Answer:

Bottom line: It comes down to eggs, sperm, and tubes. There are lots of things about fertility we don't know at all -- how the sperm finds the egg, for example. And once they join, how does a sperm and an egg form an embryo and implant in the uterus? There are big black boxes. We don't know exactly why everything happens. But to be what we call unexplained infertility, you must have a laparoscopy that rules out peritoneal factors. That is the biggest rule-out. You must have that camera through the belly button. -- Celia E. Dominguez, MD, reproductive endocrinologist, Center for Reproductive Medicine, Emory University. Her team presented data at the ASRM.

The first thing you have to do is sit down with the couple, not just the woman. It takes two to tango. You have to treat couples, except in cases where a single woman comes in without a partner and uses donor sperm. But the male in the couple is often overlooked from the standpoint of stress and for a lot of other things.

Some women who are having a hard time conceiving wouldn't have such a hard time with another husband, and some men would have less trouble with another wife. A guy with 72 sperm count -- this gives him a C, not an A -- would probably be pregnant if his wife were 21 years old and a super-fertile woman. But he might have more difficulty if his wife is 39. Similarly, a 38-year-old woman might be pregnant if her husband got an A on that sperm exam. So one starts by taking a medical history for both members of a couple.

The woman might say she was married previously and divorced, and that man now has three children by another wife. That might imply problem with her tubes or something. Given that circumstance, you might focus the interview differently. But there are always several main points: One, does the male produce sperm in adequate numbers with adequate function? Two, does the woman ovulate regularly and predictably. And three, is there any anatomic obstruction like a uterine or tubal problem. That is the crux of the evaluation. You usually can identify the problem.

Ultimately you are going to get to that point of making a diagnosis. Whenever possible, there should be a specific diagnosis and you should treat that diagnosis specifically. Let's say you see a regular gynecologist and he says well, your tubes are open, let's try Clomid for a few months. I call that empiric treatment. That is not specific. Contrast that with the woman whose tubes are open, but it turns out she rarely ovulates. In that case, Clomid is a specific treatment for a specific abnormality. We try to identify a specific abnormality that then can be treated specifically. Sometimes when you do that, there is more than one way to approach a problem. At that point, you can discuss alternatives.

So the evaluation should take two months or less, then you sit down with the couple and say here are your alternatives. You can have surgery, here are your chances of conceiving; you can have in vitro fertilization, here are your chances with that; and so on. The couple will say we are good for this and not for that. The answer depends on how successful any of the alternatives are going to be, how affordable, and how the couple's lifestyle will accommodate that. If you live hundreds of miles from the nearest IVF center, there are logistical issues. Or there may be social issues. There are a lot of reasons why people choose to do what they choose to do. We have two clinical psychologists who work through our office to help couples decide how to spend their resources -- and we're not talking just about money. All resources are not financial. -- William D. Schlaff, MD, professor and vice chair of obstetrics and gynecology and chief of reproductive endocrinology at the University of Colorado Health Sciences Center, Denver. Chaired ASRM 2003 Reproductive Endocrinology and Infertility scientific program committee.

Answer:

Each couple has emotional, financial, and moral endpoints. These need to be weighed together with the medical endpoint, given by an expert in infertility. The final decision on when to quit comes from her and her husband.

Most specialists recommend you quit trying if you are over 42 and have been trying for a while, if your eggs test poor, and if you are already perimenopausal. At that point, it may be best to look at adoption or using a donor egg.

This decision has to be made with an expert in reproductive endocrinology. Go to a double board-certified person, not just to your gynecologist. This person's question is typical of somebody who's been with a generalist too long. I recommend she talk with a subspecialist. Unfortunately for this couple, because of their financial situation, in vitro is likely the way to go for them. In terms of financial and emotional costs it may be the most cost effective thing for them to do. -- Celia E. Dominguez, MD, reproductive endocrinologist, Center for Reproductive Medicine, Emory University. Her team presented data at the ASRM.

Well, I have a tangential answer: Infertility and fertility are a misnomers. This woman who took Clomid and became pregnant, she is not infertile, she is reproductively inefficient. It is complex to explain to people. Not all people, but many couples are not infertile, they are inefficient. Unless a man has no sperm or a woman has no uterus -- unless there is a complete obstacle -- most couples have a potential to conceive during every cycle. For women in their early 20s, it's a 30% to 35% chance per cycle. But for someone 44 years old it might be 1%. For a person with a low sperm count, it might be 3%. So some couples are going to be more successful than others because they have a higher probability of conceiving every month.

When should you give up? Except for a relatively small percentage of couples, we are not talking about absolute infertility. So if your likelihood of success is 1% or 2% each month, is it worth it? Many couples would say if we do whatever procedure we discussed and it gives us a 2% chance of having a baby, should we put the resources of time and money and emotion on the line, or should we choose some other alternative -- like adoption -- with a higher chance of success.

The job of a reproductive endocrinologist is to characterize the likelihood of any given alternative as regards to success; discuss the personal, social, familial disruption; discuss the cost and physical discomfort; and contrast this with alternatives that may include adoption. When should you give up? If I say your chance of getting pregnant is 1%, do you pursue it? Or more commonly, what if there is nothing I can do to increase your chances beyond telling you to go home and have appropriately timed intercourse? Giving up fertility treatment does not mean giving up all chance of getting pregnant. After a long period of not conceiving despite treatment, people do end up pregnant. Sometimes a couple's number comes up. The nature of our treatment isn't that we can make you fertile when you weren't fertile before. What we do is look for ways to optimize your efficiency at becoming pregnant. -- William D. Schlaff, MD, professor and vice chair of obstetrics and gynecology and chief of reproductive endocrinology at the University of Colorado Health Sciences Center, Denver. Chaired ASRM 2003 Reproductive Endocrinology and Infertility scientific program committee.

Answer:

If one is infertile, the answer is if the infertility is associated with some other medical problem that can be dangerous or life-threatening, yes. But there are not many. These mostly relate to ovulation. Women who do not cycle properly might have polycystic ovarian syndrome. Left untreated, this is associated with uterine cancer and maybe other medical problems. So if the underlying reason for infertility is polycystic ovarian syndrome, yes, infertility can be associated with other medical problems.

A more compelling example is one I see botched way too frequently. A person has no periods at all and has significant hormonal problems, and her doctor treats her with hormones. But this could be a pituitary tumor. Still, these are not very common. So generally speaking, problems that cause reproductive inefficiency are not likely to be associated with significant and major medical health risks. But no doubt they are associated with stress and emotional issues. It is not just women who are affected, it is couples. -- William D. Schlaff, MD, professor and vice chair of obstetrics and gynecology and chief of reproductive endocrinology at the University of Colorado Health Sciences Center, Denver. Chaired ASRM 2003 Reproductive Endocrinology and Infertility scientific program committee.