The Infertility Consideration
The news is full of so-called ‘miracle’ births: from women in their 50s and 60s conceiving (usually with help from outside means), to the tabloidesque trials and tribulations of the Octo-Mom. Many women now believe that they can put off having kids, and simply rely on various medications and/or surgeries when they’re ready to conceive. However, age still plays a significant role in the success rates of infertility therapy.
"The healthiest, most fertile eggs are ovulated when a woman is in her teens through her late 20's, a woman's time of peak fertility. When a woman reaches her mid to late 30's, the remaining eggs have substantially less potential for fertilizing and establishing a healthy pregnancy,"says Board Certified Reproductive Endocrinologist, Gordon Kuttner. A healthy 30 year-old woman has a 20% chance per month to get pregnant; by age 40 her chance is only about 5% each month; and for women still in their early 20's, roughly 7% of them have already been diagnosed as infertile.
The Centers for Disease Control and Prevention report that approximately 7.3 million women of childbearing age within the US are infertile. Infertility is clinically diagnosed when a woman has had 12 months of unprotected, well-timed intercourse without a pregnancy, or if she has suffered from multiple miscarriages. Even for women that have previously conceived, secondary fertility issues can develop in the time frame between conceivable pregnancies.
Are You, You Know, Having the Sex?
I'm one of the millions of women in the U.S. that has experienced secondary fertility issues. I've been trying for 4 years to have my 2nd child, and 4 years feels like a lifetime. I come from an Irish Catholic family full of women that love to get pregnant. Every time there’s a family reunion, I'm reminded that I'm a mom of one. Besides my family being huge, they're also incredibly nosy. I'm constantly bombarded with questions: "Are you going to have more?" "Why can't you have more?" "What's wrong with you?" And, the grand-prize winner: "Are you having, you know, sex?"
No, Aunt Gertie; I’m trying to get pregnant the King James way.
With my first child, I thought that all one needed to do was have sex in the backseat of a ’94 Cavalier to get pregnant. The second time around, automotive coitus didn't work out so well, so I took the logical step of buying a Jeep. That didn't do the trick either. Thankfully, before I went shopping for a truck, I realized I needed an approach other than vehicular aphrodisia. Sorry, Ford.
Discovering the cause of infertility is the first step to securing a more optimistic future of fertility. According to 4women.gov, PCOS is the most common cause of female infertility. PCOS (Poly Cystic Ovarian Syndrome) is a condition that can affect a woman's menstrual cycle, hormones, heart, blood vessels, appearance, and ability to have children. One in 10 women have PCOS and many suffer with it for years before they are correctly diagnosed, as it can often be mistaken for other problems.
I was diagnosed with PCOS nearly two years ago after suffering with symptoms since puberty. It wasn't an easy diagnosis; I went through a constantly revolving door of doctors, herbalists, quacks, hacks and love gurus in order to cure this mystery ailment.
One of the first doctors I saw insisted I was pregnant after I told her that I had not had my period for months. I kept trying to tell her that I was not pregnant, that I'd already been trying for two years with no results. She responded, "Well then, why don't you have a monthly cycle?"
I told her, "That's why I'm here; you tell me."
After consulting the moon, stars, and the face of Aphrodite in a snickerdoodle cookie, she told me in no uncertain terms that I was pregnant. She then prescribed me prenatal vitamins, and made me take a urine test to check for protein, promising to schedule a follow-up appointment as soon as she got my results back. She never called to schedule a follow-up.
Maybe next time she’ll try reading tea leaves.
Another memorable doctor dutifully pronounced me an alcoholic after blood work showed poor liver function. And while we Irish are known for our (ahem) enthusiasm when it comes to alcohol, I'm the black sheep of the family—a glass of wine, maybe twice a year—I am a poor excuse for a stereotype. Anyway, the doctor insisted I was an alcoholic and said it was making me fat and destroying my liver. If he and the previous doctor had got together, I probably would have been lectured on not drinking while pregnant. While they attached leeches to my body to suck out all the evil spirits.
Finally, I found my current physician (after the pre-natal acupuncturist, the winged gypsy, and the guy with the wandering fingers who said I suffered from the hypo), who told me I wasn't pregnant and I wasn't an alcoholic—I had PCOS.
The Lack of a Cure
There is currently no cure for PCOS. While weight loss has been shown to reverse some of the side effects, some women are already thin and remain within a healthy weight range throughout their lives. 30% of thin women and a staggering 75% of obese women with PCOS have Insulin Resistance which is thought by many to be the underlying cause of PCOS.
Insulin Resistance is the body's inability to respond to and use the insulin it produces. Increased levels of insulin can affect the ovaries, preventing ovulation and causing a rise in androgens (testosterone) levels. It is this increase in androgens that affect PCOS sufferers and cause a majority of PCOS symptoms which include but are not limited to: obesity, high cholesterol, high blood pressure, insulin resistance, type-2 diabetes, infrequent or absent menstrual periods, ovarian cysts, acne, oily skin, dandruff, skin tags and patches of thickened/dark brown skin on the body, weight gain or upper-body obesity, sleep apnea, male-pattern baldness or thinning hair, male-type hair growth on the face and body, chronic pelvic pain, depression, and infertility. Women with PCOS are also at an increased risk of developing liver disease called NAFLD (Non-Alcoholic Fatty Liver Disease).
