By Dheepa Chari

As more and more South Asian women enter the workforce, they, along with their partners are pushing back the time when they’ll have their first child. When couples decide to have their children in their thirties or later, they are often plagued by the guilt, self-doubt and fear that it might be too late to have a healthy baby. These feelings are especially intensified when a few months of trying to have a child don’t lead to a pregnancy. More often than not, having better information and medical help can address the issue and reassure the parents-to-be that the biological clock can now be tempered with the gentle and knowing hands of a good doctor.

EGO Editor Dheepa Chari interviewed Dr. Frederick Licciardi, a leading specialist in in-vitro fertilization and egg donation in New York, to discuss fertility options for couples in their thirties and beyond.

	Dr.Licciardi's Website

What are some of the major causes of infertility?
In 40% of couples it’s a female issue and in 40% it’s male, which most people aren’t aware of. In the rest it’s mixed because some couples unfortunately have two problems, or at least one problem with each of the partners.

Common causes of infertility are related to ovulation as some women do not ovulate at all or not frequently enough; those problems are relatively easy to correct with medications. Other fertility problems include pelvic infection or pelvic scar tissue or what we call a tubal factor, which are problems related to the fallopian tubes. This could be a result of previous infection or prior surgery. So the concept is that when the egg ovulates, it should go from the ovary to the uterus through the fallopian tube and if the fallopian tube is blocked or not functioning properly, then ovulation will not occur.

What problems are typically seen in men that lead to infertility?
The problem with male infertility is manifested by a low sperm count or a low motility. Motility means the percentage of sperm that are moving normally. Most of the time, we can not determine why males have a low sperm count but sometimes it can be linked to a genetic problem.

How long should a couple with no success of conception wait prior to having fertility assessments done? Is this recommended period of time independent of age?
Regardless of age, if a couple has been trying for 6 months with no success of conception, they need to see a fertility specialist to determine what the potential problems are. This doesn’t mean that they need to get involved in expensive or complicated treatments, but it doesn’t hurt to get some testing done.

There may be some basic reason why they are not getting pregnant which can be corrected. Certainly, the older a woman becomes as she approaches her 40s, the harder it will be for her to become pregnant. In fact for some women in their 40s, it is too late for them to become pregnant at all.

There is a big problem with women who go to their gynecologist or family doctor who recommends that they call back in six months and everything will be fine since the physical exam was normal. However, a physical examination will tell you very little about the fertility problem of a woman. At a minimum, basic fertility testing would need to be done to make this determination.

What types of fertility tests do you typically perform?
A lot people think that fertility testing is very extravagant and complicated when in reality, it is not that complicated. There are two tests we perform on everyone and an additional test on some. The first test we do is check to see if the tubes are open and the uterus is normally shaped and this is done through an x-ray test called a hysterogram. The second test we do is a sperm count (also called a semen analysis) to count the sperm and check the motility. The third test we do is an FSH level check. This is a test we do on women to see how their ovaries are functioning and it is not a perfect test but is a pretty good guide.

FSH stands for follicle stimulating hormone and is a hormone created by the pituitary gland which is at the base of the brain. The pituitary gland controls your thyroid, adrenal grand, ovaries, and other things. Women are born with their eggs and they use them throughout their life until they run out at menopause. The problem is, at the end of your reproductive life, the eggs that are left are low in number and low in quality. As the egg number starts to fall, FSH levels increase because the body is trying to drive the ovaries to work hard and properly ovulate and the body cannot respond because there are only so many eggs left. So when we measure a high FSH, e.g. FSH>12, this is a bad sign. We do hear of rare cases where women become pregnant despite a high FSH level which is possible. This is true and I firmly believe that, but clearly it is much harder and almost impossible for a woman to become pregnant once their FSH is elevated.

Now, these three tests assume normal ovulation. If a woman is getting her period normally every month, the odds that she is not ovulating are very low. Other side tests we do include testing the thyroid and a hormone called prolactin and if abnormalities are found then we do additional testing. If the tubes are blocked, then the patient might need surgery or go right to in vitro. If the sperm count is low then we can provide treatment for that. However, if FSH levels are high, then this is a bit of a dilemma as it is difficult to treat.

What kind of fertility treatment options are available today, specifically the newer reproductive technologies? Which ones are the most invasive and which ones are the most and/or least successful?
The issue with fertility treatments is that the easy treatments are usually less effective. If it’s something simple like the woman is not ovulating, this is relatively easy to correct and the pregnancy rates are very high. The most simple treatment we can provide is Clomid. Clomid is a fertility pill that women can take for a few days to stimulate ovulation a few days later, and then she can try to get pregnant.

In couples who are trying to get pregnant, the chance of pregnancy when they first start off is about 20% per month. The way it works is that it is higher initially and for every month there is no pregnancy the odds go down. So, if a woman comes to see me who has been trying to get pregnant for one year or more, her odds of getting pregnant in the 13th month are around 3%. So everything we do tries to increase that 3%. Sometimes we also provide insemination which means that we take the husband’s sperm, process it, and place it into the uterus around the time of ovulation. The reason we do that is that even with normal sperm, most of the sperm does not make it to where the sperm are. Most of it gets stuck in the cervical mucus or swims the wrong way. So by doing insemination, we get more sperm close to where the eggs are.

