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Elaine Brown, MD  
Female, 52
Billings, MT

Specialties: Pregnancy, Gynecology

Interests: obstetrics & gynecology, Gynecology
Elaine Brown, MD - BLOG
gynecology
(406) 252-0022
Billings, MT
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What's New in Infertility, a three part series

Dec 27, 2012 - 15 comments
Tags:

Infertility

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Pregnancy

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biological clock

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Female Infertility

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male and female infertility

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Male Infertility

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endometriosis

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antimullerian hormone level

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ovulation predictors

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ovulation trackers

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unexplained infertility

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HSG

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hysteroscopy

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laparoscopy

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pre



In the United States 1 in 8 couples has difficulty when they wish to start a family.

***What's new?  The birth rate in the US reached an all time low of 63.2 per 1000 in the US in 2011.

The majority of couples who visited their doctor for infertility issues wish they had visited sooner.

When should couples visit the doctor?

Most experts advise couples to begin with a visit to her doctor (ob/gynor family doctor)  if the couple has been trying unsuccessfully to conceive for over a year. If his age is over 55 or hers is over 35 the visit should happen sooner--after 6 months without success. Of course, same sex couples will need to begin with a visit to the doctor right away.

Causes of infertility are divided approximately equally between the sexes, with female factor infertility accounting for approximately one third of cases, male factor infertility accounting for approximately one third, and the final one third is composed of couples with both male and female factors.  For a significant percentage of couples, no obvious problem is found.  Those couples have traditionally been given the diagnosis of "unexplained infertility".

What are the causes of infertility in women?

In women, causes of infertility can be divided into two very broad catagories:
1) Hormonal problems such as abnormalities of the thyroid or pituitary gland, or problems with ovulation (releasing an egg from the ovary).
2) Physical problems such as blockage of the fallopian tubes, problems with the uterine lining (polyps or fibroids), and problems with the cervical
mucus.

***What's new? Many infertility doctors now believe that many of the cases of "unexplained infertility"  in women are actually cases of very early, mild, or atypical endometriosis
                                                                                                    
What are causes of infertility in men?

As in women, causes of infertility in men can be divided into two broad catagories
1) Hormonal problems such as abnormalities of the thyroid or pituitary, or problems with sperm production caused by low testosterone levels.
2) Physical problems such as blockage of the seminal vessicles, retrograde ejaculation, or failure to achieve or maintain an erection.

***What's new?  Recent studies suggest that a significant number of cases of  unexplained infertility in men are actually cases of excessive DNA fragmentation in the sperm. (DNA is the genetic material  carried by sperm.)  Excessive breakage of DNA strands has been linked to many factors, such as excessive exposure to stress, heat or environmental toxins.

***What else is new? Fertility specialists are investigating a third, controversial category known as Immunologic infertility.   A Malfunction in the body's immune system, which  normally protects against invasion by foreign agents, causes the body to attack itself interfering with  normal mechanisms of fertility.

How is infertility diagnosed?

Traditionally the infertility evaluation begins with the female partner.  An ob/gyn physician or general practitioner can perform the basic work up.  Most physicians will begin the evaluation by determining whether the female partner is ovulating regularly.  A progesterone level at the right time in the cycle(cycle day 21) can confirm ovulation.  Ovulation predictor test strips (which are similar to home pregnancy tests) and  Basal body temperature charting is also useful.

***What's new?  There are some convenient new apps for your laptop or cell phone that can be downloaded to help a woman monitor her cycle and determine her fertile days. Medhelp.org offers a nice tracker for signs and symptoms of ovulation.  http://www.medhelp.org/user_trackers/list/603463  New digital technology such as the The Clear Blue digital fertility monitor, can be used in conjunction with this app to determine the maximum number of fertile days and the optimum timing of intercourse.
  
If the woman is NOT ovulating regularly, the clinician will often evaluate thyroid hormone levels, prolactin levels, and FSH levels.Treatment of thryoid or pituitary abnormalities with appropriate medications can often help to re-establish regular menstrual cycles, and improve fertility.If the FSH level is elevated, this may mean that the ovarian reserve(the number of eggs remaining in the ovaries) is diminished.Older age (35 and up) is the most common reason for an elevated FSH.  Premature ovarian failure is a rare condition in which eggs are depleted before age 40.

***What's new?  Antimullerian hormone level(AMH) is a new blood test that is believed by many doctors to more accurately reflect the number of follicles or eggs remaining in the woman's ovaries than the traditional FSH test. The AMH level can help to estimate the chances that a woman can conceive with her own eggs versus the need for donor eggs.

If it seems that the mom-to-be IS consistently ovulating each month, the problem may lie with a blockage of the fallopian tubes. A hysterosalpingogram (hsg) can be performed. A traditional HSG is an x ray procedure during which dye is injected into the uterus and spills out into the abdomen through the fallopian tubes.  If the dye fails to spill from one or other of the tubes, a blockage is diagnosed.

