Trouble Getting Pregnant?: Ideas And Suggestions When You Need Extra Help Getting Pregnant

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Our Experts In This Episode
Dr. Ronald Young is the Director of the division of Gynecology at Baylor College of Medicine. Dr. Young specializes in Gynecology, Reproductive Endocrinology and Infertility.
Dr. Robin Burks is a clinical psychologist and author of the book Wide Awake: The Transforming Power of Authenticity.  Dr. Burks fought her own difficult battle with infertility, and is the mother of twins.
Welcome to your Pea in the Podcast, I'm Bonnie Petrie with everything you need to know about your body, your baby and the big changes ahead in your life as you begin your journey to becoming a mommy.
This week, for some of you the journey may be a little more complicated. You may need some extra help getting pregnant. We'll talk about why you might be having a little trouble...
"Does she have an ovulation problem, does she possibly have a uterine problem, some endocrinological problem or disease that may interfere with reproduction?"
We'll talk about the cost...
"In vitro fertilization per say sort of divides the country along financial lines into haves and have nots."
And we'll help you figure out how to survive this struggle emotionally...
"I tried running and meditating and really good self care and I went through all of the meetings and I went through infertility network meetings."
We're joined by infertility expert and a therapist who fought her own battle with infertility in this Pea in the Podcast.
You and your partner have decided that you want a baby, and you have been trying for months, but so far no success. Dr. Robin Burks is a clinical psychologist and author and she says this can be a tough time for a couple.
"I think people are often shocked when they first find out that they are potentially infertile. Most people assume they'll be able to have a child and certainly our culture teaches us that you're not really a complete family or a complete person unless you marry and you have children. There's a lot of cultural pressure for that and I think certain cultural backgrounds decide that even more. So there's just an initial kind of shock, but then ultimately a lot of sadness and depression I think it goes along with each month becomes kind of a funeral without a baby and without any support."
And it can be difficult for a couple anxious to get pregnant, because often a fertility doctor won't see you until you've been trying for a year. Dr. Ronald Young is the Director of Gynecology at Baylor College of Medicine. He says that is because 85% of you will be pregnant by the end of that year.
"You've got 100 couples and if they try to get pregnant, have intercourse in a reasonable schedule and at the right time of the menstrual cycle. At the end of the year 85 out of 100 are going to become pregnant, 85-90 and 10-15 will not become pregnant. That's the infertility rate. But even knowing that only a very small percentage will be pregnant at the end of a month, maybe 30% at the end of 3 months, maybe 60% at the end of 6 months, maybe 75% at the end of 9 months and then the last 10% at the end of a year. So it may take a year to get the patients who are going to be pregnant to get pregnant."
If there is some evidence that waiting a year won't make a difference, say you have polycystic ovarian syndrome or a history of sexually transmitted diseases or abdominal surgeries, or endometriosis or you and your partner have tried to have a baby with other partners and had not success, or you're older, Dr. Young says he wouldn't make you wait a year.  But if you seem normal and healthy, and your partner seems normal and healthy, then doctors will wait to put you through a bunch of expensive tests for that year. But when the year is up they'll get busy.
First they'll take an exhaustive history.
"Not only a personal medical history if she has had any conditions or diseases that could either interfere with her uterine or tubal functions such as a long history of sexually transmitted disease or a history of emergency surgery, ruptured appendix, multiple surgeries for Crohn's Disease, scar tissue or adhesions in the abdomen or the pelvis, that kind of a history. A history of her menstrual cycle is extremely important. The fact that a woman says that she is ovulating, she is menstruating like clock work month to month, year after year doesn't prove 100% that she is ovulating normally but basically it does. So a menstrual history is extremely important. And then a qualitative history also; the length of flow and the cramps because they'll lead you in toward endometriosis."
Who knew all that was important? Well it is from this history your doctor will figure out where to go next.
Dr. Young mentioned endometriosis there, that's a major cause of infertility. Endometriosis can cause severe menstrual cramps, that is one of the first signs of it.
