Infertility Has No Easy Answer

Fertility specialist sees wide range of patients with multiple challenges and solutions

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LOUISVILLE Infertility is defined as the inability to become pregnant after a year of intercourse with no contraception, and is an emotionally charged and complicated issue for many couples desperate to start a family. Johanna Archer, MD, a board-certified reproductive endocrinologist, is dedicated to helping them find solutions.

After completing her obstetrics and gynecology residency at the Medical University of South Carolina, Archer completed a reproductive endocrinology and infertility fellowship at the University of California-San Diego. Since 2011, Archer has been at the helm of Fertility First, Reproductive Endocrine Services, providing affordable and up-to-date fertility treatments. The practice handles 95 percent fertility issues, with the remainder of patients seeking treatment for endocrine concerns.

Currently, approximately 12 percent of couples in the United States have fertility problems. After testing by their primary OB/GYN, these patients seek out possible treatment and the help of a fertility specialist. For Archer, the first step is to get an extensive personal history of both members. “Though I am an OB/GYN and take care of women, it is a couples problem. So, I ask that the partner comes in for the initial talk,” states Archer.

During this interview, Archer gets in-depth information from the woman on ovulation regularity, menstrual cycles, past surgeries, fibroid incidence, and family history. From both partners, she deduces intercourse frequency, sexual dysfunction, and any lifestyle choices that can interfere with becoming pregnant. The list of these includes smoking, drinking alcohol, and obesity. In addition, excessive caffeine consumption is tied to both fertility difficulties and miscarriages. Endocrine destructing compounds, which are manmade toxins found in the environment, have also been found to have a negative impact. Last, but not least, is stress. “You can shut down ovulation very easily if you’re highly stressed, and everyone is under stress these days,” says Archer.

After assessing the history, the next step is an ultrasound of the pelvis to look for polyps, fibroids, cysts, or other abnormalities. Laboratory testing is also done. These include tests of the thyroid, follicle stimulating hormone, and other hormone levels, and vitamin D, because, as Archer points out, “Vitamin D has now been shown to have an independent effect on fertility in both men and women.”

In 40 percent of the couples who come to Fertility First, the male is the sole or a contributing factor in their infertility. Men can undergo semen analysis, which reveals how much sperm a man has, including activity and shape. But, determining the fertility of husbands is still complicated since, “Really, there is no test that determines sperm penetration into an egg.” However, certain aspects of the male’s lifestyle also impact fertility. Certain jobs, such as welding, long-haul trucking, farming, and working within refineries seem to play a role.

Of the remaining cases, 20 percent of infertility is due to endometriosis or tubal or pelvic distortion of the female. Another 20 percent is due to irregular ovulation. One of the most common culprits is polycystic ovary syndrome (PCOS), which affects 10 percent of women, and, according to Archer, is the “most common hormonal abnormality.” During her fellowship, Archer worked with one of the premier physicians doing research on the hormonal problems of women with PCOS. The disease is hereditary and can be passed down by either the mother or father. The elevated levels of testosterone and insulin associated with PCOS can cause irregular ovulation, compromised egg quality, and possibly increase the chance of miscarriage.

It is perhaps the final group of patients that prove most difficult because the exact reason for not being able to become pregnant is unexplained. “When everything checks out okay so that you don’t see an obvious problem, it can be extremely frustrating to both the patients and us,” Archer points out.

Depending on the etiology, Archer prescribes fertility medications, provides ultrasound monitoring, performs intrauterine insemination, or conducts appropriate surgeries. If none of these methods prove effective, Archer offers in vitro fertilization (IVF) as an option by partnering with Boston IVF at The Women’s Hospital in Evansville, Ind. For women less than 35 years of age, the rate for attaining pregnancy is 50 percent. This rate is expected to rise with the addition of preimplantation genetic screening. “The push from now on when doing IVF is to only transfer genetically normal embryos to increase the pregnancy rate and decrease the rate of miscarriages.”

But, a couple’s choices for fertility treatment are often determined by finances. As Archer explains, “Insurance sometimes covers the diagnosis of fertility, but not the treatment.” IVF costs an average of $10,000. And though companies based in states with an IVF mandate demand it be covered by insurance, Kentucky is not mandated to do so.

Despite the variety of causes and treatments, infertility has one common thread – the toll it takes. “These couples run out of steam. There is as much anxiety and depression in a fertility patient as someone with a cancer diagnosis,” says Archer. For this reason, she suggests seeking couple’s counseling and psychological support from a professional.

When asked what advice she would give other physicians when dealing with patients with potential fertility difficulties, she warns against the “Just wait. It will happen.” approach. Archer goes on to say, “If there’s a known abnormality in a patient, the smart thing to do is move them to a fertility specialist.” And, for all those medical professionals treating couples coping with fertility challenges, “I hope we do a good job in listening to patients and being more empathetic and sympathetic to their situation.”