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E6: 7 Domains of Fertility

Dec 07, 2020

For many people, having children and raising children is the biggest part of their life plans. But for some, infertility—not being able to get pregnant after a year of trying—can present major challenges for a woman, and affects all seven domains of her health. Douglas Fair, MD, from Huntsman Cancer Institute and fertility specialist Joe Letourneau, MD, join this episode of 7 Domains of Women's Health to discuss the options and ethics of fertility preservation.

Episode Transcript

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Just Keep Pushing Those Buttons

That's what we do in the fertility business. We tell people, "Just keep pushing the button." It's hard, but you have to kind of leave your modesty at the door when you're talking about infertility, because we get right down to the nitty-gritty.

For many people, maybe most, having children and raising children is the biggest part of their life plan. Now, not everybody. And it isn't maybe a baby now, but having a baby eventually or raising a family is where people came from because we were raised and we were kids and it's what we know. But for some people, it just doesn't happen.

Now, when it doesn't happen, it really touches all of the seven domains. So infertility is the paradigm for the seven domains concept because the process of trying to have a baby, of not succeeding in a time that works for you, and then the consequences of physical, emotional, social, financial, intellectual, environmental, and spiritual all get wrapped up. We're going to talk about that.

What Do You Need to Get Pregnant?

The physical part may be that the basic mechanisms of getting pregnant aren't working. You need eggs, and the eggs need to be kind of young eggs. They can't be old eggs. So women over 35 and especially over 40 and really after 45 don't have eggs that are very likely to make a baby, even though they ovulate every month.

  • So you have to have young eggs and you have to have fallopian tubes, because it's the fallopian tubes that get the eggs and the sperm together.


  • And you need sperm.

It turns out that our understanding of sperm has really evolved in the last 30 years. So we thought we just needed some sperm. In fact, in the olden days, we thought if a man could ejaculate, he was fertile. But now we know it's a lot more complicated than that. But we need enough sperm and they have to be sperm that can actually bind to the egg and they have to be sperm that can get into the egg. And then they have to be sperm that can actually add good DNA, because at least half of the sperm in a healthy man are not normal. So you need to have a good sperm.

Environmental Factors Contribute to Decline in Fertility in Men

The number of sperm per ejaculate is half what it was in 1950. And we think that is probably due to environmental factors. We certainly know that the rise in obesity in men makes a difference in terms of sperm quality. When you start looking at areas where there's a lot of air pollution, you find a decline in sperm quality.

I think we're concerned about both pregnancy and fertility with respect to chemicals in our environment and the air that we breathe. I think that there's good information at the Environmental Working Group. If you're worried about putting certain kinds of lotion or using certain kinds of products or cleaning with certain kinds of products, can help you navigate the kinds of things that might be harmful for your fertility.

Infertility is the Inability to Conceive Within a Year of Regular Intercourse

Now, irregular is in the eye of the beholder, but at least twice a week intercourse. Now, clearly there are people who don't have sex, women who don't choose to have a partner that they have sex with, or they are men who don't have a woman to have sex with, because they don't choose to have a woman partner. But in general, we're talking about heterosexual couples who are trying to have a baby and can actually have sex. So it's a year.

Now, there are other reasons why people can't have a healthy child when they might actually be fertile. So they might be able to conceive, but they have conditions that will get in the way of their growing and bearing a child.

  • The woman might have a medical condition that would get much worse in pregnancy. And the poster child is pulmonary hypertension, a disease where there's high blood pressure in the lungs. People with pulmonary hypertension, women who give birth have a very high, and in our business, meaning as high as 15%, chance of dying in the first 48 hours after giving birth. So we strongly encourage people with critical heart disease not to get pregnant. And that's heart-rending.


  • There are other conditions where the disease actually is toxic to the baby. Uncontrolled diabetes is the poster child for that because people who have diabetes that's uncontrolled can have birth defects in their baby. They can miscarry and their babies can die in utero because their sugar is very out of control.


