#352 ‒ Female fertility: optimizing reproductive health, diagnosing and treating infertility and PCOS, and understanding the IVF process | Paula Amato, M.D.

Understanding the biology of female fertility and the menstrual cycle is essential, as it not only impacts conception but also the overall health of women.

Ovaries Have Limited Eggs That Decline Over a Lifetime

Women's ovaries contain a finite number of eggs that decrease in both quantity and quality over their lifetime—an important distinction from men who produce sperm continuously.

Women Are Born With Millions of Eggs; About 400,000 Remain At Puberty

Women are born with about two million eggs. However, by the time they reach puberty, this number diminishes to approximately 400,000. Peter Attia and Paula Amato discuss ovarian follicles, indicating their size and the number of follicles that can be present, such as 10 to 15 in an average unstimulated ovary—comparing its size to a plum and to a grapefruit when stimulated.

Menstrual Hormones Stimulate Egg Growth, Typically Releasing One

Each month, a group of eggs within the ovaries starts to mature due to the stimulation by the pituitary hormones—follicle-stimulating hormone (FSH) and luteinizing hormone (LH). While a cohort of eggs begins to develop, only one usually becomes the dominant egg and is released during ovulation. The selection of the released egg is somewhat random, influenced by hormonal factors.

Meiosis Errors Lead To Chromosomal Abnormalities

As women age, the quality of eggs decreases due to meiosis errors which can lead to chromosomal abnormalities. These erro ...

The podcast addresses the intricacies of infertility, guiding listeners on how to begin a workup and underlining the need to evaluate both partners.

Evaluate Both Partners For Infertility Causes

Infertility issues may arise from either partner, so it's crucial to investigate both.

Medical History, Physical Exam, Semen, and Ovulation Analysis Can Pinpoint Fertility Issues

Paula Amato underscores the importance of comprehensively understanding both partners' medical history, encompassing medical, reproductive, psychosocial, sexual narratives, and lifestyle factors. For the female partner, regularity of menstrual cycles and ovulation is crucial. In males, sexual performance is observed, and components such as sperm concentration, motility, and morphology are analyzed through semen analysis. Screening can involve blood testing, semen evaluation, and ultrasound to estimate the quantity of eggs in women.

STIs Like Gonorrhea and Chlamydia Can Cause Infertility By Damaging Fallopian Tubes

Amato brings to light that infections can lead to scarring in the fallopian tubes, impeding the merging of egg and sperm, resulting in infertility. She reveals that sexually transmitted infections, specifically gonorrhea and chlamydia, can ascend to the fallopian tubes, triggering scarring. If infections are detected early, antibiotics can successfully treat them, but delayed, unrecognized, or untreated infections may escalate, causing fertility issues. Gonorrhea and chlamydia symptoms may include pelvic pain and fever. Scarring from such infections usually remains unnoticed until attempts to conceive begin.

A procedure known as a hysterosalpingogram (HSG) is employed to check if fallopian tubes are unobstructed. It consists of injecting dye into the cervix and taking x-rays to view the uterus and fallopian tubes. Amato elucidates that scarri ...

Paula Amato and Peter Attia discuss various treatments for infertility, their approaches, costs, and potential hurdles that can arise during treatment.

Medications Like [restricted term] Induce Ovulation in PCOS

Amato delves into the process of ovulation induction, particularly for patients with PCOS, using medications like [restricted term]. [restricted term] is taken for five days during the menstrual cycle, with ovulation assessed through ultrasound. [restricted term] is an aromatase inhibitor that blocks the conversion of androgens to estrogen, which triggers the pituitary gland to release FSH and LH, leading to egg growth stimulation. Despite the potential for not understanding the management of PCOS, especially in terms of fertility treatment, well-equipped fertility clinics with reproductive endocrinologists offer the necessary monitoring services to confirm ovulation. The initial approach might include three cycles of an unnamed treatment, that if unsuccessful, will lead to using higher doses or different medications such as [restricted term] before moving on to gonadotropins or FSH to stimulate the follicles.

IUI: Effective for Unexplained or Mild Male Factor Infertility

IUI is suggested for single women, same-sex female couples, cases of unexplained infertility, or when there is a male factor such as a lower sperm count or motility. The processed sperm sample is placed directly into the uterus at the time of ovulation. IUI can be suitable when the sperm count is slightly low, but some other treatments are ineffective, such as in cases of severe male factor infertility. The chances of pregnancy through IUI vary significantly with age, from 20-25% in women in their 20s to only 1-5% in women over 40.

