Should We Seek Fertility Treatment?

Craig L. Best, M.D., M.P.H.
Assistant Clinical Professor of Obstetrics, Gynecology
and Reproductive Biology
Harvard Medical School

As a fertility specialist, one of the most frequent statements I hear from new patients seeking fertility consultation is “we didn’t know whether there was a problem with our ability to get pregnant but thought we would come in anyway”.  In the opinion of the author of this newsletter, any couple with concerns about their ability to conceive should be taken seriously and receive an evaluation.  The initial evaluation may be as simple as a history and physical examination to screen for associated risk factors for infertility or may include a more thorough work up including testing for specific causes of infertility.

Infertility is defined as the inability to conceive over a period of one year while attempting to become pregnant with unprotected intercourse.  This may seem to be a rather arbitrary definition but it actually has a rational basis considering the statistical probability of a fertile couple conceiving over a period of one year.  It is widely accepted that the chance of a fertile couple getting pregnant in one month’s time is about 20%.  Using a statistical technique know as life table analysis, we are able to determine that in six months the chances of pregnancy should be about 74% and after one year about 93%.  Therefore, if the couple is not pregnant after one year, there is a significant chance of a specific problem as the cause.  However, there are many exceptions to the “one year” rule which require either more time at trying to conceive or immediate evaluation before one year passes by a physician treating infertility.  For instance, if the couple has intercourse infrequently, more time may be needed to allow for the number of appropriately timed cycles to occur.  This is particularly true in younger couples where time may not be as critical.  The use of ovulation predictor kits or basal body temperature charts may be useful in these cases.  Since ovulation generally occurs 14 days prior to the onset of menses, an estimated time of ovulation can be made in women with regular menstrual cycles so that intercourse can take place to just prior to ovulation to enhance the chances of pregnancy in couples with no fertility problems.  In couples who have frequent intercourse or who have appropriately timed intercourse, allowing more time is generally a waste of time.  In contrast, if the woman has a known history of blocked fallopian tubes, irregular menstrual cycles or absence of menses then immediate evaluation may be required prior to the passage of any significant amount of time.  There are other examples of cases where an early evaluation can save time.  For many women in the later reproductive years such time saving can make a huge difference in the ultimate success of treatment.  If there is a question of whether there are factors which will make it impossible to conceive without the help of an infertility specialist – by all means seek an opinion and expect at least a thorough history and a plausible explanation of why you should give it some more time.

Other frequently asked questions are “how many cycles of treatment should I have before going on to another treatment” and “how aggressive should the treatment be for me to get pregnant”.  There are no pat answers to these questions but there are some guidelines to consider when making these decisions.  Two of the most important considerations are the desires of the couple seeking treatment and the age of the female partner.  The actual options to consider will obviously depend on the diagnosis.  Some diagnoses will lead to only one good option and in these cases there is less confusion.  Treatments for infertility problems range from noninvasive to minimally invasive to very invasive.  Usually the physician will offer the least invasive options first especially when there is a good chance of success or if the female partner is young (less than 35 years old).  More invasive options are usually offered if the first line of treatment fails or if there is a lesser probability of success in a female approaching the age of 40.  Considering the natural decline in female fertility which starts at the age of 30 but becomes more dramatic after the age of 35-37 years, the couple may choose a more aggressive approach if it offers a statistically greater probability of success.  On the other hand, regardless of age, the couple may choose the less aggressive approach because of concerns about side effects and costs associated with the more invasive treatments.  From a purely statistical point of view, one may turn to the life table analysis for answers to these questions.  Based on the probability for success with a given treatment, the treating physician should be able to make an estimate of the time that it would take to achieve 80-90% success rate.  This could be used to guide the couple in determining how long to continue with specific treatment before moving on to other options.  In general, if six treatment cycles do not produce a pregnancy, it may be time to move on to other treatment options.  Again the patient’s desires or concerns will be important in the decision, as will the patient’s age.  If the chances of success with any treatment are very low, the couple should be careful about continuing for too long, as the emotional toll can be considerable.

In summary, a couple should seek the advice of an infertility specialist whenever there is concern about the possibility of infertility.  The treatment options decided on will depend on the diagnosis, the age of the female and the desires of the couple.  Individualization of treatment is important.  It is important to go into treatment with a clear understanding of your ultimate goals and a good idea of the chances for success.  While the ultimate goal may be to have a healthy baby, the couple is advised to also consider their overall mental health and their relationship with each other to guide them in their decision making.  Have a successful journey.