For one in eight couples in the U.S. plagued with fertility problems, getting pregnant is an elusive -- and frustrating -- dream.
But if they seek medical help sooner rather than later, the outlook has never been brighter. Infertility treatments have improved, options have expanded, and doctors are more skilled at the techniques. Evaluations are done earlier than in years past, and the trend is to treat more aggressively, especially if the hopeful mom-to-be is older.
"Success rates have improved dramatically in the last 10 years," says Mousa Shamonki, MD, director of in vitro fertilization (IVF) and a reproductive endocrinologist at the University of California, Los Angeles David Geffen School of Medicine. The average success rates for births at fertility clinics have roughly doubled in the past decade, he says.
In 2003, more than 48,000 babies were born in the U.S. as a result of assisted reproductive technology or ART, according to the CDC. That's an increase of more than 2,000 over 2002 and 7,000 more than in 2001.
The Earlier the Better
"Often couples [who can't conceive] are told by family members, 'Just relax and take a vacation, you will get pregnant,''' says Eric Surrey, MD, former president of the Society for Assisted Reproductive Technology (SART) and a fertility specialist in Denver.
That won't work for couples with underlying fertility problems, he says. And at some point, seeking medical help is wiser than persisting on their own. If a woman is under age 39 and has been attempting to conceive for a year without success, it's a good time to seek medical help, says Surrey. If she is over 39, the evaluation should be performed after six months of trying to conceive without success, he says.
Treatment Options
Sometimes infertility can be treated with medication or surgical repair of reproductive organs. Another standard fertility treatment is to do one to three cycles of ovarian stimulation and intrauterine insemination, says Guy Ringler, MD, a reproductive endocrinologist at the Santa Monica -- UCLA Medical Center.
That involves stimulating the ovaries to boost egg production by giving medicine such as Clomid and then inserting a thin catheter into the uterine cavity to place the sperm there.
The treatment, he says, "will increase the pregnancypregnancy rate from about 3% per month to about 12% to 15% in women under age 40 and to about 5% to 7% in those over age 40."
"But many couples are saying, 'I want to be more aggressive,'" Ringler says. "Most often they say that due to age, but also to the success rate [of the more aggressive techniques]." Many ask to move on before the three months is up, he says.
If they move on to in vitro fertilization or IVF, the chances of pregnancy are greatly increased, he says. In IVF, the woman's eggs are surgically removed from the ovaries, mixed with sperm outside the body, and allowed to fertilize before the embryo is then transferred back into the uterus. "With IVF, if the woman is under age 40, the pregnancy rate is about 40% in the first attempt," Ringler says. In women over 40, the success rate is greatly dependent on age, he says.
Over-40 IVF success rates are tied to age, agrees Steven J. Ory, MD, a reproductive endocrinologist in Margate, Fla., and president of the American Society for Reproductive Medicine. For women 40 to 42, the success rate with IVF is about 15%, he says. But it's less than 5% for women over age 42. Still, he says, proceeding to IVF quickly is one of the biggest trends now, whatever a woman's age.
Donor Eggs
Donor eggs are another option, especially for older women, Ringler says. While many women balk at the idea of using another woman's eggs, "they have to go through their personal journey of acceptance," he says. Their desire to have a baby often wins out over genetics, he says. "If a woman is over age 43, donor eggs are the most realistic [approach]."
Ory agrees. "We have no patient over age 45 successfully using her own eggs," he says of women coming to his Florida clinic.
For infertility due to "male factor" problems, a technique called intracytoplasmic sperm injection (ICSI) has made a dramatic difference, says Shamonki. A single sperm is injected into an egg. "Routine use of ICSI, generally used for male factor infertility, has improved outcomes," he says. Male factor is the sole cause of infertility, he estimates, in about 20% of cases and is a combined cause in up to 40% of infertile couples.
It's important to have a basic and thorough fertilityfertility evaluation before having any treatment, especially aggressive ones, Ringler warns. Otherwise, you could jump into expensive, time-consuming treatments when the problem could have been relatively minor and treatable with less intervention.
As pregnancypregnancy rates have increased, Surrey adds, "we have been able to make significant advances in the number of embryos transferred," reducing the number whenever possible.
