Working On a Family

Sometimes, building a family is not easy for every couple. Infertility can cause emotional distress, but luckily treatment is advancing.

By Dwain Hebda

Infertility Options

There may be no more taboo issue than a couple struggling with issues of fertility. Of the many stressors that can enter into a marriage, difficulty conceiving or carrying a child to term is all too often a burden people carry alone and isolated.

“When you think of the natural life cycle, you grow up, you get married and have a baby, or nowadays you may have a baby without marriage, right? Then you have grandchildren and then you die,” said Dr. Gloria Richard-Davis, director of reproductive endocrinology at UAMS.

“When you interrupt that, it really brings people to a halt. Emotionally it is very taxing for them, because when you look at the stress levels and the grieving process that people go through, it is on line with the death of a loved one. It’s that significant.”

The National Infertility Association defines the condition as the inability to carry a pregnancy to live birth, the inability to conceive after one year of unprotected intercourse or, in women over age 35, after six months of unprotected intercourse.

One in eight couples has difficulty getting pregnant, and while media reports usually frame the issue as primarily for women, statistics show it’s an equal opportunity problem. One-third of fertility issues lie with the male partner, one-third with the female and one-third a combination of problems from both partners or as simply unexplained in origin.

In some cases, infertility can be experienced as a result of waiting to start a family. As the Pew Research Center reported in a 2015 article, birth rates traditionally dip during economic down periods when many parents feel it’s financially not the right time to have a baby. Strides in the workplace and in education have also caused many women to put off starting a family in favor of a career. These and other delays can run afoul of Mother Nature.

“No. 1 is, we are waiting longer to have children, and so consequently more people need fertility treatment because they’re not having children in their 20s or in their teens,” Richard-Davis said. “It’s not unusual for me to see women who are mid-30s, late 30s, early 40s trying to have a baby. The fertility rate at that point is on the decline, so there is more of a need for fertility services.”

Despite the commonality of the problem, it remains one of the deepest secrets in society, Richard-Davis said.

“A lot of couples don’t want other people to know that this is something that they’re dealing with. I have patients who don’t want their employers to know,” she said.  “It is definitely still something that people feel either ashamed of or stigmatized by.”

Medical science has given many of these couples hope. The NIA reported that among women who sought medical help for infertility, 65 percent gave birth, but it also reported less than half of women with infertility sought such treatment.

“I think that people are more aware; they may not be talking about it, but it’s everywhere, right?” Richard-Davis said. “It’s there, the information is there, but whether or not people choose to initiate care is a little bit different story.”

Those who do seek medical help find a broad range of treatment options at their physician’s disposal, from a simple pill to increasingly complicated procedures. Richard-Davis said the range of treatments available has become so extensive that it sometimes has a curious deterrent effect on couples.

“There are so many [treatment] options that it can be a maze for couples trying to make this decision,” Richard-Davis said. “Sometimes your decision is made based on your religious beliefs. If you can’t have your own genetically linked child, the child can be linked to one of you because we have donor eggs, we have donor sperm, we have donor hosts, we have surrogacy.

“There are lots of options, the question is whether or not it’s an acceptable option to the couple and whether it’s an affordable option for the couple.”

On balance, the American Society for Reproductive Medicine reports between 85 and 90 percent of cases are treated with surgical procedures or drug therapy, the latter of which is today much easier to administer and offers few side effects, although the risk of multiple births increases with its use.

“What’s easier is, we have fertility meds and we have more options in terms of what we can use,” Richard-Davis said. “When we move into the tiers of injectable medication, it used to be shots that women had to do intramuscular, they had to mix it with a diluent and a powder and multiple vials to get the dose that you wanted. Now it’s simply dialing the dose in a pen, almost like an EpiPen, and you inject it in.”

According to the ASRM, fewer than 3 percent of patients require advanced reproductive services such as in vitro fertilization whereby a woman’s egg is removed, fertilized in the lab, then replaced in her uterus. Here, too, science has improved the process to help boost success rates.

“When we started out, the success rate of IVF was largely dependent on two things; the woman’s age and the quality of the laboratory,” Richard-Davis said. “Our laboratories have gotten a lot better with regards to fertilization rates.

“The other thing is we have more success with culturing embryos, and that has translated into higher pregnancy rates per cycle. We’ve seen that climb from mid 20 percent [success rate] to low 40 percent.”

Combating infertility isn’t cheap; entry-level drug therapy commonly costs around $1,000 and injectables between $1,500 and $3,000, per cycle. In vitro fertilization procedures run in excess of $10,000, which may or may not be tempered by insurance. The Affordable Care Act doesn’t cover such treatments at all.

“A huge issue is out-of-pocket expense,” Richard-Davis said. “Employers, Medicaid and some of the marketplace plans may or may not cover any of the services related to fertility because, unfortunately, people still view it like it is elective.”

Richard-Davis said such thinking is not only short-sighted, it fails to grasp the emotional and quality of life issues that a child fulfills in completing a family unit.

“Even in a country like China where they used to have the one-child rule, if you couldn’t have a child, they would pay for IVF because they felt like it was important for you to fill that need for a child,” she said. “When you look at family values or when we talk about family values [having a child] is very important.”