Infertility to Pregnancy: The Medical Reality

In this episode of Moms, Minds, and Medicine (M3): Inside Maternal Health Research, Dr. Kimberly Turner and Dr. Jerrine Morris delve into the complexities of infertility, discussing its definition, causes, and the impact of age on fertility. They explore the evolution of reproductive technologies, the importance of seeking help, and provide practical advice for couples trying to conceive. The conversation emphasizes the medical nature of infertility and the need for awareness and timely intervention.

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Transcript

Introduction to Moms, Minds, & Medicine: Inside Maternal Health Research

SPEAKER_01 0:00

Hi, I'm Dr. Kimberly Turner, and welcome to Mom's, Minds, and Medicine inside Maternal Health Research. This podcast is your trusted companion on the pregnancy journey, where we break down the latest insights, answer the real questions, and empower you to make informed decisions every step of the way.

Welcome Dr. Jerrine Morris

SPEAKER_01 0:43

And your mind might say, what does infertility have to do with pregnancy? Well, there is some evidence that infertility, once a person is pregnant, puts your pregnancy at a little bit higher risk. So to talk about that, we have a reproductive endocrinologist, Dr. Jereen Morris, joining us, who works for Shady Grow Fertility in a busy practice seeing lots of patients. So welcome.

SPEAKER_00 1:11

Hi everyone. Thank you for that amazing introduction. My name is Jereen Morris, and I'm a reproductive endocrinologist and infertility specialist. I uh work with Shady Grow Fertility and I'm located in the Inner Harbor region of Maryland.

SPEAKER_01 1:26

So you're not too far. We're in Baltimore right now as well. Well, welcome again, and thank you. Um, I have been starting off every episode with us a little bit of background. Many people might not know what a reproductive endocrinologist is. Many people may not even know that OBGYN is a specialty, and you're a subspecialist. Can you talk a little bit about what led you to this point in your career and uh what a reproductive endocrinologist is and does?

SPEAKER_00 1:53

Absolutely. So I uh went to training for obstetrics and gynecology. For me, I was always drawn to treating women. I uh looked at maternal morbidity and mortality as being a driving force of getting me through medicine and wanting to combat that. From there, I saw a number of just differences in terms of how well individuals were able to build their families within the infertility space. I saw individuals who didn't have access to as many resources be less likely to conceive or family build. I saw that people who, you know, wanted to have additional children, often waited at differential paces to uh proceed with an evaluation or an assessment. And so for me, I was really drawn to the patient aspect of infertility care. Once I started to pursue uh, you know, thinking about this space, I found that the medicine behind it, some of which we'll discuss today, is particularly fascinating. So a lot of the technologies in terms of reproductive health come from this space. A lot of the advancements when you look at surgery, when you look at genetics, when you look at just medication management in general, are centralized within this particular subspecialty. The reproductive endocrinology component is centralized around just understanding female reproductive hormones, hormones that are made from the brain, hormones that are made in the ovaries, and how all these hormones impact uh the uterine anatomy. From there, infertility is uh really centralized on helping patients family build. If there is an issue with one's hormones, an issue with uh one's anatomy, or an issue with one's partner, which we see quite commonly as well. My job as an infertility doctor is to identify that issue and best help someone conceive. So, although my my journey has been long, I am so, so thankful I can practice this type of uh medicine.

Understanding Infertility and Its Causes

SPEAKER_01 4:01

And we're so thankful that you are interested in continuing this work. So, can you tell our viewers just what is infertility?

SPEAKER_00 4:11

So, infertility means that when someone is attempting conception with a partner, so we have all of the organs present, uterus, ovaries, and sperm, and they are unable to achieve a live birth after 12 months of attempting pregnancy.

SPEAKER_01 4:29

Okay.

SPEAKER_00 4:30

That's the basic definition. And uh I believe it's 2023, ASRM expanded this definition to also include someone who needs an organ or a um something that's missing in terms of gametes. If someone needs donor sperm to conceive, they are considered infertile. If someone needs donor eggs to conceive, they are considered infertile. And if someone does not have a uterus, they are also considered infertile.

