Kimberly Ma: Hi, everyone! Thanks for joining the seminar. I think we're just gonna give it one more minute before everyone joins in, just to give some people some extra time.
Kimberly Ma: Seminar.
Kimberly Ma: Thanks. Everyone for joining our seminar. We're really. I'm glad that you can make it. I know it's hard with our clinical schedules and our obligations to sometimes take some time away for ourselves.
But we have a great discussion today, and presentation by Rachel. Why not? And then also a panel portion for the second half of the talk.
Kimberly Ma: So, Rachel, why not? Is an assistant professor and associate fellowship director in the division of reproductive end chronology and infertility at the University of Washington she have changed her medical degree at the University of Toledo College of Medicine, and conceded her residency in sunny Florida University of South Florida.
Kimberly Ma: Her fellowship and reproductive endocrinology and infertility, was at the University of Iowa, and upon completion of fellowship she was in private practice in Florida, and then we happily recruited her to faculty at the University of Washington.
Kimberly Ma: She has a number of peer-reviewed publications, and currently does research pertaining to quality of life and wellness when undergoing fertility treatments. So we'd like to welcome Rachel, and she will start off with the first part of our presentation.
Rachel Whynott: Thank you so much.
Rachel Whynott: so objectives for this talk would be medically planning for pregnancy, Definitions of infertility, frequency of infertility, causes of infertility. What fertility screening? Should you do
Rachel Whynott: impacts of age on fertility, egg and embryo freezing, and any family planning talk should also include a little bit about pregnancy prevention, and then we'll get with our panelists.
Rachel Whynott: So just in terms of medically planning for pregnancy, it is important to optimize your health before conceiving if possible, including any pre-existing medical conditions that you might have, you should consider infectious disease screening, updating your immunizations.
discussing genetic carrier screening with your physician.
Rachel Whynott: starting a prenatal vitamin especially with folic acid in it we do recommend at least 400 micrograms of fullic acid. There's not a specific prenatal vitamin that is better than any others. There's a lot of well marketed brands, but they're not necessarily any better than anything else
from Cbs target. Amazon.
Rachel Whynott: Review any modifiable risk. Factors that you may have such as tobacco. Use marijuana, Use alcohol use, and then consider a preconception visit to sort of chat about what pregnancy might look like for you.
Rachel Whynott: So what does care look like during pregnancy, because we're all very busy. So how often are you going to have to see us that sort of thing? So your first visit is typically around 8 to 12 weeks, if it's a spontaneous conception. And if you have an uncomplicated pregnancy, typically visits are every 4 weeks until around 28 weeks of pregnancy. Then you'll be seeing, as every 2 weeks until 36 weeks, and then after that it's going to be weekly visits
other things to consider when considering pregnancy and sort of planning out your family and your ideal family size is that it is recommended to wait at least 12 months after delivery of a child before conceiving again.
But this does need to be weighed with the risk of age-related fertility decline, which we will chat about later in this talk
Rachel Whynott: also thinking about multiple pregnancy. So sometimes people that are undergoing fertility treatment will want to discuss how to increase their chance of twins. We often hear more bang for your buck.
So I do want to mention that we do actually try to minimize the chances of multiple pregnancy, and that is due to increased risk for mom and baby. So
with twins in higher order, multiple pregnancies, there is a greater risk at preterm delivery. Nik. You stays pre maturity related issues, sometimes delivery even before viability. So then the babies don't make it risk for moms like C Section gestational diabetes, high blood pressure disorders and pregnancy, and actually just increase costs on the back end for increased costs of medical care and things like that
that.
Rachel Whynott: So how do you know, if you need help to conceive. So the definition of infertility is actually the failure to conceive a pregnancy within 12 months of unprotected intercourse, or a therapeutic donor insemination in women that are younger than 35 years
Rachel Whynott: that does change. If you're older than 35 years to 6 months and actually if you're over the age of 40, evaluation and treatment is actually warranted right away. And this is also true. If you have any condition that's known to cause in fertility, or if you have a history of
Rachel Whynott: treatment with something that could affect fertility. So these are important to keep in mind. There is also
Rachel Whynott: primary versus secondary infertility. So secondary infertility is when you have infertility after you've already conceived and carried a baby to term after giving birth, so
Rachel Whynott: it is possible to end up with infertility after You've already had children.
