Advances in Infertility Treatments with John Schnorr, M.D.

The Centers for Disease Control and Prevention (CDC) estimates one in eight couples have trouble getting pregnant or staying pregnant. But advances in medicine and technology have helped millions of people with infertility bring children into the world. John Schnorr, M.D., has overseen the care of thousands of patients with infertility. On this episode, he discusses common causes and the latest treatments offered at MUSC Health and Coastal Fertility Specialists.

“(Persistence) is the absolute most important predictor of success. It's not female age. It's not sperm count. It's persistence. The patient who comes to me and says, ‘Schnorr, we have a problem. We want you to help us. We'll do whatever it takes to get the job done.’ They're going to have a baby.”
— John Schnorr, M.D.

Topics Covered in This Show

• Schnorr is the Division Director of Reproductive Endocrinology in the Department of Obstetrics and Gynecology at the Medical University of South Carolina and co-founder of Coastal Fertility Specialists.
• The diagnosis of infertility is usually given after a year's worth of unprotected intercourse without pregnancy when a woman is under 35 and six months of unsuccessfully trying for pregnancy if a woman is over 35.
• A reproductive endocrinologist is a specialist who can evaluate patients with infertility and conduct tests and imaging to investigate the cause of infertility. About half of all patients with infertility will have a normal evaluation. While not knowing what is causing the issue can be frustrating, Schnoor says it is the best diagnosis because things are working normally and he can start with a simpler level of treatment before moving to in vitro fertilization (IVF).
• Today IVF success rates are 70% per try, with a long-term success rate of 95% — a big improvement in the 20-plus years he has been in the field. He says, “Advances in our medical understanding of reproduction, advances in the embryology lab, advances in the medications we use, advances in the medical devices we use to do all this has really enhanced the level of care that we're able to provide to patients.”
• The cost of IVF has not changed much in recent decades; it has been and continues to be expensive, Schnoor says, averaging $10,000 to $12,000 per cycle without insurance. Luckily, he says, more employers are covering infertility treatments as a benefit to their employees.
• While infertility can be stressful emotionally and financially, Schnorr says if a patient is persistent, they will get to their goal of having a baby. “We just need to figure out what's causing the problem and what's the lowest intervention step to move forward with, and then work our way through that.”
• For couples who are thinking about becoming pregnant or undergoing infertility treatments and want to increase their odds of success, Schnoor suggests they don’t use tobacco, minimize alcohol consumption, try to maintain a normal body mass index, exercise, eat healthy, and take care of themselves emotionally and mentally.

Read the Transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well.

Starting or building a family isn't always an easy road. The CDC estimates that one in eight couples have trouble getting pregnant or staying pregnant. But advances in medicine and technology have helped millions of people with infertility bring children into the world. Dr. John Schnorr has overseen the care of thousands of patients with infertility and is here to discuss common causes, and the latest treatments. He is the Division Director of Reproductive Endocrinology in the Department of Obstetrics and Gynecology at the Medical University of South Carolina, and he is the co-founder of Coastal Fertility Specialist. Welcome to the show.

[00:00:58] John Schnorr, M.D.: Excited to be here. Thank you for inviting me.

[00:01:00] Erin Spain, MS: Dr. Schnorr. Can you explain the diagnosis of infertility? What is it?

[00:01:05] John Schnorr, M.D.: Yeah, we all grow up and we think getting pregnant is going to be easy, and it's just natural But there are couples with medical disorders of fertility and we think that diagnosis starts with generally a year's worth of unprotected intercourse.

For those couples in which the wife is less than 35 years of age, if she's over 35 years of age that definition gets tightened a little bit, which it's six months of trying. And the reason they narrow that is because as a woman gets older, the pregnancy rate gradually declines. And so they want to encourage people to be seen and assessed a little bit sooner so that we don't get into an age-related problem by delaying the diagnosis.

[00:01:43] Erin Spain, MS: So why is it important to be evaluated by a specialist like you, especially if you've been struggling and now you meet this definition of infertility?

