When Liz and her husband decided to start a family, every month without a pregnancy brought new disappointment and more doubt. “Why is this happening to us? I know we would be good parents. Why is it so easy for our friends and other family members to get pregnant?” says Liz. “These kinds of questions swirled in my head every day, over and over again. ”
Inability to conceive a child, or infertility, can cause genuine emotional distress. Fortunately, since the first test-tube baby, Louise Brown, was born in 1978, and has since had her own baby, advancements in medical technology have resulted in a number of treatments which can help turn couples into parents.
R. Scott Lucidi, MD, a specialist in reproductive endocrinology and associate professor in obstetrics and gynecology at VCU Medical School, notes that the technology and success rates for infertility treatments have steadily improved.
“We treat infertility with both science and art,” says Dr. Lucidi. “Compassion, combined with the best and most modern techniques, allow us to help many couples fulfill the dream of pregnancy. We like to tell patients that we want to help them have as many healthy babies as they want – preferably one at a time. We can’t help everyone, but we can certainly do everything possible to try to make it happen, with increasingly high success rates.”
Reproductive endocrinologists like Dr. Lucidi spend a lot of time with their patients dealing with one of the most personal issues a couple can face. Liz recalls the compassion of the medical professionals who took care of her and her husband.
“From making appointments, to having my blood drawn, to the procedures themselves, everyone was so caring, supportive and very respectful of our feelings and our privacy. The doctors and nurses all feel like family,” says Liz.
On the face of things, conceiving a baby seems rather straightforward. There are three things required for conception: an egg, a sperm, and a clear path between them. This simple equation, however, requires a lot of conditions, and if any of these are not met at the right time, conception cannot occur. The problem may be with the mother, the father, or occasionally both.
Female infertility can be caused by problems with egg development or release from the ovary, inability of the egg to travel to the uterus, poor uterine environment due to hormonal disturbances, prior surgery, pelvic infections, and uterine structural abnormalities, among many others. Older maternal age is a common problem.
Male issues may include low sperm counts, poor sperm quality from any cause (including smoking and substance abuse), impotence, and scarring of the tubules that transport sperm, among others.
When an otherwise healthy woman under 35 does not succeed in becoming pregnant after a year of unprotected intercourse, an understanding of the complex hormonal and mechanical requirements for pregnancy is in order to determine why infertility is present, and how to treat it. Older women might want to consider treatment options somewhat sooner than a year.
A number of tests will be performed. For men, testing will include examination of the sperm, looking for count, and any obvious abnormalities. In women, testing will include the following: blood testing for hormone levels to examine, among other things, whether ovulation is occurring; examination of the tubes and uterus to make sure there is no mechanical blockage; and drug or hormone challenge testing to see if the body is responding normally.
Treatment options depend on the cause, if one is found. Occasionally all tests are negative with no abnormalities at all, and the cause of the infertility is unknown. This doesn’t mean that successful treatment is impossible.
There are a number of effective approaches for infertility. The simplest is the use of oral medications to encourage the development of eggs within the ovary. If oral medications fail or are not indicated for a particular patient, injectable hormones might be used, stimulating the development of several follicles (which contain the ova or eggs). If imaging shows more than three or four mature follicles are present after treatment, the cycle will usually be cancelled because of the risk of a multiple birth, which has its own set of problems and risks for both mother and babies.
If there are mechanical blockages preventing the sperm from reaching the egg or the egg from reaching the uterus, in vitro fertilization (IVF) may be an option. In this technique, eggs are retrieved from the ovary using a very small needle and placed in a special nutrient solution with sperm. Once the sperm and egg merge at conception, the developing embryo is kept in an incubator for several days. Prior to transfer to the mother’s uterus, the embryo can be examined under the microscope for any obvious problems.
The sperm and egg are usually allowed to spontaneously merge in an IVF procedure, but occasionally direct injection of a sperm into the ovum is required. This is called intracytoplasmic sperm injection (ICSI).
The use of donor sperm for artificial insemination has been a practice for many years, and is a very successful technique. Sperm donation is typically from a donor bank, and requires normal egg production and normal female pathways. This treatment is useful when the male partner does not make sperm, or for women who want to have a child, but do not have a male partner.
In recent years, the use of donor eggs has become more common as well. In this technique, mature eggs are retrieved from a donor and fertilized in vitro, using the male partner’s sperm. The developing embryo is then transferred into the female partner’s uterus. Hormones are used to facilitate the process.
For Liz, in her late thirties and diagnosed with premature ovarian failure, the use of a donor egg was the solution. The couple was able to choose an anonymous donor, and their first attempt with IVF was successful. “I look at our son every day and can’t believe he’s here,” says Liz. “We are so lucky to have such talented doctors right here in Richmond. My husband and I think they are miracle workers.”
Female surrogacy has also become more popular, although it is less commonly used than other techniques. If the mother’s eggs are healthy but she cannot sustain a pregnancy for some reason, IVF may be performed, using either the male partner’s sperm or donor sperm. The embryo is then transferred into the surrogate’s uterus for the remainder of the pregnancy.
Concerning the likelihood of multiple births, as the technology evolves, it is easier to prevent multiple births than it was in the early days of fertility treatment. Every patient is different, of course, but there is generally less chance of high multiples (triplets on up) using oral medications to stimulate egg formation. The highest risk is with pregnancies stimulated by injected hormones. Many couples and physicians will opt to cancel a cycle rather than risk having a large number of fetuses at once.
In vitro techniques allow for the control of embryo numbers. The number of transferred embryos is a decision affected by a number of factors, including maternal age and history as well as embryo quality. If the mother is younger than 35 with good quality embryos, only one embryo may be transferred. If she is older than forty and/ or has a history of prior IVF failure, several embryos may be transferred.
According to Dr. Lucidi, the science of reproductive endocrinology is remarkable.
“New techniques have made the chances for pregnancy much better in infertile couples, and the process much easier on the mother,” says Dr. Lucidi. “We are always very aware of the emotional cost of infertility, and do our very best for every patient in furthering the goal of becoming a parent.”