Infertile patients cannot afford to wait for treatment while their eggs get older.
Dr. Sherman Silber, Infertility Center of St. Louis, is offering free video consultations for patients who need to plan now for their treatment while stay-at-home orders are in place. He is talking to and evaluating patients in their home via to comply with social distancing measures.
Dr. Silber is discovering that patients actually prefer this method of telemedicine consultation over the conventional office visit. Patients have conveyed that “it is so much more convenient and less stressful” to have a free telemedicine personal consultation than to take a day off from work to travel to the doctor’s office and sit with other nervous patients in the waiting room.
The COVID-19 pandemic is thus changing much of the way we will do things in the future, and for the better. "Our patients are surprisingly much happier with this approach. Of course, at some point we need to perform hands on treatment. But with this new manner of seeing patients, we can come to the right diagnosis and treatment plan for most patients more efficiently, quickly, and painlessly, with no loss of personal one-on-one communication.” This is a very welcome new era of telemedicine that has been forced on us by the current difficult times.
How to Get Pregnant with the New Technology – Preface
Note: This page refers to Dr. Silber’s 1998 book, “How to Get Pregnant with the New Technology”. In 2005, Dr. Silber published a completely revised and updated version of this classic book under the title, How to Get Pregnant, which lays out in clear, simple terms the basic information that will help couples understand their situation and achieve their goal – a happy, healthy baby.
The preface to “How to Get Pregnant with the New Technology”, Dr. Silber’s bestselling book, introduces the problems facing modern infertile couples and the breakthrough solutions that have been developed in recent years to combat infertility.
Twenty-five percent of couples in their thirties are infertile. Only 1 percent of teenagers are. There is a worldwide, emotionally wrenching epidemic of infertility, making it our nation’s number one public health problem. Even in a country like India with severe overpopulation, the most common reason for a visit to the doctor is infertility. From our teen years (when the last thing we really want is a child) to our mid-thirties when we finally feel emotionally and financially secure enough to start our family, there is a twenty-five fold decline in our ability to get pregnant.
If you are in your thirties, have been working hard establishing yourself, and are now just casually thumbing through this chapter at a local bookstore because you’re thinking maybe in a few years you might like to start a family, you should realize that there is a 25 percent chance you will not be able to do so without medical intervention.
These startling figures came out of the National Center for Health Statistics in 1985 and were presented to the United States Congress through a panel assembled by the Congressional Office of Technology Assessment in 1988. I was one of five physicians on that Congressional Advisory Panel. We have all witnessed an explosive increase in couples desperately struggling to have a child but it wasn’t until these statistics were formally assembled that we were stunned to find out just how staggering the problem is.
What accounts for this dramatic increase in infertility over the last twenty years? We could speculate about the increase in sexually transmitted diseases, environmental pollution, declining sperm count from absorption of toxic substances, and even the increased tension and anxiety of modern life. These may very well be contributing factors, but a major reason is simply that by the time the modern couple decides to have children, usually in their thirties, the human animal is just not as fertile as it was when younger.
Further analysis of these statistics, however, shows that age is not the only factor. In 1965, 18.4 percent of couples in their thirties were infertile, whereas in 1982, this figure had jumped to 24.6 percent. In younger, less infertile groups ages twenty to twenty-four, in 1965, only 3.6 percent were infertile; and in 3 1982, 10.5 percent were infertile. So we are no longer in a position of just speculating that there is an infertility problem which is on the rise. Hard, cold statistics show that nearly a quarter of the population that is trying to start a family cannot do so without medical help. A major contribution is the putting off of childbearing until later years, but this alone does not completely explain the increase in infertility because it is on the rise in younger people as well.
After this detailed report submitted to the U.S. Congress, what is the government doing about it? As one might expect, basically nothing. But there is help available. With dramatic new technology, virtually any couple (with a few exceptions) can have a child. But you are going to have to understand the myriad complexities of your own reproductive system in order to get the right help instead of the wrong help and also to figure out how to position yourself with your health insurance company in such a way as to get them to help bear the burden of the cost (as they should).
