What is infertility?
Infertility is difficulty in conceiving a pregnancy. This general term does not identify the cause of the problem or whether it will be permanent.
Often, physicians and researchers consider a couple to have infertility if they have not conceived, despite regular intercourse without using birth control, for at least a year. Fifteen to 20 percent of couples will not conceive despite a year of trying. However, this does not mean that they will not conceive later on, even without treatment. Some investigators consider two years without conception to be a better indicator of a couple’s need for assistance.
More than 90 percent of couples will have achieved a pregnancy within two years.
When an individual has no chance to conceive without treatment (for example, a woman does not ovulate or has two blocked fallopian tubes), it is sometimes called sterility.
Is infertility a male or female problem?
In the past, infertility was commonly considered to be solely a female problem. It is now recognized that a couple’s infertility is just as likely to stem from problems in the male partner. After couples with infertility undergo testing, about 40 percent of the cases are found to stem from female factors and another 40 percent from male factors.
In 10 percent of couples, infertility factors are found in both the man and woman. In the remaining 10 percent, the infertility remains unexplained after testing.
Because either or both may be involved, it is important to test both the man and woman before starting treatment. No matter what the cause, most treatments require the active participation of both partners.
If I had a baby once, can I be infertile now?
Yes. Secondary infertility is the name given when the problem arises in a couple who have been able to get pregnant in the past. Sometimes a new factor, such as an infection, has damaged the reproductive organs since the last child was born. Sometimes the aging process makes it more difficult for a couple to conceive, even if they had no problems when they were younger.
Secondary infertility is even more common than infertility in couples who have never achieved a pregnancy.
Generally, the diagnosis and treatment is the same. However, couples with secondary infertility may make different treatment choices as they take into account the needs of their other children. Overall, treatments are somewhat more likely to work in women with secondary infertility than in women who have not previously become pregnant with the same partner.
Couples with secondary infertility may wish to seek emotional support specifically geared to their concerns. These couples often report that they feel caught between two worlds. They feel alienated from those who easily create families of the size they want, while at the same time they are envied by childless people with infertility.
Is infertility becoming more common?
According to national data, there has not been a major increase in the proportion of couples who are infertile. However, many more women are seeking medical services for the diagnosis and treatment of infertility – particularly those who have not previously had any children.
Does age affect fertility?
In general, women’s fertility begins to decline gradually after age 30, with a steep drop between 35 and 45. This means that, on average, it takes longer for an older woman to conceive, and older women are more likely to be diagnosed with infertility. Pregnancies in older women are also more likely to miscarry.
The most predictable age-related change is a gradual reduction in the number and quality of eggs produced as a woman enters her late thirties. As she nears menopause, eggs are not released in more and more of a woman’s menstrual cycles, making conception impossible.
“The office said they don’t refer to infertility specialists until a year of trying. I said maybe they shouldn’t wait that long in someone who is 39, and she agreed.” IVF PATIENT
Also, as women age, they are more likely to have had illnesses or medical treatments that can compromise fertility. Some of these affect the reproductive system directly, such as endometriosis, sexually transmitted diseases (STDs), surgery on the reproductive organs, or ectopic pregnancies. Others are general medical problems that can damage fertility, such as hypothyroidism, high blood pressure, diabetes and lupus.
As they age, men may also be exposed to infections, medications, or occupational or environmental chemicals that can impair fertility. However, they do not experience the same dramatic and predictable age-related decline as women.
Because of the increased possibility of fertility problems, women over the age of 35 are often counseled to seek medical advice if they attempt to conceive for six months without success. However, because conception is likely to take longer in older women, some experts suggest that couples give themselves more, rather than less, time to conceive before seeking medical help.
Couples must find a balance between not allowing enough time for conception and delaying too long (making treatment less likely to succeed).
Does stress cause infertility?
However well-intentioned, the statement “just relax and you’ll get pregnant” has been very hurtful to couples with infertility. Two decades ago, researchers thought that almost half of infertility in women could be attributed to stress and psychological factors. Nowadays infertility is better understood, and stress is recognized primarily as a result, rather than a cause, of fertility problems. However, there is evidence that stress can have a negative impact on sperm and egg production. Research is ongoing to help understand how stress may influence fertility and the success of treatment.
Can infertility be cured?