[00:01:52] John Schnorr, M.D.: Well, a Reproductive Endocrinologist is an OB/GYN-trained doctor who did three additional years of training in fertility. And so if you're concerned about your fertility and you don't even need to have infertility to be concerned. But if you've been trying for three months and you say, gosh, I'm concerned, I think you should see at least your OB/GYN who's very well trained and equipped with initiating an infertility evaluation.

And that initiate generally is going over somebody's history and looking for red flags, going over your partner's history, looking for red flags in your partner's history, and then doing a basic evaluation that might include an ultrasound to make sure the muscle to the uterus is structurally normal. And during that ultrasound, they can check the ovary and check the egg count within the ovary.

Another part of that evaluation is doing some basic hormone testing. And then of course, a sperm count becomes important. And again, an OB/GYN is very well trained to initiate that. If you as a patient choose to go directly to a specialist, that's certainly your option. And a specialist would be happy to see you to discuss that.

And, part of that is looking for clues. The clue would be, you know, have you had a long history of tobacco use? Is weight a problem? Do you have any other major medical illnesses that you struggle with? Have you had any significant surgeries that might have involved the uterus or Fallopian tubes or intestines? And then, you know, do you have regular menstrual cycles? We think that's a sign of ovulation is to have regular menstrual cycles.

So, you know, those are the clues we're looking for. Have you had chemotherapy, have you had radiation therapy? Would be important. Going over our partner's history, does he have children already? Does he have any major medical illnesses? Is he on any bodybuilding hormones? Sometimes men get put on testosterone and other things that we think might help, but actually it hurts significantly. So going over both histories becomes an important first step. And there are some basic hormone tests that kind of give us some direction.

[00:03:48] Erin Spain, MS: So, there's a little detective work that goes on here.

[00:03:51] John Schnorr, M.D.: Yeah.

[00:03:51] Erin Spain, MS: And then you do uncover, a lot of times, the cause. Tell me about some of the typical causes, and then sometimes you are not able to uncover the cause as well, isn't that right?

[00:04:01] John Schnorr, M.D.: Right, it's a great question. So, we need to remember that about half of all patients within infertility will have a normal evaluation. All of their tests will be normal, and that sounds like a nightmare. But in truth, that's the best diagnosis to have.

That means that the egg count is normal. That means that the sperm count is normal. That means that the uterus is normal. That means that the Fallopian tubes are open and working and that's normal. So, it's best to have a diagnosis of unexplained infertility.

Now, that doesn't mean we can't figure out the cause. Not too long ago, we used to operate on everybody with unexplained infertility. And that surgery was very eye-opening to the doctors, that for all patients with unexplained infertility, if you operate on them, 60 to 70% of patients would have things that you could only find at surgery. Scar tissue around the Fallopian tubes, endometriosis, other things inside the body that you can't see without doing surgery. So then that would beg the question, well, why don't we still do the surgery? Right?

Well, two large prospective randomized trials showed that doing the surgery did not improve the pregnancy rate. Right? So we found the diagnosis with significant cost, pain and discomfort, but it didn't change what we do because the surgery made it so that the adhesions came back real quickly or the endometriosis wouldn't fully removed. So ,we didn't accomplish the patient's goals by doing that surgery. So as you can imagine, we decided surgery is probably not the right thing to do for unexplained infertility. But that's the best prognosis, patient's unexplained infertility, because we can start at a simpler level of treatment.

[00:05:32] Erin Spain, MS: Well, let's walk through some of those treatments and how you determine what's the best treatment for each patient.

[00:05:38] John Schnorr, M.D.: Yeah, so it depends on the diagnosis. Importantly, 20 percent of all patients have more than one abnormality causing their infertility. So what you don't want your doctor to do is to start your test, find the sperm counts abnormal, and then skip the egg test and skip the X-ray and skip all the other. You got to do all the tests so you know all the diagnoses.

And once you know all the diagnoses, then you know the different forms of treatment. So we find that male factor infertility is probably one third of all the cases. So, we care a lot about the sperm count. A sperm count should generally be done with a specialist in infertility. So it should be done in a specialist office.

You can still see an OG/GYN for your testing, but your semen analysis which is a very, difficult test to do right, should be done at a specialist office. It should be done with about three days worth of abstinence. And with that, they'll look at the amount of sperm, which is present, the motility of the sperm in the shape of the sperm, to figure out is there any male factor infertility that we're dealing with and then the second test would be, X-ray to make sure the Fallopian tubes are open and working.

