Whole Living > by Dylana Accolla, LAc
The Politics of Infertility

illustration by Jim Bliss

June is now World Infertility Month, according to Pamela Madsen, director of the American Infertility Association (AIA), co-creators of World Infertility Month with the group International Consumer Support for Infertility. World Infertility Month will take place every June, giving patient organizations and professionals all over the world a vehicle to educate and increase awareness on issues surrounding infertility. Their preview opening, on May 10, was a celebration and talk given by 20 IVF (in vitro) babies, ranging in age from four to 20 years old. Elizabeth Carver, at 20 years old, was the eldest IVF-baby to share her experience of originating from "out of the dish."

"We're trying to put a normal spin on the disease and its positive outcomes. That it to say, that people can have great kids!" said Madsen by telephone interview.

Infertility seems to be hot news of late (in the Healthy Living world, at least). The April 24 New York Times article "Behind the Biological Clock, Why So Many Women Over 35 Can't Conceive," for instance, disturbed a vast readership over the age of 35 by saying that science and technology have not advanced to the point of making late pregnancies a viable option for women who want families.

On April 28, New York City's Marriott Marquis Hotel hosted the 13th annual National Infertility and Adoption Conference, organized by the AIA. The conference, one of the largest of its kind, was sponsored by the Cornell Institute for Reproductive Medicine at Weill College of Cornell University and the Institute for Reproductive Medicine and Science of St. Barnabas Medicinal Center, NJ, two of the world's cutting edge institutions of fertility medicine. Attended by 800 patients and 300 medical professionals, the turn-out prompted organizer Madsen to comment, "It says a lot about how motivated this [infertility] population is to brave torrential rains and come out to be self-educated on their issue."

What is infertility, exactly? Medically speaking, it is defined as the inability of a couple to conceive after one year of regular unprotected sexual intercourse. "What that really means to the couple is that achieving pregnancy is a challenge," says a brochure from fertility drug manufacturer Organon, one of the conference's sponsors. "Infertility patients are very similar in attitude to cancer patients," Madsen said. "They're a little desperate. Both are life issues. Cancer is life threatening and so is infertility. Cancer threatens the continuation of a life, and infertility threatens the beginning of one."

Statistics show roughly 6.1 million couples, or 15 percent, trying to conceive experience infertility. Of these, physiological problems in the woman alone account for 35 percent of cases, while 35 percent stem from physiological problems in the male alone. In up to 30 percent of cases, infertility results from more than one cause. (Statistics vary depending on the source.) Approximately half of all couples will eventually conceive a child, either on their own or with therapy. But most couples don't seek help-just 10 percent do. "For whatever reasons-shame, money, advocacy care, many people are not seeking treatment for infertility. We're trying to show them that it's not a pox or a curse from God but a disease that can be fixed, just like many others," said Madsen.

Western medical infertility treatment
Infertility in women may be the result of either a functional or a structural problem: the inability to ovulate or obstruction of the fallopian tubes preventing the sperm and egg from uniting. In males, the most common infertility problems are due to low sperm count, low motility (the ability to move fast-basically sluggish sperm), and irregular sperm shape.
Once a couple decides to seek medical help, the first course of action is to determine the precise cause(s) that makes pregnancy difficult. The next step is determined by various factors, including the age of the woman, her hormone levels, and her income level. The usual steps that women go through include cycles of the ovary-stimulating drug Clomid, graduating to cycles of fertility drugs and intrauterine insemination, and if that fails and the couple can afford it, in vitro fertilization.

What does therapy consist of? A lot of drugs, I have to say, synthetic (not bio-identical, and therefore patented and highly profitable) hormones in particular-which do their intended jobs well, but are sometimes difficult to administer (try giving yourself a shot in the belly for a few days)-cause uncomfortable side effects, burden the liver, and in some cases have been controversially linked to ovarian cancer. These drugs stimulate the growth and maturation of the egg cells (oocytes) in a woman's ovaries so they are ready for fertilization. Fertilization may then proceed naturally or may occur in vitro (outside the body) using assisted reproductive technology (ART).

