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Interviewer: When it comes to issues of infertility, it's important that both members of the couple are involved in the diagnosis and treatment of the issue.

To find out why that is, we're joined by Dr. Kelli Gross, a men's health specialist and assistant professor in urology at University of Utah Health.

Now, Dr. Gross, why is it so important that both partners are involved when we're trying to, say, diagnose why a couple can't get pregnant?

Dr. Gross: It's incredibly common that men come to see me and they've never been considered at all in their fertility workup. We find that up to about 40% of the time, there is what we call male-factor infertility or an abnormality in fertility in the male partner. So it can be greatly underdiagnosed.

With all of the technology that we have in fertility, things like in vitro fertilization can make it so that optimizing the male partner is not as essential as it once was. But it can be a lot more expensive and have its own set of downsides.

Interviewer: So when you say that it's 40% of the time, does that mean that it is often misdiagnosed, or do we often deal with the female issues more often?

Dr. Gross: It wouldn't necessarily be that it's misdiagnosed, more that it's ignored. With couples, they may be experiencing infertility without having any major health issues or causes. It can be both sides things are a little bit abnormal. So having things that are less than optimal in one partner can still lead to issues, but sometimes we just get around these by other sorts of things.

Interviewer: And what kind of things are those?

Dr. Gross: So it would be things like intrauterine insemination or in vitro fertilization. So what that is, for intrauterine insemination, is we put the sperm directly into the uterus. So it bypasses some abnormalities if there are low counts in the sperm or if there are issues on the female side.

We can also do things like in vitro fertilization, which is where the egg and the sperm are joined outside of the body. And that can, likewise, overcome a lot of issues on both sides, such as having very low sperm counts or issues from a female partner side.

Interviewer: So if a couple is trying to identify what is causing their infertility, why is it more economical to have both partners involved from the start?

Dr. Gross: So there are things that we can improve from a male side that can make it easier to get pregnant either naturally or with help. So, for example, there are certain procedures that we do that can improve sperm counts in certain men.

So if we have somebody who has very low sperm counts, then doing something like that where they previously would not be a candidate for something like intrauterine insemination, which takes a certain amount of sperm, by raising those counts, we then make them a candidate for that, or they are able to get pregnant naturally because the sperm counts are higher. So they can save a lot of money from the cost of, for example, in vitro fertilization.

Interviewer: We spoke about why it's so important to have both partners involved in diagnosing and treating infertility. How long should a couple be trying before they technically are dealing with infertility issues, or when should they start to see a specialist?

Dr. Gross: So we usually define infertility as trying for one year. And that's kind of just because 90% of couples will get pregnant within one year.

It's kind of arbitrary. So, for example, if you've been in a long-distance relationship and you haven't been having intercourse, of course, a year may not mean that there's anything wrong biologically. And at the same time, if there's any sort of history or medical concerns that make you seek treatment earlier, there's nothing wrong with that at all. We don't say, "Keep trying," necessarily. We would typically evaluate to see if there was anything that we can improve, no matter what time it is.

Interviewer: For a couple that is having difficulty getting pregnant, as often as 40% of the time, it's actually an issue with the male partner. Why is that, and what are some of the more common things that can be causing infertility in men?

We're joined by Dr. Kelli Gross, a men's health specialist and Assistant Professor in urology at University of Utah Health.

Now, Dr. Gross, if we were to pick out the top three reasons why men might be infertile, what are they and how can they be treated?

Dr. Gross: So, number one, one of the top modifiable reasons that I see is exposure of the testicles to heat. What that commonly is, is a hot tub, bathtub, sauna. And the reason why is because sperm really likes the cooler temperature of the testicles. The testicles are outside of the body. They're about four degrees cooler than the rest of the body. And things like hot tubs, that increases the heat and the sperm just doesn't work as well, isn't produced as well.

People are surprised that those effects last about three months. Seventy-four days is the lifecycle of the sperm, so going in the hot tub once is going to potentially affect your fertility for the next three months.

Interviewer: Wow.

Dr. Gross: Yeah. People are always shocked by that number. Now, we found that things like showers don't necessarily make a big difference, the kind of underwear that you wear, those sorts of things. But a lot of direct heat from the testicle you do want to avoid.

Interviewer: I guess how big of a temperature change are we talking before we see that 74-day impact on the sperm count or functional sperm count?

Dr. Gross: I don't know if we necessarily know an exact number, but I usually advise patients the testicles are four degrees cooler than the rest of the body, so kind of keep it under that point.

Another common thing that we see is fevers. So after fevers, it's incredibly common to see abnormalities on a semen analysis.

Interviewer: Wow. Okay. So that's number one. That's pretty common. It's not something that's at the forefront of your mind. What about number two?

Dr. Gross: So number two would be something called a varicocele. Those are dilated veins to the testicle. So if you think about varicose veins in your legs, it's the same kind of thing. And they happen in about 15% to 20% of men overall, but we find it in up to about 50% of men who see a urologist for fertility issues. They are repairable surgically.

We think the reason why they have such an effect is potentially because it does trap heat. So the blood pools in those dilated veins, so it traps more heat in the testicles, which sperm doesn't like.

Interviewer: And what causes these veins? Is it just genetics? Is it just maybe lifestyle stuff?

Dr. Gross: It's mostly just genetics, kind of the way that you were born. They're incredibly common. So it's in part just the way that we're constructed, the way the veins have to travel such a long distance.

Interviewer: And so is this an outpatient procedure type of surgery? What kind of . . . what is involved in treating the varicocele?

Dr. Gross: Yes, it's an outpatient surgery. It takes about an hour more or less, depending on if we have to do both sides or what. We make an incision that's about an inch, inch and a half long, and then just divide all the veins. It's fairly straightforward as far as surgeries go. Not everyone needs it, but a fertility specialist can help determine if it's something that needs to be repaired.

Interviewer: Okay. So we have heat. We have an outpatient procedure if there are some extra veins or some varicoceles that have been formed. What about number three? What is the third most common thing?

Dr. Gross: So number three that I see very frequently is people who are on supplements that can potentially harm fertility or other medications. Testosterone, for example, is one of the biggest culprits that I see. Most other medications that are prescribed aren't going to have a big effect.

But there are certain other ones like Propecia or Finasteride, which is used for hair loss, that can potentially affect fertility. Cancer medications, unsurprisingly, can affect fertility. But the one that people don't really expect is supplements. They've done studies on supplements, and I've been absolutely shocked with what's actually in a lot of the supplements that we take. For example, there are steroid hormones. There are things like testosterone, including testosterone, that are in some of these supplements, even ones that aren't labeled, or that you would necessarily worry about. There's even oral testosterone, which is actually pretty bad for your liver. It's just not well regulated.

