Search for tag: "fertility"

Dr. Jones: So you're 34 and the clock is ticking and you haven't met Mr. or Mrs. Right yet and you want a baby someday but not now. What are your options to protect your eggs because you can hear them getting older in your body?

So women around the world have been told they can have it all, and although I may not get agree with that completely, there is a time when you make babies and there's a time when you build your career. But, in fact, the making babies and chief career building tends to overlap, and sometimes we put something off and what gets put off, as we're learning about the increasing age of women having their first child in this country, is the baby making. But your eggs are getting older and what are you going to do to save them?

In the studio today with us is Dr. Joe Letourneau, who is a fertility preservation specialist and reproductive endocrinologist at the Utah Center for Reproductive Medicine. Thanks for joining us, Joe.

Dr. Letourneau: Thank you for having me.

Dr. Jones: So a 34-year-old is really looking for her next big job and she hasn't found the honey yet, but she wants to have kids someday. She's got your name. She knows you're the fertility preservation guy. What are you going to tell her?

Dr. Letourneau: That's a very common presentation that we see in our clinic now, and it's becoming more common. We've certainly become more sensitive over the years to the idea that women are building their families later. There is an intersection with, you know, family timing and ovarian and an egg physiology that that can be important. And the way it can manifest is that, you know, achieving a pregnancy becomes incrementally slightly more, you know, difficult with time.

One thing that I like to tell patients is that there's not really a fertility cliff. I think there must be many websites on the internet to suggest there is a fertility cliff where you're fertile one day and then not the next, and it's really a gradual change with time. But for some people if they anticipate many years elapsing before they plan to build their family, it may make sense to consider freezing their eggs. Essentially freezing them in time with a higher reproductive potential that they may have at their current age and that they may have in the future.

Dr. Jones: So is there a time when you're too old to save your eggs?

Dr. Letourneau: Age is quite predictive of a quality for women in one way in particular and that's having a normal number of chromosomes. The way that I like to frame this for patients is to, one, give them an understanding of how many eggs there are in the body at a given time and, two, what percentage of those eggs are normal.

So at birth, average women are born with about 1 million eggs, and by puberty there are around 300,000. It turns out that the egg comes in a unit with something called the follicle, and the follicle is what provides support to the eggs so that it can become fertilized. It also helps to regulate the menstrual cycle and provides estrogen. So the absence of follicles is what defines menopause, which is typically around age 50 or 51. So there is a decline from the start of puberty in the early teens until age 50 of about 300,000 eggs down to the end of the egg supply.

Interestingly, in this time, only 400 or 500 eggs will be ovulated or released from the ovary because, as humans, we release one egg per month because it's difficult to raise a human baby. So most eggs in the ovary are actually not released. Most of them are sort of selected for or against in a way that we don't understand well and many of them die off.

Each month, the egg that is released has a certain probability of being normal or being abnormal. And the normality of it I'm really talking about the chromosome number. If the chromosomes that come out are abnormal, the embryo that may be created will be missing some of the instructions for it to grow.

Most typically that manifests in the absence of a pregnancy. Occasionally it manifests in an early miscarriage, and more rarely it manifests as chromosomal abnormalities that the baby may have at birth. But really most commonly these chromosomal abnormalities make it hard to become pregnant. These go up with time raising pretty steadily, but rather rapidly in the late 30s and early 40s, and that's really what drives age-related fertility concerns. So freezing eggs earlier results in more normal eggs.

Dr. Jones: So ladies, as you're thinking about planning your life, understanding that women plan and God laughs. But if you're thinking about planning your life, there are some options about freezing your eggs, but you should know what's available and decide what's right for you. And thanks for joining us on The Scope.

Dr. Jones: When parents are faced with the diagnosis of cancer in a child, they are overwhelmed with the fear of losing their child. Overwhelmed by the medications and the surgery and the testing and the last thing on their mind is thinking about their child as a future adult with hopes and dreams and children of their own. But what are the options for fertility preservation?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Over the last 40 years the survival rate of childhood cancer has gone from 10 percent to almost 90 percent. In years past, our goals in the treatment of childhood cancers were just to get kids past the crisis of diagnosis to survival for five years and now we're thinking about long-term survivorship to adulthood with what a full life means for these children. This means thinking about these kids having kids. These are decisions made often by the parents because the kids are often clueless about having kids.

So, today in The Scope studio we are joined by Dr. Douglas Fair and Dr. Joe Letourneau. Dr. Fair is an oncologist at Primary Children's Hospital and co-director of the Huntsman-Intermountain Adolescent and Young Adult cancer care program. And Dr. Letourneau is a fertility preservation specialist at the University Center for Reproductive Medicine at the University of Utah. And thanks for joining us.

Dr. Fair, how do we approach parents and children about fertility preservation? They got a really sick kid, and they just want their kid to live to Christmas, but we want them to have a whole life.

Dr. Fair: I think you said it well in that. Unfortunately, at the time of diagnosis because of the intensity of a new diagnosis, the workup, the planning, the discussion in referral for fertility preservation can be forgotten or minimized. And I think additionally, fertility preservation counseling is complicated, it's nuanced, it's consequential. And particularly, for women, it can involve an additional procedure, and it can delay the initiation of cancer therapy and, in some cases, particularly for women can be costly.

So, it's a lot to know and it's a lot to talk about. And really it was with my own ignorance that I realized that I in my training, which is not different from other pediatric or adult oncology training, didn't get a lot of understanding about what the fertility preservation process is, not to mention, all of the different nuances of having that conversation with a child, with a teenager or with a parent. So, it really is a really difficult conversation.

And what we are finding out from data and what we can also say by intuition it's a super important conversation that parents really care about and they just sometimes don't know where fertility lies in importance when their child is diagnosed with cancer and it's our job as oncologists to bring that up and to describe that.

