26.4.2023
-
12 min.
What was a miracle a few years ago is now an available therapeutic method. Thus, not only the treatment of serious diseases, but also infertility is progressing. The latter afflicts more couples today than we would expect. Silvia Mabena spoke to gynaecologist Judit Tóth.
In an interview with gynaecologist Judit Tóth, who specialises in the diagnosis and treatment of infertility, you will read:
- what hope women with cancer have of having a baby,
- which is behind the rise in infertility,
- why a couple doesn't have to run off to IVF right away,
- what power psychology has in getting pregnant,
- which makes infertility treatment more accessible and affordable.
You are focusing on a very specific field and a very demanding one at that. Why did you choose it?
You are right, infertility treatment is a very mentally challenging process. After setbacks, couples and especially patients tend to be mentally exhausted, and that's when the empathetic approach of the doctor helps a lot. What fascinates me about this field is how dynamically it is developing. In the last few years alone, we have made incredible achievements in the treatment of infertility thanks to advances in modern medicine. As a doctor, I am very pleased that we can help most couples who want to have a baby at our ReproMedica clinic in Bratislava.
Are there statistics on infertility in couples?
The diagnosis of infertility affects about one in six couples. The cause is 50% in women, 40% in men and about 10% is so-called idiopathic sterility, i.e. unexplained infertility where the cause cannot be determined even by detailed examinations.
What fertility disorders do couples in Slovakia come to specialists with?
The most common causes of infertility in women are irregular or absent ovulation in polycystic ovary syndrome, endometriosis, fallopian tube obstruction, uterine fibroids or uterine polyps. Many women are also infertile due to ovarian depletion, which occurs due to the advanced age of the patient or is toxic, for example after chemotherapy, radiotherapy and after repeated surgical procedures in the small pelvis. In men, the most common disorder of sperm production (spermatogenesis disorder) is due to harmful environmental influences, improper lifestyle, lack of physical activity, smoking, alcohol, drugs, steroids and toxic substances, cytostatics or radiation. More rare causes in males include seminiferous duct obstruction, hormonal and anatomical causes or genital infection.
If a couple fails to conceive, this is obviously not immediately solved by artificial insemination, technically referred to as IVF (In Vitro Fertilisation)... What treatments are used to cure infertility in our country?
First we need to diagnose the cause of infertility and then we suggest treatment. It doesn't have to be artificial insemination right away, as you say. In many cases, simpler treatment methods will also help. For example, we can treat irregular ovulation with hormones. We induce ovulation artificially. All we need to do is to monitor how the ovaries react by ultrasound, and when ovulation is confirmed, we can time the intercourse. Only if simpler treatment methods fail do we look for other infertility treatment options.
Is it true that in the past, not as many couples had infertility problems as in the present? If so, do we know what the causes are?
This is related to the fact that nowadays many couples do not plan parenthood until an older age. For women, fertility declines significantly after the age of 35. If a woman does not start thinking about having a baby until after her career goals have been achieved, she will be older and fertility problems may occur. I would say that the main risk factor for infertility is the older age of the partners and especially the woman.
Are there other factors besides age that significantly affect fertility in women and men?
During life, people may be exposed to influences that significantly reduce fertility or cause infertility, such as cytostatic drugs used in cancer treatment, radiotherapy and also promiscuity with the risk of infection and tubal occlusion. The impact of environmental pollution is also not negligible. Also, an unhealthy lifestyle with increasing age accumulates infertility.
There is often talk about the couple's psychological adjustment...
I remember a patient who had been unable to conceive for about five years. We did the necessary tests, she was due for hormone treatment and at the very last check-up it was discovered that her periods were late and she was pregnant. The mindset of a man can do wonders. Maybe the very attitude of a couple choosing a different path, seeking help from an IVF centre and this more proactive approach will help them in getting pregnant eventually. The patient in shock that this can't be true, we in pleasant shock with her. After all, conceiving a baby is a miracle. After that, I took care of her throughout her pregnancy and she conceived her second baby spontaneously as well. During my career, such cases have happened many times.
Do you also talk to your partners at the first consultation about psychological well-being?
This is a very difficult subject and I am not an expert in psychology. I think a psychologist can be very helpful in infertility treatment. Each patient is individual and there is no single recipe for how to get in the right frame of mind to get pregnant. For some a great desire helps others on the contrary it blocks. I usually recommend couples to see a psychologist because I think it should be part of the treatment.
What about in cases where a cancer patient wants a baby? You mentioned that chemotherapy can cause infertility. Does a woman with cancer have any hope of having a baby?
In most cases, we can preserve healthy eggs for the future, which would be lost during cancer treatment. When a patient is diagnosed with cancer, we need a statement from the oncologist as to whether she agrees to egg retrieval before treatment begins. Subsequently, in the natal cycle or with minimal ovarian stimulation, we can retrieve a few eggs, which are frozen. After successful cancer therapy, the woman desiring a baby has her frozen eggs available. A similar procedure is used for the most common type of cancer, breast cancer in women. Unfortunately, this diagnosis is already quite common in younger patients. If it is caught at an early stage, the success rate of treatment is very high. Medicine now offers procedures that can help these women preserve healthy eggs just for the period after successful treatment. For male cancer patients, the collection of the material (sperm) followed by freezing of the sample is even easier and does not require surgery as in the case of women.
