The quest for parenthood
Two Kitchener clinics guide couples through complexities of fertility assessment and treatment
WOMEN WHO GIVE PRIORITY to education, progress in their chosen field and even purchase of a home should be aware their reproductive career is gradually closing during that time, says a Kitchener fertility specialist.
Dr. Victor Akinsooto, a gynecologist who opened One Fertility in the Deer Ridge business park last December, considers advocacy and increased awareness to be part of his mandate.
He agrees women deserve time to establish themselves in business or a profession, but says they also need to think proactively about their fertility. Age is a huge factor in infertility. He’d recommend a fertility assessment for women who have had unprotected sex fairly regularly and not found themselves pregnant by age 30.
Numbers shed a fascinating light on the issue. A 20-week female fetus has seven
million eggs. She will never make more. By the time she’s born at 38 to 40 weeks, she has two million eggs, and the decline continues to age 40, when the number drops precipitously.
While fertility in a healthy man doesn’t taper off until age 70 or even 80, it is possible that an older father may have some impact on the health of a child, although not as much as an older mother does, Akinsooto says.
What is certain is that male infertility has been on the rise for the last 15 to 20 years, says Dr. Judy Campanaro, medical director of fertility at the long-established KARMA (Kitchener Area Reproductive Medicine Associates) clinic in Kitchener.
The increasing incidence may be influenced by more men agreeing to be tested, but there is good evidence that sperm counts are dropping and more men also have misshapen sperm, with double heads or tails, and low motility. The cause is likely environmental, given that toxins cross continents and oceans. Polystyrene, for example, found in disposable cups and packaging, emits an estrogen effect as it degrades.
What’s known as “the male factor” is now just as likely as female conditions to be responsible for a couple’s infertility and, Akinsooto says, more often than not both the man and woman contribute to the problem.
The arrival of Burlington-based One Fertility and developments at KARMA mean residents of Waterloo Region and the surrounding area now have unprecedented access to fertility assessment and treatment close to home.
This summer, KARMA (Kitchener Area Reproductive Medicine Associates) is expanding its range of services performed locally. Rather than take patients to an affiliated Mississauga clinic for the high-tech procedures associated with in vitro fertilization (IVF), Campanaro will do egg retrieval, fertilization and embryo transfer at the Pine Street offices.
By the end of this year, One Fertility will also be similarly equipped to perform the complete IVF procedure here rather than take its patients to the Burlington clinic. Before embarking on IVF, clinics must undergo inspection by the Ontario College of Physicians and Surgeons. The college evaluates the equipment and ensures staff are qualified. Six months later, representatives return to watch a procedure and look over the clinic’s record-keeping Dr. Roger Stronell, KARMA’s chief of imaging, says the competition will bring out the best in both clinics. Akinsooto hesitates to call it competition, saying instead that he looks forward to a spirit of consultation and co-operation, pointing out that women’s health is at the heart of both clinics.
Stronell’s experience with fertility treatment dates back to the early 1980s when, soon after completing a radiology residency, he began working with Canada’s IVF pioneers at Toronto General Hospital. Over time they realized the procedure didn’t require the infrastructure of a hospital and went on to establish clinics in Toronto and Mississauga. In the early 1990s, he was instrumental in opening KARMA.
Compared to today, early IVF procedures were invasive and less precise. Development of the trans-vaginal ultrasound probe, bringing imaging close to the ovaries for unparalleled views, transformed egg retrieval and embryo transfer, Stronell says.
In 1993, when Campanaro completed an obstetrics and gynecology residency at Queen’s University and moved to Kitchener, >>
>> she planned to open a general obstetricsgynecology practice. Instead, Stronell hired her to begin a fertility program at KARMA. Twenty years later, he describes the understated Campanaro as a powerhouse in successful treatment.
Stronell believes in a team approach to women’s reproductive health. KARMA includes two obstetrician-gynecologists, Emma Wakim and Wendy McCuaig, with busy practices. A third specialist, Dr. Andrew Stewart, is a recent addition. He maintains an office elsewhere, but supports Campanaro’s fertility practice and also does some IVF procedures.
KARMA’s large waiting room has close to three dozen chairs. Patients range from women with gynecological problems and normal or problem pregnancies, to single women or couples, including same-sex couples, who want babies. Fertility issues, which include a history of early pregnancy loss, make up 20 per cent of the caseload.