One of the views of the Congressional Advisory Panel that I was on (which consisted of lawyers, psychologists, sociologists, and religious leaders as well as doctors) was that society clearly benefit ted from this putting off of childbearing until the thirties. Both men and women are now able to obtain fuller educations, develop themselves in their careers, and contribute dramatically to the intellectual and economic prosperity of the modern world. This would not occur so readily if we were saddled with children as teenagers or in our early twenties. So if society is collectively making a decision to put off childbearing, it should be no one 5 position to advise couples condescendingly just to “hurry up and have children when they’re young. Luckily the new reproductive technology is a cost-effective solution for such couples, even though the insurance companies and government bureaucracy are often too dense to realize it. (top)
THE NEW REPRODUCTIVE TECHNOLOGY
In The New York Times Magazine in December of 1989, a forty-one-year-old writer named Paulette conveyed her sense of loss at trying to have a child in her late thirties, not succeeding, and now finding herself a successful forty-one-year-old writer who sadly “will probably never have a baby.” It wasn’t until she reached age thirty-eight that she decided to stop using birth control pills and tried to get pregnant. She read a book called Fertility Awareness and hoped she could get pregnant “naturally” with just a little bit of help from knowing more about the timing of her cycle and the quality of her cervical mucus. It wasn’t until she reached forty that she saw a local doctor who began “fertility testing,” including mucus testing, hormone testing, and “two endometrial biopsies” (a tiny piece of the lining of the uterus is sampled to see if it is capable of sustaining a pregnancy).
She was then given a grand diagnosis of”luteal phase defect.” This was a very popular diagnosis fifteen years ago, and many women were treated with progesterone supplementation in the second half of their cycle in an effort to “overcome” this problem. Later she was given an ovulatory stimulant pill, Clomid, because of the view that luteal phase defect is sometimes caused by a subtle “ovulation defect.” She then went through a procedure called “intrauterine insemination” in which her husband’s sperm was placed directly inside her uterus even though previous testing had shown that her cervical mucus was quite able to allow his sperm to penetrate on its own. These are simple, old methods of treatment that sometimes work and certainly make sense in a young woman trying to have a baby. But not for Paulette.
In fact, what Paulette went through is the conventional wisdom of trying to make a diagnosis and then using simple, non-invasive treatment appropriate to that diagnosis. The problem with this conventional wisdom is that, first, many of these “diagnoses are just normal variants which have nothing to do with why the woman is not getting pregnant, and second, when time has almost run out, fiddling around for too long with the old-fashioned approaches may waste the few precious years you have left.
With the new in vitro fertilization (IVF) and GIFT technology, we can bypass all of the incredible hurdles that sperm and eggs have to go through (even in a fertile couple) in order to achieve a pregnancy. We simply have to admit our ignorance that we often really don’t know why a couple isn’t getting pregnant. The benefit of the new technology is that we can avoid being fooled and self-deceived as doctors into making artificial diagnoses (albeit well-meaning) trying to pinpoint the cause of the problem. With the new technology, we realize that it is an amazing ordeal for sperm and eggs to actually meet each other and, if they do fertilize, for the resulting embryo to manage to implant in the womb and become a successful pregnancy. In young couples, this happens more easily. But in older couples, despite the appearance of normalcy, it just doesn’t happen so easily, and they may need all the help they can get in bypassing these hurdles.
I celebrated New Year’s with our son’s high school biology teacher (and swimming coach) and his thirty-nine-year-old wife, Pain, playing with their six-week-old baby, who never would have existed without the new technology of IVF and GIFT. She told me to make sure to tell everyone in this book how awful it is to go through the conventional series of “diagnostic” tests and ineffective treatments for years with one contradictory diagnosis after another and ineffective treatments. She had gone through seven years of this at the previous clinic she had used. She had two laparoscopic operations to remove tiny little implants of “endometriosis” and never got a satisfactory answer to her question of how her mother could have had five children despite huge implants of “endometriosis.” When surgery didn’t help, Pam was placed on progesterone, because they suddenly discovered “luteal phase defect,” and finally Clomid. She had literally hundreds of pills and doctors’ visits and tests.
