How much do you really know about your fertility, menstrual cycles, and conception? Join us to learn more with Dr. Joyce Harper, a Professor of Reproductive Science at the Institute for Women’s Health, University College London, and the head of the Reproductive Science and Society Group. She is the author of Your Fertile Years.
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Welcome, everyone to creating a family talk about infertility. I'm Dawn Davenport. I am the host of this show as well as the director of the nonprofit, creating a family.org. Today we're going to be talking about female fertility, and all about an introduction really to female fertility. We think we know a lot about female fertility. But in fact, I find when we talk with people that in fact, we don't know a lot. Today we'll be talking with Dr. Joyce Harper. She is a professor of reproductive science at the Institute for Women's Health at the University College London. She is also the head of the reproductive science and society group. Welcome, Dr. Harper to creating a family. Lovely to meet you. All right, I think that when we we need to begin with the menstrual cycle, and the menstrual cycle is more complex than we give it credit for. It's not just the monthly fluffing of the of the uterine lining, it starts in the brain, it's actually fairly complex. So can you walk us through the the menstrual cycle? What are the factors? What are the hormonal factors that are involved in, in women menstruating? Yes, it's
a very important thing that I think all women need to understand. And this is this is really important whether they want children or not, it's something that happens to almost all of us. And I started working when I started working in this field of fertility back in the 80s, I was learning a lot about menstrual cycle and other parts of fertility, and was aware that my friends didn't understand the menstrual cycle. And if you're sexually active, you're trying either not to get pregnant or to get pregnant. And for either of those situations, I think it's really important to understand this. So it's a great question to start with. So our menstrual cycles are something that really govern our lives for prolonged puberty to the menopause. And they're a huge part of our lives. And there are four key hormones that are involved. And these hormones are very powerful, and they have a profound effect on us physically and mentally. So there's two hormones that are controlling how the eggs are the key, actually the key key to events, you've talked about periods. But the two key events of the menstrual cycle are period, and ovulation. And our period only comes if we don't get pregnant. If we get pregnant, then our period won't happen. But ovulation is the time when we can actually get pregnant. And there's about six days and around the middle of our cycle that we are fertile called the fertile window. And all of this is controlled by these powerful hormones. So the first one I want to talk about is one called follicle stimulating hormone. And it's doing what it says it's stimulating the follicle to grow in to the middle of our cycle. And the follicle is the structure on our ovary that contains the egg. So that follicle stimulating hormone is maturing the egg, so it's getting it ready for ovulation. And the next hormone is called luteinizing hormone or LH. And this is something that triggers the final maturation of the egg. So just before about 40 hours before the egg is going to ovulate and be released from the ovary. And that's that's the meantime can get pregnant, this luteinizing hormone has a surge and helps the final maturation of the egg and helps the egg ovulate. So then there's two powerful other powerful hormones estrogen and progesterone. And these all for those hormones, they oscillate through our whole menstrual cycle, and the estrogen is produced by the follicle. And that's going to be related to the, again, the development of the egg and control of the other hormones. And progesterone is mainly to do with preparing our womb for possible implantation of a fertilized egg. In which case we could then get pregnant. So those hormones are oscillating all the time. They're having a profound effect, as I've said, and so they're very, very powerful. So I think it's really important for women to understand their own unique menstrual cycle. If you learned if you did learn anything about this in schools, you probably were told that we would have a 28 day cycle, and we ovulate on day 14. But that's a textbook and we're not textbook. So one of the first first key messages of my talk today is that women are individual, and all of the things I'm going to talk about will affect to women totally differently. And we've done a lot of research looking at really big data around menstrual cycles and the characteristics of them. And we found only 13% of women had a 28 day cycle. Most women have a cycle that's around about so a few days either side. But actually, anything from 21 days to 35 days is actually still considered normal. But most people 65% of our women that we looked at in an over six 100,000 menstrual cycles were between about day 26 And day 32. So that's the sort of average time so we shouldn't panic if we're not the textbook 28 days. But the important part as well is about this day of ovulation. The textbooks have always told us it's day 14. And our analysis of big data and other studies that have come out, since we published on this, have shown that ovulation overall, is probably nearer to day 16. But again, we're all individuals. So don't even think about that day 16. It'll be individual to you. So if you're having a shorter cycle, then you're probably going to ovulate earlier than that, if you have a longer cycle, you'll ovulate later than that. So if a woman is trying to get pregnant, she may want to find out when she particularly is ovulating. And there's certain ways that we can talk about how you can do that.
I was just going to scan first of all, before we talk about prediction of ovulation. Are most women fairly regular in their length of their cycle? Or is it a concern? If your cycle varies substantially between? Well, maybe not substantially? Maybe your one month 26 days? One month? 28? One month? 30? Are most women fairly predictable?
That's a very good question. So most women are regular. But But as I've said, if they're if they're 26, wonder that one month 28 The next then that's that's fine, they shouldn't really worry, really irregular would be outside those normal levels. So if they were having cycles, you know, not have 21 days, one month, 35, the next 40 and moving around like that, then that would be something that I think they should seek some advice on and get some checks done. Because that could be an indicator of things like polycystic ovarian syndrome, which I'm sure we'll talk about in a moment. But that's, that's too much it should be for that particular woman, it should be within a few days. So if she has any concerns, then it's really good to go and see her doctor and just get things checked. And see because even again, even if she doesn't want to have children, there, maybe if she's got polycystic ovarian syndrome, there are other problems with that disorder that can affect her day to day well being. That that there's treatment that could help her with that. So it's not, as I said, it's not about getting pregnant, it's about that reproductive health. How is your menstrual cycle, if you have any concerns, I think my second message will be that in our lives, we're just told, Oh, it's a women's issue, just grin and bear it. And I'm on a mission to let women know they shouldn't grin and better. And if they've got any concerns at all, please go and get checked, don't suffer in silence. If something's affecting your well being if your periods very heavy, or if it's irregular, or if it's painful, if you've got any concerns at all, don't grin and bear it. It's not a woman's issue. It's a health issue, and we need to go and get help. And there's many, many treatments that we can offer women for all of those problems I've mentioned, we just need to get empowered more and go and seek help. Before before we've suffered for years, and it really affects our day to day life.
