Physician Visits

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Mother Knows Best: Your Reproductive History

As much as we hate to admit it, it’s hard to find many things that our moms were wrong about. From the most basic (eat your veggies!) to the most complex (bad boys will always break your heart!), their words of advice were thoughtful, poignant, and basically spot on. But it’s funny that, no matter how much we talked and shared with the woman who gave us life, the sordid details of her menstrual cycle, her fertility, and her menopause are all too often taboo subjects. When did you get your first period, did you have trouble getting pregnant, did you suffer multiple miscarriages, and when did you go through menopause are questions that over half of our patients have never discussed with their mothers. When asked, they stare back blankly, and together we attempt to piece together a timeline of events based on when their mother was shouting, “I’m too hot, I’m too cold” multiple times a day.

Much of what dictates the timeline of reproductive life (first period to the last period) is unknown. Why some women go through menopause at 30 and others at 60 remains in many ways a mystery. Sure, women who are given certain types of chemotherapy or have multiple surgeries on their ovaries will frequently have a shortened “reproductive life,” but for most women who experience the premature stop, we don’t have good answers to the question of why. As frustrating as this is for the patient, it can be in many ways equally as frustrating for us as doctors. We, like you, want answers. Not knowing why something happened can often make the experience even harder to deal with.

Here’s what we do know. We know that a large piece of the reproductive life timeline puzzle can be answered by genetics. Genes inherited from your mother will frequently dictate your personal reproductive path. Because of this, when we see a girl who is late to have her first period or a woman who appears to be going through an early menopause, we ask detailed questions about the family history, specifically the female members of the family. We can often find reassurance (in a girl who is late to get her first period) or an answer (in a woman who is having an early menopause) when we put a microscope to the women on your family tree.

Despite major strides in genetic testing, most of the genes that make us who we are, particularly our ability to reproduce, still elude us. But while we may not know exactly what genes are controlling how fast our eggs disappear, we do know that how it all went down for your mom, your grandmother, and your older sisters is important. Simply stated, if your mom had menopause before the average age (~51), you should know about it, and you should consider doing something about it. In fact, research has shown us that we tend to have a pretty hard time getting pregnant about 10 years before our mom went through menopause.

So let’s do some math; if your mom had an early menopause at 45, you may have some serious fertility issues at 35! (Remember, menopause is defined as one year without a period.) If you ask your mom and she remembers mood changes, irregular cycles, and hot flashes starting at 45 but her last period was at 50, her menopause was at 51 (get it?). The fun and wonderful changes associated with menopause (aka the peri-menopause or menopausal transition) can actually go on for several years before the real hammer (menopause) is dropped.

It’s safe to say that, in 10 years, our knowledge about the genes that code for reproduction will be vastly different from what we know today. Genetics is the fastest growing field in medicine; long gone are the days of Mendel and his fruit flies! Pretty soon, you might know more about yourself (and your future children) than you even dreamed (or desired) possible. We don’t want to go all Pandora and her box on you, but remember that, with discovery can come disappointment. So while we all wish to know more about ourselves, some information can be hard to swallow.  

But here’s the simple take-home message: we can’t predict a whole lot about what will happen to your ovaries just by looking at you. But we can predict a lot by talking to you. Start the conversation with your mom, your sister, and your gynecologist early. Know your own body as well as what happened to your mom and grandmother’s body. Whether you look like your mom or not does not dictate whether your insides do. If you want to plan for your reproductive future, the best person to seek advice from is your mom. Once again, she knows best.

While much of what dictates the timeline of a woman’s “reproductive life” (first period to the last period) and a woman’s fertility is unknown, many of these answers are in our genes (aka what happened to your mom or your grandmother may very well happen to you).  What we don’t know today about the genes that dictate fertility (specifically egg quantity and quality), we will likely know in a few tomorrows. Genetics is the fastest-growing field in medicine.

A Fishy Situation: Safe Seafood for Expecting Moms

Eating when you are pregnant can be a tricky situation. What you want and what you can have don’t always jive. Menu choices can become a bit complicated, particularly when it comes to fish and seafood. While we want you to get the good stuff fish has (think Omega-3s, protein, and vitamins), we don’t want you to take in too much mercury. For those of us who are sushi addicts or fish fanatics, you may have to modify what you eat and how often you eat it to make it ok during pregnancy. Here’s how to modify the menu to make fish, sushi, and seafood acceptable during pregnancy.

Simply stated, mercury is not a mother-to-be’s best friend. While you may be close to it after or before pregnancy, during pregnancy (and while breastfeeding), you need to put your relationship on hold. The reason for this temporary breakup is the potential negative impact high levels of mercury can have on your growing baby. Mercury turns into methylmercury, which is a toxin to the developing brain/neurologic system of a fetus as well as the future vision and hearing of a child.

