The Infertility Journey
This is a journey that no one intends to start, and no one can be sure how it will end. The first step is the recognition that there may be a problem. The formal definition of infertility is failure to conceive after one year of exposure to pregnancy ("unprotected intercourse"). The concept of waiting one year reflects the reality that usually conception will take place within 6 months of trying and the full year accounts for those cycles where appropriate exposure may not have taken place due to missing the right day for example.
Most couples start on this journey at the office of the wife's gynecologist. During a routine exam, she may mention that she stopped using contraception some time ago and nothing is happening.
The initial evaluation will typically be simple. Most gynecologists will initially recommend that the patient monitor her cycles with temperature charts or over-the-counter ovulation predictor kits to assess whether ovulation is taking place. These monitoring exercises also serve the very important function of verifying whether the couple is having intercourse at the right time of the month. After this initial step, there is great variability as to how gynecologists will manage their patients who are trying to conceive.
Some GYNs will immediately give the patient some treatment, typically in the form of Clomiphene citrate (Clomid or Serophene) or Letrozole (Femara), tablets which will enhance or establish ovulation. This may be a waste of time if the cause of the infertility is not related to ovulation but it isn't completely off base as a starting point since about 20-25% of the time it is. Other GYNs will carry out some series of diagnostic tests in an attempt to establish the cause of the infertility. These tests will typically include evaluations of the husband (semen analysis, post coital tests), the fallopian tubes (hysterosalpingograms or HSG) and occasionally hormonal assessments (blood tests) or even laparoscopy to rule out endometriosis. Some GYNs will immediately refer patients to infertility specialists once the diagnosis has been made. It is certainly reasonable for a GYN to carry out an initial evaluation and even initial treatment but typically if there hasn't been success within 6-12 months, it is appropriate to see a specialist. Unfortunately, some patients may lose their opportunity to conceive as a consequence of increasing age because they were not treated by a specialist in a timely fashion, especially in those situations where the woman is over 35 years of age.
If a couple hasn't conceived under the care of the GYN, they will generally end up under the care of an Infertility specialist. Usually the GYN will make the referral, but sometimes the patient will seek out this specialized care directly or under the advice of others who have already gone through this type of evaluation. This is one of the gray areas of medicine in that there is no regulation as to who can call himself or herself an infertility specialist. Any physician (even one who is not a GYN!) can describe themselves as infertility specialists. As a patient, it can actually be hard to figure out whether one is being treated in the proper place by the right person. Those gynecologists who are truly specialists have completed further training called a Fellowship in Reproductive Endocrinology and Infertility after completing their residencies in OB/GYN. If a physician successfully completes an accredited Fellowship, she or he is then eligible to take the exams (separate written and oral ones) to become Board Certified in Reproductive Endocrinology and Infertility. The process of certification in Reproductive Endocrinology and Infertility is very rigorous and demanding. There are approximately 650 Board Certified RE/I specialists practicing in the United States compared to more than 15,000 thousand Board Certified OB/GYN physicians. As a general statement, since patients should be under the care of a properly trained physician in order to optimize the quality of care, it follows that a couple experiencing infertility should be under the care of a Reproductive Endocrinologist and Infertility specialist.
In any case, once a patient comes to see a RE/I the first step will be to review that which has been done previously. Further diagnostic testing may be required. It is striking how often a couple will be treated without a diagnosis having been identified. A thoughtful RE/I will avoid repeating tests which have already been done. The purpose of testing is to arrive at a working diagnosis for the couple's infertility.
Once a diagnosis is established, directed therapy can be implemented. For example, if the woman is not ovulating, ovulation induction will be necessary. If the husband has borderline sperm concentrations, sperm preparations, which can concentrate the available good sperm and intrauterine inseminations may be used. The medical literature has shown time and again that our therapies are surprisingly efficient; typically a couple will be pregnant within 3 cycles of a given treatment. The caveat is that pregnancy will happen that quickly if it will happen at all. Once again a conscientious RE/I will need to reassess and possibly change therapies if success is not reached within this time frame.
In some cases, all testing is normal and we cannot find the "reason" for the couple's infertility. This is the case about 15% of the time. These couples are thought to have Unexplained or Idiopathic Infertility. This diagnosis can be very difficult emotionally because couples are frustrated when a problem cannot be identified. Clearly there is a problem preventing pregnancy; however we may not have the tools yet to identify what it is. Even though this may be an emotionally difficult diagnosis to deal with, the good news is that couples with Unexplained Infertility have an excellent prognosis for success with treatment... The treatment of the infertile couple is dynamic. It is inappropriate to be dogmatic in this field. As time passes, situations change and we need to be constantly aware of possible new data which will change the diagnosis and therefore treatment. For example, if a woman seeks out therapy at age 40, hopefully one of the first tests that will be done is some assessment of egg quality. While it may have been normal when last checked, it is imperative to recheck it periodically if the couple is still not pregnant. Time is always passing! It is very important that the couple and their doctor work as a team, continuously assessing where they are, where they've been and where they are going. The point is that once a diagnosis is available, optimized therapy should be carried out for a few cycles and if there is no success, to re-assess and change course.
