How Common Is Infertility? with Dr. Alexis Melnick

Welcome to Health Matters, your weekly dose of the latest in health and wellness from New York Presbyterian. I’m Faith Salie. 

For National Infertility Awareness Week, I’m excited to share a special conversation I had with Dr. Alexis Melnick, a reproductive endocrinologist at NewYork-Presbyterian and Weill Cornell Medicine. This episode is very meaningful to me personally, which you’ll hear, because I became a mother for the first time in my 40s, entirely thanks to the medical wonders of fertility options. I had uterine surgery, egg freezing, IVF, and I love talking openly about how all of those treatments brought me my kids. All right, my husband had a little something to do with it too. Dr. Melnick and I talked about some of the big myths around infertility, compared fertility treatment for men and women, and talked about how vulnerable it can feel to discuss fertility and what it means in our lives.

It was a pleasure to share experiences with and learn from Dr. Melnick. I hope you enjoy our conversation as much as I did.

Faith: Dr. Alexis Melnick, thank you so much for joining us.

Dr. Melnick: Thank you for having me.

Faith: I am so excited and grateful to talk with you because this topic is so near and dear to my heart. And so I hope that you and our listeners might bear with me if I embed some of my own experience because I think it’s so crucial for everyone to talk about their fertility without any stigma and without even whispering, because consciousness around fertility and struggles with fertility are really ubiquitous. And yeah, and, and I really try to be outspoken about my own experience, um, because as, as you’re here to tell us, modern medicine has not just so much hope today, there’s so many options.

Dr. Melnick: It’s incredible what hearing other people’s stories can do. It’s interesting because you come to our office, you know, in the middle of the morning and patients will walk out of the elevator and the waiting room is packed. And I think for most women, They’re just, they just look at that as such a comfort because they’re just like, I didn’t know this was such a common issue. I’m so not alone in this.

Faith: And today we’re here not just to talk about what women might want to know, but men, women, everybody.

Dr. Melnick: Yes, everybody! The destigmatization of fertility treatment, of infertility, we have a long way to go. I think there’s a lot of conversation about not getting pregnant, which is understandably important, but there is a sort of a myth that it gets perpetuated that hey, it’s pretty easy to have a baby and ultimately It’s not as easy. and we don’t do a really good job educating people about how their bodies are working and what it takes to, to, you know, actually get a child.

Faith: What are some basic questions about fertility and infertility that you end up answering a lot?

Dr. Melnick: I think the first is really how easy is it to get pregnant? so I will see a lot of, of patients who come in and say, Hey, we’ve been trying for two months and nothing’s happening. What, what do you think’s wrong?

Faith: Two months!

Dr. Melnick: I know.

Faith: That’s, sorry, that’s not a lot. Isn’t that right?

Dr. Melnick: Totally. But I think that for some people: everyone will say, but all of my friends got pregnant the first time they tried. You know, I got, this person gets pregnant just looking

Faith: Or that movie they showed us in middle school told me that I could get pregnant every time.

Dr. Melnick: Exactly. Exactly. So I think that that is, I think that’s probably the most common concern. And, and I think that’s one thing I really try to tell patients early on is like, hey, it’s not that easy.

I think some of the other big things that come up are, um, birth control pills. I think there’s a very big misconception. We’re seeing a whole generation of women who were on the pill forever, you know, some 10, 20 years, and there’s tremendous benefit for that. But I think that there is a lot of fear that, oh, that’s going to have a long term effect on my fertility which is not true, being on the pill long term does not affect fertility.

It can affect menstrual cycle regularity, so it can take time for cycles to restart, um, or get more regular, so that can delay fertility. So I think that is something that a lot of women come in really concerned, like, oh my god, I’ve been on the pill for 10, 20 years, and I’m freaking out, like, is this going to affect my ability to get pregnant?

I also think lifestyle factors. So I think there’s just, again, it’s really important to live healthy lifestyle in moderation, balance but there are very few things that you’re going to really do to sort of block  the ability to get pregnant from a lifestyle perspective.

