Making Your Fertility Treatment Plan: How to Avoid Hit-or-Miss Fertility Treatment

"You had surgery before your husband was tested?" The RESOLVE group members looked at each other in disbelief.

"Well, we thought it was my problem," Shelley T. said. "I've always had pain with my periods. It made sense."

"The same thing happened to us," Steven S. commented from across the room. "We thought our doctor was a specialist. That's the way he's listed in the phone directory. But when he wanted to put Kathy through a six thousand-dollar workup and never even asked about me, we knew something was wrong."

"What did you do?" Shelley asked.

"We paid our two hundred-dollar consultation charge and found a different doctor." Steven glanced at his wife. "One who would work with us as a couple. Infertility affects the couple, not just one individual."

"But how do you know if your doctor is doing the right thing?" Shelley asked.

The group leader spoke. "Learn as much about fertility problems and treatment as you can so you'll be able to ask the right questions and spot potential trouble.

"Coming to RESOLVE is the first step," he added. "You learn a lot from our programs and from talking with our members. And if you read our newsletter, you'll see that we have resource people who can talk with you about different fertility subjects like endometriosis, artificial insemination, and in vitro fertilization. We also have an extensive lending library of books and articles on just about any fertility topic you'll want to know about."

"You mean I'm going to have to be responsible for my fertility treatment?"

"You and your husband and your doctor," the RESOLVE leader said. "If you work as a team, you'll be able to design a fertility treatment plan that will work for you as a couple."

The leader turned toward me. "Dr. Perloe, how can couples avoid hit-or miss fertility treatment?"

"I agree with all that's been said. It's unfortunate that you cannot expect the same quality of treatment from every doctor or clinic. But I guess that's true of any kind of service." I glanced at Steven and Kathy. "I guess Steven and Kathy are one of the best prepared couples I've ever worked with. Prior to coming to me, they'd read everything they could get their hands on. Before they hired me as their doctor, they wanted to know what to expect."

Shelley interrupted. "Like what?"

"They wanted to know things like what tests I'd recommend, what the results would mean, how long the workup would take, and how much it would cost."

"Didn't you feel like they didn't trust you?"

"Not at all," I answered. "The more you know about your treatment, the better you can work with your doctor. In fact, I usually give every couple an overview of fertility treatment before we even start."

"That's right, Shelley," the leader added. "If your doctor doesn't want to answer your questions or doesn't tell you what to expect, you're probably seeing the wrong doctor. Why don't you see me after the meeting and I'll give you some of our newsletters to read or where you an find information on the Internet."

"That sounds great," Shelley said. "And I want to see your library, too."

Even if you already have been through months or years of fertility treatment, it is not too late to begin a plan. Shelley and Michael T. were able to regain control once they knew what to expect and began to participate in the decisions about their treatment, and so can you.

In this chapter I'd like to acquaint you briefly with the conditions necessary for conception. And as I do with my patients, I'd like to give you an overview of fertility treatment. With this understanding you will be able to help your physician provide the best opportunity to reach your fertility potential.

I realize that many of the things I'll touch on will stir up more questions in your mind. However, hold your questions while I give you the big picture. In later chapters I'll discuss all of this information and more in greater detail.

The goal of fertility treatment is to help you have a child. If you understand the factors necessary for making a baby, you will also understand what factors your physician will evaluate during your fertility workup. The nine key ingredients of fertility are:

1. The woman's health must allow her to safely carry a pregnancy.
2. The male must be able to produce and ejaculate functional sperm.
3. A healthy egg must mature and escape from a woman's ovary at regular or predictable intervals.
4. The egg must be able to travel through the fallopian tubes toward the uterus.
5. A couple must have intercourse at the right time.
6. The sperm must be able to travel through the cervix and uterus to the fallopian tubes to join with the egg.
7. The sperm must be able to penetrate the egg.
8. The fertilized egg must be able to travel through the fallopian tube to the uterus for implantation.
9. A woman's hormone system and uterus must be able to maintain the pregnancy.

To pinpoint where things are breaking down, your physician must check out each of these fertility factors. Later in this book you will learn about the methods your doctor can use to investigate fertility problems and what treatment is available. When you understand your options, you will know how to get your miracle baby.

Your Past Provides Important Clues
First your doctor will ask you both to complete a general health and fertility history questionnaire. Your fertility problems may be rooted in your past-exposure to toxic chemicals, medications, illnesses, and infections, for example. I remember one couple whose problem crystallized when I learned that he'd been exposed to Agent Orange in Vietnam. When I added this incident to his complaints of lethargy and low sexual desire, I began to suspect he could have a fertility problem.

Your doctor should interview you not only together but also individually so you will feel free to reveal your closest held secrets having had an abortion, a sexually transmitted disease, or an illegitimate child, for example. If either of you withholds information, your doctor may perform unnecessary tests and it may take longer and cost more to identify your missing fertility factors. Honesty and completeness pay off.

