Keith Hansen, MD - Sanford Health News

From IVF to NICU: One couple’s road to starting a family

Polly Gill (guest):

I was super excited. But you know how many times we had negative after negative after negative. It was like, there’s no way we can be pregnant. Like this is just not going to happen. And that line started getting, we started seeing double lines day by day by day, and we just didn’t want to celebrate yet. But when we found out, when those were two solid blue lines and the pregnancy said positive, we just bawled. And we just said, you know, we’ve been working on this for four years, trying to have our family and it was the best moment of my life.

Cassie Alvine (announcer):

This is “Her Kind of Healthy,” a podcast series by Sanford Health. The conversations highlight topics from fertility and pregnancy to postpartum, managing stress, healthy living, and so much more. In this episode, hear one couple’s story about starting a family through in vitro fertilization. Our host is Alan Helgeson with Sanford Health News.

Alan Helgeson (host):

Being able to share stories and inspire hope and joy is important when first meeting Polly and Nikki. Their story has so much to share and like all good stories, it has to have a beginning.

Nikki Gill (guest):

So, Polly was like a really big volleyball star in high school, and when I was in high school, my team actually played against hers. And her senior year, she’s from Pierre, and they were undefeated all season. And she was a senior and I was a junior. And from our high school, in Rapid City at Stevens High School, we ended up beating them in the state championship. So that was like the first encounter and to this day she does not get to live that down. And so yeah, we played volleyball in college together and then like she said, we were roommates and then became more than roommates and fell in love and yeah, got married and had a baby (laugh).

Alan Helgeson:

So when you decided to start having those serious talks about having a family, was it hard to find the resources or figure out how to go about doing that?

Nikki Gill:

So I had always just imagined like a really traditional way of being able to start a family. So when her and I fell in love and when we got together, we really had to sit down and think about like which avenue we would want to take in order to have a family.

We knew that we wanted to, in a perfect world use like a sperm donor. So what we actually did with Theo was we had Polly get her eggs ready, so we kind of like split the IVF process together. So Polly had her eggs retrieved for the IVF process, and then those eggs were created, like the embryos were created with her eggs and the sperm donor. And then those were put into me. So like Theo would not have been able to exist without either of us put together, which is like what we were really hoping for in a perfect world.

Alan Helgeson:

Ok, so at what point did you go to Sanford and say, Hey, here’s what we want to do. We want to start a family?

Polly Gill:

So once me and Nikki decided that that’s what we wanted to do, and we started at Sanford Health, because I believe that they’re the only fertility clinic in the whole state of South Dakota. So we’re very, very blessed that they’re nearby and we couldn’t ask for the better doctors. So we kind of went back and forth, and from the very start we just worked as a team and they said, we’re going to get you guys through this.

Alan Helgeson:

At Sanford Health, Dr. Keith Hansen and his team are part of a larger group of specialists in women’s health.

Dr. Keith Hansen (guest):

I’m a what’s called a reproductive endocrinology and infertility specialist, which means that we take care of hormonal issues and some other issues like to try to help couples to achieve their dream of starting a family and having a baby.

Alan Helgeson:

With your clinic and your expertise, you’re very specialized in what you do. So where do your patients come from and how do they hear about your services in your clinic?

Dr. Keith Hansen:

Our patients usually are referred to us. Sometimes they come as primary, they make an appointment to come in and be seen, but a lot of times they’re referred to us either by their family medicine doctor or by an OB/GYN. And we then evaluate them once they come to see us. And then we do get couples to just hear about it and call and make an appointment so they don’t have to have a referral to be seen in general. Usually when we have couples who are trying to get pregnant, one of the things we really want to do is try to help them conceive with the least invasive process that’s available to us.

Alan Helgeson:

For Nikki and Polly, they had to navigate other changes as well.

Nikki Gill:

I also have PCOS, so I have polycystic ovary syndrome and that means that like my hormones are just like imbalanced in my body, which can make it harder for like my lining to get really good. So when we started IVF, we had Polly’s eggs retrieved, but my lining couldn’t get thick enough to put the embryos in, so we had to actually freeze the embryos that we had until my body could get where it needed to be to hold the embryos.

Hear Dr. Hansen explain the IVF process

Polly Gill:

And that was a long process.

Nikki Gill:

That was a really long, a lot of like failed rounds of trying. Yep. We hadn’t put any embryos in at that point.

Polly Gill:

Yep. And it got to a point where we were very frustrated, so we just had to take like a year off.

Alan Helgeson:

OK, so for Nikki and Polly, having patience is important and working with the right team is key.

Nikki Gill:

So we started with our fertility doctors.

Alan Helgeson:

Dr. Hansen, can you please talk about the IVF process?

Dr. Keith Hansen:

Usually for in vitro fertilization, first we have to do testing so we can figure out the best medications and all that kind of stuff.

Then the first part of the process is ovulation induction, where we’re giving her medications to stimulate the ovary to try to make more follicles to grow. And so what we do is we start the shots and the gals have to take shots a couple times a day, I’m afraid.

Once the follicle gets to a certain point and her estrogen’s at another point we have to start her on even another medication to try to prevent her from ovulating. And once the follicles get up to a mature size, which is about 18 millimeters in diameter, then we give a shot called the HCG, a trigger shot, which completes the maturation of the egg and starts a process of ovulation. Then 36 hours after that we take the eggs out.

And the way we do that is we go back to a little room in the back here that’s attached to our laboratory and anesthesia comes down, puts the person asleep so they don’t feel what we’re doing. Once we’re asleep, we can clean the vagina out with saline, put a vaginal probe ultrasound, and this ultrasound has a little aiming guide on it.

So we put a needle down through there, we go through the top of the vagina and we just kind of pop into the follicle. Then we, it’s attached to a pump, pump the fluid into a test tube. We take the test tube off, hand it back to the guys in the lab. They’re sitting under a big microscope that’s heated. They pour out the fluid, find the egg, and put it in the incubator. And we do off other ones on one side. Then we go over and do off other ones on the other side.

Then we take everything out and then wake her up and then the lab gets the eggs ready, which probably takes them about four hours to do. They get the sperm ready, which takes about four hours to do. And then depending on the sperm, they either put a hundred thousand sperm right on top of the egg or they do what’s called ICSI, where they go in, find a normal sperm, pick it up and inject it into the egg. Then they put it back in the incubator and the next morning we get to see did it fertilize normally or not. And those that fertilize them can develop and we want them to get up to what’s called the blastocyst stage. So what we do is once we have the blastocyst, which usually takes five, six, or seven days, then we can put it back into the uterus.

Alan Helgeson:

With any medical procedure, there are always things to watch for and why Dr. Hansen and his team have many safeguards in place.

Dr. Keith Hansen:

There’s a number of risks associated with the procedure. The biggest one is multiple babies, and we like to follow the American Society of Reproductive Medicine guidelines, which tell us how many to put in to give us the least risky pregnancy and the most likelihood of a live born baby. And for most women under the age of 35, it’s usually one embryo. For those 35 to 40, it’s one or two, but no more than that. And it depends a little bit on a number of other factors, but it’s usually one, sometimes two, between 35 to 40.

Alan Helgeson:

Are there organizations that you work with to help make sure you’re providing the best care possible?

Dr. Keith Hansen:

We’re closely monitored by, you know, a number of different agencies. The FDA, the pathology group follows us closely, the American Society of Reproductive Medicine. And then we maintain certification and board certification so that we can provide the optimal care to our patients to reduce their risk and improve the chances of a healthy baby and a healthy mom.

Nikki Gill:

So typically an IVF process from beginning to end is not as complicated as mine was, but I had a lot of hiccups along the way.

Alan Helgeson:

When Dr. Hansen talked about the IVF process, the steps were a bit different for Nikki and Polly.

Dr. Keith Hansen:

In this situation, what we did was what’s called reciprocal IVF, where we stimulate the one individual’s ovaries through ovulation induction meds. We take the eggs out, then we fertilize them, and then what we do is we prepare the other person’s uterus to accept the embryo. Then we thaw the embryo and put it in, and then hopefully she gets pregnant, which in this case she did.

Alan Helgeson:

Is it common to do it this way, Dr. Hansen?

Dr. Keith Hansen:

It’s more common than it used to be. I’d say that the more common way is a lot of people decide to do the intrauterine insemination just because IVF has so much to go through. But there are a group and it’s becoming a larger group of patients where they want to use like reciprocal IVF where we stimulate the one, fertilize the eggs, then put the embryo in the other person. And it really does, you know, it’s kind of a cool way to expand a family and have a little baby.

Polly Gill:

I was super excited. But you know how many times we had negative after negative after negative. It was like, there’s no way we can be pregnant. Like this is just not going to happen. And that line started getting, we started seeing double lines day by day by day, and we just didn’t want to celebrate yet. But when we found out, when those were two solid blue lines and the pregnancy said positive, we just bawled. And we just said, you know, we’ve been working on this for four years, trying to have our family and it was the best moment of my life.

Nikki Gill:

So we started with our fertility doctors and they helped to get us little baby embryos that that we were able to work with from the beginning. And then as soon as I got pregnant and we graduated from like the fertility doctors.

Then we went to Dr. Kemper. Oh. And man is she, she’s awesome. Ugh. She is just the best. She’s amazing. She’s amazing. She was our OB/GYN. And she, so then really after you graduate with, from the fertility doctors, it’s like a normal pregnancy. Right? So then you just have like a normal baby doctor.

Alan Helgeson:

For Polly and Nikki, their journey to starting a family has been anything but normal. So at what point did you learn that it was a high-risk pregnancy?

Nikki Gill:

Because it was IVF. That’s what labeled us as a high-risk pregnancy. But yeah, we just had like a normal experience from that at that point. And then at my 20-week scan, that’s when they do like the anatomy scan. We found that my cervix was shortening and funneling, which is a sign of labor like you can go into labor soon. And I was only 20 weeks at that point, so they had to put in a cervical stitch. So I remember at that 20 week appointment, they were like, you could have a baby within the next couple of weeks. And we were like that, that can’t happen.

Alan Helgeson:

This is where the expertise of Dr. Rachel Rodel and her team comes in.

Dr. Rachel Rodel (guest):

Sanford Health as a whole has a vast team of experts to help people start families and to help them be successful in their journey. Fortunately with Sanford, we have multiple avenues for patient care, including certified nurse-midwives, family medicine physicians, OB/GYNs, and us as maternal-fetal medicine subspecialists. So we take care of patients really once they’re pregnant or if they’re planning a pregnancy. And then of course for those who might need extra support in starting a family, we’re fortunate to have the reproductive endocrinology and infertility specialists.

Alan Helgeson:

For Nikki and Polly, this level of care was important with their pregnancy.

Dr. Rachel Rodel:

Often what we see here in maternal-fetal medicine is when pregnancies get unique. So for any patient who might conceive by IVF or in vitro fertilization, they are typically referred routinely to a maternal-fetal medicine specialist at the time of their anatomy ultrasound around 20 weeks to have a little bit more in-depth look at the baby due to risks associated with the IVF process. But for them, some unexpected findings on the typical screening ultrasound led our team to stay involved. And if we fast forward a short time after that, our team became even more involved as her pregnancy progressed.