SPEAKER_01 4:58

Oh, that's so interesting. What is ASRM? For those who may not know.

SPEAKER_00 5:03

ASRM is the American Society for Reproductive Medicine, and this is our governing body. These are the very brilliant uh change makers and policymakers in the field who often review the literature and make recommendations based on the literature so we can best, you know, take care of our patients.

SPEAKER_01 5:23

Okay. In reviewing this, because my clinical medicine years ended a couple of years ago, in reviewing this, I was reminded that the first in vitro baby occurred in 1978. And I don't know if you were alive then. I was. What's that? Um okay. Um, can you go over a little bit of the history? I know the advances are more than we can cover today, but the history of how that came about and what's happening now in this space.

SPEAKER_00 5:53

Absolutely. In terms of high-level overview, we noticed that you can use hormones to manipulate how many eggs are released from the ovary. And by using hormones to manipulate this, ultimately increase or improve one's chance of having a child. Ovulation induction was really the forefront of this. So using hormone medication to help with ovulation. From there, we noted that you can use a number of procedures to retrieve or remove eggs from the ovaries prior to ovulation to best help fertilization occur in the lab. And so when you look at IVF, it's hormone manipulation to start and then finding a way to bring the eggs and the sperm together in an artificial situation, artificial scenario in the lab to create embryos. Finally, placing an embryo into someone's uterus really can bypass different anatomical challenges or distortions. And that's another aspect of IVF. Since uh 1978, a lot of things have changed. So we're not removing one egg out of a time, usually. We're a little bit more aggressive with the medication. So patients can ultimately have lots of eggs that develop. We're able to create multiple embryos in the lab, hopefully, if that's within the patient's capacity. We're now able to utilize genetics, so testing of embryos to identify either the healthier embryo in terms of number of chromosomes or eliminate some common conditions like sickle cell disease seen in the population. And uh, we're now able to freeze gametes, whether that's egg cells or sperm cells, but namely thinking about freezing egg cells with the purposes of reproducing, hopefully, in the future.

SPEAKER_01 7:55

Great. So you did say IVF, just to clarify for those that are not familiar with uh all of these acronyms. That's in vitro fertilization, and as you said, trying to get eggs out of a woman, biologic woman, trying to get sperm and potentially putting them together and back into the uterus. Is that accurate?

SPEAKER_00 8:19

That is accurate. IVF uh is in vitro fertilization, or in vitro just means lab fertilization, egg and sperm coming together in the lab. There are a number of procedures that we attempted in the past, uh, putting egg cells and sperm cells together in the tube, or you know, trying to manipulate the process so it's less laboratory-based. But we do find that with uh IVF as we know of now, taking eggs from someone with ovaries, taking sperm cells from someone with testes, putting them together in the lab and creating an embryo typically yields the highest chance of success.

SPEAKER_01 9:02

Okay. Okay. So you also talked a little bit in your introduction about uh families that wait a little bit of time between children having problems. That makes me think that maybe it's something to do with age. So is it the age of the mother? We're hearing a lot in the TikTok world about age of the father. My 26-year-old called me about eight, is my age? Am I too old? What is happening right now? And he's 26, by the way, so it's not um what's happening right now with age and what do women do if they're aging and they still want children? Or what do people do? Excuse me.

SPEAKER_00 9:42

That's a great question, a loaded question, but a great question. Age is very impactful for human fertility. I start consults by addressing that. When you look back to the 1900s, 1950s, 1970s, we were not as a human population waiting as long to family build. You saw families that were larger, you saw the age of having one's first child as being younger. So thinking about that contribution to infertility that wasn't at the forefront of our minds. Now, as we have patients who are waiting longer for whatever reason to identify the ideal partner, to become career physicians like we are, et cetera, there are a number of reasons patients are not ready to family build, but keep in mind biology still hasn't changed. To that extent, when you have an egg, uh women, so individuals born with ovaries, born with eggs, have all the eggs they'll ever have throughout their lifetime at birth, the number decreases with time. The quality also decreases with time because those eggs have been sitting there. And the way I like to think about it is as you're getting older, yes, you are growing more wisdom, but you're also more susceptible to other things, disorders like cancer, hypertension, etc. The eggs are no different. They are susceptible to genetic abnormalities. That means that when you release an egg per month, as we get older, you're more likely to release an egg that is unhealthy, that is not capable of being fertilized. When you think back to older generations, you're not seeing a lot of individuals who conceived for the first time in their 40s.

