Ep 123: Secondary Infertility with Dr. Jeffrey Klein
Fertility Forward Episode 123:
Just as we always say, knowledge is power, and today’s guest is a massive advocate for getting more information about your fertility to make informed decisions. Dr. Jeffrey Klein is a reproductive endocrinologist and fertility specialist at RMA of New York -- Westchester with a reputation for incredible patient care and a great passion for his work. He joins us in this episode of Fertility Forward to discuss secondary infertility, what it means, why it occurs, why the workup is similar to regular infertility, and so much more! We delve into why open lines of communication and pure honesty are imperative in fertility care before Dr. Klein explains AMH and the differences between egg reserve and egg quality. Fertility is filled with grey areas, and our guest leaves us with words of encouragement to arm ourselves with information about our own reproductive health. Finally, he shares his gratitude for his health! Thank you for listening.
Rena: Hi everyone. We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Fowarrd Podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Dara: Today on our podcast we have Dr. Jeffrey Klein, who is a board certified reproductive endocrinology and infertility specialist, who leads an experienced team of medical professionals at our RMA – Westchester offices. Dr. Klein has been in private practice for over 20 years and keeps staff and teaching privileges at several surrounding institutions and is a speaker for various professional societies. While completing his reproductive endocrinology and infertility fellowship at Columbia University, Dr. Klein pursued research on novel reagents for clinical use in IVF and infertility treatments. This innovative work culminated in national recognition. presentations at international meetings in collaboration with a global pharmaceutical company. He has published both basic research and clinical reports in peer-reviewed journals, as well as chapters in textbooks on a wide range of reproductive topics, including IVF, reproductive aging, and egg donation. Dr. Klein has received many academic awards during his studies and training, including the prestigious Ortho McNeil Pharmaceutical Education Award and the Society of Laparoendoscopic Surgeons Resident Achievement Award. Dr. Klein has been recognized as a top reproductive endocrinologist and infertility specialist in Westchester Magazine's Top Doctors every year since 2007. Wow. Lot of accomplishments Dr. Klein! We're happy to have you on.
Dr. Klein: Thanks for that wonderful introduction. It's a pleasure to be here.
Rena: Oh my gosh. And can I add that anyone that knows Dr. Klein, they'll say this man is the nicest man ever. So on top of all those.
Dr. Klein: Oh, you're too kind, Rena. So nice. But now I have to be on good behavior on your podcast after all that buildup.
Dara: No pressure Dr. Klein. No pressure
Rena: Well, we're so happy to have you on. We know that you are so busy. So you work in our Westchester offices. Tell us what it is like up there.
Dr. Klein: Correct. It is the suburbs. I don't think it's that different from New York City. It's, we have a state-of-the-art lab up here. We're able to provide all services, including laboratory services, retrievals, transfers up here. You know, we're a suburb of New York City and we have patients that float between the two areas. I do think that one thing might be a little different in the suburbs is we probably have more of what's called secondary infertility, which I think was gonna be the theme of this podcast. Meaning you probably have more couples that have started their family and have now moved out of the city or, and are having difficulty with a subsequent pregnancy.
Rena: Yeah. So that's it. I'm so glad you brought that up. But that's actually, I never thought about that actually correlating in being statistically higher in the suburbs, but that makes so much sense. So for our listeners, secondary infertility is when you have conceived one child or maybe even two children, naturally, no problem. Then you go to conceive again and, and you can't. And that emotionally can be very hard for people because they don't expect it. You know, I've already had one or two kids, no problem. Now I'm on my second or third and, and why can't I get pregnant? And I find that both secondary and unexplained infertility are emotionally two of the most difficult things to deal with.
Dr. Klein: Correct. Some people think that it might be easier 'cause they may have a child at home, but you're right, they are sort of blindsided because they felt I got pregnant. No problem the first go around, what could possibly be going on? It perhaps is more unexpected.
