Optimising patient fertility transcript

Hello and welcome. I’m Caroline West. Welcome to our program on optimising fertility. This is proudly brought to you by the Fertility Coalition which includes VARTA, Jean Hailes for women’s health, the Robinson Research Institute and Andrology Australia. Now what we’ve done today is we’ve pulled together key factors that can make a huge difference when it comes to fertility. We’ll be looking at lifestyle risk factors like alcohol and smoking. We’ll be looking at the impacts of age and weight and very importantly, we’ll be looking at the timing of sex as well. Now this program has proudly been funded by the Australian Government Department of Health and Aging under their family planning grants program and if you’d like any of the resources or any of the information that we cover today then go to the Your Fertility website at yourfertility.org.au. A wonderful place to get a terrific set of resources. Now today we are going out across the vast rural health channel and you’ll be able to see this program live on the website or stream it or if you’d like to go to the Your Fertility website you’ll be able to access it there and if you’d like a DVD for free we’ll be able to organise one of those for you as well. Just go to our website for more details. Of course, today would not be possible and it wouldn’t be possible to have interesting discussion without a panel and I’d like to introduce to you now our wonderful panel who will be opening up this conversation on fertility. First up I’d like to introduce you to Rob, Professor Rob McLaughlin. Tell us Rob, what’s your particular interest in this area?

Certainly Caroline. I’m an endocrinologist with an interest in male reproductive medicine. For that purpose I am a director of Andrology Australia which is involved in community and professional education around the country in this area and from a clinical practice point of view I’m the consultant andrologist to the Monash IVF program, so I’m heavily involved in male factor infertility.

Wonderful, so we’ll be hearing from you, from the male perspective today.


Fantastic and next up I’d like to introduce you to Dr Kate Stern. Kate, could you outline for us what your particular interest in fertility is?

Thanks Caroline. Well I’m a gynaecologist and reproductive endocrinologist and fertility specialist and I’m the head of a unit at the Royal Women’s Hospital which specialises in endocrine and metabolic health for women in the reproductive age group and in my capacity as a fertility specialist I’m one of the clinicians at Melbourne IVF and I’m in charge of clinical research for that organisation.

Fantastic, so we’ll be turning to you for the nitty-gritty questions on fertility.

I hope so.

Fantastic and  I’d like to introduce you now to Professor Stephen Trumble. Stephen, welcome and perhaps you could tell us a bit about your perspective in this fertility discussion.

Well my current role is in clinical education at the University of Melbourne, the Melbourne Medical School but primarily I’m a GP and I’ve had an interest in men’s health for quite a long time and I’ve just recently started doing rural locums and I’m beginning to find out more about what is involved in providing care in rural areas and also learning in rural areas.

Fantastic. Well I hope to tap into your knowledge and wisdom there when it comes to rural health challenges. It’s a very interesting angle. So perhaps we could start of though by asking the big question, I’ll start with you Stephen, how we actually start, when it comes to this conversation, with our patients because this can be a very delicate area can’t it to actually broach with our patients. Where should we begin? Should we be proactive?

Well I think being proactive is a very important part of a lot of preventative health and health promotion. As a GP I think rarely you find this is the primary reason for presentation but it’s often something that you can throw in, in another consultation and set the scene for a more detailed discussion.

Okay, so use it as an opportunity, as a window of opportunity.

Yeah, exactly. Just plant the seed so to speak and keep on mentioning it. I mean general practice is a longer term relationship with a patient, with a couple and often it takes a few mentions before they will actually get the idea that this is an important topic to consider more fully.

So you have to build that rapport and trust.

Yeah, exactly and that’s a very important part of the first meeting you might have with a new couple or an individual who is new to the practice. It’s about building that trust and setting the scene for health promotion over the next few visits.

This is not just GP’s we are talking about here; we are talking about other people within the healthcare team.

Anybody in the primary care team. Primary care is all about finding out about people, what’s important to them and then helping them understand what might be important they haven’t actually thought of yet.

Fantastic and Kate, from your perspective today, what’s a sort of key area that you think we should be covering at some stage today?

Well I think that as you say, there are some very important lifestyle factors involved in general reproductive health and fertility. It’s not just fertility, its hormones, particularly with respect to women’s health and it’s really important I think that people understand that they can have some control over their own destiny. It’s very important for doctors and primary care physicians and all health professionals to be really aware of how important the basic lifestyle factors are so that we can try and empower our patients and help them to maximise their fertility.

That’s wonderfully important isn’t it; to really encourage patients to think yes, there is something that I can do to contribute to my fertility in a positive way.

I think that’s right. We really want to maintain reproductive health rather than have to always come in at the time of pathology. It’s really important to – and to make people realise that there are basic, easy, sometimes not so easy but manageable things to do that they can really aim to improve their overall reproductive health.

Rob, you are going to be sharing with us the male perspective today. Tell us about that.

Absolutely. I think it’s important to recognise that male fertility is a very significant cause of human fertility problems. Perhaps a third of infertility has got something to do with the male and so it’s also common in the general population, perhaps one in every 20 men have got a fertility issue. So I think it’s important to engage the guys and their partner, understand this is a common problem that things can be done to work out what’s going on and get around the problem very often. So one has to be active I think in encouraging a discussion about the male, just as much as the female.

I guess that’s one of the myths that we have to bust isn’t it.

Absolutely. It’s very clear that there is gender equity when it comes to fertility problems.

Does that come as a shock to some people do you think?

