Ep 143 IVF, Part 1: Infertility

no other underlying issues. Pcos can make it difficult to get pregnant naturally, so my doctor recommended I try entry uterine insemination. I ended up doing four iuis with him, none of which resulted in a pregnancy. Before I started seeing a new doctor who recommended I move on to IVF. My egg retrieval resulted in five healthy embryos that we had frozen, and since then I have undergone three embryo transfers,

but none of them resulted in a pregnancy either. I've done genetic testing, countless rounds of blood work and ultrasounds, a mock transfer cycle, a hissteroscopy, an HSG scan. I stopped eating gluten, dairy, and sugar. I do monthly ovulation tracking, have regular acupuncture and meditation. Sessions made my fertility a full time job, and still I have no answers. I just turned thirty nine, and I'm always wondering why not me. My friends are all having kids and growing their families

exactly as they had planned. Well, I'm just spinning my wheels. There's so much I wish i'd known about fertility when I was younger. None of my female relatives had fertility issues, and I always had totally normal results at my annual exams with my gynecologist. Plus my PCOS symptoms were masked by the pill, so I just had no idea that

I would ever end up with unexplained infertility. I always assumed that if I had trouble getting pregnant, especially since I didn't start trying until I was thirty five, which is considered geriatric in the medical world, that IVP would

be a safety net that it would definitely work. My last embryo transfer was over a year ago, and while I have two perfect embryos still sitting frozen and ready beus, I've been too scared to try again, going through the appointments, the injections, dealing with the effects of the hormones, holding onto hope, and telling myself this time will work. I'm just not sure I'm strong enough to go through it all.

who sent in your stories. We appreciate you so so, so so much.

going to focus primarily on infertility. So I'll be talking about the concept of infertility as it has changed over time, leading up to the development of assisted reproductive technologies in the twentieth century. And Aaron will go into what to expect if you go in for a fertility exam and how fertility is assessed.

about other forms of art assisted reproductive technologies. Number three present an overview of how IVF technology was developed, and for briefly discuss some of the ethical issues that have arisen with art in terms of access regulation and as an industry.

donation alongside our IVF treatment. So what that meant is that I donated half of the eggs that were harvested during the treatment to another couple, So we got nine eggs when they went in to collect them, so we gave five to the other couple and we had four ourselves. The procedure needed ixy as well, which is where this sperm is actually injected directly into the egg, so all four eggs were fertilized and then it was a very anxious weight call in the lab every day to see

if our embryos had been dividing and developing. And then three days later, we chose while the doctors chose the two embryos to transfer back into my uterus. It was a very nerve wracking day, but we did it. We went home and then it was a two week wait to find out if it had worked and if I was pregnant. We happened to go away for the weekend.

It was our wedding anniversary, and just by some coincidence, we were staying at our same hotel we spent our wedding night, and we ended up in the same room we spent our wedding night, and that's where I did a pregnancy test and we got a positive result. Then six weeks later we saw their little heartbeats and we found out it was twins. And then those twins are now twelve. I also found out that the couple that I donated my eggs too, they had a little girl

as well, so their pregnancy was also successful. So really case scenario everyhoe.

endometriosis and wanted me in surgery in two weeks. Two weeks later, I had a laproscopy and a histroscopy, and my surgeon had found stage four endometriosis affecting my uterus, ovaries, fallopian tubes, about and bladder, but thankfully she managed to remove majority of it and kind of said that for the next six month I'd probably be my most fertile, and that she'd be quite surprised if I hadn't naturally

fallen pregnant. And in that six months those boo and urinary problems had subsided, and so too did the period pain, so we were quite hopeful. Fast forward six months and still nothing was happening, so we requested a referral to a fertility specialist and she informed us that my husband

had a low sperm count. His count was roughly one and a half million sperm per meal and the normal reference point is fifteen million per meal, so she actually recommended IXY over IVF to ensure a good fertilization rate. October last year, I had my first egg retrieval and I was really lucky and had a really positive experience. I wasn't shy of the needles, being a healthcare worker, and I had a really good result. We retrieved twenty

eggs and ten were actually mature enough to fertilize. Nine did fertilize overnight, and by day five I had six really high quality blastocites. We ended up doing a fresh transfer with one of them and froze the rest, and unfortunately that transfer failed, and since then we've done a further too frozen embryo transfers that have unfortunately also failed.

