Synopsis
Unusual book
Extrait
Chapter One
Understanding the Fertility Challenge
My Patient Taylor was dedicated to her corporate career, but she always planned to have children someday. She never considered that there might be a problem. She never thought about if because her focus was always on when.
Yet when Taylor and her husband, Jared, decided that the time was right to start a family, they were unable to conceive. Taylor saw her infertility as a threat to the life she had envisioned. She fell into a depression that lasted more than 2 months.
For the first time in a life of considerable achievement, she felt defeated and out of control. She isolated herself from her friends and family, refusing to do anything but dwell on her thwarted desire to have a child.
Then, slowly, she pulled herself out of her despondency. Her intelligence and competitive nature came to the fore. Taylor resolved to fight for her fertility just as she fought for everything else she'd wanted.
As Taylor and millions of other women and men have discovered, the "fertility challenge" can be a bewildering, frustrating, and financially crippling experience. Too often, infertility patients give themselves over to physicians and treatment programs without understanding the science, the medicine, the odds or the economics. The fact is that at our clinic, we can help nearly 75 percent of the women who come to us become pregnant using quite traditional fertility treatments. And if a patient is willing to consider in vitro fertilization (IVF), egg donors, sperm donors, or surrogate mothers, the rate of conception moves much closer to 100 percent.
So there is hope, but men and women fighting infertility need to arm themselves with the latest medical science as well as commonsense practices to improve their chances. They need to become their own best advocates in their efforts to start a family.
Taylor discovered this when her initial series of treatments failed. After spending hundreds of thousands of dollars for treatments that did not result in pregnancy, she became determined to educate herself about infertility treatments--the science, the economics, and the best practitioners in the nation.
Taylor spent months immersed in research. Then she found her way to my clinic. In our initial discussions, Taylor's frustration and anger were obvious, but so was her determination. Still, she balked when I explained that I wanted to do an extensive series of initial tests, because she'd already gone through similar tests.
We insist on doing our own tests with each patient because too often we've found that we cannot rely on what has been done by other physicians and clinics. This proved true also in Taylor's case. We found that the "shells" around her eggs were much thicker than is normal, so the embryo could not break free and attach to the uterine lining.
Fortunately, we had worked with pioneering embryologist Jacques Cohen, PhD, whom one journalist described as "the IVF lab god." Dr. Cohen pioneered micromanipulation techniques for operating on eggs, sperm, and embryos. His work led to the development of assisted hatching, which promotes pregnancy by initiating the hatching process following fertilization.
Dr. Cohen observed that embryos with a thin shell had a higher rate of implantation during IVF. He deduced that making a tiny hole in the shell might help the embryo "hatch" and give it a better chance to implant in the uterus.
Assisted hatching, which has become a routine procedure, has been a boon for those whom other assisted reproductive procedures have failed, and also for older women. It also worked beautifully for Taylor. We took her through her fifth IVF cycle and she became pregnant--with twins.
More than 7.3 million women and their partners in the United States are unable to have children because of infertility challenges, according to the American Society for Reproductive Medicine. That figure represents nearly 12 percent of the nation's reproductive-age population.
There are many excellent clinics across the United States where you can seek top-notch treatment from fertility specialists. This book is based on the experiences and knowledge of our staff at the Colorado Center for Reproductive Medicine. Our clinic has consistently achieved annual birth rates that are among the highest in the United States, according to figures published by the Centers for Disease Control and Prevention (CDC) in Atlanta. It also was named as the nation's number one fertility clinic in a survey and data analysis published by Child magazine in 2005.
As astounding as it may seem, our clinic is responsible for the successful births of nearly 30,000 children over the past 20 years--most of them born to men and women who had been told that they might never experience the joys of parenthood. Because of our consistently high success rates, patients from more than 40 countries, facing every fertility challenge imaginable, come to our facility in the foothills of the Rocky Mountains. They come from a diverse mix of cultures, backgrounds, and professions.
Yet all too often they come to us burdened not only by infertility but also by inaccurate diagnoses, inadequate treatment, and a lack of the scientifically sound information they need to make intelligent and important decisions.
