Ep 221. Everything is normal, so why aren't we pregnant? With CREI Dr Katrina Rowan

0:13 Welcome to the Kick, your expert-led podcast, helping you explore and learn everything about getting pregnant, pregnancy, birth, and becoming a parent.

0:22 On the podcast and our online pregnancy program Grow My Baby, we share my experience of helping more than 4,000 babies to be born.

0:30 And our experience of running a women's health clinic and parenting for boys.

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0:43 Welcome everyone. And part of that collaboration is that Monash is giving us access to some very, very smart fertility specialists. So we can give that information to you in a way that's going to really help people who are either just starting on their fertility journey or they're going through fertility treatment.

1:10 So our first guest is Dr. Katrina Rowan. She is a CREI, which is a sub-specialist in fertility. She's based in Sydney. She has extensive experience in reproductive medicine with particular expertise in infertility, PMOS, endometriosis, miscarriage, male fertility, and LGBTQI plus family building. She's known for her compassionate and personalized approach.

1:37 She is also passionate about helping patients understand their options and achieve their family building goals. We talked to her today about a very interesting topic that is unexplained infertility. Let's take a listen. Welcome, Katrina. Thank you so much for joining us today. Thanks so much for having me, Bridget.

1:58 It's such a pleasure to have uh someone with such expertise on our podcast. I know that time is like so valuable for you. So thank you for taking the time because there's lots of people that are asking these questions that we're going to ask today. So I can't wait to get into it. My first question is what does unexplained infertility actually mean?

2:19 And is it a thing, or is it just we haven't got an explanation for it yet?

2:25 So according to our Australian guidelines, unexplained infertility is um defined as when a heterosexual couple has had regular unprotected sexual intercourse for more than 12 months, and where the woman is under the age of 40, and routine testing, um, which I can go through what that is, but routine testing has failed to show up with an explanation for that infertility.

2:51 So the routine tests that are recommended for the diagnosis of unexplained infertility are a standard semen analysis, a pelvic ultrasound to assess the uterus, a test to check whether the fallopian tubes are open, called either a hycosy or a HSG, and an assessment whether ovulation is regularly occurring, and that can be either a history of regular menstrual periods or a progesterone test in the luteal phase of the menstrual cycle, which is the second half of the menstrual cycle.

3:29 I always like to ask Pat when I've got him on, um, when would somebody be having these tests? Is it with their GP? Is it just with their gynecologist, or have they already started seeing an IVF specialist at this stage?

3:41 Well, look, I just think it depends on the experience and confidence of the GP that they go to. So many GPs with a focus on fertility would do these basic investigations before they saw a specialist. Um, but I often do see patients that have come in with minimal testing and would arrange their testing as a fertility specialist.

4:03 And as a fertility specialist, when do you look at these tests that you've just done and gone, hang on a minute, I'm not happy with this one or this one? How abnormal do they need to be before you think, well, this person has unexplained infertility?

4:16 Well, if they've got um unexplained infertility, I guess by by definition they're all going to be normal. But for example, if we we take the semen analysis test, the World Health Organization has set some very good parameters that tell us where the where where people are defined as being fertile, so they're very clear parameters.

4:35 So anything outside those UHO parameters would be considered a possible male infertility. Um, but if those parameters are all normal, then it's more likely to be unexplained infertility if the other tests are also normal.

4:49 As a fertility specialist, how educated are your patients? Do they know these parameters already? And that's why they're seeing you, or is uh do most people sort of come and they're at a baseline that needs a lot of education from someone like yourself?

5:03 Oh look, there's a there's a mixture. My particular practice is in Sydney CBD, so I tend to have a lot of very highly educated patients who ask fantastic, tricky questions, uh, which gives me great pleasure in being able to help patients through that. And certainly with um the pros and cons of social media, there's definitely a lot of discussion out there.

5:25 So people I find now are more familiar with all of these terms than they may have been five or ten years ago. But there's still a lot of inaccurate information out there. So a lot of my role now is clarifying and um trying to give patients a more evidence-based approach.

