DRUGS & CONDITIONS

OUR SERVICES

A Fertility Care Program for You

Supporting you every step of the way

CVS Caremark Specialty Pharmacy is a leading fertility specialty pharmacy that offers much more than medication. Serving patients with specialized needs for 30 years, we understand the support and personalized care you may require when undergoing fertility treatment.

You can count on us to take an active role in your care by working directly with you, your doctor and your insurance company. From reviewing insurance coverage to delivering medications to your door, we are here to serve and support you through every step of your fertility treatment.

Dedicated Fertility CareTeam

When you enroll in the CVS Caremark Fertility Care Program, a pharmacist-led CareTeam is assigned to you. This dedicated group of clinical experts provides you with comprehensive support and education on appropriate use of the prescribed medication, administration and storage, potential adverse reactions/side effects, and injection-related issues. You have access to our on-call pharmacists, 24 hours a day, 365 days a year for emergency consultations.

Fertility Drug Coverage Pre-Verification Program

By participating in our complimentary Fertility Drug Coverage Pre-Verification Program, you will receive a comprehensive overview of your fertility drug coverage before the prescription is written. These results include fertility medication copayments* for all major fertility agents. Understanding the fertility drug coverage in advance can help you and your doctor make important financial decisions about your fertility treatment.

Prompt delivery of your fertility medications

By having your doctor fax or call in your prescription to CVS Caremark Specialty Pharmacy, you can expect prompt intake and discreet, timely delivery of your medications and supplies. We ship anywhere in the United States and offer complimentary next day delivery. In certain markets, we can provide same day delivery.

Complete offering of medications and supplies

CVS Caremark Specialty Pharmacy has a broad product offering, including all medications and supplies required for a typical treatment cycle. Your medication will arrive in a temperature-controlled, secure package.

Education based on your needs

We provide education specific to your condition and prescribed treatment. In addition to the materials you receive in your Welcome Packet, you also have access to our Fertility Resource Center . Here you will find a wealth of information on the diagnosis and treatment of infertility and links to helpful resources.

Competitive pricing

CVS Caremark is one of the largest purchasers of prescription medications in the nation and can offer competitive pricing. If you do not have fertility medication benefits, you may be eligible to receive immediate savings on certain medications for the treatment of infertility. Learn more about the CVS Caremark Fertility Managed Plan.

Reimbursement services

As part of our patient-centric approach to care, CVS Caremark has reimbursement specialists who will help you maximize your fertility coverage while minimizing out-of-pocket expenses by offering a comprehensive analysis of your benefits. This team of experts will also ensure that your claims are completed and filed in a timely manner.

Egg Donor Services

Our staff of experts in the field of reproductive pharmacy understand the customized needs of an egg donor and recipient patient. We work exclusively with the recipient, clinic, and egg donor and coordinate every aspect of the donor and recipient medication therapy.

Patient Testimonial

"There are many details that need to be coordinated between the fertility clinic staff and the pharmacy. I am a detail-oriented person, but it is easy for the patient to feel overwhelmed at times during this sensitive experience. My CVS Caremark Specialty Pharmacy representative was excellent. She was always there for me and knew who to call and what to do." - Fertility Patient

To learn more about the Fertility Care Program, please call toll-free 1-877-269-4831 or begin the enrollment process here.

*Copay, copayments or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, payable by a Plan.

DRUGS & CONDITIONS

FINDING THE RIGHT FERTILITY SPECIALIST

Topics

Out of desperation, many people turn to the first fertility specialist they find in the phone book, or someone they've heard about from a friend. But it's important to find the right doctor for you, one who can come up with a treatment plan tailored to your needs and be sensitive enough to help you through the rough times. It's also crucial to educate yourself about infertility and its possible causes and treatments. That way, you can ask your doctor the right questions and make sure you're getting the best treatment possible.

What kinds of doctors treat infertility?

There are good reasons to want to stay with your OB/GYN, but don't be afraid to ask exactly how much training, experience, and success he or she has had in treating infertility. OB/GYNs, or gynecologists, are trained to diagnose and treat women's reproductive problems and to care for women during pregnancy and childbirth. Some gynecologists have acquired considerable experience in fertility issues over the years as well, but only a fraction receive formal training to treat infertility or perform more advanced reproductive technologies (ART), such as in vitro fertilization (IVF). For this sort of expertise, see a board-certified reproductive endocrinologist, an OB/GYN who has undergone several years of additional training to diagnose and treat infertility in both men and women. Reproductive endocrinologists also must have at least two additional years of clinical experience, and pass oral and written exams. Men may also want to consult an andrologist, who is a urologist certified to treat male infertility.

How do I find the right fertility specialist?

Most women begin this search with their regular gynecologist, and men consult their primary care doctor. This is fine for a first consultation and, in some cases, for an initial infertility diagnosis or even preliminary treatment. If your insurance covers fertility treatments, you may need a referral from your general doctor or OB/GYN before seeing a specialist anyway. Ask if your doctor has some experience with the specialist he or she would refer you to, and ask him or her why the specialist is recommended. That way, if the specialist had good experience with several patients, you can take advantage of that knowledge. But more and more experts -- as well as women who've been through the process -- now recommend that couples struggling with infertility issues seek out a qualified specialist early on. If you're 35 or older, you might want to go directly to a reproductive endocrinologist. A specialist can better determine the appropriate course of treatment if a woman has a history of miscarriages, irregular menstrual cycles, or pelvic infection, or if a man has had a semen analysis that shows a low sperm count.

What should I look for in a doctor?

You should feel as if your doctor is an ally in your effort to conceive. Although the issue of fertility is intimate, private, and sensitive, some patients complain about specialists whose bedside manner is cold or even dismissive. During your initial consultation with the doctor, make a point of observing how much the doctor listens to you, answers your questions, and treats you with respect. If a doctor rushes through the consultation, or declines to explain options such as surgery or drugs without discussing why, then move on. Don't waste critical time. You may be able to check out potential doctors by searching Web sites that have evaluations of fertility specialists. If you have health insurance, try to select a specialist in your health plan's network of specialists. To do so, check the provider directory, either in booklet form or online. This can save you out of pocket costs and also take advantage of the credentialing the health plan does for all network providers.

What other things should I consider in choosing a fertility doctor?

The American Medical Association and the American College of Obstetricians and Gynecologists have searchable databases of physicians by name, city, or zip code. You can also look in the Directory of Medical Specialists, which lists OB/GYNs and their specialty training. (This guide is available at most public libraries.) Other information, like the doctor's education and board certification, is available on some health plans' Web sites. Organizations like Resolve, a national infertility organization, also offer referrals to reproductive endocrinologists. They recommend interviewing several physicians before selecting one. Resolve suggests you start by asking the following questions:

Also, discuss your expectations. How aggressive do you want your doctor to be? How much risk are you willing to assume? How complex are you willing to make you and your partner's life in order to succeed? What is the physician's philosophy toward patients and their contributions to the process?

How do I know when it's time to try someone new?

The emotional roller coaster ride that usually accompanies fertility treatment can often make you unsure of your reactions to people and your ability to evaluate your doctor. However, if you don't feel you're getting the proper treatment, it is well within your rights to seek help somewhere else. Experts at Resolve say the following warning signs indicate it may be time to find a new doctor:

Be your own advocate

Even if you and your doctor are a good team, you may still need to be your own best advocate. "It's obvious that women in their forties should be priority patients at infertility clinics -- time is of the essence," writes 43-year-old Liza Glass,* an infertility patient in the San Francisco Bay Area. "Yet the overworked MDs at my clinic rarely follow my case. Most of the time, I must steward my own treatment schedule. "There are, for example, certain routine steps in the course of a medicated fertility treatment a patient must carry out each cycle," Glass reported in her treatment diary. "These include monitoring estradiol levels to make sure the ovaries have not been overstimulated and ultrasound exams to measure follicles and determine the optimal time to attempt conception." Nonetheless, she says, "I had to battle to book appointments for these procedures. At one point, my doctor was away on vacation and the tests he asked me to take had not been authorized." Denice Dirks of Southern California says two key factors were responsible for her eventual pregnancy by in vitro fertilization: educating herself about her condition and finding the right doctor. Dirks felt that the first doctor her OB/GYN referred her to was not aggressive enough, so she sought a referral to another specialist. She also made a point of educating herself about infertility and her treatment options, something she recommends to other patients. By doing her own research, she was able to overcome her feelings of frustration. "I'm not sure we would have been successful if I wasn't as diligent in taking charge of my own care, or if I'd had a doctor who was not open to that," she says. "You really have to take responsibility for your own medical treatment."

*Liza Glass is a pseudonym.

-- Paige Bierma is a freelance journalist in San Francisco who frequently covers health and medical issues.

Further Resources

American Medical Association: 515 N. State Street; Chicago, IL 60654; 800/621-8335; http://www.ama-assn.org

American Board of Medical Specialties: 1007 Church Street, Suite 404; Evanston, IL 60201-5913; 847/491-9091; 847/328-3596; http://www.abms.org

Resolve: The National Infertility Association: 1760 Old Meadow Rd, Suite 500, McLean, VA 22102; 703/556-7172; http://www.resolve.org

References

Interview with Denice Dirks, an infertility patient

Resolve, the National Infertility Association http://www.resolve.org/

Questions and Conflicts: Working With Your IVF Center, the American Infertility Association, http://www.americaninfertility.org/faqs/aia_workingwithyourivfcenter.html


Reviewed by Patrick Irvine, MD, a noted geriatrician and pharmacologist who lives in Minneapolis, MN.

Last updated June 10, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

MALE INFERTILITY

Topics

From a man's point of view, starting a family is easy. While women are on the job for nine months, men can often complete the task in a single evening. When it comes time to try for a pregnancy, they just naturally assume that it will happen. But among the couples who try unsuccessfully for months or even years to get pregnant, about half the time the problem lies either with both partners or with the man.

In the past, women nearly always took the blame when couples failed to conceive. Today we know that fertility is a two-person job. If a woman doesn't get pregnant after more than a year of trying, there's a 30 to 40 percent chance that her partner's fertility problem may play a role, according to a report in the Journal of Urology. Many men don't produce enough sperm, and the sperm they make may be too slow or oddly shaped. Without a few billion sleek, powerful swimmers working on a guy's behalf, fatherhood can be a difficult destination.

A Treatable Condition

Fortunately, male infertility is often temporary and treatable, says Larry Lipshultz, chief of the division of male reproductive medicine and surgery at Houston's Baylor College of Medicine. If a couple has trouble conceiving, both partners should be evaluated by a urologist or a reproductive endocrinologist who specializes in fertility problems, he says. Even men who've fathered children in the past should get a checkup, he says.

For the man, the search for answers will start with a semen analysis. Typically, a doctor will check at least two samples collected a month apart. If a man's samples contain large amounts of active, normal-looking sperm, chances are he's fertile. But if anything seems out of the ordinary, he'll need a thorough physical exam and lab work to get to the root of the problem.

Men may be reluctant to see a doctor for such a personal matter, but they have strong incentives to get help, Lipshultz says. For one thing, a doctor may find a solution for their infertility. At the other end of the spectrum -- and more rarely -- a doctor may determine that biological fatherhood will be impossible, a finding that could help a couple avoid years of frustration and costly fertility treatments. There's another reason to get help, Lipschultz says. In roughly 2 percent of all cases, male infertility is a symptom of a life-threatening disease such as testicular cancer. If a man ignores his fertility problems, he can lose more than a chance for fatherhood.

