Options offer hope to couples who long for children of their own

By Florene King

As much as we love to hear stories about baby bumps, the joys of giving birth and exotic baby names; as much as stories about teen pregnancies, infant couture and celebrity nurseries abound on reality television, we ironically DON’T talk about infertility, and surprisingly many Americans are affected. Close to one in six U.S. couples don’t get pregnant despite a year of trying.

 

Infertility: Introduction and Causes

Infertility is defined as a couple’s failure to conceive a child after one year of regular sexual intercourse without using birth control. In about 40 percent of all cases of infertility, the problem lies with the man; in 60 percent, it lies with the woman or with both partners.

Recent research has shown that a woman’s fertility drops off significantly between the ages of 31 and 35 and continues to decline thereafter until menopause, when it ceases altogether. A man’s fertility also declines after the age of 40, although men can remain fertile until old age.

 

Causes of Male Infertility

The Mayo Clinic identifies low sperm count as one major cause of male infertility. A count of at least 40 to 60 million is thought to be necessary for fertilization; when the count is less than 20 million, it is unlikely that a man can father a child (although, since only one sperm is needed to fertilize an egg, it is still possible).

A low sperm count can be caused by low testosterone; exposure to chemicals, pesticides or radiation; by having sex too frequently, which depletes the sperm supply too quickly; and by heat (which slows sperm production) generated by wearing tight underwear or pants, sitting for long periods in hot cars or trucks, or working near ovens and kilns.

Infertility can also result if sperm cannot move through the female reproductive tract to reach the egg, or if sperm are irregularly shaped (only sperm with oval-shaped heads can fertilize an egg).

Male infertility also can be caused by any obstruction in the tubes that convey the sperm from the testes to the penis, by varicose veins in the scrotum, or by a local infection or injury. The infertility problem will likely reverse itself when the condition is corrected.

Also, retrograde ejaculation (a disorder where semen is passed backward into the bladder to exit with the urine, rather than through the penis) can be the culprit. This condition is caused by surgical removal of part of the prostate gland, as well as the use of certain drugs for high blood pressure.

 

Causes of Female Infertility

Many conditions may cause a woman to be infertile. E-Medicine Health reports that in about 25 percent of all cases of female infertility, the woman is not ovulating. The fallopian tubes may be obstructed, often as a result of pelvic inflammatory disease (PID), which irritates the tubes and causes scar tissue to form. PID can develop as a reaction to an STD or an infection of the lower reproductive tract.

Endometriosis (the displacement of tissue from the uterine lining to elsewhere in the body) is another problem where formation of scar tissue blocks the fallopian tubes. An imbalance of the female hormones estrogen and progesterone or of other hormones secreted from the pituitary or thyroid glands can affect the reproductive cycle. An unfriendly cervical environment can also prevent sperm from surviving.

 

Diagnosing the Problem

Diagnosis of infertility begins with physical examinations and complete medical and sexual histories of both partners. A fresh semen sample from the man will be microscopically examined to determine sperm quantity and quality. The results will provide a sperm count, indicate whether the sperm are adequately mobile and whether the heads of the sperm are oval, both characteristics integral to conception.

To determine whether ovulation is occurring, the basal body temperature (temperature on awakening, before eating or drinking) will be taken every morning for several months. If the temperature rises by 0.6 degrees Fahrenheit to 1.0 degrees Fahrenheit for a few days in the middle of the menstrual cycle, ovulation is likely. An endometrial biopsy, where a sample of the uterus lining is obtained for examination, can indicate whether ovulation is occurring and whether hormonal secretion is normal.

Any fallopian tubes obstruction is diagnosed by injecting a dye into the reproductive tract and then taking an X-ray. Also, carbon dioxide gas may be injected into the fallopian tubes; if the patient feels pain, indicating that the gas is passing through the fallopian tubes, no obstructions exist.

An unreceptive cervix can be identified by a microscopic examination of cervical mucus.

Endometriosis is diagnosed by inserting a laparoscope into the abdomen, through which the doctor views the uterus, fallopian tubes, ovaries and any displaced endometrial tissue that may be the cause.

Blood tests are used to diagnose hormonal imbalances in both men and women.

 

Treatment for Him or Her

Treatment for a low sperm count caused by a testosterone deficiency is typically hormone therapy to increase testosterone levels. If the low sperm count is due to chemicals, radiation or excess heat, exposure to these factors must be avoided. If no reason can be identified for the low sperm count, likely little more can be done to increase it.

Pregnancy is still possible, however. The techniques used involve artificially fertilizing an egg from the woman with sperm from the partner or from another man. The fertilization can take place inside the woman’s body or outside the body, in which case the fertilized egg is then transferred into the woman’s uterus.

