Questions & Answers

1) What does it mean to be infertile or sterile?

Around 15% of the couples have difficulties achieving pregnancy. Infertility is defined as the impossibility to achieve pregnancy within one year of trying. Many factors can cause this problem, both in men and in women. As both members participate in the search for their baby, the couple should always be studied as a whole by the reproduction specialist. In this way most couples can overcome the problem and have a child.

2) How long should we wait to consult with a doctor if we fail to conceive in a natural way?

You should wait one year before beginning Infertility or Sterility tests. This is due to the fact that human reproduction is highly inefficient, since the monthly pregnancy rate of a couple without infertility disorders is about 7%, and after 12 months this percentage exceeds 70%.
But in general, any couple unable to conceive within the first months of trying begins to think there might be a problem. First of all, the physician should explain to them that pregnancies usually do not occur right away, and most probably, it will not be long before they come back pregnant. If pregnancy is not achieved within one year, they should consult with a specialist.
The exception to this is when is when past conditions in the medical history of one member of the couple might have had consequences for their ability to procreate, or when the woman is over 38, in which case tests should be performed without delay. First of all you should consult with a reproduction specialist, because otherwise unnecessary tests or treatments are often prescribed and this may delay and even hinder pregnancy.

3) Which are the basic tests to be performed in the first place?

In order to get a rapid diagnosis the specialist should start creating a complete medical record to set down all the history related to the difficulties in achieving pregnancy. Special emphasis should be put on sexually transmitted diseases, surgeries, chronic diseases, contraception methods, miscarriages, intake of medicines, consumption of alcohol, drugs and tobacco, etc.
Husband and wife should be studied simultaneously, because male factors in couples represent 50% of the cases.
Tests are relatively simple and consist in finding out:
1) Whether the man has a semen with normal characteristics by means of a complete semen analysis. 2) Whether after the intercourse spermatozoa reach the upper part of the vagina and go through the cervix. A sperm-cervical mucus compatibility test is performed since in the natural process, they should swim and cross the mucus up to the egg (oocyte), but sometimes there is some kind of rejection that prevents this migration. This test is known as Post Coital Test.
3) Whether the woman ovulates normally, by means of hormones tests, temperature control and transvaginal ultrasounds.
4) Whether the uterus and the fallopian tubes are normal, which is detected by means of an X-ray known as hysterosalpingography. This allows to evaluate the route that spermatozoa and eggs must follow for their final encounter.
It is also important to perform a gynecological ultrasound with the purpose of ruling out uterine myomas that may either alter implantation or cause miscarriages.
Once these basic tests have been performed, the specialist can reach a diagnosis in the 80% of the cases. The small group of couples remaining still has to undergo other tests. Laparoscopy is a more complex test consisting of the observation of the ovaries, tubes and uterus through an optical instrumental introduced through the navel. This is a minor surgical procedure. If necessary, the specialist may also order immunological, genetic or infectious disease tests.

4) Can all infertility disorders be solved?

This question generally gets a false answer, as almost every infertility disorder can be solved in theory, but actually this does not always happen. In order to clarify this it is necessary to analyze several aspects:
Success rates for these treatments are 15-45% per attempt (depending on the couple’s problem and the treatment in question). The higher the number of attempts, the higher the chances to achieve pregnancy. Thus, it is likely that the procedure will need to be performed twice or more.
The cost. Assisted reproduction treatments are expensive and the so-called high-tech procedures are not performed in public hospitals, so patients must turn to private centers.
The commitment. These treatments demand a great emotional effort and you also invest time in them. This applies mainly to women, who have to go to the physician’s office many times during the treatment, with the obvious disadvantages for their careers and economy.
When I talk in my office with patients who need an Assisted Reproduction Technique and they ask me about the chances of pregnancy, I tell them to have patience, because success is not always achieved on the first attempt. I also tell them that if the result is negative, they may have to try again and that I will do my best to help them endure the difficult situation that is the impossibility to conceive.

5) Can gynecologists who are not specialized in reproduction treat an infertile couple?

No, they cannot. Due to the major advances in human reproduction tests and treatments in the last years, non-specialized professionals have neither the resources nor the expertise to help that couple without wasting time.
It is obvious that the frustration resulting from the impossibility to procreate is enormous and that the couple will be maintaining a fragile balance. That is why they should not waste any time and consult with a specialist either by their own choice or on referral by their family doctor. In my office I very often meet couples who have undergone unnecessary tests or treatments that defer the achievement of pregnancy.

6) How long does it take the specialist to make a diagnosis?

The reproduction specialist will take about two months to reach a diagnosis of the reasons why a couple cannot procreate. Then the treatment should begin immediately, because any waste of time would involve some kind of stress, diminishing the chances of success.
When you know the cause of infertility and its origin it is simple to discuss a treatment plan to achieve pregnancy with the couple.

