Selected Podcast
Top 10 Questions Patients Ask - Part I
Fertility concerns are expected when you speak to a fertility specialist. Dr. Molina Dayal and Dr. Maureen Schulte discuss the top 10 fertility questions patients ask in this two-part series.
Featuring:
Learn more about Molina Dayal, MD
Dr. Maureen Schulte is a board certified obstetrician and gynecologist, and Fellowship trained in reproductive endocrinology and infertility.
Learn more about Maureen Schulte, MD
Molina Dayal, MD, MPH, FACOG | Maureen Schulte, MD, FACOG
Dr. Dayal is Board Certified in both Obstetrics and Gynecology and Reproductive Endocrinology and Infertility, with nearly twenty years specializing in treating infertility.Learn more about Molina Dayal, MD
Dr. Maureen Schulte is a board certified obstetrician and gynecologist, and Fellowship trained in reproductive endocrinology and infertility.
Learn more about Maureen Schulte, MD
Transcription:
Caitlin Whyte: Entering the world of fertility treatment can be intimidating and you probably already have a lot of questions to ask. What am I looking for? What options would work best for me? Am I too old or too young to even be trying? This? Fertility is a vulnerable and intimate topic to discuss with your partner, let alone your doctor, but trust me they have heard it all. So today we're going to break down some basics and the top 10 fertility questions, so hopefully by the end of this podcast you won't have to ask them yourself. Joining me for this discussion are Dr. Molina Dayal and Dr. Maureen Schulte from SIRM St. Louis. This is All Things Fertility. I'm your host, Caitlin Whyte. Dr. Dayal, let's start with you. Pretty basic. What is the definition of infertility?
Dr. Dayal: Well, infertility is defined as the inability to conceive and have a live birth after one year. If a woman is younger than the age of 35. That definition changes, if a woman is over the age of 35 inclusive of that age, where we consider infertility, the inability to conceive and have a live birth after six months of attempts.
Host: What is the impact of age on fertility, both in females and males? Is there a true like too old?
Dr. Shulte: So the impact of female age on fertility, unfortunately the biological clock impacts females. So as we age, our fertility declines. So at age 32 we have a slight decline in our fertility ability to conceive. And then at age 37 this decline actually increases and oocytes or eggs undergo atresia or cellular death at a faster rate. So usually people, women in general usually have this, you know, stark age of 35 in their mind where they think the set point is, but it really starts happening around age 32 and then the sharp decline at age 37
Host: Okay. So I am almost 30 and I didn't realize that number was so close. So, when should I consider freezing my eggs maybe?
Dr. Dayal: Well, age does play a huge role in fertility as Dr. Schulte was mentioning. And there is no perfect age at which to freeze eggs. That being said, women are at the peak of their fertility in their twenties until about 32 or 33, so if there was an ideal time, that would be an amazing time to do that because the vast majority of eggs at that time are going to be normal. Now, that changes over time. And the reason I said there is no ideal time is because if somebody is suddenly 35 or 36 or 37 I don't want them to think that they've missed their window. They should still be able to freeze their eggs. And the key is that, you know, as a woman gets older, unfortunately proportion or number of eggs that are going to be abnormal increases. So the earlier we're able to do it, the better in the sense of they don't have to go through multiple treatments in order to obtain a good number of normals, if that makes sense.
But as a woman gets older, we may need to freeze slightly more eggs in order to give the same potential outcome later. And when it comes to freezing eggs, typically we like to have six or seven eggs be frozen per attempt at getting pregnant. So when a woman is younger and let's say has multiple eggs available every single month, which is an interesting thing biologically for us is that a woman has a certain number of eggs available every single month. One ovulates typically, and the others die away, and a brand new cohort or a group of eggs is brought into play the following month and then the following month and the following month. But that quantity declines over time as well. So it's not just quality but it's quantity. So if a woman is let's say 30 and they have let's say potentially 18 to 20 eggs available that month, if we're able to get, let's say 18 eggs, hopefully that gives them three opportunities to get pregnant. Whereas a woman who is, let's say 37 she may not have that many available, she may only have 12 available. So now she has to go through multiple treatments in order to get six to seven each time.
Dr. Shulte: Yeah. And so it really goes with, as Molina is saying, like freezing your eggs goes hand in hand with the impact of female age on fertility. So, the older you get, the less ovarian reserve your ovarian reserve decreases. So if you freeze your eggs, you may need multiple cycles to harvest as many eggs as we can, in order to have an increased probability of having at least one live birth. And you know, my frustration with a lot of counseling around egg freezing is that a lot of women, if they, let's say they have 10 oocytes or eggs retrieved, they think, Oh great, I can have 10 kids. But that's really not how it works. So those eggs then are frozen and then they need to be thawed, mixed with sperm, right to create embryos or cellular babies. And there's a rate of attrition or loss at each step. So if we have 10 eggs frozen, let's say at the age of 32 that's wonderful, but maybe three of them become embryos. And then each embryo has about a 60% chance of implantation and you know, clinical pregnancy and live birth. So, I really want to stress that to patients.
