Luciano Nardo, Founder NOW-fertility, explains to Tell Me Why podcast host Maria Botros the difference between subfertility and infertility, and why people often confuse the two when facing fertility challenges.
Nardo: Infertility is when a couple has no chance of getting pregnant, so most cases are subfertile
70 - 75% of couples trying to get pregnant within 12 months would conceive, the minority (20 - 25%) face fertility problems
Nardo says in about 1 in 4 cases it's a combination of male and female factors affecting fertility
IVF treatment is sometimes recommended too soon
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Nardo: Infertility is when a couple has no chance of getting pregnant, so most cases are subfertile
70 - 75% of couples trying to get pregnant within 12 months would conceive, the minority (20 - 25%) face fertility problems
Nardo says in about 1 in 4 cases it's a combination of male and female factors affecting fertility
IVF treatment is sometimes recommended too soon
See more videos at https://gulfnews.com/videos
Read more Gulf News stories here: https://bit.ly/2HLJ2km
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NewsTranscript
00:00A case of primary fertility problems is for somebody who has never been pregnant and struggles
00:06to get pregnant.
00:08And as I mentioned earlier on, during this episode, they may be trying for 12 consecutive
00:14months with no luck.
00:16Secondary is somebody that has conceived, has had a healthy baby, and then comes back
00:23for a second cycle, for a second pregnancy.
00:29So trying for 12 months.
00:34There could be problems that have developed from that pregnancy, and there could be problems
00:38that have been acquired since that pregnancy.
00:42And examples are women that have conceived spontaneously with no problems, and they've
00:49gone into labor and have given birth by caesarean section.
00:56The caesarean section could cause some damage to the uterus, and they could actually find
01:01difficult to conceive again.
01:09We are back.
01:10It's a brand new episode of Tell Me Why, I'm Maria.
01:13As many of you already know, today's topic is an interesting one, and it is one that
01:18I feel that we don't talk enough about.
01:21And I feel like there's so much to address with this specific topic.
01:26I feel like it will resonate with a lot of people.
01:29And that topic is infertility, or let's say fertility.
01:33So infertility and fertility.
01:35And joining me in the studio is Professor Luciano Nardo, who is the founder of Now Fertility
01:41as well.
01:43And today, we really want to dig deep into this topic, because I feel like it affects
01:47a lot of people.
01:48The WHO published an article or a report in April this year saying one in six people
01:57actually face or suffer from infertility or face fertility challenges.
02:04Let's put it that way.
02:06And I think that's a shocking statistic, and that is something that we would love to address
02:11with you here today, being the professor and, you know, the professional in the field.
02:18First of all, Luciano, how are you?
02:20I'm very good.
02:21Thank you, Maria.
02:22It's been a pleasure being here today.
02:24Thanks for the invite, and thanks for offering me the opportunity to talk to your audience.
02:29Thank you so much.
02:30Before we begin, we want to get to know you first.
02:32Tell us about yourself.
02:34Tell us about, like, how long have you lived in the UAE so far?
02:38Where have you been around the world?
02:40That kind of thing.
02:41Sure.
02:42So I'm originally Italian.
02:44My family has got a mixed background, some from North Africa, some from Sicily.
02:51I was born in Sicily, grew up in Italy, moving to Switzerland and spending 25 years of professional
02:59life in the United Kingdom before moving to UAE, where I'm fully based now.
03:08And I am in the process of starting a new fertility and IVF clinic within a state-of-the-art
03:16compound.
03:17Amazing.
03:18Amazing.
03:19You mentioned North Africa.
03:20I'm North African myself, so I hold that proudly.
03:25You said that you are in the process of, you know, opening up and growing your fertility
03:32center.
03:33What made you open that?
03:35What gave you that drive or that push?
03:37Yeah.
03:38Now fertility, we have an international group of physicians, nurses, and patient coordinators.
03:48We know that fertility is a growing problem, but also we know that through fertility treatment,
03:56we can address non-fertility issues, such as having healthy babies and preserving fertility
04:04for cancer patients.