Rena: So what are some reasons that secondary infertility could occur?
Dr. Klein: You know, the workup is pretty much the same as infertility, primary infertility, infertility in general, because things can change over time. So the workup really isn't any different. It really is three basic tests. You wanna make sure there's plenty of eggs. You wanna make sure there's plenty of sperm. And you wanna make sure the fallopian tubes are open - the sperm, it can meet in the fallopian tubes. One thing that might be different with secondary in fertility is, and I know I'm speaking the obvious here, but by definition the woman is, well, at least nine months and change older. The woman could be a few years older. And fertility in women does decline with advancing age. So that is one thing when couples ask me what could possibly be going on now compared to, you know, four years ago. I have a three-year-old at home. Well, you are three years and nine months older. And that can affect female fertility in two ways. We know that the genetics of the eggs is correlated to female age and it usually doesn't change between the mid to the late twenties and early thirties. But starting in the mid thirties, the rate of abnormalities in eggs does increase. And people don't always realize that that rate of genetic abnormality isn't just correlated to the risk for down syndrome, the risk for miscarriage. But many of these chromosomally abnormal embryos don't implant. So there's less efficiency as a woman gets older.
Dara: That makes sense.
Dr. Klein: And the other thing is that that egg number can change with time as well. So you always wanna be on top of what we call ovarian reserve. So those are two aspects that can change over time, but we do a complete workup. Sometimes they got lucky with the first pregnancy and there is a male factor underlying and it takes two to make a baby here and sperm counts could be low, they got lucky with the first time and that's what's going on. Or something changed on the male side. Or the tubes were fine two years ago and now one tube could be blocked. And you don't always have a history to suggest that. There isn't always a ruptured appendix and major abdominal surgery that could cause that. There's some insidious things that can cause tubal disease. So we do a basic workup. You wanna be thorough and meticulous.
Rena: So is there something that anyone, male or female, I guess, should think about or maybe anticipate if they already have one child at home and they know they want a family-build and have more, is there anything sort of they should think about in advance or just wait until they're ready to conceive again and then try and see what happens?
Dr. Klein: I don't think that the directive changes at all with the one caveat that depending on your age, if you are, while young still, at a more sensitive age reproductively, you may not wanna wait as long before seeking help. I think that most OBGYNs, most primary care doctors, most patients these days are pretty educated that if they were 32 and now they're 36, they might wanna try on their own and hopefully they get pregnant without a problem. But I don't think at 36, 38, you wanna wait a full year like you might at 30 or 32 before seeking help. So you might wanna move things along a little faster if you are at an older reproductive age.
Rena: Well, I love how you said first a sensitive reproductive age. I thought that was so nice because people always get so upset and feel like age shamed. Right? But to say a sensitive reproductive age, I really like it.
Dr. Klein: You know, it's funny, I'm now in my fifties and yeah, I, I am turning 54 this year.
Dara: I wish you could see Dr. Klein. Yeah. He has a baby face, zero wrinkles.
Dr. Klein: Oh, thanks. Oh, I feel, I feel like I'm, I'm 53 going on 73. My, I have aches and pains and you know, but thank you for that Dara. So I have patients that are 42, they are, to be 42. They're young, but reproductively, they're not. And you kind of have to give it to them as straight as possible. But yeah, someone could be chronologically young, but reproductively not. And there are sensitivities about age, but you have to be transparent because you do wanna light a fire under somebody who's late thirties, early forties versus someone who's late twenties, early thirties. I think that's kind of obvious, but not always. And you wanna, we're here to guide patients and in order to guide them, that's a part of it.
Dara: I appreciate your, your honesty. I think that's really important. But my question is, you know, I, I think it should be something also in terms of OBGYNs when you go to, you know, I think that's why it's so important to go for your annual physical, go to your OBGYN. I wonder is this a discussion that should happen? You know, you know, are you thinking of having more children?
