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Once you understand what type of infertility problem you have, it's important that you understand your options, including the potential physical, financial and emotional costs. In most cases, there are a few acceptable options. While you will receive counseling about various options, ultimately it is your choice as to how to proceed.

The unexpected news that you have a fertility problem can create a great deal of stress and frustration. Being infertile can make you feel out of control and that the next step in your life is blocked. Faced with the loss of a natural part of life, some people feel grief, loss and guilt.

Many infertile couples aren't prepared for the emotional roller coaster of grief and loss of infertility treatments. The layers of stress are multiple:

• Financial—How will we pay for treatment that may cost thousands of dollars?

• Professional—Will I miss job promotions or will my work suffer because of treatment needs?

• Emotional—How will we cope as a couple if treatment fails?

Facing friends, family members or co-workers who have children is another stress in an infertile couple's life.

Thus, it is important that you:

• Are prepared to experience many unfamiliar and uncomfortable feelings. Understand that there are psychological reactions to infertility that are very real and related to the stress of diagnosis, treatment and lack of pregnancy. Being infertile is overwhelming. So is treatment.

• Understand that men and women cope with stress and infertility differently. While a woman is physically and emotionally dealing with the effects of treatment, her outlets may involve many people. She may want to talk a lot about her experiences with her partner or anyone else who will listen. Men, however, may be perceived as being emotionally and physically distant because they may be less likely to express their emotions outwardly, despite their deep concern for and commitment to their partner.

• Know that marriages and relationships will either be strengthened or pulled apart by infertility treatment. What happens depends on your relationship prior to treatment. Are you able to discuss intimate feelings? Do you have a good marriage? A good sex life? Are you a cohesive unit as a couple?

• Realize that infertility and its wide range of treatment options can be overwhelming. There are many complicated issues, such as preserving embryos by freezing them for future use, adoption, donor eggs, surrogacy and fetal reduction, in which a woman carrying multiple embryos is induced to miscarry one or more. Educating yourself and your partner as much as possible about treatment options makes it less likely you'll be overwhelmed.

• Understand that treatment may not be successful. It's typical for couples at the beginning of treatment to do whatever it takes to achieve a pregnancy. Eventually, however, most realize that emotionally and financially there is a limit.

However, before deciding to pursue a different course, like adoption or remaining childless, you must resolve your issues around your infertility. This means getting to the point where you both can grieve and put closure to the fact as a couple you are not going to be able to have a biological child.

Treatments for Infertility

Fertility drugs are typically the first treatment for infertility in women. Up to 90 percent of infertile women are treated with these drugs, which are designed to correct specific hormonal imbalances.

The most common fertility drugs—clomiphene citrate (Clomid) and gonadotropins (Repronex, Gonal-f, Follistim and Bravelle)— are used to stimulate the production of mature eggs. Fertility drug treatment can include the following:

• Clomiphene citrate, also known as Clomid or Serophene. Clomid is used to induce ovulation (sometimes called controlled ovarian hyperstimulation or COH). Compared to gonadotropins, this drug is inexpensive and easy to use. Clomid is similar in structure to estrogen, which makes it able to bind to estrogen receptors in the brain. In some women who fail to ovulate, inappropriate estrogen secretion is to blame .Inappropriately high estrogen levels suppress follicle stimulating hormone (FSH). As a result, the ovary doesn't get the signal to start maturing an egg. Clomiphene tricks the brain into believing that estrogen is lacking, so the brain asks the pituitary gland to increase its FSH production. This, in turn, calls forth an egg. For women with this form of ovulation dysfunction, about 75 percent will ovulate on clomiphene and about half of those will get pregnant. In all, 36 percent of women with ovulation problems who take clomiphene will get pregnant within six attempts with the drug.

  Clomid is taken in pill form and usually given for a maximum of five to six months. Some health care professionals monitor the follicular growth of women taking Clomid to test the response to the medication and some do not. Possible adverse reactions include swelling of the ovaries, multiple pregnancies, hot flashes, mood swings, depression and irritability. Common side effects include weight gain and water retention.

