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Infertility Basics

Few topics seem to need more reliable information than Infertility, yet it remains the least discussed! Here are some major issues that you need to know about infertility.

  1. Top Ten Misconceptions About Infertility
  2. Top Ten Fertility Fallacies
  3. Self Help Tips For Infertile Couples
  4. Unexplained Infertility

Top Ten Misconceptions about Infertility

infertility is quite a common problem, but is surrounded by clouds of misconceptions and myths. Getting your facts straight is the best place to start.

One of the most amusing books I have read on infertility is: A Few Good Eggs : Two Chicks Dish on Overcoming the Insanity of Infertility by Julie Vargo and Maureen Regan.

The book is targetted towards infertile women living in the US, and is written in the currently fashionable "chick-lit" style. It's amusingly written; and is a breath of fresh air , if you are the sort of person who finds a sense of humour helps you cope better with infertility.

The book has lots of Top-10 lists, and here's their list of Top Ten Misconceptions About Infertility.

10 Mis(sed)-Conceptions About Infertility

  1. Infertility won't happen to me.
  2. I can't be infertile. I already have a baby!
  3. I can get pregnant, so I don't have fertility issues. I just have miscarriages
  4. I'm too young to have fertility issues!
  5. My doctor told me I didn't need to see a fertility specialist until I had three miscarriages.
  6. I'm in great shape. I exercise all the time. I can't be infertile.
  7. I'm not infertile. I'm just not having enough sex.
  8. You can wait a long time to have a baby.
  9. Men can't be infertile. They make sperm all the time.
  10. Normal is a miracle.

Here are my comments about this list.

  1. Infertility won't happen to me.
  2. This is wishful thinking. The sad fact is that infertility is quite a common problem. It affects about 1 in 10 couples, so your chances of being infertile are about 10%. Unfortunately, there is no reliable way of being able to check your fertility ( short of actually getting pregnant !). There is no symptom or sign or clue which will tip you off that you may have a problem. This is why so many couples are "pre-infertile" - they worry ( often needlessly) as to whether they may have problems conceiving when they fail to get pregnant the first month they try !

  3. I can't be infertile. I already have a baby!
  4. Sorry. As financial consultants are so fond of reminding us, past performance is no guarantee of future results ! If you had a baby in the past, this simply means that you were fertile then - this is no guarantee that a problem may not have cropped up in the interim which is causing you to become infertile now ! This is called secondary infertility - and is often even more frustrating, because it is no unexpected.

  5. I can get pregnant, so I don't have fertility issues. I just have miscarriages
  6. An extended definition of infertility also includes women who have repeated pregnancy losses ( miscarriages) - women who cannot carry the pregnancy to term. This is because the end result in both cases is the same - the inability to have a baby to love and to hold.

  7. I'm too young to have fertility issues!
  8. Unfortunately, infertility does not respect your age ! While it is true that older women have a much higher chance of being infertile , because they have "older" eggs, young women can also be infertile for many reasons - such as damaged tubes.

  9. My doctor told me I didn't need to see a fertility specialist until I had three miscarriages.
  10. A miscarriage occurs in about 10 % of all pregnancies. Because it is such a common event, and often occurs for random genetic reasons which do not recur, most doctors will not investigate a woman if she has had one miscarriage. Not only is the testing a waste of time and money, it provides little useful information. This is why most doctors will do testing only if you have had 2 miscarriages. However, if you need additional reassurance after having a miscarriage, please ask your doctor as to what he can do to help you.

  11. I'm in great shape. I exercise all the time. I can't be infertile.
  12. There is no relationship between your general health and your fertility. For example, your fallopian tubes could be blocked without causing any symptoms or signs - and you have no way of knowing this, until you get them tested.

  13. I'm not infertile. I'm just not having enough sex.
  14. This is a possibility only if your sexual frequency is less than once a week. If it's more than this, the chances of your having sex during your "fertile time" are quite high - you most probably will "hit the jackpot" at some time over the course of a year. However, increasing your sexual frequency is an easy ( and fun !) way of improving your fertility. Unfortunately, many women use infrequent sex as a pretext to deny the possibility that they maybe infertility.