Dr. Jones: Right. Well, I remember in my own clinic when I'd see adolescents and I'd be approaching them and when the mother's in the room, the adolescence got her arms crossed and her eyes are rolling even though she's pretty sick. When her mother is out of the room, then I can actually have a conversation with her but it's complicated on this issue even talking about fertility or sex. Are the approaches different depending on the ages? Can you actually do this conversation and have technology for four-year-olds or is it mostly for teenagers?

Dr. Fair: It's a great question. I'll take the conversation piece first and I would just echo your hint that it is tailored to the patient. And that certainly includes age, maturity, but also the family dynamics and where the patient is and how well the patient feels.

And that's where it's just really important to be nimble and to be flexible but knowing that it's a super important topic that even if the parents or the child don't really want to talk about anything, certainly not cancer and not fertility or sometimes awkward things like eggs, testes, ejaculation, fertility preservation. These are really important topics that they will care about in their survivorship. And so I think that's a really important thing to state.

And to your other question about just the technology and what can we do now for patients, we typically break patients down into prepubescent or pubescent. So, meaning patients who have gone through puberty which is usually somewhere between the ages of 12 to 14 when patients go through puberty and then so older or past puberty or before puberty. And I'll let Joe talk a little bit about the options that we have for prepubescent patients.

Dr. Jones: Yeah. Joe, let's talk a little bit about let's say a 12-year-old or 10-year-old boy. So, he hasn't really developed or matured yet. Is there much we can do in that particular situation?

Dr. Letourneau: Well, one of the hallmarks of puberty is the maturation of the sperm and the eggs and the ability for them to eventually create a pregnancy. So, with young children, it can be difficult because we hope in the future that we can mature sperm and eggs from very young gonads but at this point, that remains an experimental process. It seems achievable but at this point, the gametes or the sperms and eggs that we can get from prepubescent children would not be likely to make a pregnancy so it would require a technology that can achieve that maturation outside of the body.

The sperm stem cells and the eggs that we are born with are not necessarily able to create a pregnancy, they don't have a fertilized ability in a sense. And that's a gap in our technology and research that we hope to close particularly for young patients who are prepubescent.

A lot of our focus in counseling is on education. We want people to know that even if there's not a proven treatment now, the door is not closed on family building in many ways. We don't want people to grow up and wonder if they can ever have a partner, wonder if they're good enough, wonder if they'll live a normal life. We want them to know that they have a lot of options, a lot of normal options to build a family. And sometimes that includes considering fertility treatment in the future, sometimes that includes considering donated eggs or sperm in the future, and sometimes it may include considering adoption as a very normal way to build a family.

Dr. Jones: Well, there are somewhere close to 400,000 survivors of childhood cancer living in the U.S. now, and they're trying to live their lives in ways that they now are survivors, hopefully, putting that thing in the past, "Oh, that happened to me in the past." So, that's really encouraging that we're doing so well these days.

The other encouraging bit is that really young kids, their ovaries and their testes are a little bit more resistant to chemotherapy. So, the younger the kids are the more likely they are to actually make it through with some eggs and sperm left. Do I have that right?

Dr. Letourneau: That's correct. A lot of what makes the sperm and egg cells susceptible to chemotherapy is the fact that later in life they, or the supporting cells around them, are rapidly dividing making them susceptible to chemotherapy, which targets rapidly dividing cells. Early in life when they're quiescent or sleeping, chemotherapy is a bit less likely to see them in a way.

Dr. Jones: So, I have some questions, of course, on the larger issues. But what have I not asked you about kids in the program, the oncofertility program for younger patients? Is there often a debate between the mom and the parents or are the kids mostly going along or the kids have questions too?

Dr. Fair: I think what is surprising, at least that I've found anecdotally, is that, well, once you break the barrier of talking about an awkward or difficult topic, families are super happy that you brought up that topic even if we are talking about a patient that doesn't have good fertility preservation options like we're talking about prepubescent males and females. And I think there's a couple of reasons for that and data support that. So, patients have told us in studies, in surveys that after they have been done with their treatment even if they haven't preserved their eggs or sperm, they feel that they were taken much better care by their cancer team if fertility preservation was brought up.

And to emphasize a point that Joe mentioned, just because we can't preserve eggs or sperm before cancer therapy doesn't mean that fertility preservation or oncofertility or thinking about family building is not an important part of their care and in survivorship. And that's again on oncologists to really realize that this is a really important feature of patient survivorship. And so as Joe said, there can be important timing considerations and different physiologic considerations to seeing a fertility specialist like Joe after they've completed therapy to see where exactly where are their fertility preservation options and having that conversation again even if at the beginning before therapy they couldn't preserve.

Dr. Jones: And I think that's been one of the unique things about the Huntsman Cancer Center is trying to look at the patient and the family in a really big way rather than just, "Oh, you have this cancer and you are your cancer." It's "You are this person, you have potentially this future, you are this family." And the Huntsman has done a really great job and the oncofertility consortium and the oncofertility program here has been trying to think big.

Dr. Fair: They really have. They've been incredibly supportive in adolescent and young adult cancer medicine which this falls is a big part of that with survivorship, which fertility preservation and oncofertility is a big part of that and then directly oncofertility. The University of Utah and the Huntsman have really just been super supportive since Joe and I started this program and it's really just been a series of yes, yes, yes that sounds like something that patients would really benefit from. How can we be supportive?

Dr. Jones: I think helping parents and their kids think about these options and providing access to fertility preservation technology is part of our mission. And I thank you both for being here and I thank everyone for listening to The Scope.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Dr. Jones: The mammalian miracle of growing babies inside you is amazing. Yeah, that's a lot of M's in one sentence, but what do we know and what don't we know about implantation? And what do couples do and doctors do to try to make it work better?