Nikki Gill:

So I remember at that 20-week appointment, they were like, you could have a baby within the next couple of weeks. And we were like that, that can’t happen.

Alan Helgeson:

With the physical challenges during this time, the mental stresses weigh heavy too.

Nikki Gill:

I felt a ton of pressure, like emotional pressure to like be perfect all of the time when I was pregnant. Because it’s like if I do anything wrong, like I’m going to ruin this pregnancy. So, and I think that’s for every pregnant woman. There’s the women, there’s a lot of pressure onto, it’s like they feel like it’s your job to make their family. Everything’s on you. You have to do everything perfectly. And, and when you’ve never been pregnant before, yeah, it’s scary. It’s like, is this normal? Is this not normal? Scary.

Alan Helgeson:

So let’s go a few weeks down the road. OK, 24 weeks, five days emergency delivery.

Nikki Gill:

Ugh. You’d think you would be able to like get through it after telling the story so many times. OK.

So the night before the emergency C-section happened, I had felt pressure in my vagina and they came and did like a pelvic exam and they said, everything looks good. Theo was like reading normal on like the fetal monitor. There was like, I, I had a, the cervical stitch in. So they said if you were dilating at all, there would be blood. Like, everything looked good. So they had just said like, no concerns at this point. So we said, OK.

So I woke up that next morning and I went to the bathroom. It felt like my vagina was falling out with me. I had called Polly into the bathroom and I said, this is not normal. And so we called the nurse in and she’s like, let’s get you into bed.

And I said, what is this? And it was his umbilical cord that was falling out of me. They say, so like when you’re in, like when you’re waiting and you’re in bedrest, they talk to you and they say, I hope that you never have to experience an emergency C-section, but if you do, it’s like a beautiful symphony. It’s like everybody comes in and they all have their roles and it’s just like a flawless, beautiful symphony.

And there’s really no other way to describe it. Like, they pulled the cord, people came in, they took my clothes off, they put me in a gown. So they wheeled me out and I had a nurse and I just grabbed her hand and I said, I said, is he going to live? Is he going to be OK? And she said, she’s like, we’re going to get him out of there. You have to stay calm right now and like, not give yourself anxiety with everything else that’s happening.

And it was really urgent to get him out of me because with his umbilical cord falling through, that’s cutting off oxygen to him. So we go into the emergency room and they put me on the bed and one person’s at my head and she’s saying, do you give consent to be put out? And I said, yes, just save my baby. And there’s a person like down below, like down below, and she’s just like sticking a catheter. And the surgeon comes in and they have to time the procedure perfectly because they’re putting me under general. Like they’re knocking me out completely. Normally with a C-section, they can give you like a, like a, an epidural kind of paralytic. And they couldn’t. They needed to just put me out completely. There was no time. And so they’re like scrubbing my stomach up and the person by my head is saying, are you ready for her to be put out?

And the surgeon’s saying, nope, not quite ready yet. Not quite ready yet. And then I have somebody holding my hand and I, and they’re looking for the heartbeat. And I said, is, is there a heartbeat? Is he alive? And they couldn’t find one. And so they’re getting ready to like put this mask on my face. And I said, stop. Is there a heartbeat? And they said, yes, yes, we have a heartbeat. I said, OK, put me under. And so then they said, are you ready to be put under yet? And the surgeon said, almost. We’re, we’re almost ready. And so then she said, OK, we’re ready. And so then just like that, I was out.

Polly Gill:

Everybody left and I was by myself, dropped to my knees, praying to God. I had a rush of peace over my heart. And then from that moment I knew that everything was going to be okay. And then I went and saw him for the first time and it was the most beautiful thing I’ve ever seen. And he was kicking and he was sassy. And we actually got to have a delayed cord clamping because he was such a fighter. And ever since then he’s been a fighter and just kicking butt in the NICU and dodged so many bullets. And God’s just held us in our hands.

Alan Helgeson:

Baby Theo is born one pound eight ounces. Now begins a new chapter in their story, a 120-day stay in the neonatal intensive care unit at Sanford USD Medical Center in Sioux Falls.

Nikki Gill:

He was going to have to go to the NICU regardless, like if he would’ve been inside of me and stayed until 34 weeks. We knew that that was going to happen. We just didn’t know how sick he was going to be when he was in the NICU. His first week they say that like, the baby is going off of the hormones that I had provided for him when he was inside of me and it’s like a honeymoon stage. So the first week he was great. And then after my hormones like kind of leave his body and it’s up to his little body to be like, whoa, what? Like I got to do this on my own. That’s when reality sets in. And so it’s like, you, you feel like just this sense of like desperation and, and like panic because it’s like, is this, is this like all that you can do?

And I don’t think I’ve ever prayed more in my entire life just like out of just pure desperation of like just I’ll do anything. Just, just like save my baby. You know? So I think that was like really hard is just feeling like hopeless and just feeling like you don’t know what’s going to happen and they can’t promise you that he’s going to live. Right?

Like I kept asking the nurses, I would be like, he’s going to live, right? And they would say, they would say like, we’ve got really good doctors. And they would say like, we’ve got a really good team. And they would say like, he’s just doing what preemie, preemie babies do, but nobody could ever tell me like, yes, he’s going to live. Because you can’t promise that to families and you just so desperately want somebody to just say he’s going to make it. He’s going to be OK, but you, you can’t. So you just have to like, hold onto your faith that everything is going to make it.

Polly Gill:

And just seeing your little guy hooked up to that many things is just the hardest thing to look at.

Nikki Gill:

Those nurses deserve like all of the good in the world. They are not only medically taking care of your child, but then they’re like counselors to you.

Polly Gill:

And they become like your family.

Alan Helgeson:

Four months in the NICU. Can you speak to what this was like for you and Polly?

Nikki Gill:

They say the hardest part about being in there is the beginning and then right at the end because at the end it’s like, he looks like a baby. He’s doing so good, but like you can’t go home yet. And then he’s like big enough where he just wants to be held and he just like, when he’s really little, he’s just on a machine and he’s, he’s sedated. Like when he is big enough, he is crying out and you, you want to see him and you want to love him and you want to hold him. You can’t take him home and you’re at work, right? Like you’re, you can’t just be in the NICU 24/7. So that was also a really challenging part is you still have to live NICU life with that.

Polly Gill:

That was really hard too because we’re at home with him and he, he’s just the best boy and he’s so happy and he is laughing and we finally get him to see he’s actually acting like a baby, which we were waiting for for so long and we just love him so incredibly much.

Nikki Gill:

I would do all of that over a million times if this was like the result of it.

Alan Helgeson:

In your journey, you guys have learned so much. So with your experiences, are there things you could share that might be helpful to others from your time in the NICU?

Polly Gill:

And so I think like finding your community is helpful.

Nikki Gill:

Like our NICU neighbor.

Polly Gill:

Our NICU neighbor. OK. Yes.

Anyways, and then talking to her, she, her kid, her child right next to us has gone through the same thing Theo has been. And so that was really helpful talking to her. And I think just like it’s helpful to find your community and also like, things might be really, really dark at the time and really, really tough, but like, things are going to get better.

It’s going to get better. It just takes time. And you might be in the darkest place of your life, but Sanford’s there to help you. The nurses are, the doctors are, your family is, but it does get better.

Alan Helgeson:

Dr. Hansen, you and your team have had such an important role in helping Nikki and Polly start a family. Why is it important that Sanford Health provides these services, your services and those that your peers provide for LGBTQ+ families seeking care?

Dr. Keith Hansen:

For any couple that wants to have a baby and wants to expand their family? The services at Sanford are here to supply care to patients from all walks of life to meet their dreams, to expand their family, and to stay up all night. (Laugh) I’m just kidding.

Alan Helgeson:

So what does it feel like for you knowing you are helping people become parents?

Dr. Keith Hansen:

It’s incredibly satisfying and rewarding to have a couple bring in their little one. I originally was in the Navy back when I first started, and I learned that one of the first kiddos that I helped her mom get pregnant with, his father was a Navy SEAL. The only thing he wanted to go into was the Navy SEALs. And I, I learned that he actually made it. He’s now been in, I think he’s probably getting ready to retire from it. But he was a Navy SEAL for quite a while, which is kind of cool, you know, to be able to talk to him. And some of the kids are playing baseball and it’s just really fun to see what they do with their lives.

Alan Helgeson:

Dr. Rodel, what’s it like for you?

Dr. Rachel Rodel:

You know, it’s a great feeling to see the successful outcomes such as with sweet baby Theo, given with what we do and sometimes the very unfortunate circumstances that we see, we really know that not all cases have such a happy ending and it’s, it really is a privilege to support families both in their grief and in their celebrations.

And of course it’s an incredible joy when patients can graduate from our care, don’t need us anymore. And, you know, sometimes bring us their sweet baby or babies to show off because some days can be really tricky and this is always a challenging time in people’s lives to support pregnancies. So it’s quite an honor to help families through the process.

Alan Helgeson:

And for their part, Polly and Nikki are grateful for the medical team who helped them along the way as they begin their new chapter in their life together.

Polly Gill:

They are the story. They are our beginning, our middle, and our end, and our family at the end of the day, even when we’re home. So they are our complete story and they saved his life and they helped us have a baby and our family. It’s just been a, been an awesome journey with Sanford and of course couldn’t get through this without God too. So a lot of praying and a lot of good team is what made it made this happen possible.

Alan Helgeson:

Ok, so what’s the best part of this whole experience?

Polly Gill:

Theo. That’s just it. He is like, he’s just our whole world.

Nikki Gill:

Watching her be a mom is a very close second.

Polly Gill:

You’re making me cry. (Laugh)

Get more episodes in this series

PCOS can affect your fertility and more

Courtney Collen (Host):

Hello and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Women’s. I’m your host, Courtney Collen, with Sanford Health News. We want to start new conversations about age-old topics from fertility to managing stress, healthy living, and so much more.

“Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

On this episode, we are talking about polycystic ovary syndrome, or more commonly referred to as PCOS. And joining me for this conversation is Dr. Keith Hansen, who is a specialist in fertility and reproductive medicine at the Sanford Fertility and Reproductive Medicine Clinic in Sioux Falls. Dr. Hansen, welcome. Thanks for joining me.

Dr. Keith Hansen:

Thank you, Courtney. I appreciate it.

Courtney Collen (Host):

Well, let’s dive right in. Polycystic ovary syndrome: What is it? Tell me about some of the warning signs symptoms, how it’s diagnosed.

Dr. Keith Hansen:

Well, polycystic ovary syndrome is the most common metabolic endocrine abnormality in women. And it does have a number of different presenting symptoms that can occur. One of them is it can cause infertility because a lot of these gals are either only ovulating once in a while or not ovulating at all. And of course, if you don’t make an egg, then you can’t get pregnant.