Yes. I guess some people still have the view that it’s usually the woman. I think that increasingly as a community we recognise that that’s not the case and there’s been much more public discussion of male fertility and other male health issues like erectile dysfunction and hormone problems. There is a lot more male health talked about, all the way through to the prostate of course which gets a lot of publicity. So fertility has come along with that increased recognition of the male health, reproductive health and it certainly gives the opportunity to engage the man in lifestyle discussion, which is the point I think Kate was making. They come along with fertility concern but at the same time you can tap into issues which affect their fertility and also their general health because after all, there is not much point having offspring if you are not going to be around to enjoy them or help them along. So it’s a real opportunity I think to engage generally in the male health.

Which is I think what you were referring to before Stephen, that window of opportunity to open the conversation.

That’s the whole point about men’s health isn’t it Rob, it’s not all below the belt. A lot of it’s about general lifestyle. If you can engage with the man on things that are slightly less threatening about smoking, activity and things like that, then you can sort of narrow in on the gonads once you’ve dealt with the global picture of health. I think a lot of people think that you have to have a testicular problem to think about men’s health or a prostate problem but it’s actually a global lifestyle issue for me.

The term men’s health is now very widely applied to the social determinants of health just as much as the biomedical determinants of health. So I guess today we are talking about a fairly focused area but you always find yourself blending out into more general health and lifestyle issues.

So it’s really that holistic approach that we talk about here isn’t it.

That allows men to have – you sort of have to give men often permission to be able to talk about these things because their fertility and hormonal issues are very private and often they feel emasculated by discussing them and I think it’s sort of giving them permission for a safe environment to be able to talk about these issues.

It is very tied up with masculinity though isn’t it in a way and providing somebody with a place where they can talk about this without feeling judged is hugely important.

So perhaps what we could do is bring all of these ideas together in our first case study. Are you happy to outline a case study Stephen?

Sure, well it’s a very simple case. I mean this is the way people turn up to primary care, without a lot of records, a lot of background and it’s all about finding out what is going on and building that relationship. So the first couple that we should talk about, both 31 years old, Alana and Carl. They’ve just got engaged and they’ve moved into the area where we are and that can be really anywhere in rural, remote Australia and they are attending the clinic for the first time. The reason for attending is pretty common. They have come along for travel advice. Two patients, one appointment. Not much time and it’s actually fairly complex to prepare somebody for a trip – for their first trip to Asia particularly and there is a bit of heart sink when they say we are just here for some quick injections.

Don’t you love that, they say we here for just a 15 minute appointment.

The last thing on your mind is I’m going to talk about preventative health beyond the simple immunisations but this is actually the opportunity, not to get in there and do the whole thing, but just to again, plant that seed and start people thinking about it. Move them into a position of contemplating their health more broadly. They will come with maybe a questionnaire filled out at the front desk about what their previous medical and family history is, whether they are smokers, how much they say they drink, allergies, medications and things like that. In the couple that we are talking about today, let’s say maybe both of them smoke. The first thing that you would do as a primary healthcare nurse or doctor or whatever would be to do the basic health assessment and then focus in on the reason for being there. I think any couple is going to look a bit askance at you if you go off on your agenda about what you want to talk about when they’ve come in for what they see as being fairly simple, typhoid vaccination, malaria tablets if they need them and off they go on their honeymoon, but it’s about dealing with that reason for presentation but also mentioning a few other things that are important, building that rapport, developing the trust so that when they come back and you can schedule a review appointment you can then focus on the things that are important for a healthy lifestyle.

How do you broach the subject though when people are not expecting it, because it can be one of those tricky conversations to have can’t it?

Better if they bring it up but I guess part of the skill is prompting them to bring it up. It’s just a few comments like often when you are talking it will be about occupation or something like that. She might say “I’m a partner in a law firm” or “I’m aiming to be a partner in a law firm within five years” and you are doing the maths and thinking 31 plus 5 is 36, okay, how am I going to mention this and so “tell me about the wedding, what made you decide to get engaged and what are you planning”. “We are planning on having children” or “my parents will never accept us living together without being married”. Things like that. It begins to develop a picture about what is going on in these people’s lives and then you can start to put in little things about “five years is a long time to be planning your career ahead, other things turn up, have you thought about that”. They might say “we moved to this area because there is great schools, we are planning on a family”. Little cues that you can jump on and I guess part of being the GP or the nurse is thinking about how can I grab something from that comment to put my health messages onto that’s actually going to mean something to this individual person.

Kate, do you think that young couples often have realistic expectations when it comes to their own fertility and what timeframes are the best ones to look at?

I think that’s a very good question. I think there are a lot of couples who really feel at that age somewhat invincible. They’ve got over that sort of adolescent invincibility about living excitingly and they are now onto their sort of career and other interests and I think that people forget about the impact of age and age is the most important factor in female fertility and I think people do forget about that and the other misconception is that people think that fertility treatment will fix up any age issues. So it is okay to go and wait and wait and then try and seek help when you are older because the fertility treatment will be able to override that and I think that’s the biggest misconception that we see. On the other hand, that stereotype of the high flying career woman, that’s actually not my experience. My experience with seeing patients, particularly women in the older reproductive age group who come on their own is that they just haven’t been able to find someone that they want to partner with. It’s not so much that they are perfectionists and Mr not quite right and all of that stuff and it’s not really so much “I haven’t got time for a career”, it just really hasn’t happened, but they still – it’s more the couples that are together for a while thinking it will be okay later on.

So often they put other things first don’t they. They might consider “we really want to secure our financial position” or…

Or there’s material things which…

Or travel.

I think that’s true.

Is it our role then to broach that area of timeframes then, realistically with patients?

I think it is.

I think it’s also important for the partner to understand that.

That’s a very good point Rob.

The guys – it’s a couple’s decision and sometimes I see couples where the lady is aware of it, the oncoming of age and the effects it could have on her fertility and perhaps he is saying things, “yes, but we have to pay the house off” or “we have to do this” or “we have plans for next year”. He needs to listen to the fact that what you are saying to his partner is not something that can be affected. As Kate says, IVF is not going to get around the age of the female. So he needs to listen and hear it so when they go home in the car from the consultation they are having some really meaningful interaction about this issue.

