The lining may not be thick enough for the egg to implant. Or you may have endometriosis, where, for unknown reasons, the lining of the uterus grows outside the uterus (in the fallopian tubes or abdominal cavity), possibly impairing the movement of the egg through the fallopian tube or causing hormonal or other disruptions.
These include a low sperm count, sperm of poor quality (perhaps abnormally shaped), low motility (sperm are too slow-moving), blocked or missing transport tubes (which prevents sperm from reaching the ejaculate), or absence of sperm altogether. There may also be a problem with the quality of a man’s semen, or there may be an infection.
It took the most advanced techniques of reproductive medicine—and a small coincidence—for Lori and Ken Kreher to become the parents of Blake Edward, born last January. In 1995, Ken, who has been a paraplegic since a 1989 construction accident, was working with a personal trainer, in hopes of making the U.S. Paralympics team. Learning that the Krehers desperately wanted a second child (daughter Kelli was 7 months old at the time of her father’s accident and, says Lori, “the only thing that kept Ken going then”) and that the method they were trying wasn’t getting them anywhere, the trainer suggested they contact another client of his,Sherman J. Silber, M.D., a prominent fertility specialist and director of the Infertility Center of St. Louis. In a remarkable technique, doctors were able to extract sperm directly from Ken’s testicle and fertilize Lori’s eggs through ICSI. The first attempt failed, but three months later, when doctors tried ZIFT (inserting five fertilized eggs into Lori’s fallopian tube), she became pregnant. “We just went wild,” says Lori. “It was such a good thing to finally happen.”
These problems can also kick in after you’ve had a child. Or a mild abnormality might become more severe, making it difficult~r impossible-to conceive again. Such “secondary infertility” can elicit the same feelings of disappointment and frustration, tinged perhaps by guilt that you’re not satisfied with having one child.
Standard texts define infertility as the inability to become pregnant after one year of regularly timed, unprotected intercourse. But you don’t have to wait for it to be “official.” In fact, many fertility experts believe that at six months, you might start exploring whether something’s wrong.
That exploration is going to take time. For a start, your ob/gyn may have you chart your basal body temperature (the reading you get first thing in the morning) or use a home ovulation-prediction kit for three months, to see if you’re ovulating regularly. Then you can’t just schedule all your diagnostic tests and procedures for, say, the first week of December. Many of these tests (see chart at left) need to be timed to a specific day in your cycle, and can’t all be done in the same month. Add in nonmedical delays—you have to wait for approval from your HMO, your husband is traveling-and you could be eating up even more time.
Maybe this isn’t a problem if you’re in your twenties. But as you reach your mid-thirties, you’re looking at an increasingly narrow window in which to conceive—even narrower if you hope to have more than one child.
At some point-if you’re struggling to conceive-you’ll probably find yourself muttering, “Bet if I were an unmarried teenager, I’d be pregnant by now.” Actually, you’d be on to something—not the marriage part, of course, but the youth. In your twenties, you have a 20 to 25 percent chance of becoming pregnant each month. By your forties, that drops to just 10 to 15 percent. Age is the factor that, almost always, will drive the decisions couples have to make about infertility treatments.
That is, your age—or, more precisely, the age of your eggs. When you’re born, your ovaries contain all the eggs you will ever have. Each month after you reach puberty, if things are working properly, a new egg will mature and be released, some 400 times in your lifetime.
Generally, however, the most fertilizable eggs are released earlier in life, explains Sherman J. Silber, M.D., director of the Infertility Center of St. Louis at St. Luke’s Hospital and author of How to Get Pregnant with the New Technology.
What about your husband? Because a man is continually producing new sperm—every day—his age doesn’t influence his fertility. But other factors do. Men who’ve had an STD may have blocked tubes, so sperm are unable to travel from the testes, where they’re manufactured, to the urethra, where they join the ejaculate. A man may also have been born without the necessary connecting tubes or be may have a genetically derived form of infertility. Lifestyle figures in, too: Alcohol, drugs, cigarettes, and a diet low in certain nutrients (zinc especially) have all been shown to lower sperm counts or cause sperm to become abnormally shaped.
Chances are, when you first suspect a problem, you’ll turn to the ob/gyn you’ve been seeing for checkups. Certainly, the doctor should be able to get you started on figuring out what’s wrong—confirming ovulation, doing blood tests or other preliminary diagnostic procedures. He should also be able to refer your husband to a urologist for sperm tests and semen analysis. Make sure the urologist is one who specializes in male infertility, advises Theresa Venet Grant, president of INCIID (the InterNational Council on Infertility Information Dissemination), not a general urologist
Many women stay with their gynecologists month after month, even for years. And that could be a big mistake—possibly the biggest one a couple makes. “The expertise of an infertility specialist can make the difference between years of infertility and successful pregnancy,” notes Diane Clapp, medical information director for Resolve, a national information and advocacy organization for couples experiencing infertility.
