Infertility: Understanding Your Options Webcast October 12, 2010 Erica Marsh, M.D. Introduction

Transcription

1 Infertility: Understanding Your Options Webcast October 12, 2010 Erica Marsh, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction While infertility can be frustrating, there are options to help. In this program, a reproductive endocrinologist from Northwestern will discuss infertility and how you can increase your chances to have a baby. You'll also hear from one of her patients who is now pregnant with her second child. It's all next on Patient Power. Hello and welcome to Patient Power. I'm Andrew Schorr. This program is sponsored by Northwestern Memorial Hospital. We're going to talk about infertility. I know it personally. My wife and I have three children. We were successful in having a first child but then it was tough to have a second, and we visited a reproductive endocrinologist, and it helped, and we have three healthy kids, the light of our lives. And that's the dream for so many couples. But infertility has affected so many people, so in this program we will meet a reproductive endocrinologist, that's someone who specializes in helping couples who are dealing with infertility. And we'll also meet one of her patients who I'm happy to say is now pregnant with her second child, had gone through various workups to see what was going on with her and also to help them have their first child. Let's continue now with Dr. Erica Marsh. Dr. Marsh is the reproductive endocrinologist I was speaking about. She's on the staff at Northwestern Memorial Hospital and the Prentice Women's Hospital, and she is an assistant professor of obstetrics and gynecology at Northwestern University's Feinberg School of Medicine. Dr. Marsh, I said infertility is not uncommon. What is the prevalence of it in the United States? You're absolutely right. It's about 10 percent in the United States, and in fact that's also a figure that we see pretty much globally. So, you know, one out of ten married couples is facing the challenge of trying to get pregnant. How do we define infertility? Infertility has a very specific definition medically. We define it as the inability to achieve a pregnancy after having unprotected sex for 12 months.

2 Nicole s Story All right. And so certainly someone going through this, we talked about the prevalence, that someone is not alone. And someone who experienced this in her early 30s is Nicole, who joins us from Chicago. She's an elementary school social worker in the suburbs of Chicago. Nicole, you married your high school sweetheart, Joe, and you had been on the pill for many years and then married for about four years or so and then you said, well, let's see if we can start a family. We were about to turn 30, and so we went off the pill to see what would happen. Most of our friends had gotten pregnant in the first three months of trying, and that was not the case for us. All right. And your hope was have two or three children. You and Joe were talking about that, but you thought take the brakes off and proceed, right? Absolutely. I thought it would just happen for us easily. All right. But it wasn't. So what was happening? When you stopped taking the pill what was happening with your periods? They [cycles] were very long, up to 56 or 70 days, and I was getting painful cysts during that time of that whole summer that we started to try. All right. So this goes on for several months. Eventually you go to your doctor, an OB gynecologist and what happens? I went to my OB with some charts that I had made of the summer of what we had done and how long the cycles were, and she said, you know, that's not normal, and put us on Clomid at the lowest dose to start with. And this was to try to regulate your periods. And get me to ovulate. 2

3 And have you ovulating, and sort of have everything on schedule where you could ovulate, have intercourse at the right time and hopefully have conception. Right. Was it working? No. It wasn't even making me ovulate. So what happened next? So you're seeing basically your primary care women's doctor. Right. What did you do then? In the second month of trying Clomid that it didn't work, she had put it up to the next dosage, and it still didn't make me ovulate let alone obviously get pregnant. I decided, my husband and I decided that we wanted to seek out a specialist that a friend and a cousin of ours had used. So that brought you to Northwestern's Prentice Women's Hospital and a reproductive endocrinology clinic where that's all they do is deal with fertility issues. Correct. Did you feel you'd come to the right place? I did. In our first meeting with Dr. Marsh we got to speak with her for I think almost an hour just about everything that we had tried and done and where we were at that time and place. And she was able to tell us what we hadn't done yet and what we needed to do and what the next steps were, whereas my OB hadn't, you know, brought any of that up to us. 3

