Fertility Facts Every Couple Should KnowJohn C. Jarrett, MD
Factors Influencing Your Ability to Conceive
Relatively few problems will render a couple absolutely incapable of conceiving. We all know stories of couples who have given up their attempts to get pregnant only to conceive shortly thereafter. Or couples who have adopted one child and all of a sudden they conceive and then have two children under the age of two. This is not to imply that giving up, or adopting, increases one’s chances of conceiving. But, every course—whether it be prayers and rituals, trying on your own without intervention, or pursuing the most high-tech options available—has a chance of being successful.
There is much to consider when a couple finds that conceiving a child is more difficult than they anticipated. When do you seek out treatment? And what are your options? We’ll look at considerations that can help you decide how to proceed.
How old are you and how long have you been TTC?
Many couples begin to wonder after months of trying to conceive, “What are the chances if we just keep trying on our own?” Age has a lot to do with the answer to this question. Fecundity, or the likelihood of getting pregnant each month, is tremendously age dependent. For a couple in their early 20s with no known problems, fecundity may be as high as 20 to 25 percent per cycle. For a couple in their early 40s with no known problems this number is less than five percent. There is clearly a decline in fertility beginning at about age 30. This becomes more dramatic after age 35, and after age 40, it is very significant. This decline in a couple’s chances of getting pregnant each month must be coupled with miscarriage rates that increase as a woman gets older, ranging from about 18 percent in younger women to as high as 25 to 50 percent in women over age 40.
Just on the basis of this information, a more conservative approach to fertility treatment is often justified in younger couples, whereas a more aggressive approach may be more appropriate for an older couple.
How long a couple has been trying to conceive is also important. The definitions of infertility suggest that a couple is not infertile unless they having been trying for a year to conceive their first pregnancy, or until they have been trying for six months after having been pregnant before. These are only definitions. They don’t mean that if you have been trying for a year your chances for the next month become zero. While statistically the chances may be decreased enough that some evaluation may be warranted, the chance is still there. But, at the same time, it is clear that the longer a couple has been trying, the less likely it is that they will be successful.
Data clearly show that a couple’s fecundity decreases in direct proportion to the length of time they have been trying to conceive. In other words, if a couple has been trying to conceive for five years, their chances of conceiving in the next month probably are not zero, but they certainly aren’t very good.
What are your medical considerations?
In addition to your age and duration of attempts, physicians will gather other information to tailor an evaluation and treatment plan that is appropriate for each individual couple. Physicians also use the information to try to formulate an equation that will give some idea of what your chances are without intervention, and what they would be with any given type of intervention. Studies such as semen analysis, thyroid tests, a routine physical, and more may be conducted to evaluate both partners’ health. Both female and male factors must be taken into account for reasonable treatment alternatives to be determined.
There are very few couples with whom infertility is absolute. Complete azoospermia (absence of sperm), total tubal occlusion (blocked fallopian tubes), and premature ovarian failure (POF) are the exceptions. In couples with these particular problems, determining treatment options is relatively straightforward.
For couples without absolute infertility, determining appropriate options can be much more difficult. There are a several of basic factors your doctor will consider:
- Semen analysis: The number of functional sperm is one factor that dictates which options are reasonable. If there are 30 million normal sperm present, many alternatives may be reasonable, from conservative to aggressive. If, on the other hand, the semen analysis shows only one million sperm with very poor motility, anything but ICSI (injection of single sperm into single eggs in order to get fertilization) may have virtually no chance of success.
- Status of the fallopian tubes: As long as we know the tubes are open and appear normal, many approaches may be reasonable. If they are occluded or damaged, in virtro fertilization (IVF) may be the only choice with a realistic chance of success.
- Status of the uterus: Is it normal, or is there an unusual shape or scar tissue within it
- Status of the ovaries: Are you making an egg regularly?
After assessing these factors, your physician’s task is to consider your test results and all the other data gathered. The number of identified factors that may be contributing to a couple’s inability to conceive is very important. If a couple has more than one infertility factor, the effect of each factor on their infertility is not additive. It is almost exponential!