SPEAKER_01 11:39

That's right.

SPEAKER_00 11:40

You're seeing people who conceive a lot easier in their 20s.

The Impact of Age on Fertility

SPEAKER_00 11:44

Yes. So the definition of infertility, while there is a blanket definition, and I'm sure we'll discuss this a little later, there's a time frame for which you can try to conceive, and if you're unsuccessful, you should present for an evaluation, and this is denoted based on age.

unknown 12:03

Okay.

SPEAKER_00 12:04

If you're under 35, you can uh wait till up to a year, as I mentioned. If you're 35 and older, however, the recommendation is to undergo an assessment for infertility at six months. And that's because we recognize the impact of aging on egg health and egg quality and how challenging it can be to combat that aging.

SPEAKER_01 12:27

Yes. Okay. And what is the age for men? Is there such an age?

SPEAKER_00 12:31

Ah, I love that question. So men are a little different. They're constantly producing sperm cells throughout the course of their lifetime. And so it's not uncommon to hear someone in their 70s, especially when you look at entertainment industry, someone in their 70s having a child for the first time. Now, admittedly, you don't know the details. So once again, salt. But it is easier for men to conceive at older ages. With that said, we're now realizing paternal age can be impactful as well. That's starting at the age of 40. We are seeing poor sperm quality, a higher risk of different neurodevelopmental disorders and things like autism, schizophrenia. And that is similarly linked to paternal age. So we talked about what infertility is. What causes it besides age?

SPEAKER_01 13:26

What causes it?

SPEAKER_00 13:28

That's a great question. So when we think about causes of infertility, there are so many causes. It's hard to really, you know, narrow down a list, but I always like to think about the organ system. So you have eggs. Whether or not you're releasing eggs, that's a cause of infertility. It's ovulation disorders. Okay. We talked about a quality being linked to eggs, and that is a cause of infertility. So as we get older, it's more challenging. Over and reserve can be linked to infertility, particularly if the egg count is low. We don't ordinarily say diminished reserve in itself is a cause of infertility, but if the egg count is so low that you're skipping menstrual cycles, that is now a cause of your ovulation-related infertility. Then if I move on to looking at the uterus, if you have large fibroids in the lining of the uterus, a large endometrial polyp, something in the uterine cavity that could prevent implantation, that would be a cause. When we looked at the fallopian tubes, if they're blocked, that is uh going to prevent the sperm and the egg from meeting. So that is another cause of infertility.

SPEAKER_01 14:44

Okay.

SPEAKER_00 14:45

Finally, on the you know, the male end, when we think about sperm cells, if someone has uh something like a varicacyl, which is blood uh that's pooling in the testicle, that can decrease sperm quality. It can decrease the concentration, the motility, and be a cause of infertility.

unknown 15:06

Okay.

SPEAKER_00 15:07

Now, more broadly, conditions that can affect both men and women are genetics. And so I always ask patients to, you know, what did your parents go through? Did they say it was really tough to get pregnant with you? Did they experience recurrent losses before they had you? Then we start to think about is there a genetic underpinning to why the couple's not getting pregnant?

SPEAKER_01 15:31

Okay.

SPEAKER_00 15:32

And how do you test for that?

SPEAKER_01 15:34

Oh, I'm sorry.