4 Right. Well, you had come to the right place. Dr. Marsh, when you meet with someone for an extended time like that, you're trying to understand the history and the couple because issues could come up from male or female or both. So what you're doing is you're trying to learn about them, history, could there be an underlying condition and also their hopes and dreams? Absolutely. Absolutely. I think it's very important particularly at that initial meeting to give the individual or the couple the opportunity to kind of share their story, share their experience and share what they hope to get out of the experience and how they want their experience to be shaped. You know, some patients come in prepared to have any and every possible intervention, and some patients come in really wanting minimal intervention, and I think it's important as a physician to know what your patient is prepared for. And, you know, you still certainly share all of the options, the treatment options, the available options with them, but I think it's important to meet your patients where they are. We do a lot of medical programs, and as I think about infertility I think you have more acronyms in this area than others, and we'll talk about a number of them. So when a couple meets with you and you talk about the options there's, you know, IVF, and ICSI I think is another one. There are all these different letters, but first you have to understand, well, what's going on there, and they also have to understand that they're on a journey that could be complicated and even demanding, right? And sometimes depending on insurance, in Illinois many insurance plans cover infertility to different degrees, but there could be an expense as well. And an emotional roller coaster potentially too, right? Yes. Yes, you're absolutely right. I think one of the first things I review with patients is that this journey is--the expectation should be set that this is going to be a journey that lasts months to years, not weeks to months. A lot of patients come in thinking, oh, I'm at the specialist's now, so this is just going to get fixed next month. And the reality is we have about 12 days in a calendar year that we can get a woman pregnant. The reason for that is basically tied to what we need to achieve a pregnancy. And I go over with each patient, you know, we need a healthy egg from a female, we need healthy sperm from a male, and we need a healthy uterine environment, meaning we need a healthy place for this pregnancy to implant and grow. Now, to get a healthy egg we have to allow a certain amount of time for that egg to mature, and that maturation takes place over each menstrual cycle. So in a typical 28-day cycle it takes us about 14 days to get to the point where we have an mature egg that is ready to be released from the ovary, and so once a patient tries to get 4

5 pregnant if she isn't able to get pregnant we can't just say, well, let's try again the next day. We have to give her ovary enough time, even when we help it along with medications, to mature another egg or cohort of eggs. Biology Lesson All right. Let's back up for one second and just give everybody a biology lesson in a very simple way. When there are no problems, the way it's supposed to work, you have an egg that's matured. Yes. You have sperm that are healthy and strong - and tell me if I don't get an A on this test. I'm trying here, okay? Absolutely. And so the sperm is introduced into the vagina. The egg is there. They meet up. The egg is fertilized, implants in the uterus in a healthy environment and the cells divide. Did I get it right? I would give you an A-minus on that. Oh, my. So very good, very close. I think one of the things that's important to highlight is that the egg is contained in the ovary, and the process of ovulation is the process by which the egg is released from the ovary and enters the fallopian tube, which is the tube that really takes it from the ovary to the uterine environment. And fertilization actually takes place in the tube, in a setting of a spontaneous pregnancy, and that fertilized egg actually starts to divide while it's still in the tube and making its way down to the uterine cavity. So by the time it gets in the uterus it's already in the eight-cell, about eight cells in size, sometimes a little larger. And from there you had an A plus. So that embryo implants into the lining of the uterine wall and the pregnancy continues to grow. All right. If I ever have to take this test again now I know all the right answers. 5

6 That's right. So with that couple before you, like Nicole and Joe, you're trying to find out what could be going on that's preventing that normal process. Absolutely. Testing So she comes in and she says, well, I've had irregular periods and I've taken a certain dose of one of the medications, Clomid, to try to regulate it. Didn't seem to do anything. We tried for a long time, no pregnancy. Let's get into some of the testing you do to try to understand what's going on. Absolutely. I think before you start treating any patient it's really important to understand what you're treating, and by doing that you know that you're actually treating the patient appropriately. In Nicole and Joe's case, one of the first things I honed in on was the fact that she had been having irregular periods, and the most common cause for that in reproductive-age women is a condition called PCOS, or polycystic ovarian syndrome. But independent of that specific diagnosis there's a series of blood tests that we ran on Nicole, we did an ultrasound, and helped us exclude other conditions and ultimately diagnose her with PCOS. The main challenge in the setting of PCOS is that women have a lot of follicles, meaning they have a lot of eggs available typically, but the eggs don't reach maturity and they don't ovulate. So what we offered or what had been offered to Nicole was a medication called Clomid, and we know that Clomid is the first-line agent to offer women with PCOS and most REIs like it because it's a tried-and-true drug. REI, of course is reproductive endocrinology-- And fertility, yes, I'm sorry. But reproductive endocrinologists like Clomid quite a bit because it's a very safe medication. It's an oral medication, so it's not a medication that requires you to take injections or shots every day. It's a pill that you typically take for about five days during the menstrual cycle. And it has a very low risk of multiples. One of the main challenges that we face in the field of reproductive endocrinology is helping couples achieve pregnancy without conferring the risk of having them achieve twins, triplets, or certainly anything higher than 6

