infertility and ways to treat it

by Isobel Jacobs

infertility | help and info

The body is a delicate thing. And reproduction – that complex, urgent process required to conceive a baby and carry a pregnancy to term – involves almost all of it. The man must produce enough strong, healthy sperm to penetrate cervical mucus and fertilise an egg. A woman's cervical mucus must be at the right pH and consistency to facilitate the sperm's journey to the reproductive tract; the ovaries must release healthy eggs; the fallopian tubes must be clear and open; the uterus must be suitable for implantation of a fertilised egg. And, all along, the endocrine system, the one that produces hormones, must be secreting various substances in just the right sequence and just the proper levels for pregnancy to occur.

you're not alone

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No wonder things can go wrong. Today, one in five couples have problems with fertility, with a third of cases being due to female infertility, a third due to male infertility and another third of cases remaining unexplained. Very little can prepare a couple who have been thinking of having children for this diagnosis of infertility – or for the battery of tests and procedures that will follow, should they decide to do something about it. Very little can also prepare them for the strain on their relationships, their finances, their career and their happiness.

Hilary's appendix burst when she was 16, spreading infection throughout her system and leading in turn to blocked fallopian tubes, internal adhesions and scarring. Now 35, she has had two attempts at IVF in the last 12 months. Both were unsuccessful: 'I knew about my condition for quite a long time but even then, it was still a shock. Once you start the treatment, it's like a steeple chase. You've got a series of hurdles in front of you, a series of tests you have to pass. You put all your hopes into it and, although you realise the chances are low, however realistic you are, you can't ever explain how it feels when it's not successful.'

Her partner, David, also found it difficult. 'The first time we had IVF, David was a bit freaked out about how clinical it was. He didn't understand how hard it was even to get to the first stage. The second time, he understood it much better. He's disappointed about not having children more easily but he doesn't blame me. He's been extremely supportive.'

causes of female infertility

The most common cause of female infertility is problems with ovulation (the release of a mature egg from its follicle – the tiny bag containing the developing eggs in the ovary). Fortunately, it is also the one with the best chance of successful treatment.

Other common causes include Polycystic Ovarian Syndrome, or PCOS, as well as problems with the fallopian tubes. Women with PCOS often suffer from hormonal imbalances that affect ovulation. The fallopian tubes, which carry the eggs from the ovaries to the womb and are the site of fertilisation, can be blocked by scar tissue and adhesions. These can be caused by conditions such as endometriosis in which cells that normally line the womb migrate elsewhere. During a woman's period, these cells cause inflammation and subsequent pain and scar tissue.

causes of male infertility

Male fertility rates appear to be falling; speculation centres around the growing openness of men to talk about such problems or, more frighteningly, environmental factors to explain the drop. Men can suffer from abnormally shaped sperm, high levels of antisperm antibodies in the semen, poor sperm quantity, not enough sperm or, at worst, no sperm at all, a condition known as azoospermia.

Potential causes range from obstruction of the ducts through which sperm normally pass to insufficient levels of the hormones for good sperm production. Damage to sperm production can also occur as a result of infection, physical injury and exposure to toxic substances or drugs.

what treatments are available?

The reasons for a couple's fertility problems will inform their choice of treatment. If eggs and/or sperm are damaged but fairly healthy, a couple can pursue having their own child (a child biologically related to both of them). Treatments include hormone therapy (using fertility drugs to stimulate ovulation), artificial insemination, and a number of methods that involve physically combining egg and sperm outside the woman's body. Of these last, IVF is the best-known.

If a man suffers from azoospermia or a woman's ovaries cannot produce eggs, for instance, a couple may think in terms of trying for a child biologically related to one partner but not the other. For this, donors will need to be found – but donor options are not easy options. Even though parents have the opportunity to raise a child from conception, the partner not genetically related to the child is left in a curious position: will she or he feel like a parent or not? Counselling is usually offered.

