Common Fertility Issues & Treatment Options For African Americans

Lifestyle

One factor in whether a couple can conceive, and carry, is the lifestyle they lead and the impact it has on their bodies.

For the most part, African American women who go to a fertility clinic weigh more than other patients, and have a higher Body Mass Index, or BMI. Below is data from one study on these weight disparities, and most other studies reflect a similar pattern.

BMI is a formula to identify how much weight someone has on their body once we correct for their height. The method to calculate BMI is below. BMI doesn’t take into account bone density or ethnicity, but having a BMI on the high end of the range, say approaching 30 or 40, is clearly an issue.

BMI Calculation

For women trying to conceive naturally, a higher BMI correlates with a lower likelihood of success.

BMI and Natural Conception

And this is true for men (unless they are severely underweight) as well as for women, as you can see below.

Male BMI

And if a woman, or couple, decide to do IVF, being too light or too heavy correlates with lower live birth rates for nearly all patients, as you can see here.

BMI and IVF

If you’re trying to get pregnant and your BMI is at the extremes, it’s important to talk to your doctor about realistic goals you can set to get pregnant quickly and safely.

For some women, delaying treatment to lose weight can be of real help (one example is women with Polycystic Ovarian Syndrome) but for others, especially for women approaching their 40’s, delaying treatment to lose weight can actually reduce their odds of success.

Furthermore, a woman’s weight will impact the safety of her pregnancy and the health of her children. One example of this would be pre-eclampsia, which can be dangerous or even fatal for the mother and fetus.

Here you can see the clear correlation between a woman’s rising BMI and her increased risk of developing pre-eclampsia.

On FertilityIQ, you’ll find a detailed course covering most major lifestyle factors and how they’re related to conceiving. For the moment we’ll just briefly touch on diet.

First, diets that incorporate more whole grains, vegetables & fish, like the Medittaranean diet, correlate with higher pregnancy rates for women trying to conceive naturally, as you can see below.

Med Diet

That’s also true for women who undergo IVF, with relative success rates nearly 40% higher for those who adhere to a Meditteranean-like diet.

Med Diet IVF

On the other hand, consuming higher amounts of fast food and fried food often correlate with lower rates of success. That’s true for women trying to conceive naturally or in treatment.

Fast Food

Tubal Factor Issues

Another issue that tends to disproportionately impact African American fertility patients is what’s known as a “tubal factor.” Below are three studies that compare the prevalence of tubal factor issues amongst fertility patients by race. While the definitions of “tubal factor” varied between the studies, in each one, African American women had meaningfully higher rates.

As you may remember from the first lesson on human reproduction (and can see in the diagram below), most women have two ovaries and each ovary has a fallopian tube connecting it to the uterus. If those fallopian tubes are scarred or blocked, it will make it difficult or impossible for the sperm and egg to meet, or for an embryo to reach the uterus.

Tubal Anatomy

Tubal factor issues can be caused by any number of issues, including sexually transmitted diseases like chlamydia or gonorrhea. When left untreated, each can cause damage within the uterus and fallopian tubes.

IUI Success Rates


If both fallopian tubes are blocked, IUI is not a viable treatment option — conception still won’t be possible with anything other than IVF.

If only one fallopian tube is blocked, artificial insemination, or IUI, can work. That said, the odds of success really depend upon where the blockage occurs.

If the blockage is found closer to the uterus, what’s known as proximally, after three IUIs, 36% of women will get pregnant. If the blockage is seen closer to the ovary, or distally, after three IUIs, success rates are closer to 12%.

IUI Location Tubal Success Rates

IVF Success Rates


IVF has the benefit of bypassing the fallopian tubes because eggs are surgically removed directly from the ovary, fertilized outside of the body & then placed back into the uterus. In effect, IVF takes blocked fallopian tubes out of the equation.

Success rates for women with tubal factor issues are similar to most other IVF patients. As you can see below, for women under age 35, about 40 - 45% of IVF cycles lead to a birth. However, with every passing 2 year interval, the odds of success drop by about 10 percentage points so that by the time a tubal factor patient reaches her early 40’s per cycle success rates approach single digits.

IVF and Tubal Success Rates

If the fallopian tubes aren’t just blocked, but they’re also filled with liquid, your doctor may refer to this as a hydrosalpinx. As you can see here, when doctors remove the damaged tube, or tubes, IVF success rates can sky-rocket.

Uterine Fibroids

A uterine fibroid is a 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 African American women more likely to develop fibroids than Caucasian women, the majority of African American women have at least one fibroid by the time they reach their reproductive years.

As you can see in both studies below, African American 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.

Miscarriage

Unfortunately, African American 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, and this is especially true 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.

Source of Miscarriage Image

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.

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