Everything You Need to Know About Infertility and Assisted Reproductive Technology (ART)
Infertility impacts folks in all sorts of ways and everyone has their own journey. Some utilize ART, some want to but can’t, and for some it’s not the right fit. Some of you reading this will be able to have the child you have dreamed of, and sadly, some of you won’t. This is intended to be a comprehensive guide for everyone, so not all of the sections will apply to any one person. However, even if you end up with a baby, grief is still very much a part of the process, as you will have to grieve the loss of how you dreamed the process of having a baby would go.
Same sex couples, and couples where one or both partners are intersex, can also benefit from the information this series, although their journey is different from opposite-sex couples. Same sex couples often use Assisted Reproductive Technology (ART) to create the family of their dreams and may discover along the way that one or both partners have challenges with fertility. Even if they don’t have a fertility issue, utilizing ART comes with many of its own difficulties that are discussed below.
Infertility Basics
My goal in writing this section is to arm people with a good basic understanding of infertility, treatment options, and generally what to expect. Some doctors are fantastic communicators and others… well, leave a lot to be desired. Some of you will be struggling with trying to conceive, but haven’t yet consulted with a doctor and I hope this information helps lay the foundation to make starting the process easier.
Definitions
Infertility is typically defined as a failure to conceive after 12 months of unprotected sexual intercourse. Couples are advised to seek medical help if they have been unable to become pregnant after a year of trying for couples under 35, after six months of trying for couples over 35, and ASAP for couples over 40. If one or both partners has a medical issue that is known to impact fertility (for example, cancer treatment, endometriosis, irregular periods, PCOS, etc.) they should seek assistance as soon as possible.
Note that this definition of infertility is inherently problematic, as it completely excludes LGBTQIA people, despite people of all sexual orientations and genders experiencing challenges with fertility. It also excludes single people who are pursuing parenthood on their own and may discover fertility problems along the way. Factors that impact fertility do not selectively impact only heterosexual couples.
How common is infertility?
Infertility is quite common. Almost 13% of women between the ages of 15-44 seek treatment for infertility each year and this figure does not include the women who do not seek treatment.
Unfortunately, but not surprisingly, there is little data for nonbinary and trans folks. Studies have found that a little over 1/3 of trans youth want to have biological children in the future, but very few of them end up doing fertility preservation (likely due to cost, lack of support, and bias). It is important to note that transitioning does not necessarily permanently impact fertility as is often portrayed. Transgender people deserve informative, medically accurate information about fertility options that are affirming.
What causes infertility?
Approximately 85% of infertility cases have an identifiable cause, with the remaining 15% being unexplained.
Problems with ovulation
About 25% of infertility is caused by problems with ovulation. Regular periods with premenstrual symptoms are required for pregnancy. Of these folks, 70% of them have polycystic ovarian syndrome (PCOS), which causes irregular ovulation. Eating disorders and excessive exercise can also prevent regular ovulation and cause infertility. Other medical issues that can interfere with regular ovulation are thyroid disease, pituitary gland disease, and disorders that cause elevated androgens (sex hormones that are higher in men like testosterone).
Tubal infertility
Tubal infertility, which means either the fallopian tube is blocked or unable to retrieve the egg from the ovary, is also a significant cause in infertility. This is most common in women with a history of a sexually transmitted infection (particularly if untreated for a significant length of time), but also for people who have had abdominal surgery or infection.
Endometriosis
Endometriosis can contribute to infertility and impacts 25-40% of women with infertility. It causes the cells that line the uterus to grow outside the uterus, which can block fallopian tubes or create scar tissue that can make it difficult to get pregnant.
Diminished ovarian reserve (DOR)
DOR means there is a low amount of quality eggs. Major causes of this are age, cancer treatment, a family history of premature menopause, or genetic conditions. Ovarian reserve starts to decline around age 32, gradually decreasing, especially after 35, and gets significantly worse after 40. This is a major issue given that our culture does a terrible job of properly educating people about fertility and family planning and many women are delaying starting a family due to finances, not having a suitable partner, or as they get established in their career. At the same time, you can’t slow aging, which leads to the pressure of the “biological clock.”
Unexplained infertility
The truth is, often times there isn’t an identifiable cause of infertility, though age is often blamed when this is the case. Stress is also often blamed, and while there are many stories of couples who suddenly became pregnant after they stopped trying, there are also many couples who stopped and never went on to become pregnant. Unexplained infertility can be a hard concept to grasp for people, especially anxious people who have great difficulty tolerating uncertainty and cope by trying to exert control over their circumstances (doing research, finding the problem, finding solutions, etc.).
But what about men?
