Fertility Docs Uncensored Today’s episode of Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. Today, their guest is Dr. Alex Quaas from Shady Grove Fertility in San Diego. In this episode, the group discusses how physicians develop individualized fertility treatment plans, using real-world scenarios to highlight how age, ovarian reserve, reproductive goals, and emotional considerations all shape decision-making in reproductive medicine. The discuss a 36-year-old patient with a high antral follicle count, elevated AMH, irregular cycles, and otherwise normal testing who desires two children. Dr. Quaas explores treatment options such as ovulation induction and timed intercourse as a reasonable first-line approach, while also addressing how advancing maternal age increases the risk of genetically abnormal embryos. He explains when in vitro fertilization (IVF) may be advantageous, particularly for embryo banking to support future family building. The case is then reframed to consider diminished ovarian reserve, prompting a shift toward recommending earlier IVF to maximize the likelihood of obtaining genetically normal embryos. Additional factors influencing treatment planning are reviewed, including the impact of endometriosis severity on fertility potential and how mental health, emotional resilience, and tolerance for uncertainty may guide patients toward more or less aggressive approaches. The physicians also explain how IVF protocols can be customized, including decisions around stimulation intensity, the number of eggs fertilized, and whether to pursue genetic testing. Throughout the episode, the emphasis remains on shared decision-making, in which physicians provide guidance and patients ultimately choose the path that best aligns with their goals and values. This podcast was sponsored by Shady Grove Fertility.
Episode Transcript:
Carrie Bedient MD (00:02.039)
Hello and welcome to another episode of Fertility Docs Uncensored. I’m Dr. Carrie Bedient from the Fertility Center of Las Vegas and I am joined by my two sensationally scintillating sexy co-hosts, Dr. Abby Eblen from Nashville Fertility Center.
Abby Eblen MD (00:16.967)
Hi, everybody.
Carrie Bedient MD (00:18.664)
and Dr. Susan Hudson from Texas Fertility Center.
Susan Hudson MD (00:22.118)
Good morning, everyone.
Carrie Bedient MD (00:23.766)
We have a special guest today, Dr. Alex Quaas. And Alex, make sure that I get this right. Shady Grove Fertility in San Diego, is that correct? Perfect. Okay. There’s several Shady Grove. So I wanted to make sure that I nailed the location you are in because you are a force and a personality to draw everyone into that location. And so wanted to make sure people know exactly where to find you.
Alex Quaas (00:34.637)
That’s correct.
Yeah, it’s the only one in California. it’s actually to be precise, it’s in Solana Beach, which is a little north of San Diego.
Carrie Bedient MD (00:57.14)
Excellent. So before you lived in San Diego, you have been all over the world and you were telling us that you’ve actually practiced REI in other countries, particularly Switzerland. So how did you get there?
Alex Quaas (01:13.721)
Well, I’m originally from Germany. It’s not hard to tell from my accent. And basically, I’d always wanted to come to the United States for residency and fellowship and that stuff. And so I did my residency in Boston and then my fellowship at USC. But along the way, I also met my wife who’s originally from England. so As we were…
sort of living in the United States and working here, at some point we were thinking, maybe it would be nice to go back to Europe and be closer to family. And so During COVID, I got an opportunity to become division director at the University of Basel in Switzerland. And Basel is only about a half hour by train from my hometown Freiburg. And so that was like, in some ways, a perfect opportunity. And so It was very insightful and very interesting to practice REI or practice fertility medicine in another setting and another continent. And so I got very interested in the geographic and international differences in what we do.
Carrie Bedient MD (02:18.56)
So, what’s the difference?
Alex Quaas (02:22.809)
Um, How much time do you have? mean, there’s a lot of, There’s a lot of differences. mean, Some of the core stuff is the same. So for example, of course, the, the, the general gist of what we do is similar. for you. Yeah. But then there are so many differences in the details. And, um, I usually, like, when I talk about this, I break it down, like there are some legal differences, some cultural differences, and then like health system related differences, insurance stuff. But then there’s also like something that’s also existing within the United States. And that’s the, that’s how we’ve always done it. Like, so Oftentimes in many places that I’ve worked at, there was somebody that had trained somewhere and they did things a certain way. And then that was the way that everybody did everything for the rest of time. so That’s a little bit what I encountered in Basel. There was a very, very, very charismatic and kind of famous professor who was there for many years, several decades. And so he had instituted treatment plans that were basically like the way he had trained. And it was very interesting to see some of the differences. so I was trying to…bring myself in, and, and, and, and, effect some change, from the things that I’ve learned here, but change is hard. And so, I think in the end, it ended up being a little bit of a hybrid of how we practiced. but you know, maybe for example, little example. So for example, when I arrived there, we did the egg retrievals without anesthesia, which is something that doesn’t really happen that much here. Or for example, there was a practice where it was mandatory to put a tenaculum on for the embryo transfer. And so that was actually the first thing I changed. I was like, no tenaculum for an embryo transfer. So things like that. But in the grand scheme of things, it was just very interesting to see what things were similar and what things were different. And from that, I always say, when you see completely different ways of doing things, and if the success rates are somewhat similar, then you can also see what’s actually important and what’s not as important.
