You can't bear to let anyone else hold your 6-month-old niece at family gatherings, the hat you're absentmindedly knitting seems suspiciously small, and your Netflix queue is overrun with titles like "Baby Boom" and "What to Expect When You're Expecting."
If you're ready for a baby, but not sure that your body is cooperating, it may be time to consult a fertility specialist.
Infertility—a disease of the reproductive system that impairs the body's ability to conceive children—affects about 7.3 million women and their partners in the U.S. according to the CDC's 2002 National Survey of Family Growth. And with the average cost of an IVF cycle coming in at a gulp-inducing $12,400, you'll want to maximize your chances from the start.
Get started with a free financial assessment.
Get started with a free financial assessment.
To help you take those first, er, baby steps down the path to fertility, LearnVest spoke to Dr. Alan Copperman, director of infertility at Mount Sinai Medical Center in New York City, about the anxiety, misconceptions, key questions, and finally the triumph of today's fertility treatment options to help get you started on diaper duty.
LearnVest: What does a fertility specialist do?
Dr. Alan Copperman: A reproductive endocrinologist practices all aspects of reproductive medicine, but in this day and age, we find ourselves really focusing on fertility preservation or curing infertility. There are animals that can simply look at each other from across a pond and get pregnant with quintuplets, but humans can be incredibly inefficient when it comes to reproduction. In humans, not all eggs are normal, they don't always fertilize, they don't always implant and they don't always stick. And the major reason why there's so much infertility is not because people aren't eating right or are too stressed out—it's because of reproductive aging.
For a woman in her twenties, about 90% of her eggs are normal, but by the time she's in her forties, nearly 90% are abnormal. What we do is try to maximize fertility—and that starts with encouraging a woman to take her reproductive options seriously. If she's in her thirties, and isn't ready to conceive, egg freezing is an option that's really come of age—it's no longer considered experimental, and there have been thousands upon thousands of healthy babies born. If a woman is married, then we encourage her to conceive sooner than later because it doesn't get easier over time.
What exactly is fertility preservation?
In general, fertility preservation is egg freezing, although it could also be embryo freezing. We've had many couples that aren't at the right point in their lives or careers just yet, but they want to have children in the future, so we give them fertility medications, retrieve the eggs, fertilize them with the sperm and then freeze and hold them in liquid nitrogen. In a couple of years, the couple can thaw the embryos—and their fertility will essentially be preserved at the age that they are now, instead of the age that they will be.
How do you go about trying to locate the source of infertility?
When a couple comes in, it's important to look at the basics: Are the eggs OK? Is the sperm OK? Is the uterus OK? Are the fallopian tubes normal? So we test the eggs through bloodwork and an ultrasound. We can see if a uterus is normal with an ultrasound. We can determine if the sperm is OK with a semen analysis. And we can tell if the fallopian tubes are open by doing an X-ray called an HSG, in which we inject dye through the cervix to tell whether or not it flows through the tubes.
Just by doing these basic tests, you're usually going to pick up on a reason for infertility in almost all patients. So if you find a problem with the sperm, we can start with inseminations or in vitro fertilization, which involves implanting one normal embryo. If the fallopian tubes are blocked, we can unblock them surgically or do IVF and bypass them.
What should people take into consideration when they first start seeing a fertility specialist?
They should be prepared for physical, emotional and financial challenges. Walking into your specialist's office empowered with questions to ask is my first piece of advice—and not necessary questions culled from random blogs or chatrooms that can sometimes heighten the hysteria surrounding infertility. Some questions to bring: What is your philosophy on twins? What is this going to cost? How has your practice performed compared to others? Are the technologies offered here the ones that I have the biggest need for? It's OK to ask these questions. Cancer patients are certainly asking about their expected survival—and it's only reasonable that a fertility patient know what are their chances for success.
Often, we're finding that it's more cost-effective to do a single, higher-tech treatment than multiple months of low-tech treatments.
What concern do you most often hear from patients who are just beginning treatments?
That they are going to wind up with twins or multiples. It can be unhealthy to carry twins—and certainly Octomom scared off a lot of patients—so I reassure couples that we're striving for healthy, singleton births. We've tried to change treatments in recent years to minimize that risk by putting in one embryo, rather than two or three, because there's more understanding that twin pregnancies can be complicated.
Fertility treatments are usually perceived as scary expensive. What financial considerations should you take into account?
This is such a complicated question. Different states have different mandates, and that might all be disappearing with the Affordable Healthcare Act. I would say that it's important—upfront—for a patient to understand what the financial cost could be, and what their potential out-of-pocket expenses will be.
The practice should have a designated financial coordinator who understands their plan, and who will help them understand what it is to precertify treatments, what their pharmacy benefits are, and what the short- and long-term costs are going to be. It really is extremely variable—some people have very little covered, some people have almost everything covered, and most people have at least something covered.
I don't usually like to speak to the financial side, but very generally speaking, the consultation and work-up can be in the hundreds, a cycle of fertility medications and inseminations can be in the thousands, in vitro can be $10,000 to $12,000, and getting pregnant using donated eggs can be over $20,000.
Often, we're finding that it's more cost-effective to do a single, higher-tech treatment than multiple months of low-tech treatments—i.e., trying in vitro fertilization, which has a very high success rate, rather than doing multiple low-tech treatments, such as taking fertility pills and trying to time intercourse or intrauterine insemination, which involves injecting sperm directly into the uterus. This way, you can also take advantage of any financial caps that your insurance may have on treatments.
It's clear that having as much information as possible upfront is key. But how else should a patient prepare?
If a woman wants to be a single mom by choice, she should definitely look at what her support systems are—and what the future looks like. If a couple comes in, they should have a good idea of each other's thresholds and concerns.
We see men who don't want to get a semen analysis because they're afraid there's something abnormal, and we have women who are afraid of gaining weight or that their emotions might change while on medication, so talking to each other about tolerance before walking into the visit is important. The answer to much of the stress that fertility treatments present is communication. Hopefully, articles like this will help empower patients to ask questions, control expectations and have some faith in the process—because most couples are successful.
Say a patient has decided to move forward with treatment. How do you go about finding a specialist who best fits your needs?
Most ob-gyns have relationships with specialists in the community, and they have a sense for who takes the best care of their patients, who might have a concierge environment, and who helps their patients come back to them pregnant quickly and with a healthy, singleton pregnancy.
The American Society of Reproductive Medicine can help you find a doctor who's been board-certified. There's also information available through sart.org, which profiles clinic-specific information to at least let you know what your realistic chances are at various clinics. Also, different clinics participate in different insurance plans, so a patient can call up their plan representative and ask if there's a Center of Excellency close to them, based on their criteria. All of these are reasonable ways to do some homework.
How much of a role do family genes and history play in fertility?
I think it's less reassuring than most couples would believe. In other words, it's very common for a woman to come in and say, "My mom had kids into her forties, my grandma had them in her forties, and my sister is ultra-fertile. It's unbelievable that I'm not getting pregnant!"
But it actually is believable—there isn't really a fertility gene that goes around in families. Of course, there can be something causing miscarriages in families at a higher incidence or a history of premature menopause. But while there are negative predictors of fertility that can be familial, I would not be overly reassured by the super fertility of Grandma.
Speaking of, what's the most common misconception about infertility?
That stress causes infertility—and that simply relaxing can cure it. By telling a woman to just relax, you're really blaming her or saying she's got control over something that she doesn't. There really is no evidence that taking time off or meditating is going to make someone more fertile—as long as she's having intercourse during ovulation, she has just as good a chance of getting pregnant than someone who's feeling calm.