Ask the Expert at HRC Fertility
What is infertility?
Infertility is defined as an inability to conceive after having regular unprotected sex. Infertility is classified as female factor, male factor, a combination of both, or unexplained fertility.
When is a couple considered infertile and when should they seek the advice of a fertility specialist?
If you have had relations with no contraception for greater than one year, it is time to have an evaluation with a fertility specialist. For women over 38, it is recommended to have an evaluation sooner, at 6 months. The initial evaluation can be completed rather quickly and consists of semen analysis, egg reserve assessment and fallopian tube patency determination. Treatment may be as simple as insemination or require more advanced treatment like in-vitro fertilization.
Couples without fertility issues have approximately a 20% chance per month of successfully becoming pregnant. If they continue trying, they will have a cumulative pregnancy rate of 50% within 3 months, 75% within 6 months, and 90% within one year. When a patient arranges consultation with a fertility specialist they should expect the physician to assess the five foundational factors that affect fertility: male factor, uterine factor, tubal factor, pelvic factor and ovulatory factor infertility.
What is male factor infertility and how is it treated?
Male factor infertility is when a man has sperm that aren’t effectively capable of fertilizing an egg. The foundational test for male factor is semen analysis (SA). SA is accomplished by the man ejaculating into a sterile cup, supplied by the doctor’s office, after three to five days of abstinence. Sperm are then assessed by determining sperm count, sperm motility (percent of sperm that are moving normally), and sperm morphology (percent of normal appearing sperm assessed microscopically). If the sperm parameters are abnormal, additional testing can be performed. These additional tests include hormonal studies, a physical exam, and a scrotal ultrasound. Ultimately, what can be done with the sperm is determined by the amount of sperm available to work with. These treatments include intrauterine insemination (IUI), or in-vitro-fertilization (IVF) in the event that the sperm numbers are inadequate for IUI.
What is uterine factor infertility and how is it treated?
In order to conceive and carry a successful pregnancy, a woman must have a healthy normally functioning uterus. A healthy uterus is one that is structurally normal and does not contain clinically significant fibroids, endometrial polyps, or scar tissue within the uterine cavity. These abnormalities can be detected through a variety of diagnostic studies including a pelvic ultrasound, a sonohysterogram, or a hysterosalpingogram. If any of these uterine structural abnormalities are detected, they can usually be corrected surgically through the performance of a procedure called hysteroscopy. On some occasions the uterus may have been removed due to disease, or is so unhealthy that it is incapable of carrying a pregnancy. Under these circumstances patients may elect to find a surrogate to carry their pregnancy through the use of IVF technology.
What is tubal and pelvic factor infertility?
In order to initiate a pregnancy, a woman must have normally functioning fallopian tubes and a pelvis free of scar tissue (pelvic adhesions). Tubal damage and pelvic adhesions typically develop as a secondary consequence of either pelvic surgery (i.e. removing cysts from ovaries or fibroids from the uterus) or pelvic infections. During the process of healing from these two events, scar tissue forms within the pelvis which compromises tubal function and prevents eggs from finding their way to the fallopian tubes at the time of ovulation. Tubal abnormalities and pelvic adhesions may be detected during the performance of an HSG. They may be corrected through a surgical procedure known as laparoscopy. These abnormalities can also be circumvented through the fertility technique of IVF, because embryos created in the laboratory are directly inserted into the uterus, which effectively bypasses pelvic and tubal disease.
What is ovulatory factor infertility?
Ovulatory factor infertility occurs when a woman fails to consistently ovulate good quality eggs. Inconsistent ovulation is suspected when a patient complains of irregular menstrual periods, including skipping menstrual cycles. In the event of inconsistent ovulation additional hormonal studies should be obtained, including a thyroid panel and prolactin level, to rule out medical causes of ovulatory dysfunction. Inconsistent ovulation can be corrected through the use of various oral and injectable medications. There’s an increasing risk of ovulating a chromosomally abnormal egg with advancing age. The incidence of this rises exponentially starting around age 35. Embryos created from chromosomally abnormal eggs either will not implant within the uterus, or if they do they will result in a miscarriage. Ovulatory dysfunction can be treated in a moderately aggressive way through the use of ovarian stimulation in combination with IUI, or most effectively through IVF in combination with genetic assessment of the embryos (PGD) prior to embryo transfer.
Does everyone need to do IVF?
Not everyone must select IVF to conceive in a fertility center. Following initial consultation, several studies are performed for uterine factor, tubal factor, male factor, and ovarian reserve. With infertility, less than 3 years of irregular menses and a normal evaluation, you are an excellent candidate for less aggressive strategies for conception. Typically, ovarian stimulation is combined with intrauterine insemination (IUI). Treatment is continued for no more than 6 months, and if not successful, followed by IVF.
When am I too old to have a baby?
Naturally, it becomes difficult for most women to conceive on their own in their early forties. Most women are unable to produce genetically normal eggs after the age of 43. With the help of egg donation, it is possible for a woman to conceive at any age as long as she has a healthy uterus. There have been cases of egg donation with women carrying a baby to term safely well into their 60s. The majority of fertility center experts believe it is reasonable to perform egg donation for any woman that is healthy with a normal uterus under the age of 50. After age 50, it may be higher risk and most fertility specialists recommend using a surrogate.