Abby Eblen MD (04:46.035)
Yeah. Hey Alex, quick question. I’m just curious, we had somebody on a few months ago that talked about genetics and donor sperm. I’m just curious, what kind of genetic testing could you do, just briefly, and then could you use donor sperm on same-sex couples, single women, that sort of thing?
Alex Quaas (05:06.413)
That’s a very interesting question because so first of all, like expanded carrier screening was more or less non-existent. It seems in Germany and Switzerland, it’s like, you know, something that isn’t really being done. Like You can maybe test your carrier status for cystic fibrosis, but that’s like one test and not everybody does it. It’s not universally offered. So carrier screening is something that I found is not really something that’s being done there very much. With regards to donor sperm. It was interesting. that the Swiss had a fairly archaic reproductive law up until 2017. So in Switzerland, you can always change legislation if you collect enough signatures and you put it up for a public vote. And so In 2016, they did that for the reproductive law and then many things changed. But one of the things that’s been there for a long time is that donor sperm was only permitted for married couples where, you know, there’s no functional sperm.
And so lot of the, you know, so single women, same-sex women at the time didn’t used to be able to do donor sperm treatment. And they would usually go to Denmark because apparently in Denmark, in like some suburbs of Copenhagen, there’s a lot of like midwifery practices where it’s relatively easy to do donor sperm. But, you know, The one thing that has changed in 2022, they allowed same-sex couple to marry in Switzerland. And so From that point on, at least the married same sex couples could also do donor sperm. So that was something that we started. But if you’re single or unmarried, you cannot use donor sperm.
Carrie Bedient MD (06:44.6)
Hmm, that’s fascinating.
Abby Eblen MD (06:45.531)
Interesting.
Susan Hudson MD (06:46.556)
Is PGT-A allowed in Switzerland outside of a sex-related gene defect?
Alex Quaas (06:57.027)
Good question. Yeah, that was changed with the law change in 2017. So that’s now allowed. But the rate of uptake of PGT-A was much lower over there than it is over here. And like only about like maybe 10 to 20 % of the couples that I took care of over there would do it.
Carrie Bedient MD (07:16.014)
That’s fascinating. I love hearing about what other places in the world do and do not allow and what are the cultural differences between them and the scientific and everything because it’s just, there’s so many nuances that we take for granted here that, well, of course you’re going to do PGT-A and of course you’re going to have access to donors and gestational carriers and doing cycles multiple times and whatever it may be. And that’s just not, not necessarily the case in the rest of the world.
Alex Quaas (07:43.713)
Absolutely. And it’s also interesting because I felt like one of the biggest differences was that there was still a sort of general mistrust of what we do sometimes. Like I had much more couples that came and were like highly suspicious of all this work that we do and this sort of Frankenstein’s like creating babies in the lab type of situations. And then I felt sometimes felt like a little bit interrogated. About like, but what, you know, like, are these babies healthy? And you’re like, what’s gonna happen? you know, and so Sometimes after like an hour of defending IVF, I was like, well, you came here because you want a baby, you know, like, I feel like, you know, like, I’m happy to explain everything and go over the research into long term consequences. you know, but at the end of the day, you don’t have to do this. you know, like if you’re so Yeah, so I think as a society, I think the United States has arrived largely at a place where IVF, even though of course there’s lots of controversy and things like that, but there’s a large support for it and people are also relatively open about it and they share their stories and things like that. I felt like in Germany and Switzerland, it’s a bit more private still and a little bit more stigmatized.
Carrie Bedient MD (09:11.33)
That’s, We could probably do an entire episode just on that. Alex Quaas (09:15.416)
I have a talk at PCRS, by the way, about this topic, about international differences in REI.
