Infertility: What You Should KnowJoan Hamilton
Cloned human embryos. Sixty-year-old women trying to become pregnant. Eggs harvested from aborted fetuses. In recent months, sensational, high-tech reproductive technologies have triggered an emotional ethical debate. Unfortunately, the wild notions that linger long after such headlines fade can make life for couples grappling with infertility even more painful, frustrating, and shame-filled. "The image we have to battle is that infertile people are rich, white, whiny yuppies who forgot to have babies" and will go to any lengths to do so now, says Cecile Lampton, president of the Northern California chapter of Resolve, a support and advocacy group for the infertile.
The numbers belie that: Roughly 5 million Americans of varying socioeconomic profiles suffer from infertility, meaning they have been unable to conceive a child after a year of unprotected, regular intercourse. Of that group, "50% to 70% of couples can get pregnant by standard approaches" that stop well short of exotic, invasive procedures, says Dr. David Adamson, a Palo Alto (Calif.) infertility specialist.
CLEAN HOUSE. Even when two completely healthy people have intercourse at exactly the right time, explains Dr. Cappy Rothman, a male-infertility specialist in Los Angeles, there's only a 20% to 30% chance of conceiving. That's why physicians like to give nature a year to work unassisted. Couples may increase the odds by using over-the-counter ovulation predictor tests and limiting or avoiding entirely their use of alcohol, cigarettes, medications, and drugs.
When a year is up, it's important for both partners to be fully evaluated. Once considered a woman's problem, fertility trouble is now known to be caused 40% or more of the time by "male factors," primarily problems with sperm, such as count or motility (movement). The primary female factors include ovulation problems (about 20%), tubal blockage (30%), and cervical chemistry that is hostile to sperm, even producing antibodies to them (5%). Age alone can be a negative: Women over 35 have increasing trouble conceiving and in carrying a baby to term. Multiple factors are common: a woman who ovulates infrequently, for example, paired with a man with low sperm counts. In a minority of cases, no causes are found.
Since every couple is unique, treatment plans vary widely. If a woman ovulates irregularly, the first step is likely to be treating her with drugs to try to correct that. Or she might undergo laparoscopic surgery to repair tubal damage or remove scar tissue from endometriosis. Doctors may also try to improve the chances for fertilization by inseminating a woman with her own partner's sperm after "washing" them--that is, separating the active sperm from the semen fluid.
CHILL OUT. Specialists explain that treating male factors is more problematic. Drugs don't seem to work well, and other procedures, such as surgically correcting varicoceles, or varicose veins in the testicles, are at least mildly controversial. These swollen, twisted veins cause improper draining of the blood, thus raising testicular temperature, which is usually about 93 degrees. Such heating can hurt sperm production. That's the basis for the advice that men should switch from briefs to boxer shorts and stay out of hot tubs and
Many researchers, such as Dr. Alan Zuckerman of Emory University, are convinced that infertile men with varicoceles should be treated immediately and that the relatively simple procedure can improve conception rates as much as 50%. However, Adamson and many reproductive endmcrinologists say the data are equivocal, and they recommend the procedure only when there are no female factors working against the couple. Many men with varicoceles are perfectly fertile, says Adamson. "I've seen people waste a lot of time treating male factors unsuccessfully."
IN THE DARK. Unfortunately, infertility patients must negotiate a number of professional debates over the effectiveness of certain procedures. That's because infertility research is plagued by a basic problem: It's difficult to do rigorous studies of people who believe they don't have much time to act and who may be undergoing a variety of treatments simultaneously. To properly study varicoceles, for example, would mean identifying but not treating a large number of men with the problem to compare their fertility to treated men. Few patients are apt to go for that. Also, if pregnancy results after a couple gets surgery, uses medication, stops smoking, and more precisely times intercourse, researchers can't pinpoint what made the difference.
That's why trust and fully informed discussion between a couple and the specialist are crucial. Both the American Fertility Society and Resolve can help couples choose specialists wisely. The AFS also compiles data about in vitro fertilization and other "assisted reproductive technology."
In addition to data about procedures, infertile couples must confront other tricky issues, such as donor sperm or eggs, surrogate motherhood, and adoption. Feelings about these issues can make a huge difference in what course is followed. Nor can the couple's financial situation be overlooked.
