Speaking of Infertility Awareness: The Question of Age + Pregnancy = Never-Ending Confusion?

Advanced maternal age and how it gets in the way of pregnancy is in the news again. This time, the focus is on how so many women have the misunderstanding that assisted reproductive technology can defeat age as a barrier to conception.

How many times have I heard, "Dr. Kristiansen -- I hate that term! Can't we use something different to refer to my age?" Sorry -- it's a rather tacky-sounding medical terminology shortcut that means "chronologically older than average for optimal fertility".

Here's a message that needs to be heard during this National Infertility Awareness Week:

The fact: Without intervention, most women in their 40's (and many in their 30's) would not get pregnant.

Another fact: Yes, IVF is incredible technology worth marveling at, and one of the reasons is its ability to facilitate conception in women who otherwise would not get pregnant.

The Big Myth: IVF is so effective, you can wait until you're of "advanced maternal age" to try and get pregnant -- and have a high likelihood of succeeding by way of fertility treatment.

That myth IS a fact for some women. But only for some women. Are you one of them? There's a good chance that a thorough diagnostic workup by a reproductive endocrinologist can provide clues to answer that question. Can we guarantee it? No.

I don't think either the media or fertility experts intend to confuse women about the question of age and pregnancy. But the confusion among women is apparently prevalent and ongoing.

Just as it would be overkill to suggest that all women in their teens or early 20's run out and get fertility testing to prepare for the future, it is unreasonable to recommend women put all their eggs into that future basket by expecting ART to be their surefire answer to pregnancy. (There is the option of freezing your eggs, a different but related story...)

So, the simple truth: If you're delaying conception until your late 30's or older with the intention of simply walking into any fertility center and getting pregnant easily on the first try, you're automatically decreasing your odds.

If you're like many of my patients and have delayed pregnancy for lifestyle reasons like not finding Mr. Right, wanting to give your all to your career before parenthood, or because your finances aren't in order yet, you can take heart in knowing that virtually any safe and effective technique will be made available to you here at Houston Fertility Center. Not only that, but the treatment will be delivered by a team of experienced, compassionate women.

We know how much you want a baby. We applaud your courage and tenacity in the pursuit of parenthood. We'll educate you about every treatment option. We'll be your cheerleaders in the journey. And we'll be honest with you, too.

~ Dr. Sonja Kristiansen M.D.




[Image: photostock | FreeDigitalPhotos.net]

Can You Have Too Much Information in Fertility Treatment?

Like many of my patients, my life revolves around information. Personally, I use the same technology as most of you to keep track of obligations and loved ones. Professionally, the Houston Fertility Center team uses technology and constant communication to manage our patients' treatment plans. In this era of digital info, we can all feel more empowered, more often, more quickly. It seems like there's always room for more information, doesn't it?

Is it possible we sometimes actually don't help things with our "more is better" attitude toward information?

It's quite common in my office to hear, "Dr. Kristiansen, we want a baby so badly, we'll submit to any test that exists to find out the problem." I applaud their desire to get to the root of the situation and make it better. For many patients, the "not knowing" is nearly as difficult as not having a baby.

Ironically, even when I have strong reasons to suspect a particular cause of a patient's infertility, some may feel very unsettled if I order only those tests that I know will hone in on that cause. I understand -- they want to cover every single realm of possibility, right up front, leave no stone unturned (so to speak), even if it means performing tests that have a low chance of being applicable in their situation.

Recently, an organization published fact sheets called "Five Things Physicians and Patients Should Question," authored by nine medical specialty societies such as the American Academy of Family Physicians and others. The point of this public information campaign: to encourage patient-doctor communication about eliminating unnecessary tests and procedures. The campaign was first started by the National Physicians Alliance and then further supported by the ABIM Foundation with a focus on evidence-based medicine.

There are two recommendations that are pertinent to gynecology:

1. Don't perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
2. Don't recommend follow-up imaging for clinically inconsequential adnexal cysts. 

However, there are no similar recommendations specific to fertility treatment.

If you're trying to get pregnant and are worried there may be a problem, here are the tests that I recommend for virtually any fertility patient:

• Medical history: Not exactly a "test" but a good review of your health and even a little about your immediate family's health history can give us a lot of clues.