Abby Eblen MD (09:26.045)
Well, will say Tennessee lawmakers are a lot, which I’ve talked to several in this week, they’re a lot like the patients that you talked about. They thought we were creating Frankenstein in a lab, so.
Alex Quaas (09:35.705)
And it’s so interesting, maybe we can sort of switch topics soon, but the very interesting thing about all this is that when the Supreme Court verdict happened in Alabama in February of 2024, there was more talk about personhood amendment, about embryo protection laws and things like that.
So in Switzerland and in Germany, they had these embryo protection laws in place. And in Germany, actually, that is still in place. And so We have seen there what happens if you cannot cryopreserve blastocysts. So for example, in Switzerland, up until 2017, you could freeze zygotes, so 2PN. So they call it fertilized eggs. A fertilized egg is not an embryo yet, apparently, because the sperm has entered the egg but the pronuclear haven’t fused yet. So a fertilized egg is not an embryo. And so you can freeze a 2PN, but you can’t freeze a blastocyst. And so up until 2017, what happened was a patient would get a certain number of eggs, let’s say 15 eggs, and they might have 12 2PNs. And so then they couldn’t let them all grow to the blast stage, but only as many as are likely to be able to be transferred. So then we would only allow like two or three of these fertilized eggs to grow and we had to transfer all of it. And so basically after the law changed, the single embryo transfer rate went up, the pregnancy rate went up, the multiple pregnancy rate went down. So the bottom line is when the Alabama Supreme Court verdict happened, I basically wrote an article that was published in Human Reproduction that states this is what’s going to happen.
If we change things back to these, you know, archaic embryo protection laws that we have in Switzerland, we have examples from other countries that teach us what will happen if in the United States we have that kind of legislation. So that’s the interesting part, because I think that when people advocate for those type of personhood amendments, they need to be aware that the success of IVF will go down, the multiple pregnancy rate will go up and things like
Susan Hudson MD (12:00.88)
That’s great information.
Carrie Bedient MD (12:01.058)
Yeah.
Abby Eblen MD (12:02.224)
I may need that citation from you after this. Okay.
Alex Quaas (12:04.984)
I’ll send it to you.
Carrie Bedient MD (12:05.036)
Yes.
All right, Susan, what’s our question for today?
Susan Hudson MD (12:10.454)
Okay, our question for today is, am a 36 year old who has been trying to conceive naturally for 11 months. I had stage one endometriosis excised in August of 25. I do not have a regular cycle and I am not ovulating. I have lean PCOS with an AMH of 10.6 AFC at 36. My husband’s sperm tests are normal. All my other tests are normal, including HSG. We would ideally like two children.
I am unsure if we should start with a medicated cycle for time intercourse or IUI or go straight to IVF due to my age and risk of endometriosis recurrence. Thank you for your advice. What do you think?
Carrie Bedient MD (12:49.154)
So this is a fabulous question, given that today we were gonna talk about how do we create individual treatment plans for patients. And so let’s start with this. So kind of the highlights, 36 years old trying for 11 months, lean PCOS with irregular cycles, so ovulatory dysfunction, stage one endo, and wants two kids. So looking at those things, Alex, how would you approach this type of treatment plan and probably more importantly, the counseling for this type of treatment plan? What things do you, first of all, What things do you take into consideration when you’re approaching this type of patient?
Alex Quaas (13:33.795)
Yeah, excellent case and actually a very realistic sort real world scenario because we will see somebody like this probably several times a month. Yeah, exactly. So I think some of the things to take into consideration were contained in the presentation of the case. So for example, how many children? I I think the desired family size is always a big factor. And I think that’s one of the first things and most important things that I…I ask because if somebody tells me they want four kids, then it’s a no-brainer that maybe, especially at age 36, they should have a lower threshold to move forward with IVF. The other things to consider are the acceptance of the risk of multiple pregnancy because let’s say in this patient, she has lean PCOS.
The obvious first thing to potentially consider would be letrozole plus intercourse. If the husband has normal sperm, presumably she has hopefully open tubes. I didn’t know if her…
Susan Hudson MD (14:43.322)
I think she said normal HSG.