So these are conditions where we consider them infertile because they can't bear a child, but all their mechanisms are working. And those situations are truly heartbreaking.

Gestational Surrogacy as an Option Through Infertility

Gestational surrogacy is where a couple, an egg and a sperm from an intended parent, that's what we call them, "the intended parent," is put together in a test tube, and the embryo is put in a surrogate who is healthy and young and is able to carry a baby. And although the laws vary from state to state, this is something that is available in many states, gestational surrogacy. In the state of Utah, where I live, we even have the situation where the intended parents' and the biological parents', the donors of the egg and sperm, names are put on the birth certificate.

So gestational surrogacy is a way through the infertility process when someone is too sick or has conditions that would be hard for the baby or hard for the mom.

Emotional Consequences of Infertility

There's, for women, a fair amount of shame and blame that comes with not being able to conceive a child. Shame because this is something that's natural. You should be able if you're a woman just to do this.

Blame, women often say, "If I just hadn't had sex when I was 16, I'd be fertile now," or, "If I hadn't done this, or if I hadn't gotten that sexually transmitted infection, or if I hadn't gained that 30 pounds, and now I'm not ovulating very regularly," or you name it, women blame themselves for everything.

In the darkness of the night of the hope of a pregnancy, people blame themselves. And within a relationship, they may blame each other, and that's also not uncommon. The man may be pointing his finger at the wife because she isn't ovulating or she has endometriosis. And the woman may be putting the finger on the guy because his sperm isn't so great. But in fact, infertility is a couple's problem. It's not one person's problem. It's the couple, because a couple together isn't getting pregnant.

We, in our own fertility center, have a behavioral psychologist who works with us for all of our couples who are dealing with tough stuff like surrogacy, egg donation, when it's time to quit, couples who are really struggling with the process.

I think understanding that there is help if you're struggling with your partner, and it's normal to have difficulties, like, "I'm tired of making love to a calendar. I'm tired of making love three times a week. I only want to make love once a week," or, "I just want to go out and have that beer and I don't want you looking at me because I'm having that beer." You name it and it can be a struggle for people personally, for a couple emotionally. Most infertility teams have a social worker or a behavioral psychologist who can help couples who are struggling emotionally.

The Ethics of Oncofertility

Now, what about young people who are faced with a lethal cancer that can be cured, but the cure itself may limit their fertility or end their fertility with chemotherapy and radiation?

In my career, my very first patient for whom we did fertility preservation efforts who had cancer was a wonderful young woman, a woman I knew from outside my own practice. She was brilliant and she was funny and she was gorgeous, and we saved her eggs, and then she didn't make it.

So, for me, in the back of my mind was, "I hope that somebody takes these eggs. I hope her parents take these eggs and make a baby. I want this woman that I loved to live on."

We are fortunate to have two specialists. Dr. Joe Letourneau, who is with the Utah Center for Reproductive Medicine at the University of Utah. He's a specialist in advanced reproductive technology and fertility preservation. Also with us is Dr. Douglas Fair, who's the cancer specialist and director of the Oncofertility Program at the University of Utah.

Dr. Jones: My question is, we have eggs or sperm in the bank and the person for whom we were hoping this future would unfold, and they could use them themselves, but they didn't make it. So what do we do? Why don't we start with Joe?

Dr. Letourneau: It's a difficult question. It's one that we do encounter. The reason we are doing these procedures is to focus on the future and help people build that future. But in those circumstances where patients may pass away or life circumstances for them may change . . . For example, when we met them prior to their diagnosis, they were partnered with a certain person and they may no longer be partnered with that person, but perhaps they've created embryos together. So there are questions of who sort of owns those embryos and how do we handle that?

We try to help people anticipate these uncomfortable, unexpected events, what they would want to do, so that we can either have their consent or their assent in the case of a child to get an understanding of kind of what they would want.

So some of this we truly prompt ahead of time and say, "What would you want us to do with your sperm if you died? What would you want us to do with your eggs if you died? What would you want us to do with your embryos if one of you died or the other died, or you both died? Or what would you want us to do with your embryos in the event that you divorced?"