I see patients all the time who I look at their hormone panels and I'm like, "You may not be on testosterone, but there's something that you're taking that has testosterone in it." And we usually can pick something out and stop it and then those effects go away.

Interviewer: Wow. And so are these just over-the-counter type? Are we looking at like a daily multivitamin supplement? Are we looking at, say, muscle building, those things that you get in the big jugs at the supplement store?

Dr. Gross: Not usually the multivitamin, the Centrum or anything like that. Those are usually pretty safe. But it's like pre-workouts, even ones that aren't "boost your testosterone pre-workout," just regular pre-workouts, anything that's kind of marketed towards the erectile dysfunction, men's health kind of thing. I've seen potentially having issues with that.

Interviewer: And how long does it usually take for someone to see the effects go away after they stop taking it?

Dr. Gross: It can really vary. For example, with people who've been on testosterone for years, it can take up to about 18 months for that to come back. So in 90% of men it'll come back in about 18 months, but 3 months is usually a minimum. And some people won't come back in at all.

Interviewer: Okay. So those are three common things that can be causing male infertility. Now, Dr. Gross, how long should a couple be trying before they come and see a specialist like yourself?

Dr. Gross: So it's different for every couple. We generally say if after a year, definitely come in. But we won't question if it's sooner. It's easy to check to see if things are normal or not.

Interviewer: Here to speak with us about vasectomy reversal is Dr. James Hotaling, a urologist and the director of the men's health program here at University of Utah Health. Now, Dr. Hotaling, when it comes to a procedure like this, what are some of the reasons a patient might be looking for a reversal?

Dr. Hotaling: About 6% of people who have a vasectomy will ultimately want it reversed. The most common reason is that they have gotten divorced and have a different partner and want kids with that new partner. Although we do see couples who have had kids, had a vasectomy and then decided they want more kids. So those are usually the most common reasons people want it reversed.

Interviewer: I've been seeing some rates that say, "Hey, you know, a reversal is only 30% to 90% effective." How effective is a procedure like this?

Dr. Hotaling: Yeah. It works about a 90% to 95% of the time.

Interviewer: Oh, wow.

Dr. Hotaling: So it's pretty effective. It depends a little bit on how far out you are from your vasectomy. If you're like 20 years out, it has a lower chance of success. Although it, you know, that chances of success still may be like 80%, 85% than if you're two years out, just because there's more scar tissue.

Interviewer: And we're determining success by being the ability to get pregnant.

Dr. Hotaling: Yeah. That's exactly right. You're determining success by having swimming sperm in the ejaculate.

Interviewer: And so what other factors besides just length of time since you've had the procedure?

Dr. Hotaling: Yeah. A little bit it can be exactly how the procedure was done. When you go back in there, you can either put the vas deferens back to the vas deferens, and that has the highest chance of success rate. Sometimes you have to put the vas deferens back to the epididymis or the sperm-holding tank, and that's smaller and that has like a 60% to 70% chance of success. It's lower. But if you can put the vas deferens back to the vas deferens, that success rate is really high. So if you look at all comers, you end up around 90% to 95%. That's really the biggest thing in determining the success rate and then also just, like we mentioned, how far out you are from having the reversal and to some degree just how the individual surgeon did the vasectomy.

Interviewer: If someone say listening to this and considering whether or not they should have their vasectomy reversed, what is, you know, what is the ideal candidate for a procedure like this? Like is anyone say, you know, not a good candidate? What makes a good person for this?

Dr. Hotaling: That's another really good question. So obviously somebody who wants to have kids in the future and somebody who if the wife is younger, that can be helpful, although it's not impossible to do it if their wife is older. Also for couples who want, you know, multiple kids, it can be helpful as well. And just cost considerations. You know, the cost of a vasectomy reversal is a lot less expensive than the cost of in vitro fertilization. It's like a third the price. So that's kind of the other option, the other consideration.

Interviewer: And is reversal ever covered by insurance?

Dr. Hotaling: No.

Interviewer: Okay. So it's out of pocket?

Dr. Hotaling: It's always out of pocket. Yeah.

Interviewer: What are some of the risks with getting this type of procedure, of getting it all back together?

Dr. Hotaling: Well, the biggest risk would be that it wouldn't work, which is really, really low. You know, the recovery is usually pretty minimal, a little bit of bruising, but not terrible, sore for, you know, maybe five days afterwards. We do use long-acting numbing medication that lasts for four days. So patients really don't have much pain from that. And then you have to take it easy for three weeks or so. In terms of the complication, some patients can get pain that lasts longer than that afterwards. As I mentioned, the chance that it couldn't work or just chance of some bruising or a very rare chance of infection, although that is exceptionally, exceptionally rare as in I've been doing this for eight years and I've only ever seen it happen once.

Interviewer: Wow.

Dr. Hotaling: So that's not common.

Interviewer: Okay. So here on The Scope we've talked before about vasectomies and what the procedure is like, what to expect. It's an outpatient procedure, you come on in and, you know, you heal up for a week or so, right? With a reversal, you know, like the day of the surgery, what are they expecting?

Dr. Hotaling: So they'll, you know, they won't have anything to eat or drink after midnight. They'll come in, in the morning. You know, they'll get an IV put in. They'll get drifted off to sleep. They'll go to sleep. Once they're asleep, we make two small incisions, one on either side of the scrotum, and then we go in and find where the blockage and we bring a high powered . . . we have this new digital microscope, it's like a $700,000 microscope that actually allows us to see in 3D with special glasses on.

Interviewer: Wow.

Dr. Hotaling: It actually is really helpful to do the procedure. So we bring that in. Then we put the tubes back together again with 12 sutures that are finer than a human hair and then put the local numbing medication and close everything up. Each incision is shorter than an inch on either side.

Interviewer: Oh, wow.

Dr. Hotaling: So two incisions, really small. Then you would wake up with some . . . And all the stitches melt away on their own. You'd wake up with some sort of biologic superglue over the incisions and then some gauze on the scrotum. And then you'd go home later that day. And most patients just take some Ibuprofen and Tylenol and that's it.

Interviewer: Wow. And you were saying that it's take it easy for a little bit and then three weeks until you're back to . . .

Dr. Hotaling: Yeah. It's really just no like sex, bike riding, or heavy lifting for three weeks. But you could be back on your computer doing work the next day. Often if I do the surgery on a Thursday, patients are back at work again certainly by Monday. And if I did the surgery on say a Tuesday, often by Thursday or Friday.

Interviewer: Once they're all healed up and once they're feeling good, how do we know, I guess, if it was a success?

Dr. Hotaling: Yeah. It's a great question. You know, we have had patients who get pregnant before we ever checked the first semen analysis.

Interviewer: Wow.

Dr. Hotaling: But usually we check in like 8 to 10 weeks, we check the sperm test. And it can take up to a year, even up to a year and a half, depending on the type of like reconstruction that we do.