Other symptoms that they can have include irregular periods or no periods, primarily because they’re not ovulating or only ovulating once in a while. They can also have very heavy periods because the endometrial lining gets so thick that it can cause heavy bleeding. Then if it goes on long enough, they can even get what’s called the endometrial hyperplasia in the lining of the uterus and that can even develop into endometrial cancer. So we have to be aware of this and treat these patients early so that hopefully that doesn’t present.

They can also come in with symptoms like what we call hirsutism, which is where they have excess hair growth on their face, like a mustache and beard, hair on their chest, hair on their abdomen. And if it gets really severe, they can even have what’s called virializing symptoms, which is like balding in a male pattern and other type, increased muscle mass, lowering of their voice and those kind of things. But that usually is in the more severe cases of polycystic ovary syndrome.

These patients are also at higher risk of other metabolic abnormalities. One thing is diabetes is also very common in these individuals. Increased weight and obesity can be an issue. And also they can have problems like sleep apnea and a number of other later-in-life conditions like heart disease and other cardiovascular abnormalities because of things like lipid abnormalities and glucose intolerance.

So it’s a wide spectrum of abnormalities that these patients can present with and it also depends on what stage of their life is as to what their primary symptom will be.

Courtney Collen (Host):

Let’s talk about how it’s diagnosed. How would you diagnose a woman with PCOS?

Dr. Keith Hansen:

That’s a great question. Polycystic ovary syndrome, PCOS, is diagnosed by a number of different factors. And the way we diagnose the disease has evolved over time. The most, some of the more recent studies are put forward, or the most recent diagnostic criteria are put forth by the Rotterdam criteria, or they had a consensus and came up with criteria. There are other ones, but these are basically that the patient has to have two out of three things and no what are called the endocrine mimics or diseases that can mimic polycystic ovary syndrome.

The two out of the three things is she has to have either irregular or no periods, because of the fact that she’s not ovulating a lot or she’s not ovulating at all; she has to have some evidence of elevated androgens, be that increased blood tests that show elevated testosterone or other androgens, or clinical evidence like a mustache and beard and chest hair and more male pattern increased hair growth; or polycystic appearing ovaries on ultrasound. But she only has to have two out of the three of those things. OK.

And then we have to rule out other endocrine diseases that can mimic that, such as late-onset congenital adrenal hyperplasia, where the adrenal gland is abnormal and it mimics polycystic ovary syndrome, but the treatment for it is totally different. We’ve got to rule out other conditions like hyperprolactinemia thyroid dysfunction and other endocrine and other endocrine type of diseases that can mimic polycystic ovary syndrome.

Courtney Collen (Host):

Are certain women at a higher risk for PCOS?

Dr. Keith Hansen:

Yeah, there are women that are at higher risk. And first, just so you’re aware, there are really two major categories of polycystic ovaries. There’s the obese polycystic ovary syndrome and then there’s the thin polycystic ovary syndrome. So just because a woman is thin doesn’t mean she can’t have polycystic ovary syndrome. And yeah, there are in a family, when there’s a family history of things like diabetes, women where their mothers and their grandmothers had polycystic ovary syndrome it’s thought that the male equivalent may be diabetes and male pattern balding may be a sign of the male kind of polycystic ovary syndrome.

Other things that are known to do it are if a girl has early onset of puberty, that can be a sign that she may later develop polycystic ovary syndrome and such.

Courtney Collen (Host):

As a specialist in fertility and reproductive medicine, let’s talk about pregnancy and PCOS. How does this diagnosis affect a woman’s fertility?

Dr. Keith Hansen:

It definitely can affect her fertility because, you know, before she’ll be able to get pregnant, she has to make an egg. Women who have polycystic ovary syndrome usually will not ovulate or will have a decreased frequency of ovulation, meaning that they have less chances of getting pregnant. So what we try to do in reproductive endocrinology is try to improve their ability to ovulate so that hopefully they’ll ovulate more and be able to get pregnant.

And there are a number of ways we can do that. One of the ways is to try to help through diet and exercise. If the person is overweight, sometimes by losing weight, even 3 to 5% of their body mass, they can actually improve their ability to ovulate, or they may even start ovulating on their own. So that can be very helpful.

One of the other big areas are drugs to try to help them ovulate. Like letrozole, which is an aromatase inhibitor. It basically decreases the amount of estrogen that’s made, or clomiphene citrate, which is what’s called a selective estrogen receptor modulator, which kind of tricks the body into thinking estrogen levels are lower so then they make more hormones to stimulate ovulation. The letrozole is the one that has really been – recently there was a large study showing that it works better than clomiphene citrate in women with polycystic ovary syndrome.

So a lot of times we try to treat them with letrozole to try to get them to ovulate and, and then we watch them closely. The biggest risk with letrozole is there’s about a 1 in 10 risk of having a multiple baby, like a twin or even more, ovarian cysts, which can be very uncomfortable, but it means it’s working because the cyst is, means that she’s developing follicles.

Courtney Collen (Host):

And does that go away eventually?

Dr. Keith Hansen:

Oh yeah. They’ll resolve, but they’re kind of there forever, not temporarily.

Courtney Collen (Host):

But it’s working.

Dr. Keith Hansen:

But it’s working, just doesn’t feel very good. And then it can cause things like hot flashes and they sweats and mood swings and some fool is making their hormones go crazy. Yeah, and then, hopefully once we get them ovulating, that can help them to get pregnant usually.

In the old days, we used to always say in women with polycystic ovaries, we’d say, let’s get you ovulating for six months or six cycles, and then if you’re not pregnant, then we’ll do a sperm count.

Well, in women with polycystic ovaries, we can get like 80-to-90% of them to ovulate with letrozole or with other method, other oral medications. But if the group that doesn’t get pregnant, that group, the most common reason for them not to be pregnant is something wrong with a guy. And so now we’ve pretty much changed where we now just say, look, why don’t you get a sperm count right up front to make sure there’s not something wrong with the male side of this too. It saves some time too. You don’t want to have somebody go on medicine for six months and then find out there’s no sperm.

And then if letrozole or CME don’t work, there are a number of other options. Like there’s shots, we can do human menopausal genotropin shots. The problem with those, though, is they have a very high rate of multiple babies. It’s like 30 to 40% of time, and that’s how you can get like quads and septs. And so we try to avoid that one if we can.

There’s also the option of in vitro fertilization. There’s also, sometimes what we’ll do is if we put the patient on birth control pills and just shut her ovary down for a little bit and let everything, all the hormone levels kind of get back down to normal, then stop it, then many times they’ll start ovulating on their own. Or will respond better to the medications. Probably better to say, respond better to their medications. Then if that doesn’t work, there’s a number of other combinations of medications we can do to try to help them.

And then finally, there’s even surgical options. We can go in and do what’s called an ovarian drilling, which basically the ovary, all the eggs are on the outside and the stroma is on the inside. And the stroma is what makes all the hormones the androgens, which then go out to the eggs, which then make estrogen. Well, one of the problems with polycystic ovaries is they make a lot of androgens. And so theca cells inside the ovary are just cranking out the androgens a lot. So if you can somehow lower those levels, like with a birth control pill or with surgery, get rid of some of those theca cells, then the androgens will drop and then the ovaries will be more responsive to therapy.

In fact, the very first studies that were done in polycystic ovaries back in like 1930 or 1940s by Dr. Stein Leventhal at Rush University, they actually had eight women with classical polycystic ovary syndrome. They wanted to study the ovary. So they went in and did a big incision, took a big chunk out of the ovary, and then went and looked at it under the microscope. Well, they sewed the ovary up and sewed the gal up. And lo and behold, all eight of these women who had never had a period for a long time started to have regular periods and every single one of them got pregnant.

And so it became what’s called an ovarian wedge resection, where we go and take out a big chunk of that internal part. But of course, you have to sacrifice some of the eggs, and then a lot of those gals will start to ovulate.

Then Clomid came along probably in the fifties. Yeah, exactly. In the fifties. And it kind of replaced the ovarian wedge resection. But it still can be very helpful in women who don’t respond to medications. And now we don’t do the big wedge resection anymore. We go in and we have a catheter, a little insulated needle, and we put the needle tip into the ovarian stroma and fulgurate the inside or, you know, burn the inside, fulgurate it, and it destroys part of the stroma. So, it’s kind of like taking it out, but not actually having to take it out. And then a lot of those gals will start to either ovulate on their own or will respond a lot better to medications and such. So there are a lot of different options available.

Courtney Collen (Host):

The options that you have and the advancements in medicine, just hearing some of these things – amazing. Incredible. What is it like to be able to provide this type of care to help of course, women or families grow?

Dr. Keith Hansen:

Oh, it’s wonderful. It’s very helpful. It’s very nice to be able to help people achieve what they want. Their dream, a little baby to keep them awake at night.

(Laugh)

Courtney Collen (Host):

Yes. Once a woman is pregnant, but she is living with PCOS, are there any complications or risks to her or baby moving forward?

Dr. Keith Hansen:

One of the big concerns is does she have diabetes or is she at higher risk of developing gestational diabetes later on in pregnancy? And so they want to monitor her very closely for that. So there are some other data showing possibly earlier deliveries in some of the gals with polycystic ovary syndrome. So we do like them to be very monitored very closely by their OB/GYN during pregnancy and watch and make sure that they hopefully don’t get any of those complications.

Courtney Collen (Host):

Yeah, that was my next question, what the care journey looks like. A woman comes in, you help her hopefully achieve pregnancy or at least get to ovulation and go from there. Do they stay with you in the clinic through pregnancy or can they go back to their OB/GYN, continue that care seeing you when needed? Talk about what that looks like.

Dr. Keith Hansen:

Yeah, we usually, once they’re pregnant, we like to send them on to see their regular obstetrician so they can be observed very closely and watch throughout the pregnancy and get through their prenatal care.

Courtney Collen (Host):

Would that be considered high risk if they were, if they came in with PCOS?

Dr. Keith Hansen:

No, it just makes it just sort of like alerts the OB to watch for things like diabetes and other potential issues.

Courtney Collen (Host):

Any other concerns for women who are diagnosed with PCOS or what it might lead to? Any other issues it might cause?

Dr. Keith Hansen:

Well, just a couple things. It’s really hard to diagnose it during adolescence and actually menopause. And the reason is because a lot of the symptoms of polycystic ovary syndrome are similar to the symptoms of puberty and the symptoms of menopause. And so, like irregular periods, they’re common at both ends of the spectrum. Acne is often a sign of androgens. Well, in teenagehood you know, acne is a real common finding. And so it’s really difficult to make the diagnosis at that point.

Now the nice thing about menopause is usually you have that history before of what their periods were like before they started. Puberty is a lot harder. In fact, they suggest that you don’t make the diagnosis of polycystic ovary syndrome until she’s a little bit older. Some people argue maybe even into the 20s before you say that it’s actually polycystic ovary syndrome.

