Infertility: Your Questions Answered with Dr. Marjan Attaran

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef. And you're listening to Health Essentials Podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic Administrative Campus here in Beachwood, Ohio, and we're here with Dr. Marjan Attaran. Dr. Attaran is board-certified in obstetrics and gynecology and sub-specialty board-certified in reproductive endocrinology and infertility. Did I say that right?

Dr. Attaran:  Definitely. Mouthful.

Nada Youssef:   Thank you so much for being here today.

Dr. Attaran:  Thank you.

Nada Youssef:   And today we're talking about infertility. And please remember this is for informational purposes only, and it's not intended to replace your own physician's advice. So, before we jump in the topic, I have some icebreaker questions to get to know you on a personal level.

Dr. Attaran:  Okay.

Nada Youssef:   So first of all, if you could pick one vacation destination, where would you go and why?

Dr. Attaran:  So, one of the best places that I've ever visited was in Thailand. The name of the place was Chiang Mai and I loved it because we were on an elephant reservation and it was so peaceful, so beautiful, and it really put things in perspective in terms of why we're not important, and the rest of the planet is so important. Such a sense of peace. Loved it.

Nada Youssef:   Wow. And I bet Thai food is amazing.

Dr. Attaran:  Oh, well the Thai food just goes without saying.

Nada Youssef:   Yeah. That's another [inaudible 00:01:56]. How about if you were stranded in a desert island? What three items would you want to have with you?

Dr. Attaran:  Okay. So, I've always loved reading books so my answer is obvious. I must have a storage of books.

Nada Youssef:   Yes.

Dr. Attaran:  But of course, I need food, and fire, I would say.

Nada Youssef:   Yes. Okay. That's very smart. And then if you could choose your age forever, what age would you choose and why?

Dr. Attaran:  Okay. I would say 35 was an awesome age. And I love the 30s because by that time, I knew who I was, and I felt confident in my own actions and yet there was still a sense of awe about the world, and being able to accomplish something in the world. So, great time.

Nada Youssef:   Well, you seem very young-spirited so ...

Dr. Attaran:  Thank you.

Nada Youssef:   All right. Well let's start a discussion with just the definition of infertility. What is the definition?

Dr. Attaran: Okay. So the definition of infertility is 12 months of unprotected sex that leads to inability to conceive. It affects about 15% of the population and does not mean that one doesn't proceed with an infertility investigation earlier than the 12 months. It really does depend on what kind of history you've obtained from the patient.

Nada Youssef:   So, it has to be 12 months of being unable to get pregnant to go to see a specialist, correct?

Dr. Attaran:  There are other reasons to actually go in and see the specialist earlier. But if we're just talking about the definition, it's 12 months of a couple having sex, but not getting pregnant during that time.

Nada Youssef:   Okay. Great. So, I want you also to explain the complex chain of events in order to get pregnant, and where the issues may arise.

Dr. Attaran:  Mm-hmm (affirmative). So patients are always surprised that the pregnancy rate per month is as low as it is. So, it's probably ranging anywhere from 15 to 20%, perhaps a little bit greater than that in the younger population. So, as a species, we're not very fertile, okay? And patients are always taken aback by that and there are probably many reasons for this. But the things that have to happen correctly are you have to, within the first 14 days of the cycle, grow a dominant follicle. Be able to send the right signals to the brain that leads to release of the egg. Then the egg has to be picked up by the tube, and in the tube, hopefully, by that time there's enough sperm that's sitting there to be able to fertilize the egg. The embryo then is correct. Then the embryo has to travel the rest of the way from the tube into the uterus. The environment of the uterus needs to be absolutely perfect for implantation to occur, and also, the embryo has to be absolutely perfect.

And we believe that in many, many instances, in fact, the embryo that's created is not a normal embryo. And that's why with every single time that you have sex at the appropriate time, you're not going to be establishing a pregnancy.

Nada Youssef:   Interesting. So the appropriate time to have sex [inaudible 00:05:00] ovulation, is it three days out of the month? Or is it two days the maximum?

Dr. Attaran:  Yeah. So that's a great question and it's asked by so many of our patients. So, the ideal time for getting pregnant is going to be within probably the three days prior to ovulation.

Nada Youssef:   Three days prior.

Dr. Attaran:  Prior to ovulation, right. Because essentially what you want is sperm there waiting for the egg to arrive.

Nada Youssef:   I see. Okay.

Dr. Attaran:  Okay? So, yes of course, using those ovulation predictor kits that so many of our patients do use, can make it so that we're determining that ovulation is going to be happening within so many hours of when this LH surge is occurring, right? And so when the LH surge occurs we say, "We'll have sex soon thereafter." But again, the sperm is there waiting for the egg to come out 36 hours, 42 hours, after the LH surge.

