Since ancient times, there have been gods, magical potions, and special spells for helping with fertility. The ancient Mayans prayed to the fertility god Quetzalcoatl to restore their fertility. And it worked! There are, after all, relatively few problems that render a couple absolutely incapable of conceiving. Most of the time a couple's fertility is compromised, but not absolutely. We all know stories of couples who have given up their attempts to get pregnant only to conceive shortly thereafter. Or couples who have adopted one child and all of a sudden they conceive and have two children under the age of two. This is not to imply that giving up, or adopting, increases one's chances of conceiving. It doesn't! The point is this: Every treatment, be it praying to Quetzalcoatl, trying on your own without intervention, or pursuing the most high-tech options available has a certain chance of being successful each month or with each attempt.
Finding exact numbers for your chances of getting pregnant within any given time frame can be one of the most frustrating aspects of trying to get pregnant. This chapter will examine the considerations involved in trying to decide what should be done, and when it should be done.
Age and Duration of Attempts
The first consideration must always be, "what are the chances if we just keep trying on our own?" Fecundity, or the likelihood of getting pregnant each month, is tremendously age dependent. For a couple in their early twenties with no known problems, fecundity may be as high as twenty to twenty-five percent per cycle. For a couple in their early forties with no known problems this number is less than five percent. There is clearly a decline in fertility beginning at about age thirty. This becomes more dramatic after age thirty-five, and after age forty, it is very significant. This decline in a couple's chances of getting pregnant each month must be coupled with miscarriage rates that clearly increase as a woman gets older, ranging from about eighteen percent in younger couples to as high as twenty-five to fifty percent in women over age forty. Just on the basis of this information, a more conservative approach to fertility treatment is often justified in younger couples, whereas a more aggressive approach may be more appropriate for an older couple. How long a couple has been trying to conceive is also important. The definitions of infertility suggest that a couple is not infertile unless they having been trying for a year to conceive their first pregnancy, or until they have been trying for six months after having been pregnant before. These are only definitions. They don't mean that if you have been trying for a year your chances for the next month become zero. While statistically the chances may be decreased enough that some evaluation may be warranted, they may still be very real. But, at the same time, it is clear that the longer a couple has been trying, the less likely it is that they will be successful. Data clearly show that a couple's fecundity decreases in direct proportion to the length of time they have been trying to conceive. In other words, if a couple has been trying to conceive for five years, their chances of conceiving in the next month probably are not zero, but they certainly aren't very good.
Medical Considerations
Age and duration of attempts are very important considerations, not only in deciding when to seek help, but also in tailoring an evaluation and treatment plan that is appropriate for each individual couple. And once an investigation is begun, so are the results of that investigation. Physicians use the information they gather to try and formulate an equation that will give them some idea of what each individual couple's chances are without intervention, and what they would be with any given type of intervention. The semen analysis and any identified female factors must be taken into account, and reasonable treatment alternatives determined.
There are very few couples in whom infertility is absolute. Complete absence of sperm (azoospermia), total tubal occlusion and ovarian failure are the exceptions. In couples with these particular problems, determining treatment options is relatively straightforward. In couples without absolute infertility, determining appropriate options can be much more difficult. There are a couple of "factors of discrimination" that are helpful. The first is the semen analysis. The number of functional sperm is one factor that dictates which options are reasonable. If there are thirty million normal sperm present, many alternatives, from conservative to aggressive, may be reasonable. If, on the other hand, the semen analysis shows only one million sperm with very poor motility, anything but ICSI may have virtually no chance of success. The second is the status of the fallopian tubes. As long as we know the tubes are open and appear normal, many approaches may be reasonable. If they are occluded or damaged, IVF may be the only choice with a realistic chance of success.
The physician's task, then, is to consider this information, these factors of discrimination, as well as all the other data gathered. The number of factors identified that may be contributing to a couple's inability to conceive is very important. If a couple has more than one infertility factor, the effect of each factor on their infertility is not additive. It is almost exponential! The number of identified infertility factors is an extremely important consideration.
The physician must, then, consider:
- The couple's age, particularly that of the female
- The length of time a couple has been infertile
- What problems have been identified and
- How many problems have been identified.
Based on these considerations, the physician must decide what he or she thinks are reasonable treatment alternatives. The physician should then be able to say to a couple:
- "This is alternative A. Here is what is involved in pursuing alternative A. Here is what it will cost to pursue alternative A. And these are your chances of success per attempt with this approach"; and
- "This is alternative B. Here is what is involved in pursuing alternative B. Here is what it will cost to pursue alternative B. And these are your chances of success per attempt with this approach."
