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Melanie Cole (Host):  The experts at Fertility Center of the Carolinas don’t believe in unexplained infertility and neither should you. There are many factors that can affect a woman’s ability to conceive. My guest today is Dr. David Forstein, he is a Reproductive Endocrinologist at Fertility Centers of the Carolinas at Greenville Health System. Welcome to the show. So, tell us a little bit, Dr. Forstein, about why women get that diagnosis of unexplained fertility if they have trouble conceiving?

Dr. David Forstein (Guest):  Well, thank you for having me on the show today. When we think about infertile couples, there are generally five big areas that we look at. The woman’s ability to ovulate, whether her tubes are normal, the uterus is normal, whether her partner is normal and whether or not she has endometriosis. So, about 10% of couples are labeled as unexplained infertility because they don’t seem to fall into any of those categories. Often the unexplained infertility is really underdiagnosed endometriosis. So, endometriosis usually causes some symptoms of some pelvic pain, pain with their period, pain with intercourse but sometimes the only symptom it causes is infertility. Traditionally, the only way to diagnose endometriosis is to have a laparoscopy and it’s understandable why trying to get pregnant, you may not want to have surgery. We’re doing some NIH funded research at the Center for the Carolinas to look for ways to diagnose endometriosis or at least increase our chances of finding endometriosis without laparoscopy by doing a less invasive procedure.

Melanie:  What would send someone to see an infertility doctor, a fertility doctor?  How long do you tell women to sort of keep trying before they start to look at treatment options?

Dr. Forstein:  Sure. So, if everything else is normal, she’s getting her period regularly, she doesn’t have a lot of pelvic pain, her partner seems to be normal, for women under the age of 35, 12 months of trying is about the right amount of time. If she’s over 35, we want to see her sooner than that. Now, a lot of times women will see their primary gynecologist for infertility at first and that’s great. The gynecologists at Greenville Health System do a really nice job beginning the workup and beginning treatment. Once treatment has gone on for about three or four months with some medications for ovulation, it’s time to investigate things a little further and that’s usually when we get the referrals. If there’s anything in the history, though, that suggests a problem--so she had surgery as a child for appendicitis; or she’s had surgery for ovarian cysts--things that might be causing scar tissue. If she’s got significant menstrual pain or pain with intercourse, if she knows she has fibroids or if her periods are irregular, let’s not wait six months to a year, those are things that we can treat today.

Melanie:  So, Dr. Forstein, what’s the first line of defense?  Is it something like Clomid?  What do you do for a woman to help her with fertility at the beginning?

Dr. Forstein:  Right. So, the first thing is to take a really good history and to a detailed physical exam. We take a history of both the female and male partners.  Often couples will tell you something in the history that points you in the direction because what we want to do is try and specify therapy to what’s going on. So, if she’s not ovulating or she’s ovulating irregularly, a medication like Clomid or Femara is a great first line. Sometimes even before we do that, there can be subtle abnormalities in some hormones like Prolactin or thyroid hormones in which treating that with a pill will fix the ovulation problem. Now, if it’s the issue of pain, we are going to want to do an ultrasound to look at the uterus and look at the fallopian tubes because sometimes the correct thing to do is surgery to fix an anatomic problem and not medicine to fix an ovulation problem, if she’s ovulating normally. On the male side, if the history seems normal or definitely if it seems abnormal--he’s got diabetes or thyroid disease or some other medical condition, we are going to want to do a semen analysis pretty early on because the sperm counts can tell us an awful lot about what’s going on. We have to remember that 50% of infertility is actually related to a male problem.

Melanie:  Right away when women hear infertility they think of IVF. They think of all of these painful procedures they’ve heard about other doing. Explain a little bit about some of the other treatments – insemination and in vitro--that can help women to get pregnant. And then, speak a little bit about carrying that pregnancy through to term.

Dr. Forstein:  Sure. So, we are very proud of our IVF lab. We’ve got a brand new facility on the GHS Campus and very high success rates in the top 10% in the county over the past year. We also don’t feel like we have to push women to go to IVF because it’s costly and it’s emotional and some people are just uncomfortable with having a test tube baby. We also employ lots of other therapies for women when that’s appropriate. Insemination is really easy. At the right time in the cycle--whether it’s by medication that’s causing ovulation or your own body’s ovulation – for insemination we just ask your husband or your partner to give us a sample of sperm, it’s washed and cleaned and we get the best swimmers. They go into a little catheter and the procedure is really not much more than a pap smear. It’s just like a pap smear. That increases the chance of pregnancy in women with sub-fertility or infertility quite a bit. It’s also much less expensive than in vitro fertilization. In terms of carrying a pregnancy, most women who have infertility have no difficulty carrying. There does seem to be a slight increase in delivering babies near term instead of term. So, at 36-37 weeks compared to the general population. Most pregnancies go to term and they’re just fine and everything goes really well.

Melanie:  Is there something that you can do to, aside from bedrest, if women have a history of not being able to conceive and carry to term, what do you do for them?

Dr. Forstein:  Right. So, it sounds like we are really talking about reoccurring pregnancy loss here. So, women who are able to get pregnant but they are having miscarriages. I co-direct the Reoccurring Pregnancy Loss Center at GHS. That’s a slightly different work up. It could be some of the same issues. It could be hormonal problems. It could be endometrioses. Occasionally, there’s some male factor issues but we also have to look at is there a problem with the uterus like septum that can be fixed with a simple surgery. Is there a genetic abnormality that one or the other of the parents are carrying that is causing the miscarriage? In those cases, we direct therapy towards that. When we do that workup, sometimes we don’t find anything at all and then we have some imperative therapies like high-dose progesterone therapy and sometimes some blood thinners that we use that seem to make the pregnancies go well and carry to term. Our goal is the same as the goal of our patients which is to see them have a family.

Melanie:  Are there any bits of advice you’d like to give listeners about increasing their fertility?  Is there anything they can do:  lifestyle, behavior modifications, diet, nutrition, anything you can tell them that can help increase their fertility?

Dr. Forstein:  Sure. So, like everything else being as healthy as possible is a key. So, if you’re smoking, try to reduce smoking. If you’re overweight, try and get that down through exercise and diet. If you’re diabetic or insulin resistant, then we sometimes will use some medications like Metformin to help with that. There’s a whole body of science that started at the Mind Body Institute at Harvard University by doctors Domar and Benson that show that stress relief can improve infertility and improve pregnancy outcomes. When we think about stress relief, we think about things like exercise, mindfulness, yoga, meditation, prayer. Sometimes just going for a long walk on a daily basis by yourself or with your partner can make a big difference in terms of your outlook and your stress levels and that’s been shown to make a difference in pregnancy.

Melanie:  In just the last minute, Dr. Forstein, tell the listeners your best advice and why they should come to Greenville Health System for their care.

Dr. Forstein:  Well, Greenville Health System and, specifically, the doctors in the Department of OB/GYN have an approach that’s both high touch and high tech. We have all the latest equipment and all the latest medical advances available to us but we are going to individualize your care. When you come to the Fertility Center of the Carolinas, a nurse or a medical assistant doesn’t come to get you in the waiting room, either myself or one of my three partners does. You see the doctor first. We work with you on time. We spend as much time as we need to with you. We typically spend 30-60 minutes with a patient, whether it’s a new visit or return visit. We make sure that we are learning everything we can about you and providing you the right care at the right time in the right place just for you.

Melanie:  Such great information and so beautifully put. Thank you so much, Dr. Forstein. You’re listening to Inside Health with Greenville Health System. For more information, you can go to ghs.org. That’s ghs.org. This is Melanie Cole. Thanks so much for listening.