Part of the problem may be the training, but part can also be attitudinal, observes Christo Zouves, M.D., medical director of Pacific Fertility Medical Center in San Francisco. “Doctors may be resistant to suggesting high-tech approaches. They’ll approach infertility treatment with an attitude of ‘let’s try this, then this, then this…,’ not realizing that they’re using up precious time, especially if a woman is in her mid-thirties.”
Suppose your doctor assures you that he or she is a “fertility specialist”? There are some physicians who “practically invented the field,” says Grant, and who gained all their experience in practice, not in academic training. But unless you know that’s the case, you should look for a board-certified reproductive endocrinologist. If your ob/gyn can’t refer you to one, check The Official ARMS Directory of Board Certified Medical Specialists (available in public libraries) or write to Resolve at 1310 Broadway, Somerville, MA 02144 for a specialist in your area.
When you call a reproductive endocrinologist, make sure at least some of the staff and technicians are available seven days a week. “If they’re not,” says Grant, “you’re clearly not in the hands of someone whose priority is getting you pregnant.” After all, you may ovulate on a Saturday or Sunday, and need to be seen for tests or treatments pinned to that day. What’s more, if you have a regular 28-day cycle, the same thing will happen next month and the one after and…
The Hales knew shortly after they were married in 1991 that they were going to need IVF: Jennifer’s tubes, tests had shown, were completely blocked. What they didn’t know, though, was that Andrew also had a problem, something they learned three years later during their first IVF affempt, when only two out of a dozen eggs were successfully fertilized. Two more affempts (one with ICSI, one using frozen embryos) also failed. At that point, the Hales thought they might turn to adoption. But deciding to give IVF with ICSI one more shot, in 1997 they consulted the Pacific Fertility Medical Center in San Francisco. “This time we had an angel on our side,” says Jennifer. Last July 4, Julia Elizabeth Hale was born.
If diagnostic tests show that you have ovulation irregularities, your doctor will probably suggest that you try the drug Clomid (clomiphene citrate, also marketed as Serophene) and have scheduled sex based on when tests show you’re about to ovulate. (“If your doctor simply throws Clomid at you without any testing,” says Dr. Silber, “find another doctor.”)
This is an okay game plan for a limited number of months, up to six, some suggest. Others say even fewer. “If Clomid is going to work,” says Dr. Zouves, “it will do it in three cycles.” Unfortunately, there are doctors who will urge women to keep trying with Clomid, sometimes up to a year—a suggestion that not only won’t help, but could expose you to unnecessary danger, says Carolyn Runowicz, M.D., director of the division of gynecologic oncology at the Albert Einstein College of Medicine and Montefiore Medical Center in New York. (Some studies have shown a link between fertility drugs and ovarian cancer, but until we know—the National Cancer Institute is carrying out long-term studies now—caution seems prudent.)
Eliran MorIf Clomid doesn’t work, your doctor may suggest using more powerful ovulation-induction drugs—such as Pergonal (known chemically as hMG, for human menopausal gonadotropin) or Fertinex (chemically, FSH, for follicle-stimulating hormone) to be taken by injection at home. While you’re on these drugs, you need to be monitored with blood tests to make sure hormone levels are rising properly. A few days into treatment, you should also have a transvaginal ultrasound (a sonogram done with a probe inserted vaginally) to check that follicles in your ovary are maturing. Ultrasound is also necessary to check that your ovaries are not becoming enlarged or producing too many follicles—which may lead to a potentially dangerous condition known as ovarian hyperstimulation syndrome.
All these drugs, but especially hMG and FSH, increase your chances of becoming pregnant with multiples. For couples eager to have a baby, having more than one may sound even better (and in a study several years ago, the vast majority of infertility patients surveyed expressed a desire for twins, with half even liking the sound of triplets!). But it’s not ideal. Your pregnancy will be more complicated, you’ll be much more likely to deliver early, and the babies, as a result of their prematurity, may face days, weeks, even months in neonatal intensive care. Then, they’re more likely to have developmental disabilities.
Sometimes fertility drugs are used with an in-office procedure to achieve pregnancy. In this, your husband produces a semen sample (by masturbation) and the doctor treats and inserts the sample directly into your uterus. If your husband also has fertility problems or tests have shown “penetration” problems (his sperm fail to penetrate your egg), the doctor can mix the sample with a variety of substances to help.
How long should you try IUI? Like Clomid, IUI usually works quickly if it’s going to work, says Dr. Silber. “If you haven’t conceived in several cycles, it’s time to move on,” he believes. Other specialists may suggest trying for six months or even a year.
What you need to think about: IUI isn’t cheap, costing anywhere from an estimated $1,400 to $4,000 a month. Unless there’s reason to believe that sperm getting into the uterus is your problem, you might want to cut your losses sooner. Moreover, each insemination cycle exposes you to the potential risks of fertility drugs. By going quickly or even directly to high-tech methods, you limit those risks.
