INFERTILITY

If getting pregnant has been a challenge for you and your partner, you're not alone. Ten percent to 15 percent of couples in the United States are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year.
If you've been trying to conceive for more than a year, there's a chance that something may be interfering with your efforts to have a child. Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing.
What's normal?
Most pregnancies occur during the first six cycles of intercourse in the fertile phase. Overall, after 12 months of unprotected intercourse, approximately 85 percent of couples will become pregnant. Over the next 36 months, about 50 percent of the remaining couples will go on to conceive spontaneously.

• Symptoms

  The main symptom of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms of infertility.
  In some cases, an infertile woman may have abnormal menstrual periods. An infertile man may have some signs of hormonal problems such as changes in hair growth or sexual function.

• Causes

  The human reproductive process is complex. To become pregnant, the intricate processes of ovulation and fertilization need to work just right.
  
  - Each month the pituitary gland in a woman's brain sends a signal to her ovaries to prepare an egg for ovulation.
  - The pituitary hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — stimulate the ovaries to release an egg. This is called ovulation. It is during this time a woman is fertile (usually about day 14 of her menstrual cycle).
  - The egg travels through the fallopian tube and can be fertilized about 24 hours after its release. Conception is more likely to occur when intercourse takes place one to two days prior to ovulation.
  - For pregnancy to occur, a sperm must unite with the egg in the fallopian tube during this time. Sperm are capable of fertilizing the egg for up to 72 hours and must be present in the fallopian tube at the same time as the egg for conception to occur. In order for a sperm to reach an egg, the man must have an erection and ejaculate enough semen to deliver the sperm into the vagina. There must be enough sperm, and it must be the right shape and move in the right way. In addition, the woman must have a healthy vaginal and uterine environment so that the sperm can travel to the egg.
  - If fertilized, the egg moves into the uterus where it attaches to the uterine lining and begins a nine-month process of growth.
  
  For some couples attempting pregnancy, something goes wrong in this complex process, resulting in infertility. The cause or causes of infertility can involve one or both partners.

  
• Causes of male infertility

  A number of things can cause impaired sperm count or mobility, or impaired ability to fertilize the egg. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, general health and lifestyle issues, and overexposure to certain environmental elements.
  
  Impaired production or function of sperm . Most cases of male infertility are due to problems with the sperm, such as:
  
  - Impaired shape and movement of sperm Sperm must be properly shaped and able to move rapidly and accurately toward the egg for fertilization to occur. If the shape and structure (morphology) of the sperm are abnormal or the movement (motility) is impaired, sperm may not be able to reach or penetrate the egg.
  - Low sperm concentration A normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of 10 million or fewer sperm per milliliter of semen indicates low sperm concentration (subfertility). A count of 40 million sperm or higher per milliliter of semen indicates increased fertility. Complete failure of the testicles to produce sperm is rare, affecting very few infertile men.
  Varicocele A varicocele is a varicose vein in the scrotum that may prevent normal cooling of the testicle, leading to reduced sperm count and motility.
  Undescended testicle Undescended testicle occurs when one or both testicles fail to descend from the abdomen into the scrotum during fetal development. Because the testicles are exposed to the higher internal body temperature, compared with the temperature in the scrotum, sperm production may be affected.
  Testosterone deficiency (male hypogonadism) Infertility can result from disorders of the testicles themselves, or an abnormality affecting the hypothalamus or pituitary gland in the brain that produces the hormones that control the testicles.
  Genetic defects In the genetic defect Klinefelter's syndrome, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production and possibly low testosterone.
  Infections Infection may temporarily affect sperm motility. Repeated bouts of sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. If mumps, a viral infection usually affecting young children, occurs after puberty, inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.
  
  In many instances, no cause for reduced sperm production is found. When sperm concentration is less than 5 million per milliliter of semen, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.

  
• Causes of female infertility

  The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome (PCOS), early menopause, benign uterine fibroids and pelvic adhesions.
  
