By : Lauren Rodych-Eberle

There is a reason for Expert Interviews on the blog, and it’s because there are so many incredibly important topics out there that need to be discussed, understood, and shared. Today’s topic is one that I could not have done justice to, but the wonderful Dr. Ariadne Daniel can. I am so grateful for the immense about of time, energy, and knowledge she put into answering everything in such detail.

Language is important…there are many words I’ve chosen to replace as much as possible to better suit the truth of the situation, or to help people be more seen in true context. This is especially true in pregnancy and birth terms. “Miscarriage” – you did not mis-carry…you had a pregnancy loss. “Due date” – your baby is not due…we are making a guess – guess date. “Failure to progress.” “Incompetent cervix.” I could go on and on. “Infertility” falls into that category for me. And although I still use the term (and some others) in order for everyone to understand and find it properly, I want to be clear that if you are seeking answers, or using fertility treatments – you are not ‘infertile’ – you are on your fertility journey – you are on the road to make or grow your family, and you are strong! Sending love, strength, and all the ‘sticky baby’ vibes to everyone on their path! Now, to Dr. Daniel…

Thank you so much for chatting today! What drew you to fertility within your line of work? 

I was born and raised in Edmonton. While I was growing up, I had a pediatrician, who inspired me through his kindness, intelligence, and passion for patient-centred care to go into Medicine. When I participated in my first delivery as a medical student during my rotation in OB/GYN, I was filled with awe.  During my five-year OB/GYN residency, I saw the challenges that people faced to start or complete their families. I felt the deep anxiety and sadness that people carried and yet I could see the hope that fertility care offered. The vision to walk this journey with people and provide them with the best treatments and technology, but also total care and support of their quality of life, inspired me to do further training in Reproductive Endocrinology and Infertility (REI) at Mount Sinai Hospital in Toronto. This vision was also what inspired me to be a part of the creation of Alberta Reproductive Centre (ARC), where we combine the best medicine with compassionate, supportive, holistic care.

I had people send in questions and there were so many asks about why infertility has increased so much in our generation. As a crunchy mama myself, I’ve gone down the rabbit hole of researching our products, our food, our environment, our contraceptives and how all of these factors significantly impact our bodies and our reproduction. What can you share about that and what you’ve found? 

The World Health Organization (WHO) in 2023 published a report showing that infertility affects 1 in 6 people worldwide. Infertility does not discriminate and there is no single factor that is responsible for fertility challenges. This challenge is a global medical issue which highlights the urgency to increase accessibility to high quality fertility care for all people wanting to become parents and complete their family.

Do you feel like you’re bridging the gap between western and traditional medicine? 

I think we have approached fertility care in a different way at Alberta Reproductive Centre. We recognize that everyone is different – so, too, are their needs and the path to realizing their fertility goals. The fertility journey can be an intense and emotional one where compassionate, supportive, and personalized care is fundamental. For many people, they are not only looking to integrate the best medical advancements and state of the art technology, but they are seeking a more holistic approach to their fertility care. We have created a clinic where people are seen as a whole person and are offered the opportunity to prioritize their mental health, nutrition, and physical well-being. Many of our patients are already seeking out acupuncture, massage, naturopathic medicine, and counselling. We support our patients in integrating wellness therapies to their treatments. We are the first clinic in Alberta to offer acupuncture onsite on the day of an embryo transfer, assisting those people who choose this service. [For more Edmonton resources, please check here].

What do you suggest to people (both men and women), who are trying to conceive without additional support, OR those who are using fertility support, in order to increase their chances of conceiving? 

In general, I would recommend:

  • eating a healthy balanced diet
  • prioritizing regular restorative sleep
  • limiting caffeine to 1-2 beverages a day
  • eliminating alcohol, nicotine, and drugs
  • taking a multivitamin with folic acid [folate] or a prenatal vitamin
  • participating in physical activity
  • avoiding exposures to environmental toxins
  • participating in activities that decrease stress and increase joy
  • optimizing other health conditions
  • seeking support or mental health services, when needed
  • avoiding lubricants that are toxic to sperm
  • tracking the menstrual cycle and ovulation (if possible) to narrow the fertile window
  • seeing us at Alberta Reproductive Centre for fertility care

Can you talk about the benefits of acupuncture in conjunction with assisted reproduction technology? 

