As many women postpone having a baby until later in their lives, some will face infertility. But infertility is treatable through a variety of therapies, says Howard A. Zacur, director of Johns Hopkins Medicine's Division of Reproductive Endocrinology and Infertility.
How many women are affected by fertility problems?
Roughly 10 percent of women in the United States who are trying to become pregnant are affected, and this percentage has been relatively stable over time.
Medically speaking, how is infertility defined?
The common definition is the inability to become pregnant after trying for 12 months. But this is a very imprecise definition because it is known that a certain percentage of women who aren't pregnant after 12 months will become pregnant eventually if they keep trying.
But there is the "biological clock" factor, if you will, to consider. If you have an individual at age 39 or 40 who has not become pregnant after trying for 12 months, you certainly would want to act on the assumption that she is infertile -- because if you wait longer, she may have a depletion of her eggs, so fertility may be compromised further.
What are some of the causes of infertility?
When I talk to patients about this, I say, "OK, in order to become pregnant, you have to have eggs in the ovaries. You have to release them or ovulate. You have to have a partner or a source of sperm. And the passageway from the vagina to the cervix and fallopian tubes must be open in order to allow sperm and egg to meet. So any problem along those lines will result in infertility.
For example, if there is a low egg reserve in the ovaries or if the eggs are not released and so on, this will result in infertility. Those are the standard causes of infertility.
Are there other causes?
Yes. Some other causes might include endometriosis, which is when the lining of the uterine cavity is found to be growing elsewhere in the body such as on the surface of the ovary or uterus. How endometriosis causes infertility remains unknown. We and other medical centers continue to study how best to diagnose and treat this disease. Just because you have endometriosis does not mean that you are infertile, but if your fallopian tubes are both blocked, then you will have infertility.
When should a woman or couple consult a doctor about infertility?
As a general rule, couples should consider seeking medical help if they have been unable to conceive after one year of trying to become pregnant. Also, if the woman is 38 years of age or older, an evaluation for infertility might begin after less than a year of trying simply because there is a decline in the number of eggs in the ovaries with each passing year.
Could you describe some of the available therapies?
The types of therapy include stimulating the ovary with an oral medication called clompihene citrate. This affects the brain, pituitary gland and ovaries and doesn't result in a high percentage of multiple births.
Another therapy includes the patient taking clompihene citrate with intrauterine insemination -- or artificial insemination. In this therapy, a semen sample is taken and processed so that the sperm is suspended in a known buffer and is injected into the uterus.
And there is in vitro fertilization [or IVF]. Simply put, this is when you stimulate the ovary to get more than one egg and then surgically remove the eggs with a simple procedure. Then you mix them with sperm from the partner and fertilization takes place. This results in embryos, and one or two or three of the embryos can be put back in the uterus.
It's important for women to remember that the chances of becoming pregnant through this therapy are much better before 40 than after 40 years of age.
What's new in the area of infertility?
Assisted reproductive technologies, such as in vitro fertilization, are improving and are being used more frequently to treat infertility -- even before such procedures as a laparoscopy [a procedure in which a tiny video camera is inserted through a tube into the body] are done.
Women who are older and who have decreased numbers of eggs remaining in their ovaries are now able to benefit from IVF.
And patients may benefit from a more personalized treatment plan, which takes into consideration their age, medical histories and other factors.
This is a more targeted approach to diagnosing and treating a patient's infertility issues than the traditional fixed-protocol approaches.
When a patient first seeks treatment with you, what do you typically tell them?
Infertility is something that we can treat and do a very good job of treating. What I say to patients is that it really is perseverance that matters.
If you have this problem and continue with treatment -- then chances of success are high. It is very hard not to become frustrated and give up.
What about cost?
Maryland is one of the few states that has mandated, if you will, insurance for IVF, but there are strings on that. And I think there is an effort to restrict that. I hope that doesn't happen because it is a very effective therapy, and it could mean avoidance of a surgical procedure. But it is an expensive treatment to be sure.
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