  15. You can wait a long time to have a baby.
  16. This is not a good idea, for two reasons. Firstly, if you have not conceived on your own in 1 year, the probability of doing so on your own drops considerably; and the chances of your needing medical assistance increase. Secondly, fertility drops as you get older, and there's no point in wasting time and reducing your chances of success. Everything in life comes back, except for time. It's a precious , non-renewable resource - use it sensibly !

  17. Men can't be infertile. They make sperm all the time.
  18. It is true that men produce sperm all the time. However, about 10% of men are infertile, because they produce poor quality sperm. Some have no sperm in their semen at all - and there is no way of checking this without doing a semen analysis in the pathology laboratory.

  19. Normal is a miracle.
  20. Actually, this is true (just slipped it in to make sure you were paying attention!). Given how much precise synchronisation needs to be achieved for an embryo to implant in the uterus to become a baby, every birth is truly an amazing feat - it's remarkable how the human body achieves this with such ease for so many couples !


Top Ten Fertility Fallacies

Most people assume they are fertile till they find out otherwise. Infertile couples often subscribe to mistaken assumptions that can be cleared with the right information.

The book has lots of Top-10 lists, and here's their list of Top 10 Fertility Fallacies

  1. You can have a baby easily until you're at least forty-five.
  2. Menopause happens to women in their fifties.
  3. If you are young at heart, so is your body.
  4. If_______________ (fill in the blank with your favorite post forty pregnant celeb) can do it, so can I.
  5. Once I stop using birth control and have unprotected sex, I'll get pregnant right away.
  6. If I eat right , exercise regularly, and don't smoke, my body will be able to carry a baby whenever I am ready.
  7. It's no big deal if I can't get pregnant. My doctor can always get me there.
  8. You can never be too thin.
  9. Nobody I know would ever use donor eggs!
  10. When I want to get pregnant, it will just happen.


Great list ! Here are my comments.

  1. You can have a baby easily until you're at least forty-five.
  2. Unfortunately, most women don't know much about their biological clocks; or the fact that they never produce any new eggs in their lifetime ; and that will run out of eggs as they age. I wish they would teach girls some of these "facts of life".

  3. Menopause happens to women in their fifties.
  4. Menopause occurs when the store of eggs runs out. It can happen at any age - even at 40. However, even more worrisome than the menopause is the oopause - the 10 year phase before the menopause, during which egg quality drops to impair fertility. However, because the periods remain regular, women have a false sense of assurance that their fertility is intact !

  5. If you are young at heart, so is your body.
  6. I wish ! If this were true, all of us would remain 25 all our lives. Unfortunately, hairs turn grey, the skin wrinkles, muscles start sagging - and eggs die. The drop in fertility is irreversible - time is a non-renewable resource.

  7. If_______________ (fill in the blank with your favorite post forty pregnant celeb) can do it, so can I.
  8. Don't trust everything you read in the papers ! Maybe she used donor eggs - but she's not telling you this (and why should she - it's none of your business anyway !)

  9. Once I stop using birth control and have unprotected sex, I'll get pregnant right away.
  10. This happens only in Hindi films, when the heroine gets pregnant on the first wedding night. Nature is not very efficient to producing babies, and you cannot hurry her up !

  11. If I eat right , exercise regularly, and don't smoke, my body will be able to carry a baby whenever I am ready.
  12. Unfortunately, there is no correlation between your physical health, and the health of your eggs. There is a difference between chronological ( calendar) age; and ovarian age. ( The ovarian age is usually more :()

  13. It's no big deal if I can't get pregnant. My doctor can always get me there.
  14. While infertility specialists have lots of technological options up their sleeves, to help you achieve in the lab what is not happening in the bedroom, we still have to work with the raw material you provide us - your eggs. And poor quality eggs are still the infertile specialist's nightmare, because it's not an easy problem to fix !

  15. You can never be too thin.
  16. You can. Just like it's not a good idea to be too fat, being too thin can also reduce your fertility. Today, most women know about the dangers of anorexia, and it's worth emphasising these again. Follow the "middle path" !