Dr. Dayal: And that's where they come up with that number of six to seven, because if you have six, let's say eggs, hopefully 100% will survive and you have six, and approximately three quarters will fertilize. So now we're down to four or five. And on average, it's only about a third will make it to the point where they're formed what are called blastocyst, which are the cellular babies or the multiple cells of an embryo. Where there's approximately 80 cells that typically will implant in a woman under natural conditions, but only about a third of them will make it there. So if you have four or five, you might have two, maybe maximum three, but then you have, and for each opportunity you have that 60% chance depending on your age.
Host: I love doing these podcasts, especially hosting ones, you know, centered around female issues because I sit here and I'm like, Okay. I didn't know any of this was a thing.
Dr. Shulte: Right. I know we don't want to scare you, but I do. I mean, we both believe fully in education and educating people so that they can make informed decision making around their fertility.
Host: Well, exactly. And that's why I love this top 10 list of questions. You know, just getting the basics out there, things that maybe we're all thinking about but don't really want to ask or don't know if it's like a dumb question or something. So yeah. Getting back to the list, Dr. Schulte, what are the causes of infertility?
Dr. Shulte: So there are many causes of infertility. So we usually think about female causes for infertility, so ovulatory dysfunction. So ovulation is when the egg or oocyte is actually released from the ovary. And women who have abnormal menstrual cycles, usually have anovulation. So inability to ovulate or release that egg. And that is really the crux of the matter here, right? When we're trying to get egg and sperm to meet to get pregnant. So, another large cause of infertility that we don't want to forget is male factor. So when we're in a heterosexual relationship, 30 to 50% of the time men contribute to infertility, meaning that there's an abnormality with their sperm. So a semen analysis on a male partner is a very big important part of the workup. Additionally, there can be tubal factor infertility. So I always tell my patients that the fallopian tubes are the bridge to fertility, so they're actually where sperm and egg meet to form the embryo.
And if there is for any reason a blockage in the tube, sperm and egg then can't meet. And why would we have a blockage in the tube? A history of chlamydia is one reason. Unfortunately, chlamydia can scar the tubes. A history of abdominal surgery with the formation of peritoneal adhesions can scar fallopian tubes, and endometriosis can be a culprit in scarring fallopian tubes. Otherwise unexplained infertility is another big cause of infertility, and that truly is a very hard diagnosis for couples to accept. So unexplained infertility essentially means that our infertility workup, so evaluation of the eggs, sperm, fallopian tubes and uterus has all come up normal and then patients are confused. So if everything is normal, why, why am I not getting pregnant? And I usually explain it to my patients that we just don't know enough about the nuance in reproduction to be able to exactly pinpoint the problem, but we know how to treat it. And so treatment of unexplained infertility actually has very high success rates in 70% of patients with unexplained infertility, will get pregnant and have a live birth after treatment. So those are some causes.
Host: So Dr. Dayal, you know at this point, I guess I know I want to have a baby, but when should I seek an infertility specialist care?
Dr. Dayal: So the time to seek an infertility specialist care is really dependent on a patient or a couple’s history. So if a couple has been trying to get pregnant for more than a year and the woman is younger than the age of 35 that officially gives them a diagnosis of infertility. If a woman is older than the age of 35 we usually will recommend that they seek fertility care after six months of attempts. If a couple actually has a history of having undertaken multiple intrauterine insemination or IUIs with their gynecologist and they have not succeeded, and typically the cutoff is about three inseminations. Then we request that they also seek fertility specialist care. If we see a couple who has, let's say known tubal disease, as Moe was mentioning, if a woman has a history of having had chlamydia in the past, that is one of the major causes of occluding or closing up the tubes, then they should also seek care. For the same reason if a woman has, let's say had multiple pelvic surgeries in the past where they may have a good amount of scar tissue in their pelvis.
And again potentially have their tubes impacted by that scarring in which could block those tubes. We definitely want them to be seen or perhaps they know that from the male standpoint, perhaps he's had a chemotherapy in the past or radiation therapy in the past or some sort of surgery or some inkling that something's been going on with him. It makes sense to seek care. And another reason is if we have a same sex couple who is interested in having a child, then we ask them to seek fertility care as well so that we can assist them with intrauterine inseminations. And then lastly, if a couple or a patient has a known genetic disorder that has been passed down generation to generation to generation within their family, and they would like to limit that chance from occurring again, we can actually do invitro fertilization with them, and potentially screen embryos for that particular disease or disorder. And potentially limit that from occurring in subsequent generations. So many, many reasons for people to seek care.