  - Fallopian tube damage or blockage Fallopian tube damage usually results from inflammation of the fallopian tube (salpingitis). Chlamydia, a sexually transmitted disease, is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever. Tubal damage is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.
  - Endometriosis Endometriosis occurs when the uterine tissue implants and grows outside of the uterus — often affecting the function of the ovaries, uterus and fallopian tubes. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.
  - Ovulation disorders Some cases of female infertility are caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation can cause low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation. Specific causes of hypothalamic-pituitary disorders include injury, tumors, excessive exercise and starvation.
  - Elevated prolactin (hyperprolactinemia) The hormone prolactin stimulates breast milk production. High levels in women who aren't pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. In addition, some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing can be a sign of high prolactin.
  - Polycystic ovary syndrome (PCOS) In PCOS, your body produces too much androgen hormone, which affects ovulation. PCOS is associated with insulin resistance and obesity.
  - Early menopause (premature ovarian failure) Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35. Although the cause is often unknown, certain conditions are associated with early menopause, including immune system diseases, radiation or chemotherapy treatment, and smoking.
  - Benign uterine fibroids Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by blocking the fallopian tubes.
  - Pelvic adhesions Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. This scar tissue formation may impair fertility.
  
  Other causes A number of other causes can lead to infertility in women:
  - Medications Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
  - Thyroid problems Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
  - Cancer and its treatment Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman's ability to reproduce. Chemotherapy may impair reproductive function and fertility in men and women.
  - Other medical conditions Medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, HIV/AIDS, kidney disease and diabetes, can affect a woman's fertility.
  - Caffeine intake Excessive caffeine consumption reduces fertility in the female.

  
• Risk factors

  Many of the risk factors for both male and female infertility are the same. They include:
  
  - Age After about age 32, a woman's fertility potential gradually declines. Infertility in older women may be due to a higher rate of chromosomal abnormalities that occur in the eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. The risk of miscarriage also increases with a woman's age. A gradual decline in fertility is possible in men older than 35.
  - Tobacco smoking Men and women who smoke tobacco may reduce their chances of becoming pregnant and reduce the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.
  - Alcohol use For women, there's no safe level of alcohol use during conception or pregnancy. Moderate alcohol use does not appear to decrease male fertility.
  - Being overweight Among American women, infertility often is due to a sedentary lifestyle and being overweight.
  - Being underweight Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women following a very low-calorie or restrictive diet. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid.
  - Too much exercise In some studies, exercising more than seven hours a week has been associated with ovulation problems. Strenuous exercise may also affect success of in vitro fertilization. On the other hand, not enough exercise can contribute to obesity, which also increases infertility.
  - Caffeine intake Studies are mixed on whether drinking too much caffeine may be associated with decreased fertility. Some studies have shown a decrease in fertility with increased caffeine use while others have not shown adverse effects. If there are effects, it's likely that caffeine has a greater impact on a woman's fertility than on a man's. High caffeine intake does appear to increase the risk of miscarriage.

• When to seek medical advice

  In general, don't be too concerned about infertility unless you and your partner have been trying regularly to conceive for at least one year.
  
  - If you plan to conceive and you're a woman older than 30 or haven't had a menstrual flow for longer than six months, seek a medical evaluation.
  - If you have a history of irregular or painful menstrual cycles, pelvic pain, endometriosis, pelvic inflammatory disease (PID) or repeated miscarriages, schedule an appointment with your doctor sooner.
  - If you're a man with a low sperm count or a history of testicular, prostate or sexual problems, consider seeking help earlier.

• Tests and diagnosis

  If you and your partner are unable to become pregnant within a reasonable time and would like to do so, seek help. The woman's gynecologist, the man's urologist or your family doctor may be able to determine whether there's a problem that requires a specialist or clinic that treats infertility problems.
  Some infertile couples have more than one cause of their infertility. Your doctor will usually begin a comprehensive infertility examination of both you and your partner.
  Before undergoing infertility testing, be aware that a certain amount of commitment is required. Your doctor or clinic will need to determine what your sexual habits are and may make recommendations about how you may need to change those habits. The tests and periods of trial and error may extend over several months.
  Evaluation is expensive and in some cases involves uncomfortable procedures, and the expenses may not be reimbursed by many medical plans. Finally, there's no guarantee, even after all testing and counseling, that conception will occur.
  
  Tests for men
  For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman's vagina. Tests for male infertility attempt to determine whether any of these processes are impaired.
  
  - General physical examination This includes examination of your genitals and questions concerning your medical history, illnesses and disabilities, medications and sexual habits.
  - Semen analysis This is the most important test for the male partner. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes your semen specimen for quantity, color, and presence of infections or blood. Detailed analysis of the sperm also is done. The laboratory will determine the number of sperm present and any abnormalities in the shape and movement (motility) of the sperm. Often sperm counts fluctuate from one specimen to the next.
  - Hormone testing A blood test to determine the level of testosterone and other male hormones is common.
  - Transrectal and scrotal ultrasound Ultrasound can help your doctor look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstruction.
  