I remember one woman who told me in confidence about an abortion she had before she was married. Since I knew she had been fertile at that time, I began looking for events that occurred since then. When I learned she'd had a ruptured appendix at age twenty-one, I suspected the infection and surgery could have adversely affected her reproductive organs. So I began to formulate a series of tests that would give me definite answers.

Sometimes your fertility history reveals obvious problems. If like Kathy S. you have only one or two periods a year, I quickly suspect ovulatory problems. If like Shelley T. you complain of extreme pain during menstruation, I'll look for endometriosis. Or if like Margaret B. you've had one or more episodes of pelvic inflammatory disease (PID), I'll check you for tubal blockage. You will learn more about how I diagnosed and treated each of these women and their husbands later.

Some less obvious factors that can contribute to your fertility problem are:

• Previous abdominal surgeries, which may impair fertility in both men and women
• Diabetes or a case of childhood mumps, which can lead to a poor sperm count
• Drugs and high blood pressure medications, which can impair a man's sexual performance or the ability of the sperm to fertilize the egg

As you are filling out your history form, you may not realize the significance of these events or conditions, but if you do your job well, your doctor will have the information he or she needs for piecing together the puzzle.

Highlights of the Male's Workup
To father a child you must be able to produce and ejaculate good quality semen. "Good" semen contains large numbers of normally formed sperm which can swim actively in a straight line. In addition, semen should be free of infection. To deliver your semen to your wife, you must also be able to ejaculate. This requires that you have open passages from your testicles to your penis and an intact nervous system for controlling your ejaculatory processes. Chapter 8 discusses all the hormonal and physiological systems necessary to support male fertility.

If the semen analysis is normal, I can be almost certain that the fertility problem lies with the woman's reproductive system. So I will switch my attention to diagnosing her problem.

If the semen analysis reveals a problem with the husband's fertility, he should have a physical examination to assess his general health and the condition of his reproductive organs. Shelley T.'s husband, Michael, had almost no sperm in his semen. I needed to find out if this was because he was not making sperm or because his sperm could not get out through his ducts.

Based on my examination findings, I may order additional tests to detect if the man has tubal blockage, impaired ejaculation, impaired sperm production, or a hormonal problem, or refer him to a urologist for further evaluation and recommendations.

Finding a fertility problem with the husband doesn't relieve my responsibility to make certain that the wife's reproductive system is working well. I find that in 20 to 30 percent of my cases, both partners contribute to their fertility problems. In Steven and Kathy so's case, for example, Steven had a poor sperm count and Kathy wasn't ovulating. Until I was fairly certain that Kathy's problem could be overcome, it would have been irresponsible for me to condone Steven's varicocoele surgery.

Chapters 6 through 8 describe in detail the tests that are conducted for male fertility problems, what the test findings reveal, and what courses of treatment are available for male fertility problems.

Highlights of the Woman's Workup
Even if a woman's periods are regular, I cannot assume that her menstrual cycle is working normally. So once I've reviewed the wife's history and current complaints, I do a physical examination to evaluate her general health and the condition of her reproductive organs. I also order laboratory tests that will tell me if she's ovulating and if her hormone levels are adequate.

I frequently include an endometrial biopsy in the initial workup because examining the uterine lining will tell me whether she's ovulating and whether her uterus can support a pregnancy. In addition, I may order an X ray to obtain valuable information on the structure of her fallopian tubes and uterus. Many of these tests must be performed at specific points in the monthly cycle. Therefore, I ask her to do some "homework" to help me time the tests.

I ask her to keep a basal body temperature (BBT) chart. This cycle will not only help me synchronize the tests to her menstrual cycle but also tell me what time of the month she is most fertile. If your temperature chart line remains level throughout the month, for example, I may suspect that you are not ovulating (anovulation). If you are timing sex after your temperature rises, I'll know that you are practicing rhythm birth control, which is certainly no way to get a miracle baby! (You are most fertile twenty-four to forty-eight hours before your temperature rises.)

I also perform a postcoital test to tell me if the "chemistry" between the partners is right. If the wife's cervical mucus is impairing or destroying the husband's sperm, there are a number of things I can do to improve their situation.

You will learn more about the woman's workup in and 10. You may even discover what's causing your fertility problem and learn how to overcome it.

Your initial workup usually takes six to eight weeks and may cost up to $2,500. (This cost may vary in different parts of the country.) Once your doctor has the results from your examinations and preliminary tests, you can begin to discuss your options:

• Beginning a treatment program to improve your fertility

   

• Undergoing surgery to correct anatomical problems

   

• Seeking other alternatives such as artificial insemination with donor sperm (AID), in vitro fertilization, adoption, or enlisting a surrogate mother

   

• Performing more tests to pinpoint your fertility problem Your doctor should outline a tentative treatment schedule as well as estimate the cost. Together you should develop a plan that will optimize your fertility while still taking into consideration your lifestyle needs and financial resources.

Continued