"Most women have cramps during their menstrual cycle but if the cramps are really severe or to a degree incapacitating and you couple that with a history of infertility then you begin to think along the lines of a possible case of endometriosis."
They'll also use this history to rule in or out several other possibilities.
"Does she possibly have a uterine problem, some other endocrinological problem or disease that may interfere with reproduction. Is she severely ill with autoimmune disease, lupus or diabetes, adrenal disorders, those things become very obvious immediately."
But those are just some of the things that could be causing your infertility, and may take a little time to figure it out.
Now you may have what is referred to as an HSG test in which colored dye is injected into your uterus and an x-ray will be taken to assess whether your fallopian tubes are blocked or if you have fibroids or polyps that might interfere with your ability to get pregnant, or adhesions which is scar tissue you might get after having had abdominal surgery. The male partner, of course, will be examined as well.
"We do a semen analysis to get the quantity and quality of his sperm and either it's okay or it's not okay. If it's not okay he gets sent over to a specialist in male infertility, in the field of andrology"
Somewhere around 40% of the cases the couple's infertility can be attributed to the male partner. And in some cases both partners need a little help. But hopefully after this initial round of testing you have some answers.
And at this point, psychologist Robin Burks says many couples are excited.
"After the initial consultation you'll hopefully have some encouraging news from the doctor that yes you're having some trouble but you've got xyz problem that we think we can address and hopefully with a period of several months we'll be able to correct the problem and you'll be on your way. Of course that is not always how it works out but that's how the couple hopes it will go."
So what happens next? Well it depends on the cause that has been discovered.
"If a woman seems otherwise 100% healthy but the husband has a bad sperm count then she's just got to wait and he's got to go get worked up and get his problem resolved if possible. If the woman has blocked fallopian tubes then and otherwise everything is okay with her and the husband, the tendency now a days is to go to in vitro fertilization but of course there is also the option of reparative reconstructive surgery on the fallopian tube."
We'll have more on in vitro fertilization -- you may know that it is a test tube baby -- in a moment, but let's talk for a moment about the option of unblocking the fallopian tubes. It's a laparoscopic procedure so they go in through your abdomen with a laparoscope, it's minimally invasive and the less blockage there is the more likely it is to be successful. Some people don't even have to go that far, though. Sometimes the dye from the HSG test is enough to clear a tube and allow a couple to achieve a pregnancy.
But there are several other things that may be behind your inability to get pregnant.
"If the patient has fibroid tumors in the uterus then almost certainly they are looking at surgery, a major surgery called interventional mining depending on how you can get to them. If the patient is endometriosis there are both surgical and medical treatments for that. If you suspect endometriosis you probably need to do a laparoscope to rule it in or rule it out. And if you see it you can treat it at the same time many of the times through the same laparoscopy so the diagnostic laparoscope becomes an operative laparoscope, curative also."
And then there is the possibility that you're not ovulation at all.
"If she is not ovulating properly, she can have many, many reasons for not ovulating. One is polycystic ovaries, others are stress, others are other endocrinological problems. They can be in a state of general anovulation over a lot of things, over exercise, over dieting, mental and physical stress, or hormonal conditions. That's a little bit more complex and they're, sometimes you have to do a work-up to make sure they don't have polycystic ovaries, that testosterone levels aren't too high, the hormone ratios and balances are on the proper side of the equation."
If this turns out to be the issue there are various things you can do to improve your fertility. Some women with polycystic ovary syndrome find that taking one of several insulin sensitizing drugs used to treat diabetes improves their health, encourages ovulation and allows them to get pregnant. Others who are not ovulating for whatever reason need a little extra help, a drug called clomiphene or clomid spurs ovulation. It is a pill that you take for 5 days during your cycle, then you have sex during mid cycle hoping you've ovulated and then get pregnant. Your doc will let you try this approach for between 3 and 6 months.
"We feel now that you're going to get pregnant with clomid after 3 or 4 times. You could take it 40 times but if you are not pregnant reasonably quickly, you know, at the very latest 6 months, you should probably move on. And then you move on to another series of drugs which are the injectable ovulation inducing. clomiphene is a pill"
This is when many couples start to serious crunch numbers.
