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Speaker 2Hello, this is Dr. Karen obedient from the fertility center of Las Vegas. Who's seen another episode of fertility docs on censored with my two good delightful colleagues and friends, Dr. Susan Hudson from Texas fertility center and Dr. Abby Ablin from Nashville
Speaker 3Fertility center. Hi everybody. What's
Speaker 2New? Anything
Speaker 3Fun ? Well, I don't know about Susan, but I'm getting ready for spring for one. Um, and I was just talking about with you guys just a minute ago about, you know, now that Christmas is over and all the Christmas cards have been said, you know, that's the only time I ever really mail anything out to people anymore. I never write anything down or if I do it's a text or an email or something, but I was just saying that I just got a letter from one of my mentors in , she helped me through fellowship . She actually became my fertility doctor for short period of time , um, in , in a cinder Christmas cards every year. And my kids are now in their teens, but they were both IVF babies and she helped me with getting pregnant with them. And so I sort of just like a lot of our patients, I like to send her updates on what we're doing and what they're doing and how , you know, what they look like and all that. And so just out of the blue, about a week or so ago, I got a letter and I saw her name on the outside of the envelope. And I'm like, what? I was just shocked. I didn't, I was like, why would she be sending me a letter? So I opened it up and it was the sweetest, like two-page little letter. And she filled me in on her family and what was going on with her that she's retiring and just started talking about, you know, the times that I was there and fellowship. And, and the early times when I was there as a, as a young attending and what good times that she had, and she really missed me and just said some really nice things. And, you know, it was such unexpected kind words. I, I was telling Carrie and Susan, I had to shut the door cause I was kind of in tears. It just, it hit me. I'm like, it was so sweet and that , that literally just made my week, you know, for her. And actually she mentioned our podcast. She knew about our, or she, I had mentioned in my Christmas card that we were doing a podcast and she had tuned in. She goes, well , I hope your podcast goes well. And so it just , it just was so sweet and it just really brought to the forefront about how words really can make a big difference, whether it's from somebody in your own household, whether it's from your friend, whether it's from your doctor, it's just amazing how words can make such a big difference. And, you know, the way, the way that you talk to people. And, and I always have to remind myself about when I'm talking to patients that, you know, particularly that somebody that I think has a really good prognosis. I usually like to tell them that if they, and I used to like easily , like to say, you know, I don't know if you're going to get pregnant, but I think, you know, if I had to guess you have a really good chance and you know, it's amazing how many times that really uplifts people and they'll make a comment about, oh, well, gosh, that's the best news we've heard, you know, in a , in a, and so I think we, as physicians have to be really good at trying to encourage our patients and encourage the people around us, to you guys. What are your thoughts on that?
Speaker 4I think, I think that's good advice for all of society right now. I mean, I think that , um, generally we have become relatively loose with words and, you know, we don't necessarily pay attention to all of them. And especially now that everybody is so much more distanced and hopefully we'll , we'll all be getting together again soon, but the immunizations and things like that. But you know, when, when you do have those chances to have those conversations, you know, whether it's professionally or personally , um, words matter and how, what the , how the word sounds matter as well.
Speaker 2Uh, in my office, I have a little, you know, standing cabinet for where I am my scrubs and where I hang my clothes when I change them scrubs and those types of things. And on the back of that door, cause I can no longer display everything because of HIPAA . I have , um , every single card that any patient has written me since I've been an attending. And so now it's like a couple layers deep, but I need to actually start thinking about getting organized and like buying , um, uh, an album to talk them all in. But those, those things are important. And , and especially from the perspective of , um, what we do, I mean, there, there have been days and , and whole weeks that have been rescued by, by getting a card from a patient or an email or something like that because , um,
Speaker 3Some weeks can be pretty tough in our field. Can't they, some weeks it seems like nothing seems to go right for anybody. And just , you feel just beaten down at the end of the week.
Speaker 2Um , and I had a patient who I called with, you know, really pretty bad news, but it was news that both of us were expecting. And she, she was just so appreciative and so thankful. And she was like, thank you for treating me so well, you know, I know that this was a long shot and she knew coming in, but , um, but that made a huge day. And I was like, okay. And that got me through the next several days, which happened to be just a miserable week for , for helping people. Um, and, and those, those things make a difference because the, the amount of, you know, abuse that we take and that we see and the amount of just hardship that we see sadness that we are a party to is , um, it's a lot. And so those, those words are important, whichever direction they're flowing to us , you know , all of it's . It's good. So, all right . So our question this week, we actually decided that we were just going to turn the whole episode into this question. Um, and so the question is, what are your thoughts of using donor egg or donor embryo or embryo adoption , um, for a woman to get pregnant after 45? Um, what are the chances of success in getting pregnant and are the factors impacting success? So we kind of decided to turn the whole episode into this cause it's, it's a good question. It's a very relevant question for a lot of our patients. So let's , um, let's just take it bit by bit. And so Abby, what do you think about just overall, what are the chances of a woman 45 or older getting pregnant?