04:06So in 2023, 2024, fertility treatment opens many more doors to prospective patients and
04:17members of the public compared to 24 years ago when I started.
04:22So UAE and the Middle East is a growing market because more and more people are becoming
04:30aware of fertility problems.
04:33And also, there is a large population of expats that are looking for fertility solutions
04:45and they want to rely on an international profile.
04:55And that's why we're bringing doctors, nurses to work in UAE and be part of the UAE fertility
05:02market.
05:03Right.
05:04Right.
05:05You mentioned two things.
05:06So you mentioned something along the lines of that infertility is on the rise and that
05:12more and more people are facing it.
05:14And one of the things you mentioned was preserving fertility or I would say eggs or whatnot for
05:23people to get pregnant in the future, especially with cancer patients.
05:27And that's actually one of the questions that we have from a listener that we will ask in
05:31the end.
05:32But going back to the fact that it's on the rise, I actually want to ask that question.
05:37Why is it on the rise?
05:39What are certain causes that could be causing this?
05:43The causes in 2023 are very different than the causes in 2020 and 2015.
05:50What we are seeing, there is more awareness.
05:53So more couples and individuals look for investigation that show actually there is
06:02a problem.
06:04We also know that women, because of career progression and because of not finding the
06:10right partner, may leave it too late.
06:14And we know also that in some countries, not the Middle East admittedly, but there are
06:20some health issues that affect fertility, such as infections that can cause blockage
06:29of the tubes, smoking and drinking that can affect both female and male fertility.
06:38So there are multiple reasons why fertility is rising.
06:45Some are related to underlying medical problems, whereas others are, we call them lifestyle
06:52choices or social reasons.
06:55Okay, so this topic is just so interesting and there's so many layers to this topic and
07:03so many questions come to mind.
07:05So I'll try to keep it organized so that we can keep the conversation flowing.
07:10When you mentioned infertility, first I want to define what infertility is, because I feel
07:16like a lot of people might have misconceptions.
07:18I mean, it's not so much as, oh, we've tried for two months, I'm infertile.
07:22It doesn't work that way.
07:24And we need to really shed light on the fact that infertility is not just on the woman.
07:30I feel like that misconception still exists.
07:33A lot of people think that it is only from the female side.
07:36However, it affects both genders.
07:39So I would like you to explain that further.
07:42Absolutely.
07:43So the definition of infertility is different compared to the definition of subfertility.
07:52So we often say a couple is infertile or is suffering with infertility, but most of the
07:59couples have subfertility, which means the fertility is not optimal.
08:06When we name a couple as infertile, we say actually they have no chance of getting pregnant.
08:13Okay, and that exists.
08:14And that exists.
08:15An example of that is a woman that has lost her ovaries.
08:20An example of that is a woman that has got no fallopian tubes because of previous ectopic
08:28pregnancies.
08:29Or it could be a man that has got no sperm, whether that is for an acquired condition
08:36or a genetic condition.
08:39So there are obviously some couples and some individuals that are infertile, but admittedly
08:46they are just a small proportion of the patient population.
08:53Most are instead subfertile.
08:56That's a new term for me.
08:57I never knew that.
08:58And I personally don't like to label somebody as infertile or subfertile because it's not
09:06positive.
09:07And when you embark on this journey, you need to embark with a degree of positiveness.
09:12So I always address as having fertility problems.
09:16So they want to overcome the fertility problem.
09:18They don't want to overcome something that could be infertility or subfertility.
09:23Clinically speaking, we define as infertile somebody that is unable to conceive.
09:31So a man that has had a vasectomy, for instance, is infertile.
09:35Of course, yes.
09:36But a man that has got low sperm count is subfertile.
09:43How do we reach the conclusion clinically about defining or labeling somebody as being
09:49subfertile?
09:52I'd rather say I've got fertility problems.
09:55It's by undertaking some investigations.
09:58And worldwide, we and a couple would start undergoing investigations after trying to
10:06conceive for 12 consecutive months.
