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HEALTH CHILDREN’S HOUR

Science solves the age-old infertility problem.
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MARGIE GALLAGHER is a tall, slender blonde three days past her thirtieth birthday. By profession, she’s an attorney. She’s spent seven years in higher education and five years pursuing her career. She has always attained whatever she has attempted. But right now, Margie and her husband want something they can’t seem to attain together. A child.

In an age when preventing pregnancies gets showered with attention and controversy, it is surprising to learn how many couples are on the other side of the coin. They want children, but try as they may, no pregnancy results. Infertility specialists claim the problem troubles one out of every six to eight couples.

But if there was ever an age in which to suffer from infertility, this would be the one; there is now more help than ever before for the infertile couple. And the breakthroughs continue to make headlines.

The world’s first recorded test-tube baby was born in England three years ago. At this moment, a woman near Norfolk, Virginia, is carrying a fetus that was conceived outside her body in a special culture dish. If the pregnancy is carried to term, she will deliver the first reported test-tube baby in U.S. history.

The woman’s identity has not been revealed by authorities at Eastern Virginia University Medical Center, but they say she elected to undergo the procedure because of a problem with her fallopian tubes.

Doctors in Norfolk used a glass-fiber instrument called a Laparoscope to search for ripe eggs in the woman’s ovaries. When one was found, it was suctioned out, removed from the egg cell, and placed in the culture dish with her husband’s sperm. When one sperm finally penetrated the egg, the solution was inserted into the woman’s womb through the cervix, where it is now developing as a normal baby.

While the procedure has been successful only twice after many years of research, doctors believe that test-tube baby births will increase during the next decade. But the procedure remains an important breakthrough for women who cannot conceive because their fallopian tubes have been destroyed or do not exist. Until now, even though these women ovulated, it was considered impossible for them to have a baby.

More advances have also come forth in the last five years, mostly concerning women, but some concerning men. Some of them are as controversial as the test-tube baby. The whole problem of infertility has given birth to a new gynecological subspecialty called reproductive endocrinology.

Dr. James Madden is the only reproductive endocrinologist in private practice in the Dallas/Fort Worth area. His training was in obstetrics, but instead of delivering babies Madden now spends his office hours counseling couples who, like Margie and Steve Gallagher, want a child but feel that nature is working against them.

Madden stresses that infertility is a problem for both partners, not just one, and he insists on treating the couple together, rather than just one partner.

Infertility is generally defined as the inability of a couple to conceive after one year of frequent intercourse. In unprotected sexual relations, about 80 per cent of couples will conceive in a year’s time.

The first thing Madden does is interview his patients extensively for several hours. Infertility is a delicate subject. The “difficulty” will finally be attributed to one of the partners. Madden says he tries to hone in on the problem area. The male partner’s semen is tested to see how many spermatozoon exist per cubic centimeter. The woman is examined to see how well her partner’s sperm survive once they reach her vagina. Do they mix with her body fluids? Is there a malfunction in the oviduct precluding union? Does the woman ovulate at all?

Many men wish to know from the start if the infertility is “their fault” because of a low sperm count. Some seem to think their masculinity is threatened by the problem. Madden stresses the care he takes with each couple to ward off possible psychological effects that may result from the circumstances. He tries to narrow the investigations down to a smaller set of causes. Then, depending on the problem, he looks for the appropriate treatment.

If the woman’s reproductive system is causing the problem, Madden has a choice of tools to work with. The so-called test-tube conception is only one way for a woman with severe fallopian tube damage to become pregnant and carry her husband’s child to term.

Thanks to improved technology in microscopes and surgery, many fallopian problems can be corrected by a skilled surgeon. In fact, Madden says 80 per cent of all tubal ligations (a birth control technique that completely severs the tubes to prevent pregnancy) can be reversed. The tubes measure a fraction of the diameter of a tiny fingertip. With the use of new high-powered microscopes, they can be rejoined to allow normal conception.

If the problem is not with the fallopian tubes, but with the woman’s pituitary gland and its regulation of her ovulation, there are three new drugs that may correct the problem, should the patient feel the results outweigh the risks and the cost:

– Clomid can help a woman whose pituitary signals malfunction. In this disorder, the message from the pituitary to the ovary is not well orchestrated in the body. As a result, the woman often doesn’t ovulate. Clomid is not a hormone, but it does help to synchronize the pituitary signals and force the woman to ovulate. The side effects range from possible multiple births to potentially fatal enlargement of the ovaries. It is an inexpensive drug taken for five days out of the monthly cycle.

