Posted: 5/10/2006
Infertility Treatments
By Terri Akman

Almost 30 years ago, the term in vitro fertilization entered our vocabulary. It was medical science at its best, offering couples the chance to have a child when they simply thought they had no chance. Today, treatments and technologies have been enhanced and perfected to offer even greater chances, even greater hope.

Soon after Melissa Gordon got married, she and her husband tried aggressively to start a family and live happily and normally as other couples with children do. But for eight months, their hopes weakened as their attempts were unsuccessful. Gordon repeated ovulation tests, hoping to pinpoint the exact moment that would give her the greatest chances to get pregnant. But month after month, she had to face the heartbreak of discovering she was not pregnant. Happily and normally just weren’t happening.

The Gordons’ story is common. According to the Centers for Disease Control and Prevention (CDC), infertility is often defined as not being able to get pregnant after trying for one year. In 1995, over 6 million women of childbearing age had an impaired ability to have children. Over nine million sought infertility services.

Gordon was diagnosed with a fibroid tumor in her uterus, which she needed to have surgically removed. While she hoped that would be the end of her reproductive problems, it sadly wasn’t. With each new test, it seemed more potential problems were discovered, and she began to get discouraged. She tried intrauterine insemination (IUI) five times, which is performed by threading a very thin flexible catheter through the cervix and injecting washed sperm directly into the uterus. All five attempts were unsuccessful.

"Basically, they said I had unexplained infertility," she explains. "So, I finally decided to go through with in-vitro fertilization. Unfortunately, the first in-vitro didn’t work, so I had to go through it all over again."

In order for pregnancy to occur in the traditional manner, an egg has to be released from the ovary and unite with a sperm, which is called fertilization. When fertilization fails to occur normally in the body, it can be accomplished in the laboratory by using IVF. This technique involves removing eggs from the mother’s body and fertilizing them in the laboratory. The fertilized eggs are returned directly to the uterus approximately three days later.

IVF technology first came to the US in about 1981, and live birth rates then were in the 8 to 10 percent range per treatment cycle, according to Louis Manara, DO, who is a reproductive endocrinologist affiliated with Virtua Health and Kennedy Health System. Today, IVF live birth rates are approximately forty to fifty percent. A woman’s age is the most important variable affecting that success. For Gordon, IVF was successful. In April of 2003, she became pregnant and gave birth to a daughter in December.Ten months later, she went back for IVF again. She got pregnant on the first try with twins, who were born this past July.While she admits the process was stressful, she points to her three daughters as proof that it was worthwhile.

BEYOND IVF
While the introduction of IVF in the early 80s was a significant advancement for fertility treatment, progress has continued. Advancements in medications, technology and even our understanding of reproductive function are increasing the chances of pregnancy for infertile couples.

For some women, freezing their eggs allows them to postpone pregnancy – whether they choose to do so as they begin chemotherapy or they simply want to wait to start a family. New freezing techniques and improvements in the equipment used for egg freezing have recently resulted in better egg survival and fertilization after freezing.

Since one of the factors affecting infertility is age, this technology removes that element - essentially stopping the biological clock from ticking.Women are able to freeze a group of their eggs while they are young and most fertile.

Women undergoing chemotherapy can remove and freeze their eggs before beginning treatment, eliminating the potential for damage to the eggs resulting from the toxicity of chemotherapy drugs. "Of course, a woman will have to go through a surgical procedure to get her eggs removed, but we can stimulate the ovaries once when she’s 25, get 20 eggs and put them in the freezer," says Dr. Manara. "She can go ahead and get her Ph.D. in molecular biology and find the right guy, then come back and get her eggs when she’s 40.With this treatment, she’ll have a very high chance of achieving pregnancy. If she tried to have a child with her 40-year-old eggs, the prospects for success are quite low."

SHARING EGGS
For some women, traditional fertility treatments are unsuccessful because their ovaries are either unable to produce eggs at all or are unable to produce eggs that will result in the creation of embryos and ultimately healthy children. The Cooper Center for IVF is one of the first centers to offer a shared egg program in which one patient can share half of her eggs with another patient in exchange for almost entirely free IVF services.

"One unique part of our donor program is that we enable people who can’t afford IVF to have it at basically no charge if they’re willing to share half of their eggs with another woman who needs them," explains Jerome H. Check, MD, Ph.D., Division Head of Reproductive Endocrinology and Infertility at Cooper University Hospital and Professor of OBGYN at Robert Wood Johnson Medical School. "That’s what we call a recipient, who may need eggs either because she’s too old or she’s had many failed cycles and there’s something wrong with her embryos. This woman can get eggs free."

INJECTABLES
Sicklerville resident Tracy Bonanato says that she and her husband tried casually to get pregnant for about two years, figuring that "if it happened, it happened. After two years, we figured it’s not happening, so maybe there is a problem," she says.