7) What are the pregnancy rates offered by treatments?

In the last years there have been significant changes in the study and treatment of human infertility. Nowadays, most couples can achieve pregnancy, but sometimes it is necessary to undergo several cycles of the same treatment. The specialist should offer all the available information about tests, treatments, costs (it is a known fact that neither social security institutions nor private medical insurance plans cover these treatments), duration (because sometimes it may take months or even years), pregnancy rates (which vary depending on each couple), and possible complications. Once they are clear about all this information, the couple will be better prepared to decide when to begin their treatment. Success rate per attempt is about 10% for ovarian stimulation with timed intercourse, 15-20% for intrauterine inseminations, 35% for IVF or ICSI, and 45% for egg donation. It is clear that the decision about what treatment to perform results from the disorder diagnosed by the specialist. When we repeat the procedures we will again find similar rates.

8) What should I do if I am over 35 and cannot get pregnant?

If you are over 35 and you have been unsuccessfully trying to get pregnant for some months now, you need to be aware that you should not waste the precious time you have ahead of you.
A woman older than 35 that has been unsuccessfully trying to get pregnant for 6 months should immediately see a conjugal infertility specialist to see what is going on.
I need to make this point clear because in my office I have often met couples in which the woman is 40 who have been trying to get pregnant for 5 or 6 years. They have been treated by their family doctor, who did not guide the tests and treatments in the appropriate direction, wasting 3, 4 or 5 precious years and thus making the success rate for this couple extremely low.
In my office, when I see a couple in which the woman is over 35, I should deal with tests and treatments bearing in mind that the most important problem is the woman’s age, even though the couple may perhaps present some other infertility disorder.
Then tests will be performed as soon as possible and in about 2 months we will have a quite clear and full picture of the situation. These tests will be a complete semen analysis, and a hormonal test and a hysterosalpingography for the woman.
Once these basic tests are complete, the therapy option will be decided on trying to optimize schedules so as to avoid wasting time. You can even choose to skip some treatments that might involve a significant investment of time but have a low success rate, which would be more convenient for younger women but not in these cases.
The treatments to be performed will be ovarian stimulation if there are ovulation disorders, and intrauterine inseminations if there are cervical mucus-semen interaction disorders or mild male factors.
If we find tubal occlusions or infections, severe endometriosis, severe male factors, or if 3-4 ovarian stimulation cycles or inseminations have failed, we should rapidly turn to assisted reproduction techniques such as IVF or ICSI.
My point here is that it is essential for the specialist to make accurate and rapid decisions about the appropriate treatment for these couples, without any waste of time, so that they may have the highest chances in their search for pregnancy. Time lost in this stage of life, even if we are speaking of a few months, cannot be recovered.
Even if it is certainly possible to bear a child after 38, 40 or more, the chances obviously begin to decrease as the woman’s age increases.
Summarizing, couples in which the woman is over 35 and have been trying to get pregnant unsuccessfully for 6 months should visit a specialist who will definitely offer them the best chances, by making an accurate diagnosis and choosing the right treatment in the shortest possible time. After that, they are likely to be successful and achieve that long desired pregnancy.

9) What are pregnancy risks after age 35?

After age 35, female fertility begins to decline, and it is much more difficult to achieve pregnancy after 40.
After 35, egg quality begins to decline and consequently, the possibility to generate chromosomal alterations such as the Down’s Syndrome, which has an incidence of one in 1500 in mothers under 30 but rises to as much as one in 80 by the time mothers are over 40.
If the woman actually gets pregnant, there are also more risks of miscarriage, due to the same problem (alterations in the egg quality).
Even so, these figures should not stop a couple’s decision to try to have a child, because there are many tests to determine pregnancy risks.

10) What genetic tests can I undergo to know whether my baby is fine?

In this context, women who get pregnant at a late age should undergo some tests that are designed to detect possible anomalies in the baby’s chromosomal constitution.
One of the tests regarded as non-invasive (because they do not involve any risk of pregnancy loss) is the ultrasound screening of the first trimester known as NT Plus 11-14.
This test detects an 80% of pregnancies presenting abnormalities as well as the existence of a multiple pregnancy and possible cardiac defects in the fetus.
On the other hand, chorionic villus test and amniocentesis are the most representative tests among the ones considered invasive, and involve an estimate risk of 0.5-1% of miscarriage.
In the first test, between week 11 and 14 of the pregnancy a biopsy of the placenta cells is taken by means of a fine needle introduced into the woman’s abdomen as the procedure is monitored with an ultrasound image. After analyzing the sample obtained, you can diagnose the baby’s chromosomal constitution. For the amniocentesis, you have to wait until week 15. This test consists of the extraction of amniotic fluid by means of a fine needle introduced into the woman’s abdomen as the procedure is monitored with an ultrasound image. The analysis of this material will also allow to determine baby’s chromosomal constitution.

