Infertility

Infertility

When Nature Needs a Boost

When she got married in her early twenties, Carla Harkness thought she had plenty of time to have children.

"We wanted kids, but we wanted to get a home and our careers going before we started a family," says Harkness, a 43-year-old freelance writer in Berkeley, California, and author of The Infertility Book.

But as she approached 30 and she and her husband, Bob, decided the time was right, nature didn't cooperate. "We tried for about a year, and nothing happened," Carla recalls. "Meanwhile, everyone in our age group seemed to be getting pregnant. Our friends and family started asking us what the problem was--why were we waiting so long? There was this feeling that we didn't have much time left to try. I really felt like my biological clock was my enemy and I was aging fast."

Carla and Bob's story is typical of the 10 to 15 percent of American couples who struggle with infertility. Like many other couples, they watched months turn into years and hope melt into disappointment. Sex became a chore, and each month that Carla didn't conceive made her feel a little more over the hill.

"Infertility is devastating. One of the major aspects of a woman's sense of youthfulness is her ability to reproduce," says Reed C. Moskowitz, M.D., founder and medical director of the Stress Disorders Medical Services at New York University Medical Center in New York City and author of Your Healing Mind. "There's nothing more devastating to a woman than struggling with the realization that she can't conceive a child. Psychologically, it can damage her self-esteem and make her feel like she is really getting old and decrepit."

What Is Infertility?

Most likely, you learned the ABCs of making babies in a high school sex education class. You probably remember your teacher droning on about how normally during intercourse a man ejaculates millions of sperm into the woman's vagina and these sperm travel up into the fallopian tubes. There, if the couple happens to have sex during the one or two days a month when a woman's egg is released from the ovary and is traveling down one of the tubes, the sperm and the egg meet. If one of the sperm penetrates the egg, fertilization occurs, and pregnancy begins. If conditions are ideal and the couple doesn't use contraception, there is a one in five chance of pregnancy each month.

But your teacher probably didn't tell you what could go wrong. Infertility is usually diagnosed after a couple has had intercourse without contraception for 12 months or more and has failed to conceive. Infertility can occur even if you've had children in the past. About 40 to 50 percent of the time, doctors determine that the woman has problems in her reproductive tract, says Frederick Licciardi, M.D., assistant professor of obstetrics and gynecology at the New York University School of Medicine in New York City. In another 40 percent, they can pinpoint that the man is the cause of the problem. Sometimes both the man and the woman have difficulties that are interfering with pregnancy, and about 10 percent of the time, doctors can't determine the cause.

For a woman, the basic problem usually is that she isn't ovulating (producing an egg) or that her fallopian tubes are blocked or damaged so that the egg and sperm can't meet. There are many causes for these two conditions, including hormone deficiencies, pelvic infections, fibroid tumors, cysts, sexually transmitted diseases such as gonorrhea and chlamydia and endometriosis, the disease that caused Carla Harkness's infertility. Endometriosis occurs when cells from the uterus begin growing on the ovaries and in the fallopian tubes, causing inflammation and scarring.

"At least 50 percent of women who come to an infertility clinic have endometriosis," says Donald I. Galen, M.D., director of the In Vitro Fertilization and Reproduction Medical Division at San Ramon Regional Medical Center in San Ramon, California. "No one really knows why it happens, but it definitely interferes with fertility."

Endometriosis and pelvic infections can also cause ectopic (tubal) pregnancies. About 1 in every 100 pregnancies is ectopic, meaning that instead of traveling on to the uterus, the fertilized egg implants itself and starts to grow on the fallopian tube or ovary or even in the abdomen. An ectopic pregnancy must be ended because, untreated, the growing fetus can endanger the life of the mother or severely damage the fallopian tubes and prevent future pregnancies, according to Niels Lauersen, M.D., Ph.D., a founding member of the New York Society of Reproductive Medicine in New York City and author of Getting Pregnant.

Impaired cervical mucus, a discharge that usually helps carry sperm into the uterus, is another cause of infertility. If cervical mucus is thickened or is reduced in quantity, sperm may be prevented from reaching the fallopian tubes, says Eli Reshef, M.D., a reproductive endocrinologist at the University of Oklahoma Health Sciences Center in Oklahoma City. Fertility experts suspect some women can also develop antibodies that mistakenly identify sperm as harmful invading organisms and that reduce sperm's capacity to reach or penetrate the egg.

Smoking, alcohol abuse, drugs, stress and exposure to pollution, chemicals and radiation can also reduce a woman's fertility, Dr. Galen says.

