Infertility is one of the hardest problems couples can face. It affects about 10 percent of women of childbearing age. You might find it interesting that about 40 percent of the time, the male is the only or major contributing cause of the problem. There are many ways to treat infertility, including medication and surgery, but perhaps the best known method is in-vitro fertilization, or IVF.
To get an overview of infertility causes and treatments, including IVF, listen to an interview with Elizabeth McGee, MD, division chief of reproductive endocrinology and infertility at the UVM Medical Center. Or, read the transcript of the interview below.
UVM Medical Center: So to start, what are the major causes of infertility?
Elizabeth McGee: Well, as you just mentioned, about one-third of infertility cases can be attributed to male factor, and about one-third of the factors that affect women, and then for the remaining one-third of infertile couples, infertility is caused by a combination of problems in both partners, or in about 20 percent of cases, it’s completely unexplained, which means we just don’t know why. The most common female issue is anovulation, where a woman doesn’t release an egg every month. The most common male factor is oligospermia, or the failure to produce very many sperm.
UVM Medical Center: What do you have patients try before you get to IVF?
Elizabeth McGee: Well, that depends on the diagnosis and the age of the couple. Infertility care is really individualized for patients and couples. Some patients may just need medication to help them ovulate, or release that egg each month, but others might surgery for a fibroid, or for endometriosis. The American Society for Reproductive Medicine estimates that about 80 to 90 percent of infertility is treated with conventional methods. However, for patients with say blocked tubes, or severe male factor infertility, there’s really no other option but IVF, and they would move straight to that.
UVM Medical Center: What’s endometriosis?
Elizabeth McGee: Endometriosis is a disease where the endometrial lining, that lining that’s inside the uterus can get outside the uterus in the abdominal cavity where it doesn’t belong. Because the endometrium bleeds each month when a woman has her period, it also bleeds when it’s in the abdominal cavity, and when it’s on an organ where it shouldn’t be, like on bowel, or the bladder, or the peritoneal surface, it can bleed and cause damage to a patient’s tubes, and also reduce fertility.
UVM Medical Center: Tell us about IVF and what it is overall. I know it’s complicated, but if you can boil it down for people.
Elizabeth McGee: Sure. IVF stands for in-vitro fertilization. What this means is that the eggs are removed from a woman, and then they’re placed with sperm from a man in a Petri dish, and that’s also known as in-vitro, or in-glass, and that’s where the in-vitro part comes from. After fertilization occurs, the embryo can be put back into the uterus, or it can be cryo-preserved, and that means frozen for future use. But other procedures, such as ICSI, or introcytoplasmic sperm injection, can also be used in assisted reproductive technologies. ICSI is when you take a single sperm into a very, very tiny glass needle, and under a microscope in that Petri dish, you put the sperm directly into the egg. We do that in cases where we think there may be a functional problem with the sperm where fertilization can’t occur properly.
UVM Medical Center: In other words, if they determine motility, or mobility. So the sperm just doesn’t get there, can’t penetrate the egg, and so this a way to get the sperm inside.
Elizabeth McGee: It’s a way to get the sperm inside, and it’s a way to assist with fertilization. If the mechanics that allow the process of fertilization to occur, like the sperm has to attach to egg, and there’s a really elegant dance of enzymes, and kind of eating through the walls of the egg to get the insides of the sperm and the insides of the egg together, it’s a way to facilitate that happening.
UVM Medical Center: Really amazing, when you stop and think about it. I mean, it’s sort of something people accept now, but it’s quite incredible you can accomplish this.
Elizabeth McGee: It really is. I mean, over the course of my career, IVF and ICSI and a lot of advances have occurred, and it’s really remarkable. I mean, it’s really remarkable that people get pregnant and people are even born, with all of the things that have to happen to make that occur correctly.
UVM Medical Center: What are some of the steps? Break it down a little bit. If you’re a couple, talk us through that process from their perspective. What do they expect, and what is it like for them?
Elizabeth McGee: Well, for us, we don’t have people generally coming in saying, “Hey, I want IVF.” Occasionally that happens. Usually what happens is patients come in and they’ve tried to get pregnant for a while on their own, and either their primary care physician or their gynecologist may have done a little bit of a work up already, and then they send them on to us. So, we do an intake where we take a complete history and talk about the previous medical history and other issues, because a lot of times that has something to do with things, of both the male and female partner in a heterosexual relationship. In same sex couples we take histories as well, to see what are the underlying issues that may be involved.
Then we tailor a plan for treatment, that may or may not include IVF initially, based on the age of the woman usually, but also the age of the man can be involved. Then, what are the other medical problems? Are there blocked tubes? Is there anovulation, or no ovulating, and so we just need to get ovulating first, and figure out what’s going on? We do an initial work up that’s an evaluation of, is the woman ovulating? Is the sperm count good? Is there good motility? Are the fallopian tubes open? Is the uterus normal? So, are all the things that are needed to get pregnant, are those all in place?
Then after that initial evaluation, we make the decision with the patient and with what they want to do, as far as how to proceed with infertility care. If it’s decided they need IVF, then there’s a series of labs that they need to do that are based on FDA requirements to prepare for the medications and the cycle, which can last anywhere from two to four weeks. So, preparation and medications as they progress up to the day that the eggs are retrieved, which is a big procedure. Then the lab is the part of things, where fertilization and the embryo preparation occurs – in the lab that we have actually here in this office. Then the embryo transfer.
UVM Medical Center: So, you mentioned age, and some other factors. Who’s likely to have the most success, I guess, with this procedure?
