Gone are the days when a woman was labeled “barren” when she failed to get pregnant within the first year or two of marriage. And gone is the time when she and her partner were forced to accept a future of permanent infertility. Times have changed, and so have couples’ options, says Dr. Steven Spandorfer, a reproductive medicine specialist and Associate Professor of Obstetrics, Gynecology and Reproductive Medicine at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at Weill Cornell Medicine.
Infertility is actually quite common, Dr. Spandorfer says. About 15 percent of all couples will experience infertility at some point in their lives. That’s one in six.
And infertility is not always traceable to the woman. “In about 40 percent of couples experiencing infertility,” he says, “the problem lies with the male.” For that reason, he always requires both partners to get tested before anything gets decided.
However, he adds, there is no denying that the most important factor in infertility goes back to the woman: her age. If she is under 35, we encourage that couple to try for at least 12 months of unprotected sex before seeking treatment; and if she is over 35, we cut that down to 6 months before bringing them in for a workup and developing a treatment plan.
“Some couples rush out to buy an ovulation kit at the first sign of trouble and start tracking and charting everything,” says Dr. Spandorfer. That may be appropriate later, but not at first. “All the overkill information out there puts a lot of stress on a couple. I suggest backing off from the ‘scientific’ approach to getting pregnant and just having sex a few times a week.”
And yet the process can be stressful, he acknowledges. The fact is that most couples aren’t successful at getting pregnant right away. It’s a process—one that requires openness and trust, persistence and patience.
Under Dr. Spandorfer’s care, treatment begins with a thorough workup, including blood work, semen analysis and an ultrasound to assess a woman’s ovarian reserve. He also orders a hysterosalpingogram (HSG): an X-ray that reveals the internal shape of the uterus and the state of the fallopian tubes.
If the problem lies with the male, Dr. Spandorfer will recommend a urological evaluation. “There may be structural solutions,” he says. “As well, his body weight, medications and hormonal issues may come into play, and these can all be treated. A procedure called intracytoplasmic sperm injection, or ICSI, may help as well; it involves injecting a single live sperm directly into the center of a single egg.”
Additionally, a genetic panel is part of the initial exam to see whether the couple is at risk for having a child with a hereditary disease or condition, such as cystic fibrosis, thalassemia or sickle cell anemia. “We also check to see whether the woman is immune to rubella and chicken pox. The results of these genetic and antibody tests won’t affect the couple’s fertility,” he says, “but it’s good information for them to have.”
Finally, Dr. Spandorfer performs a test to see whether a woman is ovulating—releasing an egg— on a regular basis. If not, he will treat her with oral medication to help induce ovulation. That plus unprotected sex is often successful.
And if ovulation-inducing medication alone is ineffective, “we combine other medications with intrauterine insemination for one or more cycles,” he says. “Beyond that, we use injectable medications.
“It all comes down to what risks a couple is willing to take,” he continues. “The main risk is multiple pregnancies. Multiples tend to be twins, but there could be more. Happily, we have mostly solved that problem with advanced IVF technology (in vitro fertilization), which allows us to control what we do.”
Dr. Spandorfer describes IVF as the “ultimate treatment.” The sequence goes like this: “We give the woman fertility medicatons and monitor her closely. When she’s ready, we remove the desired number of eggs. Then, in the lab, we put the eggs and sperm together, grow the embryos and decide when to put them back in. Based on her age and other factors, we decide how many. And finally, we do genetic or chromosomal testing of the embryos to see if they’re normal.”
Infertility treatment is a balance between success and reducing complications—mainly reducing multiple pregnancies, he explains.
Years ago, reproductive medicine specialists like Dr. Spandorfer used to freeze the eggs of one category of patients only: those undergoing chemotherapy or radiation therapy for cancer. With dramatic improvements in the methods used for freezing eggs, “fertility preservation” is now being offered to a much wider range of women, including those who don’t feel quite ready to get pregnant, don’t have a partner yet or are concerned about their age. These patients still undergo the same IVF process. They receive the same medications. The only difference? “We retrieve the eggs, but then we freeze them without having to fertilize them,” says Dr. Spandorfer. “Egg freezing is a great way to prevent a woman from losing the option of getting pregnant later on.”
Paying for treatment used to be a formidable obstacle for couples with incomes in the 99 percent, but nowadays, there are states, including New York, where infertility and IVF coverage is mandated. It all depends on what type of insurance you have. Even egg freezing is more likely to be covered that it used to be, Dr. Spandorder says. Before embarking on what might be a costly course of treatment, check with your insurance company to see which components are covered.
After all is said and done, the age of a woman’s eggs is the best predictor of success, not her uterus, which, paradoxically, does not seem to age. “That’s why we can grow an embryo composed of a younger woman’s egg and somebody else’s sperm and implant it into an older woman’s uterus. Best-case scenario, she can have a successful pregnancy.”
But with all the advances in IVF, egg freezing and the technologies that make these treatments possible, there’s no substitute for good communication between the couple or the woman on her own and the treatment team.
Realize that infertility treatment is stressful, not least because of the side effects of fertility medication. There are actually three psychologists on Dr. Spandorfer’s staff who can help manage the emotional impact of IVF; referrals to support groups are also on offer.
His best advice? Know your options. Make sure you can handle the financial side of the equation. And take care of yourself. If you are a good candidate for treatment and you decide to go through this challenging process, your health and wellness should be of paramount concern. So take a breath. Enjoy having sex. And take it step by step.
To make an appointment for a consultation at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at Weill Cornell Medicine, go to the center’s website here or call (646) 962-2764.