Challenges of Infertility: Ask the Fertility Specialist Health Radio September 25, 2007 John Petrozza, M.D. Barbara Collura.

Transcription

1 Challenges of Infertility: Ask the Fertility Specialist Health Radio September 25, 2007 John Petrozza, M.D. Barbara Collura Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction Hello and thanks for being with us once again. Andrew Schorr here broadcasting from, yes cloudy, drizzly Seattle. Just a couple of minutes ago I was stuck in terrible traffic. We used to have about the fourth worst traffic in the country. Now I think it s maybe the tenth, so I guess that s good news. It s still not pleasant. Hopefully you re navigating successfully where you live. You know one of the cities that also has bad traffic where they had the famous Big Dig is Boston. In a minute you are going to meet a couple of experts from there on a really important topic, and that is fertility. You know there are about six million couples who are concerned about their fertility right now in America. What s it all about? So certainly we know that people who are trying to be parents later, they get their careers going, and they want to be as set as they can financially. Maybe both male and female are working, that s very typical these days, so they wait. Well how does that affect your fertility, and then if you are having trouble, what do you do? What are the options today? If you go through fertility treatments does that raise the chance of a multiple pregnancy and what does that mean? Where does insurance come in? Can they help, and what if you don t have insurance? What are the costs involved, and then what if you are just going through this, and you are dealing with the emotional load? So many of us, you know you are in high school or if you go to college and if you carry on a sex life what you are thinking about is not getting pregnant, not parenting a child at that point. Then suddenly when you say, Okay, let s go, and then things are not happening. Then as it happened for friends of mine they had what s called secondary infertility where they had one child, and they said, All right, we are ready for a second, and then it wasn t working. The mom kept having miscarriages went through all sorts of fertility treatments. Ultimately they adopted a child, and so they have two beautiful children. 1

2 There is an organization that is very much dedicated to that. That s called Resolve. It is based in Boston but it has chapters all over the country. Actually we went to a meeting one time when we too were having difficulty getting pregnant a second time. So in a minute we are going to meet the executive director of Resolve, and we will hear more about their activities. First I want to introduce Dr. John Petrozza. Dr. Petrozza is at Massachusetts General Hospital in Boston, one of our leading medical centers in the country, if not the world. He is Chief of the Vincent Reproductive Medicine and IVF Division there, and Dr. Petrozza thank you so much for being with us. Did I kind of frame the fertility situation accurately there? Andrew, thank you for having me. You did a fantastic job. I think you did an admirable job of portraying some of the issues that we have to deal with and that patients have to deal with when it comes to trying to have a family. I think one of the points you hit on is very true in a sense that when we are ready to have kids, when couples are ready to have kids, it is one of these things that we take for granted. It s one of these things that we expect. We are going to do it. It is going to happen quickly and when it doesn t as you can imagine, it becomes a very frustrating time for the couple. You know what s going on? It s a time of stress. It s a time of emotional strife in the relationship, and I think it s one of these things that in the past we probably weren t very aware of the issue as a general public. I think with the help of organizations like Resolve I think it has been able to come into the limelight a little bit so that people are aware of this now. I think you ll be hard pressed to find somebody who doesn t know somebody who isn t going through the issue of in fertility. Well we are going to find out a lot more from you as we learn what can be done. But let s meet Barb Collura. Barb is the Executive Director of Resolve, the organization we ve been talking about, the National Infertility Association. Barb thank you so much for being with us. So when we talk about this, and again compliments to Resolve for really putting this in the public consciousness because it is affecting millions of couples today isn t it? Ms. Collura: It absolutely is, and let me just give some updated statistics for your audience. There are 7.3 million people who are diagnosed with infertility. Those are statistics according for the Centers for Disease Control. That equates to one in eight couples of childbearing age. So as Dr. Petrozza was saying, you may know someone or chances are good that you may know someone. When you look in one in eight couples I think we can all probably say we probably do know someone, but here s the interesting fact. Most people do not share their infertility 2

