The Fast Track To Fertility, A Modern Guide To Overcoming Infertility

By Sherif Awadalla

Infertility is an extremely common disorder. In the past fifteen years, the treatment of infertility has undergone dramatic change, with diagnosis and therapy becoming much more specific and targeted. Many procedures that were once experimental, such as in vitro fertilization, are now available on a routine basis and offer excellent success rates with rapidly diminishing risks of multiple births. We hope that this book, which is the result of our combined clinical and research experience as well as that of our contributing colleagues, will serve as your comprehensive, modern guide to dealing with infertility and the many facets of its treatment.
Throughout this book we have stressed the fact that, in order to enhance the results of therapy, it is essential that you do not delay in having a complete initial investigation followed by targeted, specific therapy under the guidance of a specially trained physician. Delay in the diagnosis or treatment of infertility is a significant mistake that can dramatically reduce your chances of a successful pregnancy. Remember that seeking appropriate care as soon as possible will allow you to achieve the best results as quickly as possible with the least expense. We have called this approach, aimed at achieving a successful pregnancy in the least amount of time in the most cost-effective manner, the Fast Track to fertility. Each couple must choose the best option that is consistent with their values and ethical beliefs while trying to beat the biologic clock. We wish you and the thousands of other couples struggling with infertility the best of luck.

• Language: English
• Publisher: Sherif Awadalla
• Release date: Feb 25, 2012
• ISBN: 9781466115309

Sherif Awadalla

Sherif G. Awadalla, M.D. Dr. Awadalla serves as Medical Director at the Institute for Reproductive Health (IRH). He is also co-director of the In Vitro Fertilization program at IRH, and holds the title of Volunteer Assistant Professor in the Division of Reproductive Endocrinology and Infertility in the department of Obstetrics and Gynecology at the University of Cincinnati College of Medicine. Previous positions include Director of Reproductive Research at Bethesda Hospital, Assistant Professor of Obstetrics and Gynecology at West Virginia University, and Medical Director for the In Vitro Fertilization Program at West Virginia University. Dr Awadalla has conducted and published numerous research projects in the areas of endometriosis, microsurgery, infertility, in vitro fertilization, GIFT, ovulation induction, and gamete maturation. His current areas of interest include leading edge treatments of infertility such as in vitro fertilization with all of its variation. He is active in pelvic reparative surgery both by microsurgical techniques, such as tubal reversal surgery, as well as laparoscopic laser and robotic techniques. Michael D. Scheiber, MD, MPH, FACOG Dr. Scheiber has authored numerous peer-reviewed articles as well as book chapters, and currently serves as the Co-Director of In Vitro Fertilization Services and the Director of Reproductive Research at the Institute for Reproductive Health in Cincinnati, Ohio. He also serves as Volunteer Associate Professor of OB/GYN at the University of Cincinnati, and on the Editorial Board of the Journal of Gynecologic Surgery. Previously, he served as the Director of Women’s Health at the Palau Community Health Center in Koror, Palau. Dr. Scheiber has received multiple awards and recognition, including the Ortho Pharmaceutical Award for Excellence in Research as well as the Berlex Foundation Award for Resident Education. His professional interests include IVF-embryo transfer, preimplantation genetic diagnosis, ovulation induction, PCOS, and laparoscopic/ hysteroscopic surgery. He lives in Cincinnati with his wife of more than 20 years and their three wonderful daughters. Thomas H. Burwinkel, MD, FACOG Dr. Burwinkel joined the Institute for Reproductive Health in January of 2011. He previously served as the Medical Director of Kettering Reproductive Medicine for ten years. He also served as an assistant professor, and clinical associate professor, at Wright State University in the department of Obstetrics and Gynecology for eighteen years. Dr. Burwinkel’s research has included: endometriosis, fibroids, ovulation induction, in vitro fertilization, micromanipulation, in vitro maturation, co-culture systems, polycystic ovarian syndrome, and surgical adhesion prevention. He performs pelvic surgery to help infertile women, using operative laparoscopy, robotic surgery, operative hysteroscopy as well as traditional open procedures including microsurgical techniques, such as tubal anastomosis procedures.

