Assisted Delivery
Getting pregnant seems so simple—until you have trouble conceiving. Then, infertility can feel like an insurmountable obstacle. Fortunately, experts agree there are many reasons to hope.



Deciding to have a baby is a huge step—one that most couples make with excitement and anticipation. So when things don't go as planned, it often can be a devastating blow that rocks the very foundation of a relationship. Fortunately, having some trouble conceiving doesn't mean you're destined to be childless. Reproductive endocrinologists like Thomas Kim, MD, of Reproductive Medicine Associates of New Jersey (RMANJ), are helping infertile couples get pregnant every day. Here, he shares the latest news from the frontlines in the fight against infertility.

Fertility Facts

Under the best of circumstances, getting pregnant is a bit like winning the lottery. The average couple has only about a 20 percent chance of conceiving each month; however, 90 percent of couples eventually get pregnant within a year. "Of course, that number starts to go down as a woman ages," says Kim. "In fact, the quality of a woman's eggs actually begins to decline as early as her late-twenties, and the rate of decline speeds up with each passing year. So it really is like a ticking clock."
Today, it is estimated that roughly one out of every seven couples, or about 15 percent, experience some problem with fertility. But Kim points out that infertility itself is not on the rise. Instead, he says, the primary cause of infertility these days is delayed childbearing on a woman's part, "not an increase in medical conditions that prevent conception."

So how long should a couple try to conceive before turning to medical interventions? "If a couple in which the woman is under 35 has had unprotected intercourse for a year without a pregnancy, it's probably time to seek help," says Kim. "For couples in which the woman is 35 or older, it's best to get help sooner—after six months of trying—because after age 35, issues like declining egg quality and ovarian reserve mean that every month counts."

Help When You Need It

Aside from good timing, getting pregnant depends on four essential factors: A woman and a man need to produce healthy eggs and sperm; a man needs to produce an adequate amount of sperm; a woman needs to have healthy fallopian tubes, so sperm can reach the egg to fertilize it and the embryo can travel to the uterus; and a woman needs to have a welcoming uterus, so a fertilized embryo can attach there and grow to term. Suddenly, it's easier to understand why getting pregnant isn't always so easy….

"When we work up infertile couples," explains Kim, "we usually discover that 35 percent of the time, the problem is sperm-related, meaning the man either does not have enough sperm or the sperm are not of good quality." To successfully conceive, sperm need to be able to reach a waiting egg, so if they are not properly structured, infertility can result. These problems are usually caused by factors like testosterone or other hormone imbalances, congenital defects of the testicles, certain medications (including steroids), STDs, and even chemotherapy and radiation treatments.

Another 50 percent of the time, the cause of infertility is related to the female partner. Issues include such things as chronological age, hormonal and ovulatory issues, or anatomical problems such as scarred or blocked fallopian tubes, endometriosis, a previous ectopic pregnancy, uterine fibroids, polyps, or uterine scar tissue from past surgeries. Previous infections, miscarriages, or abortions can also affect fertility.
In the remaining 15 percent of cases, Kim says, "the reason for the problem is unknown, something we refer to as unexplained infertility."

Determining the underlying cause of infertility requires an extensive checklist of exams. This includes a detailed medical history; semen analysis; a female hormonal profile, inclusive of checks of the thyroid gland, prolactin levels, and ovarian reserve; and an ultrasound and X-ray of the woman's anatomy, including her fallopian tubes and ovaries. There may also be blood tests on both partners to check for medical conditions that can inhibit fertility, and genetic counseling to uncover any additional information about a couple's medical history.

Regardless of a couple's fertility issues, their chances of conceiving at facilities like RMANJ are very good. "I'm happy to say that out of 12 similar centers in New Jersey, the statistics collected by the Society for Assisted Reproductive Technology consistently find RMANJ at the top of the pack," says Kim, "even with complicated cases such as those involving embryo implantation, a topic we're still learning about." (Go to www.sart.org to review reported IVF success rates for Reproductive Medicine Associates of New Jersey.) RMANJ's most recent IVF statistics reveal a pregnancy rate above 60 percent in women under 35; above 50 percent for women ages 35–37; and above 40 percent for women ages 38–40. They further report a 67.6 percent live-birth rate among women using eggs provided by young donors.

Treatment Options

No matter how promising the statistics, battling infertility can be an excruciating process. Fortunately, reproductive specialists have an ever-growing arsenal of techniques to help couples fulfill their dreams of having a family.

Many doctors choose fertility medications, like Clomid or injectables, as their first line of defense since they are relatively inexpensive, minimally invasive, and carry little risk. These medications alone often can help address a woman's hormonal, ovulatory, or implantation issues by bringing on ovulation, increasing egg production, and making the uterus more hospitable. Intrauterine insemination (IUI) is a simple office procedure that places sperm high in the woman's reproductive tract, enhancing the chance of fertilization. But not every case of infertility is that straightforward.

"When dealing with issues of the female anatomy, like blocked fallopian tubes, surgery used to be the standard of care," explains Kim. "But over the years, we learned that it isn't a very effective strategy. Often a tube we opened surgically would actually re-close in just a matter of months, making the available window for conception very slim." In vitro fertilization (IVF) is a treatment of choice for tubal blockage. It is not only safer, but also more efficient in helping women get pregnant—despite damaged tubes.

IVF is also a great option in cases where a man has poor sperm quality or insufficient amounts of sperm. "With IVF, we get sperm and egg together outside the body, in the laboratory, and implant the developing embryos into the mother's uterus," explains Kim. In cases of significant male infertility, doctors typically pair IVF with intracytoplasmic sperm injection (ICSI); here, an individual sperm is injected directly into each mature egg. It is important to remember that the effectiveness of IVF is greatly affected by a woman's age and her egg quality or ovarian reserve, which sometimes makes the need for donor eggs necessary.

Recently, egg freezing has also come to the forefront as a viable option for women who want to delay childbearing. "Women in their mid- to late-thirties can now freeze their eggs to use at a later date when they have found the right partner or are ready to be moms," says Kim. "And the best part is, once they are frozen, the eggs no longer age, so we can implant a woman's 33-year-old eggs into her 43-year-old uterus and deliver a healthy baby nine months later." Kim cautions, however, that despite preliminary success, egg freezing is still a new frontier in reproductive technology and has not proven to be as successful as sperm freezing. What's more, it can be pricey, costing as much as $15,000, none of which is covered by insurance.

Of course, for any woman facing infertility issues, it may be reassuring to remember that every currently accepted fertility treatment was once a new frontier, and programs like RMANJ are continuously exploring these frontiers, developing tomorrow's treatments.

For a referral to a reproductive endocrinologist, call (973) 656-2089.