Infertility: Common Concerns and Next Steps for Couples

Is it considered infertility?

Hello Dr.
Jan, I got married this February, but since we got engaged in January, my husband and I have been trying to conceive.
Due to our busy work schedules, we have intercourse about once a week.
My menstrual cycle is quite regular (27-30 days), and I notice significant changes in my ovulation discharge (it resembles egg whites and can stretch).
I also experience mild discomfort in my lower abdomen.
Over the past three months, we have specifically chosen to have intercourse during my ovulation period, yet my period still arrives right on time (it always comes 14 days after the discomfort).
I believe I shouldn't wait a year before consulting a fertility specialist, right?
Three years ago, when I was a clinical nurse (now I work as an outpatient nurse), I had some occasional irregular spotting and underwent hormone testing, which indicated low estrogen levels, and elevated prolactin and androgen levels.
An ultrasound showed normal ovarian size and no issues with my uterus.
However, I still experience brown or pink discharge around mid-cycle almost every month.
A doctor I consulted said it was ovulation bleeding, and the ultrasound also showed signs of ovulation.

So why, despite timing intercourse during my ovulation week, am I still not pregnant? Is it possible that I have a "prolactinoma," "pituitary tumor," or "hypothalamic tumor"? I'm really scared.
I wonder if the swelling in my breasts after ovulation, which subsides immediately on the day my period starts (about two weeks later), is related.
Some say breast swelling indicates too much prolactin and insufficient progesterone.
Is this related to the mid-cycle so-called ovulation bleeding, which also suggests a progesterone deficiency? (Because whenever I take progesterone, the ovulation bleeding does not occur!)
Based on what I've described, is there a simple medication I can take to improve or cure this condition? Or will I need surgery to remove something? What kind of frightening tests will I need to undergo? I'm really worried.
T_T

ai, 20~29 year old female. Ask Date: 2004/03/28

Dr. Zhan Deqin reply Obstetrics and Gynecology

Low estrogen, high prolactin, and high androgens cannot be determined by a single blood test.
Particularly for prolactin, it is best to test on the second or third day of the menstrual cycle for more accurate results.
If androgens are elevated, it is important to consider whether there is an issue with overweight, as this may indicate the possibility of polycystic ovary syndrome (PCOS).
If prolactin levels exceed 100 ng/mL, a brain CT scan may be necessary to rule out a pituitary tumor.
For ovarian ultrasounds, a transvaginal approach is generally more accurate.

Reply Date: 2004/03/28

More Info

Infertility can be a complex and emotionally challenging issue for many couples. Based on your description, it seems you have been actively trying to conceive since your marriage in February, and despite having regular menstrual cycles and clear ovulation signs, you have not yet achieved pregnancy. This situation can understandably lead to feelings of frustration and anxiety.

First, it’s important to note that infertility is typically defined as the inability to conceive after one year of unprotected intercourse for women under 35, or after six months for women over 35. Given that you have been trying for only a few months, it may be premature to seek extensive infertility evaluations. However, considering your history of hormonal imbalances and the presence of mid-cycle spotting, it would be wise to consult a fertility specialist sooner rather than later.

Your previous hormonal tests indicated low estrogen levels and elevated prolactin and androgen levels. Elevated prolactin, in particular, can interfere with ovulation and menstrual regularity. Prolactinomas, or pituitary tumors that secrete prolactin, can cause these symptoms, but they are not the only possible cause of elevated prolactin levels. Stress, certain medications, and other health conditions can also contribute to hormonal imbalances.

The mid-cycle spotting you experience, often referred to as ovulation bleeding, can be a normal physiological occurrence for some women. However, if it is accompanied by other symptoms or if it becomes more pronounced, it may warrant further investigation. The fact that you notice breast tenderness that resolves just before your period could indeed be related to hormonal fluctuations, particularly involving progesterone levels. If your body is not producing enough progesterone after ovulation, it could lead to insufficient support for a potential pregnancy, resulting in early menstruation or spotting.

In terms of next steps, here are several recommendations:
1. Consult a Specialist: Given your concerns about hormonal imbalances and the lack of pregnancy after targeted timing, it would be beneficial to see a reproductive endocrinologist. They can conduct a thorough evaluation, including blood tests to assess hormone levels, and possibly imaging studies if a prolactinoma or other issues are suspected.

2. Lifestyle Modifications: Sometimes, lifestyle factors can impact fertility. Ensure you maintain a healthy diet, manage stress, and engage in regular physical activity. Avoiding excessive caffeine and alcohol can also be beneficial.

3. Medication Management: If hormonal imbalances are confirmed, your doctor may recommend medications to regulate your hormone levels. For instance, if prolactin levels are high, medications like cabergoline or bromocriptine can help lower them. If progesterone levels are low, your doctor might suggest progesterone supplementation during the luteal phase of your cycle.

4. Monitoring Ovulation: Continue to track your ovulation signs. You might also consider using ovulation predictor kits to pinpoint your fertile window more accurately.

5. Emotional Support: The emotional toll of infertility can be significant. Consider seeking support from a therapist or joining a support group for couples facing similar challenges. Open communication with your partner about your feelings and concerns is also crucial.

6. Further Testing: If pregnancy does not occur after a reasonable period, further testing may be warranted for both partners. This could include semen analysis for your partner and additional hormonal assessments or imaging studies for you.

In conclusion, while it is understandable to feel anxious about your fertility journey, there are many avenues to explore. Early intervention and a supportive healthcare team can make a significant difference in addressing any underlying issues and improving your chances of conception. Remember, you are not alone in this journey, and there are resources available to help you navigate these challenges.

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