biopsy - a procedure in which a sample of your endometrial tissue is examined under a microscope to determine if it is appropriately developed for an implanting embryo

• Glucose screening - a blood test used to diagnose diabetes mellitus which, if left uncontrolled, increases the likelihood of miscarriage

• Antibodies tests - blood tests used to detect an immune system abnormality, ANA and others.

• Blood coagulation tests – Factor V, Lupus anti-coagulant, Anti Thrombin III, Protein C, Protein S and others.

Risk factors associated with recurrent miscarriage:

The risk of miscarriage increases with increasing age, especially in women over the age of 35.

Smoking, caffeine, and alcohol increase your risk of miscarriage.

Also, some medications, including those you can buy without a prescription, may increase your risk.

Treatments of recurrent miscarriage:

Treatment is individualized based on findings from testing.

Problems with the shape of the uterus or fibroids can be corrected with surgery (laparoscopy/Hysteroscopy).

Some immune problems or hormone imbalances can be corrected with medication.

Often no cause for the miscarriage is found. Even if no cause is found, there is still a good chance that you will deliver a healthy baby.

Fertile couples with repeated miscarriages should be evaluated for the presence of a chromosomal abnormality.

The female or male partner may be a carrier of a balanced translocation or be an aneuploidy mosaic.

For more information on recurrent miscarriage, please call 0096170906427 or schedule an appointment for an initial consultation with Dr. Najib Dagher by info@drnajibdagher.com

12) Tubal Disease:

 Tubal disease is a disorder in which the fallopian tubes are blocked or damaged. Scar tissue, infections, and tubal ligation are some of the many causes of tubal disease.

One of the many causes of infertility is tubal disease, in which your fallopian tubes become blocked or damaged. Scar tissue resulting from endometriosis or abdominal or gynecological surgery (bowel surgery, cesarean section, ruptured appendix, etc.) can block the egg from entering or traveling down your fallopian tube to meet the sperm.

Infections, such as chlamydia, can damage the cilia (tiny hairs lining the fallopian tubes) that help to transport the egg. Without normal cilia, the egg may not meet the sperm, or if an egg becomes fertilized, it may not be able to travel to the uterus. This can result in an ectopic pregnancy, which can further damage your tube.

Tubal ligation (having your "tubes tied" to prevent pregnancy) can also leave your fallopian tubes damaged. However, reconstructive surgery to reverse tubal ligation is often successful. Diagnosis of tubal disease:

The medical history and a pelvic exam are necessary in diagnosing tubal disease. However, other tests are needed to confirm the diagnosis.

You may need one or more of the following tests:

• Hysterosalpingography - A procedure that uses x-rays and a special dye injected into your fallopian tubes, to see if they are open or blocked

• Laparoscopy - An outpatient surgical procedure in which your doctor uses a narrow fiber - optic telescope inserted through an incision near your navel to look for and sometimes remove scar tissue or endometrial tissue blocking the fallopian tubes

Treatments of tubal disease:

If scar tissue in or around your fallopian tubes is causing the problem, your doctor can often remove it surgically. If your fallopian tubes are damaged, your doctor will be able to repair them using surgery, depending on the type and extent of the damage. If your tubal disease is severe, you may want to consider in vitro fertilization - a procedure in which eggs are removed from your ovaries, fertilized with your partner's sperm and then placed into your uterus. In vitro fertilization bypasses your fallopian tubes.

For more information on tubal disease, please call 0096170906427 or schedule an appointment for an initial consultation with Dr. Najib Dagher by info@drnajibdagher.com

 

13) Unexplained Infertility:

Unexplained infertility is the failure to determine a cause of infertility after a thorough evaluation of both the male and female partner.

True unexplained infertility may be related to egg and sperm dysfunction, among other causes.

These conditions are difficult to establish through conventional testing. However, many such conditions can be successfully and safely treated through In Vitro Fertilization or related techniques. 

Approximately 10% of infertility is unexplained. The evaluation of such a couple begins with a comprehensive review of all testing and treatment performed to date. It is not uncommon to uncover evidence within this past evaluation which may in fact document a cause of reproductive inefficiency.

Diagnosis of unexplained fertility:

A diagnosis of unexplained infertility is not accurate unless a laparoscopy has been performed.

In this way conditions such as endometriosis and pelvic scarring are ruled out.

For more information concerning In Vitro and how to treat unexplained infertility, contact Dr. Najib Dagher on 0096170906427 or schedual an apointment by email: info@drnajibdagher.com

14) Male Factor Infertility:

40% 0f infertility cases are caused by male factor.

Diagnosis by sperm analysis:

Count > 20 million/ml

Motility > 50%

Typical forms > 5%

Causes of male infertility:

The cause of male factor infertility is often unknown. However, some causes have been identified, including problems related to:

• Sperm production

• The anatomy or structure of the man's reproductive organs

• The man's immune system

• The man’s life style

• Increased testicle temperature.