Alex Quaas (14:45.625)
Normal HSG. So then the obvious easiest first thing to do would be oral ovulation induction combined with intercourse because that’s the cheapest and quote unquote most natural. But of course, you know, if it’s really important to this patient to have two children, then you have to also talk about the fact that she’s 36 already. And while, you know, if you did oral ovulation induction, successfully twice back to back. mean, It’s not unrealistic that that could succeed. The eggs obviously never get better. They get worse over time. And therefore I would say if like there was insurance coverage, if money wasn’t a factor, because at the end of the day, the reality is in what we do, money plays a role because not everybody has the insanely, you know, the amounts of money that are required to do an IVF cycle because it is not cheap, let’s be real. But if money wasn’t a factor, then of course it would be like the easiest and in some ways the most efficient way would be to do one clean IVF cycle, create embryos and you would likely get all the embryos that you need for two babies. I think, you know, I always tell patients there’s no couple that’s the same that another couple that I see.
And there are always so many nuances. And I always also say that I never make treatment decisions for couples. I provide options and I will say like what I would maybe do if I were in that situation or if that patient was my sister or my cousin and asking me, hey, you know, these are the options that they told me, what should I do? So the bottom line is in this patient, the things that need to be considered highly are the history of endometriosis, the incredibly high quantitative ovarian reserve, which puts this patient at risk of OHSS if she were to do treatment.
Abby Eblen MD (16:54.684)
What’s OHSS?
Alex Quaas (16:56.512)
So ovarian hyperstimulation syndrome, which can happen, it happens less and less nowadays because we have gotten much better at preventing it. But it’s essentially, you know, the concept that with every IVF cycle, there is some quote unquote controlled ovarian hyperstimulation, which, you know, it can be a good thing because we try to get multiple eggs so that we get multiple embryos so that they have all the embryos needed for the family building that they would like to do.
But if we overdo that, then it can become a situation where patients get sick and have to potentially be admitted to the hospital because there’s a leaking of fluid from the circulation. and things like that. I think there are many, like It’s an interesting and good real world case because there’s a lot of discussion points. To summarize, I think I would offer the patient the option of trying Letrozole combined with intercourse, knowing that, of course, if the patient is successful, a pregnancy takes nine months, then I would say then you might breastfeed for a while, then there’s the chaos of having a newborn, and before you know it, you’re 39, and so it needs to be taken into account that ovarian aging is something that happens, and so therefore the option of IVF should at least also be discussed.
Abby Eblen MD (18:24.307)
So Alex, for our newer listeners, explain why you’re alluding to the fact that, you know, she comes back in two years, like she’s gonna be 38, and then she’s gonna be, you know, two years after that, she’s gonna be 40. What’s the difference in a 36-year-old woman and a 40-year-old woman who wants to do IVF?
Alex Quaas (18:41.175)
The main difference is that the eggs will be older. so Eggs are, you know, very special cells in the body that are much more prone to what we call aneuploidy, which is abnormal chromosomes, because they’re in this sort of resting and hibernation stage for all these years. And so, you know, In my daily practice, I always point out that ovarian reserve, So essentially the egg pool has two aspects to it, the quantity and the quality. And this patient in this case has excellent quantity because her AMH is 11, that’s high. So basically she has lots and lots and lots of eggs. So the quantity is not the problem, but even in patients with high quantity, the quality of the eggs will diminish over time and by quality we mean usually the rate of chromosomally abnormal eggs. like, you know, what like A sort of easy way to visualize it or to conceptualize it is that at age 30, maybe out of 10 eggs, two or three are abnormal. And at age 40, it’s the other way around. Two or three are normal and seven or eight are abnormal. And so That’s the challenge. And now of course, the quantity can compensate a little bit. So for example, if this patient was to get pregnant with a Letrozole plus intercourse type of treatment plan, and then she was having trouble getting pregnant at age 39 and she still had high quantitative ovarian reserve, her chance of getting pregnant with IVF would still be relatively good. However, if the patient had the option of creating embryos at this time, then that would make things a lot easier for baby number two.
Carrie Bedient MD (20:37.77)
And easier is not just medically easier, it’s also emotionally easier and financially easier because the only thing more expensive than one IVF cycle is two IVF cycles. And so those things, those things really do play very important roles in how we, how we talk with patients. Someone who says, I only want one, maybe two is very different than someone says, I have to have two and three is fine if it happens. How do religious influences change how we approach a treatment plan? Because this is something that’s also very individual to the couple. You may have somebody come in who has no preconceived notions, and you may have somebody come in who is very, very concerned, particularly, think most commonly, we see very concerned with creating embryos.
Either just creating embryos period or creating extra embryos or doing genetic testing. How do you counsel and how do you approach those cases?