Announcer: Covering all aspects of women's health, this is the "Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: In humans, eggs are sort of squished out of the follicle, and that's the cyst that has the egg in it in the ovary when ovulation occurs. Okay. It usually works. It's not too hard to understand, and we can study it in other mammals like lab mice. The fallopian tube picks up the egg, which is surrounded by a cloud of sticky cells, and moves the egg and its cells into the tube. Okay. I got that.

Sperm, which were deposited in the vagina, swim up the cervix, uterus, and out the tube and meet the egg. Okay. That seems hard and a long way for the tiny guys, but there are so many of them. The egg and sperm recognize each other as human, and only one sperm gets in the egg. Now, that's amazing, and there are so many of them. And the egg gets fertilized.

Okay. We understand that mostly, and we can watch it happen in the IVF lab with human eggs and sperm. We do know that a lot of eggs and sperm and a lot of fertilized eggs are not normal, so there are lots of time that the process doesn't go much farther than this. But if things are normal enough, the fertilized egg starts to divide, wanders down the fallopian tube with a little help of tiny little fingers on the cells of the fallopian tube and arrives in the uterus at the time that the embryo has developed enough to have over 100 cells and specialized cells that can settle into the uterus lining and start to burrow under the lining. And, after that, we really don't have a clue as to what happens at all.

The human process of implantation is not necessarily like mice or cows. We actually are much less efficient. Removing the uterus of women at various stages of implantation to study what's going on is not going to be done. The primates that we share our genes and our reproductive biology with are increasingly rare and are protected from this kind of research. Implantation, the process of the embryo burrowing under the uterus lining, capturing some of the blood supply of the uterus lining, and growing enough to make a placenta, which then grows to feed the embryo and fetus, is mostly a mystery.

It is thought that about one in five fertilized eggs goes on to make a baby to viability in fertile couples. In infertile couples, it doesn't happen that often, and sometimes we don't know why or what to do about it. So many couples who are not getting pregnant move to in vitro fertilization. It is thought about 1% of all the babies born in the U.S. were conceived with IVF, and that makes about a million babies in the U.S. over the years. Hundreds of thousands of cycles of IVF are done each year in the U.S. But you can put lovely looking embryos into the uterus of a woman and not get pregnant for no good reason.

This leads doctors and patients to try to come up with strategies to increase the chance of implantation. In the old days, we had a woman in bed tipped upside down for a day after putting the embryo in her uterus with hopes that it wouldn't fall out. Then we had women rest for hours, then an hour, then 15 minutes, and then not at all because randomized trials showed that laying down flat after an embryo transfer didn't seem to make a difference in implantation. Some people have tried acupuncture with the hope that it might help implantation through some ancient wisdom that we understand about as well as we understand implantation. Randomized trials showed that acupuncture didn't work better than fake acupuncture and implantation, but doctors and patients were desperate to make this very expensive and life-consuming process work.

Some years ago, someone came up with the idea that if you disrupted the uterus lining the month before IVF, maybe it would cause a reaction in healing that might increase the chance of implantation. Given that we have no clue about implantation, it seemed like an idea. And some early studies suggested it might have a small effect, increasing the likelihood that the embryo would successfully implant and grow. Now, this isn't like gardening where you scratch the earth and then put the seeds down in hopes that they will grow better than just dropping the seeds on the ground, although it sort of sounds like that.

The endometrial disruption called endometrial scratching actually happens the month before the IVF cycle. It can be done in several ways, but the most common is to put a small tube with a sharp edge at the tip into the uterus, through the cervix, and move it around back and forth, sort of scuffing up or scratching the uterus lining. So does it work? Some people thought it did. Some studies suggested it might, and patients and doctors were desperate.

In a widely read medical journal, the "New England Journal of Medicine," a large randomized trial of endometrial scratching versus no scratching before an IVF cycle reported that it didn't help. There was no difference. Not exactly a surprise. At least it didn't hurt. Well, actually, it did hurt. Putting a tube in the uterus and swirling it around is uncomfortable to most women. And for doctors who charge for this procedure, it could be 200 to 600 bucks, so scratch that. Well, no, don't scratch that.

Lots of things have been tried. Word gets out on the web, and patients request some intervention or another that might increase the chance of getting pregnant. I will admit to some magical thinking of my own that I did after putting embryos back in the uterus of patients undergoing IVF in my years as an IVF doctor. There are a couple of minutes between putting a tiny drop of fluid with embryos, or better one embryo, into the top of the uterus. And when the embryologist in the lab checks the tube and makes sure that the embryos are gone, it's a couple of minutes. I would practice deep breathing and imagine the embryo in the uterus happy and implanting, and growing, and seeing children at our IVF picnic. I didn't tell patients that I did this little exercise, but it seemed like a good use of a few quiet minutes. Magical thinking. What I really wanted was some kind of tissue super glue, but somebody actually tried that, and it didn't work.

So what do we do when we don't know what to do? The world of infertility and early pregnancy loss has been filled with well-meaning therapies to try to help people have the children that they hope for. Most, at least, haven't been harmful -- acupuncture to increase IVF implantation, aspirin to prevent miscarriage, and many others. But before we suggest it or offer it to patients who want it, we should at least know that it won't hurt physically, emotionally, or financially. Large, well-done randomized trials are very expensive, and in the IVF world, usually not funded by our government, but they need to be done. As patients and consumers of reproductive health care, we should try to get the best information from our physicians and take a deep breath and do the best we can. And thanks for joining us on The Scope.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: You had a miscarriage and you're trying again, but for whatever reason, you can't get pregnant again. Is this normal? We'll find out next, on The Scope.

We're talking to Dr. Kirtly Parker Jones, the expert on all things woman. Dr. Jones, the scenario is, you and your partner got pregnant. For whatever reason, unfortunately got a miscarriage and you're trying again, but it's been a while and you can't get pregnant again. Is this normal?

Dr. Jones: Okay, good question, and the answer is, it depends.

Interviewer: It always depends.

