Infertility is no small matter in terms of the number of people affected, the complexity of the problem or the emotional toll it takes. In the United States, about 10 percent of women of childbearing age — that’s 6.1 million women — are coping with the physical and psychological pains associated with infertility.
While the medical literature uses terms like “impaired fecundity” — most simply stated, infertility means that a woman has not been able to get pregnant after one year of trying, or six months if she is over the age of 35. Infertility can also apply to women who can get pregnant but are unable to carry the baby to full term.
About one-third of the cases are caused by factors that affect the woman, one-third by factors that affect the man. For the remaining third, the cause may be a combination of problems in both partners or it may be unknown. For many couples, not knowing is the hardest part.
Childbirth truly is miraculous when you consider the intricacy of the process and all the things that could go wrong. To have a baby:
- A woman must ovulate — release an egg from the ovaries
- The egg must travel through the fallopian tubes
- Along the way, the egg must be fertilized by a man’s sperm
- The fertilized egg must then attach — or implant — in the uterus
- The hormonal and nutritional environment must be able to support the pregnancy to full term
Infertility can happen if a problem occurs during any of these vital steps.
Seeking the Cause
There are various reasons that couples experience infertility. Here are some of the most common causes:
- Problem with ovulation, like polycystic ovary syndrome (PCOS). PCOS is a hormonal imbalance that interferes with normal ovulation. The ovaries may be enlarged with many small cysts — or fluid-filled sacs with microscopic eggs called follicles — that are visible on ultrasound. Women with PCOS may have irregular, infrequent menstrual cycles, excessive hair growth or acne.
- Obesity is an additional problem found in about 50 percent of women with PCOS. But, on a positive note, diet and exercise that result in weight loss are likely to improve the frequency of ovulation and enhance a woman’s ability to get pregnant.
- Blocked fallopian tubes, which may be due to pelvic inflammatory disease, endometriosis or surgery, affect the ability to be pregnant. Physical problems with the structure of the uterus and uterine fibroids are associated with infertility and repeated miscarriages.
- Male infertility may result from the absence of sperm, a low sperm count, or abnormal shape or poor movement of the sperm (motility). The shape of the sperm or morphology can affect the ability of the sperm to fertilize the egg. Physical injury, infection or other damage to the reproductive system may block the sperm. In rare cases infertility in men is due to a genetic disease such as cystic fibrosis.
Societal changes have affected fertility rates in our country as more women choose to wait until their late 30s or 40s before starting a family. In fact, roughly 20 percent of women in the United States now have their first child after age 35. Age contributes to infertility in women in a variety of ways. Older women have fewer eggs, their eggs are poorer quality and ovaries sometimes develop ovulation dysfunction.
Adding insult to injury, women over the age of 35 are also more likely to have miscarriages. With all these factors combined, about oone-thirdof couples in which the woman is age 35 or older have fertility problems.
New Options, New Hope
Medical science is no less amazing than the wonder of childbirth. The advances in reproductive medicine in the past 30 years are astounding, bringing new hope to couples who are struggling to get pregnant.
- Depending on the causes of infertility, a wide range of medications may be used to help infertile couples. Ovulation disorders are one of the easier problems to treat with medication.
- In some cases, when a structural problem exists, surgery can increase the chances of natural conception. Men may have a vasectomy reversed. Women may benefit from laparoscopic surgery for endometriosis, a myomectomy for uterine fibroids or surgery to repair the fallopian tubes.
- Most fertility cases — 85 to 90 percent — are treated with medication or surgery, but sometimes other intervention is needed. One example is intrauterine insemination (IUI) — often called artificial insemination. IUI is a procedure in which sperm are processed in the laboratory, washed, concentrated and placed in a special culture fluid, and then introduced into the female partner’s uterus to facilitate fertilization.
- Assisted reproductive technology (ART) refers to a whole class of fertility treatments that involves removing the eggs from a woman’s body, mixing them with sperm to create an embryo and then transferring the embryo back into the woman’s body. Sometimes assistive reproductive technology procedures rely upon eggs, sperm or embryos that were donated by others — allowing a woman to experience pregnancy and birth, even though the baby may not be her biological child.
