Who should really go for IVF?


Emobileclinic Specialist

The diagnosis of infertility is often not absolute, but it is important from the onset to identify the cause of the problem to determine for whom treatment is imperative, for whom it is advisable and for whom it is probably a matter of preference or convenience.

semen quality pic

Infertility is defined as failure to conceive after a full year of regular intercourse. Fertile women under 36 years of age who have fertile partners and have regular intercourse, will experience about a 16-18% pregnancy rate per month and approximately a 10-12% chance of having a baby from such a pregnancy. In one year, approximately 70% will conceive. What is important to bear in mind is that this still leaves about 30% of cases where, in spite of no obvious barrier to fertility, the woman still fails to conceive within a year.

Why is this so?

The timing of intercourse is critical. It must occur immediately prior to ovulation, not after ovulation (even having sex a few hours later will usually be too late). The use of home ovulation prediction tests to time intercourse with the onset of ovulation is unfortunately not reliable enough. The reason for this is that the detection of the ovulation hormone LH, in the urine (upon which this test is based) does not reliably pinpoint the exact time of ovulation. Indeed, ovulation begins within 38-42 hours of the spontaneous LH surge, but the LH only reaches the urine several hours later, and very often by the time the urine is tested, it might already have been in the bladder for several hours. This is especially common when testing for the LH surge is done upon awakening in the morning or late in the day. In such cases, the urine will have pooled for some time before being tested and the women might in fact have ovulated many hours prior….thereby missing the fertility window.

semen quality pic

The diagnosis of male infertility is often made on the basis of a single semen analysis and the parameters tested (sperm count, motility and morphology) are relatively vague, imprecise and are often “in the eye of the beholder”. Since at least 50% of infertility is reportedly due to “sperm dysfunction” and this diagnosis (especially in mild to moderate cases) is often inaccurate, it is easy to see how male infertility is often misdiagnosed.

Endometriosis, regardless of its severity, is invariably associated with a “toxic factor” present in the pelvic secretions. This toxin interferes with fertilization, thereby reducing the likelihood of pregnancy per month of trying by a factor of about 4–6. Such women have reduced fertility potential. They are not totally incapable of conceiving. In such cases the chance of pregnancy might be reduced from 16-18% per month (the normal) to 3-4%, and the chance of having a baby could be reduced from 70% in one year to about 40% within 3 to 4 years. This helps explain why many women with even mild endometriosis, where the doctor often states that the cause of infertility is “unexplained” often take longer than one year to conceive, and thus end up being labeled with the diagnosis of infertility, whereas in reality they have “reduced fertility”.

Absent or dysfunctional ovulation: such women may, in spite of their condition, still experience intermittent functional ovulation, at which time they could still conceive on their own. It might take them longer to conceive but that does not mean that they are totally incapable of doing so.
There are women who have damaged, yet patent, fallopian tubes where the journey of the sperm, egg and embryo to reach their destinations is rendered much more difficult and hazardous. Since the intra-tubal environment is much less hospitable to the embryo than the uterus, embryos rarely will attach and grow inside the fallopian tubes (when they do, it results in an ectopic pregnancy, and can be very dangerous). As such, these women might take longer to achieve a pregnancy, but again this certainly does not mean that they are totally incapable of doing so on their own.

So when should “infertility” be treated and when should we delay or avoid treatment?

In answering this question, it is important to consider that waiting indefinitely might put some women completely out of the running. This is because the biological clock is relentless and cannot be “reset”. Older women (with ever declining egg quality) and those who regardless of their age, have diminishing ovarian reserve do not have the luxury of waiting to see whether pregnancy will indeed occur on its own. Also, since most couples are desirous of having more than one child, by waiting to have the first one, the rapidly ticking biological clock could make it far less likely that they will be able to have a second one. Thus, the sooner they get treated the better.

The same applies when the existence of endometriosis, moderately severe male infertility or non-occlusive tubal disease reduces the ability to conceive. Here again, time becomes important and even if such women might well have conceived on their own, they simply cannot take the chance of waiting, and in the process, of running out of time.
There are however certain situations where the infertile couple is faced with the ultimatum of undergoing definitive Assisted Reproductive treatment (IVF-related) versus accepting childlessness.

semen quality pic

These include:

  • Totally blocked fallopian tubes

  • Inability of the male partner to produce any viable sperm

  • Failure to ovulate (anovulation), due to hormonal imbalance or absolute ovarian failure (menopause).

  • The presence of high blood levels of antisperm antibodies (either the male or female)

  • Absence of, or severe disease of the uterus (here IVF using a gestational suirrogate).

  • Intractable immunologic implantation dysfunction

Most other causes of infertility are not necessarily intractable or absolute. In other words, although less likely to occur, the woman can and often does achieve a viable pregnancy without treatment.In summary, it is indeed an undeniable fact that infertility is often not synonymous with sterility. However, this does not mean that treatment should be withheld. It is also important to recognize that patient choice plays a very important role in determining who and when to treat. It is also important to emphasize that infertility treatment is often as important for the couple with reduced fertility as it is for the women with absolute sterility.


Leave a Reply