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The Path to Getting Pregnant

It used to be that the road from couple to family was pretty straightforward. But in the last few decades medical technology has devised ever more ingenious ways to help couples who’ve been frustrated by the old-fashioned method. Now the path to parenthood may lead from the bed to the clinic to the laboratory … and even beyond. Here’s a progression of the roadways to conception, from the least technological (the scientific equivalent of a sleepy country lane) to the high-tech superhighway.

Low-Tech Ways to Conceive

Start by having unprotected sex
Ditch the contraceptives and relax. Remember that most couples will have no trouble conceiving naturally. Set a time limit—usually a year (but ask your ob/gyn for specific recommendations) for “trying” before you consider consulting a fertility specialist. Women over 35 may want to see a fertility expert after six months. According to Sherman J. Silber, M.D., head of The Infertility Center of St. Louis and author of How to Get Pregnant: The Classic Guide to Overcoming Infertility (Little, Brown and Company; revised edition 2005), there’s no reason to see a fertility expert earlier, unless you or your partner have a known risk factor for fertility problems, such as a history of pelvic infections or a past vasectomy.

Try an ovulation monitor
If a few months of unprotected sex haven’t led to pregnancy, and you’re not ready to consult a specialist, try using an ovulation detector to time your intercourse for your most fertile times. These fertility monitors are available over-the-counter at most drugstores. While there are a variety on the market, the most common are ovulation test sticks, which work by detecting high levels of LH (luteinizing hormone, which triggers the release of the egg from the ovary) in urine. The test detects an LH surge the day before you ovulate, meaning you need to have sex right away if you want to become pregnant that cycle. Other monitors work by taking daily temperature measurements, assessing microscopic patterns in saliva, or monitoring chloride levels in perspiration.

 

Take the next step: see a doctor for testing
“If your deadline passes and you’re still not pregnant, schedule fertility testing for you and your partner. Contrary to popular belief, male infertility is just as common as female,” says Laurel Stadtmauer, M.D., assistant professor of obstetrics and gynecology at The Jones Reproductive Institute at Eastern Virginia Medical School.

Depending on the results of your tests, the next step in your quest for conception may be treatment for a detected problem. Doctors will usually start with the least invasive (and usually lowest-tech) options first, before bringing out the “big guns.” Super-high-tech treatments like in vitro fertilization (IVF) and embryo freezing get lots of publicity, but 85 percent of patients can be treated with simple medication or surgical repair of reproductive organs.


High-Tech Ways to Conceive 

Simple medication for women
Clomiphene citrate (brand names Clomid, Serophene)
is a relatively inexpensive drug that can be used in patients with long cycles where ovulation is unpredictable, and in women with polycystic ovary syndrome (PCOS) who don’t ovulate at all. Clomiphene works by tricking the hypothalamus and pituitary into “thinking” there’s an estrogen deficiency. In response, they produce extra FSH (follicle stimulating hormone) and LH—which stimulates follicle production. Clomiphene can also be effective in women with luteal phase defect, in which the low levels of progesterone are produced by the follicle after ovulation—leading to miscarriage. The medication is often used with IUI (intrauterine semination with sperm that has been “washed” in the lab to increase its fertilizing potential). Recently it’s been found that the success rate for some women with PCOS who don’t respond to clomiphene alone may be improved by adding the diabetes drug metformin (Glucophage).

Higher-tech drugs
There are several potent injectable hormonal drugs that cause superovulation—the stimulating of several follicles in the ovary during the same cycle. They are used in preparation for IVF (see below), but they can also be effective for women who don’t ovulate and for those with unexplained infertility. These medications include genetically engineered versions of FSH (Gonal-f and Follistim), and a combination of LH and FSH (brand names, Repronex and Menopur), which is made from the urine of menopausal women. Since the drugs “override” the natural hormonal messages from the pituitary gland and reproductive organs, they must be combined with other hormonal drugs such as hCG (a form of LH that triggers ovulation). The injections are given for seven to 12 days, and the follicles are carefully monitored with ultrasound to help reduce the odds of multiple births.

Surgical repair for women
Tubal ligation (“tube-tying” to prevent pregnancy) can often be successfully reversed with surgery. While many surgeons still do this procedure as regular abdominal surgery, a few are now doing the repairs laparoscopically. Done in the hospital under anesthesia, laparoscopy involves inserting a narrow tube containing a tiny video camera through a small incision in the abdomen. Once the surgeon has examined the pelvic organs, additional small incisions are made so surgical instruments can be used to put the tubes back together again. Laparoscopy can also be used to remove scar tissue blocking the tubes. However, if there is severe scarring from surgery or past infection, laparoscopy is only about 15 percent effective. In these cases, IVF is the best option.

Surgical repair for men
“Vasectomy [male surgical sterilization] can also be reversed with microsurgery,” says Dr. Silber. The operation is almost always successful, meaning that tests show sperm present in the ejaculate afterward. (However the rate for achieving pregnancy is lower.) Microsurgery can also be used to remove blockages of the epididymis (the long tube connecting the testicles and sperm duct).

If you’ve made it to this point and still aren’t pregnant, it may be time to harness the vast powers of high-tech medicine to help you. These are the techniques that make the news, and the techniques that are helping more and more couples to become pregnant.

Super-Tech Ways to Conceive

Ovarian tissue freezing and egg freezing
These new treatments are now being offered for women whose ovaries must be removed after a diagnosis of cancer, or whose eggs may be damaged or destroyed by cancer treatments such as chemotherapy and radiation. And egg freezing is also being offered to younger women who want to preserve their fertility. Although dozens of babies have been conceived with frozen eggs, the technology is still considered experimental.

In vitro maturation of immature eggs
This experimental technique for women with polycystic ovaries—who produce multiple immature eggs in a single cycle—is currently being attempted at a number of centers in the U.S. So far there have been only a few pregnancies recorded.

PGD
An adjunct to IVF, PGD (pre-implantation genetic diagnosis) allows embryos to be tested for genetic problems before they are implanted in IVF. PGD is often recommended for couples who know they carry the gene for a specific disorder (such as cystic fibrosis or sickle cell disease), so that only embryos that don’t carry the gene will be implanted. PGD may also help prevent future miscarriage in women who have suffered recurrent pregnant loss due to genetic problems. Scientists hope that new advances in PGD will eventually help identify the best embryos to implant for IVF in any couple undergoing the procedure, but so far its effectiveness in couples without a known genetic disorder is questionable.

Intracytoplasmic sperm injection
An adjunct to IVF, intracytoplasmic sperm injection (ICSI) can help men with extremely low or even zero sperm count to become fathers. In this technique, doctors retrieve a single sperm from testicular or epididymal tissue and then microsurgically inject it into the egg.

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In vitro fertilization
IVF is the treatment of choice
—and the final fertility treatment option—for a variety of patients, including women with total fallopian tube blockage. It leads to childbirth in about 30 percent of cases. In IVF, the follicles are stimulated with superovulation drugs, but the eggs are retrieved from the ovaries before ovulation so they can be joined with sperm in a lab dish. To reduce the chances of multiple births, most doctors today transfer no more than two embryos into the uterus at a time; any extras can be frozen.

A version of this article originally appeared in the Conceive Magazine's Special Issue 2008-2009. View the digital issue now!

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