Caroline Kilian is 3 years old and as graceful as a dancer. She loves to pick blueberries in the back yard.
She's the miracle child her parents thought they might never see.
Beth and John Kilian tried for more than a year to conceive and had no idea why they couldn't.
"Automatically, we considered me to be the primary issue," says Beth, who was 25 and working as a health-care program planner when they began.
Her doctor could find nothing wrong with her, but had her take Clomid, a powerful fertility medication, for several months. "Without a doubt, of course, it was just going to be me."
John, a 34-year-old software engineer, believed the same thing: "I think eventually the doctor did say, 'John, let's take a look at you,' but initially that was not what he was looking for."
The Kilians went through a form of torture that thousands of couples endure every year. About half of all infertility cases involve a problem with the husband's sperm — but that is rarely where doctors look first.
"I think that men in general get too little medical attention," says Dr. Larry I. Lipshultz, professor of urology at the Baylor College of Medicine in Houston. "The man is the second partner to be evaluated, rarely the first. And it's often at his wife's urging rather than his own volunteering."
Lipshultz says the problem is built into the modern health care system. When couples have trouble conceiving, they generally go to the one reproductive specialist they know — the wife's gynecologist.
Gynecologists do what they are trained to do: treat women. As a result, Lipshultz says, a woman may go through extensive testing and treatment. Half of the time, it is fruitless.
"It's going to take a much shorter period of time, less money, and certainly less discomfort, for the male to be evaluated," he says. "The woman's evaluation is usually painful and more time-consuming, so it's logical to get the man's evaluation out of the way."
In the Kilians' case, it turned out that John, otherwise healthy, had sperm with poor "morphology and motility" — in other words, they were mostly misshapen, and had trouble swimming toward an egg as sperm routinely do. It was a complete surprise to him. There was no family history of infertility; he was one of five children.
Treatment of Choice
But the solution came in the same breath as the diagnosis. It is called intra-cytoplasmic sperm injection — ICSI for short — and since its development in the early 1990s, it has become the treatment of choice for couples with "male-factor" infertility.
In the laboratory, fertile eggs are extracted from a woman the same way they would be for in-vitro fertilization. But instead of putting the egg in a Petri dish with thousands of sperm and hoping for conception, doctors select a single sperm from the husband, draw it into a tiny, hollow needle under a microscope, and inject it directly through the egg's tough outer layer.
Normally, if the sperm were more mobile, one of them would penetrate the egg on its own. With ICSI, it does not matter what shape the sperm is in, as long as the DNA inside is in good shape.
"We're so effective now in using ICSI," sayd Dr. Sherman Silber, director of the Infertility Center of St. Louis, who worked with the Belgian team that developed the technique a decade ago. "We have such an effective tool for helping 99 percent of infertile men to have their own genetic child."
Questions do remain. Researchers suspect, for example, that many cases of male infertility have genetic roots, and wonder if children conceived with ICSI will have fertility problems of their own when they reach adulthood. The procedure is expensive as well — $15,000 or more — and the Kilians did not conceive Caroline until the third try.
They say they were lucky their insurance covered almost the entire bill, but not all policies are as generous.
John Kilian says he is still a bit frustrated at the months they lost while his wife was put on fertility drugs, but having a healthy daughter has changed him.
"It changes your outlook when you think about it," he says. Parenthood "is not a given, it's a blessing."
The Kilians have tried ICSI again. They're expecting twins in the fall.