Some treatments correct factors that cause infertility. If they work, the infertility should be reversed and a couple should be able to achieve one or more pregnancies. In contrast, other therapies are used to establish pregnancy in a treatment cycle without permanently correcting the underlying problem.
In some cases, medication can improve or correct an underlying medical condition that makes it difficult to conceive. Women with endometriosis, cervical infections, polycystic ovarian syndrome, or hormonal imbalances can be treated with medications, thus easing barriers to conception.
When a woman has blocked or damaged fallopian tubes, surgery to repair them is an example of treatment aimed at curing infertility. If it is successful (meaning the tube is both open and able to function normally), she should be able to conceive one or more times without further medical intervention. However, many experts believe that, for most women with blocked tubes, the chance of becoming pregnant is greater using in vitro fertilization(a technique to get around the problem) than surgery.
When considering various treatments, ask whether each approach is supposed to circumvent infertility or cure it. Get information about the chance of success with each approach (in light of your age and diagnosis) and its costs (including learning if your insurance carrier covers it).
What can we do before seeing a doctor?
While you are trying to conceive, enjoy a healthful lifestyle. Take note of the strategies for preventing infertility (above) and consider how – such as smoking – you may be lowering your chances to conceive. Tell your doctor and pharmacist that you are trying to get pregnant. They can tell you whether any prescription or over-the-counter medications, supplements, or herbal remedies you or your partner use could be disturbing your fertility or be dangerous to use during early pregnancy. If so, ask what alternatives are available. Avoid douching or using vaginal lubricants.
Even a couple with no fertility problems have only about a one in four chance of conceiving during a single cycle. Maximize your chances by having sexual intercourse regularly during the fertile part of your cycle. If you have questions about when you are most likely to conceive, ask a health care professional. An ovulation predictor (available without a prescription) may help you determine when you ovulate so you can better time intercourse.
When should we seek medical help?
Most doctors advise you not to be concerned unless you have been trying to conceive – not using birth control and having regular intercourse around the time of ovulation – for at least a year.
Women with certain symptoms or previous medical conditions may wish to seek medical advice earlier. Some symptoms or prior conditions make fertility problems more likely, and others may indicate a medical condition that needs treatment for other reasons. Seek medical advice if:
- You have lots of pain during your menstrual period or during intercourse.
- You have an abnormal menstrual cycle (less than 21 or more than 35 days from the first day of one cycle to the first day of the next).
- You are troubled by acne or excess facial or body hair.
- You have had pelvic inflammatory disease (PID), an infection in the reproductive organs, usually the fallopian tubes.
- You have had surgery on your reproductive organs, such as a cone biopsy of the cervix.
- You have had more than one miscarriage.
- Your partner has an abnormal sperm analysis.
How is the cause of infertility identified?
An infertility work-up will involve tests to determine how well each of the systems involved in conception is working.
- EGG PRODUCTION: To determine if and when you are ovulating (producing and releasing a mature egg during the menstrual cycle), you may be asked to chart your basal body temperature. You will take your temperature before getting out of bed each morning. A slight, sustained rise in temperature is an indirect indication that ovulation has occurred. You may also be asked to use an ovulation predictor kit at home. Your doctor may check various hormone levels on specific days in your menstrual cycle, or monitor your body’s response to a dose of fertility medications.
- SPERM PRODUCTION: A semen specimen will be analyzed for the number of sperm, their shape and movement. If the results are abnormal, a man may be examined by a urologist or tested for hormonal abnormalities or infection.
- FALLOPIAN TUBES: To see whether the fallopian tubes are open, an X-ray (called a hysterosalpingogram or HSG) may be taken while dye is injected into the uterus and tubes. Alternatively, a doctor might inject a salt-water solution and view the uterus and tubes using ultrasound (called a sonohysterogram). The tubes can also be observed during a surgical procedure.
- CERVIX: To determine whether sperm are able to swim through the cervix, a sample of cervical mucus is examined after intercourse. If this post-coital test is abnormal, other tests may be ordered to find out why. Doctors disagree about the usefulness of this test, and many couples conceive despite poor results on a post-coital test.
- UTERUS: The shape of the uterus is shown in an HSG. It can also be seen through a telescope-like device (hysteroscope) inserted through the vagina and cervix. An endometrial biopsy samples the uterine lining in the last half of the cycle to see if it is prepared for an embryo to implant. The thickness of the lining can also be measured using ultrasound.
Do we both need to be tested?
