Infertility: Evaluation of Couples with Infertility
Guest: Dr. John Schnorr – Obstetrics and Gynecology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. John Schnorr who is division director of Reproductive Endocrinology here at the Medical University of South Carolina. Dr. Schnorr, let’s talk about a very common but quite serious, emotionally painful, problem which is infertility. First of all, how do you as a doctor define infertility?
Dr. John Schnorr: That is a great question. I am really excited to be here with you today, Linda. Infertility is a common disorder. We think it affects about one in nine couples. So, it is actually very common. In the field of reproductive endocrinology, reproductive endocrinologists are trained to deal with disorders such as infertility. The definition of infertility is trying to conceive for at least one year without success. There are caveats in that definition. You need to be of reproductive age. So, we are not so sure that somebody 75 years of age, trying to conceive, would necessarily have infertility. In that category, we want to make sure; of course, you are not on birth control. So, generally the definition is a year of trying to get pregnant, being of reproductive age and not on any form of birth control, and being sexually active at the same time.
Dr. Linda Austin: So, is it fair to say, then, if you have had that year and nothing has happened, you have not conceived, it is time at that point to see a doctor?
Dr. John Schnorr: That is exactly right. So, if you have tried for a year and you have not conceived, I think that is clearly a sign that there is a problem. If you look at studies of young healthy couples, having regular intercourse, about 90 percent should conceive within a year. So, if you have not conceived in a year, you are in the 10 percent group that likely has a problem. But, also, if you try for three or four months and you have not conceived but you have red flags along the way, like you do not have any menstrual cycles. That would be an obvious red flag. If you are not having menstrual cycles, you are not going to be able to get pregnant. If you have other problems, such as difficulty with intercourse or painful menstrual cycles or other things, that might be a red flag to be seen sooner than a year.
Another category to be concerned about is if you have advanced reproductive age. That age seems to vary based upon my age. As I get older, I think the age of advanced reproductive age is changing. But, most people would say above 35 years of age. If you want to have children, probably try on your own for a couple of months. If that does not work, maybe start out by seeing your local gynecologist, or a gynecologist here at MUSC, where they can evaluate you for some of the common causes and advance you into the treatment a little quicker because age become a little bit of an enemy for us.
Dr. Linda Austin: When a woman, or a couple, comes to see you after that year, how do you begin to evaluate what is going on?
Dr. John Schnorr: That is a great question. It first starts with an hour-long consult with a physician. We really spend time trying to get to know the couple, what they have been through, how long they have been trying to get pregnant, see if there are any red flags along the way. Have they had prior sexually transmitted diseases? Have they had prior surgery to their fallopian tubes? Have they had prior ectopic pregnancies? Are they having menstrual cycles? How frequently are they having menstrual cycles? How is the male partner? Has he had chemotherapy, surgery to his testicles, anything that would suggest, maybe, a malefactor cause of infertility? So, we go over the whole history and about half the time, you will start finding red flags with that alone.
Second part is in the physical exam. Of course, like any doctor visit, we will do a physical exam, make sure that everything appears healthy. Most the time that physical exam is going to include an ultrasound. The ultrasound is done with a probe that is put in the vagina. It is a very small probe, it does not hurt at all. It uses a very high resolution ultrasound to show us the details of the uterus, make sure there are not any fibroids or malformations of the uterus. It also lets us look at the right and left ovaries. The neat thing about that ultrasound is you can measure the size of the ovaries and you can see the eggs, those small little eggs that are in competition to become one of the eggs that ovulates out that month. It is interesting to know that a woman really uses around 15 to 20 eggs every month in kind of mini competition within the ovaries. The winner of the competition will ovulate out. The other 19 eggs, or however many are in competition, would die off. The neat thing is with that ultrasound, you can see how many eggs are in competition, which gives us a lot of ideas about the quality of eggs in the ovary.
Dr. Linda Austin: In other words, the more eggs in competition, the better?
Dr. John Schnorr: Yes. The winner out of 20 eggs is generally going to be a better quality egg than a winner out of two eggs.
Dr. Linda Austin: Now, at that early stage, do you also evaluate the male?
Dr. John Schnorr: We do. One of the first things we are going to do is, after we do that physical exam, sit down and say, here is your history, here are the red flags, here is what the ultrasound shows. Now, let’s start into an evaluation and this evaluation, to find the cause of infertility, might take a month. That evaluation would include, first, a semen analysis on the male partner. It is a very simple thing to do, an inexpensive thing to do, and it gives us a wealth of information about the male potential for reproduction. And we know that, believe it or not, 40 percent of all cases of infertility are male causes of infertility. So, it is very common. We want to work that up and that is one of the first places we will go.