  While Clomid treatment is generally effective in women who experience abnormal ovulation cycles, it is less likely to cause pregnancy in women who already ovulate.

• Gonadotropins: Gonadotropins are fertility medications that contain follicle-stimulating hormone (FSH). In addition to FSH, some gonadotropins also contain luteinizing hormone (LH). Gonadotropins are used to stimulate follicles and ovulation in women who do not ovulate. They are also sometimes used to stimulate ovulation in women before they undergo IVF. They include:

  Urofollitropin for injection purified (Bravelle) and menotropins for injection (Repronex) are gonadotropins that are extracted from human urine of postmenopausal women. Repronex contains equal parts of FSH and LH, and Bravelle contains mostly FSH and very little LH.

  Follitropin alfa for injection (Gonal-F) and follitropin beta (Follistim) are the first follicle stimulating hormones (FSH) to be produced by recombinant DNA technology. These drugs directly target ovarian egg production and are more potent than Clomid or urinary FSH.

  Because of their means of action, gonadotropins can be very successful in some patients. They also have a higher chance of success than Clomid, with overall pregnancy rates of 80 percent for some ovulation problems. When gonadotropins are given to patients who did not respond to Clomid, however, pregnancy rates are much lower—about 20 to 30 percent.

  These agents are much more apt to lead to multiple births, however, because they stimulate the release of several eggs. Up to 30 percent of pregnancies that result from gonadotropins are multiples, and up to five percent are triplets or higher. Additionally, in rare situations, gonadotropins may cause severe and debilitating medical complications, such as ovarian hyperstimulation syndrome (OHSS), ectopic pregnancy, and pregnancy-associated high blood pressure. Thus, they should only be prescribed by clinicians specifically trained in their use.

• Other fertility medications. These drugs include:

• Leuprolide (Lupron) is a synthetic hormone that mimics gonadotropin releasing hormone (GnRH). Drugs like Lupron are called GnRH agonists. Though these drugs mimic GnRH in action, their net effect is deplete the pituitary gland of both FSH and LH. Long-term use of an agonist also cuts off estrogen production in the ovaries and prevents a woman from ovulating. These drugs can be used to treat endometriosis and uterine fibroids. In IVF, these drugs are used to prevent a woman from ovulating while she takes gonadotropins to stimulate egg maturation.

• Nafarelin acetate (Synarel) is a non-injectable GnRH agonist administered via a nasal spray.

• Ganirelix (Ganirelix) and cetrorelix (Cetrotide) are GnRH antagonists similar in structure to Lupron. These drugs differ from agonists like Lupron in that they directly cut off the production of FSH and LH (in contrast to Lupron, which "fools" the pituitary gland to stop producing FSH and LH). Like Lupron, Ganirelix and Cetrotide help prevent premature ovulation during IVF.

• Progesterone. The hormone progesterone is essential to the reproductive process. Progesterone is typically administered with in vitro fertilization (IVF) and other assisted reproductive technology (ART) procedures because the amount of progesterone produced by the follicles after the eggs are removed is usually not enough to support the growth of the endometrial lining. Progesterone supplements are given for at two weeks or more to maintain the opportunity for an embryo to implant and to support early pregnancy.

Women who have no ovarian function and want to pursue a pregnancy through donor egg technology, for example, must also take fertility medications. For women receiving donor eggs, a combination of two or three hormonal medications is used to manipulate a regular 28-day menstrual cycle. The goal is to keep the egg recipient on the same cycle as her egg donor so her uterine lining is prepared to support the embryo once it is ready for implantation. Lupron is used to suppress the menstrual cycle, and estrogen supplements are used to get the cycle in synch with the donor's cycle.

