Infertility Causes & Treatment
Trying to conceive? Here's what you need to know about common fertility problems
Your period is late, and your cautious optimism is giving way to thoughts of a celebration.
As you rehearse exactly how you'll break this happy news to your partner, your hopes are suddenly dashed. Your period arrives, and you're discouraged once again.
This story is achingly familiar to the 1 in 8 U.S. women of reproductive age and their partners who are trying to conceive and haven't yet succeeded. Thankfully, advances in infertility care—new treatments and new knowledge—can help many infertile couples start the families they’ve desired.
Popular high-tech advances, such as in vitro fertilization and egg freezing, actually account for a minority of treatments. For most infertile couples, lower-tech approaches, such as taking medication to induce ovulation or losing weight so the ovaries function correctly, deserve much of the credit for success. Knowing your options and choosing a fertility doctor with a good track record can smooth and speed your way to parenthood. Here’s a guide to help you navigate the often complex, emotionally trying journey of fertility troubles.
What Is Infertility?
For many couples, the process of trying to conceive is so fraught with anxiety and worry—It's taking way too long to get pregnant, there must be something wrong—that any delay beyond the first month of trying sparks fear of fertility problems. But in reality, healthy couples under age 30 who have sex regularly have only a 25 to 30 percent chance of getting pregnant in any given month. Infertility is only diagnosed after a couple actively and unsuccessfully has tried to get pregnant for one year or longer.
However, age can temper that definition, says Steven T. Nakajima, MD, professor and division chief of reproductive endocrinology and infertility at the University of Louisville School of Medicine and president of the Society for Reproductive Endocrinology and Infertility. "Once women get beyond age 35, we start to evaluate them earlier," Dr. Nakajima says.
Women ages 35 and older should seek help after six months of trying without success, agrees Wendy J. Schillings, MD, a fertility specialist in Allentown, Pennsylvania. Couples often don't realize how quickly—or how much—fertility can decline with age, Schillings and Nakajima say. In her 20s, a woman has about a 30 percent chance of conceiving in any given month without birth control. By about age 37, Nakajima says, that goes down to 15 percent. After age 37, it declines even more.
Self-Help Fertility Steps
Before seeking the help of a specialist, couples can do a lot on their own to improve fertility on their own—or at least figure out what the problem may be. In fact, as many as 1 in 5 couples diagnosed with infertility eventually become pregnant without treatment. Several do-it-yourself measures get nods of approval—encouragement, actually—from fertility specialists. Among the suggestions:
- Lose or gain weight if necessary. About 12 percent of all infertility cases are due to the women weighing too little or too much, according to the American Society for Reproductive Medicine (ASRM). If you are obese (with a body mass index, or BMI, of 30 or higher), it can affect the way your body signals your ovaries, Nakajima says. "The ovary gets mixed signals so you don't ovulate properly." (Ovulation is the time in a woman's cycle when the egg is available for fertilization; this is usually 11 to 21 days after the first day of her last menstrual period.) If your BMI is 35 or greater, losing just 10 percent of your weight may help fertility, Nakajima says. On the other hand, weighing too little (a BMI less than 18.5) can cause irregular cycles and prevent ovulation.
- Quit smoking. "Women who smoke make their ovaries age more quickly," Schillings says. And that's not the only concern. Smoking can increase a woman's chance of miscarrying the pregnancy and may lower the potential benefit of fertility treatment. Moreover, women are not the only ones who should avoid smoking while trying to conceive. According to Mayo Clinic experts, men who smoke may have lower sperm counts or problems with erectile dysfunction—both potential barriers to conceiving a baby.
- Limit the booze. "It would be wise to limit alcohol," says Schillings. While experts are still debating the effects of alcohol on fertility, Schillings tells couples trying to conceive to limit alcoholic beverages to four or fewer a week. That advice, she says, is for both partners. Alcohol use during pregnancy can increase the risk of birth defects and may make it more difficult for to get pregnant. In men, drinking heavily may decrease both sperm motility and sperm count.
