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Caitlin Whyte (Host):  When you’re searching for a fertility specialist or treatment, I assume you’ve done a bit of research. Maybe you’ve consulted your primary care doctor or spent a night scrolling on WebMD. But there’s a couple of things you probably should be asking to figure out the best course of action for you and your partner. Today, we’re going over questions that patients should be asking but don’t with Dr. Molina Dayal and Dr. Maureen Schulte.

This is All Things Fertility. I’m your host, Caitlyn Whyte. So, starting with number one, I’ll open it up to you again Dr. Dayal. How much time do we really have to try on our own before seeing a specialist?

Molina Dayal, MD, MPH, FACOG (Guest):  Well it’s – that’s not a very simple – on some levels that is a very simple question to answer, but on others, it’s not very simple. Traditionally, we diagnose infertility for women who are younger than 35 after they have been attempting pregnancy for about a year without any conception. And for women who are 35 and above, we say please try for about six months before you seek a specialist’s care. And while those definitions are the official definitions of infertility, oftentimes, we’ll say does it make sense to be seen sooner.

So, if an individual or a partner might have known issues that would impact their ability to conceive; so perhaps they’ve had pelvic surgery, perhaps they’ve had pelvic inflammatory disease like chlamydia or gonorrhea when they were younger and we worry about their fertility potential or if somebody has had radiation or chemotherapy or it’s just a variety of different things that we really want people to seek care for before that 12 month period or that six month period. But if you have to use a strict definition it’s if you are younger than 35, wait about a year, that’s assuming you have regular cycles and no other factor that I mentioned before. And if you are 35 and above; try at most for about six months. Otherwise, like some couples have already sought care elsewhere meaning that they’ve started seeing their primary GYN to have fertility treatments done and if those don’t work after one or two attempts then it makes a lot of sense to see a specialist as well.  

Host:  So, jumping over to Dr. Schulte, what type of doctor should I be seeing?

Maureen Schulte, MD, FACOG (Guest):  So, on your initial journey, when you are attempting to start building your family, seeing your general OBGYN for what we call preconception counseling is a great idea. And that’s just to make sure that your immunizations are up to date and that you are taking prenatal vitamins. But then, when you’ve been trying for six months or if you know that you could have a tubal blockage because you have a history of multiple surgeries or a history of sexually transmitted infections in the past; you really want to go to an infertility specialist who has done a fellowship in reproductive endocrinology and infertility.

And so, what that is, it’s subspecialty training after physicians complete their OBGYN specialty training, there’s an additional three years at an academic institution that are completed in just infertility and reproductive endocrinology. And really there, the skills for in vitro fertilization and doing assisted reproductive technologies are honed. So, you want to make sure that you are seeing physicians who are trained in reproductive endocrinology and infertility.

Host:  All right so, question number four and again, this is questions that people aren’t asking. So, this is something I guess I’ve never really thought to ask before but how much experience does your lab staff have and why is that something that’s important?

Dr. Schulte:  Oh yeah, that’s a great question.

Dr. Dayal:  That’s a great question. And it’s super, super important because a lot of our success rates in our field are based on the lab. Again, our field is one of the very few in medicine that combines the clinical side with a laboratory side. And I think it’s really important to always know what’s their educational background, how much sort of practical knowledge do they have, and how long they’ve actually been working in the lab. So, they all have to have a lab director. And that individual is usually a PhD. So, they’ve gone beyond the Master’s degree and they’ve gone on to have a PhD and they typically – those individuals will oversee the lab and they develop what we call protocols and procedures in order for like every single sort of treatment that occurs for any sort of sample whether it’s eggs or sperm that are being handled.

And then there are also several people in the lab who are embryologists. They typically have Master’s degrees and for this what’s interesting about embryologists is that there is a learning curve. I think at the beginning, most of these individuals have been trained in a different type of laboratory oftentimes in animal labs where they’re handling sperm and eggs from animals and what’s interesting is that it’s somewhat similar to humans in terms of how you handle them, but of course the procedures and protocols are going to be very, very different but there is certainly a learning curve for those individuals so typically, the longer these individuals have been using their hands so to speak, the more likely it is for them to do very, very well.

The other things that should be looked at from a laboratory standpoint are their certifications which I know is a little bit separate from looking at lab staff but there are certain certifications that are done in order to make sure that a lab is up to par or up to standards within the industry. So, those are all really important things to look at.

Host:  Great. Yeah, I guess you never think about all the testing has to get sent somewhere and someone has to do the testing.

Dr. Dayal:  So, they are the ones who – they are the magicians.

Dr. Schulte:  Yeah, it’s huge. And it is a very large component to what we do. And unfortunately, patients don’t really realize that when they are seeking out care. So, we’re very fortunate because our lab is amazing, and they are wonderful humans as well. So, we’re fortunate. But that’s not the case everywhere and it’s a very large part of in vitro fertilization.

Host:  All right. So, Dr. Schulte, our next question, I can kind of see why this one isn’t asked as much because it might be something a patient doesn’t want to bring up. But what is the effect of recreational drugs on fertility?

