“Fertility Treatments: Who Needs What?” – with Dr. Susan Lobel

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
All right. Dr. Lobel, welcome back to the podcast. How’re you doing?
Dr. Lobel: Fine. Thank you so much for having me back, Dr. Fox.
Dr. Fox: It is a pleasure. So Dr. Susan Lobel who is a reproductive endocrinologist and fertility specialist, and you are running metropolitan reproductive medicine in New York City. New York City, how do you like it?
Dr. Lobel: Well, it’s wonderful.
Dr. Fox: I really wanted to have you back on the podcast for many reasons. First, I like to speak to you. We speak frequently and it’s always a pleasure, but also, you know, I get asked all the time from not so much my patients because I don’t do general gynecology, but more even family and friends, people listening to the podcast, questions about, you know, should I be seeing a fertility specialist? Is this normal? Is this abnormal? Or I am seeing a specialist and are they doing the right things? Are they recommending too much? Are they not recommending enough?
And I think people have a hard time gauging whether what they’ve been recommended is really appropriate for their own situations. I wanted to maybe sort through some of that to give people a sense of whether they’re on the right track or not in terms of, you know, tests or treatments or not doing them.
Dr. Lobel: Well, it’s a very important question and it’s gonna vary from person to person, but I think it’s helpful to have some background information, which is of couples who will conceive on their own, 65% will conceive within 6 months, 85% within a year, and 95% within two years. So the general recommendation is that if a woman is under 35, that it’s normal to take up to a year to conceive before going to a fertility specialist.
And because unfortunately there is a decline of fertility with age, that if a woman has been trying for 6 months and she’s over 35, that it’s the right time to see a specialist. Now, there are some caveats with this. That if someone has an underlying medical condition that they know is gonna make it harder for them to conceive, then they should go sooner.
Another thing which you’ve sent me several patients in this situation where a woman has very irregular periods being defined as periods that are more than 35 days apart, in that situation, it’s gonna be hard to conceive. And so it would be appropriate to go to a fertility specialist sooner. It also depends if a couple’s trying for the first time versus the second time or the fifth time. And also if there’s a reason to think that there might be a decrease in sperm count from the male end.
So those are general guidelines. And if someone’s concerned, they can call up a practice and say, or call up their doctor and say, you know, “Should I go or should I not?” These days, there’s so much that we can offer couples for fertility treatment and become rather sub-specialized is most of the time if someone’s having difficulty conceiving, that we recommend going to a specialist. But if it’s some basic issue, certainly to reach out to her gynecologist first.
Dr. Fox: I think that’s a really important distinction maybe for where, you know, people might read, oh, you’re supposed to see a fertility specialist after X amount of time. That’s really when it’s unexplained. There’s no reason that anyone can figure out why someone’s not getting pregnant and say, “All right. Maybe in this situation, wait up to a year if you’re, you know, healthy and under 35 and maybe wait up to 6 months if you’re over 35.”
But if there’s a known reason, like someone knows that their tubes are blocked or that they know that they’re having irregular periods and that’s why they’re not conceiving, they probably should see somebody earlier because, you know, waiting is less likely to be fruitful, so to speak. And are you finding that people are doing that? Like they’re coming to you earlier if it’s known to be a problem. Do a lot of people sort of get advice to stick to these hard rules about the months or the years to wait?
Dr. Lobel: I think a good thing about internet is that it’s helped educate patients and that if a lot of my patients come referred by their friends or their doctors, so they’re pretty much sticking to the rules. But, you know, occasionally we’ll get someone, it’s a little bit sooner and if someone’s concerned that they’re gonna have difficulty conceiving because their sister had difficulty conceiving. Now, most of the times, difficulty conceiving is not something that’s genetic and runs in the family. But if someone’s concerned, that I don’t think there’s a harm of going to see a doctor and, you know, getting a plan or a basic evaluation. But for also for people to be reassured that most people don’t conceive right away and that if it’s been four or five months, it’s okay to try a little bit longer before seeing a doctor.