Yes, what about men? Infertility is often discussed as a women’s issue (and no surprise that historically women have been blamed and shamed for fertility struggles), but in fact, male infertility is a huge contributor to not being able to get pregnant. In fact, over 1/3 of infertility is due to male factors. Men can have all kinds of issues with their sperm (for example, low sperm count or not strong enough swimmers) and should be evaluated anytime there is difficulty conceiving.
A note on weight and fertility…
It’s almost impossible to receive medical care, especially fertility or pregnancy care, without hearing all about weight. However, the research showing higher body weight “causes” infertility is highly problematic and only shows a correlation, which is likely explained by factors that researchers didn’t bother to examine, such as weight cycling, weight stigma, and health behaviors. Even if weight did cause infertility, pursuing weight loss is not an evidence based intervention, as the overwhelming evidence shows that weight loss attempts cause weight gain and increases risk for physical and mental health problems. Fat bodies are capable of healthy pregnancies.
For more information on this topic, read my article Weight and Fertility: What Does the Science Say? Also be sure to check out the reproductive health section of My Favorite Resources to Improve Body Image and Fight Weight Stigma for additional supports and information on this topic.
Assisted Reproductive Technology (ART) Basics
ART stands for Assisted Reproductive Technology and refers to the use of technology to help people get pregnant. ART is not for everyone and many people either choose not to use it or want to but can’t due to finances, oppression, or other barriers. People typically associate in vitro fertilization (IVF) with ART but the truth is this is only one kind of ART that people use to try for children. Here is an overview of the main types of ART:
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In vitro fertilization (IVF)
Medications are used to stimulate the ovaries to grow multiple eggs in one menstrual cycle, rather than the single egg that usually grows. Medications are usually injected at home. Patients are monitored with regular ultrasounds and bloodwork and then the eggs are surgically retrieved by a needle (oocyte retrieval). Anesthesia is required. Of the eggs that are retrieved, the ones that are mature enough are then combined with sperm in the lab (from either a partner or a donor) where they hopefully grow into embryos, which are either then transferred to the uterus (anesthesia not required), or, frozen for a later transfer. Not all eggs that are retrieved are mature enough to use and not all mature eggs develop into embryos, and not all embryos develop normally, meaning that you “lose” eggs at each stage. For example, maybe 10 eggs are retrieved, 7 are mature enough to use, 4 of which develop into embryos, 1 or 2 of which are normal and able to be transferred. Some patients also choose to do genetic testing on the embryos.
Intrauterine insemination (IUI)
Sperm from a partner or a donor is “washed” (the strongest and healthiest sperm is separated out) and inserted directly into the uterus to increase the number of sperm that reach the fallopian tubes when a woman is most fertile. Sometimes IUI is paired with medication to stimulate the ovaries to produce eggs. Also known as artificial insemination.
Egg freezing (oocyte cryopreservation)
Similar to IVF, except the eggs are frozen rather than immediately fertilized and transferred to the uterus. Some patients choose to fertilize and freeze embryos for future use, rather than just eggs. This is typically used prior to undergoing treatment that could harm fertility (for example, cancer treatment) or when a patient has to delay trying to conceive for another reason (lack of acceptable partner, life circumstances, etc.).
Surrogacy/gestational carrier
When a patient is unable to carry a pregnancy to term, or is considered too high risk to do so, another person can carry the pregnancy. This is either done with an egg donor (traditional surrogacy) or another person with no genetic relationship to the baby (gestational carrier). This is also used in couples without uteruses (gay couples, hysterectomies, intersex or trans couples).
Donor sperm, eggs, or embryos
If there is a problem with sperm and/or eggs, or if one or more partners is a carrier for a genetic disease they don’t want to risk passing along, a donor can be used in combination with IVF or IUI. Donors can be used for sperm, eggs, or embryos.
Non-ART fertility treatment
Not all fertility treatment involves technology. Often times medications are used to induce ovulation, etc., without the use of technology to retreive eggs, place sperm, or create embryos. Additionally, when there is a problem with anatomy, sometimes regular ole’ surgery is needed to correct the issue (for example, a blocked fallopian tube or uterine fibroid).
Who is and isn’t getting infertility treatment?
It is important to note that ART is not for everyone. For many people, it’s just not the right choice for them for any of a variety of reasons (cost, values, concerns about side effects, etc.). The reality is ART is cost prohibitive for most people and requires an enormous amount of financial privilege to be able to afford.
