Infertility

December 14, 2007

Pregnancy is a special time in a couple's lifetime, and many couples take great care to plan the timing of their pregnancy. They begin to get panicky with each passing month unfulfilled, however, and when the pregnancy will happen becomes less important than whether pregnancy can happen at all. Even though half of the causes of infertility are male-related (see below), the first stop is usually to the woman's regular obstetrician-gynecologist.

Our specialty in the care of women involves much training in the area of infertility, and an OB-GYN doctor can determine what level of infertility work-up need be started. Usually infertility is a self-resolving problem, as the couple have probably over-emphasized the exact timing of a planned conception. IVF, or In Vitro Fertilization, is often inferior to IBF, or In Bed Fertilization, and the over-anxious couple may just need to relax a little so that biology can be allowed to happen.

After six months of failure, however, it's usually time to investigate why a couple hasn't achieved pregnancy.

Getting Diagnosed

An obstetrician-gynecologist is certified to treat infertility up to a point, but then an infertility sub-specialist may need to be consulted. This is a very trying time for both husband and wife, and emotions can run high. Being sent to yet another doctor can be discouraging, and without good communication a couple may feel like they've been shoved away. But the reassurance of a definite plan by their doctor can go a long way to calm the intense worries over infertility. The prospective parents should be informed that to track down the cause, a methodical approach is important. It's not just a matter of taking "fertility" drugs and then waiting for that certain glow. First steps need be taken so that the most obvious and easily treated causes can be eliminated.

Of course it's assumed that a careful exam was done before having attempted pregnancy. A good check-up documenting normal hormonal function, good menstrual rythm, and normal female anatomy should precede conception. Prenatal vitamins prescribed during this visit can decrease the risk of miscarriage and some genetic problems. Younger women (and men, for that matter) don't take as long to achieve pregnancy as the older couples. Four to six months of failure to conceive may be a problem for the twenty-something couple, but a couple in their late thirties may need a few extra months grace time before a problem is suspected.

A good first step in infertility evaluation is a basal body temperature chart (BBT), a simple method wherein a woman takes her temperature every morning so that she can look for and record that subtle rise that indicates ovulation has taken place. Her OB-GYN doctor can supply her with the special chart and instructions needed to begin doing this. A few months of basal body temperature recordings can clearly indicate whether a woman's cycles are normal. Once this has been established, a simple sampling of the womb in the physician's office and some blood tests to verify adequate hormonal levels can determine whether these "normal" cycles are in fact adequate for fertilization and implantation of a fertilized egg. Perhaps the egg she ovulated with wasn't healthy; or the site of the ovulation--the remaining tissue bed of that site necessary to provide progesterone--may not provide enough of this hormone to thicken the implantation site. If this happens, a fertilized egg may slough with the menstrual flow, a microscopic miscarriage lost in the shuffle of what seems like just another month without having acheived pregnancy.

At any point along the way there may be trouble indicating a need for therapy. For instance, irregular cycles can be manipulated with ovulation enhancers, and a womb's inadequate tissue for implantation of a fertilized egg can be nurtured further with the hormone (progesterone) which may be lacking. All of these things may be the simplest problems in infertility.

But as I said earlier, as much as half of all infertility problems are male-related. Decreased sperm counts from surgically correctable problems or medically correctable infections can be dealt with, but low counts for unknown reasons pose particular problems for the urologist.

In the woman, blocked tubes from old infections or endometriosis pose the greatest challenges to the Ob-Gyn doctor. She can have normal cycles and all the right hormones, but if there is a mechanical blockage in the system, sperm may never meet egg. And if there is a partial blockage, fertilization may take place, but the fertilized egg may get hung up on its way to the uterus (womb), creating an ectopic pregnancy. Surgery, laparoscopic (with or without laser) or conventional, may be necessary to treat blocked or kinked tubes. But this treatment has become less popular because of the increased success of other assisted reproductive techniques, like In Vitro Fertilization and other forms of artificial insemination.

Some very unusual infertility conditions may involve antibodies to sperm or involve recurrent miscarriage for immunological reasons. Antibodies related to Lupus, and others, may point to a recurring reason for infertility and early miscarriage. A woman's regular Ob-Gyn can tell her and her husband when it's time to seek further specialists in infertility, and this is usually when the causes of the infertility are unusual or require specialized surgery or sophisticated laboratory protocols. Although an Ob-Gyn is a specialist also, it would be foolish to hang on to a particularly difficult case beyond his or her capabilities. When a certain level of difficulty is reached, a patient is best served going to a gynecologist who does nothing but infertility. The patient's regular Ob-Gyn doctor would be foolish to hang on longer than the condition warrants, for there is everything to gain in having a patient sent back pregnant.

 

The Causes of Infertility

 

Besides the scarring, disfiguring, and obstructive effects of endometriosis, sexually transmitted diseases (STDs) are the other common cause of infertility. Once called venereal diseases, this term originated from the name of the goddess of love, Venus. Gonorrhea causes a purulent (pus) discharge that is associated with severe inflammation that causes blockage of fallopian tubes. Chlamydia, a sneaky STD, can cause the same damage but often without symptoms. Either can cause tubo-ovarian abscesses (pelvic abcesses of the ovaries and tubes), which are walled off, making them particularly hard to treat with antibiotics. Often surgery is necessary which may involve removal of reproductive organs. Pelvic Inflammatory Disease (PID) is an improper term that lumps all of these inflammatory STDs together. Often indistiguishable from appendicitis, it is a leading cause of hospitalization in young sexually-active women. In fact, hospitalization with intravenous antibiotics may be the deal-breaker in trying to prevent infertility in the future when a woman suffers such an infection.

