Your Top 10 Infertility Questions
If you are facing challenges regarding fertility, I’m sure you have already scoured the internet for any and all solutions. I totally get it. It’s incredibly anxiety provoking because so much of it is out of your control and who likes to feel out of control? Not me. I regularly get asked the same questions from clients who might be on the earlier side of their fertility process and are searching for answers. This blog answers your top 10 questions about infertility because #infertilitysucks but you don’t have to walk blindly through it. Let’s jump in!
When should I see a fertility specialist?
As with most anything, there is no one-size-fits-all answer to this question. Generally, if you are under 35 years old and have been unable to conceive after one year of trying or if you are over 35 and haven’t been able to conceive after six months of trying, it’s a good time to talk to a fertility specialist, otherwise known as a Reprodictive Endocrinologist. Having a chemical pregnancy or miscarriage in that time does not start the clock over. It is defined as six months to one year without a successful pregnancy.
It can be helpful to seek help sooner than those guidelines if you or your partner have a known medical condition (examples: PCOS, endometriosis, or cancer), genetic issues (Cystic fibrosis, a balanced translocations, or fragiile x syndrome), or have had a history of repeated miscarriages or other pregnancy losses (ectopic pregnancy, molar pregnancy, or stillbirth).
When should I seek fertility help immediately?
If you are over the age of 40 and want to start a family, it would be good to schedule an appointment soon. If you have irregular periods or known reproductive disorders, this would also be a good reason to seek help immediately. Fertility naturally declines as we age and becomes much less successful after age 40 for most women. However, everyone’s body runs out of eggs at a different pace and the decline in healthy eggs is a little different for every woman. If you are approaching or have surpassed 40 years old, doing some basic fertility blood work will help you assess how urgent it is for you to seek treatment or if you have time to try naturally.
What are the causes of infertility?
There are a few primary categories for infertility but unfortunately, a lot of people have unexplained infertility, meaning there isn’t a clear reason for an inability to conceive or to maintain a pregnancy. This is part of why the process of infertility is so difficult for many. When you don’t have an answer to why, it’s hard to hold hope for success. Many people do, however, successfully reach their family building goals with treatments, even with an unexplained diagnosis.
For those who do get an answer as to why fertility isn’t working, it often (not always) falls into the following 5 categories:
Ovulation Issues - Ovarian issues can arise due to PCOS, hormone imbalances, or even stress.
Uterine abnormalities - Fibroids, polyps, uterine adhesions, Asherman’s syndrome, and structural concerns can all impact fertility.
Age - The short of it, fertility decreases as we age.
Fallopian tube issues - Blocks in either of your fallopian tubes will naturally cause a fertility problem. These can be caused by previous ectopic pregnancies, endometriosis, adenomyosis, or even STI’s.
Sperm production or quality concerns - Low sperm count, abnormal morphology, and motility are often contributors to male factor infertility.
Does age affect fertility?
Yep! Sure does. Unfortunately, for women especially. Men’s sperm quality decreases some with age but not as much as women’s egg count and quality decreases. Fertility peaks in the 20s and starts a more significant decline after age 35. This decline makes conception more challenging and the risk of miscarriage greater simply because the eggs you have are breaking down and generally are becoming more likely to be chromosomal abnormal after this age. This can lead to embryos that don’t develop properly or end in miscarriage. That’s why it’s important to seek treatment if you haven’t conceived after 6 months of trying after age 35.
What lifestyle choices negatively impact fertility?
I get this question so, so frequently. Generally, people are looking to change anything and everything in their control to get the outcome they want and most of the tweaks people are making are unfortunately not going to be the difference between a positive or negative pregnancy test. If it were as simple as eating pomegranate, we wouldn’t have fertility doctors.
That said, there are some lifestyle factors that we have strong evidence to avoid when trying to conceive. These include smoking, alcohol, and drugs (including marijuna). And the cruel reality is that your neighbor who smokes daily might still get pregnant with ease while you purge every ounce of alcohol from your house and eat organic kale for breakfast. It really is that unfair. I’m sorry!
However, these are the things that are in your control. So, be aware of what’s going into your body, be cautious of environmental toxins, eat healthy, move your body, get good sleep, and manage stress. Those are the things you can do and for some, those actually do make a big difference. So why not try?
What fertility treatment options are available?
There are a number of options available. Generally you will meet with a reproductive endocrinologist to discuss your concerns and then they will have you do a bunch of testing (blood work, genetic screening, semen analysis, and uterine/falopian tube imaging). Once the results of your tests come back, you’ll meet again to establish a plan for treatment. Often, people are given options to start more conservatively or to jump into a more advanced treatment protocol. If you are fortunate enough to live in a state that provides some level of insurance coverage, they might dictate what order of treatments they are willing to cover.
Here is a tier of treatment options that are available, generally listed from most conservative to most advanced:
Medicated Natural Cycles - This is the least invasive option. You are given hormonal medication (often oral) and monitored until ovulation, at which point you are given a specific time to try to conceive naturally. You find out if you are pregnant or not 14 days later via a beta blood test.
