Infertility

A host of fertility treatment options are available today. Physicians and their patients must collaborate to draft a course of action. One of the partners may need surgery and time to heal before starting treatment--for example, a vasectomy reversal or laparoscopic surgery for endometriosis.

Many physicians use fertility medications to try to increase their patients' chance of pregnancy. Fertility medications work by increasing the number of eggs that develop in a given month, raising the chance that at least one of them might be fertilized and develop into a pregnancy. Some couples may be able to conceive using fertility medications and timed intercourse or insemination, either with the man's sperm or sperm from a donor.

In in vitro fertilization (IVF), sperm and eggs are taken from the partners, united in the lab, and grown there for three to five days before being transferred into the woman's uterus. In general, physicians recommend the least invasive and most natural treatments first, unless advanced maternal age or an identified disorder dictate a more aggressive or specific approach. Some couples who feel like time is running out may try IVF first. However, IVF success rates decrease as women age.

For women whose eggs are of low quality, egg donors may be a solution; those who cannot carry a pregnancy on their own might consider a gestational carrier (surrogate).

This section has more information on:

Timed intercourse

Ovulation induction (fertility medications)

Ovarian hyperstimulation

Other medical treatments

Surgery

Artificial (intrauterine) insemination

Donor sperm

Assisted reproductive technology, including IVF

Surrogacy

Multiple pregnancies

Choosing a clinic

Financial issues

Sometimes getting pregnant can be as simple as learning to time intercourse so that it occurs when a woman is most fertile. It is possible to test at home for ovulation, either by measuring basal body temperature or with home kits that predict ovulation based on hormones in the urine. Read more about home testing for ovulation in the Testing section. Couples may also use these methods while the woman is taking fertility drugs. The best time to have intercourse is just before ovulation.

Ovulation induction involves the administration of medications--either orally, by injection, or by a combination of both--to stimulate ovarian follicle development. Medications must be administered daily over the course of seven to 10 days, so patients are taught to administer their own daily injections. The injections are given with a very small needle just under the skin, and it's hard to get them wrong. (This is the same way people with diabetes give themselves insulin injections.)

Ovulation induction can be performed to produce eggs so the couple can conceive through intercourse or insemination, or as a first step for IVF, to produce eggs that will be removed from the ovaries to be fertilized in the lab.

The most commonly used oral medication is clomiphene citrate (Clomid). The drug is taken for five days starting day three, four, or five of the menstrual cycle. Some other drugs may also be used. Injectable medications, most of which are the human hormone FSH, are usually taken for about seven to 10 days starting on day three of the cycle.

The woman will probably have to visit the clinic several times for ultrasounds or blood tests to monitor her ovaries and hormone levels and determine if the doses of the medications need to be adjusted. Patient response to medications is highly variable and can even vary one month to the next, so frequent and careful monitoring during treatment is critical. The doses of these medications also depend on whether you are trying to produce many eggs to use in IVF or just a few for insemination or timed intercourse.

Your doctor may want you to take progesterone supplements while you are using fertility medications to help prepare the uterine lining for pregnancy. The progesterone supplements are usually continued for a few weeks if the pregnancy test is positive. When ovulation induction is done for IVF, progesterone supplements are usually required because of additional drugs that are given to prevent early ovulation.

For IVF, it is very important that women do not ovulate early. If the ovaries release the eggs even one minute before the doctor goes in to retrieve the eggs, the whole cycle is lost. So when ovulation induction is done for IVF, you may have to take another medication (in addition to the fertility drugs and progesterone) that prevents early ovulation. The medication is either a GnRH agonist or GnRH antagonist, given as an injection.

For insemination or timed intercourse, when the doctor decides the ovaries are ready, an additional injection is given to trigger ovulation, followed by either insemination or timed intercourse.

The most important danger of ovulation induction is that too many follicles will develop. This can lead to a rare but serious condition called ovarian hyperstimulation syndrome, which is covered on the next page. If ovulation induction is to be followed by intrauterine insemination or timed intercourse, then having too many follicles could lead to a multiple pregnancy. Being pregnant with more than twins (called "high-order multiple gestations") is risky for the woman and the babies. To prevent these potential problems, treatment is usually canceled if too many follicles are developing.

