Infertility

by: Judith McBean, MD

Millions of women in the United States will face difficulty in conceiving each year. While we are hearing a great deal more about infertility in the news these days, the incidence has not actually increased in the past few decades. Greater awareness of the issue, advances in treatment technology, the increase in the number of baby boomers and a greater openness in discussing infertility have drawn greater attention to the issue in recent years.

What is infertility? Infertility is a common condition, affecting approximately 1 in 10 couples. The World Health Organization defines infertility as “the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”

What should we consider before attempting to conceive? Before attempting to get pregnant, potential parents should make every effort to improve their fertility through health and lifestyle changes. Women who are overweight, obese, or have a Body Mass Index (BMI) greater than 30-35 (ex. 175 lbs. and 5”4”) may experience difficulty conceiving and are more likely to develop diabetes of pregnancy, preeclampsia and need cesarean sections. Women who have medical conditions such as high blood pressure or diabetes, or who take prescription medications should consult with their physicians prior to attempting conception to optimize their health and decrease risk factors. We also recommend that women attempting to conceive begin taking a multivitamin with 400-800 mcg of folic acid.

Other lifestyle factors that affect pregnancy are tobacco and alcohol use as well as caffeine consumption. If you smoke, it is very important that you stop. Smoking is linked to decreased fertility in both men and women, and is associated with significant complications during pregnancy. Exposure to caffeine and alcohol should also be limited. Heavy alcohol use in women appears to decrease fertility and may affect the developing fetus. It is recommended that no alcohol be consumed during pregnancy, as no safe level has been determined. Some studies have shown that a modest amount of caffeine (>300-500 mg) is linked to subfertility and high levels have been linked to miscarriage.

Do fertility rates decline with time and age? Studies demonstrate that the majority of pregnancies occur within the first 6 months of trying, and that approximately 80 to 85% of couples will have conceived after one year of regular, unprotected intercourse. After that first year another 5 to 15% couples may be successful, but after 2 years only about 5% of couples will become pregnant. The majority will achieve pregnancy in the first 6-9 months of attempting, and fertility rates begin to decline thereafter. Fertility rates also decline gradually in women as they age with a steeper decline experienced in the late 30’s into the 40’s. It is very uncommon to have spontaneous pregnancy after age 42. Age is one of the most important factors predicting the success of fertility treatment.

When should I consider being evaluated for infertility? We recommend infertility evaluation for couples who have been attempting to conceive for over one year. If a woman has known risk factors (irregular cycles, suspected uterine or tubal disease such as fibroids, infections, endometriosis or prior ovarian surgery). In women over 35, we recommend evaluation after 6 months of trying to conceive, because delay may result in a decrease in the success of treatment. Women over 40 may wish to consult a physician when they are considering pregnancy.

What about infertility in men? While most men do not experience symptoms related to low sperm counts, some risk factors should prompt an earlier evaluation such as a history of testicular trauma, adult mumps, impotence, chemotherapy, radiation or a history of difficulty conceiving with another partner.

Infertility is a unique medical condition in that it usually involves a couple rather than an individual. Evaluation begins with a careful medical history, which is usually best directed by someone trained in fertility care. The medical history will indicate the specific diagnostic needs of the couple, and usually includes:

• semen analysis to assess male factors
• assessment of ovulation
• a hysterosalpingogram (an X-ray test that looks at the inside of the uterus and fallopian tubes and the area around them) to make sure that the tubes are open
• evaluation of the ovarian reserve and thyroid function

Additional studies may include pelvic ultrasound, genetic studies, and laparoscopy (a surgery that uses a thin, lighted tube put through an incision in the belly to look at the abdominal organs or the female pelvic organs). Infertility may be due to male factors, (25%) ovulation dysfunction (20%), tubal disease (15%) or unexplained (25-40%). Many couples are identified with multiple factors contributing to infertility as opposed to one specific diagnosis that would absolutely prevent pregnancy such as the lack of sperm or blocked tubes.

Once the basic evaluation is complete, your medical provider will want to discuss treatment options. If reversible factors such as fibroids, blocked tubes, or ovulation dysfunction are identified, the goal will be to correct these first. Infertility treatment may be as simple as medications aimed at restoring regular ovulation, or as complex as surgery or In Vitro Fertilization (IVF). It is very important to discuss and prioritize all of the findings, the options, the costs, and outcomes with your medical provider when planning treatment. It is never an easy journey to undertake, but with the right treatment and support, the majority of aspiring parents can successfully achieve their goal of a healthy pregnancy.

Dr. Judith McBean is board certified in Reproductive Endocrinology and Infertility. She practices at Brattleboro OB/GYN, a department of Brattleboro Memorial Hospital. Dr. McBean is taking new patients and can be reached at 802-251-9965.