Infertility is the inability to conceive after one year of unprotected intercourse. The emotional side-effects of infertility can be devastating. You may find yourself facing anger, blame, self-doubt, frustration, even grief. You may experience guilt and sadness. In addition, those of you who seek medical help must deal with other concerns. How long will treatment last? What will be involved? How difficult will it be? How much will it cost? Most importantly, what are your chances for success? When we uncover what the problem is and suggest what can be done to help, much of this frustration can be relieved.
On average, it takes about 5.3 months to conceive. However, after one year's time about 15% still have trouble conceiving. If you have not conceived after a year of trying, you should see a physician for a complete work-up and treatment. If you are 35 years of age or over you should seek evaluation in 6 months. Most causes of infertility are identifiable and treatable with methods readily available.
It is important to remember that infertility is not simply caused by either the male or the female. Support for both partners is critical to the success of whatever procedure you choose. A low sperm count and poor sperm motility account for about 40% of infertility problems. The other 60% are related to the woman and fall into one or more of the following categories:
Between 20-40% of the female causes are due to adhesions or damage to the fallopian tubes. Previous surgery, endometriosis or past infections often result in adhesions or scarring which can prevent the tubes from picking up an egg.
Between 15-20% have difficulty in ovulation, or monthly production of an egg.
Approximately 10-20% have cervical damage, which results in absent or poor cervical mucus.
Up to 1-5% are due to immunologic factors resulting in the woman making antibodies against her partner's sperm.
About 15-20% result from unexplained infertility. This diagnosis means that medical science does not yet have the means to determine the cause of the inability to conceive.
These percentages total more than 100%. Why?
As many as 35% of all infertile couples have more than one cause for their infertility. Two things that are critical to the evaluation is to complete the entire work-up and not to treat the first thing that is found to be wrong. By doing that, up to 35% of the time you will overlook another problem that will interfere with your treatment being successful. For this reason, choosing a doctor with expertise, experience, and the facilities to complete a thorough work-up and treatment is crucial to your success.
In many cases, insurance companies will reimburse up to 80% of the costs for the initial evaluation of infertility and many will also pay a percentage of the treatment. But for many couples there may be little to no coverage for infertility procedures. Fortunately, much of the infertility evaluation and resulting treatments are not that costly. In fact, other than the more advanced, "high-tech" procedures, there can be much success without unmanageable costs.
At ACFS, we always recommend using progesterone lozenges, not suppositories (messy!) after all IUI procedures and only progesterone injections or Crinone after all IVF and other ART procedures. ACFS did some of the original research and was one of the first IVF clinics in the country to advocate the use of intramuscular progesterone injections after an IVF cycle. Our evidence showed that pregnancy rates were improved and miscarriages rates were decreased. Although the IM injections can be uncomfortable for some women, the resulting trade-offs of higher pregnancy rates and lower rates of miscarriage was worth the occasional discomfort. Although a bit more expensive, Crinone, or a progesterone gel inserted into the vagina, has been shown to be just as effective as the IM progesterone. The choice is the woman's to decide which one she prefers to use.
ACFS feels strongly that the choice of which treatment option should be made by the couple once all the pros and cons of each treatment option has been explained fully and without bias. Once a treatment plan is chosen, although there should be a certain amount of times you should do that treatment to be statistically successful (i.e. IUI), at any time in the treatment, a woman should be allowed to change her mind and elect to move on to a more aggressive approach, like IVF; especially if she understands that she may be premature in that decision and just being a little more patient and giving the procedure one or two more attempts could be successful. This decision to be more aggressive with treatment options should be the choice of the woman and not the clinic.
Recent advances in the laboratory has led to the development of new culture systems capable of growing embryos beyond the Day 3 stage and to the Day 5 or blastocyst stage. This is achieved by using not one, but a sequence of culture media, each designed to meet requirements specific to each preimplantation stage. The availability of a number of successful sequential culture systems has led many programs of assisted reproductive technology to pursue blastocyst production and replacement.
The principal indication for Day 5 or blastocyst transfer is the reduction of ART associated multiple pregnancy. There is also some evidence suggesting slightly better pregnancy rates, since only the “best of the best” embryos make it to the blastocyst stage of development.
Approximately 40% to 60% of fertilized oocytes reach the blastocyst stage using contemporary sequential culture systems, but there are remarkable variations a patient's ability to produce blastocysts. A risk of attempting blastocyst transfer is the possibility that no embryos will be available for replacement.
It is best to check with your individual clinic to assess the availability of and the clinic's experience with blastocyst transfer.
Natural hatching of a blastocyst is a critical component of the physiologic events culminating in implantation. Conversely, the failure to hatch may be one of the many factors limiting human reproductive efficiency. The clinical application of assisted hatching has been proposed as one approach toward the enhancement of implantation and pregnancy rates following in vitro fertilization.