  Tests for women
  For a woman to be fertile, the ovaries must release healthy eggs regularly, and her reproductive tract must allow the eggs and sperm to pass into her fallopian tubes to become fertilized by a sperm. Her reproductive organs must be healthy and functional.
  After your doctor asks questions regarding your health history, menstrual cycle and sexual habits, you'll undergo a general physical examination. This includes a regular gynecological examination. Specific fertility tests may include:
  
  - Ovulation testing A blood test is sometimes performed to measure hormone levels to determine whether you are ovulating or not.
  - Hysterosalpingography This test evaluates the condition of your uterus and fallopian tubes. Fluid is injected into your uterus, and an X-ray is taken to determine whether the fluid progresses out of the uterus and into your fallopian tubes. Blockage or problems often can be located and may be corrected with surgery.
  - Laparoscopy Performed under general anesthesia, this procedure involves inserting a thin viewing device into your abdomen and pelvis to examine your fallopian tubes, ovaries and uterus. A small incision (8 to 10 millimeters) is made beneath your navel, and a needle is inserted into your abdominal cavity. A small amount of gas (usually carbon dioxide) is inserted into the abdomen to create space for entry of the laparoscope — an illuminated, fiber-optic telescope. The most common problems identified by laparoscopy are endometriosis and scarring. Your doctor can also detect blockages or irregularities of the fallopian tubes and uterus. Laparoscopy generally is done on an outpatient basis.
  - Hormone testing Hormone tests may be done to check levels of ovulatory hormones as well as thyroid and pituitary hormones.
  - Ovarian reserve testing Testing may be done to determine the potential effectiveness of the eggs after ovulation. This approach often begins with hormone testing early in a woman's menstrual cycle.
  Genetic testing Genetic testing may be done to determine whether there's a genetic defect causing infertility.
  - Pelvic ultrasound Pelvic ultrasound may be done to look for uterine or fallopian tube disease.
  
  Not everyone needs to undergo all, or even many, of these tests before the cause of infertility is found. Which tests are used and their sequence depend on discussion and agreement between you and your doctor.
  
  - Unexplained infertility
  In some infertile couples, no specific cause is found (unexplained infertility). Couples receiving the diagnosis of unexplained infertility are more likely to seek multiple health care providers and be influenced by the experiences of family and friends or literature that promises new hope. Although infertility is unexplained, the pregnancy rate for these couples with infertility treatment is among the highest.

• Treatments and drugs

  Treatment of infertility depends on the cause, how long you've been infertile, the age of the partners and many personal preferences. Some causes of infertility can't be corrected. However, a woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.
  
  Restoring fertility
  These approaches can involve steps related to the male or to the female, or both.
  Increase frequency of intercourse Having intercourse two to three times a week may improve fertility. However, too-frequent ejaculation can lessen sperm quality. Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation.
  
  Treatment for men
  Other approaches that involve the male include treatment for:
  
  - General sexual problems Addressing impotence or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.
  - Lack of sperm If a lack of sperm is suspected as the cause of a man's infertility, surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible. For example, varicocele can often be surgically corrected. For blockage of the ejaculatory duct or in the case of retrograde ejaculation, sperm can be taken directly from the testicles or recovered from the bladder and injected into an egg in the laboratory setting.
  
  Treatment for women
  Stimulating ovulation with fertility drugs
  Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. In general, they work like natural hormones — such as follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. Commonly used fertility drugs include:
  