Anything to excess can affect fertility in different ways. I mean, again, we would discourage somebody from, from using drugs who’s trying to get pregnant and there are definitely things that can be affected by health overall. So I would discourage that from a health perspective. But, really, that’s not going [00:04:00] to have probably long lasting effects on fertility.

With the exception of cigarette smoking, which has a very clear effect on fertility for both men and women, and many other bad side effects obviously, but really from the perspective of caffeine, exercise, all of these things you don’t have to give up, you don’t have to start taking 25 different supplements, in order to get pregnant, it’s really a matter of just kind of living as healthy lifestyle as you can and, and, you know, doing things you enjoy in moderation.

Faith: When is the right time for someone to start thinking about their reproductive health?

Dr. Melnick: There’s no right or wrong time. It’s something that we should be always sort of thinking about, um, with the understanding that reproductive health doesn’t necessarily mean I’m having kids ever, or I’m having kids tomorrow. The definition of infertility, in women under 35 and we use women as the benchmark, is, failure to conceive after one year of unprotected sex, um, over 35, it’s six months, but these are very sort of rigid definitions and not everyone’s going to fit into that mold. The American Society of Reproductive Medicine just recently, this year, changed the definition of fertility to include women using donor sperm. So, same sex couples or single women. So, that was a huge, huge expansion of the definition, but we have a long way to go. For example, if you’re a man, if you’re a woman without a partner, if you don’t ovulate regularly, and really you can start the conversation anytime.

Faith: Can you say a little bit about what endocrinology has to do with fertility?

Dr. Melnick: Yeah, endocrinology is just the study of hormones. So most people associate with that with things like thyroid, diabetes, really hormones are basically small molecules that are, you know, come from one part of the body and then act on another part of the body. And the reproductive system, like the thyroid, is completely moderated by hormones.

These are hormones that come from the brain and talk directly to the ovaries. And so the entire system that basically goes from the brain to the ovary is really [00:06:00] what’s regulating the menstrual cycle, but also those hormones can affect reproduction.

Faith: And I know from personal experience that when I decided to go see a fertility specialist, I was single, um, I wasn’t planning on having a baby tomorrow, and she found a structural, not hormonal, um, problem that needed corrective surgery, so sometimes it’s not just, uh, endocrinology

Dr. Melnick: One thing that we find sometimes incidentally is something called a uterine septum, which is something that a woman can be born with, which is,

Faith: Poster child here.

Dr. Melnick: I also, I also had one, so,

Faith: There you

Dr. Melnick: so, um, yes, and they’re pretty common, but you wouldn’t really know that you had one unless you went for a workup, and these are congenital issues, um, that are probably a lot more common and probably don’t cause issues in many, many women and go unnoticed, but some women will say, you know what, I want to hear this now. Others will say, I know this is an issue and down the line, I’ll take care of it. But it just, it’s, it’s empowering to have that information earlier on.

Faith: Can you say a little more about what’s different or what’s similar in fertility care for men and women?

Dr. Melnick: So the interesting thing about men and women is that it’s, it’s very similar. And we think about it from a hormonal standpoint. So in the same way that hormones in women come from the brain and affect. the ovaries in the same way, the same exact hormones come from the brain of a man and affect testicular function. So in many ways, the systems are very, very similar and men and women are basically homologous, meaning we sort of are the same in basic, you know, function, but the end organs are sort of different. Um, and, you know, ultimately what it really comes down to is that for the most part, the testing for men is just a lot easier than it is for women. Um, you can really do a semen analysis, um, at first and that’s pretty easy non-invasive testing. And then if that becomes an issue, you can sort of delve more into some of the hormonal issues. The interesting thing about semen analysis, and sperm function in men that I think gets ignored is really that that is a really major barometer for overall health.

So I think one thing that. you know, we hear a lot about, um, is that, you know, both things like issues with the semen analysis, but also things like erectile dysfunction, which you can now get a prescription for Viagra over the internet. But really, that’s been shown to be a huge marker for potential vascular issues, cardiac issues, endocrine issues.