Interviewer: Oh, wow. So it's not just you magically are?

Dr. Hotaling: Most patients, when it's successful, have sperm right away.

Interviewer: Oh, wow.

Dr. Hotaling: But it can take longer.

Interviewer: Okay. So, you know, you'll do a test and find out if it was successful and go on from there?

Dr. Hotaling: And then we would repeat it again in three to six months if we didn't show any sperm.

Interviewer: And I would imagine that this type of procedure is something you want to make sure you go to a good doctor, a good surgeon, or a good urologist. You know, what should a man be looking for in a doctor to perform this?

Dr. Hotaling: Yeah. So typically somebody who's done a fellowship in male infertility, which both myself and Dr. Gross here have. We're actually getting another partner, who's starting in September, who's also done a fellowship in male infertility. So you want someone who's fellowship trained. You want someone who does a lot of these. And I think also doing it, you know, in the operating room with the patient asleep, with kind of the best equipment you have, and we sort of tick all those boxes here. Some people do do them in the office with local numbing medication. You know, I don't believe that that's necessarily the best way to do it in my opinion.

Interviewer: So we're looking for someone with a fellowship, someone who's performed the procedure a few times and probably a lot of times, right? And a good center, right?

Dr. Hotaling: Yeah. That's exactly right.

Interviewer: For a patient who is considering getting this procedure done, what is it about say University of Utah Health or maybe another medical center? What is the things that a big center like ours can offer to them with their procedure?

Dr. Hotaling: Yeah. Typically we can also . . . we offer the ability, because we have a full IVF lab and andrology or sperm lab, we can do a little biopsy of the testis at the same time and freeze some of that testicular tissue in case the reversal doesn't work, you know, and you could use that, which saves the patient a significant amount of money because they don't have to have another procedure in case it doesn't work. You want somewhere, you know, that does a lot of them and really has the best equipment.

Interviewer: You were just telling me that you have fellows, you have other . . .

Dr. Hotaling: Mm-hmm. We have other people that we work with. And the surgeons here are still doing the entire surgery, but we have really good assistants. A lot of places, it may be, you know, a surgical technician who's assisting the surgeon, and it really helps to have, you know, great assistants, or if it's a super complicated case, myself and my partner, you know, we'll sometimes do those together.

PCO, OCP that is a palindrome, something that's the same when you read it forwards and backwards, but it also refers to a common hormonal problem in women, and something used for management. This is not a quiz game, but this is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

PCO, polycystic ovaries and polycystic ovary syndrome is a hormonal condition in women of reproductive age. It's not a disease, but a syndrome, meaning a constellation of symptoms and findings without a single common cause. The symptoms and the findings that define PCOS include irregular periods and evidence of increased androgens or male hormones. Some definitions include having multiple small cysts on the ovaries that can be seen on ultrasound. However, not all women all over the world have access to an ultrasound to look at their ovaries, so many experts just use irregular periods and evidence of androgen excess. Also, young women who have lots of eggs, have lots of follicles. So, on ultrasound, they look like they've PCOS, but they don't. So the ultrasound part is kind of controversial.

Irregular periods mean that menstruation comes more than 35 days apart, and not on a schedule. Now, some women feel that their cycles are irregular, if some months they have periods on the 15th of the month and some months on the 17th, but PCOS means that the cycles are much more irregular and often without ovulation. If women who have PCOS usually don't ovulate, they don't make the hormone progesterone, which is made by the ovulation cyst, and is important for keeping the uterus healthy each month. So having regular periods makes the uterus healthy, and having irregular periods can lead to unpleasant or dangerous bleeding and a not very healthy uterus.

The excess androgens part of PCOS means that women have more than normal levels of hormones made by the ovary that are like testosterone. Now, all women make male hormones. In fact, the female hormone estrogen is made out of male hormones. However, women with PCOS have many small egg follicles that are stuck in development that makes male hormones. That's the polycystic part of polycystic ovaries. These little follicles usually do not ovulate. They don't make the estrogen at the level of an ovulating follicle, and they don't make progesterone to keep the uterus lining healthy and that causes irregular periods.

So what are the main symptoms of PCOS? Well, irregular periods and excess hair growth on the face and other parts of the body. If a woman with PCO is trying to get pregnant and doesn't ovulate, she may be infertile. Many women with PCOS have gained weight, and this complicates the problem of irregular periods and extra male hormones. Some women have insulin resistance and may be prediabetic, partly related to the PCO part and partly related to obesity.

Now, PCOS is very common, as many as 1 in 20 to 1 in 10 women have this syndrome. It was probably less common in years past when women were much less likely to be obese, and not all women experienced PCO to the same degree. Some women have slightly irregular periods with only minimal signs of excess male hormones, and some women have extremely irregular periods and very significant hirsutism or excess body hair.

Okay, that's the PCO part. What about the OCP part? Oral contraceptive pills have estrogen and progestin in them. The way OCPs work for contraception is to block the development of follicles, so ovulation doesn't happen and they control the uterus lining, so periods are regular and light. The way OCPs work by suppressing the development of little follicles, those little cysts that can make male hormones, make them useful in controlling symptoms of PCO. Also, women with PCO have estrogen but lower amounts and the higher estrogens in the OCPs can help counteract the effects of male hormones. The progestin in the OCPs help control the lining of the uterus, so women can have regular periods. There you go.

Now, clearly OCPs do not cure PCO, but they are very useful in the control of symptoms. There's even some evidence that women who are taking OCPs for the PCOS and then choose to try to get pregnant, may actually be more likely to ovulate the first several months after stopping OCPs. Not all women who have PCO are good candidates for OCPs. Some women with PCO who are obese and have high blood pressure, which may be a contraindication to OCPs. Some women don't like the way they feel on OCPs, although many women with PCO say they feel better on OCPs.

Are you guys getting tired of the PCO or OCP palindrome? Well, hang in there. We're almost done. Some women may have other contraindications to OCPs, including a history of blood clots or migraine headache. And of course, some women want to get pregnant. For women who are overweight with PCO, their first effort might be diet and exercise with the focus on weight loss. Women with PCO who lose as little as 10% of their body weight are more likely to ovulate and to have regular periods. Then, of course, they may choose OCPs for birth control. For some young women, a diet low in refined carbohydrates, high in vitamins and minerals and good nutrition, and regular exercise may make them feel the best. However, for some women, and many women, diet and exercise do not work to control their symptoms and OCPs may be the best option.

