women
Q: We've been trying to conceive for 12 months—can the doctor identify the problem?
A: There are many factors that can increase or decrease your chances of becoming pregnant, but if you have been trying for a year, it would be sensible to contact your doctor. After an initial assessment of your general health and lifestyle, your doctor will offer your partner a sperm test and you will be offered tests to see if you are producing eggs and check whether or not your fallopian tubes are blocked. Blood tests will be carried out to check your iron levels, your red and white blood cell count, and to check how organs such as your liver and kidneys are functioning. In addition, couples are asked to agree to a sexual health screening to check for previous or current STIs, such as HIV and syphilis.
Q: My wife has been tested and has the all clear—how can I tell if I'm causing our fertility problem?
A: You will be offered a semen analysis to determine your sperm quantity and quality—how sperm move (motility) and whether they are a normal form. A healthy sperm count should have a concentration of 20 million spermatozoa per milliliter of semen, with 75 percent of these alive and 50 percent of these “motile,” or moving as well as possible. Differences can occur over time in both the quality and quantity of sperm, so if your first sample is poor, you will probably be tested again a couple of months later.

You are also likely to be advised to give up smoking, reduce alcohol intake, and to wear loose-fitting underwear to avoid overheating the testes. If a problem is found, you will be referred to a specialist. Try to avoid becoming stressed since this can also affect fertility. Learning relaxation techniques with your partner and practicing these regularly will help.

Q: We can't conceive naturally—what do we do now?
A: Assisted conception, or assisted reproduction, is the term used when women are helped to conceive without having intercourse. There are five main procedures available, listed below. Your doctor will go through each one with you, and together you can make a decision about which is most appropriate depending on your problem. You can also contact the Center for Disease Control and Prevention (CDC) for more information (www.cdc.gov/art).
  • Ovarian Stimulation (OS), or Super Ovulation (SO) , involves injections of fertility hormones to boost egg production. This is followed by intrauterine insemination (IUI) of sperm, whereby sperm are collected and sorted so that only the strongest remain and these are then artificially placed inside the uterus via a catheter. This is ideal for couples when the man's sperm is “slow” or the woman has problems ovulating, or there is a combination of both.

  • Gamete Intrafallopian Transfer (GIFT). This is for couples for whom no cause for infertility has been found. It involves stimulating the ovaries to produce eggs, which are removed, mixed with sperm and replaced directly into the fallopian tubes, allowing conception to occur inside the body.

  • In Vitro Fertilization (IVF). This is the most widely used treatment and involves a seven-step process (see What does IVF involve and IVF Treatment). This is ideal for most problems, including blocked tubes.

  • Intracytoplasmic Sperm Injection (ICSI). This is used if the man's sperm count is low, the motility of the sperm is very poor, or the woman is allergic to her partner's sperm. The treatment involves injecting just one viable sperm into an egg (see ICSI).

  • Artificial Insemination by Donor (AID). This is simply the injection of donated sperm into the cervix. This is used when a man is unable to maintain an erection or is sterile. Similarly, women may require an egg donation if they are unable to produce their own eggs, although this is more complicated.

  • Whatever treatment is provided, it is important that you and your partner are treated as a couple rather than separate patients. It is also essential that you are kept informed throughout the process and given information on any risks and benefits.

Q: What does IVF involve?
A: IVF, or in vitro fertilization, involves the surgical removal of an egg, which is then mixed with sperm in a laboratory dish to fertilize and produce an embryo outside of the womb (see IVF treatment).

IVF treatment occurs in cycles, since there are various stages that must be completed for it to be successful. Initially, a drug is used in the form of a nasal spray or injection to switch off the woman's natural cycle of egg production in the ovaries, known as “down-regulation”. Fertility drugs are then given to stimulate the ovaries to produce more than one egg (ovulation induction). Mature eggs are collected from the ovaries using a fine needle guided by ultrasound. The procedure is usually uncomfortable rather than painful. On the same day, the partner's sperm is collected and then the eggs and sperm are mixed in a dish. Within a few days, multiple embryos are transferred into the womb. If an embryo successfully attaches to the inside of the womb and continues to grow, a pregnancy results.