Dr. Jones: It all depends. So the rate of miscarriage in healthy couples under 35 is about 15 percent. It's very common. And if people got pregnant relatively easily, it means they weren't taking years to get that pregnancy that miscarried, they got pregnant easily, then it is not normal for them not to be able to get pregnant again. And the vast majority of people get pregnant again.

Now, sometimes, the miscarriage is a sign of an underlying problem. So let's take the 40-year-old who took three years to get pregnant. She miscarried, she can't get pregnant. Now it's been a year or two. That miscarriage was probably a sign, along with that three years of trying, that she was running out of eggs. And now, she's kind of more run out of eggs.

So sometimes a miscarriage is a sign of an underlying problem that's getting worse, and in fact, it's true for sperm problems. So men with abnormal sperm can have more miscarriages, and in the process, their sperm is getting more abnormal. So it was sort of abnormal and they had a miscarriage, and now it's really abnormal, they're not getting pregnant.

Interviewer: So it can depend on both the woman and the man.

Dr. Jones: Right.

Interviewer: Okay.

Dr. Jones: And lastly, sometimes the treatment for a miscarriage. For example, let's say you miscarried, you passed some tissue you didn't pass at all, so they had to go in, you had a little infection in your uterus, so they did a D&C, and in the process of doing that D&C in a scarred, in an infected uterus, the uterus got scarred. And so that can be the cause of the secondary inability to get pregnant.

But for the majority of people who are not old, and they got pregnant easily, and they miscarried, the majority of them, 85 percent to 90 percent, will be pregnant again within a year. So not getting pregnant is not normal.

updated: May 9, 2019
originally published: June 29, 2017

Dr. Jones: What if anyone, man or woman, young or old, could make eggs out of skin cells and have an unlimited and easy to access source of baby making? How could that happen? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare and this is In-Vitro Gametogenesis on The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: The holy grail of regenerative medicine is to be able to make organs or tissues that need replacing, think cartilage in your sore knees, from cells that are yours and are easy to get. In the process of human development, cells that are very early in the embryo are called totipotent. That means they can turn into any cell in the body. The time that cells are totipotent in normal human development is quite short, maybe just a few days after fertilization. After that, cells start going down a pathway of development and cannot go back. Cells become pluripotent meaning they can turn into a number of cell types of one type, perhaps the cells of the tissues of internal organs but they cannot make eggs or sperms anymore.

When you hear the word stem cells or stem cell research, it refers to cells that are not completely developed or differentiated into skin or hair or other tissues but can be turned on in natural development to replace cells in certain tissues when those cells die. Over the past 30 years, a lot of research has been focused on harvesting and growing stem cells to be used in treatment of disease. The poster child is bone marrow transplantation for the development of blood cancers like leukemia. This treatment is highly effective in using blood stem cells from cord blood or an adult's bone marrow or maybe someone's own blood stem cells to replace the diseased blood cells.

Okay. Although it isn't prime time or covered by insurance, some clinics are harvesting stem cells from tissues and injecting them into knees that have had the cartilage wear down in hopes that these stem cells will decide to make cartilage when they find themselves in the right place.

So what about eggs? What if you could take skin cells, just a little bit of skin tissue, and harvest the stem cells that help replace skin cells, turn back the developmental clock to make early egg cells? In the ovary, there is a supply of egg cells that are being very early in development and can grow and mature to ovulate each month when a girl goes through puberty until they run out at menopause.

Recently, a Japanese research group did just that in mice. They took mouse skin cells, turned back the developmental clock and made early egg cells, let the eggs develop, added sperm, made embryos, put them in a mouse, and made mouse babies. Okay. This is where what is called the yuck factor comes in. The yuck factor is when someone hears about a new development in science or medicine and it tweaks their emotional or moral sense. Think face transplants. There is a little yuck factor there. Sometimes the yuck factor calms down with a little more understanding and experience.

The possibility of making animals or humans this way to have a source of gamete cells, meaning eggs and sperm, available to men or women, young or old, sort of tweaks the yuck factor in some folks. Many people experience the yuck factor when the first in-vitro fertilization baby was born or when human egg donation became a way for postmenopausal women to bear children or when human embryo banks were established with frozen embryos to be chosen, bought, and shipped to be transferred into a surrogate uterus. So here we have the yuck factor with the process of growing eggs or sperm in the lab from skin cells or other cells. This is called in vitro gametogenesis, generating gametes in the test tube.

There are some very interesting scientific questions about early development of eggs and sperms and embryos that could be answered using this technology. And people who'd run out of eggs or sperm in the case of women, may be menopause, in the case of men or women, may be chemotherapy, might have their source of eggs and sperm with their own DNA. If a woman and her female partner wanted to make a baby with DNA from both of them, they could use this technology. Of course, although the mice were made in the lab with in vitro gametogenesis this year, that doesn't mean the technology will be available to make human embryos tomorrow.

Like cloning, making an embryo from a skin cell, think Dolly the Sheep, it never really took off for humans, and there are still a lot of questions about the safety for the newborn child to be, but it may be right around the corner and what will we do about that? Stay tuned and thanks for joining us on The Scope.

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Dr. Jones: How do you plan when and how many children to have? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is "Making Babies or Not," on "The Scope."

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on "The Scope."

Dr. Jones: Most of us want children and most of us want to have them when the time is right. However, how much are we really willing to do to accomplish this goal of family? Some people prefer to take a more natural approach and some a more technical approach. Natural family planning provides contraceptive methods and a fertility method for creating a family of the right size at the right time.

Today in "The Scope" studio, I'll be talking with Dr. Joseph Stanford, professor in the Department of Family and Preventative Medicine. Dr. Stanford has a special interest in natural family planning and in natural procreative technology. Dr. Stanford and I have spent our careers in helping people have the children they want, but we take different approaches and we're going to talk about that today. Welcome, Dr. Stanford.

