Q: Who is an infertility specialist?
A: An infertility specialist is a physician who has completed specialty training in reproductive endocrinology and infertility and has spent two to three years studying and specializing in infertility treatment. Patients should seek a physician who is board certified in reproductive endocrinology and infertility for their infertility care.
Q: When should we leave the care of our Ob/Gyn to seek assistance from a reproductive endocrinologist?
A: This is somewhat difficult to answer, as the interest and skills of Ob/Gyns for infertility vary greatly. Ob/Gyns should know the limits of their infertility interests and skills and suggest referral when they no longer have workable solutions. Your Ob/Gyn should be able to get you through the basic infertility work up (HSG, semen analysis, temperature charts). Some use medical therapy such as Clomid/Serophene well; some do not. If you are uncomfortable with your infertility treatment plan, it is time to move on. If you are comfortable, the Ob/Gyn should be able to take you through the use of Clomid/Serophene. You should not be on the medication for more than 4 months before seeking additional assistance. Most couples who will be successful on these medications will be successful within the first 4 months. Clearly, if the Ob/Gyn finds a major problem, referral is immediately indicated. Also, most Ob/Gyns are not trained to use or monitor the use of injectable medications used to stimulate the ovary (hMG: Pergonal, Metrodin, Humagon, Fertinex, Follistim, or Gonal-f). If they suggest you need one of these medications, you should be seeing an infertility specialist instead. The most important reason to consider moving on to an infertility specialist is when the woman is older, usually in her later 30s. The older the woman is, the more difficult it will be to achieve pregnancy. Thus, if a woman is older, more sophisticated and directed treatment should strongly be considered. (See below, "How does the woman's age affect her chance of delivering a baby?")
Q: My Ob/Gyn tells me that my irregular periods may be caused by a condition known as PCOS. Will this affect my chances of becoming pregnant?
A: PCOS (polycystic ovary syndrome) is a medically documented cause of infertility. Women with PCOS do not ovulate regularly and suffer from an imbalance of hormone levels. While provided with thousands of eggs at birth (like women with normal ovarian function), women with PCOS are unable to release these eggs from their ovaries. The unreleased eggs then become cystic and remain attached to the ovaries. Because of the inconsistent release of these eggs and the erratic hormone levels, pregnancy often is difficult to achieve. In most instances of PCOS, some form of treatment is necessary to re-establish predictable ovulation. PCOS is a complicated syndrome with indications beyond infertility. It is advisable to seek an infertility specialist with experience in treating PCOS.
Q: Who needs high-tech procedures like IVF?
A: Indications for IVF are multiple, but IVF is indicated when all other means of achieving pregnancy have failed. Current indications are 1) female tubal factor infertility due to fallopian tubes damaged by endometriosis, infection, sterilization or pelvic surgery for other indications; 2) endometriosis; 3) male factor infertility; and 4) unexplained infertility. This latter diagnosis requires a very thorough workup that must include a semen analysis, HSG, laparoscopy, failed Clomid/Serophene, failed hMG cycles, and normal ovarian reserve screening.
Q: How does the woman's age affect her chance of delivering a baby?
A: It is very important to understand that live birth is the only result that counts when taking into account infertility treatments. A woman's peak reproductive potential is usually before the age of 30 and declines rapidly after the age of 40. The older the woman is, the more difficult it is for her to become pregnant and deliver, and the more aggressive her infertility treatment needs to be. The problems that the older woman faces are a decrease in the absolute number of eggs available, a poorer quality of those eggs (decreased reproductive potential of the eggs), and an increased incidence of genetic abnormalities of the eggs.
Q: How does the age of the man affect the couple’s chances of a live birth?
A: Not nearly as much as the woman's age. Even if there are problems with the semen analysis for the man, with ICSI (intracytoplasmic sperm injection), the couple should do well independent of the age of the man. There is a slight increase in the incidence of genetic abnormalities in the child (i.e. Down's syndrome) as the man ages, but the increased risk with advancing age is not nearly as great for men as for women.
Q: Which couples need IVF with sperm injection into the egg?