Women and men faced with infertility are hungry for up-to-date information and medically sound guidance. Their psychological stress has been shown to equal that of chronic pain victims, or those who are diagnosed with cancer or AIDS. The dropout rate for patients undergoing infertility treatment is well over 50 percent.
Infertility diagnoses and treatments can take months, and even years. That is why it is so important that women and men who are infertile have access to accurate and up to date information before they begin lengthy and costly treatments. Too often, desperate women and men seek treatment with a fertility specialist only after wasting crucial time either denying that they have a physical problem, or relying on the advice of someone who does not specialize in infertility. Many say that they wish they'd had a greater understanding of "how it all works" earlier in their fertility fights.
The medical science addressing infertility has taken tremendous leaps in the past 5 years. This book is designed to be a comprehensive, up-to-date guide for women and men who need to educate themselves so they don't waste precious time and deplete their financial resources fighting infertility. It provides the information and answers they need to make educated, thoughtful decisions--not decisions based on emotion--about the best treatments to pursue. As you begin your fertility fight, this book will provide you with vital information on:
* Choosing the right physician and medical facility
* Deciding which tests are most appropriate
* Dealing with the emotional challenges of infertility
* Understanding the financial aspects of treatment
* Finding the latest proven treatments for each specific condition
* Learning the latest success rates for each treatment
* Working effectively with doctors and nurses
* Fostering greater understanding between spouses and partners
It also provides up-to-date medical science and other helpful information in these key areas:
* Fertility drugs
* Insemination
* In vitro fertilization
* Egg and sperm donation
* Gestational carriers (surrogates)
* Male infertility treatments
* Polycystic ovary syndrome
* Endometriosis
* Tubal and uterine conditions
* Egg preservation through freezing
* Fertility options for cancer patients
* Fertility options for women over 40
* Genetic testing and counseling
* Acupuncture and other alternative approaches
This book offers guidance to help you identify your infertility issues and to help you ask the right questions in discussions with your medical team so you can work together to find the best solution for you to achieve your dream of having a baby.
Understanding Infertility
To understand infertility, you must first understand fertility and how human reproduction normally works. As an introduction to the rest of the book, let's look at the normal reproductive functions of males and females.
One key fact is that each woman is born with all of the eggs that she will ever produce. Amazingly, it is estimated that most female babies have more than a million eggs in their little bodies at birth. By the time puberty arrives, however, that number has decreased to about 300,000. Of these, only a few hundred will actually be released during a woman's reproductive years (see Figure 1).
Figure 1: A woman's lifetime supply of eggs
The players in this complex cycle of female fertility include:
* The pituitary gland, which produces follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
* The ovary, which produces the hormones estrogen and progesterone
* The follicle, which contains the developing egg
* The fallopian tube, where the sperm and egg meet and which transports the fertilized egg to the uterus
* The uterus, which allows for implantation
Female fertility is rooted in the menstrual cycle, the time from the beginning of one period to the beginning of the next. A menstrual cycle begins with the onset of bleeding, or menses, caused by a fall in estrogen levels. This fall in estrogen causes a rise in FSH, which initiates the growth of a developing follicle. A follicle is a small, fluid-filled structure that contains the egg.
As the follicle continues to grow in size, it produces estrogen. This estrogen in turn stimulates the growth of the uterine lining, or endometrium. The endometrium increases from a very thin 1 to 2 millimeters to a thickness of 8 to 12 millimeters by the time of ovulation. At this thickness, the endometrium can support implantation or attachment of the embryo.
The follicle containing the egg continues to grow from a few millimeters up to a mean diameter of about 18 to 20 millimeters. At this point estrogen levels are elevated and as a result the endometrial lining is thickened and ready to receive the embryo.
The pituitary gland that has been directly controlling the growth of the follicle with FSH now secretes a burst of LH, which causes the follicle to rupture and release the egg from the ovary. The LH also causes the egg to undergo the process of maturation, and in this process, a genetic division of the chromosomes, called meiosis, occurs. During meiosis, the egg's 46 chromosomes are cut down to only 23 chromosomes. This prepares the egg for fertilization, when the sperm will enter the egg bearing its own 23- chromosome set. Together, the two sets of 23 chromosomes will yield an embryo with 46 chromosomes, the proper number for human development.
