Healthcare|December 24, 2023
Written by: Mayo Clinic Press
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There is a well-intentioned, though often unhelpful, refrain of advice offered to those unable to get pregnant:
“Just relax.”
“Don’t worry.”
“Once you stop thinking about it, it will happen.”
The reality of infertility and its treatments, however, is much more complex — physically, emotionally and psychologically.
“We don’t give that kind of advice for any other medical issue. It’s almost like people separate this from a medical issue and treat it like it’s not one,” says Savannah Guthrie, of Lexington, Kentucky, who began fertility treatments, including in vitro fertilization, or IVF, in 2019. “If someone had a cavity, you wouldn’t tell them, ‘Oh, just wait it out, don’t get it fixed.'”
Infertility is, in fact, a disease. It is defined as such by the World Health Organization, which says infertility affects 1 in 6 people globally. In the U.S., 15% to 20% of couples are considered infertile, which can be defined as having frequent, unprotected sex for at least a year without becoming pregnant.
“Infertility is not a lifestyle problem. It is a disease and it’s as important as making sure people don’t have unwanted pregnancies,” says Elizabeth A. Stewart, M.D., a gynecologist and reproductive endocrinologist at Mayo Clinic in Rochester, Minnesota.
Infertility affects males and females equally, Stewart says, although there are more treatments aimed at improving female function. That is due, in part, because women are more likely to go into their clinic for an evaluation, she says.
Either way, treatment can be emotionally draining and expensive. Those who have undergone it say its realities can’t fully be understood unless you experience it.
“I remember sitting there in the doctor’s office crying and feeling really defeated and not feeling strong enough to be able to do (IVF),” says Katie Bass, of Atlanta, Georgia, who eventually did undergo IVF with her husband Jason in 2018.
Preparing for IVF egg retrieval
In vitro fertilization is one of several fertility treatments, typically used after others have failed. IVF has increased in both popularity and success since the first baby was born through the procedure in 1978.
Today, about 2% of births in the Unted States are from IVF. There have been millions of babies born from the procedure since 1978.
In vitro fertilization begins with the partner undergoing IVF using contraceptive pills or other hormonal medications to suppress their natural menstrual cycle. This allows the small resting eggs in the ovaries to be ready for ovarian stimulation.
Patients are then given fertility medications, often through injections — on a very specific schedule — to stimulate the ovaries. The goal is to get the ovaries to produce as many eggs as possible, instead of the typical single egg each month.
Keeping the medications and timelines on track is a delicate balance and requires far more work and time than many patients first expect.
“I had to bring coolers places with my medication if I wanted to go somewhere else,” Guthrie says. “I had color-coded charts to mark off three different times of day to take different medications. It was a lot of work.”
She wasn’t comfortable giving herself shots, so her husband did most of them. But at times she’d enlist the help of friends, like the time she had a friend give her a shot in the bathroom during a wedding reception.
“It’s always a little bit of an ordeal,” she says. “Several of the medications had to be refrigerated right up before use and had to be (taken) at an exact time of day.”
About a day before it is time for the eggs to be retrieved from the ovaries, the patient receives a different injectable medication to begin the process of ovulation. Then the eggs are removed from the ovaries during a surgical procedure.
The careful fertilization of eggs
From there, any collected eggs (known as oocytes on the cellular level) go to a lab and are inseminated with sperm. A fertilized egg is called an embryo. The whole process is conducted by working with the embryos under a high-powered microscope using a very small pipette.
“We take one sperm and put it into one egg with a very, very small needle on a very intricate microscope,” says embryologist Katie J. Nunemacher at Mayo Clinic in Rochester, Minnesota. “After insemination of the oocytes, we place them into a small dish into an incubator that will take pictures of the inseminated oocytes every 20 minutes.”
“On day one we check fertilization of the embryos by watching these pictures and checking for pronuclei (one from the oocyte and one from the sperm). For the next few days, days two to four, we monitor the embryos that are fertilized in the dish and watch them develop. Then on either day five or six we will see them develop into a full blastocyst (the scientific term for a fertilized egg).”