- Women with ovaries but no uterus, or those who should not become pregnant due to health issues, may be able to use a surrogate or gestational carrier. Here, the mother’s egg is fertilized by the father’s sperm and embryo is placed in the gestational carrier’s uterus. The mother and father are the legal parents after birth.
Beyond the Physical
Infertility can cause a world of hurt that goes far beyond physical pain. The dream of the perfect family is on hold. The chance to carry on a name and legacy is in jeopardy. For many, the sense of loss is palpable. Patients may find comfort in joining an infertility support group.
The overwhelming emotions resulting from infertility are compounded even further by the financial pressures. Even with health insurance, the out-of-pocket expenses associated with infertility can be astounding. Some policies will cover the diagnostic workup; most do not cover the actual treatments. The bills can reach tens of thousands of dollars — beyond the reach of many couples who wish to expand their families. Some fertility clinics now offer financing options that include a money-back guarantee if a successful pregnancy is not achieved.
What Does the Future Hold?
The last three decades have led to exciting advances in reproductive medicine, but the future holds even more promise for effective new fertility treatments.
As more and more women opt to delay childbearing, egg freezing may offer a solution to the rapid decline in fertility women experience after the age of 35. A woman can have her eggs frozen at age 30 and saved for the future. Then, if she wants to start a family at age 42, she can have her frozen eggs fertilized and the embryos transferred back into her body at a time when she would have been likely to run out of fertile eggs. As far as her fertility is concerned, she will only be 30 years old.
The article is written by:
Scott Lucidi, MD, FACOG, is a reproductive endocrinology and infertility specialist at VCU Health. Reproductive medicine services are offered by the VCU Health Stony Point Campus.
Learn more at www.vcuhealthreproductivemedicine.com
Stephanie and Amir’s Story
As emergency physicians in the trauma center at VCU Health, both Stephanie and Amir Louka are accustomed to making life and death decisions in a matter of seconds. But after more than a year of unsuccessfully trying to get pregnant, they turned to another specialized area of medicine for help — reproductive medicine.
“After completing all the tests, we discovered that, like many couples, our infertility was ‘unexplained.’ There was no simple, clear-cut reason why we were not getting pregnant,” says Stephanie. But that didn’t stop Dr. Lucidi, VCU Health reproductive endocrinologist and fertility specialist, from recommending a course of action to give the Stephanie and Amir the family that they craved. “In fact, Dr. Lucidi suggested we move forward quickly, especially if we wanted to have more than one child. First, I completed medical school, then a rigorous residency program. I didn’t even consider having a baby until I was 37. Our plan called for retrieving eggs and attempting to get pregnant now, and then freezing any additional eggs, in the event we wanted to try to have another baby in a year or two.”
Things started off perfectly. Following two weeks of injections, followed by hormonal medication, Stephanie had more than 20 eggs retrieved, resulting in nine healthy, fertilized eggs, called zygotes. The couple took a chance and had only one egg transferred, and fortunately, Stephanie got pregnant with the first attempt.
Stephanie’s pregnancy progressed uneventfully, until her 32nd week, when the plan went haywire. She was diagnosed with HELLP syndrome — a life-threatening pregnancy complication that is a variant of preeclampsia. In order to protect both mother and baby, Stephanie had to be induced immediately, and on February 12, 2017, the Loukas welcomed Evelyn — or “Evie”— to their family.
Evie spent 34 days in the NICU at Children’s Hospital of Richmond at VCU. And at four months of age, she returned to CHoR for treatment of hydrocephalus — an accumulation of cerebrospinal fluid within the brain. A small shunt was implanted in Evie’s brain to drain excess fluid. Now, Evie is growing and thriving, hitting every developmental milestone.
“We’re so glad that we selected VCU Health for our fertility treatment,” says Stephanie. “They have everything we needed, including the extra care that Evie required. And we loved the way they included my husband in the process. In fact, he got to have the first peek at Evie when she was just an embryo.”
Now, Stephanie and Amir can relax and enjoy their new baby. And in a year or two, when they are ready, they will be all set to try again for another miracle — thanks to the advanced science of VCU Health’s reproductive medicine.