– Hi, I’m Susan Taylor with Scripps Health in San Diego, California. Please subscribe to our
Scripps Health YouTube channel. We’ve got great videos
featuring the latest technology, our stellar doctors, and
inspiring patient stories. So, you’ve been trying to
have a baby with no luck. How do you deal with fertility issues? It is such an emotional subject, so we wanna give you as
much information as possible to help you make an informed decision. Joining us to talk about
this are two OB-GYNs, obstetricians and gynecologists, Dr. Renee Nelson with Scripps Clinic in La Jolla, California and Dr. Brooke Friedman who
is a fertility specialist at Scripps and the San
Diego Fertility Center in San Diego, California. Thank you both so much for
being with us, we appreciate it. – Thank you.
– Thank you. – All right, let’s go back to the basics. What causes infertility? – Age is a most common cause
of infertility in women. As a woman ages, her eggs become abnormal, it makes it more difficult to conceive and carry a baby to term. Endometriosis can cause scar tissue– – [Susan] And what is endometriosis? – Endometriosis is where
the lining of the uterus grows outside of the uterus, in the pelvis or on the ovaries, and it can cause scar tissue that can prevent
conception from occurring. Also it can block the fallopian tubes so the egg and sperm can’t meet. There can also be abnormalities
of the man’s sperm, which can lead to couples being infertile. There are so many different
types of hormone imbalances that can cause a woman
not to ovulate on time or not to ovulate at all, which can lead to infertility as well. – What about a uterine
fibroid, what is that? – So fibroids are basically
a smooth muscle ball, it’s a benign tumor in the uterus. And if a fibroid is small and not close to where a
pregnancy needs to grow, it’s not gonna cause a
problem with fertility. But if fibroids get quite large or if they’re impacting
the cavity of the uterus where a pregnancy needs to grow, then that can cause a
challenge as far as fertility. – So most people think of
infertility as the woman’s issue, as the woman’s problem, but
that’s not always the case. Talk about the problems–
– No, definitely not. – With the man’s sperm. – And I think a lot of women initially always blame themselves, but at least 25% of the time–
– At least. – Or more it’s the man. And they often have no idea, they have no reason to suspect it, but they can have a shortage of sperm, where they don’t make enough,
they can be an abnormal shape that causes them not to move as well, they can be too slow
to make it to the ovary or the egg on time, some men don’t have any sperm at all. – Interesting. Okay, so what happens to a woman’s eggs and the man’s sperm as we get older? – So our fertility as women
is a little bit unfair. So we’re born with all of eggs
and we lose them over time and so because of that there’s
a decline in egg quality as we age and men get to make new sperm every 70 days forever. So it’s not really fair, but
that’s what we’re stuck with. – It’s not fair. (laughs) – It’s not, it’s not fair. But that’s really the
fundamental biologic difference that accounts for why women have a harder time
reproducing in later life and men have an easier time
reproducing as their get older. There still is a small impact
of paternal age on fertility, it’s not to say there’s no impact, but nowhere near to the
degree, unfortunately, that our age as women really
impacts our fertility. – So what happens to the
egg as the woman gets older? – So the egg is a single
cell that we’re born with. So over time those eggs
accumulate genetic mutations, so missing or extra chromosomes. And therefore it will be harder for that embryo then
to be a healthy embryo and have the correct number of chromosomes to implant in the uterus
successfully and develop. So as well as a decline in fertility there’s unfortunately an
increased risk of miscarriage. – And doesn’t the woman’s eggs get harder as she gets older too? – Not so much in terms of harder, but the main challenge is those missing or extra chromosomes as we age, yeah. – And what about the man’s sperm? What happens to that as a man ages? – So there tends to be
a decline in motility and, like Dr. Nelson
mentioned, morphology, the shape of the sperm. So the sperm quality can
decline as well, as men age. – So a lot of people are
putting off having kids, but the CDC, the Centers for
Disease Control and Prevention, say that 20% of women in the US are having their first
child after the age of 35. Is this too late? – Well, unfortunately,
like Dr. Friedman said, it’s kind of unfair. The age at which we’re best to reproduce is not really the age at which most of us are ready financially,
mentally, psychologically, so in the ideal world we
would all have our children when we were 22, 23 years old, but for most of us that’s
not the right time. So I know putting it off ’til over 35 is a gamble for many people
and definitely not recommended. If your lifestyle enables
you to have children sooner, I would recommend trying a little earlier than that if you can. – I would add, it also
depends a little bit on your family building goals. So sometimes I’ll see couples that conceived really
easily when they were 35, but are now coming back to
see me and she may be 39. So as the years advance
and we get closer to 40, it can become that much harder, so it depends a little bit on your family building goals too. – So let’s say what are you
chances of getting pregnant in your 20s, 30s, 40s? – In your 20s you’ve got
at least a 90, 95% chance that you’re gonna conceive,
especially within a year. – Within a year, okay, there’s a timeframe for that.