Yet during a twenty-minute interview with them less than a year ago, I was able to tell her more accurately that I really didn’t know why she wasn’t getting pregnant. But her husband’s sperm count was low (less than 20 million per cc), and she was in her late thirties. That was enough reason for them to be infertile, and I recommended no more tests. She was thrilled when I suggested we proceed right to the new technology with GIFT. I recommended no more hormone tests, X-rays, laparoscopies, hamster tests, endometrial biopsies, basal body temperature charts, postcoital tests, etc. She was fed up with trying to figure out why she was infertile and getting nowhere. She conceived with the GIFT procedure, and now she and her husband have a healthy baby. She has no idea why she was infertile and neither do her original doctors who spent so much of her money on wild-goose chases. (top)
MISLEADING DIAGNOSES OF THE CAUSE OF YOUR INFERTILITY
The Simple Unexplainable Effect of Age
Even in the best-conditioned athletes, age has a way of slowing us down, sometimes imperceptibly year by year, and it doesn’t mean that there is any particular physical ailment or diagnosis to explain that slowdown. This is usually (though, of course, not always) the case in a couple who suddenly starts trying unsuccessfully to have babies in their mid-thirties.
In 1982, the French reported in the The New England Journal of Medicine on 2,193 supposedly “normal” women (whose husbands had no sperm whatsoever in their ejaculate) undergoing artificial insemination with fertile donor sperm. These were “normal” women and they were being inseminated with certainly normal sperm. There is no logical reason why they shouldn’t all have gotten pregnant. Yet it was very clear that “normal” women under thirty had a high pregnancy rate, and “normal” women over thirty showed decreasing pregnancy rates the older they got. A more recent study from Ontario published in 1989 in The Journal of Fertility and Sterility looked at over 2,000 couples with “unexplained” infertility. The chances of getting pregnant with simple, conventional methods of treatment were directly related to how young the woman was. No other factor studied was significant except for age.
Just recently I saw a woman, typical of many others I see every month, who got pregnant very easily as a young teenager after her first sexual experience and gave the child up for adoption. Five years later, again she got pregnant quite easily with a single sexual experience and kept this baby as a single mother. She continued to have completely regular, normal periods for six more years, got married, and then used condoms for birth control for three years until she and her husband were certain that their marriage was a stable one. By the time they decided to try to have children, she was thirty-three years old, and her menstrual cycles by now had become irregular, varying from twenty-five to thirty-two days. All of her tests otherwise were normal, but now she couldn’t get pregnant.
What happened to her subsequently is a terrifying story which exemplifies the pitfalls I am hoping to help you avoid with this book. She saw a doctor who diagnosed her as having “endometriosis” and “adhesions,” despite the fact that her organs were quite normal. He performed major surgery on her to remove the endometriosis and release the adhesions. As long as insurance companies require a “pathological diagnosis” in order to get treatment paid for, and as long as major surgery results in no difficulty getting insurance payment (whereas in vitro fertilization requires major verbal acrobatics to get payment), women like her run a good chance of being mistreated in this fashion.
The “Endometriosis” Myth
The most common, overused “diagnosis” for infertility is “endometriosis.” Endometriosis is a condition whereby some of the lining of the uterus has leaked back into the abdominal cavity and has implanted in little tiny nodules either in the abdominal wall, on the outside of the fallopian tube, or possibly in the ovary. When doctors perform a “laparoscopy as part of an in-fertility investigation to see if the woman has a normal uterus, tubes, and ovaries, most of the time the examination is normal. Nonetheless the diagnosis of “endometriosis is frequently put on the operative note just because the insurance company is much happier to pay for laparoscopy when they see a “pathological” diagnosis. The euphemism used to avoid the guilt of outright deception is to call it “minimal lesion” endometriosis. Doctors are often so anxious to find a diagnosis to determine the “cause” of infertility (not to mention the desire for patients to get insurance reimbursement) that many couples walk out of their long series of expensive infertility tests thinking incorrectly that they now know why they haven’t gotten pregnant. This might be harmless if it weren’t for the fact that it may lead to unnecessary or improper treatment.
