Still not pregnant? When to seek infertility treatment and when to let nature take its course.
The good, if not great, news is that the latest advances in infertility treatment have made it possible for more people than ever before to become parents. The bad news is that growing numbers of couples may be jumping the gun and seeking infertility treatments without giving Mother Nature a chance. Infertility treatments, such as drugs that stimulate ovulation, are not without their risks — namely a risk of multiple pregnancies, which can be dangerous for moms and babies.
“The classic definition of infertility is the failure to cause a pregnancy within one year,” says Edmund Sabanegh Jr., MD, director of the Center for Male Fertility at the Cleveland Clinic in Ohio. This is age-dependent, however. Six months of trying is the cutoff for prospective parents aged 35 or older.
That said, “there is certainly so much anxiety and stress [about having children] that we routinely have couples coming in after only a few months of trying.” “If we move right to testing and treatment, we do a disservice because a lot of them would do just fine if we left them alone.”
Still Not Pregnant? Take a Deep Breath
The first thing we do is to reassure couples that they are still within the normal range,” he says. “Humans are efficient reproducers, but we are not rapid reproducers compared to the rest of animal kingdom.”
A little sex-ed refresher doesn’t hurt either, he says.
“If a couple comes in at three months and they are very stressed, we talk to them about what is the normal fertile time and how to best time intercourse to get the best results,” he says. “We lower their anxiety by talking about the facts of human reproduction and give them opportunities to talk to other couples who have gone through similar things so they realize that this is normal, they are normal, and that [reproduction] takes time,” he says.
To help cool anxiety, a quick physical exam and history can be done even before a year or six months to help rule out any major causes of infertility. This type of exam may help reassure future parents that there is nothing wrong and that if they continue to try, they will likely be able to conceive a child within a year. In fact, 85% of couples will conceive a child within a year of trying.
“If there is an obvious factor in their history that is suggestive of a fertility problem, such as a history of cancer or certain chemical exposures, we may do a full evaluation earlier,” he says. “In these cases, it doesn’t help to wait a year, and we may lose the window of opportunity for pregnancy.”
Other red flags that could indicate a fertility problem earlier in the game include irregular menstrual cycles.
When to Get the Full Infertility Workup
After trying for one year, doctors may recommend a full infertility workup. They may opt to do this sooner if the couple is aged 35 or older, says Mindy Shaffran, MD, a reproductive specialist at East Coast Fertility in Plainview, N.Y.
“After the age of 35, it is recommended that couples try for six months instead of a year,” she says. “The majority of couples will be successful in that time, and if you are not, there may be things that we want to catch sooner rather than later.”
“Fertility declines rapidly after age 35 and sometimes it gets to the point where we can’t really help,” she says. “It behooves women in this age group to start the process earlier even if they would have gotten pregnant on their own so they know that there is not any particular problem that they need to overcome,” she says.
There are many possible causes of infertility, and a full workup will try to identify exactly which is causing the problem. Doctors will examine potential causes of both male infertility and female infertility. The results will help dictate and guide infertility treatment.
The process starts by consulting an infertility specialist. The full workup will entail a semen analysis for the man. In women, the infertility workup consists of blood testing to check levels of thyroid hormone and other hormones, a Pap test to check for changes in the cells of the cervix or infection, and a hysterosalpingogram (HSG), an X-ray procedure that makes sure that the fallopian tubes are open. The HSG can also detect any abnormalities in the uterus.
It’s suggested that men get tested first. “Routine semen analysis is quick and relatively inexpensive.” “Before we put women through invasive, expensive, and painful tests, we better have a pretty good idea that those tests are necessary,” she says.
For couples who want to complete the evaluation as rapidly as possible, They says she will initiate a workup on both partners simultaneously. “Many couples will often have more than one factor at the root of their infertility.”
Troubleshooting Your Fertility Problem
If a problem is identified in terms of the ovulation process, the first-line infertility treatment is typically Clomid or Serophene, drugs that work by stimulating ovulation. “This is usually paired with intrauterine insemination (IUI),” They says. IUI is a fairly low-tech procedure in which sperm is injected directly into the uterus to meet – and hopefully fertilize — a waiting egg.
“We try this for three to six months and if we are unsuccessful, then I may try an injectable and IUI,” They says. Injectable drugs also stimulate ovulation, but are stronger than Clomid. As such, the use of injectables has an even greater risk of multiple pregnancies.
“If that fails, we may advance to something like in vitro fertilization (IVF).” IVF involves combining eggs and sperm outside the body in a Petri dish. Once an embryo or embryos form, they are then placed in the uterus where they will hopefully implant. After several failed courses of IVF, couples may consider using donor eggs or adoption.
Sometimes the cause of the infertility is unexplained. “This can be harder to treat, as there is nothing particular that we can identify as the problem.” “If tubes are blocked, at least we know that the tubes are blocked and we can take steps to overcome it.”
Sometimes de-stressing and taking the focus off of conception is the missing link. “There are studies that suggest stress plays a role in infertility and as a result, we offer mind and body programs that involve counseling as well as acupuncture and massage therapy,” They says.
Infertility Treatment: Risk vs. Reward
We all know the (presumptive) reward of infertility treatment – a beautiful bouncing baby girl or boy (or both), but there are risks, says Millie Behera, MD, a reproductive endocrinologist at Duke University Medical Center in Durham, N.C.
“The biggest risk seen with any type of infertility treatment is multiple pregnancies.” Risks inherent in multiple pregnancies include preterm labor and birth, which poses greater risks of illness, disability, and death. There is also a higher chance of miscarriage and other maternal complications with multiple births.
Overstimulation is a risk if women are given too high a dose of drugs to stimulate ovulation. This is marked by melon-sized ovaries, pain, discomfort, nausea, vomiting, and fluid in the belly. Women who are overstimulated may also get dehydrated and their blood can become thickened and clots may develop, she explains. What’s more, “there hasn’t been good data on the long-term outcomes of these drugs,” she says.
The bottom line? “If we are dealing with two healthy people, give it time because chances are that it will all work out and you don’t have to go through invasive, painful, and expensive testing or procedures,” she says.
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