Many women must take high doses of fertility medications to get multiple eggs for in vitro fertilization. This can lead to a rare but dangerous condition known as ovarian hyperstimulation syndrome (OHSS).

Feeling bloated and uncomfortable is normal during treatment with fertility medications. But as the ovaries get bigger and produce more eggs, women tend to have more symptoms. Some women retain a lot of fluid in their abdomen. Some become nauseated and vomit; eventually, this can lead to dehydration. Some women even have fluid in their lungs. With dehydration and fluid retention, women can have a serious drop in blood pressure and a slightly higher risk of blood clots. These severe symptoms are very rare.

Younger women are more likely to produce more eggs and thus more likely to experience the symptoms of overstimulation. Young women with polycystic ovarian syndrome have the highest risk. Overstimulation is less common in older women.

Call your doctor if you need large amounts of pain medication, can't keep any food down, think you are getting dehydrated, or stop urinating (a sign of dehydration). The symptoms aren't necessarily related to the number of eggs produced; some women who hardly produce any eggs while taking fertility medicines are very uncomfortable, while some women produce dozens of eggs with few symptoms.

If a woman has OHSS, the symptoms may get worse for three to five days after her eggs are retrieved for IVF, then will gradually get better. If your doctor thinks you are at risk for a worse form of OHSS, you may not be able to have the embryos transferred to the uterus during that cycle. Pregnancy can make the syndrome worse because hormones stimulate the ovaries more. You can freeze the embryos and wait until another cycle to transfer them. The symptoms will go away when you get your period, two weeks after the retrieval.

Sometimes infertility is caused by other health problems that can be treated with medications. For example, treating a thyroid problem may make a woman's ovulation normal.

For women who have polycystic ovarian syndrome (PCOS), doctors may prescribe Metformin, a medication that is used for diabetics. Metformin is not approved by the Food and Drug Administration for this purpose, but it can make cycles regular in some women with PCOS. For those women, weight loss often makes the cycles regular.

Women with a suspected diagnosis of endometriosis may benefit from laparoscopic surgery prior to other fertility treatment. Laparoscopic surgery may also be used for some other causes of infertility. Surgery may be recommended to remove uterine fibroids if their location or size would affect pregnancy.

Men may be advised to have a varicocele (varicose vein in the scrotum) repaired if it is affecting sperm count or motility. There are some other rare causes of male infertility that can also be repaired surgically, such as a block where the tube carrying sperm from the testicles enters the urethra.

And, finally, some couples request reversal of an earlier sterilization operation, either a tubal ligation or a vasectomy.

You might think it would be possible to repair a scarred or blocked fallopian tube, a common cause of infertility, but in most cases this surgery is unsuccessful. Fallopian tube scar tissue returns in 70 percent of cases after this type of surgery. Also, repairing a blocked fallopian tube can make an ectopic pregnancy more common. An ectopic pregnancy is one that grows outside of the uterus, most commonly in the fallopian tube. These pregnancies can burst, leading to lower belly pain, fainting, bleeding in the belly cavity, and even the mother's death. In very mild fallopian tube disease, surgery may be beneficial, but in most cases in vitro fertilization is recommended to obtain a pregnancy in women with fallopian tube damage or blockage.

This section contains more information on:

Laparoscopic surgery

Fibroids

Varicocele repair

Sterilization reversal

Laparoscopy uses a telescope and tiny incisions to look inside the abdomen. This procedure may be done as part of diagnosing infertility.

Laparoscopy may be done to remove from the ovaries cysts that can make fertility treatment less likely to succeed. Also, if areas of endometriosis are seen during laparoscopy, the doctor can remove them with a laser or cauterize (burn) them.

Women who have hydrosalpinx, a condition in which the fallopian tubes fill up with fluid, may sometimes have laparoscopy to try to open the tubes. If the fallopian tubes are very damaged, the doctor may choose to remove them; studies have found that women who have big, dilated fallopian tubes have a lower pregnancy rate when they undergo in vitro fertilization, so taking the tubes out may improve their chances. There are a few theories on why this is; one is that fluid in the tubes might drain into the uterus and create a bad environment for embryos.