- Track your cycle. See if you are relatively regular, Nakajima suggests. That means having a period every 24 to 32 days.
- Keep tabs on your eggs. Ovulation predictor kits, widely sold at drugstores and online, include a urine test strip that shows changes in the level of luteinizing hormone (LH). Once LH surges, you usually ovulate within 12 to 36 hours.
When It's Time for a Fertility Specialist
Depending on your age, if you've tried the above for 6 to 12 months without success, it may be time to see a specialist Nakajima says. "Take all the information you’ve collected with you. This will give us some hints."
Next, your doctor will order a variety of tests, depending on what the suspected problem is. "For men, the most important test is semen analysis," Schillings says. "For women, we do hormonal studies to assess ovulation." The trend of men taking testosterone supplements to build muscle mass or improve athletic performance is hard on fertility, Nakajima says. The artificial testosterone in these supplements can adversely affect sperm by causing the brain to shut down its natural sperm-making machinery.
If it appears you are ovulating and that your partner's sperm are healthy, the doctor will know to investigate other potential problems, such as a problem with your fallopian tubes. (The fallopian tubes carry eggs from the ovaries to the uterus and are often the site where the sperm meets and fertilizes the egg.) You may need a special X-ray, called a hysterosalpingogram (HSG), to evaluate your tubes and your uterus.
A specialist will also rule out, if suspected, numerous other factors that can affect fertility, including sexually transmitted infections (STIs) such as chlamydia. Your doctor will check for /marketing/library/contents.html?docid=000660&doctype=1endometriosis, in which tissues that normally lines the uterus begin to grow outside of it, and polycystic ovarian syndrome (PCOS), a hormonal disorder that affects ovulation and is common in women of reproductive age.
Choosing an Fertility Specialist
It's important to select a fertility center with a good success rate, keeping in mind that the woman’s and the man’s age and any medical problems will affect that rate, specialists say. The best metric to consider, according to the Society for Assisted Reproductive Technology (SART), is what’s called the live birth success rate (also known as the ''take home baby" rate). The take home baby rate gives a more realistic picture of a clinic's success than looking at the rate of positive pregnancies, which may or may not result in a baby months down the road. (You can look up success rates of individual clinics on SART's website.)
Fertility Treatment Options
Depending on the cause (or causes) found, your initial treatment may involve drug treatment; possible treatments include Clomid (generic name: clomiphene) or Pergonal (a mixture of the hormones LH [luteinizing hormone] and FSH [follicle-stimulating hormone]) to induce ovulation or to increase the number of eggs reaching maturity in a single cycle. These interventions may increase the chance that a sperm will meet an egg and fertilize it. Your reproductive endocrinologist may decide that surgery, to repair damaged reproductive organs, is warranted. Up to 90 percent of infertility cases are treated in these ways, according to the ASRM.
However, if you have severe tubal problems or your partner has low sperm counts, in vitro fertilization (IVF) may be your best chance for pregnancy. IVF involves surgically removing eggs from your body and mixing them with sperm in the lab. Once fertilized, the embryos are placed into the uterus. IVF has improved dramatically since it was introduced in the U.S. more than 30 years ago. According to the SART, which represents more than 85 percent of all assisted reproductive clinics in the U.S., 40 percent of IVF cycles in women under age 35 resulted in live births in 2011, while 21 percent of those in women ages 38 to 40 did. In 1989, the national rate was just 14 percent. Unlike a regular menstrual cycle, an IVF cycle does not include ovulation. Rather, the eggs are retrieved from your body when they mature. Then they are fertilized in the IVF lab.
Fertility Treatment Advances
One advance in IVF technique, Nakajima says, is the ''extended'' culture of the embryo, which allows it to mature in the lab a few days longer. ''We can culture to day five," he says. (Day one is fertilization.) The extended culture technique has pros and cons, experts say. While it is thought to improve the pregnancy rate, some research has found it can increase the risk of early delivery. More long-term study is needed, according to ASRM.