11) Until what age will I be able to bear a child?

The woman has a chronological age to bear children that begins with her first menstrual cycle (approximately between 12 and 15 years) and ends when menstruation disappears (approximately between 40 and 50 years). Although there have been many advances in reproduction tests and treatments, the period during which a woman can bear a child has not been altered.
After 35, female fertility begins to diminish and it is much more difficult to achieve pregnancy over 40.
That is why after 35 and after a reasonable period (around 6 months of trying without a positive result), it is advisable to consult with a specialist, who will make the diagnosis and suggest treatment in the shortest possible time, to facilitate the achievement of that long desired pregnancy
The maximum limit to have children recommended by medical experience is the biological limit (between 40 and 50 years), but it will all depend on the physical and psychological condition of the woman when she has to make this decision.
We know that after 38 there are more risks for the pregnant woman (high blood pressure, diabetes, etc.) and also more chances of a C-section because the tissues are less elastic than they were at a younger age. The risks for the babies are greater when the mother is over 35 because of the increase of genetic disorders (such as the Down's Syndrome). These disorders increase as the woman grows older, but she will still be able to procreate until the moment when her menstruations disappear.
When the woman is older than 40, we know that her chances of getting pregnant are very low, and the chances of miscarriage or genetic disorders in the babies are considerably higher. Even so, it is her decision or the couple's to continue their search for a child. When the woman is older than 45 or when her periods have disappeared before reaching this age, she is often informed about the possibility of undergoing an egg donation treatment, consisting of the use of eggs from younger women that are donated to the women who need them. This is a complex treatment, which requires to provide the couple with very clear information because it involves deep moral, ethical and religious issues.
In short, such decisions as having a child are very personal and profound and thus the physician’s role is not trying to impose their own beliefs on a woman, but informing her about her real possibilities of satisfying her desire and the existing risks, guiding her in her search and supporting her, offering options that enable her to be better informed to choose.

12) Do assisted reproduction treatments involve any complication?

Until today, no increase in malformations or genetic disorders have been observed in patients undergoing IVF or ICSI as compared to general population.
The main complications, ovarian hyperstimulation and multiple pregnancy, derive from ovarian stimulation.
In general, we perform a significant stimulation in order to obtain a large number of eggs. However, in some very rare occasions, egg production is much higher than the one we are seeking for. This results in a condition known as ovarian hyperstimulation syndrome, consisting of ovarian enlargement with accumulation of fluid in the belly, multiple kinds of discomfort and disorders in the blood test results. Very rarely does the patient have to be hospitalized and the syndrome is generally cured spontaneously.
The second complication, multiple pregnancies, also derives from an excessive stimulation. It is known that twin pregnancies are not considered a complication, because risks for the mother and babies are only slightly increased. However, pregnancies with triplets and more (high-order multiple pregnancies) really imply serious complications both for the pregnant woman and the babies. The delivery will be pre-term and the babies will be premature, with the huge risks involved, and the possibility of permanent problems for the babies.
Anyway, even though stimulation is significant, with IVF or ICSI all the eggs available in the ovaries are retrieved but only 2-4 embryos are transferred, depending on the woman’s age, which makes very difficult the occurrence of high-order multiple pregnancies with this technique. Most complications derived from ovarian hyperstimulation occur in low-tech treatments such as ovarian stimulation or insemination, which can be performed by gynecologists who are not reproduction specialists and sometimes do not take the appropriate precautions.

13) What are my chances of a multiple pregnancy if I undergo an assisted reproduction treatment?