Nada Youssef:   Wow. And sperm will stay there for 36 hours?

Dr. Attaran:  Yes. It will.

Nada Youssef:   Wow. How long does it stay in? Like how long can it stay for?

Dr. Attaran:  So sperm can stay for quite awhile, but up to three days for sure.

Nada Youssef:   Wow.

Dr. Attaran:  Yeah. So it can sit. So this is very interesting also in that after ejaculation occurs in the vagina, the sperm gets to the tube within 15 minutes. So many couples feel like they have to be in bed, maybe hips up for some duration.

Dr. Attaran:  Legs up. All kinds of permutations have been heard, and honestly, that's not true. It's in a very short duration that the sperm makes it up to the tubes. And then the sperm is also picked up by the crypts that are in the cervix, and so it can sit there for those next 36 hours and waves of sperm are just going up through the uterus and into the tubes, and actually out the tubes, into the peritoneal cavity also.

Nada Youssef:   Wow. Wow. It's a big process. So, you said it's pretty common. It's a common issue. Infertility, you said 15 to 25%?

Dr. Attaran:  About 15% of the population will have infertility.

Nada Youssef:   Okay. So what I want to talk about is many people seem to think of women when a couple's having trouble carrying a child or getting pregnant. Can we talk about how it's not just a woman's problem? That infertility, it's not women that's all 20 ... it's 15% . Can you talk a little bit about that?

Dr. Attaran: Yeah. Absolutely. This is also something I always talk about with patients. That don't make an assumption that it's coming on the female side. In about 20% of cases, it's a pure male factor infertility. And we can talk about some of those causes in a minute. But when you look at ... if you're looking at both the male and the female, in about 40% of cases, it's a combination of both the male and the female. So definitely the male plays a huge role.

Nada Youssef:   Yes. Huge role in that. So, what causes infertility in men? And if you can talk about maybe some of the risk factors.

Dr. Attaran: Yeah. So, in men, the most common factor of course is we begin the infertility investigation [inaudible 00:08:04] is with doing a sperm count. And so, if the sperm count is typically less than 15 million per cc, then there's concern for what we call oligospermia and of course that's going to be contributing to the person having difficult getting pregnant. But there are of course degrees of abnormalities with the sperm, right? So, the count may be 14 million which is not so awful, even though it's still below normal. But it could be zero. It could be one. And the extremes of this would determine what direction we're going to go. So usually if the sperm count is low, we ... since we're primarily ... we manage female infertility, we will send them to the male infertility specialist. And then at that time what will happen is they will undergo a more extensive history than what we've obtained.

They'll undergo a physical examination and then as a result of the extent of the amount of low sperm or perhaps some of the other factors, let's say the history has obtained that the person has problems with ejaculation, okay? Well that takes you a different direction in terms of hormonal investigation of why the individual is having these problems. And sometimes even genetic studies have to be done if the sperm count is extremely low.

Nada Youssef:   I see. So do we know some of these risk factors for these sperm counts being low?

Dr. Attaran:  So, let me just kind of go backwards because you had asked what some of the various causes were for male infertility. There could be causes that are at the level of the brain. So, problems like excess prolactin secretion could lead to lower testosterone which then could lead to low sperm counts. There could be problems just at the level of the gonad itself. So, the testicle just is incapable of making the sperm, so maybe there was some kind of trauma or perhaps an infection in the distant past. There could be problems with getting the sperm from the testicle out from ... to the tip of the penis. And so again, maybe there was a genetic problem that lead to those tubules not forming appropriately. Maybe there was an infection in the past. And of course it could be genetic issues. So, those would be the more common causes of male infertility. And then risk factors you talked about. Well, risk factors, as we're talking about these causes, you can see they're like coming out. You know?

Nada Youssef:   Yes.

Dr. Attaran: Did you have infections in the past, right? Lots of times patients ask about the age of the man, right? Because this is a really big topic in females, right?

Nada Youssef:   Yes.

Dr. Attaran:  So, the age of the man, the general broad response would be that the older we get, as men, the more time it takes to conceive. But we probably won't see those changes until the man is over 50 years of age, okay?

Nada Youssef:   Okay.

Dr. Attaran:  Other risk factors. They're softer. So, smoking. I talk about smoking with the couples that come to see me. Probably in some men, smoking does play a role. It changes their antioxidant capacity. But, for most men, there isn't black and white data that shows definitively smoking will have an impact on the quality of their sperm.

Nada Youssef:   Interesting. Interesting. How about something ... is drinking? It could be like a medication side effect? [crosstalk 00:11:40].

Dr. Attaran:  Yeah. Those are good. So, drinking again, the data is not definitive in terms of its impact on sperm, although of course, that question is always asked. And just like women, we're seeing really less than one to two drinks a day should be where we're going with that. Drugs, absolutely. They can have an impact on the quality and the amount of sperm.