10:10So if a normal couple, otherwise healthy, with no underlying medical problems and no
10:17genetic problems that would present otherwise an underlying fertility issue, have been trying
10:23to conceive for 12 months, having unprotected, regular sexual intercourse, and they haven't
10:30conceived after 12 months, then they may be subfertile.
10:37And the definition of subfertility comes from the fact that probably around 70, 75 percent
10:43of couples trying to get pregnant within 12 months would conceive.
10:47So the fact that the majority would achieve a pregnancy within 12 months means that the
10:52minority will have a fertility problem.
10:56And that fertility problem has to be investigated.
10:59So the 25 percent, 20 percent that will not achieve a pregnancy spontaneously within the
11:06first 12 months of trying undergo some investigations.
11:11And it is important at this stage to say that both the man and the woman have to be
11:16investigated.
11:17If I'm only going to investigate the female partner, I can only identify potential problems
11:22with the female partner.
11:23Equally, if I'm only going to investigate the male partner, I can only identify male
11:28factors affecting fertility.
11:32But in about one in four, we have a combination of male and female factors.
11:38So investigations are deemed appropriate after 12 months of trying, and both partners
11:45will need to be investigated.
11:46Okay.
11:47So mentioning investigations, can you tell us examples of what these investigations entail
11:53and what actually happens for you to come to the conclusion or the diagnosis?
12:00So the first, before we talk about investigation, Maria, I think the most important part of
12:06the clinical day-to-day work is to understanding the patient.
12:15What are the lifestyle factors?
12:17What are the underlying medical problems?
12:20Chronological age.
12:24These are just basic information we obtain from the patient, from the couple.
12:32Once we have completed the first step, which is acquiring information, then the investigations
12:38will be for the female partner, a blood test to assess ovarian function, and the blood
12:46test measures a hormone called AMH.
12:49AMH stands for anti-mullerian hormone.
12:55It's a very reliable marker of ovarian function.
13:00A blood test can be done anytime during the menstrual cycle, can even be done if a woman
13:06is taking the contraceptive pill, so it doesn't really affect the AMH level.
13:13So an AMH test can be done anytime in the cycle.
13:17Then we would recommend to have a pelvic ultrasound scan.
13:21Ideally, if the female partner is sexually active, which we expect to be sexually active,
13:27she's been trying to conceive for 12 months, a transvaginal ultrasound scan is more accurate
13:33than a transabdominal ultrasound scan.
13:37And the transvaginal ultrasound scan should be done between day two and day five of the
13:43cycle, of the menstrual cycle.
13:46The reason why it's important to do within the first part of the menstrual cycle, because
13:50at that stage, looking at the ovaries, we can see the follicles that are little, small
13:58cysts present within the ovaries.
14:01And according to the number of follicles, you can prognosticate ovarian function.
14:07If I was to do an ultrasound scan later on in the cycle, I may not be able to see the
14:13normal morphology and function of the ovary.
14:18So an ultrasound scan, ideally a transvaginal scan, is done within the first five days of
14:24the menstrual cycle.
14:26And the ultrasound scan will look at the ovaries and will also look at the uterus, at the womb,
14:32to make sure there are no other possible factors affecting fertility.
14:39The third test that I would encourage women to do is a test to check the fallopian tubes,
14:45to make sure that the tubes are patent, are open, because blockage in the tube could be
14:51a cause of infertility.
14:54For the men, I would recommend to do a semen analysis to check the sperm parameters.
15:02And if there is any abnormal sperm parameter, or if there is any history of testicular trauma,
15:12or surgery, or any testicular symptoms, I would also recommend an ultrasound scan of
15:19the testicles to exclude any factors that could impact on normal spermatogenesis.
15:26Okay.
15:27All right.
15:28So my next question, now that we spoke about the investigations and the kind of tests that
15:33women and men undergo, to reach the conclusion that they have challenges with fertility,
15:41as we like to put it, rather than infertility, what's the next step?
15:47Excuse my ignorance, because I think the only treatment I've ever heard of was IVF.
15:52I don't know if there are other treatments.