Sperm Production Disorders:

Male factor infertility may occur if sperm are produced in low numbers, or if many of the sperm produced are abnormal in shape or not able to move well. Abnormally shaped sperm may not be able to penetrate and fertilize an egg. Sperm that do not move well may not reach the egg.

Some causes of sperm production disorders may include a genetic defect, infection, testicular trauma, hormonal imbalance or exposure to radiation and certain medications. Anatomical or Structural Problems:

Anything that blocks the pathways in which the sperm travel may cause infertility. Structural problems may be caused by scar tissue that formed as a result of a previous surgery or from an infection in the pathways.

Varicose veins that develop in the testes may also interfere with sperm production. Some structural defects may be congenital (from birth).

Immune System Disorders:

Some men develop antibodies to their own sperm, which may attack and weaken the sperm. Also, the antibodies may attach to the sperm and interfere with their movement or their ability to fertilize the egg.

The man’s life style:

Sperm can be affected by lifestyle factors such as smoking, drinking alcohol and taking drugs. There are other lifestyle factors that you may not be aware of. The good news is, once you become aware of them, they are easy to avoid. Cycling can be a problem. It's true that men who are serious cyclists may have lowered sperm counts, poorer sperm quality and less motile sperm. We don't know exactly why cycling a lot may cause problems. One theory is that the cause is irritation and compression caused by friction of the testicles against the saddle. Another is that heat produced by wearing tight cycling shorts is to blame. You may want to bear in mind that sitting on a bike saddle for long periods can decrease blood flow to your genitals. This in turn can lead to erection problems. Don't be put off cycling if you're a regular cyclist, though. Unless you're cycling at a professional level, you're very unlikely to experience problems. And being inactive can lead to fertility problems in itself. If you're cycling long distances, lift yourself off the seat now and again. Better still, invest in a wider, padded bicycle seat that won't compress your testicles, or wear padded cycling shorts. See a doctor if you feel any numbness or pain or have erection problems after cycling.

If you play contact sports, such as rugby, wear protective gear to prevent injury, perhaps from a kick, to your testicles.

A healthy weight helps to keep your sperm in good condition. Being overweight (having a body mass index or BMI of 25 or higher) may lower the quality and quantity of your sperm. The effect is greater in men who have a BMI of 30 or higher. If your BMI is 30 or higher, losing weight before trying for a baby will improve the quality of your sperm.

Heavy drinking can be harmful to sperm. Men who drink heavily on a regular basis have lowered sperm counts and testosterone levels. The good news is that the harmful effects of heavy drinking are reversed once you cut down on alcohol. Heavy drinking can affect sexual relationships. The current recommended guidelines on safe drinking recommend no more than three to four units of alcohol per day. Drinking within these limits is unlikely to affect the quality of your sperm, so try to make this your maximum. One unit is the equivalent of a small glass of wine or a 25 ml measure.

Smoking being generally harmful to your health, men who smoke may damage the quality of their sperm. It may take longer for your partner to become pregnant, particularly if you smoke heavily.

Heavy drug use damages sperm. Using illegal drugs like anabolic steroids, cocaine, or marijuana can also lower the quality of your sperm. This will reduce your fertility. It takes about three months for the body to complete a cycle of sperm production. So any changes you make to your lifestyle will take a while to produce improved sperm.

Increased testicle temperature:

The testicles are outside your body for a reason because they feel better at 34.5 degrees C, which is just below normal body temperature. They need this cooler environment to produce the best-quality sperm. Working in a hot environment, such as a bakery or a foundry, or sitting for long periods has been linked to elevate testicle temperature. This may affect sperm's ability to mature, leading to poorer sperm quality and a temporary drop in sperm production. If you have a job that involves sitting for long periods, have regular rest breaks and get up and move around. Heated waterbeds and electric blankets are a bigger cause for raising testicle temperature than hot baths, saunas and spa baths. Even so, it's better to have only occasional hot baths, saunas and spa baths. Using a laptop on your lap and driving for long periods have also been linked to increased testicle temperature. Wearing tight underwear increases the temperature of the testicles by up to 1 degree C. It’s better to try wearing loose-fitting boxer shorts rather than tight-fitting.

If you have a fertility problem, or if it is taking a long time for your partner to conceive, taking these simple measures could be all that is required.

The initial tests prescribed by the doctor to evaluate male fertility:

Semen analysis and semen culture to evaluate your sperm.

If the analysis is abnormal, the doctor will check for a hormonal imbalance (testosterone, FSH, LH, Prolactin), and for genetic defects such as karyotype and DNA fragmentation. If necessary, a scrotal Doppler is prescribed too.

Treatment of male infertility

Includes vitamins and antioxidants, hormones, intrauterine insemination, In Vitro Fertilization (IVF), Intra cytoplasmic sperm injection (ICSI), testicular sperm fine needle aspiration (TESA), open testicular biopsy = testicular sperm extraction (TESE).

For more information on male factor infertility, please call 0096170906427 or schedule an appointment for an initial consultation with Dr. Najib Dagher by info@drnajibdagher.com

 

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