Infertility therapies

Infertility is the inability of a man and a woman to conceive a child throughsexual intercourse. There are many possible reasons for the problem, which can involve the man, the woman, or both. Various treatments are available thatenable a woman to become pregnant; the correct one will depend on the specific cause of the infertility.

Infertility treatment is aimed at enabling a woman to have a baby by treatingthe man, the woman, or both partners. During normal conception of a child, the man's sperm will travel to the woman's fallopian tubes, where, if conditions are right, it will encounter an egg that has been released from the ovary.The sperm will fertilize the egg, which will enter the uterus where it implants and begins to divide, forming what's called an embryo. The embryo will develop into a baby during pregnancy.

Infertility treatment attempts to correct or compensate for any abnormalitiesin this process that prevent the fertilization of an egg or development of an embryo.

It's important for a couple contemplating infertility treatment to examine their own ideas and feelings about the process and consider ethical objectionsbefore the woman becomes pregnant from such treatment.

About 90% of women who are trying to get pregnant and use no birth control will do so within one year. If, after one year of having frequent sexual intercourse with no contraception a couple has not conceived, they should seek theadvice of a physician. The doctor can rule out basic health problems that maybe causing a problem. If the couple is healthy, the next step is to get a referral to a fertility specialist. However, if a woman is over age 30, or hasa history of pelvic inflammatory disease, painful periods, miscarriage, or irregular cycles -- or if her partner has a known low sperm count -- the couplemay want to seek help sooner.

Treating an underlying infection or illness is the first step in infertilitytreatment. The physician may also suggest improving general health, dietary changes, reducing stress, and counseling. While most cases of infertility arecaused by physical problems, there are a host of other factors which can influence fertility success:

  • substance abuse: Even one glass of wine a month can lower the odds of getting pregnant by as much as 50% because it boostsprolactin levels, which can interfere with ovulation; occasionally, levels of prolactin rise so high it can lead to hyperprolactinemia ("too much prolactin"), making a woman essentially infertile until the prolactin level drops
  • coffee: Caffeine may interfere with fertility; drinking both coffee andalcohol can lessen fertility by 74%
  • marijuana: Some studies suggestthat men who smoke marijuana have lower sperm counts
  • bacterial vaginal infection: A vaginal bacterial infection can kill sperm; a doctor may suggest a cervical culture before trying to conceive
  • smoking: toxins in smoke can lower sperm count or slow down the sperm's ability to swim; it may take smokers up to seven months longer to conceive
  • douches, lubricants,soap: these products introduced into the cervical canal during or immediately following sex are potential sperm-killers
  • weight: women who weigh 30% more or less than their ideal body weight may have irregular periods and thus, more problems conceiving (very thin women may stop ovulating altogether)
  • stress: severe life stress can interfere with the menstrual cycle, which can make it harder to get pregnant
  • overheating: For healthy sperm, the testes should be 5 degrees cooler than a man's body temperature, so men should avoid hot tubs, saunas and steam rooms if a couple is trying to conceive
  • herbs: Taking large doses of echinacea, ginkgo biloba or St. John's wort over a long period of time damage hamster sperm, according to a recent report; more studies need to be done with humans to see if the risk is real
  • environmental toxins: Pesticides, chemicals and lead may cause somecases of infertility

Infertility treatments

Results from the tests will determine the treatments that are recommended, but 80% to 90% of infertility cases are treated with drugs or surgery. If thatdoesn't work, the next step would involve one of the new assisted reproductive technologies (ART).

Sperm production treatments

More than 5.3 million Americans ( 9% of the reproductive age population) areconsidered to be infertile; of the 80% of cases with a diagnosed cause, abouthalf are based at least partially on male problems (referred to as "male factor" infertility).

The most common cause of male infertility is failure to produce enough healthy sperm. For fertilization to happen, there must be enough sperm cells in theman's semen (the fluid ejected during sexual intercourse), and the sperm cells must have the right shape, appearance, and activity (motility). These sperm production problems can exist from birth or develop later as a result of severe medical illnesses such as the mumps or a sexually transmitted disease; ablockage caused by a varicose vein in the scrotum (varicocele); an endocrineimbalance, or problems with other male reproductive organs (such as the testicles, prostate gland, or seminal vesicles).

