Infertility

Infertility

Realizing the Dream
of Motherhood

For years you took all kinds of precautions so you wouldn't get pregnant. But now that you're trying to, you can't.

For whatever reason--you're not sure what yet--it's just not happening. So every month you and your husband go through all the physical and mental gymnastics of scheduling sex, reading and charting early-morning body temperatures and going for test after test after test. And every month, instead of hoping that your period will come, the way you used to, you hope that it won't. You used to view your menstrual blood as the signal that you were fully a woman. Now when it comes it makes you feel as if maybe you're not.

There is a certain irony to it all, that what you once fought so hard to prevent--pregnancy--you're now trying so hard to create. But this isn't the kind of irony that makes you laugh. Instead you're frustrated, confused, angry, sad and worried.

The Infertility Frustration

Experiencing infertility is extremely painful emotionally for women, says Linda D. Applegarth, Ed.D., a psychologist for the In Vitro Fertilization (IVF) Clinic at the New York Hospital-Cornell Medical Center in New York City. It's an experience they never expected to go through, and many are left feeling inadequate as women. "It really strikes at a woman's identity as a woman," she says. While careers and work are often a large part of it, "the whole notion of being a mother is still very primary to who she is as a person," she says.

While infertility can be difficult for men, too, it's often more so for women, says Dr. Applegarth. Women tend to feel more stress about infertility, she says. "They worry about it more. It's usually never far from their thoughts. They're the ones who are reminded monthly of what's happening--or not happening--for them."

Women also are faced with having to shift their definition of what a family is, says Dr. Applegarth. They may have seen it as Mom and Dad and 2.5 children; now they have to get used to the idea that it might just be him and her, she says.

There's also a lot of fear and uncertainty about making decisions about other options, such as adoption, trying donor eggs or sperm or remaining child-free.

Sometimes you can be on a different track than your husband, says Dr. Applegarth. One partner may be more interested in pursuing a high-technology form of treatment, while the other may be ready to move to adopt, she says. This difference can often put additional stress on a relationship.

Infertility can bring a sense of loss on many levels, says Dr. Applegarth. There's the loss of not being able to pass on your and your husband's genes, as well as the loss of experiencing the birth process. Some women end up feeling that their bodies are letting them down, that they're defective, she says.

The Infertility Facts

Couples are considered infertile if they have been having unprotected intercourse for a year and no pregnancy has resulted. This happens to an estimated 10 to 15 percent of American couples. In 25 to 40 percent of cases the problem is related to the man and in 40 to 55 percent of cases to the woman, says Mark Hornstein, M.D., director of the In Vitro Fertilization Program at Brigham and Women's Hospital in Boston. In about 10 percent of cases the trouble is with both partners.

Understanding the Causes

There is a host of problems that can cause infertility in women. In an estimated 30 percent of infertile women, there is failure to ovulate. This can be caused by an imbalance of the hormones, including estrogen, that are required to mature an egg and release it from the ovary. Dr. Hornstein says low estrogen levels are often seen in women who have exercise-induced amenorrhea (in which periods cease), anorexia or dietary deficiencies or who are entering menopause. Other women have very high levels of the male hormone androgen, and as a result the eggs don't develop completely. A malfunctioning adrenal gland can lead to high androgen levels.

Age can also be a factor. "Most studies find a slight drop in the conception rates at age 35, a more pronounced drop at 37 and a dramatic drop by age 40, " says Mary Martin, M.D., director of the In Vitro Fertilization Program at the University of California at San Francisco. And no one knows why.

"There's a barrier to conception at age 40 that we don't completely understand," explains Dr. Martin. "We don't understand it because many of the women who can't conceive will still be ovulating, they'll still be having regular menstrual cycles, and they appear healthy.

"But there is some change that occurs at some fundamental level within the eggs and the ovary itself--a change so significant that even if we stimulate the ovaries and take out the eggs to fertilize in the lab, the probabilities of pregnancy are much reduced.

"It isn't simply a question of not having eggs," adds Dr. Martin. "It's a question of egg quality."

Infertility can also result when the fallopian tubes are damaged or blocked, often as a result of pelvic inflammatory disease (PID) and sometimes endometriosis. Endometriosis, PID or cervical disease is the problem in about 50 percent of infertility cases.

Sometimes there are cervical problems, such as an infection, a lesion or small cervical size, which can lead to infertility. And some women produce antibodies to their husband's sperm.

Trying to Fix It

For many of us, finding out the problem behind infertility is not as important as fixing it.

The whole process usually begins with a medical history, says G. David Adamson, M.D., clinical associate professor at Stanford University School of Medicine. This involves taking a look at your age, how long you and your husband have been trying to conceive and whether you have been able to achieve a pregnancy before, either together or with other partners.

This is generally followed by a semen analysis to see if your husband is producing the quality and quantity of sperm necessary to fertilize an egg and a basal body temperature check to assess whether you are ovulating regularly. Doctors may also ask you to do a postcoital test, where a sample of your cervical mucus is examined several hours after intercourse. This test assesses the quality of the mucus and the sperm's ability to swim in it. To see if your fallopian tubes are clear, doctors may perform an x-ray screening test with dye, called a hysterosalpingogram.

"All couples should have answers to these questions within the first year," says Dr. Adamson.

If the problem lies with your husband's sperm, he should see a urologist, who may recommend medical treatment or, occasionally, surgery. There are also sperm-washing procedures that can be tried. This involves rinsing the ejaculate with a special solution and spinning it in a centrifuge so that the sperm are separated from the semen and become more concentrated. You can also consider artificial insemination, where sperm are collected and then deposited into the vagina or uterus.

If the problem is with ovulation, there are several medications you can take to try to stimulate it. Clomiphene citrate, sold as Clomid or Serophene, induces the pituitary gland to release the hormones that signal the ovary to produce follicles. Human menopausal gonadotropin (hMG), known as Pergonal, stimulates the ovary to produce more than one egg. Follicle-stimulating hormone (FSH), taken as a drug called Metrodin, is similar to Pergonal and helps the ovary ripen the follicle into an egg that can be released.

If there is damage to the tubes or pelvic cavity from endometriosis, doctors can remove endometrial adhesions and growths through a surgical procedure called laparoscopy.

Sometimes these techniques work right away, and other times it's necessary to keep trying a particular drug for months or to try several different approaches. The entire process can be time-consuming, expensive and emotionally trying.

If these early attempts fail, where to go from there often has to do with your age and how long you have been trying to get pregnant, says Dr. Adamson. A woman who has tried for more than three years to get pregnant should consider assisted reproductive technology--such as in vitro fertilization--very soon, he says. If the woman is in her midthirties, she should consider high-tech procedures after 12 to 18 months of trying unsuccessfully, he says. A woman in her late thirties or older may want to move to assisted reproductive procedures in 3 to 6 months, he says.

Coping with Infertility

The tests, the waiting and the uncertainty take their toll, both on your emotional health and on your relationship with your husband. Here are some tips that can help make coping a little easier.

Understand the timetable. "The general rules of thumb are that any couple that has not conceived after one year of exposure should see their physician. Couples should expect that after seeing their physician, they will have all the tests done and treatment initiated within four to six months, if not sooner," says Dr. Adamson. "Treatment following the testing should be for no more than an absolute maximum of 12 to 18 months before considering the assisted reproductive technologies. For older women, these time frames are all shortened significantly," he says.

Find a reproductive endocrinologist. "All couples, after 18 months of trying, should be referred to a specialist, a reproductive endocrinologist," says Dr. Adamson. "And they should be referred earlier if there are significant problems identified in the initial workup," he says. Write to the Society for Assisted Reproductive Technologies, c/o American Fertility Society, 1209 Montgomery Highway, Birmingham, AL 35216, for the names and numbers of reproductive endocrinologists in your area.

Call for help. Resolve, an organization established to help couples dealing with infertility, can be incredibly helpful, says Dr. Applegarth. It has a hot line and support group listings. You can write to Resolve at 1310 Broadway, Somerville, MA 02144-1731.

Share with a friend. "It might be important to tell just one friend or one family member," says Dr. Applegarth. Often women tell her that their husbands are supportive and that they are helping each other, she says. But that can lead to feelings of isolation and loneliness for the couple. You don't have to tell everyone, Dr. Applegarth says, but sharing your infertility experience with one other reliable confidant may help. Getting caring support from family or friends can often help couples cope at this difficult time.

Take 20. Couples who don't talk about the infertility problem are at a big disadvantage, says Dr. Applegarth. Communicating with your husband about infertility is important but difficult. So set a ground rule that you are only going to talk about it for 20 minutes each day or every other day, says Dr. Applegarth.

Get counseling. Experiencing infertility can be emotionally difficult for couples, says Dr. Hornstein: "It's important for the couple to be supported through this." So consult a social worker, psychologist or psychiatrist for counseling. Ask your doctor for a referral.

Safeguarding Your Fertility Now

Perhaps you haven't tried to get pregnant yet but are concerned about preserving your fertility. While some problems can't be prevented, there are some things you can do now to prevent certain infertility problems.

Practice safe sex. One thing women can do to prevent infertility is protect themselves against sexually transmitted diseases (STDs), says Dr. Adamson. If you haven't already done so, have your doctor screen you for all STDs, since some can be present without symptoms. Ask your partner to get screened, too. If you have multiple partners or are having sex with someone whose history you're not sure of, use condoms. Latex condoms with nonoxynol-9 are the most effective in warding off most STDs.

Find out your family history. Your family's medical history may tell you whether you are at increased risk for infertility. For example, if your mother and sisters went through premature menopause or developed fibroids that interfered with their fertility, that's a clue that you might, too.

Get him to stop smoking. If your husband is a smoker, encourage him to cut back or quit altogether, since studies indicate that smoking can affect sperm quality.

Don't overdo the exercise. Intense exercise can lead to amenorrhea, which is a sign that exercise has interfered with ovulation.

Try not to wait too long. Pay more attention to planning your reproductive life, suggests Dr. Adamson. It's important to realize that biology won't wait, he says. Women may want to wait till their job is on track or until they've moved, or whatever, he says. "There's always a better time to have a baby. But time marches on relentlessly." Just try to be realistic.