## Funny Math: How Due Dates Are Calculated for Pregnancies Conceived after Fertility Treatments

Does anyone recall sitting in math class and just staring at the blackboard thinking, “Nope, I just don’t get how X + Y * A = B.” Sure, you nodded to get Mr. Novick off your back, but in reality, you had no idea how he arrived at that answer. And while algebra and amusing are rarely used in the same sentence, that guy seemed to be doing some funny math! Much the same can be said about how we fertility doctors date (a.k.a. tell how pregnant you are and when you are due) pregnancies conceived with fertility treatments.

Most pregnancies (ART excluded) are dated based on the first day of a woman’s last menstrual period. And although you are technically not pregnant in the first approximately two weeks of the menstrual cycle (a.k.a. the follicular phase), you are growing the egg that will ultimately become half of your baby. Because the majority of menstrual cycles range between 25–35 days, the math usually works out. But when pregnancies are conceived with fertility treatments, the lead time (a.k.a. egg development) can be VERY variable. Weeks and even months may be added to get an embryo implant ready. For this reason, if you used fertility treatments to conceive, you can’t simply add a few days to your last menstrual period to calculate your due date. You may need some creative counting and a good doctor to get things sorted out.

Dates are not only numbers to an OB. We don’t break them, we don’t forget them, and we certainly don’t change them (unless we have a really, really good reason). They not only dictate when pregnancy-specific tests should be run (think genetic screening, diabetes screen, and GBS screening) but also when a fetus has what it takes to take on the world. Fetal lungs weren’t built in a day. In fact, they weren’t even built (for most babies) in nine months. They require those dreaded extra four weeks (remember, pregnancy is actually 40 weeks!) to get fully ready for a deep breath in and a deep breath out.

When most of us hear those words “You’re pregnant” (particularly after years of trying), we start to think about the end. And while it’s almost like planning for mile 26 before the race gun has even gone off, your due date is a big deal. But no matter how dynamite it is to know when D-Day is, your due date is NOT dynamic. It’s pretty dead set, especially after doing fertility treatment. IVF, IUI, and all the like leave little to the imagination. There is no questioning when your insemination or transfer was performed. Be mindful of these dates and the difference in how your due date is calculated after doing fertility treatment. While we love the web (#trulyMD), we want you to be careful when searching it for your due date. Make sure to use an IVF or fertility treatment calculator. This will save you a lot of calendar crossouts and changing-of-the-date chaos.

## IUD: When Your Bumper Sticker Reads “Babies on Board and I Need a Break!”

You know when you are out on one of those awkward first dates that are not going well? There are endless uncomfortable silences, those pregnant pauses that are just yearning for some interesting conversation. And then someone breaks the ice and says, “What animal would you be if you could be any animal?” And in that moment, you know: we are never going on a second date! But while the relationship may be over, you probably spit out something like a dolphin, maybe a horse, or even a dog. Those animals that sort of elicit a positive emotion in all of us. Come on, who doesn’t like dogs? We highly doubt that anyone has ever said a camel. I mean they have humps, they walk in the desert, and they can shut their nostrils in a sandstorm. But if you have or have ever considered using an IUD, you may be surprised to find out that the first IUDs were used in camels. Yup, camels. Story goes that many, many years ago traders put stones into their camels’ uteri to prevent pregnancy. It worked. And that, ladies, leads us to IUDs…

Fast-forward several hundred years, and IUDs (intrauterine devices) are one of the most popular forms of long-acting reversible contraception. Given that they take almost no thought (after placement), they do a pretty good job at preventing pregnancy. They allow a pause between pregnancies or a pregnancy pause that can go on between five and ten years, depending on which type you use!

IUDs come in two basic “flavors” (think your local soft-serve shop in the summer)—the Copper T or the Mirena. Recently two more IUDs have come on the market, the Skyla and the Liletta (they are very similar to the Mirena). While the three hormonal options (Mirena, Skyla, and Liletta) differ in a few minor ways—size, the amount of progesterone they release, and the length of the time they will be good at putting baby making on hold, when it comes to the major stuff, they are pretty much the same!

The Copper T is a T-shaped device wrapped in copper. It does its job (a.k.a. no pregnancy) in a couple of different ways. First, it holds the SLOW DOWN sign to both sperm and egg. By slowing down the swimming of sperm as well as changing the speed at which the egg moves through the tubes, fertilization is delayed. However, it not only acts pre-fertilization but also post-fertilization, that is, it can damage or destroy the fertilized egg. Pretty smart, huh? It is important to remember that everything that the IUD does (both the hormonal and non-hormonal types) happens before an embryo implants. The Copper T is your steady eddy or your tortoise in the tortoise and the hare race…it is good for 10 years. But while it lasts and lasts, symptoms are not uncommon. Women often complain of irregular or heavy bleeding and occasional pain. However, the majority of women are pretty pleased with their selection and don’t even know that it’s there.

