Let's not talk about the hemorrhoids!

I asked my medical assistants what topic they think I should address and I was very surprised that they said, "Hemorrhoids". They said that questions about hemorrhoids was one of the most common phone calls that they get. I guess it is easier to talk about them over the phone than in the office!

So, while hemorrhoids are usually under the hospices of the general surgeon, here I go to review them briefly.

What is a hemorrhoid? Hemorrhoids are just varicose veins around the anus and rectum. Some are more external and some are internal. Just like other varicose veins, there are usually from a blockage and backup of blood in those veins. Most commonly in my office, the blockage comes from a pregnancy. The pressure on those veins back up the blood and the veins swell until they are easy to see and become irritated. Once the blockage is removed, the veins usually decompress pretty quickly. Like a balloon though, the first time the veins are expanded it takes some force, but once they have been stretched they can pop right back up again with minimal pressure.

Symptoms: Varicose veins, in and of themselves, are not usually a problem. You may just feel them when you wipe. Usually the external ones are soft and fleshy. When they get swollen, irritated, or if a clot forms in them they suddenly become a much bigger, "pain in the butt". They are often the cause of painless bleeding with bowel movements. (Painful, tearing bowel movements that cause bleeding is usually a fissure).

Treatment: The treatment for the swelling and irritation is usually a hemorrhoid cream that includes a steroid. Topical ointments and pads, such as tucks, are soothing but don't offer any anti-inflammatory action. Prep H., anusol etc, have some hydrocortisone (a steroid) in them which will work much more effectively in reducing the irritation. These need to be used regularly, at least 2-3 times a day and maybe even 4 times a day until things get better. There are some prescription strength creams that are effective as well.

In additional to topical medications, the pressure has to be off. This means, no heavy lifting or straining. Stools should be the texture of a ripe banana. You may have to take fiber drinks-metamucil, citracel etc. to get your stools softer. (hint. start slowly with the fiber drinks and work your way up to the dose that gets you results. Going to fast will make you very gassy and bloated). Stools softeners like colace will work for the short term but if you are prone to constipation you may need the fiber for the long term.

After a pregnancy with normal bowel function, decreased lifting, topical creams and time, the hemorrhoids should go away until your next pregnancy.

If you get a clot in one of the veins you will know it. The pain is pretty intense and instant and will probably bring you to the ER. There, they will just incise the veins and remove the clot. Relief is almost instant with this treatment.

Surgical treatment of hemorrhoids is the very last resort and some say the surgery can be worse then the hemorrhoids. It is definitely worth the slimy orange drinks and the creams to avoid needing surgery.

Prevention: Preventing hemorrhoids is difficult, particularly in a pregnancy. Not allowing for on going constipation is the best prevention. Choosing your parents wisely will help too as hemorrhoids can have a large genetic predisposition.

Warning: Hemorrhoids that seem way out of proportion for your situation, that get worse and worse, or that bleed a lot, need to be seen. Severe hemorrhoids can be a sign of other problems such as colon cancer. Obviously rare in younger women who are having children, but not unheard of. Never be too embarrassed just to have them checked if they are not improving as expected.

Well, hopefully that answered some of your questions that maybe your were afraid to ask! Now back to the gynecology!

Do I really need a pap smear?

So with all the changes in healthcare guidelines you may be wondering if you really need a pap smear. I'm going to go through a few of the new guidelines with you, but remember, it's always safer just to get the exam.

My first big disclaimer is that there is more to a physical exam than just a pap smear! There are many other issues that we like to address at your physical such as diet and exercise ( I know, you don't want to hear it), good heart health (still the leading problem in women), emotional wellbeing, menopause, irregular periods, breast and skin exam etc. etc. Depending on your age and healthy you may not need a physical every year but you need to talk to your doctor about that.