Nada Youssef:   Okay. I want to go back to the age for a second.

Dr. Attaran: Yep.

Nada Youssef:   When we talk about women, there are high-risk pregnancies, lets say, what is it? 35 to 40, correct? And for men, they can be how old to be able, if they have good sperm? How old could they go to be able to get pregnant?

Dr. Attaran: There is no end point.

Nada Youssef: There is no end point? Okay. I was always wondering about that.

Dr. Attaran: There's no end point to it. I mean, I suppose there is an end point but I'm not aware of it. I think ... I always use the example, and the younger population won't have heard of Tony Randall having a baby in his 70s, you know?

Nada Youssef:   Yeah. Yeah.

Dr. Attaran:  So it can happen, definitely, but there's studies to suggest that the definitely the quality of the sperm is not the same. That there is more DNA breakage in the sperm. So you are going to be concerned potentially with more abnormalities. And also, there's some data to suggest that the rate of miscarriage is increased in women whose partner's age is significantly older. But again, they're all softer data. It's not as hardcore as what we hear about women and know about the state of eggs in women as it relates to their age.

Nada Youssef:   Now, as I was doing my research for this topic, I came across hot tubs for men that they could be damaging? Is that true?

Dr. Attaran:       Yeah. So, again, in preparation for this podcast today, I went ahead to look and see what does American Society of Reproductive Medicine say about this. And the data that they have is that there isn't really any definitive data to say hot tubs cause problems with getting pregnant on the male side. As in anything in life of course, one would say, "Why would you overdo it?" So have fun but maybe you don't want to sit there all day long, seven days a week, right?

Nada Youssef:   [inaudible 00:13:58].

Dr. Attaran:  Right, right, right.

Nada Youssef:   So we got the men out of the way. What about causes of infertility in women?

Dr. Attaran: Yeah. So, for women, it's easier for me to talk because obviously it's what I do on a daily basis, but when a woman comes in, there are three main areas that our history and physical examination focuses on. So, the number one area is getting a very detailed menstrual history on them. And the reason for that is because it gives a lot of clues about are they ovulating or not? So the majority of women that come in and describe their menses occurring within a very cyclically, normal time frame. So every 26 to 28 days, let's say. Those people are in the majority of cases, ovulating. If a woman says, "No. My cycles vary. They go from every one to three months." Automatically, I'm worried that that individual is not releasing an egg in a monthly basis. It might be randomly that it's occurring but not so consistently. And so as you can see, those 12 months are not being used as efficiently, right?

Nada Youssef:   Right.

Dr. Attaran:  By the way, that individual, that their gynecologist knows that their periods are occurring every three months, that person shouldn't be waiting a year to come in for an investigation. We know right off the bat there is a problem there, so let's do the hormonal investigation and let's proceed with what we need to do to treat that problem, okay?

Nada Youssef:   Sure, sure.

Dr. Attaran: So the menstrual history is very important. The next thing is that we're trying to figure out the tubal status of the individual. Are their tubes opened? Because that's the site where fertilization is going to be occurring. So the history that you're obtaining is going towards that, and that history would be, have there been prior episodes of infection? Has there been multiple surgeries that have happened in the pelvis? Did you have a ruptured appendix in which there was pus in the pelvis? And it potentially impacted the site of tubes. The relationship of the tubes and the ovaries. Any kind of scarring in the pelvis. Did you have three surgeries for Crohn's disease?

I mean, anything that's happening there in the pelvis could play a role with causing scar formation there. And of course, in the gynecology world, we're always worried about endometriosis as being a factor for patients because it's an inflammatory process that's happening in the pelvis, and in the low stages, while it doesn't necessarily cause problems with scar formation, the environment is inflammatory and it could impact the ability of the egg and the sperm to have a good environment to fertilize each other.

But in the higher stages of endometriosis, absolutely. There could be significant distortion of the pelvis which then leads to inability to get pregnant. So we talked about ovulatory status. We talked about tubal status. And of course the third one was the sperm issue which we've already talked about.

Nada Youssef:   Right, right. Do fibroids, uterine fibroids cause infertility as well?

Dr. Attaran:  That's a very good question. So-

Nada Youssef:   So, pretty common right?

Dr. Attaran:  They are common in certain populations and definitely people who have family histories of fibroids. Unfortunately with fibroids, we still don't understand what are the factors, the risk factors that really lead to some person being more likely to have a fibroid versus another, other than what I've just mentioned. So, fibroids, it is clear that if they're going to play a role, it's if they are sitting inside the uterine cavity, or if they are distorting the uterine cavity. But many people have fibroids that are just sitting in the muscle and sort of protruding outwards into the pelvis, so not likely to be playing a role in infertility.