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Acknowledgements

Writing this book was a two year effort. We both agreed that it should be done. We knew that the time was right because so much has changed in our field. We knew that couples were constantly searching for information. Because the field is rapidly changing many of the books out there are outdated. To give you an idea of the rapidity of change, several chapters had to be modified while the book was in preparation in order to make their content timely and relevant. What we did not know at the beginning was what a mammoth undertaking this book would be.

We want to thank several individuals for contributing a chapter each. Dr. Jason St Pierre contributed and excellent chapter on the male factor. Dr Joyce Friedman wrote the chapter on emotional concerns. Two of our expert billing specialists wrote the chapter on dealing with insurance. Sheila Lilze and Karen Hauser contributed this chapter which addresses one of the most pressing concerns of our patients. We also were fortunate enough to have two excellent contributors to the graphic content of the book. Our graphics illustrator was: . Also Shannon Kolatz who is a student at the University of Michigan contributed several excellent diagrams for the book.

We would like to thank our wives for supporting us through this project. They both assumed many of our duties at home so we would have time to work on the book. Susan Awadalla contributed the title of the book. Jayne Scheiber from the Department of Chemistry at Berkley contributed greatly to the editorial process. Our dedicated office staff made many suggestions for improvement during manuscript preparation. Several of our patients read early versions of the manuscript and made helpful suggestions. They encouraged us to continue the effort.

We have tried to make the information in this book as accurate and comprehensive as possible. It is intended as a guide and not a prescription for your infertility treatment. We have stressed in the book that medical consultation sooner rather than later will give you the best outcome. We want to emphasize that this book is not a substitute for treatment by a qualified health care professional. We therefore are not responsible for any adverse outcomes or consequences which are experienced by any individual utilizing the information contained in this book. Please use this book to help you understand medical treatment. It is certainly not a substitute for professional health care.

Introduction

This work is a contemporary guide to the efficient diagnosis and treatment of infertility. It is written for the millions of couples all over the world who suffer from this common condition. Because of the previous stigma associated with the inability to conceive, couples with this disorder suffered silently for decades. Fortunately, there is more and more discussion about infertility today. Unfortunately, much of this discussion comes in the form of tabloid covers, sensational TV talk shows, TV drama series, and advice from helpful but misinformed family members and neighbors. Much of the readily available information about infertility is outdated, extremely fragmented, or comes from random and inaccurate web site postings. The resultant discussion of infertility is, therefore, often full of myths and misconceptions.

Few people who don’t suffer from infertility understand the emotional pain associated with this condition. As two physicians who have decades of combined experience with infertility treatment, we see couples constantly searching for accurate information. Couples want to know what causes infertility and what treatment is best for them. They worry about the cost of treatment, the possibility of failure, and the risk of multiple births. Many frustrated couples turn to their primary care physicians, who often have very little experience diagnosing or treating infertility and either don’t have the answers to the pertinent questions or don’t have the time to discuss them in detail. It is for these couples that we have written The Fast Track to Fertility.

The field of infertility treatment has undergone revolutionary changes with the advent of In Vitro Fertilization (IVF) and the associated reproductive technologies. New effective treatments and medications become available every year. Now, more than ever, there is a true need for an accurate, timely book that clearly explains the truth and dispels the myths and misconceptions surrounding fertility diagnosis and therapy.

This book discusses in clear, concise, and medically accurate lay terms the basics of normal human reproduction. It discusses the causes of infertility. Most important, we outline the steps in diagnosing and treating this medical condition efficiently and quickly. It is towards this goal that we have designated the emphasis of this book as the Fast Track to Fertility. While this term is often used in the fertility community to refer specifically to a strategy of skipping certain steps in treatment and going immediately to IVF, we use the term more broadly to refer to an individualized strategy for each couple. We attempt to stress the importance for each couple of quickly identifying the cause of infertility and moving very quickly to a specific treatment plan to maximize their fertility potential with a minimum of cost and suffering. For many couples the Fast Track may mean moving quickly to IVF. For other couples the Fast Track may be as simple as lifestyle changes. But for all couples, the point remains that the sooner a problem is identified and treated appropriately by a professional, the better the chances are for a healthy conception and pregnancy outcome.