3 with others. I love to let people know that we have volunteers all over the country, some extremely active, and we have had some of our volunteer leaders who have told us that their own family does not even know they are going through infertility. Perhaps they live in a different state, and they are not right there and see what they are doing every day. It s a disease that carries a lot of shame, and people tend to keep it to themselves. So we actually did a survey a couple of years back where we asked people, Do you know someone who has infertility? and the majority of people said, No, I don t, and yet the statistic is clearly one in eight couples. Potential Causes of Infertility So Dr. Petrozza what are the causes that we know about now? Just help us understand the range, and not just the woman but the man too. Sure. One of the important things to realize, because I think when it come to infertility there is this misperception that it's a female issue and I often have couples come in, and it is just the woman, and I sit there and I say, Where is your husband? They ll say, Well he said to get worked up for us because it s probably you, and it s probably not me. That can t be any further from the truth. We probably see male factor issues at least 40 percent of the time in our practice, which to me is pretty significant. Other causes of infertility are tubal factor, meaning that the woman s fallopian tubes are blocked, either one or both of them. There are issues with the anatomy of the uterus, perhaps it doesn t have a normal configuration and isn t able to allow implantation to occur, or perhaps it's abnormal and that s the cause of miscarriage. There are other pelvic issues like endometriosis or pelvic scar tissue; let s say from a prior pelvic infection or prior surgeries, and these could be affecting the tubes. Keep in mind that the tubes don t necessarily have to be blocked in some of these situations. For example we know there are issues with blocked tubes, but if someone has really bad endometriosis the tubes could be open, but they could not be functional for example if they are being held up by scar tissue. Some women have issues with their cervix. Perhaps they have had prior surgeries on the cervix for abnormal pap smears, and of course there are the issues with age. We know that as a woman gets a little bit older the chances of her conceiving starts to go down. We are going to need to take a break Dr. Petrozza. We re going to come back with our discussion with Dr. John Petrozza who is chief at Massachusetts General Hospital Fertility Center and the Vincent Reproductive Medicine and IVF Division, and Barb Collura from the 3

4 leading organization in this area, the National Infertility Association, which is called Resolve. We'll be right back. Welcome back to Patient Power live on HealthRadio Network. This is what we do every day. I m delighted to do it, and that is connect you with leading experts to help you and your family deal with health issues that you have, ones that may come up, health issues that you are trying to head off, prevention is the name of the game and so many things. So today we are talking about an issue that affected my family, and it probably affected somebody else on my street, and it probably affects people I work with, I may not even know it; it surely may affect you or someone you care about, and that is infertility. As Barb Collura from Resolve, now based in Virginia I should correct, from The National Infertility Association mentioned over seven million couples are dealing with that right now. Besides Barb we also have with us Dr. John Petrozza who is a leading expert. He s the Chief of the Reproductive Medicine and IVF at the Massachusetts General Hospital in Boston, which is one of our premier medical centers. So Dr. Petrozza I was thinking about my friend Elizabeth. So Elizabeth had a daughter who is now almost 18 years old, a lovely girl. They tried to get pregnant again. Miscarriage, miscarriage, miscarriage and they were so frustrated. While they held out adoption as an option, and eventually did it, prior to that they tried various shots that she was having, but this whole issue of I guess what you all in the field call secondary infertility, how common is that? Where does this come from because everything worked the first time? Right. That s a good question Andrew. You know we deal with secondary infertility almost the same way we would deal with primary infertility, although as you can imagine it is a little bit more frustrating for the couple who haven t been able to achieve a pregnancy at least once. It is relatively common. Overall we see primary infertility about 15 percent of the time. Secondary infertility is probably a little bit less than that, probably somewhere between 5 to 10 percent. In your particular friend s case it is a little bit interesting in that she is not having any difficulty getting pregnant it sounds like, she s just dealing with an issue called recurrent pregnancy loss, which in many ways goes hand in hand with infertility as far as some of the causes and some of the diagnostic tests we do to try to unravel what may be causing this. The treatments are often the same in the sense that once a diagnosis has been found or hasn t been found, a lot of times we are just trying to help the couple expedite trying to get pregnant. So that s how it differs, but as far as secondary infertility per se, we sort of track it and diagnose it the same way that we are dealing with primary infertility. 4