Before we get off of the menstrual cycle, are we seeing is does a data indicate a change in the age of onset of menstruation? And does it depend on where we are? We're speaking of? Yeah,
this is all of women's health. It's a hugely under researched area. So there have been some studies that are suggesting were going through puberty earlier. menopause can be affected by many things such as smoking and different lifestyle factors. So there's data indicating these that earlier puberty, but really, we need long term big studies. And historically, we haven't asked women these questions. So we haven't got good data to sort of build on but we have to start doing this. Now. We have to see if things are changing. And if they are we have to figure out why they're changing. And one last thing say actually about the menstrual cycle, obviously for a Peri menopausal woman. I think it's so important for women to understand that they can become so perimenopause is the time before menopause and menopause is when you've been for one year without having a period, then you're postmenopausal. So menopause is a very short time when you've been up. I've been for a year then you're as soon as you realize then post menopause, but the proper term what we I think we always talk about menopause. We're actually talking about the perimenopause, which is when we can get symptoms etc. And absolutely one of the main symptoms is that our periods will change. They'll become closer together further apart. Eventually so far apart, they stop, but they can often become very heavy, very, very heavy. And women in their late 30s and early 40s are normally in denial they don't want to think about the menopause. We've given it a very negative narrative globally, and I'm on again on a mission to change that life post menopause without having a period is fabulous. For many, many women, we're getting empowering women to embrace this wonderful freedom time of their lives. But the journey there is difficult for many. And again, women shouldn't be coping with very painful periods. So if you're in your late 30s, early 40s, and you're having changes in your period, don't think, oh, it's something else. It could very well be the perimenopause. It's important to, to acknowledge that and to get the right treatment. So the perimenopause, but your periods will definitely change. Because at that one point, they will stop.
And we certainly read about the onset of administration be happening earlier. And we there's indications or there's evidence that that also happens, depending on your race or ethnicity, it can also be earlier, are there indications that menopause is happening at an earlier age?
Well, only as I said, the biggest indication is women that smoke, even passive smoking, that's definitely bringing the menopause forward, again, but historically, we don't have big data. And you're totally correct about ethnicity. Almost all studies to date, if we have done studies on women, they're normally on white women, and we haven't looked at different cultures and races. And it's really important to do this. So globally. Now, we are starting to take a note of this. But there are many factors that can influence the the age you'll be when you have your last period. And the most common association is actually the age that your mother went through her menopause. But there are lifestyle factors that are affecting us nowadays, such as smoking that are changing that and bringing it forward. For sure.
Interesting. All right. So we've talked about the menstrual cycle. Let's talk about the basics of conception. We grew up being told, be careful, you know, if you're not careful, you will concede. And then for some people, when they after, when they struggle with conception, they're like, oh, all those years I worried about it. Alright, so let's talk about the basics of conception. Now we obviously we have an egg and a sperm. But let's, let's get a little more detailed than that.
Yes. So, I mean, at school, I've been doing a lot of works in schools all in the UK, to see what they what they're being taught and on the school children themselves about the information they're being taught. And you're not going to be surprised that certainly in the UK, I'm sure it's very similar in the US, we teach them how not to get pregnant, or we don't teach them how to get pregnant and how to have a healthy pregnancy, which is hugely, hugely important. There are certain things and not rocket science things, basic things that we need to let them know. So we've set up an international fertility education initiative. And we are providing resources for teachers and for the public to understand these important things. And these are things that I again, I wrote, wrote in my book, which I published last year, because again, I wanted to make sure that people had these tools. So they make up their own mind, if they wanted to have a baby, how they wanted to do it when they wanted to do it, what factors will affect them. But yeah, so the ovulation is the important time for the woman. It's around six days of her menstrual cycle that she's fertile. The day of ovulation is the most fertile time, and the egg that's released from the ovary is only viable for about 24 hours. So once it's ovulated, then the window will basically shut after about 24 hours. But sperm can survive for about five days in the female genital tract. So for example, if she did ovulate on day 16, and had unprotected sex on day 12, she could still get pregnant. So it can be stressful if women are measuring their ovulation every month and trying to get pregnant and getting very stressed and anxious about it. And sex can become a very sort of mechanical thing. Oh, I'm ovulating now we've got it, you know, they always show this in films, you know, all the that the husband's got to come over work or they somewhere and I've watched for another day they had to do it the lift and you know, so we put a lot of stress on both parties to around this time. So it can can obviously be very stressful. But before that time and after that ovulate that fertile window and ovulation a woman won't be able to get pregnant. So it's it is important to have sex at the right time. But it's also important for both the man and the woman if they're planning a pregnancy, to think about their preconception health, so they should be very aware of what they're eating what they're drinking such as little or no alcohol. Think about caffeine reduction. It's really important for both to be quite healthy, exercise wise And to be sleeping well. So I always talk about four pillars of well being which are nutrition, which includes alcohol, as exercise, or sleep, and all of those feeding into our mental health. And it's so interesting, I've been reading a number of books recently about just general nutrition, about the risk of outsiders risk of cancer. And everyone says the same thing. It's important not just for reproductive health, not just important for preconception health, it's important for our whole lifestyle, to really try and balance those four pillars, and really look after ourselves. They don't just help with fertility and the health of our future children, but they also help with our risk of cancers, Alzheimer's, and many, many other heart disease, etc. So if there was one thing I would try to tell my younger self, which is a phrase that we often use in our field, what would you tell your younger self, I would say make sure that you balance these four pillars of well being and are always exercising, always eating, good, good nutrition, not junk food, not processed food, ideally, cooking ourselves, low alcohol, getting a lot of sleep, and really looking into your mental health. I think those are really important for everyone to think about throughout their whole life. But especially when trying to get pregnant. It's really, really important because these, these issues don't just affect chance of conception, they also affect the health of our future children, and it's the man and the woman. It's not just the woman, it's not just a women's issue. If you're trying to get pregnant, everything from that here onwards affects both. So it's really important.