Speaker 3Well, like you said, in a previous episode, you know, we, we see miracles in our field, but we don't see them often. And, you know, if you really want the best chance of getting pregnant, if you're 45 or older, it's really going to have to be with donor eggs or donor embryos. You know, we , we all know that person in our church or in our community or who we were growing up that had her 10th kid when she was, you know , 47 or 48. And there's, there are those people out there. I mean, they do exist, but it, you know, and I don't know the exact statistic, but I would say it's probably in the fifth percentile of all women at that age that are trying, you know, they're able to get pregnant, they're having sex and have a partner that produces sperm very, very low percentage. And it's usually not their first pregnancy. It's usually their , you know, double digit pregnancy or their sixth or seventh or whatever. I mean, it's not something that usually people get pregnant the first time over 45. So I would really say, you know, it's not impossible, but it's almost impossible, less than 1% chance at 45 that you're going to get pregnant using your own eggs. Unfortunately. So
Speaker 2Susan, why is
Speaker 4W why is that? Oh, well, first of all, I'll get to the white is that this is me getting on my soapbox a little bit. I think this is one of the places in the media that has hurt.
Speaker 3Let me just say an amen. I'm shaking my head up and down really hard. So I'm going to say, amen. I agree with what you're about to say
Speaker 4That has hurt women in American society, more than probably almost anything else in the last, like two decades is this false conception of that
Speaker 3Misconception misconception
Speaker 4That ovarian aging is not real in that. Um, you know, all these famous people are getting pregnant spontaneously after the age of 45. And what I tell my patients is here are the statistics, which are very, very small. As Abby mentioned, multiply that times, the likelihood of becoming that famous, I would say nine times out of 10, those people are not giving you the entire truth.
Speaker 3It's their prerogative. It's none of our businesses
Speaker 4And it is totally their progress. But the thought of getting spontaneously pregnant at 47 or 51 or whatever it is in that age group, it is not likely to happen and expecting that to be somebody's individual reality is, is so hurtful is so hurtful. And my heart goes out to my patients that come in to me and they're like, well , we're ready to get pregnant. And I'm 46. And I'm like, Ooh , we need to talk so onto that. We need to talk what exactly happens with eggs . So when baby girls are in their mama's tummies, they have about 3 million eggs. By the time they're born, they're down to about a million. By the time they go through puberty, they're down to about 300,000. The average woman is going to opulate about 450 eggs in a lifetime. The rest of those eggs in the ovaries are going to go through something called a Trecia or program cell death. They're just going to kind of disappear the rate at which they disappear. Usually significantly increases in the upper thirties and early forties. So by the time you get to your mid forties, even though you're having periods every month, you don't have a lot of eggs. Now, even when a woman goes through menopause, the average age of menopause is 51. Most women have about a thousand eggs. So even when you think you're completely out, you're not completely out, but we have issues with not only quantity, but we also have quality. So your eggs have technically been around for a year longer than you have. And as time goes on, they become very, very fragile and carry what happens when they become fragile. So
Speaker 2The eggs contain all of the chromosomes that you're going to , or genetic material that you're going to pass on to your babies. And what happens is they contain a, you know , more or less duplicate set of the chromosomes that you have as mama and half of them get jettisoned because you need to make room for the other half coming from this from and for whoever's, you know , providing sperm and , and it's gonna fill in that gap. Um, but what happens is that over 40, some odd years, there is no mechanic inside those little eggs oil , that machinery. And so like any piece of machinery that, that is not tended to it doesn't function as well. So the brain is an and the , the program that's supposed to happen is that all right , these little chromosomes divide up so that you've got a pair of, for example, the number one chromosome half is supposed to go to each side so that the other half can then come from who's ever providing sperm. Well, those two chromosomes have been best girlfriends for now, well, over 40 years and they get the instructions you need to separate. And they promptly say, screw you we're best friends, we're sticking together. And so what happens is that you are more prone to getting too many or too few chromosomes. And the body is really well program to say, if this pregnancy isn't going to work from the outset, we're just not going to play. And that can mean a negative pregnancy test. That can mean a very early miscarriage. That can mean an aneuploid embryo, if you're going through IVF ,
Speaker 4Um, what is an annual plant embryo?