Almost always. Both male and female factors can contribute to a couple’s infertility. For efficiency, diagnostic testing may focus first on tests that are less invasive (such as a semen analysis) or those that may confirm a suspected problem (such as a test for blocked fallopian tubes if a woman has had a pelvic infection).
What tests are really necessary?
Doctors and infertility programs vary in which diagnostic tests they recommend or require. Some variations reflect differing medical opinions on the value of specific tests. For example, some doctors insist on an endometrial biopsy or post-coital testing while others find them of little use. A test’s value also depends on the person being tested and the treatment being considered. For example, if a woman is in her 40s, the first priority may be to test for age-related changes in her ability to produce eggs. Until those results are in, a doctor might consider other tests a waste of time.
- Before undergoing a test, ask enough questions to assure yourself that it will be worth the time and expense involved and will help guide your treatment. Some questions to ask include:
- What will the results tell us about the chance for pregnancy with or without treatment?
- Might the results be different if the test was repeated?
- Is the test ever abnormal in people with normal fertility?
- Are there other ways to get the same information?
- How do the alternatives compare in reliability, risk and cost?
- How will the results affect the next step that we take? (If the doctor’s advice will not depend on the results, there may be little reason to have the test.)
In addition, make sure you understand what will be involved in taking the test. Ask:
- What are the risks of the test?
- Do most people find it painful?
- Must it be performed at a certain time in the menstrual cycle?
- What preparation is required?
- How expensive is it?
- Will insurance cover this test? (Your insurance company, not your doctor, is likely to be the best source for this information.)
What if all our tests are normal?
In 10 to 15 percent of couples, testing finds no reason for their reproductive difficulties. They are given the diagnosis of “unexplained infertility.” This does not mean that no reason exists, just that testing has not revealed it.
If you are told you have unexplained infertility, ask whether other tests might clarify the situation. You may want to seek a second opinion.
Medical experts do not agree on the best way to treat unexplained infertility. Despite a few years of unexplained infertility, some couples will conceive with no treatment at all, particularly if they are younger. Other couples are offered standard treatments, such as fertility drugs and intrauterine insemination (IUI), or in vitro fertilization (IVF).
In general, couples with unexplained infertility are at least as likely to succeed with these treatments as are couples with a clear medical rationale for their use. If you are considering treatment for unexplained infertility, ask your practitioner to compare your chances of becoming pregnant with and without treatment.
Is it true that, if we adopt, we’re likely to get pregnant?
No. For couples who continue trying to achieve pregnancy after adopting, the chances are the same as for couples who have not adopted. This myth has been hurtful to couples facing infertility, both because it is false and because it implies that adoption is not a joyful outcome, but simply a means to another end.
Can a program predict whether I’ll become pregnant?
Every couple is unique, and there are serious limitations in any program’s ability to predict how you will respond to treatment. You will likely be given an estimate of the chances you will achieve a successful pregnancy (either with or without treatment). It should be based on your diagnosis or test results, as well as the previous experience of that program or others in using the techniques. Be extremely cautious if someone offers you a guarantee or unrealistically high estimate of your chances.
When a prediction is made, ask what it is based on. The most directly applicable information would be your program’s previous experience in treating similar couples. Often, however, predictions are made based on information from sources outside the program:
- National averages (your program may have higher-or lower-than-average success).
- A study published by a single center (which might have a very different level of experience).
- Data submitted by a manufacturer before a drug was approved by the Food and Drug Administration (and you may or may not be similar to the people they studied).
- Ask enough questions to feel comfortable that you are making a decision based, as closely as possible, on a program’s experience treating people like you.
Can single women or lesbian couples receive infertility treatments?
Usually. According to a recent national report, most programs in the country, including all programs in New York State, treat single women.
“Nobody blinked an eye at my being unmarried. I was treated gently, kindly, and appropriately… I’m glad I didn’t have to go to a bar and get pregnant and worry about getting AIDS – to know there was a safe, sanitary way to have a child.” DONOR INSEMINATION PATIENT
These women may wish to use donor insemination or may need additional treatments. Many programs also assist lesbian couples, although this was not asked as part of the national report.
New York State law permits, but does not require, fertility programs to accept single women or lesbian couples as patients. You can ask a program about its policy or check its report on the CDC Web site (see Resources). In addition to exploring treatment options, find out if you need to take special steps to ensure your parental rights. A growing number of states, including New York, allow a lesbian to adopt her partner’s biological children without taking away the rights of the biological mother.