Like laparoscopy performed for diagnosis, laparoscopic surgery requires general anesthesia and, usually, a breathing tube. Surgery usually requires three and sometimes even four incisions because more instruments are needed.

Fibroids are very common in women of reproductive age, and most of the time they don't cause infertility. But sometimes, especially if the growths push into the middle of the uterus, they can cause problems.

If the fibroids are in the middle of the uterine cavity, the doctor can use a device called a hysteroscope to remove them. A hysteroscope looks like a laparoscope; it's a long silver tube that is inserted through the vagina, through the cervix, into the uterus. The doctor can use hot wires to cauterize the fibroids on the inside of the uterus. Because no incision is necessary, recovery is fairly quick.

For fibroids on the outside of the uterus, the doctor may choose to perform a procedure known as an abdominal myomectomy. This usually requires an incision similar to that done for a cesarean section. Usually women stay in the hospital for two to three days after this surgery, and full recovery may take six weeks.

Varicocele is the most common cause of male infertility. A varicocele is a varicose vein in the testicle. It forms when the valves in the vein, which are supposed to keep blood flowing toward the heart, malfunction. When the man stands up or strains, the blood goes back down toward the testicles, forming a varicocele.

A varicocele can be repaired relatively easily, by removing the section of the vein with bad valves. The removal is an outpatient procedure. Depending on the method used, it may take 30 minutes or a couple of hours. In either case, it can be done either under spinal anesthesia or general anesthesia. Some doctors may choose to use local anesthesia, but this is a lot less comfortable for the patient. The patient can usually go back to work the day after the procedure and go back to full physical activity in three to four weeks.

A man usually can't cause a pregnancy immediately after a varicocele repair, because he still has abnormal sperm. It takes two months for new sperm to mature in the testicle and another month for the sperm to work their way through the ducts and wind up in the ejaculate. A new semen analysis can be performed about three months after the surgery, although it may take longer for pregnancy to occur. The best results may not occur until six months or longer after the surgery.

Occasionally a couple will request that a previous sterilization procedure, such a vasectomy or tubal ligation, be reversed. While many vasectomies and some tubal ligations can be repaired by surgery and fertility restored, these procedures should be considered permanent. Some types of tubal ligation are absolutely not repairable because they involve the removal of a large portion of the fallopian tubes.

For patients who have had a vasectomy in the past five years, reversal usually works. However, many men develop antibodies against their own sperm after a vasectomy, and the persistence of those antibodies can interfere with the ability of the sperm to cause a pregnancy. Also, after a vasectomy reversal, a man usually can't cause a pregnancy immediately.

For intrauterine insemination, the woman lies down and the doctor uses a speculum to hold the vagina open. A thin catheter is inserted through the cervix into the uterus, close to the opening of the fallopian tubes. The sperm are injected through the catheter so they can swim up the fallopian tubes to the egg or eggs. For many women, the procedure does not hurt, but some find it very uncomfortable to have a catheter passed through the cervix.

After the procedure, the woman will usually rest for 10 or 15 minutes lying down, and after that can return to all normal activities, including intercourse.

Insemination may be used in conjunction with tests to predict ovulation at home or with medications for ovulation induction. The medications would be given at lower doses than those given for in vitro fertilization, because fewer eggs are needed. (For example, while 10 eggs might be a good number to work with for IVF, it would be dangerous for that many eggs to be fertilized in the body.)

Insemination used to be done by depositing the sperm in the vagina, but this is now usually done in cases where the woman wants to do the insemination at home, or cannot have a speculum inserted.

The sperm may come either from the male partner, who produces a sample of semen that is treated in the laboratory to concentrate the sperm, or from a donor.

Donor sperm is used only after rigorous screening for genetic and infectious diseases, mandated by the Food and Drug Administration, and a six-month quarantine. Using a sperm donor is a straightforward procedure for prospective parents; you order the sperm, it's shipped, and the doctor performs the insemination.

Sperm banks, or cryobanks, usually have a list of their donors that provides ethnic background, height, weight, and other basic information. Some can show you a baby picture of the donor and a more detailed profile; this may cost extra. Some cryobanks now have donors who will agree to be contacted when the child turns 18.

