Our Bodies, Ourselves (104 page)

Most of us never expect to be faced with infertility. Decisions about infertility treatments are complex; there are no easy answers. Do you
want to try only hormone therapies and minor surgeries, or are you willing and economically able to try more invasive procedures, such as IVF, donor eggs, or surrogacy? How long do you want and can you afford to undergo treatments? If they aren't succeeding as you had hoped, how will you and your partner, if you have one, decide whether to continue or stop? These are questions to keep in mind as you go through the infertility process.

An infertility workup tests all the links in the chain of events from ovulation to an established pregnancy. Because many tests are conducted separately and scheduled at specific times in your cycle, the workup can take several months to complete. These tests can be invasive, painful, and emotionally exhausting as well as expensive, since medical insurance coverage is limited, even for initial diagnosis. Many insurance companies do not cover infertility treatments or offer only limited benefits. As of 2010, only fifteen states mandated some degree of health care insurance coverage for infertility.
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Although the sequence of diagnostic tests may vary with different doctors or clinics, the infertility workup will include some or all of the following.

A general and medical history of you and your male partner, if you have one.
This should include a review of your menstrual history as well as details about any previous pregnancies, episodes of sexually transmitted infections, and abortions; your family history related to infertility, DES exposure, menstrual irregularities, or early menopause; your use of birth control; whether you have been exposed to any toxins that may have affected your reproductive system; and behavioral factors, such as stress, nutrition, smoking, drinking, and use of drugs, both prescribed and recreational.

Semen analysis.
Because the semen analysis is probably the simplest and least invasive of the tests and male factors account for about a third of all infertility, this is usually the first test recommended. The man will be asked to ejaculate into a clean container, and the specimen will be examined under a microscope to assess sperm count, shape, and motility.

A thorough gynecologic examination.
Your uterus, ovaries, breasts, and general pelvic area will be checked. This will include a transvaginal ultrasound in which a slender probe is inserted into your vagina to look at your reproductive organs.

Monitoring ovulation.
A thorough clinician will make sure you understand your menstrual cycle and will help you track your ovulation, usually by taking your temperature every morning, monitoring your cervical fluid, or using a urine test kit that can detect the hormone surge occurring right before ovulation. (For more information, see
“Fertility Awareness Method.”
)

Hormonal profile.
This involves blood tests to check the levels of all hormones related to your menstrual cycle, ovulation, and fertility, including follicle-stimulating hormone (FSH) and luteinizing hormone (LH), as well as testosterone, dihydroepiandrostone sulfate (DHEAS), prolactin, estrogen, and progesterone levels.

Ovarian reserve testing.
The term ovarian reserve refers to the number and quality of eggs in the ovaries. It can be measured in two ways: by checking blood levels of the hormones anti-Mullerian hormone (AMH), inhibin B, follicle-stimulating hormone (FSH), and estradiol; and by conducting an antral follicle count using ultrasound scans to observe the number and size of the growing follicles that contain the eggs. How best to interpret ovarian reserve tests is
controversial, since clinical experience with these tests is still evolving. Even so, most infertility patients should be periodically evaluated for the possibility of impaired ovarian reserve before pursuing any advanced fertility treatment.

Hysterosalpingogram (HSG).
An HSG is almost always needed during the initial fertility-testing phase. This test can show any impairments in the uterus, cervix, and fallopian tubes by injecting a radio-opaque dye into the vagina and uterus while a series of X-rays is taken. Such problems may dictate the type of fertility treatment needed. If a woman delays this test, it could result in wasted time, energy, and money if she learns she had a structural problem that was missed. Though an HSG is not an infertility treatment, women have a slightly increased chance of conceiving in the cycles immediately following this test, perhaps because the dye “cleans out” any minor blockages in the fallopian tube.

Hysteroscopy.
During a hysteroscopy, a lighted viewing instrument is inserted through the vagina and cervix and into the uterus, typically under general anesthesia. This is done to examine the lining of the uterus, help collect a biopsy sample if needed, and guide surgery to remove growths in the uterus.

