A Transcript of Dr. Silber’s Infertility Q&A
“Infertility Chat on Mom.com”
Monday, February 7, 2000
Dr. Sherman Silber
International Fertility Expert
Author of How to Get Pregnant
PregnancyEditor: Mom.com is proud to present Dr. Sherman Silber, one of the world’s leading fertility experts and author ofHow to Get Pregnant. If you have further questions for Dr. Silber that don’t get answered tonight, you can call and make an appointment with his office at (314) 576-1400. Dr. Silber, please tell us about yourself.
Dr. Silber:Well, it’s really a pleasure to be in this chat room. I’m an infertility physician and researcher. My infertility center is in St. Louis, Missouri. I developed most of the techniques for the treatment of male infertility that have evolved over the last 25 years, including vasectomy reversal and ICSI [intracytoplasmic sperm injection], which is the method of injecting otherwise infertile sperm in the wife’s egg. Using this, we’ve really been able to solve the worst cases of infertility. Starting in 1980 and revising it over the last 20 years, I’ve written How to Get Pregnant, a book about infertility published by Time-Warner.
Chelsee asks, “You provide treatment for exactly what ailments?”
Dr. Silber:Chelsee, first I need to explain that the majority of cases of infertility, no matter how many different tests are performed, do not really have a valid explanation. Very often, physicians fool themselves into thinking they have an explanation for the couple’s infertility. So the standard answer we would give would be 40 percent poor sperm, 40 percent female problems and 20 percent a combination of male and female problems. Except for cases where the husband has extremely poor sperm count or the wife has tubal obstruction, in most cases, the diagnosis is not really valid. When couples are not getting pregnant over a period of time, despite everything else seeming to be okay, you still must treat them. That’s where the new technology comes in.
Vps asks, “How does ISCI work?”
Dr. Silber:Vps, with ICSI [intracytoplasmic sperm injection, we pick up a single sperm by its tail and inject it into the wife’s egg. The whole thing is invisible to the naked eye. You need 400 times magnification. You do this procedure when the sperm is incapable of fertilizing naturally. But we completely correct that by delicately injecting it into the egg, so the sperm doesn’t have to do anything at all. It’s just a package of the husband’s DNA.
ElizabethB asks, “How do you determine if the infertility is caused by the male or female partner?”
Dr. Silber:ElizabethB, that is a great question! Many doctors get confused about it. We’ve done a great deal of research on that very question. Most of the time, you can’t really be certain if there isn’t a female component even the sperm count is terribly low. For example, a 20 year old woman will often get pregnant easily with her husband having a terrible sperm count. And they may have their first child successfully without any treatment. But then when she’s 30 years old and her eggs are not as fertile, now she can’t get pregnant without ICSI. And, so, if the sperm count is less than 10 million, and the motility is less than 40 percent, then usually it is the husband’s problem. But, there is often a female component as well. We solve all those problems, whether male or female, with ICSI.
Vps asks, “So, would ISCI be for sperm that is not motile?”
Dr. Silber:Vps, Most of the time, when the sperm is not “motile” there is a little bit of a shaking wiggle. So, it’s extremely poor motility, but not completely non motile. So, if there is the slightest wiggle to just an occasional sperm, then with ICSI the results are just as good as if the husband had vigorously motile fertile sperm. So, the wiggle … however slight … tells us that the sperm is alive and that the DNA is good. Now, if there is absolutely zero wiggle, we can still solve that problem by retrieving sperm directly from the husband’s testicles. Hearing this may make him wince, but we do it microsurgical and painlessly, believe it or not. The sperm that we retrieve from the testicle will always be alive and this procedure is called TESE. This is a procedure that we invented in St. Louis and in Brussels in 1993. There’s hardly any man … no matter how severe his problem … that can’t be a father.
Oberlies asks, “We have done two IVF [in vitro fertilizations], six FETs [frozen embryo transfers] and one ZIFT [zygote intrafallopian transfer], and have no idea what is wrong. We also had an endometrium biopsy sonohistogram done today, and they were all normal. Any thoughts?”