7 that. And Clomid has a very low risk of twins. Your chances of conceiving twins with Clomid are about four to eight percent, and your chance of conceiving triplets or anything higher than triplets is less than one percent. Right. I just want to jump in for a second. We've done programs with specialists dealing with multiple birth pregnancy often where there's been fertility treatments, and the concern of course is not just paying for college years later but also whether this will be a healthy pregnancy for the mom as well each of the babies. So it's not an insignificant concern. Go right ahead, Doctor. I couldn't have said it better myself. I think one of the first things I try to share with patients is that my goal is to, you know, first, do no harm, and a very close second to that is obviously safely getting an individual or a couple pregnant. And when I think of that I think of that as a healthy singleton pregnancy. We don't have ultimate and exact control over the process, so there are times where a patient does have twins or even triplets or even higher order multiples, but our primary goal as a reproductive endocrinologist is to help a patient achieve a healthy singleton pregnancy. All right. So we talked about Clomid as a safe medication. And, Nicole, you started taking a higher dose of Clomid than you had taken earlier, correct? I did, but prior to that Dr. Marsh had performed an HSG on me which is the test that checks your fallopian tubes, makes sure they're open and makes sure the uterine cavity is open. Right. So let's talk about that. Dr. Marsh, the other thing, besides ovulating properly, is to see, are all systems open, right? Absolutely. And also with the guy, to understand that his sperm count is correct and motility, I think, is one of the words. So two things were going on at once I understand. You had this HSG test. What does that stand for again, Dr. Marsh? HSG stands for hysterosalpingogram, and that's the screening test that we use to assess the uterine cavity and to assess the patency or openness of the tube. If you think about the three-bit components of achieving a pregnancy that I mentioned 7

8 earlier, we need a healthy egg from a female, we need a healthy sperm from a male, and we need a healthy uterine environment for the pregnancy to grow. In terms of testing or the evaluation of each of those key components, for a healthy egg there's two specific things that we're looking at. We're looking at egg quality, and we're looking at egg quantity. One of the best markers we have or indicators of egg quality is the patient's age. So maternal age is a very key consideration in terms of how you counsel patients and their chances of achieving a successful pregnancy with their own eggs. The way we best assess egg quantity is typically by a blood test, looking at a hormone level on a specific day of the cycle called SSH. We also may use a different hormone called AMH which stands for anti-müllerian hormone that can be checked on any day of the cycle. We may do an ultrasound and look for how many follicles we see early in the cycle. So those are the markers that we use to assess egg quantity. Okay. So we could go down a lot of different routes. Now, in Nicole's case you wanted to see were things open, and also, I understand, Nicole, you told me simultaneously Joe was giving them a sperm sample. How did Joe do, first of all, since I'm a guy? Thankfully, he did wonderfully on that. Okay. But that's not always the-- We didn't need any more problems. Okay. But that's not always the case. Good for him. But that's not always the case, right, Doctor? So we're talking about we may think that fertility deals with women but it could deal with a man as well. Absolutely. You know, it takes two to make a baby. We need healthy sperm and a healthy egg and so we do assess the sperm quality and quantity by a test called a semen analysis, which involves the man giving us a sample of semen, and we look at things like what percentage of the sperm are moving, how many sperm there are, the shape of the sperm, and, you know, there's a long list of things we look at. But, you know, that's a test that can make--can make our men quite uncomfortable, but I can't reinforce enough that's it's a very critical part of the evaluation, because no matter how much medication or treatment we give to a woman if the sperm aren't healthy or aren't there then it doesn't matter. And vice versa is true. 8

9 I've been through it, and it's important, and if you are the cause or part of the cause that has to be dealt with, so the goal is to have a healthy baby. We're going to take a break in a second but I just have a question. How did the HSG test work out? Nicole, there was something in the way, wasn't there? There was. I had a uterine septum that had formed while I was growing inside of my mom, and so it's something that I didn't know about and because of the polycystic ovarian syndrome, because I wasn't ovulating, I wasn't getting pregnant and I wasn't then bumping into that particular problem with miscarriages. Right. So the idea was this septum could get in the way of a successful pregnancy? Is that it, Doctor? Yes. The data on septums is, in terms of actually preventing a pregnancy, is a little controversial, but we do know that once a pregnancy is achieved that septums are associated with increased rates of miscarriage. And septum, we're talking about a little blockage, is that what a septum is? It's basically an extra wall in the uterus. If you think about the uterine cavity as an upside down triangle or upside down pyramid, a septum is an extra piece of tissue that typically divides the uterus in half, and it can completely divide the uterus in half to two completely separate cavities, but more typically it comes down about halfway or two-thirds of the way so the cavity is continuous but there is this kind of dividing wall in the middle of the cavity. So again that's something that you could see with this HSG test. Yes, exactly. All right. We have more tests to talk about and certainly a lot about treatments when we continue our Patient Power discussion with Dr. Erica Marsh and her patient Nicole right after this. Stay with us. 9