Transferring Fewer Embryos
The trend of transferring fewer embryos was reiterated in updated guidelines issued at the 2006 annual meeting of the American Society for Reproductive Medicine (ASRM). Under the revised guidelines, jointly issued by ASRM and SART, it is recommended that no more than two embryos be transferred in women under age 35, and that single-embryo transfer be considered. Previous guidelines recommended one or two in these women. The number recommended for older women varies by age and by how many days past fertilization the embryo is.
For instance, for women over age 40, transfer of no more than five embryos that are two or three days past fertilization are recommended and no more than three that are five or six days past fertilization.
Avoiding multiple pregnancies, ideally, is a goal of infertility treatment, Surrey says, because multiple births boost the chances of preterm labor and deliverylabor and delivery, and that can mean health problems for the infant. "For the patient, the concept of a twin pregnancy is a positive one, but health-wise, there is more risk," Surrey says.
Eastern Techniques
In infertility clinics nationwide, there's a growing willingness to consider -- or in some cases embrace -- alternative or complementary techniques. "We commonly refer patients for complementary therapies, especially when what we are doing is not working," says Ringler.
Among the most frequently tried complementary techniques to achieve pregnancypregnancy are acupuncture and Chinese herbal medicine, but acupuncture is more accepted by traditional reproductive endocrinologists. "There are studies showing acupuncture before embryo transfer may increase the pregnancy rate," Ringler says.
Acupuncture got mixed reviews in studies presented at the 2006 ASRM meeting. In one study of more than 1,400 cycles, three acupuncture sessions before and after embryo transfer improved the fertilization rate -- especially in women over age 35 who used fresh (rather than frozen) embryo transfer and in women 35 to 39 who used frozen embryo transfer.
Another study of 258 women showed that needle acupuncture (compared with laser, relaxation, or none) boosted the pregnancy rate by 10%. But yet another study showed among 83 women -- who either got or didn't get acupuncture -- that the ancient technique made no difference in whether they got pregnant.
Acupuncture and other complementary treatments may also ease a woman's stress, says Ringler, and that is always helpful in achieving pregnancy. Even though studies are conflicting about acupuncture's value, Ringler says it's not known to have any harmful effects. One caveat: "It's important that there is a dialogue between the reproductive endocrinologist and the Eastern practitioner if you are going to go along with a complementary treatment regimen," Ringler says.
How Best to Stimulate Eggs
For years, doctors used the drug Clomid to stimulate a woman's body to produce more eggs. Recently, some doctors have turned to a drug approved for breast cancer treatment, Femara, to induce ovulationovulation.
Then, in a study presented in 2005 at the American Society for Reproductive Medicine meeting, researchers had some alarming news. They found that nearly 5% of 150 babies born after the use of Femara had birth defects, compared with less than 2% of 36,000 babies born without their mothers receiving fertilityfertility treatment.
Soon, Health Canada and the drug's maker in Canada, Novartis Pharmaceuticals Canada, warned doctors there against Femara use in fertility treatments.
More recently, researchers who published their results in the June 2006 issue of the journal Fertility and Sterility found no difference in birth defect rates when they followed 911 infants whose mothers had taken either Clomid or Femara during fertility treatments.
Even so, the first study results have dampened the interest of most fertility specialists in the U.S. in using Femara, Ory says, at least until more data are in.
With all the new avenues, what are the odds of taking home a baby? According to the CDC, 37% of fresh (not frozen) nondonor egg procedures begun in 2003 produced live births in women under age 35. The percent of live births declines as a woman ages. But among women of any age who used donor eggs, 50% took home a baby, according to the CDC.
Footing the Bill
For an infertile couple, achieving pregnancypregnancy can be expensive. IVF treatments cost up to $12,000 per cycle, according to the American Society for Reproductive Medicine. Ovarian stimulation plus IUI is about $500 to $1,000 per cycle, Ringler estimates.
Whether fertility treatments are partially covered by insurance depends on where you live and which insurance plan you are covered by, says the American Society for Reproductive Medicine. Currently, 15 states have laws about infertility treatment and insurance, according to Resolve: The National Infertility Association. But the specifics vary. Best bet: call the insurance commissioner's office in your state to ask.
