Dr Warner Huh (Host): Hello, everyone. This is Dr. Warner Huh. The chair of the Department of OB-GYN here at the University of Alabama at Birmingham. I'd like welcome you to this monthly episode of Women's Health with Dr. Huh. I hope everyone's having a good summer.

So today, we're going to talk about age and the impact on fertility. And with me today is Dr. Deidre Gunn, who is an Assistant Professor in the Division of Reproductive Endocrinology and Infertility in the Department of OB-GYN here at UAB. She has developed a particular interest in what we call assisted reproductive technologies, or ART, particularly in the area of in vitro fertilization, commonly known as IVF, and has been a major key component of our IVF program over the last several years.

What's exciting is actually today on the heels of a major press release related to the first live birth from our uterine transplantation program, we actually did a podcast on this last year with Dr. Paige Porrett from the Division of Transplant Surgery in the Department of Surgery here at UAB. I just wanted to recognize for all of our listeners that Dr. Gunn was a major key component and team member of that live birth. So, super excited that we can kind of do both, the press release today as well as this podcast. So, welcome to this monthly podcast, Dr. Gunn.

Dr Deidre Gunn: Yeah, it's a great day. Thanks for having me.

Host: So, I'll just jump right into it. Can you help outline some of the risk factors associated with infertility and the definition or the medical definition of fertility? I think how we define it may be a little bit different than how the public sees it.

Dr Deidre Gunn: Right. So, infertility is defined as a disease. It's a medical disease. It's the inability to achieve a successful pregnancy after 12 months of regular unprotected intercourse if you're under 35. Thirty-five and over, we give people just 6 months of trying before we consider that infertility. And actually, at 40 and over, we recommend kind of immediate testing when people are trying to conceive. So, it's definitely an area that has gotten a lot of attention over the past few years, as people become a little bit more vocal about sharing their own journeys with fertility treatment. And I think it's still an area that people need a lot of education and awareness about as more and more people delay childbearing.

Host: And so, we commonly in the medical world use the term primary and secondary infertility. Just for our listeners, can you just define what that means specifically?

Dr Deidre Gunn: Yeah. So, primary infertility is your inability to achieve that first pregnancy. Secondary infertility, you may have been pregnant before, but you're unable to achieve pregnancy again or a subsequent pregnancy. And the workup and the testing is very similar for both. But it's important to remember, especially with regard to age and the impact on fertility, which we'll talk about today, secondary infertility, you know, can be especially insidious. If you think that, "Well, I got pregnant without any difficulty before," well, five years later, that may be a different story.

Host: Okay. I appreciate that. So obviously, the focus of today's podcast is on age and fertility or infertility. And can you comment on why that is such a profoundly strong risk factor for infertility?

Dr Deidre Gunn: So, women are born with all the eggs that we're ever going to have. And that just begins declining from even before birth, all the way until menopause. Unlike men where, you know, men are producing sperm their entire lives, women are born with this fixed number of eggs that continues to decline. And it's not just an issue of numbers, it's also an issue of quality, and quality declines as well. And so, it's sort of a two-fold contribution to infertility as women age.

Host: This is why I think this podcast is important, because I think it's important for us to explain some of the physiology and natural history as it relates to age in this area. And in fact, when I was asking about risk factors and the definition, you used this number 35, which is the perfect segue to my next question, which is are there basic rules of thumb that you use with patients, whether it's for defining the risk or stratifying who is eligible or perhaps not eligible for things like IVF in your practice or the division? Are there age cutoffs, I guess is my question as it relates to actual clinical practice management?

Dr Deidre Gunn: Certainly, there are sort of upper limits of age as far as the true reality of being able to get pregnant using your own eggs. And there are some programs that have cutoffs. I think a lot of it comes down to shared decision-making with the patient and making sure that you counsel the patient about what their chances are with IVF. But beyond about age 42, the chances with IVF with your own eggs, the chances of success are pretty slim. And at that point, we typically recommend using donor eggs. So, it's certainly important that when we have patients who are in their late 30s, early 40s, we get them into treatment or into fertility workup and treatment as quickly as possible.

