Infertility and IVF: A Womb with a View
Dr. John Janousek, M.D.
Prior to medical school I worked in reproductive medical labs performing in-vitro fertilization, or IVF. I was an embryologist, the one who joined the egg and sperm together in petri dishes to form human embryos. I saw firsthand the anguish of couples who suffered from infertility and the joy when “miracle babies” were born from assisted reproductive technologies.
The usual course of life for most couples is dating, marriage, then children, and when they cannot become pregnant everything changes. There is terrific emotional stress, feelings of guilt and worthlessness, depression, and frequently marital discord.
Infertility treatments have become very advanced and more successful. IVF has come a long way since the first American baby, Elizabeth Carr, was born 27 years ago after her mother was treated by Drs. Howard and Georgiana Jones here in Hampton Roads at EVMS in Norfolk.
What is infertility?
Infertility is defined as the inability to get pregnant after trying for at least one year. Women who have repeated miscarriages are also infertile.
What are the steps in becoming pregnant?
An egg must be released from a follicle on an ovary (ovulation), and must enter one of the fallopian tubes leading to the uterus. Sperm must be present to fertilize the egg along this journey. Finally, the fertilized egg (embryo) must attach to the walls of the uterus. Conditions that interfere with any of these steps can cause infertility.
How common is infertility?
Very common. About 12% of women have trouble becoming pregnant. In couples, about 1/3 of the time it is a female factor, 1/3 are male factors, and 1/3 are a combination or unknown.
What are the causes of infertility in women?
The most common cause is a problem with ovulation (commonly hormonal). Other causes include blocked fallopian tubes (from pelvic inflammatory disease, endometriosis, or surgery), uterine problems such as a bicornuate uterus (2 compartments) and fibroids. Advanced maternal age decreases fertility as well.
What are causes of infertility in men?
Some men produce too few sperm or even none at all. Others have sperm which have an abnormal shape or impaired ability to move (motility problems). Other sperm appear normal on microscopic exam, but for biochemical reasons cannot penetrate the egg.
Trying, but no baby; what next?
Ok, a couple has been trying for a year to become pregnant without success. What are the next steps? The couple should get an appointment with a gynecologist who has experience in infertility treatment. A woman can contact her gynecologist to ask about an infertility work up or a referral.
What are some of the steps in infertility testing?
To test ovulation, a woman can check her basal body temperature every morning, check her cervical mucus texture, or use a home ovulation test kit. Blood work and ultrasounds can also be performed.
A hysterosalpingogram (HSG) is used to check for blockages in the fallopian tubes. Dye is injected through the vagina into the uterus, and fluoroscopy (continuous x ray) enables the physician to watch its passage. Laparoscopy (surgery) involves insertion of a fiberoptic scope through the skin into the pelvic area to directly visualize the reproductive organs. This is also the definitive method to diagnose endometriosis (abnormal location of cells from the lining of the uterus).
Men typically have a semen analysis done, and they can be referred to an urologist for further evaluation. Some conditions such as a hydrocele (swollen blood vein) may require a minor surgery.
What are some infertility treatments?
Infertility medications are given to women to help them ovulate and to mature and release more eggs from multiple follicles which increases the chance of conception. Artificial insemination involves washing and concentrating a sperm sample with injection into the uterus. Treatments are targeted at overcoming the specific problems identified (see steps in becoming pregnant above). Assisted Reproductive Technology (ART) refers to more advanced treatments.
What are some types of ART?
IVF refers to joining of the egg and sperm with fertilization outside of the body, in a special type of petri dish containing specific culture media. The woman is given hormone injections causing the ovaries to produce many eggs. When the eggs are mature, they are removed usually by needle aspiration and joined with the sperm in the lab. Embryos are replaced through a catheter inserted through the cervix into the uterus about 3-5 days later.
The Jones Institute’s clinical pregnancy rate per embryo transfer procedure is about 43%. Nationwide in the best clinics, there is about 22-32% “take home baby rate” per transfer; this takes into account miscarriages and ectopic (tubal) pregnancies. The CDC has a good site about ART with data from all reporting programs.
Intracytoplasmic sperm injection (ICSI) is used to overcome sperm problems, and involves using a microscope and special tiny needles to inject a single sperm directly into an egg without harming it.
Working as an embryologist was a very interesting and rewarding job for me, although I always worried about dropping the small petri dishes containing human embryos (never happened). The patients were incredibly thankful when the process worked (but of course the doctor got all the credit).
I remember a party I attended at that time, where a woman found out what I did for work. She began telling me loudly and in detail all about her husband’s low sperm count and the problems they had conceiving. The poor fellow was standing there trying to shrink into the wood work!
Remember, infertility is a common problem that can be treated, although even now many couples are not successful. About 85% are treated medically or surgically with only about 5-10% progressing to the point of needing IVF or other ART.
Infertile couples need plenty of emotional support as the inability to produce children is a huge stressor. Sexual union, instead of being an act of love turns into a mechanical process of trying to achieve the elusive goal of pregnancy, with each menstruation bringing on feelings of failure.
The good news: There are a lot of treatment options and we have one of the world’s best infertility centers close by in Norfolk at the Jones Institute. Also, let’s keep in mind another option: adoption; some of the area’s greatest people were adopted, namely ME!
Disclaimer: This does not take the place of regular medical care, and is not a complete review of any medical conditions. Consult with a physician before any treatment or taking any medications. Seek medical attention immediately for any serious symptoms, or call 911. No current or local patients have been referenced, so any resemblance is purely coincidental.