Speaker 2So aneuploid is where the chromosome number is too many or too few. And, and that's really important because pregnancy is a risky thing for the body to do. And so if it's , if it's not going to work from the beginning and the body's life we're out, and it won't support that embryo to grow , um, and the embryo itself won't grow.
Speaker 3So , so a lot of questions we also get are , so what can I do then to make new eggs or make my eggs better, or, you know, I'm healthy. Um , I exercise frequently. I eat really well. Is that going to help my eggs? And probably we would all agree on this, that unfortunately, it's one of those things, just like aging. There's nothing you can do about it. We don't think that at least there's not strong data to show that anything really makes a significant difference there ,
Speaker 4Especially in the age group we're taught specifically talking about today,
Speaker 3The
Speaker 245 and older, for sure. It's a ,
Speaker 3The age group . Yeah. And so we think that, you know, there's probably not much, you know, certainly it's good to be healthy. I mean, if you want to carry a pregnancy, it's good to be healthy. It's good to be a normal weight. It's good to eat well, but that's probably going to not help your eggs. Because really when we talk about the 45 and older group, it's really the eggs and the ovaries that are the problem for most of the women, the uterus is fine. Most likely you can carry a pregnancy. We don't think there's a big problem with that, but it's just actually the genetic material in your eggs. And we know from data through in vitro fertilization, that if we genetically test embryos from women at 41, it's going to take about, about 90% of those embryos are genetically abnormal. Um , by 42, something like it takes, we have to retrieve or get 24 eggs to find one that's genetically normal in a 42 year old. So like Kerry was mentioning earlier, that's really the genetic issue with the eggs. They're really the big problem. It's not carrying the pregnancy or delivering the pregnancy, but Susan, what would you say about pregnancy and delivery in a 45 year old or somebody that's older than 45?
Speaker 4So now most women who are over 45 and in generally, and I think in most clinics , um, even when we're talking about using things like donor egg or donor embryo, there is a general upper limit. So in that 45 to 55 ish range , um, younger , exactly, we do know that there are, are, are increased risks in pregnancy . So there are increased risks of cardiac events, so heart issues. And so your Dr. May recommend you to get a cardiac clearance before , um , going forward with pregnancy, there is an increased risk of preeclampsia or blood pressure issues in pregnancy. There's an increased risk of diabetes and pregnancy, and all these things are even healthy, upper forties people. So please just because you're healthy, doesn't mean that these things can't or won't happen, but it's still good
Speaker 3To be healthy though. And it's still good to be ignoring your body weight
Speaker 2Better if you healthy going
Speaker 4In . We don't, we don't want to add on things exactly that , um, increased risk of preterm delivery. Um, mainly cause of some of those complications that we were already talking about, increased risk of C-section. Um, and so it's, it's not without risks now. Like I said, most people are going to be fine. You get your good medical care, you go see your OB-GYN. You'll probably be followed by a maternal fetal medicine doctor, but, but it is a higher risk pregnancy as compared to somebody who may be 10 years younger.
Speaker 2So how can you, how can you approach if you're 45 years or older and we have all pretty much just said, okay, your chances of getting pregnant with your own eggs are 1% or less due to just the realities of biology, no matter how young beautiful and in , in shape you are. And that is, I mean, I think all three of us, I know I personally have seen women who are over the age of 45, who look 10 years younger than I do, and who can run farther faster and who are just gorgeous. And unfortunately, none of those things matter about the end quality. Like it just, it is, it is that how biology works. But so if you've got somebody who's in that group of a, less than 1% chance of success, what do you tell them? Do you tell them, oh, geez . You know, Sol, I'm sorry. Or, or what can we offer them?
