Transcription:
Infertility Awareness

Melanie Cole (Host): Thanks for tuning into Back To Health, the podcast that brings you up-to-the-minute information on the latest trends and breakthroughs in health, wellness, and medical care.

Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen here for the information and insights that will help you make the most informed and best healthcare choices for you.

On this Women's Health Wednesday, we're talking about infertility awareness and egg freezing. I'm Melanie Cole, and joining me is Dr. Steven Spandorfer. He's an Associate Professor of Obstetrics, Gynecology and Reproductive Medicine at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine at Weill Cornell Medical College.

Dr. Spandorfer, it is a pleasure to have you join us today. So for this Women's Health Wednesday, we're talking infertility and egg freezing, and we'll get into that a little bit later. But as we start, tell us a little bit about how common it is to have fertility issues. And is it mostly the women? Is it sometimes the men? Tell us a little bit about what you see going on.

Dr Steven Spandorfer: Well, first of all, thank you very much for having me today. I'm honored to be able to discuss this with you, because it really is a very common theme for many women and yet it's often not really spoken about. I think many people view sort of fertility as a given, but then when they become infertile, it's almost there's some sort of embarrassment or shame for some people and they don't like to talk about it. It's clearly not dinnertime conversation.

But infertility itself is common. About 15% of all couples will experience infertility at some point in their life. So that's, you know, one in six, it's very often seen. But it is a misconception, and I'm glad you brought it up. Many people think, "Oh, it's something with the woman and always with the woman," but the reality is at least 40% of all couples, there is some sort of male component to the infertility. And therefore, one thing I always stress in all patients is we talk about their infertility and what the workup is, is that they need to make sure that their partner gets tested and we bring him into the fold to understand what's going on, and not to neglect or ignore the male component of the infertility situation.

Melanie Cole (Host): Well, then I think probably a common question that you get all the time. And I know that when I was trying to get pregnant with my first and second, it was exactly what I asked my gynecologist is how long should a couple try before they seek help? When do you advise someone see a fertility specialist about how far they're willing to take this in their pursuit of fertility?

Dr Steven Spandorfer: So I think, the most important feature of infertility does go back to the woman and it's her age, woman's age predicts about 80% of the equation of who ultimately is going to get pregnant. Therefore, because of this, we allow couples, the younger, they are little more of a lengthy time of trying on their own before they seek out the care, approximately 85% of all couples trying to get pregnant will get pregnant within the first year. But that number is about 75% after six months.

So in a woman under the age of 35, generally the thought is let them try for at least 12 months of unprotected intercourse or for a woman over the age of 35, we've cut that down to about six months. Well, we know most people are pregnant within those first six months. And therefore, after those timeframes for each of those groups of women, it makes sense to at least begin doing the workup. And then from there, talking about where are we going to go as far as treatment, or do we do anything. Unlike many aspects of medicine, this is entirely an elective procedure. And therefore what we do is a balance between how much a woman who wants to do, what risks she wants to take towards, you know, the various options we have to offer and what makes sense for them as a couple.

Melanie Cole (Host): Well, thank you for telling us about women's age because that certainly plays a role in the options that you work on with couples. What expectations, Dr. Spandorfer, do you tell couples that they should have as they start this testing process prior to any treatments that they might have?

Dr Steven Spandorfer: I think basically the most important part of what expectations they should have is probably to understand as realistically as possible, if you're looking at an infertile couple, what's potentially causing their infertility and then to realistically understand the impact of the workup including her age as to what it may mean towards treatment and treatment options and potential success.

In some couples coming in, sometimes I'll see couples who haven't even really tried yet or are coming in and maybe have tried one month, and they really just want to talk about their fertility. I think again, it's important to talk to them and explain to them that we don't get pregnant always on the first try. Sometimes I think basically often fathers will probably teach your daughters, when they're 18 that you look at a boy, you're going to get pregnant. But the reality is that maybe it's 20 something percent the first month or so, but quickly drops about 10 to 15% per month in the second through six months of trying to get pregnant. So it's important for the couple to understand that there is a little bit of a process here and it doesn't always happen immediately.

Melanie Cole (Host): I'm so glad you brought that up. And before we even get into treatments, you might try, you know, a lot of doctors, you hear them say, "Relax. Have sex. Have a lot of sex. Just relax." And when couples are worried about fertility, they can't relax. They're anxious. What do you tell couples about that because some people will ask, "How often are we supposed to? Is too often too much? Does that reduce the male sperm?" Can you tell us what you tell couples about that as an obstetrician gynecologist, when they tell you that they're trying to get pregnant?

Dr Steven Spandorfer: I think that definitely things have changed a lot because I'll often ask couples, like how long have you been trying and they're going, "Well, we didn't really start trying until we bought the ovulation kits and started tracking things and charting." And I immediately always cut them off and say, "You know, maybe call your grandparents and ask them that question," because the reality is that intercourse is really when you start trying. I actually do believe that sometimes all of that overkill of information sometimes puts too much stress on the couple and really changes the situation of trying to get pregnant into a really a work-like adventure.