5 One of the things, I know there is communication going on to a woman s uterus, hormonal changes and things like that. So we wondered though, as far as was her body sort of communicating differently to the lining of the uterus that was then aborting the development of the egg. What was going on there? Is it hormonal changes? I know it s complicated, but we wonder well why would it be different if it worked the first time? Right. I think one of the things we always get concerned about when someone is having repetitive losses, especially after conceived once before, is there anything anatomical going on? So one of the first tests we always do in these patients is we just verify that things are okay within the uterus. Does it have a normal shape? Does it have a normal contour? For example, if someone had a C-section for their first pregnancy we ve had several situations where people have developed scar issue inside there uterine cavity. All it takes is us going in and trying to remove the scar tissue, and that really enhances that person s opportunity for better implantation in a pregnancy. There sometimes could be issues going on with her hormonal status. Clearly as a woman gets a little bit older it s not uncommon for things to start to go awry. If you think about a woman s menstrual cycle in general, it a period of cyclicity. Things are going up, things are going down, hormones are changing, unlike guys where our hormones are pretty much stable throughout our reproductive life. So for women it is not unusual for things to go a little bit astray, for example thyroid issues or prolactin issues, which are all hormones which are associated with implantation and the reproductive cycle. Some of the other concerns we have, especially if someone is having repetitive loss, could there be something genetic going on? It s not unusual for someone to have a normal healthy pregnancy and a normal healthy child and still be harboring some type of genetic rearrangement within their cellular makeup that may predispose them to have recurrent pregnancy losses. We call these things in general balance translocations, or Robertsonian translocations. So all the genetic material is within the cells, it s just packaged a little bit differently, and because of this rearrangement in the packaging they may produce sperm and they may produce eggs that are going to be predisposed to be abnormal. You know obviously as I said at the beginning, many Americans are now choosing to try get pregnant the first time later. Where does age come as a factor in making it more difficult, and not just for the woman but for the man? 5

6 That s an excellent question, and I think here, Massachusetts thanks to the help of Resolve over the years, is a mandated state. I know we ll get into some of the issues about cost, but what it means for residents of Massachusetts is that, for the most part, their fertility treatment will be covered by their insurance company. What it may also mean is that things are getting delayed a little bit as far as people coming in to see us because they are putting things off. Like a lot of big cities we have a lot of young professional women who are trying to advance in their careers. They are delaying trying to get pregnant, and so the average age of our patient here at Massachusetts General Hospital is probably somewhere between 36 to 38 years of age. One of the things we are always focusing on when we see a couple with infertility is what is the woman s ovarian reserve? Ovarian reserve is the general term we use in the infertility field referring to the number and the quality of eggs that particular woman has left in her ovaries. Now that number is determined by many factors. There are some genetic factors involved, there are some environmental factors involved, but they all sort of pertain to how successful that woman will be either on her own or even with some of our treatments in helping that woman conceive. So if someone comes in with primary or secondary infertility and they are above the age of 30, we are always checking ovarian reserve because we know that statistically there are going to be decreases in fertility beginning at about age 30. Then we start to see more of a steeper drop off at age 35. Then at age 40 we see a pretty dramatic decrease in pregnancy rates, and more importantly healthy take-home baby rates in that age group. Well we have a lot more to talk about. As I mentioned also with us is Barb Collura, and the Resolve organization which we have mentioned a few times, and Dr. Petrozza has mentioned in playing a role in what coverage there is available for people in Massachusetts, and that s an issue that we have to discuss for every state. There is support available for people. Barb, just a couple of words before we have to go to commercial, is people are not alone. Certainly this is emotional; certainly for the woman, often for the man or even for the couple and their interaction with each other, and Resolve can help. Ms. Collura: Absolutely. People talk about infertility being as stressful as a cancer diagnosis, and what I have learned about infertility, I ve gone through infertility myself and have had the opportunity to hear a lot of different people speak about it and read books. It affects really every facet of your life. It affects you emotionally, physically, spiritually and financially. There really isn t an element of your life that is not affected by a diagnosis of infertility, and people need to understand that this is a very serious issue, that there is 6