Many people are also impacted by health disparities and systemic oppression. There is an incredible shortage of egg and sperm donors of color. Black, Indigenous, and People of Color (BIPOC) are more likely to experience infertility, less likely to have access to fertility treatment, and have a higher risk of maternal mortality. Same-sex couples may struggle to access fertility treatment, especially outside of liberal major cities. Women with disabilities and trans folks face enormous barriers and discrimination in their quest to have a child. And many ART clinics have BMI limits, which is straight up eugenics.
These sobering facts also serve as a reminder that the social determinants to health (access to resources and healthcare, exposure to environmental toxins, poverty, chronic stress of experiencing systemic racism, ableism, sizeism, etc.) are large and underdiscussed contributors to infertility and are beyond the control of any one individual. This is especially important given that women often blame themselves or feel shame when they struggle to become pregnant. Part two will discuss ways to access support within your community, resources for these specific groups, and strategies to self-advocate for the treatment you deserve.
Infertility treatment success rates: Will it work?
This is the question everyone wants to know, understandably so. Unfortunately, there is not a good answer. For many people, it works, and for countless others, it ends in heartbreak. ART does increase the chances of having a baby, but it is far from a guarantee.
It is vital that doctors are direct about the chances of ART working for each patient, while presenting this information in a straight-forward, sensitive manner. Doctors often cite this study to try to give patients a realistic idea (scroll down midway to see Figure 1). For example, a woman using her own eggs at age 40, statistically has around a 50% chance of one live birth if she can retrieve 20 eggs (which will likely take several cycles at that age). In general, the older you are, the fewer eggs you get per retrieval.
If your doctor doesn’t directly discuss the odds of success with you, make sure you ask them about it so that you can make an informed decision for yourself (though personally, I’d consider it a major red flag if the doctor didn’t discuss this). And if you decide to pursue IVF or egg freezing, be sure to ask the doctor what numbers they expect at each stage (eggs, mature eggs, embryos, normal embryos) so that you can manage your expectations.
Physical and emotional side effects of infertility treatment
Physical side effects
ART can create a whole host of physical symptoms, which vary wildly by procedure and person. In general, anytime the ovaries are stimulated to ovulate, symptoms similar to PMS are experienced, though often more intensely. This can include bloating, breast tenderness, dizziness, hot flashes, constipation, cramping, and headaches. Some people are quite sensitive to the hormonal medications, others breeze right through. IUI is typically, but not always, quick and painless.
After the retrieval, it is common to be quite uncomfortable with bloating and tenderness. There is also a risk of Ovarian Hyperstimulation Syndrome, in which the ovaries swell and become enlarged and painful, and fluid can fill the abdomen. This can range from mild (painful) to severe (life threatening and usually accompanied by vomiting and being unable to keep liquids down). Your doctor will educate you on the proper precautions to take to prevent this and will be closely monitoring you to keep you safe.
As with any surgery, there are always the usual risks such as infection or injury, but in general, ART is considered low risk. Make sure to discuss risks of your particular situation with your doctor.
Emotional side effects of ART
In terms of ART side effects, some people experience intense mood swings, while others experience none at all. Many people experience mood symptoms similar to PMS during the stimulation phase when they are taking medications, while others describe an experience similar to intense postpartum depression for a few days after the retrieval. Hormones can be an unpredictable ride and some people also experience anxiety about giving themselves shots.
The emotional impact of fertility challenges is by far the hardest part, whether or not you are using ART. There are of course the emotional side effects of the ART itself, but the bigger issue lies in the difficulty of struggling to have a child when you so badly want one.
Read more about how infertility impacts mental health in my article, How Infertility Impacts Mental Health.
Get Support With Infertility Therapy in Los Angeles, CA
With the help of Well Woman Psychology, you can get the support you deserve as you navigate infertility, wherever you are in your journey. While reaching out for this support can feel overwhelming, know that you are not alone. Struggling with infertility is one of the most emotionally difficult things a person can go through - don’t do it alone. Start connecting with resiliency, healthy grieving, and support through infertility therapy with these steps.
Reach out for a consultation at Well Woman Psychology
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About the Author, A Los Angeles Infertility Therapist:
Dr. Linda Baggett is a Licensed Psychologist at Well Woman Psychology, serving clients online in California, Illinois, New York, and Washington. She received her PhD in Counseling Psychology from the University of Memphis. As infertility therapist in Los Angeles, she specializes in supporting women through their journey to hopefully have a child, no matter when the end result. With a focus on women’s issues, she also has expertise in relationship issues, sexuality, pregnancy loss and miscarriage, birth trauma and postpartum issues, trauma and PTSD, EMDR, and body image and size-based oppression.
Disclaimer:
This blog is for educational and informational purposes only, is not a substitute for individual medical or mental health advice, and does not constitute a client-therapist relationship.