Host: So, I just kind of want to kind of recapture some of that for our listeners. So, what I'm hearing from you is, number one, that you're born with all the eggs that you're going to ever be born with and that those numbers decline. And as far as I'm aware of, there's no way to reverse that reality, unfortunately. Correct?

Dr Deidre Gunn: Right. Not at this time. Certainly, there's research in that area. But at this point, no.

Host: Okay. Number two is that it's also not just about quantity, but it's also about quality and that, as individual woman gets older, unfortunately, the quality of her eggs may also decrease over time.

Dr Deidre Gunn: Right. As we get older, those little mechanisms in the cells that help DNA divide between the different cells, those mechanisms don't work as well. And that's why you end up with infertility, but also live birth with chromosome problems like Down syndrome and other issues like that, miscarriage, all of those risks increase with age.

Host: And this is exactly why we're having this podcast, right? So that we can make our listeners aware of how profoundly strong a risk factor is. I'd probably say it's maybe close to the very top of the list in terms of what you look at when you take a history from a woman. Would that be accurate?

Dr Deidre Gunn: Right, exactly. And there are other risk factors that, you know, we're not covering today, history of pelvic infection, endometriosis, fibroids, those sorts of things. But certainly, age is probably the biggest contributor to infertility.

Host: So, I'm just going to ask you a somewhat tangential question, but I think it's relevant to this concept of a relationship between the age and infertility. So, you hear all of these kind of bizarre reports of women in their 60s and 50s getting pregnant and then having a baby. And I know you have an answer to this, but I think it'd be important for the listeners to understand how exactly that works. You commented about donor eggs, but just the kind of the mechanism of how it comes to be that a more mature woman can actually get pregnant at that age where naturally that rarely ever happens obviously.

Dr Deidre Gunn: Right. Yeah. You see celebrities that are in their 50s, you know, having babies and the backstory that you don't hear is that those women are using donor eggs or donor embryos or potentially eggs that they froze years earlier when they were younger. The interesting thing is that the uterus doesn't really age. And so, we can use hormones to sort of artificially create that environment for an embryo to implant. And then, the placenta develops and takes over and the pregnancy overall does fine. There obviously are some risk factors as women get older. There's some obstetric risk factors, increased risk for preeclampsia and blood pressure issues, other issues with pregnancy. But for the most part, we're able to artificially with hormones create that environment where an embryo can implant, but we can't really affect the ovaries. We can't stimulate the ovaries beyond a certain age just because, again, quantity of eggs remaining and quality.

Host: I think it's important to understand that your profession has done amazing things at really adapting and modifying the physiology of women as it relates to hormone production, like you mentioned, like the uterus really doesn't age. But just for people to understand the reality and the facts behind that and obviously, that won't go away, which goes to the earlier question I had about age cutoffs and clinical practice. And I know that's a nuanced conversation beyond the scope of this podcast. But I know that it comes up a lot in your circles as well.

Dr Deidre Gunn: Definitely. As women get toward that early to mid-40s mark, we're unfortunately having to have that conversation many times about donor eggs or donor embryos.

Host: So, my next question, which is getting really kind of more back on target of the topic of this podcast, is-- I'm just going to make a general comment and this is just for the entire world. It seems that in general, women are getting pregnant later in life, whether it's to accommodate their educational objectives or their work professional objectives. I see multiple countries where women are pushing out the number of children much later in life. And I thought you might want to comment to the listeners, what are technologies that are available that allow you to kind of "preserve your fertility" at an earlier age in the event that later on you can actually get pregnant and take advantage of some of these incredible advances in your space and in IVF?