Does IVF require invasive surgery?
Originally, IVF required invasive surgery to retrieve eggs. Laparoscopy was performed with general anesthesia and intubation. Fortunately, laparoscopy is no longer required for egg retrieval. For the past 20 years, egg retrieval has been performed in the office under light anesthesia or conscious sedation. Patients are placed in a light sleep with intravenous medication. While asleep, a needle is used to extract the eggs with no incision required. Roughly 10 minutes are necessary to complete the process and patients are instructed to go home to rest for the remainder of the day. Most patients have their embryos transferred 5 days later. Thankfully, the transfer is similar to having a pap smear and is also minimally invasive. IVF has never been better tolerated by patients.
Are there long term health risks doing fertility treatment?
As we approach 30 years of IVF treatment for fertility, there is still a debate regarding long term consequences of fertility treatment. Early studies suggested an increase in the risk of ovarian cancer for patients receiving more than one year of treatment. More recently, studies have refuted these early claims, but suggest there may be an increased risk of a less malignant type of ovarian cancer called a low malignant potential tumor. Fortunately, 140,000 or more women have IVF each year in the United States and the health consequences of IVF appear to be quite modest. In addition, with more diagnostic tools and higher pregnancy rates, women are receiving less treatment for conception. Less treatment will result in less concern for long term consequences.
Am I a candidate to freeze my eggs?
Most women under the age of 38 are eligible to freeze their eggs. An initial consultation is required to count the number of follicles, followed by a blood test on day 3 of the menses cycle. If there are more than 12 follicles identified and the FSH < 8 mIU/ml and your estradiol < 70 pg/ml, you are likely an excellent candidate for egg freezing. It is common to freeze up to 30 eggs and this may require more than one month of treatment. Vitrification of eggs for freezing is extremely successful and it is no longer considered experimental.
Is there a test to measure my egg reserve?
Women are unable to create additional eggs after birth. The egg reserve is often used to describe how many eggs remain in the ovaries. Fertility is profoundly impacted by the egg reserve. As women get older, fewer eggs remain and the risk of genetic abnormalities increases while fertility declines. Many tests measure egg reserve including antral follicle counts, FSH (follicle stimulating hormone) with estradiol (an estrogen), anti-mullerian hormone, and inhibin (a hormone). An Ovarian Assessment Report (OAR) combines FSH, inhibin and anti-mullerian hormone to project a woman’s fertility. This test predicts how fertile you are relative to other women in your age group. Any of these tests can be helpful to determine your fertility potential.
How do I find an egg donor if my egg reserve is low and I want to carry a child?
Many couples consider using an agency specializing in recruiting donors under 30. Candidates provide information regarding their family history, education, medical history, and answers to additional background questions. All donors are screened for infectious disease and fertility potential. Once screened, she will take fertility medication producing eggs for retrieval. After retrieval, eggs will be fertilized and the embryo transferred. Pregnancy rates for egg donation are approaching 90% per transfer.
Can I freeze sperm prior to vasectomy or chemotherapy?
Many urologists suggest men have sperm frozen prior to vasectomy. Although it is possible to have children following vasectomy with vasectomy reversal, or extraction of sperm from the testicle, it is more expensive than natural cycle insemination with frozen sperm. With chemotherapy, sperm counts fall precipitously and freezing sperm prior to initiating treatment is suggested. Fortunately, storing sperm at a fertility center or cryobank with nominal yearly fee storage can be arranged easily. Sperm may be stored indefinitely in liquid nitrogen until required for pregnancy.
Is surrogacy an option following hysterectomy?
It is common to preserve ovarian function when hysterectomy is performed. Most obstetricians attempt to spare at least one ovary if possible during surgery for pelvic pathology or uterine factor, a structural or functional disorder of the uterus. With an adequate ovarian reserve, eggs or embryos may be frozen to be placed in a surrogate. Finding a surrogate is straight forward with agencies specializing in recruitment. Surrogates are screened for uterine problems, obstetrical complications with prior pregnancies, and infectious disease testing. The pregnancy rates are influenced by embryo quality. After delivery, a pre-arranged adoption is initiated and you take your baby home. California has favorable laws for surrogacy.
Is it true I can choose the gender of the baby?
Fertility specialists have used many different methods over the past 20 years to influence gender. In the past few years, it has become possible to determine the genetic health of the embryo before conception. Single genes may be evaluated like cystic fibrosis or Down’s syndrome may be ruled out. Simultaneously, it is possible to know the gender of the embryo with 99.9% certainty. More fertile couples today seek the help of a fertility specialist to determine the genetic health of their baby prior to conception and confirm the gender for family balancing.
Does insurance pay for fertility treatment?
Most people have benefits for initial evaluation and testing. Larger companies often purchase a rider for fertility benefits. Smaller companies may not afford the benefit since risk is not shared by many people. Your human resources department can provide the appropriate information. Many have requested their company consider purchasing the rider. In addition, during enrollment period, you may select a plan with more comprehensive fertility benefits.
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