Have the seed planted.

It’s important that that happens together but do you see them separately as well? Sometimes there are quite different reasons going on for the two people.

Usually the couples come together and are with me together. If I sense that there are issues I will usually examine the guy and ask his partner to step out. I don’t routinely always speak to the guy separately because the wife often wants to be involved in every single discussion and is taking notes but I certainly, on occasion, if I sense there is a discordance between what page they are on, it’s important to talk to them individually.

I’m still embarrassed by the man who called me up afterwards and said “I couldn’t say at the time but I actually have fathered a child with another woman that my wife doesn’t know about but I reckon I’m okay”. That’s really quite difficult in a family medicine context but obviously he wasn’t able to say that in front of her. He needed his opportunities.

When the patients come to see me they tend to be, I think, remarkably forthcoming about their previous reproductive success. I saw a couple yesterday where she had had two pregnancies with other guys and he had had several pregnancies with other ladies and that had all been discussed before they came into the room, but perhaps my interaction as a specialist is a little bit different to the primary care and particularly if they are chronic patients of the practice and they know all the staff and whatever, it’s a bit different.

So Stephen, just sort of going back to your position as a GP in a community, what would you also like to include with this couple in terms of screening or advice just on this preconception planning?

A lot of it’s about the way that they strike you at the time about where they are in their thinking process. I mean if they are already well on the way to thinking about having a baby and all that you don’t want to say “come on, get busy”. I mean that’s not appropriate. It’s about…

It might be, they are going on holiday.

Honeymoon coming up you’d sort of hope so but it’s about – and sometimes the discussion about contraception for example is a good way to discuss this. I mean “okay, so you are obviously living together, have you thought about a baby, have you thought about contraception, if not, what are you doing in terms of thinking about having a baby”. It’s really about planting the seed I suppose but also reminding them there is a whole lot of things you need to do before you get pregnant if you are going to have the healthiest pregnancy you can. So you can engage them in that sort of discussion as well, about vaccination, the flu, rubella, varicella and things like that. Whooping cough, all much better done before the pregnancy even starts as well as getting diet and activity, smoking and things like that sorted out because often they don’t know they are pregnant when the foetus is at the most risk, the embryo.

In terms of the lifestyle factors that you might chat to them about at this point?

Well this is where I guess the GP takes a much broader view and you might talk about the general health and a lot of viewers will be aware of the SNAP program where you talk about smoking, nutrition, alcohol and physical activity more broadly, about cardiovascular and respiratory health and things like that. You’ve always got to look for a hook though for people to want to engage in that sort of activity and if they are really keen to get pregnant or starting to think about it, then it’s a good way of saying “look, you want to think about having a healthy pregnancy and then a healthy life so that you can enjoy the children as they grow up”. So preventative health and motivational interviewing and counselling is all about finding something that means something to that individual person and if they are thinking about getting pregnant then that’s when I really start to push the concept about pre-pregnancy planning appropriately without shoving it down their throat.

Is there anything you’d like to add to that one Kate?

Well, I agree with Stephen. It is sort of sometimes hard to get too much detail when they are coming to see you for something else but I always just tend to sort of barge in with a few general questions about cycles. I’d been looking for potential risk factors, warning signs, that might help us to alert the patients to the fact that they might have difficulties, such as a family history of early menopause or family history of specific cancers or really big problems with the cycles, very erratic cycles. So things that might impact on their subsequent fertility that it would be great to be able to warn them about early so that they don’t delay their coming when they actually really do want to try and get pregnant.

So the PAP test and the contraceptive review are great chances for us to talk about those sorts of things in general practice because obviously it’s a permission or ticket of entry to talk about gynaecological health.

It sort of gives you that sort of chat opportunity for chat while you are doing something. It’s like Rob talking about examining the patient. I think what we all really try and seize are the opportunistic little chats while you are doing something else to just see if it highlights anything. You know, “have you had problems with your cycles, are your periods terrible, did your Mum have any difficulties getting pregnant with you”. You know, those sort of little things.

It’s very time efficient to do that while you are doing other things as well.

Even men can do that Stephen.

You can try a bit of chlamydia screening, what other screening tests should providers be thinking about apart from the vaccination checks and the lifestyle discussion, is there anything else that we need to be thinking about from that proactive point of view?

Again, thinking very generally, probably just do a general health check. You might do some general health screening looking for signs of anaemia, urinary tract infection, things like that as well as the vaccinations but I don’t think – in the first instance you wouldn’t actually sort of technicalise it too much. It’s more or less a discussion just raising the issues, getting people thinking about it. You do an examination of course of both, looking for varicocele in men.

When they are coming for their general check?

No, sorry, I should have made that clear.You wouldn’t do this – it’s a journey. This is the joy of primary care.

This is come back from Bali with Bali belly to see you. Exactly, they’ll be back.

Another opportunity, another window of opportunity.

You’ve got to make them want to come back. If you do it all, they will freak out and never come and see you again.

Dr overdo it.

It’s all about planting the seeds. Planting the seed of doing this later on because it’s reality for the doctor or the nurse as well. What can you really do in that crammed appointment? They need to get their vaccinations, get their antimalarials if appropriate and go but they go with the plan to come back and follow up on preventative health type things later on when you can give it due attention and it’s all about saying “look, I’d love to deal with all these things now but it’s not in your best interest that we rush this, it’s something that we need to plan for over the next couple of visits”.

Rob we also need to make sure that we are always being very inclusive here, including the male partner as well as the female.