follow or subscribe to the creating a family.org podcast wherever you listen to your favorite podcasts, we now have 15 years of archived shows, many of them evergreen and directly relevant to your infertility journey. Once you subscribe, you can also scroll through our archive for even more topics related to this show. All right, so we know that the eggs are maturing based on FSH and the estrogen production that is happening because through the egg maturing, and then we get to the point where we have LH luteinizing hormone that kicks in towards the very end and helps the final maturation. So we have and generally speaking, a woman will ovulate one egg. So this is we're not talking until we start talking fertility treatment. That's the general thing. So we so at that point, we have a mature egg. What happens at that point, it's coming up to the time of ovulation, the egg is becoming ripe with them.
So the egg should be released from this follicle that's been containing it where it's been growing, it should be released and it gets wafted into the fallopian tube. So we're going to talk about infertility in a minute. But one key issue here is that if the fallopian tube is blocked, then the egg can't get from the ovary to the womb, where it has to be when it's an embryo. And the sperm also will swim up through the cervix or into the womb, and then it will swim down the fallopian tube, and hopefully meet the egg at some point. And hopefully fertilization will happen. And then the embryo will start moving down the fallopian tube and should reach the womb and should hopefully implant and different forms of contraception will block different stages of that process. But with regarding the egg, one really important thing we must be aware of is that female fertility unfortunately declines with age. So this is because of the quantity and the quality of the eggs. So we are born with about 2 million eggs. And actually when we were a fetus, we had even more eggs. By the time we're born, some of those have already died. So we have we start off at birth with about one to 2 million eggs. By puberty, we've only got about 400,000 eggs left. So most of those have died. And as you said one ovulates each month normally one, but we have about 400,000 We have about 500 menstrual cycles in a woman's life. You know, can you do the math, it obviously varies a bit, but we do about one a month so it's 1212 roughly 12 a year. And then we were normally from puberty to the menopause. So those those eggs if you think we had about 400,000 at puberty at the menopause, we will have no viable eggs left so we menopause also signifies the end of our fertile years. So if we're ovulating one, what happens to the others and what happens to the others is that every month between about 700 and 1000 eggs will actually just be reabsorbed by the body. Some of them will go a little way due to development, but most of them will just die. So we'll only have one. And we're more fertile in our younger years than we are as we get nearer to the menopause. So the quote, Those quantity of eggs are higher when we're near puberty, then then when renewing the menopause, but I also said the quality of those eggs declines. And there's various issues within an egg, mainly to do with chromosomes, but I don't wanna get too technical, but the chromosomes within the egg, which will be the mother's chromosomes, they can become very muddled. And again, this becomes more common as we get nearer in the menopause. So unfortunately, the chances of getting pregnant when you're under 3530, fives this sort of golden age. And again, it's not, we're not textbook, so this is very, every woman will be different, you know, my mom had me at 38, you know, it's not, we're not saying every woman will be infertile at 38. But around our mid 30s, the quantity and quality of the eggs will really start to be going down. And if we look at data that people present different countries present around fertility rates and pregnancy rates with fertility treatment, or just natural, we normally bunch everyone under 35 together, because if you're 34, or 28, your chances are very, very similar. But once you're over 35, if we look at the data on your chance of getting pregnant, it goes down very rapidly. And by the age of 4142, it's very, very hard to get pregnant. Again, we'll all no exceptions to the rule, of course. But with my students, we've just been discussing fertility treatment in different countries. And we discussed whether some countries have age limits, and indeed they do some clinics for fertility clinics won't treat women over 40 or 42, because the chance is so low of trying to get pregnant. So I know it's very depressing information to have. And the work we're doing on fertility education is really important to make sure that we don't have people who say, Why didn't anyone tell me this, and I've already had this in the research I've been doing women and men telling us well, nobody told us this, we didn't know. So we came to the clinic at 40, because we thought that would be okay. And then to be told that their chances are very reduced is heartbreaking. So we really want to be sure that we empower everybody with the knowledge, it's not a good message, unfortunately. But men aren't off the hook men over 40 their help their sperms not so healthy. And they will probably take it normally takes longer for them to get their partner pregnant. There's more miscarriages if the man's over 40. And there's also some other issues around genetic disease, and conditions such as autism and other issues that can happen as the man gets older. So yes, we always see the celebrity, you know, rock star, whoever had a baby at you know, you know, it can mean men do stay fertile their whole lives. But there, there's more data coming out now that the quality of this firm is not so good. So we need to, we need to, we need to not prescribe anyone to say you should have a baby by the time you're 35 or 30, or whatever. But we need to make sure people have the information to make their own individual choice of what they want to do for themselves and what works for them.
Exactly. All right. So we have you said that they when the egg is released from the follicle, it is wafted into the I love that term. And it does appear to be a wafting of sort that the fallopian tube seems to not suck, but seems to be whisking the egg towards the fallopian tube.
And it's got long, long tentacles like this at the end. And there's the ovaries like this, and the egg sort of pops off here. We had different theories in the past, we did think at one point that it went into this little pouch of fluid that it might have then got sucked up people are all different views. And it's the current view is that it's wafting the people have done videos have looked while people been ovulating and seen. It's actually sort of these tendrils are sort of wafting in. So it's a good word.