Alex Quaas (21:44.996)
Well, first of all, I say, and I think it’s always good to say that at the very beginning, that I have the utmost respect for any ethical, religious, or whatever worldviews people may have. Because I think it’s always important to acknowledge that we don’t want to force our beliefs or our value systems or whatever on the patient. We want to…Like I want to make everybody comfortable that I hear them and that their beliefs are being respected because I think that’s very important. And then the second thing I always say is, you know, like My wife and I went through some IVF treatment ourselves. And even though I was already doing this, like when I was faced with the prospect of potentially doing it, it was kind of like, Oh. And so It’s something that even if somebody is not that religious, it’s still sort of like something that you have to first come to terms with that you are creating a baby in that way. So then the second thing is to say, you know, like I usually do say, it’s not that common that we have way too many embryos. And most of my patients wish they had more embryos than less. So because, you know, in clinical I have way more patients who wish they had more embryos than patients who think they have too many. But then I would also say, you know, like I talk about where does life begin and different views of this. And that’s by the way, in this like paper that I wrote in Human Reproduction, it goes over different views and different religions and how big differences between different religions and even within religions, there’s uncertainties and like the scholars are arguing, where does life begin and all. But anyway, from a scientific point of view, you can say you have an egg that is a live organism, you have a sperm that’s alive and you’re adding them in the lab. And so to a certain extent, they were already alive. So you’re not necessarily creating new life by putting them together. And then they…form this cluster of cells that under the right conditions has the potential to turn into a human life. But it’s questionable whether that in and of itself is a human life already. But if somebody believes that, we also believe it is our duty to try our very, very best to not create excessive embryos. And if that means freezing eggs and only thawing a certain number of eggs at a time, or if it means freezing the zygotes, which is the fertilized eggs, which is the ones that in Switzerland were not considered embryos, if patients feel comfortable. Then we have to just do that. But the other thing we can do is try and use treatment approaches that are maybe more gentle and more low-stimulation, where we don’t have to get 25 eggs on each patient. And this patient clearly has lots of eggs and so maybe making a treatment plan that contains a much lower dose than for maybe other patients.
Susan Hudson MD (25:12.572)
One thing that I think it’s important for our listeners to understand is that it’s okay to come into your REI and say, listen, these are actually the things I’m concerned about because we have people who have concerns about all facets of reproductive care, whether it’s IVF, IUI, what have you. And a lot of times when people are scared, it’s because they don’t have all the information and as good as Dr. ChatGPT and Dr. Tiktok are, like they’re a little shady once in a while. And so if there’s something specific that you’re like, you know, I’m really concerned about blank, whatever it is, let your doctor know because you’re not the only person who’s ever had those fears. And so by letting them know, they can provide you more information to see, hey, is this something that you might consider doing or is it still kind of outside of your realm? Also knowing that going through fertility treatment and diagnosis and all of that, it’s truly a journey. And what you may feel comfortable with at this point in three, six, 12 months from now, you may have a different perspective, and it is completely okay to change your mind. We are never gonna be like, nope, you said a few months ago you weren’t gonna do that. We’re never gonna say that. And it’s okay. Just like as you go through your life, you have different experiences and your views change on things. Things like that happen even within your fertility treatment and that is completely okay.
Alex Quaas (26:58.467)
Yeah, 100%.
Carrie Bedient MD (26:58.798)
I would definitely say be prepared that it may take a couple of extra visits to get through all of this because this science and this technology, we were all in training for at various stages for the better part of 15 years. And it is entirely unreasonable for us to expect for you to absorb all of that within the space of a consult visit where we’re also giving you all of your testing results.
And so I find that patients who have more moral or ethical, religious, whatever concerns, it’s a lot easier to say, okay, I’m going to give you a ton of information today. You’re going to go home. You’re going to sleep on it. You’re going to talk about it. You’re going to let it sit. And then in a week or two, you’re going to come back and write down your questions. Always write down your questions because they will, there is nothing that will clear your brain faster than walking into a doctor’s office. But write down all of your questions and we’re going to meet back and we’re going to go through them because that’s when we as physicians are going to be able to pick up on, yeah, they’ve got that concept or, wait, we need to spend a little bit more time on this one and we’re not going to force you or rush you into any decisions. We need you to be comfortable because there’s so much that we’re going to do that isn’t guaranteed. You need to trust that we are doing the best by you. And that includes both medically and scientifically, but also for who you are as people. And so we may say, hey, you’re 41. Like We need to make a decision, but that’s based on the science and the medicine of being 42 is not going to do anything favorable for your success rates, but it’s with the knowledge of nobody wants to force you into anything. You got to be comfortable because there’s a lot that we’re going to go through together and being comfortable is a huge part of, of that because fertility is always a partner’s sport.