Dr. Fox: I assume there’s wide variation amongst fertility specialists and how “aggressive” they might be in recommending treatments versus expectant management. And I’m trying to get a sense, you know, when sort of either the people that you know, you know, your colleagues who are in the field or just, you know, being in this world or reading about it, is that variation something related to just, you know, personality? Some doctors, you know, like to send more tests and some like to send fewer tests or is it, you know, just practice patterns or were they trained? Or why would there be so much variation in that?
Dr. Lobel: Well, I’ll give you a politically correct answer. We don’t like to think of it but sometimes people may be financially motivated. And so, you know, I’ve seen patients from other programs where doctors, you know, they’ll go in and after a couple months of trying, go straight to IVF because that has the highest chance of getting pregnant.
Whereas the standard recommendation for a couple with unexplained fertility is to do three to four months of ovulation induction with intrauterine insemination before going to IVF. I’ve seen the opposite couples that are being just monitored with the ovulation when more aggressive treatment is in line. So, you know, there’s a lot of variation, just the way, you know, some patients wanna go straight to C-section versus others. You know, the standard is to try to have a vaginal delivery if you can.
So there’s variation into practice and, you know, part of it is personality, part of it is financial. Sometimes insurance companies have requirements that patients wait a certain amount of time. I’ve had to argue with insurance companies. You know, I have a patient actually that you’ve delivered four children from. That she’s never ovulated on her own in her life.
And when she came back to try for her third child, the insurance company was saying she had to try for a year, but I had to finally convince someone that she never ovulates. So she can try for 10 years and she’s not gonna get pregnant. So, you know, there are a lot of different reasons but I think it’s important for couples to think about what’s right for them time-wise. And some people feel more of a pressure. Some people feel less of a pressure. But I think also getting a second opinion is very valuable.
So, you know, I’ve had, you know, many times couples come to see me and, you know, they’ve been advised to do in vitro fertilization and they wanna know, “Should I do it or are there alternatives?” And, you know, sometimes I’ll say, you know, “Yes, I agree that that’s the appropriate treatment at this point.” And, you know, other times to say, “Well, you could do that but here are some alternatives.”
So I think the use of second opinion is under-appreciated. And I very much appreciate your bringing up the subject in this podcast, but I think couples should seek out a second opinion if they don’t feel comfortable with the plan.
Dr. Fox: I think it’s one of these things where…and it’s true for fertility but it’s probably true for most areas in medicine where, you know, people want everything done that’s supposed to be done but they don’t want things done that aren’t necessary or might be sort of over the top if there’s potential harm or cost or something like that. But it’s very hard for people to know.
So, you know, you meet with the doctor and he or she seems lovely and their office is nice and they, you know, seem smart and they do some tests and they make a recommendation. It sounds pretty reasonable but you have no way of knowing like, is this totally nuts or is this what everyone else would do? And it’s very hard to know that. And so, okay, you go online and you see, but these things are nuanced and what you find online is clearly not necessarily gonna be applicable to you.
And I also recommend a lot for people like see somebody else. See somebody who’s in a different place, different institution, you know, different age. Like whatever it is, pick someone who’s not like me and ask them their opinion and see how far apart they are. And if they’re really far apart, then we’ll have to, you know, sort that out and see, you know, why is that? But if they’re pretty similar and there’re just maybe slightly nuances that are different, you can go with which one you think is, you know, best for you. But that’s a good way to get reassurance that at least, you know, you’re within the box, so to speak.
Dr. Lobel: Yeah, exactly. And also to be careful what one reads online because there’s excellent information and there’s a lot of misinformation. I would recommend something like the American Society for Reproductive Medicine, the American College of OB-GYN. They have patient information that I think can give people a guide as to what is pretty standard. And it’s also gonna vary.
I mean, you can have two good doctors have two different opinions. And so that’s where the comfort level is gonna come in. And in the big picture, if someone most of the time does something not that aggressive for a few months and it doesn’t work, then they’re still gonna have the option of moving ahead and being more aggressive. But sometimes if it’s something, you know, more surgery or going straight to IVF, I think getting a second opinion is always helpful.
