UAB Medicine

Infertility: 35 is the New 25


Click the video above to watch a recording of Dr. Wright Bates' webinar "Infertility: 35 is the New 25." In this video, Dr. Bates discusses different causes of infertility, tips for enhancing your fertility with lifestyle changes and ovulation timing as well as infertility treatment options for those who have not been able to conceive on their own. Examples of those infertility treatment options are fertility drugs or procedures like IVF (in vitro fertilization) and IUI (intrauterine insemination).

Schedule a consultation with a UAB Medicine infertility specialist.  


Video Transcript

Good afternoon and welcome to our webinar.  Thirty-five is the new 25 as you see on your screen, also infertility 101 because we're going to go over a lot of the basics today of infertility.   We will talk a little bit about the age impact and hopefully will leave you with some good information, as well as a sense of optimism and much encouragement.  Thirty-five is the new 25 when it comes to my practice.  Here at UAB I am fortunate to practice with three other outstanding physicians, Dr. Richard Blackwell has been at UAB for nearly 30 years and is a really recognized national and international expert in reproduction.  Dr. Melissa Wellons, who is a noted endocrinologist who specializes in hormone changes, heart disease, and menopause.  Dr. Janet McLaren is truly a superstar in our field.  She is a Canadian who grew up in Hawaii and then went to Yale, Harvard, and Penn.  I am very fortunate to be part of an excellent team and get to be the point person to spend a little time with you today.  By the way, 35 is the new 25 or more correctly 37 and a half because the average person in our clinic is between 37 and 38.  Those of you who are pursuing fertility in your late thirties and even early forties, you're not alone.  You are the most common patient that we consider it an honor to serve.  Let's proceed with some basic information.  

You're not alone, as I mentioned.  One in four couples will conceive each month, but remember that number because one in four couples also report some difficulty with getting pregnant in some manner or form of infertility.  We don't tell our teenagers that the chance of getting pregnant is only about 25% each month, but that is the statistical fact.  At 30, that number declines to about one in six and after forty, unfortunately we will see about one in ten.  Again, that's each month so several months of effort can result in a pregnancy.  Overall, 85% of women will become pregnant in one year.  Half of those who did not conceive the first year will get pregnant in the next year so overall 93% of women will become pregnant in two years.  Often what we're doing as fertility specialists is that we're hastening the inevitable and really treating sub-fertility.  For those of you who have dealt with this often unpleasant condition, each month can become a trial and tribulation.  Each day you get your period may not be the best day for you.  Helping individuals and couples get pregnant and expand their family in a more timely manner is really often what we do.  As far as preparing to get pregnant, our pre-pregnancy planning there are really some important caveats.  The first, which we will spend quite a bit of time on later in the talk, is know thyself.  Are there signs that suggest you have obstacles to normal reproduction or are there things that you shouldn't wait about – that you should progress?  As we'll discuss in a few minutes, what is your menstrual cycle telling you?  When are you most fertile?  When is the fertile window?  When is the optimal time that intercourse can result in conception?  Knowing thyself is the very key to this process and I'll give you some pointers in a few minutes.  Our annual exams are crucial.  You all are aware of the debate on mammograms and not really the focus of today's conversation, but seeing your physician regularly if indicated having a mammogram and Pap smear up to date uncovering any subtle health issues that may make it harder to get pregnant or stay pregnant or be pregnant is crucial.  I can't stress enough the importance of starting prenatal vitamins early and taking those regularly.  There is evidence that the folic acid in them dramatically reduces the chance of neural tube defects.  Prenatal vitamins and seeing your physician early is crucial.  It's also important to be as healthy as you can and that includes mentally, physically, emotionally, spiritually – all the things that make up a whole person and one's general health.  I will get on my soap box a little bit and talk about smoking.  Clearly smoking is not a contraceptive as many people would say.  It doesn't prevent pregnancy; however, there is good evidence that I'll share with you in a few minutes that smoking dramatically reduces one's response to fertility interventions.  Along the same lines of pre-pregnancy planning, it is important to have your vaccinations and immunizations up to date. It is crucial that a woman be immune to German measles or rubella, as well as varicella and many obstetricians and gynecologists will check titers of blood work to confirm immunity.  It is also recommended that if you're going to be pregnant during the flu season that you have the flu shot.  We encourage that your vaccinations and immunizations are up to date when you start this journey.  What can a woman do without seeing a doctor?  Can you optimize your own fertility whether you're 25 or 35, even in the early forties?  I mentioned overall health status and an overall health assessment that is crucial.  Smoking cessation without a doubt is important.  It's also important to be as healthy as you can from an overall body weight and health status.  We'll talk in a minute about the best diet for fertility and again one of the important take home messages today is prenatal vitamins should be started when you're trying to get pregnant.  This is a little bit of the data I mentioned to you on tobacco and fertility.  There is evidence that there is an increased rate of miscarriage, also an increased rate of ectopic or tubal pregnancies.  Women who smoke regularly go through menopause earlier.  There is evidence of decreased sperm quality and decreased sperm function even with chewing tobacco.  A few years ago a very nice study showed several decreases in sperm function in men who chewed tobacco so tobacco in any way can decrease the quality of the sperm.  The chart you see to your right is couples undergoing IVF at another program.  Overall, about 40% got pregnant.  The reason 35 is the new 25 when it comes to IVF is that many, if not most, couples who even are 35 or less were achieving pregnancy rates with IVF that exceed 50%.  Back to the numbers that I showed you for natural fertility, while 50% may not sound great compared to 100% - if you compare 50% or 60% versus the natural pregnancy rate at 35, which is somewhere around one in eight, then it's quite impressive.  However, if you smoke that 40-60% is reduced almost in half.  In this study, if the female smoked, the IVF success was 19% even if it was the male who was the smoker, the pregnancy rate was 20%.  So almost a 50% reduction in fertility if anyone in the household smokes.  There are also issues later for the newborn child or baby that really makes smoking an obstacle in healthy reproduction.  
