SART Fertility Experts - Q&A on Infertility

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Hi everyone, this is Dr. Susan Nasab. I'm a third year Reproductive Endocrinology and Infertility Fellow at Johns Hopkins University in Baltimore, Maryland. This is an episode from SART Fertility Experts and it's brought to you by Society for Assisted Reproductive Technology.

Today I will have a question and answer session and I will be covering some popular questions about general infertility, egg freezing, IVF, and genetic testing. But first, let me introduce my guest speaker today, Dr. Valerie Baker. Dr. Baker is a Talented Professor of Obstetric and Gynecology.

She's a Director of the Division of REI at Johns Hopkins and she has years of experience in the field of REI. Dr. Baker, welcome and thank you for accepting my invite. It's a pleasure.

Thank you for inviting me, Dr. Nasab. Of course. So I will go straight to the questions.

We have a lot of questions to cover today, but I will start with the definition of infertility. What is the definition of infertility? And if a couple are trying to conceive, when do we recommend that they go ahead and see a specialist? So generally speaking, infertility is defined as no successful conception after a year of not using contraception or after a year of attempting to become pregnant. For women over 35 though, because the implications of a delay in diagnosis are so great, typically a fertility evaluation is done when couples have been attempting to conceive for approximately six months or more.

Some of these definitions don't clearly encompass the inclusiveness that we would like. And that is another important topic that for example, same-sex couples, the definitions don't strictly apply, even though those individuals or couples are facing issues related to conception. Thank you.

And what are the causes of infertility? Why a person can become infertile? So there are a number of causes and they really revolve around the required steps for conception to occur. First, there has to be a healthy egg that is released. Egg quality goes down with age.

And so one of the reasons for fertility problems are that the eggs that are being released are not normal, are not healthy. And so some of them will not then not lead to a successful conception. There also has to be healthy sperm presence.

So a lot of infertility, probably at least half has a component that's related to problems with the sperm. There can also be problems with the fallopian tubes, with the uterine lining, where the embryo needs to implant and develop. And those are hormonal issues related to ovulation not occurring regularly.

Those are at a high level, some of the main causes. Wonderful. Yes.

You always mentioned that male infertility and female infertility ideally needs to be addressed at the same time. All right. The next question.

So they want to go ahead and see a fertility specialist. How they can find a fertility specialist? Is that okay to see a PCP or going to a general OBGYN and then get referred to a fertility specialist? Or is that okay? Just go ahead and schedule an appointment. I know most of our EIs are very busy and far out.

So what are your recommendations? So it really depends on a person's individual preference and also what their insurance might might or might not require. So most fertility specialists are able to be accessed immediately without necessarily having a referral. Going to the SART website, SART.org, for example, is a good way to find fertility specialists, find a clinic.

But many OBGYNs are very interested and very competent to perform basic fertility evaluation and help to address some of the causes of infertility. So I think it's really in part a personal preference. Women who are older or who have been attempting to become pregnant for a longer time may want to go directly to a fertility specialist.

Wonderful. The sooner the better. Okay.

So next topic is one of my favorite topics. And I hear every day is fertility diet. Is such a diet exist? I hear like patients go and try paleo diet, keto diet, Mediterranean diet, you name it.

But what is exactly fertility diet? And what are your recommendations in general about lifestyle changes for a couple who are trying to conceive? So the Mediterranean diet has sort of globally been shown to be associated with highest fertility. Obviously, there are women who don't eat a healthy diet and conceive without difficulty. So we don't want to overstate the importance of diet.

But on the other hand, there are good data to suggest that maintaining a healthy weight for both men and women, avoiding smoking, avoiding drug use, and having a Mediterranean diet, which is the diet we should all eat for general health, could be really helpful for fertility as well. How about weight management? Is there any BMI cutoff that you recommend to go ahead and see a fertility specialist or they can start their evaluation and still work on their weight? I think doing a concurrently makes sense to see a fertility specialist or primary care provider, like an OBGYN physician doing a concurrently because weight loss is hard and weight loss takes time. We've I focused not, you know, first on weight loss, but there are also women who are underweight may not be ovulating regularly because because of being underweight.

And so, so I think in both the situations, both weight gain can be hard for some, some individuals and weight loss can be very hard, and it can take time. And so I think going ahead and beginning the fertility evaluation and not assuming that it's only due to issues related to weight is a good idea. Yeah, that is a really, really important issue.