Dr Deidre Gunn: So, egg freezing is the thing that comes to mind and that's the thing that I think most people are familiar with. You can also freeze embryos. You can take those eggs that are retrieved and go ahead and fertilize those, for example, with donor sperm, and freeze embryos. But for the most part, women who are trying to preserve fertility, who are, say, 32, 33, and don't plan to have a family until their late 30s, early 40s, usually are going to freeze eggs. And those eggs, as far as we know, can stay frozen sort of indefinitely. Again, we typically aren't going to put an embryo into women who are in their late 50s just because of those obstetric risks, but it does allow women to delay childbearing beyond the natural age of fertility and fecundity that they would be able to get pregnant on their own. It's no guarantee. And I think that's the most important thing. This technology has only really been available for probably about the past 10 years. And so, it's improving all the time. But just like IVF, there's never a guarantee of pregnancy. And I think that's something you have to go into it knowing. But in many cases, it may be the best chance to give yourself an opportunity in the future to be able to have a biologically-related child.

Host: Yeah, I mean, it's incredible. When I started practice, egg preservation was a purely clinical trial experimental practice. And now, you can correct me if I'm wrong, it's fairly commonplace now. Like I personally have dozens of colleagues and friends who have actually undergone that, and it's kind of remarkable to me and several of those individuals have gone on to have live perfectly normal babies. Yeah, it's really incredible actually.

Dr Deidre Gunn: Yeah, it's tremendous. It's gone from being experimental to standard of care just in the last 10 years.

Host: Yeah. And I know you know this, but for the listeners, it's become so commonplace that I think certain states, certain employers, certain institutions actually cover egg preservation as a part of their fertility benefit.

Dr Deidre Gunn: Exactly. Which I think is great. Some people argue that maybe that gives people a disincentive to try to go ahead and get pregnant when it's sort of the most optimal time. But I think in terms of access to care and just general awareness of fertility and fertility treatment, I think it's a great thing.

Host: Yeah. Again, kind of beyond the scope of this podcast, but I think we'll talk about this in a future podcast, you know, we've come so far as to even talk about ovarian tissue preservation, which is like one step even further ahead of the egg preservation. And if you have a couple of words to comment on that, that's like the next wave of interest obviously.

Dr Deidre Gunn: Yeah. Yeah. I mean, we're already doing that with particularly young patients, who are facing a cancer diagnosis, being able to freeze tissue, ovarian tissue for future use. And that has led to live births. And it's pretty remarkable that hopefully in five or 10 years, we'll be able to have the conversation here that we're doing that all the time for women who need it.

Host: Yeah, it's mind blowing. I mean, just the accomplishments in this area have been really incredible. I don't know if you have any other closing thoughts or comments for our listeners, Dr. Gunn, today, that you wanted to share with them.

Dr Deidre Gunn: Well, one thing that I wanted to mention is ACOG, the American College of OBGYNs, recommends that every patient have what's called a reproductive life plan, which I think is kind of a really cool concept. Just the sense that you are thinking ahead about when you want to have a family, whether that's next year or 10 years from now, or you know that you're going to delay until your late 30s or whatever the case may be, but just that you have a plan, you think about it, talk to your OB-GYN about it, and really readdress that sort of every year when you go to your annual exam, talk to your OB-GYN. And that way, you can stay on top of your fertility and pull the trigger at a time when, "Okay, maybe I need to think about freezing my eggs at this point," or "Yeah, I think now is a great time for me to start my family."

Host: I think that's a beautiful way to end this podcast. And I'm actually glad that you mentioned that. So, this was an incredible conversation. I hope our listeners learned something that's important in terms of the relationship between age and infertility. And again, Dr. Gunn, thank you for participating in this month's podcast.

And as always, please rate this podcast and we welcome any comments that you may have, particularly in topics that you're all interested in. And for more information on our comprehensive infertility services here at UAB or other clinical services that UAB Medicine may have to offer, please check out uabmedicine.org. And until next time, have a great day. We'll see you next month. Stay cool during this very hot summer. Peace out. Bye-bye.