Years ago, adoption was the only option for couples who wanted a family but who could not conceive naturally. Today, there are host of methods for helping infertile couples conceive. John Buster, MD, a physician with the Women & Infants' Center for Reproduction and Infertility, discusses infertility and some of the options available to couples today.

How common is infertility?
Infertility is very common. According to the most recent estimates (2002) from the National Center for Health Statistics of the Centers for Disease Control and Prevention, 12 percent of women (7.3 million) ages 15 to 44 years were having difficulty becoming pregnant and carrying a baby to term. In more recent years, there has been a slight decline in infertility because of effective treatments and shifting age demographics. Those statistics, however, will probably increase again for demographic reasons.

What causes infertility?
Infertility is a medical condition afflicting many couples. Approximately one third of the cases are caused by conditions solely afflicting the woman, one third caused by conditions solely afflicting the man, and one third are problems involving both partners. In women, the most common cause of infertility is the irregular or defective release of eggs. The most common symptoms of ovulation disorders are a lack of regular or any menstruation.

Other causes of infertility include blocked fallopian tubes or abnormalities of the uterus. Fallopian tubes can be blocked by adhesions from past pelvic infections, endometriosis, or ectopic (tubal) pregnancy. Abnormalities of the uterus include fibroid tumors, malignancy, or developmental problems. In men, infertility is caused by genetic or environmental factors that impair sperm production. This results in too few sperm or defective sperm that cannot fertilize the woman's eggs. Defective, absent or obstructed ducts also prevent sperm from flowing. The defects can be obvious during childhood, but not always.

Does anything increase the chances of being infertile?
Advanced age is the most common factor increasing the risk of a woman being infertile. Although there is considerable variance between women, reproductive efficiency begins to decline rapidly at approximately 35 years of age, has declined considerably by age 40, and is essentially gone by age 44. This decline is aggravated by lifestyle and health issues such as a poor diet, stress, being under- or overweight, smoking, excessive alcohol consumption, sexually transmitted diseases, chemotherapy or radiation, and general health problems.

For men, there is an age-related decline in fertility but it is slower. Lifestyle and environmental issues impact a man's reproductive efficiency as they do a woman's.

At what point should we consider seeking help?
Healthy, sexually active couples where the woman is under 30 years of age can usually achieve pregnancy within four to six months. For women over 30, it begins to take longer and by age 40 years it can take well over 12 months. Women under 35 with a regular menstrual cycle are advised to try getting pregnant for a year before seeking help. Women over 35 are traditionally advised to try for six months. If the woman has irregular menstrual cycles, the couple should be evaluated with more urgency. In addition, if the woman has a history of gynecologic disease or the man has known reproductive dysfunction, more immediate evaluation is recommended.

What can we expect at my first visit?
We suggest that both partners come together for the visit. In many cases, we can determine the cause of the fertility problem at the initial visit simply by reviewing just the couple's medical history. In other cases, several visits may be required to establish the cause.

During the first visit, a history and physical examination is performed and basic tests are ordered to take place over the coming month. These tests normally include: a semen analysis to look at the number, motion, and shape of sperm; blood hormone tests, which are usually done on the third day of the cycle; pelvic ultrasound; and a hysterosalpingogram, which is an x-ray to view normal uterine anatomy and determine if any tubes are blocked. This is usually enough for us to make a diagnosis leading to treatment. However, more may be required for complex cases. Occasionally, several months are needed to obtain a correct picture of a woman's ovulatory function or to resolve a medical problem that needs attention prior to beginning treatment.

What sorts of options do we have?
Depending on the ages and individual needs of the couple, we begin with the simplest, least expensive, and least risky treatment methods. At the same time, we are very conscious of the sense of urgency couples might feel and are very attentive to this in designing a treatment plan. We consider the length of time the couple has been trying to conceive, their response to previous treatments, the overall health of both partners, the amount of psychological reserve, and test results.

