Infertility Treatments: Weighing the Risks and Benefit

Healthfacts, Feb, 1999

The treatment of infertility is a $2 billion a year industry in the U.S. In most industrialized countries, couples would not be judged infertile until they had failed to conceive after two years of unprotected intercourse. In the U.S., perhaps because our medical care system is the most entrepreneurial, the definition of infertility has been shortened to only one year of unprotected intercourse.

A generation ago, infertile couples virtually had no options. Now, there are plenty. Last month, The New England Journal of Medicine published the results of a study showing a modest success rate for four different infertility treatments. It was accompanied by an unusual message to couples who may prematurely present themselves to the medical care system as infertile. Be patient, advised the fertility specialists who wrote an editorial about the new findings, because you may be overestimating the value of medical interventions, which, at best, may only help you conceive sooner rather than later. Most important, the editorial warned of the considerable health risks, such as multiple births and a possible increased rate of ovarian cancer, as well as a high financial and emotional cost.

The study that prompted this long overdue advice had compared four different treatment options given to 932 couples who had no identifiable reason for not conceiving. All had been trying for about three and a half years. The study, conducted by David S. Guzick, M.D., and colleagues at 11 fertility centers, lasted for four months. The combination of drugs and the injection of the husbands sperm directly into the uterus resulted in pregnancies for 33%. The second group, treated with drugs and the injection of sperm onto the cervix, had a 19% success rate; and the third group, which received only the injection of sperm into the uterus, had an 18% pregnancy rate. The lowest rate (10%) was shown for the last group which received no drugs and the injection of sperm onto the cervix. The drugs, which stimulate the ovaries to produce more eggs, carry the small chance of a potentially dangerous side effect called hyperstimulation.

Pregnancy rate as the definition of success is not the same as the take-home baby rate. Too often fertility clinics sell their merits on the former; whereas couples should be careful to ask for the latter. In this study, of the 186 pregnancies that occurred, 72% resulted in live births, 20% in spontaneous abortion, and 4% in ectopic pregnancy. There were three quadruplet pregnancies, four sets of triplets, and 17 sets of twins in the drug-treated groups. Six drug-treated women suffered ovarian hyperstimulation serious enough to require hospitalization; three of them were pregnant.

The high risks and relatively low success of these fertility treatments prompted a call to physicians to present a more realistic picture to their patients. In an editorial that accompanied the new study, Drs. Egbert R. te Velde and Bernard J. Cohlen of University Hospital Utrecht, the Netherlands, also suggested that improvements in high-tech treatments, the proliferation of infertility clinics, and media emphasis on the so-called major increase in infertility, have created the public perception that fertility interventions can make all the difference between having a baby in a relatively short period and being condemned to lifelong barrenness.

To support their contention that many couples overestimate the success of medical intervention and underestimate their own abilities, Drs. te Velde and Cohlen cite a 1995 Canadian study. After one year, the live-birth rate among untreated infertile couples was only about 4% lower than that of the infertile couples receiving the high-tech interventions. Obviously, some couples do need treatment, and on their behalf, the editorial called upon researchers to minimize the treatments complication rate.

Has the rate of infertility increased dramatically in the last two decades? The answer is no, according to demographer Anjani Chandra, Ph.D., at the U.S. National Center for Health Statistics. Her agency has been conducting national surveys periodically since 1965. The rate of infertility hasnt increased notably in the last 30 years, said Dr. Chandra, in a telephone interview. But the number of people who are infertile has increased because of the large baby boom generation and their pattern of delayed childbearing and waiting to the less-fertile ages.