  17. Nobody I know would ever use donor eggs!
  18. Actually, many would. It's just that they wouldn't tell you - and there's really no need for them to, is there ! After all, it's their personal decision !

  19. When I want to get pregnant, it will just happen.
  20. If it did, infertility specialists like me would be out of a job! (Which would be great ! I could then spend all my time running our free patient education library, HELP - Health Education Library for People).


Self Help Tips for Infertile Couples

How do you know if you are infertile? The medical textbook definition of infertility is the inability to conceive even after trying for a year.

Are you infertile ?

" So, when are you planning to have a baby ? " This is the commonest question most newly married couples in India are asked - sometimes even as soon as they have returned from the honeymoon ! There is a lot of pressure on couples to have a baby, especially in traditional families, where the wife's role is still seen to be one of perpetuating the family name by producing heirs.

Many couples still naively expect they will get pregnant the very first month they try ( the result of watching too many Hindi films , perhaps !) - and are concerned when a pregnancy does not occur. All of us go through a brief interlude of doubt and concern when we do not achieve pregnancy the very first month we try and we start wondering about our fertility.

Before worrying, remember that in a single menstrual cycle, the chance of a perfectly normal couple achieving a successful pregnancy is only about 25%, even if they have sex every single day . This is called their fecundity which describes their fertility potential . Humans are not very efficient at producing babies ! There are many reasons for this, including the fact that some eggs don't fertilize and some of the fertilized eggs don't grow well in the early developmental stage. Getting pregnant is a game of odds - it's a bit like playing Russian Roulette and it's impossible to predict when an individual couple will get pregnant ! However, over a period of a year , the chance of a successful pregnancy is between 80% and 90%; so that 7 out of 8 couples will be pregnant within a year. These are the normal "fertile" couples - and the rest are "labelled " infertile - the medical textbook definition of infertility being the inability to conceive even after trying for a year. Couples who have never had a child are said to have "primary infertility" ; those who have become pregnant at least once but are unable to conceive again are said to have "secondary infertility."

The chances of a couple getting pregnant in a given month will depend upon many things, and the most important of these are: o The age of the woman. As the biologic clock ticks on, the number of eggs and their quality start decreasing o Frequency of intercourse. While there is no "normal" frequency for sex, the "optimal" frequency of intercourse if you are trying to get pregnant is about 3 times a week in the "fertile period". Simply stated, the more sex the better ! Couples who have intercourse less frequently have a diminished chance of conceiving. o "Trying time" - that is, how long the couple have been trying to get pregnant. This is an important concept. The longer a couple has been trying to conceive without success, the lesser their chances of getting pregnant without medical help. o The presence of fertility problems.

What happens when a couple has a fertility problem? The chance of their getting pregnant depends upon a number of variables multipled together. Consider a couple where both the husband and wife have a condition that impairs their fertility. For example, the husband's fertility, based on a reduced sperm count is 50 percent of normal. His wife ovulates only in 50 percent of cycles; and one of her fallopian tubes is blocked. With three relative infertility factors, their chance of conception is 0.5 (sperm count) X 0.5 (ovulation factor) less X 0.5 (tubal factor) = 0.125% or 12.5% of normal. Since the chance of conception in normal fertile couples is only 25% in any one cycle, the probability of pregnancy in any given month in the case of this couple without treatment is only 3% (0.125 X 25 = 0.03125)! Even if they kept on trying for 5 years, their chance of conceiving on their own would be 60% only. Thus, infertility problems multiply together and magnify the odds against a couple achieving a pregnancy. This is why it is important to correct or improve each partner's contributing infertility factors as much as possible in order to maximise the chances of conception. If infertile couples had 300 years in which to breed, most wives would get pregnant without any treatment at all ! Of course, time is at a premium, so the odds need to be improved - and this is where medical treatment comes in. When should you start worrying and seek medical advise? If you have been having sexual intercourse two or three times a week at about the time of ovulation, without any form of birth control for a year or more and are not pregnant, you meet the definition of being infertile. Pregnancy may still occur spontaneously, but from a statistical point of view, the chances are decreasing and you may now want to start thinking about seeking medical help. There is no "right" time to do so - and if it is causing you anxiety and worry, then you should consult a doctor. Even though you may be embarrassed and feel that you are the only ones in the world with the problem, you are not alone. Many couples experience infertility and many can be helped.