5:41 Yeah, because I could imagine like they uh if someone has had uh fertility issues for a period of time, they've gone and they've started to look and they've started to get all the information that they want. And I I and I think those initial consultations would be kind of tricky for someone in in your position if they they know all these tests, they know the parameters.

6:01 Um, so for you, when you're looking at them, do you think that that sort of falsely reassures somebody if they've come back and they've gone, okay, I've got all these tests, they're all normal, so now I just have to wait. I just have to wait until I get pregnant.

6:15 Yeah, there certainly is some risk of false reassurance, and that there's certainly some patients that even though all the test results are normal, that they won't get there naturally, and that, you know, by just sitting and waiting and not doing anything, they risk getting older and less likely for the treatments to be able to work.

6:35 So look, uh I think there's um it needs to be careful counselling that um there still may be a fertility problem, even though at this stage the infertility is unexplained.

6:47 Do you think this is a harder diagnosis for somebody to accept, or do you think it's harder for them to understand? Like doctors should know everything, shouldn't you?

7:02 I think for better or or worse, that presumption's no longer there, Bridget. But um, look, uh I I think um look, it is, I think it's human nature to to want when something not is not working, you want to have something to put your thumb on that's fixable and treatable. And it can be incredibly frustrating and difficult for patients when they haven't got anything to hang their hat on and um you know often start blaming themselves.

7:27 Is it my lifestyle? Is it am I too stressed? Is it um a lot of unproven factors where there may well be a significant issue that um hasn't yet been uncovered by the initial testing?

7:43 Here in Victoria, a prominent ABC journo, uh, shared about her infertility journey. And uh one of the things that came out for her was that she actually had endometriosis, um, even though she had no symptoms of endometriosis. And she said her symptom of endo was infertility. It was really powerful how she did it, and I think a lot of people listening to that were like, okay, so next step for me is to go off and have a laparoscopy to see if I've got endo.

8:13 Like, how warranted is that, do you think?

8:16 Yeah, look, I mean, endometriosis is a common underlying feature in patients with unexplained infertility, and it's there's been some research suggesting up to 30% of unexplained infertility, there may be underlying endometriosis. I guess the question is, uh a laparoscopy in particular has some reasonable risks associated with it, including pain, time off work, time off normal activities, usually a loss of a month of conception, and then the surgical risks such as infection, bleeding, damage to surrounding structures.

8:50 So you want to have a good reason to go into that sort of surgery. Now, someone with significant pain together with infertility, then it may well be warranted because you're you're also hopefully potentially addressing their pain. But when there's just unexplained infertility, it is controversial. And the current Australian guidelines is that for in unexplained infertility alone, that laparoscopy is not evidence-based and that it doesn't necessarily improve the longer-term outcomes.

9:20 And a lot of the treatments for unexplained infertility, in particular IVF, most likely do overcome the issues that endometriosis causes. So the role of a laparoscopy prior to other treatments for unexplained infertility is is controversial and not recommended in the current guidelines.

9:40 Wow. Um, all right. Well, you mentioned sperm and sperm being normal, but there's other things that we can look at, aren't there? Like the I've I've done my little bit of research, um, and there's uh DNA fragmentation and anti-sperm antibodies. I don't know what any of that means, Katrina. Can you help me out, please?

9:59 Of course. Um I mentioned earlier, the um WHO parameters, um, so they assess the number of sperm, the concentration of the sperm, how the sperm are moving, and the shape of the sperm. I think we call them morphology. So that's your basic sperm parameters, and they're the ones that come under the diagnosis of unexplained infertility.

10:19 But they certainly don't assess sperm function, and there are other things that we can look at with, as you mentioned, so sperm antibodies and sperm DNA fragmentation. Now, what sperm antibodies are is they're an immune system reaction to the sperm. So it's a bit like other autoimmune diseases where your body's immune system's gone awry and starts producing antibodies or little proteins that latch onto the sperm and might stop it, for example, fertilizing the egg.