In this case the gentleman has gone along with his partner and so you are identifying shared problems. They may both be overweight. They may both be smoking. Well you can hardly expect her to smarten up her act and let him continue to eat and drink whatever and smoke whatever he likes. So the couple would have to begin the process of re-evaluating their life with a view down the track to conception so now is a good time to start.

Often you do things well in partnerships too don’t you. For example, if you are going to quit smoking, it’s great to have a buddy.

That’s right and there are other indiscretions. Marijuana use is quite common. There are other shared activities which you certainly would not advise in preconception where the guy has to go along with the decision as well and of course your passive smoking for example, there’s evidence that that is negative to the female partner. So you can hardly have him have a pack a day and her have nothing because she is going to get some.

Stephen, what are the sort of challenges that rural practitioners face when discussing fertility? Is it a slight different situation in terms of the things that you need to be working with?

I think it can be a little bit different in a smaller community because everybody sort of could be looking at the newlyweds, when is this all going to happen and that sort of thing. I can still recall a young woman coming in quite upset because nothing was happening and her father had said “you’d better change your bull” because things weren’t getting along which is a fairly agricultural approach. I knew exactly what he meant.

So she went to Melbourne.

Yeah, where there is a bigger choice of bulls I suppose but it is very hard I guess when the scrutiny is on a couple. The pressure is there if they feel they are not producing when they are supposed to produce but I think at the stage that our couples are at, at the moment, it hasn’t even got to that point. There is the issue about access to specialist care and I guess when we move to the point of needing to do investigations – and I can still recall, many years ago, Rob writing me a very polite letter in which you said that maybe I should have gone for a more specialised semen analysis laboratory for example rather than using the one around the corner and I wasn’t sure about that. I thought counting was counting but obviously the technique of the technicians is important. For me, I thought, just pass the sample – it sounds awful but just produce the sample locally and we will see what shows up but if you are going to do one, I suppose it’s best done in a more specialised laboratory which is hard to access if you are rural.

Certainly the second one. If it looks like there is a problem on the first, most certainly.

So screening on the first one is okay in a rural…

Probably, pragmatically speaking, if it’s 300 kilometres to the nearest specialist lab that’s a hell of an ask.

Even the issue of taking the sample to the local laboratory with your name on it. I mean obviously the laboratories are very confidential about things but there is a sense of scrutiny and having to remember your brother’s birthday because you put his name on the label when they are checking the marks. It can be quite embarrassing.

What about those other issues too, I guess the cultural considerations. We’ve got many different groups across Australia. We’ve got people from Aboriginal backgrounds, people living in remote rural areas. What sort of factors do we need to think about there?

To be honest, I’m really not sure what the view in indigenous communities is about fertility.

I guess it’s something as practitioners we need to be mindful of, that different groups will have different cultural views.

Most certainly in the cities like Melbourne where you’ve got many, many different nationalities and cultural issues at play, one has to very much adapt the level and the terms you use, the use of visual diagrams in some circumstances can be offensive. There are things you don’t mention. Donor insemination in some examples is verboten. So you wouldn’t mention it because you know that this couple would not accept that. So you have to be very flexible and understanding of what the patient is hearing and how they will take that message home with them.

So it’s really about health literacy isn’t it. Tuning into where somebody is at and what is really shared information.

I always feel safest when the patient is taking I must say. If I can actually get them to tell me what they know about infertility and what they know about conception and things like that, then you can respond but if you go into transmission mode and you are telling them what you think, often you do miss the mark. These days, if this couple has moved onto thinking about fertility in a more proactive way, they educate themselves in inverted commas through the internet and with various articles they find in women’s magazines and so on and that sets their mind as to what is possible for them and I come back to Kate’s point about people see 45 year old actresses having twins and they think if they can do it, I can do it. Well obviously they are donor sites most of the time and yet it comes across in the public press as being easily fixed through a technological fix which is not there. So people often have a lot to say based on what they think they already know and sometimes you have to kind of re-educate them about what the thing is that’s really true. That’s a gentle process isn’t it. You have to be very respectful about people’s misunderstandings but obviously steer them towards what we’ve got evidence for and we are lucky there is good evidence.

I guess that Segway’s nicely into perhaps our next case study which is on that topic of a slightly older woman who is looking at starting a family. Kate, perhaps you could outline the next case study. Perhaps she’s been reading some of those glossies and thinks that time is on her side.

Yes and this is a very common scenario we deal with and this is a 37 year old woman called Jane and she is overweight. Her body mass index is 36. So she is in the obese category. She’s just started trying to conceive for a couple of months with Bill, her partner, who is 42 and she has been reading quite widely and quite intelligently and she’s really come to just have a chat. She actually hasn’t brought Bill with her today but she’s just come to have a chat to find out about how she can optimise her fertility. So this patient is quite tuned into the fact that there might be some difficulties and she really wants some advice now that she is just embarking. So she’s really at the next step on from the first case that we had today and she wants to know what’s important and I think that some things that are really important to talk to her about are going to be her age and the impact of her age on fertility. Women are stunned that at 37 their fertility is already somewhat impaired. The number of good eggs that they have is reduced at 37. That starts somewhere in the sort of early to mid-30’s and it’s not a tangible thing. You have regular periods and you have pain with your periods and they are clockwork and you get mid-cycle symptoms of ovulation. You have no concept that the eggs might not be as good as they used to be. So I would be talking to her about the fact that fertility is starting to decline at 37 and the time to get pregnant, or what we call the time to conception is likely to be several months longer than it would have been at 33, 34 and there is a slightly higher risk of having abnormalities associated with the wrong chromosomes in the eggs and a higher risk of miscarriage. You don’t want to be overly pessimistic and you don’t want to sort of cause panic and make her think it’s hopeless at all but you just need sort of a gentle chat about the fact that it could take a bit longer and we need to be quite proactive about this and “I’m really glad that you started now, let’s see what we can do to help you, in a non-medicalised, somewhat casual way, extensively casual way, really maximise your fertility”. Fertility at 40 is a real problem for a lot of women and I don’t think women realise that 90% of their eggs are not going to be very good at 40 whereas at 35 maybe 25% of their eggs aren’t very good and so I think it is really important to reinforce that fact. The next thing that I think would be important to discuss with this woman is her weight and her BMI is 36 which makes her obese and you know, after all these years of running weight loss programs, the thing that I realise most is that women feel it’s an insurmountable hurdle. They are never going to be able to make enough of a change to make it worthwhile. This is of course the best time to garner motivation because these women want to get pregnant so you have that added motivation, as well as the long term gains of the long term benefits of reduction of risk of diabetes and heart disease and I would be talking to her about her weight which could be potentially having an effect on her ovulation and her cycles, particularly if she has a tendency or has polycystic ovarian syndrome. Even when you have regular cycles the potential to conceive is somewhat reduced when you are in the obese category and there are lots more pregnancy complications as well.