Because, you know, I always tell my patients, you know, be as healthy as possible, because at the end of the day, you want to get pregnant and you want to be like, you know, healthy during pregnancy and decrease the risk of complications. Is there any supplement that you recommend to your patients? So the supplement that is most evidence based is folic acid, which is typically in a good dose within a prenatal vitamin. We don't routinely recommend other supplements just due to really minimal evidence that they're effective.

We're not opposed to patients taking supplements such as an acetalcarol and myelin acetal, coenzyme Q10, these others, there are other supplements that are commonly suggested. However, I think that overall healthy lifestyle and healthy diet are much more evidence based than any particular supplement other than a prenatal vitamin. We do know that there's some evidence that vitamin D deficiency might have a role in fertility, although there haven't been true like randomized studies to prove that supplementing back with vitamin D is helpful.

However, it's reasonable to be sure to be getting adequate vitamin D in your diet or with a supplement as well. Wonderful. So I'm going to switch the topic to one of my favorite topics and that is egg freezing.

So we all know that egg freezing is a method for fertility preservation. And nowadays, women are considering more and more comparing to the past for egg freezing. For many reasons, if we put aside the medical reasons, there are a lot of social and personal reasons that women nowadays they prefer to defer childbearing to a later age.

But as we know, the age increases, the quality and quantity of the eggs go down. So how we can balance these two together? Yes, it's more popular. Women are more open to talk about it.

We see on social media, celebrities are talking about egg freezing. What makes me sad as a, as an RE is if a patient comes, I say, I wish I knew this option exists when I was younger. So that I think it's our job to educate everyone who wants to consider having a child in the future.

Now, main question, who is a candidate for egg freezing or in a more specific way? When do you recommend at what age do you recommend a patient go and see a fertility specialist to talk about egg freezing or start evaluation? So if women are in their twenties, and there's no reason to suspect a problem with egg supply, like the impending primary or premature ovarian insufficiency, where the supply would drop at a very young age, those women probably do not really need to see a fertility specialist for egg freezing, because the likelihood that they'll need those eggs is very small. However, women in their thirties, and particularly when women are not in a situation where they think that they can be attempting to conceive within the next couple of years, clearly that those are women that would benefit from at least a discussion. You know, like most things in life, there are pros and cons.

Egg freezing can be expensive. It's not covered by insurance. There are side effects from fertility medications.

Risks involved there are very small, but there is a burden to going through egg freezing. And if a woman is say in her mid-thirties and planning to attempt conception next year, then we wouldn't recommend that that particular individual really have to strongly consider egg freezing. However, if a woman doesn't really have sort of an arc or a timeframe in which they, she thinks that egg freezing is, I'm sorry, that conceiving is likely to be occurring, then that woman would definitely, I think, benefit from the discussion.

The other thing to consider is when sort of making family building plans, freezing eggs is definitely a very big plus. We're so glad that we have it available as an option to offer women to do, who wish to do planned egg freezing. However, it's not like the guarantee of like, like it is of currently being pregnant.

So when trying to sort of balance out when to have a child, there's often never an easy time to build a family, but I think we've, you know, we're glad that egg freezing is available, but also want women to understand that it's, it's a potential for having a child in the future, but not really a guarantee just to think about that in, in, in decision-making. Thank you. That is very helpful.

And my next question, which is harder than the first question is how many eggs is good for egg freezing? The most honest answer is more is better. More eggs, having more is better than having few. However, that has to be balanced against how many can be safely retrieved at any one time.

And for women with a lower egg supply, the body just will not allow very many eggs to develop and be, and be available for, for fertilization. If the egg supply is low, the body just only allows a few eggs to be retrieved at any one egg retrieval. So, you know, rules of thumb, often in the range of 15 to 20 eggs is considered a reasonable number for women who are in their mid thirties.

But the other thing to consider is how much weight does a woman want to put on? How much confidence does she need to have that there'll be at least one viable baby, one healthy baby coming from that group of eggs? So, because when you, when you look at making that decision, there's never like, as I mentioned, a guarantee that there'll be a baby from a group of eggs, but the more eggs, the higher, the probability that there'll be at least one baby. So, so I think it also depends on a woman's age. Older women are going to have more of those eggs being abnormal and there's no way to test them to see if they're genetically having the correct number of chromosomes and are normal.

So an older woman would want to try to freeze even more eggs than a younger woman. So it's not an easy, you're absolutely right. There are mathematical models that have been looked at to try to help women available online to help with this decision making.