There are many kinds of OCPs, but they all work mostly the same way. The combination pills with estrogen and progestin work the way we just talked about. The lowest dose pill that does the job would be the first choice. The OCPs are different in the kind of progestin in the pill, and some women feel better on one pill than another. They all work to control periods and lower male hormone effects. So, because PCO is so common, most primary care providers, which include internists, family physicians, pediatricians who see teenagers, and OB/GYNS are familiar with the signs and symptoms and routine treatments. However, there are other options in treatments for symptoms other than OCPs and weight loss and exercise and diet. If a woman with PCOS is struggling to understand her condition, is not getting help with symptoms, or is struggling to get pregnant, she may want to see a specialist in PCOS such as a reproductive endocrinologist.

PCOS is complicated in all of the 7 domains of women's health -- physical, emotional, social, environmental, intellectual, financial, and spiritual. Having irregular periods, being infertile, having the body that you don't think is really you, all those things are affected. If you or someone you know is struggling, we can help. And thanks for joining us on The Scope.

Interviewer: At-home male fertility tests that you get over the counter. You go to the drugstore, you get the fertility test, you take it. Does that give you helpful information? Are they accurate? Are they worthwhile? That's what we're going to find out today from urologist Dr. John Smith. What is your take on those over-the-counter, at-home male fertility tests?

Dr. Smith: We see a lot of people for fertility at the University of Utah, and those at-home tests really are very rudimentary. They don't tell you a lot of information. They pretty much tell you if you have an adequate amount of sperm in the ejaculate or not. And that's really all they can tell you.

So if you had a positive test where it said, "Hey, you've got enough," that doesn't tell you if those sperm are alive, if there's any motion in those sperm, the morphology or the shape of those sperm. It doesn't give you really any other information. The only thing it tells you is if there's enough sperm there to hopefully not have fertility issues.

And the way these tests work is similar to a pregnancy test where it looks for a protein that's only on the sperm. And so that's how they quantify. So you've got to have enough of that protein in order to have the test come back positive that you've got a high enough quantity of sperm to have a normal sperm count.

Interviewer: But if partners have been trying to have kids and they have not been successful, and the man goes and gets this and finds out, "Oh, hey, I've got enough sperm according to this test because they detected enough protein," but you're still not having kids. You really haven't solved anything by taking the test, have you?

Dr. Smith: No. You really haven't. And that's the other part of things that go on. There's also two parties when you're trying to have kids. You've got the male side of fertility and the female side of fertility, and we're going to talk about the male side today.

But if you have been trying unsuccessfully, having unprotected intercourse for over . . . usually the definition is one year. Some people will say six months to a year. But all in all, if you've been trying and you haven't been successful and you get that at-home test and it tells you that there's enough sperm there, that still doesn't tell you that there's not necessarily a problem. Because if there's low motility, meaning you don't have any that can move and get where they need to be, the viability of things, so to speak, and then the morphology, the shape, if they're not the normal shape where they're not going to travel in a uniform way . . . there are a lot of things that go into a sperm test.

And so when we do a semen analysis at the University of Utah in our lab, we get the volume of the semen. It tells us the total sperm count, the sperm concentration, or how much there is per milliliter that's in the sample that we received. It tells us the viability, how many of those are alive and moving. It tells us the motility, how many of them are moving in an adequate amount to be beneficial for you. And then the shape and morphology. So it really gives us a lot more information.

However, the biggest thing I find for most patients is fertility may not be covered under their insurance. So they're looking for a quick test that can give them some information. And that test may or may not be helpful for them because if there is another aspect to the semen parameters that's not good, that's not just the number, then they're never going to see that on the test.

And so I think a lot of people are looking for a cost-effective way to just get some answers, but sometimes the most cost-effective way is just to come in and get a full semen analysis done with a fertility specialist.

Interviewer: Yeah. That way you can discover exactly what the issue is, and then go about perhaps solving that issue if there is indeed an issue.

Dr. Smith: Exactly.

Interviewer: So, from a male perspective, when you get this information back, generally then when you start solving the problem, is it going to be an expensive process or sometimes are there some simple changes that can be made that can make all the difference?

Dr. Smith: It's different for every patient. Some guys come in and they have a hormone-related issue that we can solve with some medication. That can really be an inexpensive fix. Oftentimes a lot of medications are still covered by insurance, which can be helpful.

And then in some men, if there is an issue where there is a low sperm count or no sperm count, some of the procedures to check and see if the testicles have viable sperm in them can be a little bit more expensive.

However, the real expense comes if you had to have IUI or IVF, which are insemination techniques. Most of the male stuff tends to be less expensive than that.

Now, again, when you're looking at things, fertility is not cheap by any stretch of the imagination. A lot of the procedures that are done to check for viable sperm within the testis can run anywhere from $2,000 to $5,000, but then a round of IVF can cost greater than $10,000 upwards, even much more than that.

So, when I talk about cost, it's very interesting because the male side of things generally is a skosh less expensive than the total amount that it takes to get the fertility solved in some cases.

Interviewer: So it is possible that you go and you get the test, you get some solid results, and it might be an inexpensive fix. That is not unheard of.

Dr. Smith: No, not at all, and we do a lot of that. And sometimes if the sperm count looks maybe borderline, we can also try some medication to try to bolster that sperm count for a few months and then do a retest type of thing.

And so a lot of times, we usually don't run right to the higher dollar surgical procedures, things like that, unless they're absolutely needed because we do understand that a lot of times this stuff isn't covered by insurance and we want to try to make it as best we can and most cost-effective for these folks.

It's a tough road. Fertility is tough. I see quite a few folks who we have success with, and it's great to see that, but any of those couples that are having trouble, I would say just get in and see if there's something that can be done to really help you because sometimes it is a simple solution.

Fertility can be one of the toughest portions of a relationship, but also one of the most rewarding. So I would say don't delay. Just get in and see if there is something that can be done to make things easier for you.

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That's what we do in the fertility business. We tell people, "Just keep pushing the button." It's hard, but you have to kind of leave your modesty at the door when you're talking about infertility, because we get right down to the nitty-gritty.

For many people, maybe most, having children and raising children is the biggest part of their life plan. Now, not everybody. And it isn't maybe a baby now, but having a baby eventually or raising a family is where people came from because we were raised and we were kids and it's what we know. But for some people, it just doesn't happen.

Now, when it doesn't happen, it really touches all of the seven domains. So infertility is the paradigm for the seven domains concept because the process of trying to have a baby, of not succeeding in a time that works for you, and then the consequences of physical, emotional, social, financial, intellectual, environmental, and spiritual all get wrapped up. We're going to talk about that.

The physical part may be that the basic mechanisms of getting pregnant aren't working. You need eggs, and the eggs need to be kind of young eggs. They can't be old eggs. So women over 35 and especially over 40 and really after 45 don't have eggs that are very likely to make a baby, even though they ovulate every month.

• So you have to have young eggs and you have to have fallopian tubes, because it's the fallopian tubes that get the eggs and the sperm together.

• And you need sperm.