What are the alternatives to IVF?
Depending on your fertility problems, you may decide to use lower-tech treatments or no treatment at all.
In addition, two IVF alternatives are available at some programs, although their use has declined greatly. In gamete intrafallopian transfer (GIFT), the first two steps are the same as IVF. But, instead of fertilizing the eggs in the laboratory, a mixture of sperm and eggs is placed into one or both of the woman’s fallopian tubes. In GIFT, fertilization and the embryos’ travel to the uterus occur in the natural environment of the fallopian tubes. GIFT usually involves a surgical procedure and requires that at least one of a woman’s tubes be open and healthy. Because general anesthesia is usually required, GIFT is considered riskier and usually costs more than IVF.
Another procedure, zygote intrafallopian transfer (ZIFT), combines elements of IVF and GIFT. The first three steps are similar to IVF. However, instead of transferring the embryos into the uterus, they are placed into one or both of the woman’s fallopian tubes.
The general term assisted reproductive technologies (ART) is used for all treatments that involve removing a woman’s eggs and combining them with sperm outside the body, including IVF, GIFT and ZIFT.
Once we agree to undergo IVF, what decisions need to be made?
IVF is not a uniform treatment. To carry out a treatment cycle, several decisions must be made, including:
- What dose of fertility drugs to use
- When to retrieve the eggs
- How long to culture the embryos before inserting them into the uterus
- How many embryos to transfer to the uterus in a cycle
- Whether to freeze embryos for later cycles
Make certain that you understand the impact these choices could have on your chance of pregnancy and on treatment decisions you may be asked to make later on.
Where does donor semen come from?
Frozen donor semen is generally purchased from a semen bank. Some infertility programs have their own semen banks. Other semen banks are independent and may sell semen specimens to doctors all over the country. Each semen bank selects its pool of donors. It is important for you to understand how they recruit and screen the donors, and what information they make available to recipients. Any semen bank providing specimens for use in New York State must be licensed by the state and adhere to its guidelines.
Where do donor eggs come from?
Unlike donor semen, which can be frozen, typically donor eggs are collected and used immediately. Most egg donors are young adult women who are recruited and screened by fertility programs. Donors undergo the required medical procedures (taking fertility drugs, monitoring, and egg retrieval) at the same program as the recipient.
In addition, some independent companies or agents recruit and arrange for the screening of potential egg donors, but do not provide medical services.
It is important for you to be comfortable with how your egg donor has been selected and screened, and how she will be treated by the program.
Most programs allow the use of known donors, if they fit the program’s eligibility standards. If you have a friend or relative who could serve as your egg donor, ask the program about this option.
Any program providing donor eggs for use in New York State must be licensed by the state and adhere to its guidelines.
Where do donor embryos come from?
Donor embryos have usually come from couples who created and froze extra embryos during their own treatment but no longer wish to use them. Any program providing donor embryos for use in New York State must be licensed by the state and adhere to its guidelines. These require embryo donors to be screened as thoroughly as semen or egg donors.
Can infectious diseases be passed through donor semen?
Yes. Like other human tissues, semen can harbor bacteria and viruses that can cause illness in the recipient. For this reason, it is essential that semen donors be regularly tested for a variety of infections.
A man may not test positive for antibodies to HIV (the virus that causes AIDS) until several months after he is exposed. For that reason, donor semen should be frozen for at least 180 days and not released for donation until the donor tests negative a second time.
Make sure you are satisfied with the precautions taken by your semen bank to prevent the transmission of infectious diseases.
Can infectious diseases be passed through donor eggs?
Although no cases have been reported, it is theoretically possible that an infection could be passed through a donor egg. Most programs test egg donors for the same infections as semen donors.
With donor eggs, freezing is not practical at this time. This causes special concern with regard to HIV testing, since a woman may not test positive for antibodies to the virus until several months after she is exposed.
Eggs cannot be stored until a donor passes a second HIV test. This means that a recipient must rely on an egg donor’s current HIV test results or have the embryos frozen to use after the donor is retested. Most recipients of donor eggs accept the small possibility that a donor might have been recently exposed to HIV and could transmit the virus through the donor egg. Some programs take the additional precaution of requiring HIV testing for the sexual partner(s), if any, of prospective egg donors.
Can donor semen or eggs result in birth defects or inherited diseases?