At this point, the embryo will either be transferred to a patient’s uterus, biopsied for genetic testing or frozen for future use.
In the lab, precision and care are key when creating and handling embryos, Nunemacher says. Every patient has two unique identifiers used in the lab and Mayo Clinic always has a second verifier, another embryologist, to verify they have the correct patient before a task is performed.
“Not only do we need to be precise in our hand work, but we need to make sure we are precise with our thinking as well! When you are working at the micromanipulation level, any shakiness of the hand is very obvious,” she says. “When we are handling embryos we make sure we are calm and collected.”
The number of eggs that become embryos that are able to be transferred can be far fewer than the number originally retrieved from a patient. As embryos grow and are tested, they are given a rating on their best chance of success to result in a healthy pregnancy.
Most people will start with far more visible follicles (eggs) on ultrasound than will develop into viable embryos, says Ali J. Ainsworth, M.D., an assistant professor in the Division of Reproductive Endocrinology and Infertility at Mayo Clinic in Rochester, Minnesota, who specializes in reproductive endocrinology and infertility at Mayo Clinic.
Choosing to implant embryos with the highest likelihood of success is what makes the treatment so successful, Ainsworth says. But “It’s an excruciating process to watch numbers drop along the way.”
That reality is something some patients say they did not realize about IVF before undergoing it.
For Tara Eyres, who first underwent IVF treatment in 2015, doctors were able to retrieve 42 eggs.
“I thought, ‘Wow that was amazing,'” she says. “I thought, ‘Oh my gosh, I can have 42 babies,’ and yeah, that is so, so not the case.”
She ended up with seven viable embryos, two of which resulted in successful pregnancies and healthy deliveries of a son in 2017 and a son in 2019.
Even when in vitro fertilization works, the financial reality of paying for it and eventually deciding what to do about healthy embryos that have been frozen can be a painful decision.
The financial burden of IVF put a strain on Eyres and exacerbated her feelings of loneliness as she tried to get pregnant.
“I remember that day finding out the cost and I was just crying,” she says. “I thought ‘I’m never going to have children.’ I’ll never forget that day.”
Eyres’ mother ended up helping her cover the cost of the treatment, but the hefty price tag added stress.
The financial sacrifice was significant for Katie Bass, who works as a preschool teacher, and her husband, Jason, who is self-employed.
“We don’t have a ton of savings so I will admit to being pretty stressed when we’d have to go to the doctor,” says Jason Bass. “Even paying for the parking at this place, it would kill me to put the credit card in the machine to pay for parking.”
Katie and Jason eventually did conceive through IVF and delivered a daughter in 2018 and a son in 2021.
Healthy embryos that are not used by patients can be frozen and stored for a fee, donated to another family or eventually discarded. That decision is one many patients do not take lightly.
“We talk about it, but it’s one of those things that for some can be difficult to imagine how you feel until you’re in that position,” Dr. Ainsworth says about the decision of how to handle frozen embryos after a patient has already had children through IVF. It can be hard for couples to envision that decision on the back end when they just want to get pregnant in the first place, she says.
Patients say there is an emotional toll and weight of deciding what to do with frozen embryos once you’ve had children and knowing those frozen embryos are their siblings.
“It is discussed, but I also think that responses to that might change with time,” Ainsworth says of her discussions with patients.
Even with the potential success of IVF and the hope it can provide, mental health can be one of the most pernicious challenges of IVF, patients say.
“One thing I didn’t take into consideration was my mental health,” says Guthrie, who eventually conceived and delivered a daughter with her husband, Scott. “I felt like it got worse
and worse through all of this and I wasn’t very good at identifying depression at the time.”
The pain of infertility and stress of IVF is very cyclical, making it especially tough. Now that she is out of it, she has been able to see that dynamic more clearly, she says.
“When it’s a goal you’re trying to reach and you’re reminded of your failure month after month with a sad physical bleeding to remind you that your body is not doing what it’s supposed to, you can’t take a break from it,” she says. “It’s always present.”