Dr. Fox: And also if you’re not after the two opinions if they seem somewhat different and you’re not sure which way to go, it’s completely appropriate to tell, you know, each of the two doctors, “Hey, I saw this other person and they had a really different opinion. Why might that be?” And, you know, sometimes it happens I’ll see someone and I’ll say, “I recommend, you know, A, B, and C.” And they said, “Well, you know, I saw another MFM and they recommended something else.”
And I’m happy to talk about that with them. I’ll say, “Well, you know, they’re doing this. You know, this is one school of thought and this is my school of thought. Here’s why I do it this way. And here’s why they might do it this way.” And some of it boils down so, you know, personality, are you more of, you know, a risk-taker versus not? Are you more of, you know, you like to do tests versus you don’t? And so there is some leeway in these but it’s not something that’s meant to be combative between the doctors.
You know, doctors should know that there’s different ways to do this and be able to talk about it rationally with the patients, why there might be a difference of opinions, and try to help the patient decide which way they wanna go. And if it means going to somebody else for a different treatment, or it means altering what I’m gonna recommend, yeah. I mean, that’s all reasonable.
Dr. Lobel: It’s also, now I’d say not just with fertility but with the genetic testing that we’re doing now. That we had a mutual patient that was advised to do in vitro fertilization with genetic testing and you sent her to me for a second opinion, and I didn’t think it was something that needed genetic testing. And she got pregnant without it and saved a lot of time and money.
And it’s not that it would’ve been wrong to do the genetic testing, but it was so to do in vitro fertilization and test the embryos before putting them back. It was for a condition that would not directly affect the child. And so it wasn’t wrong to do it but it really wasn’t necessary. So that’s a situation where I think, you know, if she had decided to go ahead with the IVF, it wouldn’t have been wrong but in her situation, she decided not to and got pregnant very easily without doing IVF.
Dr. Fox: So I wanted to go through sort of the progression of fertility, you know, work up in treatment from the most basic, which is do nothing, just keep trying, all the way to the other end, which, you know, from IVF to IVF with egg donation, to even gestational carriers or adoption. And sort of what are some benchmarks that you can help people say, “All right, if A, B, and C, you should probably go to the next level?”
Obviously, there’s nuances and there’s differences for each person but just sort of in a general sense how you think about these things. So we spoke about, you know, who might wanna move to the next level as opposed to just keep trying. So someone who has, you know, unexplained infertility for a year, or if over 35 for 6 months, or infertility with a known reason, then that might be sort of you should get bumped up to the next level, so to speak, and see a specialist.
But what about when you do see them, or they are seeing a specialist, who would get something like ovulation induction? A, what is that? And B, who might get recommended that as a first-line for fertility treatments?
Dr. Lobel: When someone comes in, for whatever reason, that the basic evaluation consists of checking for what we call ovarian reserve, which gives us a quantitative idea of how many eggs that a woman has and indirectly the quality. And the basic tests that we do are follicle-stimulating hormones. And the testing is done in the early part of the cycle on around day three, which the hormones that the brain produces to stimulate the ovaries, estradiol, which is the hormone that the ovaries produces in response, and a rough idea of the number of eggs that can respond that month to stimulation.
And that can be gotten by doing an ultrasound and counting the little cysts on the ovary, which we call follicles, each of which contains an egg, or by measuring AMH, which is an indirect measurement. I prefer to do ultrasound and actually look at the ovaries. The other basic things that we check are a hysterosalpingogram, which is a radiology test that checks the contour of the uterus.
And also to make sure there’s not a polyp or a fibroid in the uterus that could be precluding conception. And to make sure the fallopian tubes are open and to check a semen analysis to get an idea of the sperm quality. And less commonly but sometimes if there’s a question of endometriosis or scar tissue from a previous surgery or ruptured appendix to do a laparoscopy, which is a surgery where we put a tube through the belly button and look inside and actually look at the uterus and the tubes and the ovaries.