A: The injection of a single sperm into an egg is called intracytoplasmic sperm injection, or ICSI. Many couples benefit from this advanced technology. With this procedure, a single sperm is injected directly into the egg, allowing the IVF laboratory to work with very few sperm. Indications for IVF and ICSI are severely low sperm count (usually less than 5 million sperm/mL); severely low motility (usually less than 20 percent even with normal sperm counts); normal percentage motility with a poor motility grade (grade is how well the sperm swim); severely abnormal morphology (shape of sperm head) by strict criteria; or failed or poor fertilization in a previous IVF attempt. Fertilization rates with ICSI should be about 70 percent of injected eggs, with damage rates to the egg from ICSI at less than 3 percent. Live births for couples requiring ICSI should be exactly the same as for couples not requiring ICSI, with the woman being of similar age. The Bethesda Fertility Center was the first in the Cincinnati area to achieve pregnancy and live birth with ICSI, just one year after the first international pregnancy was announced.
Q: When and where should the man have a semen analysis?
A: About 40 percent of couples having difficulty conceiving will have a male-associated factor complicating their chances of becoming pregnant. Thus, a semen analysis should be done very early in the evaluation of the couple, preferably as one of the very first tests, and clearly before any invasive or painful tests are done on the woman (HSG or surgery). The best places for the man to have a semen analysis performed are at laboratories associated with reproductive endocrinologists doing sophisticated high-tech procedures. These laboratories are board certified and report their results in a manner that is understood to anyone who works with infertility patients. Obviously, insurance coverage will direct you to a service on your provider list. Only after an analysis on more than one occasion returns abnormal, does the man routinely see a urologist.
Q: What if the man has had a vasectomy or has no sperm in the ejaculate because of genetic reasons (cystic fibrosis) or congenital (from birth) obstruction of the tubes that carry sperm outward?
A: With the assistance of our urologic colleagues, sperm can be aspirated directly from the testicle in an outpatient procedure with very little discomfort for the man. The Bethesda Fertility Center was the first in Greater Cincinnati to achieve pregnancy from this procedure.
Q: For couples diagnosed with severe male factor infertility, does the diagnosis affect the live birth rate for these couples using IVF and ICSI (intracytoplasmic sperm injection)?
A: To date, there is no data to suggest that any sperm parameters affect ICSI results. The live birth rates for couples requiring IVF and ICSI depend solely on the egg, and this is related to the woman's age and ovarian reserve.
Q: What is ovarian reserve and how is testing for ovarian reserve done?
A: Ovarian reserve is the ovary's analogy to the semen analysis for the male. Ovarian reserve is the best method to evaluate the reproductive potential of the woman. Tests for ovarian reserve include an ultrasound for the measurement of antral follicular count (AFC), or blood work for the measurement of anti-mullarian hormone (AMH) or menstrual cycle day 3 follicle-stimulating hormone (FSH) levels. The Clomiphene Citrate Challenge Test (CCCT) also can aid in determining ovarian reserve. For the CCCT, hormone measurements for FSH and the hormone estradiol are made on menstrual day 3. Clomid/Serophene is then administered orally on days 5-9, and FSH and progesterone levels are measured on menstrual day 10. Elevated FSH levels on either menstrual day 3 or 10, and/or an elevated day 10 progesterone level, are all indicative of diminished ovarian reserve. Abnormal levels of FSH must be determined for each laboratory, so caution should be taken when interpreting the results. The Bethesda Fertility Center has published multiple papers on this important screening and has helped establish hormone standards.
Q: Which women need ovarian reserve screening?
A: The Bethesda Fertility Center has published screening criteria for ovarian reserve screening. Criteria for screening are: 1) any woman over the age of 35; 2) any woman of any age with the diagnosis of unexplained infertility, one ovary or a history of significant surgery on an ovary (usually from endometriosis) or a poor response to Pergonal like medications in the past. Using these criteria, 1 out of 6 women screened will demonstrate diminished ovarian reserve. Age is the most common screening tool to pick up diminished ovarian reserve, and the incidence of diminished ovarian reserve increases with a woman’s increasing age. Unexplained infertility is also a significant risk factor for diminished ovarian reserve. Roughly 33 percent of women with the diagnosis of unexplained infertility will demonstrate diminished ovarian reserve, thus making their diagnosis no longer unexplained.
Q: What does the diagnosis of normal or diminished ovarian reserve mean to our chances of having a baby?