But the general rule of thumb is having as many eggs available to be frozen that a woman thinks that it's practical for her to do. Absolutely. Yes.

Every individual is different. And when I get that question, my answer is see a fertility specialist, talk to it. It's always better, it's always better to be more proactive in the beginning because every person has a different, you know, personal wishes, cultural, religion, and also medical background, family history.

So, and also the future number of the children that they desire to have is also, you know, needs to be taken into consideration. If a person comes at the age of 39 and one of three children, so we have to be more realistic and open to her and make sure to design the best fertility treatment. Thank you.

So I will switch my topic to IVF. I hear a lot of times and a patient says, oh, I want to see a fertility specialist, but I know they're going to recommend IVF. Going to see a fertility specialist, is it equal to IVF? Preface that was saying it perhaps depends.

I think most reputable fertility specialists would not immediately recommend IVF to all women or to all couples. We want to be able to give individuals a range of options and then also help them to decide what's best in their particular circumstance. So for example, if a woman is just not having regular cycles, her periods are very irregular and her partner is checked and the sperm is fine, what we would typically be recommending is not jumping to IVF, but instead just trying to correct the problem by inducing ovulation with a medication that's appropriate for that person.

General OBGYNs often do prescribe these medications as well, but when you see a specialist, they're often going to be doing a little bit more detailed monitoring of that type of treatment. We also don't want to waste time doing treatments that are not going to be successful. So for example, if a couple finds that they have extremely poor sperm quality and there's no correctable problem for that gentleman to improve his sperm quality, then in that situation, IVF really would be recommended initially.

So I think it really does depend. Most reputable practices though will not automatically recommend IVF for everyone and instead will present a range of options with pros and cons for each. Yes, wonderful.

So we as REA, we have different type of fertility treatments, including time intercourse, IUI, which is interuterine insemination, and of course IVF. So I, again, go back to my first recommendation, the sooner the better to get evaluated. Dr. Baker, what's the rate of success for IVF? How about women who are at the age of above 40 versus below 40? Yes, so the success of IVF is definitely needs to be individualized based on a woman's age, her ovarian reserve, which is her egg supply, how many eggs are expected to be retrieved.

And I would strongly suggest that people who want to consider that question, because it is an important one, would look to one of the predictor models available online. For example, on the SART website, there's a patient predictor model where you would indicate your age, if you know anything about your ovarian reserve, your body mass index, which is your weight and height, and that those kinds of data would help to inform what that success rate is. But I think another general principle is that success rates do on average decline pretty profoundly for women beginning in their late 30s, and then even more profoundly each year, 40, 41, 42, it just continues to decline, except with the use of an oocyte donation, where the egg is coming from a different woman who's typically under 30.

So I strongly suggest going online and looking at those success rates. And you can even plug in your current age. And then what if I delay two years? What will that look like? What if I lose 15 pounds? What will that look like? That would really help to inform that decision.

What's the maximum age for IVF and embryo transfer? So with a woman's own eggs, there's no strict cutoff. A lot of IVF programs will begin to really discourage women from considering IVF as they enter their mid-40s, because unfortunately, even with the best treatments that are possible, the success rate of IVF will be in the low single digits for women beginning in their mid-40s without the use of oocyte donation. Oocyte donation still has a very high success rate for women through the mid-40s.

So some programs have no cutoff based on age. Some programs will have a cutoff of like 45 or 43, where they really do not perform IVF over that age because their success rate would be expected to be unfortunately very, very low without the use of donor eggs. And how about the embryo transfer? Can they get pregnant at the age of 50, for example? Yeah, so for the American Society of Reproductive Medicine guidelines, which many programs follow, it's recommended that a woman not have an embryo transfer if she's over the age of 55, because we know so little about the risks and benefits for women as they reach those ages.

And those embryos that would be transferred at that time typically would not have been created with that woman's own eggs at that point in time. Either she would have frozen eggs previously, or she would be undergoing a transfer with egg donation embryos. Thank you.

This information are very helpful. Now, a patient comes to me, and let's say she's at the age of 39, and we counsel about IVF and, you know, the chance of success and also the risk. Her ovarian reserve is low, but her question is that, Doctor, I want to try as natural as possible.

