Infertility 101: What Every Rheumatologist Should Know

For patients wishing to prevent pregnancy, a discussion about contraception always includes a review of medical conditions that may preclude them from using estrogen-containing contraception, including a history of deep vein thrombosis or pulmonary embolism, lupus and antiphospholipid syndrome. I typically refer to the Centers for Disease Control and Prevention [CDC] medical eligibility criteria chart.

TR: What does it mean to ‘freeze’ eggs or embryos, and what does this process entail?

AC: Oocyte cryopreservation (i.e., egg freezing) is the process by which the ovaries are stimulated to produce multiple follicles for the purpose of harvesting the oocytes (i.e., egg retrieval) and cryopreserving them. In this way, a patient may theoretically preserve their fertility at this moment in time. That said, oocyte cryopreservation is not a guarantee of a future live birth, and patients should be counseled appropriately when they are considering this process. Some studies have found that patients must cryopreserve between 20 and 25 oocytes before the age of 35 in order to have a >90% chance of a live birth. After age 35, that number is even higher.

Oocyte cryopreservation specifically allows for independent preservation of fertility, whereas embryo banking (i.e., freezing embryos) ties fertility to another person in the form of an already formed embryo. When a patient who is about to begin treatment for a rheumatic condition inquires about fertility preservation, they need to understand this distinction.

TR: What does assisted reproductive technology (ART) refer to, and can you provide examples of these technologies?

AC: ART refers to any fertility treatment that involves the handling of oocytes or embryos. Examples of this include in vitro fertilization (IVF) and frozen embryo transfer (FET).

Dr. Chemerinski

When a patient is referred to [my department], the first step is to evaluate for causes of infertility, including disorders in the male and female reproductive tracts. Not every patient who presents requires IVF. Some patients can conceive with oral medications and intrauterine insemination. Patients who can’t conceive in this manner may be recommended to undergo IVF.

Coverage for, and access to, these technologies varies by state. Although some states mandate coverage from private insurers, others do not. The amount of coverage may vary or be limited, as well. For example, some insurers will cover the cost of ART up to a maximum dollar amount, but others cover only diagnostic evaluation, not treatment. The average out-of-pocket cost for an IVF cycle is around $12,000, but this can vary significantly by region and by the details of the treatment.