Common causes of trouble TTC:
Irregular Cycles
Fallopian Tube Abnormalities

Diminished Ovarian Reserve
Luteal Phase Defect
Male Factor
Unexplained IF

Irregular Cycles:
Long / irregular cycles can be caused by a number of issues including PCOS, thyroid problems, obesity, diet, and hormonal issues, such as elevated prolactin. It is a very frustrating problem to have as it takes longer to get through your cycle, you never know when you are going to ovulate or start AF, you may not be ovulating (anovulation) or have weak ovulation, and frankly, it means you have fewer tries per year than the average lady with a 28-34 day cycle.

Most likely your RE will try you on Clomid or Femara first to see if that helps and then would move on to injectables. You should always have testing done first so the RE can better help you pick the right protocol. If you are suffering from long cycles (longer than 35 days), or are charting and notice no ovulation (shown by erratic temps or no sustained temp shift) talk to your doctor.  Know you are not alone and this is a problem that can usually be fixed fairly easily.

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Polycystic Ovary Syndrome affects an estimated 5-10 percent of women of childbearing age and it is a leading cause of infertility. It is the most common endocrinopathy among reproductive age women. It has been found that up to 30 percent of women have some symptoms of the syndrome.
The symptoms of PCOS include, but are not limited to the following:
  • irregular or no menstrual periods (Amenorrhea)
  • lack of ovulation (Anovulation)
  • acne
  • obesity/weight gain/inability to lose weight
  • breathing problems while sleeping
  • depression
  • oily skin
  • infertility
  • skin discolorations 
  • high cholesterol levels
  • elevated blood pressure
  • excess or abnormal hair growth and distribution (hirsutism)
  • pain in the lower abdomen and pelvis
  • multiple ovarian cysts (Seen on an u/s as a “string of pearls”)
  • skin tags
Some doctors suggest that at least three of the symptoms must be present to diagnose PCOS. Others may make the diagnosis on the basis of fewer criteria (often emphasizing lack of ovulation.) While others believe that PCOS is a diagnosis of exclusion — meaning if there are hormonal abnormalities for which no other explanation can be found, PCOS is presumed.

PCOS is generally considered a syndrome rather than a disease, though, it is sometimes called Polycystic Ovary Disease. It manifests itself through a group of signs and symptoms that can occur in any combination, rather than having one known cause or presentation. There is no cure for PCOS. It is a condition that is managed, rather than cured. Treatment of the symptoms of PCOS can help reduce risks of future health problems.

Blood-work for PCOS- A good basic screening would include:
  • Fasting comprehensive biochemical and lipid panel
  • 2-hour GTT with insulin levels (also called IGTT)
  • LH:FSH ratio
  • Total testosterone
  • SHBG
  • Androstenedione
  • Prolactin
  • TSH
Polycystic ovary syndrome treatment generally focuses on management of your individual main concerns, such as infertility, hirsutism, acne or obesity.

Your doctor might recommend that you:
Schedule regular checkups: Long-term, managing cardiovascular risks, such as obesity, high blood cholesterol, type 2 diabetes and high blood pressure, is important. To help guide ongoing treatment decisions, your doctor will likely want to see you for regular visits to perform a physical examination, measure your blood pressure, and obtain glucose and lipid levels.

Adjust your lifestyle habits: Making healthy-eating choices and getting regular exercise is the first treatment approach your doctor might recommend, particularly if you're overweight. Obesity makes insulin resistance worse. Weight loss can reduce both insulin and androgen levels, and may restore ovulation. Ask your doctor to recommend a weight-control program, and meet regularly with a dietitian.

Regulate your menstrual cycle: If you're not trying to become pregnant, your doctor may prescribe low-dose birth control pills that contain a combination of synthetic estrogen and progesterone. They decrease androgen production and give your body a break from the effects of continuous estrogen. This decreases your risk of endometrial cancer and corrects abnormal bleeding. An alternative approach is taking progesterone for 10 to 14 days each month. This regulates your periods and offers protection against endometrial cancer. However, it does not improve androgen levels.

Prescribe Metformin (Glucophage, Glucophage XR), an oral medication for type 2 diabetes that lowers insulin levels. This drug improves ovulation and leads to regular menstrual cycles. Metformin also slows the progression to type-2 diabetes. If you already have pre-diabetes, you are at an increased risk for developing type-2 diabetes. Metformin can aid in weight loss if you follow a diet and exercise program.

Reduce excessive hair growth: your doctor may recommend birth control pills to decrease androgen production, or another medication called spironolactone (Aldactone) that blocks the effects of androgens on the skin. Because spironolactone can cause birth defects, effective contraception is required when using the drug, and it's not recommended if you're pregnant or planning to become pregnant. Eflornithine(Vaniqa) is another medication possibility; the cream slows facial hair growth in women. Shaving, waxing and depilatory creams are nonprescription hair removal options. Results may last several weeks, and then you need to repeat treatment. For longer lasting hair removal, your doctor might recommend a procedure that uses electric current (electrolysis) or laser energy to destroy hair follicles and control unwanted new hair growth.

