Years ago, adoption was the only option for couples who wanted a family but who could not conceive naturally. Today, a host of methods can help infertile couples conceive. In the following FAQs, experts from Women & Infants’ Fertility Center discuss infertility and some of the options available to couples today.
How common is infertility?
Infertility is very common. According to the most recent data (2006-2010) from the National Center for Health Statistics of the Centers for Disease Control and Prevention, 10.9 percent of women (6.7 million) ages 15 to 44 years have difficulty becoming pregnant and carrying a baby to term. In addition, about the same number of men experience fertility issues.
What causes infertility?
There are a number of causes of infertility. Approximately one third of the cases are caused by conditions solely afflicting the woman, one third caused by conditions solely afflicting the man, and one third are problems involving both partners or the causes are unknown. In women, the most common cause of infertility is the irregular or defective release of eggs (ovulation). The most common symptoms of ovulation disorders are a lack of regular or any menstruation. Other more common causes of infertility include blocked fallopian tubes or abnormalities of the uterus.
What increases the chances of being infertile?
Advanced age is the most common factor increasing the risk of a woman being infertile. Although there are considerable variances among women, reproductive efficiency begins to decline at approximately 35 to 37 years of age, decreases significantly by age 40, and is essentially gone by the late 40s. But if an older woman is still having menstrual cycles, she could conceive and therefore should be using contraception if she does not want to become pregnant.
The decline in fertility is aggravated by lifestyle and health issues such as a being underweight or overweight, smoking, excessive alcohol consumption, sexually transmitted infections, chemotherapy or radiation, and chronic health problems.
Men experience an age-related decline in fertility but it is slower and far less predictable. Lifestyle and environmental issues can affect the reproductive efficiency of both men and women.
At what point should one consider seeking help?
Women younger than age 35 with a regular menstrual cycle are advised to try getting pregnant for one year before seeking help. That means regular, unprotected sexual intercourse (without condoms or other contraceptives), preferably timed around ovulation. Couples should have a good understanding of when ovulation is expected to occur and time intercourse to anticipate this event by a few days.
For example, if a woman ovulates 14 days after the start of her menstrual cycle, the couple should have intercourse every day or every other day starting around day nine or 10. Women age 35 and older are advised to try for six months before seeking help. If the woman has irregular menstrual cycles, the couple should be evaluated with more urgency. In addition, if the woman has a history of gynecologic disease or the man has known reproductive dysfunction, immediate evaluation is recommended.
What can we expect at our first visit to Women & Infants’ Fertility Center?
It is helpful for both partners to come for the first visit. In some cases, we can determine the cause of the fertility problem at the initial visit simply by reviewing the couple’s medical history and initial testing. In other cases, several visits may be required.
During the first visit, the physician will review both partners’ medical histories and occasionally perform a physical examination. Basic tests are ordered that will take place over the ensuing month. These tests normally include: a semen analysis to look at the number, motion and shape of sperm; blood hormone tests of the female, which are usually done on the third day of the cycle; pelvic ultrasound; and a hysterosalpingogram, which is an X-ray to evaluate uterine anatomy and determine if the fallopian tubes are blocked. More testing may be required for complex cases.
What sorts of options do we have?
Depending on the ages and individual needs of the couple, we begin with the simplest, least expensive and least risky treatment methods. In designing a treatment plan, we are very conscious of and attentive to the sense of urgency couples might feel. We consider the length of time the couple has been trying to conceive, their response to previous treatments, the overall health of both partners, and test results.
Treatment choices include: educational interactions such as the timing of intercourse during a woman’s cycle; medical treatments such as ovulation induction in the woman; the repair of damaged sperm ducts or tubes; artificial insemination; or assisted reproduction technologies such as in vitro fertilization (IVF).
How successful are these options?
It is critical for couples to have realistic expectations about treatment. Overall, most couples who are willing to persist and make necessary lifestyle adjustments will ultimately succeed. The outcome of treatment depends on the age of the partners and the causes of their infertility. National standards show that most current treatments are successful.
Will our insurance cover treatment?
Insurance coverage in the United States differs widely by region. In New England, insurance coverage for fertility treatment tends to be more generous than in other parts of the nation, but is regulated by very strict rules. Experienced clinics are able to help their patients navigate these issues before treatment begins so couples can have realistic expectations about the costs.
What is in vitro fertilization?
In vitro fertilization (IVF) is a technique used to treat more difficult forms of infertility and is effective because it bypasses some of the most common causes of infertility such as damaged tubes or poor sperm function. It is normally reserved for cases in which more conservative and less invasive methods have failed.
In vitro (Latin for in glass) fertilization means that the oocyte or egg is fertilized in a laboratory dish under highly controlled circumstances. The woman must first inject drugs to cause her body to recruit and mature multiple oocytes. Approximately 36 hours after a trigger injection to complete the maturational steps, a doctor inserts a slender needle through the woman’s vagina to remove the mature oocytes from her ovary. A laboratory specialist then exposes the oocytes to her partner’s sperm cells, fertilizing the eggs to create embryos and leaving them to grow for three to five days. In cases where sperm are defective or few in number, or there are difficulties with the fertilization process, the sperm cells may be injected directly into the oocytes using a process called intracytoplasmic sperm injection (ICSI).
The resulting embryos are placed into the woman’s uterus through the vagina using a small catheter. For the following three to five days, the embryos float freely in the uterus and then implant onto the uterine walls. The pregnancy hormone human chorionic gonadotropin (HCG) is first detectable in a woman’s blood about 10 days after fertilization and three to five days before the first missed menstrual cycle. Pregnancy testing will usually take place two weeks after the trigger injection.
Will medications be prescribed for me?
Medications may be prescribed to the woman or her partner depending on the cause of the infertility. Here is a partial list of some of the most frequently used medications:
- Clomiphene citrate (brand name Clomid) – This is an oral medication used to stimulate ovulation. It is most commonly used to treat unexplained infertility by increasing the number of eggs that are produced (superovulation) and may be combined with intrauterine insemination to increase pregnancy success.
- Letrozole (Femara) – This oral medication is used to stimulate ovulation much like clomiphene citrate. Because its mechanisms of action are different than clomiphene’s, it may be successful in inducing ovulation when clomiphene is not. It is now the first-line agent for the treatment of absent ovulation in patients with polycystic ovary syndrome (PCOS).
- Metformin (Glucophage) – An oral medication, this was historically used to treat diabetes because it enhances the effects of insulin. It is commonly used to facilitate ovulation induction for patients with PCOS when one of the features of the condition is resistance to insulin. Normally it is used in association with other drugs such as letrozole to induce ovulation.
- Human menopausal gonadotropin or hMG (Menopur) – This is an injected drug often used to induce ovulation in women who are unable to ovulate effectively with oral medications. It is also used to induce superovulation for women undergoing IVF treatments.
- Follicle stimulating hormone or FSH (Gonal F, Follistim and Bravelle) – An injected drug often used to induce ovulation for women who are unable to ovulate effectively with oral medications. It is also used to induce superovulation for women undergoing assisted reproductive technology treatments such as IVF.
- Gonadotropin-releasing hormone (GnRH or GnRHant) analogue (agonist or antagonist) – These are injected drugs modified from the natural brain hormone that controls ovulation. They are used in various ways to prevent ovulation from occurring too early in a stimulation cycle.
- Bromocryptine (Parlodel) – This oral medication is used to induce ovulation in women who have problems with excess pituitary prolactin, the hormone that normally induces lactation (breast milk production).