IUI (Intrauterine Insemination) - Similar to a medicated cycle, you take hormonal medication (often oral) and are monitored with blood work and ultrasound until just before ovulation. You take a trigger shot and go into your clinic generally 36 hours later for a procedure in which sperm (fresh or donated) is inserted into your uterus via a catheter. It shouldn’t hurt and is very similar to a pap smear. You find out if you are pregnant or not 14 days later via a beta blood test.
IFV (In Vitro Fertilization) - This is a more complex and invasive process in which you take a combination of medications via daily shots and are monitored until just before ovulation. You take a trigger shot and go into your clinic 36 hours later for a surgical procedure where your eggs are retrieved via a needle that expresses them from your ovaries. This procedure is done under anesthesia and generally takes about 30 minutes. You’ll know directly afterwards how many eggs were retrieved. Here, you are trying to retrieve as many eggs as possible. This is also the procedure that is done for women who want to freeze their eggs for future use. All eggs retrieved are either frozen or fertilized at this point in time.
ICSI (Intracytoplasmic Sperm Injection) - If you do not have a good fertilization rate in your first retrieval or if the sperm you are using has a quality issue, you may be encouraged to add ICSI to your IVF cycle. This is done in the lab after the eggs have been collected. The embryologist injects a single sperm into each of your eggs as opposed to letting them fertilize on their own in a dish. The hope is that with forced fertilization, you’ll get a more favorable outcome in terms of how many healthy embryos are created at the end of the process.
FET (Fresh or Fozen Embryo Transfer) - For those who plan to carry their own pregnancy, you will then do either a fresh or a frozen embryo transfer. I won’t go into the difference between the two because the procedure is the same, the timing is just different and the later is obviously frozen first. Either way, you will go in for a procedure in which a doctor inserts generally a single healthy embryo into your uterus via a catheter. Some cycles are medicated prior to transfer and others are natural, depending on what you decide with your doctor. Most people then take progesterone shots for the majority of the first trimester of pregnancy if they do become pregnant. You find out if you are pregnant or not 10 days following the transfer via a beta blood test.
Donor Gametes (Eggs, Sperm, or Embryo) - If you are using donor gametes for any reason, this is where those come into play. This breaks down more depending on what donor material you are using but the fertilization takes place either during IUI or in the lab following IVF; unless you are using a donor embryo, which has already been created and stored with a clinic.
Gestational Surrogacy - This is generally one of the last stops of fertility treatments because it’s the most expensive option and not covered by insurance. There are a handful of reasons why people choose to use a gestational carrier but the decision is usually reached after many failed treatments or pregnancies. The primary reasons why people use gestational carriers are as follows: 1.They cannot get pregnant. 2. They cannot stay pregnant. 3. Pregnancy is too dangerous, mentally or physically. 4. They don’t want to be or are fearful of being pregnant.
Cryopreservation - This is the fancy term for freezing reproductive material. Whether you want to preserve eggs or sperm for future use or are holding onto created embryos for future use, they are all cryopreserved to maintain their function as living organisms. This is a true gift of modern science.
PGT (Preimplantation Genetic Testing) - If you go through IVF and create embryos, you will be given the option to send them for genetic testing. The research on this testing varies significantly based on your age but it is a good resource for ensuring that the embryos you keep are healthy enough to potentially stick after an embryo transfer. There are a few different types of PGT testing but they are all looking for chromosomal or genetic abnormalities in an attempt to make a transfer more successful and decrease your odds of a pregnancy loss.
Is male infertility a common issue?
Yes. In fact, male factor infertility makes up roughly one third of infertility cases. Female factor makes up an equal one third and unknown or both partner fertility issues make up the remaining one third of known cases.
What are the psychological effects of infertility?
Infertility can be one of the most stressful experiences an individual or couple endures. Therefore, it impacts mental health significantly and should be supported with quality mental health services. It is normal for the brain to process uncertainty and anxiety for a period of time and then return to homeostasis. With infertility, high levels of uncertainty and anxiety are often ongoing for much longer than is healthy for your brain and body. Even for those in shorter infertility journey’s, the stress of treatment cycles takes a toll mentally. It’s very demanding on your holistic health and extremely emotional. All of that, paired with large doses of hormonal medications being administered daily, makes for a precarious mental state.
Here are the top ways I see infertility impact mental health in my therapy office:
Anxiety and Depression - This is for obvious reasons. The uncertainty churns anxiety and the longer one goes without a solution, the more depressed they can become.
Grief and Loss - Unfortunately, when one is experiencing infertility, they are also more likely to experience pregnancy loss. This presents grief, particularly when losses are recurrent. Even an embryo transfer not working creates its own loss of hope and resources. There is also grief that needs to be acknowledged in not being able to build your family in the way you envisioned. It’s really hard all around.
