I am 35 years old and have been trying to have a baby for a year. Should I see a doctor? What are my next steps?

It is frustrating to try to get pregnant for a year's time and to be unsuccessful. While the age of 35 is certainly not 'old', it does approach the 'older age' of reproductive ability. Any woman who is 35 or over who has been trying for 6 months or longer to get pregnant and has not been successful has the option to see an infertility specialist. An evaluation will likely consist of a sperm analysis, an x-ray to evaluate the uterine and tubal anatomy, and some blood tests to look at hormones, which reflect ovarian potential. Treatment options will depend on the results of this evaluation. Such options include taking medications to facilitate ovulation, performing an intrauterine insemination of sperm (IUI), or in vitro fertilization (IVF), all of which can be performed here at Shady Grove.

My husband had a vasectomy but we would now like to have another child. My husband is 40 and I am 36. What are our options and is this covered by insurance?

Multiple factors are considered when determining options for parenthood following a vasectomy. As a general rule these include vasectomy reversal, surgical sperm retrieval accompanied by in-vitro fertilization (assisted reproductive technology), donor sperm, and adoption.

For couples desiring a biologic child, only vasectomy reversal and surgical sperm retrieval can be used. Vasectomy reversal is associated with a pregnancy rate of 70-80% over a two year period when performed within 3 years of the vasectomy. This rate diminishes with time elapsed from vasectomy. Cumulative pregnancy rates decline to less than 30% after 10 years of the initial vasectomy procedure. Another factor in the overall success of vasectomy is actually the age of the female partner. As female age increases, the pregnancy success rate declines. Generally, if the female partner is age 38 or older, assisted reproduction may be preferred. If a vasectomy reversal is attempted but does not result in success, assisted reproduction can be considered. If sperm is present but not sufficient for pregnancy, it can be collected and used for in vitro fertilization.

In the past decade, improvements in assisted reproduction have made this procedure often the preferred option for couples who desire children following a vasectomy. The male partner must have a "sperm retrieval" to obtain sperm. Sperm obtained in this manner can then be used to fertilize the female partner's eggs by a method known as ICSI or Intracytoplasmic Sperm Injection. The female undergoes in vitro fertilization (IVF) with injectable medications followed by egg retrieval. The eggs are then injected with the sperm obtained from the male partner. Success rates are primarily based on the age of the female partner. For women less than 35, the pregnancy rate is over 50%.

Cost is another consideration in determining the best option. Unfortunately, many insurance carriers do not reimburse for fertility procedures following a vasectomy. One could expect a vasectomy reversal to cost $5000-$10,000. Despite this cost, there is no guarantee of success. IVF with sperm retrieval has similar costs to vasectomy reversal. Patients undergoing IVF, who have no insurance coverage for treatment, may be eligible to participate in the Shared Risk program. This program allows up to six cycles of IVF for a flat fee and if the patient does not have a baby 100% of the fee is refunded.

I am 33 years old and have been trying to have a baby for a year and a half. My gynecologist did the infertility work up on me and ordered a semen analysis for my husband. It turns out I have an FSH of 15. The rest of the tests and the semen analysis were normal. He said that donor egg may be my only option. Is this true?

FSH, or follicle stimulating hormone, is the hormone secreted from the brain, which tells one of the ovaries each month to produce an egg for ovulation that cycle. If the FSH, when measured by your doctor, is in normal range, that is a good sign that the ovaries are most likely still functioning well, especially if you are young. However, if the FSH is elevated, it may mean that the ovaries are less responsive, and that the eggs left in the ovaries are not of good quality. Because women are born with a finite number of eggs, as we age, the quality of our eggs decreases and it thus becomes harder to get pregnant the older we get. That is also why the incidence of miscarriage and chromosomal defects in offspring increase in older women who achieve pregnancy.