7 support out there, and they are not alone. That is a hugely powerful message that people need to hear. Well we ll keep reinforcing it during our program today, live on HealthRadio Network, Patient Power. We are all patients for all sorts of things. Fertility issues could be one for you. We ll continue our discussion with Barb Collura from Resolve and Dr. John Petrozza from Massachusetts General Hospital right after this. Stay with us. I want to make sure you take a look at our website, where I have done about 400 hours of programs like this. If you were listening to HealthRadio Network last week, I was really touched by our program on cystic fibrosis. It s featured right at the top of the website. Maybe you remember Erin Keitges. She is 19 years old. She has a track and cross-country scholarship to the college she goes to, and she has cystic fibrosis, which definitely affects her lungs. What an inspiration, and what an example of progress. So I would commend you to listen to that. Well there has been progress in the whole field of infertility, and obviously that affects millions of couples. We have with us Dr. John Petrozza who is Chief of the Vincent Reproductive Medicine and IVF Division at Massachusetts General Hospital. Also we have with us Barb Collura who is executive director of Resolve, the National Infertility Association. Diagnosis and Treatments Options Let s find out from Dr. Petrozza, there is a whole alphabet soup of acronyms you have for different procedures. Some of us are familiar with some like IVF, in vitro fertilization. We ve heard that, but there are a whole bunch of others. I m just going to rattle off some and take us through it: IUI, ICSI, AH, PGD, and a new one I think SCT. Help us understand where this comes into play, and then we ll get Barb to help us understand how we pay for these interventions should we need it. Dr. Petrozza? Andrew, you know we like to have our own little language I guess to try to confuse everybody with all these acronyms. If I can I d like to take a few minutes to sort of frame things as far as some of the diagnostic things that we do, and then I ll try to sort of explain some of these acronyms and lead into some of the treatments real quick. Whenever someone is infertile some of the diagnostic tests that are typically done, first and foremost we do a semen analysis because once again we are going to see male factor issues at least 40 percent of the time. A hysterosalpingogram is an x-ray study that we do to evaluate the uterus and tubes. It s quick, it s easy and it s relatively comfortable. I 7

8 must admit that some women will get some cramping with this, but it s the easiest test we have out there to give us good information about the uterus and the tubes. Then we are going to spend some time as I mentioned before evaluating the woman s ovarian reserve. The best way to do that is to do a day 3 FSH and estradiol level. You have to give both together because they both feed back and relate with each other. You can t just get an estradiol level which is an estrogen level, and you can t just get an FSH level because by themselves they are meaningless; together they mean a lot. They are typically done on the 3 rd day of the cycle when they are the most sensitive. Typically the lower the number is, the better your ovarian reserve. The higher the number is, the worse your ovarian reserve. So when numbers start to get about 10, and definitely above 12, we are definitely dealing with some diminished ovarian function. Keep in mind that all of the treatments that we have to offer in the fertility center are only going to be as good as your ovaries will allow them to work. So if you have diminished ovarian reserve, chances are you are not going to get a good response to the medicine, and chances are your chances of conceiving are going to be less. Let me add a little bit of some outliers to the factor and to a woman s ability to conceive, and first is weight. I know this is a sensitive topic, but we are getting more and more literature suggesting that when a woman s BMI is above 30, and that s the obese range, that the woman s chances of conceiving are going to go down. So one of the first things we do in our practice if we see someone whose BMI is high we are going to spend some time counseling them and trying to get them into counseling and nutritional counseling to try to help them to reduce their weight because we know that ultimately that is going to help them have a better chance for success and a healthier pregnancy. The other factor is the woman s age. That relates a little bit into ovarian reserve. Most of the data out there suggests that once a woman gets above the age of 43 the chances of getting pregnant and taking home a healthy child, meaning no generic abnormalities, everything is fine, ten fingers, ten toes, everything is wonderful, it s going to drop down to probably less than five percent. So I can t stress this enough. If you are thinking about trying to get pregnant, and if you are above the age of 35, and if you ve been trying for a year, you should seek some kind of assistance whether it is through a gynecologist or an infertility specialist. If you are above the age of 35 you should start thinking after about six months or so that maybe something is going on. Now let me talk a bit about some of those acronyms that you mentioned and some of the treatments. Keep in mind that the goal of our treatments whenever we are dealing with patients is to try to help them get pregnant the easiest way possible. People come in and they say, I want IVF. You sit there and say, Well why do you want IVF? Because my friend had IVF, and I know that it works. Well yes, IVF is a great treatment for specific indications, but it s not an easy treatment to do. There are lots of medications. There are lots of injections. There are some invasive procedures, and so I think most centers try to 8

