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Fertility Care

Our guest expert in March 2011 was reproductive medicine specialist Dr. Ari Y. Baratz of the CReATe Fertility Centre at Women’s College Hospital.

Focused on providing 'patient-centred' fertility care, Dr. Baratz's clinical interests include providing all forms of assisted reproductive technologies, and reproductive endoscopic (minimally invasive) surgery.

In addition to being a compassionate practitioner, Dr. Baratz is also a dedicated researcher, focusing on medical education and several aspects of clinical infertility and reproductive endocrinology. He has presented his research at several national and international forums, and is a member of the University of Toronto’s obstetrics and gynecology faculty.

Here are the responses to your questions on Fertility Care.

Q: I am 39 and have been trying to get pregnant for a year. At what point do you suggest people seek fertility treatment? Is one year of trying normal?

A: A woman’s age and duration of trying to conceive are both primary factors in deciding when to seek consultation with a fertility specialist. In general, it is recommended that women under 35 years of age wait one year prior to a fertility consultation. Women over the age of 35 are recommended to seek advice after six months of trying. Women over 39 may seek advice within three months of trying. In couples where there is a history suggestive of sub-fertility (for example, irregular menstrual cycles, previous surgery, pelvic infection, cancer treatment), a fertility consultation may occur sooner rather than later regardless of age.


Q: If a client does IUI and has twins, does that mean that the twins are caused by the fertility treatments?

A: Not necessarily. An intra-uterine insemination (IUI) is a method to place a concentrated sample of sperm in the uterus. It may be performed during a woman’s natural menstrual cycle, during which most females will release one egg, and if successful, result in a singleton pregnancy. An IUI may also be associated with a super-ovulation cycle, during which fertility medications may cause the release of more than one egg. These are the conditions that are most commonly associated with a multiple gestation (for example, twins). Rarely, some women spontaneously release more than one egg (in the absence of fertility medications) or a fertilized egg may cleave (the cause of identical twins). In these case, the twins may have been associated with an IUI as well, but are not caused by the IUI.


Q: At what point do you recommend people try IVF?

A: In vitro fertilization (IVF) is a form of assisted reproductive technology where an egg and sperm are fertilized in the laboratory and then returned to the uterus as an embryo, a procedure that has many potential applications. IVF may be used for female, male or unexplained causes of infertility. IVF can also be used for pre-implantation genetic diagnosis – for couples with genetic conditions that can be identified by testing the health of embryos prior to being placed back into the womb. In short, the application of IVF depends on the reason for the infertility, the age of the female patient and on what other fertility treatments have been tried and have failed.


Q: Are there any treatments available to improve sperm count?

A: It depends on the severity, extent and nature of the sperm defect. Semen analysis (laboratory assessment of sperm parameters) examines the volume of the ejaculate, the concentration of sperm, the motility (percent of sperm that are moving) and the morphology (the appearance of the sperm under the microscope). Treatments to improve sperm counts may include lifestyle changes (such as smoking cessation), vitamin supplementation, medical and possibly surgical intervention. Male factor fertility treatments may include intrauterine insemination (IUI) or intracytoplasmic sperm injection (ICSI – a laboratory technique that injects individual sperm directly into isolated eggs with the aid of a microscope). In my practice, consultation with a urologist is a part of the approach to improving sperm counts.


Q: Does my weight affect my ability to get pregnant?

A: Yes, any extreme of weight can affect fertility rates, miscarriage rates and overall pregnancy outcomes. Women who are severely underweight may have irregular or absent menstrual cycles which can make it more difficult to get pregnant. Women who are overweight are at increased risk for ovulatory defects, miscarriage and fetal abnormalities. In addition, these women have more difficult pregnancies, including difficulty maintaining blood sugar control and blood pressure control, and higher risk of operative delivery (including caesarean sections), fetal injury at birth and even stillbirth. I usually recommend, if possible, optimizing BMI (body mass index) prior to conceiving. This may require the help of a nutritionist, dietician or personal trainer.


