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Fertility treatment is by no means a one-size-fits-all field of medicine. The types of treatment that can help you or your partner grow your family depends upon your diagnosis and your unique physical and emotional needs. Your fertility journey begins with diagnostic testing and evaluation, which provide insight into any physiological issues that may be hindering you or your partner from becoming pregnant. Fertility testing is needed for both male and female patients.
Your fertility journey may include a combination of surgical treatment, prescription medications, or fertilization procedures such as intrauterine insemination (IUI) or in vitro fertilization (IVF). Different treatments vary in complexity and can affect you in different physical and emotional ways. When you select a fertility specialist, also called a reproductive endocrinologist (RE), you trust and begin to understand the causes of your infertility, you can feel confident making choices for your unique needs.
Before you undergo any fertility testing or treatments, you will discuss your personal health history and goals with your fertility specialist, which may determine extra testing you need. Your pre-screening tests check for any viruses or diseases that could cause infertility, as well as any problems with the function of your reproductive organs. There are different standard tests used for male and female patients.
Male Factor Testing
Male factor infertility can occur for several reasons, including:
- Abnormal sperm production
- Inadequate sperm motility or function
- Complications with sperm delivery because of a physical blockage
Male prescreening for infertility includes semen analysis and blood work. Semen analysis will bring to light any problems with sperm count or motility and function, while blood testing will determine if a patient has any viruses or diseases that could be affecting sperm count and quality and overall health, such as HIV, Hepatitis B and C, and syphilis.
Even if a male patient proves to have some hindrances to fertility, it is important that the female counterpart in the couple, if present, undergoes pre-screening as well. In heterosexual couples, infertility is commonly a result of both male and female factors. In fact, one-third of infertility problems are related to a combination of fertility issues in both partners, according to the American Pregnancy Association.
Female Factor Testing
Female factor infertility has many more potential causes than male factor infertility. According to the University of Maryland Medical Center, about 10% of women ages 15 to 44 (about 6.1 million women in the United States) have difficulty getting pregnant or carrying a baby to term. Potential causes can include:
- Ovulation disorders, including Polycystic Ovarian Syndrome (PCOS)
- Uterine or cervical abnormalities
- Fallopian tube damage or blockage
- Ovarian insufficiency
- Premature menopause
- Pelvic adhesions and obstructive scar tissue
- Thyroid issues
- Cancer treatments, including radiation and chemotherapy
- Cushing's disease
- Sickle cell disease
- Kidney disease
- Genetic abnormalities
Female patients struggling with infertility undergo blood work, x-ray and/or ultrasound analysis, hormone testing, and ovulation analysis. As with male factor infertility, female factor infertility can be exacerbated by a patient's lifestyle, as well as environmental factors.
Factors that Contribute to Infertility
Risks factors that commonly contribute to infertility for both male and female patients include:
- Drug use, both prescription and recreational
- Alcohol abuse and tobacco consumption
- Excessive weight gain or loss
- Overexposure to chemicals and toxins in the environment, such as pesticides and radiation
- Overexposure to heat over time
- Too little or too much exercise
- Genetic factors
The University of Rochester Medical Center's online encyclopedia includes a list of risk factors that can contribute to infertility, separated out by men and women's different factors.
Surgical Treatments for Infertility
Surgical infertility treatment can correct physiological complications that are preventing egg or sperm from joining and creating an embryo that successfully implants on a female patient's uterine wall.
Infertility surgery for male patients is most often performed by an andrologist, or a male reproductive health specialist. Your reproductive endocrinologist may refer you to an andrologist if you or your male partner may have a physiological issue contributing to infertility. Andrologists commonly perform these surgeries for male infertility:
- Vasectomy Reversal - Vasectomy reversal is performed in the case that a male patient has undergone vasectomy to prevent sperm from entering semen. Reversal, also called vasovasostomy, is the reconnection of inner and outer layers of the vas, through which sperm travels. This procedure can also correct scar tissue that has developed because of an unsuccessful or poorly done vasectomy.
- Testicular Biopsy - A testicular biopsy takes a cross sample of testicular tissue in which sperm is produced. This allows for more intensive evaluation of the tissues and may provide further insight into infertility.
- Varicocele Repair - Varicoceles, or enlarged veins in the scrotum, can occassionally contribute to infertility by reducing sperm count and motility. An andrologist surgically cuts off blood flow to these veins to reduce them.
- Testicular Sperm Extraction (TESE) - Testicular sperm extraction involves the removal of sperm directly from the testes for the purpose of fertilizing an egg. Rather than for the purpose of correcting the mechanics of the male reproductive organs, TESE extracts sperm directly from the testes. Sperm extracted directly from the testicles is then used in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedures.
