If you’ve some had difficulty getting pregnant, you’re not alone. Approximately one in six American couples experience infertility at some point, many struggling to conceive longer than necessary because they go it alone. The longer they wait to seek help, the more challenging conception becomes. But with comprehensive treatment, most couples can become biological parents one way or another. The first step toward overcoming fertility issues is to understand what the label “infertile” really means. The technical definition of infertility for women under 35 is an inability to get pregnant after one year of trying; for women over 35, it applies after six months of attempting to conceive. Most of the time, though, people who struggle to conceive are actually sub-fertile, according to Alice Domar, Ph.D., executive director of the Domar Center for Mind/Body Health at Boston IVF, associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School, and author of Conquering Infertility. “It’s relatively rare to have a fertility doctor tell a patient, ‘Oh, you’re sterile,'” she says.
Causes and treatments of infertility
The causes of infertility vary widely, but it may surprise you to learn that the largest single diagnosis is on the guy’s side. “About 30 to 40 percent of the time it’s a male factor, so it’s important to make sure your partner gets tested at the outset,” says David Ryley, M.D., a reproductive endocrinologist at Boston IVF fertility clinic and a clinical instructor at Harvard Medical School. The most common problems are issues with sperm quality or semen volume, and varicoceles (tangled blood vessels in the scrotum).
Women tend to face a wider variety of roadblocks on the way to conception. About 25 percent of infertility issues are due to blocked tubes, Dr. Ryley says. That could be a result of pelvic inflammatory disease, endometriosis, or ectopic pregnancy. Another 25 percent of issues are due to ovulatory dysfunction. The most prevalent ovulatory problem is polycystic ovarian syndrome (PCOS), a hormonal imbalance that disrupts regular ovulation. Primary ovarian insufficiency (POI) is another common condition, in which the ovaries stop functioning properly in women under 40. Another 10 percent of female-related infertility is attributable to abnormalities in the uterus that require surgical correction. These commonly include uterine fibroids, noncancerous growths within the uterus, or structural problems with the uterus.
But in roughly 20 to 25 percent of infertility cases, the cause is completely unknown. That means all tests are normal and the cause is likely related to age in one or both partners.
Regardless of where the problems lie, it’s important to understand that these are medical problems, not a failure of your body to do what it’s “supposed to do.” “Women need to untie their concept of femininity and their fertility from the quality of their eggs and the lining of their uterus,” says Sheryl A. Kingsberg, Ph.D., chief of the Division of Behavioral Medicine at University Hospitals Case Medical Center and a professor of reproductive biology and psychiatry at Case Western Reserve University School of Medicine in Cleveland.
Struggling to conceive a second or third time can come as a complete shock. To address secondary infertility, doctors do a slightly different workup than they might have previously. “I like to check on thyroid hormones because we have a higher chance of having thyroid problems, particularly under active thyroid,” says Angela Chaudhari, M.D., a gynecologic surgeon and assistant professor in the Department of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine in Chicago. “That can affect ovulation and prevent women from getting pregnant.” Your physician should also check to make sure you haven’t grown a fibroid or polyp or experienced an infection or endometriosis that can lead to blocked tubes. A cesarean section that healed improperly in the past may also be a culprit. It also makes sense to evaluate the guy to make sure that he’s not taking any medication or doesn’t have a new condition that might have affected his sperm quality or volume.
When to get treated
Couples who have no known reproductive or hormonal issues and have intercourse before and at ovulation can wait up to a year before seeking medical help, but many experts like to see women between the ages of 30 and 35 after nine months of trying without any luck. “If you’re over 35 and it’s been six months, it’s time to take a look,” Dr. Ryley says. “The treatments we have are incredibly successful and will offer the opportunity to maximize the chances of success if you get in sooner than later.”
If it’s taking longer than six months and you’re 35 or older, that doesn’t make you abnormal — it just means you’re aging normally. “About 80 to 85 percent of women who are 35 will get pregnant but it may take up to a year and we don’t want to waste any time if there are other reproductive issues,” Dr. Domar says.
How to get the best help
As physicians learn more about how to treat infertility, the number of well-trained fertility professionals continues to grow. “There are, however, a lot of people who will take advantage of the vulnerability and desperation of fertility patients,” Dr. Domar cautions. “If you hear a medical provider tell you ‘Just relax, you’ll get pregnant,’ go find someone else. And if a therapist says to you over the phone, ‘I will get you pregnant,’ hang up.”
On the flip side, if someone says you’ll never in a million years get pregnant, don’t be afraid to seek a second opinion. You may also decide to combine Western and Eastern efforts and try a stress-relieving practice such as acupuncture. One German study that examined IVF success rates found that women who received acupuncture along with IVF had as much as a 50 percent improved pregnancy outcome. “There’s some clear evidence that acupuncture balances hormones and that elevated cortisol and prolactin levels come down with acupuncture,” says Jill Blakeway, a licensed acupuncturist and co-owner of The YinOva Center in New York City and co-author of Making Babies: A Proven 3-Month Program for Maximum Fertility. Whatever your decision, be sure all your treatment providers know about one another and are aware of the care you’re receiving on both sides. Many physicians object to the use of Chinese herbs, for example, so it’s important that everyone is on the same page.