The other options on the table are the hormonal IUDs, the Mirena, the Skyla, and the Liletta (the levonorgestrel IUD). They are also T-shaped, but rather than being wrapped in copper they are wrapped in hormone: progesterone (levonorgestrel). Despite these differences, the two work in a similar fashion. Both limit egg and sperm movement and, thereby, fertilization. While the Mirena has a shorter half (five years) and the Skyla and Liletta even shorter (three years) they come with fewer side effects—primarily, less bleeding. The progesterone in these IUDs thins out the uterine lining, something that is particularly good for women who have a tendency to develop thick linings from irregular periods.

A thin lining = not so much to shed = fewer annoying bleeding episodes!

News flash: most women who use IUDs still ovulate. Therefore, when the time comes, and you get ready to pull it, pregnancy can potentially happen pretty quickly because ovulation is not suppressed.

Nobody is perfect; everyone and everything has their flaws. Trust us, we have several! The same goes for seemingly flawless medical devices and treatment plans. The IUD is pretty picture-perfect…it prevents pregnancy, you don’t have to remember to take it, and when you are ready to have a baby, you just remove it and are off to the races. What could be bad?

While IUDs are pretty easy to place (most OB/GYNS learn in their first year of residency), there are occasions where a uterine perforation (hole in the top of the uterus) can occur. The perforation rate is about 1/1000. So basically, you have about the same chance of an asteroid hitting the Earth in 2182! Bottom line, it is likely not going to happen. Additionally, there is a small risk of expelling the IUD—this happens more frequently (between 2–10% can dislodge in the first year). Last, if pregnancy should occur while an IUD is in place, calling all of you super-fertile women, you are at a slightly higher risk for an ectopic pregnancy. When things (eggs, sperms, embryos) move slowly down the tubes, they may get sidetracked and start to sightsee. This delay in transit (hello, subway system!) can increase one’s risk for an ectopic pregnancy. So while IUDs don’t cause ectopic pregnancies, if you get pregnant while an IUD is in place, the chance of an ectopic pregnancy is slightly higher. This caveat is not meant to scare you, but it is meant to have you take a pregnancy with an IUD in place seriously.

Historically, IUDs got a bad rap. When you mention, “Mom I am going to get an IUD,” she may have a visceral reaction. In the 1970s, they were blamed for everything from infertility to infection and got the “I definitely don’t want to use that” verdict from many women. However, changes in the design, particularly the string that comes off of the IUD, made them much more attractive to potential users. Now even women who have never had a baby (medically termed nulliparous) as well as adolescents are cleared for boarding. There is no good data that IUDs cause infection or infertility and as a result are “in play” for almost anyone. And bonus— routine antibiotics are no longer needed when placing an IUD.

IUDs are a great go-to for women who want an extended baby-free break. Whether these are young women who are not ready, women who have a baby and want a big-time breather, or women who are done and done, it works. Placement can be performed at any time of the cycle, although right after the period is usually preferable. While we may not have inspired you to use an IUD, we probably gave you some good dinner-party conversation (#camels) or a fighting chance when watching Jeopardy. When having kids or more kids or more and more kids feels harder than trekking across the Sahara Desert without water, think about that camel. And ask your OB/GYN about the IUD.

## Step on a Crack and Break Your Mother’s Back?

While most of us can vividly remember playing this game as kids, aimlessly wandering up and down the sidewalk, we never really had any idea what this saying meant. It served as the impetus to jump over every crack, to yell at our friend whenever she landed on one, and to drive our mother crazy as it took us double the amount of time to walk down the street. Unfortunately, as we age, breaking our backs (medically speaking, our vertebrae), our hips, and our wrists becomes a reality. Osteoporosis, a bone disorder characterized by loss of bone mass, a decrease in bone quality, and a breaking down of the bone structure, affects 54 million people in this country; one in two women over the age of 50 will break a bone from osteoporosis. While you would want to play the lottery with those odds, you wouldn’t want to gamble with your life. And osteoporosis is a lot more than a cosmetic problem (broken bones, deformed spine, and hip braces). This disease not only has a significant impact on a woman’s quality of life but also her quantity of life. Approximately 3–6% of women will die in the first few weeks after being admitted to the hospital for a hip fracture and about 20% within the first year of after the fracture. Simply stated, fractures are no joke, and we should do all that we can to avoid them.