Dr. Stanford: Thank you, great to be here.

Dr. Jones: So let's just throw it out there, what is family planning to you?

Dr. Stanford: Family planning, to me, means couples being able to choose how many children to have, and when and how to have them.

Dr. Jones: I agree with that 100%. So there is a large domain of knowledge and practice around natural family planning.

Dr. Stanford: There's some considerable science and there's also . . . my interest is a lot of things we're still learning, but yes, there's a considerable body of science behind it.

Dr. Jones: Okay. So tell me a little bit about your counseling couples or your practice of natural family planning. What does that mean?

Dr. Stanford: So natural family planning means couples understanding when the woman is ovulating, when the days are that intercourse would result in pregnancy, and then making choices to either have intercourse or abstain. Or we can talk about the various choices they might make around that time to decide to either try to get pregnant or not.

Dr. Jones: So how well does it work?

Dr. Stanford: If a couple understands the days that they may get pregnant and does not have intercourse on those days, it's highly effective for avoiding pregnancy. The controversy about effectiveness comes when couples take chances or say, "Well, maybe I'll see what happens." That's where the gray areas and the controversy come for effectiveness.

Dr. Jones: Right. Well, so, for me, I would say I take a more technical approach. I certainly was raised as a reproductive endocrinology with the science of contraception in terms of birth control pills, birth control hormones, IUDs and shots, because my training told me that people are the least predictable about their behavior when they're thinking about sex and that the difference between what they intend to do and what they really do is kind of big. We know that people want to take their birth control pills and they . . . 10% of them screw up and they don't take them right. Well, what about the natural family planning? You must be looking at a very unique group of people who are motivated, highly motivated.

Dr. Stanford: Yes and no. I would say that successful users in natural family planning are highly motivated for a variety of reasons and find a way to make that work, and find it beneficial to their relationship over time. So in that sense, yes, they're highly motivated. I would also say that they, on average, tend to have a little bit different view about when they want to have children. I think natural family planning users, on average, probably have a few more, one or two more children than the contraceptive users, and that's because of their worldview of how many children they want and what methods they want to employ to get there.

Dr. Jones: So I think the people who provide this service may have a unique worldview. That would be you versus what mine might be, and the people who come to practice this method reliably and successfully may have a little bit of a different worldview, so I think . . .

Dr. Stanford: But I would also say there's a spectrum of reasons people use natural family planning or what we might call fertility awareness methods. Some are coming at it from a religious point of view, some are coming at it from an ecological point of view, they don't want hormones, some are coming at it from a point of view of not wanting to have a barrier or they like that idea of understanding their bodies. So there's a spectrum. It's not a monolithic group that use natural family planning.

Dr. Jones: Right, and I understand that, having grown up sort of in the granola culture, that a lot of women didn't want to put anything in their body or take anything unnatural and preferred -- they were well-educated women -- to make their own personal choices, and I can see that that might be very useful for them if they practice it reliably through a lifetime of contraception.

Kids who might be sexually active, when they're still not reliably ovulating or women postpartum, or women in their 40s, are there special tools that you have to use for women who aren't reliably ovulating?

Dr. Stanford: Let's talk about the women in their 40s or women who are not reliably ovulating. Those are cases where I think we do need more research, but I do think we have adequate tools to make it work for those who want to make it work. Is it always the easiest thing? No, sometimes it requires a little more patience. It can work for that group. I hope we have better ways in the future to make it work a little more smoothly or easily.

The teenager, that's another question of motivation and the whole social context of . . . . I believe that teenagers should all be educated in their sexuality, including their fertility and their fertility cycles. Whether or not that means we rely on that as the only way of them not getting pregnant, I would think you need to look at social context and social norms, and other issues. And in some social context for some teenage populations and families, they may think contraception's part of that, but I think that for all teenagers, they should understand their fertility.

Dr. Jones: Right. I thought that if they had sex, they were reflex ovulators like cats, meaning, yes, grown-up women ovulate on a schedule and teenagers only ovulate when they have sex because it seems like it only takes once, at least that's what they've told me.

Dr. Stanford: Well, you know, that's an interesting question that I actually think we need a little more research on, but it's not true that . . . there's no evidence, let's put it that way, that women can go from no mature follicle to ovulating based on one intercourse.

Dr. Jones: Even I know that. Well, so I take it . . . I come at contraception from a perspective of wanting to have a very low failure rate with almost no input.

Dr. Stanford: Right.

Dr. Jones: So for those of us who are interested in what we call long-acting, reversible contraception, or highly effective reversible contraception, we want something that's highly effective and reversible, and you don't have to think about it, that has some side effects, though. It has some downside and women, the tradeoff for highly effective and reversible is some side effects, but I guess . . . what is the failure rate if you follow the rules? Did we talk about that?

Dr. Stanford: Yeah, 1% to 2%.

Dr. Jones: One to two percent, that's pretty good, per year?

Dr. Stanford: er year.

Dr. Jones: Per year.

Dr. Stanford: So I would say that is a fundamental difference in philosophy. Natural family planning is, in some ways, the complete opposite of long-acting, reversible effective contraception in the sense that the goal is to have as little user input as possible, make it completely independent of the user.

Dr. Jones: Right.

Dr. Stanford: Natural family planning is the radical opposite of that. The user, and not just the woman, but the woman and the man together, need to cooperate and understand what's going on and cooperate to make that happen for both of their intentions. So it is a radically user-dependent method, which I think some people see as a weakness, but it is also a strength.

Dr. Jones: I think it is for strength and what I really want is for women to have their choices.

Dr. Stanford: Right.

Dr. Jones: And for couples to have their choices.

Dr. Stanford: Right.

Dr. Jones: And I think that's important to both of us, and whether you choose a very technical approach to your personal contraception, or you want a, what I call radically . . .

Dr. Stanford: User-dependent . . .

