After treating infertility cases for 23 years, I have found some pathologies that are frequently undiagnosed.

These are pathologies I refer to as ‘hidden’ pathologies as they often remain undiagnosed.

Be sure to discuss these possible causes of infertility, and/or chronic, recurrent miscarriage with your reproductive endocrinologist.

1. Urealplasmaurealyticum

These bacteria may affect the number of sperm and their ability to move.

In women, it may cause an infection that makes pregnancy more difficult to achieve.

A new study found that a particular ureaplasma known as urealplasma urealyticum is seen more often in women with unexplained infertility.

These bacterium can be spread sexually. It can also be transmitted through non- sexual contact such as sharing needles, blood transfusions and, in extreme cases, through coughing, kissing (saliva), and nose or eye secretions. Pregnant women can pass the infection on to their unborn baby.

These bacteria may have been present for many years without causing any symptoms.

Sperm DNA fragmentation (SDF) testing measures the quality of sperm as a DNA

The finding of ureaplasma and mycoplasma on cervical cultures does not in any way indicate infidelity or sexual misconduct.

Compared to babies without the infection or those who only had the bacteria detected in their nose, these very premature babies who had ureaplasma in their windpipe at birth were less likely to survive (71% compared to

90% and 100%), and they were more likely to develop bronchopulmonary dysplasia and other respiratory disorders.

Mycoplasma hominid (another bacteria), and urealplasma urealyticum may be found in the cervix (40% – 80%) or in the vagina (21% – 53%) of women.

In terms of treatment, there is an 80% chance of anti-biotics successfully treating the infection.

How to test: Vaginal swab and urine sample. The male doesn’t have to be tested. If his female partner tests positive, he has it.


Typically involves a course of antibiotics. The preferred antibiotics for Ureaplasma infection are azithromycin or doxycycline.

Is there any benefit derived from the use of acupuncture and herbal medicine in the treatment of ureaplasma?

No. This should be handled with antibiotic treatment only.

2. SpermDNAFragmentation

package carrier, and it therefore is more significant than the parameters

analyzed in previous semen analyses.

DNA damage, such as fragmentation, can have adverse effects on fertilization and

embryo development and can cause infertility.

Infertile men have a greater extent of sperm DNA damage and poorer sperm DNA

integrity than fertile men, and fertilization with DNA-damaged spermatozoa can

increase the risk of genetic diseases in the offspring.

SDF can be observed even in men with normal semen analysis results. The value

of SDF as an independent index for the evaluation of semen quality should lead it

to be incorporated into semen analysis procedures; alas, it is not.

The selection of sperm with damaged DNA when using ART can result in

undesirable results, such as lower pregnancy success rates, increased rates of

miscarriage, chromosomal abnormalities, and other genetic or birth defects in the

offspring. Therefore, it is important in the age of ART to accurately understand

and manage sperm nuclear DNA integrity. This is quite easily tested.

Natural conception

Many studies have demonstrated that sperm DNA damage affects natural conception. Zini reported that based on an analysis, high SDF made natural conception difficult.

Evenson et al. and Spano et al. also stated that natural conception was almost impossible if SCSA found SDF of more than 30%.

Furthermore, it has been reported that a higher extent of sperm DNA damage in couples planning a pregnancy without prior knowledge of their fertility could cause them to take longer to conceive naturally and reduce the likelihood of a successful pregnancy.

Therefore, SDF testing is relevant for male fertility for those who desire natural conception, as well as in the IUI, IVF setting. This is true especially for those with infertility due to an unknown cause.

Intrauterine insemination

Bungum et al. reported that the possibility of pregnancy using intrauterine insemination (IUI) was close to zero when the DNA fragmentation index was higher than 30%. DFI levels (>30%) were a predictor of decreased pregnancy and delivery rates after IUI.

Recent studies confirmed that paternal factors and sperm DNA damage affect embryo development and early pregnancy.

Zini conducted a meta-analysis of 11 studies and found a correlation between abnormal sperm DNA damage test results and low pregnancy rates.

Intracytoplasmic sperm injection

The greater the extent of sperm DNA damage, the longer it took for the embryo to reach the blastocyst stage and lower the possibility of pregnancy through ICSI.

Pregnancy loss

Current research on the effects of SDF on miscarriage after ART is limited; however, a recent meta-analysis investigated the correlation between high levels of DNA damage and an increased risk of miscarriage. Zini et al. reported that regardless of the ART type (IVF or ICSI), sperm DNA damage was a predictive factor for pregnancy loss after ART.