Surgical treatment for infertile female patients can address a number of issues, although it is only used in the beginning stages of fertility treatment for a few reasons. Female infertility surgery may include:
- Polyp, Fibroid, or Scar Tissue Excision - Removing excess or abnormal tissues in the uterus or ovaries can improve ovulation and clear the pathway for sperm and egg to join. These excised tissues are always biopsied to check for malignant cancers and other disease. These surgeries are performed by hysteroscopy and/or laparoscopy.
- Endometriosis Surgery - Endometriosis occurs when cells that would normally grow on the inside of the uterus grow on the outside of it. These tissues can lead to scarring (adhesions) that causes pain and can distort the fallopian tubes, which negatively affects fertility. The removal of this scar tissue an uncommon surgery for fertility patients with endometriosis. It is more commonly done to relieve pain.
- Reversal of Tubal Ligation - Tubal ligation, commonly referred to as having one's tubes tied, is a surgery performed to make women sterile by disconnecting the fallopian tubes. Tubal reversal reconnects these tubes to reopen the pathway for sperm and egg to join.
Surgery is more often performed in conjunction with another type of treatment, be it medication, intrauterine insemination, or IVF
Surgery is rarely a single solution to infertility. Surgery is more often performed in conjunction with another type of treatment, be it medication, intrauterine insemination, or IVF. Surgery can remove physical complications that contribute to infertility, while allowing for other treatments to work more effectively.
One of my patients, Kira, had multiple uterine fibroid tumors. She underwent a myomectomy, or surgical removal of these tumors, to clear the pathway to her uterus. In addition to this surgery, she underwent IVF, which could not have worked effectively without her initial surgery.
Fertility medication is primarily used to correct ovulation disorders in female patients. It is used as a first treatment option for many patients, and often after surgical treatments or in conjunction with IUI and IVF treatment.
There is a wide spectrum of fertility medication strengths. Two of the most common mild prescriptions on this spectrum are chlomiphene (Clomid) and letrozole. These medications, which are taken orally, stimulate the process of ovulation. They can be used as a stand alone treatment or to encourage ovulation before IUI.
Two common stronger fertility prescriptions are gonadotropins containing follicle-stimulating hormones (FSHs). Gonadotropins are given by injection at regular intervals. These more intensive medications are more costly and have higher success rates than Clomid and letrozole in stimulating ovulation. These stronger medications are commonly used to stimulate egg production for harvest and use in IVF treatment.
Because IVF fertilizes eggs in a controlled environment, it allows a fertility specialist to control the number of potential embryos a patient will receive. Today, many fertility specialists have stopped using injectable hormones with intercourse or insemination techniques, because there is no way to control the number of eggs that will become fertilized, which can result in multiple pregnancies. In vitro fertilization is a safer and more effective option.
Intrauterine Insemination (IUI)
IUI is the most common treatment used after fertility medication alone has not resulted in pregnancy. IUI is a type of artificial insemination, in which sperm are collected and inserted directly into you or your partner's uterus while she is ovulating.
IUI is the most common treatment used after fertility medication alone has not resulted in pregnancy
Intrauterine insemination can address several issues. In the case that a male patient's sperm are not mobile or are in short supply, IUI can directly place sperm where they can more easily reach a female's egg. After they are collected from semen, sperm cells are concentrated and placed in the female's uterus. Sperm may come from a donor or from a male partner in either a heterosexual or homosexual couple. IUI is successful when the sperm placed in the uterus swim into the fallopian tube and fertilize an egg.
If one IUI treatment fails to result in a pregnancy, it can be repeated several times. Studies show that generally, if IUI is to prove successful, it will work within three or four rounds of treatment. When IUI has been unsuccessful after several treatments in a row, IVF is the commonly the next step in treatment. Only you and your fertility specialist can ultimately determine when you are ready to begin a new type of treatment.
In Vitro Fertilization (IVF)
IVF is commonly used after unsuccessful IUI, or as a first treatment option for some patients
IVF is commonly used after unsuccessful IUI, or as a first treatment option for some patients. During IVF, a female or donor's eggs are placed with a male patient or donor's sperm in a laboratory setting. By joining eggs and sperm in a controlled setting, fertility specialists can highly increase the chances of fertilization.
In the first step of IVF treatment, a female patient or egg donor stimulates follicle (egg sac) development using gonadotropins, or similar hormones. Once stimulation has begun, her eggs are surgically harvested from her ovaries using transvaginal ultrasound and a needle.
After the eggs have been retrieved by a fertility specialist, an embryologist will join eggs with a male patient or donor's sperm to achieve fertilization. A patient or couple often elect to use intra-cytoplasmic sperm injection (ICSI) as a part of the IVF cycle. During ICSI, an embryologist will select individual sperms to inject directly into the cytoplasm of individual female eggs.
At this point in the IVF process, patients can elect to have preimplantation genetic diagnosis (PGD) or screening (PGS) performed on their embryos. PGD involves testing on cells taken from a newly formed embryo to check for genetic diseases like cystic fibrosis and other genetic disease. PGS, conversely, checks to ensure that the embryo has just 23 pairs of chromosomes. Excess or mutated pairs of chromosomes can cause Down syndrome and other conditions. These abnormalities are more common when an egg comes from a patient 35 years of age or older, although any patient can elect to have PGS. Any embryos having abnormal numbers of chromosomes (aneuploidy) will not be used.
