Infertility and the Role of a Reproductive Endocrinologist

A reproductive endocrinologist, sometimes referred to as an RE, is an obstetrician/gynecologist (OB/GYN) physician specialist who has completed a three-year fellowship of intense training in various aspects of endocrine disorders related to the reproductive system in both males and females. One area in which these doctors apply their skills is infertility.

By definition, a woman under 35 years of age is experiencing fertility problems if she has been unable to conceive after one year of trying. If a woman is 35 years or older, infertility is diagnosed if conception has not occurred within six months. This age-sensitive guideline is due to the profound loss of fertility potential that occurs as a woman ages, caused by a steady decline over time in the number and quality of eggs present in the ovaries.

Women with fertility issues should meet initially with an OB/GYN or medical endocrinologist to ensure they’re on the right path to pregnancy. The physician may recommend measures such as quitting smoking, losing weight, or gaining weight if the patient is too lean (described as a body mass index, or BMI, less than 18; for example, a 5' 4" woman who weighs less than 105 pounds). Smoking reduces embryo implantation and increases miscarriage rates, while eating in excess or losing too much weight may cause ovulatory problems. The physician will also review a patient’s current medications to assess if they’re safe for a woman trying to conceive and/or adjust the medications prior to conception.

Before fertility problems can be treated, the source of the problem must be identified. Most OB/GYNs and endocrinologists will likely check for blood sugar and thyroid abnormalities and conduct an ovarian reserve fertility test, a blood test usually done on the third day of a patient’s menstrual cycle. This test measures the level of follicle stimulating hormone (FSH), the main hormone involved in producing mature eggs in the ovaries; estradiol [es-tră-dī´ol] (E2), a female sex hormone that is the predominant estrogen throughout a female's reproductive years; and anti- Müllerian hormone (AMH), which can predict remaining reproductive lifespan. The levels of these hormones can be crucial in predicting the success of reproductive efforts and whether or not a reproductive endocrinologist should be seen.

Additional tests may include a semen test of the male partner and an X-ray of the uterus and fallopian [fualo ´pe-an] tubes, called a hysterosalpingogram, to determine if the tubes are open and healthy. An X-ray also shows if there are any abnormal structures in the uterus, such as a fibrous growth (fibroid) or polyp that distorts the cavity of the uterus, thus compromising the ability to become pregnant.

Other symptoms to take note of include the following.

  • Irregular menstrual cycles
  • Unwanted hair growth on face trunk or limbs
  • Acne flare-ups, especially prior to a menstrual period
  • Two or more pregnancy losses (miscarriages)
  • Prior surgery on the uterus, fallopian tubes or ovary
  • Any surgical procedure on the cervix (mouth of the uterus) due to an abnormal PAP test such as a Loop Electrosurgical Excision Procedure (LEEP) or other process that clears away the abnormal cells.
  • A family member with premature menopause (i.e., menopause before the age of 40)
  • Certain cancers in the family, for example, female family members under 50 with breast or ovarian cancer or two or more family members with breast, ovary, pancreatic or prostate cancer
  • Personal history of any sexually transmitted disease (STD) treated in the past

Some are indicators of conditions such as polycystic ovary syndrome (PCOS), which can affect fertility and may be associated with blood sugar problems that can range from having normal blood sugar levels to borderline blood sugar levels or even diabetes.

Depending on the diagnosis, either oral drugs or surgery performed by a reproductive surgeon may be used as a first attempt to help the couple achieve pregnancy. For example, fertility tablets taken for five days each month may be helpful if periods are not regular. These tablets, clomiphene (Clomid), work by stimulating the growth and release of the egg in a timely fashion. It may take several cycles to find the right dose to stimulate ovulation. If Clomid doesn’t work, more powerful, injectable hormones can be used to stimulate ovulation.

Based on the fertility guidelines mentioned earlier, a woman under 35 typically will start seeing an RE after 12 months of trying to conceive, while women over 35 would start seeing an RE at six months of unsuccessful conception efforts. For others, it’s time to see an RE if conception does not occur after evaluation and treatment by an OBY/GYN or medical endocrinologist.

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Reproductive endocrinology is a branch of medicine that identifies and treats infertility in both men and women.
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The most common surgical procedures performed in reproductive medicine are laparoscopy, hysteroscopy and abdominal myomectomy (removal of uterine fibroids). Laparoscopy [lap´ă-ros´kŏ-pē] is an operation performed in the abdomen or pelvis through small incisions with the assistance of a laparoscope attached to a camera which projects to a screen. It can either be used to inspect and diagnose certain conditions or to surgically correct an abnormality such as removing scar tissue or repairing a damaged fallopian tube. Hysteroscopy is the inspection of the uterine cavity through the cervix by a hysteroscope attached to a camera which projects to a screen. Through this technique, the surgeon can diagnose abnormalities such as fibroids or polyps within the uterine cavity and, using narrow instruments that run through the hysteroscope, remove or correct the great majority of these abnormalities.

Reproductive endocrinologists also carry out and prescribe a variety of fertility tests and treatments, including intrauterine insemination (IUI), which is more commonly called artificial insemination. A relatively simple infertility treatment, IUI consists of purifying the male’s sperm sample and transporting it directly into the female’s uterus through a small tube. The RE also can perform IVF, or in vitro fertilization, which literally means “in lab conception.” The most advanced form of infertility treatment, IVF consists of fertilizing the female patient’s egg with the male partner’s sperm in a petri dish. Typically, many eggs are retrieved from the biological mother, as not every egg will fertilize and not every fertilized egg will become a usable embryo. A few days after fertilization, the RE will transfer the best embryo (or embryos) to the mother or surrogate’s uterus via a catheter through the cervix.

The good news is that conception may occur at any time once the basic tests are encouraging, and the treatments available today through a reproductive endocrinologist can help the majority of patients within one to two years and often sooner.

Dr. Selwyn Oskowitz is one of the founders of Boston IVF, one of New England's leading infertility treatment centers and is also founder and the first president of the New England Fertility Society (NEFS). Dr. Oskowitz has the distinction of delivering the first in vitro fertilization baby conceived in Massachusetts. He also achieved the first conception and birth in Massachusetts by Gamete Intra-Fallopian Tube Transfer (GIFT), an assisted reproductive procedure which involves removing a woman’s eggs, mixing them with sperm and immediately placing them into a fallopian tube. He is Assistant Professor of Reproductive Biology at Harvard Medical School.