That can be done by your OB/GYN or it can be done by the specialist. It's done where they put a little device into the cervix and they put warm dye up into the uterus under an x-ray machine to make sure the uterus is normal. Make sure the Fallopian tubes are open and working.

[00:06:56] Erin Spain, MS: So then from that point, you can pinpoint what sort of treatments you might start with. Is that right?

[00:07:02] John Schnorr, M.D.: Right. Because if the tubes are blocked, Generally we actually remove that Fallopian tube to get the scar tissue out, which then gets us down a pathway of treatment called in vitro fertilization. That's a different form of treatment than if everything's normal and if the sperm counts slow. And we do hormone testing for a patient.
Hormone testing is a way for us to understand how many eggs are in the ovaries, make sure she's ovulating, make sure her thyroid hormone's normal, all those types of things. That becomes important for understanding are we dealing with a decreased number of eggs? Are we dealing with a decreased quality of eggs? That helps me understand what medications to use to try to compensate for that.

[00:07:38] Erin Spain, MS: You have been treating patients with infertility for decades. Explain how this field has changed, especially in recent years, then how treatments have become more advanced.

[00:07:48] John Schnorr, M.D.: It has been amazing to see the changes. You know, I've been here now in Charleston for about 22 years and was in training in the early nineties. And in the early nineties, we didn't know a lot about fertility and fertility treatment. The belief amongst the leaders was that people only have intercourse at night, therefore we should only be taking the eggs out of the ovary at night.

That may not be true. Right? But anyway, they only took the eggs out at night. They only took the eggs out in an operating room. That was at 98.6 degree Fahrenheit. And they did these things that they just thought was as close to norm as they could be. At that time we were doing four embryo transfers. We had put four embryos into uterus at a time.

Problems with multiple pregnancies there. And the pregnancy rate was around 10 to 12 percent per treatment cycle. Now, we do egg retrievals during the day because we know that's not a problem. And we do a one embryo transfer. And the pregnancy rate is 70 percent per try, and the multiple pregnancy rate with a one embryo transfer is 1 to 2 percent.

And so at the end of the day, what we find is, advances in our medical understanding of reproduction, advances in the embryology lab, advances in the medications we use, advances in the medical devices we use to do all this has really enhanced the level of care that we're able to provide to patients. Now, here's the other thing that's amazing.

The cost of care over 20 years has not really gone up. The cost of an IVF cycle you would think would've gotten higher with all these medical advances, you think it would've gotten higher with inflation and everything else. But the cost of a regular IVF cycle, without some of the additions is really been functionally unchanged over the last 15 years.

[00:09:26] Erin Spain, MS: You bring up cost because this is something that worries a lot of patients and people. There are stories out there between friends and social media and newspaper articles about how this can really cost a lot and insurance doesn't always cover it. Can you just talk about that a little bit and some of the challenges patients may face?

[00:09:43] John Schnorr, M.D.: It is expensive. You know what I said earlier is the cost didn't go up. I wasn't saying it's inexpensive because it's not, it's expensive. So you know, the cost of an average IVF cycle without medications might be $10,000, might be $12,000. Something in that range; medications might be another couple of thousand dollars

So it is expensive what we do. And if you go to a fertility center that specializes in fertility treatment, you'll quickly understand why, because it takes a gigantic team of people to make that happen. Not only do you need a doctor, but you need an embryologist, which is a highly skilled scientist who actually works behind the scenes to make this work, you need anesthesia, you need an operating room, you're going to need nurses to help you through all this.

You need an andrologist to help on the sperm side. So it takes a village to make this happen, which is why we’ve gotten good at it over time. We’ve got a lot of specialists around us to guide us through all that, and I think that's really helped out a lot. One of the things that's been a real benefit on the financial side is more and more employers are including fertility treatment in their insurance policies.

When I came to South Carolina, probably 20 percent of people had fertility coverage. Now probably 60 to 70 percent have fertility coverage. And sometimes part of our counseling is if you see a patient without coverage, if there's a will, there's a way. Let's help find an employer who can get you coverage so that sometimes even with a part-time job, you can get fertility coverage, which will cover your fertility treatment.

[00:11:06] Erin Spain, MS: You mentioned there is a financial counseling aspect, but there's also a big emotional component that can come with undergoing infertility treatments. How do you help patients deal with the stress and the highs and the lows of this process?

[00:11:19] John Schnorr, M.D.: It's very challenging and, we know that if you look at studies and looked at the amount of stress on a couple with a new diagnosis of infertility, it seems to be equivalent to a new diagnosis of cancer. Very stressful, very challenging. You always dreamed of a family. You met, a partner you want to have children with, and now you can't have children and you think it can't happen. And I think empowering them through knowledge and to have them see a specialist who says, look, this is something we deal with all the time. Your prognosis is good for these three reasons. Let's finish up an understanding as to what's causing this, and let's talk about ways we can move through this in the least expensive, least invasive manner.
We always start as simple as we can, but we know if you don't have sperm or your tubes are blocked, we're going to have to start a little bit fancier than we might normally start. But we can get to where we're going. And so often I think once patients trust you as a physician, trust the science and the medical knowledge that we have moving forward and understand that this is a medical disorder, just like any other medical disorder, with a benefit being our long-term success rate is over 95%.

[00:12:25] Erin Spain, MS: It must feel good to be able to be part of this process with your patients.

[00:12:28] John Schnorr, M.D.: I love seeing couples and they come in, you know, worried this is never going to work. And they are stressed and anxious and you reassure 'em, you help them through it. And then they come back in two years later for baby number two and their hair's disheveled and Cheerios are falling out of their pockets. And you know, it's just a whole different world that they're now in and you're just so happy for them and grateful that they trusted in you to help get you through that, and then we're persistent through the journey.
And part of the doctor's job is to do it in a safe way and that means we're generally going to be doing one embryo transfers. And actually sometimes that makes it so that we do genetic testing of the embryo before we put into the uterus. That's a newer technique. It shouldn't be used for everybody, but there are some people maybe with the family history of birth defects where we might do genetic testing beforehand, maybe due to maternal age being, you know, higher, we might want to do genetic testing. A lot of different reasons, but those are things we can employ to help make the pregnancy safer moving forward.

[00:13:22] Erin Spain, MS: You mentioned the word persistence. That's something that patients should keep in mind before embarking on this journey?

[00:13:28] John Schnorr, M.D.: It's the absolute most important predictor of success. It's not female age. It's not sperm count. It's persistence. The patient who comes into me and says, Schnorr, we got a problem. We want you to help us. We'll do whatever it takes to get the job done. They're going to have a baby. Now I guarantee they're going to have a baby. Now you might say that is an outlandish statement, Dr. Schnorr. What if they didn't have a uterus? I'd say, well, that's a challenge, and we have what we call gestational carriers who would help us with that, so somebody else would carry the baby.

Well, what Dr. Schnorr, what if they don't have any sperm? Well, that's OK. We can do testicular biopsies to get out sperm. And if that doesn't work, we can use donor sperm if we need to. What if they don't have eggs? OK, well that's a challenge. If we need to do that, we can do egg donation. OK, well, what if they don't have a uterus? What if they don't have eggs? What if they don't have sperm? Well, OK, that's a donor egg donor sperm gestational carrier cycle. So the message is, is that we'll get there. We just need to figure out what's causing the problem and what's the lowest intervention step to move forward with, and then work our way through that.

[00:14:24] Erin Spain, MS: You are also able to help patients before they are undergoing a medical treatment such as chemotherapy to help preserve their fertility. Tell me about that aspect of what you do.