10 Solutions Welcome back to Patient Power as we discuss infertility. There is a lot that can be done. Doesn't always work, but more and more, science has moved along, and if you follow the news just quite recently one of the fathers, if you will, of fertility treatment received the Nobel Prize in medicine, so it's certainly recognized that the science has come a long way, starting in the 60s with research, 70s, 80s, it just continues to accelerate, and Dr. Erica Marsh from Northwestern is here with us to understand the latest with her patient, Nicole. All right. So we've been following Nicole's story as one example where a septum was found, a little blockage that maybe could play a role in miscarriage, we're not sure about the actual conception, but also the ovulation issue, and that's was being dealt with. So, Nicole, just to understand, what happened next with you? So you were taking Clomid, and you had a surgical procedure to remove the septum. And I think that just to go back a little bit when it was determined that I had the septum and I needed that surgery, that was a major blow to our whole--at the time, our plans and what I thought was happening. I thought, okay, I have one problem, we're going to deal with this one problem. Thankfully my husband didn't have an issue, you know, and then I had a second issue. Right. And we should talk about that for a second. This is an emotional roller coaster, isn't it? It is. And it's just some days are okay, and some days you just want to cry, and some days you have both feelings. And I work in education, and every week literally in my school building women were announcing their pregnancies, and so you would want to congratulate them and then go cry in your car. Oh, my. So it was very difficult, and, like Dr. Marsh previously said, you know, it's not weeks and months. It's months and maybe even years. Did you feel--did you feel that Dr. Marsh and her clinic were on your side and well equipped to support you? 10

11 Oh, absolutely. Everyone from Dr. Marsh down to the nurses to the ultrasound technicians to the people who draw your blood, and even especially the women at the front desk. They are very good at clueing into, is this a good day, a bad day, we don't know yet, and they're very able to assist you with that. Dr. Marsh, just on the emotional side of it, how are you staffed as far as supporting couples through this journey? We take the emotional side of it very seriously, and we, because of that we have two full-time psychologists that are one hundred percent dedicated to our patients. The stress of infertility has been shown in studies to be at the level of stress of a cancer diagnosis, believe it or not, that people respond to those diagnoses surprisingly equally in terms of how much stress that they feel from it and the impact of that stress on their lives. And we take that very seriously and want to support our patients not just medically through this process but emotionally and mentally as well. Okay. Well, it's great that that support is there. So let's go on. So in your case, Nicole, after the surgery that you had for the septum and these two issues and kind of picking yourself off the floor, what happened next? Was it continuing with the Clomid, or what happened then? Yes. So then I healed from the surgery. I think it was like I needed to take a month off. And then we upped the dosage of the Clomid to three pills, so 150 milligrams, and went forward with the next cycle, and that time I had one mature follicle that did ovulate, and I did get pregnant. But unfortunately that pregnancy didn't maintain itself, right? It didn't. I miscarried after about five weeks. That's a low point, too. Absolutely. And I think it took a lot of strength from me and my husband to go through that, heal physically and mentally from that, and then know that if we still wanted to continue on this journey I had it to go back on the drugs, I had to go back downtown for the ultrasounds and the blood draws and everything that it took and that we could still--that could happen to us again. 11

12 But there was a happy result. What happened next? Beyond happy, yes. So we had to take a month off, and then we went back and did the same protocol again and conceived our beautiful baby boy. Okay. And his name is? His name is John. And he's how old now? He's 18 months old. And doing well? He's wonderful. Okay. Great, great news. Now, just one more point about your story, and then we've got to learn about other examples as well, and that is, you then decided after a while to try for a second child. Yes. How has that gone? That's gone extremely well. Sort of the way that my mindset was is that we know what works, and then, you know, it worked before and so we're just going to go into this and understand that things might be different but hopefully we know what the formula is. And so I did wait until the end of the school year this past year because I knew I would have to be going downtown so many times. And we did two cycles of Clomid with the IUI insemination, and on the second cycle we were successful, and I'm now almost 13 weeks pregnant. 12