9 find a diagnosis for the couple and then develop a treatment protocol that they think offers that couple a reasonable chance for success. Some of those treatments you mentioned are IUIs, or intrauterine inseminations. Those are typically some of our first line treatments. So if someone comes in and there are normal tubes and ovaries, and the sperm count is relatively normal, but even if it is a little bit low, intrauterine insemination, or another name is called artificial insemination is a great treatment. We often will combine that with some of the medicines that we have available. The easiest is Clomid or clomiphene citrate or Serophene. It s the fertility pill. It is a very easy medication to take, and success rates are improved over patients who don t take these medicines for certain diagnoses. The other type of medicine that we offer called gonadotropins, which are injectable medicines, much stronger. Usually we have to monitor these patients very carefully. So these aren t medicines we are going to send the patients home with and say, Come back in three months and tell me if they work. These are injectable medicines, and these are the medicines that if they get out of control, these are going to be the patients that you hear about in the news with eight babies saying, Look at my family now. Things got out of control. So with those kinds of medications we follow those patients very carefully to ensure that doesn t happen. You are doing great. Now what about some of these others though, the SCTs, AH, PGD, what do they mean? Just for a quick definition. I see ICSI or ICSI, stands for intracytoplasmic sperm injections, and all of these acronyms that I am going to explain now are related to the process of in vitro fertilization. So ICSI is a process where we can work with very, very low numbers of sperm. The process involves us getting a single sperm that looks normal, that s moving and pulling it up in a very tiny pipette, and injecting into the egg to create fertilization that way. So for IVF in general we need to have a fair number of sperm swimming around in order to fertilize the egg, but when you are dealing with low amounts you don t have the luxury having lots of sperm to put around the egg to get it to fertilize. So you have to do this process called ICSI. The other acronym is assisted hatching, or AH. That s a process that we use to try to help improve implantation. We don t use it on everybody because we don t think it is indicated for everybody. We typically do it whenever we see a thick shell around the embryo, and embryos do have a shell. It s almost like a little chicken egg if you will. There is a shell that develops to try to prevent more than one sperm from getting in. Once the sperm fertilizes the egg and the embryo develops, the shell gets very, very hard. So for some women it is hard and it s thick, and so we want to sort of open it up to allow that embryo to come out when it s ready so that it implants into the lining a little bit better. 9

10 The other acronym is PGD, which stands for pre-implantation genetic diagnosis. It s a screening tool that we use to help people with certain genetic disorders and helping them try to conceive children that don t have that genetic disorder. For example if someone comes in with cystic fibrosis, and we know the gene that s involved with cystic fibrosis. We can screen those embryos and determine which ones have it and which ones don t and only put in the ones that don t have the mutation back into the woman s uterus, and help them have a family free of cystic fibrosis. Wow, that s a relief. That s great, and then SCT? SCT is sort of a new and up and coming thing. They have been doing this in Europe for years, and it s just now starting to take hold here in the United States. That stands for single embryo transfer, because part of the concern with IVF over the years, and we ve been getting a lot of grief from our high-risk obstetrician colleagues saying, What are you guys doing there in the IVF unit? You sent us another triplet pregnancy. Part of the problem with IVF over the years is that in order to ensure a reasonable chance of success, we have to put in more than one embryo. Well part of the risk as you can imagine is that there would be a higher rate of multiple pregnancy. Even twins, as simple as it may sound, is associated with a significant amount of morbidity or issues with the pregnancy. So in Europe over the last five or six years they have been working on trying to generate better embryos and putting in one embryo versus two or three. They have been getting very good success. Here at Massachusetts General for example, we ve been doing this for about three years now. We will grow the embryos out to a stage of development called the blastocyst stage. By doing that we think that natural selection is occurring, and the better embryos are continuing to grow. Then we will take a single blastocyst and put it into a woman, and most of our patients that we are doing this on are usually below the age of 37 so that they are overall in a better prognostic group anyway, but our success rates are just as good as when we used to put back two or three embryos, but we are getting hardly any, if any, multiple pregnancies, and I think that s the goal. We want you to have a good, healthy, singleton pregnancy. Insurance Coverage Issues We have so much more to talk about but people are clamoring to ask questions. I just want to ask one though of Barb Collura. So Barb, your organization Resolve worked hard in Massachusetts where people have coverage for these fertility treatments, but that s not true across the country. Where are we now with it, and what can be done about it? 10

