Medical help for infertile couples
By Dr. Seth G. Derman
Reproductive Endocrinologist, The Medical Center at Princeton
Friday, Nov. 15, 1996
The Old Testament gave Sarah and Abraham their first child when they were, respectively, about 600 and 900 years old.
Surely, this parable of an ancient miracle gave hope to childless couples who must have felt as isolated and frustrated as today's would-be parents who face problems of infertility.
One of the first goals in counseling couples on infertility is to assure them that they are not alone. Their difficulties are not unusual and with time or treatment, the problems are often resolved. At any given time, 13 percent of couples are considered infertile and over a lifetime, 20 percent will go through a period of infertility.
On average, conception usually happens after three months of regular intercourse, but by definition, a couple is not considered infertile unless a pregnancy has not occurred after a year of regular, unprotected intercourse. Their chances for conception are best when intercourse is well timed to coincide with ovulation. But these are only statistics, and are likely to be of small comfort to a couple impatient to become parents.
Some couples fear they have problems if no pregnancy results after a month of trying, while others wait too long before seeking help. Most can wait a year, except when one of the partners has had a sterilization procedure or the woman does not have regular menstrual periods. Evaluation should also not be postponed if the woman is over 35, because at that age her fertility begins to decline rapidly.
Not only should a couple know that infertility is common, they must realize that 40 percent of the time the delay comes from difficulties the woman is experiencing, and 40 percent of the time it comes from the man. The other 20 percent face problems for a combination of reasons.
Because there are relatively few true specialists in fertility, a concerned couple may first visit a gynecologist or a urologist. Sometimes their problems can be solved by these physicians, but they may be referred to a reproductive endocrinologist who will take a detailed medical history from the couple and perform an infertility workup. A reproductive endocrinologist is a specialist in obstetrics and gynecology who has undergone fellowship training in the field of infertility, recurrent miscarriages and hormone disorders.
"On average, conception usually happens after three months of regular intercourse, but by definition, a couple is not considered infertile unless a pregnancy has not occurred after a year of regular, unprotected intercourse."The Medical Center at Princeton
The goal of the history and workup is to find the answers to four questions that will guide treatment:
- Is there a sperm problem?
- Is there a problem with ovulation?
- Can the fertilized egg implant itself in the uterine lining, and be maintained?
A semen analysis is the first step in evaluating the male partner. The semen is examined for crucial factors that may be impeding conception: sperm count, motility (their ability to "swim"), morphology (form) and the volume of the ejaculate.
As a treatment for "male factor" infertility, the physician may recommend intrauterine insemination to boost the sperms' chances of reaching and inseminating an egg. With this minor, relatively painless procedure, the sperm are washed, concentrated and then injected through the woman's cervix directly into the uterus.
In some instances of male infertility, in vitro (or test tube) fertilization is done. With this procedure, the woman is given fertility drugs to produce a number of eggs, which are then removed from the ovary. The egg and sperm are placed in a petri dish to allow fertilization to occur, or in more severe cases, the sperm is injected directly in the egg, in a procedure known as ICSI. Then, several days later, the fertilized egg can be injected into the uterus.
Problems with a woman's reproductive system can usually be traced to one of three causes: blocked or damaged fallopian tubes, thick cervical mucus or irregularities in ovulation - the most frequent cause of fertility problems in women.
Each woman's ovulation pattern is individual, but generally, her ovary releases a mature egg midway through a 28-day cycle, or about two weeks before the menstrual period. The egg then travels down the fallopian tube to the uterus. If it is not fertilized within a short window of time, the egg and the uterine lining are sloughed off, and conception cannot take place until ovulation is repeated in the next month.
Female infertility can be tested in numerous ways. Following the basal body temperature by taking a daily, morning temperature for a few months may detect the slight elevation that indicates ovulation is taking place. A blood progesterone test or urine ovulation predictor kit can also confirm that an egg has been produced. Thyroid and pituitary hormone tests also guide the diagnosis and treatment of infertility.
Other tests fit other situations. A post-coital test can be done to ensure that sperm are able to make it past the cervix on their long voyage to meet the egg. A hysterospalpingogram (HSG) is an X-ray that provides pictures of the internal structures of the uterus and fallopian tubes and indicates any abnormalities, including fibroid tumors, that may obstruct the course of egg or sperm. An additional benefit of the HSG is that pregnancies often follow quite soon after the tests, presumably because the flushing out procedure removes debris from the fallopian tubes.
Hormonal therapy helps with several of the causes of infertility. If irregular ovulation is a problem, one of several hormonal medications may be prescribed. All of them carry the risk of multiple births because they stimulate the production of eggs, increasing the chances that one will be fertilized.
Eight percent of the women who have conceived using Clomiphene (marketed as Clomid or Serophene) have had multiple births, mostly twins. This drug is an antiestrogen agent that tricks the brain into believing that the body is not producing enough estrogen. To compensate, the brain reacts by producing more eggs.
The more potent, injectable drugs, including Pergonol, Humegon and Metrodin, are more expensive than Clomiphene, but have an extremely high success rate. These drugs are also useful to help couples suffering from unexplained infertility.
In addition to ovulation problems, the woman's difficulty may be due to fallopian tubes that are scarred or damaged by infection or endometriosis. These problems can sometimes show up on the HSG and may be repaired using laparoscopic surgery to clear the way for fertilization. In vitro fertilization is also quite useful for tubal problems.
Every course of diagnosis and treatment is individualized. Moreover, promising new tests and treatments come along all the time. Couples should remain realistic but hopeful that they will be among those to benefit from a medical specialty that is helping a growing number of would-be parents to conceive the child they want so much.
Dr. Derman is a reproductive endocrinologist on staff at The Medical Center at Princeton.
Health Matters appears in the Lifestyle section of The Packet and Packet Online. It is contributed by The Medical Center at Princeton.