Canadians For Choice

Are you trying to become pregnant? Are you frustrated that it is taking too long or afraid that something may be wrong? The Assisted Conception Taskforce has created the ACT pathway, four steps to follow if you do have concerns about your or your partner’s fertility. But before discussing the steps, what is fertility? The Canadian Health Network defines fertility as being able “to become pregnant and carry the pregnancy to term within one year of trying to become pregnant”. During this year of trying you and your partner must be having sex frequently without using birth control.

Step One: Trying

Once a couple starts trying to become pregnant, the woman should stop or limit smoking cigarettes, drinking alcohol, and using recreational drugs. She should also eat healthy, well balanced meals, start taking folic acid supplements (0.4 mg/day), exercise, and talk to her doctor about any medications or herbal supplements she may be taking.

It is suggested that the couple engage in unprotected vaginal intercourse approximately every two to three days around the fertile time (ovulation). A couple can try to monitor the woman’s menstrual cycle and have sex more frequently around the time of ovulation (release of an egg from the woman’s ovary). There are a number of methods to monitor a woman’s menstrual cycle. Ovulation occurs approximately 12-14 days before menstruation, so a woman can keep track of her cycle on a calendar. This is a general approximation as each woman’s menstrual cycle varies in length and varies month to month depending on factors such as stress and illness. A second method is to observe physical changes to her body. A woman’s temperature will rise at ovulation and remain slightly higher than normal for 2 days after ovulation. Another physical change is the consistency and appearance of cervical mucus. The day before, the day of, and the day after ovulation, a woman’s cervical mucus becomes slippery and transparent.

Couples can also buy ovulation kits at pharmacies to help them track a woman’s menstrual cycle. However, it is not recommended to track a woman’s cycle for long periods of time. Trying to have sex at precisely the right time (ovulation) can become very stressful for the couple. Sex looses its spontaneity and sex on demand may lead to loss of interest in sex and erectile problems.

Figure 1 – Timing of ovulation and menstruation. Regardless of the length of the cycle, ovulation occurs 14 days before menstruation.

After one year of trying to become pregnant without success, a couple should visit their doctor or gynecologist. However, if the woman is over 35 years of age, has irregular menstrual cycles or has a history of pelvic inflammatory disease (PID), sexually transmitted infections (STIs), abdominal/pelvic surgery, abnormal pelvic exam, endometriosis, significant illness (ex. diabetes) or miscarriage, it is advised that a couple should see a doctor earlier (as early as after six months). The couple should also seek medical advice if the male partner has a history that includes urogenital surgery, STIs, varicocele (condition that does not allow the blood to drain from the testicles through the testicular vein, resulting in an increased temperature which interferes with proper sperm development), significant illness (ex. diabetes), or an abnormal genital exam.

Step 2: Seeking Medical Help

The doctor will take the couple’s history and perform a physical evaluation. Both partners should be present to provide support for each other. The doctor will look for factors that can be corrected (ex. timing of intercourse) or anything that may be preventing the couple from conceiving (pain during intercourse could be an indication of endometriosis). After this initial assessment, possible testing for infertility factors should be discussed with the couple, along with possible stresses on their relationship.

Remember you are not alone. One in six couples worldwide have difficulties becoming pregnant, this represents 90 million couples. Ninety-four percent (94%) of couples who experience problems having a baby never get treatment. This may be because of a lack of access and the stigma associated with infertility. The lack of access to the services and treatments is because more advanced tests can be very expensive and are not fully covered or not covered at all by private health insurance plans. (Note: the basic tests are covered by most provincial/territorial healthcare plans) Also, some couples may feel ashamed, embarrassed, or worry about what others might think, and therefore not go for treatment.

Infertility can be an extremely stressful to individuals and can create conflict for the couple. Couples will have to deal with life changes such as: expensive treatments, daily disruptions, the “disappointment cycle” (each menstrual cycle offers hope and then possibly despair if pregnancy does not occur), feelings of powerlessness and perhaps social isolation (friends beginning their own families, people around you not understanding your feelings). It is important that the couple openly communicates their wishes and opinions with each other and that no blame or judgment is placed. Whether or not a couple decides to proceed beyond an initial appointment with a doctor, counselling is strongly advised. Counsellors will assist the couple in discussing the various struggles associated with infertility, the couple’s fears and anxieties and help them work through possible differing opinions. Many support groups also exist; it may be helpful for the couple to talk with others going through a similar process. The Infertility Awareness Association of Canada and the Infertility Network provide and organize support groups for couples experiencing difficulty conceiving.