What's the optimal diet for getting pregnant?  All of you know there is no perfect diet and no magic pill.  Dieting is not fun and unfortunately the Southern Diet often works against us.  Someone who is early pregnant or trying to get pregnant should in general avoid raw meats and fish because of the risks of contamination.  You should also make sure that your vegetables and fruits are washed very carefully, and really limit meats, fishes, and soft cheeses that are processed.  In fact, the recommendation is that processed meats including cold cuts and hotdogs, which many people don't know, should be heated to steaming early in pregnancy.  It's very important to limit those things.  Refined sugars clearly play a role in those of you who are dealing with weight issues.  In general, I counsel my patients that carbohydrates and refined sugars should be limited in someone who is trying to get pregnant or is pregnant.  I can't recommend a life without any carbohydrates.  Some of the carbohydrate diets or low carbohydrate diets can be quite harsh, but in general lean proteins and green vegetables are your friend and your ally in this struggle with reproduction.  Alcohol is probably okay when someone is trying to get pregnant, but there is really no safe amount once someone is pregnant so I recommend that my couples who are going through fertility to use alcohol in moderation.  A glass of wine may have many medicinal effects, but once you're pregnant it really is something to be avoided.  Finally, caffeine has become a mainstay of most Americans.  The goal is to not completely eliminate it, but the goal is to reduce it or keep it in moderation while one is trying to get pregnant.  
We talked about diets and a little bit about weight.  What is the optimum weight?  This chart that you see in front of you breaks it down by height and when we talk about weight and infertility, when I teach medical students and fellows, we talk about the body mass index.  It's really weight for height.  As you can see, the goal there is a BMI of 30, which varies from 191 at 5'7" and those of you that are not blessed with tremendous height at 4'10" the weight should actually be 143 lbs.  This is actually well below the average weight in our clinic so we don't in any way discriminate, but we do help couples achieve healthy weights in order to achieve a healthy pregnancy and this is a common issue that we deal with.  You see the cover of Newsweek and it really highlighted that this is in the public's consciousness.  My former colleagues at Harvard Medical School actually commented on this fertility and diet, and the fact that women are ovulatory (that means not ovulate regularly) usually don't have regular menstrual cycles and suffer from difficulty getting pregnant if they have excess weight.  Likewise, there are more miscarriages, more birth defects, and more complications of the pregnancy if a woman carries a tremendous amount of excess weight.  Having delivered more than 1000 babies, there are many women on whom weight has no compact regarding their reproduction and many women that have normal children and uneventful pregnancies who carry tremendous weight.  Unfortunately, many of the patients I see with difficulty getting pregnant often with irregular cycles, which correlates with lack of ovulation, do suffer from excess weight and that is something we try to address in our goal to treat the whole person.  
Exercise is crucial not only for weight loss but reproductive function.  Not to bore you with medical research, but there have been two fairly impressive studies.  The one on the left hand side of your screen took women and asked them to exercise 90 minutes per week.  Three days per week 30 minutes a day.  This is not ultra-marathon and not boot camp, just getting active three days per week.  The encouraging thing was just a 5% reduction in body mass index.  If you weight 200 lbs. these women lost 10 lbs.  So just a 5% reduction in BMI overall improved how your body processed glucose or sugars.  The amazing thing was 60%, almost two out of three, had return of their menstrual cycles and are either ovulating or releasing an egg where they weren't before.  Just a little bit of weight loss and a little bit of exercise can have tremendous potential benefits on the reproductive and endocrinal hormone system.  On the right side of your screen you see another program that looked at a 24-week exercise program or roughly six months where they used a high-protein diet.  Menses returned in many of the women.  Ovulation returned or release of an egg, especially in those who exercised.  Overall, their hormone profiles including those who suffered from excess male hormones, which is often seen in women who have excess hair growth, predominantly in the middle of the body, so upper lip, on the lip, between the breasts, the lower abdomen, between the umbilicus and the bladder.  That is often due to hormone imbalance or androgen excess.  Those women had a reduction in their abnormal hormone ratios or balances when they exercised and lost weight.  Lots of encouraging information that a proper diet, exercise, and just a little bit of weight loss can have a profound impact on someone's reproductive health.  