But did you say she’s at risk for developing it later in life? There are some new guidelines coming out that say, you know, we had talked about making the diagnosis based on irregular periods, elevated androgens or hirsutism, elevated androgens and polycystic appear ovaries on ultrasound. They actually now are also saying that if we, there’s a level called AMH or anti-malarial hormone, which is a blood test that reflects how many eggs are in or how many follicles are in the ovary. And when that’s elevated, that’s often a sign of polycystic ovaries. But they’ve now adapted that for inclusion in the criteria where we can now use that as making the diagnosis of PCOS. We don’t have to rely on the ultrasound so much.

In terms of diagnosis, of course, the hard part is what does this do for women after they go through, had their kids, and they’re starting to approach menopause? Well one of the things we worry about is the hirsutism, getting a mustache and beard and hair growth. So, one of the big questions is, can you suppress the ovaries? And the answer is yes.

One of the ways we can suppress the ovary is the birth control pill. Now, of course, you don’t want to give that to somebody if they’re at high risk, but it does work really nicely at keeping those theca cells not producing a lot of androgens. And there are other options, but there are things we want to do to help out with those cosmetic issues because those are not a lot of fun.

The other one is we worry about developing diabetes. In fact, the new recommendation is that women with polycystic ovaries should probably get a glucose tolerance test every two to three years. And not just the hemoglobin A1C or a fasting sugar, but a full blown glucose tolerance because it can diagnose glucose intolerance a lot easier and better. It’s more sensitive for diagnosing that than a fasting sugar or a hemoglobin A1C. Also lipid panels, because they can, once again, insulin resistance increases the risk of lipid abnormalities.

High blood pressure is something we want to keep a watch on and make sure that they keep that under control. We also worry about developing endometrial hyperplasia and cancer. We don’t want them to get endometrial cancer. And so we want to make sure that they’re either ovulating on their own or getting some form of progesterone to prevent the development of endometrial hyperplasia or cancer. And there’s a number of ways we can give progesterone.

The other thing is, we can’t forget about sleep apnea. There are studies showing that women that have polycystic ovary syndrome see a higher risk of sleep abnormalities, specifically sleep apnea. And new recommendations are that if a woman feels like she is tired during the day, unless she has a baby at home, snores, ever woke up gasping for air or had any issues that might suggest sleep apnea, that you get a sleep study. So, yeah. So there are a lot of things that we want to monitor for sure throughout the life cycle.

Courtney Collen (Host):

Is there a connection, Dr. Hansen, between PCOS and insulin resistance?

Dr. Keith Hansen:

Well, there definitely is a connection between polycystic ovary syndrome and insulin resistance. In fact, it’s hard to know though – is it the chicken or the egg? Is it part of the process that results in the polycystic ovary syndrome or is it a result of the polycystic ovary syndrome? But we do know that they’re both interconnected. In fact, we know that that’s probably why they’re at higher risk of developing glucose intolerance and later in life, getting diabetes mellitus.

In fact, a lot of these gals will come in and will have other signs of insulin resistance. Like they’ll have what’s called acanthosis nigricans, which is darkening of their skin around the base of their neck or under their arms or in their inner thighs and then skin tags. Then elevated androgens are a result of the insulin resistance. So they’re kind of all tied together. And that’s why, you know, weight loss through diet and exercise and such can actually improve the way the ovary works is because it improves insulin sensitivity.

Courtney Collen (Host):

What do you recommend to patients as far as lifestyle, diet? You about diabetes being a concern later, potentially cancer. Are there lifestyle or diet changes that you recommend for women who are in your care?

Dr. Keith Hansen:

Well, you know, the healthy lifestyle is a really good idea. I mean, diet and exercise are very helpful for everybody who’s trying to get pregnant. We do like the gals to make sure they’re taking a vitamin with folic acid because that’s been shown to lower the risk of neural tube defects, which is amazing. And then also, a lot of people will go on their supplements, like myo-inositol is thought to be very helpful at improving insulin resistance and improving how people feel that have polycystic ovary syndrome.

Another one that has some data is cinnamon. People say that cinnamon actually can be very beneficial. And then one of the things that’s kind of hard is whether or not to use metformin. You know, it wasn’t that long ago, like maybe 10 years ago, where if you had polycystic ovaries, we automatically started you on metformin because it improves insulin resistance. And so, we got everybody on it, but it does have some side effects, primarily GI you know, like urgency to have diarrheal stools and nausea and vomiting and those kind of things. At one point we were giving pretty much anybody with PCOS, we’d give them metformin, then it kind of went back to say, well just give it to them if the person has diabetes or glucose intolerance. And that makes sense too.

And then if it also, now it’s kind of swinging back a little more that it might be beneficial for women to help them ovulate because there are some women with polycystic ovaries that if you give them metformin, they’ll actually start ovulating better and they can get pregnant because it improves their insulin resistance and improves their hormonal profile. It’s not as good as Clomid, not as good as Letrozole, but it does have a lower risk of multiple babies.

Courtney Collen (Host):

Does PCOS ever go away?

Dr. Keith Hansen:

Well, that’s a fascinating question, and the answer is no. The PCOS though, you know, is kind of one of those diseases as a woman ages, her ovaries may start actually ovulating on their own. So what’ll happen is she won’t ovulate when she’s in her 20s and maybe 30, 35, and then all of a sudden she’ll start having regular periods and be able to get pregnant because she’s finally ovulating. So as the ovaries start to kind of tune down, they’ll start to work a little better. So that’s one thing that does change.

But one of the hard parts is, you know, even if you go in and like, let’s say if a gal said, I’m tired of this PCOS, I’m going to have my ovaries taken out. She still has all the other problems, though. She still has the insulin resistance, she still has a higher rate of glucose intolerance, lipid abnormalities, high blood pressure and risks going forward. Then on top of it, she has the risk of having her ovaries taken out at a young age, which increases the risk of cardiovascular events. And we really don’t like to take the ovaries out of somebody until they’re, you know, in their 60s because of the risks that are associated with that.

And so, most people do not argue to take the ovaries out in somebody with polycystic ovaries syndrome. So it’s kind of one of those conditions where it’s more of a total body metabolic endocrine imbalance. So you can’t remove it and it doesn’t seem to get totally better over time. Wish it did.

Courtney Collen (Host):

Let’s say, Dr. Hansen, a woman is listening or a loved one of a woman who might be showing symptoms or have concerns that a lot of this sounds very familiar, at least some of those early warning signs we talked about. What might she do? How does that care journey begin and who does she talk to? Who does she reach out to?

Dr. Keith Hansen:

That’s a great question. I think one of the first persons they could talk to is their family medicine physician or their OB/GYN, whoever they’re seeing. And then, they evaluate them and start the journey. And then if they have any issues, of course they can always send them on to us. Or when they’re, you know, want to get pregnant and they want it to us to help them, we can do that. But that’s probably the first person to talk to.

Courtney Collen (Host):

Good start. How can we support a friend or loved one who might be diagnosed with PCOS? And specifically because we are at the fertility and reproductive medicine clinic, you know, if they’re trying to get pregnant we want to be able to support our friends or loved ones who are on that journey, that fertility journey. What would you recommend that we do? Or what can we do for them to show our support?

Dr. Keith Hansen:

Being supportive of the individual and helping them realizing that they have this endocrine condition and have to go through a lot of different types of therapies possibly, I think that can all be very helpful. You know, lending an ear so that they can chat with you and discuss their options and stuff if they want. The biggest thing is polycystic ovary syndrome is a very common endocrine metabolic abnormality, affecting a large number of women. And it can have some very devastating effects upon their reproductive and endocrine and their metabolic condition.

However, there are a lot of things they can do to help keep it under control, both when they’re trying to get pregnant and when they’re not trying to get pregnant. I think one really important issue that I forgot to mention earlier, when a person with PCOS is not trying to get pregnant, they still need to be treated. They should not, you know, say, oh, well I’ll ignore it. All I want to do is get pregnant. And then I don’t mind not have their baby and then say, “oh, I don’t mind having a period once every year.”

Because then if they don’t, they could go on to develop endometrial hyperplasia cancer. Some of these gals can have terribly heavy periods to the point where we have to give them blood transfusions and do emergency surgeries. They want to be treated. Sure. And some of the treatments that are good for, while you’re like, let’s say you’ve had your baby and you want to wait a year or two, which is a good idea to let your body build back up, you know, then the birth control pills are very good. They’ll keep everything kind of suppressed for us, and probably make it easier to get the woman to ovulate afterwards and prevent endometrial hyperplasia, cancer, and then there’s other progesterone agents that can also prevent the endometrial hyperplasia, but they don’t suppress the ovaries as well as the birth control pills do. Don’t ignore it, diet and exercise.

Courtney Collen (Host):

Dr. Keith Hansen, thank you so much for your time and all of your insight and expertise on polycystic ovary syndrome and all that you do here at the Sanford Fertility and Reproductive Medicine Clinic. Thank you.

Dr. Keith Hansen:

Thank you, Courtney.

Learn more about this topic

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Get more episodes in this series

Sanford fertility expert helps same-sex couples

Courtney Collen (host):

Hi there. Welcome to our “Health and Wellness” podcast by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Well, this series starts new conversations and continues the important ones, all designed to keep you well, physically and mentally, featuring our Sanford Health experts. We’re so glad you’re here. In this episode, we’re talking about the fertility journey for same-sex couples. And to do that, we have board certified reproductive endocrinologist, Dr. Keith Hansen at the Sanford Fertility and Reproductive Medicine Clinic in Sioux falls, South Dakota. Dr. Hansen, welcome. Thank you for being here.

Dr. Keith Hansen:

Well, thank you, Courtney. Appreciate it.

Courtney Collen (host):

Sanford Health provides some pretty high quality, compassionate fertility reproductive medicine care that is appropriate for all patients who come in right with various needs and concerns, no matter their sex or sexual orientation.

Dr. Keith Hansen:

That’s very right. We take care of, you know, any couples that are having difficulties conceiving or carrying a pregnancy. We’re happy to evaluate them and help them on our journey to hopefully to have a baby.

Courtney Collen (host):

Are you seeing same-sex couples in this clinic who are looking to grow their family?

Dr. Keith Hansen:

Yes. We see really any couples that want to have a baby or are trying to increase the number of babies they have, you know, whether they’re same sex, opposite sexes, you know, we will see those and help them to hopefully conceive and have a baby.

Courtney Collen (host):

For two men or two women that journey to parenthood looks a little different because they’re missing at least one essential piece to that puzzle. So Dr. Hansen, let’s talk through some of the hurdles that they might face.

Dr. Keith Hansen:

Basically they have the same hurdles as anyone else with a similar type of issues, but they do have some unique hurdles also, in terms of trying to help a couple who are trying to have a baby, no matter who or what their sex or sexual identity is, there are a number of factors that we try to help them with. You know, first of all, we always evaluate a couple to try to determine, you know, to make sure that there’s no underlying disease that could complicate a pregnancy or complicate an issue for a little baby and try to fix that before they get pregnant. So one of the issues we always do is we like to make sure that the couple, that the person who’s gonna be carrying the pregnancy, is taking a vitamin with folic acid, because that’s been trying to reduce the risk of neural tube defects by 70 to 90%. We also like to make sure that their thyroid is functioning normal. And then we check labs that may have an impact upon pregnancy, which could be very important and lowering the risk of the pregnancy and hopefully helping them to conceive and carry a natural pregnancy to term. We also like to do an in depth, you know, history, looking at their past medical history, surgical history, looking at their family history to determine are they risk of any sort of genetic illnesses that might be passed on to the infant?