Treatment choices include: educational interactions such as the timing of intercourse during a woman's cycle; medical treatments such as ovulation induction in the woman or treatments to enhance sperm production in the man; the repair of damaged sperm ducts or tubes; artificial insemination; or in vitro fertilization.

How successful are these options?
It is critical for couples to have realistic expectations about treatment. Overall, most couples who are willing to persist and make any necessary lifestyle adjustments will ultimately be successful. However, the beginning of treatment can often be difficult and this must be discussed at the outset. The outcome of treatment depends on the age of the partners and the causes of their infertility. National standards show that most current treatments are successful.

Will our insurance cover treatment?
Insurance coverage in the United States differs widely by region. In New England, insurance coverage for infertility tends to be more generous than in other parts of the nation, but is regulated by very strict rules. Experienced clinics are able to help their patients navigate these issues before treatment begins so couples can have realistic expectations about the costs.

What is in vitro fertilization?
In vitro fertilization (IVF) is a technique used to treat more difficult forms of infertility and is effective because it bypasses some of the most common causes of infertility such as damaged tubes or inadequate exposure to sperm. It is normally reserved for cases in which the woman has blocked oviducts or the man has a serious problem with too few or defective sperm.

Fertilization in vitro means that the oocyte or egg is fertilized in a laboratory dish under highly controlled circumstances. The woman must first inject drugs to cause her body to recruit and mature multiple oocytes at one time. At precisely the correct moment, a slender needle is inserted through the woman's vagina to remove the mature oocytes from her ovarian follicles. The oocytes are then exposed to her partner's sperm cells in the laboratory, fertilized, and cultured for three to five days.

In cases where sperm are defective or few in number, or there are difficulties with the fertilization process, the sperm cells may be injected directly into the oocytes using a process called intracytoplasmic sperm injection (ICSI). The resulting embryos are placed into the women's uterus through the vagina using embryo transfer. For the following three to five days, the embryos float freely in the uterus and then implant onto the uterine walls. The pregnancy hormone human chorionic gonadotropin (HCG) is first detectable in woman's blood about 10 days after fertilization and three to five days before the first missed menstrual cycle.

Are there medications I may be prescribed?
Medications may be prescribed to the woman or her partner depending on the cause of the infertility. Here is a partial list of some of the most frequently used medications:

• Clomiphene citrate (Clomid R) - this is an oral medication used to stimulate ovulation. It is most commonly used to treat ovulatory failure associated with polycystic ovarian disease, but can be used for other conditions. Letrozole
• (Femara R) - this oral medication is used to stimulate ovulation much like clomiphene citrate. Because its mechanisms of action are different than clomiphene, however, it may be successful in inducing ovulation when clomiphene is not.
• Metformin (Glucophage R) - an oral medication, this was historically used to treat diabetes because it enhances the effects of insulin. It is commonly used to facilitate ovulation induction for patients with polycystic ovarian disease when one of the features of the condition is resistance to insulin. Normally it is used in association with other drugs to induce ovulation.
• Human menopausal gonadotropin or hMG (Repronex, Menopur®) - this is an injected drug often used to induce ovulation in women who are unable to ovulate effectively with oral medications. It is also used to induce superovulation for women undergoing IVF treatments.
• Follicle stimulating hormone or FSH (Gonal F, Follistim®, and Bravelle®) - an injected drug, this is often used to induce ovulation for women who are unable to ovulate effectively with oral medications. It is also used to induce superovulation for women undergoing assisted reproductive technology treatments such as IVF.
• Gonadotropin-releasing hormone (GnRH) analogue (antagonist or agonist) - these are injected drugs modified from the natural brain hormone that controls ovulation. They are used in various ways to induce or suppress ovulation.
• Bromocryptine (Parlodel R) - this oral medication is used to induce ovulation in women who have problems with excess pituitary prolactin, the hormone that normally induces lactation.

For more information, or to set-up an appointment, contact the Women & Infants' Center for Reproduction and Infertility.


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