Another study looked at it may help me get pregnant spontaneously, but what if I've tried this and am not getting pregnant and I need treatment?  CC is chromotin citrate and that is a very common fertility pill that we'll talk about in a few minutes.  Let's look at 96 women who had quite a bit of excess weight and randomized, and that's what the RTC is.  That's the proper way to do medical research, to take one group and do one thing and another group and you give a placebo or do nothing, and look at the outcomes.  Six weeks of an exercise program and a low-calorie diet you are much more likely to get pregnant than those who diet and took the fertility medications.  Good evidence in addition to the slide before that you're more likely to have normal menses, normal hormone levels, release an egg every month, more likely to get pregnant, and more likely to respond to fertility treatment if you're as healthy as you can be by way of diet and exercise.  There are lots of misconceptions out there and I would not add to that – if you can't get pregnant just get into shape and you will.  That is not true and many women need interventions, often simple things such as fertility tablets, but sometimes more aggressive such as fertility injections or even in vitro fertilization.  Test tube babies are sometimes genetic testing.  Trying for one year without success is the definition of infertility so regular unprotected intercourse for one year without conception has classically been termed infertility.  If you're older than 35, you need to think about seeking help or care, or at least evaluation after just six months.  Likewise, if you think there's a problem – your periods are irregular, you've had pelvic surgery, pelvic infections, or you have very painful periods - then you might want to be evaluated sooner because those would suggest either a hormonal problem or a problem with the plumbing so to speak or the anatomy.  There may be scar tissue.  There are many things that I hear my patients say.  They've been told to just relax and you'll get pregnant.  Drink some cough syrup because it will thin your cervical mucus.  Take this hormone or that, on and on.  By in large, those are what we describe as the data freeze zone.  They have not in well designed studies been shown to make a difference when compared to placebos.  It is also important to know that high tech is not required.  I mentioned in vitro fertilization, test tube babies, and even genetic testing.  By in large, most couples do not need that.  Many couples, if not most, will get pregnant with a simple evaluation and simple treatment so the message is one of hope and one of optimism that very aggressive things will not be needed.  Another common misconception is if I go to a fertility specialist I am going to end up like octomom.  Instead of having a child I'm going to have a litter.  The good news is that we're absolutely intent on a healthy pregnancy.  It's not pregnancy at all cost at UAB, it's a healthy pregnancy keeping with the couples' desires on all the levels I mentioned to you before, physically, emotionally, mentally, spiritually across the board.  Not in order of importance, but clearly every couple has different parameters and different value sets that we value and consider an honor to be part of.  One final misconception is that fertility treatment is incredibly expensive.  While Alabama unfortunately has very poor fertility coverage, right now there are approximately nine states in the country that cover fertility completely and none in the southeast.  We do our very best to work with the patient's financial resources, investigate thoroughly if the patient's insurance covers anything or everything, and then factor that into our treatment approach.  You don't walk through the door and we suggest the most expensive intervention such as IVF or other high-dollar treatments.  I'm also proud to say that UAB is part of the reproductive medicine network and so many women can actually undergo a fertility evaluation and treatment at no cost.  We are participating in a trial currently to look at unexplained fertility.  So those with normal sperm, normal hormones, and normal anatomy we actually have a program where they may receive fertility evaluations and fertility tablets possibly even fertility shots with intrauterine inseminations.  All is part of a research study and armed with grants if a woman qualifies.  There are lots of misconceptions but I'm here to tell you that most of those are not based on fact and many couples are successful without breaking the bank or ending up with more than one or two babies.  I mentioned earlier that you're not alone.  One in four women at peak fertility get pregnant each month, but also one in four couples sometimes have difficulty with fertility or report the inability to get pregnant.  About one in six will actually see a healthcare provider for their infertility.  The good news is that eight out of ten are more of those women who seek care will get pregnant and there is some evidence that seeing someone who specializes in infertility may actually result in more pregnancies and shorten the time for success.  I'd like to think its because we are up on  the latest and greatest options, but often it's just tailoring the woman's treatment through years of experience to arrive at what's the proper treatment.  It may not be high-tech, but often as you see the results are good and we can share in the joy of a couple expanding their family or having a baby.  