Use medication to induce ovulation: If you're trying to become pregnant, you may need a medication to induce ovulation. Clomiphene citrate (Clomid, Serophene) is an oral anti-estrogen medication that you take in the first part of your menstrual cycle. If clomiphene citrate alone isn't effective, your doctor may add metformin to help induce ovulation. If you don't become pregnant using clomiphene and metformin, your doctor may recommend using gonadotropins — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) medications that are administered by injection.

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Endometriosis and Laparoscopies
Endometriosis is a condition in which cells from the endometrium - or uterine lining - grow outside the uterus and adhere to other structures in the pelvis, most commonly the ovaries, bowel, fallopian tubes or bladder. Like the endometrium itself, the transplanted tissue responds to the hormones estrogen and progesterone by thickening and may bleed every month. But because the transplanted tissue is embedded in other tissues, the blood it produces cannot escape. This causes irritation of the surrounding tissue which in turn causes cysts, scars, and the fusing of body tissues.

Symptoms may include:
  • Pain, which can be: Pelvic pain, severe menstrual cramps, low backache 1 or 2 days before the start of the menstrual period (or earlier), pain during intercourse, rectal pain, pain before/during bowel movements.
  • Infertility (which may be the only sign that you have endometriosis)
  • Abnormal bleeding. This can include: Blood in the urine or stool, Spotting throughout the cycle, and vaginal bleeding after intercourse.
The only way to confirm a diagnosis of endometriosis is to have a laparoscopy. In this procedure, your doctor will make 2-3 small incisions in your lower abdomen and will look for adhesions. If they are present, s/he can remove them, usually burning them off with a laser. Recovery varies depending on a few factors, including the severity of the endometriosis. Some women report being able to return to work in a day or two, while others find it can take up to a week.

Endometriosis is not curable and may return numerous times. The main treatments are continuous use of progesterone only birth control pills to prevent periods, as this helps prevent the growth of endometrial implants. Infertility is thought to affect approximately 40% of women with endometriosis. So just because you have endometriosis, this doesn’t necessarily mean you will have difficulty conceiving.

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Fallopian Tube Abnormalities:
The HSG may show that your tubes are blocked or filled with fluid (hydrosalpinx). This interferes with the ability of the egg to get from the ovary to meet the sperm, so makes conception difficult. Common causes include prior STD, endometriosis, previous abdominal surgery or congenital problems (only one tube failed to form, abnormally shaped uterus, etc). Often the cause is unknown. Surgery can sometimes help correct this, or some women may need to proceed directly with IVF.

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Diminished Ovarian Reserve:
If your day 3 labs come back abnormal (elevated FSH, low estradiol and/or low anti-mullerian hormone) you may have what is known as diminished ovarian reserve. This means you have fewer follicles, and may have poorer quality eggs. Many of these women still ovulate regularly, but have trouble conceiving due to egg quality issues. If this is your diagnosis, your doctor will likely want to treat you more aggressively. Medications such as Clomid do not typically work well for these patients, so if you choose to do IUI, you may want to use injectable medications. Some patients will also choose to move directly to IVF.

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Luteal Phase Defect:
The luteal phase (time from ovulation to start of your next period) should typically last between 12 and 16 days. You can determine the length of your luteal phase (LP) by charting. Your LP will be the number of days your basal body temperature remains elevated following ovulation. If your luteal phase is too short, it may be difficult for you to get pregnant. This is often due to low progesterone. To confirm this, your doctor will want to check a progesterone level 7 days following ovulation. It is important that this is checked 7 days after ovulation (as detected by OPK or charting) and not simply on CD21, as few women have ideal cycles. Unless you ovulate on CD14, the results of CD21 progesterone will not be accurate. LP Defect can be treated with progesterone supplements or Clomid.

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Male Factor Infertility:
If your partner has abnormal values on his SA, you will likely have to consider IUI or IVF with or without ICSI, depending on the severity of the abnormalities. Your doctor will discuss your options with you. Also see the section on Semen Analysis, for more things to do when you have an abnormal SA result.

Unexplained Infertility:
Unexplained infertility is the inability to conceive after 12 months of well-timed intercourse (6 months if you are over 35), with non-identifiable medical problem. Twenty percent of couples will have no explanation for their infertility. These couples have had a normal fertility work up including:
  • normal semen analysis
  • normal FSH/estradiol or AMH indicating good ovarian reserve
  • normal prolactin and TSH, ruling out other causes of infertility
  • normal progesterone 7 days following ovulation to show you are ovulating
  • normal HSG to ensure there is no tubal problem
Some women will undergo testing prior to 12 month cut off noted above, for peace of mind or other reasons. However, it is important to keep in mind that if all your tests come back normal, you still have a good chance of conceiving without intervention within the year. Most physicians (and insurance companies!) will not recommend treatment for women with normal test results before one year.
For more information on unexplained IF (and lots of other great information about infertility), check out the resolve.org website: http://www.resolve.org/diagnosis-management/infertility-diagnosis/unexplained-infertility.html

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