Individualized acupuncture treatment plans during preconception can optimize chances of success. Amongst others, acupuncture can potentially help with ovulatory disorders, hormone imbalances, sexual dysfunction, abnormal sperm parameters, endometriosis, and unexplained infertility. These outcomes are achieved through:

  • Hormone regulation to help normalize menstrual cycles.
  • Hormone regulation to help aid spermatogenesis (the formation of sperm).
  • Increased blood flow to reproductive organs to help with receptivity for implantation of an embryo.
  • Decreased side effects to fertility medications by helping reduce inflammation and eliminate toxins from the body.
  • Reduced stress from the daily anxieties of everyday life and challenges with infertility.

When should people reach out for help and where should they start? 

Fertility challenges can cause significant emotional, physical, financial, and psychological stress for people. The first step is identifying if you should seek assistance.

Infertility is traditionally defined as 1 year of unprotected intercourse without conception. After trying to get pregnant for 12 months (or 6 months if the egg provider is >35 years old), fertility consultation is recommended.

You should be seen immediately if you are trying to get pregnant:

Egg Provider

  • No periods, or irregular periods
  • History of surgery that may impact fertility (eg. ruptured appendix removal, bowel resection, surgery for ectopic pregnancy)
  • History of abnormality of the uterus / tubes (eg. fibroids in the uterine cavity, uterine septum, blocked tubes, history of pelvic infection)
  • Endometriosis diagnosed by surgery or MRI (especially Stage III/IV)
  • History of chemotherapy/radiation therapy

Sperm Provider

  • Known/suspected poor sperm quality
  • Previous abnormal genital exam
  • Urogenital surgery
  • Known varicocele
  • Significant systemic illness
  • History of chemotherapy/radiation therapy

If you are facing the following fertility challenges, an immediate referral to Alberta Reproductive Centre is important:

  • Oncology / Medical patients for fertility preservation (sperm or egg freezing)
  • LGBTQSIA2+ family planning and building
  • Egg freezing so childbearing can be delayed
  • Single parent by choice
  • Recurrent Pregnancy Loss (history of 2 or more miscarriages)
  • Undergone fertility investigations/treatment and want to transfer their care to our clinic

We also provide other reproductive care services with no referral required, simply call the front desk at (587) 442-0461:

  • Sperm Freezing (eg. before vasectomy or chemotherapy)
  • Carrier Screening (Genetic Testing to check if you carry a genetic disorder that may impact your child)
  • Registered Dietitian (Specializing in Reproduction and Fertility)
  • Registered Psychologist (Specializing in Reproductive Mental Health)

What can you share about your experience with (and potentially resources to learn more)? 

There are many excellent patient fact sheets available through the ASRM (American Society for Reproductive Medicine) that are evidence-based:

https://www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/

Endometriosis

Endometriosis affects 1 in 10 people with ovaries. Endometriosis is where the cells that normally line the uterus (endometrium) are found outside the uterus. It can cause inflammation and nerve irritation, although some patients have no symptoms. The most common symptoms of endometriosis are pelvic pain, painful periods, pain with intercourse, bowel/bladder issues, and infertility.

The association between endometriosis and infertility is well supported through studies. Between 30-50% of people with endometriosis may experience fertility challenges, and 25-50% of people with infertility have endometriosis. Endometriosis can affect fertility by causing scar tissue in the pelvis leading to blocked tubes or other changes in anatomy that make it hard for eggs and sperm to meet. It is also associated with inflammation and changes in immune cell functioning, which may impact egg quality and quantity, and embryo implantation.

Unfortunately, endometriosis can be hard to diagnose. Sometimes, it can be seen on ultrasound or MRI. Currently, the only way to diagnose endometriosis with 100% certainty is with a surgical procedure called a Laparoscopy, where a biopsy sample can be taken and examined. Patients with endometriosis, especially if it is advanced staged, should be seen for a consultation by a gynecologist and/or fertility specialist.