These are the superstars of infertility treatment, the procedures that have made pregnancy possible for couples who, not long ago, had no chances whatever—women whose tubes are completely blocked, for example, or men who produce no sperm at all. Basically, the treatments all start the same way: A woman takes a series of different drugs to stimulate ovulation (and to produce multiple eggs). Then, while she’s sedated, the doctor retrieves the eggs from the ovary.
With IVF, the retrieved eggs are placed in a glass (petri) dish, where they mix with sperm provided by your husband. After two days, the fertilized eggs (now known as embryos) are transferred back to your uterus.
When one of Lisa Daly’s closest friends asked Lisa to hold her newborn son at the baby’s bris (the Jewish rite of circumcision), Lisa initially demurred. “It’s good luck,” her friend insisted. “It means you’ll have your baby soon.” Could that be what would work? Lisa, a registered nurse who specializes in monitoring high-risk pregnancies, and her husband, Ira, now a social studies teacher, had been trying to have a baby for five years. The Queens, New York, couple had undergone test after test, and everything had come back normal. They’d had surgery (a laparoscopy for her, repair of a varicose vein on his testicle for him). Still no pregnancy. Four attempts at intrauterine inseminations, with Clomid to boost ovulation, also failed. Even more heartbreaking, Lisa became pregnant once on her own, and once with Clomid, but miscarried both times. “I just lost it after the second one,” she admits. And then, a month later, only two weeks after holding her friend’s baby, Lisa started another cycle of Clomid and on Rosh Hashanah, the Jewish holy day of renewal, conceived her own son. Jacob Samuel Daly was born on May 27,1997.
If you didn’t like high-school math, you’re going to have a tough time decoding the numbers that fertility centers tout as the basis of their success rates. But it’s more than worth the effort: IVF and its relatives are physically and emotionally demanding procedures, not to mention extremely expensive. Why use up your few chances to get pregnant at a center that isn’t experienced in your problem or that hasn’t had much success generally?
Fortunately, you have help: The Assisted Reproductive Technology Success Rates, a compendium of results from 300 or so clinics that are members of the Society for Assisted Reproductive Technology (SART). You can order copies by phone (888- 299-1585) or click on to the World Wide Web (Actually, it will take lots of clicks: The directory prints Out in three parts, 150 pages each.) And note: As of this printing, the directory currently available is based on 1995 records; the 1996 edition is expected to be available by year’s end. Also, starting with the 1996 directory, centers will be audited (on a random basis) as part of a government crackdown on misleading claims and practices at fertility clinics.
How do you interpret the numbers each center presents? Unscrupulous practitioners would probably like you to focus on one figure only: The number of live births achieved after embryos have been transferred to the mother’s womb. Why not? By definition, that has to be the highest figure, since it would eliminate from consideration all those cycles that had to be canceled at earlier points in the process because things hadn’t gone well—the woman had failed to produce enough good eggs, for example, or the eggs had failed to fertilize.
So the figure that’s generally most meaningful is the one that’s most comprehensive: Number of live births per cycles initiated, a figure that’s popularly called the “take-home baby rate.” But even that number isn’t as revealing as it sounds. Smaller, local centers, for example, may treat couples from the area. If the woman becomes pregnant, fine. If she doesn’t, though, she may move on to a larger clinic, which handles more difficult cases, explains Zev Rosenwaks, M.D., director of the Center for Reproductive Medicine and Infertility at New York Hospital-Cornell Medical Center in New York. The smaller center ends up with a high success rate—but all that reflects is the fact that the clinic’s largely treating couples who get pregnant more easily.
Other more insidious practices can be at work too. Centers have a great stake in publishing high success rates: They could, therefore, be bumping up couples with “easier” cases to the top of a waiting list, in hopes their higher odds will raise the center’s overall success rates. Or centers could be rejecting couples with severe problems or assigning such couples to a “research group,” so their numbers will be kept out of the overall rates. Conversely, centers whose figures seem on the low side may be more accepting of such difficult cases.
“Centers where thousands of IVF cycles have been performed and many hundreds or thousands of women have become pregnant almost surely have mastered IVF,” says Joseph D. Schulman, M.D., director of the Genetics & IVF Institute in Fairfax, Virginia. And look for experience in your particular problem, advises Dr. Kearney.
Knowing certain specifics can signal whether a center is top-notch. Find out what percent of cycles a center cancels, advises Dr. Silber. “If the cancellation rate’s higher than 15 to 20 percent in women under 39, that’s a red flag,” he warns. Similarly, if a center is doing ICSI, embryos should be placed back in the womb successfully nearly all the time. “Failure should occur less than 2 percent of the time,” says Dr. Silber, “and only in patients with few or poor eggs.
High numbers of complications signal that a center may not be paying close enough attention. You could ask specifically about ovarian hyperstimulation risk, suggests Dr. Rosenwaks. “With careful monitoring, a center’s rate should be exceedingly low, less than 1 percent.”