Q: What are the success rates of fertility treatments?
A: Success rates for treatments vary, depending on the treatments used and the health of the couple. If you want to know the success rates of individual clinics, you can ask for their ratio of “live-births-per-cycle-started.” This information is available from each clinic.

Overall, couples have a better success rate if the woman is age 23–39 years, has been pregnant or had a baby, and has a normal body weight (a BMI between 19 and 24). The older a woman is, the less likely she is to conceive and maintain the pregnancy.

Figures show that for every 100 women who are 23 to 35 years, more than 20 will get pregnant after one IVF cycle; from 36 to 38 years, around 15 will get pregnant; at 39, around 10 will get pregnant; and in women over 40, around 6 will get pregnant.

Q: IVF is so expensive—can we get help with funding?
A: Yes, in many cases, financial assistance for infertility is available. Before you embark on any treatments, it is important to check your health-care coverage. Some plans do have limited support for treatment. Public assistance programs vary by state but most do not cover in-vitro fertilization. However, office visits to discuss early management of infertility may be covered. Get an explanation of coverage by calling your state medical assistance hotline or website. Once you have decided to seek care with an fertility clinic ask about financing. Some offer payment plans or “packaging” of treatments.
Q: My partner is worried about producing his sperm sample. How can I reassure him?
A: Since fertility problems affect 1 in 6 couples in the us, reassuring your partner that this is not an unusual situation is always a good start. You could try leaving a pamphlet on fertility problems for him to read for more information. Try to empathize with him as much as possible by sharing your experiences and the tests you have undergone.

Your partner may be worried about ejaculating at the required time, when he is already feeling anxious and is in a clinical environment. Some men require a sex toy, magazines, or video clips to help. For others, restraining from sexual intercourse for a few days can make ejaculation easier. If you live fairly close to the clinic, your partner may be able to produce the sample at home and deliver it.

Sometimes a medical condition such as diabetes prevents a man ejaculating. If this is the case, sperm can be obtained through “sperm recovery”, whereby a small needle is passed through the skin of the scrotum into the testes and sperm is withdrawn.

Q: The drugs I'm taking for IVF are giving me terrible mood swings. Is this normal?
A: The drugs used in IVF treatment are female hormones to stimulate your ovaries to mature more than one egg at a time, and progesterone, which helps to sustain a pregnancy. Different levels of hormones can result in mood swings, as any woman who suffers with pre menstrual symptoms can testify, and this is also a common side effect of IVF treatment. It's worth considering too that couples undergoing IVF are under incredible stress, which has been linked to an increased risk of developing depression, so it's important to decide whether you are feeling “hormonal” or are in fact depressed. Your doctor can advise you and refer you if necessary.
Q: My partner has a low sperm count—can you tell us what help is available for us?
A: Usually, two or three semen samples are used to figure out the average sperm count and to see if there are abnormal sperm present. A healthy semen sample of 2–5 ml contains more than 20 million sperm per ml; a count below this is considered low. If your partner has abnormal sperm, further testing may be necessary. Lifestyle changes can boost sperm. There are also hormonal treatments to improve sperm count and surgery to remove blockages. You may be reassured to know that even poor-quality semen can be used to fertilize an egg with IVF or with ICSI.
Q: Can lifestyle changes really improve sperm?
A: Poor-quality sperm has been linked to excessive drinking (more than three or four ounces of alcohol per day), smoking, and to wearing tight-fitting underwear, which overheats the testicles and can affect their efficiency. Excessive stress and a poor diet are also thought to affect sperm. So yes, it is worth reviewing your lifestyle to see if improvements can be made. Jobs that may expose you to harmful agents, such as pesticides, may also affect sperm, so if you think your partner's job may pose a risk, it's worth investigating.
Q: I'm pregnant using a donor—what happens if my child wants to trace her biological dad?
A: While the UK requires fertility clinics to register donor information, including names, in a database that offspring can view when they reach 18, no such law exists in the US. Laws change over the years and guidelines for donations and regulations for sperm banking adapt to technology and public attitude. Sperm donors may have been given the opportunity to register as either anonymous or nonanonymous but data may have been lost through the decades. Some donors are known to the mother, or “private” so no records exist. There are laws which protect donors from obligations to their offspring but the number of children permitted to be born from a single donor varies according to bank policy and state statute.
Q: Is surrogacy allowed in the US?
A: Yes, but not in all states. Always obtain legal assistance and check the laws regarding surrogacy in your state before entering into an agreement. Two types of surrogacy are addressed in state laws. In traditional surrogacy, a surrogate mother is artificially inseminated, either with donor sperm or the sperm of the intended father. In gestational surrogacy, eggs are from the intended mother and fertilized with the sperm of the intended father or donor. A fertilized egg is then implanted into a surrogate mother who carries the baby. Some states prohibit surrogacy agreements in all instances while others allow only gestational surrogacy and some allow uncompensated agreements only. Some allow surrogacy contracts without regard to marital status or sexual preference while others prohibit surrogacy agreements unless it is for the benefit of a married couple.