PCOS 

Polycystic Ovarian Syndrome (PCOS) is found in 8-13% of reproductive aged patients with ovaries.  To diagnose PCOS, the Rotterdam Criteria requires two out of the three findings to be present: irregular or no ovulation, evidence of a hormonal imbalance favouring male hormones, and/or polycystic ovaries on ultrasound. Thus, a thorough history, blood work, and a pelvic ultrasound is necessary as part of the investigations. Medical implications of PCOS are an increased risk of insulin resistance, type 2 Diabetes, hypertension, and abnormal cells growing in the lining of the uterus. The first line treatment for PCOS is lifestyle changes such as healthy eating and exercise. I may recommend oral medications to regulate ovulation.

Sperm Factor Infertility

Both egg and sperm providers may have medical diagnoses that impact their fertility. Basic testing includes testing for the number of eggs, a fallopian tube test to see that they are open, baseline hormones, a pelvic ultrasound, and a semen analysis with anti-sperm antibodies. Depending on the history, some people will require more advanced testing.

The partner with sperm contributes to infertility in 30-50% of cases. Sperm factor infertility may be caused by age, genetic disorders, medical conditions, medications/supplements, cancer treatments, testicular infections/trauma, hormonal imbalances, lifestyle factors, surgery, or anatomic issues.

It is important for both partners to attend appointments, discover the underlying challenges to getting pregnant, and understand the treatment options.

Secondary Infertility  

Secondary infertility is the inability to conceive, after a previous pregnancy. Sometimes the cause is already known and other times it is not and investigations should be performed. Just like with primary infertility, the treatments will depend on the challenges that are identified, or it may be unexplained by our current available testing.

Blocked Fallopian Tube(s)

The location in which the tube(s) are blocked informs whether the tube(s) can be opened. For people with one tube that is open, there is still the possibility to get pregnant spontaneously, or to increase the chance with medications and IUI. If both tubes are blocked and cannot be opened, then the only technology to get pregnant is IVF. The first baby every born through IVF in 1978, Louise Brown, was conceived after her mother was found to have both fallopian tubes blocked.

Recurrent Pregnancy Loss (RPL)

Unfortunately, miscarriage is very common and happens in 30-60% of all pregnancies. Recurrent Pregnancy Loss (RPL) is defined by two or more pregnancy losses with the same partner. Excluded from the definition are ectopic, biochemical (very early loss), and molar pregnancies.  It is estimated that fewer than 5% of people will experience two consecutive miscarriages, and only 1% experience three or more. Causes of recurrent losses include anatomic abnormalities of the uterus, Antiphospholipid Antibody Syndrome (clotting disorder), endocrine diseases (eg. diabetes), autoimmune diseases, and genetic abnormalities in the parents. Risk factors contributing to RPL are increased age, weight (excess and underweight), and lifestyle factors such as smoking, caffeine, drug, and alcohol intake. Unfortunately, in approximately 50% of cases, no cause is found. In cases where a cause is found, many of them can be corrected or overcome, improving the chances of a live birth. When a cause is not found, there is still hope for the live birth of a baby.

There are several organizations that offer support to people struggling with pregnancy losses in Edmonton. Here are a few that people can reach out to:

When a couple has unexplained infertility, what steps are taken? 

Unexplained infertility means that available testing has returned within normal limits and there is not an explanation for why conception has not occurred. This diagnosis occurs in 10-30% of couples after infertility testing is complete and the chance per month of becoming pregnant is <4%.

When people see me, to improve the chances of pregnancy, I may recommend oral/injectable medications with intrauterine inseminations (IUI) or in vitro fertilization (IVF) as options. The decision about which fertility route to pursue happens during a consultation, where we talk about options, success rates, costs, side effects, risks, benefits, and the couples’ individualized needs.

Do you find if someone had difficulty conceiving their first baby, the likelihood of difficulty stays the same for following pregnancies, or is each pregnancy unique in this regard? 

It depends on what the reason for having trouble getting pregnant was the first time. For example, if someone has blocked tubes and needed IVF the first time, they would not be able to get pregnant on their own the second time. In the case of Polycystic Ovarian Syndrome (PCOS) or in unexplained infertility, it is possible that a second pregnancy happens without the treatment they needed the first time to conceive.