So it’s really about encouraging some lifestyle changes in that window of time.

Encouraging that you can have a relatively minor degree of weight loss that will really help your ovulation and help your fertility, to make sure that they realise it’s manageable and reachable and not just say “look, I’ll see you when you’ve lost five k’s” because that’s not giving any help whatsoever. I think you need to help them to develop strategies in terms of lifestyle management with dietary advice, exercise advice.

What are the thoughts on exercise? So is increasing your fitness going to be beneficial as well?

I think there is no doubt that exercise, quite independently of weight loss and nutritional change does benefit not just your general health but your overall fertility and it’s a mixture of resistance and aerobic exercise. Look, we would recommend 30-40 minutes three to four times a week but you don’t want to scare someone off with that so we sort of start gently and work up and I think the most important thing is to make people feel that they can do it with your encouragement.

Now she’s been on the internet, she’s consulted with Dr Google and she’s read that maybe she could get a simple blood test that would give her an idea of how many eggs she had left. What are you going to say to her?

Yes, well this is a very vexed issue. There are a lot of women who think that they can come and get an egg timer test that will tell them how many eggs they’ve got left and how to plan their lives and the tests that these women are referring to is AMH or anti-mullerian hormone which is a hormone that is produced by the small growing follicles in the ovary and it’s an indirect guide to long term fertility but it’s not an overwhelmingly useful test on most of the occasions that it’s organised and I think maybe we shouldn’t be blaming the test but we should blame the incorrect and inaccurate interpretation of the test. Now if someone has an incredibly low AMH, less than one, then that is significant in a young woman or a woman up to her mid-30’s but most women in their early 40’s are going to have very, very low AMH results and a low AMH result doesn’t mean you can’t get pregnant, it just means that you probably won’t be able to get pregnant in a few years’ time. The low middle range of AMH is notoriously misinterpreted and I find it really not useful but a very, very low, a significantly low AMH, i.e. less than one is important in a young woman whereas in a woman who is 40 an AMH of less than one means nothing, but a lowish AMH, the centile of 25-50, is really irrelevant and really shouldn’t dictate further management.

Now they’ve been to the pharmacist, the local pharmacist and they’ve said “what else could I be adding to the picture here”. Is there any advice that we could be giving our patients about any additional supplements or any additional nutrients that may make a difference? What’s the evidence there? Obviously there is folic acid with preventing neural tube defects. What about the bigger picture?

I don’t think there is a lot of evidence behind natural therapies are there? Zinc was around for a while. I don’t think that’s been proved.

There’s a great many products that are proffered on the internet and in the pharmacies to boost various – both the sexual performance and your fertility but to my knowledge they really are not evidence based. They are likely to be harmless, not harmful and so at worst they are going to cost a dollar a day.

We are in no position to criticise placebo effect I suppose, we do it all the time.

That is the issue, because to establish the particular fertility benefit of a treatment you’ve got to have a group that’s untreated, a placebo group and demonstrate a difference between the prospects for the treated and untreated and that’s almost never done. Antioxidants are probably the best example of a medication for which there is a great deal of promise and promotion with very thin evidential basis. There is some evidence that perhaps there is a benefit to antioxidants but it’s well short of grade A evidence and so many of the patients that I find are already on antioxidants, I don’t stop them but I don’t offer them myself.

That could also get back to a healthy diet couldn’t it because you can find a wonderful array of antioxidants just by eating a lot of colourful vegetables and fruit.

Antioxidants are used to sell everything now and I’m not sure there is any evidence that they’ve ever been shown to have a benefit to any human condition. There has been much promise in heart disease and so on and they’ve turned out to be essentially useless. I would comment that people do take alternative therapies and sometimes they import them from overseas and you don’t know what’s in them. I often get asked, I’m on whizzo juice from such and such, is that okay and I don’t have any idea what’s in it. When a study was done in the US, some of those chemicals actually do have biological effects which are arguably harmful. So I don’t like people taking things they’ve got off the internet because I can’t vouch for what’s in them. I’ll make one other quick comment because if I forget to do it later on, testosterone or male hormone will never boost a sperm count. It in fact suppresses sperm production. It’s a contraceptive. In the same way as the pill suppresses ovulation, testosterone will suppress sperm production. Every now and again I have a well-meaning doctor who has tried to boost his patient’s sperm count by giving them testosterone injections. By the time they see me, they’ve got a zero sperm count and they have to take several months to back out of it again. It’s reversible. Very embarrassing. Of course people who go to the gym and are perhaps taking steroids at the gym, people like that, they will also always have a very poor or zero sperm count but I guess I’m saying you do have to, in a non-confrontational way, which picks up the point that Steve made earlier on, explore what people are actually taking. “What are you taking exactly” and I can remember very well, one guy came in and I looked up on the web when he was there and it had Androstenedione and DHEA in it and I was saying “no, do not take that”. So DHEA will cause the same problem? Well this was a whole mixture of weak antigens. It’s just not a good idea. It has no benefit. It could arguably be partially suppressive. So you have to explore what people are taking and that includes people who go to the gym and generally speaking they will say “I do on occasion have a shot”. It turns out they are on bucket loads of steroids but you have to bring these out in discussion.