So, um, all of these are, are things that can come up when you’re doing a workup for male fertility or infertility, um, that may lead to finding out other issues that may be going on. So. It’s, you’re still doing a really comprehensive workup for a male, in terms of lifestyle factors, lab work, overall health, medications, you really have to take a good history, and male infertility and female infertility happen really with equal incidence.

Faith: I find that fascinating and, and frankly surprising. Um, this basically just comes from ignorance, right? As a culture, we look to women like, why, why hasn’t this couple had a baby? What’s wrong with the woman? Assuming it’s a heterosexual couple. But it’s surprising to hear that looking at male fertility issues starts in the same place. Your, your brain, what are your hormones doing? Is that something you discuss with patients frequently?

Dr. Melnick: Yeah, I mean, I take a, when I see a heterosexual couple in front of me, I’m taking a really detailed history for both, because there are often things that will come up that, um, you know, we find in the male partner that are leading us toward what could be going on.

Faith: Frankly, what a relief. Because I would imagine from a medical point of view, it often easier to deal with male fertility issues than female?

Dr. Melnick: I always say that, you know, a low sperm count or some of these issues can often be such an easy fix. So yes, oftentimes that is the best prognosis patients are people who [00:10:00] come in where it’s an issue with, you know, sperm count, sperm motility, things like that. Those are often very easy problems to solve. So yes.

Faith: We always hear that guys should stay out of hot tubs… is that true?

Dr. Melnick: Yes, so that actually is true. So of all of the things that are, you know, myths, so that is one that I do, um, say to men and occasionally I’ll find a man who loves like steam rooms or hot tubs and that is really because heat can affect, um, sperm function. So, um, I do always ask about that. Um, that’s also why we say boxers over briefs, um, because it’s just a cooler environment for the testicles.

Faith: Do you find yourself explaining what our window for fertility is and how ovulation works? Because I know I didn’t really understand it until my late 30s when I cared about it.

Dr. Melnick: I would say I explain this to probably at least 75 percent of patients that come in to my office, and this is where I feel like, we as a society, we just, we don’t do a good job of educating people about what’s really happening. I think women are taught, hey, you get a period and then you’re sort of fertile and, and then you’ll go through menopause and then you’re not. And that’s kind of all we know. Um, so yes, I spend a huge amount of time explaining to women what ovulation is, what happens in ovulation, what’s happening each month at the level of the ovary, and how that sort of changes over a lifetime.

Faith: I’m sure you have this down to a science, no pun intended. Can you give us the 60 second, uh, primer on ovulation and when we can get pregnant?

Dr. Melnick: Yep, so basically every month the woman starts each month, um, with a group of eggs in the ovaries and these are called follicles. The brain sends a certain amount of hormone, um, at the beginning of each month to the ovary to recruit one of those follicles to be the dominant one, the one that’s going to release the egg and that one grows and develops and as it does so all the other ones that are there that month die out. So, basically, each month you use one egg and you lose a bunch. Um, somewhere, typically mid cycle, so typically after about 14 days, but it can be [00:12:00] variable, that egg gets ready to be released, and basically that follicle bursts and the egg actually bursts out of the ovary, and that’s ovulation and then that egg is swept up into the fallopian tube, and fertilization happens in the fallopian tube, so after sex or after insemination sperm and egg meet in the fallopian tube, and then if fertilization happens, that egg makes its way into the uterus and implants.

If someone is pregnant, then they’re gonna have a big rise in hormones, um, particularly progesterone, and, um, will not get a period. If someone is not pregnant, that progesterone drops, and they will get a period as a result of that drop in progesterone.

Faith: So the time when, if you are having quote unquote conventional sex and not doing this with the help of a laboratory, um, the time when a woman can get pregnant is if sperm enters her uterus, what two days before ovulation?

Dr. Melnick: Basically zero to one days before ovulation is the highest likelihood of getting pregnant. So the day before and the day of ovulation.

Faith: And can you get pregnant the day after ovulation?