13 Okay. Got a question--congratulations, first of all. Dr. Marsh, what is this IUI? IUI stands for intrauterine insemination, and it's a process by which we take the semen specimen and concentrate it and directly inject it into the uterine cavity, and the thinking being that by putting more sperm closer to the opening of the tube where they can swim in and meet the egg and fertilize the egg, we're increasing the chances of pregnancy. Okay. Try to give them a head start, if you will, on their journey. Absolutely. Absolutely. And I think that the reason that we chose to do that was because Dr. Marsh just gave us the information that even though Joe's sperm analysis was--everything was great, because it took so much for me to get there and be what I needed to be you just have a better chance, a higher statistic of conceiving with the insemination. So that's why we chose to do that. Just to comment about all of this, emotional highs and lows for you, Nicole, you live in the suburbs, making trips to the big academic medical center downtown, the specialty clinic where there's, as we talked about, a whole team devoted to this. It takes a lot of fortitude and a lot of commitment, but did you ever doubt it, or you just knew you were doing the right thing? You know, I didn't doubt it. I just had felt that our goal of being parents would be realized. And we did talk about would we do IVF, and, yes we would. Would we then, if IVF didn't work, would we adopt? Yes, we would. But we, you know, we're going to try it this way first. And I think having a strong partner, husband and--you know, really brings out your strengths. Right. Right. Well, we'll talk more and I'm sure you have some advice for other women. Dr. Marsh, so we went down one journey with Nicole, the septum, the PCOS, helping concentrate Joe's sperm, etc., the Clomid. There are other stories of course. Now, we use this term "IVF." What does that stand for? What are we talking about there, and where are we now with sort of the state of the art? Right. IVF stands for in vitro fertilization, and that has been available as a treatment now for a little over 30 years. And if you think back to what we talked 13

14 about earlier in terms of what normally happens, normally again the egg is released from the ovary, goes into the tube, the sperm meet the egg in the tub, fertilize the egg, and that fertilized embryo or fertilized egg that becomes the embryo goes into the uterus and implants. In IVF we actually give a woman injectable medications that allow her to produce many eggs and mature many eggs. We then remove the eggs from the ovary and combine them with sperm. We either just put them in a dish with sperm and allow the eggs to spontaneously fertilize with the sperm, or we do a procedure called ICSI which is an abbreviation of intracytoplasmic sperm injection, a process by which we directly inject the sperm into the egg to facilitate fertilization. We allow those fertilized eggs to then divide and become embryos, and then we put a select number of the best quality embryos back into the uterine cavity. And that in a nutshell is what IVF involves. So it maximizing getting the most number of eggs, combining it with sperm, getting at many embryos as we can, which gives us the opportunity to say, let's take these best quality embryos and put those back. All right. Now, that's at the highest level. Let's get into a little more detail. So there s sort of a super ovulation that you're stimulating to get many eggs. Absolutely. And then the question is, well, how many eggs are you fertilizing, how many are you reimplanting. That's a dialogue with the family or the couple, right? Absolutely. Absolutely. All--you know, my approach to care is that pretty much most of the--the vast majority of what I do is going to be a dialogue with my patients because it's very easy for patients to feel disempowered in this process. You know, you're taking an experience which is usually quite private and quite intimate and one that you feel like you can exert a certain amount of control over, and all of a sudden you have a team of essentially strangers involved in helping you achieve a pregnancy. And I think it's very important to help a couple feel like they have--they're still calling the shots, that they still have a say in the process, if you will. It's a very significant say. Part of that is talking to them about even if they want to do IVF. IVF is not for everybody. Even though it is one of the best treatments, we have some patients just decide, you know, that's not what I want to do. That's not something I'm interested in. It's a little too invasive for me, or I'm not happy with the risk profile. For the patients that do decide to do IVF we talk in a very detailed way about each of the steps that I just went over, from how much medication they're going to get to how many eggs we'd like to see. We ask them, do you want us to fertilize all of the eggs. And then we have a discussion about how many embryos we're going to 14

15 put back because--and I think in many ways that's the most important part of the counseling process because that's the part that is going to both drive in some ways the chances of pregnancy but also it's going to drive the risk of having a multiple gestation. So that's a very key part of the counseling process. All right. Let's go over some of the issues there. Now, one issue is if more than one fetus is developing early, early, early, one of the questions, knowing the risks of multiple birth pregnancy or even if a family could accommodate two, three, even four kids, should that proceed. Now, these are moral questions, emotional questions, medical questions. How do you approach that with people? Because medical science does have a way where you could reduce the number of fetuses that are developing. Absolutely. You know, as you mention, these are very personal questions that are wed to our background. In many patients, religion or faith plays a role and, you know, I think in most patients there's just a kind of a practicality that plays a role as well. But we know that there is a very significant risk, increase in risk with increasing number of fetuses in a given pregnancy. As a species, humans were designed to carry one baby at a time, without question. Now, we can safely carry two and we've all heard stories of, you know, with the octomom, the caring of eight, but that is certainly not a goal or a standard, and with each patient our approach is to achieve a single, healthy pregnancy at a time. I did have a question for you there, and that is I know there's genetic counseling that can go on too. Yes. And of course people have proceeded with pregnancies and like when mom is a little older they're familiar with amniocentesis, is everything okay. But sometimes you may have a couple that approach it where there is some genetic concern as well. Can testing be done at that very early level too to just make sure things are okay? Absolutely. Ideally we start counseling and testing before we even start trying to achieve a pregnancy for some of the more common single gene disorders like cystic fibrosis, sickle cell anemia and other conditions depending on the racial or ethnic background of the couple. With that what we call preconception screening we're able to get a good sense of what a couple's risk profile is for certain conditions and allow them to have genetic counseling even before they get pregnant. 15