Most infertile men have reason for optimism. In a study described in Postgraduate Medicine, 76 percent of men who sought treatment for fertility problems had a potentially correctable condition. Among the men who underwent treatment, 32 percent fathered a child without any other medical help, and another 43 percent showed improvement in the number or quality of their sperm.

Blockages in various parts of the sperm pathway are a common, treatable cause of male infertility. These blockages often occur as a result of infections, including the sexually transmitted diseases chlamydia and gonorrhea. In many cases, surgery can remove the obstruction and get the sperm back on their way. Another form of obstruction is "congenital absence of the vas deferens," common in men who have cystic fibrosis. Other potentially treatable causes of infertility include hormone imbalances, inflammation in the urinary system (including prostatitis and urethritis), and retrograde ejaculation, a condition in which semen flows into the bladder.

Some experts say that varicose veins or "varicoceles," in the testicles can lead to male infertility. As reported in Postgraduate Medicine, these twisted, enlarged veins may hamper sperm production, and the effect tends to get worse over time. "The sooner these can be diagnosed and treated, the better the results," Lipshultz says. A number of doctors assert that surgical repair of the vessels can improve sperm counts and boost the odds of pregnancy, but others say the link between varicoceles and infertility isn't firmly established.

Sometimes a man's hobbies can interfere with infertility. According to a small study conducted in Austria, frequent mountain biking may contribute to a man's infertility. The study looked at 55 avid mountain bikers and found that nearly 90 percent had low sperm counts and abnormalities in their scrotums. In contrast only 26 percent of 35 non-bike riders had similar damage.

The study, presented at the Annual Meeting of the Radiological Society of North America, suggests that the frequent jolts and vibration associated with riding over rough terrain may be to blame. Infertility problems were most common in frequent bike riders who rode about 60 miles a week.

If there's no clear physical explanation for infertility, it's time to take a close look at what a man puts in his body. As reported in Postgraduate Medicine, some common prescription drugs can hamper sperm production. It's important to tell your doctor all the drugs you've been taking. The list of potential culprits includes the heartburn medication cimetidine (Tagamet), the rheumatoid arthritis drug sulfasalazine (Azulfidine), and several chemotherapy drugs. In some cases, a change in a prescription can restore fertility. Likewise, a man may be able to give his sperm a boost by avoiding cigarettes and going easy on alcohol. Heavy drinking can lead to a decrease in sperm count and movement, and smoking harms sperm's motility (ability to move). He should also stay away from recreational drugs such as marijuana, cocaine, and performance-enhancing drugs such as anabolic steroids.

Stress, obesity, malnutrition, radiation, major surgery, and overexposure to heat, chemicals, and poisons in the environment may also affect fertility. Pesticides with effects similar to those of estrogen have been linked strongly to a drop in sperm production, as has the insecticide DBCP.

Father-friendly Tips

If a man tells friends and relatives about his fertility troubles, it often unleashes an avalanche of advice -- some good, some bad. Almost invariably, someone will tell him he needs to wear loose pants and boxer shorts. This common belief is still being debated in the medical community, as studies on the impact of tight-fitting underwear on scrotal temperature are contradictory. Someone else might suggest an herbal "fertility" remedy. There's no evidence that these will take a man any closer to fatherhood, according to a report from the University of Iowa -- and worse, some herbal remedies could be harmful. Since herbs aren't tested for safety and efficacy, as prescription drugs are, men should talk with their doctors before experimenting with any supplement.

Some pieces of common wisdom actually turn out to be true. According to a report from the Mayo Clinic, a man trying to start a family really should stay clear of hot tubs or saunas: The sperm factories in the testicles don't work well under high temperatures. A Stony Brook University Hospital study found that men may also be feeling the heat from another direction -- laptop computers. Researchers found that holding a laptop computer on a man's lap for only an hour raised his testes temperature by 4.9 degrees Fahrenheit, which might be enough to impair fertility. Further research is needed to confirm the findings, say researchers.

Other Options

Even if a man takes all the right steps and gets the best treatment possible, he may still be unable to father a child the "old-fashioned" way. But as long as he produces at least a few healthy sperm, there's still hope.

In a procedure known as intracytoplasmic sperm injection (ICSI), doctors collect a single sperm and inject it directly into a woman's egg in a laboratory dish. After fertilization, the embryo is implanted in the woman's uterus. As reported in the Journal of Urology, about 25 to 35 percent of ICSI attempts result in successful pregnancies. In women under 35, pregnancy rates can be 60 percent or higher. Unfortunately, one cycle of ICSI costs from $10,000 to $20,000 -- a high price for a procedure with no guarantees.

After consulting with doctors and, more importantly, with each other, many couples decide not to try such measures. They may turn to a sperm bank or an adoption agency, or decide on a life without children. Some feelings of disappointment are inevitable, but at least they can get off the emotional roller-coaster they experienced month after month.

As easy as it seems, fatherhood isn't for everyone. It only comes to men who are either naturally fertile or willing to take action. A growing number of men are finding the courage to make that first call to the doctor. Their spouses are grateful -- and their children will be too.

-- Chris Woolston, MS, is a health and medical writer with a master's degree in biology. He is a contributing editor at Consumer Health Interactive and was the staff writer at Hippocrates, a magazine for physicians. He has also covered science issues for Time Inc. Health, WebMD, and the Chronicle of Higher Education.

References

Interview with Larry Lipshultz, MD, chief of the division of male reproductive medicine and surgery at Houston's Baylor College of Medicine.

Sandlow, J.I. Shattering the myths about male fertility. Postgraduate Medicine. May 2002. 107(2)

Mayo Clinic. Infertility. August 2001.

Jarow, J.P. et al. Best practice policies for male infertility. The Journal of Urology. May 2002. 167: 2138-2144.

Jarring Result, Extreme biking can hurt men's fertility, by Nathan Seppa, Science News Dec. 7, 2002; Vol. 162, No. 23

Sheynkin Y, et al. Increase in scrotal temperature in laptop computer users. Human Reproduction. Dec 9, 2004.

American Society for Reproductive Medicine. FAQs About Infertility. http://www.asrm.org/Patients/faqs.html

Mayo Clinic. Low Sperm Count. June 2008. http://mayoclinic.com/health/low-sperm-count/DS01049

Mayo Clinic. Male Infertility. June 2008. http://mayoclinic.com/health/male-infertility/DS01038


Reviewed by David Sable, MD, director of the Division of Reproductive Endocrinology, Saint Barnabas Medical Center in Livingston, New Jersey.

Last updated August 21, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

INSEMINATION

Topics

As thousands of women and men who are trying to start a family have discovered, sometimes you have to help nature along. Insemination -- either with a partner's sperm or using a known or anonymous donor -- is about the lowest-tech and the least expensive method of giving Mother Nature a boost.

If you have a male partner

There are two methods of insemination. The simplest is called intracervical insemination and involves placing the sperm in what looks like a common syringe but with an opening instead of a needle. This propels the semen directly into the cervix (the "neck" or opening, of the womb). Nowadays, for couples with fertility problems, a procedure known as intrauterine insemination (IUI) is considered more effective, according to Toni Weschler, MPH, author of the popular book Taking Charge of Your Fertility.

If a woman's partner has a low sperm count, intracervical insemination may be enough to help the sperm on their way. Among other problems that might call for a doctor's help, the chemistry of her cervical mucus could be impeding the sperm. Poor sperm motility (ability to swim) may also make it more difficult to conceive. For these conditions, a fertility specialist may suggest the couple try intrauterine insemination so that the sperm will have fewer obstacles.

IUI is performed with sperm that's been "washed" -- or separated from the semen -- making it highly concentrated. The process also cleanses the sperm of toxins that can cause adverse reactions or severe cramping in the uterus The liquid containing the concentrated sperm is placed in a long tube and injected directly into the uterus, giving it an advantage over sperm that have to fight their way there and then progress to one of the fallopian tubes.

If you need a donor

For women whose partners don't have viable sperm, a third-party donor is also an option. The choice then is whether to use a donor the couple knows -- perhaps a friend or a relative of her partner -- or to go with an anonymous donor from a sperm bank. As sperm banks have become more accessible in recent years, women without male partners, single lesbians, and lesbian couples are also turning to donor insemination. In fact, in some sperm banks, women in these groups make up the majority of the clientele.

For some would-be parents dealing with male infertility, "donor sperm remains the most affordable, successful, and readily available option," according to the book Resolving Infertility, written and edited by the staff of Resolve, a national nonprofit organization that aids people with fertility problems.

An IUI with donor sperm costs about $400 a try, compared to one cycle of in vitro fertilization -- in which the egg is extracted and fertilized with sperm in a lab, then implanted in the uterus -- that costs about $8,000 per cycle, not including medications. Of course, whether you are able to benefit from donor insemination depends on what your fertility problems are.

Choosing a donor

If you work with a sperm bank, you'll need to choose a donor. Most of the sperm banks in the United States conceal the donor's identity forever. But some, like the Sperm Bank of California in Berkeley, offer the child the option of obtaining the donor's identifying information after the child turns 18. That way, finding out who the donor is stays under the child's control. (The Berkeley bank and other such identity-release sperm banks send frozen sperm to clients all over the country.)

Regardless of how the sperm bank you choose operates, you can glean a lot about donors from their files. Most sperm banks give their clients basic information on donors, including height, weight, age, hair and eye color, and ethnicity. Some reveal donors' occupations and ask them to write a little about their interests and character traits. "I'm not very good with mechanical things: I call a plumber," one donor writes whimsically. "I have a good sense of humor and like to laugh and make people laugh."

Asked for the message he would like to pass on to potential mothers or couples, he wrote, "I'm smart, decent-looking, and have straight teeth. The rest is up to you."

All donors should undergo rigorous health assessments, including a complete blood workup and tests for HIV, chlamydia, and the carrier traits for such diseases as Tay Sachs, cystic fibrosis, and sickle-cell anemia. Every sperm bank should have thorough medical histories on all of their donors, according to the American Society for Reproductive Medicine.

The physician group recommends that sperm be frozen for six months before it is used to allow enough time for HIV testing. At the time of the donation, the donor is tested for HIV. He's tested again six months later, and if he's still HIV-negative, his original donation can be released.

One clear advantage of choosing a friend as a donor is that you know the kind of person he is and what he looks like. In time, your child could even have a relationship with him. The main disadvantage is that he may find he has strong feelings for the child and claim paternity rights. It's wise to discuss the arrangement with a lawyer or at least draw up a donor agreement right from the beginning.

With an anonymous donor, you have almost no risk of HIV and zero risk of ending up in a custody battle. You can shop for the genes you'd like, and you get to screen out donors with specific medical histories. The downside is that your future child may have questions about the donor that you'll never be able to answer.

Your chances

The odds of success depend greatly on a woman's age and fertility issues. Generally, with monthly inseminations, the chance of getting pregnant using frozen sperm is about 10 to 20 percent each cycle, according to the American Pregnancy Association.

The National Institute of Child Health and Human Development examined the results of inseminating women who had fertility problems with fresh sperm from their partners. The study found that women who received injections of follicle-stimulating hormone (FSH), which induces ovulation, and then had an IUI, fared the best. Over a period of four cycles, 33 percent of them got pregnant, according to the study, which was published in the New England Journal of Medicine.