Dr. Melnick: Basically no. The chances are basically zero. It’s a very short window. Very. 

Faith: So this is why it is not that easy to get pregnant.

Dr. Melnick: Exactly. It’s not. It’s a very short window. The body is very, very good at keeping this window very, very short. And there’s only one egg released. I mean, that’s the other thing. Maybe somebody releases two in a month and that’s how you can get fraternal twins, but it’s usually one. So the chances are pretty low. A lot has to happen to, to get pregnant.

Faith: Okay, and so this leads into fertility decline, which in women is, becomes precipitous. And, um, in, in men, uh, you can tell me, seems to sort of go on forever notionally.

Dr. Melnick: Yes.

Faith: Eventually become infertile because they run out of eggs completely. Is that why?

Dr. Melnick: Well, yes and no. Um, really the, the bigger issue than quantity is actually quality. [00:14:00] Women are born with all the eggs they’re ever gonna have. So, and actually the peak number of eggs you have as a woman is actually when you are in utero. So at 20 weeks in utero, women have, uh, 6 to 7 million eggs.

By the time they’re born, it’s down to 1 to 2 million. So it’s like, a very big decline. Um, you start puberty, it’s a couple hundred thousand, and then by menopause, it’s under a thousand. So each month, though, it, you know, you’re going to start with a certain number of eggs in the ovary, and that’s your sort of follicle count.

If you go to the doctor and say, what’s my follicle count? That’s what they’re going to do. They’re going to do an ultrasound and count your follicles. But when we think about this from a natural reproduction standpoint, that follicle count is sort of irrelevant because you’re really only going to ovulate from one of those follicles per month, and the rest you’re going to lose.

So, um, what really is a bigger deal than the count or the quantity is the quality. As you get older, those eggs have been in the ovary for longer, and like everything else in the body, they age. So they’re just more susceptible to, um, errors, particularly in, you know, how chromosomes are dividing and separating at fertilization. So, if you see somebody who’s 40, who has a count of 25 follicles in the beginning of a cycle, and you see somebody who’s 30, and you do their count, and they have 7, that 30 year old still has a much, much higher chance of getting pregnant

Faith: because of the quality of the 30-year-old follicles.

Dr. Melnick: And so really the decline, the, the decline in fertility happens way before the, the end of periods.

Faith: So does male fertility decline?

Dr. Melnick: It declines, but it does not decline in the way that female fertility does. Sperm is, constantly regenerated. So it’s very different. Sperm that is ejaculated was created recently. It wasn’t, men are not born with a fixed amount of sperm. Um, so they, there is not the same issues. However, there are, definitely declines in sperm function, in semen parameters, um, as men get older. And more and more we are learning about the potential for certain genetic issues that can come from older sperm, from older paternal age.

Faith: So it’s fair to say sperm quality does [00:16:00] decline.

Dr. Melnick: Definitely, definitely. and I think one thing I think that we will probably start to see is I think we will probably start to see some men actually freezing sperm preemptively in the way that women have frozen eggs, which is kind of funny that that wasn’t done already because. It’s so much easier than freezing eggs, but, um, I don’t think it was on anyone’s radar. But I’ve already definitely heard of some men who have just decided to do this preemptively.

Faith: We’ve talked about some big myths about fertility and infertility already, such as, hey, it’s easy to get pregnant. Not necessarily, not true. Are there some others that, that you often have to address?

Dr. Melnick: That 35 is this horrible age for women and that basically after you hit 35 you fall off a cliff and there is, you know, no hope for you…

Faith: Yes, because I don’t know why, you can tell me, but the medical community calls it a geriatric pregnancy after 35?

Dr. Melnick: They still do. I f you look at your chart if you have a baby, I had a baby, you know at 40 and and my chart had said I was an elderly pregnant person. So it’s, it’s terrible. There is a decline with fertility, a little bit later than 35, you know, all hope is by no means lost, um, over 35 at all.

Um, and I think that’s a, you know, I see people who say, I’m turning 35 next week, what do I do? It’s not like this week you’re going to be fine, and next week you’re done. So, that’s a really big, um, common misconception that I see a lot. 

