Overcoming Challenges Of Infertility
Interviewed by Melissa Moniz
Wednesday - January 28, 2009
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Dr. Christopher Huang
Reproductive Endocrinologist
Interviewed by Melissa Moniz
What is a reproductive endocrinologist?
I’m a sub specialist in reproductive endocrinology and infertility. In obstetrics and gynecology there are basically three specific sub specialties. One is gynecologic oncology cancer surgery, a second is perinatology or high-risk obstetrics, and a third is reproductive endocrinology and infertility, which is the study of hormonal disorders in women.
Reproductive endocrinologists work from early on in female development (puberty) all the way to menopause. There are a lot of things in between, from extra facial hair or abnormal breast discharge to more complicated areas like fibroid tumors of the uterus and infertility. Infertility is probably the biggest thing that we do and it includes all forms of evaluation from simple check-ups to advanced reproductive technologies such as in vitro fertilization (IVF), sperm freezing and artificial insemination.
What are the most common reasons why couples are unable to conceive?
The way we usually break it down is: 40 percent of the time the infertility is a cause within the woman, 40 percent of the time it’s a cause that the man might have, and 20 percent of the time it’s unexplained infertility, where we are not exactly sure of the cause. There are a number of female infertility categories. For example, there are abnormalities that can occur within the normal menstrual cycle. If we understand the normal menstrual cycle then we can really understand the problems that can lead to infertility in a woman.
As you may know, the brain controls reproduction and most of the hormones in the body, so the brain can also be involved in irregular ovulation. The most common ovulatory disorder that we see is polycystic ovary syndrome (PCOS), which is often associated with being over-weight. With this disorder, the problem arises because hormones are fat soluble, so when someone is overweight they have extra fat tissue on board. These extra hormones are slowly released into the blood stream and your brain picks up on it very well. When the brain senses these hormones, it thinks it is ready to ovulate when the ovary is not ready to. This leads to irregular ovulation, which makes it harder to get pregnant.
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Is that easily corrected?
In many cases it is, but not always. Other causes of infertility include blocked fallopian tubes, which can be caused by infections such as sexually transmitted diseases. This can block the sperm from getting to the egg and prevent the embryo from moving into the uterus. Another contributing factor includes tumors called fibroids. These are smooth muscle tumors in the uterus. They are the most common tumor in women and are rarely cancerous. Obviously, if a patient has a big tumor in her uterus, it’s going to be harder for the embryo to come down and attach.
Of course age is a very important factor because women are born with only a certain number of eggs, between 1-2 million. By the time they reach puberty they have about 450,000 eggs. Over time they use up those eggs and the quality goes down. So earlier on it’s easier to get pregnant compared to when they get older.
When you are 20-25 years old, the chances of becoming pregnant are 20-25 percent per cycle. When you reach 30, it’s about 18 percent per cycle; 35 years of age it’s 12-15 percent per cycle, and by 40 years of age it’s about 3-6 percent per cycle. It’s this big cliff.
So is age in women the biggest factor in the success rate of fertility treatments?
That is a major factor for us. It’s always harder when we have a 40-year-old walking in the door versus a 28-year-old walking in the door, as far as the likelihood of success. We do have plenty of poor responders at younger ages. And there’s a recent study that shows that Asians don’t do as well with infertility treatments as they get older. We’ve known that for a long time because we have a predominantly Asian population here in Hawaii. No question about it, we use higher doses of medications here versus the Mainland in getting women to ovulate.
Why is that?
We haven’t discovered that yet, but some of the theories include that Asians have a lower initial egg count, or maybe they use them up faster.
Can you discuss the common treatments to help with infertility and the success rates?
One of the most advanced treatments that we have is in vitro fertilization. In vitro has been a huge success. Technology has advanced dramatically as far as lab quality and success rates. However they’ve reached a maximum and we haven’t gotten much further because we can’t change the quality of the egg. One of the newer treatments is egg freezing. It’s an experimental up-and-coming procedure where a woman store eggs at a younger age if they want to delay their child bearing.
But as far as success rates with in vitro fertilization, a lot of it is based on the age of the woman or how old the eggs are. Some younger women can have very high success rates, upwards of 50 percent per try. It is very individual and depends how the individual responds. Other treatments include ovulation induction and artificial insemination.
You mentioned that the causes of infertility are 40 percent women and 40 percent men. Is correcting these causes easier or harder in men or women, or does it even out?
It just depends on the problem.
There are some men who have had testicular damage when they were younger or hormonal abnormalities. Sometimes we can’t correct the male factor, but it can be overcome. We can often overcome male factors by doing more advanced treatments. One treatment is intrauterine inseminations where we concentrate the sperm and place them into the uterus once the woman ovulates. Another is something called ICSI, where we take just one sperm and inject that sperm into the egg to help achieve fertilization. This is performed during an IVF cycle.
So with men, the common cause is the inability to produce enough sperm to fertilize the egg?
Yes, but they may not make enough sperm for a number of reasons.
Once it’s determined whether it’s a female cause or male cause, do many couples then opt for a donor?
Donors are one of the last forms of infertility treatments for us. We usually try to pursue more common treatments such as intrauterine insemination and ovulation inductions before we decide to move toward a donor. It’s sometimes very difficult for our patients to move that way. However, we are very successful with egg and sperm donors. Pregnancy rates can be as high
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