In the group that received FSH and had intracervical insemination, 19 percent conceived. Those who had intrauterine insemination without added hormones did nearly as well, with an 18 percent pregnancy rate. Only 10 percent of those who had intracervical insemination alone got pregnant.

All of these choices involve careful planning, a clear sense of when you're ovulating, and some good advice from a fertility specialist. You may find that getting pregnant is much less complicated than you think.

-- Elaine Herscher is a senior editor at Consumer Health Interactive.

References

Donor Insemination: A Guide for Patients, American Society for Reproductive Medicine.

Weschler, Toni. Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health. Quill, 2002

Guzick, David S., MD, et al. "Efficacy of Superovulation and Intrauterine Insemination in the Treatment of Infertility," New England Journal of Medicine, vol. 340:177-183. January 21, 1999, Number 3

The Sperm Bank of California, 510-841-1858 www.thespermbankofca.org

Resolve. http://www.resolve.org/

American Pregnancy Association. Intrauterine Insemination (IUI). May 2007. http://www.americanpregnancy.org/infertility/iui.html


Reviewed by David Sable, MD, director of the Division of Reproductive Endocrinology, Saint Barnabas Medical Center in Livingston, New Jersey.

Last updated July 29, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

INTRAUTERINE INSEMINATION

Topics

What is an intrauterine insemination?

If you're having trouble getting pregnant, your doctor may recommend an intrauterine insemination (IUI) -- a relatively noninvasive and inexpensive way to boost your chances of conceiving.

With an IUI, your partner provides a sperm sample at home or in the doctor's office on the same day of the insemination. Then, his sperm are "washed" -- that is, the sperm are separated from the semen and concentrated; the washing also cleanses the sperm of potentially hazardous chemicals that could harm the uterus. The resulting liquid is placed in a thin soft tube and injected high into your uterus. This positions the sperm much closer to the fallopian tubes, where it will have to be for one of them to fertilize an egg.

If you don't have a male partner, or if your partner is unable to produce viable sperm, you can undergo the same procedure using frozen sperm purchased from a sperm bank.

The procedure takes only a few minutes. You may experience mild cramping, but it's usually brief and you can resume your activities immediately afterward.

Am I a good candidate for IUI?

The procedure works well for many women under 45 with certain fertility problems (whose partners have viable sperm), and for those in the same age group without male partners who are trying to get pregnant using donated sperm. Some infertility groups say it is less likely to work if women are over 42 or even 40. It's a common treatment for women who have ovulation problems or unexplained infertility, or whose partners have low sperm counts, poorly shaped sperm, or problems with sperm motility (ability to travel).

IUI is particularly appropriate when the woman has been prescribed clomiphene citrate (Clomid or Serophene) to stimulate ovulation, since this medication can result in cervical mucous that is thick and difficult for the sperm to swim through.

Fertility specialists don't usually advise women who have blocked fallopian tubes, severe tubal damage, or very poor egg quality to try IUI. They are also unlikely to suggest this treatment if a man has more than a mild problem with his sperm quality. It's standard to have a thorough fertility workup, including an evaluation for hormonal imbalances, infections, or blockages, before trying IUI.

Single women, couples where the man has no viable sperm, and lesbian couples using donor sperm are also good candidates for intrauterine insemination. Because donor sperm is often frozen and a woman's chances of getting pregnant are reduced using frozen -- as opposed to fresh -- sperm, IUI is a relatively easy way to boost the odds. It's more effective, say doctors, than using a plastic syringe to position the sperm on the cervix, a procedure known as intracervical insemination (ICI) that women generally do at home.

Will I need to take fertility drugs?

IUI is timed to occur in the most fertile period of your cycle, or ovulation. In some cases, women receive intrauterine inseminations without having to take drugs. Although there's no universal agreement, many fertility specialists feel women have a better chance of getting pregnant if they combine IUI with a drug that stimulates the ovaries to produce mature eggs. If you are having ovulation problems, your doctor may have you take an ovulation-stimulating drug, such as clomiphene, for several weeks before doing the IUI.

If you are injected with ovarian stimulation drugs, your doctor will need to monitor you carefully with blood tests and ultrasounds beginning on the sixth day of your cycle. Women taking these drugs are at risk of ovarian hyperstimulation syndrome (OHSS), a rare but potentially life-threatening condition marked by abnormal swelling of the ovaries and fluid collection in the abdomen.

What are the other risks of IUI?

Complications of IUI are infrequent, according to fertility experts. Besides the risks of combined IUI and fertility drug treatment, they include infection and the possibility of venereal disease. To lessen the risk of disease, fertility clinics should quarantine all frozen specimens of sperm for 180 days and retest the donor for HIV before releasing the sperm, according to the American Society of Reproductive Medicine. Although some fertility clinics offer fresh donor sperm, the society recommends against its use.

How long will it take to get pregnant?

Specialists recommend from three to six cycles of IUI before you consider moving to a more invasive or expensive treatment, such as in vitro fertilization (IVF). If your doctor thinks you could benefit from IUI, at $200 to $500 per insemination, as opposed to $7,000 to $15,000 for IVF, it's well worth a try.

-- Elaine Herscher is a senior editor at Consumer Health Interactive. She formerly covered health policy for the San Francisco Chronicle.

References

Resolving Infertility, Quill books, 2001.

Intrauterine Insemination, Mayo Clinic http://www.mayoclinic.org/infertility-rst/insemination.html

Intrauterine Insemination (IUI), Reproductive Science Center of the San Francisco Bay Area. http://www.rscbayarea.com/


Reviewed by David Sable, MD, director of the Division of Reproductive Endocrinology, Saint Barnabas Medical Center in Livingston, New Jersey.

Last updated February 20, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

INTRACYTOPLASMIC SPERM INJECTION (ICSI)

Topics

Intracytoplasmic sperm injection (ICSI) revolutionized treatment for male infertility. The procedure, introduced in 1992, involves taking single motile sperm and directly injecting the sperm into the egg to initiate the fertilization process. ICSI necessarily requires the in vitro fertilization (IVF) process to directly manipulate sperm and eggs.

ICSI boasts a fertilization rate of 50 to 80 percent, according to the American Society for Reproductive Medicine, but may be as high as 85 percent at some clinics. In 2006, about 34 percent of all ICSI cycles performed in the United States resulted in a live birth. About 60 percent of all cycles using assisted reproductive technologies in the United States now involve ICSI.

Who can benefit from ICSI?

Most routine IVF procedures require at least 500,000 sperm per egg, says Paul Turek, MD, director of the male reproductive laboratory at the University of California at San Francisco. But many infertile men don't have that much, he adds.

That's why ICSI is often used when a man has a low sperm count or sperm with poor motility. When a man has a low sperm count because of a damaged or missing vas deferens, the pair of tubes that carries sperm from the testes to the penis, ICSI can be used to extract sperm. Men who have an irreversible vasectomy, and even men who were considered sterile after cancer treatment are prime candidates for ICSI.

"ICSI allows sperm that haven't been ejaculated to be used for fertilization," Turek says.

Many couples now choose the procedure simply because they believe it improves their chances for a successful IVF, especially when there are a limited number of a woman's eggs available.

How does ICSI work?

As in a routine IVF procedure, the woman must take fertility medications to stimulate her ovaries to produce multiple mature eggs. With a transvaginal ultrasound-guided needle, the eggs are removed from her ovaries and placed in a petri dish for fertilization. If a man's semen does not contain enough motile sperm, the doctor can extract sperm from a testicle with a needle. If a sperm sample reveals too few sperm, a biopsy can be taken from testicular tissue in hopes that there will be sperm attached. Similar to the egg retrieval procedure in women, this procedure can be quite painful, so it requires anesthesia.

Next, a single sperm is injected directly into each individual egg. The next day the eggs are checked to see if fertilization was successful. The fertilized eggs will remain in the petri dish for a few days as they continue to divide and become early embryos. Using a thin catheter, the doctor then places the embryos into the uterus.

The full IVF cycle takes about six weeks to complete -- from the first day of treatment until embryo transfer. In a third of ICSI pregnancies, more than one embryo implants, which can lead to a multiple pregnancy.

If there are extra embryos, they can be frozen for future fertilization attempts if the initial procedure is unsuccessful.

Risks and concerns

The processes of IVF and ICSI and other fertility procedures involve ovarian stimulation which can increase the risk of ovarian hyperstimulation syndrome, a potentially dangerous complication in which the ovaries become enlarged and, in severe cases, may lead to problems such as respiratory problems, blood clots, or kidney damage.

Although the medical research is not conclusive, in recent years a number of studies have shown that babies conceived through ICSI may have higher rates of certain birth defects and other problems. The risk of hypospadias -- a birth defect that causes the urethral opening to be located in the underside of the penis -- is higher in boys born through ICSI than in the general population. Also, because male infertility can be genetic, boys conceived through ICSI may inherit this condition and therefore have a higher chance of having fertility problems themselves as adults.

It has also been reported that ICSI babies have a four-fold increased risk of sex chromosome-linked genetic abnormalities that can result in various clinical syndromes.

A study of 5,138 Australian children showed that babies conceived through ICSI or IVF had twice as high of a risk of having a major birth defect as compared to babies that were conceived naturally. However, a study of 1,139 ICSI babies in Sweden showed that although ICSI babies had a slightly higher rate of minor or major birth defects, it was thought to be related to the higher rate of multiple and preterm births associated with fertility procedures, rather than to ICSI itself. Since there is not yet a consensus within the medical community, it's probably safest to assume that the use of ICSI or any other assisted reproductive technology may carry a small risk of birth defect.

As for whether the ICSI procedure affects children's learning skills, early research suggested that mental development may be slower among ICSI children. However, this study was small and has been refuted by several recent studies. Current research suggests that babies conceived through ICSI do not have a higher rate of learning disabilities. In 2005, the journal Pediatrics published a study of 1,423 five-year-old children from five European countries. The results showed that children conceived through ICSI or IVF did just as well as their naturally conceived peers on cognitive and motor development tests.

Some critics of the procedure argue that because it allows weaker sperm to fertilize eggs -- rather than relying on natural selection to favor the hardiest sperm – it may lead to genetic defects. However, even with a slight increase, these genetic conditions remain rare: researchers have stated risks ranging from minor birth defects in 1.2 percent of ICSI children to 4.1 percent for major birth defects. Some believe that the higher incidence of birth defects and other issues may be because couples who use ICSI tend to be older and may have other health issues.

Cost

It costs about $10,000 to $12,000 for one cycle of ICSI, excluding medications and additional options such as sperm or embryo freezing. However, it may take more than one procedure to become pregnant. Costs also will depend on where you live. Many health insurers do not cover the cost of fertility procedures, but you may be able to discuss financing plans with your doctor.

-- Melanie Haiken, MA, is the former health editor of Parenting magazine and specializes in health, business, and parenting issues. She has served as managing editor of San Francisco magazine and as an editor at Industry Standard magazine, and has written for Time Inc. Health, The Washington Post, and many other publications.