It turns out that our understanding of sperm has really evolved in the last 30 years. So we thought we just needed some sperm. In fact, in the olden days, we thought if a man could ejaculate, he was fertile. But now we know it's a lot more complicated than that. But we need enough sperm and they have to be sperm that can actually bind to the egg and they have to be sperm that can get into the egg. And then they have to be sperm that can actually add good DNA, because at least half of the sperm in a healthy man are not normal. So you need to have a good sperm.

The number of sperm per ejaculate is half what it was in 1950. And we think that is probably due to environmental factors. We certainly know that the rise in obesity in men makes a difference in terms of sperm quality. When you start looking at areas where there's a lot of air pollution, you find a decline in sperm quality.

I think we're concerned about both pregnancy and fertility with respect to chemicals in our environment and the air that we breathe. I think that there's good information at the Environmental Working Group. If you're worried about putting certain kinds of lotion or using certain kinds of products or cleaning with certain kinds of products, ewg.org can help you navigate the kinds of things that might be harmful for your fertility.

Now, irregular is in the eye of the beholder, but at least twice a week intercourse. Now, clearly there are people who don't have sex, women who don't choose to have a partner that they have sex with, or they are men who don't have a woman to have sex with, because they don't choose to have a woman partner. But in general, we're talking about heterosexual couples who are trying to have a baby and can actually have sex. So it's a year.

Now, there are other reasons why people can't have a healthy child when they might actually be fertile. So they might be able to conceive, but they have conditions that will get in the way of their growing and bearing a child.

• The woman might have a medical condition that would get much worse in pregnancy. And the poster child is pulmonary hypertension, a disease where there's high blood pressure in the lungs. People with pulmonary hypertension, women who give birth have a very high, and in our business, meaning as high as 15%, chance of dying in the first 48 hours after giving birth. So we strongly encourage people with critical heart disease not to get pregnant. And that's heart-rending.

• There are other conditions where the disease actually is toxic to the baby. Uncontrolled diabetes is the poster child for that because people who have diabetes that's uncontrolled can have birth defects in their baby. They can miscarry and their babies can die in utero because their sugar is very out of control.

So these are conditions where we consider them infertile because they can't bear a child, but all their mechanisms are working. And those situations are truly heartbreaking.

Gestational surrogacy is where a couple, an egg and a sperm from an intended parent, that's what we call them, "the intended parent," is put together in a test tube, and the embryo is put in a surrogate who is healthy and young and is able to carry a baby. And although the laws vary from state to state, this is something that is available in many states, gestational surrogacy. In the state of Utah, where I live, we even have the situation where the intended parents' and the biological parents', the donors of the egg and sperm, names are put on the birth certificate.

So gestational surrogacy is a way through the infertility process when someone is too sick or has conditions that would be hard for the baby or hard for the mom.

There's, for women, a fair amount of shame and blame that comes with not being able to conceive a child. Shame because this is something that's natural. You should be able if you're a woman just to do this.

Blame, women often say, "If I just hadn't had sex when I was 16, I'd be fertile now," or, "If I hadn't done this, or if I hadn't gotten that sexually transmitted infection, or if I hadn't gained that 30 pounds, and now I'm not ovulating very regularly," or you name it, women blame themselves for everything.

In the darkness of the night of the hope of a pregnancy, people blame themselves. And within a relationship, they may blame each other, and that's also not uncommon. The man may be pointing his finger at the wife because she isn't ovulating or she has endometriosis. And the woman may be putting the finger on the guy because his sperm isn't so great. But in fact, infertility is a couple's problem. It's not one person's problem. It's the couple, because a couple together isn't getting pregnant.

We, in our own fertility center, have a behavioral psychologist who works with us for all of our couples who are dealing with tough stuff like surrogacy, egg donation, when it's time to quit, couples who are really struggling with the process.

I think understanding that there is help if you're struggling with your partner, and it's normal to have difficulties, like, "I'm tired of making love to a calendar. I'm tired of making love three times a week. I only want to make love once a week," or, "I just want to go out and have that beer and I don't want you looking at me because I'm having that beer." You name it and it can be a struggle for people personally, for a couple emotionally. Most infertility teams have a social worker or a behavioral psychologist who can help couples who are struggling emotionally.

Now, what about young people who are faced with a lethal cancer that can be cured, but the cure itself may limit their fertility or end their fertility with chemotherapy and radiation?

In my career, my very first patient for whom we did fertility preservation efforts who had cancer was a wonderful young woman, a woman I knew from outside my own practice. She was brilliant and she was funny and she was gorgeous, and we saved her eggs, and then she didn't make it.

So, for me, in the back of my mind was, "I hope that somebody takes these eggs. I hope her parents take these eggs and make a baby. I want this woman that I loved to live on."

We are fortunate to have two specialists. Dr. Joe Letourneau, who is with the Utah Center for Reproductive Medicine at the University of Utah. He's a specialist in advanced reproductive technology and fertility preservation. Also with us is Dr. Douglas Fair, who's the cancer specialist and director of the Oncofertility Program at the University of Utah.

Dr. Jones: My question is, we have eggs or sperm in the bank and the person for whom we were hoping this future would unfold, and they could use them themselves, but they didn't make it. So what do we do? Why don't we start with Joe?

Dr. Letourneau: It's a difficult question. It's one that we do encounter. The reason we are doing these procedures is to focus on the future and help people build that future. But in those circumstances where patients may pass away or life circumstances for them may change . . . For example, when we met them prior to their diagnosis, they were partnered with a certain person and they may no longer be partnered with that person, but perhaps they've created embryos together. So there are questions of who sort of owns those embryos and how do we handle that?

We try to help people anticipate these uncomfortable, unexpected events, what they would want to do, so that we can either have their consent or their assent in the case of a child to get an understanding of kind of what they would want.

So some of this we truly prompt ahead of time and say, "What would you want us to do with your sperm if you died? What would you want us to do with your eggs if you died? What would you want us to do with your embryos if one of you died or the other died, or you both died? Or what would you want us to do with your embryos in the event that you divorced?"

Even with married couples, that can be a little awkward to say, but say, "We have a technology of freezing eggs that's just about as effective as freezing embryos. So even though you guys want to have a baby and you're very much in love, would it make sense to just freeze eggs or just freeze sperm alone?" Because once we make an embryo, that's an irreversible . . .

Dr. Jones: Commitment. It's a commitment.

Dr. Letourneau: It's a commitment, yeah.

Dr. Jones: For me, the complicated question, because I have been . . . well, I'm a mom now, but my kid is grown up. But if it's a young person who may not even know how to make that decision, if it's a 14-year-old, can the young person or can the mother ask that the eggs and the sperm from their child be given to the parents so the parents can then use that to try to create the child?

Those are the things that, for those of you who deal with this every day and the sorrow around each family, sometimes you'd say, "I would never do this," but when faced with this family right now, you'd say, "Well, maybe I would."