Dr. Jones: . . . user-dependent method, meaning your control and your body

Dr. Stanford: Right.

Dr. Jones: We want to have both people to be successful.

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Dr. Jones: "I have irregular periods, and I'm overweight. Do I have PCOS? I looked it up on the web." This is a question I hear all the time. What is PCOS, and how do you know if you have this condition? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care, and we're talking about the most common endocrine problem in women today on The Scope.

Announcer: Covering all aspects of women's health, this is The 7 Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: PCOS, I hear some people say, "P-COS," but in fact, those of us in the know just say, "P-C-O-S" is polycystic ovarian syndrome. The "poly-" part is "many," the "-cystic" part is little fluid-filled pockets, the "ovary" part is self-explanatory, and the "syndrome" part is that it's a condition with several symptoms and it's not caused by any one thing. It's not a specific disease.

So the many cysts are very small, little egg cysts called follicles in the ovary, stuck, in that they are less than a half inch, and they are ordinarily much smaller than a normal follicle. It makes an egg. They don't grow big and hatch an egg every month, and they don't go away every month. They eventually shrink, but new ones take their place.

Because they don't grow big to about an inch and hatch out of the egg every month, women with PCOS don't have regular periods. Their periods are more than 35 days apart, and they're not predictable. This is one of the symptoms of PCOS. Now, there are many different conditions and diseases that can make irregular periods. Women at the beginning of their reproductive life and at the end of reproductive life are almost always irregular for a while.

The other symptom, which may be subtle comes from the fact that all these little egg follicles in the ovary make male hormones, and this is normal. When you have a lot of them, though, you have increased male hormones. Until a follicle gets big enough to make estrogen and ovulate, they make male hormones, so the other symptom that goes with PCOS is an excess of male hormones. Now, this isn't a huge excess, nowhere near the level that men have, but enough that some women may have acne or hair growth on their face or abdomen, coarse hair, not the little fine hairs that all women have.

So you said you were overweight and had irregular periods. Although many women with PCOS are overweight and being overweight does complicate PCOS, it isn't necessary for the syndrome. What is necessary for the syndrome of PCOS has been debated furiously on both sides of the Atlantic for more than 50 years.

Europeans prefer that the diagnosis be made by two of the following three findings. Irregular periods, evidence of excess of androgens or male hormones, and multiple little cysts on the ovary on ultrasound. Well, these criteria would be seen in every adolescent with irregular periods and acne, which most 13-year-olds have. Americans like just two criteria, but you have to have both, irregular periods and evidence of extra male hormones.

If you Google PCOS, and you'll find that this syndrome is found in 5% to 10% of women in reproductive age, PCOS isn't a syndrome of little girls or post-menopausal women. But 1 in 10 to 1 in 20 young women will have this. It is very common. Also, if you make the mistake of Googling PCOS, you will scare yourself by the claims of PCOS women that they will be infertile, obese, hairy, diabetic, and die early from heart disease.

We know that women with PCOS can have a hard time getting pregnant, but most of them will if they seek medical care, and many of them will, even if they don't. Those sneaky little eggs do ovulate on occasion. Weight management is particularly important for women with PCOS, as many do have an increased risk of Type 2 diabetes, but many don't get diabetes. Women with PCOS, who are obese, have more difficulty getting pregnant and staying pregnant than those of normal weight or those obese women who don't have PCOS.

And the claims of increased coronary heart disease have not really panned out, so I wouldn't worry about that, except that all women should worry about that.

Okay, so how do you know if you have PCOS? If you have irregular periods and you aren't a teen or breastfeeding or using hormonal contraception or close to menopause, you should see your doctor. And if you have unwanted acne and facial hair, you probably want to see your doctor. If you have both, you may have PCOS.

And there are many ways to manage the symptoms or help you get pregnant if you want to. There are a few rare conditions that look like PCOS, problems with the adrenaline glands or tumors that make male hormones, but these are very, very rare and easy to rule out.

PCOS is common, and the signs and symptoms can make a woman worried and unhappy, but there are lots of things we can do. We don't have a cure, but we have some very good workarounds. If your primary care doctor or your OB/GYN can't help you get your symptoms under control, there are specialists called reproductive endocrinologists who can help you out.

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Dr. Jones: When is a human uterus like a horse or a cat uterus? Well, it's not, except when it is. This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health and we're talking about uterine anomalies today on the Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: The human uterus is shaped sort of like a light bulb, the old-fashioned kind. The metal part at the bottom is the cervix, which keeps the uterus anchored in the pelvis and keeps the baby in. The bulb part is the actual uterus. Inside the bulb is the uterine cavity where the baby grows and it's normally shaped like an upside down triangle. Two corners at the top of the triangle point into the fallopian tubes and one corner points down into the cervix. The uterine cavity is flat like an envelope until it's filled with the pregnancy.

Congenital uterine anomalies, malformations of the uterus that occur during fetal development, are common. About five percent of women, one in 20, will have some kind of uterine abnormality. Although many women have a uterus that slightly abnormally shaped and they may never know about or have any problems. Some uterine shapes can cause recurrent miscarriages or premature births or infertility.

Rarely, about one in 5,000, women have two uteruses and two cervices and two vaginas and about one in 1000 women have no uterus, no cervix, and no vagina. Understanding how the uterus develops is helpful here. In human and mammal development, there are two tubes that come together in the pelvis. These two tubes fuse together at the lower end and the middle of the fuse two tubes dissolves to make one uterine cavity and one cervix with the two fallopian tubes at the top.

Now, this is something that's really better on video than audio. So let's do an experiment. Imagine yourself taking two foam tubes, one in each hand. The kind of floppy foam tubes. So you're holding these foam tubes, you bring your hands together and the foam tubes in your hands at the lower part of these tubes fuse and the upper parts are kind of floppy on the sides. Those are the fallopian tubes so where they fused together, that makes the uterus.

