Fertility for Black Families

A uterine fibroid is a benign tissue growth in the uterus, and it can also be referred to as a “leiomyoma” or “myoma.” While the term “growth” can be off-putting, fibroids almost never become cancerous.

As you can see below, not only are Black women more likely to develop fibroids than Caucasian women, the majority of Black women have at least one fibroid by the time they reach their reproductive years.

As you can see in both studies below, Black fertility patients are more likely (than Caucasian women) to have their fertility challenges attributed to a fibroid.

For some women, fibroids can be painful or cause heavy bleeding. In this case, surgical treatment can dramatically reduce symptom severity, as you can see from the study below (conducted on over 300 women, half of whom were African American).

From a fertility standpoint, the data is hard to interpret on how treating a uterine fibroid improves a woman’s ability to conceive. The issue likely comes down to where the fibroid resides.

There is “fair” evidence that if a fibroid distorts the uterine cavity (often referred to as being “submucosal or intramural with a submucosal component”), removing it through hysteroscopic myomectomy improves pregnancy rates. Fibroids that distort the shape of the uterine cavity are an issue because they interfere with an embryo’s ability to attach to the uterine wall which, as you’ll recall from the lesson on human reproduction, is the fifth requirement for a woman to conceive.

However, if a fibroid doesn’t appear to distort the uterine cavity, the evidence is less convincing that it impairs fertility or that removing it improves the odds of success.

Removing a fibroid is a surgical procedure (though some approaches are more invasive than others), and any surgical procedure on the uterus has to be taken seriously. Removing a fibroid can cause scarring to the uterus and create further fertility challenges. It can also weaken the walls of the uterus, committing the woman to a C-section or early delivery, which in-and-of-itself has issues for the offspring.

Unfortunately, Black women are more likely than Caucasian women to suffer a miscarriage following their fertility treatment, as you can see below.

It’s rare for a woman to suffer multiple miscarriages, and often the next pregnancy will result in a live birth. Typically, around 20 - 25% of women experience one miscarriage, about 5% of women experience two and 1% experience three or more.

If a woman has a miscarriage, or is likely to miscarry, she has a few options.

Dilation and Curettage or D&C

Following a miscarriage, one option is to have a D&C, or “dilation and curettage” procedure, which is a surgical procedure to remove any remaining tissue from the uterus.

Benefits of The D&C

A benefit to having a D&C is it allows the doctor to collect the “products of conception” for genetic testing. This can provide valuable information why a woman miscarried. If a woman wants this testing done, she needs to explicit with the doctor before the D&C. It may be performed after the fact, but with more work and complexity.

If the products of conception are genetically “abnormal,” the miscarriage likely failed because the embryo had the wrong number of chromosomes. This is the case in about 60% of miscarriages.

In the future, if the woman undergoes IVF, chromosomal testing of the embryos before her transfer can lower the odds of a future miscarriage, especially in older patients. As you can see from the data below, using genetic testing (known as “PGS,” “CCS,” or “PGT-A”) can dramatically lower miscarriage rates for women 35 years and older.

If the products of conception are chromosomally “normal,” things may be more complicated. The miscarriage is likely due to another factor, for example something related to a woman’s uterus. This is the case in about 40% of miscarriages.

In this case, doing another IVF probably won’t address the underlying issue, and so proceeding right to IVF, without some sort of other inquiry and intervention, will likely result in the same outcome.

If you have a D&C performed but don’t manage to have the “products of conception” tested, you may still be able to get answers, thanks to “Rescue Karyotyping.” After most D&C procedures, a sample of the extracted tissue is sent to a pathology laboratory, and preserved in a wax block. Rescue Karyotyping allows a small slice to be shaved off of that wax block and tested, even months or years after a D&C.

Risks of The D&C and Mitigants

Doing a D&C can carry some risk. It risks scarring of the uterus or leading to adhesions that can make it harder for a woman to conceive or stay pregnant. It’s hard to say how often adhesions are left, but likely lower than 5 - 10% of cases.

There is evidence that if your doctor uses a manual pump approach, rather than a mechanical pump approach, during the D&C, it can lower the risk of scarring and adhesions. Below is data from a study of 144 miscarriage patients and, as you can see, adhesion rates tended to be lower using a manual pump approach.

Alternatives To A D&C

There are alternatives to undergoing a D&C. For one, a woman can wait to miscarry naturally, which helps avoid an intervention, but this can be a drawn-out, multi-week process. To address that, she can also take a medication to speed the process along.

However, miscarrying naturally or with medication can make it harder to have the “products of conception” tested, and if that’s what she wants, it requires her to collect the tissue herself and bring it to her provider.