What really works
Only your doctor can tell you the cause and prognosis for your situation, but there are often several treatment options. Ovarian stimulation is a common treatment for female-factor infertility, whether it’s diminished ovarian reserve (that is, fewer viable eggs than ideal) or abnormal hormone levels. It may be right for you if a blood test indicates high levels of follicle-stimulating hormone (FSH) and/or low levels of anti-Müllerian hormone (AMH). Medications that have FSH and luteinizing hormone (LH) may be used to spur egg release. Clomiphene (brand name: Clomid) assists ovulation in women with PCOS (polycystic ovary syndrome) by acting on the pituitary gland.
If ovarian stimulation is not successful, you may need an alternative treatment such as an assisted reproductive technology. The most common technologies are intrauterine insemination (IUI), a process that concentrates the most motile sperm from the man and inseminates the woman artificially, and in vitro fertilization (IVF), in which an egg is fertilized by sperm outside a woman’s body and the embryos are transferred into her uterus. Despite its prevalence in media and pop culture, IVF accounts for only a fraction of the infertility treatment (less than 5 percent) in the United States. It also comes with a large price tag, an average of $12,400, according to the American Society for Reproductive Medicine. Most states do not require insurers to cover any part of the services.
IVF can be particularly effective in treating absent or blocked fallopian tubes or low sperm counts, but it’s better to attempt it sooner rather than later. “Even if the problem is on the man’s side, the female partner has a certain window of opportunity to be a candidate for IVF,” Dr. Ryley says. “Eventually, the age of the female is going to catch up and she’ll be less likely to succeed.”
If IVF is unsuccessful and there are no issues with carrying a pregnancy, many women are excellent candidates for using donor eggs or embryos. For women who have enough eggs but cannot carry a pregnancy, implanting her eggs in a surrogate is another option.
Take good care of your body and mind
While you’re pursuing treatments, keep a laser focus on good lifestyle habits. “It’s amazing to me how many people who, when their doctor tells them to not drink, smoke, and take specific herbs, they still do those things,” Dr. Domar says. You may also want to research environmental toxins that impact fertility. Polychlorinated biphenyls (PCBs), chemicals that have been used as coolants and lubricants in electrical equipment, have gotten a lot of attention after a National Institutes of Health study showed that couples with high levels of PCBs take longer to get pregnant. Also look at some fertility zappers that are endocrine disruptors. “Antibacterial soap contains triclosan, and the FDA came out a few years ago indicating that that was a known fertility disruptor,” says Alisa Vitti, a New York City-based integrative nutritionist and author of WomanCode: Perfect Your Cycle, Amplify Your Fertility, Supercharge Your Sex Drive, and Become a Power Source. “Making a simple switch in your bathroom to regular hand soap that’s not antibacterial is sufficient.” Vitti also recommends temporarily changing toothpaste to a fluoride-free version. “The fluoride in toothpaste can interfere with the production of thyroid hormones and can affect your ovulation if you’re sensitive to underactive thyroid.”
Be aware of the mental and emotional challenges that come with infertility. Constant doctor visits and probing procedures can feel like you’re on the mental equivalent of a runaway train. “It’s no surprise that approximately 40 percent of couples experience depression, anxiety, or both when going through fertility challenges,” says Steven R. Bayer, M.D., a reproductive endocrinologist at Boston IVF fertility clinic. Studies show that stress and depression do hamper fertility. “It’s not that people who are stressed and depressed don’t get pregnant; it’s that they’re less likely to get pregnant or it might take longer,” Dr. Domar says. Dr. Domar has developed a renowned mind/body program for fertility that includes relaxation techniques, cognitive restructuring, group support, and lifestyle habit changes. “We don’t know what the active ingredient is, but women who followed this program were more than twice as likely to get pregnant than the control group.”
Understand what you want out of motherhood
When it feels like all hope is lost, Dr. Kingsberg recommends that infertility patients break down the three essential goals in becoming a mother. The first, and most common, is to pass on your genes and bear your own genetic child. The second goal, which applies to women more than to couples, is to experience and carry a successful pregnancy. “For many women, that is incredibly important to their body image and sense of femininity,” Dr. Kingsberg says. The third goal is to be a parent, which she notes is very different than the first two goals. “As couples, or women in general, are going through this process, they really need to tease those out as separate but related goals and recognize that they are very much entitled to grieve any that are not achieved.” You may discover you’re through with the process if you can’t pass along your own genetics and are content to be child-free. Or you might find that the experiences of recurrent miscarriage were too traumatic and ultimately opt for surrogacy or adoption. Your feelings are likely to change over time. Dr. Kingsberg frequently sees this in patients who always thought they wanted to forgo IVF and adopt instead. “One thing that comes as a shock is that it is generally easier and less expensive to go through IVF, even with donor eggs or sperm, than it has been to adopt,” she says. Don’t judge your emotions, and be honest with your partner about any shifting priorities. “You may want to keep a positive attitude, but it’s healthy to discuss the more negative ‘what-ifs’ in advance so you’re not caught off guard,” says Mindy R. Schiffman, Ph.D., clinical psychologist and sex therapist at New York University’s Fertility Center and in private practice in New York City. That way, you won’t be stumped and shocked by your partner’s feelings if the ultimate fertility outcome you’re faced with is not what you hoped for.