Having a Baby

“Just relax, take a vacation.” “Maybe you should try acupuncture.” “I hear supplements can be effective.”

A woman who has difficulty conceiving a child is likely to hear such well-meaning suggestions. But treating infertility, which affects at least 13 percent of the population, is not so simple. The issue may be with the woman (estimated 60 percent) or the man (40 percent), with both or in the reaction between the two. Sometimes no cause can be identified.

Infertility is defined as failure to conceive after one year of unprotected sex. Dr. Karen Witt, obstetrician/gynecologist at Women’s Health Care of Nashua, an affiliate of Southern N.H. Medical Center, lists medical issues that can interfere with conception: ovulatory dysfunction; fallopian tube problems; uterine factors; anatomical issues; hormonal problems. Within each category, there are several possible concerns.

“For example,” says Dr. Witt, “a woman’s failure to ovulate could be the result of hormonal imbalance. Obesity can interfere with ovulation. Stress, excessive drinking or intense exercise can also interfere. A history of sexually transmitted diseases can disrupt ovulation.” Medication is usually the chosen treatment for failure to ovulate. Chlomiphene citrate (Clomid) is often used, to boost egg growth and stimulate release. If medication is not effective, Dr. Witt refers the patient to a fertility specialist for further assessment.

Problems may also occur in the fallopian tube and/or the uterus. If the tube is blocked by anatomical factors, pelvic inflammatory disease or endometriosis, the egg and the sperm cannot meet. The uterus must be healthy and “welcoming” to the pregnancy. Fibroids or polyps in the uterus will interfere with the process.

Age is a major factor. About two percent of women in their 20s are infertile. By the late 30s, 30 percent of women are infertile. From age 39 to 43, the infertility rate rises to about 40 percent. Both the number and the quality of the eggs may be compromised. The increase in infertility correlates to changing family patterns of later marriage and childbearing.

There are also several possible causes of male infertility. How vigorous is the sperm? Is there enough and does it have adequate motility? Is the vas deferens, a duct that carries the semen, blocked? Prolonged exposure to certain chemicals can be a factor. Sometimes the problem lies in the reaction between the sperm and the egg. Both are healthy but the antibodies of one reject the other. “We need a better understanding of male infertility,” says Dr. Witt, “but specialists in urology and hormonal disorders are seeking the answers that we need.” Dartmouth-Hitchcock Medical Center has a reproductive science laboratory, which studies male factors in infertility and embryology.

Infertility assessment will begin with a detailed history from each partner, noting menstrual difficulties, previous pelvic surgery or infections and any trauma to the testicles in the man. The woman will have a physical, including a pelvic exam. The man may have a semen analysis, usually performed by a urologist who specializes in male infertility. The woman will likely have further tests, including pelvic ultrasound and a laparoscopy to assess pelvic anatomy. Detailed explanations are beyond the scope of this article, but the process of diagnosis can be demanding. Dr. Witt notes that some infertility remains unexplained, even after extensive testing.

Treatment also is likely to be a lengthy process, especially for couples that must go beyond medication and the timing of intercourse. One option is Intrauterine Insemination (IUI) in combination with the use of medication to enhance egg production. The male partner’s semen is collected, the sperm is cleansed of other matter in the ejaculate and injected into the uterine cavity of the female at the most favorable time.

The most widely known option is in vitro fertilization, or IVF. Both sperm and eggs are extracted and mixed in a laboratory setting. After a few days, one or more fertilized eggs are implanted in the womb. IVF is a good choice for older women and for those with unexplained infertility. Success (a live birth from one cycle) is 37 percent in women under age 35 and declines to 11 percent for women in their early 40s (2003 figures). Many couples choose to have more than one fertilized egg implanted, creating a greater possibility of success, but also of multiple births. Dr. Witt says, “We are looking for better ways to manage this, for multiple births carry risk.”

There are other methods of assisted reproductive technology. In addition, the use of donor sperm, donor eggs and gestational surrogates expand the possibilities. A younger woman who wants to maintain the possibility of becoming pregnant at a later time can opt for ovarian tissue freezing. A thin layer of egg containing tissue from one ovary is extracted and frozen. When the owner decides to conceive, the tissue is implanted, assuring a supply of eggs from her younger years.

In the 1980s IVF was often regarded with fear and suspicion. Dr. Witt says that the procedure is now widely accepted. For people whose religious beliefs preclude using IVF, IUI is acceptable because conception takes place within the womb.

Whatever treatment is chosen, the process from diagnosis to conception is likely to be long and frustrating. “It was extremely stressful,” says a Concord woman who preferred not to be named. “Forget romance; this was hard work for both of us. But just when we were ready to give up, I got pregnant.” Many hospitals offer support groups for people involved in infertility diagnosis and treatment.

Cost is sometimes a barrier. Not all insurance carriers cover infertility treatment. A bill filed this year in the New Hampshire House to require coverage did not pass. NH