So really, it’s about getting back to our original point which is developing rapport and trust and really understanding from the patient’s point of view what their knowledge is and what they are actually doing themselves and pushing those sort of key lifestyle messages the whole time about the things that can make a difference, but on this point of men, perhaps that could bring us into your case study, if that’s alright Rob. From the male perspective, perhaps you could describe your case for us.

My gentleman is 41. He’s come along basically because his wife was concerned about the fertility and the local doctor arranged a sperm count and it’s come back at one million per mil. Very low sperm count and he’s completely twitched out about this. He comes along and really he says “I smoke a bit, I drink a bit, could that be the cause of it, is that why I’m infertile, can I reverse this”. The difficulty about male infertility is that on the whole it is likely to be a sperm production problem which is inborn to the man. It’s a genetic problem and those ultimately aren’t able to be treated directly but this comes to the key point which has been made several times, the guy has to be evaluated thoroughly with a thorough medical history and a physical examination and in that medical history you are focusing on previous fertility attempts, normal sexual development, sexual function, evidence of testosterone sufficiency or deficiency, history of trauma to the genitals, undescended testicle surgery as a little child or inguinal hernia surgery as a small child. These are very important pointers towards possible sperm production problems. So this gentleman, my 41 year old guy, it turns out that he actually had an undescended testis when he was little and that’s already getting my mind towards thinking that this guy’s got a sperm production problem which is inborn and whilst it’s clearly a bad thing to be smoking and drinking too much and I will encourage him not to do that, one really couldn’t point the finger at those and say this is likely to be the problem. The thing is, when you are evaluating a patient with infertility, you’ve got obligations and the first obligation is to try and make a diagnosis, give an explanation for what’s going on. With any luck, it will be reversible. With good fortune, you can restore natural fertility and get his sperm count up. Even if you can’t fix it, you owe it to him to tell him that the problem is there, “I can’t fix it” and then discuss options and there are a whole range of IVF options and so on that are available and the other thing to emphasis is that fertility problems in men is associated with a high risk of certain conditions such as testicular cancer and testosterone deficiency. So it could well be, although he came along to see you worried about a low sperm count, you will pick up, during your investigation, that he’s got some problem with his testosterone production or with his sexual function or testicular cancer. So there are multiple reasons why the guy needs to be thoroughly evaluated.

We so often thoroughly evaluate women don’t we and we have that opportunity when they come in every second year for their PAP test to have the conversation, have the physical check-up whereas men often just slip through the net don’t they.

They do not get routine genital examinations in adulthood and we know this I think by one classic condition which is the archetypal condition of male reproductive health, Klinefelter’s syndrome 47 XXY chromosome. This is one in every 600 men in the population and we know from epidemiological studies that only about 30% are diagnosed for their entire life. So seven out of ten Klinefelter’s men are never diagnosed. They die unrecognised, usually at a fairly normal lifespan but nonetheless, they have missed out on the opportunities for treatment with hormones and so on throughout their life. Why is that? It’s likely to be that some of these guys are not particularly health literate, they perhaps don’t go seeking to be examined or whatever but it’s also that there is not a culture of routine genital examination in general practice very often because if you examine these guys for one second, his testes are unequivocally small. They are the size of the end of your finger, like a small sultana grape. You couldn’t miss it if you examined it and I make the diagnosis for this 35 year old guy because I am the first person to ever examine their testes since puberty. So I think it tells us something about the level of comfort we have for genital examination. So Andrology Australia one of the major points we make for general practitioners, is to normalise reproductive health evaluation, both in the infertility context but also in the general medical health review context. It’s okay to examine the genitals. This might be the first time they’ve actually come for a consultation because all the men’s health focus tends to be on prostate and 40’s onward.

Heart disease, diabetes prevention.

So coming along with their partner might be really the only time for your opportunity.

There are other reasons to examine men in their life.

The PAP test is the ticket of entry to the female genital examination. There is not really something in young men.

There used to be. In fact Dr Klinefelter made the diagnosis on military recruits in the second world war because they all got examined and he said “gee, there are all these guys with these very small” – and that’s how Klinefelter’s syndrome was discovered, because it was routine examination during military exams.

The small arms inspection they called it.

Small arms inspection, right, but I think it’s entirely reasonable to at least do one routine examination of young men. It’s not a big deal. It only takes a second.

I was surprised doing the reading before the broadcast just how common factors are, environmental factors and health factors, for men’s fertility. As a GP I didn’t realise about aging for men particularly. I think we do know pretty well about women but it was quite astonishing to read the decline in fertility.

There is a measurable, if you like modest effect of age on male fertility. After the age of 40 or 50 you can see declines in natural fertility which is partly due to less intercourse as you get older but also due to a modest decline in sperm quality and in IVF programs, if you control for female age and just look at the male age you can see an effect of male age but to be fair, it’s pretty modest compared to the female. I have a slide which shows a gentle slope like this and a cliff and I think that’s the sort of message. I think you can oversell the effect of age on male fertility. It’s certainly there but relative to the issue of supporting women to make the reproductive choice at a time when success if more likely as Kate was eluding, then I think the most important age factor for men is to support their partner as much as to worry about their own age. We obviously know that many men in their 40’s, 50’s and 60’s and beyond have children.

