By Harry H. Hatasaka, MD
Few things in life are as anxiety-provoking as having the overwhelming desire and need to have children, but being emotionally devastated month after month when the much anticipated event doesn’t happen. Infertile couples often develop resentment and jealousy when they see other women who get pregnant without any effort. One of the first things that the infertile couples do is to turn to family and friends seeking advice. Yet, often nobody seems to understand the intense personal pain that they are enduring. Many times friends and family are quick to offer up well-meaning (but often misguided) advice that may actually hinder the couple’s attempts.
Over the ages, the treatment of infertility has been slowed by the widespread circulation of numerous old wives’ tales and folk remedies, many of which persist today. Fortunately, the study and practice of reproductive medicine has made dramatic advances in the past 30 years. Indeed, because infertility is so distressing and common (approximately 1 in every 10 couples are affected by infertility) an entire subspecialty of medicine has been established to address it. Reproductive endocrinologists are ob/gyn physicians who have gone through an additional 3 years of fellowship training after their OB/GYN training, focused on treating disorders of the reproductive systems of men and women. The best things that friends and family can do are to be supportive and understanding, resist the temptation to offer up homespun solutions, and to assist their loved one in getting some professional guidance.
When is it Time to Seek Help?
Infertility is most often defined as the inability to conceive after one year of regular intercourse without using contraception. However, it is critical to understand that because a woman’s fertility slows substantially with age, that the American Society for Reproductive Medicine has recommended that women over 35 should begin a fertility evaluation after only 6 months of attempts.
Women are born with all the eggs that they will ever have and each appears to have its own internal biological clock dictating when it will be released. In general, the genetically better quality eggs tend to come out first when a woman is younger which helps to explain decreased fertility in the later reproductive years and why abnormal chromosome disorders such as Down’s syndrome, birth defects and miscarriages are more common in older mothers. An alarming statistic is that by age 41, with every pregnancy a woman conceives with her own eggs, nearly half will end in miscarriage. Therefore, the message is clear that if a woman is 35 or older and having difficulty conceiving she shouldn’t waste time before seeing a specialist in order to maximize her chances of success.
Where to Get Expert Help?
Couples can go directly to a reproductive care center where men often feel more comfortable compared to going to their partner’s gynecology office for evaluation. However, many women prefer to start with their OB/GYN with whom they have established a long-term bond. Many OB/GYNs are well-trained and comfortable initiating an infertility investigation. They can also manage some office infertility treatments that can be highly effective, such as prescribing fertility tablets for women who do not ovulate on their own. Most often if conception has not occurred after 6 months of treatment or if the OB/GYN diagnoses other infertility factors that are unlikely to respond to office treatments (such as low sperm quality, diminished ovarian reserve, blocked fallopian tubes and severe endometriosis) then they generally choose to refer to a reproductive care center at that time.
What to Anticipate When at the Reproductive Care Center?
When a couple meets with a reproductive endocrinologist, a thorough investigation begins with a careful history to account for all important variables that may impact fertility. The essential components needed to make a baby include healthy sperm and eggs along with a healthy home (the uterus) for a baby to implant and grow in. Other necessary items needed to make a baby the old-fashioned way include open tubes and the presence of all of the hormones that orchestrate the reproductive process. Making sure that all of these components are present and working well is the main focus of the evaluation. Semen quality, ovulatory function, egg quality, hormone levels and female reproductive anatomy are evaluated. This process has become quite efficient and streamlined. Fortunately, many of the expensive and invasive tests that were used to evaluate infertility just 15 or 20 years ago have now been retired after we determined that they just weren’t very helpful. Now, the whole evaluation process can often be completed in about a month’s time.
Then, with all the tests in hand we can determine which problem or problems may be contributing to the infertility. Only then can a rational plan of action be drawn up for each individual couple. Here, we can take advantage of decades of clinical research into infertility treatments which has shown us which treatments work and which ones don’t for a particular infertility problem. Often there are treatment options available and it is important for couples to actively participate in the decision process along with the physician so that they can balance their preferences with the risks, expenses and expected success rates of each option.
What Treatments Are Available For Infertility?
Naturally, the goal of infertility treatment is to achieve a healthy pregnancy quickly, using the safest, least invasive and most economical methods possible. Surprisingly, sometimes the best approach turns out to be one of the assisted reproductive technologies even though their up front costs are pricey. The costs of repeatedly using less effective treatments can certainly add up to more than the cost of an advanced infertility therapy and just as importantly, may lose precious time. It is worth reiterating that for peak fertility using a woman’s own eggs, time is of the essence once a woman approaches age 35.