Yes. If a donor has a genetic disease, or is healthy but carries a gene associated with a genetic disease, it can be transmitted during semen or egg donation.
Some semen banks and egg donation programs take thorough genetic histories and perform many genetic tests on all donors. Others test only for common genetic diseases or those required by state regulations. Many genetic abnormalities cannot be detected through existing tests. Before starting treatment, make certain you are satisfied with the extent of planned donor screening and testing.
Tell your doctor about any genetic diseases that are present in your family or are more common in your ethnic group. This might include sickle cell disease in those of African heritage or Tay-Sachs disease in French Canadians or people of Ashkenazi Jewish heritage.
If you are uncertain about your family history or the likelihood that you carry an inherited disease, you may wish to seek genetic counseling before proceeding. For assistance in finding a genetic counselor, contact your doctor or the National Society of Genetic Counselors.
Can we meet our donor?
It depends on the program. A few semen banks and egg donation programs specialize in helping donors and recipients who want to know each others’ identities and arrange for some level of contact.
Can we use the semen or eggs of a relative or friend?
Sometimes. In New York State, a known donor is subject to the same State Health Department regulations as an anonymous donor. A known donor’s semen must be collected, prepared, frozen and stored for six months by a licensed semen bank until he re-passes tests for HIV and other infectious diseases. Because of the risk of genetic disease, a woman can not be inseminated with the semen of a close blood relative.
At some programs, a woman may bring in a friend or relative to serve as an egg donor. This woman must undergo the same screening as other egg donors, and the program will want to take precautions to ensure that she understands the medical risks and other issues.
Because of the risk of genetic disease, the donor can not be a close blood relative of the intended father. In order to ensure that a woman does not feel pressured to donate because of her emotional or financial ties to the recipient, some programs place restrictions on the relationships they allow. For example, some programs do not permit an employee or young adult daughter of a woman to become her egg donor.
In addition to the medical issues raised by using a known donor, you must consider the many legal and psychological issues that can emerge at a later date. For example, will you tell your child that his uncle is actually his biological father, or that her older sister is genetically her mother? What would you do if a friend/donor suddenly wanted to be recognized as your child’s parent?
Should we tell our relatives and friends we’re using a donor?
It is entirely your decision. However, many who have used donors strongly advise you to tell others only if you plan to inform your child.
“We’ve said at this point we won’t tell him unless there is a clear reason to do so, and it has to be agreed upon by all involved. My parents do not know. I haven’t gone out of my way to find other infertile couples for support, and that comes largely from the decision to keep the egg donation private. It’s somewhat alienating.” WOMAN WHO GAVE BIRTH TO A CHILD CONCEIVED WITH A DONOR EGG
Can our donor find out who we are?
If you are using a commercial semen bank, the donor should not have access to your identity. In fact, he is unlikely to know whether anyone got pregnant using his semen. Programs differ in how much they tell egg donors about the outcome of their donations. Ask about this before you select a semen bank or egg donation program.
Will I be the legal mother if my baby was created with a donor egg?
As the woman who gives birth, it is highly unlikely that anyone would ever challenge your status as the legal mother of the baby. However, the issue has been raised in a few custody disputes between a birth mother and her husband or partner. In these cases, the father argued that he should have greater rights because he has a genetic link to the child that the mother does not. If a question arises, it would be decided in accordance with state law. Laws in several states make it clear that the birth mother, and not the egg donor, is the legal mother.
Under New York State law, a birth mother – whether or not she is also the genetic mother – is the legal mother unless she later gives up her parental rights. However, the use of donor eggs by unmarried women is not specifically mentioned in the New York laws.
Why are so many twins born after infertility treatment?
Certain drugs and procedures greatly increase the chances of multiple births.
For example, clomiphene citrate results in an 8-10 percent twin rate in those who conceive. This drug usually is not associated with births involving three or more fetuses. Injectable fertility drugs (such as human menopausal gonadotropins or folliclestimulating hormone) may result in many eggs maturing within a single menstrual cycle. About 15 percent of pregnancies induced by these hormones result in twins. Five percent involve three or more infants. The risk depends on the dose, the patient’s diagnosis and her response to the hormones.
In an IVF cycle, more than one embryo is usually transferred into the uterus to increase the likelihood that at least one will implant. However, whenever more than one embryo is transferred, there is the possibility of a multiple birth. According to recent CDC statistics, transferring two or three embryos increases the chance of pregnancy – as well as the chance of twins or triplets. Pregnancy rates decline when four or more embryos are transferred, but the chances of multiple births stay high.
