Fertility is often more complicated than couples may think.
As an infertility specialist, the first, and sometimes hardest, thing I have to accomplish is to assess a couple's understanding of how the whole getting pregnant thingnaturally or otherwiseworks. Despite widespread sex education and increased public awareness of the issue of infertility, many people still don't really get it; a study from New Zealand, for instance, showed that 74% of women presenting to a fertility clinic had inadequate fertility awareness.
An extreme example: I once had a couple come in for an infertility consultation, and only after probing some of the most esotericand as it turns out, irrelevantminutiae of the biology of reproduction did I find out that the husband wasn't able to ejaculate during vaginal intercourse. (Yes, this is generally considered a prerequisite to conception.)
So if you're in the baby-making market, here are some of the more common mistakes I see people make. And don't be embarrassed if you learn something new; you may or may not save yourself a consultation, but either way, you're certainly not alone.
1. 40 is the new 30
Since the days of Adam and Eve, never have so many women deferred childbearing until their mid-30s or later. The Centers for Disease Control and Prevention reported that in 2006, about 1 out of 12 births in the U.S. were to first-time mothers older than 35, compared to 1 out of 100 in 1970. In other words, only about 1% of first-time mothers were 35 or older in 1970; this number increased eightfold to about 8% in 2006.
The same social and economic forces that have contributed to this reality have also led many women to believe that fertility typically lasts into their 40s. Unfortunately, there's bad news: Historical data suggests that the overall risk for infertilitydefined as more than one year of regular unprotected intercourse without conceptionincreases with age, from 6% between ages 20 and 24 to a whopping 64% between ages 40 to 44. Need more evidence? Take a look in my waiting room. Women in their 20s are few and far between, and most are there to donate eggsto women in their 40s and 50s.
2. There's no rush
A groundbreaking study of more than 5,000 couples in the 1940s and 1950s showed that at least 85% conceived within one year of trying for a baby. Historically, this one-year landmark has defined infertility, and many couples postpone evaluation until they have met this milestone.
This is a reasonable rule of thumb for women younger than 35 who are in otherwise perfect health. But anyone older than 35, or anyone with gynecologic or medical problems (irregular or painful periods, diabetes, thyroid problems, or just about anything else), should seek evaluation by a fertility specialist or her ob-gyn. There are numerous fertility problems that can be treated easily but make it nearly impossible to conceive without medical assistance. The key is to be informed. Don't wait, as time is precious when it comes to fertility.
3. We have sex often enough
It never ceases to amaze me how much our fast-paced lifestyles and schedules interfere with conception. I have met so many busy professional couples who are surprised they aren't pregnant, yet they only sleep together in the same bed, let alone on the same continent, once every month or two.
Just remember: Even someone very fertile and her partner, both in their 20s and in perfect health, will, at best, have about a 25% chance of conceiving in any given month, even with perfectly timed intercourse. This so-called fertile window is open four to five days prior and through ovulation, and it's suggested you have intercourse every 24 to 48 hours during that period. Statistically speaking, this rate of success decreases to about 10% to 15% per month if you're not pregnant within three months, and 5% or less if you're not pregnant after a year.
Now think about this same woman; let's call her Jane. She's 36 and has irregular periods. If she doesn't check her ovulation and plan accordingly, it will be very difficult to conceive during the occasional conjugal visit from her partner (no matter how romantic and passionate his visit may be).
4. It's gotta be me
Multiple historical, cultural, and religious forces have led many women (and, conveniently enough, men) to assume that fertility problems almost always arise from the female side. It's not an illogical assumption. After all, a woman's reproductive system is a lot more complicated than a man's, and therefore has more components that can be broken. Case in point: Most infertility specialists (including myself, for full disclosure's sake) are trained first as ob-gyns, not doctors specialized in male anatomy.
But the reality is that men can have plenty of trouble too. Sperm issues such as low sperm count or abnormal/unhealthy sperm are the primary problem in 25% to 35% of infertile couples, and some reports indicate that worldwide, male infertility is on the rise. The reason why is still unclear, but some theories suggest toxins from environmental exposure could be at work.