Nada Youssef:   Sure. Now I want to talk about endometriosis just a little bit. It seems like it's very common. Can you explain exactly what it is? What endometriosis is?

Dr. Attaran: Sure. So, normally there is a tissue in the uterus that we call the endometrial cells. This tissue is released every month. It's under the influence of hormones and every month it's released, and that leads of course to the menstrual bleeding that women experience. So this same exact tissue, if it occurs different places in the pelvis, on the sidewalls, on the bladder, on the rectum, then every month when you bleed, it's still under the same influence. Of course it bleeds also. But it is within the pelvis, and so therefore it can lead to a lot of pain for the individual, scarring and inflammation for that person.

Nada Youssef:   Sure. And there's different stages to endometriosis, correct? Like one to four.

Dr. Attaran: Yeah.

Nada Youssef:   How can you tell how bad someone's endometriosis is? Is it just through an ultrasound?

Dr. Attaran: Yeah. I wish it was. Yeah. Endometriosis really still remains an enigma today. What's funny about endometriosis is that it is not easy to diagnose, and the degree of pain that the individual is experiencing is not related to how much endometriosis actually exists, okay?

Nada Youssef:   Really?

Dr. Attaran:       So, there will be people walking around with severe stage four endometriosis, not one iota of pain. There will be people with horrifying pain. And they barely have three spots of endometriosis. So what you're looking for, to kind of give you the clues that somebody might have endometriosis for the general in between population, not those two extremes that I talked about is, are you having a lot of pain with your periods? Some people do. And the next group Of people are having not only pain with their periods, but also pain maybe the week before their periods. Then, you might decide to do an ultrasound on those individuals. And in most cases, in fact, the ultrasound is normal. Okay? But sometimes, what you'll see is what we call an endometriotic cyst that's on the ovaries. It has a very specific look to it. It's still not 100% diagnosed as having endometriosis. The only way you make 100% diagnosis is by actually doing surgery and looking inside and saying, "Yes. This is the endometrioma that I saw", or, "Yes, I see those particular legions that I was just talking to you about on the sidewalls."

Sometimes, some individuals have enough endometriosis that's deep, that when you do certain types of ultrasounds and that you have good readers of the ultrasound also, you can see that maybe organs are not sliding against each other as they should, so it gives you a clue. And MRI certainly can give you a better idea about deep infiltrating endometriosis.

Nada Youssef:   So what about treatments? Are there ... because I've heard that something like maybe birth control would work on endometriosis which is not going to work if you're trying to get pregnant, right?

Dr. Attaran:  Yes. Yeah.

Nada Youssef:   So what do you do with something like you open up someone and you see that they have endometriosis? Do you then remove some of the organs? I mean are you scraping it off? What are you doing with all this tissue?

Dr. Attaran:  Yeah, so you have to kind of put the whole story together, right? So, if an individual is coming in and their primary issue is pain, okay? And yes, of course, they want to maintain their ability to get pregnant, then you maybe have gotten a good history on them. You've done some kind of imaging on them. But because of the degree of the pain that maybe has not been responsive to birth control pills, you then proceed forward with surgery. And then at the time of the surgery, your goal is to get the reproductive organs in their best shape possible. You're trying to minimize the amount of damage to the ovaries, and inevitably, if you're trying to remove endometriomas, you will end up removing some eggs. Because that's the way an endometrioma is created, okay? So, you remove as much endometriosis. Get the relationship of the tubes and the ovaries back to normal. And then leave.

And then usually you're telling the patient, "Okay. If you actually have a partner at that time, please make sure that you try to get pregnant in the next year or two because you want to see the value of the surgery that you went through." You do not expect that just because you removed endometriosis it's gone forever. Inevitably, it does come back. Because we don't understand what brings on endometriosis, we don't know. Will it take-

Nada Youssef:   No preventive measures.

Dr. Attaran:  Yeah. We don't know. It'll be five years. It'll be three years. What is it? And we see all kinds of patients like that.

Nada Youssef:   Yeah. Yeah. So, is this considered a chronic pain condition for some of these patients?

Dr. Attaran:  Absolutely.

Nada Youssef:   Absolutely.

Dr. Attaran: It's one of the most common reasons for chronic pelvic pain in the GYN world.

Nada Youssef:   Wow. Okay. So, we've talked about the causes. I want to also go back to the same thing we asked about the men. The risk factors. Are they the same to men with infertility in general now that we're done with endometriosis? Is it smoking? Is it medication? Is it different for women, the risk factors?

Dr. Attaran: You mean risk factors for getting pregnant, for women?

Nada Youssef:   Right. Mm-hmm (affirmative).