SPEAKER_00 15:36

I'll continue with thought and then I'll ask answer how to test for genetic related conditions. But finally, you know, it has to be underscored the importance of different lifestyle factors and their contribution or contribution, I should say, to infertility. So if I have someone who's engaging in lots of tobacco use, alcohol use, tobacco, also including vaping, if I have someone using illicit substances, marijuana use, even if approved with a marijuana card, all of these factors can contribute both to female and male infertility. I don't usually describe it as that's the sole cause, because yes, we do see patients who engage who are able to conceive, but that is not helping. And so those are both factors that can contribute as well. To answer your question about genetics, I genetics is tough because there are genetic conditions that we can test for through a blood test. Some of these tests will test for the number of chromosomes, some will test for the shape of the chromosome. But a lot of things that are genetic are just not discovered yet. They're not well known. And so if you have a strong family history, but we don't have a blood test that picks up on your condition, it still can be something genetic, just not necessarily something that we have a clear genetic, you know, test for at that time.

SPEAKER_01 17:03

Okay. So if I'm 30 years old, I'm not. If I was 30, or when I was 30 years old, if I was having a problem and I was in a heterosexual partnered relationship, who should I see first? Should I go see my primary care doctor? Should I go see you right away? And at what age or what conditions does that change?

SPEAKER_00 17:27

That's a great question. I would say at 30, it's reasonable to follow with your OBGYN doctor or primary care doctor. I tend to rely on my OBGYN colleagues a lot because the evaluation for infertility is fairly standard. Um, whether you see me or your OBGYN, both of us can order the tests. And oftentimes insurance may um uh require you have a referral from your OBGYN to even see me as a subspecialist. So do keep that in mind uh in terms of covering the visit. If patients wanted to see me first without seeing their OBGYN, or if I've actually found a lot in my practice patients don't have an OBGYN, you can also terrible. Yes. Um, but I do find that, you know, if you're otherwise young and healthy and you don't have an immediate need for um any testing or PEP, et cetera, that's not uncommon for patients not to have an OBGYN or PCP or primary care doctor. And so I'm comfortable seeing patients who haven't had an assessment at all. Between 35 to 39, you know, it's reasonable to go with either, although you really want to make sure you're seeing an infertility specialist or at least undergoing the assessment after six months of attempting. At the age of 40, because treatment uh treatment success rates do tend to decrease quite dramatically, it wouldn't be uncommon and it would probably be encouraged to consider seeing an endocrinology specialist like myself at the outset. Um, some patients, even after only three months of trying to conceive, will undergo an assessment with an infertility doctor instead of waiting the full six months or instead of seeing an OBGYM. Got it.

SPEAKER_01 19:20

Is

Counseling for Couples Trying to Conceive

SPEAKER_01 19:21

there anything special that you counsel couples to do when they're trying to conceive? In terms of timing and you we talked a little bit about abstaining from alcohol, tobacco, that type of thing. Anything else?

SPEAKER_00 19:36

That's such a great question. I am a minimalist. I usually counsel on regular intimorse. And we are, as you mentioned earlier, in the area of TikTok and all these things where you're getting a lot of information uh from social media, which a lot of it can be accurate. It's just it's very nuanced. Getting pregnant or trying to get pregnant can be challenging, it can be stressful. And so I don't tend to recommend doing much else than having regular intercourse. And by regular, I mean every three days.

SPEAKER_01 20:14

Okay.

SPEAKER_00 20:16

To add a little bit more nuance to it, there are a few things you can consider. One is at minimum tracking your cycles. This way you have a better idea of how frequently you're getting the onset of menses. Are you noticing any other symptoms along with it? Lots of pain, heavy bleeding, uh, presence of clots. Are you noticing spotting before period? Uh, prolonged spotting afterwards, spotting after intercourse. These are things that, if you don't conceive, will be helpful for a clinician in terms of thinking about you as an individual and why you're not getting pregnant.

SPEAKER_01 20:56

Right.

SPEAKER_00 20:57

I also will recommend looking at an app if you have it and looking at that fertile window and then looking at when your predicted menses should occur next. If the app is able to predict that, then that tells me that the fertile window that they're anticipating is probably correct. And so if you can't have intercourse every three days, then trying to maximize it during that predicted window, as long as the app has shown pretty good predictions in the past, is helpful.

unknown 21:30

Okay.