So when should you see your doctor?  I stressed earlier that for preconceptual visits, annual exams, and then definitely if your cycles are irregular or unpredictable, if you have pain with your periods or pain with intercourse, pain with activity.  If you've tried for six months and you're older than 35 or 12 months overall, again keep in the back of your mind as you get older the clock is somewhat ticking.  We're all aging and reproduction can be a challenge especially in the late thirties and early forties.  If you are 35 and listening, there are lots of reason for optimism, but even those that are a bit older, we've come a long way in our ability to intervene.  We can't reverse the clock and can't completely fight the ravages of time, but often can provide hope where there may seem like there is none.  Why is the title of this 25 and 35?  The fact of the matter is that we're waiting later as a society and a population to have children.  You see in 1970 the average age was less than 21 for the whole population and now it's almost 25.  Four and a half years doesn't seem very impressive, but on a population scale that is tremendous.  There is a tremendous delay in the age at the first child.  Also if you look at the number of women who have babies later in their reproductive years – it was only 1% in 1970 and now it's almost 10%.  Again, going from 1 to 10% on a population basis for a whole society really reflects the shift that 35 is the new 25.  If women who once got pregnant at 20 now may wait until 30, and 25 may now wait to 35 because of social situations, pursuit of academic or career excellence – for many reasons we're seeing these women at a much older age than was even seen when I was younger.  We talked a lot about infertility, but you see that one in three times it's due to problems with the tubes or uterus so adhesions, scar tissue, maybe endometriosis (that's where the lining of the uterus grows outside the uterus) something is interfering with the fallopian tube picking up the egg, the sperm and egg meeting in the fallopian tube, and then being transported to the uterus.  So one out of three couples have problems with tubal disease.  About one out of three also have issues with sperm production or sperm function, and then you see about one out of six have difficulties with ovulation.  In our practice at UAB and in Alabama in general, we tend to see more problems with ovulation in part because of our states difficulty with excess weight.  So you see that it's about one-third anatomy, one-third hormones, and about one out of six problems with ovulation, and other things fall into the unknown and other.  The passage at the bottom makes a very key point.  It really does take two to tango.  Fertility, more often than not is the couple diseased and about half the time we see defects or difficulties with the male and the female so they really are in this together.  Not always, it is individuals that get pregnant and we're happy to treat those individuals, but know that in many couples both face obstacles.  We stress at UAB that it's important to not only find the treatment that is right for the couple on many levels, but also not to do a host of tests that aren't going to change the outcome.  Many things have been tried – immune testing.  Across the board things have been suggested, but not been shown to result with more babies in the nursery or more successful outcomes. That is really what I and my colleagues ask ourselves every day, is this test going to help that couple?  Is this intervention going to help this woman or this couple get pregnant?  We've arrived at a fairly minimal approach that fortunately is often covered by insurance, clearly not always, but often and that involves basic blood tests for thyroid, the pituitary or the brain function, and then is the ovary normal?  Does it have an adequate number and quality of eggs?  We'll talk about that in a minute.  Finally, we do some imaging, not always, but in many cases either an x-ray or an ultrasound to make sure the uterus and fallopian tubes are normal.  Finally, women bear the brunt of reproduction so we insist that almost all couples have a semen analysis to make sure there is not a problem with sperm function.  The semen analysis is rarely, if ever, covered by insurance.  Typically it's only about a $40 test and provides very useful information.  Women have to deal with periods, much of the fertility treatment, and childbearing so we do insist that men get checked early.  As far as the semen analysis, you may wonder what's normal and it's actually not very stringent but in general there will be 1.5 to 5 ml or cc in a sample, more than 20 million swimming per each cc.  About half of those will be swimming and about half will appear normal.  If you look at them through the microscope and just ask yourself is there one tail and one head.  Clearly collection of sperm is a very personal thing and we really try to recognize the privacy and the sensitive nature of all fertility evaluations and treatments, and approach this in a very professional but compassionate manner.  It is very important to make sure that there is adequate sperm production, numbers and function, before putting the woman through what could be unnecessary fertility treatments.  How do we know if a woman is ovulating?   Again, the answer is there are lots of ways to determine this.  Many are not required.  If you'll look at the bottom of the screen, if you have regular, predictable cycles and moliminal symptoms.  What does that fancy medical term mean?  Simply put, if you have breast tenderness, bloating, moodiness (premenstrual syndrome) before your period every month, more than nine times out of ten you're ovulating so no high-tech testing is required.  Regular cycles with classic PMS or moliminal symptoms, most women are ovulating.  I say most but not all.  Nine out of ten with one caveat.  In women who have a tremendous amount of facial hair, in fact if you've seen the billboard ads or other ads elsewhere you know that I have a beard.  Unfortunately, I do see women that have to shave, use electrolysis, wax, or laser on a regular basis.  If that's your story, if you're suffering from excess hair growth and dealing with that very annoying condition, then there may be a problem with ovulating even if your cycles are regular.  You see other things on the screen there about basal body temperature.  There are lots of different tests out there to detect ovulation.  This is what we look at when we look at an ovulation chart.  If your temperature rises consistently mid-cycle about 0.6 degrees F you're probably ovulating.  Once the egg is released from the follicle, the follicle then begins making progesterone.  That progesterone elevates body temperature and you see this biphasic or two levels of body temperature.  It's a basal body temperature; however, if you miss your morning temperature, have your coffee, go to the bathroom, then drink orange juice that morning's temperature level is not valid so I do recommend that patients do not rely on basal body temperature.  It's stressful and inaccurate, and finally it's retrospective.  I can't tell you if you're going to ovulate, I can only tell you that you ovulated in the past.  I'm not a big fan of this, although many couples still rely on it.  There are lots of treatment options that are out there that are available, is timed intercourse.  It means just continuing to try, trying to know your cycle and optimize.  What do I mean by knowing your cycle?  You hear about these 28 days or monthly cycles and that really is kind of the ideal of the norm, but maybe not be what is normal for some women.  Anywhere from 22-23-24 days up to 32-33-34 days is probably normal if it's regular and predictable with those PMS symptoms.  If your cycle is 28 days, you're probably ovulating on around day 14.  On the other hand, if your cycle is 35 days and consistent with PMS symptoms, your ovulation is 21 days.  So 14 days after ovulation women will get her period.  That is said in almost all women.  It's the first part of the cycle from the start of menses until ovulation occurs that varies so knowing your fertility window, knowing your time of ovulation can dramatically increase your chances of getting pregnant.  We will come back to that in just a little bit.  