Yeah, there's a good way of kind of creating a flow in the right direction. And we, if you're trying to get pregnant, then you're hoping that the sperm meets the egg. The sperm penetrates the egg, and fertilization takes place. About how long does it take this is happening in the fallopian tubes. So how long does it take for the egg to get from the fallopian tube into the uterus? And then once in the uterus? How long does it take for it to implant? Yes,
so once sperm and egg have met, hopefully fertilization can happen within a few hours. And then it's the next day so about 24 hours later, but just under 24 hours. If we were looking in the fallopian tube and look Get it, we should see now that the the chromosomes from the egg and the sperm have now both identified themselves. And then the next day, so about two days after ovulation, the embryo then starts to divide. So it's should have made itself into a two three or four cell embryo, and the next day by the eighth cell, and then about six, seven days after ovulation, it should now have be entering the womb, or the uterus, and should start to implant and at that stage, the embryo is called a blastocyst. And it has lots and lots of cells, hundreds of cells, and it's going to make cells that will hopefully burrow itself into the whole thing will bury itself into the wall of the of the womb, and then set up a blood supply with the mother so that you can start to take the nutrients from the mother. And there's special cells on the outside of the embryo that helped do that. And then they will form quite quickly, they'll start to form the placenta, which will be the nourishing pad that will help the embryo expel waste products and take up the good products from the mother's blood supply. And then there's some other specialized cells which will then start dividing and dividing. And they will start to make all the parts of the of the baby of the fetus. So some cells will make skin cells some will make hearts and will make brain and everything else. It's an amazing processes. Absolutely amazing that we were all once a blastocyst. I was telling my students and and then implanted Yeah, so about day seven. After ovulation, the blastocyst just start to implant into the womb.
Okay. And before we move off of conception, we promised to talk about different ways to determine if you are ovulating. Now, obviously, there are over the counter ovulation predictor kits, which I think most women who are actively trying to conceive now are utilizing. However, there are other ways that we can tell whether we are ovulating. And so anyway, let's talk about ovulation and ovulation prediction.
Yeah, yeah, I had done a lot of long story, but I've talked about it in my book. But I ended up having seven years of fertility treatment in the end to have my children. And when I was trying to get pregnant, it was we didn't have such easy access to these ovulation kits. But I'd recommend that that's I think that's the easiest way. And the great thing about the ovulation kits is that they're measuring luteinizing hormone. So when you measure it, it as I said, it's about 40 hours from its surge, that the egg will be released. Now you would normally use these ovulation kits in the morning, you just urinate it onto a little stick, and it will tell you whether you're ovulating or not. So you may have ovulated the night but not often, the LH surge may have happened the night before. So when when the stick tells you you're ovulating, we say is probably 25 to 40 hours because it could have happened anytime in the last 24 hours at the surge that it's measuring. So I like that because it gives you a few days to prepare for intercourse so that you can hit the time. And there are other the other ways a very simple way is to measure your temperature every morning before you get out of bed. It's called measuring your basal body temperature. So it's just measuring your body temperature. But in the morning, it's weights inside a basal level. And this slightly rises on the day you ovulate. So the problem with this method is that's the day oscillates. So if you're trying to get pregnant, you've really got less than 24 hours to then have intercourse. But it is an easy way. It's a cheap way to do it. And there are a period tracker apps and fertility apps where you can input this information and they'll help learn about you and help you predict in the future. And then cervical mucus or cervical mucus around the time of ovulation, it changes. It's something you really need to be shown how to do. But it's again, it's a free free method, but it it changes his consistency and becomes more prominent. So you can see some in your underwear normally around the time of ovulation. So that's another way of determining if you're ovulating. But then the main three ways I always tell people not to think about dates. So I'm a big fan of a period Tracker app. So I think I think they're great things to help women monitor and understand you normally put in the day you have your period, and it tells you some information about yourself and roughly tells you when your next period will be but some of them just looking at dates will tell the woman the day they're going to ovulate. And if you're just looking at dates, as I said at the beginning, we're all individual They normally use the 14 day rule. So no matter what the length of your cycle, they're normally say on day 14, or you're ovulating. But we're not we're not an app. We're not an algorithm. We're not a textbook, we're individual. So I think one of the other methods is much more advisable, especially for those women trying to get pregnant, because they're really measuring something that is a marker that ovulation is going to happen. So I think be a Be careful, don't don't just concentrate on dates. Because the date problem is, is that it's not it's not accurate. It's just the textbook algorithm basically.
Yeah, I also think that I'm also a fan of, of anything, that any technology that helps us, but honestly, I also think that women should understand their cervical mucus and how it follows the cycle. That's just good information to have. And there's lots of information online with pictures that will show you what you're looking for the consistency. And once you're tuned into it, it's not information, you're just you become tuned into your cycle in a way that I think is, is much easier and much easier and then taking your temperature. And I think that women need to be tuned into to their cycle in general, not that you would rely on that for birth control. But yeah, but just so that we understand our cycles. All right, now we're going to be moving to the basics of infertility. So people who so first of all, let people try to conceive. So how is infertility defined? I think that we are tend to be impatient. So, you know, we've tried for two months, and, by golly, we have tracked, we have got the apps going, we've got everything running, and we haven't gotten pregnant. So how is infertility defined?
So the World Health Organization defines infertility as if you've been trying actively trying for one year, and you've not got pregnant. But our international partners, Education and other organizations will say that, that is a good rule of thumb for under 35 year olds. But if you're over 35, really, if you've been six months are your chances over there, as I said, are lower. But every six months, when you're over 35 is a big jump. So we're just saying, if you've gone for six months and not got pregnant, and you're concerned about it over 35, it might be the time to go and get some investigations done to see if there's anything causing the lack of pregnancy
in May, because your time is not on your side at that point. So a year. It's not to say that that wouldn't happen. But it's that you're also using up an additional six months, right?