Some physicians are aware that the drugs are hard on the body and are now cautious about over-prescribing. For example, Serena Chen, MD, of St. Barnabas, and Fady Sharara, MD, from the Virginia Center for Reproductive Medicine in Virginia, speakers at the Infertility Conference, stated that Clomid (clomiphene citrate) is a "very safe" drug. They later, however, pointed out that the drug is over-used for unexplained infertility and that a woman should take it for no more than three cycles. If you've been taking Clomid for more than three cycles, talk to your physician about how to get off and what to do next.

High-tech advances in infertility medicine
Fertility drugs, including Clomid (the "fertility pill"), in vitro fertilization (IVF), male factor infertility treatment, and cryopreservation of embryos were the "pivotal advances" of fertility research in the last century, said conference speaker Margaret Graf Garrisi, MD, also of St. Barnabas Research and Treatment Center.

"What the last century contributed to fertility medicine was ovulation induction. We learned how to help women who were having only one or two periods a year have regular monthly periods," Graf said. This was done through the extensive use and development of fertility drugs, called gonadotropins. There are many types of gonadotropins, used alone or in combination for ovulation induction. During the use of these drugs, careful monitoring is required to minimize the risk of side effects.
In vitro fertilization developed after the drugs, said Garrisi. One of the side effects of the fertility drugs is that many eggs are produced per cycle. When doctors realized that they could take advantage of the extra-eggs side effect by fertilizing in the dish, the pregnancy rates rose from single to double digits overnight in the early 1950s, she said.

Another major advancement of the last century was intra-cytoplasmic sperm injection (ICSI), which is assisted fertilization when the sperm is actually injected into the egg. This assists a couple with low sperm count. "For years, scientists were at the drawing board, killing eggs, basically, trying to develop a smaller needle to get that sperm in the egg without breaking it. This revolutionized the treatment of male infertility," said Garrisi.

Frustratingly, these advances have not yet happened for women, said Garrisi. What we really need to deal with in advanced maternal age is the cryopreservation of oocytes, she said, and that has not yet become a consistent and safe practice (although it has produced a child already). Cryopreservation has a long history, from frozen male sperm in snow to freezing human blastocysts (pre-embryonic masses of cells) to get pregnancies (1985). Oocytes were first frozen in 1986. Once oocyte freezing becomes widespread, Garrisi suggested that it will become a part of women's reproductive planning while they are younger, making genetic pregnancy an option later in life.

Grafting ovarian tissue to promote the development of eggs is technology of the future and could help younger women facing potential loss of ovary function due to chemotherapy, radiation, or surgery. Experimental studies of ovarian cryopreservation and transplantation on laboratory animals began in the 1950s, write Kutkuk Oktay, MD, and Zev Rosenwaks, MD, ("Ovarian Cryopreservation and Transplantation," In Focus, Spring, 2002). Later studies showed that fertility could be restored by ovarian transplantation. The first pelvic ovarian transplantation was performed in 1999, resulting in ovarian function for over nine months. In a second case, reported in 2002, ovarian graft in a cervical cancer patient resulted in the release of oocytes. Menopause has been reversed by this procedure as well, but further research is needed to determine whether pregnancies can result.

Wallet size determines quality of care
"No other field of medicine has to negotiate with the patient about what treatment she will opt for, based on cost," said Jeryl Natofsky, MD, an IVF doctor from New Jersey. "The American Medical Association has recognized infertility as a disease for a long time," said Madsen. As such, infertility should be regarded as a medical condition that should be covered under insurance policies. But it's not. Currently in New York state, most insurance policies exclude infertility from premiums, seeing it as a correctable and costly issue-not life-threatening.

State mandates for coverage of infertility treatment can help patients get access to the care they need to have a child, said Kim L. Thornton, MD, Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School. But currently New York is not a mandated state. Coverage in New York is sometimes included in employment insurance as an employment perk or a means to retain key employees, she said. But otherwise, "it isn't much."

In the past, insurance companies argued that providing infertility coverage would dramatically increase insurance premiums, but studies have shown that it actually costs less than one percent of a premium, because not everybody utilizes his or her benefit even if eligible, said Thornton. She said the general public still has to be convinced that infertility treatment won't add a lot to insurance premiums.

There is actually a mandate being tossed around Albany, where it has languished for several years. The problem is that the Assembly and the Senate in Albany have passed two differently worded bills, and while the bills remain different, the mandate does not become law. The main differences in the bills are:

· The Senate bill (S.1265), passed on May 7, 2002, makes coverage available only for women aged 21 to 44, and it includes a maximum lifetime benefit, excluding the cost of drugs, of $60,000. The Assembly bill (A.2003) does not contain these limitations.