Infertility treatment does not have to take forever! In fact, using the Fast Track approach outlined here, the majority of cases can be resolved within six to seven months and many cases even sooner. We offer advice on how to deal with the emotional trauma associated with infertility, as well as practical guidance on lifestyle issues that impact fertility. This book offers a sobering warning to those who attempt to defy the biologic clock. It also offers hope for those who seek out the facts and have the courage to pursue their dream of parenthood.

We have been privileged to have worked with thousands of couples over the years and have obtained a successful outcome for the majority of those couples. We have learned that infertility treatment is more of a journey than a destination. This book is intended as a tribute to the perseverance and endurance of those who have journeyed with us. It is also intended to offer hope and guidance to those of you who are just beginning your own journey and to ensure that your journey takes the Fast Track!

Chapter 1

The Big Picture

Why this book is written just for you…

If you’re reading this book, most likely you or someone you love is suffering from infertility. You already know the heartbreak of facing a menstrual period month after month and possibly year after year. The average couple suffers through two to four years of this ordeal before seeking help. We regularly see couples who have suffered with infertility for more than ten years.

Infertility is painful enough to deal with in and of itself. But none of us lives in a vacuum. While you’re not getting pregnant, you take note of the fact that everyone else around you seems to be! Your friends and family are constant reminders of your ordeal. Baby showers, pregnant women, strollers at the mall, and holidays are all powerful reminders that everyone else has what you don’t have! Many couples rate infertility as the most emotionally stressful experience of their lives. It can damage your self-esteem as a man or a woman. It can cause depression and extreme anxiety. And infertility can be traumatic for your relationship as a couple. While it is true that hardship can bring you closer together as a couple, it can also tear you apart.

Adding stress to the couple’s relationship is the fact that men and women often see the same picture from different angles. In our experience, women often view infertility as an urgent problem in need of immediate resolution. Men are more willing to take a let’s keep trying and maybe it will happen approach. Be careful. This latter approach can throw you right off the Fast Track to fertility and severely limit your treatment options and odds of success.

There can also be a great deal of denial associated with infertility. The majority of naturally conceived pregnancies will occur within six to nine months of unprotected intercourse. The couple who says, We’ve only been trying for a year but hasn’t used any form of contraception for five years, has really experienced at least five years of infertility. They have already wasted precious time with the diagnosis and treatment of their condition.

Even one month of trying to get pregnant unsuccessfully can be an ordeal. The month starts and you wonder when you will ovulate. Maybe you’re using an ovulation prediction kit or a temperature graph. You get up every day to test your temperature, urine or both. You may be worried that you are not having sex at the right time of the month. Should you have sex every day, every other day, or several times a day? Can having sex too frequently also be a problem? The most intimate part of your lives can become a burdensome chore under these circumstances, driving a wedge between you.

During this ordeal, everyone you know seems to be telling you to relax and you’ll get pregnant. What could be more annoying! How can you relax when you’re going through all this? You get through the ovulation time and you wait day after day, hoping and praying that your menstrual period won’t start. It does start. How depressing! No one needs to face failure in addition to cramping and bleeding every month. Your friends and family have already offered unsolicited, well-meaning, and probably useless advice. Every month you must decide anew if you should go to see your family physician, your Ob/Gyn or a specialist. Or should you wait and just keep trying (and possibly suffering)?

If this scenario sounds all too familiar, you have come to the right place. This book is about one thing: helping you to get pregnant as quickly as possible. In most cases pregnancy should be possible within six to seven months or even sooner when handled appropriately by a qualified and caring physician! When doctors treat a medical condition, their goal is to obtain a cure as soon as possible. Why then is the treatment of infertility usually so dragged out? It is because doctors and patients have been taught to view it as a non urgent condition. We beg to differ! If you can’t get pregnant, then it is an urgent issue for you! The biologic clock, as you will come to see, never stops ticking.

You may have understandably already waited a little too long to start thinking about getting pregnant. You wanted to finish your education, get established at work and maybe buy a house. But don’t delay any further. It is important to consider that you may want to have more than one child. If treatment for the first pregnancy takes forever, the second chance may be gone. All of these issues make staying on the Fast Track urgent! If you feel this sense of urgency, then this book is written just for you.