Laparoscopy.
Laparoscopy allows a practitioner to view the tubes, the ovaries, the exterior of the uterus, and the surrounding tissue of the pelvic cavity. It is the only test that can confirm endometriosis. Performed under spinal or general anesthesia, usually on an outpatient basis, laparoscopy involves making a tiny incision near your navel (belly button). Carbon dioxide gas is used to inflate the abdomen and allow the practitioner to view the pelvic organs. Sometimes a dye is flushed through the fallopian tubes to see whether they are open. If endometriosis, polyps, or scar tissue is found, it can be removed during the procedure as well.

Once you have pinpointed the most likely cause of your infertility, you can work with your practitioner to decide the right treatment path for you. Infertility treatments don't always involve expensive high-tech methods such as IVF. In fact, the vast majority of infertility cases are treated though less expensive, lower-tech treatments. Since not all treatments work for everyone and it's impossible to predict exactly what will work for you, treating infertility is as much an art as a science. Carefully consider the pros and cons of all your options.

A variety of drugs is used to correct hormonal imbalances, induce ovulation, suppress ovulation, and prepare the uterus. They can consist of natural hormones or synthetic drugs designed to mimic or block the action of natural hormones. Some are taken orally, while others require injections. Depending on your diagnosis
and clinic experience, there are many fertility drug protocols involving several different types of medications, dosages, and schedules. Some of the most commonly prescribed infertility drugs are:

Clomid.
Clomiphene citrate (brand names Clomid or Serophene) is usually the first choice for treating infertility because it's relatively cheap and effective and has been around for more than forty years. Clomid is a pill given to women who are not ovulating normally. Approximately 60 to 80 percent of women taking Clomid will ovulate, and about half will become pregnant, with most pregnancies occurring in the first three months. Like all fertility drugs, Clomid can increase your chances of multiple births, although it's less likely than with some injectable fertility drugs.

Femara.
Femara, also known by its generic name letrozole, was not originally meant to be a fertility drug. Instead, it is commonly used to treat postmenopausal women with breast cancer. Many clinicians have concluded that Femara is as effective as Clomid when inducing ovulation. However, this medication is used less frequently because studies have shown a risk of birth impairments if taken while a woman is actually pregnant. To eliminate any potential problems, clinicians who prescribe Femara for ovulation induction need to ensure that it's used only before conception and not during an actual pregnancy.

Follicle-stimulating hormone (FSH)
(Follistim, Fertinex, Bravelle, Gonal-F, Metrodin). These injectable hormones mimic FSH and promote ovulation. They can be created in a lab using recombinant DNA technology or extracted and purified from the urine of postmenopausal women.

Human menopausal gonadotropin (hMG)
(Pergonal, Repronex, Humegon, Menopur). These injectable drugs combine both ovulation hormones FSH and LH to increase egg production.

Gonadotropin-releasing hormone (GnRH) agonist
(Lupron, Zoladex, Synarel). These injectable drugs work to prevent ovulation from occurring naturally, allowing doctors to control ovulation via other drugs. Sometimes GnRH agonists are also used to affect the growth of the uterine lining.

One of the drugs, Lupron, is commonly used but has never been approved by the FDA for this particular purpose. Many women have reported serious problems with the drug. More information about its potential harms is available at Lupron Victim's Hub (lupronvictimshub.com).

Gonadotropin-releasing hormone (GnRH) antagonist
(Antagon, Cetrotide). These injectable drugs work quickly against the hormones LH and FSH, suppressing ovulation to prevent the eggs from being prematurely released before they can be retrieved.

Human chorionic gonadotropin (hCG)
(Pregnyl, Novarel, Ovidrel, Profasi). These injectable drugs are generally used along with other fertility drugs to mimic LH and trigger the ovaries to release the mature egg or eggs.