Dr. Attaran: So, age is the most significant risk for the women, right. So we know fertility in general is just declining as we get older, but a significant decline is happening in our mid 30s onward, and then a dramatic drop 40 onward. But of course your family history is very important in this case. There are women who will say, "Mom went through early menopause at age 40." Those women should never be waiting till their 30s to try to get pregnant. They really should be trying to get pregnant in their 20s, right? So, age is a big factor and just to be clear for the audience, that is because women are born with all the eggs that they're going to be ever born with and then from the minute they hit life on this Earth, they are just losing eggs constantly versus men are regenerating sperm constantly. That's why they continue to procreate well beyond 50 years of age, even.

So age is a big factor. Then you go, well what are the factors that can impact this egg, right?

Nada Youssef:   Sure.

Dr. Attaran:  And so smoking. Smoking in women actually has been shown to diminish fertility compared to men. What does it do? It leads to earlier menopause by one to four years. They've actually seen the products related to smoking in the follicular fluid and in the egg. So, it's likely leading to loss of eggs earlier. Okay?

Nada Youssef:   Sure. Sure.

Dr. Attaran:  Smoking does. Alcohol, the data is very confusing. It's clear cut. No alcohol the minute you're pregnant because nobody knows the degrees to which it can lead to the problems that will lead to fetal alcohol syndrome. So, no alcohol once you become pregnant. But, most of the studies which are not great, randomized clinical trials will say no more than one to two drinks per day.

Nada Youssef:   I was going to ask about that. Yeah.

Dr. Attaran: Which still, in my world, is excessive. What else am I missing? We talked about smoking, alcohol, age.

Nada Youssef:   And then genetics, right?

Dr. Attaran:  Genetics, we talked about. Right. In terms of your family history of-

Nada Youssef:   So that's really interesting. So, if a woman's trying to get pregnant, she should find out when her mother hit menopause because based on that age, we should do it like 10, 20 years before.

Dr. Attaran:  At least 10 years before that. Right. Right.

Nada Youssef:   That is very interesting.

Dr. Attaran:  Right. But it's hard. I mean, this is not ... it's not fair to say-

Nada Youssef:   It's not easy to [crosstalk 00:25:24].

Dr. Attaran:  ... to my 28 year old.

Dr. Attaran:  Go ask your mom what her story is because people's stories, as we know, is what makes life so interesting, are convoluted and so many moms have had their own issues. Maybe they had a hysterectomy. Maybe they don't know exactly when they went through menopause.

Nada Youssef:   Right. Right.

Dr. Attaran:  But for the most part what I'd be telling my daughter is, "Yeah. Try getting pregnant in your 20s."

Nada Youssef:   Your 20s. Okay. That's very good to know. So, if a woman is on birth control, let's say for most of her menstrual years as soon as 13, 14 and then now she's 20s or 30s and trying to get pregnant. Removes let's say IUD or whatever birth control they use. Does that affect your rate of getting pregnant based on how many years you were on the pill or on some kind of birth control? Does it make it harder?

Dr. Attaran: Yeah. That's a good question. So, any of the forms of contraception, so that's birth control pills, IUDs, Depo-Provera, the implant, none of them will actually cause you to become infertile.

Nada Youssef:   Okay.

Dr. Attaran:  Okay?

Nada Youssef:   Okay.

Dr. Attaran:  However, there is a difference in them in that how quickly you become pregnant depends on what agent you were on. So, if you had the IUD in place, you remove it, the agent is gone and you never ... you had never stopped ovulating so you just kind of go right on ovulating and you just have the same probability of getting pregnant the next month, okay?

Nada Youssef:   Right.

Dr. Attaran: If you were on Depo-Provera, well that drug can stay in your system for awhile.

Nada Youssef:   Is that pill form or what is it?

Dr. Attaran:  The Depo-Provera is the injection-

Nada Youssef:   Oh, the injection.

Dr. Attaran: ... of high-dose progesterone, medroxyprogesterone acetate that's being given every 12 weeks. It's incredibly effective for contraception, but it can stay in the system for awhile, and so until the person says, "My periods are back to normal", then they're most likely not ovulating. But when it gets back to normal, they will be ovulating and so they will get pregnant. But just because you were on it, didn't make you become infertile. Okay?

Nada Youssef:   Sure.

Dr. Attaran: And the same thing with birth control pills. People are different with birth control pills. Some individuals come off and next month, they're totally back to normal. Other people, it might take up to three months.

Nada Youssef:   Okay.

Dr. Attaran:  Which happens a lot in which patients say, "Well, I was told to stop trying to get pregnant when I finished the birth control pill. Wait three months and clear it out of my system." And I'm like, "Nope. The minute you're done with the birth control pill, start."

Nada Youssef:   Just go.

Dr. Attaran: If the drug is out of your system, the question is, "Are you ovulating or not?"

Nada Youssef:   Okay.

Dr. Attaran: So, use your opportunity.