Dr. Fair: I think these questions are really interesting. They're really complex and perplexing because there's a lot to them. And I think to highlight one of the things you mentioned, what makes them so complex and perplexing is just that they are so dynamic and personal. They really depend on the family. Patients are often put in situations, and that's inherent in cancer, where they weren't expecting or weren't thinking about . . .

I think that's what makes all of this really hard. And this is where I, as an oncologist, really rely on the expertise, both in knowing some of the science, but also knowing some of the ethics and the communication skills around these very difficult topics. When fertility comes up, or what to do when we have collected sperm or eggs and how can and should they be used, I think, are really difficult ones.

But they're really difficult, and I think from my humble opinion in dealing with patients who do die and how their families deal with them, I think grief can take a lot of different forms. So I do think this is a question, while rare, is very interesting and one that we in oncology and in oncofertility do face.

Dr. Letourneau: I agree with Doug that there are a lot of really complex emotions, and often having someone who's an expert in mental health can be very helpful. Certainly any decisions made around something as serious as a future potential person should be done in a very balanced, sort of sober mindset.

There's a natural grief period where people think about things in ways that they may not have otherwise. So I think making sure that people have had an opportunity to grieve and they are able to process those emotions and they know that their decision is coming out of a point that really makes a lot of sense to them and is a healthy decision is really important.

I think when people think about this that aren't thinking about it often or in the popular media, or when people ask me at dinner, they do say, "Well, what if someone is about to die? Do you still consider doing this and why? What are they going to use the sperms or eggs for?"

And a lot of times people can be very sick and sometimes they do well and they live for a long time afterward. Sometimes, even for someone who may not have a long predicted duration of their life, improving their quality of life can be really helpful. And this is one of these things that really does help people focus on the future, and it helps to improve their quality of life. So we see a benefit to fertility preservation and these oncofertility services and at least in education for really anyone who's facing a significant illness.

For people who want children and are working hard to have children, our goals here in our fertility center at the University of Utah, and around the country for people who do infertility services in an honest way, I think that we recognize the importance of helping people meet these personal goals. It's not just like a new car. It's bigger than that. It's fulfilling a personal and often spiritual goal.

So I think the hard part of walking through the infertility journey is feeling that you're alone. Often, people don't talk about it because of the blame and shame. They don't talk with their friends that they've been trying for over a year, or they've had a couple miscarriages.

It turns out that infertility becomes part of the lives of one out of eight couples. You don't always know that. Even though people are asking all the time, "Well, when are you going to have kids?" you don't know that they may have been trying for two years and you just sent an arrow into their heart. But if people share their story, they won't be so alone.

We have technology that will help the majority of people with infertility have a child one way or the other, but only you can help yourself with the emotional, social, and spiritual aspects of being part of a bigger community by sharing your struggles.

Get help not just from us as your healthcare providers and specialists, but get help from your community because they'll be there to back you up when that pregnancy test is negative again.

A baby maybe?
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Dr. Jones: We have so many choices in our lives now, but some things we don't have choices about and that's when is it time to have a baby and when is it too late? But there are some choices.

Today in the studio we're with Dr. Joe Letourneau, who is a reproductive endocrinologist at the Utah Center for Reproductive Medicine and director of our oncofertility program and also for fertility preservation.

Well, you've planned everything in your life just right and you kind of didn't have kids because you were looking to find the right person to have kids with or you were looking at your job, and now you're older and you find out that you don't have many eggs left. What are your choices then?

Dr. Letourneau: This is the circumstance in which having frozen eggs can be quite helpful. At that point, it would be possible to consider thawing some or all of those eggs to try to create embryos and use them for fertility treatment.

In the last 10 or 15 years, we have developed a new type of technology called vitrification. And with this process we use a safe sugar type of solution to dehydrate the egg as we freeze it. This takes the water out of it and prevents the ice crystal injury. When we then use the egg in the future, we warm it back up and we allow it to refill with water, and it's a very healthy egg. So the survival rate of eggs currently is very high. It's in the 80% to 90% range. Whereas in our own field with our best technology 20 years ago, it was probably only 1% or 2% survival rate.

Dr. Jones: That's been the biggest change in IVF. So if a woman then decides she wants to use her eggs, some of them are thawed, and then sperm are added and then the embryo grows in the labs. So they go through an IVF process once they're finally ready to make a baby?

Dr. Letourneau: That's correct. After five or six days of growth, we would put the embryo into the uterus the same way it would sort of roll out of the fallopian tube, but we actually place it through a natural opening in the cervix.

Dr. Jones: So if a woman is lucky and maybe she has 20 eggs, they'll go into the freezer. She might have more than one chance at IVF, maybe more than one chance at having more than one kid perhaps?

Dr. Letourneau: Absolutely.

Dr. Jones: And how successful is it? And that probably is a function of how many eggs you get and how old the patient is, but what's the ballpark?

Dr. Letourneau: You've intuited there that age and the number of eggs has a big impact. So one egg for any woman could make a baby. But it really comes down to a probability. So one egg in one's early 40s has a much lower chance of one egg in one's early 20s. And as such, it helps to have many eggs. So likely getting as many eggs as we can safely achieve is probably the best method to preserve fertility. But probably each egg has somewhere between a 5% to 10% chance of making a single baby.

Dr. Jones: So what happens for now a woman's 42 or 43 and she's tried a couple of times with her own eggs and IVF hasn't worked? What are her next options?

Dr. Letourneau: It's important to think of the frozen eggs as one method of helping one conceive, and it's not 100% success rate as we spoke about earlier. Not every egg makes a baby, but coupled with the idea that some people their circumstances in life may change where they're ready to try to conceive their first baby at 38 or 39, they may be able to do that.

It may be that the frozen eggs are most helpful for the second baby or some other aspect of their family building. So some people may conceive on their own, some people may require some fertility treatment, and some people may even consider fertility treatment to have that first baby if they've been trying to conceive at 42 using their eggs at that time for new IVF and then saving the eggs from age 34 for, you know, their second baby. So it's a pretty dynamic process, but in general, having the frozen eggs does involve sometimes revisiting kind of the IVF process in order to use the frozen eggs.

Dr. Jones: And then the option if for some reason none of those things are working, we have donor eggs from young women that can be an option for people who find that appealing or they're willing to think about that choice.

Dr. Letourneau: Absolutely. We've been using donor eggs for 30 years or so in our field, and it's a very normal thing to do and it's an excellent way to build a family. A common concern that patients have about the relatedness, you know, I won't be related and my partner will or I won't pass on my genes. The reality is that most of us humans have most of our genes that are exactly the same, just about and so there is certainly a uniqueness to us. Part of that comes in our genetic code and then part of it comes in the way we use our genetic code.