So osteoporosis is thin bones…Who gets thin bones and why? Are thin bones just a natural part of aging like grey hair and wrinkles? The answer is somewhat grey (no pun intended). While age is the most important determinant of bone quality, not all postmenopausal women will have osteoporosis. Genetics, race, and ethnicity are also key players. Caucasian women have the highest rates of osteoporosis, and African American women, the lowest. Other important risk factors include smoking, prolonged periods of no period (no period = no estrogen, no estrogen = no “water” for the bones), weight, excessive alcohol consumption, inactivity (a.k.a. couch potatoes!), poor nutrition, family history, and certain medications or medical conditions.

Another important piece to the bone jigsaw puzzle has been locked in for years and years. While it may be hard to believe, most of what will happen to our bones as adults is determined by how we lived as adolescents. During our late teens and 20s, we achieve what is called our peak bone mass. Our peak bone mass is mostly influenced by things like genetics and ethnicity (inherited factors). But even if the cards had you slotted for some good bone numbers, lifestyle, health, and environmental factors during your formation and oh-so-fun years can hinder what you can achieve (in the words of your parents…you aren’t living up to your potential!). This is why it is so important for young women to get that milk mustache, a good steady dose of estrogen, a good amount of exercise, and a good daily complement of vitamins.Even if you failed to live up to your bones’ expectations, any time you make a change is helpful: basically, better late than never.

Diagnosing osteoporosis is fairly simple, painless, and pretty quick. If done in women with some serious risk factors or at a specific age, it can be picked up years before really bad stuff and bad breaks happen. A DEXA (dual-energy X-ray absorptiometry) makes the call. A DEXA takes a picture of the lumbar spine and the hip and provides the necessary information to make the diagnosis of osteoporosis. Additional pictures are often taken of heel and wrist; these images are not as useful for making a diagnosis or for monitoring treatment (if you need it) but can provide helpful information about the extent of the underlying process. Through the DEXA, something called a bone mineral density score for each site is calculated. The numbers at each site are then compared to a young and healthy female to produce another number (ugh, math, math, and more math!). Once you get to the end of this very long equation, you can answer the question: do I have osteoporosis?

When your T score is ≤ -2.5 at ANY of the sites, you have got yourself a diagnosis.

If the T score is ≥ -1, you are in the clear.

For those between -1 and -2.5, you have what is called osteopenia.

Osteopenia is sort of like a yellow light. Your bones are slowing down, but they have yet to stop. This information can be incredibly powerful because lifestyle and medical changes can keep the road ahead clear. DEXA screening should begin no later than 65. However, for some women with any of the previously mentioned risk factors, screening should be initiated even earlier.Bottom line, this issue is fragile and needs to be handled with care! If your doctor doesn’t bring it up, you should!

We all knew milk was good for us, but who knew it was this good? Get that milk mustache ready, because a few glasses a day can help keep the cast away. Good lifestyle decisions such as calcium and vitamin D, exercise/activity, and healthy eating habits can all make a big difference. Currently the recommended daily dose for ALL women is:

1,000–1,300mg/day of calcium and 600–800 IU of vitamin D/day (specific dosing based on age). Postmenopausal woman (51–70) need 1,200 mg/day of calcium and 600 Vitamin D/day. Bottom line, milk really does do a body (and bones) good!

Unfortunately, sometimes even our best efforts can’t stave off a disease. You can drink gallons of milk and eat cartons of yogurt and still get osteoporosis. But don’t get all sour; there are excellent medical treatments that can help rebuild your bone and stop future bone destruction. While many options exist, your doctor will tailor the appropriate medical treatments to your lifestyle, the extent of your disease, and your personal needs. Bisphosphonates (Fosamax) are often the first line (inhibit the cells that break down bone); while they have gotten some negative press lately, when taken under the guidance of an experienced physician, they are safe and often quite successful at keeping the damage at bay.

Just in case you were wondering where that saying, “step on a crack and break your mothers back” actually comes from (no, it has nothing to do with osteoporosis!), it is rooted in some serious old-school superstitions. It seems to have originated in the late 19th century when racism was rampant. The original verse was “step on a crack, and your mother’s baby will be black.” Pretty terrible stuff. Somehow, from that we got to the mid-20th century where the saying took some “alternative” paths. Some said that the number of cracks equaled the number of china dishes you would break, while others told children that the number of cracks equaled the number of bears around the corner waiting to eat them for lunch (that’s one way to parent!). While all beyond ridiculous, for some reason the saying has stuck. If for nothing else, use it to remember to be mindful of where you walk and to watch out for bumps in the road. Try to avoid cracks. Let’s face it; you don’t want to trip. Then you may really break some bones!