I've actually just done my second historiscopy in just over twelve months to see if there's some kind of issue local to my uterus that might be preventing implantation, and I've also done multiple blood tests to rule out other issues such.

cycle is a full cycle of grief. But we're so grateful we have the means to do this, and at a time where science is learning more and more every day about infertility and how to overcome it, and hopefully one day we'll get our little baby.

infertility being on the rise. Are on the rise, And I'll get into more of the possible reasons for that a little later on, But I wanted to start with these headlines because I think they provide an opportunity for us to think about what infertility can mean for us today, and how those definitions are fluid across space, across time,

and across intent. There's the medical definition of infertility, which the WHO says is twelve months of regular unprotected sex without pregnancy, and that definition actually has been like the medical definition has been revised over the years. There's primary infertility it's like no pregnancy ever, and secondary infertility at least one pregnancy previously. And then there's what insurance companies will consider to be infertility, which changes what they're willing

to cover for fertility treatment. There's how infertility is used politically as a scare tactic to reinforce gender roles. There's fertility rate, which some headlines conflate with infertility rate, so you know, like the average woman in twenty twenty four is giving birth to fewer kids than in the nineteen fifties, so infertility must be on the rise, that's not, yeah, something having like two.

to couples or to individuals? Does intent matter? If someone cannot become pregnant due to a medical issue, but they have never intended to become pregnant, does that count as infertility? Along those same lines, if someone never seeks treatment for infertility because of lack of access, personal beliefs, other reasons, are they counted in these measures of infertility? Will their

voice be heard? The bottom line is that infertility can mean many different things to many different people, and it can be difficult to get a handle on where these modern measures of infertility are coming from, who they are capturing,

and who they are failing to capture. This is one reason why we should scrutinize headlines claiming a rise in infertility rates, first of all, compared to when the data that go into modern measures of infertility are incredibly messy, let alone estimates from the early twentieth century or before, when infertility was even more shrouded in silence than it

is today. Secondly, these headlines tend to ramp up during periods of backlash against progressive movements like women's liberation in the nineteen seventies, which was followed by claims that the traditional nuclear family was at risk because career hungry women were waiting too long to have kids. And then this called for a return to a traditional working husband's stay at home mom arrangement. And it's you know, we're seeing echoes of that today with this tradwife trend and all

of the birth controlled disinformation that's circulating around social media lately. Yeah, And the last thing I'll say about these headlines is that right alongside them are reports of out of control global population growth, which shows that it's not about infertility overall, but it's rather concern over who is having babies and who isn't. If infertility in its bio medical definition is truly on the rise globally or regionally or within populations,

we should investigate why that is. Just because infertility is hard to measure, it doesn't mean that we shouldn't try. And if we want to do that, we have to take in all of the various meanings of infertility, what it means to people measuring it, what it means to people experiencing it, what it means to people treating it, and how those meanings change over space and time. For

a truly amazing overview of this subject. I highly recommend that Paul Grave Handbook of Infertility in History, edited by Gail Davis and Tracy Lofgren, which was my main resource for this first episode. It's a wonderful collection of essays and chapters and works that I really just all across the board. I mean, I was like completely overwhelmed, but I loved it. So I want to first take a step back and consider what it means to look for

traces of infertility throughout history. Humans have experienced infertility forever, but infertility doesn't leave marks on the bone, and it doesn't get logged in yearly mortality rates or disease tallies. With the exception of the last century or so, it is rarely openly discussed by those who are experiencing it, maybe because they didn't know how to read or write, maybe because their writings were not seen as important for preservation, or maybe because shame or pain kept them from including

it in their writings. There do exist some examples of letters or diaries where women have described their feelings about not being able to have children or not being able to have additional children. Secondary infertility is even more difficult to spot in history, but these writings are fairly rare. So I'm going to read you a quote from Henriette Obermuller Vena Dat, writing in her autobiography in eighteen seventy quote. I bought books, I talked to women's doctors. I decided

to do everything they told me to. I saw the midwife, I was told this and that. I heard that there was a recipe, but that it might kill me. I wouldn't have minded. If only I could have become a mother, if only I could have born Gustave a child. I was so certain it was my fault.