If both the male and female partners in a relationship are unable to create children, the couple may try for a child through embryo donation, when a fertilised embryo related to neither the man or the woman is placed in the woman's uterus. Implanting an embryo in an unrelated woman is called surrogacy. Finally, adoption or accepting a child-free life are options that require no medical intervention but, again, counselling is offered.

success rates

National average success rates are given under the individual treatments below. However, it should be remembered that the chances of success depend very much on individual circumstances, in particular the cause of your infertility and your age – younger women are more likely to get pregnant than women over 40. These success rates should also be considered alongside the statistics for an average couple with no fertility problems, who have about a 20-25% chance of getting pregnant in any given menstrual cycle.

in vitro fertilisation (IVF)

what happens?

IVF or test-tube fertilisation is the process of collecting eggs from a woman and fertilising them with sperm outside the body. The woman is given drug therapy to encourage the ovaries to produce more eggs. This will often consist of drugs designed to suppress hormones followed by another course of drugs designed to super-stimulate the ovaries to produce eggs. The almost menopausal state that results from the suppressants seems to encourage the ovaries to respond more actively when the stimulants are given. As soon as the drugs are stopped at the end of treatment, the 'menopausal' effect ceases.

The treatment can have significant effects on mood and physical condition. 'The first time around, I felt terrible,' says Hilary. 'I didn't know what was going on. The next time, I had a different treatment which didn't involve the menopausal bit until later and I felt really good. I was hyper-fertile, having wickedly filthy dreams every night and responding really well to treatment.'

Once the eggs are ready, they are removed from the woman's ovary and mixed with a fresh sample of her partner's sperm. If fertilisation occurs, the developing egg or embryo is then placed back into the woman's uterus. Two, or occasionally three, embryos are inserted into the uterus, after which the woman may take progesterone to support any possible pregnancy. Most couples then have to wait two weeks, one of the most difficult times, before finding out whether a pregnancy is developing.

If sufficient embryos of good quality develop, there may be an option to freeze them and replace them, after thawing, in a subsequent cycle.

IVF requires a great deal of commitment from a couple; some couples find it difficult to carry on working during a treatment cycle when they may be expected to attend clinics at unsociable hours (there are only specific times in their cycle that drug treatment can start or eggs can be collected). Many women also find the collection of eggs uncomfortable.

Hilary's first treatment was difficult but she looks back on it positively: 'The first time you do it, don't take too much notice of it. It's a way of them finding out about you so that they know how you're going to react. Don't be discouraged, no matter how difficult it is.'

who is it suitable for?

Women with:

• blocked or damaged Fallopian tubes
• endometriosis
• hostile cervical mucus
• problems with ovulation

Men with:

• poor sperm quantity or quality
• antisperm antibodies

IVF is, surprisingly given the press coverage it gets, suitable for only about 20% of couples suffering from infertility.

success rates

The average success rate for IVF is 17% per treatment cycle, and slightly less (12%) for frozen embryo transfer.

gamete intra-fallopian transfer (GIFT)

what happens?

A variation of IVF, GIFT involves taking an egg and sperm from a couple, mixing them together and putting them back, right away, into the fallopian tubes. Fertilisation can then take place within the fallopian tubes, as it would do naturally. This is the treatment's main difference to IVF.

who is it suitable for?

• Couples with unexplained fertility

Women with

• endometriosis
• hostile cervical mucus

At least one fallopian tube must be healthy and functioning for GIFT to take place.

Men with

• mild infertility problems

success rates

The success rates for GIFT are up to 30% per cycle.

artificial insemination (AI)

what happens?

Artificial insemination refers to a range of techniques of placing sperm directly into either the cervix or the uterus. The procedure takes about five minutes during which – often after a course of drug therapy to stimulate the ovaries – the doctor places a carefully prepared semen sample into the woman's cervix or uterus, or at the top of her vagina. Fertilisation is then allowed to take place naturally.

who is it suitable for?