Dr. Schulte:  Oh yes. Recreational drugs do impact fertility. So, we know that cigarette smoking decreases sperm counts and can age our ovaries. So, essentially diminish the amount of follicles that house eggs, so diminish the amount of follicles that we have in our ovary and basically advance us to menopause quicker. Marijuana also has been shown to decrease sperm counts and that’s really more habitual use and they are still doing studies on short-term use or use in your college years versus now but from a habitual standpoint, if people are using marijuana daily for multiple years, it can impact the sperm counts. They’re studying the effect on the ovary now at this point. So, that’s the effect of recreational drugs on fertility.

Dr. Dayal:  I was going to say the one interesting thing also just about recreational drugs, so the main ones are the ones that Mo was discussing, it’s like the smoking, marijuana and alcohol sort of thing. And what’s interesting about smoking in particular is there is definitely good evidence that there’s decreased fertility and actually a slight increased chance of miscarriage if you are a heavy smoker. But then what’s also interesting is that a lot of the – even if you slow down smoking or stop smoking all together, a lot of the damage has been done and I’m not saying okay if you are smoking don’t stop smoking. You should definitely try to stop just from a general health standpoint. But it’s additive that you have – you have already had that exposure and if you decrease that, it might improve things but you’re still already – you’ve already decreased your follicular pool. And I think Mo, I think there’s some studies coming out looking at secondhand smoke as well. That I think it’s going to be somewhat similar which is interesting. It kind of makes sense but we just kind of don’t think about that.

Host:  Yeah, just seeing it literally on paper you are like oh okay. I guess – All right so, question number six Dr. Dayal, the effect of male testosterone supplementation on fertility. Why is this important?

Dr. Dayal:  Male testosterone supplementation is really bad on fertility. [00:09:31] [overlapping] exactly, exactly. So, what’s interesting is that we often do see men come in and they say that they are taking a little bit of testosterone and it could be because they’ve had maybe decreased energy, they are lethargic, maybe their libido has been decreased, perhaps their sexual function has changed and what testosterone does is it does the exact opposite of what you’d expect it to do for fertility. So, if we kind of think about how the testes and testosterone are produced, the testes are functioning to make both sperm and testosterone; what happens is that it’s supposed to be your brain that controls all of that.

Kind of like in women, the brain controls when follicles or eggs are being produced; the same thing for men and so there’s a certain number of – amount of testosterone that’s made in order to maintain sperm production. But if a man starts taking testosterone, your body thinks that you have enough of it so then you slow everything down so then you actually stop making sperm. It’s a feedback loop in a way. So, if a man is exposed to testosterone; they’ll stop producing sperm and at least the nice thing is it’s not a permanent effect. So, if that individual stops taking testosterone; their sperm counts will eventually come back but it will be a minimum of three months. Usually it will be almost up to six months before you will see a significant improvement. So, anybody out there who wants to get pregnant, please do not take testosterone.

Dr. Schulte:  Please.

Host:  All right so the next question kind of even before we hit fertility Dr. Schulte, how much sex should we be having in order to get pregnant? I guess is there a number?

Dr. Schulte:  There is. There is.

Dr. Dayal:  Because you just wrote a prescription today.

Dr. Schulte:  I did.

Host:  Get out of here.

Dr. Schulte:  So, we have too much fun here. But so, I always joke around with my patients that I’m always the husband’s favorite doctor because I’m always like prescribing intercourse. And so, one of my patients today said he wants a prescription for that. So, I literally wrote a prescription for sex today which was just really fun. But no actually, so intercourse is really important obviously when trying to get pregnant and timed intercourse is really what we worry about. So, when you’re trying to conceive, if you have normal cycles; there’s really only six days out of the month where you can conceive. So, it’s the five days before ovulation and then the day of ovulation. So, for everybody out there who is tracking their cycles; your LH kit, your ovulation predictor kit is going to turn positive 24 to 48 hours before ovulation. And that’s why it’s a great test because it tells you when you should be having sex. So, as long as you’re having sex the day your kit is positive; you’re hitting that fertile window, that six days when you can conceive.

So, but I have a lot of patients who say I don’t want to mess around with ovulation predictor kits, it’s too much, it stresses me out. I recommend then sex every other day so that you know that you are going to hit your window. But for those who are travelling and if they are in a different area than their partner, it can be difficult. So tracking your cycles and really knowing when you are going to ovulate and so you can do this by writing it out on a calendar because the second half of your cycle is fixed. So, if you mark the first day of your period which is the first day of full bleeding and then the next month you write down the first day of your period; you count backwards two weeks from that first day and that’s the day that you ovulated. So, then it will help you the next month have an idea of what’s normal.

So, you can do it that way or you can go to the grocery store and get ovulation predictor kits. They also sell on Amazon. Now everybody is going to Amazon.com. 

Host:  So, what that though I mean we know the days but is there an amount on those days. Is that more of just a couple’s preference?