• Semen analysis: It really does take two, so there's almost no point in only looking for infertility causes in half of a couple.

• Pelvic exam: Even if you've had annual well-woman exams for years, it's possible that something's been missed or that things have changed in terms of your reproductive structure.

• HSG, unless you're using IVF: Hysterosalpingogram is the best way to determine tubal patency. If there's not a definite plan for in vitro fertilization (which is a very successful workaround for tubal factor infertility), then we need to know the pathway for your eggs is clear.

• AMH & Day 3 FSH: Simple blood tests, testing these two hormones give us a wealth of information about the quantity and quality of your eggs, for patients of all ages, and enables us to start your treatment plan most appropriately. There's no point being caught by surprise later down the line by an ovarian reserve that was in decline all along.

Of course, there are more diagnostic tools at our disposable if necessary. And that's my point: Simply having a wider array of tests and procedures does not make them all necessary. So why go through the expense of both time and money, not to mention additional anxiety, by submitting to every test -- unless we find, one step at a time, that your initial tests aren't revealing enough information to optimize your treatment path.

Can we have too much information? Not really, especially when it comes to our comfort level. We've all become very accustomed to the sense of control over our lives that comes from having all that data. But there are costs to being inundated with data, both financially and emotionally. Part of my job as a fertility specialist is helping patients find what's necessary and truly helpful from among the abundant but sometimes confusing options.

(Image: Jeroen van Oostrom | FreeDigitalPhoto)

For Women with Cancer, the Fertility Preservation Pipeline Is Clogged

Here's a situation that illustrates how fantastic medical advances don't always translate to patients benefiting in the clinic. For that to happen, the science needs to be carried along a pipeline of practitioner communication, all the way to the patient.

Cancer patients' fertility is in the hands
of cooperating physicians. 

More women are surviving cancer. We know that some of the cancer treatments will leave them less fertile or even completely sterile. Fortunately, the assisted reproductive technology exists to help young women preserve their fertility for later use, post-cancer. But a new study in the journal Cancer says very few of these women take the steps to save their eggs or embryos before infertility-causing cancer treatment.

Of the 1,041 women sampled from the California Cancer Registry, ages 18 to 40 at time of diagnosis between the years 1991 and 2007, and who participated in the survey, only 4 percent underwent fertility preservation techniques.

One of the study's authors, Dr. Mitchell Rosen of California, cites a couple of reasons. One is cost. Another is the limited amount of related counseling that oncologists are providing to these frightened patients.

The good news is that more cancer doctors are informing their patients of the connections between cancer treatment and future infertility, partly due to guidelines instituted by the American Society of Clinical Oncology back in 2006. But just what constitutes adequate information is in question.

According to Rosen in this Huffington Post article, an oncologist may refer vaguely to the problem ('The treatment might affect your fertility, but let's figure out how we're going to go ahead and save your life') and "That brief sentence might be considered counseling..."

Another issue this study brings to light: it appears not every woman is equally informed, based on demographics like age, race, and even educational level. The article says:

"Those who had gone to college were 20 percent more likely to be counseled than those who had not.
Women who were childless, younger, white and heterosexual were also more likely to be told about the possible effects of cancer treatments on their ability to conceive."

In 2008, Houston Fertility Center published a website called BabyLater.com to inform the public that we offer a number of techniques for deferring conception by way of preserving fertility. The purpose of our website and my related outreach activities is to educate not only patients, but the abundance of professionals in the cancer care field here in Houston.

This Huffington Post article says a panel of recommendation experts is revising guidelines now, but they won't be made public for another year or more. The article also quotes Dr. Kutluk Oktay, co-chair of that expert panel, commenting on the current state of that crucial information pipeline:  "On the cancer side, there's no official training for this."

Physicians on the front line of cancer treatment are holding the cards in terms of letting women know that they have choices, that they can save their ability to have children in the future. I will continue to do what I can to spread the good news, that not only is there very often life after cancer, but parenthood, too.

~ Dr. Sonja Kristiansen M.D.