“Some of the information I was naive about – like the multiple birth risks. After they found out it was triplets, they mentioned fetal reduction but didn’t have a lot of information. The obstetrician gave us more information about the risks, saying we could lose them all, and that kind of scared us.” MOTHER OF PREMATURE TRIPLETS WHO DIED SHORTLY AFTER BIRTH
Yes. The more fetuses, the higher the risk of complications to both mother and babies. A woman pregnant with multiples is more likely to miscarry, to develop high blood pressure, diabetes, or anemia, and to have her uterus rupture or her placenta detach prior to delivery. She is more likely to go into early labor, which requires medical treatment (with its own side effects) and often means hospitalization and prolonged bedrest.
Despite treatment, delivery usually occurs four weeks early for twins, eight weeks early for triplets, and ten weeks early for quadruplets. After delivering multiples, a woman is at increased risk of serious bleeding.
If twins or triplets are OK with us, what’s the problem?
Only you know whether you are prepared to raise two or more children – which means caring for two or more infants – at once. But it is important to realize that children from multiple births have a much higher chance of prematurity and low birthweight. Premature babies may suffer from several long-term medical problems that require extraordinary care or may even result in early death. Low-birthweight and premature babies are more likely to need prolonged hospitalizations after birth and to develop cerebral palsy, mental retardation, blindness and deafness than normal-weight infants.
As one example, consider the chance that a baby will die before it is one month old. According to national statistics (not all involving IVF), compared with a single baby, early death is four times as likely in twins, 10 in triplets, 13 in quadruplets, and 30 in quintuplets. More than half of all twins and nearly all newborns from pregnancies involving three or more babies are low-birthweight, with some born dangerously tiny and premature.
When results are reported after IVF or GIFT, a live birth means at least one infant showed signs of life after delivery. It does not tell you whether any or all of the infants survived or went home from the hospital in good shape.
Can multiple births be prevented?
Since the early 1980s, there has been an astonishing rise in multiple births. About two-thirds of the increase is thought to be the direct result of fertility therapies, including the use of fertility drugs and IVF.
Many of these multiple births can be prevented. Several countries in Western Europe, and also Australia and New Zealand have federal laws or regulations that limit the number of embryos that may be transferred during a cycle. For example, in the United Kingdom, doctors may transfer no more than three embryos in a cycle, and they are encouraged to transfer only one or two. In the United States, these decisions are left to the individual doctor and patient. However, prominent medical organizations, such as the American Society for Reproductive Medicine (ASRM) and the American College of Obstetricians and Gynecologists (ACOG), have called on doctors to make the prevention of multiple births a high priority as they plan fertility therapy (see Resources). In the interest of preventing the maternal and infant complications stemming from multiple births, a responsible doctor will:
- start with the lowest dose likely to develop enough eggs for an individual patient, including frozen IVF cycles.
- use injectable fertility drugs only if they can provide careful ultrasound and blood hormone monitoring can be provided.
- not give drugs to induce ovulation if hormone levels are too high or if ultrasound shows that too many follicles are maturing; and will counsel patients not to have unprotected intercourse during that cycle.
These restrictions are especially important if the cycle involves IUI or drugs alone (rather than IVF) or in an IVF cycle in which freezing is not planned.
- limit the number of embryos transferred in a single IVF cycle and eggs transferred in GIFT.
“The issue was discussed and discussed up front. They said they limit transfers to four embryos and said that three might be more appropriate for me. I decided three would be maximum.” DONOR EGG RECIPIENT
Although decisions about how many embryos to transfer must depend on the individual patient and program, the ASRM advises that, usually, no more than two good quality embryos should be transferred in women under 35 (who have extras to freeze) and no more than three in women under 35 without frozen embryos. For older women, the ASRM suggests that no more than four embryos be transferred to women between 35-40, and no more than five in women older than 40 or those who have already undergone many failed IVF cycles. In a donor egg cycle, the age of the donor is used to determine the number of embryos to transfer.
In a GIFT cycle, the chance of a multiple birth rises along with the number of eggs transferred back to a woman’s fallopian tubes. However, since all eggs may not fertilize, ASRM guidelines permit one more egg than embryo to be transferred in each age category.