“We offer a clinic that is staffed with local people and we have an outstanding track record,” Stronell says proudly. “We are open 363 days a year and have helped 3,000 couples get pregnant since we opened.”
Research shows about 15 per cent of couples don’t conceive naturally, but only half ever seek an assessment.
The causes of infertility are varied and complex. Akinsooto, who has a double specialty in endocrinology and reproductive technology, says it’s uncommon for a woman to be completely infertile, but a number of conditions can contribute to what’s known as sub-fertility.
One of the most common is polycystic ovarian syndrome, an endocrine condition in which women don’t ovulate regularly and may only have one or two menstrual periods a year. Their blood tests show a high level of male hormone which prevents egg follicles from maturing.
The condition has long-term implications beyond fertility. Without at least three or four periods a year to renew the endometrium, the uterine lining has the potential to become pre-cancerous. Women with the syndrome also tend to be overweight, and doctors often recommend more exercise and a healthy diet as the first step in treatment.
Another cause of infertility is premature ovarian failure, which results in poor-quality eggs and early menopause. It’s silent, and women may not suspect they have it until blood tests reveal the problem. In hormone tests, Campanaro says, “you can have 20 (year-olds) looking like 40; 40 (year-olds) looking like 20.”
Akinsooto says up to 15 per cent of fertility patients may need surgery to correct problems such as fibroid tumours in the uterus, or a condition in which a band of tissue called a septum partitions the uterus. He does such surgery for his own patients, and also on referral, at McMaster Medical Centre.
In theory, women wanting to postpone having a baby could freeze eggs for a future time, as men with testicular cancer freeze sperm, but the technology for eggs is still developing, Akinsooto says. Unlike frozen sperm, frozen eggs have a low pregnancy rate.
However, young women facing cancer treatment that could harm their fertility sometimes choose to have eggs frozen, and for them it’s an acceptable alternative, he says. Better yet, if they have a committed partner, is to fertilize the eggs as soon as they are retrieved because there are very good results with frozen embryos.
Some cases of infertility can only be helped with donor sperm or eggs. Although anonymous donations of sperm are permitted in Canada, donation of eggs is not, Campanaro says. Canadians tend to look to a U.S. egg donor for help. In such cases, frozen sperm is sent across the border to fertilize the egg, and a frozen five-day embryo, known as a blastocyst, is returned for transfer to the woman hoping for pregnancy.
Clinics see sperm or egg donations by a relative as fraught with potential problems, possibly heartbreak. Campanaro says if a couple insists, the identified donor would require testing, and both the couple and the donor need independent legal advice and group counselling to discuss the donor’s future relationship with the child.
Fertility treatment can be a roller-coaster of hope and disappointment. It’s hard for young couples to watch friends get pregnant seemingly at will, and many have put up with years of hints, jokes, even pointed questions from their eager families.
Patients of One Fertility are regularly
reminded that counselling is available through the clinic if they want it. However, it isn’t required. At KARMA, a one-hour session with counsellor/nurse Ann Louise Woodward is mandatory for all fertility patients. In 17 years of working with Campanaro, Woodward has developed a host of questions aimed at getting a sense of what two people are like as a couple. She asks about their education, hours of work, home life while growing up, finances, sexual relationship, drug and alcohol use and abuse in their families, how they solve problems and leisure activities they enjoy together. She’s not only looking for sources of stress or unresolved issues, she’s also considering how their future parenting skills might be influenced by personal experiences.
If there were previous marriages with children, she tries to judge their sense of responsibility by asking if they provide support and see those children regularly. A newer question is whether the couple is physically abusive with each other, which is more acceptable in some other countries than in Canada. She looks for signs of depression, asking about sleep patterns and eating habits. Depending on their culture, patients may respond in detail, or with little more than yes or no. At the end of the session, she tells them her impressions and what she’ll recommend to Campanaro.
If one or both seem like perfectionists, she may suggest stress counselling, explaining it “will make them even more effective and better able to cope.” If one or both grew up in a chaotic or dysfunctional household, she may recommend community parenting classes to compensate for the lack of positive role models in their childhood. Campanaro relies on Woodward’s assessments, impressed by the range and depth of information patients share with her. For example, “it’s frightening the number of people who have been sexually abused as children,” she says. Although just 30 to 40 per cent of couples>>
>> in fertility treatment will need IVF, most arrive braced for the ballpark cost of $10,000 per cycle, including $6,000 for the procedure and $4,000 for drugs. If they’re fortunate, an employee health plan helps with drug costs.