– And that starts declining. As long as you’re less than
35, you’re still 75, 80%. It then starts going down from there, especially after the age of 40. – So if you’re in your 30s, what’s the chance of
getting pregnant each month? – Yeah, so the most fertile
couple in the world in their 20s is about a 25% chance of
getting pregnant each month, but by the time we’re 40,
there’s a less than 5% chance. So it does really change
dramatically as we age. – So if you are having
problems getting pregnant, how long should you wait
before you go see a doctor? – Well you have to look at if a woman is having regular
menstrual cycles or not. I always tell my patients if they are not having regular cycles then they need to come in a lot sooner. If they are, generally if a
woman is under the age of 35 it’s recommended to try for about a year if their cycles are regular. If over the age of 35,
typically we recommend starting to do tests when
they’re six months from trying. – And so what kind of
tests can be performed to determine the cause of not
being able to get pregnant? – So we have to gather the puzzle pieces. So there’s a lot of
different moving parts. So we have to look at egg supply and we can do that a
couple different ways, but a blood test can be very helpful. Checking to make sure the
fallopian tubes are open and that’s typically done
with a test in radiology where they put dye in the uterus to make sure the tubes are open. – [Susan] And explain to the
folks what fallopian tubes are. – Yes! So basically, the uterus has these tubes and basically if you look at the picture it looks like a Texas longhorn. That’s not really what it looks like, but there’s little finger-like projections at the end of the tube that
have to pick up the egg and the sperm has the
swim into the uterus, up into the fallopian tube to
fertilize the egg in the tube. So it’s very important that
the fallopian tube’s open, otherwise the sperm and egg are not gonna have an opportunity to meet. – Any other tests that
need to be performed? – We definitely need to check out the male partner in the couple and do an analysis of the
sperm or semen analysis, and also usually an
ultrasound is performed of the woman’s uterus and ovaries to make sure all of that looks normal and checking hormones as well. – So in a couple of minutes we’re gonna talk about the emotional toll that infertility can take
on you and your partner because miscarriage is also
a part of this equation. So we’re gonna come
back and talk about that in just a couple of minutes. Let’s talk about the treatment options. Let’s say that you have
some fertility issues, what kind of treatment
options are available? – Well the good news is we have wonderful treatment options available. So if you are struggling with infertility, I would just want people to
know that they’re not alone. There’s wonderful fertility options, really depending on what
the cause of infertility is. So if a woman’s not ovulating, sometimes there’s medications
to help her ovulate or the ovary to release an egg. There’s IUI or intrauterine insemination and there’s also IVF or
in vitro fertilization. – What are those? (laughs) – So many of my patients refer to IUI as the turkey baster approach. So basically that’s when a man would provide a sample of sperm, we would process that sperm in the lab, concentrate the sperm into a tiny catheter and that catheter goes inside the uterus closer to where it needs to go, typically in conjunction with
the woman taking medication to have the ovary release
more than one egg. So we’re trying to get
higher numbers of sperm closer together to those egg targets. That’s what we’d consider
our low tech approach of IUI or intrauterine insemination. And IVF, or in vitro fertilization, is more of our high tech approach. – And IVF is what? – So IVF is when a woman takes medication to encourage the ovaries
to make multiple eggs and those eggs are taken out
with a surgical procedure and then the eggs are
fertilized with sperm in the lab and then that fertilized egg or embryo goes back into the uterus. – And so when you’re doing that, if you’re trying to get more
than one egg to be fertilized, how many will you try and get and then implant back into the uterus? – So that’s a really good question. And so as fertility treatment has gotten more and more
effective and successful we are really advocating
transferring just one single embryo and I know that our OB-GYN colleagues, we’re all on board on that. Our goal is one healthy baby at a time. So a single pregnancy, which is why we typically
recommend transferring one embryo. – And then fertility medications, what are they and how do they work in terms of hormonal imbalance? – Well it depends on what the problem is, but one of the medications that general OB-GYNs often
prescribe is called Clomid. It’s an oral medication
that is used to help a woman who is not ovulating or maybe not ovulating
early enough in her cycle. It kinda tricks her body into thinking that she needs
more stimulating hormone, so that comes from the brain
to stimulate the ovaries. And so that’s something that is successful in certain types of hormone imbalances where they can just take a pill at home for five days in the cycle and that can sometimes work
to help a patient to ovulate. Sometimes other hormone imbalances, or for the process of initiating
in vitro fertilization, they actually have to use injections of hormones to stimulate the
ovaries which is something that you have to see a
fertility specialist for. (all laughing) – And what is PCOS, what is that? – That’s polycystic ovarian syndrome. So that is a pretty common disorder which we see in a lot of women where there’s a predominance
of male hormones which is typically caused actually by a resistance to insulin. So these imbalances can cause
a woman to not ovulate at all or to ovulate extremely late in the cycle where the egg isn’t very good anymore or the lining of the uterus is old and not prepared to receive the egg and also it makes it
harder to get pregnant when you don’t know idea when you might ovulate in the cycle. So that is a disorder that can be treated sometimes with Clomid
and other medications. We see it often in women
who are very overweight, that can play a big role
in hormone imbalances. – And then what about a
high level of prolactin? Explain what prolactin is
and what is that high level? ‘Cause I know that’s a really long word, that’s really a mouthful.