Anger and Shame - Anger comes up in many places but often people express anger about their body or the situation they find themselves in, at no fault of their own. It’s unfair and anger is a common emotion when things don’t make sense and there isn’t a lot you can do about it. Shame also comes up a lot. Infertility still holds a stigma that some people feel immense shame around. Whether it’s family expectations, cultural messaging about a woman’s worth being tied to childbearing, or internalized self-blame, shame can be very pervasive when fertility issues arise.
PTSD (Post Traumatic Stress Disorder) - When people endure a lengthy infertility process, experience repeated losses, have difficult pregnancies, or face mental and emotional harm from medical providers, PTSD can surface. Again, the brain isn’t designed to sustain this level of stress for a long time.
Isolation and Relational Strain - Whether one is isolating due to shame, because of unfortunate relational encounters surrounding their process, or due to exhaustion, it’s common for people to feel lonely in their journey. Loved ones often aren’t good with problems that don’t have a clear solution and can be unhelpful in response to them. This, along with difficulty engaging friends and family who are progressing easily with family building can cause some individuals to withdraw from otherwise meaningful relationships. Additionally, partnerships can feel the strain of infertility on their relationship as both individuals experience the stress of it in their own ways. The constant decision making and financial pressure can be difficult for some couples to navigate. Also, the bizarre combination of restrictions and demands on your sex life isn’t doing anyone any favors.
Low Self Worth - When you are facing multiple of these psychological implications, it can be difficult to maintain positive self worth. Please hear me when I say, “Your worth is not equal to your fertility status. You are worthy just as you are.”
Difficulty Concentrating / Job Performance - Anytime we endure prolonged stress, we lose mental capacity. Juggling the stress of managing very specific, expensive, and time demanding medical protocols, along with emotional distress, is a difficult combination for the brain. It’s natural to lose concentration and to be less than your best at work. Give yourself grace. It won’t be forever and you can take breaks as needed.
When should I see a therapist for stress related to infertility?
That list you just read of psychological impacts of infertility might be leaving you feeling more depressed or at least questioning, “What can be done about it?” If you have the resources to seek therapeutic care around infertility, please do. This provides a safe space for you to process your experience with someone who really gets it (find a specialist) and provides you with skills to help with all of the mental health impacts listed above. I can’t overemphasize the importance of therapeutic support in this process. At the very least, your clinic should have short term counseling support available.
As mentioned, finding a fertility specialized therapist is ideal. However, we are in short supply. If you can’t find someone with specific infertility or third party reproductive training, your next best option is to find a perinatal mental health certified therapist (PMH-C). They will have a general idea of reproductive mental health and are generally experienced with grief and loss pertaining to pregnancy. If you can’t find either of these, it is possible to forge a positive relationship with a therapist who doesn’t specialize. You just need to accept that you’ll likely be doing a little bit of educating about the process.
On a personal note, I already had a long-standing therapeutic relationship when I was going through my own treatment process. She was not specialized in any sort of reproductive mental health but she was hands down the most supportive and appropriately responsive person in my life through that time. Good relational connection, empathy, and willingness to meet you where you’re at are the most important factors in a therapeutic relationship. If they know the ins and outs of infertility, that’s a bonus.
How will a therapist or coach help with infertility?
There are a number of ways that a professional can be supportive of you through infertility. First, I want to discuss the difference between fertility therapy and fertility coaching.
Infertility Therapist: Has a graduate degree in a mental health counseling field. Practices under a professional license issued by their state. Has a number of years of supervised clinical experience and additional training specifically pertaining to infertility or third party reproduction, pregnancy, grief, and trauma. Is limited to seeing clients in the state(s) that they are licensed in.
Infertility Coach: Is not governed by any regulations or requirements. Is generally a person who has been through the process themselves and is now offering peer support to others. Can be helpful with practical support, education, and resonance as you navigate infertility. Is not a professionally experienced or licensed provider and therefore runs the risk of causing harm during a fragile psychological period in your life.
Here is a chart that details what services each provider is able to offer:
As you can see, a licensed therapist is able to offer you the most comprehensive support. A coach should in no way be addressing your mental health but simply providing emotional support and resources. Whereas a licensed therapist who also offers coaching can serve you in most areas. Why would a therapist offer coaching? Because it’s not bound by location. However, this does mean that if you do not live in the state of the therapist, they are not able to offer direct mental health diagnosis, treatment, or any sort of insurance covered services. They should not be treating your trauma under this relationship, as they would need a clinical treatment plan to do so and that should only be provided under their professional license, which again, is location dependent.
This is a lot of information but hopefully gives you knowledge and support as you navigate the difficult terrain of infertility. I obviously highly recommend working with a therapist or coach to support your psychological and emotional wellbeing through your process. It’s an investment in yourself with benefits that can’t be overstated. If you are in need of support or are looking for a particular resource, I’d be happy to help you find what you’re looking for. You can reach me at rachael@rachaelalba.com.
From one fertility warrior to another, I wish you the very best!
Rachael