Helping women who are having fertility challenges
By Dr. Danielle Lane
1. How do I know that there is a problem?
Women and their partners should be concerned about infertility when they have had unprotected intercourse for a period of time and have not conceived. The American Society for Reproductive Medicine has recommended the following guidelines. For women under 35 years old, it is reasonable to try to conceive for a year on your own. The only caveat with this is that if it takes you a year to conceive your first child, by the time you attempt to conceive your second, it will likely take even longer and by then, time will not be on your side. In women 35 years of age and older, six months is reasonable to try on your own. In women 40 years and older, consider coming to visit us at once. It is important to have a realistic outlook on family planning to make sure that you have adequate time to achieve the number of pregnancies that you wish in the time that you have available.
These, however, are just guidelines. Therefore, if you have abnormalities in any of the tests mentioned, or a family history of early menopause or ovarian failure, you should feel comfortable discussing fertility with your fertility specialist or obstetrician-gynecologist immediately.
2. What should my first steps be?
People should not be afraid to come and visit a fertility specialist. If you have exceeded the timelines that I mentioned above or have other concerns regarding your fertility, there is no harm in educating yourself.
An initial evaluation is going to include a detailed medical and gynecologic history. In addition, the evaluation can be broken down into three sections, an evaluation of egg quality, an evaluation of the presence of sperm, and an evaluation of the uterus and fallopian tubes. Evaluating egg quality includes menstrual history, reproductive hormones called follicle stimulating hormone (FSH) and estradiol, and an ultrasound to evaluate the number of antral follicles (or immature egg sacs) in the ovary. Evaluating sperm is done be a semen analysis that requires men to submit a sperm specimen. Evaluating the reproductive organs is accomplished through a combination of ultrasound and a radiologic study called a hysterosalpingogram that evaluates whether the uterine cavity is normal in shape and the fallopian tubes are open. With these few pieces of information, a fertility treatment plan can be developed.
3. Are there lifestyle changes that can improve my chances of getting pregnant?
The answer is yes, but this is when it becomes important to understand the cause of the reproductive challenge. If the issue is that a woman is not releasing an egg each month, then maintaining a healthy diet and maintaining a body mass index that is between 20-25 kg/m2 has been shown to improve regular release of eggs and also increase pregnancy rates.
In most women, however, while decreasing stress and maintaining a healthy diet and exercise regimen will certainly improve general health, they will likely not be the difference between conceiving and not conceiving. It is known that fertility decreases in women over the age of 35, therefore, I think that it is important the women do not solely approach their fertility challenges through lifestyle changes because this is unlikely to be independently sufficient.
4. What sorts of treatments are available to help women conceive?
In terms of medications, there are oral medications (pills), such as clomid, that are helpful in women who do not release an egg each month, often due to a condition called Polycystic Ovary Syndrome. Oral medications can also be helpful in some women who need to release more than one egg in a given cycle. In cases where this is not an aggressive enough approach, or when it has not been successful, then injectable gonadotropins are an option. There are many cases in which these injectables are an appropriate first-line medication.
In terms of procedures, there are intrauterine inseminations and a process called in vitro fertilization. In intrauterine insemination, sperm is placed into the uterine cavity, and the eggs and sperm must find one another in order for fertilization to occur. This insemination procedure is usually combined with some form of medication (either oral or injectables). Typical success rates in are 15-20% per cycle. In in vitro fertilization, injectable medications are used to produce multiple eggs, these eggs are then removed, mixed with sperm or injected with sperm, and the embryos are allowed to develop in a laboratory for 2-5 days. After this, embryos are placed into the uterus. The number of embryos transferred should follow guidelines that reflect the age of the patient and the quality of the embryos. Success rates are a function of age and predicted egg quality of a given patient.
In any fertility treatment, the goal is to achieve a singleton pregnancy. Multiples are not the desired outcome because of increased risks to both mom and baby. Multiple rates are ~25-30% with any of the fertility treatments described and the vast majority are twins.
5. What if I am not successful?
The reality is that as far as we have come in reproductive medicine, there are some women and partners who will not successfully conceive with their own eggs and sperm. This does not mean that these individuals and couples cannot become parents. There are still several options available in this case. Both egg and sperm donation is available in cases where a patient's own egg or sperm cannot be used. There are also some embryos that are available for adoption. Additionally, some individuals decide to adopt children.
6. What about the octuplets? I frequently tell my patients, that if there is a sensational story about it on television, that it is not the norm. That applies in this case. I have never treated a patient in my career who falls into the category of having 6 children and desiring in vitro fertilization.
The most important part of my job is education and making sure that patients umderstand the risks and benefits of their treatment. In addition, I am very clear with my patients what are reasonable risks to take, and what are risks that I as a practitioner am not willing to take.
About Dr. Danielle Lane:
Dr. Danielle E. Lane, M.D. has expertise in treatment of women 35 years of age and older having difficulty in becoming pregnant. With her extensive clinical experience, including serving as Director for the Kaiser Permanente Center of Reproductive Health (Napa-Solano Service area), Dr. Lane has treated a broad range of fertility issues, including recurrent miscarriage and polycystic ovary syndrome. Dr. Lane completed her clinical training in Obstetrics and Gynecology and Reproductive Endocrinology and Infertility at the prestigious Yale University and University of California, San Francisco Schools of Medicine. Dr. Lane is board certified by the American Board of Obstetrics and Gynecology. Her expertise is complemented by an outstanding Embryology Lab Director (E.L.D.) certified by the American Board of Bioanalysis (A.B.B.) and her highly experienced team.
Dr. Lane's outstanding success rates in pregnancies with her clients, are the result of her rigorous practice model in which she individually follows all patients from initial consultation to their final visit. Dr. Lane also integrates mind and body into her approach toward fertility. She holds a Bachelor's Degree of Science in Physiology from McGill University and a Doctorate in Medicine from the University of Pittsburgh School of Medicine.
Dr. Lane is a resident of San Francisco with a practice in Novato and draws clients from Marin, East Bay and San Francisco. For more information, visit the Web site at afamd.com.