10:47 It's a fairly uncommon cause of infertility and more likely when there's been, for example, a significant history of trauma, like if there's been testicular surgery or someone that's had a vasectomy before that's had a reverse or something like that. In terms of the guidelines, because it's so uncommon, it's not usually recommended as a routine test, but it could be something that is considered if there's a risk history.

11:15 Now, in terms of sperm DNA fragmentation, um, what that is is little um small amounts of damage to the DNA of the sperm. Um, and I I say it's it's akin to wrinkles in the sperm. So you get it from older men are more likely to have DNA fragmentation if there's been significant lifestyle exposures, like a history of a lot of chemical or radiation exposure through occupations, that sort of thing, can cause damage to the DNA of the sperm.

11:44 Now, there's mixed data in terms of its role in unexplained infertility. It doesn't come into the definition of unexplained infertility, but it is something that some fertility specialists will look at as a way to try and triage people into the best next steps, what the best next step of treatment is.

12:01 But look, in general, it's not on the Australian recommendations as a routine test for unexplained infertility. But look, my personal views, I think it can be helpful, particularly if you've got, say, an older couple and we're making the decision whether to do IVF or uh one of the more simpler treatments like IUI.

12:20 I think it can come into that mix in terms of working out the prognosis for the simpler treatments working and who and when to start IVF.

12:30 I'm fascinated by both those things. So I want to start with the immune system. So are you saying that there is something within the sperm that is creating an immune response, or is it that woman's uh immune system that is rejecting the sperm?

12:48 Yeah. Well, there's actually two types of sperm antibody testing. So one is within the woman to check that. That's really not been validated by any testing. That's not been shown to be helpful. But the other sperm antibody testing is sperm antibodies in the men, and we actually tested in the semen. And how that works, so the sperm, it's only half, it's only got half the chromosomes of a cell.

13:13 So to a to a male body, a sperm is actually foreign genetic material because it's only got half of his chromosomes. Now, when there's a thing called the blood testis barrier, and so that's a little um essentially a wall between the sperm and the blood, so that normally the blood and the immune cells can't reach the sperm and can't react against it.

13:37 But if, for example, you've had surgery in the testicular area, that blood testis barrier can be broken down, and um therefore the blood can get in to where the sperm is. It can say, hey, what's this abnormal genetic material here, i.e., the sperm, and start to create antibodies as it would against a virus or a bacteria, and that those antibodies can then latch onto the sperm and reduce the sperm's ability to swim, reduce its ability to fertilize the egg.

14:05 Wow. So I, you know, I'm a mother of four boys, so I often think about uh what an easier run they have, um, and also how unsort of connected they are with their own medical history. But and I'm imagining some men out there are, and and when you're asking them, did you ever have anything happen to your testes or did you ever have an accident or whatever, like are they good at reporting their medical history?

14:29 Often when the trauma's been significant, they remember the the day, the time, the weather. It's um one of those things that really sticks in in them in their memories. Look, it's very normal for boys growing up to have little knocks and bumps along the along the way. Um, but something significant, for example, that would land them in hospital or have pain for days afterwards.

14:50 That may be a history where I personally look at anti-sperm antibody testing just in case.

14:56 So we've mentioned quite a lot of tests, and these are just really in the fertility workup. I'm imagining by now somebody has racked up a fair spill in getting some of these tests done. Um are they all necessary, in your opinion, to have to do a proper infertility workup?

15:15 Yeah, look, I'd say most certainly a pelvic ultrasound and semen analysis. I mean, the menstrual history is enough. So in terms of those tests, uh, I think that that's certainly the the minimum. Look, we're one test that if we're being budget conscious that we may be able to, and I sometimes leave for a later date, is the tubal patency testing.

15:37 And that's particularly in someone that's you know significantly older, that we're more likely to move to IVF. And if your tubes are blocked, it doesn't matter with IVF. But we can't technically say that the infertility is unexplained without testing the tubes. But it may be a decision there that look, if we're going to do IVF anyway, we might not need to do the Philippine tests.

