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High-profile celebrities such as Mariah Carey, Sarah Jessica Parker, Courtney Cox, Nicole Kidman and Brooke Shields have been outspoken about their struggles to conceive as well as fertility options they have pursued including in vitro fertilization and surrogacy. As much as infertility seems to be misunderstood by the general public, the media often portrays it in a sensationalized light, only feeding that larger cultural misunderstanding about infertility. With all the swell of media attention on baby bumps and just how those bumps came to be, we’re operating in a new age of public discourse about infertility, privacy and simply reporting the facts correctly.
“Infertility is a complex and often misunderstood condition, which is why there's so much confusion surrounding it,” says Dr. Carl Herbert, Board Certified by The American Board of Obstetrics and Gynecology in both Obstetrics and Gynecology and in Reproductive Endocrinology and Infertility; and president of the Pacific Fertility Center in San Francisco, a leading international center for infertility treatments. “Although infertility is often considered a taboo topic, the truth is that millions of couples grapple with this issue. The pathway to parenthood is not always smooth.”
According to the Centers for Disease Control and Prevention, about 10 % of women (6.1 million) in the United States ages 15–44 years have difficulty getting pregnant or staying pregnant. Although many people still think of infertility as a “woman's problem,” in about 40% of infertile couples, the man is the sole cause or a contributing cause of the inability to conceive.
“Annually, nearly five million American couples experience infertility,” says Dr. Herbert. “Infertility is defined as the inability to conceive after 12-months of active attempts for women under age 35, but in just 6-months for women over age 35.Just over one million couples seek medical advice regarding infertility on a yearly basis. At Pacific Fertility Center, our mission is to promote reproductive health and to ensure equal access to all family building options for men and women experiencing infertility or other reproductive disorders. We are helping to improve the lives of women and men living with infertility.”
What Couples Should Do Before Getting Pregnant
While most women are concerned about what happens after they conceive, doctors say more should be thinking about what to do before they even try. “We've attempted to get the message out there, but I don't think enough women and men take advantage of the fact that there are things you can do prior to conception to not only ensure a woman’s own health during pregnancy, but also that of their baby,” observes Dr. Herbert.
No Drinking and Smoking. We all know women should not drink and smoke during pregnancy as it can cause serious harm to their baby – ranging from heart problems to mental defects. But it’s a good idea to cut back while you’re trying to conceive. Men should also scale back since excessive drinking and smoking can lower sperm count.
Make an Appointment with Your Dentist. Poor dental hygiene increases the risk of bacterial infection, which is associated with premature birth and preeclampsia. So get a dental checkup and make sure your mouth is healthy before you conceive.
Folic Acid. Over and over again, women are told to take folic acid to help prevent birth defects, but did you know that you should start taking folic acid as soon as you start thinking about getting pregnant? In addition to reducing the risk of serious birth defects like spina bifida, folic acid has been shown to improve fertility. But it’s not just women who need to up their intake; men also need folic acid to maintain the quality and number of their sperm. Dark green leafy vegetables, like spinach and broccoli, are a great source of folic acid.
Vitamin D. Low vitamin D levels have been linked to pregnancy complications, congenital rickets, as well as poor outcomes in assisted reproduction. Insufficient vitamin D levels are found in 40-50% of healthy pregnant women. Pacific Fertility Center conducted a Vitamin D Study in 2011, evaluating vitamin D deficiency in infertility patients and found a similar rate of deficiency. This study received the award for best research by a practicing physician at the 2012 Pacific Coast Reproductive Society Annual Meeting.
Here are some more facts from the National Women's Health Resource Center (NWHRC):
· Women are most fertile during ovulation, which occurs around the 14th day of their menstrual cycle, if they have a 28-day menstrual cycle. However, the exact time of ovulation varies among women due to normal differences in cycle length.
· After ovulation occurs, an egg remains viable for about 24 hours. Sperm, on the other hand, can live in a woman's reproductive tract up to 72 hours.
· When no fertility problems are present, the average couple, with a female partner between ages 29 and 33, has about a 20 to 25 percent chance of becoming pregnant during any given cycle of exposure.
Delaying Motherhood: 40 is the New 20
Women are delaying having children until they are in their mid-30s or later. Many are disregarding their biological clocks to establish careers, build financial nest eggs, and travel the world. Others delay having children until they find the right partner or “retire” into parenthood. And some older moms conceive unexpectedly even after years of unsuccessful attempts.
“The challenge for this age group is as a woman’s body undergoes a natural aging process, her eggs age as well; and this phenomenon can lead to significant infertility and high miscarriage rates,” says Dr. Herbert. “Getting pregnant and staying pregnant after age 40 is a challenge for women that may have no other impediment to conception.”
The decline in fertility potential or ‘ovarian reserve’ means that not only do the ovaries have fewer eggs to offer, but the eggs they have are of poorer quality, and thus are less capable of being fertilized and less likely to result in a healthy pregnancy. “All women are born with a certain number of eggs, which are gradually lost over their reproductive life span,” explains Dr. Herbert. “At some point— about 10 years before the onset of menopause— the number and quality drop to a level where your fertility is seriously compromised.”