They visited her doctor for a complete history and physical. Standard tests today include a detailed semen analysis, an assessment of the woman’s endocrine system to be sure that she is ovulating and her ovarian function is normal, and an assessment of the fallopian tubes and uterine cavity to be sure that the anatomy is normal and the fallopian tubes are open. At 30 years old, Tracy wasn’t too concerned with her age being a factor.

"If a woman is older than 34 and is having a delay in achieving pregnancy, we usually evaluate the effects of age on her fertility potential by checking two important hormone levels on the third day of her cycle," explains Dr. Manara. "In addition, we would recommend a careful ultrasound examination to obtain a ‘follicle count’ which helps in evaluating the woman’s potential for successful pregnancy as it relates to her age. Follicle counts will typically be depressed in women who are experiencing age–related sub-fertility."

Bonanato hoped the doctor would find something wrong and be able to fix it. Unfortunately, he did not. It is common for doctors to complete a work-up and not find any specific problem affecting fertility. Unexplained infertility occurs in about 40 percent of all cases, according to Dr. Manara.

"The fact that they couldn’t find anything wrong made it worse for me. If they had told me, ‘This is what’s wrong. This is why you aren’t getting pregnant,’ I could have accepted that better than, ‘There’s no reason why.’ In the beginning I was a basket case," Bonanato admits. Bonanato began using the injectable medication, Gonal F. She gave herself daily injections in the thigh for 7-14 days each month.

"I usually started the injectables on day three of my cycle. A couple days after that, I had a vaginal ultrasound to see how many follicles there were and how big they were getting," explains Bonanato. "I also had blood drawn to check my hormone levels.Usually, about 14 days into the cycle, we did a simple insemination process in the office, and then I took progesterone suppositories vaginally."

Progesterone suppositories are used to support the implantation of the embryo by promoting the proper development of the uterine lining. Bonanato had very good success with this process, actually becoming pregnant on the second try. Unfortunately, she miscarried on three occasions. Finally, her fourth try proved successful, and she is now the proud mother of an eight-month-old son. She is also eagerly trying again for her second child using the same medication.

"I think infertility is so common now that there is nothing to be ashamed of," Bonanato says. "I was afraid to tell my family about it in the beginning.Most of my family still doesn’t know, only because it was just so upsetting. I didn’t want them, every month, to ask what was going on. But I think the more you talk about it, the more you realize it is very common, and there is help out there."

CHANCES OF MISCARRIAGE
With each pregnancy, a woman has about a 15 percent chance of miscarrying, according to David R. Corley, MD, Director of the Delaware Valley Institute of Fertility and Genetics Early Pregnancy Loss and Gestational Wellness Program who practices at Virtua Health.

"It’s considered a miscarriage if you’re under 20 weeks and lose a pregnancy. When you’re looking at different causes, there’s a huge difference between those people who miscarry before 12 weeks and after 12 weeks," explains Dr. Corley.

There are some women who miscarry spontaneously with one pregnancy, but may never miscarry again. Other women experience recurrent pregnancy loss, which means they miscarry three times or more in a row. Dr. Corley explains that the number one cause of miscarriage, in general, is chromosomal anomaly.

In early pregnancy there are two cells, the sperm and the egg.When they first unite, they have to combine their genetic material. If there’s a problem at that first stage, then from that point on, there’s a chromosome problem. That chromosomal problem is why many early, first-trimester miscarriages occur.

Trying to get pregnant can be stressful in itself, but when a couple finally conceives and then miscarries, the stress becomes even greater. Can stress affect a pregnancy? Dr. Corley believes that stress can be a potential cause in some recurrent pregnancy losses, though there is very little research on the subject. "Once someone has a first miscarriage, they fear miscarrying again, which can potentially cause them to develop irregular cycles, making it more difficult to conceive," he says.

"If a woman has no other medical problems, meaning she doesn’t have diabetes, thyroid disorders or other metabolic problems, the odds of miscarrying again are pretty small. The odds of actually conceiving after only one pregnancy loss and carrying the next child, can be as high as 90 percent or even better," he suggests.

THE BENEFITS OF PROGRESS
The development of new fertility technologies and treatment is bringing hope to many couples. "The vast majority of infertile couples (85%) will not require high-tech procedures but can be helped through simple office treatments.We can usually help by using simpler techniques that don’t involve surgery," says Dr. Manara. "For those people who do need further treatment, what we can offer is wonderful and it works great."

Dr. Check agrees that every year pregnancy rate statistics get better and better. And, in many cases, the oldfashioned types of corrections still work. "IVF and IVF with Intra Cytoplasmic Sperm Injection (ICSI,) have been the greatest innovation," he says, "but of course, that started about 27 years ago. It’s not brand new, but it just keeps getting better."

Published by SJ Magazine
http://www.sjmagazine.net/medicaltechnology.html