Nada Youssef:   Yeah. And the menstrual cycle is a big factor to see if you have a normal menstrual cycle again. That's when you're ovulating, correct?

Dr. Attaran:  Usually, you are ovulating.

Nada Youssef:   Okay.

Dr. Attaran:  Usually.

Nada Youssef:   Excellent. So, it all depends on what birth control you're taking and it really depends on the person of how long you would take before getting pregnant [inaudible 00:28:14] on that.

Dr. Attaran: Correct. It's your personal history. So if you were a person that before you got on birth control pills, you had very irregular cycles, then of course when you come off the birth control pills, you're likely to go back to the same rhythm. And it's not the birth control pill that caused the infertility. It's the fact that you were never really consistently ovulatory.

Nada Youssef:   Sure. Okay. That's very good to know. So what other things should a woman do before trying to conceive?

Dr. Attaran:  So, you want to make sure obviously that you are at your best weight.

Nada Youssef:   Okay.

Dr. Attaran:  Weight is known to have an impact on your ability to get pregnant. Excess weight or being underweight will have an impact on fertility. And its prime way of doing that is it impacts ovulation. Okay?

Nada Youssef:   Yes.

Dr. Attaran:  Also excess weight can lead to higher rates of miscarriages. So miscarriages are always, always sad but they're even sadder when you've tried so hard to become pregnant and now you're sitting at this position. Also, both excess weight and lower weight can lead to problems during pregnancy itself. So if you're overweight, you're worried about gestational diabetes. You're worried about hypertension. You're worried about preeclampsia. If you're underweight, you're worried about preterm delivery. You're worried about problems with the baby after the baby grows up in terms of their obesity status. Okay? And preterm delivery, I think I already mentioned. So getting your weight under control is important, so that means healthy eating and healthy dieting prior to attempting pregnancy.

Usually, the recommendation also is to be on prenatal vitamins, or some kind of a multivitamin. Usually with multivitamins you are getting your folic acid. You're getting your iron. You're getting your calcium in place. All the things that your body needs and the baby needs once you become pregnant.

Nada Youssef:   Sure, sure. Now with folic acid, I remember my doctor was always very adamant about getting high levels of that. Why do pregnant women need high levels of folic acid and iron and calcium? Can you talk about that?

Dr. Attaran:  So folic acid is necessary because it plays a role in development of the neural tube. And so it is such a simple thing to do. Most times, we are taking ... getting folic acid of course through our diet, and a lot of the food that we have in the United States certainly is fortified with folic acid. But, it's simple to decrease the probability of neural tube defects by supplementing with folic acid.

Nada Youssef:   Okay. Great. And then we talked about obesity being linked to infertility. How about stress? Can stress cause infertility?

Dr. Attaran:  Yeah. What a great question. I would love it if there was a randomized ... I would love an answer, and I would love it if there was just sort of a randomized double blind trial that would show this. And I think there never will be, because as humans, what we can tolerate is so variable.

Nada Youssef:   Yes.

Dr. Attaran:   For all of us. So, in the extremes, I believe yes. But in the extremes, our body is very protective of us, right? So, there is something atrocious that has happened and our body is going to skip a period. What did we say? If your periods are not normal, then most likely you didn't ovulate and therefore, you're not going to be getting pregnant. But usually that state doesn't last. So I tell patients, "Stress can, I believe, delay your getting pregnant. But it's not going to cause five years of infertility."

Nada Youssef:   Okay.

Dr. Attaran:  Okay? So yes. Walk in the door and undergo an investigation, should those 12 months go by.

Nada Youssef:   Okay. And speaking of investigations, I want to talk about finding the cause of infertility is a long complex process, emotional process for the couple. When you first see a couple regarding infertility, what kind of questions do you ask and then do you test them both from the get-go or is that based on the questions? You go to a specialist for the male? Or how does that work?

Dr. Attaran:   Yeah. So, I think you asked a couple of questions in there.

Nada Youssef:   Yeah, I'll just give you all of them at once. But basically, when a couple comes to see you for infertility, what kind of questions do you ask?

Dr. Attaran:  Mm-hmm (affirmative). So we ask questions both of the male and the female. During that interaction, you get an idea about the level of anxiety that exists and sort of where each individual is sitting in regards to should you be at all intervening about seeing a therapist or something because the degree of anxiety is so high. But both individual's questions are being asked and depending on what they say, yes it's going to take you a direction. So, if the partner for example says, "Yes, I was married to another individual for 10 years, and I did not get pregnant", first stop is you're going to do the sperm count. And not do the tubal testing on the woman upfront, because that's a painful test, and I would rather not have her experience that until we know what the sperm count is.

If the story is completely clean, there are no red flags on either individual, then I just say, "Start the tests of sperm, tube, ovulation testing all together. Whatever pattern works for you."