When Time Marches On

But for many women, the real problem is time, because as a woman ages, her fertility--that all too real biological clock--gradually winds down.

"Age 40 is a critical time for women, because that's when we start to see dramatic declines in their fertility rates," Dr. Galen says.

"Infertility occurs in less than 1 percent of couples in their teens," says Sherman Silber, M.D., a fertility specialist at St. Luke's Hospital in St. Louis and author of How to Get Pregnant with the New Technology. "In the twenties, it rises to 13 to 15 percent and climbs steadily until 35, when it takes a dramatic turn upward. Twenty-five percent of couples between the ages of 35 and 40 are infertile, and after 40, nearly 50 percent will not be able to conceive."

So although infertility is usually considered a possibility after one year, couples older than 35 who have tried unsuccessfully to conceive for six months should seek medical help, Dr. Licciardi says.

"After six months, come in and at least get some testing started," Dr. Licciardi suggests. "It doesn't mean you have to do anything at that point, but at least you'll get rolling with the diagnostic process."

Beating the Clock

Overcoming female infertility often requires the help of a gynecologist or reproductive endocrinologist, who, after testing, may suggest fertility drugs or high-tech wizardry (more on that later). But there are some natural ways you can try to boost your chances of having a child. Here's how.

It takes good timing. Make sure you're ovulating when you try to get pregnant. Remember that you produce only one egg a month and that it can be fertilized only during the one or two days after you ovulate. "Yes, most woman know approximately when they ovulate, but sometimes they're not exactly sure," Dr. Licciardi says. To find out if the time is right, you can keep track of your basal body temperature. Each day, take your temperature when you awaken, before you do anything else. Your temperature should drop just before ovulation and rise after an egg is released. If that seems like too much hassle, then consider getting an ovulation predictor kit, an over-the-counter urine test that changes colors if you're about to ovulate. It's available at most pharmacies.

Soothe your stress. "Stress can disrupt ovulation and cause spasms of the fallopian tubes, which interfere with the passage of the egg down the tube," Dr. Moskowitz says. Practicing stress reduction techniques such as biofeedback or progressive muscle relaxation can help.

Make sure you're turned on. Women who are really aroused produce higher hormone levels, and that may increase their chances of getting pregnant, Dr. Lauersen says. Allow at least 20 minutes for foreplay, he suggests.

Close the escape hatch. Immediately after intercourse, lightly press the lips of your vagina together with your fingers for several minutes, Dr. Lauersen suggests. Doing this will help keep sperm inside you and give them a chance to begin swimming toward the fallopian tubes.

Don't move. After sex, lie on your back with a pillow under your pelvis for 20 to 30 minutes. This will encourage sperm to move toward your fallopian tubes, Dr. Lauersen says.

Try cough medicine. Cough medicines containing the active ingredient guaifenesin (such as Robitussin) thin out cervical mucus and help sperm swim through it easier, Dr. Lauersen says. Take one or two teaspoons a day, beginning three or four days before you ovulate.

Put a cap onlubricants. Jellies and other lubricants may make sex easier, but they can impair the sperm's motility even if they don't contain spermicides, says Wolfram Nolten, M.D., associate professor of endocrinology at the University of Wisconsin­Madison Center for Health Studies.

Ease up on extreme exercise. Intense exercise such as running 40 or more miles a week may cause irregular periods and disrupt ovulation, says Mary Jane De Souza, Ph.D., an exercise physiologist at the University of Connecticut Health Center in Farmington. The reasons are still unclear, but torrid exercise may suppress production of reproductive hormones.

However, moderate aerobic exercise such as walking, swimming or biking, three times a week, 20 to 30 minutes a session, shouldn't affect your ability to get pregnant, Dr. Reshef says.

Whack the weed habit. If you smoke, your chances of becoming a mom may literally be going up in smoke, Dr. Galen says. Women who smoke produce fewer eggs. Even if she does get pregnant, a woman who smokes is more likely to have a miscarriage than a woman who doesn't.

Steer clear of carbon monoxide. Studies suggest that carbon monoxide may drive down fertility rates. That's another reason to quit smoking and to stay away from secondary smoke, since both produce large amounts of carbon monoxide. Wood-burning stoves and fireplaces also create carbon monoxide, so make sure that your flues are clear and that your rooms are well ventilated, says Jarnail Singh, Ph.D., professor of biology and environmental toxicology at Stillman College in Tuscaloosa, Alabama. The federal Environmental Protection Agency also recommends that you have your home heating system checked annually to make sure that the exhaust system is working properly.