Hormonal dysrythmia ("imbalance of hormones") can make ovulation unreliable. There's been a recent explosion of information about PCOS (polycystic ovarian syndrome, formerly called "Stein-Levinthal" syndrome), that has come to the forefront of infertility evaluations.  Alcoholism and smoking can affect sperm count. Other illicit drug abuse can cause impotence, infertility, recurrent miscarriage, and birth defects.

Pelvic adhesions can cause mechanical kinks in or blocks to the fallopian tubes.  Barriers like these can prevent egg from meeting sperm for conception.  Besides infection, pelvic surgery is a major cause of adhesions.  (See Previous Surgery as a Cause of infertility.)

Infertility Involves Both Men and Women

When a couple who "schedule" a pregnancy begin to get panicky with each passing month unfulfilled, the obstetrician-gynecologist can determine what level of infertility work-up need be started. Usually infertility is a self-resolving problem, as the couple have probably over-emphasized the exact timing of a planned conception. There are first steps to work up the femal patient, but the male must no be ignored, for nearly half of all infertility is male-related. It makes no sense to put a woman through expense and discomfort with exotic tests before a man merely has to render a sperm sample. Still, it's amazing how many men are reluctant to provide this while their wives are pressing on with gynecological routines. Gynecologists must be vigilant to make sure the spermal analysis is part of the work-up as well.

 

Assisted Reproductive Techniques and the Costs of Making a Baby the New-Fashioned Way

 

The science of infertility has seen an explosion of progress since Dr. Steptoe succeeded with the first "test tube" baby more than two decades ago. This milestone, called in vitro fertilization (IVF), changed everything. At the time, most people were pinning their hopes on the exotic technique of microsurgery, where one (usually two) infertility surgeons looked at the entire operation through a microscope, using tiny-tipped instruments so as to be as non-traumatic to the reproductive tissues as possible. The respect for the delicacy of reproductive tissues that brought about the somewhat passé advances of this GYN surgical subspecialty has in large part, because of Dr. Steptoe, been replaced by the chemical roadmaps of reproductive endocrinology that were first laid down by the secrets learned with in vitro fertilization. No longer trying to put tubes back together with suture thinner than hair, now the levers-and-pulleys surgical skills of laparoscopy are used to practice the alchemy of reproduction.

Ingredient A + Ingredient B = Baby C.

Eggs are retrieved from the ovary through a laparoscope to mix with sperm in a lab dish for insemination after external fertilization (in vitro fertilization)
- an egg is retrieved from an ovary via a laparoscope and then mixed with sperm, but instead of using a lab dish, the mixture is directly inserted into the fallopian tube so that fertilization can take place there (Gamete IntraFallopian Transfer, or "GIFT");
- a fertilized egg (zygote) is laparoscopically introduced into the fallopian tube (Zygote IntrFallopian Transfer, or "ZIFT")
- a sperm's genetic component is microscopically injected into an egg in a type of "ram-rod" technique
- low-sperm-count men have their sperm concentrated in preparation for insemination with a count that increases the odds of conception.

Sperm washing and other assisted reproductive techniques have also added to the tricks up a infertility doctor's sleeve to stack the deck the prospective parents' way. The specialist of the day for infertility is the reproductive endocrinologist in association with the infertility subspecialist.

Me? I just want to deliver them nine months later.

 

The Cost of Infertility

 

The cost of medicine has risen proportionately similar to the rise in the cost of a good restaurant steak over the years. Yet you're still getting the same steak now as you did fifteen years ago. I can assure you you're not getting the same medicine. There are babies being born today that would have never had a chance back in the days of a five-dollar steak. Unfortunately, for the couple yet to succeed on their "investment" into assisted reproductive techniques, they're consumed by the fact that all of this does come at a cost.

Most insurance won't cover this, and it is extremely expensive, as most cutting edge medicine is. The financial awareness of infertility (the real money-pit) makes a couple realize how lucky their fertile friends are. It's also easy to see how couples suffering the bankrupting costs of infertility naturally have resentment for the pregnancies that happen in the back of cars for the cost of a drive-in movie and cheap wine. (Are there really any more drive-ins? You'd think the mosquitos would be an effective contraceptive.)

Costs of tens of thousands, sometimes up to six figures, are not unheard of with assisted reproductive techniques. Even though it's expensive, what's a baby worth after the fact? The concept of a baby being priceless is no comfort when there is still no baby and the second mortgage runs out.

But let's look at this more closely. The cost of, say, a mid-priced car today is about 30-something thousand. This is pretty close to the average price of a successful conception via assisted reproductive techniques. Yet three years later the car is junk. You get maybe a few thousand back on trade-in, and the cycle repeats. The average commuter gets into six figures easily during his or her car-buying career, and still future automotive obsolescence is the recurring reward. On the other hand, a baby is...well...everything.

Certainly the cost of having a baby is justified when you compare this expense to a Buick.(Unlike a steak, you can't send a baby back when he or she doesn't turn out the way you wanted it. You are the chef.)

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