When you introduce IVF, it becomes a full football, basketball, soccer, hockey, pick your sport of choice kind of team. And being comfortable is a huge part of that. And understanding, okay, I’m not going to know all the science, but I at least am comfortable with this is hugely important with it. And understanding that, okay, your team’s going to do the best by what you want, which is to get pregnant and how you want to get there.
Abby Eblen MD (29:23.859)
I find too when patients come in, some of the patients that I’ve had that I really would like for them from a medical stand to do IVF, when they come in, I find that if they really don’t want to do it, if you really start talking to them, and I’ll usually just say, just tell me kind of what you’re worried about. And it’s really interesting when you start doing that, all of a sudden when they tell you, like, oh, well, can, you kind of like what you saying, Alex, well, we don’t have to fertilize all the eggs. We can do this or we don’t have to do genetic testing. If you’re uncomfortable with you know, making a call about the embryo to transfer, we don’t have to do genetic testing. And I find once I can get them to at least tell me what they’re concerned about, usually about 90 % of the time we’re able to work around it. They’re like, okay, I feel much better. I think I do want to do IVF now. So whatever concerns you have, I would just echo what Susan and Carrie said, just talk to your doctor about it, because I think probably a lot of what you’re concerned about we can work around and, you know, end up with hopefully a healthy pregnancy at the end.
Susan Hudson MD (30:21.1)
I have a question for you. So we often will have patients come in and I would say these are most likely people who potentially have a diagnosis of PCOS. They’ll be like, my OBGYN, new patient appointment, my OBGYN has diagnosed me with PCOS. Can we start treatment right away? And you’re like, well, hold on a second. Why would you take a pause and not just necessarily jump into something right away and potentially do some additional testing? Why is that very important?
Alex Quaas (30:54.671)
Well, first and foremost, because PCOS is the most misdiagnosed condition in our field.
Abby Eblen MD (30:59.123)
Everybody’s got PCOS when they come to see us, it seems like.
Alex Quaas (31:04.185)
Yeah, exactly. some people, yeah, exactly. It goes both ways. Some people have blatant PCOS and have never heard of it before. And some people have like literally zero of the three criteria required for the diagnosis, but they’ve been told that, and they’ve already joined a support group. you know, I mean, I wrote an editorial about this because that, you know, I was invited to write a commentary about diagnostic criteria, like ultrasound criteria for PCOS. And anyway, so in the opening paragraph, I wrote that, that it is literally something where the, the, I don’t know, like the sensitivity and specificity of outside diagnosis is like mind bogglingly low, but anyway, so that is an important part. So first of all, I usually say, Because oftentimes people come in and they say, one person told me I had it and then another person told me I didn’t. And it’s actually not that difficult to diagnose it. The diagnostic criteria are very clear. But I think the other problem in the defense of general OBGYNs or primary care providers is sometimes people meet the diagnostic criteria at one point of their life, but not at another. Because sometimes they may have irregular periods at one point and then regular periods later or they may lose weight and their whole situation might change and things like that. But the bottom line is, I think it’s very important to first establish the diagnosis yourself and make sure that that was on a clear grounds. And just to remind people that you need two out of three of irregular periods, then polycystic ovarian morphology on ultrasound, which the AMH level, you know, like that AMH level of 11, we kind of know that this patient checks that box most likely and AMH is in discussions to be a diagnostic criterion for PCOS. And the third thing is either lab evidence or clinical evidence of high testosterone levels. And that would be things like hair growth, acne, and things like that. So I go through those and then I usually also go through the four areas of PCOS that I like to cover. And I’m not going to go into all those in detail, but it’s like, lifestyle and future health effects of PCOS, uterus effects of PCOS, cosmetic effects, if there are any, and then of course the fertility aspects. And so I usually like to take some time to talk about the diagnosis. Why were they told that they have PCOS and then those different areas. Now, if she’s got lean PCOS, then most likely a lot of the general health things don’t apply quite as much.
So for example, we don’t need to talk maybe as much about nutrition and lifestyle and exercise and those type of things. But anyway, so I like to usually have a broader discussion about that and then maybe talk about treatment.