Once one or more embryos have successfully been created, they transferred to a female patient or donor's uterus usually within three to five days. Depending on embryo number and qualities, a reproductive endocrinologist will determine what day is best to transfer embryos in the hopes that they will attach to the uterine wall and begin a pregnancy.
Planning for the Future
In many cases, patients are able to have their eggs, sperm, and even embryos "frozen," or cryopreserved for future use, as in Kira's case, should a cycle of IVF treatment not result in pregnancy. Vitrification is a specialized type of ultra-rapid freezing that is preferred by most fertility specialists today.
There are several benefits to cryopreserving eggs, sperm, and embryos. The process of harvesting eggs can be expensive and time consuming. Egg vitrification preserves any excess eggs to be fertilized in the future should the original IVF cycle prove unsuccessful. Similarly, male patients who undergo surgical sperm extraction may choose to cryopreserve sperm for future use. Embryos that have not been transferred during a cycle of IVF can also be cryopreserved (vitrified).
When the time comes that a patient decides to use frozen eggs, sperm, or embryos, they are thawed in a controlled setting and ready for fertilization or implantation.
Some patients are uncomfortable with the idea of creating embryos by joining egg and sperm when not all of the embryos will necessarily be used. Because of this, "limited" IVF was designed. This treatment is exactly the same as traditional IVF, except fewer eggs (two or three) are fertilized, and all embryos created within a cycle are transferred to the uterus.
For some patients, it is important that each of their embryos is given the potential to result in pregnancy. "Limited" IVF simply controls the number of embryos that is created so none are discarded or frozen with the possibility that they may not be used in the future.
If you are a member of the lesbian, gay, bisexual, or transgender community, a fertility specialist can help you determine what type of fertility assistance is best for your needs and budget. LGBT patients visit fertility centers for all of the same reasons that many heterosexual couples and individuals visit:
- To receive a donor egg or sperm through a donor program.
- For male and female fertility screening.
- For infertility treatments including IUI, IVF, surgery, and medication with the aid of a donor egg or sperm.
- For egg or sperm cryopreservation.
- For PGS and PGD testing for embryos.
- For alternative insemination for a female patient, or using a male patient's sperm to inseminate a surrogate.
There are several alternative therapy options that some patients have found were helpful in their fertility journeys.
The process of diagnosing and treating infertility and the journey to become pregnant can take an emotional and mental toll on patients. Stress-relieving tactics can help patients better deal with the ups and downs of fertility treatment. Common treatments for stress include:
Additionally, the American Pregnancy Association states that acupuncture can help address problems such as an over-functioning thyroid (hyperthyroidism) or under-functioning thyroid (hypothyroidism). The primary benefit of these kinds of therapies is to help patients continue with treatment even after a disappointing diagnosis or unsuccessful round of treatment. In many cases, patients can become successful with multiple treatments, but their largest struggle is continuing with treatment.
"I would tell first-time fertility patients to stay as calm as you can, and try not to feel overwhelmed," said my patient, Kira. "If you are stressed, it can impede your chances of success. It is a step-by-step process, and you can achieve your dreams of having a family one way or another, but you need to be patient and stay positive."
Exercise and Weight Loss
Being overweight can have a negative impact on fertility. By maintaining a healthy diet and losing excess weight, patients can do a great deal to improve their chances of fertility and reduce stress. The healthier the individual, the healthier his or her eggs or sperm, and the increased likelihood for a successful pregnancy.
One of my patients, Anne, had significant physical improvement after weight loss.
"I was significantly overweight and had polycystic ovaries," Anne said. "I lost a significant amount of weight, and the cysts on my ovaries were gone."
Pregnancy rates are improved by a 5 to 10% weight loss
While weight loss does not directly cure any type of physical or hormonal hindrance to pregnancy, it can improve the body's overall health, which is beneficial to fertility. According to a study published in the Journal of Human Reproductive Sciences, pregnancy rates are improved by a 5 to 10% weight loss.
Conversely, patients should be careful not to exercise too often or lose too much weight. Patients who are too thin can have difficulty conceiving as well. Female patients who are too thin, for example, can temporarily stop ovulating.
Avoiding Tobacco, Alcohol, and Drug Use
Tobacco, alcohol, and prescription and recreational drug use can hinder a patient or couple's chances for fertility substantially. These substances contribute to overall poor health, which contributes to infertility. They can also have a negative impact on sperm and egg production. Patients should consider avoiding these substances entirely while trying to become pregnant.
Determining the Best Path for Your Needs
A fertility specialist can help you understand the causes of your infertility and select treatment options that work best for your emotional and physical needs. With help from your specialist, you can make the most informed decisions for you and your family.
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