– It is hyperprolactinemia. It’s a mouthful. So it’s a relatively uncommon
cause of infertility, but prolactin is a hormone where, if it’s secreted by the brain at higher amounts than is normal it can cause irregular
periods and other impacts which can make it a little
bit hard to get pregnant, but typically if someone has that they’re gonna have other symptoms
such as irregular periods which would sort of tip them
off that to be evaluated. – Let’s talk about donor
eggs and also donor sperm. – So that’s something that is
a big part of our tool box. So we’ve helped many,
many patients conceive with assisted reproductive technology in terms of what we call
third party reproduction, donor eggs, donor sperms, or surrogacy and it can be a really wonderful way for people to build their family. – And so what’s the process? Let’s say that your eggs
are not working anymore and you wanna get a donor egg. How do you go about that? – So there’s different ways. So at my clinic, at San
Diego Fertility Center, we do have our own egg donor database and so patients can look
at the egg donor database and select an egg donor that they feel like is
a good match for them and then that young
woman under the age of 30 is going to through the
process of taking medications, we’d retrieve her eggs with the procedure, typically fertilize her eggs with the intended
parents’ husband’s sperm, create the embryo and
then transfer the embryo to the egg donor recipient. – And what about donor sperm? Let’s say a woman’s eggs are fine, but she needs the donor sperm? Is there a similar bank for that? – We see this in many type of couples, sometimes same-sex couples,
they need a sperm donor or if the man’s sperm is so abnormal that even IVF is not
gonna solve the problem, there’s banks where you can pick out sperm based on many characteristics of the man. So they can look and maybe be as close to
the husband as possible. – Absolutely. And also single moms by choice. You know, we’re seeing a lot of women who just maybe they
haven’t found Mr. Right and they’re choosing to then start that process to parenthood. – All right, so let’s come back to this. Let’s talk about the emotional toll that infertility can take
on you and your partner because miscarriage is also
a big part of this equation. – Yeah. So infertility can really
cause a tremendous toll, not just on the
individual, but the couple, the relationship of the couple and so it’s important
that we try to emphasize that infertility really affects one out of every eight couples, so these patients going
through it are not alone. It’s very common and
it’s a medical disorder like really any other. So those patients who are
struggling with infertility need that extra emotional support because it is such an emotional journey. But they’re not alone and we do have very effective treatment, which is the good news. – But what are the odds of miscarriage? How common is it? – Well at least 25% of all recognized
pregnancies will miscarry and that’s from getting
your positive pregnancy test to the first three
months of the pregnancy. So that is also very, very common and that’s important to know that just because you have a miscarriage doesn’t mean you won’t
be able to have a baby because many women have a miscarriage and go on to have many
healthy babies after that. – So what’s the cause of miscarriage? – So most miscarriages are caused by missing or extra
chromosomes in the embryo, or the pregnancy being then
being genetically abnormal. So it’s really important,
we always try to emphasize if someone’s gone through a
miscarriage, it’s not her fault. It’s really very common for
women to blame themselves and feel like it’s something
I did that caused this, but that’s really not the case. – So what causes you
to have a miscarriage? – Well, typically something
isn’t right with the pregnancy, so either the embryo is abnormal or even a little later
in the first trimester the development might not
be normal, of the organs, and basically it can cause the pregnancy just to stop living. Something I always tell patients, it’s like Mother Nature
knows that this isn’t normal and is taking care of the problem before it gets to the
point of where the parents may have to make decisions about, “Is this baby normal or not?” That is taken care of a
lot of the time for us, fortunately, I think that is the case. I like to remind people that
when they have a miscarriage that of course they
should be sad about it, but on the flip side that
something wasn’t right with it and so they really want
a healthy, normal baby and so they have to kinda
move on to the next pregnancy and focus on that rather
than focusing on the loss. – But what about some
outside factors like smoking, excessive alcohol, extreme
weight gain or loss, or excessive physical or emotional stress? Kinda just go through that whole list. – No, those are good questions. I mean, certainly there are
certain environmental exposures, like cigarette smoking does increase the risk of miscarriage, extreme obesity can also
increase the risk of miscarriage, so there are definitely, you
know, uncontrolled diabetes, there are certain medical conditions that can increase the
risks of miscarriage. So certainly those are factors that an OB-GYN would go through a patient and try to reduce or