Furthermore, even in couples with female-related fertility issues, mild sperm defects often contribute just enough to make achieving a pregnancy difficult, if not impossible, without help. For these reasons, it's crucial that men be involved with the infertility evaluations from the outset, usually starting with a semen analysis. If a serious abnormality is identified, consultation with a urologist or further testing will likely be necessary.
5. All I need to do is relax
There is no question that high stress is associated with infertility, and that infertility is associated with lots of stress. While the exact biology of how stress might come into play is not fully understood, substances such as cortisol, epinephrine, melatonin, opioids, and others are known to affect stress and reproduction. Along these lines, one recent Israeli study of women undergoing in vitro fertilization (IVF) showed higher pregnancy rates in those who saw a 15-minute clown performance after their embryos were transferred.
This so-called mind–body approach to infertility treatment has gained enormous popularity in recent years. But whether stress can actually contribute to infertilityand, more importantly, whether reducing stress can actually help you get pregnantis still a controversial issue.
Acupuncture is probably the best example of this debate. In 2008, a thorough review combining the results of 13 of the best studies on acupuncture and IVF patients did suggest some benefits, prompting many specialists to incorporate acupuncture into their treatment recommendations. Conversely, in 2010, three new larger studies were published showing no increase in pregnancy rates from acupuncture.
Given this uncertainty, I tell my patients that if they can do things to reduce stress in their lives while trying to conceive, there is no doubt this is, at some level, a good thing, regardless of how much it improves their ability to conceive. But the one thing they should not do (and I have seen this happen many times) is to "stress" over scheduling or making time for treatment; I can pretty much guarantee this will not be helpful at all.
6. Fertility treatment means I'm going to end up like Octomom
Nadya Suleman became the poster child for everything scary and reprehensible about fertility treatment when she gave birth to octuplets in 2009. But pursuing fertility treatment does not mean you need to price the newest double strollers and build an addition to your home.
While multiple pregnancies have always been the biggest risk of fertility treatment, professional fertility organizations have been working to reduce multiple pregnancies since the early 1990s. For example, guidelines for the number of embryos to transfer have helped reduce the IVF "triplet-or-more" rate by more than 70% since the late 1990s, with only less than 2% of IVF pregnancies in that category in 2008.
I see many patients who start their infertility journey extremely wary of any medications or other "unnatural" interventions. A good fertility doctor can, and will, work with you to try and to avoid an aggressive treatment plan, but he will also be honest with you about your chances and when it's time to try something with a bit more oomph.
7. I can't afford IVF
In vitro fertilization is undoubtedly an expensive option for those struggling with infertility--one treatment can cost upwards of $10,000. But because of the strong demand for IVF and its remarkable successes, many commercial insurance plans now include IVF coverage. Several states have even made commercial insurance companies legally obligated to provide some level of IVF coverage in their plans. Furthermore, some fertility practices have implemented sliding-scale payment plans or other financial arrangements to help overcome the economic burdens of treatment. Even pharmaceutical companies have begun offering special programs to make fertility medications more affordable.
So the next time you need to choose or renew your health insurance, think about whether IVF might be in your future and consider strategizing accordingly. At the same time, while many doctors accept insurance for IVF, many do not, so make sure you know how much you'll be paying out-of-pocket before deciding on treatment.
8. Celebrities have babies using IVF in their 40s and 50s--I can too
While IVF is very successful in younger women--nationally, 48% of IVF cycles resulted in a pregnancy in this age range in 2008--it cannot ultimately overcome the problem of reproductive aging. In women 43 and older, only 9% of IVF cycles resulted in a pregnancy in 2008, and more than half of these pregnancies ended in miscarriage. Most IVF clinics will not even offer treatment to women 45 or older using their own eggs.
So what about those celebrities in their late 40s or 50s having twins? Almost certainly these are donor-egg IVF babies, where the embryo is produced from an egg donated by an anonymous younger woman, and is then implanted to grow in the uterus of the older woman. Donor-egg IVF is a wonderful family-building option for many couples, but people need to adjust to the emotional and psychological reality of not contributing their genetics to their baby.
Joshua U. Klein, MD, is a board-certified OB/GYN and a Clinical and Research Fellow in Reproductive Endocrinology and Infertility at Columbia University Medical Center, in New York City. After earning his medical degree at Harvard Medical School, he completed residency at Harvard's Brigham and Women's Hospital and Massachusetts General Hospital.