## Thankful

This month, in schools across America, from pre-K all the way up to 12th grade, kids will take a moment to reflect on the concept of thankfulness. Prompted by projects designed by their teachers (#weLOVEteachers), they will answer the question: What are you thankful for? Whether they draw it or write it, act it or emote it, in some way, they will reveal what is most important to them. And while some of the answers may make you laugh and others may make you cry, they will all make you stop, think, and reflect.

Unfortunately, as adults we don’t have a teacher giving us assignments. You are, in many ways, on your own. There is no one checking your homework or prompting you to think about the positive things in your life. How you live your life and if or when you reflect upon your life is up to you. Sometimes, this practice can be isolating. It can make you lose direction, and it can make you forget to appreciate all the good that surrounds you. You can, albeit unconsciously, miss those homework assignments that forced you to stop and reflect. And although we can’t tap our foot, shake our finger, or prepare our red marker for corrections, we are going to take a moment and play the role of teacher. So grab a piece of paper, pull out a pen, and start working on your Truly, MD, homework.

Your assignment is the following: “What are you thankful for?” We will go first….

Jaime:

“It’s hard to pinpoint the one or two things that I am most thankful for—a good problem, I know! And unlike that never-ending to-do list, there is nothing on my long “thankful” list that I want to cross off—I have been blessed with friends, family, health, and opportunities. I am a lucky girl. But this year, what I am most thankful for is evolution. I have been able to witness my parents evolve into grandparents, my little babies evolve into toddlers and children, my friends evolve into surrogate sisters, and our words evolve into a website. And as these areas have evolved, I, too, have evolved: as a daughter, wife, mother, doctor and now advocate. I will be eternally thankful for the opportunity to not only watch these developments but also to live these developments. What an amazing journey it has been.”

Sheeva:

“I am thankful for my environment. And while I do love myself a fall Central Park day, I am not referring to my physical surroundings. I am alluding to the passion, the conviction, and the endurance of the individuals around me both at work, at home, and at play. Be it to themselves, to others, or to the collective good, those around me are committed. And their commitment has provided me with endless opportunities. I am forever thankful for these opportunities and the chance to make a difference. I promise to use my voice to shape the environments of others.

Truly-MD:

We are thankful that you have allowed us “two girls in the know” to join your journey. Whether it be as you are flying solo or as you are mommying, being there alongside you has been nothing less than incredible. We THANK you for inviting us to share some of life’s most special and intimate moments with you. We are humbled by your honesty and your hospitality. We hope that our relationship continues to evolve and you continue to invite us back to your “table” for years and years to come.

In the words of one of our role models (you know who you are!), we are lucky not only to be alive but also to have the chance to live. Take a minute, and reflect upon what makes you live and what you live for. And while no one is checking your work (this one is straight-up honor code), here, there are no failures. Be thankful, be thoughtful, and be true. That’s worth way more than an A+ in our book.

## It’s Not You, It’s Me: When Is It Time to Break Up with Your Pill?

As much as it hurts to remember, we have all been the victims of a painful breakup at some point. Whether it was your high school sweetheart, your first kiss, or the guy whose professions of love sounded convincing after numerous tequila shots, we have all been there.

While some are more painful and memorable than others, breaking up with your pill (or thinking about breaking up with your pill) can be pretty frightening. For many of us, it keeps us pain free, it keeps us headache free, it keeps us acne free, and most importantly, it keeps us baby free. However, when you start to think about having a baby, you start to wonder: could all those years on the pill be doing something bad to me?

Although voices don’t carry over the Internet or through the written word, picture us shouting NOOOOOOO as loud as possible! The pill did not harm your fertility, and the pill is not causing your infertility. The pill did not harm your ovaries or your eggs or your uterus or your tubes. Whether you spent one, five, ten, or twenty years on the pill, it does not matter. Fertility issues arise totally irrespective of the length of time you were on the pill. In many ways, the pill protected you from some of the fertility monsters (think fibroids and endometriosis) as well as some of the other monsters in GYN (ovarian and endometrial cancer).

One of the most common complaints we hear is “I spent so much time on the pill I don’t know what my period is like.” And while this is true, it doesn’t matter so much. Yes, it might have tipped you off to menstrual irregularity before you started to try and led you to stop the pill a couple of months sooner, but in the grand scheme of things, it won’t make a huge difference in your fertility or your future pregnancies.

While you may not know you had something going on, the delay is unlikely to change the outcome. The only time it may have blinded you to important information is for women who undergo an early (a.k.a. premature) menopause. In these rare and select cases, had a woman not been on the pill, she might have seen her cycles becoming shorter and more irregular and therefore sought treatment earlier. However, premature menopause is very, very rare (affecting an infinitesimally small subset of the population). Bottom line, breaking up with your pill to rule this diagnosis out is completely unnecessary.

