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How do you know if you are getting good infertility treatment?
With national “take-home baby” rates at 36.9% for patients under 35 years of age (2002 SART statistics, CDC), how do you choose a good program?
Prior to undergoing any infertility treatment, you should “interview” your doctor and ask a few questions about the laboratory that the physician is using. The laboratory staff and physician will both affect your chances of becoming pregnant.
Questions your doctor should ask you and questions you should ask your doctor
• Complete medical history review. Your doctor will review your past medical history to look for past medical interventions or disorders, such as prior surgeries and previous treatment cycles that will help him or her design a treatment plan for you. An incomplete medical history may delay diagnosis and waste your money, your time, and your emotional resources.
• Pelvic exam. Your doctor may perform a pelvic exam to rule out any obvious anatomic anomalies that could cause infertility. At the time of your fertility work-up, make sure your general health is good. Have that annual PAP smear and breast exam done. If you have chronic health problems like diabetes or thyroid disorders, make sure that these conditions are being appropriately managed. Your physician should determine that you are in generally good health before proceeding with infertility treatments. In women over forty, this may also include a cardiac evaluation.
• Hormone analysis. A reproductive endocrinologist can determine whether other hormones are in balance (e.g.,. thyroid, prolactin) that also have the potential to affect your fertility. These chronic conditions can be managed with drugs that are compatible with pregnancy.
• Complete semen analysis. Thirty percent of infertility problems experienced by a couple are due to only male factor, another 30% is due to both male and female factors. Your partner should have a complete semen analysis to rule out abnormalities as part of the infertility check-up. If the semen analysis is abnormal, there are many treatment options today.
• Fallopian tube examination. Blockage of the Fallopian tubes is a primary cause of infertility. Part of the infertility work-up should include testing to determine if the tubes are open. Natural fertilization of the egg by the sperm occurs in the Fallopian tubes, and open tubes are required to allow the sperm and egg to meet in the tube. At least one tube must be open in order to use intrauterine insemination. One diagnostic procedure that may be ordered to determine if tubes are open is called a hysterosalpingogram (HSG). Dye is passed through the fallopian tubes unless a blockage is encountered. Open areas contain dye and the dye can be visualized using X-rays.
• Treat endometriosis. Endometriosis is the growth of uterine lining cells outside the uterus (pelvic wall, fallopian tubes, ovaries where they cause pain and can inhibit the normal fertilization process. Endometriosis may require treatment before fertility treatments begin. Laser surgery treatment on an outpatient basis is available to treat endometriosis. Find out if your physician performs this mini-laparoscopy type of surgery to detect or treat endometriosis or if he/she can refer you to someone who can. IVF can be used to treat infertility even if endometriosis is present, but success rates are typically better in the absence of endometriosis.
• How does your physician monitor procedures? Is the physician able to monitor your response to the stimulation protocol? Is he/she evaluating follicular growth by ultrasound and blood hormone levels (i.e estradiol, progesterone, LH) while you are taking stimulation drugs? Failure to adequately monitor a cycle can result in a poor cycle, higher risk of multiples and/or hyperstimulation. Hyperstimulation of the ovaries can be life threatening due to the vascular complications that may occur in some cases. Fertility drugs are safe if monitored closely.
• Success rates. Ask about the program’s statistics for live births or the “take home” baby rate. Be sure to ask about success rates for patients in your age group with similar diagnoses. It is important to know that on average women under age 35 will have a better pregnancy success rate than women over 40, regardless of the program they use or the physician who treats them. Fertility naturally declines in women as they age, with or without fertility treatments. The 2002 percentage of ART cycles resulting in live birth varied significantly depending on the age of the woman (source: 2002 Assisted Reproductive (ART) Report: 2002 Fertility Clinic Report by State: National Summary, reported online at www.cdc.gov) .
Years of age: Nationally reported “Take home baby” rates:
Under 35 36.9%
35-37 30.6%
38-40 24.7%
41-42 10.7%
Call CRBI for current pregnancy rates for your age group. Typically, they run at 50% for all age groups combined.
Ask questions about the laboratory.
Are private, comfortable, clean facilities available on-site for production of semen samples? Production offsite is generally not recommended due to the adverse effects of transport time on the semen sample. Is the laboratory inspected and certified or accredited by federal inspectors?Can the laboratory cryopreserve (freeze) your embryos for future attempts if you do not transfer all the embryos in the present treatment cycle? Is the laboratory available on weekends and holidays if you should need a procedure? Likewise, the physician or nursing staff should be available during treatment cycles.
Who is on staff at the laboratory?
According to the American Society for Reproductive Medicine (ASRM) , minimally, an Assisted Reproductive Technology program should have the following personnel:
• Physician with training and experience as a reproductive endocrinologist (RE). He or she should be board-eligible, if not already board-certified in reproductive endocrinology and infertility. The medical director must be a licensed physician and preferably be a board-certified reproductive endocrinologist. All of CRBI’s physicians are already board certified, not just board-eligible, in the specialty of Reproductive Endocrinology and Infertility (REI). This board certification requires additional training and certification beyond that required for Obstetrics and Gynecology.
• Physician with training in pelvic reparative (infertility) surgery as well as experience in laparoscopic and ultrasound-guided oocyte retrieval techniques.
• An embryology laboratory director who is either a qualified M.D. or Ph.D. with experience in the organization and maintenance of a basic or clinical embryology laboratory. Board certification as a High Complexity Lab Director (HCLD) by the American Board of Bioanalysts, is required by federal statute (CLIA ’88, final revisions).
• An ultrasonographer should be available on-site to provide monitoring of follicular development.
• An individual experienced in male reproduction (an andrologist) or urologist should be available to the program for consulting.
• Personnel with specialized experience in cryopreservation, micromanipulation or hormone assays should be available if these services are offered.
Minimum ASRM standards are described for the embryology laboratory, ethical and experimental procedures, record keeping and informed consent on ASRM’s Web site. (link to www.arsm.org)
Other resources
The Society for the Advancement of Reproductive Technology (SART) and the Center for Disease Control (CDC) have been working together to collect success rate data on individual infertility practices since 1995. Contact the American Society for Reproductive Medicine (1-205-978-5000) for more information on individual practice success rates for physician practices you are interested in. Keep in mind that SART statistics are three years behind (i.e., 2002 data is available in 2005).
Please see our links for other sources of information and support on infertility.