Speaker 3Well, I think for some of those patients, even though you've just given statistics that I absolutely agree with some of those patients just emotionally have a really hard time accepting that. And so, you know, honestly I give them the statistics I've talked to him about the, you know, the chances, but I will say in a lot of those situations, I'll have somebody say, well, let me just try it . Cause you know, kind of deep down, we all feel like we're going to be the exception to the rule. And so sometimes, you know, I say, okay, if you want to try for a few months, two or three months, let's just try it, see what happens. And more times than not the great majority of times, it doesn't work effectively. And so usually at that point, that's when we really get serious about talking about using either donated embryos. So an embryo would be , um, something that was created from another woman's egg and another man's sperm , um, that embryo was created. And then we would prepare the uterus with estrogen to thicken the lining up and with progesterone to help the pregnancy implant. Um, and we would transfer that embryo in. So that would be an embryo that wouldn't be biologically related. Um, the other possibility would be that we would take a donated egg from a different woman. And then depending on what that person's situation was, if they were, if they had a male partner, then we could use the partner, sperm, create an embryo that would biologically be linked to him. Um, and you would still be able to carry the pregnancy. So with either one of those two options, donor egg, or donor embryo, as the female partner in that situation, you would still be able to carry the pregnancy, deliver the pregnancy , um , breastfeed the child , um, and you know, still be able to do all the things that you know, people really think is cool about motherhood. Um, with the exception of having the biologic component and for some people that's , they don't want that, but for other people they say, you know, it's really important for me to raise a child together with my partner. And that's the thing I'm more focused on and it's disappointing that I can't have a biologic connection, but I'm okay with, you know, being able to carry and deliver the pregnancy .
Speaker 2So Susan, what are the pros and cons of using an actor?
Speaker 4So pros effect donors is they , um , and when I say egg donor, I'm going to be right now referring to anonymous egg donors. Um, cause that is what is most common in the United States. I think all of us work with some known egg donors, but for the most part, we mainly work with the dominant anonymous egg donors is that they generally tend to be younger. So they're usually less than 32 . Most of them are in their twenties. Um, they produce more eggs. Um, you get to you, if you have a male partner who has sperm, you can have a child that is at least has half biologic ties. Um, you get to have, I think you can be a little bit pickier when it comes to what I would consider demographics, you know, height, weight, hair, color, eye, color, ethnic background, educational background, medical history , um, because there's more of them , um, as compared to embryo donation. Um, so there there's, there's, there's a little bit, like I said, more, you can be a little pickier about what you're potentially looking for. Um, you have the option of fresh versus frozen eggs. So, you know, you can buy eggs through an egg bank , um, that have already been procured. That's becoming more and more common. Um, though I do think most clinics still have some access to a fresh donor pool where you would choose a donor who would then go through and they would freshly create embryos. So I think those are kind of the big advantages of what I would consider egg donation over embryo donation.
Speaker 2So embryo donation is a different ball of wax. It is a couple who has already created embryos that they have been said, our family is complete. We are done. We want to give these embryos to another family to help build their own family. And so the advantage of this is that all the hard work has, has been done. There's already, eggs are already out. Embryos are already created, they're already frozen, they're ready and waiting to go. And so that is the, probably the biggest benefit of embryo donation now and costs and costs because a lot of those costs have already been absorbed by the couple and while pretty much every clinic, you know, still has the fee for preparing the uterus and all of those types of things, we have to do FDA testing. So all of that covers that, you know, nobody is getting paid for embryo donation in the sense that you're not paying that other couple for their embryo. You're, they're donating it. And you are paying for the services of, of doing the FDA screening and doing the , the testing and the preparation for a couple. At least that's how it works in our clinic.
Speaker 4I would say it depends on how, how the system works. So I , I have kind of two levels of experience. We at TFC have an embryo donation program. And then I have worked with patients who have purchased embryos from embryo donation charities or nonprofits and those types of things. So my experience with those is that generally embryos costs between one to $2,000 per embryo. And you have to go through a selection process , um , that is similar to adoption where you create a portfolio and you have to be selected at home study and different things like that. Um, our process at our clinic, we have our own embryo donation program and we actually make it much more transactional. It's essentially you can purchase two embryos in a frozen embryo transfer. Now we usually transfer one embryo at a time. Yeah. That's kind of how our packages and it's, without all that other drama per se, I it's, it's a very nice situation, but the do pay for the embryos