Absolutely, absolutely. So that's, that's really important. But nowadays, we have a lot of people with what we call social infertility. So if we've got a couple in the same sex relationship, they haven't got everything you need to get pregnant, you need some sperm, some eggs and a womb, and depending on their gender, they might not have that combination. So that will also so social infertility is also another term, which you don't have to wait because there is a snapshot. So if you're getting
exactly, you know, going in that you are going to need something, you know, in addition, yeah, absolutely. And let me when we say that somebody is actively trying, what we mean is that they are having sex during their fertile time during the time they're ovulating. If you're not doing that, that obviously is the is the first step. All right, how common is infertility?
Well, if you look at different figures, they always vary slightly, that the lowest you might sometimes see report is about 7%. In the US, it's between 10 and 15% of couples. But what what we found and others have found in our research, is that certainly for under 30, fives, which is reflected by the 10%. But 90% of people within that year of trying and actually under 30 fives most will be pregnant within six months, but if quite a few more would gain a pregnancy after that. So 90% of under 35 should be pregnant within the year. And if they're not that remaining 10% Then it's up to them whether they want to just keep trying or whether they want to take it further and get some investigations done.
Okay, and what percentage of infertility is attributed solely to female factor what percentage to male factor and what percentage for combined?
Well, you will see different people again give different figures. The figures that I normally use is as it's about a quarter each. So a quarter is the male quarters, the female quarters both and then a quarter is we just don't know it's unknown infertility, but As we're, as we're learning more and learning more about genetics, we're we're slowly chipping away at that last quarter. So if you wanted to take out that unknown, we could say a third, so a third to a quarter. So it's pretty equal. Again, we shouldn't be blaming, the woman was always blaming the woman, we've historically always blamed the woman, but we shouldn't be blaming the woman. And men are equally as responsible for infertility as women are.
So what conditions would warrant an immediate infertility workup without waiting the recommended amount of time, which the recommended amount of time as you point out, as depends on the age, but roughly one year for under 35, and six months for over 35. But he's already mentioned one condition is social infertility, which is obvious, because you know that they're going to need some form of help. It may just be the addition of an egg hard addition, well, an egg and a uterus. Or it could be the addition of sperm, but I bet there could also be other issues. So what other conditions would if somebody is approaching deciding they want to they want you to consider having a starting their family? Would would say you should not wait? Yeah, that's,
that's really an important question. I think one now that we are really trying to get this message out there. In Denmark, they've got a brilliant clinic where that again, they're doing research on this, but they're asking couples that are just thinking about the idea at some point in the next few years to come and get some checks done. But the main process they do is just some basic information. So age is obviously very important of the man and the woman is this the menstrual cycle, as we've discussed, is it very irregular, if it is, that's that's a warning, if either of them have ever had a sexually transmitted infection, a lot of these infections can be cited like chlamydia, and that can affect the fallopian tubes and block them. So that would cause infertility. For men. If they've ever had mumps, it can cause a problem if they've had an undescended testicle, if they feel their testicles are quite small. So just some of these health checks are really, really important for the man and the woman to think about. And if they're if they're there, rather than spend a year getting distressed that they're not getting pregnant every month, it would be much more sensible. And also very important we haven't discussed yet is endometriosis. So for the woman, endometriosis is where the lining of the womb has come out and is in the abdominal cavity. This will give very, very painful periods. So if the periods are irregular, which could be polycystic ovary syndrome, or very painful, which could be endometriosis, and endometriosis, and PCOS really can affect a woman's fertility, and chances are, she wouldn't need some help to get pregnant. So those are really the key issues that they need to think about. They've got any other things like thyroid problems as well, any other hormonal problem? If they've got any of those issues, then they should get some checks done sooner rather than later. And I would say not even wait the year, get the checks done.
As they're thinking, Yeah,
I think yeah, I think life goes past very, very quickly. And you know, this six months a year, you know, when you're, I think I'm only 30, I'm fine. And the next thing you're 34, you know, you're 38 think, Oh, it's fine, we'll wait another year. And then you know, then then you're closer to 40. So, unfortunately, the clock is against us, we often talk about the biological clock, it is against us. So I think, I think again, giving people this information and making them be aware, we don't want to scare monger, we don't want to offend or upset them or make them anxious. But I think having this information when you're younger, is really really it gives you the power to plan your reproductive journey. And the studies we've done, we've been asking people, you know what age they want children and all the studies, we've done them in many different countries. Most people want to have their family around about the age of 3035. Most people want two to three children. And the data globally is that people are not having two to three children. There's many countries that are having that the fertility rate as we call it, the number of children a person has is around 1.3 You know, which is not not what people want to have and the the age that women are having their first child is going up and up in every country and is close to 34 In some countries, their first child, so it's just arming people with that important information.
Yeah, there are things that you need to consider egg freezing being one of them. There are things that you need to know but there are things that it. Knowledge is power. So I agree with you. Let's talk now about another aspect of infertility and that is recurrent pregnancy loss. How do we define what is recurred? We obviously know what pregnancy loss is. But what is defined as recurrent pregnancy loss? In other words, when should we start to worry? Obviously, any pregnancy loss is a tragedy and a sadness. But it's also not uncommon to go ahead.
Yeah, so the first thing to say is that it's not uncommon. And again, if I go into schools, this is something that I tell them, but around again, depending what number you look at, but between 20 and 25% of pregnancies could miscarry, and then, again, miscarry more as you get older, unfortunately. So when you're over 35, and over 40, the chance of miscarriage increases quite a lot.