Further Resources

American Society of Reproductive Medicine
http://www.asrm.org

American Fertility Association
http://www.theafa.org/

RESOLVE
http://www.resolve.org

References

Interview with Paul J. Turek, MD, director of the male reproductive laboratory University of California at San Francisco Center for Reproductive Health

University of California at San Francisco. Intracytoplasmic Sperm Injection. http://www.ucsfivf.org/ucsf-icsi.htm

University of Pennsylvania. Intracytoplasmic Sperm Injection. http://www.obgyn.upenn.edu/IVF/Intracytoplasmic.html

Advanced Fertility Center of Chicago. Intracytoplasmic Sperm Injection. http://www.advancedfertility.com/icsi.htm

American Society for Reproductive Medicine. Assisted Reproductive Technologies – A Guide for Patients. American Society for Reproductive Medicine.

Cornell Institute for Reproductive Medicine. What's New in Male Infertility Treatment at Cornell – ICSI. http://www.maleinfertility.org/new-icsi.html

American Urological Association. Management of Male Infertility. http://www.urologyhealth.org/print/index.cfm?topic=129

San Diego Fertility Center. IVF Example Calendar. http://www.sdfertility.com/ivfcalendar.htm

Gerris JM. Single embryo transfer and IVF/ICSI outcome: a balanced appraisal. Human Reproduction Update. 2005 11(2):105-121.

Mayo Clinic. Ectopic Pregnancy. http://www.mayoclinic.com/health/ectopic-pregnancy/DS00622

Ponjaert-Kristoffersen I, et al. Pediatrics. 2005 Mar;115(3):e283-9.

Hansen M,et al. The risk of major birth defects after intracytoplasmic sperm injection and in vitro fertilization. New England Journal of Medicine. 2002 Mar 7;346(10):725-30.

Wennerholm UB, et al. Incidence of congenital malformations in children born after ICSI. Human Reproduction. 2000. 15(4):944-948.

Van Steirteghem A, et al. Follow-up of children born after ICSI. Human Reproduction Update. 2002 8(2):111-116.

Ovarian Hyperstimulation Syndrome Practice Guidelines. Fertility and Sterility. 2003 Nov;80(5):1309-14.

Bonduelle M, et al. Prenatal testing in ICSI pregnancies: incidence of chromosomal anomalies in 1586 karyotypes and relation to sperm parameters. Human Reproduction. 2002. 17(10):2600-2614.

CDC. ART Success Rates 2005. http://www.cdc.gov/ART/ART2005

CDC. 2006 Assisted Reproductive Technology (ART) Report: ART Trends 1996 ? 2006. http://cdc.gov/ART/ART2006


Reviewed by Victor Fujimoto, MD, director of the IVF program at the University of California at San Francisco. Dr. Fujimoto is board certified in obstetrics and gynecology as well as reproductive endocrinology and infertility.

Last updated July 27, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

THE EGG FACTOR

Good Eggs, FSH Levels, and Ovarian Reserve

Topics

The concept I describe most frequently to anyone interested in fertility is that of ovarian reserve, or the "egg factor." As of this writing we are quite capable of bypassing the problems of poor quality sperm, low sperm count, and problems stemming from dysfunction or disease of the female reproductive system such as endometriosis, or tubal disease.

Still vexing, though, is the problem of women in the reproductive age group whose eggs do not seem to respond to the tools that we have available. Eggs are not replaceable. Women are born with all of the eggs they will ever have, and the number of eggs rapidly depletes as women age. Even before a first menstrual period, the number has shrunk from the millions present just before birth to the hundreds of thousands, and many more are lost monthly. Each menstrual cycle sees hundreds of eggs start the journey to maturity, a journey that only one or two will complete successfully. Each woman's ovaries have their own rate of egg depletion, a sort of ovarian career that lasts from puberty to sometime before menopause.

Over time, the chance of conceiving in any particular month drops. For years we debated whether this decline was a result of the aging ovaries or the aging uterus, but the discovery that a woman's reproductive potential could be greatly increased by the use of donated eggs demonstrated that the eggs, and not the uterus, were the cause of the decreased fertility.

Sperm: A DNA-filled bag

Why would that be so? Think about what an egg is and what it does. Compare an egg to a sperm cell, which is essentially a DNA-filled Ziplock bag with a tail. Its job is to deliver DNA to the egg and safely usher it inside. A good sperm cell contains normal DNA and has an effective way to gain entry into the egg. This process is so inefficient that nature sends millions of sperm cells out for each egg, to insure that one individual sperm cell gets the job done. Once the sperm has delivered the male DNA, however, the egg itself has to do the important work. It must provide an environment for the effective combination and replication of the now combined male and female DNA, and it must split again and again in an equal fashion.

A "good egg" has two functions: it must have good normal chromosomes, and it must let those chromosomes combine with those from a sperm cell and subsequently divide efficiently. The cause of the difficulty that women experience with fertility as they age are eggs with abnormal chromosomes or eggs with cytoplasm (the non-DNA containing portion of the egg, in a simplified but not entirely accurate explanation) that cannot foster the effective distribution of chromosomes as they split.

Unfortunately, egg quality is not easy to judge. Although egg quality declines as women get older, going by a woman's age is not enough. Two women at the same age can have vastly different possibilities of conceiving on any given month. Differences seem particularly wide in the 36- to 41-year-old age group. And while we can easily look at sperm, look at its shape and watch it swim, we can directly view eggs only after they have been somehow removed from the ovaries in an unnatural way.

FSH: The cruelest number

We have to look for our clues to egg quality in indirect ways. One possible way is by observing the menstrual pattern. As women age, their cycles shorten. Unfortunately, this is such a late phenomenon in a woman's reproductive career -- and most women's cycles vary somewhat month to month -- that observing menstrual patterns is a very imprecise method of determining egg quality. So are measurements of estrogen levels or follicle sizes on ultrasound scans.

So far, the best simple test we have been able to come up with is an early cycle FSH level. FSH stands for follicle stimulating hormone, and is one of the more important ways in which the brain talks to the ovaries.

Simply, the brain releases FSH when it wants the ovaries to mature an egg; as the ovaries choose and mature the egg, hormone products from the ovaries signal the brain to decrease the release of FSH. This is an example of a feedback loop. An important concept to recognize is that the communication between the brain and the ovaries seems to be controlled by the eggs, or by the cells that surround the egg. And if the communication seems to be poor, it is an indication that there may be a problem with the eggs themselves. We are not sure what the exact nature of these problems are, whether they are in the DNA or in the cytoplasm or just in the eggs' ability to respond to stimulation, but we know that a breakdown in the communication between the eggs and the brain correlates with very poor pregnancy rates in infertility treatment.

The FSH test is the simplest method we know of to test the ability of the eggs to talk back to the brain. If the system is functioning the way it should, then the FSH level early in the cycle should be on the lower end of the scale. How low? That depends on the laboratory doing the testing. Each lab, by nature of the way the test is done there, will report a different level for a given test. One of the great confusions regarding FSH testing is that a similar level means very different things at different places. Also, some clinics characterize their tests very carefully; others less so. FSH is reported in "units" and results from 2 units to 7 are probably normal in just about any lab. Levels above 25 are probably abnormal. The area between 9 to 24 may represent normal or abnormal levels, depending on how the test is performed.

Adding to the confusion is that FSH bounces around quite a bit. One month the result may be a 7 and the next month may be a 13. For a while we thought that it might be possible to wait for a month with a better level to improve the odds that a given cycle would work. Unfortunately, we learned that intermittently high FSH is as bad a prognostic sign in months with normal FSH levels as it is in months with high FSH levels.

Pregnant with decreased reserve

Now I know someone, somewhere is reading this and saying, "Wait a minute -- I know someone who got pregnant after being told she had a high FSH." Yes, you can get pregnant with a high FSH. But we are virtually incapable of bringing it about. Almost all of the tools we use to treat infertility need the ovaries to respond to extra stimulation: make extra eggs, higher hormone levels at the least. Ovaries with diminished reserve still have eggs that can turn into a pregnancy; unfortunately those ovaries respond to the most aggressive stimulations at a baseline level only. One of my colleagues compares the situation to a car that runs perfectly well at 30 miles per hour, but when you push the gas pedal all the way down, it still goes 30 miles per hour.

Further, the eggs produced by ovaries with diminished reserve seem quite fragile. The tools we use, particularly HMG and IVF are often too much of a stress on these fragile eggs. Many fail to mature at all, many quickly move from immaturity to postmaturity (a sort of overcooking). The few that do withstand fertilization outside of the body rapidly dissolve into numerous fragments since the ability of the resulting embryo to foster even cell division is compromised. The body, when left to its own devices, can still gently nurture some of these fragile eggs towards maturity, and pregnancy is still feasible (although not nearly as common as we would like). However, when we bombard these same eggs with FSH or FSH and Lupron, or try to develop them in vitro, they do very poorly.

In these circumstances we are left with two polar extreme choices to offer patients: either to try on their own and hope that one of the infrequent natural pregnancies occur, or do IVF using a donor's eggs. In the unfortunate cases where there are blocked tubes or a severe male infertility, where a natural pregnancy is extremely unlikely even if a perfect egg were matured and released, the only real option, at present anyway, is oocyte donation.

Returning to the subject of testing, I mentioned earlier that the FSH bounces in and out of the abnormal range during the diminished reserve period, that waiting for a "good month" is not helpful, and that once the level starts appearing in the high range the ovaries as a whole can be considered unresponsive and the eggs more fragile. This leaves open the possibility of being misled by a normal value when the FSH is on the downswing of its variability. Are there ways to avoid this? Actually there are two. Recall that a finely tuned communication between the ovary and the brain will result in a low FSH value on days 2,3, or 4 of the cycle. We have noted that the same fine-tuning results in a low estradiol (estrogen) level at the same time. Further, an abnormally high estradiol level can artificially decrease the FSH and lull us into a false sense of security about the ovarian reserve. For these reasons we usually look at the estradiol (or E2) level when testing FSH. And while there is no specific E2 level that precludes successful infertility treatment the way FSH levels can, E2 levels that are high (above 100 is a good benchmark) are good indications to look beyond just one FSH level for reassurance that the ovarian reserve is adequate.

How do we look beyond the one FSH level? One way is just to repeat the day 3 tests several months in a row, but this is obviously inconvenient and wastes a lot of time. A quicker way is by using the second method of extended ovarian reserve testing, called the clomiphene citrate challenge test (CCCT).

Clomiphene citrate challenge test:

Day 3: FSH and E2 level

Day 5-9: clomiphene citrate 100 mg (2 tablets)

Day 10: FSH and E2 level

The basis for this test is that the FSH level should be lower on day 10 than on day 3. Using clomiphene citrate (Clomid or Serophene) on days 5 to 9, the FSH will actually rise on day 10 in women whose ovaries lack the ability to properly signal the brain. A high FSH level on day 10 is as bad as a high level on day 3, and can keep us from mistaking the bottom part of a bouncing FSH curve for false reassurance on the state of the ovaries.

I hate all of these tests. They are nothing but bad news. A bad level is always bad, good levels might still be bad, and I can't fix the underlying problem. And while oocyte donation offers many couples an excellent and fulfilling way to bypass the problem of diminished ovarian reserve, FSH testing is a constant reminder that we are still unable to help one of the largest groups of people who seek us out to help them conceive. Hopefully, advances in our ability to either rejuvenate the eggs in these women or to better separate the genetic from the growth components of eggs (and then use donor eggs with a woman's own chromosomes) will change this scenario. Cytoplasm transfer is an important step in this direction; others are coming. I look forward to using FSH testing to help choose the right tools, rather than having the tests tell me I have none.

