When Lisa Perdue and her husband Michael had difficulty starting a family, she was diagnosed with advanced endometriosis at 33 and learned it affected her fertility. "Aside from being in pain every month, I was angry and sad that a medical condition took away my ability to have a family," she says. "I blamed myself for concentrating on my career. I felt every woman on the planet could have a baby--except me."

Under a reproductive endocrinologist's care, Perdue has endured tests and multiple surgeries over the past five years. "Doctors advised in vitro fertilization (IVF). It took a while to become healthy enough to undergo the procedure." She became pregnant on the third IVF attempt.

Perdue thanks Michael for being so supportive through the medical appointments and research. He administered hormone injections during treatment cycles and kept her spirits up. "Modesty goes right out the window. Clear your social calendars, because your life is under a doctor's control. I worried constantly about financial drain. Insurance didn't cover $15,000 to $20,000 per-cycle treatments."

Openness with family, friends and co-workers helped. "Hormones can make you crazy," Perdue says, laughing. She found online bulletin board support through the local chapter of RESOLVE: The National Infertility Association, headquartered in Somerville, MA. When group members met, Perdue learned infertility occurs to couples in all walks of life. "I didn't feel like a freak anymore, and I definitely wasn't alone."

One in every six couples nationwide struggles with infertility, defined as the inability to achieve pregnancy after one year of unprotected intercourse. Treatments, lifestyle changes and support groups offer them hope.

"Every day, people say, 'I'm glad this isn't happening to my sister, because she has no coverage and does not have means to finance treatment options out of pocket,'" says Erin Kramer, RESOLVE's advocacy director. Nationally, Kramer says 25 percent of insurance plans pay for some level of infertility treatment, but most limit coverage to diagnosis, medications or lower-tech treatments.

In 1985, Maryland was the first state to pass a law mandating insurance coverage for IVF. However, the law excluded HMOs from having to provide coverage, required couples to document a five-year history of infertility and did not include male factor infertility as a criterion for coverage. A 2000 amendment made the requirement of HMOs, reduced to two the number of years a couple had to suffer with infertility before coverage was provided and required coverage for treatment of male factor infertility. Virginia and Washington, D.C. have no such mandate. "There's no option to purchase an individual insurance plan to cover infertility in states that don't mandate coverage," Kramer notes.

A federal statute governing self-insured health plans exempts those plans from insurance mandates. Some self-insured plans voluntarily provide coverage, but are not required to even in states where a mandate exists. Kramer says there's currently no infertility coverage for federal workers, and even the Maryland law doesn't cover businesses with fewer than 50 employees or groups opposed to assisted reproductive technologies for religious reasons.

"I urge couples not to wait too long before starting families," says Fady Sharara, M.D., FACOG, director of the Virginia Center for Reproductive Medicine in Reston and Hagerstown. "This happens too frequently, and they experience much anguish. If you're over 35, don't wait longer than six months before seeking treatment. If over 40, come and see us yesterday," he says.

Doctors say that in 40 percent of infertility cases it is women, and in 40 percent of cases it is men who contribute to infertility, and, in 20 percent, both partners contribute. Women are born with about 2 million eggs, and the process of losing them starts in utero (peak number there is 7.1 million); by puberty, only 400,000 are left. A typical woman releases about 450 eggs from her ovaries during her reproductive life. The majority are lost through attrition, which varies from woman to woman. "A woman's ovarian age should not be worse than her chronological age," Sharara says. Men with low sperm counts, sedentary lifestyles and hobbies like frequent bike riding and hot tub usage may contribute to difficulties. "I learn a lot from family history, lifestyle choices and a diagnostic work-up," he adds.

Some clinics offer financial counseling, accept insurance and offer money-back guarantees if treatments fail. "What works for one couple may not fit for another. The couple should feel comfortable with a clinic's services, procedures and staff. Tour a facility and ask questions. The reproductive endocrinologist should be Board Certified," Sharara says.