There definitely is a difference between what I would call recreational and procreation intercourse. It definitely becomes much more work-like. And so I think it is important that there is some truth to that "just relax," although I would never use that term because I think it just drives people crazy. But the reality is just have unprotected intercourse, a few times a week should cover it. Clearly, some couples, "Look, if you want to have intercourse every single day, by all means." But the reality is is that for most couples, every two or three days keeps them from sort of getting "burnt out" where they stop having intercourse and maybe miss the ovulation. So I think initially it probably makes more sense to just sort of back off and take a less scientific "approach" and really just go about things like forever and a day that humans have. But I think at some point, some of that other stuff does make sense, but not initially.

Melanie Cole (Host): Yeah, it takes the workload off and that was beautifully said by you, Dr. Spandorfer. So now, what are some of the treatments that are available? Speak first about the non-surgical treatments? Are there any medications, new medications that you're excited about that you'd like to tell the public about, things you would try first?

Dr Steven Spandorfer: First of all, most importantly is to do the full workup and there really aren't a lot of things that are involved in the full workup. I mean, the workup includes assessing what a woman's ovarian reserve is. You get a sense of that by doing an ultrasound and looking at the ovaries and looking at what we call the resting follicles that have the eggs inside them, what type of number does it look like she has. There's blood work that we get, whether it's an anti-Mullerian hormone test that we can get anytime during the cycle or specifically blood work on the second or third day of her cycle as another way of assessing her ovarian reserve. We always want to make sure that we get a semen analysis on the husband. And we generally get what's called a hysterosalpingogram, which is radiologic examination that allows us to evaluate the uterine cavity as well as to make sure that both her tubes are patent.

And then from there, that's the basic testing, now it's always also important to check just preconception information. And I think sometimes this gets lost. Like in other words, we actually do a preconception genetic panel for tests like cystic fibrosis, sickle cell anemia, thalassemia, that is important for the couple to know if they are at risk for having a child with such. So we get that on both the husband as well as the wife. There's also other preconception testing, whether it's checking to make sure she's immune to rubella or chicken pox, all of this I think is important part of the workup. Even though it doesn't affect their fertility, it's nice for them to know.

Once we've got the workup, then it's a balance between what we can do to create success versus what type of risk multiples and success rates we can have. And, importantly, you want to assess, first of all, if a woman is ovulatory because if a woman is not ovulating or releasing an egg on a regular basis, and this is quite a common disorder, if that's the case, then sometimes we will treat the woman simply with just oral medications to help induce obvulation. And often that is successful just with intercourse alone.

As we talk about the more general patient population, whether it's sort of unexplained infertility or mild male factor infertility, sometimes we will proceed with oral medications, like I mentioned, and then combine that often with intrauterine insemination and try that for a few cycles. But again, that starts to have the risk of multiple pregnancies. And it's very important to have that frank discussion with the couple about what risks they are willing to take for potentially having multiples, mostly twins, but obviously not completely limited to such.

And then finally beyond that, we will use injectable medications. Previously, when I did my training, we would sometimes do the injectable medications with just intercourse or insemination. But for the most part, we don't do that now because of that risk of high order multiples. In fact, I think one of the most important things that our society has worked on is trying to reduce the high level of multiple pregnancies created through infertility treatments. And I think we've been very successful in doing that, particularly through IVF and controlling what we do.

The ultimate sort of treatment is going to be something with IVF, which is in vitro fertilization where we give the woman fertility medications. We monitor her closely. When everything looks "ripe and ready," we then remove the eggs. And then in the lab, we actually put the egg and sperm together, grow the embryo in the lab. And then we can decide about either putting the embryos back in. Based on her age, we decide how many, but also at that point in time, we could actually do genetic or chromosome testing of the embryos as a way to potentially test to see if this embryo is normal.

So there's a wide variety of things that we can do, but I think the most important overarching principle is a balance between success and reducing the complications and the most important complication that we really try to reduce is the multiple pregnancies.

Melanie Cole (Host): Well Dr. Spandorfer, as we said, this is also about fertility preservation. We mentioned egg freezing in the beginning. Can you tell us a little bit? Just give us a brief overview of fertility preservation, who that might be for and, you know, what does that mean to say your eggs are getting frozen?

Dr Steven Spandorfer: So many years ago we started doing egg freezing. In particular on patients, God forbid, that had some sort of cancer, we're going to get chemotherapy or radiation. But the way we used to freeze eggs, it was really based on how we used to freeze embryos and it wasn't a very good method and it wasn't very successful. But we really had nothing better to offer these women at this point in time.