Madden says one problem with Clomid is that it has gained a widespread reputation as the “fertility pill.” Unfortunately, if a woman who is not suffering from a specific synchronization problem uses it, it can actually compound infertility; Clomid was even used in the late Fifties as a contraceptive. Even worse, if a woman is taking Clomid for an “unexplained infertility” problem, and she decides to take more than the recommended dosage (thinking it will make her even more fertile), she may actually be lessening her chances of ever conceiving a child.

– Parlodel is so new that the FDA hasn’t ruled on its application for infertility yet. Parlodel can help a woman whose body makes too much prolactin in the pituitary. Prolactin is the same hormone that generates milk in the mammary glands after pregnancy, and it works as a natural contraceptive. Thus a woman who has too much prolactin in her body has a sort of built-in contraceptive device. Par-lodel not only cures the trouble, it also effectively dries up the milk in a new mother who doesn’t wish to breast-feed her baby.

– The hormone Pergonal has been used for several years to make a woman’s body produce an ovum even in a patient lacking a pituitary gland. (The drug regulates the ovaries’ actions.) Pergonal has also become known as the multiple-birth drug because women who take it for infertility often give birth to quadruplets or quintuplets. Multiple births are the only known side effects.

Infertility specialists agree that if the woman is the source of the couple’s conception problem, she is easier to treat than the man. But if the problem is found in the male reproductive system, the techniques for correction are much more limited.

For example, it was generally believed that if a man has had a vasectomy, the procedure could be reversed at a later date. Now there is evidence that shows that this may not be the case. A vasectomy creates an obstruction in the male vas deferens. His body still generates sperm, but instead of being ejaculated externally, the obstruction forces the body to absorb and dispose of the sperm internally. Some men’s bodies get so good at doing this that repairing the vas deferens obstruction fails to reverse the sterilization.

In some cases, doctors must try to retrieve the semen and place it inside the spouse’s cervix. This is known as artificial insemination. Madden says that it is mythical to believe that artificial insemination is more efficient than natural intercourse. He says any cattleman will tell you natural is always better unless, of course, Mother Nature isn’t doing her task. That’s when medical science steps in.

For the man whose semen holds little or no sperm (say, less than 20 million sperm per cc, although the counts vary greatly from clay to day) there is almost nothing medical science can do to help him. His wife, however, can become pregnant by a procedure known as Artificial Insemination by Donor (AID).

There are a number of reasons why some men have low or no sperm counts. Mumps can cause sterility if contracted later in life. Women who have taken DES during pregnancy have given birth to boys who later suffer from sterility.

In an innovative program at the University of Texas Southwestern Medical School in Dallas, women have been inseminated with donor semen for six years. It was started in 1977 by Dr. James Aiman, an obstetrician and gynecologist. Since the program’s inception, 67 women have become pregnant by donor semen. The man running the program now, Dr. Gary Ack-erman, says most of the pregnancies have taken place in the last two years as more people have become aware of it.

It sounds a little Orwellian -having a stranger’s semen injected into a female cervix to create a baby – but to the couples who have no other recourse, it’s a miracle. Southwestern has had an 80 per cent success rate with the program, which is identical to that of natural unprotected intercourse during one year’s time. There is a waiting list for the program, currently about two months. (Madden, in his private North Dallas practice, is now booking appointments for late October.) The medical school also does extensive infertility screening, beginning the moment the couple walks in the door with a conception problem. Once the source has been spotted, it is treated by available methods, if any exist. Artificial insemination by donor is a last resort for the couple with a low or zero sperm count, and even then the method is used only after extensive screening and counseling by Southwestern physicians.

Assuming the couple has gone through the infertility tests (either at Southwestern or through a private physician), and assuming all indications point to a very low sperm count in the male partner through repeated testing, and assuming the couple decides to use donor insemination – here’s what happens:

The couple schedules a counseling appointment that lasts approximately one and a half hours. The procedure is explained at this time. A donor will be selected from the school’s list of medical students participating in the program. He will be selected for his pedigree-a background relatively free from inherited disease and containing healthy physical attributes. The woman will first keep a record of her basal body temperature to find out when she ovulates. She does this every morning at home simply by taking her temperature. She will register the day her temperature starts to show a small rise, and make notes of mucus changes from her vagina. These are the signs that point toward her ovulation day.

After a pattern has been set, she will come in on the day before her temperature is expected to rise. She will be inseminated every other day until the expected ovulation has passed. For most women, this means two or three inseminations a month by the same donor. The average time to conceive by this method is about three months, although the school will inseminate women for up to six months. After that period of time, if the woman has not become pregnant, it is unlikely that she ever will and other options, including adoption, are discussed.