Now what John and Mary need is as much information about those alternatives as they can get. It is the physician's job to determine which options are reasonable and to provide the couple with all pertinent information concerning those options. It is the couple's job to decide what they want to do! All decisions must be made by the physician and the couple as a team.
Personal Considerations
Only the couple can take the information the physician has provided and evaluate it in terms of their life situation. Real-world constraints and considerations are extremely important in this whole process. Some of the "real-world factors" that must be considered include:
Work
Very few women in this day and age have the luxury of being able to devote all of their time to trying to get pregnant. They have to pursue their careers at the same time. How much time away from work will each alternative require, and how much can you afford? Can you pursue an alternative and still work? Some women even schedule certain treatments during vacations.
Stress Levels
The stress associated with infertility is second only to the stress associated with the death of a loved one! How much of a toll has that stress already taken on you, your self-esteem, your marriage? How much more can you tolerate? For example: Given two alternatives, a couple who has been trying to conceive for five years may decide to pursue the alternative with the best per-attempt chance of success simply because they just can't tolerate a whole lot more. One inexorable force couples face as they pursue fertility is the "ticking of the biological clock," making it seem as if their efforts are taking forever. It can make you feel old long before you should. This clock is often every bit as much an enemy as it is an ally. It makes every cycle that ends with a menstrual period that much harder to tolerate. And it can make couples do silly things out of desperation. Don't ever do something just to be doing something. Make sure the options you pursue are reasonable and offer you a decent chance of success.
Geography
Fertility services are not available everywhere. If you have to travel several hundred miles, your choice of alternatives might tend to be more aggressive than it would be if you only have to go across the street.
Cost
Insurance coverage for fertility services is extremely variable. Medications, testing, procedures, etc. may or may not be covered. And fertility services can be expensive. The cost/success ratio of each alternative must be a consideration.
Deciding on a Treatment
A couple needs to be well informed by their physician regarding their reasonable treatment alternatives. And they have to be in touch with their perspective in order to decide which of those alternatives they are most comfortable pursuing. If your physician evaluates your particular case and provides you with reasonable information concerning your alternatives, and if you decide between these alternatives within the framework of your real-world factors, then there are no wrong decisions. You can't make a bad choice!
But you and your physician must constantly reevaluate. Each and every form of therapy, from praying to Quetzalcoatl to attempting in vitro fertilization, has a cumulative success curve that will "flatten out" after a given number of attempts. In other words, if you have tried one approach for several cycles and it hasn't worked, the chances that it will work in the next cycle begin to diminish. And after a certain length of time, that approach may not increase your chances at all. Any approach should be pursued only as long as it is clearly keeping you on the steep part of the cumulative success curve.
Percent Pregnant
If, after a given while a certain choice is unsuccessful, talk it over again with your physician, examine your alternatives and decide what you should do next. Communication is key, and proper decision making requires a partnership between you and your physician. An informed, well-thought-out decision can't be wrong.
And don't hesitate to take breaks. Many couples feel that if they take some time off and stop concentrating on trying to conceive for a while, they are being negligent and their chances will be that much less when they do start trying again. This just isn't so! Infertility is very stressful, and there is no doubt that the stress can take its toll. Breaks, or treatment vacations, are wonderful ideas. They restore the emotional energy required to pursue treatment and deal with the results. They also remind a couple that intercourse is something that can be done for fun rather than just on certain days at certain times. Don't hesitate to take breaks. They are good for the soul!
Reaching Resolution
The obvious goal of every physician who treats couples with infertility is to help each and every one of them conceive. This is an unattainable goal. While the vast majority of couples with infertility can be helped, and do conceive, there still exists a certain percentage who never will conceive. A much more realistic goal would be to help each and every couple reach resolution. The more couples for which this means pregnancy, the better. But those couples who don't conceive need to reach resolution as well. When all available alternatives have been attempted, and when they have been attempted enough times that the success curve is flat, the physician must be willing to inform a couple of this. The physician must be willing to inform a couple when they have exhausted all reasonable treatment options. And when a couple feels they have given it their all, when they feel good about their efforts and can look themselves in the mirror and say "we did all we could do," they have reached resolution. Achieving pregnancy for every couple is a very lofty goal indeed. Achieving resolution for every couple is what the job is all about.