The LH surge also transforms the follicle--after its release of the egg-- into a structure called the corpus luteum. The job of the corpus luteum is to not only continue manufacturing estrogen but also to begin producing progesterone. Progesterone transforms the uterine lining into a secretory pattern that will allow the endometrium to nourish the embryo, which in turn will allow the embryo to attach or implant into the uterine wall (see Figure 2).
Figure 2: Changes across the menstrual cycle
Once ovulation occurs, the egg is captured by the fimbria, the finger-like structures at the end of the fallopian tube. Cilia, or hair-like structures inside the tube, beat in the same direction to propel the egg down the tube toward the uterus. It is at the entrance to the fallopian tube where the sperm meets the egg and the magic of fertilization occurs.
But the journey is far from over. After fertilization, the embryo takes a leisurely trip down the fallopian tube for 3 to 4 days, even as it is dividing into two cells, four cells, and so on, up to approximately 16 to 20 cells. At this stage, called the morula stage, the embryo leaves the fallopian tube and enters the uterus. By day 5 to 6 of growth, the embryo reaches a stage called the blastocyst. Remember that name, as it becomes an important aspect of the fertility challenge if something goes wrong (see Figure 3).
Figure 3: From ovulation to implantation
At the blastocyst stage, the embryo is like an aircraft with two compartments. In first class is a group of cells called the inner cell mass, which are baby-makers. In coach class you'll find a group of cells called the trophectoderm, which will compose the placenta. These placenta or trophectoderm cells surround an inner, fluid-filled cavity called the blastocele cavity. It is at this stage that the embryo is ready to attach to the uterine wall. The blastocyst hatches out of its shell, which is called the zona pellucida, and attaches to the uterine lining. This process is called implantation--another term worth remembering.
The uterine lining has been pumped full of estrogen and progesterone, which are produced by the ovary to prepare for implantation. The ovary continues to make estrogen and progesterone for about 14 days from the time of ovulation. If a pregnancy begins, the embryo produces a hormone called human chorionic gonadotropin, or hCG, that signals the ovary to continue the production of estrogen and progesterone. These hormones help ensure that the uterine lining remains intact, thus allowing the embryo to maintain its growth. If there is no pregnancy, hCG is not produced, and 14 days after ovulation, estrogen and progesterone levels fall. This drop initiates the shedding of the uterine lining, or menses, to begin again, and a new cycle starts.
Of course, fertilization can't occur without sperm. Created in a man's testes, sperm pass through a series of coiled tubes called the epididymis, which stores and nourishes the sperm. The male's contribution to conception then travels through the vas deferens. The prostate gland and seminal vesicles add secretions to the sperm. When a man ejaculates, the sperm mix with fluid to create semen (see Figure 4).
If the sperm are healthy and able to travel, they move from the vagina through the woman's cervix and cervical mucus into the uterine cavity. They can then pass down the fallopian tubes to encounter and hopefully fertilize an egg. It is quite a journey for these sperm, and that is why nature normally provides each man with from 20 million to 100 million sperm to accomplish this task.
Figure 4: Male reproductive system
Contrary to what some men may like to think, their reproductive abilities are also governed by hormones. Like women, men also use FSH and LH to control their reproductive function. FSH stimulates sperm production, and LH stimulates the production of testosterone.
The Ticking Clock
We may live longer, healthier lives than any previous generation but our reproductive abilities are still on the same clock. As women get older, it is harder for them to conceive. This is because they produce no more eggs than they are born with, and their eggs age as they age. At a certain point, the eggs are no longer fertile.
Fertility rates slide downhill at around age 30 in most women. After 35, the rate of decline is steeper. Once a woman hits 40, her eggs face a challenge analogous to the most difficult black diamond ski run at Vail Mountain. This decline in fertility is all part of the normal aging process and doesn't mean that there is anything wrong with the body (see Figure 5).
Figure 5: Infertility and miscarriage by age
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