"So you do a few months of clomiphene and those cost a few hundred dollars over the course of each month with the course of the drugs and the monitoring at a few of the offices and things like that. Outrageously, backbreaking expensive, and then you don't get pregnant so now you have an option, should you go spend the money that you saved on the in vitro fertilization, should you go to the middle step there. But the middle step is taking injectable drugs, controlled hyper stimulation of the ovary; you drop another 0 onto the end of the cost. You know you go from a few $100 a cycle to a few $1,000 a cycle. Now if you do a few cycles of that it is starting to burn the money you saved up for the IVF and you may not be able to go much further along those lines if you don't get pregnant."
So injectables are cheaper than in vitro fertilization but there are risks with injectables. What are they?
"There are risks of big ovarian cysts and even hospitalization from over stimulation of the ovary. In in vitro fertilization you can control the number of babies to a certain degree by how many embryos you put back in but in this you can't because you're not touching the egg, you're just hyper stimulating the ovary.  You're not touching the eggs and if she ovulates five eggs and gets them all pregnant then you've suddenly got a patient who is pregnant with quintuplets which is pretty much of a disaster for the most part. Premature babies, developmental problems, mental problems, things like that. And even though they are doing better and better all of the time but it is still a risky business. So a lot of people will jump over this middle thing and go right into in vitro fertilization."
But IVF is very expensive.
"In vitro fertilization for say sort of divides the country into along financial lines into haves and have nots. You know people who can afford it and people who can't because with the exception of very few states in the United States and a few specific insurance carriers the vast majority of people cannot afford the out of pocket expenses that in vitro fertilization entails."
By this time, Clinical Psychologist Robin Burks says infertility may be taking an emotional toll. She knows what she is talking about. She went through 4 years of fertility treatments and 5 in vitro attempts.
"You know it really becomes more and more of an emotional roller-coaster, as we were talking about earlier that again every month when the woman's menstrual cycle starts it is again back to that kind of going from hopeful to extremely disappointed. And when you start to get into things, procedures like in vitro fertilization where often upwards of $10,000 is shot it's that high stakes situation where you know a couple begins to wonder can we even keep doing this. This is getting to be very expensive and emotionally very challenging."
So what if you can't keep doing it? For some people this is where they have to stop. Some for financial reasons, some for emotional reasons. Burks says fertility treatments can be very hard on a couple.
"It takes a definite toll on a relationship and on the marriage. Instead of the sexual relationship being something very fun and supposedly more light hearted that the couple does for mutual pleasure and enjoyment. Instead it becomes a chore that has to be timed around the woman's ovulation and it becomes kind of a stressful, high-stakes kind of a task."
But if you decide to move forward with in vitro fertilization, this is what happens: your doctor will put you on hormones to control ovulation and encourage several of your eggs to mature and then they will go in with the needle and they will get them. They'll go in through your vagina or your belly. And then they let the male partner fertilize as many of them as possible in a petri dish.
"If you have 30 embryos you freeze them and then the patient goes back if she doesn't get pregnant or if she does get pregnant she can go back at a later date and have another embryo put in or another embryo put in and try to get, and the cost of that is much less than if you start with zero and go through in vitro fertilization from the get go each time. So you average the overall cost over 2 or 3 pregnancies and it becomes a little bit more reasonable."
Now, because it is so expensive, some may be tempted to implant several embryos in hopes of getting one healthy baby out of an IVF cycle. But should all of the embryos that are implanted survive, you may be facing a pregnancy with several babies, which is dangerous for mom and the baby. Many European countries will not allow a doctor to implant more than 1 or 2 embryos. Dr. Young says that is not true in the US.
"Let's say we can't pass a law mandating 2 embryos, or 1 embryos or 3 embryo but standard of care dictates that you don't put more than 2 embryos in. If you then put 4 embryos in this woman has quadruplets and 2 of them die and 2 of them are severely retarded or something then they are going to come at you and say you violated the standard of care clearly the recommendation of the fertility society, clearly the recommendation of the College of OBGYN say you know the maximum you put in is 2 so why did you put in 4."