[00:14:34] John Schnorr, M.D.: That's a great question and something I'm particularly endeared to is couples with a new diagnosis of cancer who are going to get cancer treatment. If you're a male with a new diagnosis, we know that chemotherapy or radiation therapy can decrease your sperm count and make it so you can't have children in the future. Freezing sperm before you start your chemotherapy, before you start, your radiation therapy can be used so that that frozen sperm can be used later in life when you want to get pregnant. It's important that's done before the chemotherapy is administered. Your local Reproductive Endocrinologist Specialist can do that for you, and they'll generally schedule that on a short-term kind of emergency basis. If you're a woman with a diagnosis, we know that chemotherapy and radiation therapy can hurt the number of eggs in the ovary and the quality of eggs in your ovary. And it'll depend a lot on what type of chemotherapy is being used, what the dose is going to be, what the duration is going to be, and what your age is at the time of diagnosis. If you're younger getting chemotherapy, you tend to respond a little bit better than if you're older getting chemotherapy. I would recommend any male or female who's getting chemotherapy, radiation therapy, discuss this with their oncologist and if they feel appropriate, discuss it with a reproductive endocrinologist. We can take out eggs before the chemotherapy is started. Those eggs can be frozen and then later used to get pregnant after you're a survivor. And so that is a very important tool available. Sometimes instead of freezing eggs, we can just suppress the ovulation and quiet the ovary during the chemotherapy and get a benefit with that also so many different options. And I think it's worthy of a discussion. I know it's a hard time to have a discussion when you're worried about your new cancer and are you going to survive it? To now be thinking about reproduction, but I think it's important to bring up and discuss.

[00:16:16] Erin Spain, MS: So you see patients both at MUSC Health Women's Care Fertility Services, and at Coastal Fertility Specialists. Explain how MUSC Health helps you offer the very best care to patients.

[00:16:28] John Schnorr, M.D.: MUSC Health is amazing. I mean, they're amazing at the very beginning. They teach and train medical students, residents, and fellows, all the way through the journey of OB/GYN. They got a very, very good, very strong department. We are very happy to be part of the educators in the department of OB/GYN. And then when we're in department of OB/GYN, we're always exposed to latest research, latest medical studies, all those things that make us better as physicians. And so love being part of MUSC.

[00:16:57] Erin Spain, MS: What advice would you give to someone they're thinking about getting pregnant down the road? How can they possibly prepare to be in the best health, to have the best chances of pregnancy?

[00:17:08] John Schnorr, M.D.: I think there's a couple of factors that are moving along at the same time. The first one is female age is probably one of the biggest predictors for outcome, and it has to do with egg quality and egg number. And so we think female age matters a lot. We think that above 35 years of age, female age becomes an increasing problem. Above 43 years of age, it becomes an almost insurmountable problem using a person's own eggs. And so if you haven't found the partner that you want to have a child with, remember there is egg freezing available, which gives the ability to take out eggs and freeze eggs so they can be used later in life.

I think we also need to remember the environment that we subject our bodies to, and I think our body needs to be healthy to get pregnant and to carry a baby and have a low chance of miscarriage and a low chance of birth defects. And that means make sure we're not using tobacco. Make sure we're minimizing alcohol. I'm not saying eliminate alcohol, but I think it needs to be minimized and that's generally less than four glasses of alcohol per week. I think our weight matters a lot and so I think we need to keep our weight down. We tend to use a body mass index to understand weight.

There are calculators available on the internet for that.

Understand your weight and try to get it as close to normal as you can. I think exercise is good for us mentally and physically, and I think eating a healthy diet is also going to be very important. So it's kind of taking care of yourself, taking care of your body, taking care of yourself emotionally and mentally. And then making sure that female age doesn't get in the way. Male age, probably not quite as important as female age.

[00:18:35] Erin Spain, MS: The last question is what we ask everyone who comes on this show. What do you do to optimize your health and live well?

[00:18:42] John Schnorr, M.D.: I really try to keep my body weight normal. I try to keep exercising and I really believe that a healthy diet is important. And to me a healthy diet is going to be low on fat intake, it's going to have a lot of phytonutrients in it, so a lot of the colorful vegetables and fruits and all that kind of stuff are going to help you out. Minimizing alcohol intake and then eliminating tobacco.

[00:19:02] Erin Spain, MS: Well, thank you so much Dr. John Schnorr for coming on the show and explaining all the work that you do for folks with infertility. We really appreciate it.

[00:19:10] John Schnorr, M.D.: Thanks for having me.

[00:19:11] Erin Spain, MS: For more information on this podcast, check out advance.muschealth.org.