· The Senate bill includes a provision promoted by t he New York State Catholic Conference that exempts an employer or insurer that is controlled by a religious entity from being required to provide coverage for any treatment that would violate its religious tenets.

· The Senate bill expires in two years (without further action by the Legislature), and requires the Superintendent of Insurance to conduct a study of the cost of providing this coverage.

· Both bills require coverage for the cost of drug therapy and for a maximum of four IVF cycles.

Low-income women do not benefit from an insurance mandate at all. As the un-insured (artists, musicians, and lower income women) and women on public assistance, they are light years away from expensive fertility treatments. Are there infertility treatment options out there for these women? I asked Madsen. "Very little," she said. "Unfortunately," she added, "it's easier to get help for working women with insurance than for women on Medicaid. It just is."

While it has been argued that childbirth is a human right that every American should have, it seems that this right is clearly tempered by the ability to pay for it.

Complementary infertility treatment
Well, there were no speakers on complementary therapies at the International Infertility and Adoption Conference. It was a disappointment, since complementary therapies, particularly Chinese Medicine, have shown themselves to significantly improve pregnancy rates when used with Western treatment methods. Both modalities are being practiced side to side to treat infertility; it should be acknowledged and explored.

Hush-hush on causes
In light of the practical nature of the lectures and the long list of pharmaceutical companies sponsoring the National Infertility and Adoption Conference, it came as no surprise that there was no lecture on the underlying causes of infertility in this and other industrialized countries.

One plausible explanation is offered to us by two doctors who weren't at the conference, John R. Lee, MD, and Jesse Hanley, MD, co-authors of What Your Doctor May Not Tell You about Pre-Menopause. They are convinced that the main cause of infertility in both men and women is estrogen dominance, or an inadequate production of progesterone produced by the body. The origins of estrogen dominance vary, but the bottom line is that the proliferation of xenoestrogens, derived from petrochemicals, is the culprit.

Xenoestrogens are powerful chemical estrogen-mimickers that throw off hormone balance in animals and humans. There are animal studies that definitely link xenoestrogens to infertility. Dr. Hanley believes that these environmental xenoestrogens are elevated to the point that they suppress women's LH (luteinizing hormone), the pituitary hormone that signals the ovaries to release the egg and to make progesterone. Although women affected by xenoestrogens continue to produce estrogen and have menstrual cycles, the follicles of the ovaries of female embryos are damaged such that progesterone production is lost in early life. The authors point out that luteal phase failure (lack of ovulation) is now the leading cause of early miscarriage and infertility, and it has skyrocketed in the 50 years since petrochemicals were introduced.

Of course there are probably a myriad of other causes. Another taboo subject is stress and psychological issues. Doctors insist that stress doesn't cause infertility-we'd all be infertile if it did. But there have been studies that undeniably link stress to infertility. A study in Italy of women going through IVF or ET (embryo transplant) found that both vulnerability to stress and working outside the home were associated with a poor outcome of IVF or ET treatment, even though the straightforward medical causes of the infertility were distributed equally throughout the group (F. Facchinetti et al, "An Increased Vulnerability to Stress is Associated with a Poor Outcome of In-Vitro Fertilization-Embryo Transfer Treatment," Fertility and Sterility, vol. 67 (1997), pp. 309-14). Chinese medicine sees stress and emotions as factors that constrain Liver Qi, which is intimately involved in the menstrual cycle and reproduction, and Liver Qi Constraint is a cause of infertility in Chinese Medicine. So for me, the connection is obvious.

Thinking about it all
Although the National Infertility and Adoption Conference provided useful and valuable information that obviously helped infertile couples, there is a big picture here that is being ignored. That is, what are the causes of epidemic-rate female infertility? How should these causes be addressed? Can women do anything to protect themselves from environmental, food, and psychological components of infertility?
Faced with a disease that is at least partly the result of (petro)chemical proliferation in our food and environment, I find the emphasis on chemical solutions schizophrenic. While all this technology is revolutionary and life changing, it's also like building bigger and better rockets to the moon-moving reproduction further and further from individual women's control. What are more natural and grounded methods to encourage fertility that can balance and be used in conjunction with modern medicine? This is the kind of conference I would pay to attend next year.