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Week: 571.7 Guest: Dr. Mark Perloe, Atlanta Reproductive Health Care, Author Topic: Infertility Producer/Host: Steve Girard

NEMA: When a couple tries to have a child, and can't... there are all kinds of questions and concerns, considerations and costs. And there are many underlying emotional issues that may need to be identified and addressed. A lot of that comes under the job title of Dr. Mark Perloe, founder of the Atlanta Reproductive Health Centre. When does a couple know they're having problems conceiving?

PERLOE: Well the standard definition of infertility is one year without conception. But if a couple knows that they have a problem... if the woman's menstrual periods are irregular, or the man previously has had a trouble conceiving or knows that the semen analysis is abnormal... then a work up should begin earlier. Those women who are 35 years or older, because the biological clock is ticking, we recommend that after six months that they undergo evaluation.

NEMA: I always hear about problems that couples have in conceiving that they'll call a doctor about, a specialist about, and they'll find out that maybe it's something they're doing wrong. Are there things, a kind of checklist, or some advice you would give them before they have a work-up to try this before?

PERLOE: Well, we've had one couple that religiously monitored their basic body temperatures to determine the time of ovulation and at that point they began having intercourse... and they were practicing great rhythm contraception. The temperature charts are helpful at giving us a general idea whether a couple ovulates or not, but we advise couples not to use this to time intercourse. If they want to time intercourse, so that the fertility is maximized, there are a number of urine test kits that are available over the counter that will help them predict their most fertile period. The other thing before a couple tries to conceive is, it's important to make sure they're in good health and preconceptually, a visit to their physician may pick up a medication that might interfere with the pregnancy. We recommend prenatal vitamins, because it cuts down on the risks of certain defects. So, smoking ought to be discontinued if possible, alcohol use should be decreased. So it's important that a couple trying to conceive make sure they're up to date in routine health care.

NEMA: So, after a couple checks on general health with their physician, and finds they may have a problem, what should they do next?

PERLOE: Well I think it's to find a physician who is competent and experienced in dealing with infertility, and to recognize that this is a problem that involves both husband and wife, it's not just the wife's problem. Even when we find that there may be a problem with irregular periods, we also can find problems with the sperm. So it's important that both the man and the woman undergo an evaluation at the same time.

NEMA: What percentage of the patients who come to you get pregnant...?

PERLOE: I think somewhere between 65 and 85 percent of patients will get pregnant. I thought you were going to ask me the question and that is what percent of these people can you help. And I think that we can help all of them because if we aim just to help those who get pregnant we're going to have a lot of unhappy people. And I think what I want to do is to make sure patients understand all the options. Some people may not be able to afford certain therapies or ethically find those therapies distasteful. So that looking at overall pregnancy rates are not very helpful, because some people may choose not to go certain routes.

NEMA: Now, when you are advising them about whether they should go ahead with therapy, how do you handle their emotional feelings at that point, the way they're approaching this... and how hard is it? I mean I guess some of the couples have a harder time with it then others and others will pay a higher price then others.

PERLOE: Well I think the emotional factor is a very important thing. I see myself as a physician specializing in building families. Hopefully, that family will involve more people than when a couple comes to me. Sometimes it doesn't, but there's still a family there and as a physician, I have to recognize that the process of infertility treatment potentially can destroy the family... unless there the resources available to help the couple. So I think whenever there's stress, whenever you're put to the test, the relationship in a couple will be either strengthened or fall apart. And it's incumbent upon me to kind of keep my finger on the pulse of the marriage so to speak. And if there are issues that appear to be interfering to get people to counselors to try and build the relationship back.

NEMA: I have friends and acquaintances that have gone both those roads. One where they realized through the process of trying to conceive just why it had become so important for them to conceive and realize they had tremendous problems and didn't go ahead with it which was good but that's a heck of a job to try and to play the medical side and of course to try and gage their emotional strengths.