And that’s the basic evaluation. Also with some hormone tests to check for things like thyroid. Most of the time, we will be able to identify an abnormality and about half the time, it will be related in all or in part sperm. And the rest of the time, something in the woman’s system. So, you know, if a woman has a polyp in her uterus, then we’re gonna go and take that out. You know, if both the fallopian tubes are blocked, then it would make sense to go straight to IVF.
If a woman is ovulating regularly, then giving her medication to augment ovulation will not increase her chances of conceiving. And that’s something that unfortunately is fairly common. Someone’s been trying for six months, they go into their OB-GYN and they’re given Clomid, which is a pill that raises FSH levels. And it’s not uncommon, you know, for regular OB-GYN to do that but it doesn’t do anything to increase conception.
Dr. Fox: It does increase the risk of twins though.
Dr. Lobel: Actually not sure if someone’s ovulating regularly if they’re taking it for a non-indicated procedure risk if it does. But if someone has irregular ovulation, then it would be indicated to take the Clomid but it would be indicated to monitor it because if someone’s producing four or five follicles, then they are gonna have a significant increased chance of having multiples and, you know, would wanna avoid trying that month.
So to answer your question eventually, so ovulation induction, which is with pills to stimulate the ovaries is indicated if a woman has irregular periods and she’s not ovulating regularly, or if it’s unexplained infertility, which happens about 20% of the time when all of the major testing is okay. And in that situation, what’s probably going on is there are multiple small factors that in combination are precluding a couple from conceiving.
And in that situation, doing something like Clomid and combining it with insemination where we take the sperm and put it inside the uterus close to the timing of ovulation will augment conception, but only when it’s done with insemination for unexplained infertility. So basically to answer your question, it’s indicated if someone has irregular periods or with unexplained infertility in combination with insemination for three or four cycles.
Dr. Fox: Why would the ovulation induction be helpful with insemination but not be helpful without insemination for someone who has regular periods and unexplained infertility?
Dr. Lobel: We really don’t know but the data clearly support that. I tell patients the way I explain it is that it probably is because with unexplained infertility, there are multiple factors involved. So it’s not just that if you take Clomid alone, it’s not gonna increase the chances over just doing nothing. But also if you do insemination alone, it doesn’t significantly increase the chances but the combination of the two does. So what it probably means is that there’s both male and female factors and you need to address both of them to facilitate conception.
Dr. Fox: I see. And then if someone is coming to you, are there people who you would say even though it’s been, you know, 6 months for someone, you know, 35 or over, or 12 months for someone who’s under 35 and you do all the tests and they’re normal and it’s unexplained infertility, how do you make the decision whether to start down this road or to wait more time? Is it just, you know, preference of the patient, you know, how eager she is or, you know, anxious she is? Are there any other factors that might lean you towards, hey, maybe you should just wait a few more months versus let’s start doing these treatments?
Dr. Lobel: Given that if someone’s been trying for a year, that we know that the chance of conceiving on their own is gonna be pretty small, I would rarely recommend just trying more time. Now, if someone’s 20 years old and they wanna wait a little bit longer, that’s fine. You know, but, you know, if someone’s 35 and they’ve been trying for a year and it hasn’t happened, then I would push them to do treatment.
Dr. Fox: Okay. So someone is starting down the road and they’re doing ovulation induction. So number one, you’re saying basically you wouldn’t do it for unexplained infertility without doing intrauterine insemination. But for someone who has, let’s say, irregular periods, and you’re pretty clear that that’s the reason, you might recommend ovulation induction without insemination, is that correct?
Dr. Lobel: Yeah, unless, you know, presuming that the husband doesn’t have a known low sperm count. And so, you know, if a couple comes in and the wife is getting her period every two months, you know, I’ll offer the couple, “Well, we can check the sperm count,” but usually to say, “Okay, let’s three months of Clomid.” And oftentimes they’ll conceive but if they don’t conceive after three months to say, “Okay, let’s check the sperm before doing any more Clomid alone.”
Dr. Fox: And for ovulation induction, do you ever recommend some of the agents other than Clomid that are available?