Courtney Collen (host):

How can Sanford Health help same-sex couples conceive? I know the patient journey obviously looks different from males to females. So let’s start with females.

Dr. Keith Hansen:

In same-sex, female couples where there’s no male, well, they have to use a donor sperm, you know, or the possibility of donor embryos, but usually it’s a factor of donor sperm where what happens is you have to go to an to a cryo bank, which there’s multiple cryo banks throughout the country they look on. And in the old days we used to have piles and piles of books that people had to go through and this was for any couple with severe male factor infertility. And what we would do is they would go through the books, find a donor that met the criteria that they wanted, select the donor, and they’d ship the sperm here. Now it’s all online. So they can actually go online, look up the donor that they would like to pick, select, and then pick that donor and have the cryo preserved sperm sent here where we can keep it cryo preserved and then when ready to be used, we can do intrauterine insemination, hopefully that’s how they could conceive.

It’s important, I think, to realize that males who give, you know, that cryo preserved sperm is very carefully evaluated before releasing it for use. First of all, the males that donate it, undergo a thorough history and physical examination, including family history. And a lot of them have screening to make sure that they don’t have any underlying genetic illness such as that they’re not carriers of a disease like cystic fibrosis or spinal muscular atrophy, or one of these other devastating genetic illnesses.

When the couple goes online, they can actually find that information out about that individual and then decide to, you know, like if the only donor they can find is a male who carries cystic fibrosis, then we can go back and make sure that we screen the person who’s given the eggs, the wife, or we can screen her to determine are her, you know, does she carry that same genetic mutation or not? And if she does, then they, we have to sit down and talk about that and their options that are available, including at that point in vitro fertilization, with biopsying the embryo and making sure it’s normal before we put it back.

So in same-sex, female couples, once they picked out the donor, they ship it up here. The easiest way for them to get pregnant is to do in insemination. And so what we do is if the woman has regular periods, what she’ll do is ovulation predictor kits. When it turns positive, she’ll give us a call. And like, if it was positive today, which is Friday, we’d have her come in tomorrow on Saturday, thaw out one vial of sperm and inject it up inside the uterus. And then we’d have her come back on Sunday and do the exact same thing. In San Francisco, they did this large study where they compared single insemination versus dual inseminations and they had a higher pregnancy rate with dual insemination when you’re using frozen sperm. So we really like to do that.

If that doesn’t work, you know, like if let’s say they’re not pregnant after three to four cycles, then at that point, we usually start to look at things like, are her fallopian tubes open? We’ll do a hysterosalpingogram to make sure the tubes are open. How do her ovaries look? Is there any evidence of like premature menopause or anything like that? So usually for couples who have severe male factor or same-sex female couples, usually we try to help them to conceive with, intrauterine insemination to give them the best chance of having a successful pregnancy.

If that doesn’t work, then we can do further testing and we can move on to other therapies. One of the things we do offer, you know, like, we’ll talk with them about if there’s a factor, like let’s say if one of the gals that’s planning to carry the pregnancy, if she’s had a history of like a ruptured appendix, then we’ll do an HSG before they do the IUI to make sure that the tubes are open before we pursue that. Or if we have a couple that say, look before we invest any money in donors sperm, we wanna make sure those tubes are open and the ovaries are working good. Then we’ll test those before they proceed. But a lot of people like to try before they do any further testing and that’s fine.

Courtney Collen (host):

Now what about male couples?

Dr. Keith Hansen:

Their journey is a little bit more difficult mainly because we have to get an egg. And then we also have to have someone carry the pregnancy. So there’s really two factors involved there.

In the past, the only way we could get eggs would be to have a woman, you know, undergo the same like ovulation test to see if she was ovulating and then do intrauterine insemination with one of, with a person’s sperm that was gonna father the pregnancy. And that was what’s called traditional surrogacy where you would just take, and then she would get pregnant and carry the baby to term.

Nowadays, with in vitro fertilization, most people have turned to donor eggs and a gestational carrier, and they don’t have to be the same person. For donor eggs, in the past, the way we would do it is we would have, the couple would find a donor who’s willing to go through the stimulation. We’d stimulate ovaries, take the eggs out, fertilize it with the sperm, and then put the embryo up inside her uterus or a different, or a gestational carrier’s uterus. It doesn’t have to be the same person.

Nowadays though, they actually have donor banks for eggs, just like they do for sperm. And actually a couple can go online, look up the donor, you know, find a donor that’s consistent with what they want, they pay for it. And of course they ship the eggs up to us. We thaw out the eggs and then we can fertilize them. Or the other option is we can take the sperm and ship it down to them and then they can fertilize it and ship the embryos up here. And there’s different reasons for doing it both ways.

And then once we have the embryo, we can place it into a gestational carrier which is, you know, is a little more complicated mainly because the person has to go through so much when they, you know, we have to see the gestational carrier, do a history, physical examination, testing based on what’s going on. And then we have to, you know, prepare her uterus and put the embryo back up inside her uterus.

There is, you know, testing that’s required also, you know, for both people who use donor sperm and people who use donor eggs. And it’s the same. I mean, they have to go through, you know, a battery of tests to make sure that there’s no potential infectious diseases that could be spread. We usually require the American Society of Reproductive Medicine has come out with guidelines, like for gestational cures, they have to go through extensive screening with psychological consultation. You always want to check with your insurance company and make sure they cover pregnancies that conceive from that method.

Courtney Collen (host):

Are there any additional support services that the clinic offers alongside the fertility treatment? Be it, you know, emotional support, financial support to … kind of talk through some of that.

Dr. Keith Hansen:

That’s a great question. We do. We offer pretty much the same services to all of our couples. I mean, we do suggest, you know, a counselor. They can be very beneficial and help with some of the stressful situations because a lot of time it’s kind of like being on a roller coaster, you know. First of all, the hormones go up you know, and then they come crashing down and that can be kind of like a roller coaster of emotions. On top of those of the hormones, acupuncture has been trying to improve blood flow of the uterus. And I don’t know why, but a lot of gals tell me it’s very, very relaxing, even though, you know, they’re sticking needles in you. So I don’t know how that’d be relaxing, but they swear to God it is. And then it also, one of the kind of sad things is a lot of times insurance does not cover infertility. And so, you know, it is a lot of it is up front, which is, you know, I wish we could get more support for it and stuff, because we’re just trying to help them have a baby.

Courtney Collen (host):

If a patient or a couple listening, doesn’t live near a Sanford Health fertility clinic like this one with our reproductive endocrinologists, where do you suggest they begin? If they’re looking to grow their family?

Dr. Keith Hansen:

Well, that does make it difficult, especially in you know, a rural area where people can be a long distance away from a clinic that actually offers these services. And so a lot of times, you know, nowadays with telemedicine, we can actually connect with people over a long distance. We can do a lot of the discussion and work out a lot of the details and then really have minimized the number of times they have to travel to like Sioux Falls or to Fargo. Yeah. Or one of the other facilities where they do this and then have them come in and do the actual procedures here because we really don’t have the option of doing it in other places, but we can reduce the number of times they have to travel nowadays and try to minimize it and maximize their chances of getting pregnant.

Courtney Collen (host):

That’s always a win.

Dr. Keith Hansen:

It is.

Courtney Collen (host):

If couples listening are shopping around for fertility clinics, what would you want them to know about the care experience that they can expect here at Sanford?

Dr. Keith Hansen:

One of the nice things about Sanford is we do offer our care to really, to any couple that wants to expand their family or have their first baby. And we try really hard to offer compassionate care to these couples to hopefully achieve their dream, which is to not sleep well for at least two years.

Courtney Collen (host):

<Laugh> More than that.

Dr. Keith Hansen:

Yeah. It’s actually, I’d say 18 years, but it even goes beyond that, believe it or not. Well, we are here to help couples to conceive and achieve their dream. And we have, you know, a really dedicated staff from the front office all the way, you know, through to our nursing staff, the doctors, everybody is dedicated to trying to help couples achieve their dreams of having a successful, healthy baby and a healthy mom.

Courtney Collen (host):

Or dad.

Dr. Keith Hansen:

Or dads. Yeah. Moms or dads at the conclusion of their visits and, help them achieve that. The other thing is, is both Dr. Von Wald and I are board certified in reproductive endocrinology and continue to maintain certification. We try to stay up on all the newest and latest technology to try to achieve the best outcomes for our patients.

It’s a long, complicated journey, but you know, it’s a very – for us, it’s a very rewarding experience. And for the couples, it helps, you know, to really, to achieve their dreams of having a lot, you know, having more children and increase or having their first child. And it’s very rewarding in terms of that. And we try very hard to be compassionate and try to help them to achieve that dream you know, as fast as we can, of course it takes a while, but we try, you know, we’re very open to all those couples and try to help them through this many times complex and highly technological process that in the past was not highly technological at all and you know, sometimes there can be little bumps in the road or sometimes big mountains in the road, but we can hopefully help them to get around those, those mountains and achieve their dream.

Courtney Collen (host):

Yeah. Well, appreciate all that you do to help in that process to be a part of couple’s journey from the beginning, guiding them through the process and then ultimately helping them hopefully welcome a new baby. What is that like for you?

Dr. Keith Hansen:

Oh, it’s, it’s really rewarding to be able to help couples to achieve their ultimate dream of having a baby. And just so they don’t bring ’em back. There’s, there’s no returns, you know, especially if you have more than one, <laugh> no return, especially when they get to be teenagers.

Courtney Collen (host):

No returns. For sure.

Dr. Keith Hansen:

Yeah. None. <laugh>

Courtney Collen (host):

Well, Dr. Hanson, thank you so much for your expertise. When we talk about couples going through fertility treatments and hopefully having a baby appreciate all of your time and thank you for all that you do.

Dr. Keith Hansen:

Oh, you’re welcome. Thank you so much, Courtney. It’s great to chat with you and hopefully we can help more couples out there to achieve their dream.

Courtney Collen (host):

This was another episode of the “Health and Wellness” podcast by Sanford Health. I’m Courtney Collen. Thanks for being here. We’ll see you soon.

Learn more about this topic

• LGBTQ+ patients can find high-quality care at Sanford Health
• When to refer to fertility, reproductive specialists
• What’s it like to go through fertility treatments?

Get more episodes in this series

When to refer to fertility, reproductive specialists

The following data in this episode was accurate as of April 16, 2021 upon the recording and publishing of this podcast. Edited to note 1 in 6 couples struggle with infertility. 

Courtney Collen (Host): Hi there. Welcome to our medical series Called to Care by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. Called to Care brings forward medical experts who can give fellow clinicians some advice and guidance that they can use in their primary care practice and more information about when it’s time to refer patients and families to more specialized care. Joining me for these conversations is Dr. Joseph Segeleon, who is vice president and medical officer for Sanford Children’s Hospital and a leader in pediatric critical care. He’s here to help us dive even deeper into these topics to provide the best insight and care for our patients and communities. Welcome, Dr. Segeleon, good to have you here.

Dr. Joseph Segeleon: Courtney, it’s great to be here. Wonderful to see you again.

Host: We are talking about infertility and raising awareness about the challenges a lot of couples face when trying to start – or grow – their family. More specifically, talking about referring to a fertility specialist and the patient’s journey from there.

Dr. Keith Hansen specializes in reproductive endocrinology at the Sanford Health Fertility and Reproductive Medicine Clinic in Sioux Falls, South Dakota, and we’re happy to have you, Dr. Hansen. Welcome.

Dr. Keith Hansen: Thank you. And thanks for having me, Courtney, it’s a pleasure.

Dr. Joseph Segeleon: Hi, Dr. Hansen. It’s good to see you again, a wonderful having you here and I know our providers are quite excited to hear about the information that you have to offer.

Dr. Keith Hansen: And it’s nice to see you again, Dr. Segeleon.

Dr. Joseph Segeleon: Just to start off, reproductive endocrinology, give us a little idea of your background and the training that goes into becoming a reproductive endocrinologist.

Dr. Keith Hansen: Sure. Basically, the training to be an a reproductive endocrinologist, usually you do an obstetrics and gynecology residency and then we do a three years of fellowship training at one of the fellowships throughout the country. There’s another way you can also approach it through internal medicine and then do another three years of fellowship and reproductive endocrinology but most people go through it the OB/GYN route.

Host: According to the national infertility association, infertility is increasing. And right now one in eight couples are having trouble achieving pregnancy, whether it’s their first, third or fourth child, is there any rhyme or reason why so many couples are facing these challenges?

Dr. Keith Hansen: You’re exactly right. That there is a large percentage of couples who have difficulty either getting pregnant the first time or after that. There’s a lot of theories on why it may be why we may be seeing more couples with infertility over time. Is it just the more it’s becoming more aware and people are seeking care for it? That’s one possibility. Is it the fact that women are delaying childbirth so they can get into their professional lives and continue to practice, you know, to get their practices or their other jobs more well-situated and get started in that area before they try to get pregnant? Is there changes in male fertility that’s occurring? I mean, there’s a lot of studies going on looking at, you know, is there a lowering of the total sperm count over time and males and other potential factors that may be impacting a couple’s ability to conceive?

Dr. Joseph Segeleon: Just to level set, for the pediatrician in the room, we define you would define infertility as…?

Dr. Keith Hansen: That’s a great question. Infertility is for a woman under the age of 35, we define it as the inability to conceive for at least one year of trying of, you know, unprotected intercourse. However, the definition changes when the woman is over the age of 35. Then we like to, if they have not conceived after six months of trying to conceive, then we want to see them for evaluating fertility, mainly because of the effects that age have on ovarian function. We also want to see couples, like if there’s some history that suggests that they might have trouble getting pregnant, like if a young woman stops her birth control pills and has no menstrual cycles. Because of that, we know that she’s not ovulating, we want to get her in as soon as possible so we can figure out why she’s not ovulating and get her on medications to help her ovulate so she can get pregnant. If there’s a history, like if the male has had a history of chemotherapy for cancer, we want to get him in so we can evaluate the sperm count and make sure that there’s adequate levels of sperm so that they can get pregnant or if there’s some other history that might suggest an infertility problem, we want to see them earlier rather than later.

Dr. Joseph Segeleon: Great. Thank you. And so I’m thinking that most patients come to you after some time in their primary care provider and they’ve discussed this issue or they’ve brought it up. For our primary care providers who are listening, are there groups of patients to refer to you? Is there anything as a primary care provider that I should do, with regards to a workup, treatment, or counseling prior to referring to a reproductive endocrinologist?

Dr. Keith Hansen: It is nice when the primary care provider, you know, really sits down with a couple and evaluates them in terms of a history and physical examination, especially looking for diseases that might impact pregnancy or their ability to get pregnant, as well as a family history, trying to determine are they at high risk for any sort of genetic illness that could be passed on to the baby. If that’s the case, then we need to know about that. I think from a primary care provider, one of the things, you know, we really kind of divide infertility into three major groups: One is the male so it’s important to know, you know, what is his history? Has he had any history of pubertal abnormalities? Has he ever been on steroid hormones? Steroids can suppress the testicle… especially testosterone therapy is bad for sperm counts. Has he ever had any other history that would suggest a problem with sperm, including using tobacco? Tobacco is very bad for sperm, both smoking and chewing tobacco is really bad. So, we really like those guys to get off of the tobacco products. And then one thing they could do is get a semen analysis and let us figure out, does the guy have a normal sperm count? Does he have a good motility? What does the sperm morphology look like? So that, you know, can be sort of a basic understanding of the guy. The other area is looking at the woman and the best indicator we have of how good or ovary is working is her history of her menstrual cycles. Hopefully she’s had a normal age of onset of her menstrual cycles of menarche and then, if she’s having regular periods every 28-30 days, she can tell when they’re coming. She tells when she ovulates those gals, you know, are pretty sure that they’re ovulating. And so it’s good to know that there are, you know, that that’s going on, that they’re having regular ovulatory cycles. The other thing that we like to evaluate, especially if the woman is over 35, is how good is her ovarian function and the way we do that is with what’s called an anti-malarial hormone, also known as AMH. And if that is suppressed, then that’s a sign that her ovaries are starting to go through dysfunction. Like in the most common one is menopause. Menopause causes a very low AMH level, undetectable. So we’re worrying that they’re starting to do that. The other thing we like to do is get a FSH, LH and estradiol level when they’re on day two, three or four of their menstrual cycle. And then also at the same time, get an ultrasound while they’re on the second, third or fourth day of their cycle and get a good look at the uterus and look at their ovaries and count all the little follicles in there. Those three tests: the antral follicle count the FSH LHS estradiol on day three and the anti-Malarian hormone. Give us a really, really good idea about how good the ovaries are working.

Dr. Joseph Segeleon: Are those tests that you would do, or the tests that a primary care provider might do?

Dr. Keith Hansen: Either one. We get some primary care providers who do them, you know, all the time. We have some that automatically get those. We have others just refer the patients here and we’re happy with either way. The other test that’s nice is a hysterosalpingogram or HSG, for short. That’s where we go to x-ray put a catheter, the uterus inject contrast, and we get to see as the inside of the uterus normal and are both fallopian tubes open or not. Once again, that’s a test that a lot of times the primary care doctors will send to us and we’ll do the test. We do have some that are comfortable doing it. And that is wonderful if they’re willing to do it. Then if they do do it, it’s nice if they could, when they refer the patient to us, if they could just send us the films, because it’s nice to look at them. But a lot like to send us and we were happy to see the patients and get them started.

Dr. Joseph Segeleon: Great. Thank you. When I do these podcasts, my goal is always to learn something and I had no idea that tobacco had an effect on sperm count. So that’s my fact that I gained today. So thank you for that. I heard you mentioned family history, a couple of times, infertility runs in families?

Dr. Keith Hansen: Once again, that’s a great question. And yes, I mean, there are a couple of diseases that can result in infertility. One of them is endometriosis, which actually the very first studies that confirmed that it was familial in nature, came out of Yankton, South Dakota. We actually were, the, the state here was one of the first places to ever suggest that it was familial. Since then, we now know that it definitely has a familial history to it. And also uterine fibroids can be more common in families. Both of which can cause problems getting pregnant or staying pregnant. The other thing though, one of the other reasons we asked family history, is for birth defects. If there’s a family history of cystic fibrosis, spinal, muscular atrophy, or one of the other genetic illnesses. If we know that a couple are carriers of a genetic disease, we can actually then test the embryo and make sure we can do in vitro fertilization, test the embryo, make sure it’s normal before we put it back in. We get referrals quite frequently where couples have had a baby with like cystic fibrosis or spinal muscular atrophy and they come in and they want to prevent it from happening again. So then we’re able to do that. We just, we get their blood and it’s fascinating. We send it to a lab and they determine exactly where the mutation is and then they develop primers around that. Then they have to develop primers along the ilial so that they can tell that, you know, if that they actually have that ilial or they don’t. And so they, we can test the Ambrose and find one that doesn’t have that disease, put it in and they can have a totally normal embryo. So, that’s why we ask the family history. We also ask them if they want to be screened for a lot of these mutations. Cause we can do, what’s called the it’s called the council screen. What they do is they give a blood sample or saliva. We send it to a lab out in California or there’s other labs, but they just tell us if they’re carrying the most common mutations versus cystic fibrosis, spinal muscular atrophy, fragile X syndrome, and a whole bunch of other genetic illnesses, all of which, as you are aware are very, very serious illness.

Dr. Joseph Segeleon: Interesting. This is fascinating. I didn’t know any of this. I’m curious, we talked about family history and endometriosis. Is there any other groups of patients that you see more commonly… I guess what’s coming to my mind is polycystic ovary disease. Is that a population that you see?

Dr. Keith Hansen: Yes. We see quite a bit of, of individuals with polycystic ovary syndrome. You know, those are the ones that come in with no menstrual cycles and they’re not ovulating. So we have to treat them with medications to help my violate. We also see patients with tubal disease either due to endometriosis or scar tissue from like a ruptured appendix, tuberculosis, gonorrhea, chlamydia or major abdominal surgeries. We see a lot of male factor with guys that, you know, where the sperm counts are low, the motility is low or the way that the sperm looks, the morphology is low. If the morphology is low, the sperm can have a real dickens of a time getting into the eggs.

Dr. Joseph Segeleon: And, and just to be clear, you see both men and women in your practice?

Dr. Keith Hansen: Yes.

Dr. Joseph Segeleon: Okay. So thank you for that. I think we’ve got the patient now. We’ve got them worked up from the primary care they’re referred to you. And I know that there’s a myriad of different pathways, but for the, for the, for the providers listening, what what’s a typical journey look like through this process for, for their patients?

Dr. Keith Hansen: Well, once again, like you said, I mean, it depends a lot on what the definition is. One good example is those with unexplained in fertility, you know, the couple where you absolutely have no idea why they’re not getting pregnant, they have open fallopian tubes, she’s ovulating every month in the sperm count is totally normal. In that situation, a lot of times what we’ll do is we’ll treat them with like ovulation induction agents, like clomiphene citrate, where we give them five days of the medicine to help them ovulate, to try to recruit more than one follicle. Then, we do what’s called the intrauterine insemination. Where what we do is we have the husband come in close to ovulation and he gives us a sample, we wash it and then we put it right up inside the uterus, you know, to get them going in the right direction.