Susan Hudson MD (34:10.564)
Also realizing that a lot of times realize we have two patients. And so just because we know we have somebody who may not be ovulating, one, honestly, we’re hopefully hoping it’s PCOS because the other extreme are the people who have been told they have PCOS and they actually have severe diminished ovarian reserve. But that doesn’t mean your partner has excellent swimmers or that the tubes are fine or you know, you don’t have endometriosis or any of those other things. and I know there’s some Latin phrase in medicine that essentially says if you can track everything down to one thing, that’s probably what the diagnosis is. And I believe that’s probably true in everything except for fertility medicine.
Alex Quaas (34:55.036)
Yeah, there’s a lot of overlap. And in this patient scenario, one of the things that I’ve learned, and I didn’t learn this in fellowship, actually, I learned it in practice, is that there is actually some overlap between PCOS and hypo-hypo. You know, Sometimes you get these patients who have, especially in the lean PCOS, who have high ovarian reserve, and you think they clearly have PCOS, but then they also have features of what we call hypo-hypo, which is essentially hypothalamic dysfunction. It’s like an under function of the whole reproductive axis, often in the context of people who exercise a lot or have a lot of stress or maybe a little bit underweight. And so I’ve had a lot of patients who had sort of features of both of those.
Susan Hudson MD (35:43.684)
My personal hope is one, they rename PCOS because they’re not cysts.
Carrie Bedient MD (35:50.188)
I will die on that hill.
Susan Hudson MD (35:51.981)
And number two is that I really think as you were mentioning, I think that PCOS is actually a spectrum disorder and you have lots of people who may be on the edge of one or another diagnosis and you know, we’ve all seen those hypo-hypo patients and those are some of the people who have 40 follicles on each ovary. And it’s like, well, that’s not.
That’s not just the brain not functioning right. Like Your ovaries aren’t supposed to be structured that way. And I do think that there is a continuum. It’s just, it’s amazing that we’re still fighting those battles.
Alex Quaas (36:29.36)
Yeah, it is being renamed by the way PCOS. think if you saw, There’s an initiative from Australia and that’s a global initiative. So I think within the next 12 months, it’ll have a new name. So at least there’s that.
Abby Eblen MD (36:46.386)
No, no, that’s okay. So I was going say, since we’re talking about treatment plans, on a different but related note, if you had that same 36-year-old, say she had a really low AMH and she wanted to have two children, how would you counsel her differently in terms of a treatment plan?
Alex Quaas (37:02.586)
Then we would, in addition to the quality, be worried about the quantity going forward. And then I definitely would have a lower threshold for, quote unquote, recommending. Again, I never recommend things completely. I mean, it’s always shared decision making. But I would say if you are very, very, very interested in having two children, then you should probably think more strongly about IVF.
I don’t say things like you have to do IVF because I feel like sometimes people get told you have to do this and nobody has to do anything. Like When you walk into the emergency department with appendicitis and probably you have to have your appendix removed if you want to survive. And then you just have to sign a form and the surgeon takes you back to the OR. But in what we do, nobody has to do anything. anyway, but I would probably say if I were you and if I really wanted two children because age 39 and an AMH of seven is different from age 39 and an AMH of 0.2 or something like that. So if somebody has the ability to create embryos in the context of lower quantitative ovarian reserve at an earlier age, then that’s of course preferable.
Susan Hudson MD (38:22.534)
Just to add another wrench to the system, mentioned this listener had mentioned that she was stage one endometriosis. How would you vary your perspective on stage one versus stage four?
Alex Quaas (38:39.463)
Well, there’s more anatomic disruption with stage four, so that needs to be taken into account. And more severe endometriosis may also have more severe fertility effects. I think In stage four endometriosis, we also would probably be a little quicker to recommend IVF because the chance of either natural conception with, for example, ovulation induction, even if the tubes are open, you know with stage four endometriosis natural conception or conception with IUI might be lower probability, so that factors into the discussion as well.
Carrie Bedient MD (39:22.286)
So one last thing that I think all of us consider as we’re creating treatment plans is the emotional state of the patient or the couple as they’re coming in. And so How does that play a role if you’ve got somebody sitting in front of you who is very relaxed, very chill versus someone who is highly distraught by every period that they get and runs highly anxious? And it’s not that we see a dichotomy of one or the other. Most patients are a range of something in between those. But how does the patient’s emotional state factor into what you do and how you do it?