Dr. Klein: Definitely. You could take one step back and I know the theme for today's secondary infertility, but more and more OBGYNs are having discussion on not just fertility, having a child or another child, but also on fertility preservation. You know, I, 20 years ago, 20 something years ago when I started in practice, we didn't have the technology to be able to freeze eggs. But now we do. So it's kind of an equalizer. You know, it's kind of, it's not egalitarian between the sexes here. You know, male age doesn't affect male fertility the way female age does, but you have the opportunity to freeze eggs and suspend eggs. You could be 30 years old. If you freeze eggs when you're 30, you have 30 year old eggs forever. Now there's never a hundred percent guarantee of success. But if you have a dozen, 20, 30 year old eggs, you have to be pretty unlucky when you're 38, 40 if you need to fall back on those, so, not to have success. So I think many OBs now, but perhaps not enough, or even sending patients for a consultation to discuss egg freezing, they wanna know that they've covered all the bases and they wanna do the best for their patients. So the best for a particular patient may be, you know what, this is not for me, but at least have the discussion. You know, everything we do is elective. So I wanna get back to your honesty part. It's not easy, but I find myself, I'm very transparent and I feel like we have to be in an elective field of medicine. So sometimes I'm brutally honest. You know, if somebody is 45 with low egg reserve, I, I give them the percentages. You know, I sometimes talk people out of doing certain treatments that are invasive and costly. The flip side of that is, if I have someone with good egg reserve who's, you know, at an age where our batting average is really good, I'm, the parting words are, I know it's been a year, two years, it's a hugely stressful process. But I, I kind of, I let them know, I feel like you're gonna have success. I, it's a matter of when and how, not if, and nothing's a hundred percent. So it goes both ways. Where I can be very reassuring in a very honest way. But I lay all the cards out there because it is elective and my modus operandi is to give them options, the pros and cons of the options, and then let them make an educated, informed decision. So, ultimately, they know as much as I know to make the right decision for them. And for some couples it might be, you know what, we're anxious, we wanna have three kids. Let's go to IVF and have extra embryos frozen for future use. Other couples, very reasonably, same characteristics might say, let's start with simple treatments. If we can't have a sex child down the road, I don't feel a pressing need. We only want one or we love the idea of adopting and they might not put a premium, for example, on having extra frozen embryos for future use when they are that much older and entering their forties or what have you. So this field, like life, has lots of shades and gray and occasionally it's black and white. Your tubes are blocked, you have to do IVF. I mean that's the gold standard, but there's lots of shades of gray. So I think we have to be open and honest about the prognosis, the options, and then patients can make the most informed decisions.
Rena: Can we also go back to, I wanna touch a little bit more on egg reserve. You know, you keep bringing that up and I think that's such a buzzword, buzzy topic, you know, AMH and you know, low AMH or high AMH. And a lot of times people get very concerned,
Dr. Klein: I don't dunno if your listeners know what AMH is, it's a let me just, sorry to interrupt. It's a blood test of egg reserve. So there are various ways of assessing it, but it spits out a number. It's kind of a quantitative assessment of egg reserve. You can't directly count eggs the way you can sperm on a semen analysis. but we have indirect markers for basically how many eggs a woman has left. It's kind of the female correlate, if you will, of the semen analysis. But go ahead Rena. Sorry to interrupt.
Rena: No, please. I just wanted to bring it up though, because I think a lot of times people hear, you know, if they have a low AMH then they think they have no eggs and that their chances of conceiving have plummeted. So can you touch a little bit upon that and what it may mean if you have low AMH versus high AMH and and egg reserve and your chances of…
Dr. Klein: Sure. Egg reserve is a marker for egg number. That's important to know. And egg number, just like anyone's organ system, can age at a different rate. The ovaries are even more prone to variability. So for, I, I went to college with someone who had a heart attack at 48. You know, most people's hearts, if you're destined to have a heart attack, it's gonna be in their seventies. The ovaries are more prone to variability. So variability, it's independent of age as an assessment for egg number. It does not correlate, importantly does not correlate to egg quality. And there's lots of data to support that. So yeah, it's nice to have more eggs and our success rates are in large measure dictated by egg reserve because the more eggs you have, the better the odds of finding a winner embryo and having success. But the second important piece is age, female age correlates to egg quality and you wanna make sure that there's a distinction between the two because it's not so rare to have someone who's young, and I don't mean to scare your listeners, but there are plenty of 40 year olds to be clear, that never need to walk into our offices. There are plenty of 38 year olds that we see that have blocked tubes. They do IVF and they have 20 eggs and get pregnant like that. We also have 30 year olds and 32 year olds and a 28 year old that every now and then will have low egg reserve. Those are the patients where they might go on the internet or they might talk to people and it's a very scary thing. Their AMH could be very low sometimes, but we do more with less because age correlates to the genetics of the egg and the probability of finding a winner embryo, chromosomally normal embryo, which has a good success rate. So if you get three eggs from a 30 year old, you're in the ball game, you know, you can have very low egg reserve. You definitely wanna move in that case to a treatment that has higher success rates because time is that much more of an issue. But you do more with less in someone who's younger. So you definitely wanna distinguish between egg reserve, which is number and egg quality, and it's the combination of the two that correlates to prognosis outcomes. And we have quite good success rates in women of all ages with low reserve, but especially in your younger patients with low reserve. And it's not good or bad. It's not a black and white thing. Sure egg reserve can be really, really good and really, really bad. But again, like medicine and life, there's variability. And the way I manage egg reserve is again, in a very open way. And it's a very tricky thing though. It's hard to predict future egg reserve. In fact, you can have someone with mildly low reserve and it can hang in there for a couple of years. You can have someone with normal egg reserve and it could at some point drop more precipitously. Nothing's gonna change in two, three months, but in, in a year, you know, you can't, that's the whole idea behind freezing eggs. That 34 year old may never need those eggs. They might have fantastic egg reserve. It might stay good when they're 44. It might drop when they're 36. That's the whole idea. So egg reserve is a point in time – how many eggs you have. It doesn't predict what it's going to be like a year from now, two years from now. It varies greatly. So there's not a lot of visibility into long distances of time. Moving ahead and egg quality is really correlated to female age.
Dara: So it's a snapshot in time. Your AMH…
Dr. Klein: It's a snapshot in time that nothing is gonna change in a month or two or three, but you wanna be careful about making predictions. Longer term you really can't. Now if you have good egg reserve in someone who's 28, 30, is it likely that it's gonna be really good at 30 and suddenly really bad at 31? It's a very low probability. Is it a higher risk when you go from 40 to 41 to have a steeper drop? Yes. But data has shown that at some point in a woman's reproductive life, there's a more rapid loss of eggs. They've looked at this and it's not, you can't even check egg reserve three times and draw a slope and connect the dots. It doesn't work like that. The curve is biexponential. At some point there's a rate of decline that could be very slow, but at some point it accelerates for some women that that point in time is when they're 42, 38. Every now and then it's 32. Which is why sometimes you have younger patients who do have low egg reserve. But again, it could be mildly low, prognosis could still be good. So I, I think if you're ever asking your gynecologist or your fertility specialist, you know, what is my egg reserve? It shouldn't just be good or bad. There should be more granularity around that. And that matters in terms of how I guide my patients. Again, the decisions, it's an elective field are always theirs. I have someone who's just starting their family, they could have normal egg reserve. An AMH of over one is normal, but if they're 36 with an AMH of 1.1, I'm not worried about baby number one, great prognosis. I don't know what it's gonna be like for baby number two when they're 37 or 38. That couple might wanna think about doing IVF and having banked embryos for future use. Conversely, same couple, they have two kids finishing their family for a third. They might say, you know what? IVF is something I might do sooner than later. I am 36, but I only want one more kid. Let's try simple treatments. It's not, it, it doesn't matter to me if I don't have, you know, so low normal egg reserve might be different to a different couple depending upon how large a family they want, what they want. And a 1.1 is very different than a 2.1. There's less of a cushion. So egg reserve, it could be good, it could be bad, but you can get more quantitative assessments and more color around it to help guide patients. So do the right thing for them in terms of their family building goals.
Rena: Well I'm so happy that you touched upon this and broke that down. I think this is so helpful. I mean, I think there's a lot of misinformation out there. And then I think too, it's, it's being really pragmatic and you know, realistic. And I think a lot of times for people it feels really maybe foreign or not romantic or like playing God to think about these things. But you know, we're so lucky with science and technology and, and we have available to us to preserve fertility or take control of family building. And so it's just important to have this information so that you don't find yourself in a situation where you're really struggling and you know, not able to, to conceive.
Dr. Klein: You know, I sometimes have friends, friends of friends, OBGYNs, that say, you know, is this an appropriate patient to send? I mean the AMH is fine, it's 1.7 though, but they're only th you know, I say, you know, it's normal, they're, don't alarm them. But it can never hurt to get more information. There are plenty of people that will come into my office or do a Zoom and they just get more…what's the harm in spending a half hour, 45 minutes, an hour, and just being informed? So if there's ever any shade of doubt, any cloud hanging over you, there's nothing wrong with just getting more information. It doesn't mean you have to act on it. Plenty of patients come in, they get information and you know what? The plan is, they try on their own for a few more months and they never need to do any treatments, but at least they've gotten information, they're making that decision to try on their own from an informed standpoint.
Dara: Yeah, being properly informed and also, you know, meeting with an expert. I think, you know, sometimes that doctor Google route can, you know, be mixed with a lot of misinformation and some scary stuff and not customized. So I think…
Dr. Klein: Yeah, I, there's a lot of good information out there. I think it's fantastic that people have access to that. But there's also, as you said, some, you know, bad information or misinformation and I know it's cliche, but information is power, so why not get the information and then make an informed decision?
Rena: Well, I think, and we say that in our fertility board intro, we say knowledge is power.
Dr. Klein: Oh, I did not know that.
Rena: Yes. And I think too, it's really important to note that just because you do a consult or you have an appointment, maybe even do some blood work and, and a scan, it doesn't mean that now you've signed up and committed to doing fertility treatment. You can do the consult, you can do some a routine workup and just get the facts. And it doesn't mean that all of a sudden now you're doing IVF. So it, it making the appointment, seeing a reproductive endocrinologist doesn't mean that you're infertile or you're signing up to do treatment. It's just getting the knowledge and, and information.
Dr. Klein: I'm gonna add to that, that sometimes somebody is more than the sum of one blood test. Also, there's variability. There are other markers of egg reserve that are, that usually jive with your blood test and are complement, but they're complementary. And every now and then you have someone with borderline egg reserve, but the ovaries look really good and you know, so there's always more information to be gleaned if you just got an AMH that's alarming with your gynecologist. So again, you're gonna go on the internet, it could be concerning, but the news could be corroborating or it could be better actually if you get some additional testing done.
Rena: A hundred percent.
Dara: That's a good point.
Rena: Yeah, great point.
Dara: Wow. So informative. I'm thank you. I learned a lot today.
Dr. Klein: Oh, you guys are experts in this already.
Rena: So tell us, Dr. Klein, if anyone wants to meet with you, how do they find you?
Dr. Klein: Maybe is there a way in your podcast where you can give the phone numbers or the information, but I'm
Rena: Yes, they can just call up RMAs main number. They can ask for you. See what's,
Dr. Klein: I'm not hard to find. You can Google me. RMA’s website has a link to my contact information, my bio. If anybody's having a hard time getting an appointment, we have a concierge service. I have givem, I give every patient my email. So every now and then when I, I get the scuttlebutt that someone's having trouble adding on, I will even give patients my personal email. So
Rena: I think you do that a lot. You I'm, again, Dr. Klein is so nice. Prboobably at his own expensive. We'll tell listeners, Dr. Klein is skipping his lunch today to record with us. So, which we don't advocate for.
Dr. Klein: No, you did me a favor. I, I I am 53. I could, I could trim down a little bit. I've got a wedding coming up actually.
Dara: I didn't hear that – earmuff!
Dr. Klein: No, but, but back to the email thing. Yeah, I do give my patients my emails. Look, not everyone does it. You can provide perfectly good care without it, but this whole process is, do I need to tell you, Rena, as a therapist? It's emo it's not just physically and sometimes, but it's emotionally taxing and things are time sensitive. So I want patients to have an easy line of communication and look, we're not perfect either. You can be on hold for a little while or you're pregnant and you're bleeding and you just, you know so I feel like it's, for me, it's the right way. It's comfortable for me to practice that way, to have an easy line of communication both ways.
Dara: But I'll tell you, that's why. Oh, see, that's why you have that reputation, Dr. Klein. And that's why your patients and people that work with you really appreciate you because we can see your passion and your, and your care.
Dr. Klein: Thank you. You're very kind for saying that. Thank you, Dara.
Dara: So we love to end our podcast with words of gratitude, the things that we're grateful for today. So Dr. Klein, to put you on the spot, what are you grateful for right now?
Dr. Klein: Oh gosh, you are putting me on the spot! Well, I'm literally looking outside and it's a beautiful sunny day. I'm glad for the last days of summer and fun and, and my kids get a sunny day to play outside. I have a lot to be grateful for.
Dr. Klein: There was actually a kind of a, a, a tragedy at my son's camp actually. So I don't wanna share it on this podcast, but I'm just, I'm, it goes deeper. But I'm very grateful to be here, be, be well, be healthy, and be able to share today with you guys. I, that may sound corny, but you're coming off the heels of an event last week. So…
Dara: We like corny, we like corny.
Dr. Klein: Free to feel free to cut that out of the podcast! Feel free to edit it!
Dara: You're, you're human. You're human. And, and it's nice for for people to hear that human side.
Rena: Yeah. That's really nice.
Dr. Klein: By the way, this is my first podcast, so I'm a podcast virgin here. So…
Dara: You are not anymore!
Dr. Klein: You put me on the spot and I'm not always so quick on my feet here.
Dara: No, you are perfection.
Dr. Klein: But what are you grateful for, Dara?
Dara: Oh, Dr. Klein!
Dr. Klein: I'm turning the tables!
Dara: I love how he knows what, what we were gonna say next. You, you took the words out of my mouth! I am grateful for, I got to see my parents this weekend. I went home to Canada and got to see my in-laws and my parents and my brother and my nieces and nephew. So I'm just grateful for, for family time. I love the summer in Toronto and I'm grateful for that opportunity to spend some quality time with them. And Rena, what about you
Dr. Klein: I’m grateful to not be with my family now and have peace and quiet! No, I'm just kidding. I adore my family!
Rena: We’re just warming up! I am grateful for my daughter. She is just such a little light and spark and she's just so funny. And I just love her. She just lights up my life. She is just so funny. So I am just very grateful for, for her. She gives me purpose.
Dara: So nice. Wonderful. Well thank you again, Dr. Klein, for being on. You've already done this podcast for having me, so it's not, you're not, you're not a neophyte anymore.
Dr. Klein: I'm a veteran now podcast
Dara: And we hope to have you on again in the future.
Dr. Klein: I would love that. Thanks. Thanks a lot. It's a pleasure.
Dara: Thank you so much for listening today and always remember, practice gratitude, give a little love to someone else and yourself, and remember – you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.