Rachel Whynott: So the frequency of primary infertility actually differs per country. But for married women in the United States that's
Rachel Whynott: the study that I've got for you today happens about 7 to 9% of the time in women, ages 15 to 34. That increases to 25% in women, 35 to 39 years old, and it's about 30% in women ages 40 to 44.
There's a lot of causes of infertility. The most common reasons would be issues with ovulation, mail factor, fallupian tube issues, and also unexplained in fertility, meaning, we do a full evaluation, and everything looks pretty good. So we don't actually have
a specific answer.
Rachel Whynott: So what fertility screening should you do? There's a lot of marketing surrounding little kits that you can do. I don't know if You've seen the targeted ads on social media for modern fertility, or some of these test kits where you can hook your finger and send off your blood and get some tests done. So we'll talk about those
Rachel Whynott: one common hormone. That is part of these test kits, or sometimes people will come to us asking for is something called anti eulerian, hormone or amh.
Rachel Whynott: That's one test for ovarian reserve that's used in infertile populations for us to help guide treatment. Options. There's also something called an anti- follicle account, which is something that we do with ultrasound to get a sense of someone's ovarian reserve.
But the use of this blood test. Amh is not recommended as a routine screening tool for people who are low risk or haven't tried to conceive. And that's because it's been shown to have too high a variability in fertile women to be a very good index, and it also doesn't tell us, you know, if you haven't tried to conceive. If you're fertile or not, there's a lot of reasons like we just saw on the last slide that someone may have infertility.
Rachel Whynott: It may not be tied to ovarian reserve. We also know that you know it just takes one egg in a a month to be ovulated. So just because the reserve may be low doesn't mean that you can't conceive. So we don't want to scare people unnecessarily, but we also don't want to give false reassurance.
Rachel Whynott: so that ultrasound also does not reliably predict failure to conceive. And then there's some other blood tests that are sometimes touted for fertility, but also are not really reliable measures. So essentially. I'm saying, there's no good predictor for pregnancy, and people who haven't tried.
But it is a discussion with your physician. So if you're thinking you know. Should I freeze my eggs? You know what are your overall plans? It is worthwhile to get a consultation with your local, friendly fertility, Doctor, to kind of discuss what your options are, and what things are looking like.
Rachel Whynott: But regular periods are not an indication of fertility either. Sometimes we do hear that in addition, there is no test for a quality. So
Rachel Whynott: as women were born with all the eggs that we're ever going to have, and over time the numbers of those eggs, and also the quality of the eggs can decline. It happens at a different rate for everyone. But there is no test to tell us what the quality is looking like for our eggs.
Rachel Whynott: It's now kind of chat about age-related fertility decline
Rachel Whynott: so for people born with ovaries and have eggs, the
Rachel Whynott: fertility declines actually beginning around age 32. It happens gradually at first, and then accelerates, and then there are actually few spontaneous libraries occurring in women over the age of 43.
So why is that just like I said, we're born with this fixed number of eggs, which decreases with age as well as the quality. As we're older, we have more abnormal eggs, and the body cannot actually differentiate
the normal ones from the abnormal when being selected for ovulation, and the quality decline is due to increasing myotic errors. So since our eggs are sort of arrested at one stage as they're trying to get started again.
Rachel Whynott: they tend to have more genetic issues. That also leads to increased race of miscarriage. As we got older, as well related to that Also, as time passes, there is a greater chance that some life, circumstance, illness, or accident, can impair your fertility, or increase abnormalities in the offspring.
Rachel Whynott: There is age related fertility decline in males as well. There's not really a specific definition for advanced paternal age, but sometimes it's considered starting at age 40 or 45.
But it is associated with increased time to pregnancy and decrease Pregnancy rates separately from female age. Spermatility decreases over time and unfragmented DNA increases, and of course
over time there's a greater chance for rectile dysfunction to occur, negative environmental impacts on the testes, etc.
Rachel Whynott: So other things that can happen for men as they get older is the association with a variety of genetic issues as well. So increase in you autosomal, dominant mutations, like mar fan syndrome increase in spontaneous germline mutation and x-linked genes
in increase in an employee, but smaller than comparable females increase in congenital anomalies, increased rates of schizophrenia and offspring and increased risk of autism spectrum disorders and other neuro cognitive disorders in the offspring.
Rachel Whynott: So what can we do to prevent age-related fertility decline? So
Rachel Whynott: basically oo site or egg freezing and embryo freezing has been around initially, with sort of considered need based where it was sort of designated for people with maybe cancer or some other treatments for things that were toxic to the ovaries versus what we call now planned at overite crowd preservation or embryo prior preservation, which used to be known as social egg freezing or embryo freezing, or at least
collective.