Step 3: Testing and Diagnosis

If a couple does decide to proceed to the next stage, testing and diagnosis, there is hope. Approximately 80% of people with persistent infertility eventually conceive. The couple will be referred to a fertility specialist for testing and an appointment should be made right away. Couples need to know what to expect and be mutually committed. Testing and treatments result in the loss of privacy, frequent vaginal exams for the woman, the need for frequent sperm samples from the male partner, missing work often for appointments, and great financial costs.

It is important to shop around for a fertility clinic. There are no absolute success rates, therefore do not select a fertility clinic on success rates alone! Consider the reputation and the qualifications of the clinic and look at the costs associated with the procedures. Currently clinics can charge whatever they like for the tests and treatments they offer. Only in Ontario is treatment for women with double oviduct occlusion (both fallopian tubes blocked) covered by provincial health care, so it is important to review your private health insurance plan to see if the costs for the tests and treatments are covered. Also, in order to feel more at ease throughout the process, make sure you and your partner feel comfortable with the staff and the clinic.

A systematic battery of tests will be completed. There is no specific order to complete the test. The general guidelines are to begin with the least invasive tests. There are several factors that lead to infertility, ovulation defects (30%), sperm defects (22%), tubal defects (17%), endometriosis (5%), unexplained (14%), and other disorders (12%).

Figure 2 – Female and Male Reproductive Organs

Ovulation Defects
Problems with ovulation may be due to lack of hormones, stress, excessive exercise, low body weight, thyroid gland or adrenal gland malfunctions, serious illness (ex. diabetes), or environmental factors. If the female partner has an abnormal menstrual cycle, blood tests can be performed to test for several things.

1. On day three of a woman’s cycle, a test may be done for Follicle Stimulating Hormone (FSH). The desired value is less than ten, as higher values indicate reductive reproductive potential. The desired result means that the woman’s ovaries should be functioning and the woman is potentially fertile.
2. On day three of a woman’s cycle, a test may be done for estradiol (an estrogen). The desired value is greater than 150, which again indicates that the ovaries are functioning and the woman is potentially fertile.
3. On day 23 of a woman’s cycle, a test for progesterone may be done. The desired result is greater than 10 nmol/L. This test monitors the function of the corpus luteum. The corpus luteum is a ruptured follicle (the enclosure for an egg within an ovary) after ovulation and it secretes the hormone progesterone. Therefore, higher progesterone levels can indicate that ovulation has occurred and that an egg should be able to implant into the endometrium (lining of the uterus).
4. A mid-cycle test for the Luteinizing Hormone (LH) may be done on a daily basis. LH peaks, known as the LH surge, at ovulation. This test can help to predict when ovulation occurs. The LH tests can become very expensive if repeatedly used and may not always give accurate results.

Figure 3 - Changes during the Menstrual Cycle

Blood tests can also be administered to test for the Thyroid Stimulating Hormone (TSH) and for the presence of raised prolactin, which can both affect fertility. If the woman is having a regular menstrual cycle, continued testing of FSH, estradiol, progesterone, LH, TSH and prolactin may of be less value at which point another infertility factor should be considered and tested.

Tubal Defects

Uterus

Cervical Problems

Sperm Defects

Unfortunately, after all these tests have been completed the infertility still may be unexplained. The prognosis of the couple conceiving is still good, even without treatment, if less than two years has passed and the woman is under the age of 35.

Step 4: Treatment

There are several treatment options depending on the diagnosis. Following is a list of useful questions to review and to ask the fertility clinic when considering treatment.

1. What are the potential side effects of the treatment?
2. What are the financial costs associated with treatment, including administration, consultation, drugs and laboratory procedures?
3. What are the indirect costs, including time lost from work during or after treatment?
4. How many cycles (attempts) should be considered for any given treatment?
5. How long will we have to be on this treatment before stopping or trying another treatment?
6. What should we do next if this treatment does not work?
7. What are the risks of multiple pregnancy (twins, triplets, etc.)?
8. For any given treatment, especially in-vitro fertilization (IVF), what is the current live birth rate per cycle started, for women attending the clinic? What is the success rate for women of my age?
9. How do you measure your pregnancy rates?
10. For IVF, how many embryos do you transfer? What is the policy at the clinic?

The first option is a Day Clinic. Surgeries are performed to correct abnormalities and to increase chances for conceiving. Day surgeries can remove tubal or uterine adhesions in women by using a hysteroscopy or laparoscopy and correct varicoceles in men.