  - Clomiphene citrate (Clomid, Serophene) This drug is taken orally and stimulates ovulation in women who have PCOS or other ovulatory disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
  - Human menopausal gonadotropin, or hMG (Repronex) This injected medication is for women who don't ovulate on their own due to the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, which stimulates the pituitary gland, hMG and other gonadotropins directly stimulate the ovaries. This drug contains both FSH and LH.
  - Follicle-stimulating hormone, or FSH (Gonal-F, Follistim, Bravelle) FSH works by stimulating the ovaries to mature egg follicles.
  - Human chorionic gonadotropin, or HCG (Ovidrel, Pregnyl) Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to release its egg (ovulate).
  - Gonadotropin-releasing hormone (Gn-RH) analogs This treatment is for women with irregular ovulatory cycles or who ovulate prematurely — before the lead follicle is mature enough — during hMG treatment. Gn-RH analogs deliver constant Gn-RH to the pituitary gland, which alters hormone production, so that a doctor can induce follicle growth with FSH.
  - Letrozole (Femara) This drug is in a class of medications called aromatase inhibitors, which are approved for treatment of advanced breast cancer. Doctors sometimes prescribe letrozole for women who don't ovulate on their own and who haven't responded to treatment with clomiphene citrate. Letrozole is not approved by the Food and Drug Administration for inducing ovulation. The drug's manufacturer has warned doctors not to use the drug for fertility purposes because of possible adverse health effects. These adverse effects may include birth defects and miscarriage.
  - Metformin (Glucophage) This oral drug is taken to boost ovulation. It's used when insulin resistance is a known or suspected cause of infertility. Insulin resistance may play a role in the development of PCOS.
  - Bromocriptine This medication is for women whose ovulation cycles are irregular due to elevated levels of prolactin, the hormone that stimulates milk production in new mothers. Bromocriptine inhibits prolactin production.
  
  Fertility drugs and the risk of multiple pregnancies
  Injectable fertility drugs increase the chance of multiple births. Oral fertility drugs (Clomid) increase the chance of multiple births but at a much lower rate. The use of these drugs requires careful monitoring using blood tests, hormone tests and ultrasound measurement of ovarian follicle size. Generally, the greater the number of fetuses, the higher the risk of premature labor. Babies born prematurely are at increased risk of health and developmental problems. These risks are greater for triplets than for twins or single pregnancies.
  The risk of multiple pregnancies can be reduced. If a woman requires an HCG injection to trigger ovulation, and ultrasound exams show that too many follicles have developed, she and her doctor can decide to withhold the HCG injection. For many couples, however, the desire to become pregnant overrides concerns about conceiving multiple babies.
  When too many babies are conceived, removal of one or more fetuses (multifetal pregnancy reduction) can offer improved survival odds for the surviving fetuses. This presents serious emotional and ethical challenges for many people. If you and your partner are considering fertility drug treatment, discuss this possibility with your doctor before starting treatment.
  
  Surgery
  Depending on the cause, surgery may be a treatment option for infertility. Blockages or other problems in the fallopian tubes can often be surgically repaired. Laparoscopic techniques allow delicate operations on the fallopian tubes.
  Infertility due to endometriosis often is difficult to treat. Although hormones such as those found in birth control pills are effective for treating endometriosis and relieving pain, they haven't been useful in treating infertility. If you have endometriosis, your doctor may treat you with ovulation therapy, in which medication is used to stimulate or regulate ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.
  
  Assisted reproductive technology (ART)
  ART has revolutionized the treatment of infertility. Each year thousands of babies are born in the United States as a result of ART. Medical advances have enabled many couples to have their own biological child. An ART health team includes physicians, psychologists, embryologists, laboratory technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.
  
  The most common forms of ART include:
  In vitro fertilization (IVF) This is the most effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended when both fallopian tubes are blocked. It's also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility, male factor infertility and ovulation disorders. IVF increases your chances of having more than one baby at a time because often multiple fertilized eggs are often implanted back into your uterus so that there is a greater chance one will develop into a baby. IVF also requires frequent blood tests and daily hormone injections.
  Electrical or vibratory stimulation to achieve ejaculation Electric or vibratory stimulus brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who can't otherwise achieve ejaculation.
  Surgical sperm aspiration This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if the ejaculatory duct is blocked.
  - Intracytoplasmic sperm injection (ICSI) This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.
  - Assisted hatching This technique attempts to assist the implantation of the embryo into the lining of the uterus.
  
  ART works best when the woman has a healthy uterus, responds well to fertility drugs, and ovulates naturally or uses donor eggs. The man should have healthy sperm, or donor sperm should be available. The success rate of ART gradually diminishes after age 32.
  