Dr. Schulte:  Oh yeah, that’s great. That’s a great question. So, from an amount standpoint, right so there are multiple millions and millions of sperm in the ejaculate. So, the ejaculate is really made up of sperm, and semen which is all the nutrients and content from the seminal vesicle that gets – that kind of gets packaged around the sperm and so, when you are having intercourse, you’re depositing millions of sperm into the vagina as long as your partner’s sperm counts are normal. And then they have to swim their way up the uterus and into the fallopian tube. So, only about 200 sperm are actually making it into that fallopian tube from the multiple millions.

Yeah, it is crazy. Around the time of ovulation, I say that at least once a day and if you want to have sex more often, there’s no harm. It may or may not benefit you. So, because the other thing we have to think about is daily ejaculation in a man who has normal sperm counts does not decrease his sperm counts, however, if there’s any abnormality, we could decrease that sperm count because spermatogenesis or the making of sperm takes about three months fully and so, it’s stored so it’s there but the counts could just be lower. So, one to two times a day for a simple answer.

Host:  I feel like it’s so wild that I am 29 years old and know none of this. like –

Dr. Schulte:  Do not worry, you are not the only one. I mean Molina and I went to school for – we trained for eleven years to be able to really be able to explain this so, I mean and people – when we talk about the sperm and egg meeting and forming an embryo in the fallopian tube; people’s minds are blown.

Host:  It’s just so interesting. It’s like it’s stuff that we all do and whatnot and it’s just such a mystery for the most part unless you really go out and seek the information, right. I guess these are questions that people aren’t asking so that’s why we’re not knowing. All right, we’ll do one more here. How about when should couples seek counseling? I’m sure that probably, it’s not brought up because it’s probably something people don’t really want to be asking or want to even know the answer, but I guess why is that good to ask early on and then when is that kind of moment to pull the trigger?

Dr. Dayal:  I think with when it comes to seeking counseling, it tends to be sort of on an individualized basis. I mean we – Mo and I see patients all the time who come in and you can see that perhaps they’ve had multiple miscarriages and with miscarriages, there is a lot of guilt and there’s a lot of blame that is felt. And it’s usually, in fact it’s almost never because there’s something that that individual did. And it’s so hard to sometimes explain that to a couple or to a patient and so, oftentimes, when couples come in with multiple miscarriages, I will offer that up even if I can’t really even get that sense from them. Because I will say look, there’s a lot you are going through, each loss is a major loss and that sadness that can come from it or perhaps it’s the guilt or perhaps it’s being blamed, whatever the situation is; I think it’s always important for individuals to seek counseling in that situation but also couples. Because sometimes that can be extraordinarily taxing and stressful to a couple. And I’ve seen many, many relationships really suffer without that open communication that can occur with counseling.

I also will recommend it from a fertility or infertility perspective as well. Same sort of issues that can come up. What’s interesting is there are many studies that have come out that have shown that the stress that a woman feels undertaking a fertility treatment is very similar to what individuals feel who are undertaking chemotherapy. If you just kind of look at their stress levels on a very objective scale; they are very, very similar. And so I tend to send or at least recommend or mention it to many, many patients who come through the door because we don’t know long-term like what could happen. Could it affect them long-term, could it affect their relationship long-term and I think if anything, I tend to recommend it very, very quickly because I want them to be in a good place as they move forward. And I think it also helps give them a sense of sort of understanding where their feelings are, and it definitely opens up communication.

Host:  So, the theme of this episode was questions that patients should be asking but don’t. And just to wrap up, can you talk about the importance of being open and honest with your doctors?

Dr. Schulte:  Oh yeah, I think that when you sit down with any physician, physicians are educators and one of the greatest joys of our job is really just to get to teach couples and women about their bodies and fertility in general.

Host:  Like me.

Dr. Schulte:  Yeah. I mean it’s so fun and what’s nice about it is we get an hour to discuss and tailor our educational talks to the patient. So, there is no silly questions. So, any question that you have, and trust me, we have heard them all and I really take every single one of them sort of to heart and provide an answer because it’s weighing on your mind. This fertility journey is hard enough. So, you should feel comfortable asking everything. And being honest. I know that my friends and family sometimes are silly. They’ll call me and say you know Mo I didn’t tell my doctor that – you should have. Yeah because they are only there to help you. And there’s no judgement. Like they are only there to help you and we want the best for the patient and to help them achieve their goal. So, the more that we know, the easier of a time it’s going to be and the better treatment you’re going to get. So, I don’t think that the doctor’s office is a place where you should hold back your questions because you think they are too silly. They definitely are not.

Host:  Absolutely.

Dr. Dayal:  Ditto.

Host:  There you go. All right.

Dr. Schulte:  The Mo Show.

Host:  Well another great episode just chock full of information. Thank you both again so much. To learn more about the team at SIRM St. Louis, or to schedule an appointment visit www.stlouisfertilitycenter.com. If you enjoyed this podcast, find more like it in our podcast library and be sure to give us a like and a follow if you do. This has been All Things Fertility. And I’m your host Caitlin Whyte. I’ll catch you next time.