And let's pause a moment to say that is because of chromosomal abnormalities. And you had mentioned that earlier, and that is for both the egg and the sperm as they age, sorry, go ahead.
Yeah, let's not blame that not blame them. It's not just so recurrent pregnancy loss is normally if you've had to, some people want really would prefer to just talk about to, but officially, certainly in the UK, a doctor wouldn't normally start investigations until there's been three. But I can't imagine how stressful having three miscarriages can be. And unfortunately, when they've had three, there are some tests that we can do. But we we hit a very dark area of trying to find out what the causes are. And I go to conferences all the time. And people always asked me to talk about recurrent pregnancy loss. And they hope that we have some magic one that will be able to say, Oh, it's this than the other but it can it can be many things. So the first thing we do is look at the womb, because if if a couple of making an embryo and the embryos implanting, is there something wrong with the womb that's causing the embryo to then shed, you've already mentioned chromosomes abnormalities. And there's many factors that could could be involved that there can be immunological problems that can cause the embryo to be or the fetus to be rejected at certain point. There's not enough knowledge and advice that we can give people it's always the question that people ask and unfortunately, we just don't know enough about it to to really say exactly what's happening.
We want to pause a moment to thank our sponsors our partners, who have made this show possible. The first is crisis international sperm and egg bank. They are dedicated to providing a wide selection of high quality extensively screened frozen donor sperm and eggs from all races, ethnicities and phenotypes. They prepare for both home insemination as well as fertility treatment. Prayas International is the world's largest sperm bank and the first freestanding independent a bank in the United States. Another partner is Reproductive Medicine Associates of New York. They are one of the largest fertility practices in the state of New York as well as one of the largest in the country. By combining the latest innovations in reproductive science with compassionate and customized treatment plans, RMA of New York is able to provide the very best possible care. So what would cause a woman not to ovulate? We've talked about the importance of ovulation. Obviously, you're not going to get pregnant. Well, other than using donor egg, but generally speaking, if you're going to be conceiving without intervention, a woman needs to ovulate. What causes what issues might cause a woman not to ovulate?
Well, issues with her hormones. So the majority of our ovulation is linked to our hormones and our hormone profile. So if they don't ovulate, then it can be that those hormones are slightly out. So that obviously happens with polycystic ovarian syndrome. That happens as a woman ages she won't ovulate every month anymore. So unfortunately, age and PCOS are the two main issues that cause ovulation issues, but they can be other problems that any other health reasons that the woman's got such as thyroid problems that could cause ovulation to not happen. So if she's using our ovulation stick and not seeing any ovulation there, then again, it's a indication to go and start getting some further tests to see what's what's causing this not to happen.
What about weight or BMI?
Yes, weights weights a very tricky one. We absolutely know that fertility in the man and the woman is really affected by people that are obese. In the UK, we don't fund treatment for A woman that is overweight. So if she's got a overweight, BMI, she they won't they won't get funding. So it's we definitely know the success rate of getting pregnant naturally or with fertility treatment will go down with a higher BMI. So it's so hard for a woman and this happened to me, I'm someone who's always struggled with my weight. And I was the person in the fertility clinic that was told you have to lose some weight, before you should try to proceed. And you were always trying to lose weight. So it's, it's really, it's really different. It's a really difficult one to say. But there is so much data not just about fertility and conception, but also the health of the pregnancy and the health of the future children. So if the mother and father were obese, there are several really big pieces of data, but the health of the child, the future child is also affected negatively. So those are issues that we really need to think about. But it's very hard.
Yeah, yes, it is. As you point out, there's no one who goes in and who has, generally speaking, is not aware that they need to lose weight and has already tried. So it's Yeah, it is a challenge and some conditions lend themselves to continuing to fight weight problems PCOS beings and, and other endocrine abnormalities make it harder for women to lose weight. All right, so what is the initial workup? And this will just talk about women here? Since we're talking about female fertility? What is the initial workup for a woman who meets the definition of infertility? Although let's say a semen analysis should be an obvious first as well. But putting that aside, if we're just looking at the woman, what would the initial workup consist of?
So it's important to look at her menstrual history. So many people now come to the fertility clinic with their period Tracker app, but it's really useful information to know that their appearance been regular or irregular and painful or not painful. So finding out about the menstrual cycle history is really important, but then her own medical history. So as well as her weight that we've mentioned, are there any other medical issues that she's had that could have affected fertility, I mentioned earlier about chlamydia. And there's several things like that, that need to be taken into account, they would normally do a physical examination just to feel feel the womb, through the abdomen, etc. And then there are obviously hormone tests that can be done to see that the hormones that some of them have to be done in certain days, that can help see if ovulation is happening, or the hormones are doing the right thing. So as a woman ages and gets nearer to the menopause, the follicle stimulating hormone I talked about starts going higher and higher. So it's something that sometimes is measured around the menopause. But with all of these hormones, the trouble is, is that they fluctuate daily. So if we just take a test one day, we're just getting a snapshot of that one day, and the next week, it could be totally different. So we they give us some information, but they often have to be repeated to see what's what's happened the next day, the next week, the next two weeks next month. So that's really, really important, checking that she's ovulating. There are different ways that in the clinic, we can do that. And there, there are tests that we may want to do to look at her fallopian tubes to see if they're open and to also look to see the womb is that is the womb, okay, has she got any fibroids, fibroids are, unfortunately quite common. And they're gross within the in the in the womb, and they can cause an obstruction and prevent implantation happening. They can also be a cause of recurrent pregnancy failure as well. They they're very hard to define. And different clinicians will look at different sizes, and some will have a view that this size is too big, we better take it out and others think no, it's not. So it's a unfortunately, still quite a gray area. But certainly if there is either they're not getting pregnant or recurrent pregnancy loss, and there are five boys, it may be worth taking those out. But if they're very large, then the clinician would normally definitely take them out. So yeah, lots of issues around that. If she's undergoing fertility treatment, then she would have in a very reserved test. There's a lot of debate about having a very reserved test when you're not trying to get pregnant. We can talk about that if you wish. I definitely wouldn't recommend it. I'm not the only one that wouldn't recommend it. I think it gives very misleading information but if she's going to go through fertility treatment or egg freeze thing, she would have to have what we call an ovarian reserve test where they look at several things in hormones, etc, in a particular format. But the main reason for this is to know which dose of fertility drug to give her, and the fertility drugs just mimic those normal hormones that I told you about. And every woman again, is individual and would need a different dose and different length of time. So this is a very reserved test helps determine what's going to be the right dose for her. So that's the main reason for getting that done.