There have been many amazing developments along the way for women and women’s reproductive rights. Oral contraceptive pills are definitely at the top of this list. And while your friends, your mom, or any stranger willing to give you advice on anything and everything, we want you to stop worrying about how many years of your life you have devoted to this daily ritual; you did NOTHING wrong by engaging in chronic pill use. In fact, you did just the opposite—you were proactive in thinking about your reproductive health. This wise and thoughtful decision definitely gets a double thumbs up.

## Limbo Land: Making a Decision about Treatment?

Often, making a decision about what we are going to wear to work, eat for breakfast, or make for dinner can be challenging. We have to admit that even for life’s most basic questions we resort to the pros and cons list! And while resorting to the plus-minus activity to answer the red vs the black shoe debate, imagine how long the list will be when you are deciding on what treatment plan to choose when it comes to your fertility. Timed intercourse vs IUI (intrauterine insemination), Clomid vs letrozole, IVF with a fresh transfer vs IVF with a frozen transfer—the list goes on and on. Like a buffet table in an all-inclusive family resort, it can become overwhelming.

We are not here to recommend that you isolate yourself to “half of the buffet” (a little variety is always good!) but to help you decide how to make the best decision for you and your fertility. As a simple rule, we have found that, when you are faced with a difficult decision, you should remember your ABCs. No, your eyes are not deceiving you, and no, we aren’t recommending that you break out into song…we are recommending that you Ask questions, get Answers, and then weigh the Benefits and the Cons of each option. The more you ask, the more you know, the more you know, the better equipped you are to make the right or the best “right now” decision for you and your partner.

Identifying the ABCs and deciding when, where, and what treatment to embark on can take time and work. We often see women and couples who are in the throes of infertility treatment struggling with these decisions. This “lost in limbo land” phenomenon can be debilitating, depressing, and overwhelming. In many cases, couples/individuals are not only wrestling with what sort of fertility treatment plan to choose, but also simply accepting that they are in our office and are going to need fertility help.

And to make matters worse, imagine that someone might be telling you that you won’t be able to use your own eggs or your partner’s sperm or your own uterus. It can be devastating. While we don’t expect an immediate decision, we do want to help you find the tools and the answers that you need to come to that decision. We promise you: the sooner you make up your mind and can initiate treatment, the sooner you are on the path to what you really want—becoming a parent.

Closing the chapter on any phase, any age, any idea, or any process is no easy task. It takes time; it is a process. There may be denial, there may be anger, and there may be grieving. If you are feeling or have felt any of these emotions when dealing with treatment decisions, we are here to assure you that they are normal. Making peace with what has happened in the past will help you move into the future, forward in the treatment process, and ultimately help you out of the dreaded “limbo land.”

The buffet has many options—fruits, veggies, pasta, pizza, chicken, steak, and fish (and don’t forget dessert!) Where to start, when to end, and how many times you should go back for more is really up to you. Your doctor will be your guide as you navigate your choices, but ultimately you put the food on your plate. Although they will point you towards the healthiest options and tell you when your plate is full, you decide when enough is enough. Listen to your gut, and remember your ABCs. They will help you as you review the menu and decide what’s best to order!

## Oops, I Missed a Pill…Did I Mess Everything Up?

One of the most frequently Googled GYN questions is “What do I do when I miss my pill?” Pill oversights, although common, can cause a lot of panic and fear. Getting pregnant now is not an option! Staring at the pack and realizing you are up to Tuesday but it is Thursday can be horrifying. However, the reality is that, if you haven’t at some point in your pill-taking career missed a pill, you deserve a medal. Almost all of us have had an oops or an uh-oh over our one, five, ten, or fifteen years of taking the pill. You are most certainly not alone.

When you miss a pill, the first question to ask yourself is, how many did I miss? When you miss just one pill, it’s no big deal. Just take the missing pill as soon as soon as the light goes off in your head. If it is not until the next day, take the missed pill plus that day’s pill together.

If you miss two-plus pills, that is slightly more of an issue and requires some more effort. Again, once you have your “a-ha I missed my pills moment,” take both ASAP. Then resume your daily pill schedule.

However, forgetting to take a pill is like forgetting to brake when approaching a red light. The ignition will rev up, and you may roll right through an intersection. Without the daily suppressive effect of the pill, your brain may start to develop a follicle and get ready to release an egg. So to prevent pregnancy, the best thing to do is use an additional form of contraception (a.k.a. condoms) until you have taken seven days of active pills.