15:57 But certainly in younger patients who might continue trying to conceive naturally or consider treatments such as RUI, it's definitely good to get the tubal patency as well. Um, and there are other tests that I haven't mentioned yet that do allow, so it's not not necessarily part of saying whether their infertility is unexplained or not, but do allow us to help go into decision making into the next steps of treatment.

16:21 So where AMH is not necessarily a test that we would do for finding out the cause of infertility, it has and it doesn't actually tell us who's going to fall pregnant and who's not. I do believe it's an important test to get done and consider because it helps us to determine the next steps in terms of options, whether it be IUI or or IVF, and um particularly with with IVF, how that's likely to go and helping people manage their expectations.

17:19unknown Yeah.

17:20 So there are other tests as well. In my um IG uh deep dive, I found um lots of other tests and people who are um looking to become pregnant and they're just not becoming pregnant within the time frame that they want. I I get it. I I get that they are looking for all the one percenters, but these are some tests that I run want to run through with you to see if there's any evidence that these tests improve the live birth rates.

17:43 So the first one is endometrial receptivity testing.

17:47 Yeah, there's no evidence that it improves live birth rates either for unexplained infertility or for couples going through IVF.

17:54 Wow. Um most people, including myself, won't know what that is. Could you just give us a brief description of what that is?

18:01 Um, so what it's is it's a test looking at some of the cells within the lining of the uterus. So it requires a small biopsy of the uterus, so a small procedure to take some cells out. And then it's run under an analysis and they look at a whole lot of proteins and um create a profile that basically is meant to triage people into whether the uterus is ready to implant an embryo or whether it's in the pre-implantation stage, so a bit early to implant an embryo or a post-implantation phase where it's a bit late to implant an embryo.

18:35 The initial data was promising and it was was used um was getting quite routine, particularly for unsuccessful IBF. Um, but then further research actually came out that it was not helpful.

18:49 Um the next one is microbiome testing. It's the latest thing. Latest and greatest thing.

18:55 Yeah, it's a very interesting area of research. And currently our Australian guidelines do say it should be just looked at as a in research context only at this state. So it's not recommended as a routine test. But look, certainly, you know, in terms of gut health, that sort of thing, the microbiomes um becoming increasing.

19:15 Research that that can be a significant factor in many, many illnesses in medicine. And infertility is an area that's started to be looked at, but nothing particularly for unexplained infertility. We haven't got any research as to its value yet. Okay.

19:32 Um we've touched a little bit on immune, but only to the sperms. But immune testing and even NK cells.

19:39 Yes, certainly none of that has been shown to have a role in unexplained infertility, and there's no evidence of increased live birth rates by doing those tests.

19:49 Um and just to explain what an NK cell is?

19:53 NK cell is a natural killer cell, and that is a part of a normal human immune system that's involved in the immune balance within both the immune system in the peripheral blood, but also within the uterus. But there is, and it's a it's a tempting theory that you've got little immune cells that are gobbling up embryos, but um the reality is that the uterine immune environment is incredibly complex.

20:19 Um, an incredibly complex thing that um my view is we don't have enough understanding of it yet, and certainly not enough understanding to recommend these as routine tests for infertility. One area of um immune testing or autoimmune conditions that may be looked at, and there is some evidence of benefit, is screening women for celiac disease and screening women for thyroid problems, and quite commonly thyroid problems are immune issues.

20:46 Um, so there is some some research that um those they can be beneficial tests for unexplained infertility. Fascinating.

20:53 Uh, the last one on my list is acupuncture.

20:58 Um, so there's no good data that acupuncture improves live birth rates in unexplained infertility. It can be a helpful adjuvant for patients, particularly in helping them with the psychological side of going through infertility. And if they move to IVF, it can be helpful in managing the side effects of IVF.

21:17 There's good data there. But in terms of live birth rates, unfortunately, acupuncture overall, there's been quite a lot of studies, and overall that hasn't been shown to improve those life birth rates.

21:30 I wonder sometimes it's a bit like birth too. You know, um, some things are totally out of a woman's control. And some things can feel like you're in control a little bit, and going off and and doing something or doing your research or going having acupuncture. It sort of feels like it's bringing it back to what that woman can control and have agency over.