Okay, and the if you're going in for fertility treatment, or from the male standpoint, your male partner will also need to have their medical history assessed, and as I mentioned, a sperm analysis, or semen analysis would be helpful or required, not helpful required,
and I'm a medical history and a physical exam. I think we, unfortunately, some clinics just do a sperm count. And that's really wrong. They really should have a physical examination as well, they there's a lot of problems that can happen in the testes, varicose seal, etc, that can lead to infertility. And that and they need a medical exam as well, just to medical history being taken, just to see if there's anything there that could affect their fertility, or sperm count such a rough idea of whether the sperm are fertile or not. It's not it's not, you know, it's not it's not a yes, no at all. It's just saying it's okay. It looks okay. It's not really telling us that's going to make a baby.
Okay, it's the basics. This is the beginning. Yeah. So what imaging technology is usually recommended to detect things like tubal patency, and pelvic pathology, and even assessing ovarian reserves. What's the standard thing that you should expect that if you're going in for infertility treatment,
so there's something called the history of cell pinga gram where they can use radioactive dye, which sounds worse than it is, but they just put some put some dye through the cervix into the womb, and then on the X ray, they can see where the they can, they can also do with the colored fluid, they can see where the fluid goes, they can see this will help them see the outline of the womb, and it will also help them see is the liquid it should come out of the end of the fallopian tube by the ovary. So you should be able to see the fluid go through the tube and come out out of the fallopian tube, then there's also a hysteroscopy hysteroscopy, which just looks more at the lining of the womb. So that those those are the two sort of gold standard, there are variations that you can do that a more low key that you can do something called a high cosy, which you can do normally just in the fertility clinic. So it depends on how much information they want. But these can really help decide if the fallopian tubes are blocked, then the only way the woman's going to get pregnant is through IVF. So it because there's no way the egg and the sperm can actually meet them. So it's, it's really important to do those tests sooner rather than later.
And what can cause blocked fallopian tubes.
Chlamydia is one of the main cause there may be pelvic surgery that can have happened. If there's the surgery, if you've had an appendicitis or something, any abdominal operation around there, that during the operation, it might cause scarring. So these these broken tubes are basically a tube and if there's something that's caused blockage of that, some people are born with abnormalities of their fallopian tube where they're just not paitent as we say, clear, so there are several reasons why that can happen.
Okay, so now the woman or the couple is trying to get pregnant is not succeeding. depending on their age, they have met the definition of infertility, they come into an infertility clinic or a reproductive endocrinologist. And the their options are generally an intrauterine insemination are in vitro fertilization. So let's distinguish the just basically the difference between those two.
Yep, so intrauterine insemination, the laboratory will for both techniques than abaci will prepare the sperm in a very similar way. They the sperm and intercourse would be deposited at the cervix so it wouldn't the neat sperm wouldn't swim through the cervix and get into the womb. It's just individual sperm that will swim through and they'll leave the main fluid behind. And also in any sperm sample, there'll be live sperm, there'll be dead sperm and there'll be some debris themselves. That's all quite normal. So what the lab will do without they'll wash the sperm in culture medium prepared enough. number of different ways to concentrate the live sperm without any of the fluid, the seminal fluid that the sperm came in. So intrauterine insemination, we would often give the woman some fertility drugs. So she's maybe reducing making sure she's producing at least one one egg, we have to be very careful with twins. So we don't want to be producing four or five eggs, the eggs would ovulate normally, so the tubes would need to be open, and then that abort tree and again, the clinician would inject the prepared sperm into the womb. So with intrauterine insemination, the sperm has now been sort of cleaned up. And it's bypassed where, what the first hurdle the sperm has is the cervix and getting into the womb. So it's usually insemination gets over that hurdle and puts it in the womb, giving it a bit of a head start. So now it's just got to swim down the fallopian tube to meet the egg. But unfortunately, the success rate globally within tutor insemination is very low, it seems to be less than natural conception. I mean, we're dealing now with people who have tried natural conception. But obviously, we're dealing with a different group now who had fertility problems, but it's around 10 to 15%. Again, it depends on age of both partners, etc. But overall, we'd say it's about 10 to 15%, but the most about 20%. And there are recommendations that couples should use this as their first treatment, it can be very expensive. I had lots of IUI. So but I was trying to get pregnant. So it's again, very, very individual, very individuals, or how many cycles a couple would like to try with IUI.
And in the US, it may be dictated by insurance some Yeah,
yeah. Yeah. So there's a National Institute for Clinical advice that says that couples should try six cycles, but that's a lot. But for most people, that's a lot to go through, before moving on so so that again, individually the couple's choice, or that might be with the vise on the, from their doctor, when they move to or if they move to full IVF. But full IVF is definitely more successful. But it's much more expensive. It's much more invasive. And there's you know, it's it takes a toll physically, mentally, emotionally on on the couple. So it's, it's hard. It's not easy to go through for life. It's not easy to go through IUI. But it's not it's not easy to go through IVF.