If male infertility is caused by varicose veins, surgery may be required. If an obstruction exists somewhere in the tubes leading to and through the man’s penis, microsurgery to open the blockage is used to correct the problem.

Failure to ovulate is often treated with the drug clomiphene, which stimulates production of the hormone that regulates ovulation. About 60 percent of the patients who receive clomiphene become pregnant, and the chances of multiple births are very low. A stronger drug is available (a combination of certain pituitary gland hormones), but there is a greater likelihood of multiple births.

Obstructed fallopian tubes may require microsurgery to unblock them or a procedure in which an egg is removed and replaced beyond the point of the obstruction, where it may be fertilized normally. A cervix that prevents the survival of sperm can be treated with the female hormone estrogen. Some­times sperm can be placed directly into the uterus, bypassing the cervix completely. Endometriosis is treated by surgically removing displaced tissue and the scar tissue that has formed around it. Hormonal imbalances are corrected with hormone therapy.

Test-tube, or in vitro, fertilization (IVF) is a well-known technique in which egg and sperm meet in a petri dish, then embryos are placed in the uterus, helping the process along. While the procedure improves on the 20 percent chance of pregnancy women have when their fertility is at its peak, the success rates drop steeply with age and IVF isn’t cheap, given that most couples pay for treatment out of pocket.

Another technique used to treat infertility is called gamete intrafallopian transfer (GIFT). With this procedure, clomiphene or another fertility drug is given to the woman to stimulate ovulation. When an egg is produced by the ovary, it is removed via laparoscopy and immediately mixed with sperm from the man. This sperm-egg mixture is then transferred by laparoscopy into a fallopian tube, where fertilization may then take place normally. Fertilization occurs in the woman’s body and not in a test tube. GIFT is complicated and expensive and should be used only by couples who have not been able to conceive using standard treatments.

Another very common treatment for infertility is artificial insemination (AI). AI is the introduction of semen (from the woman’s partner or from a donor) into a woman’s vagina or uterus by means other than sexual intercourse at or before the time of ovulation.

AI using semen from the partner is sometimes done when he has a low sperm count. To obtain enough sperm, several collections may be required; the sperm obtained is frozen, pooled and used in one insertion. AI may also be used when one or the other partner cannot perform sexual intercourse or when the man carries a genetic defect that he does not want to transmit to the child.

 

Other Methods of Assisted Reproductive Technology

When AI doesn’t work, ICSI (“ICK-see”) may be recommended. Sperm is injected into an egg. If fertilization occurs, the embryo is inserted into the woman’s uterus, just as in IVF. ICSI may also be recommended when the man has had a vasectomy or has retrograde ejaculation.

Another less common treatment is gamete or zygote intrafallopian transfer (GIFT or ZIFT). GIFT is the transfer of eggs and sperm into a fallopian tube through a small incision in the belly. ZIFT is the in vitro fertilization of an egg. The egg is then transferred to a fallopian tube through a small incision in the belly.

Success rates with IVF are as good as with GIFT and ZIFT or better. And IVF is less expensive. It is also less risky, because it doesn’t require a surgical procedure.

 

Complementary and Alternative Treatments

These treatments include:

• Acupuncture

• Dietary changes

• Relaxation techniques

• Mind-body medicine

Discuss any complementary or alternative treatments with your doctor.

 

The Latest Fertility Breakthrough

A new technology, vitrification, could soon become standard medical procedure, allowing women to flash-freeze their eggs for implant in their wombs years or even decades later. Unlike conventional slow-freezing, which often led to the formation of ice crystals in the eggs, this high-speed method greatly improves success rates. But it is expensive ($10,000 to $15,000); it requires daily hormone shots for two weeks to stimulate egg production, followed by egg-retrieval surgery; and it isn’t fail-safe: “Freezing a batch of eggs when you’re 30 gives you a 60 percent chance of a baby,” says Jamie Grifo, M.D., Ph.D., director of NYU Fertility Center’s division of reproductive endocrinology and infertility. “That means there’s a 40 percent chance you don’t get pregnant.” Costs should come down over time, and the odds should improve.

 

Take Time to Plan

Before any treatment, discuss how far you want to go with your partner. For example, you may want to try medicine but don’t want to have surgery. While you may change your mind during treatment, have an idea where you want to draw the line. Treatment for fertility can be expensive and out of pocket. If cost is a concern, ask lots of questions, then determine if your insurance covers any costs. Agree with your partner about what you can afford. Planning your strategy ahead of time will help keep you from becoming emotionally and financially drained as you embark down a path that has inherent risks along with — hopefully — the reward of pregnancy and childbirth at its end.