21:50 I suppose, you know, if that's a benefit. Yeah, that's I love a bit of acupuncture.

21:55 Yeah, there's a a lot about fertility that that people can't control. And it it's it's difficult. She has most of the rest of our lives we can just try harder and do things and get the outcomes that we want. So infertility is particularly difficult from that point of view, is that there is a lot that it that's out of your control.

22:13 Let's say a patient you've you've got to the point as a clinician and you've gone, yes, your infertility is unexplained. What's your next step with that patient? Do they do you say, look, go away you could conceive naturally, or let's try an IUI, or let's now move to IVF? What are you what are your sort of parameters that helps make decisions around that?

22:35 So I think it depends a lot on the patient and being Various parameters. So the first thing I would look at is the age of the woman. Have we got a lot of time up our sleeves, or is she near the end of her fertile window? I think it's important to have a discussion regarding the couple's desired family size in total.

22:54 Are they only looking at having one child or do they want to have multiple children? In which case we'd sort of want to expedite the time to the first pregnancy. And then something like the AMH that I mentioned before, anti-malarian hormone, which allows us to assess the woman's reserve of eggs compared to other women of her age, that would be a factor that would come into the decision making as well.

23:19 So, for example, if the AMH was quite low and she wanted to have several children, her window to have several children might be running out. And that might be a circumstance where we would think about IVF rather than continuing trying naturally. And then the other factor that comes into just looking at treatment decisions is their prognosis.

23:40 So how particularly how long they've been trying before seeking assessment and also whether they've had any other fertility treatments. So all of those would go into the mix. For look, you know, a reasonably young couple where there is unexplained infertility, the Australian guidelines are it's reasonable to start with IUI or intrauterine insemination.

24:02 Whereas for an older couple or if there's been a very long duration of infertility, we might lean towards IVF as a as a first step. And then, you know, for for someone where there's been a fairly short duration of infertility, um, good egg reserves, they're reasonably young, it may well be an option just to keep trying naturally.

24:22 I don't really understand. In IUI, if the tube is normal, there's ovulation happening, the sperm is okay. What is IUI actually doing in unexplained infertility?

24:35 Look, I don't think we know for sure, but the the current the theories are it may well be so IUI by itself hasn't been shown to improve the pregnancy rates, but IUI with ovulation induction, so some sort of stimulation of ovulation does help. And so call it stimulated IUI does improve live birth rates for unexplained infertility.

24:58 The theory, so the theory there is it may well be the stimulation. So whether you're actually just getting another egg stimulated and upping your chances that way, it does mean that it comes with an increased risk of multiple pregnancy. So it may well be just a numbers game of getting another egg. But the other factor is we're concentrating the sperm, we're getting it through the cervix.

25:19 So if there's some sort of undiagnosable cervical problem that the woman's not letting the sperm through, perhaps it's getting through the cervix and then getting that sperm a little bit closer to the egg and making sure we have absolutely optimal timing of the egg and sperm getting together. So it's probably the combination of those three few things that help nudge the stats towards a higher rate of live birth.

25:42 Yeah. Does when you go through, say somebody then is going on to IVF and you're going through the process, either they they get pregnant or whatever, does that ever reveal the cause for the infertility?

25:57 Yeah, it can, not always, but it it often can. So for example, sometimes we might see that um there's a lower than expected fertilization rate. So that means we put the end sperm together, but there's a lower number of embryos that we would get out of the number of eggs that are collected. So that sometimes does reveal some answers as to the cause of infertility.

26:17 The other thing we sometimes see within IVF is poorer than average embryo development, and that usually means probably egg or maybe sperm quality is not as good as that should be. So, yes, we often do get more answers with IVF. Often we don't get any answers, but if it works and if it improves the live birth ration, they've got their baby in the arms, it becomes academic.

26:39 What was the what was the cause?

26:42 The big one that people often think, and again it comes back to that agency, and that is is my stress causing my infertility? Is there any sort of evidence or data around that?