And what we've found in research in big studies of human populations and in other mammals is that the maternal environment during pregnancy impacts the way the baby and then even their babies and their grandchildren after that use their DNA. And so there is a big impact on genetics. There's a big biological relationship that's created between the mom who carries the pregnancy from the donated egg, and I think it's a really excellent way to build a family if that should be needed.

Dr. Jones: Well, I think that knowing that you have options, whether you can exercise those options or not, for women who are trying to think about making a family someday is important for us as providers and for women who have the questions it's good that we actually have those options here. Thank you for talking to us about it, Dr. Letourneau, and thanks for joining us on The Scope.

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.

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Dr. Jones: So you're having trouble getting pregnant. It's been six months and you really want to have a baby, but you know that fertility therapy can be very expensive and involved. Is there another way? And what's the difference between taking different kinds of ways to getting your baby? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care, and this is "Making Babies" 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 we'd like to have children in a timely manner. But if you're not getting pregnant in the time that you want, we always have said, "Well, go to your doctor or your family doctor, and then if you're not getting pregnant, come to see a specialist." But are there ways that you can actually enhance your own fertility without intervening with medications or interventions, at least for the start?

Today on The Scope studio, we are talking with Dr. Joseph Stanford, professor in the Department of Family and Preventative Medicine. And Dr. Stanford has a special interest in natural, procreative technology. And we're going to be talking about that, how to make yourself as fertile as you can be using natural methods. Thank you for joining us, Joe.

Dr. Stanford: Thank you, it's a pleasure.

Dr. Jones: So can you tell me about what is natural restorative or reproductive medicine? I'm a reproductive endocrinologist and everything that I do is not very natural. I do some really big hormones, and we do some really big procedures, and we do help people get really pregnant. But maybe there's something on the way to coming to me that actually might be very successful. So go with it.

Dr. Stanford: So natural procreative technology actually has a spectrum of things. The entry level is for couples to understand their fertility better, to understand what factors improve it, what factors are detrimental. And make lifestyle changes and also understand when the best times are for having sex.

Dr. Jones: Okay. What things make it better? What makes your fertility better?

Dr. Stanford: Adequate sleep, good diet. These are things you probably tell patients just as much. Moderate amount of exercise and weight that is not too high or too low, especially for women but also for men.

Dr. Stanford: Okay. And what things make things worse? All those converses meaning, an unhealthy lifestyle, not getting enough sleep, alcohol, and cigarettes smoke and unhealthy weight for men and women?

Dr. Stanford: Right, other drugs, marijuana, all those things.

Dr. Jones: Right. And then not enough sex?

Dr. Stanford: Well, not appropriately timed sex. That's one of the myths, is that you have to have sex either every day or every other day. But for couples with infertility, it's often the case that the fertile window is narrower for the woman. It may be three days instead of five or seven. It may be one or two days, the days that are functionally most likely for conception to happen. Couples can learn to track that and know when those days are with fertility awareness or natural family planning as one component of the natural procreative of technology.

Dr. Jones: Okay. So, education about things which enhance your fertility in your own body and timing and appropriate frequency of intercourse. And then you mentioned that was one. So what's two?

Dr. Stanford: So number two for natural procreative technology is really very similar in some ways to a medical . . . We do a full medical history exam for the woman and the man. We're trying to identify underlying factors that may be inhibiting fertility. I think we could both agree that a healthy woman, healthy man, healthy couple that didn't have any health issues, part of their healthiness would be being able to reproduce when they're in their reproductive age range.

So if there is not fertility at a normal level, something organically, physically is wrong. And usually, in our research with looking at this with couples, there are usually multiple underlying contributing factors. So what we're trying to do is identify all of those contributing factors and make them better to the extent we can. Some of them are lifestyle issues, some of them are medical issues. It may be thyroid, it may be polycystic ovary syndrome, it may be an endometriosis it may be a varicocele. It may be other things affecting semen quality. So we were trying to identify all of those things and find whatever we know that we have in our toolkit currently to correct and restore the possibility of natural conception.

Dr. Jones: So let's take endometriosis for an example. In my world, if we think someone has endometriosis and maybe we can feel it. Maybe someone's had a look inside their tummy, and they saw it, we feel an abnormal ovarian cyst and we can tell on ultrasound it's endometriosis. In my world, we operate on that and say, "Now we've restored your pelvis, at least for a little while, to its better fertility so go for it."

Dr. Stanford: I would I would applaud that. I think that the only definitive treatment we currently have for endometriosis is good surgery. And when I say good surgery, I mean surgery that's not just removing it but also minimizing the risk of subsequent adhesions. So adhesion-free surgery. I don't personally do surgery, but I have a short list of surgeons that I trust to refer to for patients that need that. So I think surgery can be part of the restorative process. And in endometriosis, it's what we currently know we have for that. I hope down the road, we'll find some other ways to reverse endometriosis or prevent it without surgery, but we're a ways away from that.

Dr. Jones: So for guys, if we have a gentleman who comes to us at the Utah Center for Reproductive Medicine and he has maybe half the numbers of sperm that he should or less. He has less than 20 million sperm per CC, and they don't look right, we move right away to . . . maybe we'll look for a varicocele, but we might do inseminations or might move to IVF. What do you do for guys to enhance their fertility? Do you go back to the lifestyle and the health issues?

Dr. Stanford: Definitely start there because that's kind of the foundation and it's a rare man that doesn't have some lifestyle issue, right? We definitely start there, but there are also some limited trials, some of the supplements that have been done for antioxidant and other types of supplements. And I think, in many cases, it's worth the trial of those with a follow-up semen analysis to see which way things are going, paying attention to the fact that semen analyses have a natural fluctuation as well.

Dr. Jones: So here's the problem that I face often here in Utah. And that is, and it can happen anywhere, and that is a young couple, they're 25. They've been trying six months. They haven't become pregnant. They want to be pregnant yesterday. And they want to immediately jump to my toolbox. And I don't even want to open . . . I don't even go looking for my tool box yet because they haven't tried long enough and hard enough for. . . And if I tell them I think they should try for another year using, actually, things that you're recommending, sometimes they walk out of my door and walk into my partner's door. So maybe if I send them to you, you'll keep them in your arms until you decide they need to come back to me?

Dr. Stanford: I would certainly do my best. And I think we have a reasonable track record. One of the things we find from studies of infertility treatment is that there's a high dropout rate from all types of fertility treatment. IUI, IVF, also the natural procreative technology, we all struggle with the keeping the couples engaged enough to say, "You really can succeed if you give it the full try." And couples often give up before we think they should, medically.

