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Infertility Awareness
Lori-Linell Hollins MD discusses the importance of age and infertility from both the male and female aspects. She shares how obesity affects infertility and she tells us the importance of a comprehensive evaluation of both male and female patients for couples trying to have a baby.
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Learn more about Lori-Linell Hollins, MD
Lori-Linell Hollins, MD
Lori-Linell Hollins, MD specialties include Reproductive Medicine, Infertility, Obstetrics & Gynecology, Reproductive endocrinology, Women's Services.Learn more about Lori-Linell Hollins, MD
Transcription:
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing infertility awareness. Joining me is Dr. Lori-Linell Hollins. She's a Reproductive Endocrinology and Infertility Specialist with the Carle Foundation Hospital. Dr. Hollins, it's a pleasure to have you join us today. So, tell us a little bit about how common infertility is and the importance of age and infertility from both male and female aspects.
Lori-Linell Hollins, MD (Guest): Well, infertility, unfortunately is becoming more and more common. About one in eight couples, will have an infertility problem in their lifespan. It's becoming more and more common. Age is huge. So, if a woman is over the age of 35, we get very concerned because the chances of becoming pregnant start to dramatically decrease over the age of 35. Actually, people don't realize that fertility starts to decline at about age 28. So, when we see women over the age of 35, and especially as they approach 40; we get very concerned and recommend fairly aggressive treatment and evaluation.
Host: There are some other factors and I'm glad you mentioned age that affect fertility. Tell us a little bit about some of the comorbid conditions that one or other partner might have that could affect their fertility, such as obesity.
Dr. Hollins: Obesity is more and more common as we all realize. And one of the things that can happen with obesity in women is that periods can become irregular. Also in men, we can see lower sperm counts in men as well. Fertility probably happens about 50% in women and about 40% of the time and a little bit often in men and then about 10 to 15% of the time, it may be both partners that contribute to an infertility problem. One of the most common things we see is also irregular menses or what we call polycystic ovarian syndrome. So, the syndrome, there are three things that are involved with the syndrome, irregular periods, like for example, only having six periods of a year, polycystic ovaries. That's when we look at the ovaries, there may be more than 15 to 20 follicles on the ovary on each ovary. And then also, abnormal male hormone levels or signs of what we call androgen excess with acne and abnormal hair growth on the face and body. And sometimes women may also show signs of balding, which can all be signs of androgen excess. So, that's one of the more common things we see as far as women not ovulating regularly.
Host: How long do you advise a couple and for other providers listening that are advising their couples, whether they're gynecologists or primary care providers, how long do you advise a couple to wait before seeking help for fertility issues?
Dr. Hollins: And that is a really important question. Thank you for asking me that. If a woman or a couple is under the age of 35, then we usually recommend that they try for about a year. So, that's one year of unprotected sex. However, if a woman has irregular menses like maybe she's only having six periods a year, she should see somebody right away. Over the age of 35, between age 35 and 40, we recommend six months of trying and at 40 we recommend seeing someone like myself right away.
Host: So, how do you evaluate the situation for a couple, Dr. Hollins, tell us the importance of the comprehensive evaluation of both the male and female patients. And really, what is your age cutoff for doing these kinds of evaluations?
Dr. Hollins: Well, once again, like I said, I tend to be fairly aggressive. Obviously we're doing a lot of Telemedicine now, so our initial visits are usually by Telemedicine where I do a complete history, not only discussing how frequently they're having periods, whether or not they have pain with their periods, how often they're having sex, those kinds of things, and also discuss whether or not they may have problems with their weight and obesity.
So, those are the first things. And also with the men, I'm asking questions about whether or not they might have problems with erections and ejaculation, whether or not they use hormones, whether or not they have had any trauma to their testicles. So, those are all things that we ask initially in the evaluation.