I mentioned chromotin citrate as a fertility tablet.  There is a new tablet on the block or new fertility treatment called letrozole or femora.  This was originally designed to treat breast cancer in that it lowered the risk of recurrence of breast cancer as an adjunct or an additive to other forms of chemotherapy.  We found that in low doses it actually induces ovulation.  It is cleared from the body quicker.  One of the things we're doing in that trial I mentioned to you for unexplained infertility is comparing clomen to letrozole versus the injectable gonadotrophins.  Again if you are randomized to gonadotrophins that can be a several hundred if not a thousand dollar saving each month on fertility medication so we're real excited about being the only representative of this study, reproductive medicine network in the entire southeast.  Down at the bottom you see that some women need surgery.  I'll come back to who exactly needs IVF or very aggressive things such as donor sperm or donor eggs, which are called donor gammies.  The timing of intercourse – I'll throw in another study not to ask you to remember and there will not be a test later – but this is from the New England Journal of Medicine.  Clearly one of the leading journals in all the world of medicine and medical research.  It looked at 221 patients and 625 cycles.  You'll notice that there are six bars.  A single act of intercourse over a period of six days resulted in pregnancies.  Most pregnancies occurred the day of ovulation one or two days before, but notice that +1 in the bottom right hand. Out of 625 cycles, there were zero pregnancies in women who had intercourse one day after ovulation.  It is important to know thyself, to known your own cycle you've got to be proactive.  Intercourse has to occur on or before, preferably before, ovulation if there is any chance of pregnancy, but also know that there is not a lot of pressure like you might see from Hollywood.  You don't have to run home now is the time, if we don't act like a couple we're not going to get pregnant this very moment.  If someone's being a jerk or there are headaches involved, it can be stressful and fertility treatment is often stressful.  There is up to a six-day window when intercourse can result in a pregnancy so it's important to be proactive.  It's important to have intercourse prior to ovulation, but by no means is there a magic hour when life has to cease and intercourse has to occur.  That's important to know because life is busy and there is a wide window.  Another study that looked at this issue from an European group was even more pronounced.  If you look on the bottom right where it says day of intercourse zero, zero is the day of ovulation.  Most pregnancies occur the day before to even three days before ovulation.  The authors actually said that intercourse on the day of ovulation may be sufficiently late to preclude pregnancy so the egg is not waiting.  The egg may be good between four and 16, even up to 24 hours, but not much longer.  Intercourse needs to occur before ovulation so timed intercourse really means before ovulation occurs in couples wishing to enhance their fertility.  What about if you don't ovulate?  In general, about one egg is released each month, but dozens if not hundreds actually begin that process.  A couple of months before the egg is released, several begin their journey to maturation and for some reason, maybe sensitivity to hormones or other stimulus, one egg wins the race and becomes the dominant follicle and is release.  That in part explains why age is a factor.  if a woman is losing dozens if not hundreds, maybe some months a thousand eggs to get one released, you can see that there might be a small number in decreased quality later in life.  In fact, there is some evidence that women start with 6-7 million eggs.  There is less than a million at birth down to a half  million or less at puberty, and then there's this tremendous loss so that when menopause occurs, which is in the US about 50 or 51 there is less than a thousand eggs remaining.  This still sounds like a lot, but when you compare that to the millions that were present before birth, not many remain.  I mentioned PCOS specifically.  It is polycystic ovarian syndrome.  It's almost epidemic proportions in many parts of the southeast and Alabama is no exception.  These are women who have menstrual or ovulatory dysfunction.  They don't have regular cycles, they don't have regular PMS, have difficulty getting pregnant and often have signs of excess male hormones (hair growth, acne, and the inability to get pregnant).  The name comes from polycyst or many cysts on the ovaries.  Fortunately, we have tremendous expertise in this area.  I recently participated in an NIH-sponsored reproductive medicine network trial for PCOS so this is something that we deal with commonly, and most of these women can successfully conceive even when they feel like their hormones are completely out of whack.  