Dr. Lobel: Okay. So, the answer is yes, the basic medications that we have is Clomid which is Clomifene Citrate but everybody uses the brand name, which has been around for, I don’t know, 40, 50 years. So there’s been a lot of babies born and a lot of women who’ve taken it and has a long-term record. More recently, there’s been the use of Letrozole, which Clomid blocks estrogen receptors in the brain, and therefore stimulates the brain to produce more follicle-stimulating hormones.
Letrozole blocks the production of estrogen and has the same net effect of the brain not seeing estrogen and producing more FSH to stimulate the ovaries. Recent data has shown that for women with polycystic ovaries syndrome, letrozole has a somewhat higher pregnancy rate. So that’s become the drug of choice for women with polycystic ovary syndrome. For women with unexplained infertility, the data are pretty much the same for Clomid and Letrozole.
So, you know, I usually present the patients with the two of them, the pluses and minuses, and let them choose. There’s also direct shots of what’s called gonadotropins, which is the actual follicle-stimulating hormones. That is not a first-line choice and should be reserved for situations where a patient doesn’t respond. We can’t get them to ovulate with either Clomid or Letrozole. And it carries its efficacious because you’re actually giving the hormone rather than indirectly trying to get the brain to produce the hormone.
But it runs a much higher risk of multiple gestations. And as wonderful as your practice is about delivering twins, we do try to aim for one and certainly wanna avoid getting pregnant with more than two. So we use gonadotropin very sparingly. If someone ovulates with Clomid or Letrozole and doesn’t get pregnant, the next step is to go to IVF rather than trying gonadotropin.
Dr. Fox: Right. And then how long would you recommend someone continue ovulation induction or ovulation induction with intrauterine insemination before they make the jump to IVF? Now, obviously like you said, if they have a problem that clearly needs IVF, like the tubes are blocked, for example. Okay. But if someone either has unexplained infertility or maybe an ovulation, and it may be a different answer for those two situations, when do you tell them, “You know what, it’s time, we really should switch to IVF?”
Dr. Lobel: So if someone isn’t ovulating at all or ovulating irregularly, we generally say to do three ovulatory cycles. And if she doesn’t conceive, to sort of reassess. So if it’s been a situation where a woman has very irregular periods, so we put her on Clomid, she ovulates for three months, doesn’t get pregnant, then that might be a situation to say, “Okay. Well, let’s evaluate the husband’s sperm. And if that’s normal, again, it’s per patient preference, also patient age.
So if I have a patient who’s 22 and we’ve done three cycles, she hasn’t gotten pregnant, her husband’s sperm is normal, then I’d be more inclined to say, “Okay, well, let’s try a few more months before jumping to something more aggressive.” You know, versus if someone’s 38, then, you know, that’s gonna push you more to be more aggressive. With insemination, most couples who will conceive with insemination will do so within three or four cycles.
Again, age is gonna be a factor. Some insurances will limit the number of inseminations they cover based on patient age. So someone under 35, they’ll cover 4 cycles versus if someone’s 40, they’ll cover 1 cycle.
Dr. Fox: It’s interesting. I think that a lot of listeners might be thinking, “Hmm, how do I know if my doctor’s being too aggressive and recommending IVF too early and I don’t want that to happen?” But I don’t think that people realize that sometimes patients are stuck in the opposite situation where they’re seeing a doctor who’s just doing, you know, ovulation inductions and inseminations and billing them over and over and over and over again maybe because they don’t do IVF and they should be sending them for IVF.
So I think it goes both ways with this decision that, yeah, you don’t wanna be too aggressive because, you know, who wants to be too aggressive? But on the other hand, you also want to be appropriate that if this is not a treatment that’s likely to work, why subject someone to them, to the cost, and also to waiting? Because every time you do this, it’s another month or two that it’s gonna delay.
Dr. Lobel: Exactly. A number of years ago, I saw a patient who had done 12 cycles of insemination before she moved on to IVF and conceived on her second cycle of IVF. And then she came to me when she wanted a second child. Like I was very surprised that she’d done 12 cycles of insemination. And she said, “Well, actually, the doctor did recommend moving on to IVF earlier but I didn’t wanna do IVF.”