Unfortunately some couples will not get pregnant with simpler therapy. Yet many of these couples will be successful with more complex therapies. The "big guns" of infertility treatments fall under the name of the Advanced Reproductive Techniques (ART). There have been many different techniques described over the years, usually alluded to by their abbreviations such as IVF, GIFT, ICSI, TET, ZIFT etc. Today, the dominant procedure (and the original one!) is IVF or In Vitro Fertilization.
IVF is a very powerful tool in that it bypasses non-functioning tubes, it can minimize the impact of endometriosis, and it can bypass male factors. The biggest change in the treatment of infertility in the last 15 years has been the growth of IVF. This is for the very good reason that success rates have risen steadily. As recently as 10 years ago, the best IVF programs in the country had "take home baby rates" of 20%. The best programs today have rates that are almost 3 times higher than that.
The future trend is for IVF to be used earlier in the course of treatment than before. This is not only because it is the most successful therapy option we have available today but also because it will treat just about all problems which may be preventing pregnancy. As the per cycle success rates continue to rise and as we continue to reduce the likelihood of multiple pregnancy, it is only a matter of time before IVF becomes the procedure of choice for the treatment of infertility.
We know that all women have a "biological clock." The difficult part is to determine when a given woman has undergone the transition from having "good" eggs to "bad" eggs. We know that typically this will happen in the decade between ages 35 and 45 but it can actually happen at any time.
Furthermore, this transition is not necessarily related to timing of menopause, so a woman will not have any hints or symptoms that her eggs may be decreasing in quality. By the time symptoms such as irregular cycles, hot flashes etc. appear, it may be too late. It is imperative that a physician treating an infertile couple checks for egg quality. If a woman has abnormal egg quality (usually referred to as "abnormal ovarian reserve") all therapies which rely on her eggs will have a very poor likelihood of success (less than 5% chance of healthy live born babies, unfortunately). Furthermore, our treatments, regardless of complexity or simplicity, will not increase the baseline likelihood of success. This raises the question of ethics in that if the therapy we offer a couple is not going to make pregnancy any more likely, should we carry it out?
If a woman over 35 has normal ovarian reserve, however, she deserves aggressive efficient therapy. Time is of the essence and the couple should proceed quickly trough the options. Obviously whoever is taking care of the couple shouldn't waste any time.
Sometimes the couple won't be able to establish a pregnancy because of egg quality issues. The traditional options for these couples have been to remain as they are as a family or to pursue adoption.
Those are still the right options for many couples. For others however, these are not the right choices. By using in vitro fertilization techniques, we can establish pregnancies using eggs donated by another woman. This is analogous to the situations where the husband is sterile and a sperm donor is used. In the process of egg donation, healthy eggs are retrieved from an egg donor and by means of IVF, these eggs are then inseminated with the husband's sperm and the resulting embryos are transferred back into the uterus of the wife who is the egg recipient. Technically the process is fairly straightforward and these are highly successful IVF procedures. Emotionally, however, this may not be the right option for all couples. Obviously this is a very individual decision and all couples should undergo extensive evaluation and counseling to ensure that this is the right path for them on their journey to create the family they envision.
Sometimes our treatments don't work. The vast majority of couples presenting for the treatment of infertility will be successful and will do so in a short amount of time. Most don't need complex, expensive therapy, such as IVF, and will conceive with simpler office based therapy. Unfortunately, some couples will not conceive. Sometimes we know why, e.g. poor quality eggs as a consequence of age. And sometimes we never find out the why. Regardless of this, we have to deal with this outcome since human beings are emotional creatures.
The work of the psychologist Elizabeth Kubler-Ross has shown us that human beings will go through a series of emotional steps as they deal emotionally with being told that they have a terminal illness. Her original work described the stages patients went through as they came to grips with their illness leading to their death. She identified sequential stages which included Denial (I'm not really sick), Anger (Why me, it's not fair?), Bargaining (If I do XYZ, I'll get some more time, right?), Depression, and finally Acceptance when the individual ends up at peace with self and the world. Interestingly, we can identify similar emotional stages anytime that we deal with losses even those less severe than one's own death. If we think back to how we reacted to losing something important to us whether it was a job, a promotion, our grandparents and so on we can frequently identify having gone through similar stages emotionally.
Infertility is a loss. The couple will find that they are unable to have that which comes naturally to others and being human, it is reasonable to expect that the couple will have to go through similar emotional stages of emotional adaptation. Infertile couples who do not succeed will ultimately find acceptance of their diagnosis. It is not an easy or pleasant process but it is a necessary one.
After couples have resolved their situation, different choices will be available. If the lack of success is due to poor quality eggs, donor eggs have enabled these couples to be parents. Adoption is the right choice for some couples. Other couples may choose to remain as they are, remembering that they married and decided to make a life together because of each other and not because of possible future progeny. While treating infertile couples, we have found that the process is as important as the outcome. Of course we wish every couple could have a healthy baby, and we're ecstatic when that happens. In the cases where it doesn't happen (and in the ones where it does!) it is most important that after all is said and done we can look back and be at peace with what took place. It is critical that the couple as well as the physician can look back and conclude that we followed the right path in that we didn't do too much and carry out unethical treatments but we also didn't stop short and not do enough.