By Desireé McCarthy-Keith, MD
Published in Resolve for the journey and beyond, Summer 2013
Thanks to continued advances in reproductive medicine, in vitro fertilization (IVF) has become a highly successful treatment for infertility. IVF treatments are more invasive than other treatments and can be a costly option, particularly for patients lacking fertility insurance coverage. Many patients believe that IVF provides their only chance of having a baby; however, this may not be the case. There are a few absolute indications for needing IVF, such as absent or damaged fallopian tubes, desire for preimplantation genetic testing, severe male factor, or unsuccessful attempts with less invasive treatments. If one of these indications does not exist, there are often less invasive, lower cost fertility treatments available that give patients a good chance of success.
Before starting fertility treatment, a thorough assessment of general health, ovarian function, and hormonal balance is needed. Detection and treatment of thyroid disease and high prolactin levels can restore normal reproductive function for some women. Screening for and correcting metabolic abnormalities like insulin resistance can also improve reproductive and overall health. Men should complete a semen analysis early on to evaluate any problems with sperm production or function.
The initial female fertility evaluation includes an assessment of the uterus and fallopian tubes. Uterine fibroids are the most common non-cancerous gynecologic tumor in women and are often diagnosed in women having difficulty conceiving. Uterine polyps are soft tissue growths that are also commonly detected in women seeking fertility care. Fibroids or polyps inside the uterine cavity can interfere with implantation and removing them can restore fertility. Damaged or blocked fallopian tubes can also cause infertility. An x-ray test called a hysterosalpingogram is often used to determine if the fallopian tubes are normal.
Ovulation problems affect up to 20% of women who are having trouble getting pregnant. Women who are overweight or underweight may ovulate less frequently and this can contribute to trouble conceiving. For overweight women, losing 5-10% of their body weight can restore normal ovulation, without further fertility treatment. Women who are underweight can also see a return of regular menstrual cycles with weight gain. Polycystic ovarian syndrome (PCOS) is the most common hormonal disorder in reproductive aged women and many women with PCOS also experience problems with ovulation.
A common treatment for women with irregular ovulation is ovulation induction (OI). With OI treatment, a woman takes an oral medication, like clomid or letrozole, and then may have an ultrasound to determine how the ovaries responded to the medication. OI can be combined with intercourse timed around expected ovulation or coordinated with an intrauterine insemination (IUI) procedure. The same medications used for OI can be used for superovulation in women who ovulate regularly, but are having difficulty conceiving. Clomid or letrozole treatment in ovulatory women will usually stimulate two to four eggs to develop. The superovulation treatment is then combined with either timed intercourse or an IUI procedure. A good candidate for OI or superovulation has at least one normal fallopian tube and normal sperm from a partner or donor. The natural fertility rate for fertile couples is 20-25% per cycle, and rates for couples treated with medication and IUI can reach 15-20% per cycle.
Fertility treatment should be individualized to a patient’s unique situation. While some patients have an absolute indication for IVF, many will not. Oftentimes, medical treatment of a hormonal imbalance or correction of a metabolic disturbance can improve reproductive function. Surgical removal of fibroids and polyps from inside the uterine cavity can also increase the chance of pregnancy. Ovulation induction or superovulation treatments cost a fraction of IVF treatments and can achieve pregnancy rates close to those of fertile couples.
Desireé McCarthy-Keith, MD, is a reproductive endocrinologist at Georgia Reproductive Specialists in Atlanta, Georgia. Dr. McCarthy-Keith earned her medical degree from the University of North Carolina at Chapel Hill and also a Master of Public Health in maternal and child health from the University of North Carolina. She completed her obstetrics and gynecology residency training at Duke University Medical Center and a fellowship in reproductive endocrinology and infertility at the National Institutes of Health in Bethesda, Maryland. She has special interests in fertility evaluation, uterine fibroids, and reproductive health disparities. Dr. McCarthy-Keith was a lieutenant commander in the United States Public Health Service Commissioned Corps and held the position of assistant professor of obstetrics and gynecology at the Uniformed Services University of the Health Sciences. She is board certified in obstetrics and gynecology and was recently honored by Black Health Magazine as one of Atlanta’s most influential African American doctors.