The second option is oral medications. Oral medications (usually Clomiphene Citrate) are used to stimulate ovulation in women that are not ovulating on their own. Women take the oral medications for three to six months, in which time; they will hopefully begin ovulating and become pregnant. A woman will take the medication for a maximum of six months or up to a maximum dosage of 150 mg/day and if it is unsuccessful she will stop taking the medication and try another treatment option.

The third option is hormonal treatments for either partner. The hormones can be administered at home, with regular supervision by a doctor. Examples of hormonal treatments are Human Menopausal Gonadotropin (hMG), Follicle Stimulating Hormone (FSH), and Human Chorionic Gonadotropin (hCG). Individuals can take the hormones for two to six months and if it is unsuccessful they can stop taking the hormones and try another treatment option.

The fourth option is Assisted Reproduction Techniques or Advanced Reproductive Techniques (ART). ART is used if fertilization is the problem. There are several different techniques or technologies used.

In-Vitro Fertilization (IVF)
IVF is used for all types of infertility. One cycle of IVF costs at least $4000 and that does not include medication costs. IVF involves the stimulation (ovulation induction) and removal of eggs by using an ultrasound to find eggs and then inserting syringe into the abdominal cavity to “draw eggs”. The egg is then fertilized in the lab and 2 to 5 days later the embryo is transferred by using a flexible tube or catheter to place it in the uterus through the vagina.

Intra-cytoplasmic Sperm Injection (ICSI)
ICSI is used for severe sperm problems and to assist with IVF. It involves injecting a single sperm into an egg after it has been retrieved from the woman. After fertilization, the embryo is transferred after 2 to 5 days.

Gamete Intrafallopian Transfer (GIFT)
GIFT involves inserting an egg and sperm into the woman’s fallopian tubes where fertilization occurs through the use of laparoscopy. Laparoscopy, as previously mentioned, is a surgical procedure where a small incision is made below the naval and a small fibre-optic scope can be inserted. This procedure is rarely used, mainly because it is invasive.

If previous ART treatments have been unsuccessful, the couple may use donor eggs or sperm. If using donor sperm, the sperm from a healthy donor is inserted once or twice a month around ovulation. Women donating eggs are given fertility drugs and the eggs are retrieved. The eggs are harvested in the lab then transferred to the recipient’s uterus.

There are other treatments and techniques that can be used; this is not an exhaustive list. Therefore, discuss all of your options with a health care professional at a fertility clinic. With the help of a fertility specialist, you and your partner can select a unique treatment plan that you are both comfortable with.

The Future of Assisted Reproduction Techniques

On March 29, 2004, the Assisted Human Reproduction Act received Royal Assent. Under this Act, a regulatory agency was created. The Assisted Human Reproduction Agency of Canada, also known as Assisted Human Reproduction Canada (AHRC), was established in January of 2006. It consists of a president, chairperson, and 11 board members. The AHRC’s mandate is “to protect and promote the health, safety, human dignity and human rights of Canadians and foster the application of ethical principles in relation to assisted human reproduction and other matters to which the Act applies”. In short, the purpose of the AHRC is to bring much needed rules and regulations to the field of assisted human reproduction. As prior to this, there was no regulation whatsoever, which did not benefit couples having difficulty conceiving. In the future, the Agency will review licensing requirements, inspect clinics to ensure health and safety standards are met, regulate the costs and fees of assisted reproduction and advise the Minister of Health.

References:
Canadian Health Network. (2006). What do I need to know about taking care of my fertility?
http://www.canadianhealthnetwork.ca/servlet/ContentServer?cid=1137350422369&pagename=CHN-RCS%2FCHNResource%2FFAQCHNResourceTemplate&lang=En&c=CHNResource

Assisted Conception Taskforce. (2006). The ACT Pathway Booklet
http://www.assistedconception.ca/english/resources/ACT_Ratgeber.pdf

Assisted Conception Taskforce. (2006). Press Release – ACT Launch.
http://www.assistedconception.ca/english/resources/Press%20Release%20-%20ACT%20Launch.pdf

In Support of Women and Men Striving to Overcome Infertility. Pamphlet from Dr. B. Norman Barwin (B.Sc., M.B., Ch.B., B.O.A., M.D., F.R.C.O.G, F.S.O.G.C., F.A.L.O.G.)

Canadian Fertility and Andrology Society. (2002). CFAS Consensus Document for the Investigation of Infertility.
http://www.cfas.ca/english/library/cfasconsensus-eng.pdf

Health Canada. (2006). Assisted Human Reproduction Canada.
http://www.hc-sc.gc.ca/hl-vs/reprod/agenc/index_e.html

Figures 1 -3: Crooks, R. & Baur, K. (2007). Our Sexuality. Thomson Nelson; Scarborough, ON.