15:53I don't know how successful they are.
15:56Maybe if you could explain to us, to me and the listeners, what are the types of treatments?
16:02Which one do you resort to, and in which cases?
16:07Because I'm assuming certain cases need special attention, and others will require certain
16:13treatments.
16:14So if you could just talk to us about that.
16:17I think doing the investigations is very important, because from investigations, you can first
16:23find out if there is a problem.
16:27If you do not find a problem, then you need to speak to the couple and make them aware
16:32that maybe the treatment you're going to propose is not going to be effective, because you
16:38haven't nailed down the problem.
16:41So investigations are very important.
16:44Based on the investigations, you can then propose different management options.
16:49Again, it's important that we explain the difference between management and treatment.
16:59Treatment normally guarantees an outcome, but with fertility, there's not always the
17:07guarantee of an outcome.
17:09And also with fertility problems, you may need to trial different options before actually
17:17you achieve that outcome.
17:20So calling IVF, for instance, a treatment may raise expectations, rather than calling
17:29IVF a management option of fertility treatment.
17:35So once we do the investigations, we then find out what is the problem, if there is
17:40a problem.
17:42And the problems could be associated with the male partner or the female partner.
17:49The problems in the male partner, most of the times, are amenable by IVF.
17:58So men that have low sperm count, men that have abnormal appearance of the sperm, men
18:07that have low sperm motility, they're a good candidate to IVF.
18:16In my 25 years' experience, they're the ones that have the highest success rate.
18:23Because IVF will overcome the problem associated with the male partner, with the male factor.
18:33The female, there are different reasons or different causes of subfertility.
18:40Could be to do with ovulation.
18:43And if women have a problem with ovulation, they do not need to have IVF.
18:50They may just need to take some medications to turn around the ovulation problem and actually
18:56ovulate.
18:57There could be problems with the thyroid function, where the thyroid may produce some antibodies
19:10or may affect the ability of the woman to conceive naturally.
19:16It is important that that thyroid issue is resolved before any fertility treatment.
19:22Because if the woman undergoes fertility treatment, she still has an underlying thyroid problem,
19:30will still be an unsuccessful outcome.
19:35There could be problems associated with the normal anatomy of the pelvic organs.
19:41So for instance, women could have a polyp, which is a benign lump within the uterus.
19:48Again, that is a factor that will affect fertility, both naturally and by means of IVF.
20:00So there is no point to recommend fertility management in the form of IVF to somebody
20:07that has got a polyp, because that will still be a barrier to a successful outcome.
20:13Right.
20:14So treating the problem in order to get, I mean, because some problems might hinder the
20:18progress that you do, that you get, sorry, with a treatment.
20:22Correct.
20:23Very specific.
20:24The main indications to IVF, male factors, so abnormalities in the sperm parameters,
20:36blocked fallopian tubes.
20:41And in other cases is the need to do IVF with a view to testing the embryos, should there
20:51have been repeated miscarriages or repeated unsuccessful attempts to conceive.
21:02Sometimes IVF is recommended too soon without undertaking the correct investigations.
21:11And in that case, couples may undergo two, three, four cycles for IVF to no avail, finding
21:21out that the problem is not actually one that can be overcome by IVF.
21:26So I'd like to reiterate to the audience that it is very important to have investigations.
21:35And it is very important to wait for the results of the investigations before choosing the
21:41best management option, which in my experience, only in about probably 35% of cases is IVF.
21:50Wow.
21:51In other cases, you may need hormone treatment to resolve an ovulatory cycle into ovulatory
21:59cycle.
22:00You may need surgery to remove a polyp or fibroid.
22:05You may need to have treatment of the thyroid.
22:11You may simply have to wait a bit longer.
22:17But one thing that we are facing daily in clinical practice now is IVF for advanced
22:28maternal age.
22:30So women that are chronologically older than 35, they're aware of the impact that their
22:38age could have on future fertility.
22:41So they use or they request IVF to shorten the time to pregnancy.