IVF Is Necessary After Unsuccessful Treatments or Severe Fertility Issues

IVF becomes the next step if other treatments have been unsuccessful or in cases of severe fertility issues, such as completely scarred fallopian tubes, obstruction in the fallopian tubes, or very severe male factor infertility. IVF involves several steps beginning with stimulating the ovaries with medications like FSH to produce multiple eggs. Next, eggs are retrieved and fertilized in the lab, with a success rate of roughly 7 ...

Paula Amato and Peter Attia discuss the complexities of fertility, with a primary focus on how age and lifestyle factors such as diet, exercise, stress, and sleep affect the ability to conceive, and how conditions like polycystic ovary syndrome (PCOS) contribute to infertility.

Age Most Important Factor in Fertility due to Declining Egg Quality

Age is the most significant factor influencing fertility, primarily due to the declining quality of eggs as women age.

Women 35+ Have a Lower Conception Chance per Cycle Than Younger Women

As women age, particularly after 35, the chance of conception per cycle decreases. Despite ovulating, older women may release eggs with chromosomal abnormalities, which are less likely to fertilize or lead to a healthy pregnancy. Paula Amato explains that women over 35 should be tested for fertility issues after six months of trying to conceive, rather than a year, due to the lower conception chances with increasing age. She also notes the practical issues that arise from women waiting later in life to start families, contributing to increased rates of infertility.

Lifestyle Factors Impacting Fertility: Diet, Exercise, Stress, Sleep, and Age

Lifestyle factors exacerbate infertility; thus, maintaining a health-promoting lifestyle may align with fertility-promoting choices. Diet is critical, with the Mediterranean diet being noted for its fertility benefits. However, excessive exercise can lead to REDS (Relative Energy Deficiency in Sport), affecting menstruation and, by extension, fertility. Healthy weight management and addressing menstrual irregularities early are crucial for fertility. Stress management techniques like meditation and adequate sleep also contribute positively to fertility.

Polycystic Ovary Syndrome (PCOS) Disrupts Ovulation, Contributing To Infertility

PCOS, often linked to [restricted term] resistance, can disrupt ovulation.

Pcos, Linked To [restricted term] Resistance, Affects Fertility

PCOS is a comm ...

In recent discussions, the focus has been on how genetic testing and new reproductive technologies are transforming fertility treatments and potentially overcoming age-related fertility declines.

IVF Embryo Testing for Chromosomal Normalcy Selection

Testing Improves IVF Success By Addressing Chromosomal Abnormalities Causing Failure

The use of pre-implantation genetic testing in IVF highlights a significant advancement in fertility treatments. Paula Amato discusses this, implying the role of genetic testing in selecting chromosomally normal embryos. She notes that while her clinic does perform a lot of genetic testing, each patient should thoroughly discuss the pros and cons before proceeding, and the cost of IVF, estimated at $20,000 per cycle, typically includes genetic testing.

During IVF, an embryo is observed from the zygote stage and is later evaluated for genetic testing with the intent of ensuring chromosomal normalcy. The advent of genetic testing has meant that embryos with the best chance of success are selected based on more than morphology—good genetic testing results take precedence over good morphology if there is a conflict. This approach can significantly increase IVF success rates, although it doesn’t guarantee implantation for all chromosomally normal embryos.

Embryo selection has evolved from morphology to genetic testing. Genetic tests primarily look for aneuploidy and other specific genetic mutations. Embryos with poor morphology are generally not subjected to further stages. Genetic testing is standard in IVF, involving a biopsy of a few cells and vitrification, a freezing method that maintains embryo viability. Results from these specialized tests are frequently used to identify aneuploidy and inform embryo selection.

Emerging Technologies Like Mitochondrial Replacement and in Vitro Gametogenesis Offer Promising Fertility Options

Overcoming Age-related Fertility Declines for Genetic Parenthood Beyond Traditional IVF

As technology advances, next-generation reproductive options such as mitochondrial replacement and in vitro gametogenesis enter the discussion. Paula Amato mentions in vitro gametogenesis as promising but notes its complexity due to meiosis. This process, which is still likely 10-20 years away from application in humans, involves creating eggs and sperm from skin cells—an option for indiv ...