If the oops was in the last week of the active pills, don’t take the placebo week; restart a new pack a week early.

If the error was in the first week and you had unprotected sex, you should strongly consider emergency contraception (a.k.a. Plan B) as well as continue with your current pack for maximal protection. Call your doctor, and let him or her know what happened so that together you can design a plan that will prevent pregnancy.

When thinking about pill errors, think in terms of sevens:

• It takes about seven days of continuous pill use to prevent ovulation.
• Never take fewer than 21 consecutive active pills.
• Never have more than seven pill-free days (any longer than this gives the body a chance to ovulate).

While seven may not be your lucky number, if you follow those rules you will make sure you stay lucky (and not pregnant)! One notable news flash: if you forgot to take the sugar pill (a.k.a. the placebo one), don’t sweat it. Those pills are not doing anything more than keeping you in the habit of taking a daily pill. However, if you miss any of the active pills, even if you followed the back-up schedule, take a pregnancy test. Although many women on the low dose or the low, low dose pills don’t get a period, it’s best to check and confirm a negative.

The majority of unintended pregnancies on the pill occur from missed pills. If you are one of those who seem to suffer from forgetfulness as it relates to the pill, then oral contraceptives are probably not right for you. There are several other forms of reliable hormonal and non-hormonal contraception that can do the same trick without requiring the daily light bulb to go off.

Remember, mistakes happen. Most of these momentary lapses are not a big deal. In an effort to minimize these hiccups, pair your pill pack with a daily activity that you never forget—brushing your teeth, washing your face, taking your contacts out. This will help minimize mistakes and maximize effectiveness. We want this to work for you until you are ready to work on becoming a mom!

## One Plus One Plus One Plus One = Five: How to Analyze a Semen Analysis

When you think about it, men sort of have it easy. As women, we have to get poked and prodded, stabbed and jabbed, and pushed and pulled (all before 8AM) to figure out if things are working on our end. It’s about as easy as jumping on one foot while patting your head, rubbing your belly, and reciting the ABCs (backwards!). Sometimes, it’s just not easy being a girl! But even with all that we endure, it’s not uncommon to hear complaints from our significant others of the opposite sex when they are asked to provide a sperm sample. What we most commonly hear is, “Why do I have to do this anyway? What is it really going to show?”

Here’s the quick lowdown on what we are looking at with the sperm sample.

1. Volume: The first parameter that is evaluated is the volume of the ejaculate (a.k.a. how much is in the cup). Normal volume is greater than or equal to 1.5mL.
2. Concentration: Simply stated, how many sperm are there? By counting sperm, we are able to calculate the concentration. Normal concentration is greater than or equal to 15 million.
3. Motility: While you may have sperm, can they swim? Sperm that just chill out are not going to get the job done! By assessing motility, you can answer this question. Normal motility is greater than or equal to 40%.
4. Morphology: The last piece of the semen analysis involves analyzing each piece of the sperm (the head, the tail, and the middle). The percentage of normal sperm is calculated. Normal morphology is greater than or equal to 4%.

After all of the basic calculations have been completed, we are ready to get fancy. We plug the above values into a formula and by multiplying the volume by the concentration by the motility, we come up with parameter #5 = Total Motile Count (TMC). The TMC is important when deciding on how best to get the sperm to meet the egg. Above and below certain levels may mandate IVF vs. IUI or ICSI vs. insemination (for IVF).

Additionally, a borderline or failing grade on any, some, or all of the parameters will usually cost your guy a trip to the urologist. Abnormal semen analyses can be more than just markers of reproductive health but of overall health as well. Therefore, an abnormal semen analysis should always be repeated (this is not a one and done-type of situation) and never be ignored.

## When the Going Gets Tough…the Tough Get Pumping!

There may be no bigger love-hate relationship than that between a breastfeeding mother and her breast pump. You love what it gives you (#foodforBABY) but loathe the process of pumping. Plugging it in, preparing the parts, putting the pump on, and processing the milk can be a pain, to say the least. For all of you who have done it or are in the process of doing it, you are likely nodding in agreement. But no matter how much angst our plus one (a.k.a. the pump) brings us, it can bring you and your baby many benefits. Here’s how to make this relationship last as successful and as long lasting as possible…

First, it’s okay to acknowledge that the breast pump/breastfeeding relationship is definitely not love at first sight. No one looks at that piece of machinery with adoring eyes and thinks, Wow, this is what I’ve been dreaming of! So before you decide to go steady (a.k.a. the baby is here and you need to make extra milk), get to know each other.