22:50Admittedly, the chances of conception, natural conception, in anyone healthy having a regular
23:00unprotected sexual intercourse is about 20-25% per month.
23:06So it is not very high if you have expectations.
23:12The chances of success with IVF could be twice that, 50-55-60%.
23:20So in some cases, IVF is done as a way to shorten the time to pregnancy.
23:25Okay.
23:26But for that, I was saying earlier, it's not actually a treatment because a treatment means
23:32you have got an underlying problem.
23:34You have got a condition and you're treating that condition, but sometimes it's not.
23:41And I don't think we can say that chronological age is a condition.
23:46Of course.
23:48And therefore an indication for IVF or any fertility management option.
23:53Yes.
23:54But that's what we're seeing today where more and more women in stable relationship, married,
24:04they are thinking to have a family later on in life and they may just come for IVF after
24:12two or three months of trying.
24:15To speed up the process, as you said, and to shorten that period.
24:18Okay.
24:19My next question is about, because I've seen this with some cases with some friends and
24:25people in my close circle who had an easy first pregnancy, but their second pregnancy
24:32was not as easy or vice versa.
24:35Is it possible for someone to be fertile and then infertile or face fertility problems
24:40for the second pregnancy and vice versa?
24:43It is absolutely possible.
24:44In fact, we call primary subfertility or infertility and secondary infertility or subfertility.
24:55And I'll give you different examples of a case of primary fertility problems is for
25:02someone who has never been pregnant and struggles to get pregnant.
25:06And as I mentioned earlier on during this episode, they may be trying for 12 consecutive
25:12months with no luck.
25:14Secondary is somebody that has conceived, has had a healthy baby and then comes back
25:21for a second cycle, for a second pregnancy after trying for 12 months.
25:32There could be problems that have developed from that pregnancy and there could be problems
25:36that have been acquired since that pregnancy.
25:41And examples are women that have conceived spontaneously with no problems and they've
25:48gone into labor and they've given birth by caesarean section.
25:54The caesarean section could cause some damage to the uterus and they could actually find
25:59difficult to conceive again because of some scarring or defects that occur at the site
26:07of the caesarean section.
26:11So there is a condition which is called caesarean section scar defect which affects their chance
26:21of conception.
26:25Other women may have conceived the first time no problem and since then developed thyroid
26:31problems, may have developed some blood clotting problems where the blood becomes sticky and
26:40that could impact on fertility.
26:43The fact that they have conceived once does not guarantee that they can conceive any times
26:48they want thereafter.
26:50And also Maria, what we need to bear in mind is that it depends on when the next pregnancy
26:56is going to happen because somebody may have tried to conceive at the age of 34 and actually
27:01is now set to conceive at the age of 38.
27:05So age is an important determining factor when it comes to fertility.
27:11So I always say to patients and to my colleagues and to the public, just don't bank on the
27:21fact that you conceived once because there is no guarantee.
27:27And to be honest there was, my uncle is a gynecologist, he's actually the head of gynecology
27:35in a hospital here in the UAE and he was saying every pregnancy is different.
27:42Every pregnancy, we're not talking from woman to woman, we're talking from the same woman.
27:48One pregnancy can be one way and the second one can be completely different.
27:53There are so many ambiguities and so many, you know, there are different factors in each
27:59pregnancy you can, it's never, oh this is how it's supposed to be or this is how it's
28:04going to go.
28:05It's very unique, every pregnancy is unique, every pregnancy has its challenges, every
28:10pregnancy has its journey and you can't generalize when it comes to pregnancy so I absolutely
28:15agree with you.
28:16Okay, I know that time is tight and that your time is gold so we are going to ask two questions
28:22from listeners.
28:23The first one, Liana messaged in saying, I'm 32 years old and we have been trying for over
28:28a year now to conceive.
28:30I still don't want to go to a doctor because I don't think it's necessary but if I do end
28:35up going, can the doctor identify the cause of the infertility if I end up getting diagnosed
28:42and how do they identify it?
28:45As we mentioned earlier, there is no guarantee that there is a condition, there is no guarantee
28:51that there is a cause of infertility.
