Introduction
For couples who are having difficulties conceiving a child, infertility can be a challenging time. Fortunately, there are many tests and tools physicians can use to identify and overcome reproductive barriers. This podcast – featuring fertility specialist Dr. Rachel Ashby of the BWH IVF program – will answer commonly asked questions about infertility.
Dr. Ashby, how common are infertility problems?
An infertile couple is one that has been unable to become pregnant after one year of trying. Roughly 75 percent of couples who are trying to become pregnant will be successful in the first six months and about 85 percent after 12 months of trying. Approximately 10 to 15 percent of all couples do not get pregnant after a year of trying and thus may be infertile. With more women delaying child-bearing because of careers and other life choices, infertility is on the rise.
Does the age of the woman have an impact?
Yes, it does. The chances of conceiving a child are sharply impacted by a woman’s age. Pregnancy rates decrease from 86 percent, when a woman is between the ages of 20 and 24, to 52 percent when she is between the ages of 35 and 39.
How should you decide when to go for an evaluation for infertility?
This really depends on the woman’s age. Although infertility is defined as not becoming pregnant after one year of trying, some couples should be evaluated before one year of trying has passed. If the woman is less than 35 years old, it is reasonable for her to try for one year before getting a medical evaluation. However, as a woman ages her chances of getting pregnant do decrease, and an earlier evaluation is recommended. Generally, women ages 35 to 40 should probably seek evaluation after six months of trying while women over 40 should begin evaluation immediately.
Could you tell us what causes infertility?
There are many different causes of infertility, and often there may be more than one cause for a couple. Approximately 30 to 40 percent of infertility is caused by male factor issues, 25 to 30 percent related to ovulatory dysfunction, and 20 to 30 percent related to fallopian tube and uterine dysfunction. In another five to 10 percent of couples, endometriosis – a disorder in which cells of the uterine lining implant onto pelvic organs – is the cause. For 10 to 20 percent of couples, the infertility is unexplained as there is no obvious cause.
What is included in the initial evaluation?
The goal of the initial evaluation of the couple is to determine the likely cause of the infertility, and to determine the most logical approach to treatment. A careful history includes a detailed discussion focusing on questions such as: How long have you been trying to become pregnant? Have you had any prior pregnancies in this or in other relationships? Have you had any medical conditions or prior surgeries? Have you ever had any prior conditions of the female reproductive tract? Are any medications being taken? What is the history of your menstrual cycle and did your mother use DES when she was pregnant with you? What is your history with contraception? Do you have problems with your sexual function? How frequently do you have intercourse? Have you had any previous infertility testing and treatments?
What types of tests are included in the evaluation?
Most couples are very anxious to get started with evaluation and treatment. Ask your primary care physician or gynecologist to perform as many preliminary tests as soon as possible before your visit to the infertility specialist. For the male partner, the standard test is a semen analysis to determine sperm count. For the female partner, standard tests include testing for ovarian function that is done with blood work at a specific time in the cycle.
Are there other tests?
Testing of the fallopian tubes and uterus is also commonly performed. This test is an HSG, also called a tubogram, and uses X-ray and dye to assess the uterus and the fallopian tubes to see if they are open and have the ability to function. Sometimes a laparoscopy, in which a magnifying scope is used to look inside the abdominal and pelvic cavity, is performed if endometriosis or adhesions are suspected. A hysteroscopy may be performed using a small scope that is inserted into the uterus and cervix to view the inside of the uterus for any abnormalities. A pelvic ultrasound is ordered if enlarged uterine size or ovarian masses are noted on an exam.
Is treatment for infertility successful in most cases?
The field of infertility treatment has seen a variety of medical, surgical, and technological advances that are greatly impacting the success rate of treatment. For most but not all women, the outcome will ultimately be successful.
What are some of the treatment options?
Along with medications that can stimulate ovulation, treatment options include IUI, TDI, IVF, AND ICSI. Intrauterine insemination, or IUI, involves the collection of the male’s sperm that is then injected into the female partner’s cervix during ovulation. IUI is most appropriate for couples with unexplained infertility or male factor infertility. Success rates for IUI range from 2 to 20 percent per cycle. Therapeutic donor insemination is for couples where the man may be without sperm or for same sex couples of single women. TDI involves injecting donor sperm into the female’s cervix during ovulation. In vitro fertilization, IVF, is most appropriate for patients facing severe endometriosis, blocked tubes, low sperm count or unexplained infertility. IVF is a four-step process involving the female partner taking medication to stimulate egg production and a surgical procedure to retrieve the eggs. The eggs are combined with the sperm in a dish and, once fertilized, are incubated and implanted in the woman’s uterus a few days later. IVF has a success rate of roughly 35 to 40 percent. Intracytoplasmic sperm injection, or ICSI, is most appropriate for couples with male factor infertility. With ICSI, a single sperm is injected directly into the cytoplasm of an egg.
Who treats infertility?
The first discussions of infertility are usually with the primary care physician or gynecologist who can determine the need for further evaluation. If further evaluation is necessary, the patient would see an infertility specialist who manages complex problems related to reproductive endocrinology and infertility. Together they would make a plan for treatment. Also, because infertility and its treatment can be a physically and emotionally bewildering experience, many couples also seek the help of mental health providers – including psychiatrists, social workers, and psychologists – who specialize in infertility.
For more information on infertility, to make an appointment, or to learn more about the services and locations of the Brigham and Women’s Hospital Center for Reproductive Medicine, call 1-800-BWH-9999 or visit us at www.brighamandwomens.org.
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