The Infertility Evaluation

Dealing with infertility is intimidating for many people. Less than 50 percent of couples who are referred to an infertility specialist end up making an appointment. They’re afraid their problem can’t be treated or that the cost will be too high. But evaluation by a caring physician may uncover simple causes that allow many patients to conceive on their own.

How to know if you’re infertile

The formal definition of infertility is failure to conceive after one year of trying to become pregnant. Conception usually takes place within 6 months of trying, so if you’re having sex at the “right” time (within 2-3 days of ovulation), then it’s time to look at causes. If travel, illness, or stress is preventing you and your partner from having sex, then a frank discussion of lifestyle may help identify stress and ways to improve chances for spontaneous pregnancy.

The initial infertility evaluation should involve a physical exam, focusing on signs or symptoms of anovulation, hormonal imbalance or pain. If not previously done, documentation of ovulation with temperature charts or over-the-counter ovulation predictor kits can be reassuring. These tests also help verify that sex is happening at the right time of the month.

Other diagnostic tests can help establish the cause of infertility. These tests typically include evaluation of the husband (semen analysis), the fallopian tubes (hysterosalpingogram or HSG), hormonal assessments (blood tests) or even laparoscopy to rule out endometriosis.

Basic Treatment

Sometimes treatment will be recommended, even if there’s no real cause identified. Clomiphene citrate (Clomid or Serophene) or Letrozole (Femara), tablets will enhance or establish ovulation. 10-15% of women may conceive with this treatment. There are concerns about use of Clomiphene for an extended period of time, as there is an increased risk of breast cancer in women using this medication for more than 12 months. (1)

When to see a Specialist

If pregnancy doesn’t occur after 3-6 months of simple treatment, the next step is seeing a Reproductive Endocrinologist (RE) who specializes in the evaluation and treatment of infertility. Seeing a specialist in a timely fashion is important, since the likelihood of conceiving goes down as women and men age.

Is Stress Causing Infertility?

Once a patient comes to see a RE the first step will be to review prior testing. Further diagnostic testing may be required, but often taking a step back to look at the patient’s environment is more important. Too often, physicians fail to recognize the interaction between hormones, nutrition, stress and genetics.

Both men and women can develop stress induced reproductive compromise and infertility. In men, reduced hypothalamic-gonadal function (how the brain controls hormones) may result in abnormal sperm counts and no other symptoms, or can cause decreased libido, loss of muscle mass and fatigue.

Chronic stress causes abnormal activation of the adrenal system, with increased levels of the stress hormone cortisol. These interfere with normal function of the hypothalamic-pituitary-gonadal axis, which signals the ovaries or testes to produce eggs or sperm and normal hormones. The stressors may be nutritional, metabolic or psychogenic. Stress is definitely a cause of reduced fertility. Stress can affect a couples ability to have sex at the “right time”, and even prevent ovulation or implantation. We all know people who seem to thrive on stress, but most of us will be affected by stress in subtle or obvious ways.

Stress induced reproductive compromise is all too often ignored during the infertility evaluation, often with the assumption that fertility treatment can reverse the problem without dealing with the underlying issues. Potent fertility drugs and in vitro fertilization may induce ovulation, allowing pregnancy to occur. However, ignoring the underlying causes of infertility may lead to increased side effects from medications, and higher risks of prematurity or birth defects. Taking time for a thorough evaluation and appropriate treatment of metabolic (energetic/nutritional), or psychogenic (emotional, such as with depression, anxiety, PTSD, etc.) problems increases the likelihood of a healthy pregnancy and baby.

Since stress is so common in patients with infertility, even when stress is not the primary cause of infertility, it makes sense that better outcomes can be expected when stress reduction is a part of the pretreatment plan. Once psychosocial/metabolic/stress issues have been addressed, and a diagnosis has been established, directed therapy can be implemented. For example, if the woman is not ovulating, ovulation induction will be necessary. If the man has low sperm concentrations, intrauterine insemination with sperm preparation to concentrate the healthy sperm may be used.

Outcomes

The medical literature shows that fertility therapy is reasonably efficient, with most couple becoming pregnant within 4-6 cycles of a given treatment. Some patients may take longer to conceive, or may have to resort to high tech treatment, such as IVF. Reassessment and possible change of therapy is indicated if a healthy conception is not reached within a reasonable time frame, but these decisions are often based on emotional, financial and religious/ethical considerations of the individual patient.