The most common medicine prescribed for PCOS patients with Insulin Resistance is Metformin. Metformin works to regulate the production of glucose, thereby reducing a woman's need for insulin. In turn, it helps to decrease body mass, improve cholesterol levels, control blood glucose, and lower testosterone production. Metformin has also been known to help women ovulate within a few months of use.
From the self-defecating humor department...Metformin is one of the worst medications I've ever been subjected to. My doctor didn't warn me of the one major side effects—constant diarrhea. The first few months I was on it I went through different doses because I spent 75% of my day sitting on the toilet. I had no idea the human body could produce that much waste, and I told my doctor that my bowel movements were counterproductive to trying to get pregnant. Thankfully he listened and my dosage was reduced to 500mg a day, down from 2000mg. The toilet and I don't spend as much time together now as we used to, I'm happy to report.
Lack of ovulation is usually the root of fertility problems in women with PCOS. There are several medications available for PCOS patients that can stimulate ovulation. Usually the first therapy choice is Clomid. If this fails, Metformin coupled with Clomid is tried. Gonatropins—shots, can also be used to stimulate ovulation; however, these are more expensive and increase the risk of multiple births. Some of the last fertility options for women with PCOS are IUI, IVF, and Ovarian Drilling.
IUI (intrauterine insemination) injects washed sperm directly into the uterus by threading a very thin flexible catheter through the cervix. IVF (In vitro fertilization) unites an egg and sperm in vitro (in a lab). The embryos produced are then transferred into the uterus through the cervix. IUI is done in conjunction with ovulation induction through drugs, monitoring of hormone levels and follicle scans done by ultrasound.
IUI and IVF are incredibly costly procedures that many insurance providers do not cover. The only states that currently mandate IVF coverage are Arkansas, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, and West Virginia. And only two states mandate insurance providers to offer IVF as a course of treatment, which are Connecticut and Texas. For women paying out of pocket, IVF is a more viable option as it has a success rate of 42% for women under the age of 35, whereas IUI only has a success rate between 4 and 20 percent.
Ovarian Drilling, or Laparoscopic Ovarian Cautery, is a surgical procedure that helps to stimulate ovulation. Studies show that ovarian drilling yields an 80% success rate of ovulation and a 50% rate of achieving pregnancy. Ovarian drilling is usually done through laparoscopy (a small incision) with general anesthesia.
I've tried oral meds and injectables; none worked and my next step is IUI. I have to say, I'm glad the injectables didn't work. My cyster (non-relation PCOS sister) just gave birth to triplets that she achieved with injectables. I want one baby, not three—although, having three in one shot would make up for all the time I've spent trying and I'd finally catch up with my baby-crazy family. And then Aunt Gertie would stop asking me if I knew how to have ‘the sex’.
From Crestfallen to Frightened
Not only do women with PCOS have to deal with infertility, but they also have to worry about developing endometrial cancer. PCOS patients who have anovulatory cycles are exposed to chronic estrogen to their endometrial lining, which increases their risk of cancer. To make the effects of infertility worse, women who have never been pregnant are at three times the risk of developing endometrial cancer compared to women who have been pregnant. Women who are 21—50 lbs overweight have a threefold risk of cancer and women more than 50lbs overweight have a tenfold increase in risk.
I had my cancer scare on November 1st, 2007 and I'm positive I'll have another in my lifetime. The lining of my uterus had spent six months building up to an extreme thickness, and I didn't have any menstrual cycles within that time to shed it. My doctor requested an ultrasound to see what was up and my results were abnormal. The paper he handed me said, "Endometrial cancer in this patient cannot be ruled out on ultrasound criteria."
No one wants to see cancer anywhere on a piece of paper with their name on it. I was prescribed hormone therapy (birth control pills) to try and thin my lining and was forced to wait for over a month for another ultrasound to see if the therapy worked. Thankfully, there was a significant decrease in the thickness of my endometrium and I was finally able to breathe a sigh of relief—after holding my breath for nearly 45 days.
While PCOS is just one of the many causes of infertility, it carries more risks than other disorders and also offers more treatment options. The key is being diagnosed early and having a Reproductive Endocrinologist that you can communicate openly with.
Every woman deals with her infertility in a different way, and while few things can cure the anger, frustration, and emotional distress she feels over her inability to get pregnant, comfort may be found in knowing that 85% to 90% of infertility cases can be treated with conventional medical therapies. So for many women, while starting a family may take much longer than it does for others, it is still possible. Whether you've been trying for years or want to hold off for a few more, it's never too late to take charge of your reproductive health and secure yourself a positive fertility future.