Faith: When I was 29, I very much remember seeing my gynecologist who was like, tick tock, And she was like, you’ve really got to start thinking about this. You know, it’s, it’s not so simple as just biology.

Dr. Melnick: No, not at all.

Faith: I hardly need to tell you, I [00:18:00] get emotional about this, mostly out of gratitude. This is a hugely emotional topic, and people come to questions about fertility with all kinds of expectations and ideas about how this relates to their identity. It’s, their visions of their future identity, their worth, their family, and their hopes and their dreams. How do you help people navigate the really intimate and emotional side of, of making choices about fertility?

Dr. Melnick: So for me, one of the first things I will say to patients, um, is look, if you want to be a parent, one way or the other, you will be a parent. There are a gazillion ways to build a family. What you have to get on board with early on is that, like most things in life, this may not happen the way that you thought it was going to happen.

And if you’re sitting in front of me, it may already mean that things have not happened the way that you thought they were going to be. But I think that that’s really important for, for people to hear.

Faith: That’s such good preparation for actually becoming a parent, because once you do become a parent, it also doesn’t go the way you think it was going to go.

Dr. Melnick: Exactly. And I’ve had patients come back to me and say, you know, you told me I was going to be a mom, and I didn’t believe you, but, and if you told me this is how I was going to do it, I would have told you absolutely not, but look, I’m here, I’m a mom, and, thank you.

So I, I think that’s, to me, that’s the most important thing you can say to somebody who comes in and is struggling and just give them that reassurance like, look, I don’t know how it’s going to happen. I can’t necessarily map it out for you, but this ultimately can happen.

Faith: So one of the things that I am most proud of myself for in my life was at 38 when I was single, but knew I wanted to be a mother sooner than later, was just going to a doctor to have what you called a workup and being brave enough to be like, Okay, I’m going to take a deep breath and get all the information.

Some of it I may dread, but I need to know now, right? And by the way, when I did do that, I found out that I needed to have a procedure done, and then after that all the choices opened [00:20:00] up. When it comes to fertility treatment, when is it the time to start the process?

Dr. Melnick: if you’re actively trying to get pregnant and you’re not, then I would say, again, I would not wait any more than six months if you’re over 35, and I wouldn’t wait more than a year if you’re under 35, but it can be earlier than that, it can be even before you’re, if you know you’re about to start trying and you’re just really nervous about it and you’re, I have a lot, a lot of couples who say, look, we’re in our late 30s.

We suspect this may not be as easy as, as it is, would have been for somebody younger. Can we just do some of the testing now? So there’s no really right or wrong time to do it. And I don’t ever, I don’t turn people away and say, hey, it’s too early. I think information is really helpful. Um, I think from the perspective of just getting sort of a, you know, a check on where things are.

So one of the Big, another big myth is that you can come into an office and check your fertility. Hey, I want to know what my fertility is. I want to know how fertile I am. Well, until you have unprotected sex, you know, you can’t, you don’t know how fertile you are. That’s the problem. The only way to know if you’re fertile is to basically try to get pregnant.

So, but what we can tell you are What does your ovarian reserve look like? We can make sure that it looks like you’re ovulating regularly. If you’re a man, we can make sure that your sperm, you know, semen analysis looks good and that there don’t seem to be any major medical issues. You don’t have erectile dysfunction.

That could be, you know, an issue. Um, we can do, you know, look at the uterus and look at structural issues that may become an issue. So there’s a lot of just, you know, basic testing that we can do to see if you might need more help down the road, um, and just be more prepared. And I don’t think that there’s really a, You know, it’s never too early to really do that.

Faith: So in other words, going to a fertility doctor doesn’t necessarily mean you’re going to start a course of intense medical interventions.

Dr. Melnick: No, and that’s another big, now, now all these myths are coming, that’s another big myth. You go to a fertility doctor and the next day you’re, you know, injecting yourself and you’re going through an egg retrieval. No. Um, and I think more and more I am seeing couples where they come in [00:22:00] once, and then I’m not seeing them back for, you know, sometimes more than a year, two years even, because they just wanted some information.