Once we do an initial consultation, like I said, because of COVID it is initially done by Tele-medicine, often we will have the patients come in to the office. For women, we will often do an ultrasound to evaluate the ovaries. We'll also do a special ultrasound called a histosonogram to evaluate the uterus. And we can often tell if the fallopian tubes are open. And then, like I said, with the ultrasound, we also can look at the ovaries and do what we call an antral follicle count. With men, obviously a sperm analysis is extremely important. We tell the men to abstain for two to five days before we actually do the sperm analysis. And often we may have to repeat the sperm analysis if it comes back abnormal. I also will often have men come in for evaluation, particularly if we find out that the sperm count is extremely low, or that motility is low, examining men for what we call a varicocele. So, men are extremely important in this process. Sometimes I see patients where the woman has been evaluated and even treated with oral fertility medications, and they've never gotten a sperm analysis. And then we get a sperm analysis and find out that there's significant male factor.
Host: So interesting. And I think one of the underlooked aspects of infertility treatments and awareness are the expectations. We're going to get into a few treatments briefly and some of the latest research and things that are exciting in your field, Dr. Hollins, but, what would you like other providers to counsel their patients about as far as expectations? What do you want them to have as they go through testing prior to starting treatment and beyond?
Dr. Hollins: I think providers who aren't fertility specialists do have to be careful. And what I mean by that is sometimes people assume because a patient is 40, that they won't get pregnant and they won't refer the patient. But the thing is, with technology, we often can get people pregnant. So, I think that sometimes people delay referring a patient and they even treat them themselves when time is of the essence. So, I think it's really important that they not diminish the patient's ability to conceive, but also they refer the patients right away. Often too, I see what happens is that patients maybe have a problem with like I said, PCOS, or they don't ovulate and one of the things I see that is really somewhat frightening is that sometimes people will go a year or more without having periods. And then we worry about things like what we call endometrial hyperplasia, which can be a precancerous condition. So, I would say that listen to the patients. Really do a good history and physical when somebody is coming to see you initially and pay attention, because there are some long-term risks that patients can have that maybe are not immediately being addressed. And I often will have a patient I'll talk to them and like they would tell me I haven't had a period in a year and a half and I'm like, you need to get in here right away, so, I can take a look and see what your lining looks like and potentially do an endometrial biopsy because I'm worried about sometimes precancerous conditions. So, I think sometimes when patients have infertility, they're not taken as seriously as they should be. And they're not sent to the right place as soon as possible.
Host: Doctor, there are so many options available to people today. Tell other providers, what are some of the exciting treatment options available that they may not know about?
Dr. Hollins: The go-to fertility medicine for ovulation is a medicine called letrozole or Femara, which is actually a breast cancer drug. But we've been using it for fertility for almost 20 years. So, that's exciting. We almost never give patients like what we call FSH medications on their own, just because of the risk of multiple births. So, that's something that people may get worried about whether or not people are going to get pregnant with like quintuplets. Well, that almost never happens anymore. IVF is certainly one of the things that pregnancy rates are dramatically improved over the last 20 years, for example, if somebody is under the age of 30, they have about a 50 to 60% chance of getting pregnant.
If they're over 35, the chances decrease, but they're still really good like about 40 to 30%. And even at 40, we almost, we have about a 20 to 30% chance of people conceiving. So IVF is a big one. ICSI, I-C-S-I where we can inject the sperm into the egg. I mean, 20-30 years ago, we didn't have treatments for male factor infertility. People used to do donor sperm, but now hardly anybody does donor sperm except for people that are maybe in an LGBTQ relationship or people that are single, a single woman. So, ICSI has revolutionized how we treat male factor, however, not everybody needs to do ICSI. Sometimes treating with supplements or medication for men is also helpful and sometimes can improve sperm counts and motility.
So, it is really exciting. That's one of the things I love about this field is that it has evolved so rapidly and that we can help so many more patients. Whereas, even 20 years ago, the success rates were probably less than 10 to 20% and now the success rates are dramatically improved. And then we also have egg donation for women that are over the age of 40, or even if they are women who, for whatever reason have what we call premature ovarian insufficiency or premature ovarian failure. We have the ability to get eggs from a donor, fertilize it with the patient's partner's sperm and create an embryo and that embryo can be put into the woman's uterus so they can actually experience pregnancy and give birth. So, there's just so many exciting things that are going on in the field of reproduction and it truly is exciting and gratifying to be able to work at the cutting edge.