So, Clomid with insemination in a woman who ovulates regularly will give her a pregnancy rate of about 8%. This is not much higher than the 3%, but with a few tries this may be all she needs and it is relatively simple and inexpensive.

The next step is fertility hormonal injections where we teach women to give themselves the injections everyday for about 8 to 10 days and then we do the insemination. The effectiveness of this treatment is about 20% but it is really age-dependent. For women in their mid 30s and under it is 20%, and for women in their 40s it is 5%. So there is a big difference due to age.

The most aggressive treatment we have but also the most effective is in vitro fertilization. Women in their mid 30s or younger will have a 50% chance of conceiving on their first try in the right program. Pregnancy rates are program specific and it is important to know that there are differences from clinic to clinic. Some clinics have a pregnancy rate as low as 20% or 30% which is less than half of what a good clinic can provide them. This means it might take a woman twice as long to get pregnant or she might not become pregnant at all. For those people who have insurance that doesn’t cover the procedure, it is very expensive to repeat this process over and over again and there is also an emotional benefit to becoming pregnant quickly.

How does in vitro fertilization work and what are the potential risks involved?
Women are taught to take the hormone injections, sometimes at a higher dose, and they are brought into the clinic for monitoring through blood tests and ultrasounds. Rather than doing the insemination after a week or two, a retrieval is done which means removing the eggs from the ovary using a needle under anesthesia through the vagina, so there is no cutting involved even though it is considered a minor surgical procedure.

The eggs and sperm are mixed together the same day. The next day we look at the eggs to see how any are fertilized, and a few days later we put the embryos back into the woman’s uterus (which does not require anesthesia). There are two ways to fertilize eggs: one is to let the sperm swim into the eggs, and the second is to pick up the sperm and inject into the eggs which is called ICSY – intercytoplasmic sperm injection. The second treatment is used when the sperm count is low.

Risks are related to three things: the drugs, the procedure itself, and the potential long-term complications. As far as the drugs go, the biggest complications involve over-stimulating the ovaries. We want to have a good number of eggs to be developed for in vitro fertilization, around 10 to 15. Some women who are very sensitive to these drugs might be on track to make 40 eggs. If that is the case, many times we will cancel the cycle or lower the dose of drugs to account for that.

Some women’s ovaries will actually twist as they enlarge. Normally the ovary is about the size of a walnut, and these drugs will make the ovaries about the size of a lemon, which is appropriate, but in women who are sensitive to these medications they can get even larger still. When they are larger, they can twist inside the abdomen and we can do a surgical procedure to untwist them which is relatively simple.

The point is, the complication rate is less than 1% but we still tell our patients about them so they are aware.

As far as the retrieval procedure, there could be bleeding or infection which again, occur in less than 1% of patients. Long-term risks that people ask about are breast cancer and uterine cancer, but currently there is no evidence to support that there is an increased risk of any cancer associated with in vitro fertilization. We may need another 50 years before we know more details about the complications associated with it.

People also ask about a higher incidence of birth defects in children born through IVF and currently there does not seem to be a higher rate. There are, however, some laboratory studies that show that there may be a potential for genetic abnormalities in children born though IVF. If this does exist, it is an extremely rare event.

Do women who use fertility treatments have less normal pregnancies than those who conceive naturally?
We know that women who become pregnant through IVF have a slightly higher pregnancy complication rate, which means a slightly higher chance of delivering early or having a small baby. No one knows why that is.

Are you seeing a trend in women having children at a later age?
In general, I do not see a trend because I think this is something that has been going on for quite some time but it is clearly a factor, especially in the metropolitan areas where women work. But unfortunately, this is not made clear to women that this will lower their chance of becoming pregnant with in vitro.

The problem is that there is a lot of false press out there. In other words, there are older famous women who become pregnant and people seeing this think they can wait until they are ready, when in fact many of these women have done egg donation which the public is unaware of. I do not have a problem with women not disclosing how they become pregnant, but I do have a problem with people who disclose it in a dishonest way as it affects the general population in a negative way.

What advice would you give to a couple that would like to delay pregnancy until their mid to late 30s?
My advice to any couple getting pregnant is that they need to see a fertility specialist. Someone who does a little bit of fertility testing and a little bit of obstetrics/gynecology does not have the time or expertise to treat you they way you should be treated. Time is of the essence so if it’s not done properly, you’ll lose time, get older, and be in a worse place when you finally get to the person who should help you.

For people who want to delay their pregnancy, my advice is that they should not delay if they are ready to have children now. Chances of pregnancy decrease a couple of points every year after the age of 23 and as you approach your late 30s, your chances are substantially lower. If a couple is not having success in getting pregnant, it is a good idea to get basic testing done in the right hands.

Image courtesy Corbis