Host: All right. This top 10 list is actually a two part podcast. Stay tuned for episode two and the rest of the list. To learn more about the team at SIRM St. Louis or to schedule an appointment, visit 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. I'm your host, Caitlin Whyte. We'll catch you next time.
Caitlin Whyte: Entering the world of fertility treatment can be intimidating and you probably already have a lot of questions to ask. What am I looking for? What options would work best for me? Am I too old or too young to even be trying? This? Fertility is a vulnerable and intimate topic to discuss with your partner, let alone your doctor, but trust me they have heard it all. So today we're going to break down some basics and the top 10 fertility questions, so hopefully by the end of this podcast you won't have to ask them yourself. Joining me for this discussion are Dr. Molina Dayal and Dr. Maureen Schulte from SIRM St. Louis. This is All Things Fertility. I'm your host, Caitlin Whyte. Dr. Dayal, let's start with you. Pretty basic. What is the definition of infertility?
Dr. Dayal: Well, infertility is defined as the inability to conceive and have a live birth after one year. If a woman is younger than the age of 35. That definition changes, if a woman is over the age of 35 inclusive of that age, where we consider infertility, the inability to conceive and have a live birth after six months of attempts.
Host: What is the impact of age on fertility, both in females and males? Is there a true like too old?
Dr. Shulte: So the impact of female age on fertility, unfortunately the biological clock impacts females. So as we age, our fertility declines. So at age 32 we have a slight decline in our fertility ability to conceive. And then at age 37 this decline actually increases and oocytes or eggs undergo atresia or cellular death at a faster rate. So usually people, women in general usually have this, you know, stark age of 35 in their mind where they think the set point is, but it really starts happening around age 32 and then the sharp decline at age 37
Host: Okay. So I am almost 30 and I didn't realize that number was so close. So, when should I consider freezing my eggs maybe?
Dr. Dayal: Well, age does play a huge role in fertility as Dr. Schulte was mentioning. And there is no perfect age at which to freeze eggs. That being said, women are at the peak of their fertility in their twenties until about 32 or 33, so if there was an ideal time, that would be an amazing time to do that because the vast majority of eggs at that time are going to be normal. Now, that changes over time. And the reason I said there is no ideal time is because if somebody is suddenly 35 or 36 or 37 I don't want them to think that they've missed their window. They should still be able to freeze their eggs. And the key is that, you know, as a woman gets older, unfortunately proportion or number of eggs that are going to be abnormal increases. So the earlier we're able to do it, the better in the sense of they don't have to go through multiple treatments in order to obtain a good number of normals, if that makes sense.
But as a woman gets older, we may need to freeze slightly more eggs in order to give the same potential outcome later. And when it comes to freezing eggs, typically we like to have six or seven eggs be frozen per attempt at getting pregnant. So when a woman is younger and let's say has multiple eggs available every single month, which is an interesting thing biologically for us is that a woman has a certain number of eggs available every single month. One ovulates typically, and the others die away, and a brand new cohort or a group of eggs is brought into play the following month and then the following month and the following month. But that quantity declines over time as well. So it's not just quality but it's quantity. So if a woman is let's say 30 and they have let's say potentially 18 to 20 eggs available that month, if we're able to get, let's say 18 eggs, hopefully that gives them three opportunities to get pregnant. Whereas a woman who is, let's say 37 she may not have that many available, she may only have 12 available. So now she has to go through multiple treatments in order to get six to seven each time.
Dr. Shulte: Yeah. And so it really goes with, as Molina is saying, like freezing your eggs goes hand in hand with the impact of female age on fertility. So, the older you get, the less ovarian reserve your ovarian reserve decreases. So if you freeze your eggs, you may need multiple cycles to harvest as many eggs as we can, in order to have an increased probability of having at least one live birth. And you know, my frustration with a lot of counseling around egg freezing is that a lot of women, if they, let's say they have 10 oocytes or eggs retrieved, they think, Oh great, I can have 10 kids. But that's really not how it works. So those eggs then are frozen and then they need to be thawed, mixed with sperm, right to create embryos or cellular babies. And there's a rate of attrition or loss at each step. So if we have 10 eggs frozen, let's say at the age of 32 that's wonderful, but maybe three of them become embryos. And then each embryo has about a 60% chance of implantation and you know, clinical pregnancy and live birth. So, I really want to stress that to patients.