Who needs surgery?  I'm happy to say that we are operating a lot less than we did in the past in that there is evidence that if you do a laparoscope or operate on everyone who has infertility, you have 30-40 surgeries to get one additional baby.  That's a lot of surgery.  Many of us both here and at the leading institutions nationwide and in the world don't recommend routine laparoscopy for everyone.  We've come a long way.  We're very proud of our robotic program at UAB.  I do very large myomectomies and tubal reversals as an outpatient with the robot so surgery is an important part of my practice, but should not be done on everyone suffering from infertility.  Who needs surgery?  Those who have chronic pain, as well as infertility.  Those who have abnormal x-rays.  I mentioned the ultrasounds and the histosalpingogram or x-rays.  Often, in those who simple things have failed and who have no other options before proceeding.  Finally, there is one case where the tubes are very dilated and fill with fluid or hydrosaphinx.  Those women need their tubes removed before doing in vitro fertilization.  Although it seems backwards to remove parts to help with pregnancy, in that case if the tubes are filled with fluid it is actually an inflammatory environment and needs to be addressed before IVF.  So surgery is not for everyone, but surgery really is state of the art for some women and we're very active in that endeavor.  
Who needs IVF?  IVF is in vitro fertilization.  It is really not test tube, but means in glass fertilization.  It is actually done on a petri dish as you see here.  I had two sets of IVF procedures this morning and am thrilled to be part of a program that is experiencing all times success with IVF often with difficult patients.  Those who have few sperm need IVF so we can take a single sperm and inject it into a single egg.  Instead of needing millions of sperm for each egg, we just need one.  Those who have tubal blockage, that was the original IVF (Mary Louise Brown in 1978).  She now has grandchildren so her daughter born from IVF now has her own children.  So more than a million babies have been born worldwide with IVF with very good safety and now tremendous outcome results.  It's not for everyone.  Those who failed simple therapy, have low sperm, or their tubes are not functioning clearly – they need IVF.  There are some cases where genetic testing is required and we're very fortunate to help couples who have a known genetic defect have a healthy, beautiful offspring by testing for their specific genetic issue.  Genetic testing is not designer babies.  We're not cloning.  We're not doing anything that is on the far reaches or is worrisome as a society, but for a couple with a known defect it is revolutionary to help them have a healthy baby.  
In conclusion, I don't mean to stress on age, but we are all getting older and evaluations and treatments should be age sensitive, tailored to individual circumstances.  We really take the individual at heart, take the sensitive and personal nature of fertility and make that a very crucial aspect of our practice.  As a patient you want cutting edge medicine.  You want leaders in the field.  You want those who are training the fertility specialists of tomorrow and I'm very proud of the fact that we're the only fertility fellowship in the state of Alabama and one of only two in the entire southeast.  Those programs are at UAB and Emory.  We are committed to academic excellence, but we're also committed to the personal touch and helping couples achieve their goals of expanding their family.  A specialist is not required initially.  We talked about timing and ways to optimize your fertility, but timing is the key.  As you get older, if things are obviously not normal, seeing a fertility specialist may help you achieve your dream much quicker so don't delay if you're older or have a suspected or known problem.  I very much appreciate and am honored to spend some time with you today.  I want to give you a couple of contact points.  The study I mentioned to you or to get access to our system, I have two wonderful research nurses, Susan and her number is 801-8207, and Leslie is the other.  Some outstanding clinical nurses and I couldn't do my job without them are Pattie and Leann. They would be happy to hear from you if you have further questions or if you'd like to access our ongoing study. 
Let me start with a few questions.  The first one is from Holly on Facebook.  Can certain medications cause infertility in males such as Adderall?  This is a very good question and it really depends on the individual medication.  There is no way to know ultimately without checking a sperm count or doing a semen analysis.  Normal sexual function, normal erectile function, normal libido do not mean that the sperm are healthy.  Again, I recommend a semen analysis.  I will say that it's very concerning that I see many couples where the man is supplementing hormones, usually testosterone through creams, gels, or even injectable pellets.  That has a dramatic negative impact on sperm production.  Hormones do play a role.  General health is important and it's important to be checked early in this process.  