If sperm production or quality is a problem, your doctor may decide to do intracytoplasmic sperm injection (ICSI). This involves injecting a single live sperm into each egg to achieve direct fertilization.
Yet another approach is to use donor sperm and/or donor eggs.
Once an egg has been successfully fertilized, the resulting embryo can be frozen, so your doctor can transfer fewer embryos (reducing the chance of carrying twins, triplets or more, which can be risky for the mother and the developing fetuses) and freeze those embryos that remain for later use. Embryos that are frozen and then thawed, Nakajima says, still have a good success rate.
Egg freezing has advanced, too. This technique used to be offered as an experimental treatment option mainly to women with cancer who wanted to freeze eggs and save them for later use before they underwent radiation or chemotherapy. (Some types of radiation and chemotherapy, including those used to treat breast cancer and ovarian cancer, can reduce or damage the eggs in a woman’s ovaries). In late 2012, ASRM lifted its experimental label from egg freezing, although it did so cautiously. It based the decision on evidence that, in young patients, egg freezing produces pregnancy rates comparable to fresh eggs. However, ASRM is not promoting the freezing of eggs just to defer childbearing; there must be a more medically compelling reason.
For now, ASRM views egg freezing, as appropriate under certain circumstances, such as providing alternative sources for couples who need donor eggs. Eventually, Nakajima says, he hopes the technique will be perfected to the point where ''any woman could be her own egg donor," freezing her own eggs while she’s still young for potential later use.
Another advance is the technique of checking the embryo for chromosomal abnormalities before implanting it, Schilling says. The process is called pre-implantation genetic testing.
Footing the Bill
Insurance coverage for fertility treatment varies widely among insurance plans and states, says Schillings. According to ASRM, 14 states have laws requiring some health insurance coverage of infertility treatment.
If a couple needs just oral medication to induce ovulation, the total cost of care can be about $1,000 or so, Schillings says. "If you are talking IVF, it can be $10,000 to $15,000 per cycle." And with the average couple attempting several IVF cycles before a viable pregnancy occurs, the bill can add up quickly.
How to Survive the Emotional Fertility Roller Coaster
Fertility treatments demand not only time and money but also the ability to cope with wildly ranging emotions as you may travel from despair to hope and back again, perhaps over and over.
That time commitment adds up. In one study, couples who sought specialized fertility care such as IVF spent the equivalent of more than 15 days over an 18-month time period getting that care.
It's an emotional, stressful time, says Schillings. After repeated attempts, your doctor may suggest alternatives, such as surrogacy, adoption or foster parenting. If patients seem especially stressed, Schillings suggests psychological counseling along with stress-reducing exercises such as yoga. Many fertility specialists try to de-stress the office visits. "In our office," Schillings says, "we try to have a relaxed atmosphere, with soft music [playing]."
Reducing stress can help you manage not only the day-to-day emotional ups and downs and it may boost the chances of conceiving. In one study published in Fertility and Sterility, women undergoing IVF who went to a mind-body stress-reduction program had more than double the pregnancy rate on the second IVF attempt as women who did not go; 52 percent compared with 20 percent.
And no one could argue that learning stress-reduction techniques now, when you're trying to conceive, will no doubt come in handy when you’re dealing with newborn colic, toddler tantrums, sleep deprivation and the other blessings and realities of parenthood that lie ahead.
Kathleen Doheny is a Los Angeles-based journalist who reports on health and behavior.
Reviewed by Shira Goldenholz, MD, MPH on May 13, 2014.
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Interviews:
Steven Nakajima, MD, professor and division chief, reproductive endocrinology and infertility, University of Louisville School of Medicine; president, Society for Reproductive Endocrinology and Infertility (affiliate of the American Society for Reproductive Medicine); phone interview 3/22/2013.
Wendy Schillings, MD, Board Certified Reproductive Endocrinology and Infertility Specialist, Reproductive Medicine Associates of Pennsylvania; phone interview 3/26/2013