***What's New?  Selective salpingography is a cutting edge technique in which a tiny cather(tube) is placed inside the hsg catheter and directed into the opening of the tube itself. In this way it is possible to determine whether a tube which might appear blocked on hsg is actually open, but might have spasmed due to the dye.
It is also possible to measure the pressure inside the fallopian tube.  In some cases of endometriosis, the pressure can be elevated causing reduced pregnancy rates.

If the female partner is BOTH ovulating regularly AND her tubes are not blocked, the next step is to investigate the uterus. Ultrasound can be used to evaluate the patient for problems such as cysts or fibroids. Historically, the next step was surgery in which either one of two or both a laparoscopy and hysteroscopy were performed  A hysteroscopy is an evaluation of the lining of the uterus, in which a scope is placed into the uterus through the cervix. Laparoscopy, a minor surgical procedure in which a small scope is placed into the abdominal cavity  is employed at times to evaluate the patient for evidence of endometriosis or other abnormalities of the pelvis such as adhesions which may not be detectable with ultrasound.

***What's new?  Recently, the trend has been toward a less invasive office procedure known as Saline Sonogram--Sterile saline solution is injected into the uterus while the doctor watches with transvaginal ultrasound.  Less expensive, less invasive and less painful, the saline sonogram can disclose a lot about the lining of the uterus, as well as having all of the advantages of traditional transvaginal ultrasound.

The least common abnormality, and usually the last to be investigated,  is a problem with the amount or quality of the cervical mucus.  The sperm must swim through the mucus to reach the egg. Normal mucus is nourishing to the sperm, allowing them to survive for 3-6 days.  Cervical conization or LEEP procedure can cause scarring of the cervix which can contribute to problems with the scanty or hostile cervical mucous.

If the evaluation of the female partner is normal, attention is then focused on the male.

Part two in this three part series will be devoted to diagnosis of fertility problems in the male partner, and treatment of infertility.

Part three will go into more depth on some of today's most relevant topics such as Polycystic Ovary Syndrome and new technologies which are making the biological clock obsolete.

Comments
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by Kaysid6, Jan 04, 2013
I am scared i may be infertile and also have other problems due to having PCOS!  13 months ago my periods just stopped, nothing no spotting or anything since!??! Before I had them every month sometimes it'd follow different GF's cycle, but it did always come! Ontop of not having a period in over a year I have also gained an enormous amount of weight for my size! 30lbs in just the past year, I had never passed 105lbs prior to my periods stopping. Is this related to PCOS or Am I in early menopause? I am 28 yrs old, the period stopped when was 27 and started having cysts around 22, only a few sexual partners in my lifetime, no stds & haven't had sexual encounter in 11 months bc my sex drive has left the building!!?! I am super scared and need help! I have no insurance so I don't know what to do bc i cant go to a bunch of specialists but something needs to be fixed I'm sure!! So my worries are, where should I start, will the weight gain reverse once treated, and am I infertile now? I have no children and have NEVER used birth control ever and haven't used protection with the two relationships I had over the past 10 years. So was I already infertile or just lucky? What are your thoughts on the cause of pain, weight gain, infertility, loss of sex drive, constantly hot and the best place to start without health insurance or much $$? Thank you for your time! Kaysi

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by Kaysid6, Jan 04, 2013
Also too I read somewhere that I could still be ovulating but not bleeding? Is that a cause of the weight gain? Going from 105 to 135 in just a few months seems pretty drastic with no changes to habits. Obviously I want to get rid of the excess weight gained but tore importantly I want to know the cause and fix the issue bc I'm scared this is a major health concern for a 28 year old female. Any thoughts would be a huge help! Thank you!

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by BooBop3, Feb 12, 2013
Hello,
I could not figure out how to post a comment on your profile. I found out I have endometriosis about a year ago by having the laproscopic surgery done. I have had a lot of pain problems. Ive taken ibuprofen, advil, etc. and I use a heating pad and back cream to try to help the pain. I cant get in to see a doctor because the new patient wait is so long. I dont know what I should do. Im also on the three month birth control shot and Ive been bleeding for about two or so weeks now and im not suppose to.
Thank you for your time.

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by evewisewoman, Mar 19, 2013
Hello, Dr. Brown,
I also could not figure out how to post a comment on your profile or so that you could answer my questions.
I'm scheduled for an endometrial biopsy later on this week. I under went a pelvic and transvaginal ultrasound about
three weeks ago. My family doctor referred my to a specialist and a ob gyn. I met with her about 2 weeks ago and
the intern that is working with her. The intern asked me a number of questions. Anyway, I met with the ob gyn.
She seems nice and my doctor says she's lovely, I'm guessing her personality. The ob gyn told me to take 2 misoprostol 200 mcg , 4 hours prior to the endometrial biopsy. She also told me to take some ibuprofen for the pain.
I've been doing some research about endometrial polyps. Apparently of these kinds of polyps are beneign but the
ob gyn stated some can be cancerous. If the polyp were cancerous, would this mean the cancer of the utereus?
If you could reply to my post, I would be really grateful as I am very nervous about this procedure. Thank you.

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by rachael434, Mar 20, 2013
My boyfriend and I have been together for 1 year and 4 months and I still havent gotten pregnant. We are always unprotected, I got the depo about 3 in 1/2 months ago and now im off of it so ive been off for a total month. Why haven't I got Pregnant? Please help!!