This book can be your starting point on the Fast Track to fertility. It will provide you with the basic facts about normal and abnormal reproduction and guidelines for the efficient diagnosis and treatment of infertility. In our combined experience of treating infertility seven days a week for over three decades, we have learned most of the pearls and potholes that you may encounter. This book will let us help you take advantage of the pearls and avoid the potholes so that you can stay on the Fast Track to fertility.

Infertility: Fact vs. Fiction

Infertility is defined as the failure to conceive after one year of intercourse without any form of protection. Infertility is a global problem that affects 15 to 18 percent of couples of childbearing age worldwide. The Center for Disease Control (CDC) estimates that 7 million U.S. couples have difficulty with fertility.

Although knowledge in the field of infertility has expanded dramatically, there have been barriers to the delivery of healthcare in this area. Infertility can cause a couple to experience both physical and emotional stress. Patients with infertility should receive the same quality of care and the same kind of insurance coverage as patients with other medical conditions. Most developed countries, including England, France, Australia, Japan, and many others, offer much better infertility benefits than the United States. In order to improve the delivery of these services, we must educate patients, physicians, nurses, and hospital administrators as well as Congress and health insurers. Today, more than ever, we are able to treat successfully most conditions that cause infertility. Evaluation and treatment of infertility should not be delayed because of myths and misconceptions held by both healthcare professionals and the general public.

For instance, it is widely believed that stress causes infertility. In truth, physical and emotional stress is more likely the result rather than the cause of infertility. Perhaps because infertility is an issue that generally affects women, it has unfortunately been trivialized for decades. It is often easier to tell women to relax and you will get pregnant than to deal with the underlying disease process that is causing the infertility. It is both frustrating and annoying for someone going through infertility treatment to hear that if they just relaxed they would get pregnant. Relaxing has never been shown to unblock damaged tubes or change a sperm count of zero!

One common misconception is that if you are patient and just keep trying, pregnancy will eventually occur. The unfortunate fact is that if one year has passed without conception, it is relatively unlikely that pregnancy will ever occur without medical assistance. After the first year of infertility, the yearly conception rate will not exceed 4 to 5 percent for most couples.

Another misconception is that having intercourse at the wrong time within the menstrual cycle can lead to infertility. It is highly unlikely that a couple having intercourse as little as twice a week on average will experience infertility of any significant duration due to poor coital timing. In addition, studies have shown that, even in couples who are not trying to conceive, the frequency of intercourse tends to be greatest around the time of ovulation, perhaps related to hormonal effects on human behavior.

One thing that is crystal clear is that the age of the woman (and to a lesser extent the man) does dramatically affect her odds of ever conceiving. This is commonly known as the biologic clock. It is now understood that the egg supply undergoes constant attrition during human life and that this attrition starts while the woman is still a fetus. It is therefore ideal that evaluation and treatment of infertility occur as early as possible to obtain the best possible outcome. Sperm quality in men will also decrease with age somewhat, but the change in pregnancy potential is much less significant that that with women. Delaying evaluation and treatment may leave patients with fewer options and lower success rates.

Don’t let any of these myths bump you off the Fast Track to fertility. Remember, the sooner you get help, the sooner you’re likely to get pregnant.

When should you look for help?

Couples often wonder when they should seek evaluation and treatment. In young, healthy couples without fertility concerns, the conception rate per menstrual cycle is approximately 22 percent. At six months of attempting conception, roughly 50 percent of all couples have been successful. At one year, roughly 85 percent have conceived. In couples that have not conceived after one year, the monthly conception rate decreases dramatically with each subsequent cycle. Therefore, it has been traditional to recommend that couples seek treatment after approximately one year of unprotected intercourse. If the wife is thirty-five or more years of age, it is now recommended that they seek treatment after six months due to the effect of the biologic clock on the ovary.

Women in their mid-twenties are at their peak fertility potential. Following the age of thirty-two, there is a significant decrease in monthly fertility rate. Following the age of thirty-eight, there is further dramatic decrease in monthly fertility. Another reason to seek therapy early is that the incidence of miscarriage rises significantly after the age of thirty-five and dramatically after the age of forty. For women in their mid-twenties, the miscarriage rate is roughly 20 percent. Women who are greater than forty years of age have miscarriage rates that approach 40 to 50 percent. In patients in their late thirties and early forties, the incidence of chromosomal errors such as Down syndrome also increases dramatically, making early treatment not only more successful but safer as well.