So, you know, that is an outlier but, you know, I would’ve said like, “It’s very rare that you should do more than six cycles of IUI. So, you know, sometimes doctors will accommodate patients but it’s not really in their best interest to do that.
Dr. Fox: If so someone is offering IVF to patients in the U.S, they’re gonna be specialists, right? They’re gonna be people who trained and did IVF because it involves procedures. There are no general OB-GYNs who do IVF, I assume. Correct? I don’t know of any. Does that exist even?
Dr. Lobel: Well, I know a case where there was a non-reproductive endocrinologist running an IVF program that no longer exists. In this current situation, I can’t say for every place in the U.S but I would think at this point, it would be rare that a program is not run by a reproductive endocrinologist, but it’s a good point because some programs do have non-reproductive endocrinologists participating in the program.
So, it would be a good idea before doing in vitro fertilization to check to make sure that the doctor is a reproductive endocrinologist, that the program is registered with the society for assisted reproductive technologies called ART. Now, comparing success rates with IVF is pretty much impossible to do because there’s…especially now when we’re doing fresh cycles and frozen cycles and genetic testing and there are programs that, you know, will push people into IVF to up their statistics and refuse patients who they feel will lower their statistics.
And so I think it’s very hard to use statistics to compare a program, and that’s where recommendations from your general gynecologist or obstetrician who’s familiar with the program or people that you know have gone through. But I wouldn’t, you know, pick a program saying, “Well, this program has a 62.5% pregnancy rate and another program has a 60% and that’s an insignificant difference.” But I would, you know, look to see where the doctor trained and, you know, check out to see that the doctors are reproductive endocrinologists.
Dr. Fox: Yeah. I think it’s a couple of really important points there. And I’ll start with the second one about the rates. And I actually wrote down in my own notes that exact question, I was gonna ask, how helpful are they? And I would imagine like you said, they’re not because they could indicate quality. Right? A better success rate means a better place but they could also indicate they’re recommending IVF to people who don’t need it, which will bump up their success rate or turning away people who might need it more and refusing to see them or say, “I don’t wanna see, you know, this patient because it’s not likely to succeed and I don’t wanna hurt my rates.”
It’s sort of like we have with C-section rates, people ask to compare them and we’re like, “Well, you know, the C-section rate could indicate how patient your doctor is versus more eager to do a C-section. But it could also indicate a higher C-section rate that your doctor takes care of sicker patients or more complex patients and might be better.” And so it’s hard to get apples to apples on these comparisons.
But going back to who’s doing IVF and reproductive endocrinologists, I think there is an important distinction, and that’s what I was gonna ask before, to do ovulation induction and insemination, you don’t have to be a reproductive endocrinologist. And there’s a lot of people around the country I imagine who do these things in some capacity.
And I think it’s important to know, is your doctor doing this because where you are it’s difficult to find a reproductive endocrinologist and they’re trying to save you sort of, you know, long travel and, you know, that they’re gonna do anyways? Or is it because they’re hesitant to send you to a specialist, you know, because you’re gonna leave their practice for all those, you know, procedures and treatments? How would someone know if that’s what’s happening?
Dr. Lobel: Well, nowadays you can pretty much go online and find out, you know, what the doctor’s training is. And if the doctor doesn’t have a website or a listing, you know, you can call the office. But, you know, just the same way that your internist may identify that you have a heart problem, you know, an internist can treat basic high blood pressure. But if someone has a heart condition, they’re gonna wanna see a cardiologist, you know, to manage their heart condition.
So in the field of fertility treatment, there’s basic training in obstetrics and gynecology. And then there’s a fellowship program, which is generally three years of additional training. And then there’s board certification. Optimally, someone would wanna be going to a reproductive endocrinologist who’s fellowship-trained. If they’re right out of training, they may not have their board certification. But if they’re more than a few years out of training, they should be board-certified in reproductive endocrinology.