Infertility Diagnosis
Fertility diagnosis starts with a search for major fertility factors for the male and female partners using systematic individualized testing. In addition to infertility diagnoses, there are multiple risk factors that can adversely affect a woman’s or man’s fertility, like inadequate or excessive weight, smoking, or alcohol abuse. Identification of these factors with appropriate intervention is important. Fertility diagnosis starts by attempting to determine the impact of several major factors for the male and female partners with testing and diagnosis.
Female Fertility Diagnosis and Testing
Age. The impact of aging on female reproduction is well known. Overall, a woman’s age is one of the best predictors of whether or not she will conceive with her own eggs. After about age 35, when declines in natural fertility become sharper, many women are simply experiencing what we call age-related sub-fertility. That is, there is no specific fertility problem other than as a woman gets older, the eggs she ovulates may be less capable of creating and sustaining a pregnancy.
After about age 43, the odds of success fall low enough (as miscarriage and chromosome abnormality rates rise high enough) that the best option becomes substitution of a younger woman’s egg, a process known as egg donation.
Ovulation. Without ovulation, there is no conception. Regular monthly menstrual cycles indicate regular ovulation. Polycystic ovarian syndrome, hypothalamic anovulation, luteal phase insufficiency and problems with other hormones such as thyroid hormone or prolactin may interfere with ovulation. However, young women who do not ovulate regularly can usually be induced to ovulate with either oral or injectable fertility medications.
Although most women will ovulate well into their 40s and even 50s, it is the quality of the eggs being ovulated that is critical.
Ovarian Reserve. This is the term used to help describe a woman’s reproductive potential and helps estimate the chances that a woman will be able to conceive a healthy, viable pregnancy with her own eggs. We test for ovarian reserve with blood tests as well as an ultrasound of the ovaries to obtain an antral follicle count.
Tubal Status. Infection, post-surgical scarring or endometriosis can cause fallopian tubes to be blocked, kinked or distorted. This prevents eggs and sperm from getting together, therefore blocking fertility. Internal tubal damage can increase the risk of tubal (ectopic) pregnancy. The dye test HSG (hysterosalpingogram) is the only accurate non-surgical way to evaluate the patency and condition of the fallopian tubes – that is to determine whether or not the tubes are open and healthy.
Uterus and Endometrial Lining. Fibroids, polyps, and intra-uterine scarring from prior surgery are some of the things that can cause the uterus and it’s lining to be abnormal and to cause an embryo to fail to implant. Pelvic ultrasonography, performed just prior to ovulation, is often sufficient to diagnose any these problems. However, if the ultrasound is not perfectly clear, sono-hysterogram (ultrasound done while putting sterile saline fluid into the uterus) or hysteroscopy (surgery to look inside the uterus) can be performed. Many of these problems are surgically correctable.
Genetic. Some patients carry genetic diseases that can cause infertility, such as Fragile X syndrome. Some women (and men) have rearrangements of their chromosomes such that their eggs and sperm have abnormal chromosomes creating chromosomally abnormal embryos which can lead to repeated miscarriage or infertility. These problems are rare but do exist.
Endometriosis. This is a disease of the female reproductive years, which is strongly associated with infertility. Surgery (laparoscopy) is the only way to make a definitive diagnosis. However, surgical intervention is only minimally helpful in improving the odds of conception even if endometriosis is found and treated during the operation. This is because the disease can be multifocal with many affected areas and it has a high recurrence rate. For this reason, it is no longer common to perform surgery just to go looking for endometriosis. As a result, some women who are carrying the diagnosis of “unexplained infertility” may actually have endometriosis but it does not change the treatment plan for them.
Male Fertility Diagnosis and Testing
Sperm Count. The basic semen analysis, which is collected after 2-5 days of abstinence and examined microscopically, is one of the mainstays of making a diagnosis. A semen analysis should be done even when there is a female factor identified as male factor will contribute to infertility in as many as 40% of couples.
Sperm Function. The ability of a sperm to penetrate a human egg is an important aspect of fertility. Low sperm counts and low motility on the semen analysis can often predict whether the sperm that are present are sufficient in numbers and activity to reach the eggs, and then bind to and penetrate them. When a semen analysis identifies a low sperm count with low motility, these sperm may not be able to reach the egg or fail to bind or penetrate the egg. Assessments such as sperm survival tests or detailed sperm morphology may help in predicting fertilization but IVF is the only definitive way to prove that sperm are functioning properly. In rare cases, some men with a completely normal semen analysis may be found to have sperm that cannot bind nor penetrate into human eggs.
Sperm DNA Integrity. There has been recent interest in evaluating patients with unexplained infertility, repeated reproductive failure and recurrent miscarriage by evaluating the male partner’s sperm for DNA fragmentation. This test is still being evaluated clinically but may indicate in some cases whether the sperm, rather than the egg is creating the fertility problem.
Age. Some studies have suggested that advanced male age (usually over age 50) may lead to increased infertility and increased rates of miscarriage. The data in the literature on this is mixed: some studies showing paternal age to have an effect and some not finding it to be very predictive. If there is an effect of paternal age, it appears to be small.