Dr. Silber: Oberlies, I’d like to know your age and how many eggs did they retrieve in those cycles?
Oberlies says, “I am 32. Wee had 16 eggs, and nine were fertilized in last cycle. We had ICSI done.”
Dr. Silber:Oberlies, I know you’re disappointed but you need to recognize that even in a favorable case like yours, the pregnancy rate in the best centers is still only 50 percent per cycle. And so the chance that you would have a pregnancy in two cycles is still only going to be about 75 percent. So my recommendation is to choose the best center with the best results. And also, be persistent and don’t give up.
Josephine asks, “This might sound silly, but will weak sperm effect the health of baby?”
Dr. Silber:Josephine, that question does not sound silly to me at all. It is the key question. Our answers are very favorable, but I would like to specify the results so they can have full information. We have carefully studied the first 1,000 ICSI babies for any pediatric problems over the last 7 years. And, we’ve also studied the chromosomes of the first 1,000 ICSI babies and what we find is that there is no greater incidence of abnormalities in ICSI babies than in any normal population. About 2.5 percent of all babies have some sort of problem that they are born with, whether mild or severe and this is the same for both ICSI babies and a normal population. However, our genetic research with chromosomes tells us that in some cases the male babies will have the same infertility that their father had.
Pcq asks, “Has infertility always been as widespread, or do we just know more about it and talk more openly about it now?”
Dr. Silber:Pcq, infertility is an epidemic that is increasing. About 25 percent of couples in their mid-thirties are infertile. About 16 percent of couples in their mid-twenties are infertile. Probably, the majority of women who are 40 or older are infertile. So, it’s a huge problem and it is increasing. There are two major reasons that it’s increasing. Number one, people are putting off their child bearing efforts until they’re in the thirties nowadays. And you are 25 times less fertile in your mid-thirties than in your early twenties. The second reason is that there’s evidence from detailed European studies that tells us the sperm count is going down. We think in our research that we’ve pinpointed the genetic reasons for this decline in sperm count. So, yes, infertility is on the rise.
Westphal says, “Dr. Silber, we are 99.9 percent sure that I don’t ovulate without help. I had my first child with the help of Clomid. I still haven’t had a period since my son was born six months ago. What is the likelihood that I will have to use Clomid again?”
Dr. Silber:Westphal, how old are you?
Westphal says, “I’m 30, and if it makes any difference, I was on the pill for about 10 years in order to have periods. I was off the pill for a year before I was successful with the Clomid. Also, are there other options than the Clomid?”
Dr. Silber:Westphal, in first place, Clomid is the easiest, simplest way with a person with your problem can get pregnant. You’re very lucky to get pregnant. The problem could be that as you get older, you may need something more serious than Clomid, such as shots and, of course, IVF. So, if you want to get pregnant again, I would recommend you not waste any time. Try the Clomid, but keep in mind that it may not work the second time because you’re older. You may need a more aggressive treatment.
Californiagirl asks, “Aside from the statistics, which can be depressing, do you have suggestions for dealing with the emotional side of infertility — how to stay positive in the face of many failed attempts at getting pregnant?”
Dr. Silber:Californiagirl, well, you are right. The emotional aspect of this is very crucial. In fact, it’s controversial, I admit. But often if you don’t have emotional counseling, that could even lower the pregnancy rate because of contractions of the uterus that can get aggravated by intense anxiety. I have found that forcing yourself to say that there’s no problem and that you will get pregnant doesn’t work. It makes you more anxious. The only way of dealing with the terrible emotional impact this has is to get more knowledge. Knowledge is power and the more you truly understand about how you do and don’t get pregnant, and how your body works, the more emotionally comfortable you’re going to be. But it’s something you can’t force. You simply have to devour information.