A few weeks before your baby is set to arrive, assemble the pieces, become comfortable with the parts, and set up your system. This will serve you well in the weeks and months to come. If you are unsure about this “match,” seek out a “matchmaker” (a.k.a. someone who has been there before). Don’t be afraid to ask for a tutorial. And if you are the first in your line of friends and family to do the baby thing, look online. There are several legitimate sites that can serve as a guide. Additionally, lactation consultants will not only help when it comes to breastfeeding but also when it comes to breast pumping.

After you and your pump exchange pleasantries, it’s time to solidify this relationship. While most of us like to practice the “take things slow” motto when it comes to relationships, the sooner you start making milk, the sooner you can start storing and saving. This is particularly helpful for mothers who plan to go back to work and want to continue giving breast milk.

Milk production is highest in the immediate postpartum period. Maximize what you make then by pumping after the baby feeds and setting it aside for those “rainy days.” The more you have saved up now, the more you will have to offer your little one later. By maximizing your supply now, you are in many ways matching their demands later. Frozen breast milk can last for months.

Keep track of all of your dates, even the ones that didn’t end so well. Every ounce of milk that you produce and package appropriately (#date) can be used later. Therefore, you want to clearly date each bag of milk that you produce (think black Sharpie) so that you know when it needs to be used by. Unlike the milk you buy at the grocery store, frozen breast milk can go the distance. In fact, it can last up to six months in the freezer.

Because time keeps moving on, you want to use what you made first, first and what you made last, last. And be sure to store your frozen milk in the coldest part of the freezer, not on the door! This system will ensure that you don’t let all of your hard work go to waste (making milk is not easy!)

Give your significant other some space. And while we aren’t talking about relinquishing some of that coveted closet space or clearing a spot on your bathroom counter, we are talking about rearranging your freezer. Milk that you plan to store for a later date needs to be frozen, so it’s a good idea to clean out your freezer before and free up some room before you start the milk process.

Invest in a “new outfit.” Let’s face it: getting dressed for a first date is never easy. Is that skirt too short, are those shoes too bright, is that shirt too tight? And while breast pumping seems far from glamorous, investing in a good hands-free bra can make all the difference in whether you call your pump back for a second date! Hands-free bras allow you to produce and be productive all at the same time! And when you may need to pump several times a day, a hands-free bra can make all the difference.

Be creative. It’s easy to get into a rut in your relationship. Sleep, eat, work, pump, repeat can take a toll on any new mom. It can make you forget what you are doing and why. When cleaning parts and preparing your pump bag for the next day, “wear” your baby in the carrier. While it may not be the traditional “rock-a-bye-baby,” it accomplishes that skin-to-skin closeness that we all yearn for. It also helps with bonding and brings you back to why you are busting your butt making all that milk.

Last, divide and conquer. Figuring out who and what can help you make this relationship work will help ensure that you and your pump go the distance. The pump has to be cleaned, sterilized, and cleaned again (sounds like fun, right?). This takes time, time that no new breastfeeding mother has to spare. Consider asking someone for help (partner, friend, family member, hired help). Dividing up tasks will make the process more tolerable.

There is no doubt that this relationship will have its ups and downs. No doubt you will want to break up at least once a day. And at some point, you will. Whether you get back together in the future (#anotherBABY) is up to you. But in order to make this go around as fruitful, forgiving, and far reaching as possible, it is important to remember our dating tips. While we certainly are not matchmakers, we do know a bit about how to make the breast pump/breast feeding relationship a long-lasting one—take it from us, this one is a keeper!

## Peeing in Public: Female Incontinence

When you are afraid that your friend will make you laugh and both you and your bladder will lose it, it’s not a good situation. The inability to hold your urine (medically termed incontinence) is not anyone’s idea of a funny situation. It can be incredibly embarrassing and isolating. While you certainly won’t kick the can because of incontinence, it may kick the quality of your life. Women often report depression, anxiety, and isolation because of it. Admitting it out loud can be difficult; but once you say the words, you will probably see several of your friends nodding in agreement. You are certainly not alone.

You may be asking yourself: how the heck did I find myself leaving the pharmacy with Depends? I used to buy tampons and pregnancy tests, and now I am buying Depends! How did this happen? Well, despite your love for your little ones, they are usually somewhat to blame. And the larger your brood, the better the chance that you will experience incontinence. Furthermore, if you avoided a C-Section and pushed those kids out, you are even at greater risk. Wow, being a woman is so much fun!

While pregnancy and delivery are big players in the incontinence game, obesity is also one of the biggest risk factors for urinary incontinence. Believe it or not, obese women are three times more likely to suffer from incontinence. It’s a real risk factor. And not surprisingly, rounding out the top four is age; age is the A-number-one risk factor for incontinence. While about 4% of women age 20 to 29 report incontinence, this number jumps to 40% in women older than 80 (getting old is not easy!)

