- The Washington Times - Sunday, March 25, 2001

For many months, Toni DiChiacchio carefully predicted the best days to conceive a baby. She bought several pregnancy tests so she could find out the good news as soon as possible.

The good news never came, though. For more than a year, Mrs. DiChiacchio and her husband, Vince, got their hopes up and then crushed.

"Every month, I said, 'This is it,' " says Mrs. DiChiacchio, who now lives in Port St. Lucie, Fla., but lived in Fairfax during her fertility investigation. "I was so devastated each time. Even my [gynecologist] did not know what was wrong. We were young. Blood tests indicated my hormones were fine."

Further testing by a specialist at the Shady Grove Fertility Center showed that Mrs. DiChiacchio's fallopian tubes were blocked. She had laparoscopic surgery to clear them, then took Clomid, a mild fertility drug, to improve ovulation. Two months later, she conceived, but miscarried. Two months after that, she was pregnant again.

The DiChiacchios' son, Dominic, is 4 years old.

"The year we tried was like wasting 12 months," says Mrs. DiChiacchio, now 30. "Once we found out what the problem was, the resolution was pretty quick. The whole experience has given me a much better appreciation for birth and conception. I truly believe my child is a miracle."

The DiChiacchios are among the 6.1 million people about 10 percent of the reproductive population in the United States who have experienced infertility, according to the American Society for Reproductive Medicine (ASRM).

The couple is also an example of how, in the majority of cases, a simple fertility investigation can lead to resolution of the problem through medication or surgery.

"If a couple is trying to conceive and is having no success after one year, they are safe in assuming there is a fertility problem," says Dr. Suheil Muasher, medical director of the Jones Institute for Reproductive Medicine, a Norfolk clinic that recently opened a branch office in Fairfax. "After 12 months, it is a good time to begin a fertility investigation."

There are exceptions to that rule, however, says Atlanta fertility specialist Dr. Mark Perloe. If a couple has a known previous condition such as irregular menstrual cycles, prostate surgery, pelvic infections or cancer treatment, it would be worthwhile to see a specialist beforehand, he says.

Because age plays a big factor in fertility success, women older than 35 should seek a work-up sooner. Dr. Muasher recommends that a woman older than 35 see a doctor if she has been trying for six months with no luck. Women who are older than 40 and trying to conceive would be wise to see a doctor for initial testing immediately, he says.

"At 30, I wouldn't worry, you can wait a year," Dr. Muasher says. "But age is extremely important. Ferti-lity decreases as a woman gets older. At age 35, we notice a signi-ficant drop in fertility and egg quali-ty. After 40, fertility drops sharply."

In any given month, a woman younger than 30 with no evidence of fertility problems has a 20 percent chance of conceiving. For a woman older than 40, that number drops to 5 percent, he says.

Testing the man

Dr. Muasher says it is easy and wise to begin a fertility work-up by testing the man. In 40 to 50 percent of infertility cases, the man is either the sole cause or a contributing cause.

"We do a simple male semen analysis," he says. "It is quick and does not cost a lot of money. If the problem is found to be with the male, then we don't have to subject the female to expensive and invasive testing."

In a semen analysis, sperm are examined under a microscope and graded for motility (movement) and morphology (appearance and shape). Treatment for some male-factor conditions includes antibiotic therapy for infection, surgical correction for vein irregularities or hormone treatment, Dr. Muasher says.

Testing the woman

Tubal problems, such as in Mrs. DiChiacchio's case, account for about 35 percent of female infertility problems, Dr. Muasher says. When tubes are blocked, the sperm and egg cannot meet in the fallopian tubes, where fertilization typically occurs.

Causes for tubal blockages include infection and endometriosis, a condition in which the lining of the uterus grows outside the uterus, resulting in painful adhesions and scar tissue that can affect fertility.

"We don't know what causes endometriosis, but it is fairly common in women in their 30s, "Dr. Muasher says. "Endometriosis creates an unfavorable environment for eggs and sperm."

A hysterosalpingogram (HSG) is an X-ray of the fallopian tubes that is used commonly to determine a tubal blockage. Laparoscopic surgery, in which a small camera is inserted through a tiny hole in the abdomen, can further reveal details. A doctor can remove problems such as adhesions during the laparoscopy, Dr. Perloe says.

Irregular ovulation plays a part in about 25 percent of infertility cases, according to the ASRM. One of the easiest and least invasive ways to investigate whether a woman is ovulating regularly is to chart her basal body temperature (BBT) daily.

To create a BBT chart, a woman must take her temperature orally each morning before she gets out of bed. Normally, the release of the hormone progesterone at the time of ovulation (typically around days 14 to 16 of a 28-day cycle) causes a temperature rise of 0.5 degrees to 1.0 degrees. If ovulation occurs, body temperature will rise and stay elevated until the drop in hormones just before menstruation. If ovulation does not occur, the pattern will be a jagged line with no dramatic change.

Looking back at several months of BBT charting can help a woman determine whether she ovulated. Examination of cervical mucus (which changes to a clear color and slippery texture around the time of ovulation) combined with BBT charting can help pinpoint a couple's best time for conception, Dr. Perloe says.

"Charting BBT is very effective in determining if ovulation is occurring," he says. "It is less effective in saying when it is occurring. If you see a pattern, you are probably fine. If you don't see a pattern, you should get an evaluation."

If it is determined that a woman is not ovulating, further blood testing can be done to figure out why. Common reasons for anovulation (the lack of or irregular ovulation) in-clude an excess of hormones such as prolactin or a lack of progesterone in the latter half of the cycle.

Another common but more complex cause of irregular or absent ovulation is polycystic ovarian syndrome (PCO), an imbalance of hormones that can interfere with metabolism and ovulation, Dr. Muasher says. PCO can be determined by a blood test and ultrasound, he says.

In the past, PCO has been treated with surgery or by prescribing the drug clomiphene citrate (Clomid). However, researchers recently determined that PCO is related to insulin resistance, and many physicians are successfully treating PCO and irregular ovulation by prescribing the diabetes drug Glucophage, Dr. Perloe says.

"It is becoming evident that Glucophage is a more appropriate treatment than Clomid in many cases of PCO," he says. "By doing this, we are treating the underlying cause of the irregular cycles, and we are cutting down on the chances of multiple births."

Sometimes a couple's fertility work-up will show more than one factor, making getting to the root of the problems a more complex process, says Dr. Paul Gindoff, a reproductive endocrinologist at George Washington University Medical Center.

"We have to look at the patient holistically as a couple," Dr. Gindoff says. "We can't just key in and isolate one factor, such as ovulation. Even if that is correct but only part of the issue, the patient still won't get pregnant."

In about 20 percent of couples, doctors will find no specific cause for infertility, according to the ASRM. However, a good number of couples whose diagnosis is unexplained infertility will conceive in time. The ASRM estimates about 35 percent to 50 percent of those couples will conceive within two years. Sixty to 70 percent of couples with unexplained infertility will conceive within three years.

Sometimes a couple who had no trouble conceiving their first child will need to seek an evaluation and possibly treatment when trying without success for a second baby. This is called secondary infertility. There may be an unknown problem, such as an infection that blocked one or both tubes, or a couple's fertility simply may have declined in the time since the first child was born, Dr. Gindoff says.

"Secondary infertility obviously takes a lot of people by surprise," Dr. Gindoff says. "What we see in a lot of people is really an artifact of age. They may have waited three or four years before trying for the next baby, and those years could be at that critical juncture where fertility drops dramatically."

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