You share responsibility in reaching decisions and following medical advice aimed at reducing the chance of a high-order multiple pregnancy. Your doctor may recommend that a specific number of embryos or eggs be transferred, based on your diagnosis or past reproductive history. You have the right to ask your doctor to transfer fewer in order to lower the risk of a multiple pregnancy. If your doctor is not willing, seek treatment elsewhere. If you wish to have more eggs or embryos transferred than is recommended, your doctors are not required to comply. Doctors are not obligated to help create a situation that is likely to cause harm to a patient or any resulting children.
If a woman becomes pregnant with many fetuses, she can be offered fetal reduction (also called multi-fetal pregnancy reduction). In this amniocentesis-type procedure, a lethal chemical is injected into one or more fetuses, leaving an agreed-upon number. The goal is to decrease the chance of miscarriage or premature delivery.
Fetal reduction lowers, but does not eliminate, the risks involved in multiple gestation. The procedure itself sometimes results in miscarriage. Many couples find it emotionally trying; some believe it is ethically unacceptable.
Before taking fertility drugs or pursuing IVF or GIFT, ask your doctor about the fetal reduction procedure. If you decide that fetal reduction is something you will not consider or wish to avoid, your doctor should know that and agree to provide treatment that will limit the chance of a multiple pregnancy.
If all the embryos aren’t transferred, what happens to them?
Before you begin an IVF cycle, you and your physician should agree on what will happen to any extra eggs or embryos. In most cases, excess embryos are frozen for possible use in a future cycle. However, other options are open to couples who do not wish to freeze embryos. Depending on the program, excess embryos can be discarded, donated for research or donated to another couple. Couples who object to all of these options can limit the number of eggs that are mixed with sperm. That way no extras can be created. However, no one can know with certainty how many eggs will fertilize or what the quality of the resulting embryos will be. Therefore, this option could significantly limit your chances of delivering a child.
In New York State, programs that freeze embryos must be licensed and adhere to state regulations on safety and recordkeeping. A program should not offer IVF unless they have the ability to freeze and store embryos.
Does freezing hurt the embryos?
Not all embryos survive freezing and thawing. The proportion of embryos that will be usable after freezing can be difficult to predict. Program and patient factors (such as age and diagnosis) can affect embryo quality. Embryo quality differs from cycle to cycle. Embryos created during the same cycle may also vary widely in quality. If those appearing to be of better quality are transferred in the initial cycle, those that are frozen may be less likely to result in pregnancy. This is not a result of freezing per se, but reflects the initial selection.
How long can I wait to use the embryos?
Some programs will keep frozen embryos indefinitely if you continue to pay the storage fees. Others limit the time embryos may be stored. At that point you may need to transfer the embryos to another facility or select a different option for their use or disposal.
According to the available evidence, how long embryos are stored does not seem to affect their quality.
If I never use the frozen embryos, what will happen to them?
Depending on the program, you may be offered any or all of the following options:
- You can allow the program to donate them to another couple. In New York State, because of the risk of transmitting infection through the embryo, you may donate your embryos only if you undergo the same testing as semen or egg donors.
- You can allow the embryos to be thawed and discarded.
- You can donate the embryos for use in medical research.
Couples can have strong preferences or religious and ethical concerns about any or all of these choices. Make sure that you are comfortable with the choices offered and be sure to express your wishes, in writing, before embryos are frozen.
Who is allowed to make decisions about the embryos?
Although a fertility program may have custody of your embryos, in most circumstances program staff can not make decisions about their use without your consent. When embryos are created by a couple (whether or not donated eggs or semen were used), the couple usually retains joint decision-making authority over the embryos.
Before freezing any embryos, make note of what you are required to do while your embryos are stored. You must keep the program informed of your intention to continue storage or to have the program carry out your instructions for disposing of the extras. If you decide to change your instructions, inform the program in writing.
“It’s weird to go through all the scenarios. After everything you’ve been through, it’s hard to think about what could happen to the embryos.” IVF PATIENT
What if we get divorced or one of us dies?
Serious questions and disagreements could arise if you divorce or if one or both of you die or become incapacitated. It is important for you to think about these possibilities before you begin treatment. To the extent possible, you should indicate – in writing – what you would want to happen to the embryos in case of death or divorce.
In some states, these documents may be legally binding unless both of you agree to change them.