The “Male Factor” Myth and “Varicocele”
There are there many popular “diagnoses” which may lead to inappropriate surgery that gets an infertile couple no closer to getting pregnant. The doctor may obtain a sperm count on the husband, find that it is “low” (below 40 million per cc), and not be aware of the fact that patients with low sperm counts often have little difficulty getting their wives pregnant. The husband may then be put on all kinds of totally ineffective drug treatments such as Clomid, Pergonal, HCG, testosterone, or, worst of all, be given that common diagnosis of “varicocele.”
A varicocele is a varicose vein of the testicle (usually on the left side) that is present in 15 percent of all males on the planet. It is just a common, normal anatomic variant, but it has been blamed for close to 40 percent of “male infertility.” In many of these cases of “male infertility” there is really nothing infertile about the man’s sperm anyway, but even so the varicocele has little to do with it. A careful study of 651 infertile couples with varicocele was published in the British Medical Journal by the Australians in 1985 demonstrating absolutely no difference in pregnancy rate among couples whose husbands had the varicocele operated on versus those who did not have the varicocele operated on. Similar studies have been repeated in Belgium and in Sweden. Fifteen percent of the men who come to the office for a vasectomy because they already have had all the children they wanted are found to have a varicocele on physical examination, and in my experience that is the same incidence of varicocele-; in infertile couples. It has been argued that 40 percent of infertile men have varicoceles, and it is implied that the varicocele is the cause of the infertility. But many of these so-called “minimal lesion” varicoceles are really not varicoceles at all by the common definition and are no different from what is found in a normal, fertile population.
But what happens to these couples once the diagnosis of varicocele is made in the man? Typically, the men get operated on, sometimes on one side, sometimes on both sides, and then they wait six months to see if the sperm count improves. Since sperm counts, like the weather, vary from month to month around a mean average value, it only makes sense that if you get one sperm count before this unnecessary surgery and one sperm count after this unnecessary surgery, at least half of the men will appear to have some improvement. But this is an illusion created simply by the variability, the up and down of sperm counts, and the failure to make note of those whose sperm counts have gone down after varicocelectomy.
We see many men who were sent by their wives’ gynecologists to a local urologist, who then makes a diagnosis of varicocele (even though there is none). He tells them the sperm count is too low, puts the man through surgery, and then claims some kind of improvement in sperm count. Meanwhile, the wife has wasted a year without treatment. The wife, her husband, and her gynecologist have all been under the illusion that they knew what the problem was, and that the “problem” was being corrected.
Sometimes the diagnosis of “poor cervical mucus” leads a woman to being placed on cough medicine in an effort to loosen up the mucus. Sometimes the diagnosis of “autommunity,” i.e., that the wife is in some way allergic or immune to her husband’s sperm, leads to the couple’s being told to use condoms for a year in order to lower her “antibody levels.” Sometimes the diagnosis of “low sperm count” which doesn’t improve despite a wide variety of different therapies leads the couple to try artificial insemination with “donor” sperm, and the woman still doesn’t; get pregnant because the “low sperm count’ really wasn’t the cause of the problem in the first place.
In fact, the ability of the sperm to fertilize has very little to do with the sperm count but rather with a combination of not too fully understood factors, including quality of sperm motion, structure of the sperm, and, quite shockingly, the quality of the wife’s eggs. Very poor sperm can often fertilize excellent eggs, whereas the best-quality sperm may be required to fertilize an egg from a relatively infertile woman. The most interesting example of this comes from cases of artificial insemination with donor sperm.