“Racial, Socioeconomic, and Demographic Disparities in Access to Fertility Preservation in Young Women Diagnosed With Cancer.” Joseph M. Letourneau, James F. Smith, Erin E. Ebbel, Amaranta Craig, Patricia P. Katz, Marcelle I. Cedars, and Mitchell P. Rosen. CANCER; Published Online: March 26, 2012 (DOI: 10.1002/cncr.26649).

Traveling the Other Direction for Fertility Treatment

Medical tourism is growing, and for United States residents, the promise of less expensive fertility treatment is one of the reasons why. But not everyone who travels for fertility treatment is flying from here to there. Some are coming here, to Houston Fertility Center.

A new report commissioned by UK-based medical tourism site, Treatment Abroad, reveals where people are going and why. Traveling to other countries for fertility treatment has become more popular in the UK because of tight government restrictions on who can access varying types of fertility treatment. Among the more than 1,000 European patients who took part in the study, 4 percent were seeking treatment for infertility. The most popular destinations for those patients were Spain, Cyprus, and the Czech Republic. The biggest reason cited? To avoid waiting lists for treatment in their home countries.

The U.S. gets bonus points for leaving questions about treatment access up to physicians and patients, not government agencies. Still, patients from America are also finding reasons to bundle up their vacation time and fertility treatment cycles, sometimes flying to the other side of the world to try and achieve pregnancy. But as this article in the International Medical Travel Journal reported in 2009, more and more Americans are traveling to... other states in the U.S.

We often have patients from other states and regions of the world, including Mexico, South America, and even Scandinavia. Their reasons? When they combine all the factors -- sophistication of medical care available and all costs involved in fertility treatment -- coming to Houston Fertility Center makes the most sense.

Photo: TracyMorris.com

Houston is a great place to visit, and here's why:

• Two large airports and a central U.S. location make flying here relatively inexpensive.

• Big city culture and amenities -- thriving arts community, world-renowned restaurants and shopping -- yet neighborly friendliness abounds.

• It's just a quick drive to the Gulf Coast for fun on the beach.

• Our weather is usually moderate (maybe not so much in summer, but every place you go has great air conditioning!)

• The cost of living is lower than in nearly every other big city in the States, so visitors find savings in accommodations and travel around town.

When you match all of Houston's benefits with Houston Fertility Center's locations, highly experienced staff, state-of-the-art laboratory, and variety of patient discounts, it makes a lot of sense to come this way for fertility treatment. And you won't even need to learn a new language.

~ Dr. Sonja Kristiansen M.D.

How Much Activity Enhances Fertility? A New Study Says...

Balance is one of the hardest things to achieve in life, and it seems like that's especially true for women who are trying to get pregnant. You know that overall health and fitness play a role in fertility, but you've also heard that there really can be too much of a good thing. Trying to keep up with the "do this, do that" of research data can make you want to throw your hands up and say "I quit!"

Image: Ambro / FreeDigitalPhotos.net 

But you don't have to be an exercise physiologist or a registered dietitian to understand a few simple points amid the building database of knowledge about fertility's connections to weight and physical activity.

And here's the latest: Moderate activity wins the game. Again.

A just-released study (from Fertility & Sterility) of more than 3,000 Danish and U.S. women ages 18 to 40 found that moderate levels of physical activity resulted in "small decreases in time to pregnancy" for women of all body mass index (BMI) levels.

If you're struggling to get pregnant, that finding may not seem so exciting. But factor in the rest of the story and fertility patients may feel a little uplifted by this study.

Importantly, the subjects in this study were drawn from the general population, not from among fertility patients. Requirements of participation included:

• being in a stable relationship with a male partner
• planning to get pregnant
• not receiving fertility treatment

Participants were followed for a year or until they conceived. The researchers looked at several variables, including differences in length of time to conception for women throughout the BMI range. They found that vigorous physical activity either works against you (for women of "normal weight," BMI under 25) or doesn't do anything for you (for overweight or obese women, BMI of 25 or above) in terms of time it took to get pregnant.

In this study, vigorous activity included running, fast cycling, aerobics, gymnastics, and swimming.

The "winners" -- in this case, those who took the shortest amount of time to pregnancy -- were women who engaged in 20 to 39 MET hours (total metabolic equivalents assigned to different kinds of activity) per week of physical activity. And moderate activity was key.