Now, for cervical cancer. The only thing that a pap smear checks for is cervical cancer. Sure, we may get a little yeast on the smear, and sometimes some endometrial cancer cells, but the purpose of the pap is to screen for cervical cancer. We know that cervical cancer is from the HPV virus (Human papilloma virus). This is sexually transmitted but it can be skin to skin contact and not penetration. It is a very, very common virus. There are many strains of this virus. A handful cause cervical cancer and a handful cause genital warts. Unfortumately, you can not tell if you have the virus that causes cancer until you start getting precancerous cells on your pap smear. Occassionally we will check if you have the virus but this is not covered by insurance except in certain conditions. Sooooo, you have to get your pap smear if there is any chance you may have been exposed to the virus in your lifetime.

Okay, now I know that there are many of you that say it is impossible for you to have a STD as you and your partner have been monogamous. I really wish that this was always the case and that all partners were faithful. Not wanting to cast any doubt on your true love, I'd still recommend getting a pap smear per the following recommendations. I've seen too many surprised women and blushing men.

So here are the current recommendations from the American College of Ob/Gyn (ACOG);

Young women under 21 should not get a pap smear. Young women have great immune systems and even if they get the virus their bodies can usually fight it off.

Paps should be done every 2 years from 21-29 years

Women 30 and older, if they have had three consecutive negative paps, and no prior history of precancerous cells (CIN) and no medical conditions that compromise their immunity, and get their paps every 3 years.

Women who have had a hysterectomy and no history of abnormal paps can forgo any further pap smears.

Women over 65 with no prior abnormal paps, can stop having paps.

Women with prior abnormal paps needs to continue to be screened for at least 20 years after treatment.

Women who have had the immunization should still follow the above guidelines.

There. I hope that helps. Again, I want to stress that appointments for physical should go well beyond just a pap smear. A yearly pelvic exam may still be needed to screen for other cancers such as ovarian, vulvar and colon cancers. Addressing other issues in your life should be equally as important and hopefully, as your physician we can make these appointments worthwhile!

What if I don't want to get pregnant?

So, I've talked about getting pregnant but I want to talk a little about what is out there for birth control options. This is by no means comprehensive but just a little overview.

First, there are different types which include barrier methods and hormonal methods. I'll first summarize the differences and then talk about each one.

Barrier methods are just that, a barrier-keeping the sperm and egg apart. This includes condoms, diaphragm, copper IUD, and sponges. Barrier methods are not usually as good as hormonal methods. The analogy would be liking trying to keep a spilled drink from dripping on your favorite purse by trying to contain the liquid vs by removing the purse. Hormonal therapy just removes the purse. Barrier methods are trying to control the spilled drink.

If you use condoms and diaphragms regularly and follow the directions they are fairly effective. You know there are pros and cons for each. The biggest point of barrier methods it that they do not control anything hormonal. They will not change your moods, treat PMS, or alter your periods.

Hormonal methods will prevent pregnancy by stopping ovulation. These include the pill/ring, the depot provera shot and the implanon. These do affect your hormones and may alter your periods, PMS and moods ( for good or bad).

The mirena is somewhere inbetween. It acts as a barrier but has some hormones that will at least affect your period. In some women it may stop ovulation and may change moods, cause acne etc., but the main effect is on the uterus.

Lastly, there are permanent methods which are all ways of blocking the tubes-tubal ligation, ariana and essure.

Barrier methods:
condoms-used at the moment, about 89-93% effective, less mess for the woman, decreased sensation for the man. Low cost.
diaphragm-put in before and taken out about 8 hours later. Best with spermacide. Buy one and reuse it.
copper IUD-placed in the office, lasts up to 10 years, can make periods heavier and crampier. 1/1000 chance of getting pregnant.