Rachel Whynott: or what we considered to be prevention of anticipated gamete exhaustion. So oftentimes women are delaying childbirth for reasons outside of their control. So we've been trying to get away from terminology, suggesting that this is sort of like a social thing or a non medical thing. But this is actually a treatment to prevent anticipated gamete, exhaustion.
Rachel Whynott: and also I and sperm crowd preservation are great options for trans patients who are going through transition to allow for genetic offspring in the future.
Rachel Whynott: So interestingly, a preservation for any indication was considered experimental until 2,012. But the first birth from a frozen egg was actually back in 1,986, and the first birth from a frozen embryo was in 1,984. So this technology has been around for a long time, although it has
changed how it's done and has become more successful.
Rachel Whynott: So when thinking about preserving your fertility, there is the option to freeze eggs which you can see here versus embryos. So the benefit of choosing eggs versus embryos is that it is more versatile. So it hasn't been fertilized Yet so it does leave that door open in the future for using whatever partner sperm that you might have in the future, or choosing a donor
Rachel Whynott: in the future versus an embryo. It's already been fertilized. So whatever partner donor that you've chosen is already sort of used, but
Rachel Whynott: the embryo has sort of gone through the drop out process that we do see with Ivf. So it does give us a better sense of the reproductive potential per transfer.
Rachel Whynott: Many people do have pretty unrealistic expectations of reproductive potential with age and the ability for reproductive medicine to restore that potential. We see all the time in the media. Janet Jackson's getting pregnant at 50. S. Lindiyong is pregnant at 50, and I think celebrities do a great disservice by not sharing their journeys.
Rachel Whynott: You know the vast majority of these people have used either donor eggs or embryos, or maybe they froze eggs or embryos in the past.
Rachel Whynott: Are there age limitations to when you can do this, and the suitable range of ages for freezing is still sort of being determined. There's not an official recommendation, but we do know that when using egg donors, our society for
reproductive medicine does suggest that egg donors should donate between the ages, of 21 and 34 to decrease those genetic risks associated with egg age.
Rachel Whynott: However, when it's for yourself, people have more looked at cost, effectiveness. So there is a nice study that looked at cost, effectiveness for people who required marriage versus not, and when they should freeze their eggs.
so they did find that it was least cost effective to freeze eggs for people ages 25 to 30, and that's because usually the reason people are putting off child bearing based sort of resolve, and then they go on to complete their families, and then they may not need the eggs. And the most common reason people end up delaying child bearing is because they Haven't found
that partner that they wanted to have a baby with, so
Rachel Whynott: they also found that if someone did require marriage when sort of
Rachel Whynott: putting into their model the probability of marriage. They found that it's most cost effective at each 35, because the chances of getting married are getting lower. Less. People are are getting married these days. So
Rachel Whynott: age 35, if you absolutely like, would never have a baby by yourself. Or if you'd have a baby with a partner when you're not married. and then, if the patient felt like they did not require marriage before attempting pregnancy, then it was most cost, effective to do it at each 37.
Rachel Whynott: So the older that you are at the time that you decide to do this, some more eggs will be needed to store for a reasonable chance of a live birth.
Rachel Whynott: and that's because of sort of the quality of the eggs going down over time. And then also the older the patient, the more likely you might need several cycles to freeze eggs, just because the numbers of eggs are also likely to have decreased
so For example, at h 38 a patient may need to store around 25 to 30 eggs for a reasonable chance of one live birth. So reasonable chance is very variable, depending on who you are. So there was another nice study that I use when counseling patients that looked at the probabilities of having at least 1, 2, or 3 children.
Rachel Whynott: based on number of eggs that were frozen and then formed. So you can see there by age categories here, and
Rachel Whynott: you know, in the 30 to 34 year old range. There is a 90% chance of having at least one child. If you froze 30 eggs and you'll see that it never is a 100, because we can never.
Rachel Whynott: You know it's not an insurance policy. We can't say, you know, for sure that there wasn't else something else going on that could lead to not having a live birth.
Rachel Whynott: So limitations, unfortunately it is, can be expensive, and is often self pay for the University of Washington. We do have discounts for our employees, you may need several cycles for a reasonable chance of a live birth sort of depending on your own
Rachel Whynott: big numbers and your age. It may be unnecessary to do it if you end up, never using those eggs, if you end up conceiving on your own, and then possible feelings of regret. Studies have shown that this has been due to having fewer eggs for freezing or feeling like you had inadequate information or emotional support going through the process.