probably keeping infertility partially shrouded in silence. Theat history is its affiliation with sex, which has always been pretty taboo in Western culture. Especially sex without procreation, as well as the fact that bearing children has been the expectation, the norm throughout all of history, and when that didn't happen, it was a noticed and be tinged with shame, indicative of a problem. Finally, infertility has mostly been seen as

a woman's issue, thus not as important for documenting. Who is doing the writing after all, who is actually deciding what is important in history, you know, and what should be preserved or not? Would they have viewed a woman's infertility as relevant to the historical record or just to

whatever story they're telling. As Davis and Lochrin, the editors of this book put it, quote, these problems are magnified when tackling infertility experiential state that exists as an absence, the failure to engender pregnancy that plays out on the bodies of women, a historically marginalized group, and that, it seems, often further stigmatizes its subjects, thus rendering them inarticulate or

silent end quote. Where we see the most references to infertility, or maybe more precisely, involuntary childlessness is in medical writings with hypotheses as to why someone is not able to become pregnant or treatment handbooks to target different perceived causes of involuntary childlessness, ranging from the biological, to the psychological to the spiritual. Today, if someone goes in for fertility testing, doctors will try to pinpoint the precise issue and come

up with treatment based on that. But we know a whole lot more now about reproductive science than, for instance, ancient Greek physicians, who largely viewed reproduction in like plant soil terms. The man provides the seed semen the active dynamic material, and the woman provides the substrate, the soil

the menstrual blood in which the seed is planted. And this agricultural metaphor reinforced the role of the man as the active partner and the woman as passive, which still finds its way into the way we talk about some of these aspects of fertility or reproduction. The sperm invading the egg, you know, like this very much active role and then passive role. And it also explains why the terms fertile, barren, and seed are associated with producing offspring.

way to medieval times. They tend to center around either balancing out the humors, of course, or prescribing recipes that included ingredients associated with fertility, like the sexual organs of animals, of certain animals in particular, plants that produce a whole lot of seeds, or animal dung which was used to fertilized fields for planting crops.

of seven, ten or fourteen nights. At the end of this time, if the fault lay in one partner, then the pot containing his or her urine would stink or contain worms. But if neither pot contained worms, then may men help them to have a child through medicines.

mean we all need the reminder. You couldn't go out and get a test to tell you within a matter of weeks that you were pregnant. You had to wait like a long time.

And also, I mean, of course, I want to acknowledge that unexplained infertility makes up a huge proportion of infertility cases, or people who seek infertility.

there's often room for blame. Women historically and even today, tend to shoulder more of the blame when it comes to difficulty conceiving, and it's not uncommon to hear modern stories where a straight couple goes through fertility testing. The doctors find a potential contributing factor in the woman, they take steps to treat that, and then months or years down the line, finally like still nothing's happening, and they

finally test the man and find additional issues. In this Palgrave Handbook of infertility book, I came across the story of a woman who, quote, over a two year period in the late nineteen forties, underwent two dilation and curati operations, a tubal insulflation, a selpindrogram, an endometrial biopsy, and a host of injections, courses of tablets and douches before her husband, Seamen was tested and found to contain no spermatozoa end

quote wow wow, So yeah. We can see this blame with many royal families, where women were seen as responsible for producing an air and a spare, as well as other children for forming political alliances. If a woman failed to fulfill her royal and marital duties in that way,

at the least, she was frowned upon. At the most she was disposed of, as Henry the Eighth famously did to several wives, even though scholars think that he was probably the common denominator and that it was actually quite common because at the time forty percent of Tudor marriages had no children. Really really, that's what at least historical

calculations estimate. A marriage without children could be seen as a sign of God's disapproval or later on unpatriotic, because a thriving population was important for military and economic strength. But of course there's the caveat that I had.

was thought to be less conducive to child bearing. Ah, one of the more depressing things I've I've read.

complications from these infections compared to men. One physician R. A. Gibbons said in a nineteen ten address to the Medical Graduates College that quote, in many cases of sterility about which you will be consulted, it is undoubtedly the fault of the woman.

