Pursuing Fertility: Options for Achieving Pregnancy

Having children is something many of us see as a natural part of our lives. For one in eight couples, primary infertility will become a roadblock to this goal; and some couples will discover, after having one child, they face secondary infertility.

There are also many women who want children in their lives, but wait until later in life –and the biological clock is beginning to sound off in the background.

Everyday, technology is making progress with ways to overcome infertility and preserve a woman’s ability to have a biological child later in life.

Discovering the path to parenthood can be a long journey that will wind through new technology designed to assist in the baby pursuit.

Maximize fertility
For most couples, infertility will not be diagnosed until after they have tried for at least a year to achieve a pregnancy. Women older than 35, however, should consider taking the next step if conception has not occurred within 6 months.
Sometimes it can be a simple matter of the “timing” being off. There are many over-the-counter products to use when trying to determine when ovulation will happen. These products test for specific hormones indicating ovulation is about to occur and can be very accurate. If, though, after a year conception has not occurred or there have been multiple miscarriages, it may be time to seek a professional’s help.

In the book “The Baby Solution,” Dr. Daniel Kenigsberg (with Lauren Hartmean) suggests starting treatment with a gynecologist can be a good initial step. He wrote, “There are some instances when you may want to start care with your ob-gyn, particularly if you are under 37, your insurance does not cover reproductive endocrinologist visits, or there is no reproductive endocrinologist in your area.”

A board-certified ob-gyn is a doctor who has completed four years of college as well as medical school. In addition they have taken a four-year residency in ob/gyn, and then passed their written and oral exams. While infertility is not their speciality, the subject is covered during their training. After Shelly had a miscarriage, her gynecologist suggested running some tests to see if there was a hormone imbalance to possibly cause the miscarriage. Shelly felt comfortable with her doctor and said, “I already had a working relationship with this doctor and had confidence in his abilities.”

Board-certified reproductive endocrinologists are doctors who have not only completed the training to become an ob-gyn, but they complete an additional two to three year fellowship in reproductive endocrinology, pass a written test, then do a two year practice, and then pass a three hour oral exam. Doctors who choose not to do the oral exam are considered board eligible in reproductive endocrinology. Martha and her husband saw a gynecologist for a year, and then began researching their options. “We liked our gynecologist,” Martha said, “but, we still weren’t pregnant and felt it was time to move on. We decided that we wanted to see someone who specialized in infertility.”

Fertility clinics are another option; you’ll find both gynecologists and/or reproductive endocrinologists. These clinics generally have a lab to run tests and most procedures can be done at the clinic. Karen and her husband decided to go to a fertility clinic: “At the fertility clinic we could get all of the treatment options in one place. The whole focus is on obtaining a pregnancy. We felt this was where we would have the best chance to get pregnant,” Karen said.

Specialists for men
Men need to be checked out, too. Most men will initially see a urologist. If there seems to be a problem, a urologist with a sub-specialty of andrology will be consulted as a specialist in the field of male infertility.

Initial female work-up
The first step in trying to discover why conception has not occurred is to see how the entire cycle is working. Tests are done to evaluate the woman’s ovulation cycle including taking a medical history, a physical exam and blood tests. A test to determine a woman’s level of fertility will also be done.

This blood test involves looking at FSH and estradiol levels on the third day of the menstrual cycle. Tests will also be conducted to see how the uterus is responding to hormones and preparing for possible conception. This second half of the cycle is referred to as the luteal phase, and a progesterone blood test will be conducted, along with an endometrial biopsy, which involves taking a sample of the uterine lining. These tests will show if the uterus is ready for conception.

There will be more invasive tests to determine if there are any abnormalities within the female reproductive organs.

These can be caused by endometriosis, scar tissue or fibroids.

