When to refer to fertility, reproductive specialists

Podcast: Sanford reproductive endocrinologists offer wide variety of options to help couples achieve pregnancy

When to refer to fertility, reproductive specialists

Episode Transcript

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. We also take care of transgender kids and adults, getting them on appropriate therapies. Then 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. 

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Posted In Family Medicine, Parenting, Physicians and APPs, Pregnancy, Women's