a couple. This became a self fulfilling prophecy because if physicians were taught that male infertility was rare, then they were less likely to examine the husband of a couple having difficulty conceiving because also, I say husband, because for the most part in this period of time, the only people who were seeking, or the vast majority of people who were seeking and would be seen by physicians, had to be a married couple. There was that sort of

morality component to it. Some physicians did recognize that it wasn't necessarily the wife's fault, the woman's fault with eugenic y undertones. So quote A great many women are, through no fault of their own, incapable of becoming mothers. The reason for this is that they have been infected by venereal disease, which is the great foe to the reproduction of the race. The husband has infected his wife and thus robbed her of the power of maternity.

to assume the responsible role of mother. Is she so much absorbed emotionally in other life tasks that she fears motherhood? And above all, has the sterile woman overcome the narcissistic mortification of her inferiority as a woman to such an extent that she is willing to give the child as object full maternal love?

get a handle on in some degree. And although the psychogenic model of infertility fell out of favor in subsequent decades as we learned more about how human reproduction works, it still lingers in some ways, like the advice that you will come across, Oh you're just too stressed, try to relax and then you'll get pregnant, or you just don't want it enough. Maybe it's your body's way of

saying this wasn't meant to be. All of these types of things have echoes of the psychogenic model, but the more positive legacy is that the recognition that Experiencing infertility and going through fertility treatments can have profound impacts on mental health, revealing a need for mental health professionals infertility clinics not as gatekeepers for who is deserving of fertility treatment, which is kind of what they started out as in

some degree, but as support. The twentieth century, which i'll talk much more about next episode, dramatically changed not only the way that infertility was studied or treated, but also the way it was experienced, which I haven't really talked about, in part because it's so big, it's so personal, it's

not at all universal or generalizable. As our understanding of human reproduction grew, and as technologies like IVF developed in the late nineteen seventies, as these opened the door to new possibilities, infertility became something to overcome through science, but not for everyone. Stigma, silence, or a lack of access prevent people from seeking treatments in the first place, and the treatments aren't always successful or the cause of the

infertility remains unexplained. In some ways. The improvements in reproductive technology have given us this illusion of complete control over our fertility, and many modern narratives of infertility tend to reinforce that control by highlighting stories where there's a beginning, a middle, and a happy ending, either through pregnancy and birth of an IVF baby, or adoption or surrogacy or something similar, something that's like and then here is the

happy ending that everyone expects. The stories of people in the middle of IVF or who have tried IVF but have not gotten pregnant or delivered a baby. These are less common stories, which can add to the silence surrounding infertility, perpetuating the myth that fertility is a universal or universally desired experience. The idea of having it all plays into this, suggesting that if you don't have kids, whether that's voluntary or involuntary, you're missing something. You can't have it all.

We could do a whole episode on the problem with the phrase having it all it's one of my least liked phrases, or doing it all. But silence can also be protective, preventing intrusive questions or platitudes like maybe this is the way it's meant to be for you. And these days, with the advent of contraceptives that in general allow us to have more control over reproduction. We can better control our own narrative, whether we want to tell

anyone or whether we want to keep it private. Sharing stories of infertility or hearing those stories can reawaken painful feelings, or it can create a sense of community, or both, or neither, or something else. There's no simple answer or universal experience. And the same applies to the concept of infertility. On the one hand, thinking about infertility in purely biomedical terms, as we often do these days, reduces this multi dimensional

experience to one aspect. But on the other the understanding that we gained throughout the twentieth century about the biological causes of infertility has helped to reduce the stigma and blame surrounding it, not globally but in many parts of the world, and it has allowed so many people to fulfill their dreams of having children. And so Aarin, I'll now turn it over to you to tell us all what to expect if we go in for fertility testing.

the egg retriple. In February of twenty twenty two, I did a frozen instead of frush transfer because of overstimulation during the retrieval process. In April of twenty twenty two, I had a successful embryo transfer and implantation, followed by a healthy baby boy born in December of twenty twenty two.

it's very painful, not a great experience at all. During this time, Rachel became pregnant, and it was very difficult for me because she was able to become pregnant with the first transfer and I was continuing to have unsuccessful transfers. It was very taxing on a relationship and my mental health, but we kept pushing on. By this time, our son was born and it made all the insecurities I had about not being his birth parent disappear. On my fourth

transfer attempt, I did become pregnant. However, I started a bleed about two weeks after. I went in for an ultrasound and I found out I had a sub qoreanic chematoma that was bigger than the fetus itself. But there was still some hope because the fetus was still there and the bleeding had stepped. However, when we went in for the heartbeat check, it wasn't there. It was literally heartbreaking.

