Fertility treatment can be daunting, but preparation and learning about the side effects and risks can make it a lot easier.
By Amy Klein
This guide was originally published on June 18, 2019 in NYT Parenting.
I can’t say I was excited to begin in vitro fertilization, but after a year of trying to conceive and nothing but two failed pregnancies and lots of disappointment to show for it, I was looking forward to having modern medicine help me start our family.
“At least I’ll know that the sperm and egg have come together at the right place and at the right time,” I thought. The science of so-called test tube babies (which are actually created in petri dishes) would take the guesswork out of the “whens” and “how oftens” to have sex for procreation.
But I.V.F., an assisted reproductive technology that fertilizes eggs with sperm in the laboratory and places one or more embryos back into the womb, brought up a whole host of new questions: which doctor to go to, what medical protocol to follow and for how long?
Over the four years it took me to have a baby, I saw 10 doctors, did four intrauterine inseminations (when a doctor injects sperm directly into the uterus) and nine rounds of I.V.F. For this guide I spoke with three top reproductive endocrinologists and reviewed the published scientific evidence to help you figure out how to get through treatment.
The American Society for Reproductive Medicine recommends that if a woman is under 35, she should try to get pregnant for a year before seeing a fertility specialist; and if she’s over 35, she should try for six months. But some doctors believe there is no reason to wait so long since there are tests and checkups your gynecologist can do first.
Dr. Aimee Eyvazzadeh, M.D., a reproductive endocrinologist in private practice in San Francisco, said that people are sometimes told their infertility is unexplained without even having basic tests done. She advised that, before seeking a fertility specialist, women should first get their fertility hormone levels checked with a simple blood test, have their uterus and fallopian tubes examined and, if they have a partner, have his semen checked as well.
“You don’t want to spend one year trying and then find out you have problems,” said Dr. Eyvazzadeh. “Make fertility screening part of your health checkup.”
When it comes to finding a fertility specialist (or a reproductive endocrinologist, as they’re officially called), word-of-mouth is helpful. Ask your friends, your social media “friends” or your medical providers about whom they recommend. There are often Facebook groups just for this topic.
If going public about needing help isn’t for you, look at online resources like FertilityIQ — a Consumer Reports-like fertility review website that allows verified patients to evaluate their clinics and doctors. You can also search the Society for Assisted Reproductive Technology’s website to find clinics in your area and compare success rates for each age group.
“You gotta do your homework,” said Jake Anderson, who founded Fertility IQ with his wife, Deborah Anderson-Bialis. “You’re going to spend a lot of money.”
It’s difficult to know what I.V.F. treatment will cost before you know what procedures you’ll need, whether your insurance covers them or how long it will take you to get pregnant.
A single I.V.F. cycle, for instance, can range (on average) from between $12,000 and $17,000 (without medication), according to the National Conference of State Legislatures, to closer to $25,000, according to FertilityIQ.
Generally, most people need at least three to four I.V.F. cycles to be successful.
Read more about how to pay for I.V.F.
The first step in fertility treatment is usually intrauterine insemination, a non-invasive procedure in which sperm is placed inside your uterus around the time of ovulation. Doctors typically try three to four I.U.I. cycles (usually with medication to increase the number of eggs you produce to increase your chance of pregnancy).
If I.U.I. isn’t successful, the next step is the more invasive I.V.F. procedure. In vitro fertilization is a “short-circuit” of the system,” said Dr. William B. Schoolcraft, M.D., founder and medical director of the Colorado Center for Reproductive Medicine. In a normal menstrual cycle, he said, a woman has to produce one egg, then that egg needs to “get captured” by the fallopian tube, then the sperm has to get there and fertilize the egg and that embryo has to make its five-day journey to the uterus. “That’s a lot of things that have to go right — with only one egg,” Dr. Schoolcraft said. “We bypass the mechanical steps of natural conception or even I.U.I. and deliver the embryo directly to the uterus.”
During I.V.F., medication helps stimulate your ovaries to produce multiple eggs. Then, your doctor will extract them, and embryologists in the laboratory will fertilize them with sperm in a petri dish. After three to five days, your doctor will transfer the resulting embryo or two into your uterus, and you will wait almost two weeks to see if it implants, resulting in a pregnancy.
Before starting I.V.F., your doctor will decide on your individualized protocol: the type and amount of medication you’ll need, when you’ll need to take it and when you’ll be scheduled for egg retrieval. Your doctor will consider things like your age, menstrual cycle regularity, ovarian reserve, B.M.I. and medical history, according to Dr. Eric Forman, M.D., the medical and laboratory director of Columbia University’s Fertility Center in New York City. After your doctor decides on a protocol, you’ll then get an ultrasound and bloodwork on day two or three of your cycle to assess your hormone levels and make sure you’re ready to begin I.V.F. Then you will begin taking medication, Dr. Forman said, which can include:
Gonadotropins to get your ovaries to produce more eggs and grow those eggs at the same rate, so they’ll be ready for retrieval at the same time.
Antagonists to make sure you don’t ovulate on your own.
A trigger shot to make you ovulate.
After about eight to 10 nights of medication, Dr. Forman said, when your eggs are mature, your doctor will prescribe the trigger shot and then proceed to the egg retrieval about 36 hours later.