Alex Quaas (40:06.619)
I think that’s very important. think that, you know, like, I mean, I don’t see a lot of patients that are completely relaxed, to be honest. But, I mean, I will say it is completely, number one, it’s natural and normal to be maximally stressed out. It’s also normal to be a different, slightly different person. You know, I compare it, you know, when I’m…at the airport and they’re telling us our flight is delayed for the third time or our luggage got lost, I become a different person. Also, if I’m on the phone with my cable company and I’m on hold, I become a different person. And I think those are obviously that’s not the same as wanting a baby, which is such a deeply emotional thing. But it’s just different examples how this journey can change you.
So first of all, I think every fertility clinic, including the doctors first and foremost, need to accept that people are maybe not completely themselves and that’s okay. But the other thing is, I think that people come to us at different stages of their journey. And if a couple comes to us and they’ve tried for six months, they’re both 32 years old and they just wanna know like that everything’s okay.
That will be sort of on the more relaxed stage or end of the spectrum. Then clearly they need maybe a little bit less hand holding and they might really just need that fertility workup and then tell them go and try six more months and you know, most likely you’ll be successful. Whereas a couple that’s been through four years of infertility, three miscarriages and maybe unsuccessful IUIs somewhere else, they may already like be
like their, their, their, their like threshold, their tolerance for further disappointment and further wait might just be not be there. And so then of course that needs to be taken into account as well. But I would say most patients come to us when they’re pretty much ready to get pregnant, like yesterday or two months ago or two years ago. And when they’re usually also ready to say, okay, well, let’s do something about this.
Susan Hudson MD (42:26.018)
One thing I would like to mention is that post-COVID, a lot of us have gone to doing quite a bit of telemedicine compared to what we did, you know, five, ten years ago. And one thing that I encourage our listeners to do is that if you don’t have an in-person appointment, make sure you’re somewhere that you can at least have video for your telemedicine appointment because there’s so much of what we read in your body reaction, your facial expression that helps us guide how do we make this conversation be the conversation that you personally need. There’s a lot of physical cues that we use. And if we’re only hearing you, I mean, we pick up a lot in audio, but if we can see you, I think we are able to deliver in a more personal nature even if it’s over over telemedicine, I think we’re pretty good at doing it But having those visual cues can be very helpful as well.
Abby Eblen MD (43:32.434)
Well, and that’s an interesting point, Susan. I think the opposite is also true. I think for patients, if you’re just looking at somebody on a TV screen and certainly just hearing their voice, it’s kind of really hard to make a connection. You almost look like you’re just watching TV. And I think it’s really important for everybody, for both the doctor and the patient, to sort of get that connection and just kind of get to know them as a person a little bit. Because a lot of times when I take the patient back to do the exam, I’ll be like, So now how long have you lived here? You you’re originally from here, where’d you, you know, and those are the kinds of things that I think help me connect to the patient and vice versa. And so I think you miss out on a lot of that if you do a telemedicine visit. So I do telemedicine visits for new patients, but I really would prefer to see them in person and I just think it’s better for all of us.
Alex Quaas (44:19.656)
Yeah. Well, The other thing is the number one criticism or one of the number one criticism of fertility clinics is that patients feel like a number and it’s so easy that that can happen. so of course we, mean, None of us have completely encyclopedic memories and of course remembering every single couple is always going to be a little bit hard, but I think it would be nice if every patient feels like they have a clear and also personal connection with their treatment team and they’re not just a number that’s shuffled through this conveyor belt of fertility.
Carrie Bedient MD (45:01.806)
Exactly. This has been a fabulous episode. I hope that our listeners get a ton of value out of hearing that nobody is just a number to any of us. There’s dozens of different factors that input into how we create treatment plans for people. So thank you so much for joining us, Alex. We have Dr. Alex Quaas of Shady Grove Fertility in Solano Beach near San Diego for anyone who’s interested in seeing him.
Carrie Bedient MD (45:28.994)
Thank you so much. were very appreciative that you joined us.
Alex Quaas (45:32.68)
Thank you so much for having me. This was so much fun.
Carrie Bedient MD (45:35.806)
And to our audience. Thank you for listening. Please subscribe to Apple Podcasts to have next Tuesday’s episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.
Abby Eblen MD (45:50.6)
You can also visit us on fertilitydocsunsensored.com to ask questions for our Ask the Docs section. Also check out our new book, the IVF Blueprint, to help you understand IVF in detail. You can find it on Amazon, Barnes & Noble, and bookshop.org.
Susan Hudson MD (46:05.98)
Check out our Instagram and TikTok for quick hits of fertility tips between weekly episodes. And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye.