What is Infertility?

Infertility is a disease of the reproductive system that impairs one of the body’s most basic functions: the conception of children. Conception is a complicated process that depends upon many factors: production of healthy sperm by the man and healthy eggs by the woman; healthy fallopian tubes that allow the sperm and the egg to unite; the ability of the sperm to fertilize the egg when they meet; the ability of the fertilized egg (embryo) to become implanted in the woman’s uterus; and sufficient embryo quality.

Finally, for the pregnancy to continue to full term, the embryo must be healthy and the woman’s hormonal environment adequate for its development. When just one of these factors is impaired, infertility can result.

Who is an Infertility Specialist?

An infertility specialist is a physician that has completed a fellowship of specialty training in Reproductive Endocrinology and Infertility after completing a four-year residency in Obstetrics and Gynecology. An infertility specialist has spent 2-3 years studying and specializing in infertility evaluation and treatment. You should look for a physician that is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility for your infertility care.

What Causes Infertility?

In rough terms, about one-third of infertility cases can be attributed to male factors, and about one-third to factors that affect women. For the remaining couples, infertility is caused by a combination of problems in both partners or, in about 10 percent of cases, is unexplained.

The most common male infertility factors include azoospermia (no sperm cells are produced or none in the ejaculate) and oligospermia (few sperm cells are produced). Sometimes the vas deferens is blocked. For some men, the sperm cells are malformed or they die before they can reach the egg. In rare cases, infertility in men is caused by a genetic disease or a chromosomal abnormality.

The most common female infertility factor is an ovulation disorder. Other causes of female infertility include blocked fallopian tubes, which can occur when a woman has had pelvic inflammatory disease or endometriosis (a sometimes painful condition causing adhesions and cysts). Congenital anomalies (birth defects) involving the structure of the uterus or uterine fibroids are associated with infertility or repeated miscarriages.

How is Infertility Diagnosed?

Couples are generally advised to seek medical help if they are unable to achieve pregnancy after a year of unprotected intercourse. The doctor will conduct an examination of both partners to determine their general state of health and to evaluate physical disorders that may be causing infertility. Usually both partners are interviewed about their sexual habits in order to determine whether intercourse is taking place properly for conception.

If no cause can be determined at this point, more specific tests may be recommended. For women, these include an analysis of ovulation, x-ray of the fallopian tubes and uterus (HSG), and possibly a laparoscopy. For men, initial tests focus on semen analysis and evaluation of sperm function.

How is Infertility Treated?

Most infertility cases — 85 to 90 percent — are treated with conventional therapies, such as drug treatment or surgical repair of reproductive organs. About 10-15% will require In Vitro Fertilization (IVF) or Egg Donation.

Do Insurance Plans Cover Infertility Treatment?

The degree of services covered depends on the type of insurance plan you have. Insurance coverage varies greatly in the scope of what is and is not covered. It is recommended that you check with your insurance carrier for a description of your infertility coverage.

How does the woman’s age affect her chance of delivering a baby?

It is very important to understand that live birth is the only result that counts following infertility treatment. A woman’s peak reproductive potential is usually before the age of 30, and declines rapidly after the age of 37. Understanding that there are no absolutes in infertility, the older the woman is, the more difficult it is for her to become pregnant and deliver, and the more aggressive her infertility treatment needs to be. The problems that the older woman faces are a decrease in the absolute number of eggs available, a poorer quality of those eggs (decreased reproductive potential of the eggs), and an increased incidence of genetic abnormalities of the eggs which results in increasing miscarriage and other issues.

How does the age of the man affect the couple’s chances of a live birth?

Not nearly as much as the woman’s age. Even if there are problems with the semen analysis for the man, with ICSI (intracytoplasmic sperm injection), the couple should do well independent of the age of the man. There is a slight increase in the incidence of genetic abnormalities in the child (i.e. Down’s syndrome) as the man ages over 45, but the increase risk with advancing age is not nearly as great for men as for women. New studies show a slight increase in autism when the man is over 40.

What is ovarian reserve and how is the testing for ovarian reserve done?