Since the number of identified factors is so important, your doctor will need to consider:
- Your age and your partner’s age (particularly that of the hopeful mom-to-be)
- The length of time you and your partner have been infertile
- What problems have been identified
- How many problems have been identified
Based on these considerations, your physician must decide what he or she thinks are reasonable treatment alternatives. Your physician should then be able to present you with one or more treatment options, and tell you the costs, side effects, percentage of success, and more.
Understanding Treatment Options
Before making a decision, be sure that you and your partner are well informed by your physician regarding all reasonable treatment alternatives. If your physician evaluates your particular case and provides you with reasonable information concerning your alternatives, and if you decide between these alternatives within the framework of your real-world factors, then there are no wrong decisions. You can’t make a bad choice!
But you and your physician must constantly reevaluate. Each and every treatment has a cumulative success curve that will flatten out after a given number of attempts. In other words, if you have tried one approach for several cycles and it hasn’t worked, chances that it will work in the next cycle begin to diminish. After a certain length of time, that approach may not increase your chances at all. Any approach should be pursued only as long as it is clearly keeping you on the steep part of the cumulative success curve.
It is your doctor’s job to determine which options are reasonable and to provide you with all pertinent information concerning those options. But, it is your job to decide what you want to do! All decisions must be made by the physician and the couple as a team.
Deciding How to Proceed
Only you and your partner can take the information your doctor has provided and evaluate it in terms of your life situation. Real-world constraints and considerations are extremely important in this whole process. Some factors you’ll need to consider are:
- Work: Very few women today have the luxury of being able to devote all of their time to trying to get pregnant. They have to pursue their careers at the same time. How much time away from work will each alternative require and how much can you afford? Can you pursue an alternative and still work? Some women even schedule certain treatments during vacations.
- Stress: The stress associated with infertility is second only to the stress associated with the death of a loved one. How much of a toll has that stress already taken on you, your self-esteem, your marriage? How much more can you tolerate? For example: Given two alternatives, a couple who has been trying to conceive for five years may decide to pursue the alternative with the best per-attempt chance of success simply because they just can’t tolerate a whole lot more.
One inexorable force that couples face as they pursue fertility is the ticking of the biological clock, making it seem as if their efforts are taking forever. This clock can make couples do silly things out of desperation. Don’t ever do something just to be doing something. Make sure the options you pursue are reasonable and offer you a decent chance of success.
- Geography: Fertility services are not available everywhere. If you have to travel several hundred miles, your choice of alternatives might tend to be more aggressive than it would be if you only have to go across the street.
- Cost: Insurance coverage for fertility services varies wildly. Medications, testing, procedures, and so on may or may not be covered; and many fertility services can be expensive. The cost-success ratio of each alternative must be a consideration.
Facing Success and Failure
If after awhile a certain choice is unsuccessful, talk it over again with your physician, examine your alternatives, and decide what you should do next. Communication is key, and proper decision-making requires a partnership between you and your physician. An informed, well thought-out decision can’t be wrong.
Don’t hesitate to take breaks. Many couples feel that if they take some time off and stop concentrating on trying to conceive for a while, they are being negligent and their chances will be that much less when they do start trying again. This just isn’t so; infertility is very stressful and there is no doubt that stress can take its toll. Breaks, or treatment vacations, are wonderful ideas. They restore the emotional energy required to pursue treatment and deal with the results. They also remind couples that intercourse is something that can be done for fun rather than just on certain days at certain times. Taking a break is good for the soul!
The obvious goal of every physician who treats couples with infertility is to help each and every one of them conceive; however, this isn’t always an unattainable goal. While the vast majority of couples with infertility can be helped and do conceive, some never will. For those couples who don’t conceive, a resolution must be reached as well. Having a good physician means finding a doctor willing to inform you when all reasonable treatment options have been exhausted. For a good doctor, resolution for every couple is what the job is all about. Whether that resolution be a successful intervention-free pregnancy, an assisted pregnancy, or help with adoption, fostering, or a positive outlook on child-free living, a good physician will be at your side throughout the whole process.