Dr. Fox: Shifting gears here for a second, I was just thinking, do you have patients, you must, who come to you and, you know, you go through this and you talk to them and tell them what you think and they wanna be more aggressive? They said, “You know what? It’s only been four months and I wanna start, I wanna do IVF right away.” How do you handle that situation? Is that something where we go with autonomy and say, “Hey, they want IVF, I’ll do IVF.” Versus, you know, how hard you may try to talk them out of it or even refuse to do it. What do you do in that situation?
Dr. Lobel: I just had a patient that I had that conversation with, and she’s like…she said, “Well, my dad’s the numbers guy and he said the pregnancy rate with IVF is over 50. So why am I trying with Clomid that has, you know, a 15% chance of conceiving?” You know, she’s in her 20s. And so I explained that, you know, you might need IVF but the costs and the risks are much lower with natural conception than with IVF.
And also there are, you know, higher pregnancy complications with IVF babies and people can get into ethical issues. You know, if you have a lot of extra embryos, what do you do with the embryos? And so, you know, we prefer if someone can conceive on their own. So, you know, if someone had unexplained infertility and wanted to do IVF, I don’t think personally I would do it, you know.
But in my experience, most people are just thinking, “Well, I just wanna get there as quickly as possible.” But once you sit down and you explain the rationale for waiting longer or doing further tests or, you know, walking before you run, most people, you know, understand and follow the general medical guidelines.
Dr. Fox: On the other side of that equation, what might be a red flag that one of our listeners could look for if they’re worried that their fertility doctor’s being too aggressive? Meaning other than getting a second opinion, meaning what might be a situation where, you know, warning light should go off, “Hey, I think this person’s recommending IVF sooner than it really needs to be?”
Dr. Lobel: So again, it’s how long they’ve been trying. You know, if someone’s been trying for four months and there’s no obvious reason for conceiving, and then there’s little reason to jump straight to IVF. Or if someone has unexplained infertility and the doctor says, “Well, you know, your chances of getting pregnant with IVF are higher than with insemination, so let’s just do IVF.” Again, that’s not the standard recommendation.
And in the long term, if you spend three months doing insemination and you don’t get pregnant, you know, your chances of getting pregnant are generally not gonna be different three or four months later. But, you know, a significant number of patients will conceive with insemination. So it’s worth doing that. Also, you know, when I have patients that do insemination and they don’t get pregnant and we do IVF, oftentimes I’ll learn something about, you know, their cycles, their lining of their uterus. So you can learn things in doing less aggressive treatment that can help you be more successful with IVF.
Dr. Fox: And I think it’s also important, you know, what you mentioned before just to reiterate, it’s not just an issue of money. Right? If someone said, “Well, you know, I don’t mind dropping the money.” Or, “It’s covered by my insurance.” Or, “My workplace has, you know, benefits for this.” There’s risk with IVF. There’s procedures involved and you have a higher risk of getting twins, and in pregnancy, there’s higher risk of complications compared to natural conception.
And it’s not so high that we try to scare people out of doing IVF because it’s amazing. Right? It helps people have families when they otherwise wouldn’t, but it’s not something that should just be taken lightly and thinking, “Oh, you know, I’ve got the money, I’m just gonna buy it.” It doesn’t work like that. There is risk involved and it should be done if it’s appropriate but not, you know, just because it may be two months quicker, potentially.
Dr. Lobel: Correct. And also it doesn’t work every time, you know, that IVF has a higher success rate in general per trying per month but it doesn’t always work. And the analogy that I use with patients, it’s like doing a C-section versus a vaginal delivery. You know, you can make the argument to say, well, why bother with vaginal delivery? You know, that can take hours and hours, just go straight to C-section. But while, you know, getting the baby out is oftentimes faster with C-section though woman’s recovery is generally much more difficult with C-section than a vaginal delivery. And, you know, there are implications that may weaken the wall of the uterus, etc., for further pregnancies.
So all things being equal, you wanna try for a vaginal delivery before doing a C-section. And if you try for a vaginal delivery and the baby gets stuck and you end up doing a C-section, you know, it’s still worth trying even though, you know, you didn’t end up with a vaginal delivery. So I think it’s somewhat analogous, you know, to try less invasive measures than, you know, going straight to IVF.