Some want to go straight to IVF, but responsible clinics exhaust other options first. “Emotionally, IVF is draining, and there are risks associated with it,” Campanaro says.
Ontario pays for IVF if women have two blocked fallopian tubes, a policy Akinsooto and Stronell consider sexist because it doesn’t cover IVF in the case of men without testes or without sperm. Akinsooto is optimistic the policy will change.
“Health is a complete state of mental and physical well-being,” he says. “The issue of reproduction is a very important factor in this health. Some, through lack of awareness, minimize what is a very important need.”
In fertility care, the doctor determines the course of tests and procedures, but it is registered nurses and sonographers who see fertility patients most frequently, and daily at times. A battery of tests launches the investigation of a couple’s infertility, which is defined as failure to conceive after a year of unprotected intercourse.
The woman’s blood hormone levels are measured and she is checked for sexually transmitted disease with blood work and a vaginal culture. There are also tests for HIV and hepatitis.
The man’s semen undergoes detailed analysis: all the sperm in the ejaculate may be dead, or they may move slowly or not at all, lacking the energy to travel through the vagina to the fallopian tubes where fertilization takes place. If there’s doubt, sperm can be put through a lab simulation to determine their ability to reach an egg.
Once testing is complete, the woman’s normal monthly cycle is monitored to see where a problem might lie. “What happens in the two weeks before ovulation plays a role in what happens over the following two weeks, explained nurse Judy Renwick, KARMA’s IVF co-ordinator, who has worked with Campanaro for 20 years. Daily testing also offers a couple their best chance of precisely timing intercourse to try to conceive naturally.
On Day 3 of the cycle, monitoring begins with daily ultrasounds of the ovaries and
blood tests to measure changing hormone levels. By Day 9, ultrasound should detect a follicle growing on an ovary, while rising hormone levels indicate an egg maturing within the follicle. Even if there’s no sign of activity, ultrasound continues until Day 15 in case a follicle makes a late appearance. Sometime between Days 5 and 11, a type of ultrasound called a sonohysterogram is done to ensure the fallopian tubes are open to receive a mature egg. If just one tube is open, it has the ability to lean over to collect an egg released by the opposite ovary. Ovulation occurs between Days 12 and 15, pinpointed by ultrasound which reveals a collapsed follicle and blood tests reporting a change in hormone levels. Women are notified daily of test results so they know precisely when they are at the peak of fertility.
A week later, a biopsy shows if the uterine lining is thickening as needed to welcome >>
>> a fertilized egg. “The body likes two weeks to prepare the uterus for implantation,” Renwick explains. “Tissue sent to the lab reveals if the necessary cell changes have occurred or if medication is needed to build up the endometrium.”
To this point, OHIP has covered all costs except for the sperm’s simulated trip to the fallopian tubes. If everything appears normal, the reassured couple may be sent home to try for another six months. Sometimes they’re not heard from again.
If the judgment is that conception is unlikely without help, the couple may move on to IVF, at which point all costs fall to the patient.
Now they’re nervous, Renwick says. They’re worried about cost, frightened by the prospect of the woman taking powerful drugs “and devastated about turning (conception) into a mechanical process.”
The IVF cycle also features daily blood tests and ultrasounds, plus daily injections of follicle-stimulating hormone and a drug to suppress ovulation. When the time is right, the doctor retrieves eggs by aspirating each of the swollen follicles under the guidance of the trans-vaginal ultrasound probe.
Fluid from each follicle is examined. In the worst case, no eggs are found.
Ideally, five to 10 eggs are retrieved and fertilized in the lab. On Day 3 or Day 5, again under ultrasound guidance, the most promising embryo is transferred to the uterus, where the lining has been bolstered by supplementary progesterone. As for whether IVF results in pregnancy, Renwick says “we can’t make this pure science. We have to rely on what the body does.”
Each IVF cycle, from the first to the last, has a 40- to 50-per-cent chance of success. “If it hasn’t happened after three (IVF cycles), it’s probably time to stop,” Campanaro says. “Thirty per cent of infertility is unexplained. I tell those couples it’s time to move on, perhaps consider adoption.”
To them, counsellor Woodward would offer this thought: “Two people are a unit. Don’t let anyone tell you you’re not a family.”