28:53Like a specific cause, yeah.
28:56And also depends on the investigations.
28:59So the preliminary investigations I mentioned at the beginning of this episode, such as
29:04the AMH test, the ultrasound scan, the tubal patency test and the semen analysis and potentially
29:11an ultrasound scan for the male partner, they are not going to cover all the problems.
29:21There could be some genetic conditions and the female and male partner need to be investigated
29:29by having a blood test for a chromosome analysis.
29:33So I think the easy reply to your listener is probably in about 60 to 65 percent of cases
29:44we do identify a problem.
29:48We do find a cause.
29:50But that cause may not be found the first time you go to your specialist because the
29:56preliminary investigations are not going to be covering every single possible problem.
30:07And the reason why is because by doing all the investigations at the outset means that
30:15the cost will be very high when we know the majority, which means more than 60, 65 percent
30:22of the population will have no problems.
30:25Right.
30:26Right.
30:27No, absolutely.
30:28I hope that helps, Liana.
30:29It's a good question.
30:30And I feel like a lot of people don't want to admit that there's something wrong or if
30:33they do end up, you know, addressing the issue, they want a specific cause.
30:38They just want to hold on to that.
30:40But sometimes that's not the case.
30:42OK.
30:43This person preferred to be anonymous, but we're going to ask it because it's actually
30:47an interesting one.
30:48It's one I thought of.
30:49I don't have an issue, but I found it fascinating that so many twins were born after infertility
30:55treatment.
30:56Why is that?
30:57It's an interesting one.
30:58It is an interesting question, and I would like to, again, say before talking about why
31:04that there is a worldwide attempt and perhaps adopted practice to reduce the risk of twins.
31:14OK.
31:16So many regulatory bodies and many authorities are insisting and imposing some sort of guidance
31:28to clinics to ensure that only one embryo is transferred at any one time.
31:35This leads to, I think, to speculate, to answer that actually the reason why there are so
31:43many twins or there were so many twins, perhaps, is because multiple embryos were transferred
31:49at the same time.
31:50Oh, OK.
31:51So if you look at the instance of somebody conceiving naturally, you will have one egg
31:59being fertilized by one sperm and one embryo that implants inside the uterus.
32:04It is possible that that embryo splits and you have identical twins.
32:09Yes.
32:11But when it comes to IVF, if you transfer multiple embryos, they are not identical twins.
32:18And they are caused by having more than one embryo implanting at the same time.
32:24So by reducing the practice of transferring multiple embryos, we are reducing also the
32:32risk of twins.
32:33And twins are not ideal because the space within the uterus is limited.
32:42Twins have got some risks in pregnancy for the babies, but also they have got risks for
32:52the mother.
32:53For the mother, of course.
32:54We know that women that carry twins have increased risk of gestational diabetes, of mid and second
33:01trimester of pregnancy problems, increased risk of high blood pressure, increased risk
33:07of having a caesarean section.
33:10And for the babies, I think the main risk is that if they come premature, which is very
33:20likely, then they can come up with some neurological problems.
33:25And the common one being cerebral palsy.
33:28So you want to ensure that you minimize the risks of twins in order to optimize the life
33:36birth rate.
33:37Okay.
33:38So the short answer to this anonymous person's question is that more than one embryo is transferred,
33:47at least in the past, before this warning has been issued.
33:51Yes.
33:52All right.
33:53Fantastic.
33:54Luciano, it's been a pleasure.
33:56Thank you so much for joining us.
33:57We'd love to have you back.
33:58I feel like this topic is going to get a lot of responses.
34:01If any of our listeners want to send in their questions, please feel free.
34:06We are on social media, on the Gulf News Instagram account.
34:10And you can always email us on podcast at gulfnews.com.
34:15Get in your questions.
34:16We'd love to have Luciano back, answer them.
34:19And we can have like a Q&A session, which we discussed actually before the show.
34:23Thank you so much for your time.
34:24Thank you, Maryann.
34:25Thank you very much.