All of this talk about money may be frustrating for you. It's frustrating for Dr. Young.
"Yeah if the success rate was 100% you could tell them to do anything, mortgage their first born. People do, do that, they mortgage their house and they go running around trying to desperately scrounge up the money and if you could promise them 100% you're going to get pregnant, fine. But unless you can do that it is really unethical to send patients out to mortgage their future against the 30 or 40% chance that they might get pregnant."
And counting up costs adds to the emotional agony the infertile couple may already be feeling as well as the hormonal fluctuations from the medications and the treatments. And Clinical Psychologist Robin Burks says for the woman the struggle to beat infertility, well, it can just be devastating.
"A lot of the research I've seen on depression in infertile couples and in the women in particular that the depression levels are comparable to depression seen in women seen with terminal cancer diagnosis. You know, that it is really that devastating."
If you are in the middle of this journey, as Dr. Burks once was, struggling with depression, Burks reminds you to do something that may seem simple but for some is very difficult, take care of yourself.
"That's something that I think doctors tell you to do all of the time, that particularly when you're going through a grueling process such as infertility, especially when it has been months, even years of living your life around doctors appointments and going through lots of painful procedures, that self care becomes even more important. So getting proper rest, exercising regularly, meditating in the mornings, or any kind of relaxation technique. All of the things that normally help you feel good are going to be just that much more important to help you get through this difficult time."
And you don't have to go through this all alone.
"Maintain your friendships and really surround yourself with people who you trust, who really are able to make comments that feel good and that feel emotionally supportive. There also are some organizations that an infertile couple or an infertile woman can turn to like RESOLVE, which is a national organization that helps infertile couples or locally I think there are infertility networks."
Dr. Burks did all of these things and found that her emotional work took her to a surprising place.
"Well one thing that I think was very helpful to me, and I know that this is a very individualistic kind of thing, but there was a point when it was maybe about a year prior to when I had the final, 5th in vitro attempt that ended up being successful. Where I started to look into adoption and even though that didn't end up being the route that I went, it gave me a lot of piece of mind to know that one way or another I was going to end up with a baby at the end of it. That IVF wasn't my only choice."
So as a therapist, and as one woman who struggled with infertility to another...
"The take home message for the moms out there listening is don't give up and try not to close your mind to other options if that is how it needs to be. And if the ultimate thing is that you're going to be child free, then do the grief work that goes along with that, and if you need to find a good therapist to help you through it. Find a way to be at peace with the ultimate conclusion whatever it ends up being."
Of course you hope the ultimate conclusion will be a healthy pregnancy and a healthy baby, but when you get that positive pregnancy test, don't be surprised if your first emotion isn't sheer unadulterated joy.  Dr. Burks's wasn't.
"Extreme relief and kind of cautious optimism. You know I wanted to be sure that I wouldn't have another miscarriage so we really didn't even tell anyone in the beginning and waited I think until we also had some genetic testing done just to be sure that not only had I not miscarried but there aren't any genetic abnormalities."
She didn't miscarry; she went on to deliver a healthy set of boy/girl twins. A wonderful ending to a long and tiring struggle for mom and dad...and, believe it or not, even after helping 100s of babies come into the world, it is still a thrill for this doctor...
"Even at my age I feel elated. I think that I'm not a particularly, you know not a classic definition sense, say, a religious person, but I consider myself an extremely spiritual person, and I think it is a miracle."
It is a miracle, mommy.   You're a miracle. Whether you conceive your baby the old-fashioned way or with a little help, or if your little one is conceived in your heart and carried by someone else, your baby is your miracle.
We hope you've enjoyed this Pea in the Podcast for those who need a little extra help getting pregnant. Please visit our website for more information about our experts, to find links and transcripts and to register to get tailored week by week shows for each week and stage of your pregnancy. It's everything you need to know about your body, your baby and the big changes ahead in your life in your journey to becoming a mommy. For Pea in the Podcast, I'm Bonnie Petrie. Thanks for listening.