• Couples with sexual difficulties

Women with

• endometriosis
• cervical mucus hostility

Men with

• problems ejaculating inside their partner's vagina
• low sperm count

success rates

6-9% for high vaginal insemination. 10-12% for cervical or intrauterine insemination.

intra cytoplasmic sperm injection (ICSI)

what happens?

ICSI, a relatively new procedure, involves injecting a single sperm into the very centre of each egg, thus helping the sperm through natural barriers it may not be able to tackle on its own.

who is it suitable for?

• Couples who have failed to achieve fertilisation following standard IVF treatment

Men with

• poor sperm quality

success rates

22% live birth rate.

complementary treatments

People often turn to alternative medicine when conventional treatments have failed to cure the problem. Its holistic aspect – treating the body and the mind and looking at diet, and psychological as well as physical factors – make it an attractive option but many of its practices are untested and unproven. However, there have been some undeniable successes. Chinese herbalism, for instance, has been credited, anecdotally, with increases in male sperm levels although care must be taken – cases of reduced sperm counts have also been known.

Each discipline approaches infertility according to its beliefs. Acupuncture operates on the principle that infertility may be caused by blocked energy pathways; cranial osteopathy works on a woman's skull and pelvis, looking for problems with the natural rhythm of the spinal fluid so as to correct energy flow; hypnosis relaxes people.

Before her second attempt at IVF, Hilary went to see a homeopath. 'Initially, I was very sceptical but I followed my homeopath's advice to the book. I was taking dietary supplements of vitamins, minerals and herbs; I also gave up drinking – not a drop for two months before treatment started. There's a lot of scepticism about some alternative treatments but, even though I didn't get pregnant, all the conditions for it were much better this time. I also usually suffer from really bad PMT and even that improved.'

surrogacy

Another alternative for couples who can't conceive, or have had repeated miscarriages or other health problems, is surrogacy. This is where a woman agrees to have a child on behalf of another woman or couple, then gives it to them at birth. It's not an option to be taken lightly, as it involves all sorts of emotional and legal issues.

Surrogacy can either be partial or full. With partial surrogacy, the egg is provided by the surrogate mother and the intended father donates the sperm, which is then inseminated. With full surrogacy, the surrogate mother is merely a carrier of a baby for another couple, as the pregnancy uses both the sperm and eggs of the intended parents. Assisted reproduction techniques such as IVF are used to collect and implant the eggs and sperm.

Surrogacy does work for some couples and gives a chance to those who can't have children themselves. But anyone considering acting as a surrogate needs to think long and hard about it before committing. Not only can it be emotionally demanding to go through the physical act of carrying a baby for nine months, giving birth and then handing it over, but it can also put a strain on existing relationships. As much as your partner may agree in theory to the idea, when you're actually going through with it, it can unleash all sorts of unexpected emotions. Having a good level of support is essential for all those involved in surrogacy.

For the woman carrying the baby – even if it isn't genetically her child – she can be affected by all sorts of unexpected reactions due to the change in hormones during pregnancy. Her body will have altered, she'll has to undergo the physical demands of giving birth and her body will be all geared up ready to breastfeed, yet the baby won't be hers to feed. It takes a strong and determined woman to go through all these changes on behalf of someone else.

It's not just the woman acting as a surrogate who can be emotionally affected by the process, but also the couple who will bring up the baby. Psychologist Dr Sandra Wheatley says, 'Couples can end up feeling like they're not a real mother and father. If the father's sperm has been used, then he can feel vulnerable because he effectively had a relationship with the surrogate as well as his partner.'

Surrogate mums are recommended to have had at least one child previously and ideally have finished their own family. If they're donating their own eggs, then an upper age limit of 35 is recommended. This is because of the extra problems that can occur in pregnancy for older women.

'Surrogacy contracts are not legally enforceable. All arrangements are individual and they can fail in all sorts of ways,' says Dr. Wheatley. 'Any of the people involved, at any state, can change their mind and this is a concern. Adults are able to take adult decisions, but you need to keep in mind that there is a baby involved, and it has no say.'

(updated January 2008, resources updated June 2005)

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