Right before retrieval is a good time to think about or ask some questions, such as:
Will I be getting local or general anesthesia? Some clinics make that decision based on the number of eggs you have. If you only have a few, they might do local.
Are you using fresh or frozen sperm? If you have a limited amount of frozen sperm, because you purchased it or it had to be extracted via surgery, discuss how much of it will be defrosted. Fresh sperm should be used within an hour after its produced.
Will you be doing intracytoplasmic sperm injection (I.C.S.I.)? With standard I.V.F., an embryologist puts some 50,000 to 100,000 sperm into a petri dish with an egg and hopes the egg fertilizes. I.C.S.I., which involves microinjecting one sperm into an egg to create the embryo, is typically recommended if you’re dealing with male factor infertility (because you have few or slow sperm) or if you’re using donor sperm (because it’s limited). Doctors may not use I.C.S.I. for your first I.V.F. cycle, but you can sign up for “emergency I.C.S.I.” to be used in that cycle in case no eggs fertilize with the standard protocol.
Are you going to do a fresh embryo transfer? While some doctors prefer to transfer a “fresh” embryo a few days after egg retrieval, others prefer to freeze all the embryos to transfer in later cycles. Doctors who advocate for frozen transfers believe that it will give your body a chance to recover from the retrieval process. However, some say freezing harms embryos, so if you are a “poor responder,” meaning you haven’t produced a lot of eggs or embryos, you may need to do a fresh transfer.
Will it be a day-three or a day-five transfer? Most clinics prefer to transfer embryos five days after egg retrieval, believing that the longer an embryo survives, the stronger it is. But if a woman is older, did not produce a lot of eggs or there is reason to believe her embryos may not survive, some clinics will transfer after three days. Studies show that day-five embryos have about a 51 percent chance of implantation, while day-three embryos have a 30 percent chance.
How many embryos will you transfer? In the past, I.V.F. produced many twins and triplets because doctors were transferring multiple embryos. Today, due to better technology, doctors are able to select fewer, healthier embryos to reduce the chance of multiples. The American Society for Reproductive Medicine recommends transferring as few embryos as necessary for one healthy baby.
Will you be testing embryos? Pre-implantation genetic testing (P.G.T.) can be used to ascertain which of your embryos are chromosomally normal before transferring them. If you decide to test your embryos, they will be biopsied, then frozen at least until your next cycle, so a fresh transfer is not an option. Keep in mind, however, that some doctors believe that P.G.T. is not effective and cannot discern healthy embryos from bad ones.
One of the biggest risks of I.V.F. is ovarian hyperstimulation syndrome, a sometimes painful condition that can be caused by medications that stimulate egg growth too well, causing enlarged ovaries, fluid retention and weight gain. It can be controlled by giving less medicine, especially to young and highly fertile women.
Other side effects from I.V.F. medications can include cysts, abdominal pain, local skin reactions from the injections, mood swings, nausea, and headaches, said Dr. Forman, noting that many women have few side effects.
While there is a correlation between infertility and increased risks of breast, ovarian and endometrial cancers, there is no solid evidence that infertility drugs themselves cause cancer. According to a 2018 review of the evidence in the journal Current Opinion in Obstetrics and Gynecology, “While infertility per se is a risk factor for some female cancers, including breast, endometrial and ovarian cancer, most studies do not show a significant risk of these cancers with the use of fertility medications.” The review found that some studies have shown a “possible increased relative risk of borderline ovarian cancer,” but the increased absolute risk is “small without a clear causal relationship.” Ask your doctor about the potential health risks of I.V.F.
Social support is important during this physically and emotionally challenging time, whether it comes from your partner, friends, online communities, group therapy or private counseling.
Tell your partner and friends what you do and don’t want to talk about. I used to tell people, “I’ll let you know if I have something to share,” because I wanted to process losses and disappointments on my own timeline.
If you’re going to try therapy, find someone who specializes in infertility. Otherwise, you might spend half your session explaining what an I.U.I. is or why you’re so upset you’re not pregnant.
If you find out that you aren’t pregnant, or if your pregnancy fails, it’s time to meet with your doctor before continuing with another I.V.F. cycle. “Even with the best prognosis patients, failed cycles are still unfortunately too common,” Dr. Forman said. “Sometimes it’s a matter of continuing to try and hope the next embryo works better.”
Discuss why the cycle failed, what you can do differently for the next cycle, and whether you should be adding any procedures, such as I.C.S.I. or P.G.T.
Although many clinics advise trying three to four I.V.F. cycles to have your best chance of success, a 2015 study published in JAMA of more than 150,000 women suggested that even more cycles than that can be beneficial. After six cycles, the study showed, the cumulative success rate was about 65 percent.
There is no single factor for how many cycles you should try, Dr. Forman said, noting it depends on your age, prognosis and financial situation. Still, he thinks six is a good number.
“As long as there is a chance for success,” said Forman,“it is reasonable to continue.”
Amy Klein wrote the Fertility Diary column from 2013 to 2015 for Motherlode, a New York Times blog. She is the author of “The Trying Game: How to Get Pregnant and Get Through Fertility Treatment Without Losing Your Mind.”