In addition to age, other factors should prompt couples to seek help sooner. If there is a history of gynecologic surgery such as removal of a tube or ovary, you should be evaluated earlier. If you have had a pelvic infection in the past such as Chlamydia or gonorrhea, then earlier evaluation is better. If your menstrual cycles are irregular, then you should seek help immediately. Similarly, a history of infertility in a previous relationship should prompt you to seek help quickly.

Waiting too long will frequently lead to poorer results with treatment. People tend to delay evaluation because of hope and fear. They hope that they will get pregnant if they just keep trying. They are afraid that treatment will be difficult and expensive. Ironically, waiting too long is the best way to make treatment more difficult and more expensive. Early diagnosis and treatment is your ticket to success with the least amount of pain!

What type of specialist should you see?

In most communities the obstetrician/gynecologist (Ob/Gyn) will be the first contact point. He or she is a doctor trained specifically in all aspects of care of the woman’s reproductive system. The Ob/Gyn treats pregnant and non pregnant women, delivers babies, performs hysterectomies, and provides other gynecological services. He/she is also involved in annual screening exams that include Pap smears and mammography. To some extent he/she will also be involved in the care of the infertile patient. During residency training, the Ob/Gyn will have had some brief but specific training in infertility. If your Ob/Gyn has time, he/she can certainly be involved in the initial diagnosis and treatment process. If you are thirty-five years or older or, if after working with the Ob/Gyn for four to six months you have still not conceived, then referral to an infertility specialist is critical. Once you conceive, your Ob/Gyn or nurse midwife can then take care of you again and will be the one to deliver your baby.

A family practice physician treats adult men and women as well as children. This primary care physician has had some minimal training in obstetrics and gynecology. He or she will usually do very little infertility diagnosis and treatment. Your family physician can be an excellent source of referral to a qualified specialist. Some family physicians still do deliveries and will resume your care once you are pregnant.

For a variety of reasons, you may choose to see an infertility specialist. Perhaps your doctor has referred you, or you as a couple have made the decision to seek expert care because too much time has passed without conception. Reproductive Endocrinology and Infertility (REI) is a formal subspecialty of Obstetrics and Gynecology, and a true infertility specialist is called a Reproductive Endocrinologist (RE). A Board Certified RE has been trained twice: once for four years of residency as an Ob/Gyn, and then a second time for three years of fellowship as an RE. He or she has had to pass four separate board certification examinations, two for general OB/GYN and then two more for REI, to become a board certified infertility specialist. Typically an RE only treats infertility and female hormonal disorders. He or she will not do deliveries or general gynecologic services. Focusing only on infertility treatment allows the RE to dedicate sufficient time and resources to treat the more complex cases of infertility in the community.

It is important to distinguish between someone specializing in infertility and an infertility specialist. Any physician can advertise to specialize in infertility treatment. However, only a Board Certified Reproductive Endocrinologist has been specifically trained and certified to be an infertility specialist.

For the male member of an infertile couple, a family physician, Ob/Gyn, internist or urologist can order the initial semen analysis. If the semen parameters are abnormal or if there is some physical difficulty such as with a prostate infection, then a urologist will be consulted. He or she is a specialist in the male reproductive tract. All urologists have been trained in male infertility. They can do basic evaluation and testing. Some urologists have been subspecialty trained in male infertility and routinely perform vasectomy reversals or testicular sperm aspirations. These techniques are discussed in detail in later chapters. Your Ob/Gyn or RE can refer you if necessary to a urologist who specializes in infertility treatment.

How Do You Choose a Specific Doctor or Practice?

Once you have made the important decision to seek help from either an Ob/Gyn or a specialist like an RE, you have the task of selecting a particular physician or group. This choice is extremely important, as these professionals will be the conductors on your Fast Track to Fertility. You want to work with a doctor who is competent, communicative, and understands how you feel about the situation. If you have been trying for a long time or are over thirty-five, then you will probably want to see an RE right away. If you are just beginning the investigation or are younger, then an Ob/Gyn will be able to help you with the initial diagnosis and treatment of infertility. You can often get a recommendation of a specific doctor or group of doctors from friends and family. Your primary care doctor can also suggest a physician or group for you to see. Some local or national infertility organizations also maintain referral lists. If