After how long of a period of trying for a baby should a couple seek help?
We define a fertility disorder if regular unprotected intercourse does not result in pregnancy after one year. This applies to women under 35 years of age. After one year, the couple should seek a first-contact gynaecologist. Older women should not wait so long.
What all awaits the couple during fertility tests?
Basic examinations include an interview with the patient focusing on detailed history and gynaecological examinations such as gynaecological palpation, mirror examination, cervical oncocytology, vaginal and cervical swabs to rule out infection, ultrasound examination of the patient, blood collection for hormonal profile including Anti Müllerian Hormone, which is an indicator of ovarian reserve. In males we also take a medical history and examine the spermogram. Other additional investigations are ordered directly at the reproductive medicine centre based on the results of the initial investigations possibly related to previous failures of infertility treatment.
Are these examinations time-consuming and expensive?
The examinations mentioned above do not. Even the hormonal profile of the patient is covered by the insurance company. Men can have a spermiogram done in urology clinics or even in IVF centres.
What is the success rate of fertility disorders treatment in Slovakia?
Fortunately, we can help most patients. The success rate depends on the treatment method chosen. With insemination, which is an outpatient procedure where we use a catheter to insert sperm into the patient's uterus during timed ovulation, the success rate is around 10% to 15%. This is a relatively low figure and the public is not very aware of this fact. Another option for a couple with a fertility disorder is IVF therapy (In Vitro Fertilization). In this method, the patient is stimulated with hormones. The aim is to get more eggs, ideally around 12 to 15, and if they are mature, they have a better chance of successful fertilization with sperm. We watch the resulting embryos as they develop and carry out their transfer into the uterus. With this method of treatment, the success rate of pregnancy is 40 to 45%. We can further improve this success rate by culturing the embryos, where we follow their development for five days and are able to select the best ones. When embryos are inserted into the uterus after 5 days of culture (the embryo is at the blastocyst stage), the success rate of achieving pregnancy is close to 50% to 60%. Another option for infertile couples is the use of donor eggs. These come from young healthy women and the success rate of getting pregnant is the highest at over 60%.
Are these the latest infertility treatments that are also being used around the world?
Yes, these are the most innovative medical procedures and they are also allowed by Slovak law. In the neighbouring Czech Republic, surrogacy is also permitted by law, when another woman carries the couple's offspring. This is indicated when a patient repeatedly loses her unborn child. These abortions happen, for example, because of a developmental defect of the uterus, because of fibroids, there may be an immunological factor. Slovak legislation does not currently allow surrogacy.
The doctor MUDr. Judit Tóth comes from Dunajská Streda and has been working as a gynaecologist and obstetrician for 12 years. For many years she worked at the gynaecological and obstetric department in Nové Zámky and Galanta. She started to work with Planned Parenthood and infertility treatment after she often encountered cases of infertility in women in the hospital ward, who had to be referred to reproductive clinics. Currently, she specializes in the diagnosis and treatment of organic and functional disorders of female reproductive organs in a team of experts at ReproMedica Reproductive Medicine Clinic in Bratislava and ReproGenesis Reproductive Medicine Clinic in Brno.
Is the IVF method time-consuming and expensive for the woman (couple)?
One cycle of IVF therapy lasts about a month, including embryo transfer. The hormone treatment lasts about two weeks, followed by egg retrieval, ideally a 5-day-old embryo is inserted into the uterus, and a pregnancy test is done in 14 days. With the pregnancy test, we close the cycle and evaluate whether or not it was successful. This is the actual treatment, which is preceded by examinations. From the patient we need the already mentioned hormonal profile, because based on it we can plan the stimulation. From the man we need a spermiogram, if the parameters are not quite ideal, we recommend vitamins, a visit to the urologist and a repeat spermiogram after three months. Before IVF, we also do collections for sexually transmitted diseases and scrapings to avoid any complications. The good news is that the first three cycles of IVF therapy up to a woman's 40th birthday are largely covered by insurance companies.
What if the IVF method does not result in pregnancy?
In the vast majority of cases, IVF is successful. If a woman does not become pregnant, it depends very much on what other options the couple can accept. The patient may be in the situation that with her own eggs getting pregnant is not possible because they are of poor quality. In that case, the couple is advised to consider the option of trying with eggs from the donor in order to make the pregnancy successful.
Who can donate these eggs? For example, can it be someone within the patient's family?
No, egg donation is a strictly anonymous program. However, we do try to find a donor with a similar outward appearance for the recipient. In particular, we look at eye color, hair color, height, weight, complexion, and blood type. The donors also fill out a questionnaire about what hobbies and interests they have, what education they have attained. When choosing an egg donor, we look first and foremost at the physiognomy of the donor.
Is it a fact or a myth that with artificial insemination a woman is more likely to conceive twins?
In the past, it was more common to have geminal (multiple) pregnancies after artificial insemination because two or more embryos were transferred into the uterus. Nowadays, we prefer a single embryo transfer because we can culture the embryos and select the most viable embryos for transfer. Multiple pregnancies are associated with more complications during pregnancy. There is up to a 30% risk of premature birth with a geminal pregnancy and it is also more challenging for the mother herself than a singleton pregnancy. In infertility treatment, we try to avoid all possible complications, so a single embryo transfer is preferable.
The original version of this article can be found at Good News.