11 Ms. Collura: You know Resolve is a patient advocacy organization, and we really take that to heart. What that means is that we are here to speak on behalf of the 7.3 million people with infertility, and advocacy is an area that we take very seriously. We have 15 states that currently have some level of mandated coverage or a mandate to offer, meaning their state legislators have passed laws stating that employers who fit into a certain category are either mandated to provide insurance coverage or mandated to at least offer insurance coverage. In the rest of the country we do not have mandated coverage. There is, and continues to be, in almost every congress a bill to mandate insurance coverage for any health insurance plan that covers obstetrics, and there is a current bill in play right now. Congressman Anthony Weiner from New York has sponsored that bill. If you want to find out more about that particular bill you can go to our website at click on the button that says take action, and you can find out all the information about what is going on in the federal arena as well as at the state level. I will tell you that in 2005 Resolve helped pass legislation in the state of Connecticut, and we had volunteers working in that state for almost 15 years. So I don t want to discourage people, but you need to start now. You need to start talking to your state legislators, you need to meet with them, you need to tell them about your story, and really it s an outrage. It s an outrage that this disease is not covered by insurance, and I don t even want to go into it, but there are a lot of crazy things that the insurance companies do regarding diagnosis and treatment for infertility, even getting a referral to a specialist in some places is very, very difficult to get. So I encourage people to speak out, to seek help. I ll also tell you that we started a new initiative in the last two years looking at employers. What people can do who are employed and who have health insurance through their employer, is to get their employer to take action. We have seen some amazing results in this area, and again our website has some great information and tools for people to convince their employers to offer coverage, and to get their insurance company to offer coverage. It s a very costly proposition, as you know, and we know there are many, many people who never get the coverage they need. Listeners' Questions Right. Thank you so much and thanks so much for all you do. Let s fire some questions away. They are predominantly clinical questions. Michael wrote in from Georgia, and it is something I ve really worried about, Are hot tubs really bad for men, particularly if you and your wife are trying to conceive? 11

12 Are hot tubs? Right. Okay, I thought you said hot dogs, and I'm thinking, "Andrew, I haven't heard anything about hot dogs.' <laughing> And I'm sure you're a Red Sox fan, and you're eating hot dogs pulling for them, but "hot tubs." The question; in general the answer is probably yes. Part of the concern is that if a man is sitting in a hot tub frequently or for long periods of time that there is going to be some diminished sperm quality because there is a reason why the tentacles are in the scrotum, hanging outside the body. They typically need a cooler temperature. So if you are sort of warming them up to these nice comfortable hot tub temperatures, unfortunately that might not be the best thing for the sperm. For the women it s a little bit iffy during the infertility treatment stage or in the process of trying to conceive because the ovaries are well inside the body, and the fluctuations in temperatures will be less. However, once you do conceive there s lot of information suggesting that if you are exposed to higher temperatures there is a higher risk for neural tube defects in your offspring. So it s one of those things, much as I hate to say it, you should probably limit or get rid of during this pre-conceptional stage. Okay here s another sort of related issue, but it s kind of different too. Laura writes, and she is actually worried about her son. She said, I have a six-year-old boy whose left testicle was undescended at birth. Then at three years old he had surgery and it brought the testicle down to its normal position. She wonders if there could be a problem with his fertility because of that. That s a very good question, and thank goodness that guys have two testicles because typically if one isn t functioning well, the other one will compensate. Part of the reason a testicle doesn t come down, and there are several reasons, but one of the more common ones is that it wasn t producing enough testosterone, because testosterone, which is the male hormone, is what drives the testicle to come through the body and down into the 12