"Couples think they can wait until the woman is in her 30s, or even 40s, to start a family. But women achieve maximum fertility in their 20s," says Victoria A. Jennings, Ph.D., director of Georgetown University's Institute for Reproductive Health. For couples having trouble getting pregnant, Jennings says the approach used depends on the difficulty. If the woman is not ovulating, hormonal treatments can help. If a blockage in the fallopian tubes keeps sperm from fertilizing the egg, surgery may be the answer. For some it's timing, and there is an easier, natural approach. Jennings and her colleague at Georgetown, Dr. Marcos Arevalo, developed the Standard Days Method (SDM) of family planning initially to help women avoid pregnancy. The SDM focuses on the few days during her menstrual cycle when a woman can get pregnant--the day she ovulates and the five days before ovulation. Most women using the SDM use CycleBeads^TM, a color-coded string of beads representing the menstrual cycle. Couples wanting to get pregnant find the SDM and CycleBeads^TM helpful. "Even if they don't get pregnant in a few months and decide to seek infertility treatment, having used the SDM gives them important information about the woman's cycle length and when to have intercourse," Jennings says. "Because CycleBeads^TM are a visual representation of the menstrual cycle, both partners can literally see whether or not the woman is likely to get pregnant if they have sex that day." The clinical trial of the SDM has been completed, and CycleBeads^TM became available last October.

Julia Indichova, director, Fertile Heart Learning Center in Woodstock, N.Y., leads workshops on natural fertility, in Washington, D.C. The work grew out of her own infertility problems before she had two children. IVF wasn't an option, and she felt more comfortable improving overall health. "The desire to have a baby inspires couples to do whatever they can on spiritual, emotional and physical levels to enhance conception, which can also help them avoid health problems later. Nutrient deficiency, immune system problems and digestive disorders are often part of the problem. It's accepted practice to improve health and nutrition to prevent cancer and heart disease. Why not employ these principles to achieve fertility? Fortunately, mainstream medicine has widened the door to accept these practices. But couples should always let their doctors know what they are doing," Indichova says. Her regimen includes avoiding caffeine and sugar and adding more fiber, fruit and vegetables, especially greens, and antioxidants to the diet. Equally important are improving communication between spouses and resolving internal conflicts about pregnancy and having children. Visualization exercises and dream analysis are part of the program.

After a seven-year struggle, "Vicki" became pregnant on her fourth IVF treatment. She and her husband have an 18-month-old son. She never considered alternative treatments until she read studies saying acupuncture increased blood flow to the uterus. She found doctors and an acupuncturist she trusted.

"Acupuncture was relaxing," Vicki says. "Stress melted away. I walked on air every time I left her office. She was committed to her patients' treatment, and she persuaded me to believe it, though a lot seemed crazy. She had me light moxa, a stick of rolled-up dried herbs, and wave it over my stomach regularly. I drank water at room temperature and avoided cold beverages. Visualization exercises helped. I had time off from work. It was better to have that break."

Couples need to know how to communicate with friends and family, and vice versa. Baltimore, MD licensed clinical social worker Linda Hellmann counsels infertile couples. "This is not the first difficulty or sadness that will happen to you. You may feel a loss of control, but that will pass," Hellmann says. "How you deal with unexpected tragedies makes a difference in the amount of control you feel. Participate and stay connected, but you have to communicate what you need from other people and identify personal boundaries--things that are too upsetting. If you cannot attend your best friend's baby shower, send a gift, and let her know you'll be with her in your heart."

Hellmann offers suggestions for family and friends: "Never say, `Just relax. It'll happen eventually,' 'You'll have a lot of fun trying,' and 'Just adopt.' Those statements emphasize sadness and compound the problem. Don't give out advice unless asked. You might be overloading the couple emotionally. Listen, and avoid behaviors that may cause pain, such as only talking about grandchildren and pregnancy or dismissing, or not respecting, the couple's need to grieve if a procedure doesn't work or if a miscarriage happens. We all need support. Family and friends can be the best allies."