SPEAKER_00 21:32

Finally, for couples that um have shift work where they don't see each other as frequently and it can be really challenging to have regular intercourse. I recommend ovulation predictor kits. There's no one kit that's the best, but you can use a kit to optimize when you're having intercourse if you're only able to have limited attempts.

Incidence of Infertility and Age-Related Risks

SPEAKER_01 21:56

Okay. Okay. Yeah. Once I I I used to think, especially in clinical, that once it got to um really concentrating on those five days where you're fertile, it starts getting stressful even from then. So thank you for that. We've talked about the definition, the causes. What about the incidence? How common is this? Seems like everybody's pregnant sometimes. How common is infertility?

SPEAKER_00 22:26

I would say infertility is quite common in the general population. You're looking at about 12%, but I think the challenge with that definition is uh when you look at the one in eight couples, it's not taking into account age. It's certainly going to be more common if you're older. And so if I have uh someone who's coming to me in their 40s, I'm going to say most patients in their 40s who are trying to conceive are going to have difficulty as compared to someone who's in their early to mid-20s.

unknown 22:56

Okay.

SPEAKER_01 22:57

That's a staggering thing. And I I often found that was really difficult to discuss because people that are 40 are still young. Many of them are still quite healthy, having regular periods. And they don't understand how what you've already explained about the eggs and the quality of the eggs. So what happens if I do conceive at 40? Is that more dangerous?

SPEAKER_00 23:20

It's a great question. The long and short of it is yes and no. Um conception, as we get older, there are different conditions that are just more prevalent. Preeclampsia, which is high blood pressure in pregnancy, diabetes in pregnancy, preterm delivery, these are all more common in individuals who are older and they conceive. But also, we have to keep in mind that as we age, there are other comorbidities that we're just more likely to have had, which then will impact your risk of more adverse outcomes in pregnancy. So while you may feel great, you may feel that you're at your youngest, you may feel like you're still 20, your body probably isn't feeling the same. When you think about your blood vessels, when you think about, you know, insulin sensitivity and how you know food is processed, you are not the same as you were at 20, at 40. And that is definitely going to be reflected in terms of obstetric complications. Uh fortunately, I think the ACOG, which is, you know, our Congress in terms of obstetricians and gynecologists and their guidance on pregnancy, they are very clear that at 35, you should start initiating additional testing during pregnancy to make sure that if you are at risk for any of these conditions, that they're being identified and being treated appropriately.

unknown 24:48

Sure.

SPEAKER_01 24:49

Anything to wrap up our first part of this, that's a take-home message. I know that I've learned that 40 is advanced paternal age. That was maybe not the case when I was still practicing. What else do we want to drive home to the viewers?

SPEAKER_00 25:07

Yeah, the big thing that I want to drive home is infertility is a disease. This is a medical condition, not dissimilar to high blood pressure, not dissimilar to cancer. It is stressful to be infertile. Anyone who is attempting pregnancy and is unsuccessful should undergo an assessment from someone. So who you feel comfortable with is not as important as that you go to someone and be heard regarding the fact that you have proceeded along this journey and has been unsuccessful.

SPEAKER_01 25:42

Okay.

SPEAKER_00 25:44

I think that the older we get, it gets more challenging. And so as you have been trying to conceive and you're of an older age, 35 plus, make sure that you're being thoughtful about seeking this evaluation sooner. Finally, if there's anything in your history that you know is unique, something about your periods being painful, being told that you have fibroids, having irregular cycles, being told you had PCOS. If there's anything about you that is unique or different, or that you've been told in the past, consider undergoing this assessment sooner.

SPEAKER_01 26:25

Okay.

Conclusion and Future Topics

SPEAKER_01 26:26

So we're going to talk a little bit more about some of those conditions, the particularly the PCOS, polycystic ovarian syndrome, um, at a later episode. So we're so grateful for your time and expertise, and you're making it plain for our viewers. So thank you so much, Dr. Mars. Absolutely. Thank you for having me.