Understanding Infertility

By Dr. Anitha Nair, Reproductive Endocrinologist, Shady Grove Fertility Centers, Washington, DC

Posted on | By Dr. Anitha Nair

Eighty five percent of all couples trying to conceive will become pregnant within one year. Approximately 7 million, or 1 in 6 couples, will have difficulty conceiving and may need medical help to identify and treat the possible causes of infertility. The good news is that there are treatments now to help almost everyone.


Infertility is a disease of the reproductive system that inhibits a couple's ability to have a baby. Infertility affects men and women equally without discrimination and for this reason both partners should actively participate in the diagnosis and treatment process .  Infertility is not uncommon and you are not alone.


Forty percent of all infertility cases may be attributed to the woman, 40% to the man, in 10% of cases both partners contribute to the problem, and 10% of the time the cause can not be identified and it is unexplained.

Defining Infertility
The standard definition of infertility is the inability to achieve a pregnancy after one year of unprotected intercourse in couples where the woman is under age 35. Because a woman's fertility declines naturally as she gets older, couples should consider seeking medical help after 6 months of trying when the female partner is over age 35.


The Importance of a Woman's Age
A woman's fertility peaks in her mid-20s, begins to decline around 27 and drops off more steeply after age 35. A woman's fertility is measured by her ability to achieve a pregnancy on a given month. For women, the ability to conceive is tied to the quality of her eggs. As women age, hormonal changes begin to take place. There is a lot going on but of particular interest are the 2 main hormones controlling the development and release of the egg each month. These are FSH (follicle stimulating hormone) LH (lutenizing hormone).


A rising FSH level is linked to a decreasing egg quality. Decreased egg quality means it becomes more difficult for the sperm to fertilize the egg naturally. There may even be chromosomal abnormalities occurring within the egg itself, which is why amniocentesis is recommended for pregnant women over 35.


To illustrate this point, the natural pregnancy rate for women under 30 is 20-30% per month, but by age 40 the likelihood of conception occurring drops to less than 5% per month.


If You Suspect Infertility
If you are over 35 or if you suspect that past medical history may be impacting your fertility, run don't walk to the nearest fertility center. If you are under 35, a good first step is to consult with your primary care doctor or OB/GYN who can do the basic testing and determine a diagnosis. Don't let cost get in the way of scheduling that first appointment because most insurance plans will cover an initial consultation, and what you learn will be invaluable and may even put you on the road to parenthood.


Top 10 Fertility Tips

  1. The woman's age is a key indicator for future success.
    This point cannot be repeated enough. The single most common misperception among women is that they can achieve a pregnancy at any age. It is not true. A woman's fertility naturally decreases with age and fertility treatment results follow the same lines, down over time, beginning in the early 20s and dropping more rapidly after 35. Even with IVF, the big gun of fertility treatment, pregnancies over the age of 42 are uncommon. But what about those Hollywood stars who are having babies at 45, 48 and even 52? These women are most likely using donor eggs. 
  2. Know when to seek help.
    For women under 35, infertility is defined as 12 months of unprotected intercourse without conception. For women over 35, it is defined as 6 months of unprotected intercourse without conception.  If you stopped taking birth control a few years ago but haven't been actively "trying," you should also consider speaking to your doctor just to be sure everything is ok.
  3. Know where to seek medical help.
    Seventy-five percent of women begin at their OB/GYN and 15% of women go directly to a reproductive endocrinologist or fertility center. Both doctors will begin the same way, an infertility work-up of the male and female to uncover any potential causes of infertility. The OB/GYN may do surgery to improve physical conditions or possibly prescribe clomiphene citrate treatment to induce ovulation or to overcome a very mild male factor. For anything more advanced, most will refer out to the specialist. These days, particularly in metropolitan areas, more and more OB's are referring patients out to a specialist when the patient first suspects infertility, citing the advantages of patients going to a specialist whose entire practice is staffed and resourced to provide focused care for infertility.
  4. Infertility doesn't discriminate.
    Infertility is a disease of the reproductive system and it affects both men and women equally. For this reason, during the inital infertility work-up it is imperative that the male partner's fertility is tested as well as the females. Testing for male fertility is simple and non-invasive; a semen sample is taken to a laboratory and the sperm are observed under microscope. This test is called a semen analysis. Because 40% of fertility problems are attributed to the male, no treatment should be initiated before knowing the results of this test.
  5. Understand you are not alone.
    It seems that everyone knows someone who has had trouble conceiving. The fact is that 7 million couples, on average, 1 in 6 couples of reproductive years, will be infertile. The good news is that if they seek treatment and have the emotional and financial wherewithal, even couples with the most complicated cases can be successful in having a baby. Patient advocacy groups and online patient networks are great resources for information. You are not alone.
  6. More of the same treatment is not always better.
    When you are going through any fertility treatment it is important to understand that your chances for pregnancy are most likely going to be optimized by 3-6 treatment cycles. If pregnancy isn't happening and if no new information has been found to help improve the current treatment plan, then it is time to move on to the next option. If you have been taking clomiphene citrate for 6 months or more, it may be time to consider your next steps, especially if you are over the age the age of 35.
  7. In Vitro Fertilization (IVF) is not usually your first option.
    Many patients will begin with "low tech" treatment, achieve a pregnancy and never have a need for IVF. Others because of their diagnosis, blocked fallopian tubes or advanced age, will have to go straight to IVF or donor eggs to help them conceive. Patients who go to a fertility center are not typically pushed into IVF. Most specialists will take a stepped care approach to balancing your chances for success and the simplicity of the procedure. IVF offers outstanding success rates, no question, but it is also expensive, complex and time consuming, and, fortunately, it may not be necessary.
  8. IVF is not experimental and the incidence of high-order multiple births are decreasing.
    Over the past 25 years, IVF technology and our knowledge about the reproductive processes have improved remarkably affording many more couples the ability to conceive. Let's consider the fact that nearly 150,000 babies have been born since Louis Brown appeared on the scene back in 1970. Pregnancy rates have nearly doubled, Intracytoplasmic Sperm Injection (ICSI) has almost eliminated the need for donor sperm, and high-order multiple births have nearly been eliminated in center's like Shady Grove Fertility who are leading the charge in putting back only one embryo whenever possible.
  9. Do your homework first, especially if you know you need a fertility specialist.
    Infertility impacts couples medically, emotionally, and financially. You want to be sure that you are going to the best place for you and your partner. From a medical perspective, evaluate your doctor's training, the clinic's track record of success, and their treatment volume. From the emotional perspective, what kind of resources for support do they offer and is it integrated into the practice or part of an outside service? Are you comfortable with interactions you've had with staff? Cost is a big issue - do you get the sense they are on your team when it comes to insurance and payment options? Most importantly, seek the recommendation from people you trust, your doctor or friends who have gone to the center.
  10. Insurance does cover fertility treatment.
    Most infertile couples, if they have insurance, will have some coverage for testing, treatment or medications and many fertility centers across the United States offer innovative financial alternatives for couples without insurance benefits or limited resources. The alternatives include treatment discount options, 100% refund options, and even the option to finance treatment over time. Additionally, many pharmaceutical companies offer cost saving programs for the fertility medications and there are even organizations such as The Cade Foundation that offers grants for adoption or fertility treatment. Don't let money stop you from seeking treatment until you know more about the treatment you will need and have exhausted all possible avenues of support.

Article written by Dr. Anitha Nair
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