PERLOE: One of the first steps we do is have the couple fill out a questionnaire about why they're doing this, how do they see their lives now, how do they hope to see their lives once they have children. And it's amazing how many couples who don't have fertility problems and are not tested this way never really take the time to explore what this will do to their relationship and why they want to do this. So if we can get couples to communicate about their desires before entering into treatment or as they first start this there's less likely to be conflicts when the husband says," well I'm doing this for her", and she says," well if we would only have kids boy the relationship would be better or I could quit my job." And focusing on the reasons to go through fertility treatment is very important for couples.

NEMA: Is there an average period of time as to when you can gauge whether or not a treatment is going to work?

PERLOE: No, there really isn't an average, and what I advise couples is that if a given treatment has not worked in 3 months, it's probably not going to work... or the couple needs to sit down with the physician and review the therapy. Too often, a patient gets involved with an OB/GYN generalist, and gets placed on Clomid, to see what it will do... without the appropriate testing... and this medication will be used for month after month after month. And then, 2 years after unsuccessful treatment, they come in for further evaluation... where after 3 or 4 months we really know that this is not the problem, and something else ought to be identified - or look at another type of treatment.

NEMA: Can you elaborate on Clomid?

PERLOE: Well, many physicians believe that placing patients on the fertility pill Clomiphene will increase the fertility. This is just not the case. Using Clomiphene alone, or Clomid, will not increase the patient's fertility unless they have an ovulation problem. So the woman who has normal menstrual cycles the use of Clomiphene is not going to improve their fertility. Now in some patients who are younger, combining the Clomophine with insemination... when we have no other reason for the infertility... will improve the pregnancy rate. But as a women gets older, the effectiveness of this therapy is much less, so that the woman over 38 really needs to see a reproductive endocrinologist and begin with more aggressive therapy, because the simpler treatments are just not going to be as effective.

NEMA: IVF is very familiar to me but there are some other things on your web site for instance that I'm not really familiar with. There's one called "gift" and one called ICSI and I'm familiar with the donor/egg sperm system as well. But can you kind of outline some of the ways in which programs are separate avenues that you might take with a couple in order to help them.

PERLOE: Well in-vitro fertilization right now is the, one of the most successful and best last resorts that we have for couples. What it involves is using medication to get more eggs, removing the eggs from the ovaries with a simple procedure performed under local anesthetic, with sedation, mixing those eggs with the sperm, checking them 2 to 3 days later and translating a few of the embryos back into the uterus. Clinical pregnancy rates are in the 40% range, where actual delivery rates are somewhat less in that in the mid to high 30's, depending upon the woman's age. That's a wonderful technique if the tubes are bad, or if there's unexplained infertility. Now, ICSI is the procedure where a single sperm is injected into the egg. This way we know that fertilization isn't a problem and, particularly in cases of male fertility or unexplained infertility, we are increasingly adopting this because we get such good fertilization rates, and good pregnancy rates with it. "Gift" is a procedure that we are performing less often. Gift involves retrieving the eggs and mixing the sperm and eggs together and doing a laperoscopy to place the sperm and egg back in the fallopian tube. It was initially thought that this was a better environment for their growth and would allow a higher pregnancy rate. And initially it did but as IVF improved Gift did not and now there's no difference in the pregnancy rates and the cost of doing that surgery just doesn't make sense anymore.

NEMA: Now about cost. One of the things people ask all the time is, gee, what does it cost ballpark..? And I imagine it's a very big ballpark.

PERLOE: Well it is, certainly the drugs are very expensive for this and the large part in the cost is determined by how much drug is used and we certainly individualize treatment on that. So there's a wide range. For IVF the costs are in the 8 to 10,000 dollar range. For donor egg, the cycles will vary from program to program... and they're from 11 to 15,000. Again, depending upon the individual program, and the donor's response to the drugs.

NEMA: Dr. Mark Perloe at the Atlanta Reproductive Health Centre. Get to their web site for other information, including links to all kinds of support areas for couples having problems with fertility. Here it is: www.ivf.com/

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.

NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.NEMAhealth.com/ ...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.


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