How are you going to counsel that patient? So I think I'd say the consequences of delaying more advanced treatments are more serious for women in their late 30s, and particularly with diminished ovarian reserve. It is frustrating also that the chance of success would be lower if a woman's 39 and has diminished ovarian reserve than might otherwise be possible. But I would still counsel that patient that if she wants to optimize her fertility, some of the things that we just spoke about a few minutes ago, related to general health, maintaining healthy weight, having good health habits, also having intercourse frequently, that has been shown to be more helpful than having intercourse infrequently.

And it kind of makes sense that that would be the case. Sometimes people get discouraged and they sort of stop trying because they think there's just no hope. And there's always still hope as long as the basic factors are there, there's sperm present, fallopian tube is at least one fallopian tube is open, woman's ovulating, there's always still hope that a pregnancy, a successful pregnancy will occur for women in their late 30s or older.

But I think that it has to be a sort of an informed decision where that individual balances the downsides of doing treatment with the downsides of delaying or not doing the treatment at all. Absolutely, absolutely true. So next topic is multiple pregnancy.

We all know fertility treatment can increase the chance of multiple pregnancy, twin gestation. But what we should exactly tell our patients, because I see a lot of patients that concern and they kind of delay their fertility treatments of concern of multiple gestations, how would you counsel those type of patients? So I think the most important thing to consider is that with in vitro fertilization, that risk of multiple pregnancy can be dropped to a very, very low risk. If a couple will choose a single embryo transfer, so only placing one embryo back.

So there's still always a chance that a single embryo could split to become identical twins. But the problem of multiple gestation, including twins, and historically, even triplets, has been greatly, greatly addressed by transferring fewer embryos, and in most cases, really trying to aim for transfer of a single embryo for a younger person, or a single embryo for an older person who's done screening of that embryo to check to see if it has the correct number of chromosomes. That's called pre-implantation genetic testing.

So I think that there still can be a risk, but we can really, really reduce that. Doing IVF does not mean that you're going to get twins or triplets. Yes, thank you.

So you just mentioned pre-implantation genetic testing, and that's my last topic for PGTA, which is technically for checking the chromosomes. Patients come and say, should I test my embryo? What is genetic testing? And what are the pros and cons of embryo testing? This is a very big topic in our specialty right now. So pre-implantation genetic testing for aneuploidy, that's PGTA, is checking a few cells from an embryo to see if that embryo has the correct number of chromosomes.

So each of us has 46 chromosomes, which is the correct number, but embryos that have the wrong number of chromosomes will either not develop and implant, or they will cause just a positive pregnancies test and stop developing, or maybe a first trimester miscarriage. And in more rare situations, an embryo with the wrong number of chromosomes can continue to develop and become a developing baby. The most well-known example of that is trisomy 21, which is also known as Down syndrome.

So it is possible to remove a few cells from an embryo. Typically in the United States, we're doing this when an embryo is five or six days old, doing what's called a trophectoderm biopsy, which is sampling a few cells from the outer portion of the embryo that will become the placenta. So the pro of doing this is obvious that you get more information about the embryo.

You can determine if that embryo does have the wrong number of chromosomes, and you can then more confidently do a single embryo transfer and still expect a very good success rate. The downsides of doing pre-implantation genetic testing are that there are some inaccuracies with the testing. There have been embryos that have been thought to be abnormal based on the results of PGT that ultimately were able to become developing babies.

This is not an extremely common phenomena, but there are certainly reports of that occurring. In addition, we don't really know a lot about the long-term implications of doing embryo biopsy. We've been doing it for decades, but not commonly until more recent times.

So we're still looking at, no health risks have been proven, but it is something that we're still continuing to study. And then for some couples particularly, for example, if they have only one embryo and they do the genetic testing, there could be an advantage because then they could do another, if they found out that the embryo is abnormal, they could proceed for doing another IVF cycle more quickly rather than, for example, having a pregnancy, having it develop as a miscarriage, and then needing to delay further attempts at conception. But on the other hand, letting nature screen out the embryo, because nature will typically not allow most embryos to get very far if they have the wrong number of chromosomes.

So that can be an option that couples could consider if they don't really, they're concerned about, legitimately concerned about that risk of getting a result that shows an abnormality when perhaps that embryo may have been viable. So it's a discussion that we have with our patients. It's, there's not like one easy answer for that, for that question about when PGT is right, but I think it still does have a valuable role in the IVF process.

It just, we need to make sure that the pros and cons are well understood. It's also typically not covered by insurance. So that may be another issue, because it can add significantly to the cost of this treatment.

