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Having babies is the most natural thing in the world. But for the one in 10 people in this country with fertility problems, becoming and staying pregnant can be a costly, physically taxing and emotionally draining ordeal. The upside is that reproductive medicine offers an ever-widening spectrum of infertility medications, surgeries and low- and high-tech procedures that are making the dream of parenthood a reality for an increasing number of people each year. Today, about half of all infertile couples who obtain treatment ultimately achieve pregnancy.

What is infertility?

Infertility is a disorder of the reproductive system that impairs the body’s ability to conceive a baby or sustain a pregnancy. Infertility affects males and females in equal numbers. Doctors generally diagnose infertility and initiate diagnostic testing after one year of unsuccessful, well-timed attempts at getting pregnant. However, if you have been unable to become pregnant after six months of trying and:

  • Are over age 30
  • Have a history of irregular periods, endometriosis, pelvic inflammatory disease, miscarriages or another reason to believe you may be infertile; or
  • Your male partner has a known, low sperm count, there is no need to wait a whole year before consulting an infertility specialist.

Scope of infertility

An estimated 6.1 million people of reproductive age in this country are infertile. According to the American Society for Reproductive Medicine (ASRM), 85 percent to 90 percent of infertility cases are treated with conventional therapies such as medication to induce ovulation or surgery to open blocked fallopian tubes or to remove fibroid tumors from the uterus. While in vitro fertilization and related high-tech treatments get the most publicity, the ASRM points out that these technologies account for less than 5 percent of infertility services rendered in the United States.

Basic Infertility Diagnostic Tests

The detective work needed to identify the cause of your infertility can be time-consuming, expensive and even painful. One way to save time is to have your family doctor send copies of your medical histories to your infertility specialist (preferably a reproductive endocrinologist or a gynecologist who specializes in infertility treatment). These are some of the standard tests an infertility specialist may order:

Semen analysis

A semen analysis measures semen volume and quality, as well as sperm quantity, concentration, morphology (shape) and motility (how well they swim). The analysis also looks for the presence of white blood cells in the semen, which might indicate an infection.

Hormonal tests

If possible, schedule your first consultation on day 3 of your cycle, since baseline blood tests for follicle stimulating hormone (FSH) and luteinizing hormone (LH) should be done on that day. (Day 1 is the first day you bleed.) Blood levels of LH are measured again around mid-cycle when you are ovulating, and for a third time about a week later. Sometime during your cycle, the doctor will measure blood levels of some or all of the following hormones: prolactin, thyroid stimulating hormone (TSH), free T3, free thyroxine (T4), total testosterone, free testosterone, DHEAS and androstenedione.

Other tests

Blood from both partners is tested for such diseases as AIDS, hepatitis and bacterial infections known to affect fertility. In addition to blood work, your doctor might order one or more of the following diagnostic procedures:

  • Hysterosalpinogram (HSG). To conduct this examination, radio opaque radioactive dye is injected through the cervix into the uterus and fallopian tubes. The pelvic region is then scanned by a special X-ray machine before the fluid is allowed to flow back out. The X-ray images can help the doctor diagnose fibroid tumors, an unusually shaped uterus, scar tissue or blockages in the fallopian tubes. Ask your doctor or radiologist to inject the dye very slowly to minimize discomfort. If you have a blocked tube, the procedure can be extremely painful. It may help to take ibuprofen about half an hour before having an HSG.
  • Hysteroscopy. If the result of the HSG suggests the presence of a uterine abnormality, your physician may perform a hysteroscopy to directly visualize the inside of the uterus. The procedure uses a hysteroscope — basically a thin telescope that is passed through the cervix into the uterus.
  • Post-coital test (PCT). This painless office procedure should be done the day that you ovulate and several hours after intercourse. The procedure involves removing a small amount of cervical mucus and examining it under the microscope. Among other things, the PCT assesses compatibility of a man’s sperm with his partner’s cervical mucus.
  • Endometrial biopsy. The main purpose of this procedure is to discover whether you have a “luteal phase defect”, a progesterone deficiency that can lead to early miscarriage. The doctor collects a small sample of tissue from the endometrium(uterine lining) between 11 and 13 days after the LH surge that spurs ovulation.
  • Laparoscopy. After the patient is given regional or general anesthesia, a narrow fiber-optic telescope is placed into the pelvic cavity through a tiny abdominal incision. This allows the doctor to inspect the exterior of the uterus, the fallopian tubes and ovaries for any evidence of endometriosis, pelvic adhesions or other abnormalities.

Don’t give up hope if your diagnostic work-up yields no discernible cause; this happens in nearly one in five cases. The tests can rule out many problems, such as blocked fallopian tubes, and can only help you and your doctor develop a logical treatment strategy.

Infertility Surgery

A variety of surgeries are available to correct fertility problems, and most reproductive surgeries can be done on an outpatient basis. The surgeon’s skill and experience largely determines whether your surgery will be successful. Before consenting to surgery, consider asking your surgeon the following questions:

  • What is your complication rate for this procedure?
  • How many times have you performed this particular operation?
  • What percentage of your patients achieved pregnancy after having the operation?
  • How do these numbers compare with other surgeons?

Female infertility surgery:

  • Therapeutic hysteroscopy
  • Therapeutic laparoscopy
  • Laparotomy microsurgery
  • Falloposcopy
  • Myomectomy

Male infertility surgery:

  • Varicocele repair
  • Sperm duct microsurgery
  • Sperm harvesting

When Should a Couple Seek Treatment for Infertility?

Deciding when to seek help for infertility is often a difficult decision for couples to make. Infertility is a very private health matter and couples often feel anxious and embarrassed about seeking professional help to overcome infertility.