ICSI (Intracytoplasmic Sperm Injection)

This procedure may be used when it is thought that the quality of the partner's sperm may be responsible for fertility problems.

If the sperm count is low or movement is poor, sperm may be “assisted” in fertilizing the egg. An individual sperm is injected directly into the egg and, if fertilization takes place, the resulting embryo is placed in the uterus.

Surrogacy

A surrogate mother is a woman who reaches an agreement to carry a baby on behalf of another woman. She can either conceive the baby with the partner's sperm, in which case she is the biological mother, or the infertile couple may fertilize their own egg through fertility treatment, which is then transferred into the uterus of the surrogate mother for her to carry the baby through pregnancy and deliver at birth. This process can be beset with problems: such as the conflicting emotions of both the surrogate mother and the receiving couple, or legal issues if, for example, the surrogate mother has a change of heart after the birth and wants to keep the baby. For this reason, it is important that all parties entering into the agreement have carefully considered the implications and are confident and happy in their roles.

A growing bond:

Some couples develop a strong relationship with their surrogate mother, supporting her during the pregnancy and birth, and maintaining a close link with her after the baby is born.

NOTE

If you have been trying for a baby for over a year, it may be time to talk to your doctor—there may be a simple solution

NOTE

The best way to improve your sperm count is to consider your lifestyle: eat healthily, drink less, and avoid tight pants!

Conception problems Conditions preventing conception

There are a range of reasons why a couple may have difficulty in conceiving. Investigations and tests may uncover specific conditions, which may be treatable, or you may be offered help to conceive.

Q: What can affect a man's fertility?
A: A semen analysis may reveal various reasons why sperm have difficulty in fertilizing an egg. The sperm count may be low (less than 20 million sperm per ml); the motility of the sperm (how they move) may be poor; and there may be a high percentage of abnormally formed sperm. Some men experience a failure to ejaculate at orgasm. There may also be damage to the tubes that connect the testicles to the seminal vesicles where sperm are produced, and this may have been present from birth or caused by a later infection.
Q: What can affect a woman's fertility?
A: Conditions such as polycystic ovary syndrome (a hormonal imbalance that causes ovarian cysts) and endometriosis can disrupt fertility. Other hormonal imbalances, such as low levels of FSH and LH, can affect ovulation; or levels of progesterone may be too low to sustain a fertilized egg. Damaged fallopian tubes, caused by an ectopic pregnancy, surgery, endometriosis, or pelvic inflammatory disease, which may be caused by an infection such as chlamydia, can prevent conception. Damage to the ovaries can occur from scarring as a result of surgery or infection, or the supply of eggs may be low. Some women have an abnormally shaped uterus, or have uterine scarring, that can prevent the successful implantation of an egg.
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