Every situation is different. The opposite may also be true, where the first baby is conceived quickly and then having another baby is challenging, which is called Secondary Infertility.

At what age does a women’s healthy eggs decrease significantly? And what about when it comes to men and their sperm count? 

Reproductive aging is real.

As we get older the quality and quantity of eggs decreases. According to research, the optimal fertility for people with eggs occurs between the ages of 18-31 years old. Egg numbers begin to decrease after age 32. The number of eggs a person is born with and how quickly they lose them is unique. Egg quantity is affected by factors such as genetics, environment, lifestyle, medications, and surgery.

Unfortunately, we have no test for egg health or quality. With increased age also comes increased risk for complications in pregnancy such as miscarriage, genetic abnormalities, high blood pressure, diabetes, bleeding, placental abnormalities, and need for delivery by Caesarean section.

For people with sperm, the number and quality of sperm begins to decline after 40 years old. The chance of pregnancy decreases as does the risk of miscarriage, and perhaps even the risk of autism.

If the plan or circumstances may mean that childbearing will be delayed, there is the option to freeze eggs or sperm for the future at Alberta Reproductive Centre. This option empowers people to have children on their own timeline.

How do you help people decide how long to try conceive?

There is so much to consider from a physical, mental, and financial standpoint. This question is a tough general question to answer.

Before treatment – Hopefully, I have answered it in an earlier question.

During treatment – This is an ongoing discussion as treatment occurs and information is learned through our investigations. There is no one answer to this question as each person is individual and their situation is unique.

Can you speak to the rules in Canada around implanting more than one embryo? 

The SOGC (Society of Obstetricians and Gynaecologists of Canada), CFAS (Canadian Fertility and Andrology Society) and the ASRM (American Society for Reproductive Medicine) have guidelines on the number of embryos to transfer, which physicians in Canada reference.

The decision on number of embryos to transfer is based on many factors – age of the egg provider, diagnosis, number of IVF cycles, previous successful embryo transfer, quality and stage of embryos development, genetic screening of the embryos, medical conditions of the parent carrying the pregnancy, and risk of twins or triplets from a transfer.

The goal is always a healthy pregnancy and baby after an embryo transfer. It is important for us to have a discussion prior to an embryo transfer about how many embryos are recommended for them to transfer based on their unique situation.

How long of a journey can people expect when working with you? I’m sure it’s a range! 

Every patient’s journey is different. This timeline varies widely, depending on what investigations they need and the treatment they choose to pursue. I respect their emotional and physical needs as well as their goals and limitations.

When it comes to financial support for assisted reproduction, where should people look? 

I think that there is a misconception that you must pay for all the costs related to seeing a fertility specialist, and that everyone will require IVF. At Alberta Reproductive Centre, all of the consultations, follow up appointments, and basic testing are covered by provincial health insurance. You may have third-party insurance providers that may assist in covering the costs of medications or treatments. Most people do not need IVF to get pregnant and it is my ethical responsibility to make an individualized fertility plan. You need to feel comfortable with your fertility doctor and confident in their ability to make a medical plan, while considering your goals and needs. I encourage people to come to Alberta Reproductive Centre for an initial consultation with one of our doctors and undergo investigations to see what the barriers are to getting pregnant. We can then discuss the treatment options that apply to your specific situation and the costs, so you can make an informed decision. 

Unfortunately, in Alberta it is true there is no provincial coverage for fertility treatments. You can check with your health insurance provider through your employer to find out if they cover part or the whole cost of fertility medications and treatments. Advocacy groups are working hard to bring awareness to the issues surrounding the lack of provincial financial support, so hopefully this situation will change over time so that fertility treatments are financially accessible for everyone.

Where can people find out more from you? 

You can visit our Alberta Reproductive Centre (ARC) website or check us out on Instagram, email us at [email protected], or call us at (587) 442-0461. If you are interested in a consultation at ARC, you can have your family doctor, nurse practitioner, walk in clinic, or any other doctor involved in your care fax us a referral to (587) 442-2757.

Thank you for this opportunity!  I hope this is helpful!

Thank you, Dr. Daniel, for your expertise!

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