JoyceB says, “Dr. Silber, I had a miscarriage in May of last year. I used to be so fertile that my husband and I had to be really careful about intercourse. Since the miscarriage, we’ve tried to conceive, but my period gets really intense and I think I may be miscarrying again. Do you have any thoughts on that?
Dr. Silber:JoyceB, did you have a period of infertility of maybe a year or more before you got pregnant and miscarried? Also, I’d like your age.
Joyce b: No, I was celibate and I’m 34.
Dr. Silber:JoyceB, at age 34, about 25 percent of pregnancies will end in miscarriage. In your situation, it is not necessarily a worrisome sign for the future because in almost all those cases, eventually you get pregnant and carry the baby. Now, the reason for the miscarriage that you had is almost certainly, a genetic error in the concept occurred. It’s just nature’s way of eliminating such an error. Actually, the fact that this happened should be reassuring. The reason I say that is that I don’t think you are infertile and when you do get pregnant again, the chances are 75 percent that you’ll carry the baby because it will be a normal baby. But, if there is an abnormal fertilization, you might very well miscarry again and there’s a 25 percent chance of that happening. Human reproduction in the thirties is just that chancy. The odds are 75 percent that, when you get pregnant, it will be okay.
Tad2u asks, “In your book, you say that it is possible to get pregnant even if the male has no sign of producing sperm, as long as there are sperm precursors present. What percent of men show no signs of sperm production, and what are the reasons behind it?”
Dr. Silber:Tad2u, 2 percent of men appear to have zero sperm. And we used to consider them to be, of course, hopeless. But, now with a sperm recovery procedure called TESE, we can microsurgically operate on these men under local anesthesia and, in the great majority of cases, we can find a few sperm. All we need is a few sperm. And then the ICSI procedure will be just as successful as if the man is normally fertile. We have to hunt around to find those few sperm, but most of the time we’re successful. Now in cases where we still don’t find any sperm in the testicle, we currently are in the midst of a research project to force those sperm precursors, which we call spermatocytes, to continue their development into sperm. This is very complex but we have strong hopes that we’ll have this solved in the next year.
Pcq says, “I desperately want a child but I worry about the potential of multiples.”
Dr. Silber:Pcq, that’s a legitimate concern. This is because you’ve always heard publicity about these really terrible cases where women have had as many as seven children born at a time. This is extremely dangerous. When this happens, it’s the result of terribly stupid blunders on the part of the physician. In other words, if you go to a good doctor at a good infertility center, they won’t let this happen to you. It’s possible you might have twins or triplets, but certainly not worse than that.
Oberlies asks, “If you have had several failed reproductive procedures (IVF, FET, ZIFT)age 32 and suspect implantation problem what tests would you run?”
Dr. Silber:Oberlies, first place … some infertility centers have higher pregnancy rates than others. So, firstly, before you do any other testing, make sure you’re going to a center that has the best results. Assuming you’ve done that, you need to get you and your husband karyotyped. That means that we’ll look for chromosome imbalances in your husband and you that could be resulting in abnormal embryos.
Secondly, you need to have a hysteroscopy and HSG x-ray to make sure that the structure of your uterus on the inside is normal. Some physicians will recommend a large series of immunology tests but our studies demonstrate that these tests are not of any help for your problem and will just a huge amount of remuneration from you to the laboratory. So, therefore, I don’t really recommend all of these immunology studies.
Pcq asks, ” How do they prevent multiples from happening? The thought of selective reduction is unsettling to me”
Dr. Silber:Pcq, if you go through IVF or GIFT of ZIFT, your physicians will select the best two or three embryos and only transfer them. All of the extra embryos will be safely frozen and given back to you at some other time so you can have all the children you want but you won’t have a dangerous multiple pregnancy. And, this requires that the infertility center have a good freezing program. Now, if you’re over 40 years old, you definitely don’t’ have to worry about a multiple pregnancy. And then the physician can transfer more embryos without any fear. Finally, if it’s hard to make a determination two days after fertilization or three days after fertilization of which are the best 2 or 3 embryos we can culture them until day 5, and make a much better selection. In any event, extra embryos should not be transferred to you but rather should be safely frozen.