Q: I hear a lot about people over 35 having problems conceiving. I’m not ready to have a baby but might want to in the future. Do you recommend that women freeze their eggs before the 35 age cut-off?

A: The issue of fertility preservation is gaining increasing popularity (i.e. “biological insurance”). Reproductive aging, which refers to the decline in one’s ability to conceive, starts to become more significant at the age of 35. Oocyte cryopreservation (egg freezing) is an option for women up to the age of 38. The efficacy of this technology depends on a number of factors, including one’s age, background fertility potential and current ovarian reserve. I recommend that anyone concerned or anxious about their fertility seek a consult with a fertility specialist regarding this issue and to discuss the entire range of fertility preservation options.


Q: Are there tests available to check the quality of eggs? I am 37 and will start trying to conceive soon, but how will I know if I need to seek fertility treatments? Is there prescreening available or do I just have to wait and see what happens after a year of trying?

A: Non-invasive tests for the “quality” of oocytes (eggs) do not exist . However, there are quite a few tests available (blood tests and ultrasound measurements) to examine the “quantity” of eggs in a woman’s ovary – this is referred to as the “ovarian reserve.” Women over the age of 35 who are concerned about their fertility or have a history of irregular menstrual cycles, previous pelvic /abdominal surgery, previous pelvic infections, a concerned male partner or family history of sub-fertility should seek fertility consultation sooner rather than later (within three months or less of trying). In the absence of any obvious infertility factors, it is recommended that any women over the age of 35 seek fertility consultation within six months of trying to conceive. Preconception consults are always available for anyone (male or female, at any age) anxious or concerned about their reproductive potential.


Q: I am 27 and have been trying to conceive for three years. Everything I’ve read focuses on women over 35. Are there any symptoms I should be aware of that affect younger women?

A: In general, women under 35 have higher fertility rates. Most women under 35 will conceive within 12-18 months of trying. If you’ve been trying for three years, then this would be considered a long duration of infertility for your age group – and should raise concern. Some symptoms that are linked to infertility may be obvious to you; for example:

  • irregular menstrual cycles are associated with ovulatory defects
  • severe pelvic pain or painful intercourse may be associated with endometriosis

Unfortunately, some infertility factors may be completely asymptomatic; for example:

  • blocked fallopian tubes
  • very low sperm counts in the male partner

I would highly recommend a consultation with a fertility specialist to examine you and your partner for any male or female infertility factors that may be present.


Q: I've had four pregnancies: one successful (with the help of serophene) and three that ended in miscarriage. The last two pregnancies I was able to get pregnant with metformin as I was diagnosed with mild PCOS. I was advised to stop taking metformin at six weeks and nine weeks respectively, but still ended up miscarrying. I've read that many women continue to take metformin until 12 weeks and some even take it for the entire pregnancy. What are the newest and current findings on metformin and its use during pregnancy? Thank you.

A: There are many factors that contribute to recurrent miscarriages – an endocrine defect such as polycystic ovary syndrome (PCOS) is one of them. There is no question that insulin-sensitizing agents (such as metformin) are useful adjunct treatments for ovulation induction or even IVF treatments for patients with PCOS. The role of metformin in preventing pregnancy loss is still not conclusive. Currently, there is no consensus on when metformin should be stopped in the first trimester. In our practice, we stop metformin in the first trimester at approximately eight to nine weeks. Recent reports suggest that metformin is safe to take throughout pregnancy, but have not shown significant improvements in outcome measures beyond the first trimester.

In cases of ‘secondary recurrent miscarriage,’ (someone like yourself, with a previous successful pregnancy), I am always concerned about other factors that may be involved. A common contributing factor may be changes in body weight. Many women with PCOS are not at their ideal weight or their previous pre-pregnancy weight. We know that women who make lifestyle changes (diet / exercise) improve all aspects of fertility, pregnancy loss and obstetrical outcomes.

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