The parents never know, or see, or actually learn anything about the donor other than his physical pedigree. All couples who choose the procedure must sign a notarized consent form. Basically, the husband states that he consents to the insemination and declares that the baby resulting from the pregnancy is his legitimate child. The same sort of statement is signed by the mother. (Texas is one of very few states that require such consent forms.) The form eliminates the remote possibility that the father will, at a later date, disown the child and claim it is not his. The same type form is signed by the donor, essentially saying he will never claim the child as his own, will not try to determine the identity, and will not put any restrictions on the specimen.

At Southwestern, donors undergo personal interviews by the physicians in charge of the program. (This is not the case at all teaching hospitals that have donor programs.) The donor is asked to fill out a health questionnaire and family disease history. Candidates are selected on the basis of health, some being excluded for histories of inherited diseases or specific medical problems. Ackerman says medical students and residents are the only donors used in the program because they are physically closer to the office where the insemination takes place. He also says medical students tend to be healthier than most students, and they tend to understand the problem.

The student signs the consent form and his name is then placed on a list of possible donors. When a patient needs sperm, the list is checked against the needed physical qualifications. Doctors do not try to match the donor to fit the husband’s exact description; Ackerman says it is sometimes impossible to match the father’s physical appearance from among the 25 donors. Besides, many children are born to a couple bearing only a faint resemblance to one of the parents. Thus the doctors feel they do not have to imitate the father’s physical characteristics in order to have the child resemble the family. Sometimes they try to find a donor who matches the mother’s description.

The student is paid $25 for each semen specimen, which is what the patient pays the medical school. The sperm is injected into the woman, just inside her cervix, and she’s asked to remain in a reclining position for a few moments. The procedure is no more painful than a Pap smear. Ackerman says the sperm is usually not injected directly into the uterus because it can cause an allergic reaction and intrauterine cramping. More semen is injected that month during the patient’s anticipated ovulation time. If she calls in two and a half weeks with news that she’s missed her menstrual period, the procedure is considered to have been a success.

The only records that are kept in writing are the list of donors and a small notation in the patient’s chart reading “AID.” No names are ever recorded. The only person who knows the identity of the donor is the doctor-in this case, Ackerman. And he says the information is kept in his head where it’s bound to be lost in a few days.

Artificial insemination by donor can cost a couple about $450 at Southwestern for three months of treatment. Some insurance policies cover these costs. The charge covers the donor sperm, the office visits, and tests necessary to determine if donor insemination is needed. Madden sends his patients to Southwestern to be inseminated. There are no laws regulating the use of artificial insemination in Texas, nor in any state, for that matter. The question arises, what’s to keep someone from opening an insemination clinic for infertile couples? Doctors say they hope the expenses involved would do that. And furthermore, any OB-Gyn who would form such a practice could stand a good chance of losing his or her board certification. Only medical centers and teaching hospitals have the staff and resources available to keep a donor insemination program running properly. For example, the physicians at Southwestern try to rotate and change the donors constantly to eliminate the remote possibility that the patient’s child and the donor’s future children meet and marry.. .or that two children from the same donor marry.

There is one other option that remains open to couples who cannot conceive children together. It’s really an old-fashioned method that was kept quiet in the past, although people in the infertility field say it has always been available. It’s called surrogate parenting, where one woman has a child for another.

This works when the father can provide the sperm, but the mother cannot conceive or carry a child. In the old days, the husband simply mated with the other woman until she conceived a child she later gave away. But there have been cases recently where women have undergone artificial insemination with the father’s sperm. Then the baby is carried to term by the surrogate mother. At birth, it’s given to the childless couple. A group in Louisville, Kentucky, called the Surrogate Parenting Association, is now actively helping couples who wish to become parents by this method. Kentucky is the only state in the nation with no laws specifically banning such procedures.

Donor insemination and surrogate parenting may raise a few eyebrows, but so far neither has incurred the wrath of any special interest groups. Madden says that in the 10 years he has worked with infertile couples, he knows of no overt, vocal opposition to any of the treatment methods. Couples who feel their religion is against AID disregard that option. The Catholic Church has no formal doctrine on AID, but Madden says the religion’s leaders are not very enthusiastic about it. The only area that has created some moral heat is the embryo transfer -the test-tube baby. Right to Lifers seem to be concerned with leftover cells after fertilization. Often, doctors will fertilize four or more eggs in a solution. Only one egg will be implanted in the mother; the others are usually discarded.

Another physician says special interest groups haven’t attacked AID because so few people really know about it – the very nature of infertility usually forces many couples into keeping their troubles confidential. Ironically, the situation is rather like that of abortion: The people who’ve experienced it are pleased their problem has been solved, but they still don’t feel comfortable enough to tell anyone else the way in which their problem was solved.

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