So I had two choices, give up on having a biological child or see if my wife, Rachel could get pregnant with my embryo, and after much discussion, we did a reciprocal IVF Rachel would attempt to carry one of my embryos. The first attempt has resulted in a chemical pregnancy. The embryo started doing plant and then detatched for an

unknown reason. It could have been a genetic issue with the embryo or the embryo quality itself, but they weren't sure, so we did the same protocol and tried it again, which was successful.

our miracle baby home. Through one and a half egg retrievals due to one canceled because of poor outcomes, COVID closed clinics, moving our two precious tested embryos to a clinic five hours away, we finally reached a time where we were able to transfer our embryo and have our miracle baby. Without the science of IVF, my family would not be what.

if that's what we're calling it. So governments, all governments cite fertility rates like that's the data that we have. We have data on birth rates, and yes, birth rates have declined substantially in the US, for example, in like thee in nineteen fifty women had close to five children

on average. And as a disclaimer, all of the language around fertility and infertility is so incredibly heteronormative, and so I use the term women here because that is what all of the data sites, and we do not have good data on the experience or the lived experience in transgender and gender diverse individuals, not to mention the fact that definitions of infertility don't even take into account people

who are gay or anything like that. So I apologize in advance that that is the reality of the situation. But when I say women talking about people with the uterus here. So on average women had five children in nineteen fifty.

not just the US. The global fertility rate has more than had from again close to five four point eight in nineteen fifty to two point two three in twenty But much of this decline is quite intentional, and some of it is a very good thing, because some of the statistics when you look at what has been on the decline year over year, is things like birth among those age fifteen to nineteen children, babies, having babies has been on the decline.

increase in infertility? In everything that I was reading, I didn't find any data to show that the things that we're going to talk about that cause infertility, the underlying things that can cause it to be difficult or close to impossible to conceive without medical intervention don't seem to be on the rise. And what's interesting is that nowhere in the reports that I read about fertility statistics do

they say that the infertility rate has increased. But that is absolutely the takeaway of a ton of websites and news articles that take data from these fertility statistics. Now, what is true is that the demands for assisted reproductive technologies, including IVF, have increased, though in some cases they've started to level off and in some countries they're still continuing to rise. But that still doesn't mean that we can

conflate those two things, fertility and infertility. And I think that's one of the things that's really tricky when we in medicine, as we do in medicine, define and view infertility as a disease, as this medical phenomenon, because some of this decline infertility rates might be due to things like an overall increase in the age at first birth, which has been increasing, and we know that and I'll talk more about this. The age of your eggs.

on what society is writing it. Per the who is the inability to achieve a pregnant and if that is desired after twelve months of regular unprotected sexual intercourse, again heteronormative as heck, but that's where we are. This is a medical definition, and per the World Health Organization and so many societies, it is seen as a disease of either the female or the male reproductive tract or both. And so that is the point, twelve months of unprotected

sex without a pregnancy. That's usually the point at which an investigation into what the cause of infertility is would begin. So a question that people often have, because it's a logical question, is like why twelve months? And in part it's because of just the odds. So if you look on large population scales. Most sources estimate that conception rates in the first month of attempting to get pregnant are

about thirty percent. So the first month thirty percent. Then if we look out at six months, the cumulative conception rate at six months is about seventy five percent. And then if you go to twelve months, it's about ninety percent of couples that are trying to conceive will have conceived in twelve months. So that's the main way that we get there.

up to five days. So the fertile window really starts about six days before ovulation, peaks about two days before ovulation, and then is done essentially by the time that ovulation happens, because the sperm also need time to swim all the.

