The Right To Know: use of laparoscopy to help diagnose unexplained infertility

One of the most challenging aspects of infertility care is helping couples understand why they have not yet become pregnant. About 20-30% of couples will have no definitive diagnosis after completing a standard infertility evaluation[r1] .  In today’s fast-paced treatment paradigm, some patients prefer to move forward with treatment without further clarification. Although oftentimes appropriate, this strategy should not be applied to every patient/couple. Laparoscopy and hysteroscopy are minimally invasive, out-patient surgeries [r2] that can provide a diagnosis and sometimes even offer improved pregnancy rates if scar tissue or endometriosis is found and treated at the time of surgery.

Women with infertility are about eight times more likely to have endometriosis than women that have been pregnant. Treatment of endometriosis can not only reduce pain but also improve pregnancy rates as well. In fact, a large, randomized meta-analysis[r3]  of the available research found that treating endometriosis was associated with about a 60% increase in the chance for a successful pregnancy. Additionally, if there is scar tissue preventing the egg from reaching the fallopian tubes this can also be identified and treated. So consideration of diagnostic surgical procedures can be beneficial. The challenge is in deciding which patients should pursue this option further.

A more recent study [r4] investigated the usefulness of these diagnostic surgical procedures from a financial perspective. They found that laparoscopy was cost-effective in improving pregnancy rates/outcomes based upon many factors including the potential impact of endometriosis. Finally, they also found that undergoing diagnostic surgery was associated with a lower rate of patients “dropping out” of fertility treatment before becoming pregnant. This suggests that having all of the information available prior to treatment is preferred by some couples experiencing infertility. In summary, if you are having trouble conceiving and want more information, minimally invasive surgery may be your best next step.

Robert Greene, MD, FACOG

CNY Fertility Center

e-mail me at

Call our toll-free number at 800.539.9870 or request a consult here.

Are environmental toxins hampering your chances of becoming pregnant? Here’s what you need to know.**

**About a week ago, I submitted this post to Conceive Magazine Online [r1] for publication. The very next day, another study [r2] came out finding an increase in sperm DNA abnormalities in men exposed to higher amounts of PCB’s. Although I mention other studies below with similar findings, I wanted t include this recent and compelling data.

According to the U.S. Government Accountability Office, there are 80,000 industrial chemicals currently in use, with another 700 added each year. Oftentimes it takes years or even decades to discover if or how these products influence our health. Worse still, many of these chemicals are classified as “hormone-disrupting agents,” meaning that they can trigger a hormone imbalance if you’re exposed to them. The hormonal chaos that results can cause infertility, miscarriages, birth defects and may even contribute to certain types of cancer.

You can take an active role in reducing your exposure to these potentially toxic agents by actively taking steps toward achieving hormone balance. Get informed and create a diet and lifestyle that can reduce your exposure to specific chemicals that have been linked to problems. A great place to start: Consider what you can do to reduce your contact with polychlorinated biphenyls; commonly known as PCBs.

PCBs were banned from use in the United States in 1979 due to their toxicity. Even though three decades have passed since they were widely used in construction and insulation, these hormone-disrupting chemicals persist in our environment. Today our primary exposure to PCBs is through contaminated water, polluted air, and the consumption of high-fat foods made from fish or animal products.

Since PCBs are stored in fat cells, switching to a low-fat diet can dramatically reduce your risk. For example, endometriosis is a problem commonly associated with infertility. Several studies have demonstrated that women with high levels of PCBs are three to four times more likely to develop endometriosis. One interventional study indicated that women with endometriosis can reduce their risk of reocurrence by 40 percent or more simply by reducing their consumption of beef and ham and replacing these calories with fresh fruit and vegetables.

Making these healthy choices can also improve male fertility: A 2009 study found that men exposed to water pollutants (including PCBs) were at higher risk of infertility. These toxins can disrupt male hormones as well as interfere with sperm production. Rather than worry about the impact that water may be having on you, check out the database created by the Environmental Working Group. Not only do they report on pollutants that may be present in your tap water, they also provide links to simple water filtration systems that you can use to improve your health and that of your family.

If you needed even further proof that PCBs may be affecting your chances of becoming pregnant, a study published in 2010 found significant levels of this toxin in the fluid surrounding eggs that is collected during IVF cycles. More recently, U.S. research found that not only did a woman’s PCB level impact her chance of becoming pregnant, but it also may increase her risk of having a miscarriage. So clearly it is in your best interest to minimize your exposure to PCBs. Here are some simple steps that you should consider:

  • Eat low fat—in particular reduce your consumption of beef and ham while boosting your intake of fresh fruits and vegetables.
  • Avoid farm-raised salmon and catfish since these have been shown to be prime sources of PCB exposure.
  • Drink filtered tap water instead of bottled water, which can often contain a variety of hormone-disrupting chemicals.
  • If you live in an older home with hard-wood finished floors, consider having them professionally treated with safer products.

Endometriosis, PCB’s and Infertility: the link becomes even more compelling

For the last several years, I have been trying to make my patients and colleagues more aware of the how both the rising rates of infertility and endometriosis may be related to environmental causes. Here is an excerpt from my book PERFECT HORMONE BALANCE FOR FERTILITY (p. 29[G1] ):

An estimated 5 million women in the United States have endometriosis—a painful condition in which tissue from the endometrium travels to the ovary, fallopian tubes, and other surfaces in the pelvis. It also contributes to infertility. Endometriosis researchers have been looking for links between environmental BioMutagens and this condition. The strongest associations have been found with dioxin and polychlorinated biphenyls (PCB’s)—both toxic by-products of manufacturing and waste disposal plants. Studies show that women exposed to these chemicals have a three- to fourfold increased risk of developing endometriosis. Typically exposure occurs through contaminated air and water. This may be the strongest direct link between BioMutagens and a condition known to reduce fertility.

Since the time that my co-author and I published that, even more data has come out supporting this relationship. In a recently published study[G2] , they found concentrations of PCB’s frequently found in the bloodstream of women in the USA were associated with a reduced pregnancy rate in women that were going through IVF. In fact, these women actually had about ½ the pregnancy rate following embryo transfer suggesting that this hormone disrupting chemical may interfere with implantation.

In my opinion, the data is compelling enough. Since there are steps that we can all take to reduce our exposure to these harmful chemicals; it seems reasonable to share this information with couples trying to conceive so that they can make healthier choices like:

  • Reducing consumption of animal fats where these chemical tend to accumulate
  • Avoid fish/shellfish caught in waters most commonly associated with contamination
  • Minimize your exposure to food and water packaged in plastics with the #3, #6 and #7 and instead seek out glass, metal or plastics labeled #1, #2, #4 and #5
  • Consider installing a reverse osmosis water filter in your home for drinking/cooking purposes
  • Check out my book for more helpful diet/lifestyle tips to reduce your toxin exposure