Infertility specialists divide treatments into two groups: low-tech and high-tech treatments.
In low-tech treatments (such as ovarian stimulation, inseminations, etc.), either as a single treatment or as a complement to others, we try to make the woman produce several eggs by means of ovarian stimulation, with the purpose of increasing the chances of pregnancy. In these treatments, egg release, their union with spermatozoa, the formation of embryos and their implantation in the uterus are all processes that take place in the woman’s body in a natural way, without intervention of the specialist who is treating her.
In these cases it is not easy to control how many eggs the woman will generate, how many embryos will form or how many of them will implant in the uterus and continue the normal pregnancy. For this reason, the way to prevent multiple pregnancy in low-tech treatments is to control the quantity of eggs that the woman is likely to produce in that stimulation cycle by means of ultrasounds and blood tests. If the quantity is likely to be excessive and consequently there are many chances of a multiple pregnancy, the specialist should advise the couple not to have intercourse that month and try again the following month with a lower hormone dose.
If we are talking about an insemination, as in the previous case, it will not be performed that month but the following, in a new ovarian stimulation cycle with a lower hormone dose. It is important to emphasize that it is precisely in these low-tech treatments where you have the highest rate of multiple pregnancies, mainly quadruplets or more. This is mostly due to the fact that as these treatments do not require advanced technology they are performed by physicians who are not reproduction specialists and thus ignore the appropriate controls to anticipate and prevent multiple pregnancies.
On the other hand, there are many factors of conjugal infertility for which sperm and egg cannot meet spontaneously in the woman's body and require a high-tech treatment to help this meeting to occur, in a process which will take place outside the body. These methods are In Vitro Fertilization and ICSI, which are indicated for more severe infertility cases. In these patients we also use ovarian stimulation, but eggs are retrieved from the ovary and inseminated “in vitro” (that is, outside the woman’s body) with her partner’s sperm, forming the embryos that are then transferred by the gynecologist into the female uterus. In my opinion, the ideal quantity of embryos to be transferred is 2-3, which enables the couple to have a success rate of 35% with low chances of a multiple pregnancy. It is important to know that when that number of embryos is transferred, an 80% of the births will be of a single baby and the remaining 20% will be multiple (mainly twins and a few triplets).
In these high-tech treatments, the woman is monitored more closely, as ultrasound and hormonal tests are performed daily.
As you can see, the greater danger of multiple pregnancies are in the simpler treatments, and the specialists should be specially cautious with these.
Once there is a multiple pregnancy, it should be understood that in general twin pregnancies do not involve major problems, but triplets or more bring about frequent and significant problems.
Reproductive medicine has made a big advance in the last years, enabling many couples that previously could not have a biological child to have one or at least try with high chances. However, specialists should further adjust control mechanisms in treatments in order to prevent multiple pregnancies that put the normal development of a pregnancy and the birth of the future babies at risk.
The Ethics Code of the Sociedad Argentina de Esterilidad y Fertilidad (Argentine Society of Sterility and Fertility) advises to avoid the gestation of more than two embryos because of the risks involved. In low-tech treatments, the code leaves the physicians free to decide whether he should advise the patient about the discontinuity of the treatment when there are risks of a multiple pregnancy. In high-tech treatments, it is advised to transfer the lowest possible number of embryos, which enables a good chance of pregnancy with a minimum risk of multiple pregnancy.

14) Why don’t you transfer a single embryo to prevent multiple pregnancies?

If we decided to transfer only one embryo instead of 2 or 3, we would surely run no risk of multiple pregnancy, but the chances of success for this couple would drop from 35% to 10%, which would make these complex and costly techniques unviable.

15) What happens when there more than four embryos?

If more than 3 or 4 embryos have formed, we cryopreserve (freeze) the rest either as pronucleate oocytes (prior to the formation of the embryo), or as embryos, for their future transfer in subsequent treatments.
Undoubtedly, the decision to cryopreserve must be made by the couple themselves after being clearly informed about this procedure and their ethical and moral implications.

16) What is embryo cryopreservation?

When you perform a high-tech assisted reproduction procedure such as IVF or ICSI, the ovaries are stimulated with the purpose of producing a significant quantity of eggs. These eggs are aspired by means of a transvaginal ultrasound transducer. In the laboratory, the eggs are inseminated (IVF) or injected (ICSI) with sperm for the purpose of forming embryos. If the couple agrees with the concept of embryo cryopreservation, a significant quantity of eggs will be inseminated or injected (6-12).
If the couple does not agree with this concept, 3-4 eggs will be inseminated or injected and the rest will be discarded. If cryopreservation is accepted, once the embryos are formed (up to a maximum of 8) 2 or 3 embryos will be transferred and the rest will be cryopreserved to be transferred in subsequent cycles without having to perform ovarian stimulation, which makes this second treatment simpler.
Needless to say, the specialist should discuss cryopreservation thoroughly with their patients, providing them with all the information available, explaining to them what this procedure is about and letting them choose according to their own thoughts and feelings.

17) What is egg donation?

Female organs involved in reproduction are several: vagina, uterus, fallopian tubes and ovaries. The ovary has the capacity of producing eggs, which are the female gametes forming the embryo when joining the spermatozoon. Female ovaries produce eggs during women’s reproductive life, that is, from the moment they begin to menstruate to the moment menstruation disappears at 45, 50 or 55 years (menopause). A woman may no longer ovulate because she ceased to menstruate before the age of 40 (precocious menopause or premature ovarian failure). Also, a woman may ovulate, but still her eggs may be inadequate, unable to form an embryo and consequently unable to achieve pregnancy.
In both cases, the woman will not be able to have biological children and may turn to donated eggs.