Robinson et al. reported that IVF or ICSI using sperm with high levels of DNA damage had a 2.16 times higher risk of early pregnancy loss. Carrell et al. suggested that sperm DNA damage was higher in the male partners of couples that had experienced recurrent miscarriages (35%) than in the general population (22%) or normal fertile men (12%).

In a study researching 106 men in couples struggling with fertility issues who had miscarriages in the past, Check et al., found that a DFI of 30% or higher was related to high miscarriage rates and low ongoing pregnancy rates.

Khadem et al. also reported that recurrent miscarriages and high levels of sperm DNA damage had a positive correlation. In conclusion, SDF measurements can be seen as a useful tool in predicting miscarriages related to paternal factors.

Treatment strategies for patients with high levels of SDF

1. Lifestyle modifications

Physical agents such as radiation and heat, cigarette smoke, airborne pollutants, chemical agents such as anticancer drugs, sexually transmitted infections, and biological factors such as increasing male age, elevated body mass index, and diabetes are environmental and lifestyle factors known to affect sperm DNA integrity. Lifestyle modification is the most fundamental, important, simple, and easy way to improve sperm quality. Men with impaired sperm quality should quit smoking and drinking; engage in exercise and manage their weight; wear loose underwear; avoid environments with high temperatures such as saunas, lower- body bathing, and high temperature workspaces.

2. Infection control

Studies have observed male genital tract infection and inflammation in 8%-35% of cases of male infertility and infections of the male reproductive system are known to cause sperm DNA damage. Inflammatory cells produce reactive oxygen species, which are known to cause DNA damage. White blood cells detected in semen originate from the epididymis, and male genital tract, and antioxidants in the seminal plasma scavenge the reactive oxygen species produced by the white blood cells. However, when a large quantity of reactive oxygen species is produced, the sperm DNA is damaged by oxidative stress. Such patients can be treated with antioxidants and acupuncture and herbal medicine to decrease the amount of reactive oxygen species produced by the white blood cells in order to improve the fertility of sperm.

3. Oral antioxidant therapy

Fifteen percent of reproductive-age couples experience fertility issues, and 50% of those cases involve issues associated with the male partner. However, many male patients do not know the causes of sperm problems. Oxidative stress is known to be an important factor that causes male infertility by damaging sperm DNA.

Greco et al. found that patients who took antioxidants before an ICSI procedure did not show differences in the fertility rate, cleavage rate, or embryo morphology, but had higher clinical pregnancy and implantation rates.

Imamovic Kumalic and Pinter conducted a meta-analysis of 32 studies published between 2000 and 2013 related to male infertility and antioxidants and found vitamin E, vitamin C, selenium, coenzyme Q10, N-acetylcysteine, zinc, and L- carnitine to be effective. Among these, vitamin C and vitamin E were most effective in reducing DNA fragmentation, and zinc and selenium had similar effects as well.

Acupuncture and herbal medicine have been proven to show significant decreases in sperm DNA fragmentation and thus, is implicated in promoting successful outcomes of couples struggling with infertility as a result of sperm DNA fragmentation.

3. Polyps

Endometrial polyps are frequently seen in subfertile women, How polyps

contribute to subfertility and pregnancy loss is uncertain and possible

mechanisms are poorly understood. It may be related to mechanical interference

with sperm transport, embryo implantation or through intrauterine

inflammation or altered production of endometrial receptivity factors. Different

diagnostic modalities such as two- or three-dimensional transvaginal ultrasound,

saline infusion sonography or hysteroscopy are commonly used to evaluate

endometrial polyps with good detection rates.

In a retrospective study involving 230 subfertile women undergoing hysteroscopy and polypectomy, Yanaihara et al. concluded that the location of the endometrial

polyp may influence spontaneous pregnancy rates and fertility outcome. The

pregnancy rate within 6 months after surgery was 57.4 % for polyps located at the

uterotubal junction, 40.3 % for multiple polyps, 28.5 % for posterior wall polyps,

18.8 % for lateral wall polyps and 14.8 % for anterior uterine wall polyps.

These results suggest that the mass of polyps may interfere with the

reproductive processes such as sperm transport, embryo implantation or early

pregnancy development. Conversely, in another retrospective study 83

subfertile women with a history of menstrual disorder, hysteroscopic

polypectomy appeared to improve fertility and pregnancy rates irrespective of

the size or number of the polyps.