-- Dr. David Sable, MD, is a board-certified obstetrician and gynecologist specializing in fertility issues and a reproductive endocrinologist at St. Barnabas Hospital in Livingston, New Jersey, where he serves as director of the division of reproductive endocrinology. He has also taught obstetrics, gynecology, and reproductive endocrinology at Harvard Medical School.


Last updated April 28, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

DONOR EGGS AND EMBRYOS

Topics

If you are in your early to late 40s and trying to conceive a child, you are probably considering whether to use the eggs of a younger woman, known as donor eggs. Sometimes the donor is a relative or friend of the patient, but more often the donor is anonymous. In women age 42 or older, fifty-five percent of all assisted reproductive technology (ART) cycles rely on donor eggs. For women older than 47, close to 90 percent use donor eggs.

While advanced maternal age is the most common reason for using donated eggs, other indications for choosing to use donor eggs include a history of genetic disease and premature ovarian failure. This last condition occurs when a woman experiences menopause before age 40, often as a result of treatment for cancer or another disease. In 2006, 5,393 babies were born using donor eggs.

How do I select an egg donor?

Start by considering the characteristics that are important to you in an egg donor. Would you be more comfortable using eggs from a family member or friend if that were a possibility, or from someone you don't know? Potential egg donors will be screened for:

Because there's a considerable amount of time, pain, and inconvenience involved in donating eggs, most donors are paid. (Average payments range from $4,000 to $8,000.) Although state laws differ slightly, donors usually sign away the rights to any children born as a result of the use of their eggs.

In some cases, the resulting baby isn't genetically related to either parent. Some people choose to use embryos donated by a couple who also had recourse to ART and produced more embryos than they could use.

How does it work?

Synchronizing the development of your uterine lining with the growth of the donor's follicles and eggs is important to a successful egg donation. In order to get your cycle in sync with that of the donor, you will take a combination of Lupron (a synthetic hormone) and birth control pills. The donor will take a fertility drug to stimulate the maturation of multiple eggs at once. Simultaneously, you will receive estrogen either by mouth, injection, or skin patch for two weeks.

During this time, you'll be monitored via ultrasound and blood tests to ensure that your uterine lining is prepared to support an embryo. You'll then be given the hormone progesterone, which causes changes in your uterine lining that will help the embryo implant. Once the donor's eggs are mature, your doctor will remove the donor's eggs from her ovaries by inserting a needle through her vaginal wall.

From this point on, the procedure is just like that of in vitro fertilization (IVF); your partner -- or a sperm donor -- provides semen, which is then used to fertilize the donated eggs in a laboratory. After a few days, the embryo is placed in your uterus. And after about 14 days you will take a pregnancy test to see if everything worked as planned.

What's the success rate of IVF using donor eggs?

Although the success rate varies depending upon the donor's age, the sperm quality, and the health of the women involved, the chances are better for donor eggs than for many other ART procedures. In 2006, 54 percent of women using donor eggs experienced a live birth.

What are the risks related to egg donation?

The primary risk for the recipient is multiple pregnancy. Most egg donors are young and have healthy eggs, therefore multiple pregnancy rates are high. In 2005, nearly 43 percent of successful egg donations resulted in the births of twins, triplets, or more, according to the Centers for Disease Control and Prevention. The egg donor may be at risk for ovarian hyperstimulation syndrome, which causes the ovaries to become swollen and painful and, in rare cases, can lead to more serious symptoms. If you become pregnant using donor eggs, your risk of having a child with a birth defect is 3 to 5 percent, the same as for any other pregnancy.

Some women find the medications they are required to take have uncomfortable side effects including hot flashes, depression, headaches and insomnia.

-- Melanie Haiken, MA, is the former health editor of Parenting magazine and specializes in health, business, and parenting issues. She has served as managing editor of San Francisco magazine and as an editor at Industry Standard magazine, and has written for Time Inc. Health, The Washington Post, and many other publications.

Further Resources

RESOLVE
http://www.resolve.org

The American Surrogacy Center
http://www.surrogacy.com

American Pregnancy Association
http://www.americanpregnancy.org

The American Fertility Association
http://www.theafa.org/

Society for Reproductive Endocrinology and Fertility
http://www.socrei.org/

References

American Pregnancy Association, Donor Eggs:
http://www.americanpregnancy.org/infertility/donoreggs.html

The Ethics Committee of the American Society for Reproductive Medicine. Financial incentives in recruitment of oocyte donors. Fertility and Sterility. August 2000, Vol. 74 No. 2.

CDC. ART Success Rates 2005. http://www.cdc.gov/ART/ART2005

Interview with Paul J. Turek, MD. University of San Francisco Center for Reproductive Health.

Centers for Disease Control. Figure 4 Types of ART cycles by Age Group -- United States 2006. December 2008. http://www.cdc.gov/art/ART2006/sect1_fig1-4.htm

Centers for Disease Control Figure 44 Percent of ART Cycles Using Donor Eggs by Patient's Age 2006. http://www.cdc.gov/art/ART2006/sect4_fig44-48.htm#f44

Centers for Disease Control. Figure 46 How successful is ART when donor eggs are used? http://www.cdc.gov/ART/ART2006/section4.htm


Reviewed by Victor Fujimoto, MD, director of the IVF program at the University of California at San Francisco. Dr. Fujimoto is board certified in obstetrics and gynecology as well as reproductive endocrinology and infertility.

Last updated May 28, 2009

Copyright © 2006 Consumer Health Interactive

DRUGS & CONDITIONS

DETECTING OVULATION

Topics

What is ovulation?

Ovulation is the fertile time of your menstrual cycle, which occurs when a mature egg -- or ovum -- is released from one of your ovaries. After the egg is released, it travels down the fallopian tube, where it can be fertilized if sperm are present.

How do I know when I'm ovulating?

It can be tricky to figure out when you're ovulating and even trickier knowing how to time intercourse. Your peak fertile time occurs during the two or three days immediately before ovulation, but fertilization can occur up to 12 to 24 hours afterwards. Sperm can live in a woman's body for as long as five days, but an egg will last no longer than 24 hours, so the timing of intercourse or insemination has to be as precise as possible.

Although you have two ovaries, ovulation does not necessarily alternate back and forth between them each cycle. Furthermore, scientists have recently come to believe that in the event that one of the fallopian tubes is blocked, the other tube's fingerlike tentacles -- which whisk the ovum into the tubes -- can actually "walk" to the other side and grab an egg from the other fallopian tube.

There are several ways to know when to try to get pregnant: Pay close attention to the changes in your body for several months by recording your period cycles, documenting your temperature every morning with a special thermometer, using a commercial fertility monitor or ovulation predictor kit, or monitoring the texture of your cervical mucus. In general, if your cycles are regular, it's easier to predict fertility time intervals.

For a rough idea of when you ovulate, figure out when your next period is due to begin, and then count back 12 to 15 days.

Calendar method

If you have a written record of your menstrual cycles over eight to 12 months, you can roughly estimate your fertile period. To find out your first day of fertility, subtract 18 from the number of days in your shortest cycle. When your next period begins, take this new number and count ahead that many days. This will be a reasonable guess for the start of your fertile days. Although this is an easy exercise, it is often unreliable for predicting fertility, especially if you have irregular cycles. Factors such as illness and stress can affect the timing of ovulation from month to month.

Changes in cervical mucus

Cervical mucus offers many women their best clue: As your estrogen level rises before ovulation, you may notice your natural discharge becoming whitish-clear and sticky, with a consistency like raw egg white. According to the American Academy of Family Physicians (AAFP), as many as two out of three couples who don't have fertility problems will conceive if they have sexual intercourse on the days that the cervical mucus is clearest and most stretchy.

Basal body temperature

You can also try charting your basal body temperature (your body's temperature when you're at rest) using a special thermometer. This has long been used as a traditional measure of fertility, because your temperature can increase by about 0.5 to 1 degrees following ovulation.

However, because the temperature jump occurs after you've already ovulated and your peak fertile time occurs prior to ovulation, this method does not give you an advance prediction of when you are going to be most fertile. And in addition to the inconvenience of having to take your temperature every morning at the same time, the temperature changes are very subtle and can be difficult to interpret, especially if infertility might be a factor. Many women, however, have found it helpful to follow their temperature through several cycles in order to make an educated guess about when it's going to spike in the future.

Ovulation predictor kits and fertility monitors

Many women rely on commercial ovulation predictor kits, which can be very useful. The kits work by detecting a surge in the production of luteinizing hormone (LH) in your urine. Women's levels of LH rise about 16 to 48 hours before ovulation, so the theory is that you're most fertile shortly after that.

The downside is that these kits don't tell you whether an egg was released or whether your cervical mucus was conducive to fertility. And they will be much less reliable if you are taking fertility drugs or if you are over 40. In recent years, a new device for predicting ovulation called a fertility monitor has become available in many retail stores. The monitor works by analyzing urine samples and identifying days of low, high, and peak fertility. Scientists are still studying its effectiveness, but results thus far have been encouraging. If your cycle is longer than 42 days or shorter than 21, this monitor may not be helpful.

Mittelschmerz

You may also notice a crampy abdominal pain; for some women it's a sharp twinge; others feel it as a dull ache. Known as mittelschmerz, this signals the moment the egg erupts from the ovary. The pain is believed to be caused by fluid, possibly blood, released from the ovary that irritates the abdominal lining. It can last anywhere from a few minutes to a few hours. Abdominal discomfort, however, is an extremely unreliable predictor of fertility because the pain often comes after ovulation, and you are trying to identify the period just before it.

Talk to your doctor about which of the above methods for detecting ovulation will work best for you. For a more complete picture of your fertility, you may want to use more than one method.

Am I most likely to get pregnant while I'm ovulating?

Yes and no. The best strategy, some experts say, is to have sex multiple times for the six days leading up to and including the day of ovulation. The reason: although sperm can live in your body for three to six days, an egg is able to be fertilized for only 12 to 24 hours after ovulation. The American College of Obstetrics and Gynecology recently announced results from a University of Utah study that found that a woman is most likely to become pregnant if intercourse occurs one to two days before ovulation rather than on the actual day of ovulation, as popularly believed.

What are my chances of getting pregnant in any given cycle?

As long as you're relatively young and don't have an undiscovered fertility problem, the odds are pretty good. Fertile women under 30 who have sex during the ovulation period have a 20 percent chance of getting pregnant each cycle. The odds get worse as you age, however; women over 40 have only a 5 percent chance in any given cycle.

-- Melanie Haiken, MA, is the former health editor of Parenting magazine and specializes in health, business, and parenting issues. She has served as managing editor of San Francisco magazine and as an editor at Industry Standard magazine, and has written for Time Inc. Health, The Washington Post, and many other publications.

References

Mayo Clinic. How to Get Pregnant. http://www.mayoclinic.com/health/how-to-get-pregnant/PR00103

Stanford JB et al. Timing intercourse to achieve pregnancy: Current evidence. Obstetrics and Gynecology. December 2002, Vol. 100 No. 6:1333-1341.