16 Now, once they're pregnant there are a number of screening modalities available. In the case of a specific condition where there's a specific gene or set of genes associated with that, there's testing that involves taking amniotic fluid once the pregnancy is in place or taking cells from the placental bed to test. There's also testing that can be done on the embryo in the setting of IVF. There's a window of time, a very brief window of time where we can test an embryo between its development in the embryology lab and before it's placed back in the uterine cavity. And there's--again that testing can be done for single gene disorders, and it can be done for something called aneuploidy as well, which is looking for chromosomal anomalies that the embryo may have. Okay. Well, we talked about IVF and ICSI and all that. Now, what are the risks of these procedures? The primary risk with IVF is the risk of multiples. I think in terms of the personal impact and the public health impact that's the risk that we spend the most time on with patients. I think it's very important to explain to patients also that IVF is not a magic bullet, that there's no guarantee at all that, oh, because we're doing an IVF cycle that you're absolutely going to get pregnant. The chances of getting pregnant with IVF vary significantly with the age of the female partner, and so you--for women under 35 you can see IVF success rates in the 50 to 60 percent range per cycle, and that goes down to, you know, less than five percent for women who are in the 40- to 45-year-old range. We also counsel patients about the risk of something called an ectopic pregnancy, which is a pregnancy that develops in the tube instead of in the uterine cavity. When the embryo is transferred or put back in the uterus we typically do this under ultrasound guidance so we know that the embryo is initially placed in the uterus, but we don't, you know, put crazy glue on the uterus--i mean on the embryo that holds it in to a specific spot, and sometimes the embryo can reenter a tube and develop in the tube. And this is a very serious condition, or it can be, so we follow patients in early pregnancy very closely to make sure that we are seeing the pregnancy develop in the appropriate place, and if we're not seeing that, that we offer patients early treatment which can typically be a medical treatment to stop the growth of the pregnancy. One other complication that I know that can happen, we talked about this super stimulation for ovulation. What is OHSS? OHSS stands for ovarian hyperstimulation syndrome, and it's a condition where, you know, we don't know the true cause of it, just to be frank. There's a lot of research going on. But it's a condition that's really only seen in the setting of patients who are taking injections to stimulate their ovaries. And what happens is 16

17 in some women who respond very vigorously to the medications they--the vessels can become leaky in the body and they start accumulating fluid in their abdomen, fluid that we call ascites. A small amount of fluid is not necessarily harmful, but if patients start accumulating a large amount of fluid that finding can be associated with a predisposition for forming blood clots, and in the very extreme situation these patients can have a stroke. Not common, I hope. No, not very common at all. And essentially, largely preventable by following a patient's course very carefully. All right. Well, what we're going to do is in our last segment of this program we're going to understand what happens when somebody is going through this. You talking about following and, Nicole, you talked about trips downtown and blood tests and monitoring, etc., whether it was for what you had or further, someone going through IVF, what might be required of them at the clinic and what might be required of them at home or just in their lifestyle to end up with that healthy baby. We'll discuss all that when we come back with more Patient Power right after this. Welcome back to Patient Power as we're discussing in detail treatment for infertility that affects a significant percentage of couples, but there are people on your side such as at the reproductive endocrinology clinic at the Prentice Women's Hospital at Northwestern, and we have with us of course Dr. Erica Marsh, who is a reproductive endocrinologist there. And we'll hear also more from Nicole, her patient, who, we're happy to say, not only has a healthy 18-month-old boy but she's also pregnant again, and that pregnancy is now going well. Dr. Marsh, so we've talked about sophisticated intervention like IVF, but it doesn't always--some people try IVF more than once, hopefully with a success, but some people don't ever get to that point. So help us understand the range, really, because some people, it may be more straightforward. Right. There is absolutely a spectrum of treatment, and this is something that I try to go over with patients at that initial visit. Even before we know necessarily what the outcome of their evaluation is going to show I think it's important for patients to know that at one end of the spectrum of treatment they re really just continuing to be at home and do what you're doing and, you know, having intercourse. And at the other end of the spectrum is the process that we've discussed called in vitro fertilization, and at the far end that can be done with eggs that have been donated from what we call a third party donor, and as well as sperm donation if that's needed. 17