Hormonal methods:
Pills- there are many, many different pills. They will give you regular cycles and lighter periods. They can help acne and occassionally PMS. They are protective against ovarian and endometrial cancer. You can also use them to time your periods, skip periods etc. On the bad side, they can alter you moods for the worse, cause irregular spotting and make you nauseous. Each pill works differently on different women and so trying several of them may help you find the perfect one. The nuvaring is just a different way of getting the same hormones-you just don't have to remember to take a pill. I rarely see weight gain and you can get pregnant soon after coming off. If fact, in some infertility cases we use a month of pills to help increase fertility.

Depot Provera-a once every three month shot given in the office. Should make your periods disappear but may cause spotting for 3-6 months. Can increase appetite and weight gain can be a problem. Will thin your bones if used for a long time but most bone density will increase when you stop taking it. Can take some time to get pregnant after coming off. May cause some depression.

Implanon- a rod placed in the upper arm in the office. Lasts for three years. Should get rid of periods but may have spotting. Should reverse quickly but may take some time to concieve. Manufacture reports no weight gain.

Mirena- IUD placed in the the uterus. Has progesterone but it usually just affects the uterus. This causes the lining to be thinner and so your periods are light to non-existant. It shouldn't affect your moods, acne etc but it does in some women. Lasts up to 5 years. Very quickly reversible. As effective as a vasectomy for birth control. Can cause some acne and mood changes in some women. Will have spotting for 2-6 months.

Remember, hormonal problems have to be treated with hormones.

Permanent sterilization
Tubal ligation-done in the OR or post partum- effective immediately, can cause periods to be a little heavier and crampier. Requires entering into the abdomen (a little more risk to the surgery) .
Ariana/ essure- done in the OR (some MD's will do it in the office), placed by going through the cervix and plugging the tubes. No incisions required. Are not immediately effective and you are supposed to get an HSG (tubal study done in radiology) 3 months later to be sure it is effective. Not currently recommended to to other surgery with it-like an ablation- but some practitioners do.
Vasectomy-safest for the women :). Done in the office. Not immediately effective. Test for effectiveness should be done in 2- 3months.

Hope that gives you a little better understanding of what is available.

sleepy docs

I was reading an article in the American Journal of Ob/Gyn and thought you might like this quote-especially if you're doctor missed your delivery.

"The average practicing obstetrician gynecologist works hours significantly in excess of those allowed for younger resident physicians. In addition, obstetrics remains the only medical specialty in which the attending physician is rountinely expected to both manage a critical and potentially life-threatening process for 2 patients during labor and at the same time seeing office patients or performing elective surgery. Although some might see this as part of the general devaluation of women and children's health care, patient expectations are at least as much to blame. Given the realities of clinical practice, it is simply impossible for every woman to be delivered by the obstetrician of her choice, without accepting the occurrence of sleep deprivation-induced congnitive impairment of that health care provider." Aug 2009 pg 136.

There are times when I will have the on-call doctor deliver one of my patients because I'm just too tired to think straight. I hope you all understand that it is really in your best interest. We really do want the best care for you. I love to deliver my own patients, and would deliver all of them if it were safe. There are some areas, like in Arizona, where they have laborist; physicians who just stay in the hospital and deliver everyone's patient that may come in. In these places you will have about a 1 in 15 chance that your doctor will deliver you. I hope it doesn't come to that everywhere but with new health care policy etc. it may even happen here. (No plans for it in the near future!) Just a little insight I thought you might like.

whats with the Vit D?

Vit D. deficiency is something that is fairly new. It has been surprising how many women, even in sunny areas, that are low in vit. D. Vit D. is used for calcium absorption and calcium is used for bone growth and muscle function. Being low in vit D and calcium can affect your bone density as well as your muscle function. There may be other benefits of vit D as well that are still being studied. These benefits may include decreased colon cancer risk, better prognosis with breast cancer, and decreased risk for pre-eclampsia in pregnancy.

It is thought that since we are staying out of the sun and drinking less milk-both sources of vit D-may be the cause of so many people having low levels.