If a low sperm count is the problem, it's possible to restore fertility by:

  • Treating underlying infections
  • Timing sex to coincide with ovulation (when the egg is released from the ovary and starts to travel down thefallopian tube to be fertilized)
  • Having sex less often to build up the number of sperm in the semen
  • Treating any endocrine imbalance withdrugs
  • Having a surgical procedure to remove a varicocele

Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence. Treatment of the underlying problem may help this problem.

Fertility drugs

If infertility is due to a woman's failure to ovulate, fertility drugs or hormones can help bring hormone levels into balance, stimulating the ovaries andtriggering egg production. Therapy with the fertility drug Clomid or with amore potent hormone stimulator (such as Pergonal, Metrodin, Humegon, or Fertinex) is often recommended for women with ovulation problems. The benefits ofeach drug and the side effects (which can be minor or serious but are alwaysrare), should be discussed with the doctor. Multiple births occur in 10 to 20percent of births resulting from fertility drug use.

Between 80% and 90% of women using these methods will start ovulating, but the pregnancy rate is lower, depending on what other factors may be affecting your infertility.

It's quite common for women taking fertility drugs to experience depression,which can sometimes be quite severe. A recent Harvard University study foundthat women undergoing fertility treatments showed depression levels equal toa woman facing treatment for cancer or AIDS. The condition of infertility itself can be a depressing condition for many couples. In addition, fertility drugs trigger hormonal changes that can cause depression by interfering with estrogen (a natural antidepressant).

Surgical repair

Surgery to repair damage to a woman's your ovaries, fallopian tubes, or uterus may be recommended. In some women, infertility is due to blocked fallopiantubes. The egg is released from the ovary, but the sperm is prevented from reaching it because of a physical obstruction in the fallopian tube. If this isthe case, surgery may help repair the damage. Microsurgery can sometimes repair the damage to scarred fallopian tubes if it is not too severe. Not all tube damage can be repaired, however, and most tubal problems are more successfully treated with in vitro fertilization.

Fibroid tumors in the uterus also may cause infertility, and they can be surgically treated. Endometriosis, a condition in which parts of the lining of the uterus become imbedded on other internal organs (such as the ovaries or fallopian tubes) may contribute to infertility. It may be necessary to surgically remove the endometrial tissue to improve fertility.

Artificial insemination

Artificial insemination may be tried if sperm count is low, the man is impotent, or the woman's vagina creates a hostile environment for the sperm. In this procedure, the semen is collected and placed into the woman's cervix with asmall syringe at the time of ovulation. From the cervix, it can travel to the fallopian tube where fertilization takes place. If the partner's sperm count is low, it can be mixed with donor sperm before being transferred into theuterus. However, the procedure is not always successful. If there is no spermin the male partner's semen, then artificial insemination can be performed using a donor's sperm obtained from a sperm bank.

Sperm banks

A sperm bank maintains frozen sperm donated by healthy men, which are then screened for diseases and made available for implantation. In the United States, donating sperm is a commercial enterprise and donors are paid for their donations. (This is not the case in most other countries, where sperm donation is viewed much like giving blood -- as an altruistic service to help others.)

There are more than 400 sperm banks in the United States, some of which are state-licensed and regulated; however, throughout the country, complying withlicensing regulations and standards are still fairly voluntary. Current spermbank standards require initial and interval testing for at least some infectious diseases, including AIDS, syphilis and hepatitis B and C. Donors also should be occasionally tested for chlamydia and gonorrhea. Because a donor's sperm could be infected with a disease such as AIDS or hepatitis, most banks freeze and quarantine sperm for six months while the donor undergoes repeated testing for these diseases. The semen is released when the tests are negativefor at least 180 days after the donation. In addition, sperm banks guaranteea minimum number of live sperm per specimen.

Most sperm banks charge a fee or require a physician referral. Prepared semencosts between $100 and $250, depending on the location of the bank, the quantity of semen in each vial, and (among banks that reveal detailed characteristics) the popularity of the donor.