Assisted reproductive technology is an infertility treatment in which both egg and sperm are handled. The most common of these is in vitro fertilization. For IVF, the woman takes fertility drugs so her ovaries make several eggs at once; these are extracted just before ovulation and mixed with sperm in the lab. After three or five days, embryos are transferred into the woman's uterus and she waits to see if one or more implant so she gets pregnant.

In vitro fertilization may be an option for patients with blocked fallopian tubes, diminished ovarian reserve (ovaries that aren't working very well, as determined by blood tests of FSH), male-factor infertility, endometriosis, or unexplained infertility.

Pregnancies that result from IVF are basically identical to those that arise from natural conception. The main difference is that women who have IVF have a much higher rate of multiple pregnancies. But twins from IVF and twins that are spontaneously conceived have about the same risks. There are some conditions that are more common in women with infertility that may predispose them to certain pregnancy complications or birth defects, but these conditions are rare.

IVF is expensive and often not covered by insurance.

This section contains more information on:

Egg retrieval

Sperm retrieval

Fertilization

Embryo transfer and implantation

Preimplantation genetic diagnosis

Freezing

Donor egg

GIFT and ZIFT

In vitro fertilization requires extracting several eggs from the ovaries just before ovulation, so the eggs can be fertilized in the lab. Not all eggs will fertilize successfully, so it is best to start with several and have multiple embryos to choose from when it's time to transfer them into the uterus.

The egg retrieval is done with vaginal ultrasound and a needle. The ultrasound is used to guide the needle into the ovaries. The ovaries are actually located very close to the top of the vagina, so the doctor extracts the eggs by sticking the needle through the top of the vagina and into the ovaries.

The only puncture is the hole the needle makes, so it doesn't require any stitches. Egg retrieval is done under light anesthesia; women wake up very soon after the procedure and can go back to work the next day. Some women feel fine after the procedure, while others have cramping, swelling, and soreness.

In vitro fertilization is normally performed using sperm from a semen sample. However, for men who have a low sperm count or no sperm in their ejaculate, it may still be possible to retrieve some sperm. Some men with no sperm are actually making sperm that can't get out--either the men have had vasectomies or they have a blockage that prevents sperm from leaving the testicle. Only one sperm is needed to perform intracytoplasmic sperm injection (ICSI) and in many cases a doctor can extract hundreds of sperm directly from the testicle.

The most common technique uses a thin needle. Under local anesthesia, a doctor inserts the needle into the epididymis, a structure that sits on top of the testis and holds sperm while they mature. The procedure only takes a few minutes, including the time to inject anesthetic. He extracts fluid from the epididymis and an embryologist immediately checks the fluid to make sure it contains sperm.

If there is no sperm in the epididymis, the doctor can use a biopsy gun, which shoots a needle into the testicle itself and takes a sample of the tissue and sperm. The doctor may take several samples. After extraction with a fine needle or a biopsy gun, the man should be back to normal activities the next day.

If neither of these techniques works, the doctor may take a larger wedge of the testicle. This requires making a small incision in the scrotum, which means recovery will be longer and more painful.

The IVF laboratory starts preparing for your eggs the day before the retrieval by setting up the culture dish where fertilization will happen. Immediately after the retrieval, an embryologist looks at the material retrieved, finds the eggs, and inseminates them either by adding sperm to the dish or by performing intracytoplasmic sperm injection (ICSI). ICSI is used for sperm that are unable to fertilize an egg on their own. In this technique, a technician uses a powerful microscope with a very tiny needle to inject a single sperm into an egg. At some clinics, fully half of the IVF cycles are done using ICSI.

The embryos are cultured in a very special lab. Everything that touches a human embryo has to go through an extensive process of testing and cleaning. Everything from the culture dishes to the countertops (heated to body temperature) to the floor (sticky, to hold dust) are specially designed for human embryo culture. Patients don't need to visit the lab; between egg retrieval and embryo transfer, the process goes on without you.

Sixteen to 20 hours after insemination, the embryologist checks for fertilization, setting aside any eggs that did not fertilize normally. The lab can then update you on how many eggs fertilized. The embryos are left to divide until day three, when they should have six to eight cells each.

On day three, the embryologist grades the embryos based on the number of cells and how well they appear to be developing. The embryos are usually transferred to the uterus on day three, but in some cases they may be cultured longer. Culturing the embryos until day five--when embryos should have formed into a hollow ball known as a blastocyst--lets the embryologist get a better sense of how healthy they are. This gives couples the opportunity to improve their chances of a pregnancy without the risk of a high order multiple gestation.

In some cases, the lab may perform assisted hatching, which means it makes a tiny hole in the zona pellucida, the shell that surrounds and protects the embryo. When the embryo implants, it has to break through the zona pellucida; assisted hatching may help the embryo get out of the shell.

Most embryologists are not medical doctors, but have a background in biology with several years of education in embryology (the study of embryos and how they develop). Most have certification in embryology and andrology from the American Association of Bioanalysts.

After the embryos are grown in the lab, and the best ones are selected, they are transferred into the uterus. The woman lies on a table and the embryos are put in the uterus through a thin catheter, similar to that used for intrauterine insemination. The doctor may use ultrasound to guide the catheter into the uterus. After the procedure, you will rest for about half an hour. After that, clinics give varying advice on how long to rest. Your doctor might advise you to get right back to your normal activities, or to rest for several days or longer.

The number of embryos transferred is based on the medical and reproductive history of the patient, the quality of the embryos, and the quality of the uterine lining. The woman's age also is part of the decision, as well as how she feels about the risk of having twins or triplets and whether she is at higher risk for pregnancy complications, which are worse with multiple pregnancies. The more embryos transferred, the higher the risk of a multiple pregnancy. So, a woman who is 42 years old and has had three failed IVF cycles might get five embryos, while a 29-year-old on her first cycle might have only one or two transferred.

Most transfers are done on day three (day 0 is the day the eggs are retrieved). In some cases, the transfer does not happen until day five. This is more common with patients who are at high risk for having multiple pregnancies, which means doctors would prefer to transfer fewer embryos. It is also more common in patients who have a lot of good-looking embryos on day three and can wait a few days longer to see which are the best. Five-day-old embryos have had a longer time to develop, which means the embryologist may be able to better tell which ones are healthiest. However, most patients do not need to wait until day five. Embryos that are not transferred may be frozen to use in later cycles.

A week after fertilization, one or more embryos may implant into the lining of the uterus. Then the hormones of pregnancy are detectable in blood.

Two weeks after the egg retrieval, the woman will take a pregnancy test. If she is pregnant, the IVF doctor will continue to monitor the pregnancy with blood hormone tests and ultrasound. If all is going well, she'll be transferred to her obstetrician by the end of her first trimester.

Preimplantation genetic diagnosis is a technique used to identify embryos with chromosomal or genetic disorders so they are not transferred. It can also be used for sex selection.

PGD was first performed in 1989. It was originally developed for couples who know they are carriers of genetic disorders and want to be sure they aren't passing the bad genes on to their children. This procedure has made it possible for couples with serious genetic disorders to decrease the risk of having an affected child. Examples of disorders that are caused by a single genetic defect, and thus easy to test for, are cystic fibrosis, Tay-Sachs disease, and hemophilia. Most disorders have more complex causes and cannot be identified with PGD. Only a few labs are able to do the single-gene testing, but many clinics send their samples to those labs. It is important to remember that not all disorders can be diagnosed with this technique and that further genetic testing may be recommended.

PGD can also be used to test for aneuploidy (extra or missing chromosomes), which can occur randomly in nature and increases with maternal age. Down syndrome is an example of aneuploidy; it results when an embryo has three copies of a particular chromosome instead of two. Aneuploidy is the most common cause of miscarriage, so women who have had multiple miscarriages may want to do PGD for aneuploidy.

On the third day of development in the lab, when an embryo has six to eight cells, a single cell is removed from each embryo and analyzed for the presence of genetic disorders. Test results come back a day or two later; only embryos without the genetic abnormality are placed in the woman's uterus.

Cryopreservation, or freezing, is a tool that allows for the preservation of sperm, eggs, and embryos. Freezing sperm has been possible for decades, and embryo freezing is now routine. Egg freezing is performed more rarely.