So what do you do? First, get your vit D level checked-a simple blood test. If it is low then you may need supplementation. The amount you need will depend on how low your levels are. If severely low you may be put on 50,000IU's for 8 weeks. If borderline, you may just be given an over-the-counter vitamin. Pregnant women should probably be taking around 2,000IU. It is important for pregnant women to have adequate vit D for the health of your baby's bones.

There is no known "toxic level" of vit D. but megadoses are not recommended. In fact, some supplemention with vit D and calcium may cause kidney stones.

Again, I've been surprised at the number of tan, active women who have had low vit D levels. I've also been surprised that many of these women feel better when on their supplements. They feel stronger and will some increased energy.

If nothing else, enjoy a little sun (with SPF of course) and drink your milk!

Pregnancy, turkey and hotdogs

What can I eat when I'm pregnant?

This post has taken me awhile as I wanted to do some research first. Unfortunately, in regards to nutrition and safety in pregnancy, there is very little "proven". As you know, there are many claims of vitamins, herbal remedies, diets etc out there. Because most of this stuff is not controlled, there are very few studies that prove efficacy or safety of any of these things. I've tried to go through the scientific literature and get you the best answers I could find. I will not address herbal and natural remedies. I agree that these may work, but I can not attest to their safety. I do want to talk about obesity in pregnancy but I will do that in a later post.

So, back to diet, you're not supposed to eat tuna or hot dogs or foods that cause allergies or soft cheeses, or melons, or smoked seafood.....and you need to take your vitamin everyday or your baby will have three eyes, right? Wrong.

The thing about nutrition is that it should be commonsense. If a good balanced diet is good for mom, it is good for the baby. Nothing extreme. All things in moderation. Exercise, good diet, appropriate food handling, avoidance of drugs and alcohol; these are all recommended to all women, pregnant or not.

So lets look with a little more detail.

Listeriosis: The topic that made me even think of writing this blog is deli meats. I can't tell you the number of phone calls that I get asking if someone can have a hot dog at their family reunion. This recommendation is based on some science, though probably blown way out of proportion. Listeriosis is a bacteria that can be found in many sources, including deli meats. It is not killed by refrigeration and so can be on many preprocessed foods. It is found in dirt, on drinking fountains, in deli meats, melons, soft cheeses, hummus, corn salad, many animals, food from delicatessen counters, pasturized and unpasturized dairy products, fruits and vegetables. In otherwords, it can be found most everywhere. Two large outbreaks were from turkey meat, thus the warning against that. For some reason, when people are exposed to listeriosis, it is the immunocompromised (cancer pts, HIV) and pregnant women in the third trimester that are most succeptible to getting sick. If a third trimester patient gets listeriosis there is a risk of fetal death as well as maternal death. There is no doubt this is a terrible disease.

The important thing to note, though, is that it is a very rare disease. The risk of getting it is 3 people per 1 million (all-comers, not just pregnant women). On the other hand, there is a 4100 women/million ( pregnant women) chance of getting hospitalized for a trauma-most are car accidents. There are some areas where the biggest risk to a pregnant women is homicide. From what I can indirectly calculate, you are approximately 1000 times more likely to be murdered in your pregnancy then you are to get listeriosis. That being said, cautious intake of cold, preprocessed foods is probably wise.

The FDA provides a website www.fda.gov/food/resourcesforyou/healtheducators/ucm082539.htm for more information.

Just keep things in perspective.

Macronutrients: There are many sites that talk about protein, fat and caloric intake. I think it is safe to say, again, that a balanced diet is best. You only need about 300 more calories a day when you are pregnant if you start at a healthy weight. Obviously if you are underweight or overweight you may need to eat more or less. I'll address this more next time with a chat about obesity.