Speaker 2For the embryos, but it's not as though, but in most cases you're not with any kind of egg donation or embryo donation you are paying for what allows it to happen. It's not like you're going to somebody and saying, you know, I'm going to give you X dollars to, to give us this. It's you're paying for, you know, in the case of the nonprofits or clinics, like, you know, you're just those fees just about cover the storage, the maintenance, the tests that are required. Like it is not really a , there's no profit generation for anybody on that. But when you're using those embryos, you don't get to choose a whole heck of a lot because those, those embryos are scarce. And , um, it's not like you can say, oh, I really want a woman. Who's five, 10 to six feet tall. And , and if everything they've got is women who are five, four or five, five, like that's , that's what you got. Um, there's no, there's no selection. It's just, these embryos are created. They may or may not be genetically tested. They may or may not be from a woman who is young. In many cases, they're from women who are in their mid to late thirties, sometimes forties. Um, there's just a lot more of, this is what we have. So if you want it, here you go. But , um, but you don't really get a whole lot of choice and it's not like there's an unlimited supply either. Not that there's ever an unlimited supply of embryos. Um, but, but if this couple created X number and there's only two left or there's only one left, once you get
Speaker 3One other point I wanted to bring up too , before we finish is, you know, it's really interesting over the course of my career, the genetic component and the genetic issue has really changed or at least what we talk to patients about now. Um, when I first started out, that was way before 23 and me and way before , um, you know , being able to find out biology and, you know, at the time I will say when I started out early on, I would say that a lot of couples said, oh, we're never going to tell the child, well , you know, this is a secret that we're going to keep. And of course I'm sure pretty much every fertility center then, and now did, you know, implications counseling where we had, you talked to a counselor about what are the implications of having a baby that's not biologically yours or biological your husband's . Um, and you know, I think a lot of people, particularly in certain situations just decided it was probably easiest and best to keep that secret. Although we have always counseled, it's probably best not to have big family secrets. And I think now it's really, you know, 23 and me, and just the genetics that we're able to do have really opened up a can of worms that nobody could have ever anticipated 15 or 20 years ago. And so, you know, if you guys have done that, you know that, you know, if you did 23 in may and your sister did 23 in may, or one of the other genetics groups out there that, that do that kind of testing, you don't come up and show that your first degree relatives, your major has a mother, father, brother, sister of this person. And so the way we counsel patients now has changed dramatically because there really are no secrets left anymore in the genetics world. And who knows what's going to be out there, you know, when your child grows up 10 or 15 years from now, or 15 or 20 years, who knows what, they'll probably be able to come up with pictures of relatives and things that they can't come up with now. And so, you know, I think like anything we do, it's good to be transparent early on, let your child know early on. We really wanted to have you. And we went through all these steps. And even though I may not be your biological mother, I really wanted you, or I wouldn't have done all this, you know, and I think there's ways to do that, where it just becomes part of your family history and their family history. And it's not that big of a deal if you , you know , think about that and talk about that with your child really early on.
Speaker 4Absolutely. I think there is , and to kind of, to , um, make this come full circle, also understand that these options that we're talking about are not necessarily going to be the right options for everybody and what may be the right option for you right now may not be the right option for you in a couple years from now . So, you know, I want people listening that if you listen to this and you're like, oh, I would never choose donor. I would never choose donor embryo. And that's where you are. It's okay. And we all very much respect that opinion, but also, no , we are not going to cast any judgment if a year or two down the road, you're like, okay, we're ready. We're , we're just happy to see you. We're happy to help you. And , and we want to help you on your personal journey.
Speaker 2And when we bring up , um, I've had patients who have been really offended in the past because other docs have said, you really should go with a donor egg or donor embryo when we're offering those, those options. Most of the time, it's just to make sure, you know, everything that's out there because a lot of people haven't ever considered that they haven't, or they haven't ever considered it for them. And, and really what we're trying to do is just make sure, you know, your options and your well counsel , because if you want to try the , the mode of success that gives you just a couple of percentage points, you know, that's, that's your prerogative. You know, we, we make sure, you know, okay, what we're doing may not have a high likelihood of success, but if you got to try and you got to try and, and so it's never something personal and it's, and I've had patients who have been really offended at their prior docs of, well, how could they do this? They didn't, they didn't even examine me. They just looked at my birthday. Well , you know, there's, there's some truth to that and it's never meant to be offensive. It's just, you came to us to help, help you get pregnant. And so that's what we're trying to do. Yeah . All right. I think we have covered a lot of the, a lot of the issues and a lot of ground and half an hour. Um, all right. So we are so delighted to do our audience that , um, that you are listening and thank you so much. Be sure to tune in next week for more, be sure to subscribe and leave us a review on iTunes. We love to hear from you.
Speaker 4You can also visit fertility DocSend since to schedule an appointment with any of us or submit subs. I can't talk specific questions about infertility. All questions will be answered on the podcast anonymously in our ask the doc segment. So don't hold back. Love to hear from you. Sorry, Susan. I made you do the hard part. So now all I get to say is
Speaker 2[inaudible]
Speaker 4Next week.