We have a question that says what can you do to prevent Down's syndrome when you're trying to conceive at 40 years of age.  As a woman ages, not only is it harder to get pregnant but you're more likely to have pregnancy complications.  Down's syndrome is three copies of chromosome 21 and is a concern.  If you have a known genetic abnormality, then we can look for that, but chromosomal abnormalities such as Down's that are just associated with age or random it is not recommended that you screen for that as part of preimplantation or genetic testing; however, we do counsel those patients ahead of time and we partner with our colleagues in maternal fetal medicine to ensure that proper testing is offered.  There is no way to completely prevent it.  The rough risk of that is about one in two hundred at 35 and it increases thereafter, but we do everything we can to address that prior to pregnancy and then afterwards as well.  
The next question is does obesity affect fertility in males.  This is from one of our followers on Twitter.  It does.  There is evidence that you have decreased sexual function and a decreased number and quality of sperm.  Just like in the female being as healthy as you can from a weight standpoint, not exposing yourself to tobacco, excess alcohol or illicit drugs.  It's equally important in the male so absolutely male fertility can be decreased by obesity.  
Someone asked about having a fibroid tumor and can it affect pregnancy.  Eight out of ten women have fibroids at some point in their life so it's very common.  Most is after the reproductive years, but removal of fibroids is our most common surgery.  Fibroids are a little bit like going into business.  A business will be successful based on three factors, location, location, location.  A little bit of simplification, but likewise fibroids have the greatest impact on fertility if they distort the uterine cavity.  So with fibroids it's location, location, location, and maybe a little bit size.  We have remove fibroids that entirely filled the abdomen and the woman looked like she was a full term pregnancy or beyond.  I've taken out a single fibroid that weighed 22 lbs.  These are difficult and challenging surgeries and clearly those women have sub-fertility; however, if you have a marble or pea-shaped fibroid but it's sitting right in the endometrial cavity, likewise if you have scar tissue in the lining of the uterus or polyps, which is an overgrowth like polyps in the colon or skin tags, an overgrowth of the uterine lining is a polyp and they are more common in women who don't have regular menstrual cycles.  Anything in the uterine cavity may prevent pregnancy or lead to early miscarriage.  It is absolutely important to have fibroids addressed.  We have come a long way and have made tremendous advances in fibroid surgery.  Women who needed a large incision and three or four days in the hospital and six weeks to recover, now often go home the same day and are fully functioning within one to two weeks.  Robotic myomectomies have really revolutionalized our ability to treat fibroids and fibroids absolutely need to be addressed when they impact the uterine cavity.  
What role if any do anti-sperm antibodies play in fertility?  This is a common question that we see and falls under the category of immune testing.  Antibodies to sperm, you rejecting your partner in some way, are there like cells in your system that attack anything that is of male origin, on and on.  By in large, immune testing has not been shown to increase one's pregnancy rate. Not only my time at UAB, but also my time at Harvard and other places have not done any sperm antibody testing.  Many argue that it may be needed in certain cases – many men have had vasectomy reversals, and those undergoing in vitro fertilization.  By in large, it is a test that is not based on sound, data that is reproducible in multiple labs around the country.  It's not part of our routine testing and it's not generally what I would consider standard of care for fertility treatments, although there may be rare cases where it applied.  I mentioned earlier cytoplastic sperm injection.  Those couples going in for fertility, should you always inject the sperm into the egg or is it okay to do insemination meaning laying the sperm over the egg and let the sperm find it's way.  We do not do XC or CSI (cytoplasmic sperm injection) routinely, but do it specifically tailored to the individual patient.  Likewise, the American Society Reproductive Medicine is working on a physician statement, which is also soon to be released, also says that XC or CSI used for all patients or is it universal part of IVF that is not wanted and is not based on the available evidence.  Those smarter than me, those that are at the lead of our society are saying the injection of sperm is not recommended for all and I would in parallel that to say anti-sperm antibodies does not have a place in the routine evaluation for infertility, although there may be some very rare exceptions.  
A very difficult question that I'll jump to is do you recommend freezing or preserving eggs, embryos, or maybe even ovarian tissue if you're 35 or older?  Fertility preservation is a very exciting part of what we do. We have had grant funding to develop fertility preservation for cancer patients and if you or anyone you know is faced with the diagnosis of cancer and would like to have children in the future, we would love to at least talk with them to address their fertility concerns.  We have a very active fertility preservation program and provide the full gamut of options from freezing of eggs, freezing of embryos, to even freezing ovarian tissue.  They all have their unique roles in the treatment options.  In some women we will also suppress hormone function to in essence try to preserve the egg quality after chemotherapy is complete.  For men and women facing chemotherapy or facing cancer during their reproductive years who might want to have children later or start a family later, we have a very active fertility preservation program with some remarkable success stories.  
The most difficult question is what about declined fertility due to age?  The data is not as impressive.  The research has not shown a clear benefit to freezing eggs at a young age, although it is often done.  We take this on a case by case basis and really try to address the full gamut of a patient's concerns emotionally, physically, ethically, financially, spiritually – treat the whole person. I think in some cases freezing eggs at a young age may be warranted.  I do not think technology is to the point where it should be offered wholesale.  Again, our society still defines egg freezing as experimental and we counsel patients on that fact.  I'm going ahead somewhat and say we don't know. There may be cases where it's justified, but keep in mind the American Society of Reproductive Medicine still considers egg freezing experimental, although I think we're right on the cusps of it being standard of care, but we're not t here yet.  