Nada Youssef:   Okay. So what are the main tests, some of the most common tests that a woman has to get when there is a risk of being infertile?

Dr. Attaran:  Yeah. It's pretty basic. So, if again, it's a very normal history that's been obtained, we're going to do ... usually, there's multiple ways of testing for tubal patency, but the classic way is what's called the hysterosalpingogram. It's an x-ray that's done in the radiology department and with this x-ray you can see the caliber of the tubes and whether the tubes are open or not. There are other ultrasound guided ways of assessing the tubes also. And in the male, of course, it's going to be checking the sperm count, shape, motility, and the final test is to actually prove that the individual's ovulating. The female's ovulating and that would be using an ovulation predictor kit, but a week later, checking their progesterone status to determine that yes that ovary made the progesterone that is reflective of ovulation a week ago.

Nada Youssef:   Sure. Sure. And then you did say if the couple seemed to be distressed, do you take them to therapy or you tell them to see a therapist as well?

Dr. Attaran:  I recommend it. Yes. You can see infertility just honestly eats away at the soul of the couple. Puts so much stress between them, especially if they're not exactly on the same page. Women usually come in far more anxious than men. Men, if they are at all worried that there's something sperm related, take on such a huge burden upon themselves. They make it be a my problem, your problem, although honestly we do view it as an our problem. It's way, way too stressful to be blaming yourself, and people do blame themselves.

Nada Youssef:   I can imagine. I'm glad that option is there for them as well. So let's talk about treatments of infertility. First of all, are there medications that you can take to help fertility?

Dr. Attaran:  Yes. So you always have to say, "Well what's the problem?" And then try to address that problem, right? And so, if the problem is an ovulatory dysfunction, then yes, there are medicines to assist the woman with ovulation. So, some of the ones that most people are familiar with is clomiphene citrate. It's a really, really old drug and what it does is it fakes the brain into thinking that there's no estrogen around, so the brain sends a signal of FSH that makes the follicle grow. And once the follicle grows, it becomes self-sufficient and then sends a signal for ovulation. There are newer drugs which are like aromatase inhibitors that can almost do the same thing. Although, via a different pathway. There are just injections of FSH that one can take to try to grow eggs, and then give the signal for the person to ovulate.

So ovulatory problems usually have very good success rates with getting pregnant. Unfortunately, if there are sperm problems, it's not easy. The majority of cases, when we were talking about the various causes of male infertility, in fact it's idiopathic, meaning in about 50% of the cases, we don't know why the sperm count is low. And so depending on how low it is, the male infertility doc might have various options. In the very, very severe cases, unfortunately, the option really just becomes in vitro fertilization.

Nada Youssef:   So when you mentioned pills and from the very get-go you said the brain tells your body to ovulate, right? So it kind of starts with the brain. Is it the same way for a man then?

Dr. Attaran:  Yes. Absolutely. Everything is controlled by the brain.

Nada Youssef:   Everything is controlled by the brain. Yeah.

Dr. Attaran:  Right. The brain has to send the right signal, which then works on either on the ovary or the testicle to do what it's supposed to do, and then what the ovary and testicle produce feeds back to the brain to kind of keep this loop active and controlled.

Nada Youssef:   Which again, makes so much sense for stress and how that could affect-

Dr. Attaran:  Absolutely.

Nada Youssef:   It all starts in your brain.

Dr. Attaran:  Right.

Nada Youssef:   So let's talk about some common methods of ... it's called ART. Is that assisted reproductive technology?

Dr. Attaran:  Mm-hmm (affirmative).

Nada Youssef:   So can we talk about what it is and some of the common methods?

Dr. Attaran:  Yes. Assisted reproductive technologies. So there's definitely a spectrum to that. One of the smallest things that most patients come in having read about and would like to give a trial is intrauterine inseminations. There's lots of different terms that are in the literature. Artificial insemination with husband. Artificial insemination with donor. So AIH, AID and IUI, intrauterine inseminations. So, intrauterine inseminations is very low-key in that the husband or partner is ejaculating into the cup. The sperm is washed, so the semen is removed and it's just sperm that's placed in a very small amount of fluid. And then this fluid is compatible with the female body. The sperm is picked up by an incredibly thin tube and then placed through the cervix into the uterus. There are actually multiple ways of doing intrauterine inseminations but this is the one that I just described.

So, just from what I described to you, it would seem like an intrauterine insemination would be of value for somebody who had something done to their cervix. Some kind of damage to their cervix potentially. Or perhaps it would play a role in a case where ejaculation can't happen consistently inside the vagina. Because I had told you that within 15 minutes, the sperm is where it's got to be, right?

Nada Youssef:   Right.