  Complications of treatment
  Certain complications exist with the treatment of infertility. These include:
  - Multiple pregnancy The most common complication of ART is multiple pregnancy. The number of quality embryos kept and matured to fetuses and birth ultimately is a decision made by the couple. If too many babies are conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.
  - Ovarian hyperstimulation syndrome (OHSS) If overstimulated, a woman's ovaries may enlarge and cause pain and bloating. Mild to moderate symptoms often resolve without treatment, although pregnancy may delay recovery. Rarely, fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. This accumulation of fluid can deplete blood volume and lower blood pressure. Severe cases require emergency treatment. Younger women and those who have polycystic ovary syndrome have a higher risk of developing OHSS than do other women.
  - Bleeding or infection As with any invasive procedure, there is a risk of bleeding or infection with assisted reproductive technology.
  - Low birth weight The greatest risk factor for low birth weight is a multiple pregnancy. In single live births, there may be a greater chance of low birth weight associated with ART.
  - Birth defects There is some concern about the possible relationship between ART and birth defects. More research is necessary to confirm this possible connection. Weigh this factor if you're considering whether to take advantage of this treatment. ART is the most successful fertility-enhancing therapy to date.

• Prevention

  Most types of male infertility aren't preventable. However, avoid drug and tobacco use and excessive alcohol consumption, which may contribute to male infertility. Also, high temperatures can affect sperm production and motility. Although this effect is usually temporary, avoid hot tubs and steam baths.
  If you're a man who's uncertain about whether you would eventually like to become a father, don't undergo permanent sterilization, such as a vasectomy. Although surgery to reverse this condition is possible, risks are involved that could affect fertility in other ways.
  
  A woman can increase her chances of becoming pregnant in a number of ways:
  
  - Exercise moderately Regular exercise is important, but if you're exercising so intensely that your periods are infrequent or absent, your fertility may be impaired.
  - Avoid weight extremes Being overweight or underweight can affect your hormone production and cause infertility.
  Avoid alcohol, tobacco and street drugs These substances may impair your ability to conceive and have a healthy pregnancy. Don't drink alcohol or smoke tobacco. Avoid illegal drugs such as marijuana and cocaine.
  Limit caffeine Women trying to get pregnant may want to limit caffeine intake to no more than 250 milligrams of caffeine a day (one or two cups of coffee).
  Limit medications The use of both prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly.
  
  Men should avoid hot tubs

• Coping and support

  Coping with infertility can be difficult. It's an issue of the unknown — you can't predict how long it will last or what the outcome will be. Infertility isn't necessarily solved with hard work. The emotional burden on a couple is considerable, and plans for coping can help.
  
  Planning for emotional turmoil
  
  - Set limits Decide in advance how many and what kind of procedures are emotionally and financially acceptable for you and your partner and attempt to determine a final limit. Fertility treatments may be expensive and often not covered by insurance companies, and a successful pregnancy often depends on repeated attempts. Some couples become so focused on treatment that they continue with fertility procedures until they are emotionally and financially drained.
  - Consider other options Determine alternatives — adoption, donor sperm or egg, or even having no children — as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of hopelessness if conception doesn't occur.
  - Talk about your feelings Locate support groups or counseling services for help before and after treatment to help endure the process and ease the grief should treatment fail.
  
  Managing emotional stress during treatment
  - Acupuncture This ancient therapy may benefit some couples who are undergoing fertility treatment. Although it's not clear exactly how acupuncture may improve fertility, it's thought that acupuncture reduces stress.
  - Practice relaxation Cognitive behavior therapy, which uses methods that include relaxation training and stress management, has been associated with higher pregnancy rates.
  - Express yourself Reach out to others rather than repressing guilt or anger.
  - Stay in touch with loved ones Talking to your partner, family and friends can be very beneficial. The best support often comes from loved ones and those closest to you.
  
  Managing emotional effects of the outcome
  
  - Failure The emotional stress of failure can be devastating even on the most loving and affectionate relationships and for people who've prepared well for the possibility of failure. Don't hesitate to seek professional help if the emotional burdens become too heavy for you or your partner.
  - Success Some studies have indicated that even if fertility treatment is successful, women experience increased stress and fear of failure during pregnancy. Other research suggests that women who achieved pregnancy using fertility treatments felt increasingly better and had higher self-esteem and less anxiety as the pregnancy progressed than did women whose pregnancies didn't involve medical intervention.
  - Multiple births A successful pregnancy that results in multiple births introduces new complexities and emotional problems. The risk of depression is higher in women who have multiple births.
  - Parenting Once a child arrives, parents are more likely to be more anxious and have less confidence and self-esteem. Discuss becoming parents with your partner and plan for the many changes — challenging and rewarding — that a child will bring to your lives.