Fish/fat and IQ: Fat is a necessary evil. Low cholesterol and saturated fat is going to be best. There is some strong evidence that long chain fatty acids found in fish is very good for brain development. Several studies show that there is a significant increase in IQ of young children born to women that eat fish or take fish oil. The warning about this is mercury. We also know that mercury can cause brain damage. So do you eat fish or not?
The best advice I can give is to avoid big fish that contain more mercury-swordfish, fresh tuna and shark for example. A can or two of tuna per week has been deemed safe by the fda. I would encourage you to eat other fish though, such as salmon, trout, talapia, cod. In this area (UT) the river fish are safe. Some areas of the country the rivers are polluted with mercury and so you should check with the local health depts. One to two servings a week would be good. Of all the vitamins and nutrients out this, this is one of the most studied and most convincing.

Micronutrients: The other most studies nutrient is folate. It is clear that folic acid helps to prevent spina bifida. I've also been to conferences where they have reported some decrease in heart defects and abdominal well defects. This has not been published yet that I've seen. Regardless, we know it is a good thing. Our flours and cereals are now fortified with folate so we are getting more than ever now. The key point of this is: the folate needed for spine and heart formation is what is in your body when you concieve--NOT what you take afterwards. If you are planning on concieving, that is when you should be taking vitamins.

All the other vitamins have not necessarily been proven to give better outcomes for the pregnancy, the baby or the mother. My advice it that if you feel better on a prenatal vitamin then continue to take it. If it makes no difference, or if it makes you sick and you can otherwise eat a normal diet, then dump the prenatal vitamin for a healthy diet.

If you are undernourished for whatever reason, (heavy smoker, vegetarian, lactose deficiency, carrying twins) vitamins have been shown to grow a little larger baby.

Iron has only been shown to be helpful if you are already anemic. This is usually tested in your first prenatal labs.

Caffeine:
There is no good data on caffeine. One study I read only found a correlation with bad outcomes when consuming 6 cups of coffee a day. It has been linked with miscarriage and so you may not what to drink large amounts in early pregnancy. (more than 200mg) One can of coke has 46 mg. 1.5 oz of Hersheys had 10mg. 8 oz of brewed coffee has 135mg. to give you an idea.

Artificial sweeteners have not been linked with any ill outcomes though these are still being studies.

Flouride: Supplementation with flouride has not been seen to make any difference in your baby's teeth and is not recommended. Topical flouride-with washes etc-has been the only source shown to make a difference.

In summary the motto of nutrition in pregnancy is balance and moderation. What is good for you is good for your baby.

Don't make me laugh or I might pee my pants....

So what is leaking urine all about? Will it get better? Is there anything that can be done?

Let's start with the different kinds of urinary incontinence. There are two basic causes: first tissues can be stretched out and injured usually from childbirth (stress urinary incontinence- SUI). Second, there can be a neurologic problem where the bladder will squeeze even though your brain told it not to (Urge incontinence).

SUI is usually associated with childbirth-though it only takes one baby. Having a c-section lessens the risk of SUI but doesn't eliminate it as there is some stretching and nerve injury just from carrying a baby. It can also be caused from heavy lifting and just from having genetically relaxed pelvis. When you cough and sneeze you apply pressure to both the bladder and the bladder neck (the urethra). If the pressure is equal and the bladder neck has something to press against, the bladder neck should close off and you won't leak. If you have some relaxation of the vaginal wall, the bladder neck now has nothing to push against and it will leak. A good example is a garden hose. If you step on a hose on cement you can close it off and block the water. If you step on the hose on grass it is much more difficult to close it off.

Because SUI is an anatomical problem the treatment is to tighten up the tissues around the urethra or at least provide a "cement" foundation for it to sit on. Doing exercises to strengthen the muscles of the pelvic floor (kegels) can help some. This is done by flexing the muscles that would normally stop a stream of urine while you're urinating. If you are bouncing in your seat you are doing it wrong. If you want to put a finger in the vagina and try and squeeze it you will help you know that you are doing the exercise correctly. This is not for the faint of heart. You really need to do about 70 of these a day to start and then maintain with about 50 a day. That means every red light or every commercial you should be doing some.