Dr. Attaran:  So you got to figure out, is there value for all the other people that don't have these problems, right? It can play a role for people who maybe the volume of the semen is incredibly low, and maybe the sperm is sitting on the right side of the vagina and not right where it's supposed to be sitting, cupped underneath the cervix itself. But there are studies to suggest that doing intrauterine insemination, in conjunction with some of the fertility medications, together they can enhance fertility outcomes.

Nada Youssef:  How about is that ... that's not called IVF. That's very different, correct?

Dr. Attaran:  Correct. Correct.

Nada Youssef:   So what is IVF?

Dr. Attaran: Yeah. In vitro fertilization. In vitro. As opposed to in vivo. In vivo in the body. In vitro outside the body. Okay?

Nada Youssef:   Okay.

Dr. Attaran:  So, things are happening in a dish. And so with in-vitro what we're doing is, we are growing eggs in the female because unlike men, it's not easy to access the eggs in a woman, right? So we have to grow the eggs. The eggs are growing in the follicles, and then eventually, the woman has to go through a surgical procedure typically through the vagina in which those follicles are sucked out the fluid, and the egg is obtained and then the egg is sitting in the dish. The sperm is obtained from the man and that's being put in the dish also. And then either the egg and the sperm are just spontaneously fertilizing each other, or we do a process called ICSI, intracytoplasmic sperm injection, where you take the sperm and put it inside the egg. The mature egg. And then you wait to see if fertilization occurs. So that would be in vitro fertilization and ICSI.

Nada Youssef:   Outside.

Dr. Attaran:  Outside the body. So now the embryo is created outside the body. It grows in culture for several days. In our program, it's five days. And then at that time, the best embryo is selected and placed through the cervix, into the uterus.

Nada Youssef:   Wow. And how long can that stay in that container before putting it in? You said you wait five days and then it has to be on the fifth day?

Dr. Attaran: Programs are a little bit different. Some programs day five. Some programs day six. The majority are a day five. But, remember the embryo has to be supported by the media and the culture that it's sitting in. It needs various nutrients of course for it to grow appropriately. So at this point, we can only sustain till about day five or six. Then after day six, either the embryos are good enough to be frozen or maybe they were even frozen on day five certainly, or else they haven't grown to the stage that they need to grow and they're declaring themselves, and then they are discarded.

Nada Youssef:   So what are the rates of success on these procedures?

Dr. Attaran: Mm-hmm (affirmative). So it is totally age dependent.

Nada Youssef:   Okay.

Dr. Attaran:  So, many patients, maybe in the past. I think people are far savvier nowadays. But, IVF does not overcome age, okay? So, the 25 year old has a far greater pregnancy rate than the 42 year old is going to, right? Because the eggs are 25, versus the eggs are 42. So I would say the under 35 crowd, again, it depends on the particular program that you go to, but you should expect a pregnancy rate close to 60%.

Nada Youssef:   Wow.

Dr. Attaran:  Okay. That's different still than the live birth rate because there's a lot of other issues that will present as a pregnancy is progressing of course.

Nada Youssef:   Right. Right. Great. Well, is there anything else that I didn't talk about or didn't ask you about that you wanted to bring up? Because we're out of time.

Dr. Attaran:  I think the only other topic that I would have brought up also is given what we know about our culture, people are very busy. We want women to be out there taking care of their life, and moving forward and having those great 30s I was talking about. To have a little thought about potentially fertility preservation. Like are there some options for young women who might be thinking about delaying child bearing?

Nada Youssef:   Is this freezing your eggs?

Dr. Attaran:  Yeah.

Nada Youssef:   Is that what that is? Okay.

Dr. Attaran: Yeah. Yeah. I would say to come in and ask questions from your fertility specialist. Is this something that might be good for you or not?

Nada Youssef:   Okay. So if a woman, lets says is 33, 34, still not married, wants children, that she should see an infertility specialist?

Dr. Attaran:  Yep.

Nada Youssef:   And be able to talk about maybe freezing the eggs [inaudible 00:43:35] options?

Dr. Attaran:  Correct. Correct.

Nada Youssef:   Okay. That's a very, very good message. Thank you.

Dr. Attaran:  Okay. All right.

Nada Youssef:   Thank you so much for being here today.

Dr. Attaran:  Thank you. I had fun.

Nada Youssef:   Thank you. It's been a pleasure. And thanks again to all of our listeners who joined us today. We hope you enjoyed this podcast. And to learn more about infertility and treatment options, you can go to clevelandclinic.org/fertility, and download our free fertility treatment guide. And to listen to more of our Health Essentials Podcast from Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcast, or you can subscribe on iTunes. And for more health tips, news and information from Cleveland Clinic, make sure you're following us on social media. We're on Facebook, Twitter, Snapchat and Instagram at clevelandclinic. Just one word. Thank you. We'll see you again next time.