These tests include:

  • A hysterosalpingogram. This is a test where dye is run through the uterus and fallopian tubes and then x-rays are done. The doctor reads the x-rays looking for any abnormalities that may be causing trouble in conceiving.
  • A hysteroscope. This test is conducted by inserting a small tube with a telescope through the cervix and into the uterus. It is used to look for any abnormalities, including fibroids, endometriosis and scar tissue.
  • A laparoscopy. This is sometimes combined with a hysteroscope, and it is considered surgery. A telescopic lens is inserted into tiny incisions in the abdomen. It is done to look for physical problems impeding conception.

Before having surgery or even beginning the testing, it may be a good idea to educate yourself in regards to what will happen. Resolve, a national nonprofit organization committed to helping people who are dealing with infertility, has chapters across the country and their Web site contains many educational tools to assist couples facing the infertility challenge.

Initial infertility treatment
If there are no issues with blocked fallopian tubes, the use of fertility drugs may be recommended to induce ovulation. This may be done in conjunction with inter-uterine inseminations to maximize conception possibility. Shelly discovered she had a luteal phase problem and a fertility drug was recommended to help her overall ovulation. “I was able to get pregnant the second month on the medication,” — and had a healthy baby girl.”

Advanced reproductive techniques
When the initial use of fertility drugs and inseminations hasn’t worked, the next step is a group of advanced techniques for conception. These include in vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT) and intra-cytoplasmic sperm injection (ICSI).

These technologies also use fertility drugs to stimulate the ovaries to produce many follicles, which contain eggs. Dr. Kenigsberg explains the retrieval process this way, “Under sterile conditions, a needle will be put through your vaginal wall into your ovary to aspirate (draw up) follicular fluid. The follicular fluid will be removed and inspected under a microscope to identify the oocytes (eggs).”

With IVF, the eggs will be placed in a petri dish and sperm will be introduced for conception to occur. With ICSI, the sperm will be injected into the egg. This can assist in conception when a man has a low sperm count or problems with sperm mobility. The fertilized eggs are incubated for several more days, and then transferred into the women’s uterus by using a catheter. In GIFT, the eggs and sperm are placed together in the fallopian tubes, where fertilization can then take place. In order to return the eggs and sperm to the fallopian tubes, a laparoscopy needs to be performed.

During this process, some people discover a problem with the quality of eggs, sperm or even the embryos. With today’s technology this can be overcome by using donor eggs, sperm and embryos. Surrogacy is also another option if a woman is unable to carry a baby. In addition, during these advanced procedures, there are often more embryos created than can be transferred. The remaining embryos can be “frozen” and transferred in subsequent procedures.

Karen was thrilled to know if the initial procedure did not work, they would then be able to do another cycle with the frozen embryos. “We felt it gave us more of an opportunity to achieve a pregnancy. We were lucky that we got pregnant during our first procedure. Two years later we used our frozen embryos and got pregnant again.”

These procedures are costly, and many insurance companies won’t pay for them. Some couples decide in advance how many of these treatments they can afford before they begin treatment.

Martha and her husband decided three IVF treatments were the maximum they could emotionally and financially afford. “We knew that after 3 tries we needed to close this chapter and move forward to other options,” Martha said.

Options to preserve fertility
For women seeking ways to keep the door open to having a biological child later in life, technology is coming up to speed. One option is to “freeze” embryos. Women looking at this option, will go through the process of IVF and use a sperm donor. The embryos can then be “frozen” and transferred back to the woman when she is ready for motherhood.
Women now have the option to “freeze” their eggs. With this choice, the women will use fertility drugs to stimulate the follicles and produce multiple eggs. The eggs will be removed, like in IVF, but, instead of creating embryos, the eggs will be “frozen.” This procedure allows the woman to delay pregnancy and the choice of a sperm donor to a later point in their lives.

Either choice allows a woman to preserve the ability to have a biological at a later time in their lives. There are women now having children when they are in their fifties by using donor eggs.

Adoption is another path to parenthood, and for many this is the right choice. Martha and her husband adopted; “We have two wonderful children, and know this was how it was meant to be for us,” she said.

Technology is moving fast, affording infertile couples more choices with which to create their families.


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