is considered regular enough sex. What's interesting about this timing of twelve months is that if you were to follow again on a population level, couples who haven't conceived at that twelve months for another twelve months, fifty percent of those couples would conceive in that next twelve months within two years, so the cumulative can option rate increases to about ninety five percent at two years.

this starts at around age thirty five. Realistically it starts to decline a little bit before that, but between ages thirty five and thirty nine, the spontaneous conception rate at that one year mark is actually only sixty percent compared to ninety percent if you're younger than thirty five, and at two years it's eighty five percent.

first to the doctor. But all of the literature says this should be an evaluation of the couple. It should never just be an evaluation of one partner. If there's a two partner scenario, which in all of the texts that's the assumption, and then the next step that's going to happen after this kind of history gathering to see if there's any clues as to what the problem could be.

There'll be a bunch of blood tests and probably some imaging studies for the female and a semen analysis and maybe some blood work, but honestly often not even blood work for the male.

fibroids or or something that could be contributing. They might also do what's called a histroosyl pingagram, which you mentioned a little bit Aaron as well in one of your quotes, And this is quite a painful procedure from my understanding, but it's very good for looking at the entire shape of the uterus itself and to see if there's any blockage of tubes or other abnormalities of the uterine cavity that could be contributing, and in some cases people might

end up even undergoing exploratory surgeries depending on again what they find on all of these initial evaluations. Interesting again, for the men, you look at the sperm and you see how many there are, you see what the shape of them are, and you see how well they move. So you're also looking at things like motility. Now there might be more depending on what you find, but that's kind of the first start, and it gets you to a lot of these different causes of infertility. So let's

get into what these are. If we look super broadly, like really really broad, there's kind of three huge categories. It could be male factor infertility, it could be female factor infertility, could be both and that happens, or it could be unexplained infertility, and we'll get there. So at its core, if we're looking at male factor infertility first, at its core, this is going to be an issue with sperm, either amount of sperm or the effectiveness of

those sperm. So this could be an issue with spermatogenesis. So either you're not making enough sperm, or you're making sperm that are morphologically abnormal.

being able to help the sperm be transported. And you can also have hormonal or endocrine disorders that affect sperm production. Those are kind of the three biggest categories that contribute to male factor infertility. When we look at female factor infertility, the way that I think of it is it's most easy to split it up by like organ or area of the body. So you can have issues with your ovaries,

either you have irregular or non ovulatory cycles. We see this in things like PCOS or other hormonal disruptions, maybe thyroid disorder or prolactin, or issues with the ovaries from ocite aging or depletion, either because the eggs themselves are of life or quality because of age, or there's just not as many eggs to be ovulated. But you can also have blockage of the floapian tubes, and this is most commonly caused by things like pelvic inflammatory disease or

severe endometriosis. You can then have problems with the uterus itself that might impair implantation. This could be structural things like fibroids or acceptate uterus like me or or an insufficient lining of the uterus. You can also have cervical factors, either from previous trauma to the cervix or a reduced cervical mucus that impairs sperm transport. Then there's even more rare causes like autoimmune diseases. There is a very very long list of possible causes. Then, for both men and women,

you could have karyotype abnormalities. Right, you might have certain genetic disorders that just make it really difficult to either get pregnant in the first place, or a cause of recurrent miscarriage could be a karyotype abnormalities. That means abnormalities in your chromosome that are small enough that they usually don't affect you, but it does affect the egg or

the sperm that you're trying to produce. And then there's unexplained infertility, which is exactly as dissatisfying as it sounds, because what it means is that you have done all of this work up, you have gone through all of these tests, all of this blood work, and we didn't find anything, and you're still not pregnant and you want to be.

about and then I didn't because who boy. But anyways, it's like it's a bunch of different things that might cause it to be a little bit harder or take a little bit longer to achieve a pregnancy, but all combined together, right, So like maybe you have slightly on the low side of a sperm count, and maybe you have a slightly less receptive endometrium, and maybe you have slightly hostile cervical mucus something that is that the term

it's a term. I don't know that it's a good one, but right, like, maybe you have a little bit of a lot of things, right, or maybe you have pcos so you're ovulating but not on a very regular cycle, and then your partner also has like a little bit of a low sperm count or something. But again those you would think that, Okay, well we've identified some causes.