If you are contemplating seeking medical advice for infertility, you are not alone. According to the National Center for Health Statistics, approximately 4.5 million couples experience infertility each year. About 2 million of these couples actually seek help.

One of the biggest factors affecting how soon to begin treatment for infertility is the age of the woman. A woman is most fertile during her early 20s. With each passing year, her fertility begins to decline, hitting a more rapid descent after age 35. Additionally, the chance of conceiving a baby with a genetic abnormality increases as the mother gets older.

For these reasons, the American Society of Reproductive Medicine recommends that couples in which the female partner is over age 35 should seek help after six months of being unable to conceive. Couples who already have known causes of infertility (examples include endometriosis, fibroids, irregular periods, previous abortions, DES mothers, varicoceles, chemotherapy administration) are also advised to seek help early.

Ultimately, the decision of when to seek treatment for infertility is a personal one, which each couple will contemplate individually. Overall, the decision to seek treatment is often fueled by the sense of urgency that a couple is experiencing about their ability and desire to have a child.

Fortunately, for those couples that do seek help, 90 percent of all cases of infertility can be traced to a specific cause. The chances of becoming pregnant when infertility exists depend primarily on the cause(s) of infertility. Statistics show that with appropriate medical diagnosis and treatment, over half of infertile couples will conceive children of their own. Other infertile couples may be able to conceive with assisted donor sperm or eggs.

Who Can Provide the Best Medical Care for the Treatment of Infertility?

Once you have decided to seek treatment for infertility, deciding whom to contact is the next logical step. Your family physician or gynecologist often can refer you to a fertility specialist. If you know a friend or relative who has undergone fertility testing, they may be able to help you find a physician in your area.

In general, the physicians who are most qualified to diagnose and treat infertility are called reproductive endocrinologists. These doctors have specific training in infertility care and usually devote their medical practice to helping infertile couples. It is advisable to seek treatment from doctors who have received board certification in Reproductive Endocrinology and Infertility.

What Can You Expect From Your Initial Visit?

img style=”float: left; padding: 5px;” src=”” />Infertility is a couple’s problem and should be viewed that way from the onset of treatment. Many people erroneously believe that if pregnancy is not occurring, it must be the woman’s problem, and, therefore, only she needs to be treated.

Statistics tell us that in about 35 percent of all cases of infertility, the problem can be traced to a female factor, and in another 35 percent of cases, the problem can be traced to a male factor. In other cases, infertility may be due to problems with both partners. In nearly 10 percent of all cases, the cause of infertility is unexplained. A complete infertility work-up must include both partners.

When scheduling your first doctor’s visit, you may be asked to make an appointment that corresponds to the beginning of the woman’s menstrual cycle. This will allow the doctor to perform certain blood tests that must be obtained during the first few days of the woman’s cycle.

During the initial visit, medical histories of both partners will be obtained. A physical examination, including gynecological evaluation for the woman, is often performed. You will answer questions about your reproductive history (for example, whether either partner conceived a child previously, has a history of sexually transmitted disease, whether you have menstrual periods or have used any ovulation predictor kits to help with conception). Routine blood tests to screen for HIV and hepatitis are often done at the initial visit.

At this time, you will have an opportunity to ask questions about treatments and procedures, and your doctor will begin to explain his/her routine for beginning an infertility work-up. Don’t expect to get a lot of answers about why you have not conceived. More tests will need to be performed, in an effort to determine where the problem(s) may lie.

How Much Does Infertility Treatment Cost?

Treatment for infertility can become very expensive and cost may be the biggest barrier for many couples. Insurance companies traditionally have been reluctant to cover many of the costs associated with infertility care.

Many couples are dismayed to discover that even though a doctor may accept their type of medical insurance, the couple themselves will be responsible for many of the costs associated with treatment. During your initial visit, the cost of treatment is often discussed. The amount of money that a couple is able or willing to pay will impact greatly on the plan of care that is developed. Some infertility specialists will allow you to set up a payment plan, while others require that procedures be paid for when they are performed.

It is a good idea to contact your insurance carrier personally, to discuss what type of coverage your plan offers. If you decide to seek infertility care from a specialist who does not accept your insurance plan, you should always ask your insurance provider whether you are eligible for “out of network” coverage. If you are, you will often receive a higher percentage of the usual fees that are paid by your insurance.

In general, the more advanced and invasive the treatment, the higher the cost of treating infertility. It is not unusual for couples undergoing assisted reproductive technology to be forced to assume large loans or to take out second mortgages on their already mortgaged homes.

What to Ask When Shopping for a Fertility Clinic

  • Are your staff physicians board-certified in reproductive endocrinology, or are they gynecologists who have specialized in infertility treatment for many years?
  • Do you work with an urologist who specializes in male-factor infertility?
  • Are your physicians members of the American Society of Reproductive Medicine?
  • Do you maintain your own laboratory staffed by an embryologist?
  • Is your lab certified to do semen analyses?
  • Do you have an egg donor program?
  • Do you have ultrasound equipment on the premises?
  • Are your doctors and technicians available seven days a week?
  • Do you have any age limitations? (Some programs won’t accept women over age 40.)
  • How many treatment cycles have you performed? (Look for a clinic that completes at least 100 treatment cycles per year.)
  • Is there a waiting list for IVF?
  • What is your live birth rate, and how does it compare with rates reported by other clinics your size?
  • What are my actual chances of getting pregnant at this clinic? (Ask this after you have been medically evaluated.)
  • Do you have a locking room in which my husband can produce a sperm sample?
  • Do you offer counseling or a support group, or can you refer me to a psychotherapist skilled at helping infertile couples?
  • Do you accept my health insurance?