13 scrotum. So there is a good chance the testicle may not be working very well anyway, but if the other one descended well there is a good chance it is producing lots of sperm, and he ll have an equal chance of conceiving down the road, but he should definitely keep that in mind. When he reaches the age and is thinking about having a family, it will clearly be one of the things he should lock away in the back of his mind and say, If this is not happening this may be a bigger issue than I thought. And Laura it sounds like you will be grandma with that kid. There you go. That s right. Preserving Eggs for Post Cancer Treatment Hopefully you can look forward to that. You know a lot of who people listen to this show are people who have had cancer treatment, and that is a big issue about fertility after cancer treatment. Of course even younger women with breast cancer or other cancers are treated for that, and we are trying to have less toxic therapies. Where does that come in? Often there is a question of well should you save some eggs prior to treatment so that hopefully as the cancer treatment is successful then you can go on and raise a family. Where are we with that now doctor? That is a fantastic question and I m glad you brought it up Andrew, because we ve been freezing sperm. Everyone knows that we can freeze sperm and that it s out there. We hear about sperm banks. I think for many years oncologists weren t very good about directing their patients to freeze their gametes. Then I would say probably over the last 10 years there has been increased awareness about getting these folks to at least cryopreserve some of their gametes, especially with the man in freezing sperm, but eggs have been more of a difficult issue. You know sperm you can freeze very well, and it thaws very well. Eggs are a different entity all together. The eggs are typically a larger cell. They don t freeze very easily. There is a lot of damage when you thaw these eggs, but now things are getting a little bit better. Probably one of the largest groups in freezing eggs has been in Bologna, Italy with Dr. Porcu who has been doing this for the last 10 or 15 years. Even then her success rates have slowed climbed from about 10 percent to about 20 percent success, which overall is still kind of low when you compare it to regular IVF treatments and success rates. More and more centers are doing it in the United States. We are doing it here at Massachusetts General Hospital. It s still considered investigational, and it is something that women should clearly think about. 13

14 When women are diagnosed with cancer, and they are going to go through some of these agents that may render them sterile because of the effects that it has on their eggs within the ovaries, I think they need to come in and see a fertility specialist. There may be an opportunity where they are in a relationship, and we can freeze embryos because we can clearly freeze embryos much easier than we can freeze eggs, and success rates are very, very good with frozen embryos, but if a woman doesn t have the opportunity to have a partner, then I think freezing eggs is a reasonable option for her. One other question that is related and it s not just cancer, but a lot of people are taking medicines. You may take medicine for cancer, but you may take it for some other chronic condition. How much should we worry? I know it is going to vary by drug of course, related to even if it is supposedly safe, that it will change your eggs or genetics somehow so that you would have to worry if you could get pregnant that that would be a child with some difficulty. You know you could probably take that one step further Andrew, and say what about all the environmental things that we are exposed to, not just medications. You know some medications do have an affect on the genetic makeup of some of the cells, and that we use for different types of things. Methotrexate is one, colchicine for gout. Methotrexate is for rheumatoid arthritis. There are all these medications that we think may have a subtle role with the ovarian reserve and the quality and number of eggs, but it s hard to quantify. We are working, for example, with the Harvard School for Public Health on looking at some environmental agents, and we are finding some very astonishing results as far as some of the compounds in plastics. One of them is called phthalates, which is what allows plastic to be flexible. We are finding very high levels in the fluids that are around the eggs in a lot of women, and we are trying to sort of see if it is associated with reduced outcomes. We are looking at Teflon, which is very commonplace, and we are starting to see whether or not they may have an affect because that s metabolized the compounds that have been associated in the past with decreased egg quality. We are looking at some of the compounds that we see in wrinkle-guards, the thing that keeps our clothes from wrinkling, keeping us from having to iron every day. You know those types of things. We can go on and on and on, but those are some of the things we are always thinking about, but it s hard to quantify. I think what we are going to need to do Dr. Petrozza as things have flown by and Barb Collura too, is people have tons of questions and I think we have done a great job today in kind of laying out the groundwork, and we will have to have you back just to take 14

15 questions because there are so many. I will mention if people go to the website they can navigate to your fertility center, right Dr. Petrozza, and Massachusetts General is one of the leaders in the field and certainly Dr. Petrozza and his team are. Also there is and that s how you can not only become an advocate as Barb Collura was describing but also know you are not alone, and then you have chapters all over the country, right Barb? Ms. Collura: Absolutely, local support, which is hugely important for people going through infertility. Well I know I went to a meeting like that and just to know that you are not alone in a safe space where people could talk. We are going to wind up. I want to thank both of you for being with us. Remind your friends folks that the replay will be on It will also be on We welcome your questions. We will get our experts back again. This is what we re devoted to. Coincidently we are going to have a replay of a program with an expert from Massachusetts General on tomorrow, Dr. Darin Dougherty, who is a psychiatrist there. We are going to talk about helping people who have drug resistant depression. So this is what we do. It s all about having knowledge so you can make smart decisions. Thank you for being with us today. Have a great day and remember, knowledge can be the best medicine of all. I m Andrew Schorr signing off. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 15