In couples whose husbands have absolutely zero sperm in the ejaculate, the use of donor sperm for artificial insemination results in a high pregnancy rate. For couples in whom the sperm count is low (i.e., there are some sperm present), the use of donor sperm results in a much lower pregnancy rate. Thus, we are often fooled into thinking the low sperm count was the cause of the infertility, when, in truth, in many, many cases it is not a cause of infertility. Only when the sperm count in the husband is zero is it clear that the cause of the infertility is bad sperm. Thus, infertility is in most cases a problem of “the couple,” and cannot easily be attributed specifically just to the husband or just to the wife. (top)
THE NEW TECHNOLOGY (IVF AND GIFT) BYPASSES EVERYTHING THAT CAN GO WRONG NO MATTER WHAT THE SO-CALLED “DIAGNOSIS” IS
The new technology of in vitro fertilization (IVF) and GIFT takes into account all of these problems and solves the quandary of our frequent ignorance of why couples are not getting pregnant. If the cause of the problem really is “low sperm count,” the new technology allows sperm to be placed right next to the egg where they do not have to go through the incredible ordeal of transport up through the vagina, then the uterus, and finally the fallopian tube, a journey which results in only 10,000 out of the original 100 million sperm making it. If the cause of the problem is poor ovulation on the part of the woman, the hormonal stimulation of the ovaries and the removal of eggs from the ovaries removes the obligation for ovulation. If the problem is poor cervical mucus blocking the entrance of sperm into the womb, the new technology bypasses that problem. If the problem is “endometriosis” (a highly questionable but very popular viewpoint), again the new technology bypasses the theoretically unfavorable environment for fertilization that endometriosis supposedly creates in the woman’s pelvis. If the problem is poor pickup of the egg by the fallopian tube from the surface of the ovary (a tricky feat in which the fallopian tube has to “reach over” and grab the egg by twisting back on itself), IVF and GIFT once again bypass this event.
Almost anything that can go wrong in the arduous process which sperm and eggs normally have to go through is bypassed and made easy by the new technology. In a sense, we are introducing” the sperm directly to the egg in an ideal environment in which they can truly get to know each other and making things much easier for them to get along. The fact is that no matter what the diagnosis (except that of completely blocked fallopian tubes or terribly low sperm count), the GIFT technique will; result in a pregnancy rate of 45 percent for each treatment cycle attempted despite many, many years of prior infertility and despite what the diagnosis is, whether correctly or incorrectly having been made.
Change in Thinking Now from the Early 1980s
My first book, How to Get Pregnant, emphasized simpler treatments for infertility in the 1980s. It also explained as much as we knew at that time about the details of just exactly how difficult it is for the sperm and egg to meet and result in a successful pregnancy. I have received hundreds of thousands of happy responses from people who have read that book, and the methodology described in much of that book is still valid (particularly the chapters on the function of the male and the function of the female). But now, years later, there is a whole new technology; that has vastly simplified the problem and, indeed, for many couples may well be the most cost-effective, quickest, and least painful way of solving their infertility problem. In the early 1980s, in vitro fertilization remained a last-resort, new-horizon-type approach available only to those unusual couples in whom other treatments simply wouldn’t work. It was much more expensive than any of the other available fertility treatments, and the pregnancy rates were estimated to be 2 percent or less. But now it is different.
In vitro fertilization techniques, and particularly modifications of in vitro fertilization such as GIFT, are yielding pregnancy rates as high as 45 percent per attempt, are being performed without the need for surgery, and are being done on an outpatient basis or on a one-day hospital stay. These high pregnancy rates are being achieved despite the fact that the infertility problems we see today are worse. First, couples are waiting until their late thirties to try to have children. Second, many infertile couples are getting pregnant using the simpler, conventional methods described in my earlier book, and that leaves large numbers of “more difficult” cases remaining for whom the conventional techniques didn’t work.
We know now that it is a waste of time for the man to have a varicocelectomy operation, or for the woman to go on a half year of Danocrine therapy to shrink up her endometriosis. We know the treatment of the husband with Clomid or routine doses of Pergonal and various other drugs will do nothing to increase his sperm count (see Chapter 5.) In other words, after going through the 1980s, we now know better what really works and what doesn’t work.
We understand more fully, by virtue of the in vitro fertilization experience, just how people do and don’t get pregnant, and we can bust some of the old myths. We can save the woman unnecessary surgery for “minimal lesion endometriosis.” We can actually see the follicle developing in the ovary with a simple ultrasound test and know exactly when she ovulates by when the follicle disappears or reduces in size, and we can avoid the emotional drain of literally years of fruitless testing and slingshot-style therapy. Paulette does not have to waste her few valuable remaining years of potential fertility by just testing her mucus and wondering whether she’s having sex at the right time. Tammy, who got pregnant easily as a teenager and now in her late thirties is happily married and wants a child, does not have to go through unnecessary surgery for endometriosis. Further-more, her husband doesn’t have to go for years on Clomid to try to increase a low sperm count that really isn’t too low.