Incontinence comes in many shapes and sizes (as do the women that it affects). Close your eyes, and imagine four drawers—one that holds your bras, one that holds your T shirts, one that holds your tanks, and one that holds your long-sleeved shirts. Now, if you live in New York City, you may be thinking: I only have space for one drawer, and all that stuff is mixed together. However, the rest of the country is digging the metaphor. Each drawer is a part of a dresser that holds something that you wear on your top. Incontinence is similar; there are four main types of incontinence, all which hold their own “drawer.” There is stress, urgency, overflow, and mixed. It is important to identify which type you have so that you can get the right treatment.

Ah, stress…the big S impacts us on a daily basis, from morning to night, from work to home, from friends to spouse. And much like the pressure it causes in our daily lives, stress incontinence results from increases in intra-abdominal pressure. Think cough, sneeze, laugh, push—all of these actions increase pressure in your abdomen and can lead to the leakage of urine. It is more common in younger women (40s) and generally occurs because the urethra (that’s the hole from which your urine comes out of) changes position. It becomes hypermobile (or uber flexible); this change results from poor support in the pelvic floor (pregnancy, deliveries, obesity, chronic coughing, high-impact activity).

Moving right along from the T- shirts to the tank tops, we have urge incontinence. Think gotta go, gotta go, gotta go right now…and that’s urge. The need to go right now is called urge. This usually happens as we age and often occurs alongside other medical conditions. The urge to urinate comes whether the bladder is full or basically empty. Due to bladder contractions, you are always on the go, searching for a bathroom.

The next drawer down is overflow incontinence. In an overflow situation, the urine is always flowing; whether it is a stream or a dribble, it never stops coming. In general, it results from an inability to completely empty the bladder, and it can be a real bummer.

Putting it all together, or choice A + B (stress and overactive), you get mixed incontinence. The combination effect makes treatment slightly more difficult and diagnosis definitely more clouded. You will likely need a specialist to help you solve this problem. To figure out if you have it and what you have, we need to do some tests. After a thorough history and exam (focused on the pelvis and pelvic organs), we will likely check your urine for infection. Believe it or not, bugs in the urinary system can lead to incontinence, so this is one of the first places we look.

Usually, we will ask you to keep a diary (Dear John…I think I may be in love with Tom…no, not that kind of diary) documenting when you urinate, how much you urinate, and what you drank before you urinated. It is also likely that we will schedule you to undergo something called urodynamic testing. While totally different than any test you have ever gone through (think sitting in a chair with catheters coming out of all orifices below your belly button), it will shed a lot more light on why your urine is making unsolicited appearances throughout the day. Furthermore, if surgery is in your future (and we are not saying that is where you are headed), this is super helpful in planning the procedure.

Before any medical treatment is initiated, be it pills or surgery, we ask you to look at your life and see what, if any, changes need to be made (and to get a second opinion!). If you are smoking, you need to quit. If you are overweight, you need to lose weight. If you are suffering from constipation (chronic pushing is not good), you need to take a stool softener and eat more fiber, and if you are drinking tons of caffeine, you need to cut back. While basic, these can be the biggest beasts to tackle (we know; we have some habits that would be nearly impossible to break).

We will also suggest learning and implementing daily Kegel exercises. No, we’re not kidding. Strengthening your pelvic floor muscles can help reduce incontinence. We also take you back to those magical days of potty training your toddler (“Sammy, do you have to go pee-pee?”) over and over again until they finally get it! Retraining your bladder to void frequently and keep bladder volumes low can be quite helpful. Despite our best efforts, many times, lifestyle changes ≠dry underwear. We may need medication and/or surgery to get us there. It’s not a bad thing; it’s just a slightly bigger deal. But with new advancements in medicine and surgery, we can find the right treatment to tame your bladder.

Whatever you call it, the ladies room, the bathroom, the loo, or the potty, the bathroom is a pretty essential part of all of our days. You stumble in bleary eyed in the middle of the night without giving it much thought. However, when you start to experience incontinence, everything to do with it—the bathroom, where it is, how long it will take you to get there, and what you will do if it is full—becomes a big, big deal.

Unfortunately, it is not an uncommon problem. Millions of women experience it, and most do it in silence. While we don’t suggest updating your Facebook status to reflect “incontinent,” we do recommend sharing it with your doctor and those who are near and dear to you. Their support will make a difficult situation easier and will guide you to get the treatment you need. Don’t suffer in shame; it’s so not worth it!