There's no aspect of infertility, that is easy. All right, so let's talk about the basics of the fertility medications that are used primarily with IVF. And what types of meds are? In this case, it is the woman who is taking them?
Yes, unfortunately, it's the woman taking them. So I'll just speak generally, rather than giving any specific company names or anything, but there's a number of ways that what we do first is normally shut down the woman's own menstrual cycle hormones, we don't want the fertility drugs to be competing with what's going on, we want to have a blank canvas. So we normally shut down her own menstrual cycle. And then we add on the drug. So the first drug to add on is follicle stimulating hormone basically, because again, we want to reproduce that. So it's in higher doses. Because with IVF, we're trying to produce a larger number of eggs now, to try and give us more embryos, so we can have a good chance of selecting the best embryo for that couple. So as we normally give them FSH or a variation of FSH, it's normally unfortunately injected into the woman on a daily basis. And if we think about our normal menstrual cycle, and how emotional week can be one of the big problems with these drugs is they cause a lot of emotion. I think also going through the treatment is hugely emotional. But the drugs themselves as I said at the beginning, these are very powerful hormones. And when we've got a large amount of our body and the FSH will produce multiple follicles to grow much more than they would. And so these follicles are all producing estrogen. So we've got a large amount of estrogen going around our body. So all in all together, that's going to have a profound psychological effect on the woman. And then the clinicians will normally scan the woman to see how the follicles are developing, they might do estrogen test to see what the level of estrogen is. And when they feel that the woman's almost ready and that the eggs are of a good size and it's looking looking good. They will mimic the LH surge so they'll give them a single injection that mimics that surge of LH. And we collect the eggs about 36 hours later. So the ovulation would happen about 40 hours later as it would naturally. So the eggs are collected that about 36 hours before so that so that we can collect them and keep them in the lab.
Okay. And the success rate for IVF is highly dependent on the age of the woman. But basically, what is the success rate depending on age?
Yeah, well, as I said earlier, what most everyone I've ever used set of data, I've looked at it that will do the under 30 fives together, and then 35. And over normally in two year batches. So we see the results go down. In the US, it's around 50%. But the way the data is reported in the US and in the UK is slightly different. So in the US, it's around 50%. And it's what we call per transfer. So it's not taken up by the number of cycles. So if this if a woman's had her eggs collected when she when she's ready, so have her eggs collected. And that's that, in my view is one one cycle of treatment. And some women don't have any embryos to transfer, very few women nowadays don't have any embryos fertilize, or maybe the embryos don't develop properly, and they don't have a transfer. So the way to get the data to look much more successful is to just talk about the success rate per transfer. And that's that's how the USA data is done. And it's done. The average number of embryos that are transferred in the US is about 1.7 per transfer. So it's Trent they're transferring more than one embryo. In the UK, the way we express and I don't think either of them are right, to be honest. In the UK, the data is expressed as a percent of embryos transferred. So if one embryo is transferred, it's going to give a different data then if we transfer if we transferred 1.7. So you can't unfortunately, that that's probably really confusing. Someone doesn't know what about maths. But basically, the data the UK, the US, it's not the US is hugely more successful than us. It's the way the data is expressed. So if we, if we expressed the US data, by per embryo transferred, and the average is 1.7, I think we'd have results around about 30 30% for under 30 fives. So that's the best best group. What I would like people to do is to express the data, which we used to do, but we don't do now. And I think it's wrong is per egg collection. So if they had an egg collection procedure, and then they had embryos transferred, what was the percent so if say, if you had 100 women that had a egg connection, we might only transfer embryos might be in 90 of them. So if you do it per transfer, that you're going to get a better success rate than if you did it for a collection. So I think personally that my take home message on this, I think the way the results are expressed in both countries are very optimistic. They're not telling women or couples, what this is in relation to your egg collection procedures. They're doing it per transfer and what happens in some countries, but every country actually at the moment, almost every country is that they might do some tests and things in between, and they may freeze embryos or age do lots of other things. So doing it, they might do several egg collections, and then choose embryos to go back. So doing it per transfer does give a very optimistic result where it's not per egg collection. So I think people have to be very, very aware of that, and get good advice to that themselves, but it's per transfer.
And the last thing I want to touch on is how does the infertility workup or the fertility workup? differ if we're talking about members of the LGBTQ plus community, or does it?
No it? Not? Not really, but they're very individual as well. And when I'm talking in schools and all of the work we do, we obviously want to give the LGBT community the information about what they need to think about when they're having children. For those in a lesbian or gay or bisexual relationship, it just depends on what they've got between them in effect, so they got what's the Yeah, they got a they got lots of eggs. Have they got a couple of wombs, what have they got, so it's very individual to them. And they obviously need an egg, a spurt, some sperm and a womb so that we can obviously help in between that, but for the transgender community and non binary They, they really need to be aware that if they take hormonal treatments or if they have surgery, these are highly likely going to make them infertile. So they may want to freeze their eggs or their sperm before they embark on this. Some trans men decide to keep having periods, some decides that they're okay about being pregnant, and having a baby some that there couldn't be anything worse for them to do that. So they, if they want to have a child, they need a surrogate, or depending on their partner. So it's so so individual, the important thing for us is to make sure they're aware of their options so that they can make that informed choice because again, knowledge is power. So just making sure that they're totally where they've got, they may have so many other things going on, it may be really difficult for them to start thinking about having a family, but we don't want anyone to miss out if they could have had some information and we don't want anyone to say I wish someone told me this before. So yes, apps absolutely make sure that they're included it and involved in any fertility education
and knowing what their options are. Thank you so much, Dr. Joyce Harper. She is a professor of reproductive science at the Institute for Women's Health at the University College of London, and the head of reproductive science and society group. She is also the author of a terrific book called your fertile years. Thank you so much
Transcribed by https://otter.ai