Dr. Fox: I wanted to touch on your recommendation for using an egg donor. At what point do you either switch to that recommendation? Right? You’ve been trying IVF and it’s not working versus from the outset saying, “You know what? If we’re gonna do this, we should do it with an egg donor.” Are there sort of standard rules for that and lines or is it much more just about percentages and odds and people’s comfort level with using an egg donor?
Dr. Lobel: Well, first of all, there’s some patients that are menopausal and it’s not something that people think of but I have patients that are menopausal before they go through puberty or have for autoimmune factors, there are other factors that unfortunately go through menopause at a very early age. And so there really is no option of conceiving with their own eggs.
Likewise, if someone’s older being defined generally, you know, after age 45, the chances of conceiving with their own eggs are extremely small. So those are patients where pretty much your best option or perhaps your only option is to conceive with IVF with donor eggs. There are other patients where we may sometimes…it’s not common but it happens. We do IVF and we see that the eggs are very abnormal.
Usually, after, you know, if someone does two attempts at IVF and there’s significant abnormalities of the eggs or very poor embryo formation, that could be a situation to use egg donor. Or if it’s a situation where there’s a fair number of eggs but even when we go to pre-implantation genetic testing, that all of the embryos are chromosomally abnormal and that happens with several cycles, then egg donor is the best option.
What’s trickier is if you have patients who have decreased ovarian reserve where they’re not getting very many eggs or embryos, and the situation there is, do you keep trying with your own eggs or do you go straight to egg donor? And that’s gonna be often more of a personal choice, you know. So first of all, that’s a good situation to go for a second opinion because a different doctor may have a different approach that can help, you know, produce embryos that are normal or more embryos.
You know, that’s a situation where there can be other options but, you know, if someone has decreased ovarian reserve and has tried several ways and they’re not getting there, it’s gonna depend on the individual. You know, I have some patients that say, “I just wanna have a baby the best way. You know, I wanna have a healthy baby. And this is the baby that’s gonna be in my uterus for nine months and then I’m gonna love it. So, you know, that I wanna do what’s gonna get me there most quickly,” then egg donor is the best option. You know, for other patients, the genetic connection is more important and they may wanna try a few more cycles before moving on to the egg donor.
Dr. Fox: I think that makes a lot of sense. Is there a point where you recommend gestational carriers just for fertility? You know, a lot of the times, gestational carriers are more so pregnancy-related issues, you know, hysterectomy or they have multiple medical problems. But is there a role for gestational carriers purely for fertility?
Dr. Lobel: There is a role but this is one area where I really would recommend a second opinion because I see a fair number of patients that, you know, after two attempts at IVF, they’re told, you know, you need a gestational carrier. And, you know, oftentimes, it will be something that the woman has a thin lining of the uterus but there’s different treatments where you can, you know, enhance the lining of the uterus and it may take a couple months but to get there and carry the child successfully.
You know, or someone’s not getting pregnant but it’s an embryo quality. So moving to a gestational host is not gonna help. There are other situations where someone has recurrent miscarriage of an autoimmune nature and, you know, unfortunately, you can’t get around it and that gestational carrier would be the best option. But it’s something that I personally have seen a fair number of patients that it’s been recommended to.
And, you know, I disagreed with that it’s necessary and they’ve been able to, you know, get pregnant either through persistent trying, you know, going back to the program where they were for persistent trying or for us trying something different. So, you know, if it’s recommended just because it’s not working, you know, that’s not necessarily the best option.
Now, unfortunately, it’s rare but there are some women who probably are missing some kind of receptors in the lining of their uterus where they’ve done multiple tests of IVF with relatively good embryo quality. You know, the lining looks good but embryos just aren’t implanting. And those are women who probably would benefit from using a gestational host. That’s an area where I definitely would get a second opinion before going there.
Dr. Fox: Dr. Lobel, thank you so much. This is so helpful. I always enjoy talking to you and getting your opinion on this because you’re quite reasonable, and yeah, thanks again.
Dr. Lobel: Well, thank you, Dr. Fox. It’s always a pleasure speaking with you and I look forward to speaking with you again.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
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