Aerobic exercise will also make you flex the pelvic floor without hardly noticing it. You may leak initially, but as you do more exercises that require heavy breathing you will see your SUI is getting a little better.

Surgery is the usual mainstay for fixing SUI. This is often done at time of hysterectomy but can be done alone. Typically, the surgery will require an incision inside the vagina under the bladder. Some tissue will be brought under the bladder to hold it up and often a mesh will be placed to provide the "cement" needed to support the urethra. This surgery has a 85-92% "dry" rate in 5 years-meaning most women are very happy with it. The symptoms may occur years later as tissue stretch out again but the intent of the surgery is hopefully to never need surgery again. There are risks to the surgery. First, of course is just the surgery itself-risk of anesthesia, infection, bleeding etc. Second, you can have things heal too tight and have trouble emptying your bladder. This may require catheritizing for a few days or even weeks. You will almost always void a lot slower than before. Generally someone with SUI can be in and out of the bathroom in record time, after this surgery you will be the slow one that has to manuever on the toilet for awhile to be sure that all is empty. You may also get some urge incontinence (see below) after surgery from the inflammation and irritation. This usually improves over time but can always be there. Lastly, the mesh can erode into the vaginal wall or the bladder and my need to be trimmed or removed.

So when do you give up on kegels and have surgery. Because there are risks, I usually tell my patients that if they are giving up activities that they usually like-running, horseback riding, softball-it's time to get it fixed. Also, if you are wearing a pad everyday due to the incontinence you should probably get it fixed.

Will it get worse? We used to think that it would always get worse and so fix it now. There has been some new research though that shows some women will actually get better over time. If you have recently had a baby, I would wait a year or so to see if things improve (unless you were leaking before your got pregnant as well). If you just started leaking with a recent cough, I'd probably try the kegels and give it time to see if things will tighten up again as well. It has to be worth the potential side-effects before you have surgery. Having said that, women who leak all the time and have the surgery love it. It can really be life changing.

So what about urge incontinence. This is usually from a nerve "misfire". You brain will talk to your bladder and tell it that it's not time to squeeze but occassionally the bladder says, "I don't care" and squeezes anyway. If you have a really tight urethra this would just cause pain, but if you have any age to you, or injury, you will probably leak, and leak alot. Urge incontinence will usually make you void quite a bit of urine before you can control it again. Because this is a nerve problem it is usually treated with medication. The medications are very good but can give you some constipation and dry mouth at times as well. The medications work best when taken daily but I do have some patients that just take them when they are traveling long distances or for specific events. Cutting back on things that can irritate the bladder will help as well. Especially caffeine and soda. Cutting back on your overall fluid intake may also help-less than eight 8 oz glasses really is fine.

You can have mixed incontinence as well. You can have a little urge that will cause the SUI to be worse and visa versa. Women with both will often undergo urodynamic testing to evaluate what would be the best treatment options. Because surgery for SUI can make the urge incontinence worse, it would be worthwhile to see how much urge incontinence you already have.

There are a few other reasons for leaking that I haven't talked about as they are rare. If you are bothered by incontinence take a day or two to write down a journal of when you leak, what you were doing, and how much you leaked. This will help you and your physician decide what would be your best treatment.

Why can't I get pregnant?

I know it's taken a year to finally start writing but my plan is to pick a topic each month or so and give you some advice, and maybe a little science about these things. Some of the topics will be my "most asked questions"(how can I lose weight?), some will be an opportunity for me to vent about misconceptions out there (if I raise my arms above my head will the cord wrap around my baby's neck?) , some may even be for fun (what's the worst phone call I've received on call). I'm not going to pretend that I know everything. And while I will do some research on these topics I'm not going to present a review of the literature on each topic either. I want this to be practical and easy to understand. Something you can take away and use. So here goes....

My first topic is about trying to get pregnant. This is one of the most trying times in many couples lives. We're already going to assume that you are in agreement with your spouse about even getting pregnant. There are some many pschological complexities about conception but I'm not really going to talk about those here.