26:53 Yeah, look, I think often women in particular are unfairly blamed for infertility and and people saying, just relax, you'll be okay. Look, there's some studies that have shown a correlation with slightly higher stress hormones for people that uh take longer to conceive. But the problem is we don't know which way around it is.

27:13 So infertility is stressful. It may well be that the fact that they're not conceiving has increased their stress hormones rather than vice versa. But certainly overall, it's quite rare here. I mean, someone with a significant amount of stress in their life sometimes can start to have ovulation problems and not ovulate.

27:32 Um, but that's no longer unexplained infertility. That's uh that's an ovulation problem. So if women have got regular cycles still, um, it's not likely that stress is causing their infertility.

27:46 I I'm sure so many people will be happy to hear that because they would be told over and over again, you know, just take a holiday or have a break or you're working too hard, or no wonder you're not getting pregnant because you're working 10 hours a day, or you know, nobody needs to work 10 hours a day.

28:01 But you know, like this is like you said, it women are aren't fairly um positioned in this in terms of their stress.

28:07 Yeah, that's right. Look, it does come back to the agency. You want an explanation, you want to know what the cause is, and ideally something you can do something about. But if we look at the evidence for stress, it it's very weak as a cause of infertility.

28:21 Now, I would be remiss in not asking this question with a fertility specialist right in front of me to our audience, would be wanting to know is there any evidence behind different supplements or types of diet that promise improvements in egg quality or endometrial lining or implantation or embryo development.

28:41 Like that, that's coming into people's feed all the time.

28:44 Yeah, well, certainly in terms of basic supplements, it's important everyone in Australia trying to conceive takes a folic acid supplement and an iodine supplement. Iodine's low in our soil, so we need to supplement that. And folic acid does um reduce the chances of neural tube defects, so spine and brain abnormalities.

29:02 So they're a given. Beyond that, there's no strongly proven supplements to improve outcomes. Look, what there is some early week data for supplements such as CoQ10, which is an antioxidant, may improve the quality of eggs and embryos we get in an IVF lab, but there's been no correlation with actually increased pregnancy rates with unexplained infertility.

29:33 Similarly, there's supplements some people consider like DHEA and in IVF cycles. Sometimes we look we could consider testosterone supplementation, but again, it's very early and pretty weak data, conflicting results in different studies, and it's not something that we would do routinely for everyone.

29:53 There would be very specialized clinical circumstances where that would be considered. In terms of diet, look, there have been some observation, there's been no proper randomized studies for any of these things. So diets, other supplements have not had good quality scientific data. But some observational studies, so just looking at you know this group versus that group, have shown a maybe beneficial for a Mediterranean-style diet, but no one's ever done a proper trial of it.

30:23 All right. So we've talked about a lot of things that are in people's spheres. Like they might have heard of the different tests that we've been talking about the whole way along. Some work, some don't. It sounds like most don't. But as a specialist, what is the the thing that you think we would need to really advance this area of unexplained infertility?

30:47 I would love a test of egg quality. I think that would be incredibly helpful for people going through unexplained infertility so that we could identify those patients that might struggle with IBF to get them on that path earlier if needed. So I think that would be ideal, and it would also be quite helpful for patients that are looking at things like freezing eggs to determine whether to freeze eggs, how many to freeze, that sort of thing.

31:13 So an egg quality test would be number one on my wish list. Other tests look um people are looking at more non-invasive uh options for non-invasive testing of endometriosis. Um, there's some promising things on the horizon there. And um maybe a test of egg and sperm interactions. So we can tell where patients might be with, for example, the sperm isn't fertilizing the egg.

31:38 That would be quite helpful for couples with infertility that are then considering moving on to other treatments.

31:46 If if we're talking about unexplained infertility, is there an age cohort that is more represented?

31:52 Well, certainly fertility declines with age, particularly from the late 20s onwards. And um as I mentioned earlier, unexplained infertility is women under 40. So just by definition, I would say that the majority of unexplained infertility, we're probably looking at women in the 35 to 40-year-old age bracket.

