Will the Stork Ever Come?
Coping with Infertility

For most couples, it is a major decision to have a child. It is important for both people to agree they are ready, financially and emotionally, to be parents. When a couple is hoping to conceive, they usually expect to become pregnant right away. Some couples do achieve pregnancy the first month of trying, while for others it may take a few months to a year to see that elusive second line or plus sign that indicates a positive pregnancy test. About 10 to 15 percent of couples may still be trying after a year or more.

“We typically diagnose infertility after one year of trying with no success,” says St. John’s OB/GYN
Christina Litherland, M.D., who practices at St. John’s - Clinic - OB/GYN - Fremont. “But if the woman is 35 or older, has had previous fertility problems, or has had previous recurrent miscarriages, we don’t wait that long to begin trying to figure out what’s going on.”
The first step in determining the cause of infertility is a full medical exam and history, including surgeries, illnesses, infections and medication.
“We also ask about the woman’s menstrual cycle and about the couple’s lifestyle habits, such as tobacco and alcohol use,” says Darren Lehnert, M.D., who also practices at St. John’s - Clinic - OB/GYN - Fremont. “It’s important to look at infertility from both the female and male perspective and not just assume the problem lies with the woman.”

Charting the woman’s menstrual cycle can provide more clues. After a few months of charting, a full infertility work-up may be ordered, which includes hormone testing to determine if the woman is ovulating and a semen analysis to check the count, motility and shape of the man’s sperm.
“If the problem is that the woman is not ovulating, we can prescribe medication to promote or induce ovulation. If the problem is with the man’s sperm, we can refer him to a urologist for further evaluation and treatment, which may include surgery,” Litherland says. She adds that a semen analysis is always performed before prescribing the woman fertility medication.

Lehnert says the diabetes drug Glucophage is now being used to promote ovulation in women with polycystic ovarian syndrome, a common cause of infertility.
“PCOS usually inhibits ovulation. Glucophage lowers the blood sugar, which can promote ovulation in women with this condition,” he says.

Further infertility testing may include procedures to determine if the woman has a tubal blockage, uterine septum, scar tissue from previous surgeries or infections, or other problem that is preventing conception.
“A hysterosalpingogram, commonly called an HSG or the ‘dye test,’ can be done to visualize the inside of the uterus and determine if the fallopian tubes are open,” Lehnert says.

Depending on the cause of the fertility problem, additional procedures may be performed in combination with medication.
“We usually start with Clomid because there is less of a risk for multiple embryos with Clomid than with injectable gonadotropins such as Pergonal," Lehnert says. If one or more procedures have been performed and pregnancy still hasn’t been achieved, St. John’s OB/GYNs can inform couples about infertility specialty clinics in Kansas City, St. Louis or Columbia, which provide assisted reproductive technology.

"Before informing couples about reproductive specialists, I try to get them thinking about the financial and ethical considerations that must be weighed when pursuing aggressive infertility treatment,” Litherland says.

The Emotional Component of Infertility

Dealing with infertility has been cited by psychologists as one of the most difficult experiences in life, sometimes even more stressful than divorce or the death of a loved one. Hopelessness, anger, depression and frustration are common feelings.
“Reproduction is seen by many people as a basic human function. People never anticipate not being able to have children. Infertility can really take its toll on a marriage, and depression is very common,” Litherland says. “How a couple reacts emotionally to infertility often depends on where they are at in the process. Everyone reacts differently, but I see the most depression in people who have been trying unsuccessfully for a year or two. The couples who have been at it for several years have made some peace with the possibility that they may not have a biological child and are beginning to consider adoption or other alternatives.”
Lehnert says partners often blame themselves or each other for the fertility problem, and anger, guilt and resentment are common.
“Infertility is tough,” Lehnert says. “There is often a tremendous amount of guilt when a couple goes through this. Your intimate life together can start to resemble a science experiment when you’ve been trying to conceive for a long time.”
Taking a break from trying to conceive is often emotionally helpful for couples. Talking about infertility with others who have experienced it, educating yourself, staying busy, maintaining a healthy lifestyle and not assigning guilt to yourself or your partner for the problem are also effective coping methods.

What Causes Infertility?

Many different factors and problems can cause infertility, including problems in the female reproductive system, the male reproductive system, or a combination of the two.

Female Factors

• Ovulation dysfunction. The woman's reproductive system does not produce the proper amounts of hormones necessary to develop, mature and release a healthy egg. This can be caused by polycystic ovarian syndrome or it can be unexplained.
•  Anatomical problems. Abnormal development or function of the female anatomy can prevent the egg and the sperm from meeting. The most common anatomical problem is blockage of the fallopian tubes. Other anatomical problems may include the presence of pelvic scar tissue in the tubes or uterus from previous surgeries or infections.
• Endometriosis, a condition in which the tissue that lines the uterus develops outside the uterus, usually on other reproductive organs inside the pelvis or in the abdominal cavity. Each month, this misplaced tissue responds to the hormonal changes of the menstrual cycle by building up and breaking down, resulting in internal bleeding which can cause scar tissue to form and affect reproductive organ function.
• Birth defects. Abnormal development and function of reproductive organs resulting from birth defects can affect fertility. One of the most common reproductive system birth defects occurs following a woman's exposure to DES (diethylstilbestrol) taken by her mother during pregnancy. Fetal DES exposure often causes abnormal development of the uterus and cervix.
• Immunological problems. A problem with a woman's immune system can lead to pregnancy loss. Antibodies (immune or protective proteins) in a woman's system can fail to recognize a pregnancy, or there may be an abnormal immune response to the pregnancy. Women can also develop antisperm antibodies, which attack and destroy sperm.
• Infection.


Male Factors

• Low or absent sperm production.
• Abnormal sperm function
• Varicocele, a condition in which varicose veins develop around the testes. It is a very common cause of male factor infertility and is usually reversible.
• Lifestyle. Use of recreational drugs, heavy alcohol use, smoking, certain medications and excessive heat (as in hot tubs) can affect sperm quality and function.
• Hormonal disorders.
• Chromosomal defects
• Birth defects
• Immunological problems

Resources

• Resolve, a local support group for couples dealing with infertility. Call 417-886-5239 for the meeting schedule. Resolve is also on the Web at www.resolve.org.
• “The Fertility Sourcebook,” by M. Sara Rosenthal.
• “Resolving Infertility : Understanding the Options and Choosing Solutions When You Want to Have A Baby,” by the staff of Resolve with Diane Aronson.
• “Getting Pregnant and Staying Pregnant : Overcoming Infertility and Managing Your High-Risk Pregnancy,” by Diana Raab.
• “Overcoming Male Infertility,” by Leslie R. Schover and Anthony J. Thomas.
• “Infertility”(videorecording), Time Life Medical.

These materials are available to the public at St. John’s Community Health Library, which is located inside St. John’s Cancer Center at 2115 S. Fremont in Springfield and on the Web at www.stjohns.com/libraries.