University of California San Francisco Center for Reproductive Health. The Menstrual Cycle: Female Anatomy and Physiology. http://www.ucsfivf.org/ucsf-menstrual_cycle.htm

American Academy of Family Physicians. Natural Family Planning. http://familydoctor.org/126.xml

The Cleveland Clinic. Mittelschmerz (Painful Ovulation). http://www.clevelandclinic.org/health/health-info/docs/2400/2424.asp

American Pregnancy Association. Ovulation: Frequently Asked Questions

Link: http://www.americanpregnancy.org/gettingpregnant/ovulationfaq.htm

American Pregnancy Association. Ovulation Frequently Asked Questions. http://www.americanpregnancy.org/gettingpregnant/ovulationfaq.htm

American Pregnancy Association. Fertility Awareness: Natural Family Planning (NFP). http://www.americanpregnancy.org/preventingpregnancy/fertilityawarenessNFP.html


Reviewed by Victor Fujimoto, MD, director of the IVF program at the University of California at San Francisco. Dr. Fujimoto is board certified in obstetrics and gynecology as well as reproductive endocrinology and infertility.

Last updated May 28, 2009

Copyright © 2006 Consumer Health Interactive

DRUGS & CONDITIONS

LIFESTYLE AND FERTILITY

Humans are closely tuned to their surroundings - especially when it comes to making babies. Just as bears and elk wait for the right season to sire offspring, our bodies reach the peak of fertility only when conditions seem right for raising babies. If there's any sign of illness, malnourishment, or an unhealthy environment, our bodies may decide to put parenthood on hold.

That said, you may feel ready to start a family, but is your body getting the right signals? Many men and women are putting their fertility at risk without realizing it. If you hope to have children in the future, now's the time to start protecting your fertility. If you and your partner are already struggling to conceive and there's no medical explanation for your problem, a few lifestyle changes may help put you on the road to parenthood.

Here are some tips for a fertility-friendly lifestyle:

Maintain a healthy weight.

The sex hormones of both men and women are closely tied to weight. According to the Mayo Clinic, heavier men may face fertility problems. Part of the reason is that an increase in abdominal fat is associated with insulin resistance and a rise in insulin production, which wreaks havoc on sex hormones. It's a problem for women, too: According to the American Society for Reproductive Medicine, a weight loss of 5 to 10 percent may dramatically improve a woman's chances of getting pregnant. When obese women do become pregnant, they are more likely to have miscarriages than lean women of the same age.

Get your exercise -- but don't overdo it.

Regular exercise is a great way to stay trim and healthy. But if you push yourself too hard for too long, you might throw your hormones out of balance. How much exercise is too much? There are no hard-and-fast rules. But as a general guide, the American Society for Reproductive Medicine says men and women trying to conceive probably shouldn't run more than 10 miles a week. In addition, grueling mountain-biking (2 hours a day, 6 days a week) has been associated with lower sperm counts and abnormalities of the scrotum, according to a recent study. If you enjoy hours of biking, consider investing in shock-absorbers and cushioned seats.

Eat a balanced diet

Shortfalls in nutrients such as Vitamin C, zinc, and folic acid can slow sperm production in men. Women who are trying to conceive should also take a supplement containing at least 400 micrograms daily of folic acid, a nutrient that can prevent birth defects, according to the Food and Drug Administration.

Don't smoke

Smoking can slightly lower a man's sperm count and may even contribute to impotence. But as reported in the journal Nature Medicine, smoking is especially hard on prospective moms. Smoking can interfere with virtually every aspect of a woman's fertility, from ovulation to early development of the embryo. If you're a female smoker with fertility problems, kicking the addiction should be your top priority.

If you drink, go easy

As reported in Nature Medicine, moderate drinking usually won't lower sperm count in men or harm fertility in women. But large amounts of alcohol (usually defined as more than two drinks per day for men and more than one drink per day for women) may lower your odds for parenthood. Women who are trying to conceive should stop drinking entirely, according to federal health agencies: pregnancy may occur before the woman is aware of it, and alcohol can permanently harm a developing fetus.

Stay clear of recreational drugs

According to the Mayo Clinic, marijuana, cocaine, and anabolic steroids can all contribute to infertility in men. Women trying to get pregnant, of course, should avoid recreational drugs and alcohol because of the potential danger to the fetus.

Check your medicine cabinet

Some prescription drugs can impair fertility in both men and women. For men, the list of potential culprits includes the heartburn medication cimetidine (Tagamet), the rheumatoid arthritis drug (Azulfidine), and several chemotherapy drugs. A woman's fertility may be hampered by certain antibiotics, painkillers, antidepressants, and hormonal treatments. Ask your doctor if any of your medications could be causing infertility. A change of prescription just might solve the problem.

Men, don't take infertility sitting down

Whenever you spend long hours sitting -- whether it's in front of a computer screen or behind a steering wheel -- the temperature of your scrotum and testes may rise a few degrees. As the heat rises, sperm production can plummet. Although there's no hard evidence on this point, Nature Medicine warns that "our increasingly sedentary habits" threaten men's fertility. If you want to increase your sperm count, the theory goes, it's best not to spend all day planted on your backside. You should also avoid saunas or long soaks in hot baths, which can lower sperm count.

A Stony Brook University Hospital study found that men may be feeling the heat from a new direction -- laptop computers. Researchers found that holding a laptop computer on a man's lap for only an hour raised his testes temperature by 4.9 degrees Fahrenheit, which might be enough to impair fertility. Further research is needed to confirm the findings, say researchers.

On the whole, the game plan for protecting fertility looks much like the basic strategy for good health: Watch your weight, exercise, eat well, and avoid smoking and heavy drinking. These habits are good for anyone. With any luck, you can pass them on to your kids.

References

Sharpe RM and S Franks. Environment, lifestyle and infertility-an intergenerational issue. Nature Medicine. October 1, 2002. 8 (S1), s23-s28

Sandlow, JI. Shattering the myths about male fertility. Postgraduate Medicine. May, 2002. 107(2)

Mayo Clinic. Infertility. August 2001.

American Society for Reproductive Medicine. Patient fact sheet: Exercise, weight, and fertility. 1996.

Scientists say laptops a risk to male fertility. Newsday. December 9, 2004

Mayo Clinic. Infertility: Causes. June 2006. http://www.mayoclinic.com/health/infertility/DS00310/DSECTION=3

American Pregnancy Association. Male Infertility. http://www.americanpregnancy.org/infertility/maleinfertility.html


Reviewed by David Sable, MD, director of the division of reproductive endocrinology at Saint Barnabus Medical Center in Livingston, New Jersey.

Last updated May 27, 2008

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

CAFFEINE: DOES IT AFFECT YOUR ODDS?

Topics:

I've heard that caffeine affects women's fertility. Is this true?

You've probably heard that even moderate amounts of caffeine can affect a woman's fertility by delaying conception. The truth is, no one's certain that's true.

An often-cited 1993 study compared women who didn't drink coffee to those who did. Women who had more than moderate amounts of caffeine -- the equivalent of three cups of coffee a day, or about 300 milligrams -- lowered their likelihood of conceiving by as much as 27 percent. What researchers actually measure in such studies is the time it takes a woman to conceive. That time to conception is 27 percent longer on average among the women in this study. Modest consumption appeared to have a slight effect as well: Women who drink only one to two cups daily lowered their chances of conceiving by 10 percent per cycle.

A Danish study followed 430 couples for three years and found that caffeine had a far less significant effect. Compared with women who had less than 300 mg of caffeine per day, those who consumed 300 to 700 mg of caffeine lowered their odds of conceiving by only 12 percent. Drinking more than 700 mg per day reduced their odds by 37 percent. The researchers assumed that anything less than 300 mg was the baseline, as most studies don't find a significant difference at these levels of caffeine.

Studies on lifestyle and fertility are often criticized for not taking all related factors into account. In fact, researchers at Harvard Medical School recently conducted a review of the literature and claimed that there was no convincing evidence that caffeine delays conception. For example, one study from the San Francisco Bay Area found that caffeine had no effect on a woman's odds of conceiving, and that moderate tea drinkers were actually twice as likely to conceive per menstrual cycle. Among smokers, drinking caffeine doesn't seem to hamper fertility any further than smoking already does, possibly because caffeine is metabolized faster among smokers.

So what should you believe? Maybe it's best to rely on your own judgment. If you've been trying to get pregnant for several months without success, and you've already given up alcohol and smoking, you may want to try limiting your total intake of caffeine from coffee, soda, and chocolate -- especially if you regularly get more than 300 mg a day. Although there's no compelling reason to swear off your morning fix and occasional latte, you might even prefer to give up caffeine entirely.

If you're in your 30s, and you've been trying to conceive for more than six months, it may be a good idea to consult your physician to find out if you or your partner might have a fertility problem. It's more common than you might think.

What about men? Can they drink all the coffee they want?

Studies since the 1980s show that small amounts of caffeine increase the percentage of mobile sperm in semen. (The speed of the sperm was unaffected). However, these studies were conducted by adding caffeine to sperm samples -- in real life, the effects of caffeine may be different.

One study published in the journal Human Reproduction looked at men whose partners were undergoing either in vitro fertilization (IVF) or gamete intrafallopian transfer(GIFT). Men participating in the study who increased their normal caffeine intake by the equivalent of one cup of coffee per day were found to have double and, in some cases, triple the odds of multiple gestations. Discussing this and other findings, the researchers concluded that the findings, if replicated, suggest that "couples undergoing IVF or GIFT might benefit from a reduced caffeine intake before the initial clinic visit."

How much caffeine do different foods and drinks contain?

The average person consumes about 120 mg of caffeine a day, which is a moderate amount. We get about 75 percent of our caffeine from coffee, 15 percent from tea, 10 percent from soda, and 2 percent from chocolate. Caffeine is a common ingredient in food, so 300 mg adds up more quickly than you might think. This chart lists a few common items that contain the stimulant. Tea and chocolate also contain other stimulants related to caffeine, called theophylline and theobromine, and these have an unknown effect on human fertility.

Approximate caffeine content in milligrams (mg)

Coffee and tea

Coffee, brewed, 8 oz, 65-135 mg

Coffee, instant, 8 oz., 60-85 mg

Coffee, espresso, single 1 oz. shot, 30-50 mg

Starbucks coffee (tall 12 oz.) 375 mg

Starbuck latte (tall 12 oz) 35 mg

Tea, black, 8 oz., 20-110 mg

Tea, green 8 oz., 30-35 mg

Tea, iced 8 oz.,10-50 mg

Tea, instant 8 oz., 25-30 mg

Cocoa, 8 oz., 5-30 mg

Soft drinks

Coca cola, 12 oz. can, 34 mg

Diet Coke, 12 oz. can, 45 mg

Pepsi, 12 oz. can, 38 mg

Diet Pepsi, 12 oz. can, 36 mg

Sunkist or Dr Pepper, 12 oz. can, 41 mg

Barq's Root Beer, 12 oz. can, 22 mg

Mountain Dew, 12 oz. can, 55 mg

Sprite, 7-Up, Mug Root Beer, 12-oz can, 0 mg

Other foods

Ben and Jerry's Coffee Fudge Frozen Yogurt, 1 cup, 85 mg

Dannon Coffee Yogurt, 1 cup, 45 mg

Haagen-Daaz coffee ice cream, 1 cup, 58 mg

Chocolate, milk, 1 oz., 1-15 mg Chocolate, dark, 1 oz., 15-35 mg

Drugs

Anacin, 2 tablets, 64 mg

Excedrin, 2 tablets, 130 mg

Vivarin, maximum strength No-Doz, 1 tablet, 200 mg

If you're planning to cut back or give up caffeine altogether, you may prefer to avoid it during pregnancy as well. Many women develop a caffeine aversion when they're pregnant, so it may be an easy decision!