Host: Well it certainly is. As we wrap up, do you have any final thoughts for other providers of when you feel it's important that they refer to the specialists at the Carle Foundation Hospital and how you want them to treat their patients as they're going through these infertility treatments?
Dr. Hollins: Anytime the thought crosses your mind that you need to refer the patient, you should refer the patient. That's number one. Number two is if anybody, like I said, has been trying for a year or six months, if they're over 35 or if they're 40, please immediately refer them.
Also ask young women what their reproductive plans are. So, I think one of the things that I would love to see is for the family practitioners and general OB-GYNs, when they're seeing somebody in their late twenties or maybe even early thirties and they have not been pregnant. Just say, hey, what are your plans for fertility? Do you want to have children, do you want to have a family? And then really closely question them because sometimes people don't think about it, or they're so focused on their career. One thing that we really can't do much about is age, except for egg donation.
So if they're be willing to ask that question about what are your plans for childbearing? What are your plans for having a family? How important is it to you to be a mother or even a father, if men are being seen. So, I think those are some important questions that I would love for our providers to ask, because I often will see women who are 41, 42 43, and they'll say, well, nobody ever talked to me about this stuff.
I didn't know that my age was going to be an issue. I spent all this time working on my career, becoming a professor or doctor or whatever, and nobody really talked to me about it. The other thing I want to mention is that we do egg freezing. So, before it was primarily for cancer patients, but now, we're doing egg freezing for what we call social indication. So, people may not have a partner. They're looking at maybe freezing their eggs for future use. So, it's just amazing all the things that we can do and how we provide hope to people, so that they can have a family, either now or in the future. So, it is a very exciting field and I feel privileged to be able to help people build their families.
Host: Thank you so much, Dr. Hollins for joining us today and really telling us about your exciting field. Thank you again. And for a listing of Carle providers, and to view Carle sponsored educational activities, please visit our website at carlconnect.com for more information. That concludes this episode of Expert Insights with the Carle Foundation Hospital. Please be sure to share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.
Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole and today we're discussing infertility awareness. Joining me is Dr. Lori-Linell Hollins. She's a Reproductive Endocrinology and Infertility Specialist with the Carle Foundation Hospital. Dr. Hollins, it's a pleasure to have you join us today. So, tell us a little bit about how common infertility is and the importance of age and infertility from both male and female aspects.
Lori-Linell Hollins, MD (Guest): Well, infertility, unfortunately is becoming more and more common. About one in eight couples, will have an infertility problem in their lifespan. It's becoming more and more common. Age is huge. So, if a woman is over the age of 35, we get very concerned because the chances of becoming pregnant start to dramatically decrease over the age of 35. Actually, people don't realize that fertility starts to decline at about age 28. So, when we see women over the age of 35, and especially as they approach 40; we get very concerned and recommend fairly aggressive treatment and evaluation.
Host: There are some other factors and I'm glad you mentioned age that affect fertility. Tell us a little bit about some of the comorbid conditions that one or other partner might have that could affect their fertility, such as obesity.
Dr. Hollins: Obesity is more and more common as we all realize. And one of the things that can happen with obesity in women is that periods can become irregular. Also in men, we can see lower sperm counts in men as well. Fertility probably happens about 50% in women and about 40% of the time and a little bit often in men and then about 10 to 15% of the time, it may be both partners that contribute to an infertility problem. One of the most common things we see is also irregular menses or what we call polycystic ovarian syndrome. So, the syndrome, there are three things that are involved with the syndrome, irregular periods, like for example, only having six periods of a year, polycystic ovaries. That's when we look at the ovaries, there may be more than 15 to 20 follicles on the ovary on each ovary. And then also, abnormal male hormone levels or signs of what we call androgen excess with acne and abnormal hair growth on the face and body. And sometimes women may also show signs of balding, which can all be signs of androgen excess. So, that's one of the more common things we see as far as women not ovulating regularly.