Dr. Dayal: And that's where they come up with that number of six to seven, because if you have six, let's say eggs, hopefully 100% will survive and you have six, and approximately three quarters will fertilize. So now we're down to four or five. And on average, it's only about a third will make it to the point where they're formed what are called blastocyst, which are the cellular babies or the multiple cells of an embryo. Where there's approximately 80 cells that typically will implant in a woman under natural conditions, but only about a third of them will make it there. So if you have four or five, you might have two, maybe maximum three, but then you have, and for each opportunity you have that 60% chance depending on your age.
Host: I love doing these podcasts, especially hosting ones, you know, centered around female issues because I sit here and I'm like, Okay. I didn't know any of this was a thing.
Dr. Shulte: Right. I know we don't want to scare you, but I do. I mean, we both believe fully in education and educating people so that they can make informed decision making around their fertility.
Host: Well, exactly. And that's why I love this top 10 list of questions. You know, just getting the basics out there, things that maybe we're all thinking about but don't really want to ask or don't know if it's like a dumb question or something. So yeah. Getting back to the list, Dr. Schulte, what are the causes of infertility?
Dr. Shulte: So there are many causes of infertility. So we usually think about female causes for infertility, so ovulatory dysfunction. So ovulation is when the egg or oocyte is actually released from the ovary. And women who have abnormal menstrual cycles, usually have anovulation. So inability to ovulate or release that egg. And that is really the crux of the matter here, right? When we're trying to get egg and sperm to meet to get pregnant. So, another large cause of infertility that we don't want to forget is male factor. So when we're in a heterosexual relationship, 30 to 50% of the time men contribute to infertility, meaning that there's an abnormality with their sperm. So a semen analysis on a male partner is a very big important part of the workup. Additionally, there can be tubal factor infertility. So I always tell my patients that the fallopian tubes are the bridge to fertility, so they're actually where sperm and egg meet to form the embryo.
And if there is for any reason a blockage in the tube, sperm and egg then can't meet. And why would we have a blockage in the tube? A history of chlamydia is one reason. Unfortunately, chlamydia can scar the tubes. A history of abdominal surgery with the formation of peritoneal adhesions can scar fallopian tubes, and endometriosis can be a culprit in scarring fallopian tubes. Otherwise unexplained infertility is another big cause of infertility, and that truly is a very hard diagnosis for couples to accept. So unexplained infertility essentially means that our infertility workup, so evaluation of the eggs, sperm, fallopian tubes and uterus has all come up normal and then patients are confused. So if everything is normal, why, why am I not getting pregnant? And I usually explain it to my patients that we just don't know enough about the nuance in reproduction to be able to exactly pinpoint the problem, but we know how to treat it. And so treatment of unexplained infertility actually has very high success rates in 70% of patients with unexplained infertility, will get pregnant and have a live birth after treatment. So those are some causes.
Host: So Dr. Dayal, you know at this point, I guess I know I want to have a baby, but when should I seek an infertility specialist care?
Dr. Dayal: So the time to seek an infertility specialist care is really dependent on a patient or a couple’s history. So if a couple has been trying to get pregnant for more than a year and the woman is younger than the age of 35 that officially gives them a diagnosis of infertility. If a woman is older than the age of 35 we usually will recommend that they seek fertility care after six months of attempts. If a couple actually has a history of having undertaken multiple intrauterine insemination or IUIs with their gynecologist and they have not succeeded, and typically the cutoff is about three inseminations. Then we request that they also seek fertility specialist care. If we see a couple who has, let's say known tubal disease, as Moe was mentioning, if a woman has a history of having had chlamydia in the past, that is one of the major causes of occluding or closing up the tubes, then they should also seek care. For the same reason if a woman has, let's say had multiple pelvic surgeries in the past where they may have a good amount of scar tissue in their pelvis.
And again potentially have their tubes impacted by that scarring in which could block those tubes. We definitely want them to be seen or perhaps they know that from the male standpoint, perhaps he's had a chemotherapy in the past or radiation therapy in the past or some sort of surgery or some inkling that something's been going on with him. It makes sense to seek care. And another reason is if we have a same sex couple who is interested in having a child, then we ask them to seek fertility care as well so that we can assist them with intrauterine inseminations. And then lastly, if a couple or a patient has a known genetic disorder that has been passed down generation to generation to generation within their family, and they would like to limit that chance from occurring again, we can actually do invitro fertilization with them, and potentially screen embryos for that particular disease or disorder. And potentially limit that from occurring in subsequent generations. So many, many reasons for people to seek care.
Host: All right. This top 10 list is actually a two part podcast. Stay tuned for episode two and the rest of the list. To learn more about the team at SIRM St. Louis or to schedule an appointment, visit 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. I'm your host, Caitlin Whyte. We'll catch you next time.