While Black men aren’t necessarily more prone to having fertility issues, they may be more reluctant to have their fertility tested or acknowledge there could be an issue. Generally speaking, a male factor issue is identified to be a major contributor in roughly 50% of couples that struggle to conceive.

Semen Analysis

The first step in identifying if there is a male factor fertility issue is for the man to have a semen analysis performed (some doctors advocate for two to be taken). The test involves the man abstaining from masturation or intercourse for a few days before providing a semen sample. Often, that’s the extent of it.

Skipping the step of doing a “semen analysis,” is a big mistake. It can blind the doctor and couple to the true, underlying issue and cause the woman and couple to undergo painful, costly, and needless treatment.

The semen analysis is not perfect, but it can be a good indication if a man’s sperm “concentration,” “motility” or “morphology” are below normal ranges.

Men can still conceive with below-normal ranges, but as you can see in the table below, it may take longer to achieve a pregnancy, especially if there are multiple parameters that are low (or if one crucial parameter is extremely low).

TMC, or Total Motile Count, is a great shorthand for the results of a semen analysis: it’s the number of sperm that swim forward in a man’s ejaculate.

As TMC goes down, so too do the odds of success with treatments like IUI. But as you can see in the graph below, the rate of decrease is pretty subtle between each interval. Many wonder whether should there be a hard cutoff for “TMC and IUI,” but based on this data, it can be hard to say precisely where that would be.

If a couple needs to resort to IVF because of a male factor issue, success rates are typically in line with other patient types, and are often still most correlated with a woman’s age.

Factors That Impact Male Fertility

Male factor infertility can be caused by a number of factors.

Varicocele

For instance, a third of men with a male factor issue have a varicocele, when the veins in the scrotum have become enlarged. If the varicocele is big enough, surgery on it can improve semen parameters. As you can see from the data below, when surgery is done before IUI, it can improve the success rates compared with doing IUI alone.

That same phenomenon is also true with regard to IVF, as you can see in the Esteves study below.

Azoospermia

Azoospermia is a phenomenon whereby the man produces no sperm. Azoospermia impacts 10 - 20% of couples with a male factor issue. Depending upon the cause, azoospermia can be relatively easy to treat or incredibly hard.

The most common (and challenging form) of azoospermia is called Non-Obstructive Azoospermia (or Testicular Azoospermia). In this case, the testicles are prompted to produce sperm, but simply can’t follow-through. Here, sperm needs to be surgically retrieved from the testicle, using a procedure called TESE or MicroTESE. As you can see below, in about 45 - 63% of cases sperm can be found and retrieved.

If sperm is retrieved, it can be used to fertilize the eggs during IVF. But, as you can see below, success rates for patients with Non-Obstructive Azoospermia tend to be lower compared with other forms of male factor infertility.

Hormonal Imbalances

Finally, hormonal imbalances can influence sperm quality and oftentimes these issues are easier to fix and allow the couple to conceive naturally, with no treatment.

Lifestyle Adjustments

There are lifestyle changes men can make to improve their semen parameters, so hopefully IUI or IVF can be avoided, or will be more likely to work if needed.

For starters, men should eliminate smoking altogether, which, as you can see, correlates with significantly worse concentration and morphology.

Next, moderating coffee consumption down to 2-or-fewer cups per day can be helpful, as you can see below in the correlation between male caffeine intake and IVF success rates.

Moderating coffee intake can have real benefit not just for being able to conceive, but in helping to avoid misscarriage, which as we showed in our lesson on success rates, disproportionately impacts African American patients.

As for alcohol intake, the data shows there’s likely a threshold effect for drinking. Beyond a certain limit, it clearly has a negative impact on semen parameters.

Exercise is a double edged sword. Generally speaking, more exercise is a good thing, especially if the man is overweight. As you can see here, more exercise generally correlates with improved semen parameters.

However, when investigators looked at extreme levels of exercise, there was clearly a drop in semen parameters. High levels of biking can be especially problematic.

Finally, testosterone replacement therapy (or TRT) has such a negative impact on male fertility it’s been looked at as a form of male birth control. Yet, 20 - 25% of urologists get this wrong and actually believe exogenously-taken testosterone improves male fertility. If men are taking testosterone, it’s best that they begin to stop. We say begin, because while testosterone is catastrophic for male fertility, stopping cold turkey can leave men depressed.

It’s worth noting that when men take clomiphene citrate (or clomid, the same drug we alluded to in the first lesson) or aromatase inhibitors this often raises the level of serum testosterone without affecting sperm parameters. However, this is an off label use of these medications.