Elizabeth McGee: Well, at certain ages IVF is less likely to be successful than just doing less invasive, or non-IVF treatments. Then, so as far as screening and stuff, for any fertility treatment the patient needs to be healthy enough to be pregnant. We also require that people stop smoking before they do IVF, that has a real effect on egg quality. I would say the people that are most likely to be successful with IVF, are younger women with tubal factor. When they have normal ovaries, normal eggs, there’s normal sperm, it’s just getting the egg and sperm together, it can’t happen because of tubal issues. Either tubal ligation has occurred, or maybe there’s tubal disease. But, there’s a wide variety of patients that can be successful. Part of the initial visits and counseling is individualizing that assessment, and letting patients know what their individual likelihood of success is, because it’s going to vary based and medical condition.
UVM Medical Center: So, are there any risks to this whole process?
Elizabeth McGee: Relative to other medical procedures the risks are fairly low. There’s ovarian hyperstimulation, because we giving medications to make the ovaries make a lot more eggs for the retrieval, the ovaries can become overstimulated. Certainly injury or infection can rarely be associated with the needles used to do the retrieval, but that’s very, very rare. Also, multiple gestation can occur if too many embryos are returned to the uterus. I’d say, probably the biggest issue for patients, that happens more often, is stress. Stress is such a big factor in undergoing an IVF cycle. It’s really can be quite intense for couples, and we really try to prepare and support our patients in this process.
UVM Medical Center: How do you do that?
Elizabeth McGee: First of all, we talk about it. We bring it up from the early visits. We make it okay to feel stressed, and not something that the patient feels like they have to hide from us, or to be strong about. That they feel open to talk about how they’re feeling with their whole care team. Our team is available every day to talk, not just about medical aspects of treatment, but also the psychological aspects of care. We treat the whole patient, the whole couple, and stress is such a factor in care, that just acknowledging it, and helping patients talk about it, and helping the couple talk about it, so that they’re not both trying to be strong for the other one, but that they’re able to talk about how they feel.
Then the other thing is I encourage patients to practice self care from the very beginning of their infertility journey. I think things like yoga or mild exercise, making sure that they do something daily that brings them joy. All of those are key to kind of keeping centered, and keeping the stress of the medical care in focus. The couples really, we encourage them to communicate with one another, and to try to stay balanced together.
But when that’s not enough, then I strongly recommend that couples seek counseling with professionals with experience in dealing with fertilization, miscarriage stress, and grieving. In the past, we participated in a study of a structured online program for stress counseling. That study’s been completed, but I hope that additional resources for the community may soon become available out of that research. There’s also support groups. Northern New England Resolve has a support group here in Burlington that meets in a yoga studio. I think really, the thing to keep in mind is that everyone experiences stress differently, so the solutions for each patient, for each couple, are going to be different as well.
UVM Medical Center: I want to ask about men. Aside from their biological contribution, what is their role? I’m wondering if this sort of handling stress, supporting the woman is a big part of that.
Elizabeth McGee: I think it is part of it, but also, as we mentioned early on, male infertility is roughly half of the issue. So, I think that’s part of it as well. It’s not just helping the female partner, but it’s also being healthy themselves. Not smoking, either tobacco or marijuana. Not drinking excessively, because that can affect sperm function. Making sure that the medications that they’re on don’t decrease sperm count or function. Maintaining a healthy weight, obesity can also cause male infertility. But I think the idea of couples, same sex couples, heterosexual couples, supporting one another in a process that’s difficult is really key. Having those lines of communication open before they start the stress. Finding out that you’re poor communicators in the middle of the IVF cycle can be even more stressful.
UVM Medical Center: I would think so. Talk about the program here at the University of Vermont Medical Center. We are an academic facility, and I’m sure as always, with all of our medical treatments, that brings an extra dimension of things. So, just talk about what you’ve got for staff and other aspects there.
Elizabeth McGee: We have a really tight team of nurses and laboratory professionals, financial and pre-certification specialists, physicians, and our clinical specialists that work together to provide very specific patient-centered personalized care in our academic setting. Our nurses are excellent, they’re all currently undergoing specialized training from the American Society of Reproductive Medicine to become certified infertility nurses, and they’ve been working hard and learning a lot in that program. Our nurses and physicians are also in daily contact with our patients undergoing treatment cycles. Then we also have fellows, and they’re fully trained OBGYNs already. They provide another layer of thoughtfulness, and they keep us focused on evidence based care and bringing new knowledge into the practice.
Being in a teaching environment as a physician keeps you really fresh and young in your culture and your perspective, but it also keeps you fully engaged in the intellectual side of medicine. We really focus on every patient individually to provide the best care to that patient, but also to listen and to learn from that patient. We’re not satisfied with how things are, but we really want to use every opportunity to get better within our own group, but also to advance our field generally by using what our patients teach us to improve care for infertility patients, not just here, but regionally and nationwide.
UVM Medical Center: Talk about costs. What are we looking at for that, and what’s the situation here?
Elizabeth McGee: Well, Vermont’s not a mandate state, so meaning that it’s mandated that insurance companies cover infertility. Some employers in Vermont provide really good infertility coverage, and some provide little or even none. As a result, we’ve developed a global financial plan the provides a fairly inclusive panel of IVF services and medication. Our global fee currently is just under $7,000, and it includes baseline and cycle ultrasounds, cycle blood work, the egg retrieval, IVF with ICSI, that’s the intracytoplasmic sperm injection, if needed, cryopreservation, that means freezing, and the first six months of storage of embryos if it’s needed. Uniquely, it also includes medications for the cycle. We’ve really worked very hard to get our costs down for IVF services for our community, and infertility care is really so much of a family value, we really want to provide cost effective care for our community.
UVM Medical Center: You’re listening to Dr. Elizabeth McGee. She’s been our guest today on Health Source, professor and director of reproductive endocrinology and infertility at the UVM Medical Center and Larner College of Medicine at UVM. I want to thank you for being with us.
Elizabeth McGee: Thank you very much for having me.