The second part is to go back to our ultrasound, make sure that shows healthy-appearing ovaries and a normal uterus. The next step is to actually measure the hormones of the woman during the menstrual cycle. We know that the key time to do that blood work is the third day of the menstrual cycle. That is the time when we know the FSH, LH and estradiol levels. These are prominent hormones of the reproductive cycle. We know what those levels should be and if they are not normal, they can start to guide us in one direction or another as to the cause.
The last component that we think is critical is making sure the fallopian tubes are open. The fallopian tubes are the bridge between the uterus and the ovaries. They help to pick the egg up off the ovary when the egg ovulates out. The egg gets transported down the fallopian tube where it meets sperm and becomes an embryo in the fallopian tube, and then the embryo ends up inside the uterus. There are a variety of things that can cause obstruction, or problems, of the fallopian tubes, such as prior sexually transmitted diseases, tubal surgery and other pelvic surgery. So, we can do special x-rays which help us understand if the fallopian tubes are open and working.
Dr. Linda Austin: Now, I want to go back to this issue of the male. We hear so much about in vitro fertilization, and so forth, and the female problems, but not so much discussion about the male problems. What sorts of problems in the male can cause infertility, and can those be treated?
Dr. John Schnorr: They can be treated and it turns out that most male causes of infertility can now be successfully treated. However, it is interesting, it is not done by making the male’s sperm count better. In most cases, the treatment is optimizing the female side and applying higher technology, such as assisted reproductive technology or in vitro fertilization. So, rarely can we make the male better. But, we can work to optimize the female and apply technologies for high success rates.
So, things that look for in malefactor infertility are, maybe he cannot get an erection. Maybe they just simply cannot have intercourse. Maybe he is a paraplegic, or quadriplegic, and they cannot have intercourse. It could be that they have normal sexual function but his sperm count is low, where the number of sperm in the ejaculate is just lower than it should be.
Dr. Linda Austin: And what do you do for that?
Dr. John Schnorr: We do an evaluation to figure out if it is a hormonal cause that can be corrected. Most of the time, it is not. Then, you work on the female side to make it optimum by using assisted technologies. Sometimes you have a normal sperm count but they do not move. Sometimes you have a normal sperm count and they are moving just fine but they are all abnormal in shape. Sometimes you have a normal sperm count and the ejaculate is so viscous, the sperm cannot get out. There can be a lot of different causes of malefactor infertility. If we start to see a severe cause, we would refer you over, first, to a urologist, a specialist in the male anatomy. The urologist would look to see if there are any anatomical causes that can be corrected, is there a surgical correction that could be performed? Along the way, we would also look for hormonal causes.
As I mentioned earlier, the minority of those causes of malefactor infertility can be fixed through surgery or hormonal manipulation. Most the time, we learn this is what it is right now. Then, we work on technologies that allow us to use it. One of the greatest concerns is if you have a low sperm count now, you may have a really low sperm count in a year or two. It can sometimes continue to dwindle to the point where you do not have any sperm at all, and we cannot help you. So, another part of that malefactor evaluation is to try to assess if we are going to have problems in the future, how will we buffer those problems? Buffering the problems can be getting pregnant now. They can also be freezing sperm now so that the sperm can be used at a later date, to help a couple conceive.
Dr. Linda Austin: This is your daily work and you have spent years, your entire professional life, studying this, it is what you do. I am sure though, for the couples who come, it is such an emotionally sensitive, painful, part of their life. How do you deal with that sense of vulnerability that they must have?
Dr. John Schnorr: It is very difficult. I think that vulnerability impedes people from coming into the doctor to be seen. Studies show that less than half of all couples who have infertility come into be seen. So, a small percentage of people come in for infertility treatment. The most important thing is, if you come in for treatment, over 90 percent will conceive. It is clearly emotional. They go to the mall and see kids all over and do not know why they cannot have children. I think the message is that infertility is a medical disorder, just like asthma and diabetes, and other things. We have ways to evaluate it and we have ways to treat it. I know of very few medical disorders in the world today that have over a 90 percent long-term cure rate, which is exactly what we have with infertility. I know it is emotional and I know it is hard to get through that. But, if you can step back and see it as the medical disorder that it is, with the high long-term success rates, I think we have a lot of reason to be able to help you and we encourage you to come in.
Dr. Linda Austin: Let’s stop here and pick up where we left off in another podcast, talking about how you helped a particular woman.
Dr. John Schnorr: Perfect.
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