I'll end with a fairly simple question.   If I have excess facial hair, what kind of doctor or test do I really need?  It's very simple.  The first question is are you interested in pregnancy or not so much, is birth control okay?  Your primary care physician may be adept to handling this, but more often than not it requires someone who is comfortable with endocrinology of women and OB/GYN so I do recommend a woman's healthcare provider for the entry level treatment of excess hair growth.  If you're not trying to get pregnant or contraceptives, or treating underlying insulin or glucose dysfunction, or elevated insulin, pre-diabetes so to speak and then there are specific medications both orally and topically to reduce hair growth.  If a woman desires pregnancy, again getting as healthy as you and with medication could possibly reverse diabetes or pre-diabetes. Losing weight and get ting healthier, and then those women will often need medications to induce ovulation so it really depends on the goal of the treatment, hair growth plus or minus fertility would direct where I went for healthcare.  If this is a longstanding problem, especially if it is associated with infertility, if you spent your life savings on laser, electrolysis hair removal, and your cycles are completely unmanageable and you have difficulty getting pregnant, difficulty managing your weight, it really might behoove you to see a fertility specialist or an endocrinologist, or at least an OB/GYN with expertise in polycystic ovarian syndrome, hirtusism, and the treatment of fertility including advanced fertility.  
We're going to wrap up in a couple of minutes.  I want to thank you for your time here today.  We'd love to be part of the solution and help you on the journey to parenthood and a successful pregnancy we'd like to you to consider being involved in our research if that's proper for you. For women who are unexplained, we have the omigos trial and you can reach Leslie or Susan at 801-8207.  Likewise, I have two outstanding nurses, Addie and Leann, who can be reached at 801-8225 or 801-8201.  We would love to participate in your care if needed.  There is also tremendous information with the American Society of Reproductive Medicine and through the UAB website we can be contacted.   So again, thank you. 
Another question:  What is the age range where healthy sperm production drops off?  In somewhat the cruel, twist of biology, is that female reproduction and successful pregnancies do begin to decline much earlier.  As I mentioned, it is in the late 30s and early 40s.  It becomes quite a challenge in the mid-forties.  It is often not successful.  Men, on the other hand because sperm is constantly remade every two to three months, don't suffer the same ravages of time so to speak and can father children well into the fifth, sixth, or even seventh decade.  There is some decline in sperm quality, but by in large age is not a dramatic issue for men in their thirties, forties, even well into the fifties like it is for women.  It is somewhat cruel and unfortunate, but age is much less of an issue; however, I still absolutely recommend the semen analysis.  I did have questions about the Glucophage and that's the medication, Metformin, that I eluded to that may be useful for women who have pre-diabetes, who have signs of abnormal glucose metabolism.  If you carry all of your weight around your mid-section, we call that truncal obesity and in some it clearly plays a role in predominantly those that have problems with ovulation and pre-diabetes.  A very good question was about ovulation kits.  I don't have any commercial stake in any of them, but many women have commented that reading the urine kits are difficult.  There are computer monitors including Clear Blue that has been shown in at least one study to increase the chance of getting pregnant the first month.  The electronic monitors really play a role.  They help you know your cycle, know when you're ovulating, and is far easier to read than those that you have to try to interpret the two lines, are they the same, and that can be very challenging.  Someone asked are there any other studies or what about holistic treatments?  Shouldn't those questions go hand in hand?  We have a very nice study that is looking at the spiritual aspect of infertility involving focus groups.  One of my colleagues is conducting that and women address their own spirituality, their own Judaea-Christian background, and how fertility struggles deal with that.  It is a very nice way to address the whole person. We are also involved in a study looking at weight loss so even women who don't desire fertility would have polycystic ovarian syndrome, signs of hormone exces and again they could have polycystic ovaries.  On ultrasound, we have a colleague with Dr. Barbara Gower, a very well defined study to help those individuals lose weight and in term we assess what impact that might have on ovarian function.  So women who want to lose weight but don't necessarily want to get pregnant, we offer studies.  We are also looking at the spirituality or faith and how that relates to one's infertility.  And finally, the trial for unexplained infertility that is part of the reproductive medicine network.  It may provide free testing and treatment including insemination for those couples that quality.  Dr. Wellens, one of my colleagues, is looking at the impact that glucose fluctuations and insulin levels on IVF so that's a possibility.  We are partnering with Dr. Holly Richter in Urogynecology to look at the impact of pregnancy on a woman's pelvis, bladder, and pelvic structures.  We have a lot of exciting studies and are proud to work with individuals who are at the cutting forefront of reproductive medicine, and I think that only improves the care we provide in a very personal and sensitive nature.