Now if that fusion doesn't happen normally, if you got those two foam tubes in your hands, you get to uteruses and two cervices. If at all fuses and dissolves, your hands come together and you get no uterus or cervix. If it fuses but doesn't dissolve completely, you can have a uterus that's Y shaped with two horns or uterus with the wall down the middle.

Men, by the way, had these two tubes when they were developing but males make a chemical that makes the entire uterine system disappear well before they're born. That's why guys don't have a uterus.

Women without a uterus or cervix don't have periods so that's usually discovered when they're teenagers. We want to end with just a little dent on the top of the triangular uterine cavity, like horses, have about we call arcuate uterus or heart-shaped uterus and they may never know it as it doesn't cause problems.

Women with the Y-shaped uterus, we call it bicornuate, and that's the normal shape for mammals to have lots of little babies like cats, may find out that this is the uterus when they have premature babies. Women with the wall in the uterine cavity, called a septum, may find out that they when they have recurrent miscarriages.

There are many other less common uterine anomalies, but what do we do about this? Well, the majority of women with uterine anomalies have no problems except with pregnancy. We don't recommend that all baby girls or young women have imaging of the uterus to find out if it's normally shaped or not.

Some women find out that they have an abnormally shaped uterus when they have a cesarean section, maybe for a breech baby, and an abnormally shaped uterus is more likely to lead to a breech presentation of the baby.

Women who have had a very premature baby for no good reason may be advised to get imaging of their uterus. Depending on the problem, this might be done with a special kind of ultrasound or an X-ray that puts a special fluid in the uterus so the uterine cavity can be evaluated on a screen or an MRI.

Women with recurrent miscarriages usually get some kind of imaging to see if they might have a septum or wall down the middle of their uterus. The good news is that reproductive medicine specialists can surgically remove this wall with excellent results for the next pregnancy.

If someone has a uterine anomaly, what kind of doctor should they see? At the U, we have a team of reproductive endocrinologists, specialists in reproductive problems, who often team up with our high-risk pregnancy specialists to work out a plan for each woman and her uterine problem.

Surgical correction of the problem is often is an option. When there's no way to correct the problem, we often talk about gestational surrogacy where we use someone else's uterus to carry your biological baby, which we can do at the University of Utah Hospital in our Center for Reproductive Medicine.

Human development is amazing and interesting and, of course, I think the reproductive system is the coolest. But when things don't go exactly right, there are specialists who have experience and probably they can help you out. And thanks for joining us on The Scope.

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Dr. Jones: The recent uterine transplants performed here in the United States and in Europe have given new hope for women who were born without a uterus. This is Dr. Kirtly Jones from Obstetrics & Gynecology at University Health Care and this is The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: The development of the human uterus is complicated and as complicated as the development of the heart. It starts in the first months of pregnancy and sometimes things don't go right. Although some kind of variation in the development of the human uterus is common, about one in 20 women has some mild change in the shape of the uterus that will never affect them or their childbearing. About one in 5,000 women is born without a uterus.

Now, there are several reasons this might happen, but one of the most common reasons is called Rokitansky Syndrome or if you want to impress the medical students and they will totally forget it, it's Mayer-Rokitansky-K¸ster-Hauser Syndrome or MRKH Syndrome. In fact, using the names of people who discovered something in medicine isn't really helpful because it doesn't tell you what it is. I prefer the term M¸llerian agenesis, meaning the M¸llerian system, the uterine system, didn't develop.

Women with M¸llerian agenesis have ovaries and they go through puberty in the normal way, outwardly. They develop breasts, hair under their arms, they roll their eyes, and they get curvy like every other girl. They just don't have periods and this is what usually brings them to the doctor. When I see an adolescent of about 14 or 15 that developed breasts and pubic hair at about the right age of 12 but still hasn't started their period, I worry that they might not have a uterus or might have a blockage that keeps their menstrual blood from coming out.

Some girls have a blockage at the level of the hymen, just at the opening of the vagina. That's an easy thing to fix, just open up the passageway, but some girls don't have a passage. No vagina, no cervix, no uterus. Now, this is a very difficult diagnosis for young women to hear and even harder for her mother who brings her in for this evaluation. Moms often feel as if there was something that they did when they were pregnant that interfered with their baby's development. But there's nothing that they did to cause this.

The diagnosis for the young teens can be traumatic, but young teens aren't usually thinking about having a baby and not having a period can be perfectly fine for them. They aren't usually thinking about sex yet so the fact that they don't have a vagina isn't right up front on their radar screen.

Eventually, though, these things, babies and sex, they become an issue for the young woman with M¸llerian agenesis. A vagina pouch can be created with a non-surgical procedure that stretches the skin at the entrance where the vagina should be so a vaginal opening is created. This takes time and persistence on the part of the young woman to do the stretching exercises. Sometimes, a skin graft or graft of other tissues is used for the surgical creation of a new vagina.

Well, that can help for the intercourse part, but it doesn't help with the baby part. For most of my career, when I met with a young woman with M¸llerian agenesis, I talk about adoption. About 15 years ago, I started to have a discussion about gestational surrogacy. This is a process, legal in our state of Utah, of taking the eggs from the ovaries in a woman with M¸llerian agenesis, adding the sperm from her partner, through in vitro fertilization and transferring the embryo that's created through this process to the uterus of a gestational surrogate.

A gestational surrogate is a healthy woman with a normal uterus who carries the biological fetus of a couple who provided the embryo and gives the baby over to that couple at birth. In Utah, the biological parents don't have to adopt this baby as the courts recognize that they were the intended parents from the conception. Now gestational service is expensive, insurance doesn't often cover it and it requires some legal arrangements at the outset. It is, however, quite successful with pregnancy rates about 50% per try.