Even with married couples, that can be a little awkward to say, but say, "We have a technology of freezing eggs that's just about as effective as freezing embryos. So even though you guys want to have a baby and you're very much in love, would it make sense to just freeze eggs or just freeze sperm alone?" Because once we make an embryo, that's an irreversible . . .

Dr. Jones: Commitment. It's a commitment.

Dr. Letourneau: It's a commitment, yeah.

Dr. Jones: For me, the complicated question, because I have been . . . well, I'm a mom now, but my kid is grown up. But if it's a young person who may not even know how to make that decision, if it's a 14-year-old, can the young person or can the mother ask that the eggs and the sperm from their child be given to the parents so the parents can then use that to try to create the child?

Those are the things that, for those of you who deal with this every day and the sorrow around each family, sometimes you'd say, "I would never do this," but when faced with this family right now, you'd say, "Well, maybe I would."

Dr. Fair: I think these questions are really interesting. They're really complex and perplexing because there's a lot to them. And I think to highlight one of the things you mentioned, what makes them so complex and perplexing is just that they are so dynamic and personal. They really depend on the family. Patients are often put in situations, and that's inherent in cancer, where they weren't expecting or weren't thinking about . . .

I think that's what makes all of this really hard. And this is where I, as an oncologist, really rely on the expertise, both in knowing some of the science, but also knowing some of the ethics and the communication skills around these very difficult topics. When fertility comes up, or what to do when we have collected sperm or eggs and how can and should they be used, I think, are really difficult ones.

But they're really difficult, and I think from my humble opinion in dealing with patients who do die and how their families deal with them, I think grief can take a lot of different forms. So I do think this is a question, while rare, is very interesting and one that we in oncology and in oncofertility do face.

Dr. Letourneau: I agree with Doug that there are a lot of really complex emotions, and often having someone who's an expert in mental health can be very helpful. Certainly any decisions made around something as serious as a future potential person should be done in a very balanced, sort of sober mindset.

There's a natural grief period where people think about things in ways that they may not have otherwise. So I think making sure that people have had an opportunity to grieve and they are able to process those emotions and they know that their decision is coming out of a point that really makes a lot of sense to them and is a healthy decision is really important.

I think when people think about this that aren't thinking about it often or in the popular media, or when people ask me at dinner, they do say, "Well, what if someone is about to die? Do you still consider doing this and why? What are they going to use the sperms or eggs for?"

And a lot of times people can be very sick and sometimes they do well and they live for a long time afterward. Sometimes, even for someone who may not have a long predicted duration of their life, improving their quality of life can be really helpful. And this is one of these things that really does help people focus on the future, and it helps to improve their quality of life. So we see a benefit to fertility preservation and these oncofertility services and at least in education for really anyone who's facing a significant illness.

Infertility Affects 1 Out of 8 Couples

For people who want children and are working hard to have children, our goals here in our fertility center at the University of Utah, and around the country for people who do infertility services in an honest way, I think that we recognize the importance of helping people meet these personal goals. It's not just like a new car. It's bigger than that. It's fulfilling a personal and often spiritual goal.

So I think the hard part of walking through the infertility journey is feeling that you're alone. Often, people don't talk about it because of the blame and shame. They don't talk with their friends that they've been trying for over a year, or they've had a couple miscarriages.

It turns out that infertility becomes part of the lives of one out of eight couples. You don't always know that. Even though people are asking all the time, "Well, when are you going to have kids?" you don't know that they may have been trying for two years and you just sent an arrow into their heart. But if people share their story, they won't be so alone.

We have technology that will help the majority of people with infertility have a child one way or the other, but only you can help yourself with the emotional, social, and spiritual aspects of being part of a bigger community by sharing your struggles.

Get help not just from us as your healthcare providers and specialists, but get help from your community because they'll be there to back you up when that pregnancy test is negative again.

Health Haiku

A baby maybe?
Let's start now, tonight, tonight
No luck, yet again

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