Then that changed pretty dramatically a number of years ago, to where we learned how to change the methods of how we freeze eggs, to where we've actually now set it up where fresh eggs and frozen eggs are fairly equivalent in their success. And that has allowed us to sort of open this up now to not just patients that are, God forbid, having cancer and going to get some sort of treatment, but this now is allowed us to open it up for fertility preservation for people that either are not in the right place to get pregnant or don't have a partner or concerned about their age, for whatever reason. And basically, they still undergo the same IVF process. We give them the medications, we get the eggs, but then we can just freeze the eggs themselves without having to fertilize them. Years ago, the only successful method we had to really offer was perhaps to fertilize, but obviously that required having a partner or using some sort of donor sperm.

Now, the major principle behind freezing eggs is based on the fact that we know about 80% of the equation of who we have success with is based on the age of the eggs. And what I tell all my patients is that the woman ages, her ovaries age, her eggs age, I age, her husband ages, but her uterus doesn't seem to age. So you could take a woman who's 35, 45, 55, not that we're going to be doing this in somebody in their 50s and 60s, but we could, we could use their uterus, younger eggs, somebody's sperm, fertilize, grow that embryo, put that embryo back into that uterus and you can have a successful pregnancy. So the most important predictor of success is ultimately the age of the eggs. And this now has allowed people to sort of freeze their eggs as a way to potentially preserve their fertility.

I do distinctly remember when we first started doing this and somewhat using the term elective or whatever you want to call it, but basically when we first started freezing eggs in the non-cancer patient, we were all worried that basically are we sending the wrong message out to women that, "You know what? Freeze your eggs. Pursue your career. Don't worry about having children or a family," and I think what we've learned is it's quite the opposite, that most people coming in wanting to freeze eggs, it's not that they're necessarily saying, "Oh, you know what? I'm 35 now, but I don't want to have kids until I'm 50." Most of them are still 35, looking for the person they wanted to have a family with. And I think basically this becomes a great option to be able to offer these people as a way to, not sort of lose the option of having a family of something that most of us consider so basic in life that we don't even consider it or think about it as ever a possibility that it may not happen to us.

Melanie Cole (Host): You explained that so well. What a great educator you are. So tell us a little bit as we wrap up, Dr. Spandorfer, what you tell couples every single day about going through this process. I mean, people are worried about the cost, whether insurance covers a certain amount or a certain type of infertility treatments, kind of wrap it up for us with your best advice about infertility awareness and all of the things we've been discussing here today.

Dr Steven Spandorfer: It's very important I think for the couple or anybody going through any treatment, whether it's even an individual on their own, to really sort of thoroughly understand what's happening, what their chances are, what their options are. So I think basically first and foremost is to have a good ability to communicate with your doctor and treating team.

The other part that this highlights, particularly for couples going through infertility is that infertility is quite stressful. When you look at all these psychological studies, the amount of stress people have that have infertility is tremendous. And some of it is certainly based whether it's financial, but some of it's just based on the mere fact of wanting to have children and you try one month and then you have wait to see if you're pregnant and then you have to try again and it's another whole month that goes by. It really wears on one's patience without a doubt.

So I think what's also important is to have a very good communication between the couple. We have long since recognized this in our own group. We actually have three psychologists that have been with us over 20 something years and they provide an invaluable service, and just talking to couples about how to talk about this, how to express your feelings of what people are going through. The amount of guilt that someone may feel is incredible when you really talk to them and try to understand it.

I still remember the most eye-opening experience I've ever had is I once had a medical student many years ago, who for her thesis project was a fly on the wall in our waiting room and just sort of walked around, listening to people, talking what their fears and anxieties were, and it was a very eyeopening experience just to hear what she had to say and what patients felt and what they were talking about.

I think the other part that you mentioned is as far as insurance, and we've definitely seen changes. There are definitely states and New York has sort of become one of them where infertility coverage and IVF coverage is mandated, although it depends on the size of the company you work for. Different insurances and different plans definitely covered things differently.

Egg freezing itself in fact is even becoming more likely to be covered than it used to be by certain companies. So I think it's always important to explore what your financial possibilities are and also obviously what is covered and not covered. And I think, understanding as much as you can about all of that together makes it a much easier process because there is no doubt, this is not an easy process. It just isn't for anybody. But that is what we're here for. And I tell everybody, you know, "Call if you need to." We offer lots of reassurance, we give all the time, that's what we're there for. And we have resources of people to help you with the various either issues or problems that you may run into as you try to seek treatment.

Melanie Cole (Host): Well, you are lovely. And I can hear the passion in your voice. I imagine that the couples that see you are very very lucky indeed. So thank you so much, Dr. Spandorfer. What an informative episode this was. And I hope you'll come back and join us again because there are so many factors that we weren't able to cover in this podcast, but so many issues that arise for couples that are trying to get pregnant. Thank you again.

Dr Steven Spandorfer: Thank you very much for having me. I really enjoyed being a part of this today.

Melanie Cole (Host): And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. We're so glad you joined us for Women's Health Wednesday. We hope you'll tune in and become part of a community and fast-growing audience of women looking for knowledge, insight, and real answers to hard questions about their bodies and their health.

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