Unfortunately, while infertility is always an important problem, it is usually never an urgent one. This often means that couples keep on putting off going to the doctor - " we'll take care of it next month" . Tragically, many find that time flies, and before they realize it, their chances of getting pregnant have started to decline, even before they have had a chance to take treatment properly. Remember that everything in life comes back - except for time !

A note of caution..... There are certain conditions that warrant seeing a doctor sooner: * Periods at three-week (or less) intervals. * No period for longer than three months. * Irregular periods * A history of pelvic infection. * Two or more miscarriages. * Women over the age of 35 - time is now at a premium ! * Men who have had prostate infections. * Men whose testes are not felt in the scrotum

Tips for Self-help :

Before seeking medical help, remember some of the things you can do to enhance your own fertility potential. Body weight, diet and exercise. Proper diet and exercise are important for optimal reproductive function and women who are significantly overweight or underweight can have difficulty getting pregnant. Although most of a woman's estrogen is manufactured in her ovaries, 30% is produced in fat cells. Because a normal hormonal balance is essential for the process of conception, it is not surprising that extreme weight levels, either high or low, can contribute to infertility. Body fat levels that are 10% to 15% above normal can contribute to infertility, with an overload of estrogen throwing off the reproductive cycle. Body fat levels 10% to 15% below normal can completely shut down the reproductive process, so that women with eating disorders, such as anorexia nervosa or bulimia, or those who are on very low-calorie or restrictive diets are at risk, especially if their periods are irregular. Female athletes, marathon runners, dancers, and others who exercise very intensely may also find that their menstrual cycle is abnormal and their fertility is impaired. Stop smoking. Cigarette smoking has been associated with a decreased sperm count in men. Women who smoke also take longer to conceive. Stop drinking alcohol. Alcohol (beer and wine as well as hard liquor) intake in men has been associated with low sperm counts. Review your medications. A number of medications, including some of those used to treat ulcer problems and high blood pressure, can influence a man's sperm count. If you are taking any medications, talk with your doctor about whether or not it can affect your fertility. Many medications taken during early pregnancy can affect the fetus. It is important to tell your doctor or pharmacist that you are attempting to become pregnant before taking prescription medications or over the counter medications, such as aspirin, antihistamines, or diet pills. Stop abusing drugs. Drugs such as marijuana and anabolic steroids decrease sperm counts. If you have used drugs, discuss this with your doctor. Both partners should stop using any illicit drugs if they want a healthy baby. Limit your caffeine (tea, soft drinks and coffee) intake. Frequency of intercourse. The simple rule is - as often as you like; but the more often you have sex, the better your chances. Thus, for couples who have sex only on weekends (often the price they pay for a heavy work schedule) the chance of having sex on the fertile preovulatory day is only one-third that of couples who have sex every other day - which means they may take three times as long to conceive. Many couples complain that they are too stressed out to have frequent sex. Here are some simple measures you can take to increase sexual frequency. 1. Use sexual toys like vibrators or body massagers, to make sex more fun 2. Using a lubricant like liquid paraffin can help to make sex more exciting 3. Playing sex games can help - try taking turns seducing each other ! 4. I tell all my patients - it's much more fun making a baby in your bedroom than coming to me ! (And think of all the money you'll be saving - it's like being paid to make love to your wife !) 5. Viagra can also be helpful for some couples.

Timing of intercourse. Unlike animals, who know when to have sex in order to conceive (because the female is in "heat" or estrus when she ovulates), most couples have no idea when the woman ovulates. The window of opportunity during which a woman can get pregnant every month is called her "fertile phase" - and is about 4-5 days before ovulation occurs. Timing intercourse during the "fertile period" ( before ovulation) is important and can be easily learnt . However, some couples are so anxious about having sex at exactly the right time that they may abstain for a whole week prior to the "ovulatory day " and often the doctor is the culprit in this overrigorous scheduling of sex. This overattention can be counterproductive (because of the anxiety and stress it generates) and is not advisable. As long as the sperm are going in the vagina, it makes no difference which day they go in , so you can have sex daily as well, if you so desire!

