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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?
Let's start now, tonight, tonight
No luck, yet again

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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: 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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