18 If you think about the spectrum beginning from the most conservative end and moving toward IVF, some patients just need help with the appropriate timing of intercourse. You can envision that if you're having intercourse at a time when you're not ovulating then it won't necessarily be of any benefit, so for some patients we just start by, particularly patients that have a completely normal workup and that are very young and may not have been trying for a full year we talk about what we call appropriately timed intercourse. So those are the patients that I may go home and have use an ovulation predictor kit, which is just a urine kit that you can buy over the counter at a drugstore that lets a female know when she's about to ovulate. When that test is positive then the patient knows that she's probably going to be ovulating in about 24 to 36 hours, and that's a good window of time for she and her husband or partner to have intercourse. Beyond that, there are some oral medications that we can try. Nicole mentioned one, Clomid. There's also another class of medications that we try called aromatase inhibitors, both of which are designed to help a woman achieve ovulatory cycle. Another intervention that we try that we used with Nicole and Joe is intrauterine insemination, and again that's concentrating the sperm and actually directly injecting it into the uterus. Beyond that we get into a category, kind of a midway category that involves the patient taking injectable medications and doing intrauterine insemination. Now, injectable medications have to be monitored very closely or patients taking injectable medications have to be monitored very closely because this is the class of medications that has the potential to get a patient to make a good number of eggs. And outside of the setting of IVF we only typically want patients maturing two, three, depending on their age maybe four eggs at a time. We don't want patients doing injectables with intrauterine insemination to mature, you know, seven, eight, nine eggs. And that's why we have patients come back very frequently for ultrasounds and lab testing sometimes every other day, sometimes every day to make sure that we are adjusting medications appropriately and keeping their risk of having multiple gestation and developing OHSS, to the bare minimum. Just one point about that is, that may be a situation, though, where your partner or friend is trained to give you a simple injection. You need the monitoring, but you might do the injection at home. Yes, absolutely. We do have patients come in and have what we call a shot class with one of our nurses, and we encourage the couple--if the patient is in a couple or in a relationship we encourage the couple to come in together. And not all of our patients are a couple. There are a lot of single people who are interested in having children and they either come in alone or bring a friend with them to do the shot class. 18

19 All right. So now a woman or a man wonder, well, what could we be doing ourselves. You mentioned some of that. What about nutrition? For instance, some people may say, well, I need a super healthy diet, or I am a strict vegetarian, or I go to the gym ten hours a week or whatever. Do you look at that and say, gee, is this promoting what they need to be optimized, if you will, for pregnancy? Yes. Again that's one of the things that we talk about in that initial visit, how lifestyle changes can help enhance a couple's or individual's ability to achieve a pregnancy. One of the things I focus on is weight management particularly in the setting of patients who are overweight or obese. Those are patients that I have a very candid conversation with of the benefits of losing even five percent of your weight can have a significant impact both on your ability to get pregnant but also your ability to stay pregnant. You know, weight loss lowers your risk of having a miscarriage once you get pregnant, and that's in addition to all of the other cardiovascular benefits that we know exist from being in a healthy weight. So weight loss is something that we talk about. Smoking cessation is something that we talk about. Healthy nutrition overall is certainly something that we talk about. And being too thin as well. Oh, yes. Yes, there are certainly patients that come to see me and are not ovulating because they've lost too much weight or they've exercised too much, and those are patients that also get counseled on healthy nutrition and perhaps cutting back on their exercise regimen. And a lot of these patients because we are based at an academic medical center, at Northwestern Memorial Hospital, we have literally at our fingertips a full team of specialists that can help us take care of our patients. There are patients that I have had to send to the center for lifestyle medicine in terms of weight management. There are patients that I've sent for a consult with a maternal fetal medicine specialist, which are specialists that manage high-risk pregnancies. And I send patients before we get them pregnant about their specific risk in a setting of, say, being obese and being pregnant or if they have, say, diabetes, and they want to get pregnant or another serious or chronic medical condition. Sure. And stress management too. Yes. Yes, that's very key, and it is growing in prominence in the field. I think stress is one of those factors that's still pretty challenging to define and quantify, but we, most providers absolutely believe that it has a very real effect on fertility and we ask patients--or help patients manage it with things like acupuncture and various other relaxation techniques and counseling, exactly. 19