A: Women with normal ovarian reserve can be counseled that their chances of having a live birth with their own eggs can be estimated by their age, and most infertility specialists can give relatively accurate estimates. If the testing demonstrates diminished ovarian reserve, the likelihood of live birth with the woman's eggs decreases significantly to less than 1 percent, independent of the technology used (timed intercourse versus IVF) and independent of the woman's age. Ovarian reserve screening is not absolute in its interpretation. Some women with diminished ovarian reserve will conceive and deliver a child, but not nearly as often as those women of similar age with normal ovarian reserve.
Q: What are our options if the diagnosis is diminished ovarian reserve?
A: The options will depend, of course, on other infertility diagnoses, if any. All infertility problems that are correctable should be optimized. Treatment then is dictated by the diagnosis that is unrelated to diminished ovarian reserve. In general, more aggressive treatment is indicated than for couples with normal ovarian reserve. Whatever options couples are offered and choose, they must consider the need to try with the woman's own eggs, the need for psychological closure on their infertility if treatment fails with the woman's own eggs, and the cost/benefit ratio for treatment with a poor prognosis. IVF is an option for couples with diminished ovarian reserve. An alternative that offers a much better cost/ benefit ratio is egg donation, where a younger woman donates eggs to another couple.
Q: Who needs egg donation?
A: Egg donation is indicated for women who are menopausal, for women who have failed multiple IVF cycles with their own eggs, independent of age, for couples whose embryos are consistently of poor quality, and for couples with genetically inherited diseases. Our center has achieved live birth rates as high as 75 percent using donated eggs. Advantages of egg donation are that while the genetics of the child are not those of the woman, the genetics are those of the husband or partner. The pregnancy is that of the woman, with all the symptoms of pregnancy. The woman, and later the man, can feel the baby move as the pregnancy progresses, allowing bonding to occur. The woman can labor, deliver and nurse. Finally, you as the couple, control the intrauterine environment for nine months by keeping out toxins like alcohol, drugs, and smoke; getting good prenatal care; taking vitamins and eating well. Thus, you can start providing for the child from the moment of conception. Egg donation is not for all couples. Counseling is always advised, and only an infertility specialist has an egg donation program to offer.
Q: How long should I be on any infertility treatment plan, whether it be timed intercourse, Clomid/Serophene ovulation induction, hMG ovulation induction or IVF?
A: All infertility treatment plans should have a finite beginning and ending. Depending on the age of the woman, most medical treatments will be successful within the first three to four attempts. After that, the chances for success go down significantly for each additional attempt. The place one starts in their infertility treatment and the rate that they progress through subsequent cycles, depends on the woman's age and what is learned from the current treatment cycles.
Q: What are the risks of multiple births while taking infertility medications?
A: When used by infertility experts with careful monitoring of their patients, multiple births with Clomid/Serophene should be 6 to 8 percent, with hMG 15 to 20 percent, and with IVF 15 to 25 percent. High multiples are always undesirable, and careful monitoring of the woman's response to medications will minimize this risk. With IVF, the risk increases with the number of embryos transferred, the quality of the IVF lab, and the use of assisted hatching. With the use of blastocyst transfer, however, the risks for multiples from IVF has sharply reduced.
Q: Does your center have counseling and support groups available?
A: Because infertility can be one of the most emotional crises a couple may face, comprehensive psychological and emotional services are available through our center.
Q: What is assisted hatching and how do I know if I need it?
A: Assisted hatching, also known as assisted zona hatching (AZH), is a technique that involves creating a small hole in the shell (zona) of the embryo prior to embryo transfer. The outer covering of the embryo, called the zona pellucida, is a clear shell that protects the embryo during early development, but in order for the embryo to attach to the uterus, the embryo must "hatch" out of the shell. Some studies have shown that the embryos of certain patient groups may benefit from assisted hatching. Our IVF laboratory routinely performs assisted hatching on embryos from couples where the woman is 39 years and older, as well as most embryos after they have undergone a freezing and thawing cycle. For the remainder of patients, embryos are assessed individually, and only embryos that have a thick zona just prior to transfer, or those that are dividing poorly, undergo assisted hatching. While there is still debate over the value of this technique for all patients, we are certain that there are no detrimental effects form the procedure with the exception of a very slight increase in the risk of monozygotic (identical) twins.