Success rates following the use of assisted hatching in different ART programs have varied considerably. At ACFS, we have found improved success with AH in a number of clinical circumstances. Well-designed studies suggest that assisted hatching might best be used in patients > 38 years old ,multiple prior failed IVF cycles, elevated FSH levels and transferring of thawed embryos.
ART clinics attempt to individualize each couple's treatment plan to the couple's particular problem, preferences, and resources. Because of some uncertainties about the 'best' approaches in many cases, the range of treatment philosophies among clinics, and the vagaries of insurance coverage, it not surprising that what seem to be similar situations may be treated differently in various clinics. In order to help decide on the most appropriate treatments, clinics perform certain tests, and establish certain criteria for the test results, by which treatment decisions are guided. For instance, many clinics have established limits which, if exceeded, will preclude certain therapies because the expected success rate in those circumstances is so low. Currently, common examples of these limits include women over age 43, or those with elevated FSH levels, who may not be permitted to undergo routine IVF in some clinics, but are permitted IVF in others so long as the couple is informed of the low chance for pregnancy. At ACFS, we feel strongly that all patients should be allowed to attempt pregnancy regardless of age or FSH levels as long as they have been well counseled on success rates and other options. Statistically, since these patients can be successful in achieving pregnancy, we continue to support and encourage this philosophy. Many clinics recommend stopping IVF if a certain number of prior IVF attempts have failed. All of these policies are designed to provide the best match of available treatments to the particular patient situation.
The objective of infertility treatment should be the birth of a single, healthy child. Many of the treatment options presented to infertile couples, however, are associated with high risks of multiple gestation. Moreover, many couples view multiple gestation as desirable and are unaware of the risks they pose to both the mother and babies. Couples should understand these potential risks before starting treatment.
The ability to limit the number of embryos or eggs transferred is an effective approach to limit multiple pregnancies. The Society for Assisted Reproductive Technology (SART) and the American Society for Reproductive Medicine (ASRM) have published guidelines recommending an optimal number of embryos for transfer based on patient age, embryo quality, and other criteria.
In the United States, the decision regarding the number of embryos to transfer is made jointly by the physician and the patients. This decision should be based upon the best interests of the patient and the future offspring. However, ART is centrally regulated in England, and no more than one embryo may be transferred in most circumstances. In Canada, a recent Royal Commission recommended the transfer of a maximum of three embryos.
The ultimate goal is to achieve a high pregnancy rate while transferring a single embryo. Recent laboratory improvements have allowed programs to transfer two embryos while maintaining acceptable pregnancy rates. Eventually, the transfer of one embryo will resolve the issues surrounding multiple pregnancies.
Some clinics see more than the average number of patients with difficult infertility problems. Some clinics are willing to offer ART to most potential users, even those who have a low probability of success. Others discourage such patients or encourage them to use donor eggs, a practice that results in higher success rates among older women. ACFS does not adopt this practice and feels that every patient should be given the choice as how to proceed. Clinics that accept a higher percentage of women who previously have had multiple unsuccessful ART cycles will generally have lower success rates than clinics that do not. In contrast, clinics that offer ART procedures to patients who might have become pregnant with less technologically advanced treatment will have higher success rates than clinics that do not.
The Society for Assisted Reproductive Technology (SART) is the professional society for doctors and laboratory scientists who work together as a team to provide in-vitro fertilization services. It is an affiliated society to the American Society for Reproductive Medicine (ASRM). SART is the place for these professionals to share information and experiences. Many SART members meet on a regular basis at the annual ASRM meeting.
SART is setting the standards for the practice of IVF and provides its members with many guidelines for the continuing improvement of the practice of IVF. Guidelines for ovarian stimulation, numbers of embryos to transfer and the appropriate use of donor gametes are examples of a few of such guidelines. In addition, guidelines regarding ethical considerations, laboratory practice and proper advertising are also published. SART members are obligated to abide by these guidelines.
SART has rigorous requirements for membership. SART members must agree to:
Patients seeking IVF services can be reassured that a SART member has satisfied these rigorous requirements. ACFS is a CAP certified embryology laboratory and has been a member of SART and CAP for many years with no deficiencies.
Federal Law requires the publication of assisted reproductive outcomes from all clinics providing such procedures in the United States. Validation is the process whereby, through random sampling, the veracity of the entire database to be published is established. This process is performed by the Validation Committee in conjunction with the CDC. The Validation Committee is composed of fourteen professionals from both SART and non-SART member programs. ACFS has been a member of SART almost since its inception and early on had a site visit with no deficiencies. Sites to be visited (currently forty) are randomly selected by the CDC, with site visits performed by teams of two Validation Committee members. Currently, about twenty variables are validated from 50 randomly selected cycles. Additionally, all live births reported by the clinic are validated. The data collected from site visits are compiled, and reviewed jointly by the CDC and the Validation Committee. Programs are notified regarding the overall outcome of validation and their specific program results.
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