Particularly with young wife’s.

That’s the stereotype isn’t it.

There is plenty of evidence for us of a measurable increase in birth defects and certain medical conditions in the offspring of older men which point to the fact that there may be more subtle mutations in sperm of older men but these are very unlikely events, but it does show you that age does affect the male. My point is it’s not as profound and precipitous as it is for the female.

What about the impacts of stress on fertility? Is there any evidence there that stress has an impact?

Well, in the male, stress would be manifest by a reluctance or an inability or less frequent ejaculatory intercourse. That would be the most likely. Depression and so on is associated with sexual dysfunction, erectile dysfunction so sure, if you are saying does stress directly lower sperm production in the testis, it’s pretty hard to evaluate in the human. In the animal models you can demonstrate it so I guess it’s possible.

It’s one of those very grey areas. I guess patients will sometimes come and they’ll say “we’ve been trying and trying and trying and we went on a holiday and hey presto” and in their mind it’s been cemented with a less stressful environment as being conducive.

What about the female? Is ovulation affected by stress? It’s a good question. There are the obvious things like extremes of weight and change in eating habits and exercise associated with stress. Both ways will affect ovulation. There is no doubt about that, but the more subtle markers – a lot of women come and say “my job is so busy and we are trying to get pregnant and I’m so stressed, should I give up my job because that’s making me so stressed” and there are lots of studies on stress but good research on stress is very difficult to achieve because the end points are very intangible and I guess you would say that significant stress can have a very subtle effect on your fertility but really, I say to people there is no problem being busy, it’s when you are worrying about how busy you are and how stressed you are that has the biggest impact and aside from the impacts of your weight. I think that’s where the natural therapies come in. A lot of women feel better by doing acupuncture and having herbs, either Chinese medicine herbs or naturopathic herbs and I guess if they feel better in themselves… The same with the guys taking antioxidant therapy. One likes to be in control of one’s destiny and even if it’s harmless and empirical you are likely to do it and I do not judge. I would do probably the same thing myself but it’s a difference between accepting it like an expression of the human’s desire to be in control and do something as opposed to proffering it as a direct treatment. If I can just come back to my case for one second because another thing that one sees is advice being given to my 41 year old guy with the sperm count of a million and they’d been trying for 12 months and they are not pregnant yet and he thinks that they are never going to get pregnant, there is a background chance of pregnancy, even in men with very low sperm counts. For example, this is the work of Gordon Baker, a very renowned colleague of Kate and I, many years ago he followed couples were the sperm count was at various levels, perhaps between one and five million and from the time they started trying to get pregnant until conception did and didn’t occur. About 30% of those men with counts of one, two, three million, which is pretty low, got their partners pregnant within two or three years and so what you see is that those fortunate ones who are going to get pregnant despite the low count will do so in the first 18 months or two years. Then their chances really flatten off and so when you are consulting with people about what should they be thinking about doing next, clearly the degree of sperm impairment, the duration and conscientiousness with which they’ve been having sex and for how long is the next factor. Obviously the age and reproductive health of the partner, because the outlook is entirely different if you’ve got this guy here who’s been trying for a year but his partner is 39, has got a blocked tube and has polycystic ovary syndrome. You can imagine how the two things add together. So the advice that you give about the natural prospects are very much informed by his level of defect, her level of issue and the consciousness and duration they’ve been trying and these are the equations that we in the fertility area are always putting together on a personalised basis trying to give advice to the patient about what is the next thing they can be considering. Absolutely agree, absolutely.

It’s something with little steps along the way and every case is truly individual isn’t it, in terms of the factors that are involved and I guess our role in general practice is often to work through those factors.

In the rural setting particularly I guess where the people are going backwards and forwards from the big city, where inevitably the fertility specialists tend to be and I guess it’s important for the GP or the primary care clinic to have information about what messages to continue promoting and what to continue to do between the visits because it is difficult getting to the city.

That’s where resources come in handy as well isn’t it, resources like Your Fertility where you can go online with a patient. I had somebody in the other day and we were talking through the age conundrum and we just went on the internet together and pulled it up and watched the clip and explored that and it was a great talking point and I could have been here or I could have been in Darwin. I could have been anywhere.

I think that’s particularly important Carolyn with things like caffeine and alcohol. The sort of consistent general messages between the primary care physician, the specialist, the community, every magazine you read, so resources like that, that give consistent and practical information are really good. Alcohol is such a difficult one isn’t it. There’s so many mixed messages. Getting pregnant on holiday it’s probably more the pina colada effect I guess than anything else but too much is too much. It’s about moderation I suppose.

I guess we are dealing with a community who is largely resistant to alcohol messages aren’t they. Safe levels of alcohol consumption across the board, that’s a challenging area for us.

I suppose there is no safe level when you are trying to get pregnant. That’s the thing. It’s quite a challenge.

So how do we bring that up with patients and what do we advise them there?

I would personally tie it into a whole lot of messages and just try to point out that if they really want something to happen, it’s about expectancy, literally in this case. If you expect this outcome what can you influence that can actually give you the best chance of achieving that outcome and sure, alcohol is pleasurable, however, the connection between alcohol and lowered fertility is quite clear as is with smoking and weight and the other things. So really, if you want to achieve that outcome, you are going to have to do some work and I’m here to help you do that as part of the team but it does require you to make some effort in order to achieve the outcome that you both want.

So it’s capitalising on that motivation isn’t it. Yeah. Perhaps working out what’s in it for them and what they feel they can actually target first.

Why would you do anything if there was nothing in it for you? That’s what it’s about isn’t it. If you really want this outcome, we’ll help you work towards it.

I guess those lifestyle interventions will have far reaching effects because we are not just talking about fertility, we are perhaps talking about setting up a blueprint for a healthier future across the board. So you will be healthier parents.