Fertility drugs may cause a variety of physical and emotional side effects. There is also some concern that they may increase the risk of ovarian cancer. However, this connection is still very tenuous. Plus, infertility itself is a risk factor for ovarian cancer, while having children and using oral contraceptives protects against ovarian cancer.

Assisted Reproductive Technologies (ART)

Assisted reproductive technologies offer another step in infertility treatment. These include:

• In vitro fertilization (IVF). During this procedure, the ovaries are stimulated with one or more fertility drugs so they produce multiple eggs. Several of the eggs are then removed, usually in the doctor's office under a local anesthetic.

  The eggs and sperm are then combined in a Petri dish, which is placed in an incubator in specialized media to promote fertilization. After 18 hours, the eggs are examined to see if they have been fertilized. If fertilization occurs, one or more embryos are transferred to the uterus during another procedure several days later, or frozen for later use. The success rate for IVF is 30 to 35 percent for women under ages 35, 25 percent for women ages 35 to 37, 15 to 20 percent for women ages 38 to 40, and six to 10 percent for women over 40.

• Gamete intrafallopian transfer (GIFT). This procedure, while rarely performed today, uses the same stimulation process as IVF, except eggs and sperm are combined and immediately placed in the fallopian tube so fertilization occurs within the body. GIFT is available only to women who have normal fallopian tube function. The procedure takes place during one operation and usually requires general anesthesia. The success rate of GIFT is approximately 22 percent.

• Zygote intrafallopian transfer (ZIFT). This is a combination of IVF and GIFT. The primary difference between ZIFT and IVF is that the fertilized eggs are implanted into the fallopian tube instead of the uterus. Its success rate is approximately 31 percent. ZIFT also requires that a woman's fallopian tubes be functional. Eggs are retrieved via laparoscopy under general anesthesia and combined with sperm for fertilization in the Petri dish. The zygotes remain in the Petri dish for 18 to 52 hours and are then returned to the fallopian tube during a second procedure.

• Intracytoplasmic sperm injection (ICSI). ICSI is used when there are problems with sperm function or number, or to improve chances of fertilization. With ICSI, a health care professional directly injects a sperm into the cytoplasm (the biological soup that fills a cell, excluding the nucleus) of a single egg.

  ICSI is a highly specialized procedure. Not all IVF centers have the equipment or expertise to perform it. However, it is considered standard care today, so if your center doesn't offer it, you may wish to find another center. Used with IVF procedures, when ICSI is performed, the fertilized egg is allowed to grow in the Petri dish for a few days, and the resulting embryo or embryos are returned to the uterus.

• Donor Egg. Donor eggs are an option for women who cannot produce eggs or for whom egg quality is an issue. Another woman donates her eggs to be used for an IVF procedure. A woman using a donor egg becomes the biological mother to the offspring, but she doesn't share the child's genetic make-up. However, if the male partner's sperm was used in the fertilization process, the child shares his genetic background. Approximately 30 to 50 percent of women have a successful pregnancy using donor eggs. This procedure is most often recommended for women over 40 and for younger women with poor quality eggs.

• Donor Sperm. This ART procedure uses donated sperm in assisted reproduction, IVF or related procedures. The resulting offspring shares the mother's genetic make-up.

• Gestational Hosting. This is an option for women who cannot carry a pregnancy. A couple's egg and sperm, or embryo, are placed in another woman's uterus; she is known as the gestational carrier, or surrogate mother, who will carry the fetus to term and deliver the baby. However, she has no genetic relationship to the baby. Genetic surrogacy is another option, in which the surrogate also donates her eggs. eggs.

• Assisted hatching. This procedure is sometimes done in addition to IVF. After the embryo forms but prior to its transfer to the uterus, a special solution is used to thin or open the outer covering of the embryo (called the zona pellucida). This helps the cells of the embryo emerge from the outer shell, or hatch, and increases the chances that it will implant in the uterus. This method is suggested in women over age 35 or patients who have failed one or more IVF attempts, though some doctors recommend its use in all cases.