32:12 And I think probably what it comes down to, I sometimes I think about unexplained infertility and fertility as a bit of a roulette wheel. So if people have got not many numbers on board, when you get older, you're taking some of those numbers off so that you eventually have a pretty low chance of spinning that right one.

32:30 And so basically, if you've got a you know mild thing, like I don't know, a mild ovulation problem that we can't diagnose, or a mild cervical mucus problem or something like that. When you're younger, you've got lots of numbers on that board. You may well get away with being fertile and overcoming that problem.

32:52 Whereas we see this and endometriosis is a classic one as well. Young women with a bit of endometriosis might not have a problem. Whereas if you're getting older, endometriosis tends to get a bit worse with time. But then compounding that with the effects of age, often we then see infertility.

33:10 All right, Katrina, I'm gonna move into some quickfire yes-no questions. If you're anything like Pat, you won't stick to yes-no, and that's fine too.

33:21unknown I'll try.

33:23 All right, so a normal AMH means my fertility is normal.

33:28 No, not necessarily.

33:31 Yes, and and I I'm gonna be the the person that marks this up now because already I can see if you're saying that you can have your AMAH test, but you want an egg quality test as well. So an AMH isn't testing the egg quality, is it? It's just how many you've got in reserve.

33:48 That's correct. So you can have a low AMH and be extremely fertile. You can have a high AMH and have quite significant fertility problems. So there's really no correlation with the chances of pregnancy. It does, AMH does somewhat impact the prognosis with IVF. So we get generally tend to get more eggs and more embryos when you've got a better AMH.

34:11 Um, but again, it's not absolute, and we can certainly see really good outcomes of IVF in people with quite low AMH results.

34:21 Regular periods plus well-time sex is enough to get pregnant.

34:26 Not always. It's I mean both of those are required, but not always.

34:31 If I am over 35, I should skip everything and go straight to IVF.

34:36 No, not necessarily, and and certainly a a chance of natural but for most people trying natural conception for a while first. Other options could, such as IUI if there is unexplained infertility, so you don't have to jump straight to IVF.

34:52 Normal semen analysis rules out male infertility.

34:56 Uh not absolutely, no. There can be other other male factors.

35:01 If all our tests are normal, IVF won't help.

35:05 No. So IVF can be quite helpful. And if we go back to our roulette wheel analogy, like say IVF gives you say 10 spins a month if you've got 10, if you've got 10 eggs. So it's often a numbers game, just upping those chances, even if there's no explanation to your infertility.

35:25 Okay, so as a clinician and you you somebody's listening to this episode and they're thinking, oh wow, I have actually been trying for longer than 12 months if I'm under 35, or six months if I'm over 35, and I think I now need to have a further look into why we're not getting pregnant. What would you counsel somebody to do now?

35:48 So I think the first step would to be to see your GP. And um, if you don't have a GP to look for someone with a particular area of interest in fertility, and then um that GP can run those initial tests. Um, but then um, if in doubt, fertility specialists are very happy to see people for for counseling, decision making as to what to as to making sure all the right tests have been done and helping to determine the best next steps.

36:18 Great. All right. Well, Katrina, that is all my questions. You have answered them so well. I'm sure people are going to get so much out of that. Uh, thank you so much for coming and joining us today on the kick.

36:29 Absolute pleasure, Bridget. Thanks again for having me.

36:32 Thank you everyone for listening. I hope you enjoyed that really great chat with Dr. Katrina Rowan. We'll be bringing you uh fertility specialists over the next six months, every fourth episode or so. So if you've got some questions that you have that are burning about either getting pregnant or if you're already in that infertility treatment cycle, uh just send them through the speakpipe.

36:54 That helps to inform other episodes, and we would really like to help you out there. Okay, until next week, everybody. Keep well, keep growing those babies, and we'll be in your ears next week. Bye for now. Hey, even though Dr. Pat is, well, a doctor, and we get lots of other doctors and other experts on our podcast, I just need to remind you that this podcast is for informational purposes only.

37:23 We share lots of medical insights and experience, but everything we talk about is general in nature and may not apply to your specific situation. Please always consult with your own healthcare provider for your individual medical advice when you grow your baby.