Progesterone.
If a pregnancy occurs after infertility, some clinicians recommend progesterone supplementation. Progesterone can be taken orally, by injection, or as a vaginal suppository or gel for as long as ten to twelve weeks to help maintain the pregnancy until the placenta is fully functional.

Most of these medications, especially the injectables, can be very expensive, costing thousands of dollars. The cost is often not covered by insurance. Because all fertility medications contain hormones, a variety of side effects can occur, such as hot flashes, cramping, bloating, discomfort, nausea, breast discomfort, headache, uterine bleeding, and mood changes.

As with all medications, fertility drugs come
with risks. The most common risk is the risk of multiple pregnancies. Carrying twins, triplets, or high-order multiples presents risks to both mothers and babies. To minimize the chance of multiples, careful monitoring of ovulation is critical. Your doctor should always keep track of how you are responding to the medications and take the necessary precautions to limit having too many eggs fertilize.

Another potential complication of fertility drugs is ovarian hyperstimulation syndrome (OHSS). OHSS happens when the ovaries, after being stimulated, become large and produce too much fluid. Women with mild OHSS may experience abdominal distension, nausea, diarrhea, and some weight gain. With moderate OHSS, women can have substantial weight gain and abdominal distension because of the enlargement of the ovaries and liquid accumulating in the abdominal cavity. In addition, vomiting and diarrhea can cause symptoms of dehydration, including decreased urine volume, thirst, and skin dryness. Severe OHSS may also lead to accumulation of liquid in and around the lungs, shortness of breath, and in extreme cases lead to acute respiratory distress syndrome. Moderate to severe OHSS occurs in about 1 percent of all ovarian stimulations. In most cases, the administration of hormones is stopped and the cycle canceled to help your body recover. Infertility treatment can often be resumed later on, changing the stimulation protocol.

Before taking any medication, discuss costs, possible side effects and health risks with your clinician and do your own research. If you take the medication, let your provider know if you have an adverse reaction.

The long-term safety of many of these drugs has not been adequately studied, although some good large studies are now under way. Some epidemiologic studies have suggested an increased risk of ovarian and uterine cancer among women treated for many cycles with some infertility drugs. It is not known whether the excess cancer risk is due to the drugs or to the underlying infertility. The International Agency for Research on Cancer has stated that there is inadequate evidence from animal or human studies to tell whether Clomid is carcinogenic, but it has not reevaluated the evidence in more than ten years. More research is needed to fully understand the possible long-term risks of these medications.

Surgical techniques can sometimes correct structural problems of the cervix, uterus, and tubes. Microsurgery may repair tubes and remove adhesions. Balloon-catheter techniques have also been successful in outpatient settings to open blocked fallopian tubes. Laser surgery using the carbon dioxide or argon laser, often in combination with microsurgery, may remove scar tissue or endometrial adhesions. However, if there is significant tubal damage, in vitro fertilization (IVF) may provide a higher chance of a successful pregnancy than surgical repair of the fallopian tubes.

IUI, or intrauterine insemination, is a relatively simple infertility treatment in which a very thin flexible catheter is used to place specially washed and prepared sperm directly into the uterus. IUI may be used in some cases of male-factor infertility, such as low sperm count, or if a sperm donor is being used. IUI may also be used if the woman's cervical mucus is not ideal. In cases of unexplained infertility, IUI may also be tried, especially before moving on to more advanced treatments. Sometimes doctors recommend that prior to IUI, women take drugs that are known to stimulate egg production. (These drugs require monitoring to prevent multiple
births.) Success rates with IUI vary greatly but are typically between 4 percent and 20 percent. IUI generally costs about $1,000 per attempt. It is increasingly common (and some health care insurance plans require it) for women to try several cycles of ovarian hyperstimulation (via medication) combined with IUI before attempting IVF. These treatments are expensive, given the cost of the drugs, but less expensive than a cycle of IVF.