-- Deepi Brar is the multimedia editor at Consumer Health Interactive.

References

BBC Health Ask the Doctor http://www.bbc.co.uk/health/ask_doctor/sperm.shtml

International Food Information Council. Caffeine and Women’s Health. August 2002. http://www.ific.org/publications/brochures/caffwomenbroch.cfm

International Food Information Council. Questions and Answers About Caffeine and Health. January 2003. http://www.ific.org/publications/qa/caffqa.cfm

International Food Information Council. Fact Sheet: Caffeine and Health. August 2007. http://www.ific.org/publications/factsheets/caffeinefs.cfm


Reviewed by David Sable, MD, director of the Division of Reproductive Endocrinology at Saint Barnabas Medical Center in Livingston, New Jersey.

Last updated January 21, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

CHOOSING A FERTILITY DOCTOR

Topics:

Out of desperation, many people turn to the first fertility specialist they find in the phone book, or someone they've heard about from a friend. But it's important to find the right doctor for you, one who can come up with a treatment plan tailored to your needs and be sensitive enough to help you through the rough times.

It's also crucial to educate yourself about infertility and its possible causes and treatments. That way, you can ask your doctor the right questions and make sure you're getting the best treatment possible.

What kinds of doctors treat infertility?

There are good reasons to want to stay with your OB/GYN, but don't be afraid to ask exactly how much training, experience, and success he or she has had in treating infertility. OB/GYNs, or gynecologists, are trained to diagnose and treat women's reproductive problems and to care for women during pregnancy and childbirth. Some gynecologists have acquired considerable experience in fertility issues over the years as well, but only a fraction receive formal training to treat infertility or perform more advanced reproductive technologies (ART), such as in vitro fertilization (IVF).

For this sort of expertise, see a board-certified reproductive endocrinologist, an OB/GYN who has undergone several years of additional training to diagnose and treat infertility in both men and women. Reproductive endocrinologists also must have at least two additional years of clinical experience, and pass oral and written exams.

Men may also want to consult an andrologist, who is a urologist certified to treat male infertility.

How do I find the right fertility specialist?

Most women begin this search with their regular gynecologist, and men consult their primary care doctor. This is fine for a first consultation and, in some cases, for an initial infertility diagnosis or even preliminary treatment. If your insurance covers fertility treatments, you may need a referral from your general doctor or OB/GYN before seeing a specialist anyway. Ask if your doctor has some experience with the specialist he or she would refer you to, and ask him or her why the specialist is recommended. That way, if the specialist had good experience with several patients, you can take advantage of that knowledge.

But more and more experts -- as well as women who've been through the process -- now recommend that couples struggling with infertility issues seek out a qualified specialist early on.

If you're 35 or older, you might want to go directly to a reproductive endocrinologist. A specialist can better determine the appropriate course of treatment if a woman has a history of miscarriages, irregular menstrual cycles, or pelvic infection, or if a man has had a semen analysis that shows a low sperm count.

What should I look for in a doctor?

You should feel as if your doctor is an ally in your effort to conceive. Although the issue of fertility is intimate, private, and sensitive, some patients complain about specialists whose bedside manner is cold or even dismissive. During your initial consultation with the doctor, make a point of observing how much the doctor listens to you, answers your questions, and treats you with respect. If a doctor rushes through the consultation, or declines to explain options such as surgery or drugs without discussing why, then move on. Don't waste critical time. You may be able to check out potential doctors by searching Web sites that have evaluations of fertility specialists.

If you have health insurance, try to select a specialist in your health plan's network of specialists. To do so, check the provider directory, either in booklet form or online. This can save you out of pocket costs and also take advantage of the credentialing the health plan does for all network providers.

What other things should I consider in choosing a fertility doctor?

The American Medical Association and the American College of Obstetricians and Gynecologists have searchable databases of physicians by name, city, or zip code. You can also look in the Directory of Medical Specialists, which lists OB/GYNs and their specialty training. (This guide is available at most public libraries.) Other information, like the doctor's education and board certification, is available on some health plans' Web sites.

Organizations like Resolve, a national infertility organization, also offer referrals to reproductive endocrinologists. They recommend interviewing several physicians before selecting one. Resolve suggests you start by asking the following questions:

Also, discuss your expectations. How aggressive do you want your doctor to be? How much risk are you willing to assume? How complex are you willing to make you and your partner's life in order to succeed? What is the physician's philosophy toward patients and their contributions to the process?

How do I know when it's time to try someone new?

The emotional roller coaster ride that usually accompanies fertility treatment can often make you unsure of your reactions to people and your ability to evaluate your doctor. However, if you don't feel you're getting the proper treatment, it is well within your rights to seek help somewhere else.

Experts at Resolve say the following warning signs indicate it may be time to find a new doctor:

Be your own advocate

Even if you and your doctor are a good team, you may still need to be your own best advocate. "It's obvious that women in their forties should be priority patients at infertility clinics -- time is of the essence," writes 43-year-old Liza Glass,* an infertility patient in the San Francisco Bay Area. "Yet the overworked MDs at my clinic rarely follow my case. Most of the time, I must steward my own treatment schedule.

"There are, for example, certain routine steps in the course of a medicated fertility treatment a patient must carry out each cycle," Glass reported in her treatment diary. "These include monitoring estradiol levels to make sure the ovaries have not been overstimulated and ultrasound exams to measure follicles and determine the optimal time to attempt conception." Nonetheless, she says, "I had to battle to book appointments for these procedures. At one point, my doctor was away on vacation and the tests he asked me to take had not been authorized."

Denice Dirks of Southern California says two key factors were responsible for her eventual pregnancy by in vitro fertilization: educating herself about her condition and finding the right doctor.

Dirks felt that the first doctor her OB/GYN referred her to was not aggressive enough, so she sought a referral to another specialist. She also made a point of educating herself about infertility and her treatment options, something she recommends to other patients. By doing her own research, she was able to overcome her feelings of frustration.

"I'm not sure we would have been successful if I wasn't as diligent in taking charge of my own care, or if I'd had a doctor who was not open to that," she says. "You really have to take responsibility for your own medical treatment."

*Liza Glass is a pseudonym.

-- Paige Bierma is a freelance journalist in San Francisco who frequently covers health and medical issues.

Further Resources

American Medical Association: 515 N. State Street; Chicago, IL 60654; 800/621-8335; http://www.ama-assn.org

American Board of Medical Specialties: 1007 Church Street, Suite 404; Evanston, IL 60201-5913; 847/491-9091; 847/328-3596; http://www.abms.org

Resolve: The National Infertility Association: 1760 Old Meadow Rd, Suite 500, McLean, VA 22102; 703/556-7172; http://www.resolve.org

References

Interview with Denice Dirks, an infertility patient

Resolve, the National Infertility Association http://www.resolve.org/

Questions and Conflicts: Working With Your IVF Center, the American Infertility Association, http://www.americaninfertility.org/faqs/aia_workingwithyourivfcenter.html


Reviewed by Patrick Irvine, MD, a noted geriatrician and pharmacologist who lives in Minneapolis, MN.

Last updated June 10, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

MEN: SUPPORTING YOUR PARTNER


Barring some unexpected scientific breakthroughs, pregnancy will always be a woman's job. A man can feel a baby kick and love it before it's born, but he can never truly know what it feels like to have a life growing inside him.

Likewise, men often have trouble understanding the pain felt by women who are struggling with infertility, says Diane Clapp, RN, a fertility counselor and director of medical information for Resolve: The National Infertility Association. "[Infertility] is particularly intense for women," she says. "It's hard for men to resonate with the loss."

The emotional gulf between men and women can have serious consequences. A study of 525 infertile couples presented at the 57th annual meeting of the American Society for Reproductive Medicine found that women were more likely than their partners to be depressed. Female depression was especially common in couples in which partners feel different levels of stress.

Practical Advice

Understandably, Clapp has spent much of her career helping men support their wives through this difficult time. Every couple is different, but certain issues pop up time and time again. Here is some of her tried-and-true advice for men:

-- Chris Woolston, MS, is a health and medical writer with a master's degree in biology. He is a contributing editor at Consumer Health Interactive and was the staff writer at Hippocrates, a magazine for physicians. He has also covered science issues for Time Inc. Health, WebMD, and the Chronicle of Higher Education.

Further Resources

For more information on coping with infertility, visit Resolve's Web site at http://www.resolve.org

References

Interview with Diane Clapp, RN, a fertility counselor and director of medical information for Resolve: The National Infertility Association.

American Society for Reproductive Medicine. In couples with incongruence in stress related to infertility, women are more likely than men to experience depression. October 2001.


Reviewed by David Sable, MD, director of the Division of Reproductive Endocrinology at Saint Barnabas Medical Center in Livingston, New Jersey.

Last updated January 20, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

FINANCING INFERTILITY TREATMENTS


Laura Lynch was only in her 20s when she found herself unable to have a child, despite years of trying.

So when a fertility specialist advised her to try in vitro fertilization, a then-experimental procedure that involved fertilizing her eggs with her husband's sperm in a petri dish, she jumped at the chance. Lynch's odds of giving birth were estimated to be less than 25 percent, and she wasn't sure how much, if any, of the bills her insurance would cover. "I didn't care how much it cost," she says. "I was obsessed with having a child." Lynch's determination paid off -- in 1984, she gave birth to twins, a girl and a boy.

Fortunately, the spend-your-last-dime approach to starting a family worked for the Lynches. But it left the couple with a staggering $25,000 bill, which Lynch, then a public school teacher in Utah, and her husband, an entry-level employee at an oil company, could barely pay off.

"We almost lost the house because we were in arrears. We sold our Toyota Celica. We sold our other car, a pickup truck. Then we bought a station wagon for $2,000 because that was all we had," recalls Lynch, now 44. "By the time we finished paying the bills off, the kids were in fourth grade."

Fortunately, a family member extended the Lynches a loan, saving them from foreclosure. But their situation is a common example of the financial setbacks many couples face in their quest to have a biological child.

Paying out of pocket

In 2001, the last year for which data was available, infertility treatments cost Americans about $2.7 billion. The vast majority of recipients did not have insurance that covers fertility treatments. Even if insurance pays some of the costs, many couples undergoing treatment must scrimp to pay for the rest themselves. "We have people that have either borrowed money from family members or have second-mortgaged their homes," says Susan L. Treiser, MD, PhD, a reproductive endocrinologist and co-director of IVF New Jersey, a fertility clinic. Others, she adds, take out loans or max out their credit cards.

Those sacrifices have led to an outcry among infertility experts about the need for such health coverage. "That's the heartbreak," says Pamela Madsen, executive director for the American Fertility Association. "Not everyone's wealthy. Not everyone has a house that can be mortgaged."

A single round of IVF averages about $12,400, not including blood testing or hormones, which can add up to $5,000. If a woman undergoes intracytoplasmic sperm injection (ICSI), in which a sperm is injected into an egg before being implanted, it costs an additional $1,500 or more. In 2006, the average success rate for a live birth for a woman under 35 was 39 percent, according to a report from the Centers for Disease Control and Prevention (CDC). For women 41 to 42, however, that percentage dropped to 11 percent. That's why most IVF cycles have to be repeated, and why it is not unusual for the bill to come to $30,000 or more.