eliminate those risk factors– – Excessive alcohol? – Absolutely. I mean, I think that tends to be a lower cause of miscarriages,
at least in our population, but certainly that definitely contributes to abnormal embryos which would
then result in miscarriage. – So how do you minimize
the chances of miscarriage? And what should you do to, I guess, to prepare before you try to get pregnant? – I think the most important thing is trying to have your
babies younger, if you can. (laughs) And then just being healthy. Not anything too extreme,
but eating a healthy diet, not smoking, exercising
a realistic amount. Also we can see problems with people who do things
to excess, you know, excess training for marathons, triathlons, athletes, dancers, things like that can sometimes have difficulty also because they’re on the
extreme end of fitness. – So is there an ideal age
to try and get pregnant? – So ideally if someone
wants a larger family, it’s best to start trying
as soon as possible. So we’re most fertile in our 20s, but that may not be the right time, like Dr. Nelson was saying, from other aspects to get pregnant. From a fertility perspective,
we’re at our peak in our 20s, but certainly if someone
wants a larger family, starting that journey under
age 35 would be important ’cause as we move into our later 30s, or particularly closer to 40, it can become substantially
more difficult to get pregnant. – So you folks deal with the
highest of highs, I think, and I suspect, with miscarriage as well, you deal with the lowest of
lows in terms of the emotion. How do you cope with the emotional toll that fertility issues can have, those extreme emotional highs and lows? – Well I think one important thing is letting the patient know
that it’s not their fault, they’re not causing this to happen, that they didn’t do anything wrong, most of the time it isn’t
something that they did wrong, and just helping them and
support them through that because I think blaming
themselves or blaming each other can cause more problems
in their relationship and turn something that’s
supposed to be a healthy, fun activity into something
that’s very stressful and can cause lots of
problems with the marriage. – Absolutely. And I typically often encourage patients if they’re having a
hard time to seek help, absolutely see a mental
health professional, there are support groups and just to know that they’re not alone. And it’s really important to
know that there are options, there’s support and there’s help. – Let’s say someone is
having fertility issues and they have to use fertility
treatments many times in order to become pregnant. Does that take a toll on
someone if they do it too much, using those fertility treatments? – Well I think fertility
treatments or not, when you’re trying to get pregnant every month feels like
an eternity, you know? It’s forever ’til you ovulate, forever, you feel like, to
find you if you’re pregnant. So certainly as the months
turn more like more than a year that can be a painful process and so certainly fertility
treatment can be challenging, that’s why it’s important
to assemble a team, both medically and sort of also socially and have that support
to help you through it. – But let’s say you’re
taking hormone injections and you’re taking them if you
wanna have two or three kids and you’re having a really
hard time conceiving, can ingesting all those extra hormones take its toll on your
body later on in life? Is there any risk for it? – Yes. The good news is studies have been very
reassuring to that affect, and so fertility injectable medication has really not been shown
to increase the risk of disorders like breast
or ovarian cancer, so patients should really feel reassured that the medications they’re
taking to get pregnant are not gonna negatively
impact their health downstream later on. – Any final thoughts? – I think it’s most important just to remember that the relationship that started the whole
process is important and sometimes everyone
gets so focused on the baby that they forget about each
other and they forget about what initially started the whole journey. And also remembering that there’s lots of options
out there for having a family, there’s many different ways to be parents. – Absolutely. There’s a lot of different
paths to building a family. So knowledge is power, so it’s really important if
you’re struggling to conceive to try to get some answers. So particularly if you’re over age 35 and it’s been over six months, see your OB-GYN for an evaluation. It’s important to have
that fertility evaluation, to have a semen analysis
done to check the partner, to gather those puzzle pieces. Knowledge is power, so when
you have that information you’re in a better position to really evaluate your next steps. – [Susan] Knowledge is power, I like that. Thank you both so much for being with us, we really appreciate it. – [Both] Thank you. – If you want more information
on fertility and miscarriage, please click on the link or
go to Scripps.org/videos. Want more critical
information about your health? We take care of you from head to toe. Please subscribe to our
Scripps Health YouTube channel and follow us on social
media at ScrippsHealth. I’m Susan Taylor, thanks
so much for joining us. It’s our mission at
Scripps to help you heal, enhance, even save your life.

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