Position and technique of intercourse. Pigs are very efficient at conserving semen - the boar literally screws his penis into the vagina of the sow, obtaining a tight lock prior to ejaculation, to ensure that no semen leaks out. Humans do not have such well-designed mechanisms and perhaps this is because they are really not necessary. Leakage of semen after intercourse is completely normal. While many women worry that this means that they are not having sex properly or that their body is rejecting the sperm, actually leakage is a good sign it means that the semen is being correctly deposited in the vagina ! Of course, you can only see what leaks out and not what goes in ! Most doctors advise a male superior position; and also advise that the woman remain lying down for at least 5 minutes after sex; and not wash or douche afterwards. A number of products used for lubrication during intercourse, such as petroleum jelly or vaginal cream, have been shown to affect sperm quality. Therefore, these products should be avoided if you are trying to get pregnant (a suitable alternative is liquid paraffin).

Balancing a career and fertility :

Women pursuing a career often have a hard time balancing their biological urge to have a baby and the demands of their professional career. Unfortunately, Indian companies still do not give a high priority to family building, and many bosses frown on women employees who are trying to get pregnant, because they are concerned that this will cause them to spend more energy on their family, and detract from their ability to perform their job efficiently. For a minority, putting off getting pregnant means that their fertility declines as they age, and they often regret their earlier decision to postpone childbearing. Professionals often have a harder time coming to terms with their infertility, because this is usually the first time they are forced to confront their own biological frailty and limitations.

Which is the "right time" to plan a baby ?

While there can be no simple answer to this question, remember that a woman's fertility is maximal between the ages of 20 and 30. Beyond the age of 30, fertility starts to decline; and this drop is quite sharp after the age of 35; and precipitate after the age of 38. From a purely biological point of view, nature has designed women's bodies so that they have babies between the ages of 20 and 35. However, the right time to have a baby is a very personal and individual decision, which each couple needs to make for themselves. Public anxiety over infertility is fueled by countless magazine articles warning couples not to wait too long to start a family. As a result we now see many patients who are "pre-infertile" who assume they'll have trouble conceiving even before difficulties actually arise just because they are more than 30 years old !

Is fertility lower at present?

Has the fertility of couples declined in modern times? Possibly. The reasons for this include: 1. the increasing age of women at the time of marriage and childbearing 2. the increased incidence of sexually transmitted diseases or STDs which damage the reproductive tract in both men and women 3. decreasing sperm counts in men which is a global phenomenon. An interesting observation made recently has been that men's sperm counts worldwide have been falling in the last few decades . Whether this is due to environmental pollution or to the stresses of modern day life remains unclear.

The good news is that there is definitely an increasing awareness about infertility in society today. It is no longer a taboo topic, and couples, supported by their families, are much more willing to seek medical assistance.

Where to get help?

Most couples consult their family physician who will refer them to an obstetrician - gynecologist when infertility is a concern. This first visit should include both husband and wife. The doctor will usually outline the possible causes of infertility, and provide an evaluation plan. The first step should be to achieve an accurate diagnosis to try to find out why pregnancy isn't occurring. Once a diagnosis has been determined, the couple and physician should talk again about a treatment plan. For difficult problems, referral to an infertility specialist may be suggested. Some studies show that it may actually be more cost - effective for couple to seek treatment by an infertility specialist right at the outset. This may be because an infertility specialist can design and implement a treatment plan more efficiently than a general gynecologist.


Unexplained Infertility

In some cases, the patient cannot conceive even when all the infertility diagnostic tests come out positive. It is an understandably frustrating situation. But, it's best to keep in mind that a successful result is more important than finding out the medical explanation.