Ovarian reserve is the best method to evaluate the reproductive potential of the woman’s ovaries. The testing requires measurement of menstrual day 2-4 follicle-stimulating hormone (FSH) levels, B3 inhibin and the clomiphene citrate challenge test (CCCT). Clomiphine citrate is Clomid/Serophene. For the CCCT, hormone measurements for FSH and estradiol are made on menstrual day 2-4, Clomid/Serophene is administered, 2 tablets on days 5-9, and FSH levels are measured on menstrual day 10. Elevated FSH levels, on either menstrual day 2-4 or 10, are indicative of diminished ovarian reserve. Abnormal levels of FSH must be determined for each laboratory, so caution should be taken when interpreting the results. An “antral” count on day 2-4 can be performed with an ultrasound for additional information on the number of “immature” follicles available for stimulation.

Which women need ovarian reserve screening?

Criteria for screening are 1) any woman over the age of 35 years, 2) any woman of any age with the diagnosis of A) unexplained infertility, B) one ovary or a history of significant surgery on an ovary (usually from endometriosis), or C) a poor response to gonadotropin-like medications in the past. Using these criteria, one out of six women screened will demonstrate diminished ovarian reserve. Age is the most common screening tool to pick up diminished ovarian reserve, and the incidence of diminished ovarian reserve increases with increasing woman’s age. Unexplained infertility is also a significant risk factor for diminished ovarian reserve. Roughly 33% of women with the diagnosis of unexplained infertility will demonstrate diminished ovarian reserve, thus making their diagnosis no longer unexplained.

What does the diagnosis of normal or diminished ovarian reserve mean to our chances of having a baby?

Women with normal ovarian reserve can be counseled that their chances of having a live birth with their own eggs can be estimated by their age, and most infertility specialists can give relatively accurate estimates. If the testing demonstrates diminished ovarian reserve, the likelihood of live birth with the woman’s eggs decreases significantly independent of the technology used (timed intercourse vs. IVF) and independent of the woman’s age. Ovarian reserve screening is not completely predictable. Some women with diminished ovarian reserve will conceive and deliver a child, but not nearly as often or as quickly as those women of similar age with normal ovarian reserve.

What are the options if the woman has diminished ovarian reserve?

The options will depend, of course, on other infertility diagnoses, if any. All infertility problems that are correctable should be optimized. Treatment then is determined by the diagnosis that is unrelated to diminished ovarian reserve. In general, more aggressive treatment is indicated than for couples with normal ovarian reserve. What ever options couples are offered and choose, they must consider the need to try with the woman’s own eggs, the need for psychological closure on their infertility if treatment fails with the woman’s own eggs, and the cost vs. benefit for a treatment with a lower chance of success. IVF is still an option for couples with diminished ovarian reserve but has a decreased success rate. An alternative that offers a much better cost to benefit ratio is egg donation, where a woman under age 32 donates eggs to another couple.

What are the options if the woman has diminished ovarian reserve?

In vitro fertilization (IVF) is used when a woman has blocked or absent fallopian tubes, or when a man has a low sperm count. In IVF, eggs are removed from the ovary and mixed with sperm outside the body in a Petri dish. After about 40 hours, the eggs are examined to see if they’ve been fertilized and are dividing into cells. Some of these fertilized eggs (embryos) are then placed in the woman’s uterus. The cost of an IVF treatment at the ART Fertility Program ranges from $7,600 – $8,700, excluding medications and monitoring.

What is IVF and how much does it cost?

In vitro fertilization (IVF) is used when a woman has blocked or absent fallopian tubes, or when a man has a low sperm count. In IVF, eggs are removed from the ovary and mixed with sperm outside the body in a Petri dish. After about 40 hours, the eggs are examined to see if they’ve been fertilized and are dividing into cells. Some of these fertilized eggs (embryos) are then placed in the woman’s uterus. The cost of an IVF treatment at the ART Fertility Program ranges from $7,600 – $8,700, excluding medications and monitoring.

When is a donor egg used?

Donor eggs are an option for women who cannot produce eggs or for whom egg quality is an issue. Another woman donates her eggs to be used for an IVF procedure. The woman using a donor egg becomes the biological mother to the offspring, but she doesn’t share the child’s genetic make-up. However, if the male partner’s sperm was used in the fertilization process, the child shares his genes. Approximately 50-60 percent of patients will have a successful pregnancy from using donor eggs. This procedure is used most often by women over 40.

Does the ART Fertility Program provide counseling?

Because infertility can be one of the most emotional experiences a couple may face, we offer patients an opportunity to work with Susan Trimm, a licensed social worker who sees patients at our Birmingham office. Additionally, Dr. Curt Newell sees patients in his office in Birmingham.


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THE ART FERTILITY PROGRAM OF ALABAMA