Rachel Whynott: and others may feel like they have this sense of security that may be false, because success rates to vary by Ivf program, and there are age limitations to carrying a pregnancy safely. So per society guidelines. We don't do transfers after the age of 55. But if you're below that age it Also, You know we want to weigh sort of your own health risk and things like that
with, you know whether or not a pregnancy is safe for you. So you might be seeing someone like Dr. Ma to see. You know how safe pregnancy might be if you have any special things to think about.
Rachel Whynott: And then this last part is more a historical thing. There used to be some programs that actually had mobile egg freezing where they would go around like San Francisco and New York City, and have these things that they called egg freezing parties, where they would actually have
Rachel Whynott: like wine and cheese, and talk to women and talk about how they needed to freeze their eggs. So
Rachel Whynott: it's keeping your eyes out.
Rachel Whynott: So a lot of celebrities have come out with that. They've, you know, frozen ex or embryos.
Rachel Whynott: the keeping up with the Kardashians. Courtney froze her eggs for future use.
People doing this are sort of on the rise. You can kind of see that, you know, since 2,007 it's been sort of an exponential increase, and then 2019, actually 36.8 of Ivf cycles were for egg or embryo banking.
Rachel Whynott: So what does this process entail? So basically you would come in to see someone like me, and we'd chat about your history, medical history, goals for family building.
timeline of things. And then we would do some testing for ovarian reserve so that we could pick a proper ivf protocol for you.
Rachel Whynott: That would involve a blood test for that em. H. And then also an ultrasound for that anthra follicle account.
Rachel Whynott: Then, depending on your ovarian reserve and your age and some other factors, we create a protocol for you. Oftentimes you'll start some pre medications that kind of help keep the ovaries from making any hormone producing Cis. So you might be on oral contraceptive pills for a couple of weeks, or sometimes loop around, sometimes nothing.
Rachel Whynott: Then you start the stimulation medications which are injections under the skin and the abdomen. Most people are on those for about 8 to 14 days. During that time you might get 2 to 4 ultr sounds, and also some blood work while we track how the growth is going, and how your body is responding.
Rachel Whynott: Once everything is looking good, we give you something called a trigger shot, which is going to basically tell your ovaries to mature any eggs that are there and get them ready for ovulation, and then we actually collect them via an egg retrieval before they ovulate. You get some anesthesia, so you're asleep, and then everything is done through the vagina with an ultrasound and a needle on a byip. See, guide. We obtain any eggs that are there, and then, if you're doing egg freezing.
Rachel Whynott: Well freeze eggs later that day, and if you're doing embryos, they'll be put with sperm that day, and then we'll grow the embryos in the lab until it's time to freeze them.
Rachel Whynott: Risk of the process Anytime you do any procedure. There is a risk of pain, bleeding, or infection. It's really rare for those things to happen. Less than half a percent of the time
Rachel Whynott: risk of the stimulation medications. There is something called a variant hyperstimulation syndrome, so that's sort of. When the fluid from inside the blood vessels sort of gets into the abdomen so you can get him a concentration inside of the blood vessels, and
Rachel Whynott: third space accumulation of fluid which can lead to nausea, vomiting electroly abnormalities and sometimes blood clots. So we take it very seriously, and it's quite rare nowadays. But here's an ultrasound picture of fluid around the uterus
Rachel Whynott: also, as you're on these stimulation medications. The ovaries are growing and getting quite large, and since they're sort of suspended on their blood supply when they get large, there is a chance of the possibility of the ovary twisting on its blood supply, which is called a variant torsion, also quite rare, but a possibility.
And then
Rachel Whynott: anytime that we're doing this, there is a possibility of failure. So there is the possibility that we may not be able to get any follicles to grow, or may not get any eggs from the follicles. If you're
Rachel Whynott: freezing eggs, maybe down the road they don't saw. If we're doing embryos, maybe they don't fertilize, or they don't grow in the lab. So there are many steps to the process.
Rachel Whynott: and then sort of moving to family planning on the other aspect. You know it's always good to know what your options are when you're not trying to conceive. So there are different birth controls on the market. They all have a sort of different chance of
Rachel Whynott: working, so that bottom realm is sort of the ones that don't work as well. So withdrawal method, fertility, awareness, condoms
Rachel Whynott: about 12 to 24 and a 100 women. We'll get pregnant within a year of using those methods, so it is better to use one of the the top 2 lines if you are trying to prevent pregnancy.