Now, with uterine transplants, would this be the answer for a woman born without a uterus? Well, we still have some work to do to find out if these transplanted uteruses actually can carry a baby in a healthy way. Is the blood flow normal? Will the baby be affected by the drugs taken by the mom to prevent rejection of the uterus? Will the baby grow well, be nourished well by the placenta? Will the labor go well?

We don't know these things yet and uterine transplantation will be much more complicated and expensive than gestational surrogacy, which provides a healthy environment for the growing fetus. Still, for some women, if this technology goes well for women and babies, it may be a choice. My goodness, we have come a long way. I hope for all women that they can have the opportunity to have the babies they hoped for. I hope for all babies the opportunity to be wanted and have the best start possible. Thanks for joining us on The Scope.

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Interviewer: There's been a lot of buzz about BPA in plastics and how that can affect human health. We think we know a lot about it, but do we really? Up next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking with Doctor Christy Porucznik, Associate Professor of Family and Preventive Medicine and Associate Chief of the Division of Public Health at the University of Utah School of Medicine. Where does BPA come from? It's kind of everywhere, right?

Dr. Porucznik: Most of us get most of our BPA exposures from food. It occurs in packaged foods, it's not in the food itself, it's in the packaging. And so it's in the lining of things like soup cans or it's in plastic packaging that your food comes in and also medications. Sometimes the capsules or even the tablets, there's BPA involved in the manufacturing process. It's everywhere. You can't avoid it.

Interviewer: Turns out there's a lot we don't know about BPA.

Dr. Porucznik: BPA is an endocrine disruptor. What we know is that it interacts with substances in your body in the way that hormones do. We've seen effects of BPA on many different hormone pathways. In men, we see sexual dysfunction. In our study, we've observed an association between BPA and semen quality. The primary focus of our study is examining levels of BPA in couples so both the man and the woman who are trying to get pregnant and then seeing if people with higher levels take longer to get pregnant.

Interviewer: Why are you studying couples?

Dr. Porucznik: Actually the reason that we're studying couples is that it takes both of them to get pregnant.

Interviewer: Good point.

Dr. Porucznik: It's obvious, but it's shocking. In the land of reproductive epidemiology, almost no one studies couples. They study women. And mostly they study pregnant women. But since our question is about time to pregnancy, we would have been missing half the story if we left out men. We know that BPA affects sperm and so men might actually be the most important part of this particular relationship.

Interviewer: How exactly are you doing this work?

Dr. Porucznik: We've recruited couples in the community who are planning to get pregnant. For our couples, when they recognize that they're in their fertile window, both the man and the woman collect a daily first morning urine specimen. The men stop collecting urine after the fertile window is done because at that point they're either pregnant or they're not. The women continue collecting through the menstrual cycle so that should they have conceived that cycle, we actually have urine specimens for the time of during implantation that we can study for exposure to environmental chemicals.

Interviewer: Are you trying to determine whether levels of BPA can affect conception or whether this might be a critical window for the new baby?

Dr. Porucznik: We think both of those. There are a lot of researchers who are studying what's called developmental origins medicine with the idea that what happens to you in utero can have lifelong consequences. Most of those studies don't start until babies are actually born, though. If there was a transient exposure that happened during pregnancy, we've missed it. My prospective study design is going to be the way that we could discover potentially environmental exposures that are linked to, say, a heart defect, that happen during that critical phase where the heart was developing.

Interviewer: If researchers have not been examining this window, what have they been doing up to this point?

Dr. Porucznik: Most of the studies that we have right now that talk about early exposures to BPA and then childhood outcomes have come from prenatal samples collected during a routine prenatal visit. In our best studies, they have three urine specimens, maybe one from each trimester. But here's the problem with that. BPA metabolizes very quickly. The half-life is six to eight hours.

Interviewer: Oh, wow.

Dr. Porucznik: What that means is if I examined you urine from this morning, it would tell me about your exposures yesterday. But if yesterday was not a normal day for you, then it might not tell me anything about your typical exposures or your exposures during a relevant window.

Interviewer: Is that true? It's completely passed out of the body, it's not stored in any way or anything like that?

Dr. Porucznik: Ninety percent of BPA is actually excreted in the urine within the first day of exposure.

Interviewer: What that also means is that if you make a change in the way you consume foods or the types of foods you consume, where they come from, that can have immediate implications for you.

Dr. Porucznik: Yes, it really can. We've collected thousands and thousands of urine specimens and it's very rare that we've ever had a specimen in which we could not detect any BPA, but we see a wide variation in levels. Some people are consciously trying to avoid BPA. Their levels are lower.

Interviewer: Interesting. What have you found with your research so far?

Dr. Porucznik: One thing that we've found so far is that we've actually been able to quantify how much day-to-day variability we see in BPA levels within an individual. The upshot of this is that at a minimum you need at least six urine BPA specimens in order to have good confidence that you're going to classify somebody in the same high, medium or low BPA category. Six. Most studies have one to three.

Interviewer: This just illustrates how little we know about BPA exposure. What remains to be done? What are sort of the next steps for you?

Dr. Porucznik: In terms of BPA research, I think at this point everybody is convinced that BPA is a hormone disruptor and it's probably something we should think about how we're consuming and where it's being used. But it's not so strong that it's causing widespread effects. By that, I mean if exposure to BPA was causing infertility, we would have noticed.

Interviewer: Yeah, true.

Dr. Porucznik: Right? But our idea is that even if it's just increasing time to pregnancy, then for some couples who might be on the edge of sub-fertility already, then the BPA exposure might be something that on a population level is pushing us to more infertility workups. It's pushing us to more IVF and as a society, that's costing a lot. Not in just money, but it costs a lot in terms of anguish four couples who are trying to get pregnant or in terms of low birth weight or adverse birth outcomes that are associated with assisted reproductive technology.

Announcer: Interesting, informative and all in the name of better health. This is the Scope Health Sciences Radio.