Pcq asks, “At age 37, do I have to worry about multiples?”
Dr. Silber:Pcq, at 37, it would be important to be careful how many embryos to transfer. You’re right on the borderline where we should still be cautious and only put back three.
Pcq asks, “Can a tilted uterus effect fertility?”
Dr. Silber:Pcq, absolutely not! No affect at all.
PregnancyEditor: Can a woman freeze her eggs for later?
Dr. Silber:Normally, eggs cannot be frozen. Embryos can be frozen. So, naturally a 25 year old career woman would much rather freeze her eggs now and try to get pregnant when she’s 40 with those frozen eggs which would be 25 years old when she’s 40. They would be very fertile and, in fact, that’s true of embryos. If the woman is 25 and we fertilize her husband’s eggs with her husband’s sperm and freeze those embryos, we can put them back into her when she’s 60 and she would have no problem getting pregnant. The problem is that in order to retrieve eggs, we have to get them into a mature state as they are inside a follicle. Eggs in that mature state have such a complicated structure (microstructure), which we call the spindle, that they don’t tolerate freezing. The embryos, or the fertilized eggs, tolerate freezing, but the unfertilized eggs don’t. But there is a solution and it’s a radical solution. We can actually take out an entire ovary, shave off the outer surface where all the eggs are, freeze it just like we freeze an embryo – and because they’re immature and they will tolerate the freezing just fine. Then we don’t even need to do IVF 20 years later. All we’d have to do is thaw that ovary, place it back in the woman’s pelvis, and she would get pregnant naturally. We call that ovarian tissue freezing.
Oberlies asks, “Can a t-shaped uterus effect conception?”
Dr. Silber:Oberlies, yes. Usually, a t-shaped uterus is caused by your mother having taken DEF. The pregnancy rate is much lower. We have gotten women pregnant with a t-shaped uterus, but, if they don’t get pregnant after putting good embryos in, an option might be to use a surrogate and our favorite surrogate would be to use either your sister or your mother. Most likely, the mother would have no problem carrying the baby. So, the mother would be carrying her own grandchildren.
Dragnfly asks, “What is the process to carry a child for a friend — is it more likely that someone who’s carried a child successfully in the past to get the IVF to take?”
Dr. Silber:Dragnfly, well, no, it will work fine whether you’ve been pregnant before or not but it’s very important to look at the emotional side of this in selecting a surrogate. Someone who has not yet had her own children may have a difficult time giving a baby back to the genetic parents. We feel it’s important that the surrogate not be doing this for pay, for any money, or per contract, but simply out of love. That’s why a previously pregnant sister or mother or extremely close girlfriend would be the ideal surrogate.
TerryWilliams asks, “I’m thinking of surgery for endometriosis. Will I have a better change of getting pregnant?”
Dr. Silber:Terry, I think you need to read in detail how I explain endometriosis in my book because it’s very controversial. Frankly, I am not an enthusiast for 95 percent of surgery-type cases for endometriosis because most of the time, it really doesn’t help and sometimes it can cause a situation to be worse. In short, I am not an enthusiast for endometriosis surgery.
PregnancyEditor: Ah folks, thanks so much for your questions! We’re almost out of time, and we’re about to wrap up. Sorry if we didn’t get to you. Stay tuned for Dr. Silber’s closing words.
Dr. Silber:Infertility is a terrible emotional burden, but you’re not alone because, as I’ve said, almost 25 percent of the modern world is infertile. But, the technology that’s available to solve the problem really works in most cases. You have to research it, be knowledgeable, and go to a good center. Just continue to become more and more of your own expert. You really have to be an enlightened consumer to benefit from this technology. But you need to read and understand more. Go to the library, and come to websites like this to learn more. Thank you all very much!
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