Faith: So, I’m really excited about this next question because I think it might have been, the most important decision I ever made in my life. Um, women increasingly wonder about freezing their eggs nowadays. Some seem to agonize over the decision. Um, I saw it as an absolute game changer for me. If someone is considering egg freezing, what factors should they consider?

Dr. Melnick: Do I think that there’s a possibility at any point in the future that I may want to be a parent, and is this something that is not happening in the near future? Um, and to me, if that, the answer is yes, there, I don’t see any real downside of egg freezing other than cost.

And obviously cost can be prohibitive, but I really think we need to look at this as a preventative health issue. Um, I think that it should start being looked at that way, and primary care physicians are doing a great job of bringing this up earlier and earlier. Um, and so I’m seeing women earlier and earlier for discussions about this.

And it may be that they come in at 27 and I say, look, Everything looks great. Statistically, we’re not going to see much change in the next three or four years. And if this is an issue where you need to save some money up, then spend the next couple of years doing that. Um, I think, to me, this is, like you said, it’s a game changer.

It just gives you a huge amount of options. You are not tied to using those eggs, um, when you, if and when you want to have a baby. It doesn’t mean you have to use those eggs. This is not going to affect your ability to get pregnant naturally. There is really little to no downside in doing it.

And the way that I tell patients is, look, what I wouldn’t want is for you to go back and be like, Regretful. I should have done this. It’s happening less and less, but I will have. Women who come in and they [00:24:00] sit in the office in front of me and they cry That they’re having this conversation freezing eggs, like it’s a failure like oh my god I can’t believe I can’t believe i’m here and I always say like, you know, turn that frown upside down.

Faith: I’ll just add that the, the emotional, mental health, and empowerment side of it is, hard to fully express. The, the change it can make in someone’s life to have done that.

Dr. Melnick: Absolutely. I feel so privileged to do what I do, and I think as a woman, being able to kind of understand, having gone through a lot of this, these issues myself, being able to understand it, it just, it’s, it’s so special to share that with patients, um, I mean, it’s, it’s just, it’s so rewarding.

Faith: If someone has some big questions or is looking to go to someone for guidance, where should they start?

Dr. Melnick: I think it really depends. You can start either with your OB GYN, um, who may be a great resource. Um, most OB GYNs who feel that what the questions are are sort of out of their purview will say, look, Go see a reproductive endocrinologist. You can also go right to a reproductive endocrinologist. I see a lot of, of patients who have very distant goals for family building. They’re nowhere near, they’re nowhere near that stage in their life, but they just have questions about their timeline, issues. I think if they have other, other health or other medical issues or other issues with like the menstrual cycle, for example, it’s kind of a good idea to get a hands on, you know, make this be more challenging when they do want to try to get pregnant.

We have an entire field out here that really seeks to help people build families in the way that they want to build them, and science has really allowed us to make that happen for many, many people who didn’t think it was a possibility. Um, I think there is never any downside to kind of starting the conversation Um, and getting the information. Information is tremendously empowering when it comes to this.

Faith: And I also want to reiterate your message that if, if you decide you want to be a parent, [00:26:00] you can be a parent. Some way. It, it can happen

Dr. Melnick: Absolutely. Yes. Yes. That is, that’s my number one message always.

Faith: Dr. Melnick, um, thank you for this conversation. I feel like what you do and what we’ve been talking about is this kind of magical intersection of science and miracles and hope and empowerment.

Dr. Melnick: Thank you. It’s so, it’s very special. I’m very, very lucky to do what I do.

[Outro]

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[Kicker]

Faith: Um, and so, um, the woman who told me in the nineties that I should not sit on cold floors because that will, um, keep me from having babies: she wasn’t a doctor?

Dr. Melnick: No, she was not, and that is not true. Yeah, that is not true.

Faith: Okay, I’ll get in my time, my time travel apparatus and let her know.