The diagnostic modalities that are commonly used to evaluate endometrial polyps include a two- or three-dimensional transvaginal ultrasound, best performed in the early proliferative phase of the menstrual cycle, saline infusion sonography and hysteroscopy.

A systematic review and meta-analysis suggested that saline infusion

sonography has a high degree of diagnostic accuracy in the detection of all types

of intrauterine abnormalities.


A number of publications indicate that removal of endometrial polyps is beneficial for natural conceptions, intrauterine insemination (IUI) and assisted reproduction technologies (ART).

Natural Conception

Three nonrandomized studies found an association between polypectomy and improved spontaneous pregnancy rates. Varasteh et al. studied infertile women with and without endometrial polyps and found a pregnancy rate of 78.3 % after polypectomy compared with 42.1 % in those with normal uterine cavity. Spiewankiewicz et al. reported a pregnancy rate of 76 % where 19 out of 25 infertile patients conceived within 12 months after polypectomy, whereas Shokeir et al. reported a 50 % pregnancy rate after polypectomy in such patients. These studies suggest women with otherwise unexplained infertility may benefit from polypectomy.

Intrauterine Insemination

In another study, 120 infertile patients planned to have IUI and diagnosed with endometrial polyps were randomly allocated either to hysteroscopic polypectomy or no intervention. All patients were scheduled to receive four cycles of IUI. The cumulative pregnancy rates were significantly higher in the study group (38.3 vs 18.3 %; p = 0.015), suggesting that hysteroscopic polypectomy prior to IUI is an effective measure and improves pregnancy rates.

Is there any benefit derived from the use of acupuncture and herbal medicine in the treatment of polyps?

No. This is handled by surgery only.

4. Endometriosis

Endometriosis is a gynecological condition that affect many women. One third of

these women are likely to present with infertility.

Endometriosis occurs when the lining of the uterus starts growing outside the uterus causing scar tissue and adhesion. This problem results in tissue destruction and anatomical distortion. This can lead to infertility.

Some women may not have any symptoms whatsoever to suggest endometriosis.

It can often come as a surprise diagnosis discovered during surgery. Because of this, we know that the severity of the disease does not necessarily go hand in hand with symptom severity.

There is no reliable way of diagnosing the disease without surgery. Imaging modalities such as high-resolution pelvic ultrasound scan and MRI performed by specially trained experts may help to diagnose the disease and provide information about severity. However only up to about 50% of cases can be diagnosed using imaging scans.

Endometriosis affects fertility essentially by tissue destruction and anatomical distortion. The female reproductive system, including the ovaries and fallopian tubes are quite delicate and are easily compromised by endometriosis.

When the fallopian tubes are affected, the delicate fimbrial ends of the tubes are matted together. The fimbria sweep the surface of the ovaries picking up the egg during ovulation. When they are destroyed, they lose this function. Hence the fallopian tubes do not have to be fully blocked to lose the function as a conduit for egg and sperm.

The Endometriosis Diet

It is important that women with endometriosis know about the scientific advances in the role of nutrition in controlling and alleviating the symptoms of endometriosis.

Dietary Recommendations

. Reduction of foods that are high in saturated fats.

. Increase of foods rich in essential fats such as olive, oil, nuts, seeds and oily fish.

. Organic foods whatever possible, to avoid ingesting higher levels of xenoestrogens and other unacceptable chemicals used in the growing of preserving process.

. Eliminating caffeine, including that found in tea, colas, coffee and chocolate.. Weight control, as excess weight can lead to higher estrogen levels.

. Reduce alcohol intake in order to improve liver detoxification of estrogen.

. Regular exercise, which can help to decrease pain.

Endometriosis may also affect your fertility by inducing inflammatory changes within your pelvis to create a “hostile” environment for the egg, sperm and embryo. The uterine lining known as endometrium is often affected in severe cases of endometriosis and this in turn can affect the implantation of an embryo.

The mean time to diagnosis is 11.6 years.

Supplement Program

. A multivitamin and mineral supplement.

. B complex vitamins (50 mg of each B vitamin per day). Magnesium (300 mg per day)

. Vitamin E (300 iu per day)

. Zinc citrate (15 mg per day)

. Vitamin C with bioflavonoids (1000 mg twice per day). Fish oil (1000 mg per day)

. Probiotic.

Note that each nutrient represents the total intake per day

so if the multivitamin and mineral contains 100 mg then additional magnesium supplement only needs to contain 200 mg.