Host: How long do you advise a couple and for other providers listening that are advising their couples, whether they're gynecologists or primary care providers, how long do you advise a couple to wait before seeking help for fertility issues?
Dr. Hollins: And that is a really important question. Thank you for asking me that. If a woman or a couple is under the age of 35, then we usually recommend that they try for about a year. So, that's one year of unprotected sex. However, if a woman has irregular menses like maybe she's only having six periods a year, she should see somebody right away. Over the age of 35, between age 35 and 40, we recommend six months of trying and at 40 we recommend seeing someone like myself right away.
Host: So, how do you evaluate the situation for a couple, Dr. Hollins, tell us the importance of the comprehensive evaluation of both the male and female patients. And really, what is your age cutoff for doing these kinds of evaluations?
Dr. Hollins: Well, once again, like I said, I tend to be fairly aggressive. Obviously we're doing a lot of Telemedicine now, so our initial visits are usually by Telemedicine where I do a complete history, not only discussing how frequently they're having periods, whether or not they have pain with their periods, how often they're having sex, those kinds of things, and also discuss whether or not they may have problems with their weight and obesity.
So, those are the first things. And also with the men, I'm asking questions about whether or not they might have problems with erections and ejaculation, whether or not they use hormones, whether or not they have had any trauma to their testicles. So, those are all things that we ask initially in the evaluation.
Once we do an initial consultation, like I said, because of COVID it is initially done by Tele-medicine, often we will have the patients come in to the office. For women, we will often do an ultrasound to evaluate the ovaries. We'll also do a special ultrasound called a histosonogram to evaluate the uterus. And we can often tell if the fallopian tubes are open. And then, like I said, with the ultrasound, we also can look at the ovaries and do what we call an antral follicle count. With men, obviously a sperm analysis is extremely important. We tell the men to abstain for two to five days before we actually do the sperm analysis. And often we may have to repeat the sperm analysis if it comes back abnormal. I also will often have men come in for evaluation, particularly if we find out that the sperm count is extremely low, or that motility is low, examining men for what we call a varicocele. So, men are extremely important in this process. Sometimes I see patients where the woman has been evaluated and even treated with oral fertility medications, and they've never gotten a sperm analysis. And then we get a sperm analysis and find out that there's significant male factor.
Host: So interesting. And I think one of the underlooked aspects of infertility treatments and awareness are the expectations. We're going to get into a few treatments briefly and some of the latest research and things that are exciting in your field, Dr. Hollins, but, what would you like other providers to counsel their patients about as far as expectations? What do you want them to have as they go through testing prior to starting treatment and beyond?
Dr. Hollins: I think providers who aren't fertility specialists do have to be careful. And what I mean by that is sometimes people assume because a patient is 40, that they won't get pregnant and they won't refer the patient. But the thing is, with technology, we often can get people pregnant. So, I think that sometimes people delay referring a patient and they even treat them themselves when time is of the essence. So, I think it's really important that they not diminish the patient's ability to conceive, but also they refer the patients right away. Often too, I see what happens is that patients maybe have a problem with like I said, PCOS, or they don't ovulate and one of the things I see that is really somewhat frightening is that sometimes people will go a year or more without having periods. And then we worry about things like what we call endometrial hyperplasia, which can be a precancerous condition. So, I would say that listen to the patients. Really do a good history and physical when somebody is coming to see you initially and pay attention, because there are some long-term risks that patients can have that maybe are not immediately being addressed. And I often will have a patient I'll talk to them and like they would tell me I haven't had a period in a year and a half and I'm like, you need to get in here right away, so, I can take a look and see what your lining looks like and potentially do an endometrial biopsy because I'm worried about sometimes precancerous conditions. So, I think sometimes when patients have infertility, they're not taken as seriously as they should be. And they're not sent to the right place as soon as possible.
Host: Doctor, there are so many options available to people today. Tell other providers, what are some of the exciting treatment options available that they may not know about?