Fertility treatment can be expensive, with a complete evaluation often costing about $2,000 and procedures running from $800 to $15,000 per cycle. And a treatment course often must be repeated a number of times with no guarantee of success. About 10 states require insurers to cover fertility treatments, with Massachusetts, Rhode Island, and Illinois laws the most comprehensive. All policies have limits, however. Some will pay for fertility testing but disallow claims for impregnation procedures.
LONG ODDS. The last high-tech resort for infertile couples is assisted reproductive technology, such as in vitro fertilization (IVF), which involves fertilizing an egg outside the woman's body and reinserting the embryo. Only about 2% of infertile couples embrace this option. It may be performed with the woman's or a donor's egg, and her husband's or a donor's sperm. Variations on IVF include GIFT, which involves harvesting an egg and sperm and mixing them together in the woman's fallopian tubes in the hope of facilitating conception.
The first test-tube baby, Britain's Louise Brown, turns 16 this July, and in those years, tens of thousands of procedures have been performed, with an average pregnancy rate per embryo transfer of only about 15%. Patients must realize that to achieve success can require several tries, costing from $6,000 to $14,000 apiece. "It can be hard to step off the [treatment] treadmill when you've already spent so much money," says one woman who ultimately turned to adoption after several surgeries and IVF cycles failed to produce a baby.
One of the most exciting new techniques is called intracytoplasmic sperm injection, or ICSI. Pioneered in Belgium, ICSI is a laboratory technique that involves micro-injecting a single sperm into an egg. "It's spreading like wildfire," says Dr. Mary Martin, director of the IVF Program at the University of California, San Francisco. It offers hope, but for a specific problem: males who produce extremely low amounts of weak sperm. The procedure is still experimental, but the AFS can refer patients to specialists exploring ICSI in the U.S.
It's no surprise that infertility can cause stress in a marriage. One in six infertile couples, says Adamson, has trouble even having intercourse at optimal times. That's one reason that many fertility doctors recommend counseling for their patients. Organizations such as Resolve also can help with emotional pressures. Its goal is to assist couples in resolving infertility problems. That could mean achieving a pregnancy, opting for adoption, or ultimately deciding to live without children.
TERMS AND PROCEDURES
INSEMINATION Insertion of semen into a woman's vagina for purposes of conception. Cost: $800-$3,000 per cycle.
VARICOCELE Varicose vein of the testicles. A varicocele, which can be treated with a simple outpatient procedure, is believed to raise the temperature in the testicle and affect sperm production. Procedure cost: $2,000 to $5,000.
IN VITRO FERTILIZATION (IVF) A woman's egg is removed from a ripe follicle, fertilized in a laboratory, allowed to divide, and reinserted into the woman's uterus. Cost: $6,000-$14,000 per treatment.
GAMETE AND ZYGOTE INTRAFALLOPIAN TRANSFER (GIFT AND ZIFT) In GIFT, an egg is removed and immediately mixed with washed sperm, then reinserted in the woman's fallopian tube in hopes that fertilization will occur. In ZIFT, a fertilized embryo is returned to the tube. Cost: IVF plus $1,000.
INTRACYTOPLASMIC SPERM INJECTION Experimental technique in which a
single sperm is inserted into an egg, then the resulting embryo is reinserted into the woman's uterus or tubes. Cost: IVF plus $1,000.
DATA: AMERICAN FERTILITY SOCIETY, SERONO SYMPOSIA, BUSINESS WEEK
WHERE TO TURN FOR HELP AGENCIES AMERICAN FERTILITY
SOCIETY Birmingham, Ala.,
205 251-9764. Professional
society that provides extensive
consumer information, including a bibliography of books and pamphlets
NORTH AMERICAN COUNCIL ON ADOPTABLE CHILDREN
St. Paul, Minn., 612 644-3036. Newsletter and clearinghouse for adoptive-parents groups
RESOLVE Somerville, Mass., 617 623-1156. Counseling and support group for infertile couples, with chapters in 59 cities
DESIGNS ON LIFE by Robert Lee Holtz, $21, Simon & Schuster
FAMILY BONDS; ADOPTION AND THE POLITICS OF
PARENTING by Elizabeth
Bartholet, $21.95, Houghton Mifflin
HOW TO BE A SUCCESSFUL
FERTILITY PATIENT by Peggy
Robin, $15, William Morrow