YOUR GUIDE TO FERTILITY AND GETTING PREGNANT
Here’s a primer on how to conceive, whatever your sexual orientation, gender identity or relationship status.
By Brooke Borel
- Doctors define infertility as the inability to get pregnant after one year of regular, unprotected sex (if you’re a woman under 35) or after six months of trying (if you’re a woman 35 or older).
- Age has a significant impact on fertility; especially for women, whose fertility tends to drop after age 35.
- For women, other causes of infertility can include irregular periods, polycystic ovary syndrome, hormonal imbalances, being underweight or overweight, blocked fallopian tubes, an unusually shaped uterus or cancer treatments.
- For men, age may still factor into infertility; those over 40 could see a fertility decline. Male fertility problems can also stem from irregularities in the amount, shape or movement of sperm; blockage or trauma in the testes; or cancer treatments.
- It’s no magic pill, but most doctors recommend following basic health guidelines to improve your chances of conceiving: Get enough sleep, don’t smoke, curb the use of alcohol, follow a nutritious and balanced diet and maintain a healthy weight.
- See a fertility specialist if you’re a woman who meets the above definition of infertility; are single, in a same-sex relationship or are transgender; or if your doctor has told you that any existing illnesses, conditions or medical treatments may affect your fertility.
The early scenes of “Private Life,” a 2018 Netflix film about a New York City couple who are trying to conceive, present an unsettling scenario for anyone pondering their biological clock: A 40-something woman wakes up after an infertility procedure to find that things can’t progress as planned. Her doctors successfully extracted her eggs — but they also realized that her partner can’t produce any sperm. There might be a fix, but there’s a catch: It’ll cost another $10,000. Oh, and the doctors need the check today.
The scene, of course, is fictional and is meant to draw laughs, but it’s also a good reminder of how unpredictable and costly infertility treatments can be. If you’re thinking about having kids, what’s the best way to achieve that goal without unexpected and costly medical intervention?
For most heterosexual couples, the first step is to try to conceive the traditional way, said Dr. Sherman Silber, M.D., director of the Infertility Center at St. Luke’s Hospital in St. Louis, Mo.: “I recommend, frankly, if they are young and fertile to make sure they have enough sex.”
But intercourse isn’t always a sure-fire route to pregnancy; many couples struggle with infertility because of age, illness or reasons that aren’t yet known to science, said the two fertility doctors and one researcher I spoke to for this guide. Around one in 15 married American couples are infertile, according to the most recent published data from the Centers for Disease Control and Prevention. And there are special considerations for people who are transgender, single or in same-sex relationships.
Then there’s the high cost, which “Private Life” got right: According to the Society for Assisted Reproductive Technology, as well as a fertility benefits expert I interviewed for this guide, treatments may run to thousands or tens of thousands of dollars and aren’t always covered by insurance.
WHAT TO DO
For many, the first step is to time sex with ovulation.
First, some Sex Ed 101: In order to become pregnant, a sperm has to meet an egg at the right time. The ovaries typically release one egg once a month during ovulation. The egg travels through the fallopian tubes, where the sperm has to fertilize it. Next, the fertilized egg has to make its way to the uterus, develop a little more, and then implant in the uterine wall.
For heterosexual couples, it’s important to time unprotected sex with ovulation. (Women who have irregular periods and people who are single, transgender or in same-sex relationships are likely to skip this step and head straight to a fertility specialist.)
“We know that women ovulate about 12 to 14 days before their next menses,” said Dr. Esther Eisenberg, M.D., a medical officer in the Fertility and Infertility Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. “If you have regular periods, you can kind of figure it out.”
One option for tracking ovulation is to use a regular calendar and count back from the first day of your next projected period, although both free and paid smartphone apps will do the math for you. (If you’re using an app, read the fine print to make sure you’re comfortable with the data collection policies — some period trackers have come under scrutiny for sharing user health data with third parties.)
Another option, according to Dr. Eisenberg, is to use over-the-counter ovulation kits, which are a bit like at-home pregnancy tests. You pee on a stick, which measures luteinizing hormone. A surge in this hormone indicates ovulation, although it doesn’t prove it has happened (a woman can have the hormone surge but then fail to ovulate).
Doctors’ recommendations for how much sex you should have around ovulation vary, but it’s a good bet to try every other day or so in the days leading up to ovulation. Sperm can survive for several days in the female reproductive tract, but once you’ve ovulated, your egg has about a 12- to 24-hour window for fertilization. So, for the best chances of conception, have enough sex in the time leading up to that brief window.
Experts also recommend following basic health practices — such as sleeping on a regular schedule; avoiding alcohol and cigarettes; maintaining a healthy weight (being underweight or overweight can contribute to infertility) and following a balanced diet — to improve your odds of getting pregnant.
If you aren’t getting pregnant, decide when to see a fertility specialist.
If you’re having trouble calculating your ovulation because of an irregular period, or if you’re not in a heterosexual partnership, it’s a good idea to seek the services of a fertility specialist at the beginning of your quest to conceive.
If you’re transgender, the American Society for Reproductive Medicine recommends that you discuss with a doctor how certain medical treatments — such as hormone injections or gender reassignment surgeries — may affect your fertility, as well as options for preserving eggs or sperm prior to transitioning.
For heterosexual couples, see a fertility specialist if you haven’t conceived after a year of regular, unprotected sex (if the woman in the partnership is under 35) or if you haven’t conceived after six months (if the woman in the partnership is 35 or older). As with any medical treatment, your health insurance (if you have it) will largely determine which fertility doctors you can see without having to pay fully out of pocket. But it’s still a good idea to make sure you feel comfortable with whichever clinics are available to you, said Dr. Silber. Consider asking: What are the live-birth success rates? What sort of testing do they do? When doctors answer, Dr. Silber said, “see if they look you in the eye.”