Dr. Hollins: The go-to fertility medicine for ovulation is a medicine called letrozole or Femara, which is actually a breast cancer drug. But we've been using it for fertility for almost 20 years. So, that's exciting. We almost never give patients like what we call FSH medications on their own, just because of the risk of multiple births. So, that's something that people may get worried about whether or not people are going to get pregnant with like quintuplets. Well, that almost never happens anymore. IVF is certainly one of the things that pregnancy rates are dramatically improved over the last 20 years, for example, if somebody is under the age of 30, they have about a 50 to 60% chance of getting pregnant.
If they're over 35, the chances decrease, but they're still really good like about 40 to 30%. And even at 40, we almost, we have about a 20 to 30% chance of people conceiving. So IVF is a big one. ICSI, I-C-S-I where we can inject the sperm into the egg. I mean, 20-30 years ago, we didn't have treatments for male factor infertility. People used to do donor sperm, but now hardly anybody does donor sperm except for people that are maybe in an LGBTQ relationship or people that are single, a single woman. So, ICSI has revolutionized how we treat male factor, however, not everybody needs to do ICSI. Sometimes treating with supplements or medication for men is also helpful and sometimes can improve sperm counts and motility.
So, it is really exciting. That's one of the things I love about this field is that it has evolved so rapidly and that we can help so many more patients. Whereas, even 20 years ago, the success rates were probably less than 10 to 20% and now the success rates are dramatically improved. And then we also have egg donation for women that are over the age of 40, or even if they are women who, for whatever reason have what we call premature ovarian insufficiency or premature ovarian failure. We have the ability to get eggs from a donor, fertilize it with the patient's partner's sperm and create an embryo and that embryo can be put into the woman's uterus so they can actually experience pregnancy and give birth. So, there's just so many exciting things that are going on in the field of reproduction and it truly is exciting and gratifying to be able to work at the cutting edge.
Host: Well it certainly is. As we wrap up, do you have any final thoughts for other providers of when you feel it's important that they refer to the specialists at the Carle Foundation Hospital and how you want them to treat their patients as they're going through these infertility treatments?
Dr. Hollins: Anytime the thought crosses your mind that you need to refer the patient, you should refer the patient. That's number one. Number two is if anybody, like I said, has been trying for a year or six months, if they're over 35 or if they're 40, please immediately refer them.
Also ask young women what their reproductive plans are. So, I think one of the things that I would love to see is for the family practitioners and general OB-GYNs, when they're seeing somebody in their late twenties or maybe even early thirties and they have not been pregnant. Just say, hey, what are your plans for fertility? Do you want to have children, do you want to have a family? And then really closely question them because sometimes people don't think about it, or they're so focused on their career. One thing that we really can't do much about is age, except for egg donation.
So if they're be willing to ask that question about what are your plans for childbearing? What are your plans for having a family? How important is it to you to be a mother or even a father, if men are being seen. So, I think those are some important questions that I would love for our providers to ask, because I often will see women who are 41, 42 43, and they'll say, well, nobody ever talked to me about this stuff.
I didn't know that my age was going to be an issue. I spent all this time working on my career, becoming a professor or doctor or whatever, and nobody really talked to me about it. The other thing I want to mention is that we do egg freezing. So, before it was primarily for cancer patients, but now, we're doing egg freezing for what we call social indication. So, people may not have a partner. They're looking at maybe freezing their eggs for future use. So, it's just amazing all the things that we can do and how we provide hope to people, so that they can have a family, either now or in the future. So, it is a very exciting field and I feel privileged to be able to help people build their families.
Host: Thank you so much, Dr. Hollins for joining us today and really telling us about your exciting field. Thank you again. And for a listing of Carle providers, and to view Carle sponsored educational activities, please visit our website at carlconnect.com for more information. That concludes this episode of Expert Insights with the Carle Foundation Hospital. Please be sure to share on your social media and be sure to check out all the other interesting podcasts in our library. I'm Melanie Cole.