Rachel Whynott: so take away messages. The most successful and low cost way To have a baby is going to be conception through sexual intercourse or donor insemination prior to the mid thirties. If you have been trying to conceive without success, or, if you have a risk factor for infertility, consider seeing a reproductive endocrinology and infertility specialists, because
delays can decrease chances of success due to that time. Factor
Rachel Whynott: Egg freezing is no longer experimental, but it's not perfect like we discussed.
Rachel Whynott: and then it is difficult to predict who will have fertility issues if there are any risk. Factors so egg or embryo freezing may be a preventative medicine for some people for future and fertility. So something to think about.
Rachel Whynott: And then any questions.
Kimberly Ma: Thanks, Rachel. That was great. That was a lot of information to cover in 30 min. I feel like you could have 2 h for sure. Yeah. we have a comment. We have a couple of questions in the chat for people who can either direct message, or just throw it in the chat as well. I think this is a pro, probably a common scenario just given our trajectory for our careers and education. A lot of people have been on birth Control for a long time, whether it's Marina or or control pills.
Kimberly Ma: and then they stop and Don't have regular periods, but they're not quite right to conceive. Do you think it's better to wait until somebody is actually ready to conceive to see fertility specialists, or do you think sooner is a little bit better, since most people are like in their thirties is by then.
Rachel Whynott: Yeah. So if you stop your contraceptive method, and you're not getting a period after like 3 to 6 months or so, I would say that we we would consider that to be secondary a monoria. So we would definitely want to investigate. Why, that was happening. Because what if there's you know, a hormonal abnormality that we can
Rachel Whynott: can adjust, or you know what if there's something going on that could affect fertility? So maybe you're not ready for that conversation yet. But
Rachel Whynott: it it may be something that you want to know about sooner rather than later, especially for that time factor.
Kimberly Ma: Yeah. And then we have another question of like, how long, realistically does it take to get into a fertility, doctor, because I know it's not going to be next week, or is it going to be?
Kimberly Ma: What is the average count of? I guess.
Rachel Whynott: Yeah. So I know that we were booking out quite a bit before I started. But
Rachel Whynott: i'm not sure. Actually, Dr. Ryan, my boss, is here as a panelist, you might. Yeah, I think I heard I heard today actually, that it was into June for us, and I think it's similar
Ginny Ryan (she/her): around the area in the private practices as well.
Rachel Whynott: and we are getting another physician starting in September, so that will certainly help reduce wait times.
Kimberly Ma: Yeah. And I certainly, for my patients tend to refer a little bit, for, like I don't necessarily always we right at 6 months for somebody who's like 38. I kind of oh, You've been 4 months. Let's put your for all in, and you can keep trying.
Kimberly Ma: Yeah, what have you and I never turned someone away for? Not you know you haven't been trying for 6 months. So yeah, can you talk a little bit more about the you dev discount
Kimberly Ma: for? Yes.
Rachel Whynott: thanks. I don't have a specific quote for you. I've been told that I cannot give this specific quote because they're still working on packages. But
Rachel Whynott: if you come to see us, just let us know that you are Uw employees, so that when we refer you to our financial counselors that they're aware so they can give you the the employee package pricing.
Ginny Ryan (she/her): Yeah. And I just to add to that, I was just talking to our service Line administrator today about this, because I was wondering about the now the integration with the Fhcc. And we've been wondering about how that
Ginny Ryan (she/her): the I mean the bottom line is that if you have a husky card. You can get this discount, and my understanding is, it's about 30% over what's charged to insurance companies. And so it's a
Ginny Ryan (she/her): it's basically at cost. But yeah, as you were saying, Rachel, the we're working on we have an updated pricing for 3 or 4 years now. So so they are hesitant right now to give that exact numbers
Ginny Ryan (she/her): because we're updating the costs.
Ginny Ryan (she/her): And there's a lot of work important to know, too. There's a lot of work being done within our group and out, you know, and outside in the community, to to pass a a a law in the State of Washington, that that certain size employee employers will cover in fertility. So we're. We're hopeful that that will
Ginny Ryan (she/her): sooner rather than later apply to the institution, so that there's just straight out better coverage, and we don't have to worry about those discount packages.
Kimberly Ma: Okay, Great thanks again, Rachel. And of course we'll have time for more questions at the end. After we are done with our panel. I think, Kat, we can stop recording, since we're going to start with.