Though the authors concede more data is warranted to investigate different types of physical activity in relation to fertility, their study suggests that overweight or obese women might benefit from any physical activity and lean women will likely enhance their fertility by switching to moderate, rather than vigorous, activity.

So what's moderate?

Brisk walking, leisurely cycling, golfing and gardening.


Source: A prospective cohort study of physical activity and time to pregnancy
             L. A. Wise et al., Fertil Steril 2012

Depression, Even Among Infertile, Should Never Be Shrugged Off

Speaking as a physician who has specialized for years in helping infertile men and women get pregnant, the high rate of depression among fertility patients is understandable. And for some patients, it's a little bit of a chicken-and-egg situation: Which came first, the struggles of infertility or the clinical depression? Whichever the case, something we do know is that treating your depression is crucial.

Image: imagerymajestic / FreeDigitalPhotos.net 

A common question in my office: "Dr. Kristiansen, should I continue taking my depression medication while we're going through fertility treatment?"

My general answer: If it works, keep it up, but there are a few exceptions.

This is a really tough decision for most patients, because they've often done enough of their own research to be confused by the data, even from well-done scientific studies. You can find large-scale, carefully conducted research that says depression, itself, seems to decrease fertility, even with fertility treatment. You'll also see studies that say women who are using depression medication have higher rates of fertility treatment cycles canceled.

Men, too, may have something to worry about if they're trying to become a dad and need to treat their depression. A small 2009 study demonstrated that men using paroxetine (Paxil) had significantly higher rates of sperm DNA fragmentation, which can lower their fertile potential.

Until we know more about links between fertility and depression and depression medication, physicians and patients are instituting choices based on the more established data about impact during pregnancy. Here, fertility treatment provides an advantage over conceiving without fertility assistance. The benefit has to do with timing.

Women using fertility treatment virtually know the moment conception takes place. There are far fewer mysteries when you're inseminated or you've had embryos transferred. And since we know some depression medications when taken during pregnancy are closely linked to congenital defects, essentially scheduling conception allows the woman to make choices in advance. She may choose to stick with her current medication, or she may talk to her prescribing practitioner about using an alternative treatment.

I and my staff at Houston Fertility Center encourage our patients to speak frankly with the health care professional who prescribes their depression treatment. Tell them you are trying to get pregnant, even before you make the choice to use fertility treatment. In no case do I ever recommend that you simply avoid making a choice.

The hormonal fluctuations that every woman undergoes through both fertility treatment and pregnancy can have a tremendous impact on  your emotional well-being. If you already know you experience depression, or if you start to experience mood swings or emotional dullness that are worrisome, keep all of your health care providers in the loop. That way we can work together as a team for the benefit of you and your hoped-for baby.

~ Dr. Sonja Kristiansen M.D.

"Big News" About New Eggs Is a Big Maybe

This week, a study published in the journal Nature Medicine is promising to scramble a long-held belief about women's eggs.

Scientists at Massachusetts General Hospital have isolated egg-producing stem cells from human ovary tissue. Then, in laboratory conditions, the cells eventually resulted in new egg cells.

Image: Carlos Porto / FreeDigitalPhotos.net

It's the big health news du jour. (So I'm sure my inbox will fill with hopeful "Dr. Kristiansen, did you see the news?!")

For years now, we've all believed that females are born with the most eggs they'll ever have and that when the number dwindles down, natural infertility is the result. This new finding is exciting in terms of possibilities for related infertility treatments.

But good research takes time. Often, a very long time.

Do you recall when we started learning more than a decade ago that, contrary to long-held beliefs, human brains can generate new cells? It's very exciting to consider people with brain injury may be able to recover more fully! But now, many years of research later, experts in neuroscience are skeptical again.

There are still far more questions that must be addressed before this knowledge about "new" egg cells is usable by fertility specialists in helping women with age-related infertility or premature ovarian aging. In fact, I'd bet that the necessary details will come too late to institute a related plan for any woman who is currently considering fertility treatment. For those who want to delay conception but take advantage of their youthful fertility, the best options remain egg or embryo freezing via IVF. And my team at Houston Fertility Center will be happy to serve you with those tried-and-true techniques, today.