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Introduction: Expert Insights is an ongoing medical education podcast. The Carle division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please click on the link and complete the episodes Post-test. This podcast forum is brought to you to share expertise and insights within our integrated delivery system, to help us improve the health, the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host. Melanie Cole.

Melanie Cole: Welcome to Expert. Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing reproductive medicine and infertility. Joining me is Dr. Lori Hollins. She's a Reproductive Endocrinologist and Infertility Specialist with the Carle Foundation Hospital. Dr. Hollins, it's a pleasure to have you join us today. Let's start by discussing infertility. How common is it? What's the prevalence of it?

Dr. Hollins: Fertility is very common. So approximately 15% of people in the United States will experience infertility in their lifetime. So that's, when you think about couples, that's pretty high. Pretty much everyone wants to have a family, no matter what their sexual orientation is. And I think one of the reasons in fertility is so prevalent nowadays is because most people are waiting longer to have children. So that's probably one of the most common things that I see is that people are now waiting till their late twenties and mid thirties, if not 40, before they really start to think about whether or not they want to have a family. And if they wait that long, then a lot of these people will have problems conceiving.

Host: As you see fertility issues, do they occur mostly with the woman? Is it sometimes with the man? Is this equal? Tell us a little bit about some of that.

Dr. Hollins: Well, I think the misconception is that infertility is a female problem and it's actually not. So about 40% of the time it's male. And I think people are flabbergasted by that number. And then we often will see a couple that they have both male and female infertility. And so that's probably about 20% of the time. So it is definitely not just a female problem. And I think that's one of the misconceptions that we need to get out is that male fertility is very prevalent in this country, if not throughout the world and that we need to take the stigma away so that men will also be evaluated and seek treatment.

Host: Well then how long should a couple try before they seek help? When's it important to refer to, or to see a fertility specialist? When do you advise that someone would visit you or that a referring physician say, this is the time now?

Dr. Hollins: So, if a couple, if they're under the age of 35 and they've been trying for a year, then that is the definition of infertility. If they're over 35, between the age of 35 and 39, six months. And if they're 40 and over the recommendation is that they should see an infertility specialist, like pretty much right away. One of the things though is that if people have a history of irregular periods or polycystic ovarian syndrome, those couples don't need to wait and try a year because if they're having periods, if the woman is having periods twice a year, then there's no point in that person waiting a year to try because they're not going to get pregnant because they're not having regular periods. So I think once again, it's important to take a history. If somebody has had a history of pelvic infections, if they've had a history with sexually transmitted disease, if there's been trauma to the testicles, for example, or if people have undergone cancer treatment. So these are all things that can be red flags and those patients need to be referred as soon as possible

Host: What expectations, Dr. Hollins, would you like couples to have as they go through testing prior to starting treatment?

Dr. Hollins: So, I think one of the things is that over the year’s fertility treatments have become highly successful. And that's the thing I've been doing this for 30 years. And actually the first baby in the world was born through invitro fertilization in 1978. 1982 in the United States, so when IVF was first being performed, the success rates, weren't very good. And we started doing funny things like what they called, gift, where we would put the egg and the sperm in the fallopian tube, because we didn't have the laboratory techniques that we have now, but nowadays the chances of people getting pregnant if they need high tech treatments like IVF or intracytoplasmic sperm injection, where we inject the sperm into the egg are highly successful. And I think that there's a, once again, a misconception that these treatments are effective.

For example, somebody under the age of 35, the chances of getting pregnant with IVF are almost 60%. So I think people have to recognize that the success rates are good, but if people are older, so age is hugely important. And that's why I like to see people as soon as possible because we can't change how old a person is. And as people get older, the success rates do decrease, even in men, if there's a male infertility problem, we do see changes in sperm parameters as men get older. And that pregnancy rates, if the man is older, aren't as good. So once again, age is huge, particularly for the woman, not so much for the man. And it's really important that we see people as soon as possible, but they should also recognize that the chances of conceiving with any treatment that we do are actually pretty good.

Host: Well, thank you for that. So let's talk about some of the treatments that you might try. And since infertility fertility treatments are about family building and there are many options available right now. What are some of the first things you would try explain the difference between ovulation induction with Clomid, superovulation tell us a little bit about many of these options that are available today.

Dr. Hollins: Yes. Well, there are lots of options as you stated. So one thing I would like to say is that we hardly ever use Clomid anymore as a fertility, as first line fertility drugs. So Clomid is a, what we call an anti-estrogen and it kind of fools the brain into sending out a signal to get the ovary, to release an egg, but we don't use it as much anymore because there are side effects, more side effects associated with Clomid. For example, it sends out the cervical mucus, thins out the lining. So, the primarily first line drugs that we use is a medication called Letrozole or Femora, which is a breast cancer drug, but we've been using it for fertility for probably the last 20 years or so. It's highly effective. So a lot of times that will be the first line treatment particularly for people that don't ovulate with for like patients with polycystic ovarian syndrome, or we might use it in patients that have unexplained infertility. We occasionally might give people injectable fertility, drugs in conjunction with Letrozole.

We hardly ever use medications like FSH or what we call gonadotropins without in vitro fertilization, because when you give people gonadotropins there's a high risk of multiple births. There's about a 10% risk and multiple bursts with Letrozole or Femora. But if you use injectables, it's much higher and we don't want people to get pregnant with triplets and quads because of the risk of prematurity, etcetera. So we primarily use drugs like FSH medications when we're doing things like invitro fertilization, and we want to get more eggs and we fertilize the eggs, those eggs with the partner's sperm and then create an embryo. And then we can put one embryo back. Nowadays, we try to do what we call single embryo transfers because we don't want to increase the risk of multiple births and complications during pregnancy. And because our lab techniques are so great nowadays and have come such a long way, we're able to do that.