There are three things you need to get pregnant: an egg, sperm, and a happy meeting place. Let's start with the egg. If you are having regular cycles (every 25-35 days) you are probably ovulating. Ovulation should occur around 14 days from the start of your period. Some women will feel the ovulation as a pain on one side, most women will get a watery, clear discharge with ovulation. Some women will even spot a little with ovulation. If you still aren't sure, you can do a temperature chart (BBT chart) by taking your temperature every morning before you do anything else. After ovulation your temperature should rise by a 10th of a point or so. These charts can be difficult to read but if you drop one by I can look at it for you. Lastly, you can use an ovulation predictor kit that you buy over the counter. These are actually pretty good at identifying ovulation. You must have a negative reading before you have a positive reading for it to be accurate. If you test is "alway positive" you are not ovulating. Occassionally you think you are ovulating around day 14 and so you always have intercourse then, and after doing some testing you find you ovulate day 17 and you've been missing the timing all along!

So let's say you can't identify any ovulation. You're periods come every 3 months, or maybe even every 2 weeks. If you are not ovulating you will not get pregnant. Occassionally someone will only ovulate every 3 months or so. These are women who may take years to concieve and then suddenly it happens. Regardless, if you can't identify ovulation that is when you come in and talk about ovulation induction. This involved medication that will encourage your ovaries to prepare and ovulate a follicle. There are risks to this-including twins/triplets, but it tends to work fairly well. The details of ovulation induction will have to be given at another time.

Sperm. Lots of sperm. While it only takes on to fertilize an egg, it takes millions to get the one to the right spot. 40% of infertiliy is male (40% is female and 10% have both). So, if you are ovulating regularly and having timed intercourse and you are still not pregnant in 9-12 months, a semen analysis should be done. This is a simple test and fairly inexpensive. A sample is given to the lab ( I have a specific person who does them in my office) and they will look at the sperm counts, as well as seeing if there are abnormalities (sperm with two heads etc). If the counts are good you husband is off the hook. If they are low he will need to see a urologist to see if there are ways to increase it. As a man makes sperm all the time many things can temporarily influence his count. If he is an avid biker, if he wears tight pants, if he sits in hot tubs all the time, even a cold or flu can affect counts for awhile. He may also have a hydrocele or vericocele in the testicle that can influence counts. If he has borderline low counts we can often try intrauterine insemination (IUI) here. If the counts are low the only way to concieve is through a process called ICSI done along with IVF in Salt Lake.

Happy meeting place. The uterus is the meeting place and has to be of normal shape and size. There are some developmental abnormalities that may cause the uterus to have a septum or for half of the uterus to be missing and these can cause infertility or miscarriages. The tubes have to be open. Tubes can be blocked from various reasons-usually an infection but sometimes just developmentally as well. The cervix has to be accepting of the sperm. There can't be any antibodies or other things that may kill sperm as they try to swim up. There are many theories about cervical problems. Most are unproven and few have any treatment except doing IUI. Lastly, there can't be any outside influences, specifically endometriosis. Endometriosis is when the normal lining of the uterus grows outside of the uterus. We are not sure how this causes infertility but it is believed that it "poisons" the embryo in a way. It is usually symptomatic beforehand by causing crampy, painful periods, painful intercourse, bowel symptoms with your periods etc. The only way to diagnose endometriosis is through laparoscopy (surgery) but it can be suspected just by symptoms and your exam.

Remember though, only about 20% of couples concieve each month. You are not considered infertil until after 1 year of trying. If you have a clear problem, like no periods on your own, seek help earlier, otherwise try and document ovulation and do worry too much. Sometimes it happens when you least expect it. Take your prenatal vitamins or folate if you are trying to concieve. If you are on medications or have medical problems your should probably be seen before you get pregnant. Stay healthy and happy trying!