Get your protein. Of course it's hard to avoid all the places where there are high concentrations of carbon monoxide, but a protein-rich diet can be a good way to fight back, Dr. Singh says. In laboratory studies, Dr. Singh found that mice exposed to carbon monoxide and fed a diet that was only 8 percent protein were five times less fertile than mice in the same environment that were fed 16 percent protein. "The best suggestions I could make for women who are trying to get pregnant are to increase the amount of protein in their diets and to avoid any kind of environment where carbon monoxide is present," he says.

If you want to boost the protein in your diet, a typical day's menu might include a cup of oatmeal and a cup of yogurt for breakfast, a tuna salad sandwich and a cup of navy bean soup for lunch, a cup of yogurt for an afternoon snack and a cup or two of lasagna for dinner. Avoid traditional sources of protein such as fatty beef and other red meats because they're loaded with saturated fat and cholesterol, which contribute to heart disease.

Keep your weight in line. Reproductive hormones, including estrogen, are thrown out of balance if you're too skinny or overweight, and that will make getting pregnant much harder, Dr. Lauersen says. For maximum fertility, try to maintain a weight within the range suggested by your gynecologist.

Curb your caffeine. Coffee, tea, colas and other beverages containing caffeine may increase your risk of some types of infertility, says Francine Grodstein, Ph.D., an epidemiologist at Harvard University School of Public Health in Boston. In a study comparing the caffeine consumption (prior to conception) of 3,833 women who had recently given birth and 1,050 women who had infertility problems, Dr. Grodstein found that women who drank more than two cups of caffeinated coffee or four cans of cola per day had greater risk of having tubal damage or endometriosis. She speculates that caffeine either constricts blood flow and damages the fallopian tubes or stimulates estrogen production, which can lead to endometriosis.

Dissect your drugs. Although most medications do not affect your chances of conceiving, some prescription drugs such as antidepressants and illegal ones such as marijuana and cocaine increase your risk of infertility and other sexual problems, according to Dr. Lauersen. Discuss any over-the-counter, prescription or illegal drugs you are taking with your gynecologist.

Limit your liquor. Excessive amounts of alcohol can cause irregular ovulation. "Drink in moderation," Dr. Galen says. "I'd say no more than one or two alcoholic drinks a day."

High-Tech Conception

Okay, so like Carla Harkness, you and your partner have tried everything natural, and you're still not parents. Don't give up hope yet. In most cases, experts can pinpoint and treat infertility problems with dramatic advances in drugs and surgery. More than half the couples seeking such treatment will get pregnant. RESOLVE, a support group for infertile couples, can refer you to a specialist in your area. Write to 1310 Broadway, Somerville, MA 02144-1731.

So what will a doctor do? After thorough testing, he may prescribe fertility drugs such as clomiphene (Clomid) or menotropins (Pergonal) to stimulate ovulation. If you have endometriosis or blocked fallopian tubes or have had an ectopic pregnancy, your doctor may recommend corrective surgery. In Carla's case, she had two surgeries over five years to remove her endometriosis and tried several medications. Within three years, she had a daughter, then a son seven years later.

If there has been scarring of the fallopian tubes or a patient doesn't respond to fertility drugs, doctors will suggest one of the many high-tech fertilization methods.

These aren't cheap--they can cost more than $15,000--and often aren't covered by insurance. Here's a sample of some of the most successful high-tech options.

Artificial insemination. Semen is deposited directly into the vagina or uterus. If the man's sperm is of poor quality, the couple could try donor sperm.

In vitro fertilization (IVF). Eggs are surgically removed from a woman's ovaries, transferred to a petri dish and mixed with her partner's sperm for fertilization. After a two-day incubation, usually a few fertilized eggs (or embryos) are placed into the uterus.

Gamete intrafallopian transfer (GIFT). Eggs and sperm (gametes) are inserted into the fallopian tube, where, it is hoped, fertilization takes place.

Zygote intrafallopian transfer (ZIFT). As in IVF, eggs and sperm are combined in a petri dish and incubated for two days. But rather than being placed into the uterus, the embryo, or zygote, is placed into the fallopian tube. From there it will travel a natural course down the tube and into the womb for implantation. The advantage of this procedure over GIFT is that you know fertilization has taken place.

Zona drilling. In this laboratory test-tube technique, a surgeon uses chemicals, a laser beam or a needle to open part of the outer layer of the egg, or the zona pellucida, so that sperm have a better chance of penetration.

Microinjection. In this procedure, which is in the experimental stage, a thin needle is used to insert a single sperm into an egg.