But, having said that, I do think that what I do is a lot different than just saying, "Okay. Try for another year," or, "Learn how to time it, and then try for another year." We're actively managing the cycle. What I mean by that is we track it with the woman's fertility tracking, charting biomarkers. We're looking at the mucus score. We quantitate the quality of the cervical fluid or cervical mucus production. We look at the bleeding pattern, including little bits of spotting making us nervous. We look at that. I usually just do a single [inaudible 00:08:21] hormone level seven days after ovulation.

So we're looking at these parameters and their timing of intercourse to look at 12 optimized cycles, not just trying for a year, but let's get 12 cycles where we can document that the cycle looks optimized for conception, based on the woman's charting, based on the timing of intercourse, based on the hormone levels.

Dr. Jones: So after that, what do you do if it's been 12 cycles and they haven't conceived, and you haven't either found a reason, or you found a reason, but they still haven't conceived. Where do they go from there? Do they get to decide about where the next steps are?

Dr. Stanford: They certainly always get to decide, but my recommendation to them at that point is, "We've done a full course of treatment, I can't promise you anything further. If you want to keep going, because that's what you want to do, I'll support that, but I'm not recommending that in the sense that we have done a full course of treatment. And you can look at other options, whether that's other fertility treatment or adoption or accepting your childlessness with saying you've done what you wanted to do." So those are always the couple's choices. So, for me, a full course of treatment is those 12 optimized cycles after having corrected all the underlying issues that we can.

Dr. Jones: Right. Well, I think most of us who do this want people to have the family that they want and we don't want any kind of therapy dragging on for too long because the clock is ticking, especially for women. But in the fertility business, I would say, I think it's important not to intervene with the big guns too soon, but not to avoid the big guns, meaning in-vitro fertilization, if it's something that's a choice for them.

And I think that what you've done, I've seen many of your patients over the years be pretty happy and successful with doing their own fertility once you've ruled out . . . you wouldn't . . . Somebody with no sperm, no eggs or no tubes, you would probably send them on pretty quickly.

Dr. Stanford: Right. If they don't have a possibility for natural conception because their both tubes are blocked, I'll certainly advise them of that upfront. This approach, I think, is a viable approach for the vast majority of sub-fertile or infertile couples, but there are a few that have absolute reasons that they can't conceive naturally.

Dr. Jones: Right. So I think both of us want the same thing in the end. I don't want to over-treat young couples that might get pregnant on their own with either specially adapted cycles to look at their own peak natural fertility or just time. And you probably don't want people jumping into high-tech fertility before it's time for them as well.

Dr. Stanford: Definitely, I agree with that. And I think that one of the things that are a little different about the restorative approach is we, ourselves, are also trying to take a longer view. Not just getting them pregnant, and I know that you would agree with this too, we want a healthy baby. We want a full-term life, ideally singleton baby. In other words, not twins when we can avoid that because of the risk. Not because we don't like twins, but because they just have more risks to the mom and babies. And we want that baby to grow up healthy, and we want the mother to be healthy later in her life. So I think the idea is to look at the overall health picture and not just, "Do you get pregnant next month?"

Dr. Jones: Great. Okay. Well, so for people who are attempting to get pregnant and are still young, of course, 45-year-olds might get a different approach, our goal is to do the right thing at the right time. And both of us are planning on doing that. And call us if you need us and thanks for joining us on The Scope.

Dr. Stanford: Thank you.

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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.

Interviewer: Polycystic Ovarian Syndrome causes irregular periods, unwanted hair growth, sometimes weight gain and infertility, but it's very treatable with lifestyle and medication. We'll examine the condition and what you can do if you think you have it coming up next on The Scope.

Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Polycystic Ovarian Syndrome is a common but under-recognized disease. It is very treatable and we're going to learn more about it from Dr. Joseph Stanford. He's with the University of Utah Healthcare. First of all, what is Polycystic Ovarian Syndrome?

Dr. Stanford: Well, the main features of the syndrome really don't have anything to do with the ovaries: irregular periods, unwanted hair growth on the face or other parts of the body and then there are multiple small cysts on the ovaries and that's where the name comes from. Women only have to have two of those three to have the condition.

Interviewer: Oh, okay. When does it usually come on in a woman's life? Could it come on young, old, anytime?

Dr. Stanford: Usually young So women who have it will usually develop it in the teen years.

Interviewer: And is it literally at one point all of a sudden you start getting some hair growth?

Dr. Stanford: It could be more gradual. I wouldn't say it's sudden overnight.

Interviewer: Okay. And typically, where do you find that hair growth?

Dr. Stanford: On the face. So women who have to pluck and remove hair on the face and sometimes other parts like the chest or belly that's unwanted hair growth.

Interviewer: How common is it? How many women get this?

Dr. Stanford: So Polycystic Ovarian Syndrome as a whole is about 10% of women and that would be similar numbers for the unwanted hair growth. There can be other causes of that as well. It's not the only cause.

Interviewer: All right. And why is it unrecognized?

Dr. Stanford: I think women, if they've heard anything about it, they think about cysts on the ovaries. And that's, like I said before, not the main feature of the condition. It's one of the three pieces and not one that women know about unless they've had an ultrasound or something like that. The public is not generally aware that this syndrome involves these other problems, severe irregular menstrual flows, irregular periods and unwanted hair growth.

Interviewer: And what causes it?

Dr. Stanford: So what we know now is that it has a lot to do with insulin resistance. Sort kind of like a pre-diabetic condition where women don't use insulin quite as well and the ovaries don't respond to insulin quite as well and that causes hormonal imbalances like the excess male hormones that cause hair growth and the irregular periods.

Interviewer: And why is it bad?

Dr. Stanford: Certainly it can cause problems with the unwanted hair growth and it can make it harder for women to lose weight or make them gain weight that they don't want to. In the long run, it can give them a higher risk of diabetes and other complications that come from diabetes like heart disease.

Interviewer: Are there any other effects other than the symptoms that could be negative on a woman's body?

Dr. Stanford: Certainly, it can cause infertility for women who are at the point they want to get pregnant. This can be an issue. So it's definitely something to pay attention to and treat for better health.

Interviewer: And what are some of the treatments?

Dr. Stanford: Briefly, I'd say treatments include diet and medications.

Interviewer: Oh, okay. And does it go completely away?

Dr. Stanford: It can be managed to where it's pretty much not a problem.

Interviewer: All right. And what about the cysts? Do they just go away as well?

Dr. Stanford: They often get better as well.

Interviewer: Without surgery?

Dr. Stanford: Right.

Interviewer: Oh, well that's probably a relief for a lot of women.

Dr. Stanford: Right.

Dr. Stanford: Surgery usually is not necessary.

Interviewer: Okay. Outstanding. So are there any final thoughts you have? Is there a question I forgot to ask or anything you feel compelled to say?

Dr. Stanford: I would just say for women who have irregular periods or unwanted hair growth should get it checked out and not just think, "That's the way I am. I have to deal with it." And we're here to answer any questions. Happy to be of help.

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