Very often, by the time a couple has gone through years and years of wasted, inappropriate infertility treatments, they’re just; too worn out or their funds are absolutely exhausted, and they can’t even consider the new technology of GIFT or IVF, which would have been so much more likely to have helped them. Cynthia is a thirty-two-year-old woman treated for infertility for ten years with Clomid, artificial insemination, several laparoscopies, two varicocelectomies on the husband, and several operations to lyse adhesions despite the fact that in truth the cause of her infertility all these years had been completely idiopathic; (that means we just don’t know). Yet now that she would have a 45 percent chance for pregnancy per treatment attempt with GIFT, she is just too tired, frustrated, and emotionally depressed to go any further. (top)
ACHIEVING PREGNANCY WITH CONVENTIONAL METHODS VERSUS THE NEW TECHNOLOGY It is important not to be overly negative about the convention treatments that have certainly helped thousands of couples. So do not misinterpret the focus of what I am saying. Shortly after my first book came out, I heard from a lady who wanted to thank me for my simple solution to her problem. I had seen her and her husband almost a year earlier after being told that his sperm count was too low. She reminded me that I had taken one look at her oily skin, her history of acne, the hair on her toes, an told her she probably had an elevated male hormone level affecting the quality of her ovulation. She was writing to thank me and to let me know that despite several years of being told nothing could be done for her because of the husband’s lo sperm count, she got pregnant just two months after she started on Clomid.
That same day I also heard from a lady whose husband was about to undergo a varicocelectomy operation because his sperm count was “so low.” But she got pregnant before he had a chance to have his surgery. When they rechecked his sperm count, it was very high (over 50 million), despite his never receiving any treatment. She got pregnant after simply timing their intercourse to her ovulation day in the cycle. There was one couple who had been infertile for many years in whom the wife ovulated perfectly on day fourteen of every twenty-eight day cycle like clockwork. In fact, it was because her ovulatory cycle was so perfect and so regular; she always ovulated on Tuesday or Wednesday, and her husband, who is a traveling, workaholic businessman, was only in town on the weekends. So for all these years, they were infertile and never got pregnant simply because they were having sex only on the weekends. With her absolutely regular, predictable cycles, she always ovulated during the middle of the week. A simple rescheduling of their intercourse resulted in her getting pregnant rather quickly without any high technology.
One lady begged me to review her case even though she and her husband couldn’t travel to our clinic in St. Louis. At that time, we were estimating the quality and time of ovulation from basal body temperature charts (rather than ultrasound and simple LH urine testing, which is available today). Her basal body temperature charts clearly showed poor ovulation, but her doctor had insisted on not treating her because he felt the husband’s sperm count was too low. In fact, the local urologist had put the husband on the male hormone testosterone, which would only make his muscles bigger but would certainly lower rather than raise his sperm count. After her husband discontinued taking these steroids and she went on Clomid, she promptly became pregnant and I still receive a Christmas card every year from her despite the fact that we never met. There are countless, similar stories which tell why we should not completely throw out the old methods of fertility treatment. (top)
THE INFERTILITY PROBLEMS WE TREAT TODAY ARE WORSE THAN THOSE IN THE EARLY 1980s The problem of infertility in our modern society is getting worse, and the simpler methods don’t work for everyone. They should be discontinued after they have been shown not to be effective for a couple, and the newer technology used before too much time, energy, emotion, and money have been wasted on old-fashioned approaches.
It is years since I originally wrote How to Get Pregnant and first made the public at large aware of this rising epidemic of infertility. Since then, the problem has gotten much worse, but the solutions have gotten better. With refinements in the new technology of in vitro fertilization, GIFT, ICSI, and microsurgery, the most seemingly insoluble cases of infertility can be solved and most people can get pregnant. In addition, simple infertility problems can be solved more quickly. However, you are not likely to be able to benefit from this new technology unless you learn how it works. (top)