20 Cost for Treatment Dr. Marsh, just one other question. Let's talk about cost. So we mentioned in Illinois there are insurance plans that are mandated to cover to some degree infertility, but what are the costs typically? The costs vary dramatically with what type of treatment you're having. So if you re having a Clomid cycle, for example, where you're taking an oral medication and you need a few ultrasounds, a couple of ultrasounds and maybe one dose of an injectable medication, that that's going to be in the hundreds of dollars range. Whereas treatments at the other extreme, like IVF or the in vitro fertilization, are typically going to run you around $10,000 per cycle if you're paying out of pocket. That does not include the medications, which can be quite expensive, and sometimes the medications can be the $4,000 range, $5,000 range by themselves. Wow. Okay. So to sum up with you, Dr. Marsh, I suggested we made a lot of progress. It is not a sure thing at all, and it requires a lot of commitment over an extended period of time for a woman, a man, a couple, but how do you feel about your ability to help? I think it's an extraordinary job to have. I love what I do. I love coming into work every day, and I think the field has come tremendously far. And, you know, I look forward to the next 30 years of the field because I think the future holds a lot of promise and is progressing us even further in being able to help patients that are facing challenges that we can't be particularly helpful with today in terms of patients that don't have a lot of eggs or have poor egg quality. There's not a lot that we can offer those patients other than helping them to access an egg donor today. But I think in the future that's going to change. We're going to see changes in how we can assess embryo quality as well as egg quality. That's going to help us bring more patient-specific treatment or individualized treatment to each patient. And I also think patients are going to continue to be really empowered. This is a field where there's a ton of information on the website. There are a lot of people utilizing these therapies, so people are talking to one another. And the only caveat that I would give to that is I would encourage each patient or couple to remember that you are unique. You know, you are absolutely unique, and your treatment is going to be unique. Your evaluation is going to come up with a unique set of findings, and so keep that in the back of your mind. As you educate yourself, as you empower yourself remember that just because you have three couple friends that have gone through this, you know, your treatment may be completely different because the cause your infertility may be completely different. 20

21 And have those conversations with your physician. Find a physician that you feel comfortable with, that you can sit down, that you have trust with, because that relationship is key and it's really essential to a successful process. Wow. Well, you are so dedicated. Dr. Erica Marsh, I want to thank you for sharing all this with us. Thank you for having me. I want to mention, as a guy we need to also go through that whole workup, right? Oh, yes. We didn't go into detail, but there are things to do there, and we're kind of in it together with our partner. Yes. Final Comments Thank you. I want to give the last word to Nicole. So, Nicole, I want to first ask you about the last thing that Dr. Marsh said, about the dialogue with your doctor. How has it gone for you? How do you feel about Dr. Marsh? That's a big question. I feel that we over the years now have really connected and really can have that open and honest conversation with each other and with my husband as well because there's trust. And when she knows the answer she says it and when she doesn't know it, she says it, and she will find it and then she gives it to us. And that has really helped us in advocating for what we need and what we want, is by having that relationship with her. And of course nobody knows at the outset how it's going to turn out or even what you'll find along the way. Right. 21

22 But I'm sure, and if you want to do it publicly now, you're thankful. Absolutely. Anything you want to say to her? I say thank you for giving me my family and being a part of that. Well, thank you, Nicole. It was a blessing and a pleasure for me to be part of. And I can't tell you, but I--it's a privilege to do what I do, and I am happy to be a part of your lives. That says it all. One last thing, Nicole. We have people listening who are maybe at the starting point, trying to decide, not knowing what's in store for them. Any advice, because they may feel very alone or not--people around them are having babies or maybe they know, have heard about other couples dealing with it, but it's not something you always want to talk about. Any advice for them on moving forward? I think in general when people think they want to start trying and if they're on the pill, to go off the pill and see what their body does and see how it reacts to going off the pill and hope for the best and hope that you're going to be one of those normal couples that can do it on their own. And then if they get to, you know, even up to a year with us, it was a little bit before a year because the cycles were so long, just really, like Dr. Marsh was saying before, educate yourself. Now, the caveat to that is you can't just go on the internet and look up anything because there are things that aren't true and that will scare you beyond belief. So it's really finding the sites that can be helpful and knowing once you educate yourself then you can advocate for yourself better. And speaking up and knowing with your own intuition when you think you need to go to that next step. And then connecting with a provider, as you did, a whole team really. A whole team, and also, like Dr. Marsh said, to really connect with that doctor. There might be a different doctor in the practice that you might like better. You're going to be spending a lot of time with that doctor in that office, all those people that work there, and you need to feel comfortable and safe and that they are there to help you achieve your goal. 22

23 And there you are, pregnant with your second child. Hope it happens for our listeners. And I know you and Joe still have to talk about--well, first, have healthy baby number two. Yes. Is it still on the table whether you would consider a third child? He says that we'll see Dr. Marsh in about two or three years. We'll see what happens. I'm waiting. I'm going to be waiting for you guys, arms wide open. All right. Well, I hope it can work out for people, however they want. Absolutely. One child, two, three, or more, and we're talking about good health for the family and for the kids too. Thank you so much for being with us. Nicole, we wish you all the best. Dr. Marsh again, thank you for your dedication and your whole team there. This is what we do on Patient Power time after time is connect you with leading experts from Northwestern and wonderful, inspiring people like Nicole, who is gracious and sharing her personal story. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. For more information or to schedule an appointment with a Northwestern Memorial physician, please contact our Physician Referral Service at or visit us online at Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 23