Harry Fisch, a specialist in male infertility, says he, too, often finds that antibiotics lead to pregnancy. “It’s amazing,” says Fisch, who is the director of the Male Reproductive Center at New York–Presbyterian Hospital/Columbia, “but [bacteria] is overlooked all the time.”
Such was the case with Jennifer, the aforementioned journalist. Her failed inseminations eventually led her to David, who promptly diagnosed ureaplasma bacteria in both her and her husband and an acidic vaginal environment. He prescribed antibiotics and a baking soda douche. One month later she was pregnant with her daughter.
It is, of course, possible that Jennifer would have become pregnant without David’s fixes. Richard Paulson, the director of the University of Southern California’s fertility program, points out that “the population of women with unexplained infertility has a pregnancy rate of about 3 percent per month with no treatment. That doesn’t sound like a lot,” he says, “but it adds up to all of these anecdotal cases where a patient says, ‘I took cough medicine’ or ‘I took antibiotics, and I got pregnant.’ The science on these things is just not there.”
Like Paulson, Norbert Gleicher, medical director of the Center for Human Reproduction, a fertility clinic with offices in New York and Chicago, believes that such low-tech fixes are rarely of use. He does, however, agree with David’s basic premise that diagnostics in the fertility field are not what they should be. His 2006 paper, “Unexplained infertility: Does it really exist?,” published in the journal Human Reproduction, kicked off a lively debate on the subject. Gleicher’s answer to that titular question is a resounding no. “How much evaluation is done and how deep that evaluation is varies hugely between practitioners,” he says. “Therefore, you find very different levels of so-called unexplained infertility between various physicians.”
According to Gleicher, many women who are labeled as “unexplained” are actually suffering from fallopian tube disorders. To get a picture of the tubes, most infertility patients undergo an HSG test, in which dye is injected into the uterus and flows through the fallopian tubes. But Gleicher believes that many doctors focus only on whether the tubes are free of blockages—whether the dye can pass through them—and neglect to determine whether the tubes can adequately perform their functions. If a patient has endometriosis, for example, the tubes can become scarred and thus less elastic, which makes it difficult for them to ferry the fertilized egg to the uterus. The elasticity of the tubes can be measured by the pressure needed to force the dye through the tubes. “There’s data in the literature that if the pressure goes above a certain point, you don’t see pregnancies,” says Gleicher. “This is often overlooked.”
But the more frequently missed tubal abnormality, says Gleicher, is a condition in which the delicate, fingerlike folds at the ends of the tubes get glued together, thus preventing the tubes from performing their other important function: grabbing the eggs as they’re released from the ovaries. The HSG dye eventually will pass through anyway, he says, “so the HSG will come back normal when in reality this tube will rarely, if ever, allow the egg to be caught.” If the physician studies the HSG more carefully, he insists, the doctor will notice the tube swelling as pressure builds, forcing the dye through. In such cases, inseminations are of little use, and IVF, which bypasses the tubes, is the patient’s only real hope of conception.
Still, says Gleicher, the number of women with overlooked tubal abnormalities pales in comparison to those with undiagnosed premature ovarian aging. According to Gleicher, who is a visiting professor of obstetrics and gynecology at Yale University and editor in chief of the Journal of Assisted Reproduction and Genetics, half of women diagnosed with unexplained infertility actually suffer from this condition. Whereas in most women the ability to conceive and carry a child to term begins to fall off sharply at about 37 or 38 and ends altogether at about 45, for approximately 10 percent of women, says Gleicher, those milestones can occur much earlier. One way of determining the quality, or “age,” of a woman’s ovaries is to test the level of follicle-stimulating hormone, or FSH, in her blood. Generally, women with FSH levels lower than 10 are considered normal. The problem, says Gleicher, is that women in their 20s are judged by the same standard as women in their 40s. “If you’re 9.9 at age 45, you have great ovaries,” says Gleicher. “But if you’re 9.9 at age 28, your ovaries are not aging on the standard curve.” Gleicher advocates that doctors abandon the universal cutoff and instead take into account a patient’s age. By his system, for example, a woman younger than 33 should have an FSH of less than seven.
This aggressive approach translates into a quicker path to IVF for more young women. His worry, he says, is that missed diagnoses of premature ovarian aging are leading women to waste precious chunks of their reproductive years “futzing around” with therapies like Clomid and insemination when they should be on a fast track to IVF.
However, Zev Rosenwaks, who is director of the top-ranked Center for Reproductive Medicine and Infertility at New York–Presbyterian Hospital/Weill Cornell, cautions against relying too heavily on FSH levels when determining how to treat patients. “FSH is a relative test of the probability of conception, but it is not absolute,” he says. “We’ve had hundreds of exceptions in our program where women have been told that they will never have a baby with their own eggs because of FSH elevation and then they’ve gotten pregnant with their own eggs. There are many, many different parameters that you can look at [such as estrogen level and follicular count] which, together, actually give you a better index of a woman’s probability of achieving a pregnancy. FSH alone doesn’t do it.”