A couple can select a donor after reviewing donor characteristics (the amountof donor information varies from one bank to another). Some sperm banks offer just a brief physical description and a medical history, whereas others provide detailed information featuring donor hobbies, IQ, awards, education, personality, occupation and reasons for becoming a donor. By 1980, at least one"superbaby" sperm bank was established in order to allow Nobel Prize winnersto sell their sperm. Twelve years later, two more sperm banks in California began to specialize in selling the sperm of "gifted" men. One bank, the Repository for Germinal Choice affiliated with the Foundation for the Advancement of Man, provides detailed descriptions of each donor for approved applicants.

In the past, all sperm banks kept information about donors confidential, implying that payment for sperm severed all rights the donor might otherwise havehad. More recently, a few more progressive sperm banks release information about the donors to children born as a result of donor insemination, once theyreach 18. The Sperm Bank of California in Berkeley was the first bank to offer this service, releasing the name, address, phone number, social security number, driver's license number and hometown of donors. This "sunshine" policyis still fairly unusual in the United States, although fertility experts believe it may become more common over time. In Sweden, this "open donor identity" has been mandatory since 1989.

Many sperm banks also limit the number of children who can be born as a result of insemination from one donor to lessen the chance of closely-related biological children marrying each other. Most banks voluntarily set a limit of five children born per state and another five out of state. (It's possible, however, that the same donor may provide semen to another sperm bank, thus exceeding the recommended limit). To guard against marriage of closely-related biological children, some countries such as England and Sweden maintain a central registry that limits the total number of children from one donor's semen.

Assisted reproductive technologies

Some fertility treatments require removal of the eggs and/or sperm and manipulation in a laboratory to assist fertilization. These techniques are called assisted reproductive technologies.

When infertility can't be treated by other means or when the cause is not known, it's still possible to become pregnant through in vitro fertilization (IVF), a costly, complex procedure that achieves pregnancy 20% of the time. IVFmakes it possible to combine sperm and eggs in a lab to produce a baby that is genetically related to one or both partners. IVF is often used when a woman's fallopian tubes are blocked.

In this procedure, a woman's eggs are removed by withdrawing them with a special needle. Attempts are then made to fertilize the eggs with sperm from herpartner or a donor. This fertilization takes place in a petri dish in a laboratory. The dish is then placed in an incubator; about two days later, three to five fertilized eggs (embryos) are then returned to the woman's uterus. Usually one or two of the embryos survive and grow into fetuses, but sometimes three or more fetuses result. A child born in this method is popularly known as a "test tube baby," but in fact the child actually develops inside the mother. Only the fertilization of the egg takes place in the laboratory. If the woman does not become pregnant, she may try again in the next cycle.

A couple may prefer in vitro fertilization with a donor egg if, for example,a woman has impaired ovaries or carries a genetic disease that can be transferred to the offspring. In this case, eggs are donated by another healthy woman and fertilized in the lab with the partner's sperm before being transferredto the uterus.

In a variation of IVF called intracytoplasmic sperm injection (ICSI), singlesperm cells are injected directly into each egg. This may be helpful for menwith severe infertility.

A technique called gamete interfallopian transfer (GIFT) is a type of assistive reproductive technology similar to IVF, used if a woman has at least one normal fallopian tube. In GIFT, sperm and eggs are placed directly into the woman's fallopian tubes to encourage fertilization to occur naturally. This procedure is done with the help of laparoscopy, in which a small tube with a viewing lens t one end is inserted into the abdomen through a small incision. The lens allows the physician to see inside the patient on a video monitor.

If infertility is caused by a low sperm count, zygote intrafallopian transfer(ZIFT) can be tried. Also known as a tubal embryo transfer, this technique combines GIFT and IVF. With this technique, in-vitro fertilization is first performed so that the actual fertilization takes place and is confirmed in thelaboratory. Two days later, instead of placing the embryo in the uterus, thephysician performs laparoscopy to place the embryos in the fallopian tube, much like the GIFT procedure. A woman must have at least one functioning fallopian tube in order to participate in ZIFT.

Women who take fertility drugs have a higher likelihood of getting pregnant with more than one child at once. There are also rare but serious side effectsto fertility drugs.

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