They actually did a big study called the faster trial where they basically showed that the most efficient way cost and cost effective way to treat unexplained infertility is to do three cycles of Clomid 90 Y. And if they aren’t pregnant, moved straight to in vitro fertilization, and you have the chance of getting a successful pregnancy at the lowest cost for the couple Other options, like for somebody with polycystic ovary syndrome, a lot of time we’ll use ovulation induction agents like Letrozole is the most common one, which is also known as Femara. It’s a aromatase inhibitor and it’s not been approved by the FDA for ovulation induction, but it works wonderfully and especially in polycystic ovary syndrome, it works a little bit better than clomiphene does. And so we like to use that drug to help those people. In male factor, it depends on how severe the problem is. If it’s mild, many times we can do like Clomid or clomiphene citrate and intrauterine insemination. If it’s severe, then we’re having to turn to things like in vitro fertilization where we go in under a big microscope, pick up a normal sperm or the closest to normal we can find, and inject it into the egg or turn to things like donor sperm or donor embryos or adoption.

Dr. Joseph Segeleon: So just curious, you had said that in the cases that you do not know the etiology for the infertility, what roughly what percentage of your practice is it unknown?

Dr. Keith Hansen: Probably about 10%.

Dr. Joseph Segeleon: Okay. thank you. Thank you. Now let’s say the couple are pregnant. Do you follow them then through their pregnancy?

Dr. Keith Hansen: Once a couple is pregnant, we usually follow them like for the first 12 weeks. Most primary care physicians and OB/GYN really wait to see the patient until around 10 to 12 weeks. So what we do is we see them and then we tell them to call up and make an appointment with their primary care doctor or their OB/GYN doctor. Then, they can make their appointment and be seen by them and, and get to get their care set up.

Dr. Joseph Segeleon: Do you see them later in the pregnancy?

Dr. Keith Hansen: Just when they come back to show us, you know, like the little baby, hopefully, or babies.

Dr. Joseph Segeleon: I did not know that.

Dr. Keith Hansen: Yeah, that’s really fun when they bring the little babies back and show them off and stuff.

Dr. Joseph Segeleon: Incredibly rewarding. I know I’ve read before about the cost of infertility being being something out there in the public eye. Can you expand on that a little bit or what are the options?

Dr. Keith Hansen: The problem with infertility is as many times it’s not covered by insurance. So it’s very similar to the cost of other medical care, you know, other surgical procedures and all of that. But, it is expensive. I mean, if you go through in vitro fertilization, there’s about $12,000 to $15,000 for that from us. And then it’s usually about three to $5,000 in medications. So it usually comes out probably about 18,000 by the time you’re done, which you know, is very similar to a lot of other medical procedures. We’re hoping that we can slowly get it approved by insurance and hopefully, at some point, it will be covered.

Dr. Joseph Segeleon: Anything else. In the remaining minutes that we have that you’d want the referring providers and the primary care providers listening to know about your practice or about you?

Dr. Keith Hansen: We’re very happy to see couples with infertility and we’re happy if they do part of the workup or if they want to refer them directly to us. We also see patients with recurrent pregnancy loss, which are sad cases where a woman has had two or more miscarriages and we can work those up. Many times we can find something to help them with, which is nice. I also take care of pediatric and adolescent gynecology, too.

Dr. Joseph Segeleon: It sounds like your practice is incredibly varied and incredibly busy. I know that you’re the reproductive endocrinology is a fairly scarce resource. So for our listeners, how would we refer patients to you?

Dr. Keith Hansen: You’re right. I mean, there are very few of us around. We’re happy to, you know, to take referrals directly from the primary care doctors or we have patients we’ll actually just call up and come in and see us. So, I mean, we’re happy to see them whichever way they want to refer to us.

Dr. Joseph Segeleon: Wonderful. I can’t thank you enough, Dr. Hansen. This was very enlightening and it’s always a pleasure talking to you. I always learned something and Courtney, I’ll send it back to you.

Host: Dr. Segeleon, Dr. Hansen, thank you for being here and for all that you do for Sanford. Our Called to Care podcast series by providers for providers continues right here with our Sanford Health experts. I’m Courtney Collen. Thank you so much for being here. We’ll see you soon.

The following data in this episode was accurate as of April 16, 2021 upon the recording and publishing of this podcast. Edited to note 1 in 6 couples struggle with infertility. 

Learn more:

• Sanford Health helps navigate fertility option
• Ep. 16: Sanford fertility expert helps same-sex couples
• What to know about an ectopic (tubal) pregnancy

Fertility navigation program for cancer patients

Courtney Collen (Host): Hello, welcome to our podcast series ‘Beyond the Diagnosis’, focusing on embracing life after cancer, through Sanford Health survivorship programs. I’m your host, Courtney Collen with Sanford Health News. We’re so glad you’re here. Once a patient hears those words, “you have cancer”, that patient becomes a survivor. Through my conversations with health providers on topics related to survivorship, we’re learning more about how Sanford continues its commitment to help people live their best life beyond the diagnosis.

Our topic today is Oncofertility. I’m pleased to have not just one but two experts on this topic. Dr. Shelby Terstriep is a medical oncologist at the Sanford Roger Maris Cancer Center in Fargo, North Dakota, specializing in breast cancer and survivorship care. Dr. Keith Hanson is a specialist in obstetrics, fertility and reproductive medicine in Sioux Falls, South Dakota. Thank you both so much for being here. Welcome.

Dr. Keith Hansen: Thank you for having us.

Dr. Shelby Terstriep: Thank you so much.

Host: Dr. Terstriep, as the medical director of the Sanford cancer survivorship program, you have really led these efforts from the very beginning. Give us an overview of what the program is all about.

Dr. Shelby Terstriep: What I found out in training was that the cancer treatment is just such a very minute part of a person’s life. All the other things that go along with the diagnosis, we can really help improve those things along the way as well. What survivorship is, is really focusing on wellbeing. It’s, you know, the physical, the mental, emotional the social and financial wellbeing. So, really taking a look at the other things beyond the cancer treatment. Now the cancer survivorship program, what we really focus on is listening to the cancer survivors and having them tell us what they think they’re missing along their journey and then we really focus on our efforts on creating programs to help address those issues. One of those issues has been oncofertility. And so I’m really pleased to be able to talk about some of the things that we are doing to help improve that process for our patients.

Host: What is oncofertility?

Dr. Terstriep: The intersection between oncology treatment and a person’s fertility and their desire to have children. We know that cancer treatment can affect fertility in some cases, so our goal with oncofertility is really to think about those cases and try to address that before those treatments happen so that we, we can make sure that those patients can accomplish their family planning desires.

Host: Dr. Hanson, how does cancer affect somebody’s fertility?

Dr. Keith Hansen: Well, thanks for asking. It’s not really the per se that affects the fertility, but at the treatments, Many of the treatments are directed at rapidly dividing cells and that’s why they work so well because cancers are kind of uncontrolled division. So, these cancer therapies like radiation and chemotherapy usually are directed towards rapidly dividing cells. And one of the areas in the body that has cells that are dividing include the ovary and the testicle. Besides getting rid of treating the cancer itself, they also have side effects where they can damage other organs like the testicle and the ovary. The other thing is for certain cancers like GYN cancers, the surgery itself can be damaging to the ovaries. Let’s say it’s ovarian cancer and they have to remove an ovary and take samples out of the other ovary that reduces the amount of ovary that the woman has and can actually impact her fertility, too.

Host: What options do patients have for preserving their fertility before beginning a cancer treatment?

Dr. Hansen: Well, that’s a great question and there’s a lot of different options available depending on the type of cancer and also the type of treatment that is planned and what’s going on. One example is in many of our young girls that have a big ovarian tumor. A lot of times the GYN oncologist will try to do is go in and try to do an ovarian preserving surgery so that they can hopefully save the ovary, the part of the ovary that has the eggs in it, or at least save the other ovary so that we can have future fertility possibly. And then if they’re planning to do radiation, especially if they’re planning to do pelvic radiation or low back radiation, one of the things we can do is we can actually move the ovaries up out of the, out of the radiation field.

Most of the patients who come in are planning to do either chemotherapy or radiation therapy. For chemotherapy, there’s a couple of different options available. First of all, you know, the chemotherapy has adverse effects upon the ovary and those adverse effects depend on a number of factors – one of them being the age. A young pre pubertal girls ovaries are a lot more resistant to chemotherapy than a post pubertal girl. And then a 19 year-old woman’s ovaries are much better,  more resistant to chemotherapy than a 20 year-old, 29 year-old girl who’s are much more resistant than a 39 year-old girls. So as the ovaries have reduced number of eggs with the natural process of aging, they become more sensitive to the effects of chemotherapy.

So what can we do? Well, one of the options available is, and probably one of the ones that’s most accepted, is to do in vitro fertilization and go in and retrieve eggs, and then either freeze eggs or if they have a husband or want to use donor sperm, we can fertilize the eggs and then freeze embryos. The nice thing about freezing embryos is they’re a lot more resistant to the freezing thawing process than eggs are. So it takes a lot more eggs to achieve a pregnancy than it does embryos. So one of the processes is to do in vitro fertilization, retrieve eggs, and then either freeze them or fertilize them and freeze the embryos. The only problem with that is we need time. You know, we need at least probably 8-to-10 days to stimulate the ovary and take the eggs out. We’ve made a lot of advances in that we’ve done. We now are able to stimulate the ovaries at pretty much any time in the menstrual cycle to try to speed that process up. That’s one option. Another option is to use a drug like Lupron or Lupron glide acetate, which is what’s called a GnRH agonist. What it does is induces a pre-pubertal state. Now, what that is trying to do is reduce the number of cells that are dividing actively in the ovary. And by doing that, then we can hopefully they’ll become more resistant to the chemotherapy as long as they don’t get a huge dose of chemotherapy. And hopefully they’ll survive the process of the therapy. One of the problems that can happen in young girls who get chemotherapy is their white counts can drop their platelet counts, can drop. They can have very heavy periods. And so the Lupron or the loop light acetate, the GnRH agonist actually can stop their periods during this process of chemotherapy and actually stabilize them. So they don’t get into trouble with very, very heavy periods. So we kind of liked that drug, and we can even combine that within vitro if we need to. Another process that’s available is to actually freeze the ovary. But you have to go to surgery to do that. You do a laparoscopy, you know, where we put the incision in the belly button, put the scope in, we take out an ovary. You only just remove one in case the other ovary will survive the chemotherapy. And by doing that, then we can freeze the ovary, which we usually have to mince it up into small pieces, and then we can freeze it. Later, when the person is done with our chemo, you can throw out the pieces and put them back into the pelvis. The only problem with that is you better be absolutely sure that there’s no metastatic disease or any cancer cells in that ovary before you put it back in. We don’t have good ways to test that now we’re working on it, but we don’t have good ways. The other thing they’re working on is trying to make it so they can stimulate the eggs out of the ovary without in vitro, without having to put them back in our body, just do it outside the body. And so those are really kind of the big areas for a woman, a guy, you know, a male who’s getting ready to do chemotherapy. We can do you know, have him give us a semen sample. And then we can, cryopreserve it.

Dr. Terstriep: I think the bottom line for us as an oncologist is to really think about it right away and make the referrals right away so that we can not waste any time. Most of the time, we have eight days to before we really need to start treatment. It’s really a change in our pattern of, of thought processes to think fertility first and then treatment second, which is great. I mean, when you think about it is we’ve come that far with cancer treatment that we’re really concerned about them having kids afterwards. I mean, I think that’s a Testament to oncology advancement.