Many times it is obvious which infertility treatment should be used. Donor sperm are necessary when a man can not make any sperm, and donor eggs when the like situation happens in a female partner, and IVF is a great option if the fallopian tubes have been removed or damaged beyond repair.
The term “assisted reproductive technologies” (ART) includes all of the infertility treatments in which sperm, eggs and/or embryos are handled. In vitro fertilization (IVF), and the injection of individual sperm into egg cells (termed intracytoplasmic sperm injection or “ICSI”) are two of the most common examples. Other ART procedures range from relatively low tech procedures such as artificial inseminations clear up to major projects such as the use of gestational surrogacy. Other ART treatments that are available at the Reproductive Care Center include the use of donated eggs, sperm, and even embryos (“embryo adoption”).
Until recently, we have only been able to freeze sperm and fertilized eggs (embryos). However, freezing eggs has proven much more difficult because they are relatively large cells with a high water content that expands upon freezing which causes damage or loss of the eggs. The ability to successfully freeze and thaw eggs, although still considered investigational, is beginning to come of age and we have already had success. This technique offers the hope to preserve some eggs for women who need to undergo cancer chemotherapy or radiation (which most often eradicates the eggs). Also, some women will be able to bank their eggs in the freezer while their eggs are still of good quality when they know that it may be years until they are in a position to have children.
IVF has been the cornerstone of the ART procedures. The first IVF baby was delivered in 1978. Since then the technique has become more effective and far easier for women to go through. It was originally used to bypass blocked fallopian tubes but has since been found to be effective for a number of other infertility problems such as ovulation disorders, endometriosis and most sperm problems (with the help of ICSI).
In vitro fertilization also offers the advantage of condensing time by allowing the retrieval of multiple eggs that would otherwise take months to ovulate out one by one. For couples where the causes of their infertility may be unexplained even after extensive testing, IVF usually yields invaluable information as to what the infertility problems may be by allowing scrutiny of every step of the process in detail.
The process of IVF involves having a woman take injectable medications for about two weeks in order to stimulate the development of multiple eggs from each ovary. During this time, several visits are needed to monitor the development of the egg sacs (called follicles) within the ovaries using blood hormone levels and ultrasounds. When the follicles have grown large enough, indicating the likely presence of maturing microscopic eggs within them, the eggs are collected during a quick outpatient procedure. The eggs are then introduced to sperm in the laboratory the same day they are collected. If they fertilize, the resulting embryos are then grown in the laboratory for several more days until the best appearing embryo or embryos are selected to transfer back into the uterus. The ability to sort through the embryos to select the ones most likely to become babies is yet another important advantage that IVF allows. Altogether, the active part of IVF takes several weeks to complete and the entire process is done as outpatient treatment.
What Are My Chances?
Every individual and every couple have different fertility capabilities depending on their diagnosis or combination of diagnoses. Therefore, specifying a single overall pregnancy success rate for a given treatment such as IVF can be quite misleading. So for each couple, a full assessment of all their pertinent infertility variables must first be made to be able to make the most educated prediction about their prognosis. Bear in mind that of all the infertility variables, the most important remains the age of the woman. For example, women who are less than age 35, on average will have greater than a 50% chance of delivering a baby with each try of IVF compared to women who are over 43 where, with all other factors being equal, can only expect a success rate of about 2%. If the couple is quoted a 30% chance of success, it may sound low to them and unworthy of consideration, yet most people are surprised to learn that even for young, healthy, fertile couples, their monthly chance of conceiving using their own eggs is only about 20%.
An amazing statistic is that by the year 2002, 1% of all children born in the United States were conceived with the help of ART and this figure has only climbed steadily since then and is now approaching 2%. This has lead to an estimated 3 million babies born world wide with the help of ART. During this ART “revolution”, another remarkable transformation has taken place in the United States. The Pew Research Center recently reported (May 2010) that more children are now born to women beyond the age of 35 than to teenagers. Advancements in reproductive medicine have contributed to making this possible. But realistically, IVF can help speed up the time it takes for a woman to get pregnant but it doesn’t solve the problem of poor quality eggs. Many people have received a false sense of security by seeing a number of celebrities in their forties having children, but the truth of the matter is that many of the stars have turned to the use of donor eggs. So if a couple has their heart set on having children only from their own sperm and eggs, they need to pay close attention to their biological clocks.
Other couples just want to be parents. In that case, beside adoption, ART procedures open up some wonderful opportunities. Compared to adoption, using any combination of donated sperm eggs or embryos affords a woman the ability to experience a pregnancy, provide good prenatal care, be able to nurse, and to nurture and bond with her child starting right from the moment of implantation. It is comforting to know that if a couple can avail themselves of all the treatment techniques that are possible in this day and age, then we can help the vast majority to become parents.