Genetic. Men with Klinefelter’s syndrome (47 XXY chromosome makeup instead of 46XY), men with deletions of parts of the Y chromosome, men with balanced translocations, and a few other rarer genetic abnormalities are likely to experience infertility and/or recurrent miscarriages with their female partners.
Infertility Treatment & Care
What is in vitro fertilization (IVF)?
IVF literally it means "fertilization in glass,” because the woman’s eggs were originally fertilized with sperm in a glass Petri dish. During the IVF process, a patient’s ovaries are carefully stimulated with fertility medications to produce not one but a number of useable eggs. When mature, the eggs are retrieved from the ovaries using light anesthesia and an ultrasound-guided needle aspiration. On that same day, the male supplies a sperm sample or a stored, frozen sample is used. The eggs and sperm are placed in a Petri dish to allow fertilization and early embryo growth. At the proper time, one or more of the resulting embryos are transferred into the woman’s uterus.
When is IVF recommended? IVF is considered one of the most efficient forms of fertility treatment, in that it provides the highest rates of successful conception for any one-treatment cycle. For patients with severe male factor or blocked fallopian tubes, it may be the only realistic treatment option. However, it is also recommended for age related infertility or in unexplained infertility when other treatments have been unsuccessful.
Fertility Preservation/Egg Freezing/Embryo Freezing
Women who wish to delay childbearing now have the option of freezing their own eggs so that these may be fertilized and the resulting embryos transferred at a later date. This significant step forward in fertility management enables a woman to take advantage of her reproductive potential at a time when the eggs are at their healthiest.
A woman has on average about 1,000,000 eggs at birth, and this supply inevitably and consistently diminishes right from the day she is born. This decline is part of the natural aging process, and is commonly referred to as a woman’s biological clock. The loss of oocytes from the ovaries is relentless and continues even in the absence of menstrual cycles, and even when a woman is pregnant, nursing or taking oral contraceptives. The constant diminishment in egg numbers among women through their 30s and 40s generally means they have fewer good eggs available to attempt successful conception and many women lose their natural ability to have children by their mid-40s. As important, egg quality also diminishes with time; miscarriages and chromosome defects becoming more common; in pregnancies conceived at a later age.
For younger women who know in advance that they may want to extend their fertility potential, egg freezing (also called fertility preservation) provides the ability to preserve a woman’s own genetic material when young, for use later, when she is ready to pursue parenthood. Egg freezing is a risk reduction strategy that provides a way to reduce the risk of age-related infertility.
Embryo freezing is also a viable and attractive option for many older would-be parents. A woman wishing to use her own eggs can harvest them through IVF and then fertilize them with her partner’s sperm or use anonymous donor sperm. The resulting embryos would then be frozen, stored, and eventually transferred at the appropriate time.
Comprehensive Chromosome Screening (CCS)
Comprehensive Chromosome Screening is a treatment for women who wish to improve implantation rates, reduce miscarriage rates, and reduce the risk of multiples after IVF by transferring fewer embryos. CCS is a technique that allows selection of the healthiest embryo from a group, which has been proven to have normal chromosome numbers. After in vitro fertilization and growth to the blastocyst stage of development, a few cells are removed from each embryo and sent to the genetics lab where chromosomes are counted. The embryos with a normal number of chromosomes are selected for future transfers.
Embryo selection by conventional imaging techniques assessing embryo morphology, is not very accurate. Early development is to some extent independent of the number of chromosomes in the embryo, so an embryo with an abnormal number of chromosomes can look just like a chromosomally normal embryo. To compensate for this lack of accuracy, IVF programs may transfer several embryos, risking a multiple gestation pregnancy. CCS refines embryo selection, offering a means of choosing the best embryo, the one most likely to succeed out of the group and avoid the risk of multiple gestation.
About Pacific Fertility Center
With its extensive array of services, from intrauterine insemination (IUI) and in vitro fertilization (IVF) to cutting edge technology such as cryopreservation of a woman’s eggs (egg freezing) and genetic testing of embryos, Pacific Fertility Center provides state-of-the-art infertility treatment and care to patients. Located in San Francisco, Pacific Fertility Center consists of a unified team of devoted physicians providing patients with individualized fertility care. The team of physicians is recognized nationally and internationally for their extensive clinical experience, outstanding academic credentials and research contributions, as well as for their success in treating the most challenging fertility cases. At Pacific Fertility Center, infertility is seen as a workable challenge. Each Pacific Fertility Center Partner physician is a Certified Subspecialist in Reproductive Endocrinology and Infertility (REI) with the American Board of Obstetrics and Gynecology and plays an integral role in assisting individual patients through the entire treatment cycle. Pacific Fertility Center physicians have held faculty positions at leading research universities. Each physician has actively participated in clinical research to advance the safety, success and affordability of infertility treatments. As a group, Pacific Fertility Center physicians have performed IVF procedures longer than any other program in the San Francisco Bay Area. Alongside its team of experts and stellar patient care, Pacific Fertility Center's state-of-the-art lab facility has repeatedly received the coveted "perfect score" certification from the College of American Pathologists-American Society for Reproductive Medicine. www.PacificFertilityCenter.com
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