We know from several good studies that FSH levels are very good predictors of IVF outcome in women over the age of 35, however, in a younger infertile population the test may not be as predictive. Some studies suggest that in young patients, their young age may help to compensate for a mild elevation in the FSH level with a stronger stimulation protocol, however, with markedly elevated levels of FSH, this may not be the case. We therefore need to treat each case on an individual basis: we take into consideration the age of the patient, the absolute FSH level (the higher being worse), whether she has ever been pregnant, her diagnosis, how many basal antral follicles we can see on her ovaries on cycle day 3, and her ovarian volume. After we take all that information into account, we can then, and only then, make a recommendation on whether she can try a cycle with her own eggs or whether she should proceed directly to donor egg.

I have been trying to conceive for over two years without success. My doctor recently diagnosed me with PCOS and told me this condition can be difficult to treat. I read that there is a new drug, metformin that is giving good results. How does that work?

An oligoovulatory woman with PCOS has a good prognosis with regard to fertility potential. Confirming the diagnosis is typically the biggest challenge. PCOS affects up to 5% of reproductive age women - many do not present with classic symptoms. Once the diagnosis has been established, achieving pregnancy may be only a matter of getting the woman to ovulate. There is an association between PCOS and insulin resistance (a type of "pre-diabetes"). Metformin (also known under its brand name, Glucophage) is an insulin sensitizing medication originally designed to treat diabetes. This medication is now also used to help women with PCOS ovulate. Some women will ovulate simply by taking metformin alone. It usually takes at least 3 months to start working and is taken daily. Metformin can also be used to help women who do not ovulated in response to clomiphene citrate (Clomid, Serophene). When metformin is taken together with clomiphene the two medications can work together to induce ovulation. A study published in the New England Journal of Medicine showed that 90% (19/21) of women ovulated using this combination.

I have had a tubal ligation but would like to have a child. My gynecologist has recommended a tubal reversal or possibly IVF given my age. I am 37 years old. What are my chances of success with each option and are they covered by insurance?

Published rates for pregnancy after tubal reversal range from 30-70%; however, this may be modified based on many factors, including your age, previous pelvic infection or surgery, problems with ovulation or problems with you husband's sperm. In addition, after tubal reversal, the chance for a successful pregnancy requires a period of "trying"; the published success rates are after a follow up time of anywhere from 1 to 3 years. The procedure is most successful for women in their late 20s or early 30s. With advancing age, the chance for success is decreased. This is due to the fact that as you get older, there is a decrease in the quality of the eggs in the ovaries. At 37 years old, the chance for pregnancy with IVF is approximately 40% per attempt. Cumulative pregnancy rates after 3-4 attempts are higher.

Coverage for infertility treatment varies widely among the various insurance companies. Even within one given insurance carrier, the coverage can be quite different depending on the insurance package that your specific employer has negotiated with that carrier. It is best to check with your insurance company to determine the extent of your coverage for specific infertility treatments.

I have heard that IVIG may help with recurrent miscarriage. Do you treat with IVIG?

Thank you for your question. First let me explain what IVIG is and what it does. Intravenous Immunoglobulin (IVIG) is a protein secreted by the immune system (immunoglobulins). Since they are produced in relatively small amounts, even 1 dose of these proteins is derived from the blood of many donors. As such, it is a human blood product and can carry some of the same risks as a blood transfusion. It is most commonly used for patients, including children, who have a genetic disease that prevents them from producing these proteins. It can also be used in some cases of severe hepatitis and other life-threatening infections. Some reproductive health professionals have suggested that it can be helpful in the setting of some forms of infertility or recurrent miscarriage. The cost of IVIG can run from 7K - 14K per treatment. Large studies have shown that it is not useful for these disorders and not justified, especially given the cost and potential risks. We do not use IVIG in our practice due to its unproven efficacy in many studies. The American Society of Reproductive Medicine takes the following position on the role of IVIG: "The effectiveness of IVIG as a treatment for recurrent pregnancy loss remains unproven. IVIG does not prevent further losses among women with primary recurrent pregnancy loss… For the management of recurrent spontaneous pregnancy loss IVIG is an experimental treatment."