The main danger in freezing delicate eggs, sperm, and embryos is that ice crystals will form and destroy the cells. To avoid that, materials called cryoprotectants are added to the mixture holding the cells to protect them during freezing. Still, most cryopreserved specimens are not quite as viable as fresh specimens.

After embryos are transferred to the uterus for in vitro fertilization, any excess normal-looking embryos may be frozen for later IVF cycles. You must pay to have the embryos frozen, stored, and thawed later, but this is generally cheaper--and less trouble--than going through ovulation induction and egg retrieval again. Storing embryos usually costs a few hundred dollars per year.

There are few circumstances in which eggs need to be frozen. Most of the women who choose to freeze their eggs are patients with cancer or other diseases who know their ovaries will be affected by treatment. Some women decide to freeze eggs when they are in their 30s and aren't sure when they will be ready to have children. Eggs that have been frozen must be fertilized using intracytoplasmic sperm injection (ICSI), in which a single sperm is injected into an egg.

Researchers are constantly working on better cryopreservation techniques that improve the chances that embryos and eggs will survive freezing and be viable after they are thawed.

Patients whose own eggs are of poor quality can use eggs from donors, usually young women who are paid for their donation. The majority of women who use donor eggs are women in their 40s. Some, but not all, have failed IVF many times; a 45-year-old woman who comes in for the first time is so unlikely to be able to get pregnant with her own eggs that a doctor may recommend trying donor eggs first. Although there are always reports of women becoming pregnant well into their 40s and even their early 50s--which gives the impression that women can become pregnant at these ages--the majority of these pregnancies were achieved using egg donors.

Younger women with premature ovarian failure are also candidates, including women who have had cancer treatment. Women who carry a genetic disorder that they do not wish to pass on may also choose to use donor eggs. Donor eggs may also be a choice if an earlier attempt at IVF produced low-quality embryos or failed for some other reason.

The embryo transfer procedure is the same as for women who are using their own eggs; the only difference is that women using donor eggs don't go through egg retrieval a few days earlier. Instead of taking fertility medications to stimulate the ovaries, they take estrogen to stimulate the lining of the uterus to thicken and progesterone, which also helps prepare the uterus. They start these hormones at about the same time the donor starts taking fertility medications so the two women's cycles are synchronized.

Some people have a friend or relative who is willing to act as a donor, but most people go through agencies that recruit donors all over the country. Agencies offer varying amounts of information on donors. Sometimes the agency makes the choice, picking a donor with the same ethnicity as the recipient. At other agencies, recipients can look through books full of 20-page profiles, and may even meet the donor. The cost for a donor found through an agency is in the thousands of dollars.

Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) are rarely used now. For these procedures, as for in vitro fertilization, sperm and eggs are obtained. But in GIFT and ZIFT, the transfer is made much earlier than in IVF.

In GIFT, the sperm and eggs are mixed together, then immediately placed in the fallopian tube in the hopes that fertilization will happen. In ZIFT, the fertilization happens in the lab, but the fertilized eggs are placed in the fallopian tube the next day, rather than waiting for the embryo to divide several times, as occurs in IVF.

GIFT and ZIFT are much more invasive than IVF. While the embryo transfer in IVF is done through the vagina, GIFT and ZIFT require the doctor to make a laparoscopic incision in the abdomen, in order to get the gametes or zygote into the fallopian tube.

Because several eggs are transferred, GIFT and ZIFT have a higher risk of multiple births than does IVF.

GIFT and ZIFT have declined as laboratory techniques have improved. Now technicians can observe fertilization, grow embryos for several days, and select the embryos that are most likely to succeed. At the time when GIFT and ZIFT were used more, these processes were less well understood and it was worth taking a chance with putting gametes or just-fertilized zygotes into the fallopian tubes. When pregnancy doesn't occur in GIFT, no one knows whether it was a problem with fertilization, embryo development, implantation, or something else; with IVF, there is a better chance that a problem could be pinpointed.

Women who are unable to carry a pregnancy might consider the use of a gestational carrier (surrogate). Surrogacy requires a complex legal and financial arrangement, as well as carefully coordinated and synchronized medical oversight. Many states and countries do not recognize surrogacy. Couples in these places may choose to travel to a state that recognizes surrogacy in order to pursue this option.