Absolutely. Yes. PGT, pre-implantation genetic testing, we have different type of PGT.

We have PGTA that Dr. Baker just mentioned very nicely. It shows the number of the chromosome as well as the gender, because it shows the sex chromosome. So that's one of the valuable information that some of the couples, they want to know ahead of time.

We have other different type of PGT, which is checking for a single gene and also structural or rearrangements. So if you have any concerns about the genetic background in your family, please see a genetic counselor or talk with your RE or even general OBGYN, and you can get more information about that. Other question Dr. Baker is, we want to be clear with our audience.

So is the genetic testing of the embryo is the same of the carrier genetic testing? Can you explain? Yeah, that's a very good question because this commonly comes up when we're talking about genetics with patients. So there is the genetics at the level of finding out if an embryo has the correct number of chromosomes, and that's an individual egg by egg, embryo by embryo assessment. As I mentioned, you can't really access the test eggs specifically, but eggs having the wrong number of chromosomes are commonly what causes embryos to have the wrong number of chromosomes.

So that's called testing for euploidy or aneuploidy. How many chromosomes does the embryo have? And there's no blood test, for example, just for that, that you could know whether or not your embryo is going to have the correct number of chromosomes. The testing for single gene disorders, such as cystic fibrosis, sickle disease, spinal muscle atrophy, fragile X syndrome, various hundreds of genetic disorders can be tested for.

A couple can find out if they're at risk for having a child with a single gene disorder by doing each of them doing a blood test or for someone working with an oocyte or sperm donor, the donor can also be tested. And that is testing for what's called monogenic disorder or PGTM, if an embryo is biopsied for specific genetic disorder. So one of the other principles is that most couples who ultimately end up having a child affected with a serious genetic disease never saw it coming, they didn't know that it ran in their family.

And so that's why we offer routinely couples to have genetic carrier screening. And that is testing to see whether or not you have specific gene mutations that would be leading to an increased risk for a child to have a serious genetic disease. It's a very personal decision whether or not to do such testing, because some couples will decide for themselves that well, whatever is going to be is going to be and we're going to accept whatever genetic disease that child has.

And so that couple might not decide to do that type of genetic carrier screening. Other couples might decide to do the genetic carrier screening even just for more information. But we do think it's important that at least that each person is offered the option to do the genetic carrier screening, so that they could make the decision right for them.

Do they want to biopsy embryos that they're found to be at risk of having a child with a serious genetic disease? Would they want to test during pregnancy, but then they would have to face a decision of carrying or terminating the pregnancy for the developing baby that has the serious genetic disease. So there's really two main sort of categories of genetic problems. One is having the wrong number of chromosomes.

That's what you can't really specifically test for by a blood test. And then there's also having a specific genetic disorder that would affect the health of the child. And then as you mentioned, Dr. Nassab, there is also what are called structural rearrangements.

So that is something that is detected by a blood test. That's a person who say has a balanced translocation that may be a cause for their recurrent pregnancy loss. So that is one situation.

It's a relatively rare, but it is a situation where a blood test could help to determine if an embryo is going to have the wrong number of chromosomes, because if a couple has a structural rearrangement in the chromosomes, that can lead to embryos that are not viable. However, it is not routinely recommended that all couples need to have a karyotype, which is to check for these structural rearrangements because they're not common unless the couple's been having a recurrent pregnancy loss. Wonderful.

Thank you so much for explaining. I would like to keep asking you questions, but we have to kind of wrap up this podcast as a take home message. What is your final recommendation or let's say in one sentence or two sentence, what are you going to say to a patient who is trying to conceive? Just be proactive in your family building plans and seek out answers.

If you're having difficulty conceiving, I think that what we all want to avoid is the would have, should have, could have when people don't go forward with evaluation and then later regret that they missed the best window they could for having a successful pregnancy. Absolutely. Absolutely.

Thank you so much for taking the time and answering all my questions. I want to take advantage of this opportunity and introduce two great websites for infertility patients. One of them is SART, Society for Assisted Reproductive Technology, and ASRM, American Society for Reproductive Medicine.

There are also some pages for patients. There are very simple and easy to understand information over there. Please reach out to those websites.

We are here for you. We are trying to help you to build your family. Dr. Baker, thank you so much again, and hopefully we can see you more in our future podcasts.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates. These are provided as a source of general information and are not a substitute for consultation with a physician.