Infertility Treatment Video
Seeking the correct diagnosis and treatment for infertility
Infertility treatment options explained by Dr. David Barad, from Center for Human Reproduction in New York, NY.
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Title: Infertility Treatment
Speaker: David H. Barad, MD
When should a couple seek medical help with infertility?
"Well I think we have to talk about what infertility is. It's the inability to achieve a pregnancy technically within a year; other people define it as within two years. So really the important thing is not what an insurance company or a government might define it as or even the World Health Organization, who happens to define it as two years, but what the couple defines it as. And it really changes for individual couples. You have to individualize the definition. For instance, for a young couple who's twenty years old and trying to get pregnant you're not going to get worried if they don't get pregnant in one month, two months, or three months. But after six months you would expect most young couples to have been successful already. So you already start identifying people who might have a problem. But for the young couple who is twenty, it's probably not a big deal if you don't make the diagnosis for another six months because their potential will still be there. For an older couple, over the age of 38 or 40, the fertility changes so quickly that losing that extra six months is a big deal. So for a couple who is say 40 and trying for 4 months, they might start wanting to wonder what's going on and having some testing done to be sure they're not missing the boat. Because if they wait for a year or two years you're going to have a problem."
How is infertility diagnosed?
"As we think about the couple who comes to us with the inability to get pregnant in the time that they have hoped to conceive. Our first step is to evaluate them and see if their anxieties are well founded and the second step is to begin to reassure them and look at the different parts that might be responsible for their infertility. So it's like any system, in order to make a baby we need eggs, we need sperm and we need a way for the sperm and the eggs to come together. And it's fairly easy to begin that evaluation with a few simple tests."
What are some of the major tests and procedures used to determine the cause of infertility?
"I think that we can cover 80 to 90 percent of the issues in the first few weeks after we first meet the couple. By doing some blood tests to test for ovarian function, doing a semen analysis to test if the husband is okay and then ultimately testing to see if there are problems with the fallopian tubes or not and I think all of those things can be done relatively quickly. The other test that they do, that is part of the basic work up, is called a hysterosalpingogram. A hysterosalpingogram, which we abbreviate HSG because nobody can say, hysterosalpingogram, is looking at the shape of the inside of the uterus and whether the tubes are open or not."
Are there any new infertility tests developed recently?
"Many centers have required women to come back on the second or third day of their cycle for FSH and estradiol and those are still very important tests but in recent years we have increasingly been using a new determination known as anti-Müllerian hormone, otherwise abbreviated AMH. AMH is an interesting test because you don't have to do it on a specific day of the cycle. There may be some slight changes as a woman goes through her cycle but not enough to really influence it greatly. So, we can draw a blood test on a woman on the first day she comes in for her first visit and get the results back within a week or so. And that is highly predictive of her ovarian potential. So we'll already know within a few days after her first visit where she stands with regard to ovarian function."
What is "unexplained infertility"? What are some of the major conditions that can be behind unexplained infertility?
"There is this class of so called unexplained infertility and we have some very strong feelings about that here at CHR. Its true that if you do that basic testing you can account for 80 to 90 percent of the causes of delaying conception. But there may be other things that who are normally put in this garbage pail diagnosis of unexplained infertility that many clinics don't look for. There can be women who have subtle changes in the way their ovaries function that may explain their inability to conceive in a timely manner, that aren't picked up by the routine kind of testing that other fertility centers tend to do. In a similar way, there can be problems with the embryos or with implantation, secondary to immune factors that we can pick up by some of the extensive immunologic testing that we do here. I'd say that at the end of the day, whereas many centers will have 15 to 20 percent of people that they'll consider to have unexplained infertility, there are very few people that walk away without a diagnosis at CHR. And it's important because if you don't make a diagnosis, you can't approach a specific treatment. And we like to tailor our treatments to the individual patients based on what we know about them and the diagnosis that we see. There could be somebody who by traditional criteria, the old World Health Organization criteria, for semen analysis, had a normal semen analysis but when you look at it carefully, looking at strict morphology, there may be less than the required number of perfect sperm that would explain a delay in conception. Similarly, there may be a woman who has FSH that's higher than we would expect for her age or AMH that's already low, we also have age criteria for AMH, that others would identify as being close to the normal range but we would identify as having an ovarian problem. In each of those cases we can tailor our approach to increase their chances of success."
What are some of the major treatments for different types of infertility?
"It will always be true that the most effective thing we can do is in vitro fertilization. If you think of this as a step-wise process, IVF and all the related procedures that are IVF will always be the most effective way to help people get pregnant in the shortest period of time. But it doesn't mean it's the only way. So that a young couple with open tubes, who has time, could go through a few cycles of what might be a less effective but perhaps less costly, perhaps somewhat fewer procedures way of achieving their goal. And what we've done over time, over the years, is a procedure known as intrauterine insemination, and there are really a couple of parts to intrauterine insemination. We originally thought of IUI as a way of addressing a couple with normal ovarian function and low sperm count. And the notion was that if we took that semen specimen, which maybe had, lets say it had 20 percent of the normal count, and we then concentrated the sperm into a very small volume, we could put a larger dose of sperm into the uterus. What ovulation induction does is helping the woman to produce more eggs. Now we used to use ovulation induction just for women who didn't ovulate and there certainly are still a number of those and they're helped by taking fertility meds to ovulate. But the more common usage today in infertility is to take a woman who normally cycles every month and produces one egg and helping her to produce multiple eggs. By producing multiple eggs its like presenting multiple targets, multiple opportunities for the sperm and so you increase the likelihood that some sperm and some eggs are going to find each other, just because there are more numbers. So if we do the intrauterine insemination, we mentioned before, which increases the dose of sperm into the female system and ovulation induction, which increases the number of eggs, we increase the likelihood that some egg and some sperm will get together and thereby increase the chances of pregnancy. IVF as I started out by saying will always be the most effective way but there are other things we can do along the way."
Dr. Barad joined the Center for Human Reproduction in 2003 as Director of clinical ART. Dr. Barad has been active in clinical research, including his role as investigator in a major menopause study conducted by the Women's Health Initiative (WHI). Together with Dr. Gleicher, Dr. Barad has published many peer-reviewed scientific papers in medical journals. In addition, Dr. Barad has been recognized by the American Infertility Association for his, "continuing dedication and support to individuals experiencing infertility."
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Last Updated: June 7, 2012