Understand the basic fertility tests.
If you’re a woman in a heterosexual partnership and are struggling to conceive, you may assume that there is something wrong with you. But in many cases, the male partner is responsible as well, so both partners should get fertility testing from the start.
The type of testing you receive will depend on your sex and situation, said Dr. Janet Choi, M.D., medical director of CCRM New York, part of a nationwide network of fertility clinics.
For most women, Dr. Choi said, basic testing starts with blood work to check for certain infections and hormone levels — the latter of which is part of an ovarian reserve test to estimate how many eggs you have left. There may also be a blood test to check thyroid levels since certain thyroid disorders can affect the menstrual cycle or increase the chances of miscarriage.
Next comes a transvaginal ultrasound, which is another part of an ovarian reserve test. A practitioner will insert a wand-like instrument into the vagina, allowing her to visualize the reproductive organs and to check the ovaries for cysts or other abnormalities, as well as to get an idea of how many eggs are left.
Your doctor may also order an X-ray called a hysterosalpingogram (H.S.G.), which helps show whether anything in the reproductive tract is blocking sperm from reaching the egg. A practitioner will thread a tube through the cervix and inject an iodine dye into it, which fills the uterus and flows through the fallopian tubes; the X-ray picks up the dye to show whether the uterus is shaped normally and whether the fallopian tubes are blocked. Comparatively speaking, most men have it easy when it comes to basic fertility testing: A doctor might order blood work to scan for certain infections or to check if hormone levels are normal. Men will also probably be asked to produce a sperm sample so that a practitioner can assess how much sperm is in the semen, how well they can move and how they are shaped. If the sperm fall short in any category, they may have a harder time reaching the egg — and the man may have to go through additional testing.
Know which treatments are available.
As with fertility testing, the type of infertility treatment you receive will depend on your unique health and medical history. If you’re a woman with a blocked fallopian tube, for instance, you may need surgery to remove the blockage or to repair the damage before trying other fertility treatments. If you’re a man who isn’t producing sperm,it’s possible you have a blockage as well, and your doctor might recommend a procedure that retrieves viable sperm directly from the testes, or a surgery that removes the blockage.
If you’re a woman under 35, treatment will likely start conservatively, said Dr. Choi. For example, your doctor may prescribe oral drugs such as Clomid or Letrozole, which increase the odds of pregnancy by boosting the number of eggs you release during ovulation. This approach is also common for women with certain hormonal conditions such as polycystic ovary syndrome, in which ovulation doesn’t occur regularly.
Your doctor might instruct you to combine oral drugs with sex at home; or to time taking them with ovulation or with an in-office procedure called intrauterine insemination (IUI), in which a clinician prepares a sperm sample then inserts it directly into the uterus to increase the odds of conception.
Women who are over 35 may also start conservatively with oral drugs or IUI, but if those measures don’t work after a couple of tries, or if it’s clear from your medical history that they aren’t likely to work, Dr. Choi typically recommends moving more quickly to more aggressive treatments, such as in-vitro fertilization (I.V.F.). Here, the idea is to fertilize the egg outside of the body and then put the resulting embryo back in.
Fertility treatments will also vary for people who are single, in same-sex relationships or transgender. If you’re a woman who’s single or in a same-sex relationship, for example, you may try IUI or I.V.F. with sperm from a donor, depending on your age and your fertility status. Women in same-sex partnerships will also need to decide which partner should carry the baby, which will depend on preference, age, and health. (It is also possible for one partner to harvest eggs and the other to carry the embryo, a process sometimes called reciprocal I.V.F., shared maternity or co-maternity.)
Men who are single or in same-sex partnerships will need a surrogate to carry the embryo, whether she uses IUI, I.V.F. or some other means of conception. Men in these circumstances may also need an egg donor. If you’re transgender, your fertility treatment will depend on your individual history regarding sex reassignment surgeries, hormone treatments and so on. For example, if you’ve already had sex reassignment surgery, you may need donor sperm or eggs, unless you froze your own beforehand. If you only had hormone treatments, you may be able to reverse this process temporarily through new hormone treatments (under the guidance of a physician), in order to produce viable sperm or eggs.
Before you jump into treatment, check cost and insurance.
Most insurance companies will cover fertility testing. But every expert I spoke to for this guide agreed that it’s a good idea to check with your provider before you start fertility treatment. There are no federal laws that require insurance to cover infertility diagnosis and treatment, and only 16 states require insurance companies to either cover or offer to cover it. “Under traditional coverage, if you have it, or if you don’t have coverage, you’re going to start acting a bit like an accountant and start adding up the dollars to figure out if you can afford it,” said David Schlanger, chief executive officer of Progyny, a fertility benefits management company.
Even in states that require coverage, details can vary. Some insurance plans cap the amount of money you can spend on fertility treatments. Say, for example, your plan allows up to $25,000, which sounds like a lot. But that could go quickly. According to the National Conference of State Legislatures, the average cost of one I.V.F. cycle is between $12,000 and $17,000 (without medication), and many people will need multiple cycles. Other insurance companies may require you to try IUI before I.V.F., even if your medical history suggests the latter is a better choice, which chips away at your allotted coverage. Still other plans don’t cover I.V.F. at all.
Even if your insurance covers a procedure, it may not cover other key factors. Prescriptions, for example, may not be included, and some fertility drugs can cost thousands of dollars. People who need sperm or eggs should check to see if donor tissues are covered. And laws regarding surrogates are “different all over the country,” Schlanger said. In New York, for instance, surrogacy isn’t even legal, although there have been proposals to lift the ban. If your insurance doesn’t include fertility treatments, RESOLVE, an infertility advocacy nonprofit, recommends asking your employer if it’s possible to expand your plan.