Host: If a newly diagnosed cancer patient has concerns or questions about fertility, when is the best time to have that conversation?

Dr. Terstriep: The moment they’re diagnosed.

Host: …and who should it be with?

Dr. Terstriep: Our navigators are one of the first people that will be discussing who they’re all going to be seeing. I think it’s appropriate to start addressing it with the navigator and their oncologists right away.

Host: Let’s talk about after cancer treatment. When is it appropriate for a cancer survivor to have children?

Dr. Hansen: We usually work in concert with the hematologist oncologist and find out from them how long they think the patient needs to wait with no evidence of disease before they try to conceive. We also chat and have the patient meet with a maternal fetal medicine doctors who are our high risk OB/GYN doctors. And we of course meet with the patient and all of us together sort of help the patient decide when they should start to try to get pregnant. And we discuss, especially with breast cancer patients, when can we safely start them on estrogen because pregnancy has a lot of estrogen in it. So, you know, so we do communicate a lot with people.

Dr. Terstriep: I think it’s very different depending on cancer and depending on the age of the person. We think of cancers, really as thousands of different diseases. And so each of those diseases have a different likelihood of recurrence and difference in how fertility could impact that.

Host: If we’re talking about considering fertility preservation, is there any financial assistance available? How might somebody go about looking into that?

Dr.  Hansen: That’s a great question. We’ve actually, you know, one of the problems is that, you know, a lot of these procedures are expensive and they’re a lot of times the insurance companies won’t cover them. The American Society of Reproductive Medicine, and a number of other groups, are in the process of trying to get states to mandate insurance coverage for oncofertility because a lot of the insurance companies will come back and say, ‘Well, we don’t cover infertility’. Well, this is not infertility. This is preserving fertility. They’ve already got a number of states to mandate coverage. But right now, when in our area and in a lot of places, it’s not covered by insurance. So we work with a lot of groups. We work with Fertile Hope, you know, and they help to sometimes fund part of it. We’ve talked with Sanford and they’re willing to give us a write-off or ready to reduce the cost of the procedures that we do, but they are really willing to work with us to try to help these people, you know, to be able to achieve this process because it really does help them improve their mood, improve their ability. When I meet with a lot of these gals and you know – Dr. Terstriep might be better at answering this – after we talked to him and he say, you know, they just go from crying to happy that there’s a possibility that they might build a preserve their fertility in the future. So we do a lot of things to try to help them to get help with covering it. If they decide to do Lupron, to shut everything off, a lot of AbbVie who makes it as willing to help cover it for us and stuff. So we, we do a lot of work with those groups.

Dr. Terstriep: We make every effort to try to make it as affordable as possible for our cancer survivors. But it’s a problem. And we’ve been really strongly advocating in the in the states to try to get this funded. But in the meantime, until that happens, one of the easiest and quickest things that we have been successful with is really using GoFundMe’s for these patients. These patients will you know, people want to know how they can help. And that is a peer-to-peer fundraising has been really effective for this it’s, you know, not what we want to have to do. We’d rather have insurance cover it. But when, when it’s a matter of somebody getting this treatment before or not getting it because of financial reasons, it’s, it’s pretty effective.

Host: If a patient undergoing cancer treatment does not wish to pursue fertility preservation, what other family planning options might be available?

Dr. Hansen: Well, first of all, you know, some people will go through chemotherapy and they will still maintain perfect fertility. So, it’s not always sterilizing. Now it depends, once again, you can get doses that are always sterilizing, both of chemo and radiation therapy, but some of the chemotherapies are a lot less sterilizing. There are a lot of different options. One option, if it’s the male, a donor sperm is, is always an option for them to use. The other, if it’s the female, is use donor eggs. There’s two, major ways you can do donor eggs. One is if you have a known donor, like a sister who wants to donate her eggs, we can go in and stimulate her ovaries, take the eggs out, fertilize them with her husband’s sperm and then put the embryo backup in and that has a very, very good fertility rate.

There’s actually now what are called donor egg groups where they actually have you know, cohorts of eggs that have been cryo-preserved from young, usually college age women who go through the process and will freeze their eggs. So it’s kind of like a egg bank as compared to a sperm bank and you can actually purchase them and they can send them up to us. We can thaw them out, fertilize them, and then put them up inside and inside the uterus and the gal can have a baby that way. There’s donor embryos where couples that have went through in vitro fertilization, and let’s say have triplets, and ‘I have leftover embryos, you know, we’re done’ and they decide they can give them to other couples and it’s, they can have a baby that way there’s adoption. And then finally, there’s some very interesting studies going on. A guy at Magee Women’s Hospital is doing with trying to reconstitute the gonads, either the testicle or the ovary. He’s been successful in reconstituting the male rats’ gonad, which is kind of science, amazingly science fiction from basically from the skin STEM cells. So who knows what will happen in the future. There are other options that are available and things that can be done.

Host: Thank you. Let’s talk the oncofertility navigation program at Sanford. Dr. Terstriep, tell me about this navigation program, what it is, and how did it start?

Dr. Terstriep: As a solution to what our cancer survivors were telling us that were holes in their care. And what they felt was there was, we needed to have a bridge between the reproductive endocrinology department and the oncologist. What this navigator will do is really help to assist with education and help with some of the financial issues so that is not a barrier for them having to even be referred to reproductive endocrinology. We know a lot of times they won’t even go to that appointment because they’re worried about the financial issues. The other thing is really collaborating between the two departments, a facility facilitating that collaboration. Finally, you know, one of the things that we heard loud and clear from the cancer survivors were that it’s very hard for them to bring up when should they use their embryos or their frozen sperm, or when should they think about having more kids, because they really felt when they were with the oncologist, if the oncologist wasn’t bringing it up, they should just be thankful that their cancer wasn’t back and that it probably wasn’t the right time to be thinking about that because their oncologist wasn’t talking about that. When reality, you know, often as oncologists, we think, ‘well, they’ll bring it up if it’s important’. And so it was just a little, you know, a, one of those kind of miscommunication type of moments that can happen. What that navigator will do to really help keep the family planning front and center until those cancer survivors feel that their family is complete. So, we’re really excited about this program and really think that that will help bridge that gap that our survivors we’re seeing. And this is really something that is, you know, innovative and not being done everywhere. As we start to really listen to the cancer survivors, that we really can come up with these innovative programs to meet needs, you know, before anyone else can.

Host: At what point does a patient get involved in the fertility navigation program and talk about what that looks like.

Dr. Terstriep: I can give you an example. Yesterday, I had a patient who was going to be starting breast cancer treatment and I wanted to get her in to see reproductive endocrinology. I had a navigator come down and help to educate them about that process and about some of the financial issues and how can they help to alleviate some of those issues. After they were seen by reproductive endocrinology, they worked with their team there to make sure that I knew when the eggs were going to be harvested, when I could be starting chemotherapy, and how would that go. She will be starting treatment after the eggs are harvested, and then our navigator will keep in touch with her and we will make a plan for when it will be appropriate for this person to start having to start thinking about having kids and implanting those embryos. Then, the navigator will touch base with her at those times to start that process and, make sure that I’m thinking about that as well.

Host: And Dr. Hanson, we were talking earlier about pediatric oncofertility. We’re not just talking about adults who are cancer survivors and looking at potentially having children in the future. Talk about what you’re seeing in the pediatric space.

Dr. Hansen: Well, very similar to adults, you know, there’ve been a lot of, of progression in the treatment of cancer in children. Now, upwards of 80-85% of those kids survive. When you have that many children that are surviving chemotherapy radiation therapy, it does increase her risk of having infertility or sterility. And that of course is really important when they get older. So, the issue with the children is the pre-pubertal, it’s a little more difficult because of course they’re not making actually gametes at that point. So the ovaries are totally quiet. They’re not making eggs. The testicle is quiet. They’re not making sperm. So, people are looking into potential ways to help in those kids, especially those that have to have very high levels of dose of chemotherapy or radiation therapy. What’s being investigated now is either taking a biopsy, or an entire ovary out of the young girl, and possibly taking a biopsy, or an entire test account of the young guy, and then hopefully be able to use the cells that are within the testicle or within the ovary to reconstitute the testicle or ovary after they’ve gone through other chemotherapy and help them to be able to reverse their sterility and help them to be able to go through a natural puberty. It’s still considered experimental. Once they go through puberty though, then they have the other options that we’ve already talked about for a post pubertal person. It’s a little bit different though, because of all the stuff, you know, it’s a lot to go through for a young woman anyway.

Dr. Terstriep: I think these are situations where the navigation is going is so critical because these kids are so young and they have many years before they’re even thinking about starting to have families. So to even know where their tissue may be stored sometimes can be forgotten. I think that navigation program will really help to alleviate some of that stress for these young kids.

Host: Yeah. Dr. Torres, drip, what is it like for you to see cancer and reproductive endocrinology teams working together to address these concerns and really give patients even more specialized fertility care?

Dr. Terstriep: Oh, I mean, it is absolutely awesome. When you see a cancer survivor bringing their new baby into the clinic with you, it’s one of those days that you cry happy tears. I mean, it is absolutely some of my favorite days that I work in, in the cancer clinic.

Host: Love that. So if somebody has questions or might be looking for resources, where should they begin?

Dr. Terstriep: I think the cancer survivorship program in each region has cancer survivorship navigators who they can be put into contact with. Then we can take it from there and help to facilitate those referrals and conversations.

Dr. Hansen: We’ve had a navigator that’s started to work with us, and she’s wonderful to have. I mean, it’s really nice to have somebody to bridge the large gap between or the gap. I don’t know that large is true, but the gap between the oncologists and us, and then allow for better communication because, you know, to find out, well, what treatment are they planning? And then tell them what, you know. And so it really is a very, very nice program. And I think it, I think it’ll really help our patients by letting them know what’s available and somebody to just kind of keep track of everything. ‘Cause man, it’s really complicated.

Dr. Terstriep: We have our reproductive endocrinologist practice state-of-the-art care that, and they are so incredibly responsive to our cancer patients. I would say they would drop it, you know, they would drop everything, you know, extend their hours to get, to get these patients in. And I think we are so lucky to have that type of expertise, but also that care and compassion that they bring.

Host: Yeah. So important. And what other areas of support would you recommend for cancer survivors?

Dr. Terstriep: An additional area of support that cancer survivors can utilize is our Facebook Sanford Health Cancer Survivorship page on that is an area that we really drive all of our events, information, our educational efforts and our cancer survivorship retreats. It’s a one-stop shop for you to be able to get information. So we’d love for you to connect with us so that we can keep you informed of new and exciting programs and educational series.

Host: I learned a lot today! Dr. Terstriep, Dr. Hansen, thank you both so much for your expertise and for teaching us more about oncofertility navigation program at Sanford Health. This has been another episode of our cancer survivorship podcast series Beyond the Diagnosis. I’m Courtney Collen. Thanks for being here. Have a great day.