Is there any benefit derived from the use of acupuncture and herbal medicine in the treatment of endometriosis?

Yes. An important thing to remember is that even after laparoscopy, some endometriosis can remain. The reason for this is that some endometriotic tissue looks exactly like normal tissue and therefore the surgeon may not be able to resect all of the endometriosis.

This is typically the case when a younger woman with endometriosis had a laparoscopy and still can’t conceive. This is a perfect time for the utilization of acupuncture and herbal medicine.

Traditional Chinese medicine is successfully used to greatly eradicate the inflammatory process of endometriosis, which, in and of itself can be causative of infertility.

5. Hydrosalpynx

A hydrosalpinx is a fallopian tube that has become filled with toxic fluid due to injury or infection.

The swollen and fluid-filled tube is called a hydrosalpinx. A normal pregnancy in the uterus may not occur because the tube may be severely damaged and blocked and not work properly.

A pregnancy may develop in the tube (ectopic pregnancy) which can be life threatening.

In addition, as the tube is blocked, toxic secretions that collect in the tube may

backflow into the uterus and prevent a pregnancy from occurring.

Is there any benefit derived from the use of acupuncture and herbal medicine in the treatment of hydrosalpinx?

No. This is best treated by surgery.

6. Blood clotting disorders(thrombophilia)

The most common cause of miscarriage is chromosomal abnormalities in the

embryo. This type of genetic problem happens randomly, although it

becomes more common as women get older. Other causes of miscarriage

include hormonal and immune system problems. However, recent research

has found a new area to investigate-thrombophilia.

What is Thrombophilia?

Thrombophilia is a condition where the patient tends to form blood clots. It can be dangerous if the blood clots obstruct blood flow.

Recent research suggests a connection between Anti Phospholipid Syndrome and recurrent pregnancy loss, and indicates that patients with one or more markers for APS were more likely to suffer miscarriages. These markers are abnormal antibodies in the blood that attack proteins. Some research suggests that clots can cause abnormal blood flow to the uterus and make miscarriage more likely.

Many patients with blood-clotting-issues don’t show any symptoms. If your family has a history of clotting disorders such as stroke, heart attack or blood clots, blood tests to look for markers of thrombophilia are appropriate. If you have polycystic ovary syndrome, these tests are appropriate in the face of two or more miscarriages with normal embryos being transferred (IVF) because patients with PCOS often have clotting factor abnormalities associated with high insulin resistance.

Markers of thrombophilia include anticardiolipin antibodies, lupus-like- anticoagulant, mthfr, factor V Leiden, antiphospholipid antibodies, PAI-1 insufficiency, and others.

Part of the controversy that characterizes this assumption derives from the


Treatment involves preventing blood clots with careful monitoring to make sure you don’t bleed internally. Lovenox may be recommended to prevent clotting.

Is there any benefit derived from the use of acupuncture and herbal medicine in the treatment of thrombophilic disorders?

No. Lovenox will work.

7. Autoimmune causes of infertility

Several lines of evidence suggest that autoimmune mechanisms may influence the reproductive life and fertility of both sexes, commonly manifesting as infertility or pregnancy. Autoimmune conditions in the absence of symptoms or as a result of the limited physician awareness may be an undiagnosed contributing factor to infertility and/or chronic, recurrent miscarriage.

Numerous autoimmune diseases, including but not limited to systemic lupus erythematosus and anti-phospholipid syndrome, may be associated with infertility and pregnancy loss through different putative mechanisms.

First, serum autoantibodies such as anti-phospholipid, anti-thyroid, or antinuclear antibodies may be directly associated with infertility, regardless of the presence of a clinically overt autoimmune disease.

Second, autoimmunity may affect all stages of fertility, via ovarian failure, testicular failure, implantation failure, and pregnancy loss.

Third, infertility may also be secondary to vasculitis associated with other conditions such as systemic lupus erythematosus and diabetes mellitus.

Treatment is easily administered with the appropriate Western medicine which may or may not include an intravenous-infusion of intralipid therapy.

This is totally safe and very effective.

Is there any benefit derived from the use of acupuncture and herbal medicine in the treatment of autoimmune causes of infertility or chronic recurrent miscarriage?

Perhaps. Generally speaking, this is an issue best treated with Western medicine.

The best utilization of acupuncture and herbal medicine in the context of fertility challenges are:

1. Improvement of egg quality

2. Improvement of sperm quality

3. Improvement of uterine lining quality

4. Miscarriage prevention

5. Stress reduction.

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