Patients with unexplained infertility often find it very difficult to accept this diagnosis, and their commonest plaint is - I wish I knew why I wasn't getting pregnant. They are also not sure how to proceed - "After all, if the doctor cannot find out what the problem is , how will he be able to fix it ? "

Unfortunately, they are so focused on trying to find out what the problem is they often get paralysed into inactivity . Since they do not get any clear answers , they keep on doctor shopping. This increases the confusion, because they get widely varying opinions and treatment options, so that they don't know what to do next. ( By contrast, for a woman with damaged , blocked tubes, the absence of alternatives makes decisions making easier ! They only have 3 choices - remain child-free; adopt; or do IVF - In Vitro Fertilization).

Unfortunately people get so obsessed with diagnosing problems so that they can fix them, that they end up doing a zillion investigations, and identifying millions of minor irrelevant problems, which have no bearing on the fertility problem. However, they concentrate their energies on correcting these so called problems ( whether it's pus cells in the semen; minimal endometriosis; high levels of NK cells , an abnormal SCSA result, or whatever) that they lose sight of the important goal, which is a baby ! It's important to focus your energies on your goal, so you don't waste time and energy or irrelevancies.

It is interesting to see how fashions in medical science also change with regard to these patients . For example , many years ago , the diagnosis of luteal phase defect was very commonly invoked, and this was a very popular diagnosis to explain the infertility in some of these couples and many investigation protocols and treatment protocols were also designed to treat this "problem ". After all, doctors , just like patients, are happier when they have a name to put on a particular disease .

The problem with treating unexplained infertility is that anything can work , which is why there are so many anecdotal successes with all forms of treatment. Since infertile couples are emotionally very vulnerable , they are often willing to try any treatment fad , in the hope that it'll work for them.

Also since everything is "normal" , many of these couples are hell-bent on achieving a natural pregnancy in their own bedroom. After all if everything is normal , then there really is no reason why they can't get pregnant in their own bedroom, is there ? And all of us have heard success stories of people who have conceived after ten to fifteen years of trying . Unfortunately , these couples often end up wasting a lot of precious time . The fact remains that if people haven't got pregnant in their own bedroom within three years of trying , the chances of their conceiving on their own are very low. It is no longer cost effective or time effective for them to keep on waiting , because they pay a price for this waiting - and the price they pay is a loss of their reproductive potential. This often means that by the time they seek infertility treatment , there is little an infertility specialist can offer them .


I always remind my patients with unexplained infertility that the quality of the answer depends on the quality of the question , and the question should NOT be - "Why am I not getting pregnant ?" After all , no one cares about problems - people only care about solutions ! The right question is - " What can I do in order to get pregnant ?" Rather than waste time and money on irrelevant tests , it's important to formulate a treatment plan of action to maximize the chances of success . Never do a test or investigation if it does not change your treatment plan !

The good news is that even though our medical technology for diagnosing problems in the area of infertility is not very good , our technology for solving them today is brilliant .

This is the reason why IVF - In Vitro Fertilization is such an effective treatment option for patients with unexplained infertility - it allows us to bypass all the possible barriers to the eggs and sperm meeting within the human body - even if we cannot name these barriers , or come to an "accurate diagnosis " in the individual patient. I remind my patients that IVF allows us to do in the lab what should normally have happened in their bedroom , and is not happening because Nature has let them down . We still may not be able to pinpoint where Nature has let them down , but once they have a baby in their hands , this then becomes a question of merely academic interest .

This success-oriented approach to infertility means we need to turn the conventional medical principle of making a diagnosis and then deciding the correct treatment upside down, but it's easier to understand this approach by looking at a simple analogy. Suppose you want to go from Boston to New York, and your car breaks down half-way. One option is to take the car to the garage , let the mechanic diagnose the problem, and then let him fix it. The other option, which is much better if you are in a hurry, is to just take another car and drive it down to New York. The important this is to reach New York - how you get there is really not important ! Similarly, as long as IVF allows us to bypass the medical problem ( even if we don't know what the problem is and we can't put a name to it), and allows patients to get the baby they want, then it makes much more sense to go in for IVF, rather than waste time on testing , and fixing minor and often irrelevant problems.