In some cases, all testing is normal and we cannot find the “reason” for the couple’s infertility. This is the case about 15% of the time. These couples are thought to have “unexplained” or Idiopathic Infertility. This diagnosis can be very difficult emotionally because couples are frustrated when a problem cannot be identified. Clearly there is a problem preventing pregnancy; however we may not have the tools yet to identify what it is. Even though this may be an emotionally difficult diagnosis to deal with, the good news is that couples with unexplained infertility have an excellent prognosis for success with treatment.

Next steps

Unfortunately some couples will not get pregnant with simple therapy, such as lifestyle/stress management, fertility medication, acupuncture, or intrauterine insemination. Usually the next step for infertility treatment is In Vitro Fertilization (IVF). This involves removing eggs from the ovaries, and bypassing the fallopian tubes by mixing the eggs with sperm in a petri dish. Once embryo development is documented, an embryo is placed directly into the uterus, and then hopefully normal implantation and pregnancy will occur.

IVF is a very powerful tool in that it bypasses non-functioning tubes. It may minimize the impact of endometriosis, and it can bypass male factors, allowing men with very low sperm counts to father a child. While IVF can solve many problems that prevent pregnancy, there is still an increased risk of multiple birth, as well as more difficult deliveries (2), and lower birth weight in babies born as a result of IVF. Recent studies have indicated a slightly higher risk of birth defects in babies conceived from IVF. (3)

Effect of Age on Fertility

We know that all women have a “biological clock.” The difficult part is to determine when a given woman has undergone the transition from having “good” eggs to “bad” eggs. We know that typically this will happen in the decade between ages 35 and 45 but it can actually happen at any time. Ovarian “reserve” testing to assess the lifecycle of the ovaries should be an integral part of an infertility evaluation.

Unfortunately, a woman may not have any symptoms that her eggs quality is decreasing. By the time symptoms such as irregular cycles, hot flashes etc. appear, it may be too late. If a woman has abnormal egg quality (usually referred to as “abnormal ovarian reserve”) then treatment is usually much more aggressive, and success rates may be low (as low as a 10-20% chance of a pregnancy occurring, but with an increased risk of miscarriage as well). Treatment may not improve outcome, depending on other fertility factors, so a prompt evaluation is important to determine if there is any benefit of treatment.

Other Options if Fertility Treatment Doesn’t Work
Infertility is a loss. The couple will find that they are unable to have that which comes naturally to others. Grieving this loss is an important part of moving on. It may take months or longer to process grief and adapt to childlessness. (4) Unfortunately, miscarriage occurs in 10-15% of pregnancies, which may make the grieving process worse. A study of women who miscarried after infertility therapy found patients had a variety of responses: a sense of profound loss and grief; diminished control; a sense of shared loss with their partners; injustice or lack of fairness; ongoing reminders of the loss; social awkwardness; fear of re-investing in the treatment process or a subsequent pregnancy; the need to make sense of their experience; and feelings of personal responsibility for what had happened. Clearly, processing and healing from the experience is necessary before moving back into treatment. (5)

Once patients have grieved, processed, and reached resolution, different choices will be available. Adoptionis the right choice for some patients. If the lack of success is due to poor quality eggs, donor eggs have enabled many couples to be parents. Other patients may choose to remain childless, deciding to find family in different ways, whether it be with adult relationships, or including friends and family with children in their lives. Regardless of the outcome, fertility treatment is stressful, and there may be long term outcomes that are frequently not considered, such as ongoing depression (6) and potential long term effects of fertility medication treatment.

With infertility, sometimes the process is as important as the outcome. Of course every patient hopes to have a healthy baby, but no matter the outcome, what’s important is to be able to look back and be at peace with your decisions.

References

1. Breast cancer incidence after hormonal treatments for infertility: systematic review and meta-analysis of population-based studies. Gennari A, Costa M, Puntoni M, Paleari L, De Censi A, Sormani MP, Provinciali N, Bruzzi P.
2. The Risk of Major Birth Defects after Intracytoplasmic Sperm Injection and in Vitro Fertilization. Michèle Hansen, M.P.H., Jennifer J. Kurinczuk, M.D., Carol Bower, M.B., B.S., Ph.D., and Sandra Webb, Ph.D.
3. Is there an association between assisted reproductive technologies and time and complications of the third stage of labor? Aziz MM, Guirguis G, Maratto S, Benito C, Forman EJ.
4. Unresolved grief in women and men in Sweden three years after undergoing unsuccessful in vitro fertilization treatment. Volgsten H1, Svanberg AS, Olsson P.
5. The experience of spontaneous pregnancy loss for infertile women who have conceived through assisted reproduction technology. Harris DL, Daniluk JC.
6. Mental health in women 20-23 years after IVF treatment: a Swedish cross- sectional study. Vikström J, Josefsson A, Bladh M, Sydsjö G.