to do it. And so maybe there is for some people an answer, but they just can't get it because they don't have access to what they need to get that answer.

necessarily fall into medically assisted reproduction MAR or ART. And we'll get into that specific definition in a minute, but that couple would still meet the criteria for diagnosis of infertility, which I think is important. Okay, yes, But the other thing, in addition to what the cause of infertility is in terms of what the next steps are going to be will very much depend on what your access is like and what your finances are like. And that's true here

in the US, but also everywhere. Access to all forms of assisted reproductive technologies is absolutely incredibly unequal because it's incredibly expensive everywhere, not just in the US. So what are some of these different options. One of the first is ovulation induction, and this is something that can be done with either oral medicines or sometimes injectable medications. And

it's what it sounds like. It's inducing ovulation in someone who isn't ovulating or who's not ovulating on a regular schedule. And so this can be done with timed intercourse, so like using a medicine and then just having sex when you're like on the right schedule with this medicine, or depending on the cause, it can also be done in

combination with IUI or intrauterine insemini. Intriuterine insemination involves taking the sperm, washing it because did you know that if you don't wash the sperm, you're going to have a massive like reaction to that unwashed sperm if you inject it straight into the uterus.

a partner sperm or it can use donor sperm. And so that is one of kind of often the first areas that you see this being able to be applied to more than just heterosexual couples is ovulation induction with IUI, and those are kind of the main options that we have, and then we get into ART or assisted reproductive technology. ART is the broader term and I don't know if people say art or art, but I'm gonna say art.

might be the first line in that case. A time when IVF might not be the first line would be if somebody has something like PCOS, for example, then you might reasonably try ovulation induction either alone or with IUI, And the decision there really just depends on the couple. It depends on the situation. So it's not like a black and white there. It's very much a gray area, and there are kind of a lot of other cases

where you might try other things unexplained infertility. Generally, the recommendation is to start with ovulation induction and IUI combined. The thought again being that if there's multiple things that are all contributing to cause this relative subfertility. Then if we can induce ovulation and put the sperm right at the top of the uterus at the right time, then we have maybe the highest chance of success before we jump to something as expensive and time consuming as IVF,

IVF with ICSI. With that, intra cytoplasmic sperm injection is first line for severe male factor infertility because in many cases with severe male factor that's the only way that you're going to have a successful pregnancy. And depending on the age of the couple, especially the age of the woman, it may be that the recommendation is to go straight

to IVF. Also depending on how long they've been trying for, So it's also the case that if a couple has been trying for greater than two years or greater than three years, regardless of what you find as the cause, it's possible that someone would recommend IVF as the first just because statistically there's such a small chance of the other options being as effective, like per cycle. And similarly, if the age of the female is greater than thirty

five or definitely greater than thirty nine. But it all is just kind of depend a little bit on each individual circumstance.

of things like sickle cell or cystic fibrosis. IVF can often be first line for that, and it is used in combination with things that we'll talk about later, and that is pre implantation genetic testing for these specific disorders. So there's a very wide range.

What numbers go into that? Great question.

the timing of intercourse. We don't get taught that in high school biology class, right, We're so focused for so much time on like not getting pregnant, often not always, but so even that most of this initial workup is very reasonable to be done by most like general practiceers

what they're called in most places. That being said, not all physicians are trained in women's health equally and so or in like reproductive health in general, because again we have to look at both women's and men's health, and so it's very possible that some like GP type physicians wouldn't feel comfortable initiating that depending on where you are depending on what you have access to, So then you might be referred to an obgian who might focus just on again, the female reproductive tract.

that incredible book that I've mentioned a few times now. Second, third, fourth shout out the Paul Grave Handbook of Infertility and History, edited by Gail Davis and Tracy Loughgrin, which that was just a great It was a really interesting resource and had so much like very commentary and like scholarly research on the subject that was sort of all over the place and but also really comprehensive.

well as a textbook on reproductive medicine. And we will post all of the sources from this episode and all of our episodes and the next episodes on our website, this podcast would Kill You dot Com under the episodes tab.