You are creating a family here so let’s think about the whole family health and what sort of lifestyle you are going to lead as parents and what sort of diet messages you are going to give your children and smoking and things like that. So the evidence or the reasons start to mount up for people to actually change their behaviour and getting pregnant is the first step but there is a whole lot of stuff downstream and I think this then should snowball from there.

So on that area of lifestyle interventions Stephen what do you think is the take home message from today, from your point of view?

Getting pregnant is one of the major events in anybody’s life I suppose and for a couple it’s often what they’ve come together to achieve as part of their relationship and in some ways it gives you the ultimate justification for lifestyle change and sustained lifestyle change. Unfortunately, being a parent is stressful and if anything is probably going to make you look for some of those comforts in life, maybe it’s the struggle of being a parent but that’s where a longitudinal relationship with a primary care service is so important to anticipate people running into problems with the terrible twos and when the next child comes along, school and things like that and it’s continuing to give those positive messages all the way through the person’s life so that they lead a healthy life and that the next generation of children then grow up with those healthy lifestyle messages as well.

The primary care team can really be involved with that as well. So we are not just talking about the GP, we are talking about the practice nurse, healthcare workers.

It’s the whole community really is the thing. I mean a healthy community is really what this is all about and bringing children into a community that’s going to be healthy and support them. Sporting teams and clubs and things like that. Keep them busy.

Kate, from your point of view, it’s targeting lifestyle changes in a sustainable way. That’s the message that I’ve heard again and again today. Can you tell me about that?

As Stephen says, what we are doing is harnessing an opportunity with a short term goal which will make changes that will really affect the long term and to me the important thing is for patients to realise this is not just empty rhetoric that your doctor is filling out because they have had their education seminar. This is really important stuff that actually makes a big difference to not just your fertility but your reproductive health and the long term but you need to be able to do it in a sustainable way.

We need to have confidence as practitioners to be able to bring it up and gently explore some of these areas as being a health issue.

Without driving our patients away, as Stephen was saying. Without them going “I’m not going back to that person on their soapbox”. It’s a fine balance.

Encouraging those little changes and as you say, small steps, having realistic goals so that you can enjoy the momentum, creating some momentum. Okay, good and Rob, from your perspective on the lifestyle front?

Obviously I agree with the comments made and I guess it’s important to remember that the guy contributes not only individually but by support of his partner to all of those outcomes and that for his reproductive health and his long term health and the ability to be a good and long lived father, looking after your exercise, weight, smoking, drug use, other related behaviours is important. It’s important to support the guy, that he’s not sort of left out of these discussions. It’s not just the lady going to the fertility specialist, it’s us going and it’s great to see the couples addressing this problem shoulder to shoulder rather than one person taking all the weight and the worry. So I try and get the guys to understand what their partners are going to go through and what might be involved for her and how he can help her to that goal. So I think it’s a team effort. You can’t be infertile by yourself. You need to be a team.

I guess as you say, encouraging the couple to come along together to be there in the consultation because very often women go through many consultations alone and then they have to go home and relay what they’ve been told and sometimes that message can be changed in the translation and it’s difficult to sometimes include everyone.

By the time they come to see me they are already pretty open to what needs to be done and discussed and most couples I find are very cohesive in listening and asking questions and I can imagine them going home in the car afterwards and they ring back with questions they forgot to ask and so you really can’t give them too much time or too much feedback on their concerns because they may not be all asked in the first consultation. You do get phone calls at funny times and people coming back because they had something else they thought might have been important that they forgot and of course the local doctor is in an ideal position to give that continual reflective support whilst getting hopefully good service from people like Kate and myself.

This is an opportunity for a plug for your website. Where can men get more information or couples get more information on men’s health?

Andrologyaustralia.org is a very open portal. Andrologyaustralia.org and we will supply – there are downloads and booklets and everything of course is at no change and that covers a whole range of male reproductive health including prostates, erectile function, testosterone as well as fertility issues.

Would either of you like to add anything else at this stage?

No. I think this is a great example of prevention.

I think there will be a lot of surprises. I think there are a lot of myths and misconceptions. We’ve covered them today. Things like timing. Things like the impact of age that we don’t have forever and even things like weight. I think that a lot of people understand the connection between weight, diabetes and heart disease but people may be quite surprised that weight can also impact fertility and the good news there is that even small amounts of weight loss can actually start to turn that picture around. So that’s encouraging news for patients and for their practitioners.

That’s a switch around for a couple too, isn’t it. To go from spending the first part of the relationship desperately trying not to get pregnant to suddenly switch it around to trying to get pregnant. It’s a change in mind set.

That’s right. So thank you very much for being part of our panel today and I hope that you’ve enjoyed this programme on optimising patient fertility and the importance of lifestyle factors, those factors like age and weight, alcohol, smoking cessation and, as we’ve heard, the timing. So if you’d like any more information on any of this we’ve mentioned the Andrology Australia website and also the website at Yourfertility.org.au. So thanks to the Fertility Coalition for making this programme possible and thanks also to you, our audience for attending. If you are interested in obtaining any more information on the programme, if you’d like to watch it again on the website, if you’d like to obtain a free DVD, please contact us at Fertility.org.au. Yourfertility.org.au and don’t forget to complete and send in your evaluation forms to register for CPD points. Thank you once again for joining us. I am Carolyn West. Thank you very much to our panel. Goodbye for now.

Your Fertility is brought to you by the Fertility Coalition: the Victorian Assisted Reproductive Treatment Authority (VARTA), Jean Hailes for Women’s Health, Andrology Australia and The Robinson Institute. This Project is supported by funding from the Australian Government Department of Health and Ageing under the Family Planning Grants Program.