Infertility: What is it?

Most American women spend their late teens and early 20s trying NOT to get pregnant. A period might be an inconvenience for some, but it’s a regular reminder that they’ve made it through another month without an unwanted pregnancy.

Then priorities change, and it’s time to start a family. Now, that same period is a frustrating reminder that another month has passed without a successful conception. (I would be remiss to not acknowledge that because half of pregnancies in the United States are unplanned, there is clearly a less methodical way to get from avoidance to parenthood.)

Most women know how babies are made, so it’s relatively rare for me, as an obstetrician gynecologist, to see a woman who is just getting started on her baby-making journey in my office. Typically, they have been trying for a few months and are beginning to worry.

Occasionally, a patient in for an annual visit will mention a plan to start a family and ask if I had any recommendations. My advice is always to go low-tech: take a prenatal vitamin to make sure that folic acid is on board, and then consider having sex every day or two for about two weeks after your period ends. For most women, this would cover their “fertile window,” which includes the three to five days before ovulation.

This low-tech advice can be enhanced with an ovulation predictor kit and doesn’t work for women with irregular cycles, but for the majority of young couples, it’s a low-stress way to start trying to conceive. With nothing more than regular sex, 85-90% of couples will be pregnant within a year.

What’s more common is for obstetrician gynecologists like me to see women who are having trouble conceiving. We define infertility — difficulty conceiving — as 12 months of regular sex for women under 35 or six months of regular sex for women 35 and over. These are arbitrary definitions, but they reflect the truism that the longer couples go without a pregnancy, the less likely they are to achieve one.

Couples who see a doctor to figure out why they aren’t on their way to parenthood go through a series of tests — a semen analysis and some measure of ovulation are the most important — and sometimes identify a treatable cause of their infertility. What happens most of the time is that the couple ends up facing some fairly common treatments for unexplained infertility.

There are dozens of variations on infertility treatment, but they all boil down to some combination of a) cleaning the sperm and injecting it close to the egg and b) tricking the ovaries into producing more than one egg at a time. The combination chosen seeks to maximize success while minimizing the risk of multiples (twins, triplets, etc.), the cost, and the complexity of the procedures.

A very common first-line treatment involves the use of clomiphene citrate (Clomid), which is an easily tolerated, inexpensive oral medication that causes the ovaries to ovulate, often with several eggs, combined with in-utero insemination (squirting processed sperm high into the uterus where it is more likely to encounter the eggs).

The most involved and most expensive treatment is in-vitro fertilization, which requires the choreography of expensive injected medications, an ultrasound-guided procedure to retrieve eggs with a needle, mixing of sperm and eggs in a petri dish, and replacement of the resulting embryo some days later.

Parents of children conceived through IVF will swear it’s worth it: the time, the expense, the stress. Couples who spent their life savings on IVF and were unsuccessful generally don’t talk about it, except to their close friends. So keep in mind that as a result, stories of success far outnumber stories of failure.

I always tell couples to take the long view: go slow, try not to get stressed out every month, be patient and try the low-cost treatments first, and remember that families come in every form imaginable, and each kind is beautiful.