Yet many couples and single women are tempted to beat the odds. Because assisted reproductive technologies (ART) such as IVF have improved over the last two decades, success rates have jumped, giving new hope to people grappling with infertility problems. Couples who have waited to have children until their 30s or 40s are increasingly paying for fertility procedures, and the number of doctors trained in performing fertility procedures on men and women across the US has grown.

Those are a few reasons why the number of ART procedures has also jumped. According to the CDC, 138,198 assisted reproductive technology procedures were performed in 2006.

Lack of insurance coverage

Unlike other health-care treatments, coverage for fertility treatment remains a controversial issue in the United States. One-fourth of corporations in America with 10 or more employees have plans that pay for fertility treatments, according to a 2001 report from the Mercer Human Resource Consulting. According to American Society for Reproductive Medicine, 14 states across the country have adopted laws governing insurance for fertility coverage, and some statutes are stronger than others. Some states, including California, have a law that requires health plans to offer coverage for infertility treatments, but does not require the health plan to pay for IVF, the most expensive infertility procedure.

But it's been a boon for some patients who are lucky enough to live in states with the highest rate of insurance coverage, such as Illinois, Massachusetts, and Rhode Island. In New Jersey, which passed a bill mandating companies with more than 50 employees to provide insurance coverage for fertility services, some people switch jobs to larger employers just to be eligible for such insurance, Treiser says. But even in states covered by the insurance mandate, many aren't eligible because they work for small companies that are exempt, or because they're self-employed. At IVF New Jersey, the fertility clinic in New Jersey, for example, only about 30 percent of the clinic's patients have some form of coverage, and even then only for certain types of treatment, Treiser says.

That's why most reputable clinics offer some sort of insurance counseling and financial planning assistance when patients first come in for fertility services. At some clinics, doctors work with patients to establish an extended payment plan for their treatment. Most also accept credit cards, and some work with financial services firms that find third-party loans to finance treatments. In this arrangement, payments can be made over a one-to-five year period instead of in one lump sum.

In recent years, however, the lack of insurance coverage has forced some doctors to provide flexible payment programs for patients who lack insurance coverage. One such program, developed by Advanced Reproductive Care, Inc., based in California's San Francisco Bay Area, has now spread to 90 clinics across the country. Doctors can offer discount rates for these procedures and medications, says company CEO and reproductive endocrinologist G. David Adamson, MD.

"We have patients who tell us they could not have afforded their infertility care if we didn't have our package pricing. They can plan, and that takes away a lot of the financial anxiety for people," Adamson says. In return, he says, "we ask our clinics to give a bit of a discount. We ask them for a package price discount. On top of that, we will finance that package -- so the patient can make it affordable."

The lack of insurance has also produced more creative financing. One new program, often called a refund guarantee or shared-risk program, involves offering a refund to women who don't give birth to a child. At Advanced Reproductive Care, for example, if the woman gives birth on a first attempt, but pays for three IVF cycles, the plan costs $28,735. Whether she gives birth after the first or third round, the doctor gets to keep the difference. But if a woman fails to give birth to a child following the third attempt, she gets a refund of $20,640.

Critics of the shared-risk program, however, say such programs are rife with flaws. Because the applicants are screened for eligibility, many clinics offer the money-back guarantee only to women under 35 -- those who are most likely to become pregnant. Critics also say doctors are more likely to implant more than one embryo in the hopes that a woman gets pregnant in the first round -- which would save them the costs of doing more cycles, but raises the risk of a multiple birth. In fact, according to one study, the risk of multiple pregnancies went down in states where insurance for IVF was offered. Still others charge that wagering doctors' fees on the success of treatment is not only unethical, it's a medical gamble.

"It is a gamble," says Adamson, the CEO of Advanced Reproductive Care. If couples are adequately counseled about their chances of pregnancy, then they should know how many cycles to try before they give up, he says. "Some couples say, 'If we don't have our baby, we want some money back to spend on adoption.' "

At other clinics, such programs aren't feasible. Instead, because of the growth of fertility clinics across the country and the competition for patients, they've opted to drop prices instead. At IVF New Jersey, for example, patients can pay a flat rate of $8,000 (plus the cost of medications) for a single cycle of IVF, regardless of whether it results in a live birth.

But even with the most advanced fertility treatments, women should be aware that a baby may not be in their future, says Madsen, the executive director of the American Infertility Association. In that case, they should investigate whether they can live without their own biological child, or consider adopting.

"One couple may feel they've done enough and want to move on. Another may feel they want to spend their last dime."

"Setting a limit may be hard, but they should set a plan when they go in about what they're willing to spend. What are they going to do if the cycle fails?" she says. "There should be a place where they stop and reevaluate, and look at their lives to see where they want to go."

-- Psyche Pascual is an articles editor at Consumer Health Interactive. She formerly worked as a staff writer at the Los Angeles Times and as a business writer for the Contra Costa Times.

For tips on how to pay for fertility treatments, click here to read Sources of Fertility Financing.

References

Interview with G. David Adamson, MD, infertility specialist and CEO of Advanced Reproductive Care Inc. and board member with the American Society of Reproductive Medicine

Interview with Susan Treiser, MD, PhD, reproductive endocrinologist and co-director of IVF New Jersey

Stephen, EH, et al. Updated projections of infertility in the United States: 1995-2025 Fertility and Sterility 70: 30-34 July 1998

Insurance coverage and outcomes of in vitro fertilization. Jain Tarun; Harlow Bernard L; Hornstein Mark D N Engl J Med 2002 Aug 29; 347 (9): 661-6

Why a Finance Issue, report from the American Infertility Association, May 2001

Assisted reproductive technology in the United States: 1998 results generated from the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology Registry, Fertility and Sterility, Vol. 77, No.1. January 2002

State Health Facts Online, Henry J. Kaiser Family Foundation, State Mandated Benefits: Infertility Diagnosis and Treatment, 2001

American Society for Reproductive Medicine. Frequently Asked Questions About Fertility. http://www.asrm.org/Patients/faqs.html

Centers for Disease Control. Assisted Reproductive Technology Success Rates. December 2006. http://ftp.cdc.gov/pub/publications/art/2004ART508.pdf

Centers for Disease Control. 2005 Assisted Reproductive Technology (ART) Report: Section 1. December 2007. http://www.cdc.gov/art/art2005/section1.htm

Centers for Disease Control. 2005 Assisted Reproductive Technology (ART) Report: Section 2. December 2007. http://www.cdc.gov/art/art2005/section2_questions.htm

Centers for Disease Control. 2005 Assisted Reproductive Technology (ART) Success Rates. November 2008. http://www.cdc.gov/ART/ART2006/508PDF/2006ART.pdf


Reviewed by David Sable, MD, director of the Division of Reproductive Endocrinology at Saint Barnabas Medical Center in Livingston, New Jersey.

Last updated April 29, 2009

Copyright © 2002 Consumer Health Interactive

DRUGS & CONDITIONS

COPING WITH INFERTILITY


When getting pregnant doesn't happen easily, it may come as a surprise. But when pregnancy is unattainable after repeated fertility treatments, the stress can precipitate a crisis among even the most loving couples.

Each time a treatment is unsuccessful, many couples begin to doubt the value of going through further procedures, especially if they are expensive, as in vitro fertilization (IVF) can be.

A woman or her partner are considered to be infertile if they have tried unsuccessfully for a year to create a pregnancy. If they're in their 30s or older, the couple may need to be evaluated by a fertility specialist after trying diligently for six months. Infertility doesn't mean there won't ever be a pregnancy – just that there's a problem that could warrant intervention.

"Couples dealing with infertility have a horrific time," says Alice Domar, PhD, founder and director of the Mind/Body Center for Women's Health at Boston IVF and author of Conquering Infertility. Domar says it may be the first time that a couple has dealt with a crisis, and many don't know how to face it.

That stress of infertility is one of the reasons why the American Society of Reproductive Medicine calls it "one of the most distressing life crises that a couple has ever experienced together."

It's also the reason why many fertility clinics like Boston IVF also have mental health services to respond to the depression that can come with infertility. Many of the clinics offer psychological counseling, yoga, stress management, and other relaxation techniques that can lessen the strain.

What signs should you watch for?

Many of the feelings that infertility brings on can be similar to depression. They include:

People should also examine whether they can handle the financial sacrifices that are necessary. Many who turn to fertility treatments are straining their bank accounts and don't know when to stop. The average IVF cycle, for example, costs about $12,400, and many women undergo multiple treatments before they give up.

Even when insurance is available for medical services, "studies show that 50 percent of insured couples undergoing infertility treatment drop out before completing the number of cycles they're covered for," according to Domar.

What can you do to lessen the strain?

Think realistically about how much you're willing to pay for fertility treatments. If you have to go through two or three cycles of IVF, how much will it strain your budget? Do you have to mortgage your house? Can you turn to savings or relatives to help with the effort?

Many clinics offer financial counselors who can set up long-term payment plans that do not involve large payments every month.

Experts suggest that patients should take advantage of fertility clinics offering mental health services for people going through treatments.

Domar, for example, teaches patients at the Boston IVF clinic a number of strategies to help minimize stress, including relaxation techniques and deep breathing exercises that minimize their anxiety at night. Domar counsels them not to fall prey to the cycle of hope and despair that comes with each cycle of infertility treatment.

Not only do these programs alleviate the mental strain, they also seem to help with the medical success of treatment. A small, ground-breaking Harvard study showed that infertile women who participated in a relaxation program became significantly less anxious and depressed, and 34 percent became pregnant within six months of completing the program. Since then, other researchers have also noted the connection between stress levels and pregnancy. According to another study of 151 women undergoing in vitro fertilization, those with higher stress levels produced fewer eggs for retrieval and had fewer embryos transferred than women feeling less stress. Finally, experts say, don't think of fertility treatments as the last chance to have a child in your life. Many couples consider adoption when treatments are unsuccessful.

Domar urges her patients to join a support group, where they can share their feelings and find understanding among men and women who also face infertility. Sharing these thoughts among others can banish the sense of isolation and discourage negative thinking.

"You look around the room and realize you're not the only one," she says.

-- Melanie Haiken, MA, is the former health editor of Parenting magazine and specializes in health, business, and parenting issues. She has served as managing editor of San Francisco magazine and as an editor at Industry Standard magazine, and has written for Time Inc. Health, The Washington Post, and many other publications. Psyche Pascual is a former Los Angeles Times reporter and executive editor at Consumer Health Interactive.

References

Interview with Sara Rosenquist, PhD, Sara Rosenquist, a psychologist in Chapel Hill, North Carolina

Interview with, Alice Domar, PhD, director of the Mind/Body Center for Women's Health at Boston IVF and author of Conquering Infertility (Viking, 2002).

Domar AD. Impact of psychological factors on dropout rates in insured infertility patients. Fertility and Sterility. February 2004 81(2).

Domar AD, et al. The mind/body program for infertility: a new behavioral treatment approach for women with infertility. Fertility and Sterility. 1990 Feb;53(2):246-9.

Klonoff-Cohen H, et al. A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer. Fertility and Sterility. 2001 Oct;76(4):675-87.


Reviewed by Victor Fujimoto, MD, director of the IVF program at the University of California at San Francisco. Dr. Fujimoto is board certified in obstetrics and gynecology as well as reproductive endocrinology and infertility.

Last updated May 28, 2009

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