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by munenyasha, Apr 16, 2013
I hv been married for a year and half and im 24,i hv a regular period bt nt conceiving what myt be the problem plz help.

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by Clora17, Apr 24, 2013
Dear Dr. Brown,
Hello I am a 17yr girl and I have a few questions. See a two years ago I got pregnant. However 3 months later I miscarried. Now I have had a total of three miscarriages and I am starting to worry. I know my family has hormone and thyrode problems. This worries me because, what if I am infertile. I told my gf who wanted me to carry our children because she is so small and she left me. I am just worried with all the health conditions in my family that I will never be able to have a kid... at all. And I always wanted a son.
Do you think there is anything I can do other than going to the doctor and having to tell my mom?

With My Deepest Care,
Clora17

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by MaraT, Jul 13, 2013
Hi Dr. Brown, where do I find part 3 of this with the info on Polycystic Ovary Syndrome? Thanks

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by shellbell502, Aug 01, 2013
my periods are not normal at all & im on meds that make it come & go well i havent had one but dr had gave me pregnacy test before meds & was not pregnant .. this morning i woke up & was bleeding figured i had started well the bleeding got heaver & i started to cramp really bad like contractions i go to the bathroom & it felt like i had too poop & i misscarried in the toilet =[ && it was in the sack & you can tell it was a baby so i was more than a week or so far along.. i have not went to the er because everything seemd to pass & i sent my 12month old baby girl with a friend for the day & night so i was lifting her so the bleeding isnt real heavy but the pain comes & goes like contractions .. Should i go to the Er && friend keep telling me they will do blood work & ultra sound what is the blood work for & what do they test??

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by Ravi2511, Sep 21, 2013
Thanks a lot, very good information.... extremely helpful.

I would like to know some thing abt PCOS... i have PCOS and unable to conceive... i am taking medicines such as Glycyphase, All Nine, Duphaston, Siphine.

Glycyphase - on regular basis - 500mg
All Nine - on regular basis - 1500mg
Duphaston - starts it 10 days before periods - 2 tablets a day
Siphine - after getting my periods, i take it for next 5 days only. 100mg

and on 5th day of periods - Eugon 75U

FSH-4.89mlU/ml


Please assit on your suggestions.

Thanks,
Ravi

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by Arizona2013, Oct 23, 2013
I have been having periods since May. Some months I'll bleed 20 days, not straight, but just added up together. Whether it's heavy light or spotting. It's rare I get more than a 4 day break with no blood. On the 13th was the last time I bled. I didn't think anything of it, until 3 days ago. When out of no where, my nipples started hurting really bad. So much that nothing could touch them unless it was the palm of my hand pressed against them. Even then they still kind of ached, some days have been worse than others. I've been having yellow discharge, today there was a little more than normal. I've been unusually tired, and hot when normally I'm cold. & The past week I've sort of felt like I was coming down with the flu but it never got worse. Today I'm a little better, but my nipples still hurt, I can't let the shower water hit them.
I've ruled out a lot of possibilities. The only thing I can think of is pregnancy but I took a test yesterday and it was negative. I know what day I would of conceived, last month on the 26th. I've known since then it might of been a possibility but I didn't think I was till now. Is it possible for me to be pregnant with my irregular period, is something else going on?

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by scaredalwaysscrr, Nov 29, 2013
Sent by scaredalwaysscrr Nov 28, 2013
hi :) Can I get pregnant if a couple minutes after touching his.. ehm package..(which was kinda wet) I showered myself??? you know.. i showered EVERYTHING... could sperm still be in my hand (i washed my hands first but i was already in the shower)...
It all started when he fingered me (first time ever..) and i tried to give him a HJ but i was grossed because he was kinda wet... and after a couple minutes i went home and showered (what i told you at the beginning).. I washed my hands in the shower and then myself.. is there a prob that i might be prego?? We had clothes on... but obviously his hand and mine where down there...I am totally a virgin.... And to me it woul!!d be sooooo lame to get pregnant without actually having sex.. but i read in some places that you can if you have semen.. in your hand..thnks


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by E789, Jan 16, 2014
Hi can dr answer my question ? Drinking 2 glass of red wine is safe befor ovulation or conciveing ? Tnx alot

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by deepakshi, Mar 07, 2014
my last period was on 20 march and my husband ejaculate sperms on 2nd and 3rd march ,then i took i-pill {emergency pill} on 4rth march at night on 5th march i didn't bleed not any sign of side effect.Earlier i took 5-6 months back, i bleed, but not this time.is their pregnancy ?? pllsss reply iam very much tensed and eager to know something positive.......

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by wickedgreeneyes, 12 hours
I have high prolactin levels. My doctor would not do a scan of the pituitary gland. My first test was 42 second test was 20. My husband and i have been trying to get pregnant for 2 yrs. I do have weird hypoglycemic episodes. Though the doctors don't have an actual reason to why this happens, i wonder if they somehow go together. It makes me feel like less of a woman not being able to become pregnant at 29 yrs old.

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