When disagreements arise, courts have taken various approaches in deciding who, if anyone, has the right to use the embryos over the other’s objection or what should happen in unforeseen circumstances. This is likely to be an area of ongoing legal uncertainty.
What will treatment cost?
Infertility treatment can be extremely expensive. Depending on the type of treatments and how long they last, your out-ofpocket costs will vary.
In order to minimize the unexpected costs, be sure to include these expenses (which may not be included in prices quoted on a per-cycle basis) in your estimates:
– Diagnostic tests
– Donor fees and medical bills
– Prenatal care costs
– Missed time from work and impact on career
– Lodging and transportation for treatment away from home.
The costs to treat medical complications – should they occur in you or a donor treated on your behalf – may be substantial, but they cannot readily be predicted in advance.
Should we pick a program with a money-back guarantee?
For many couples, cost is a major obstacle to undergoing treatments such as IVF and GIFT. In addition, most programs require full payment prior to beginning each cycle.
In recent years, some infertility programs have instituted creative pricing plans that attempt to make the cost of becoming pregnant more predictable. Some programs allow couples to pay a flat fee that covers all the costs of one full IVF cycle, plus additional cycles (if needed) to transfer frozen embryos that were created in the first attempt.
The most controversial pricing plans offer partial refunds to couples who do not succeed. Each plan differs somewhat in its details, but several elements are usually present:
- The cost for a money-back cycle is far higher than the cost for a cycle without a refund option. In general, this means that couples who succeed in becoming pregnant are subsidizing the refunds of those who do not.
- Couples must meet rigorous medical and age requirements to enter a refund program. By accepting those couples most likely to become pregnant easily, a program can minimize the number of refunds it must pay.
- Not all costs are refundable. In the contracts for refund plans, many charges (often those for tests to determine whether you qualify or for medications used during treatment) are not subject to the refund provisions. These may add several thousand dollars to your out-ofpocket costs.
- Programs typically define success as establishing a pregnancy of a certain length, often 12 weeks. If a miscarriage occurs after that point, you may not be eligible for a refund or for further treatment.
- A program may require that you let them make certain medical decisions, such as how many embryos to transfer. If you do not consent, you may lose your refund eligibility.
Money-back payment plans have led to heated debate among health professionals, ethicists and consumer advocates. The major argument in favor of the plans is that they allow couples without insurance coverage to spend a fairly predictable amount for treatment. If it is successful, they will be well on their way to becoming parents. If it is not, they will have the refund to use for further treatment or to pursue adoption or other means of family-building.
“It’s important to research your insurance right at the beginning. We didn’t have a clue what would be covered.” IVF PATIENT
Some of the arguments against these plans are based on concerns about how refunds might affect the doctor-patient relationship. The American Medical Association, for example, objects on the grounds that it is unethical to link payment for medical treatment to a specific outcome. Other arguments focus on the potential for consumers to sustain medical or financial harm. Some organizations, including RESOLVE, are concerned that these plans create incentives for doctors to try to increase the odds of pregnancy by taking greater medical risks. There are particular concerns about any plan that requires couples to consent, in advance, to all treatments that may be recommended during the cycles it covers. In reality, your experience during the first cycle (such as a miscarried multiple pregnancy or the side effects of fertility drugs) may make you rethink the dose of medications and the procedures you wish to have used in the second cycle.
As you decide whether a refund program is right for you, proceed with caution and make certain you understand the medical and financial details. Some questions to ask include:
- How will my medical treatment be different if I participate? (For example, will I be required to undergo more tests than I would as a regular IVF patient?)
- What would my chance of pregnancy be if I had less aggressive treatment (such as using fertility drugs without IVF or GIFT)?
- What happens if I withdraw from treatment before I have finished all cycles covered by the plan?
- What happens if I miscarry?
- Can I limit the number of eggs/embryos transferred, or does the program decide?
When a cycle of infertility treatment doesn’t work, should we try again?
Those who have undergone infertility treatment often describe feeling as if the next step were inevitable. If one regimen doesn’t work, they feel they should proceed, as soon as possible, to the next attempt or a new level of therapy. But fertility experts and former patients stress the importance of planning treatment breaks to re-evaluate your options and prognosis. Ask your doctors to be realistic about your likelihood of success and to tell you what, if any, aspects of your treatment might be changed to maximize your chances.
Weigh that in the context of how the process is affecting your life. If your circumstances or priorities have shifted, you always have the option to forgo further treatment.