Host: As you're telling us about these many options, what special considerations might you consider for same sex couples that want to start a family as well?

Dr. Hollins: So, for same sex couples, here's the option of doing donor sperm, for women. Often we will combine that with doing an oral fertility drug like Letrozole. There are sperm banks throughout the country where patients can get sperm. They go on and they register and they choose a sperm donor. We usually do recommend that those patients have an evaluation to make sure that their fallopian tubes are open. And then we do intrauterine insemination with the donor sperm, highly effective once again, pregnancy rates per try with donor sperm are a little bit less than if you were using fresh sperm. Nobody uses fresh sperm nowadays, just because of the risk of STDs. So we always use cryopreserve sperm, but chances of getting pregnant are about 10 to 15% per try. So that's an option. If it's the same sex male couple, people are sometimes doing what we call gestational surrogacy and what that is where they may use a donated egg with their sperm and create an embryo that a woman carries.

So that's common. They also may use donated embryos in a woman, and the woman carries the pregnancy. And then also for transgender couples, depending on before, you know, somebody goes through sex reassignment surgery. There's the option of if it's a female to male, there's an option of doing an egg retrieval, stimulating them and doing an egg retrieval and keeping those eggs available for fertilization at a later date. So there's all kinds of options that are available to people. I think the problem is that sometimes people are reluctant to refer those patients, but I strongly believe, like I said, you know, pretty much all of us want to have a family and there are certainly options. And I really like to help couples figure out what's going to be the best option to help them create the family that they want.

Host: So, Dr. Hollins do insurance plans cover infertility treatment these days? And while you're talking about that, please speak about the impact that fertility treatments have on the psychological wellbeing of the couple. There's well-meaning family and friends that want to get involved that speak to them daily. So speak to both those things, if you would, as far as insurance and the wellbeing as you're going through these treatments.

Dr. Hollins: So, I think one of the things that is frustrating, I think to a lot of us in this field is that fertility is often not covered by insurance in the state of Illinois. There is a mandate that insurance plans cover infertility, but I think it also depends on how big the company is. And what I see is that some plans will cover everything and then other plans will just cover the diagnosis and won't cover the treatment. But I think about 60% of patients in the state of Illinois have covered some type of coverage for infertility. That's not true throughout the country. I just moved from Florida where virtually 90 to 95% of the insurance plans in the State did not cover fertility treatments. So that is very frustrating to patients as well as to providers. Fertility treatments can be expensive depending on what people need. And unfortunately a lot of times it isn't covered and that prevents, you know, there are barriers to people being able to get treatment.

One of the things I always tell couples who are embarking on fertility treatment, that it can be stressful. We do know that if patients do have a lot of stress, that it can potentially affect their ability to conceive, even if they are going through treatment. And we do provide psychological counseling to patients, for example, here at Carle we have a psychologist who is well trained in the issues that couples deal with going through infertility. There can be a lot of anxiety. There can be depression. We often do a lot of, you know, a lot of ultrasounds and monitoring, and there's a lot of hope riding on what we do. So as you can imagine, it can be very stressful for patients. Sometimes what I find is that family is not always the couple’s best friend, because they often do not understand all of the things that they're going through.

You know, they'll give, okay, just stand on your head or tell just advice that's not always helpful. So what you find is that sometimes people are in a little bubble and don't necessarily have places to go to discuss, you know, what they're going through. There is a National Fertility Organization called Resolve, which does offer, you know, some support groups. That's something that we are going to be doing at Carle shortly as well. Cause it is really important. There was a researcher, Alice Domar out of Boston that has shown that when patients are supported from a psychological standpoint, cognitive behavioral therapy and things like that, that their pregnancy rates are actually better.

Host: Wow. That is so interesting. And this is such an informative topic and such an informative episode, Dr. Hollins, as we wrap up, tell other providers what you'd like them to know about the importance of early referral and helping their patients to build that family as it was by encouraging them. And as you say, stress reduction and referral to a fertility specialist.

Dr. Hollins: First of all, I think providers need to bring up the subject and ask people what their plans are for having a family. Particularly if you're seeing somebody who's 35 I think it would be really important to kind of bring that up in your, you know, if you're doing well-woman visits or even if you're a family practice or internal medicine Doc, and you're seeing a woman of reproductive age, you know, kind of ask them, what are your plans for having a family? I think that would be the first, first thing. The second thing, I think anybody who expresses an interest or concern that they may have a fertility problem, please refer them. I mean, seriously, I think it's really important because you know, this is what we're trained to do and we can certainly help, you know, patients pinpoint options, talk to people about weight. Obesity has become a huge problem in this country and it can actually interfere with people ovulating normally, but don't hesitate to still refer the patient.

Even if you think they may be potentially too heavy for fertility treatments. I still think they, they deserve a referral. So I really think that anybody that has a concern about their fertility I think they should be referred. I think they deserve to have their questions answered and to be given a direction because like I said, I think there was a study about maybe 20 years ago that looks at how infertility patients feel compared to patients that are undergoing cancer treatment. And actually infertility patients had just as much depression and anxiety as people going through cancer treatment. So it's hugely important. I feel like I'm a good resource here at Carle and I would love to help providers with this important topic and please consider referring patients sooner than later.

Host: Well, I am quite sure that you are and what an excellent guest you are. Dr. Hollins, thank you so much for joining us today. And that concludes this episode of Expert Insights with the Carle Foundation Hospital. For a listing of Carle providers, and to view Carle sponsored educational activities, please visit our website at carleconnect.com for more information, and to get connected with one of our providers. We hope the information gained will be applicable to your work and life. If you found this podcast informative, please share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.