Clinics that work with surrogacy usually do gestational surrogacy, in which the baby is not genetically related to the surrogate mother. In gestational surrogacy, both the sperm and egg come from the intended parents or from donors. Traditional surrogacy, in which the surrogate is inseminated with the intended father's sperm but uses her own egg, is rarely done at fertility clinics now because it is legally complex.

A woman without a uterus or with a uterine abnormality might also choose to use a surrogate and, rarely, so might a woman who has had many miscarriages. Still, most of the patients who use a surrogate do not have infertility, but instead have a medical condition that makes it difficult for them to have a healthy pregnancy. For example, some women have such bad morning sickness that they have to be hospitalized for months, and might choose not to go through a second pregnancy. Or a woman who has had an organ transplant and is not healthy enough to be pregnant might use a surrogate.

Multiple pregnancies--pregnancies with twins or more--are a risk of both in vitro fertilization and fertility medications. Younger women are more likely to have multiple pregnancies than older women. For example, if an older women produces three eggs when she's taking fertility medications (or has three embryos transferred during IVF), chances are that all three will not fertilize and develop successfully. However, a younger woman who takes fertility medications and produces three eggs may well become pregnant with triplets.

There are always risks in pregnancy; women are at risk of developing high blood pressure and gestational diabetes, for example. With twins, the risks of these and other complications goes up. This includes the risk of cesarean section, premature labor, and premature delivery. With triplets, the risks are even higher. The more prematurely a baby is born, the higher the risk for health and developmental problems. While a singleton pregnancy averages 39 to 40 weeks, twins are usually born at about 36 weeks, triplets at 32 weeks, and quads about 30 weeks. Babies from triplet pregnancies and higher often have serious problems.

In cases where a woman becomes pregnant with triplets or more, she may choose to have a reduction performed at the end of the first trimester. This reduces the risks to the mother and babies. However, in about 3 to 5 percent of reductions, the whole pregnancy will be miscarried. For women who are opposed to reduction, the doctors may be more conservative with treatment, choosing to give lower doses of fertility medications or transfer fewer embryos in IVF.

For cancer surgery, or any kind of surgery, it's best to choose a surgeon who does the procedure all the time. The same is true of infertility clinics; doctors recommend picking a place with a lot of experience in whatever procedures you might have. This doesn't mean you have to pick the clinic that does the most IVF cycles per year, but a clinic that only does 10 a year probably doesn't have enough experience.

Ask the clinic about its success rates, and find out if it publishes that information anywhere. In your initial visits to the clinic, ask as many questions as you can; you want to be sure that the clinic is able to do what you expect, and also to be sure that the clinic staff is comfortable answering questions and listening to your concerns.

The U.S. Centers for Disease Control and Prevention collects data on assisted reproductive technology (including IVF) from several hundred clinics across the country. The report can be viewed on the CDC website. Direct comparisons of pregnancy rates aren't necessarily the best way to choose a clinic; clinics have different populations of patients, so a clinic that takes only the easiest patients might have an artificially high pregnancy rate. But at the minimum, a clinic that is willing to report its data might be a better choice.

A typical IVF cycle costs more than $10,000, and most patients pay for it themselves. Assisted reproductive technologies require costly medications and the services of skilled personnel who use specialized medical and laboratory equipment. While many countries have national health insurance plans that cover fertility treatment, there are no federal guidelines about insurance coverage for fertility evaluation or treatment in the United States. Several states have laws that require insurance companies to offer coverage, but there are tremendous variations even among the states with laws. Insurance companies may have age requirements or other strict eligibility criteria that must be met. They may also limit the number of treatments or the kind of treatments covered, the number of treatments per year, or other aspects of fertility treatment.

Those considering fertility care should verify eligibility and the specifics of their benefits with their human resources departments and insurance carriers before starting treatment.

Some infertility clinics offer financing packages or guarantee a child or your money back. Ask a lot of questions to be sure you understand what these plans include.

Be sure to ask up front about the costs of any procedures you are considering, and let your doctor know if you are paying for everything yourself. She may be able to work with you to develop a more cost-effective treatment plan.