Infertility is not an absolute like it once was, but more research is needed
When a couple of child-bearing age has not been able to get pregnant after having frequent unprotected sex for at least a year—or at least six months for women 35 and older—health professionals define this as infertility. Couples who are infertile define it by the emotions they feel that range from depression and anxiety to guilt, anger and powerlessness. Between 10 and 15 percent of couples in the United States experience these issues.
Couples consulting a fertility specialist will be faced with difficult decisions. “I think education is needed to let couples know what is available without resorting to the more aggressive technologies because sometimes couples are reluctant to utilize them due to religious or financial concerns or the perceived risks to the baby or themselves,” says Dr. Mary Wood Molo, a specialist in reproductive endocrinology/infertility at the Women’s Health Consultants and director of the in vitro fertilization program at Rush University Medical Center. “It doesn’t make any sense to be a dictator and tell the couple what they should do. We should always discuss the risks and benefits of the options and work within the people’s comfort level. I tell patients that it is a difficult journey and that we can create a treatment plan that is specific to their issues.”
When couples seek medical help, during the first visit, the fertility specialist will try to determine the cause of the infertility. “The basic key tests are to find out whether the woman is ovulating and to assess her ovarian reserve and to make sure that her anatomy is normal and do a semen analysis, which can all be done in about a month,” says Dr. Jennifer Hirshfeld-Cytron, assistant professor in obstetrics and gynecology at the University of Illinois Hospital and Health Sciences System, who sees patients in the reproductive endocrinology and infertility clinic within the Center for Women’s Health. The evaluation does not take as long as it used to. “Historically, the text books from 20 years ago had a whole host of tests that professionals did, but now, the evaluation has become much simpler. Ideally, you want to create more of a zen environment, where people don’t feel they are being medicalized by a host of tests.”
In some cases, there is a genetic element to infertility. Women might have diseases, such as polycystic ovary syndrome (PCOS), an endocrine disorder, or endometriosis, which can be treated with standard or innovative procedures. In some cases, premature ovarian failure has a genetic cause.
Dr. Ilan Tur-Kaspa, president and medical director at the Institute for Human Reproduction and the director of the Clinical IVF-PGD Program at the Reproductive Genetics Institute, says that men with cystic fibrosis or who are carriers of the genetic disorder are infertile because their sperm cannot be ejaculated from the testes. “We can take sperm directly from the testes and use Intracytoplasmic Sperm Injection (ICSI) with in vitro fertilization to fertilize the egg, which is a very successful way to achieve pregnancy,” he says. ICSI can also be used for men who have a low sperm count, poor mobility or quality of their sperm, or sperm that is unable to penetrate the egg.
If infertility is caused because a woman is not ovulating, a doctor can recommend a medication that stimulates the ovaries to release eggs. If, after six months, the woman has not become pregnant, in vitro fertilization (IVF), is an option, although it is an expensive one. But Hirshfeld-Cytron points out that in Illinois, health insurance companies are required to cover the procedure, so couples often turn to it at the earliest sign of difficulty.
The first so-called test-tube baby conceived outside the womb was born in England in 1978. Hirshfeld-Cytron says the procedure, now called IVF, is much safer than it used to be. It begins with a medication to stimulate the ovaries to increase the number of eggs it releases. “We have adjusted how we stimulate women in order to minimize problems like ovarian hyperstimulation, which is a potential complication of IVF,” says Hirshfeld-Cytron. The eggs are retrieved by using a needle guided by an ultrasound. “Twenty, thirty years ago, this procedure was done as a kind of surgery, but now it is an office procedure and has become safer and more effective since the first IVF baby,” explains Hirshfeld-Cytron, “And the success rates keep going up because the lab work has gotten better.” She points out that patients taking fertility drugs may experience side effects such as soreness or bruising at the site of injection, gastrointestinal disturbances and bloating, hot flushes and mood changes such as irritability.
One of the concerns about treatments for infertility is the increase in a pregnancy with twins, triplets or a higher number of babies. “The human system was designed to carry one baby at a time,” says Wood Molo. “Each additional passenger in the uterus increases the volume, and that decreases the length of the pregnancy on average three to four weeks per additional fetus and increases the risk of a Caesarean section. There is also a condition called twin-to-twin transfusion syndrome, where one of the twins is getting more of the blood supply, which is bad for that twin, and the other twin is getting much less than necessary, which is bad for that twin as well.” Infertility treatments today are designed to avoid these risks.
“We know that it is healthiest to have one baby at a time, so with IVF, we can [now] control the number of embryos and use one at a time, which gives the woman the greatest chance of having a healthy pregnancy,” Hirshfeld-Cytron explains.
If the woman does not respond to ovarian stimulation or there is a problem with the quality or quantity of her eggs, she has the possibility of using an egg from a known or an anonymous donor, which would be fertilized with her own partner’s sperm. “If someone is using donor eggs, the ideal is to have enough to use them fresh so they can be transferred immediately for an IVF cycle and have embryos to freeze for a subsequent cycle,” Hirshfeld-Cytron says. “We’ve gotten much better over the past 30 years at how we freeze and thaw embryos.”
Dr. Mary Stephenson, professor of obstetrics/gynecology at the University of Chicago Medicine, sees couples who have had recurring failures with IVF. “My most important role as a clinician is to try to figure out if the cause is the genetic seed, the egg, the fertilized egg or the soil—the endrometrium, the lining of the uterus.
“I want to obtain as much information about what happened in the past cycles to find out if the woman had a good response or a poor response to fertility drugs, if there was a lot of fertilization or poor fertilization with the sperm and lastly, how the endometrium responded to the medications.”
In some cases, Stephenson might discuss the possibility of using a donor egg or donor sperm. If the endometrium appears to be the cause of unsuccessful IVF, she will try to determine the specific problem with the lining of the uterus. That might include performing a biopsy of the endometrium and looking for an infection and/or looking at how the endometrium is developing in a non-IVF cycle. “It is difficult to assess the endometrium, but with some new technology using molecular markers, we can stain the endometrium for molecules that should or should not be present at the time of the cycle. This is useful to help make recommendations about whether to proceed with another IVF cycle or to consider changing either the egg or the sperm,” says Stephenson.
“Recurrent failures with IVF is an area of infertility that is highly controversial because we don’t have a lot of definitive answers in the research.”
While treatments for infertility have become simpler, safer and more successful, more research is needed in the field so that every couple seeking help will be able to experience the birth of their own bundle of joy.
Published in Chicago Health Summer/Fall 2012