While you can be exposed to mercury in many ways, it is most frequently found in fish, particularly large fish. For this reason, swordfish, shark, king mackerel, and tilefish are totally off limits during pregnancy and while breastfeeding. Fish that is low in mercury (think shrimp, wild salmon, trout, catfish, cod, tilapia, canned light tuna) should be on your table at least once a week. In general, about 8 to 12 ounces (2–3 servings) of low mercury fish/week is recommended. White albacore tuna can be added to the list above, but consumption should be limited to 6 ounces a week.

Fish caught in local waters are a slippery situation. You can check with your state or local health and environmental agencies to find out what the mercury content is, but if there is no answer, you should probably limit your intake to 6 ounces/week.

A discussion about seafood would not be complete without the temperature situation (a.k.a. raw vs. cooked). And while the CDC and the FDA say no to raw fish, this is one area in which we have set sail in a slightly different direction. Although undercooked, seared, or raw fish has a higher chance of harboring a parasite, a bacteria, or a virus, women from other parts of the world have been consuming raw fish for centuries without a problem (think Japan).

Additionally, because most of the fish used in sushi in the United States has been flash frozen before it makes its way to your local jaunt, the majority of parasites and bacteria have already been eliminated. However, while we may let raw fish slide (or swim!), what we don’t deviate on is where you consume this raw or undercooked food AND the type of raw fish you choose to eat.

Make sure you are getting your food from a reputable establishment that not only handles and stores food properly but also serves it soon after purchasing it. Last, choose the low mercury menu choices (a.k.a. fresh or wild salmon) rather than the high mercury options (farmed salmon and the like).

Your taste buds will change faster than your body. One week, you will be obsessed with shrimp, and the next, just the sight of it will make you want to vomit. It’s totally normal. The tides of eating and cravings move fast in pregnancy. Make sure to chat with your captain (a.k.a. your OB/GYN) before you embark on a new food journey. Safety is first no matter where you choose to set sail.

When You See Red, Don’t Panic: First Trimester Bleeding

     There is nothing more disconcerting than looking down and seeing red. Whether it’s dark or bright, light or heavy, it can make you hold your breath and start praying. Blood is viewed as the harbinger of very bad things to come. (For all of you Game of Thrones fans, it’s like winter is coming!) But the reality is that blood, be it red or brown, with or without cramping, does not mean this pregnancy is case closed. It could mean absolutely nothing at all.

     And while we get that this is hard to believe and even harder not to panic over, bleeding in early pregnancy is incredibly common. In fact, it is the most common call an OB/GYN gets. It occurs in up to 40% of all pregnancies! It is so common that we can recite the list of dos and don’ts, shoulds and shouldn’ts, whys and why nots in our sleep (which is good, because these calls usually come in the middle of the night!).

     First things first, bleeding in pregnancy is not always pregnancy related. Pregnant women still have intestines, vaginas, and cervices that will bleed irrespective of that baby on board. So while the first finger everyone points is towards your belly, we need to make sure that the uterus is really where things are coming from. Things like cervical polyps, cervical irritation, vaginal tears, and vaginal warts can cause vaginal bleeding. While they are not harmful for you or your pregnancy, identifying them early can ease anxiety and allow us to treat them. In very rare cases, such bleeding can be indicative of a cervical or vaginal cancer, so a good look inside by your OB is important.

     On a slightly different note, the rectum can bleed for a number of reasons during pregnancy. Pregnancy is marked by constipation, pressure, and changes in our bathroom habits. This can exacerbate or lead to things like hemorrhoids, anal fissures, and polyps (not fun). And not only can they cause pain, itching, and discomfort, but they can also bleed. Rectal blood is often mistaken for vaginal blood. While no blood is good blood, rectal bleeding has nothing to do with the health of the pregnancy.

     The big three of early bleeding in pregnancy are the following—miscarriage, ectopic, implantation or physiologic bleeding (a.k.a. nothing to worry about). How we differentiate between the three usually requires both a good chat and a good check. During the chat part, we will ask you questions about timing, quantity, pain, and the events that preceded the bleeding (intercourse, activity, etc.). We will also want to know when your last period was, if you took fertility medications, and if you have recently seen an OB. This will allow us to narrow down the culprit. The “check” part will include both a pelvic exam (who doesn’t love that speculum?) as well as an ultrasound and blood work.

What we are looking for are things like:

  • Is the cervix open?
  • Can we see a pregnancy in the uterus?
  • Is there blood surrounding the pregnancy (subchorionic hematoma) or in the pelvis?
  • Is your pregnancy hormone appropriately elevated?
  • What is your blood type?

These checkpoints, combined with a good chat, will clear the way for a diagnosis (and hopefully a cease fire to this bleeding).

     Sometimes the reason behind bleeding in pregnancy isn’t so clear. And while we certainly don’t want to torture you, it can take a few visits and even a couple of weeks to answer the questions where it is coming from and if this pregnancy is going to be a go. Oftentimes, we need to take a second or third look with the ultrasound and at the pregnancy hormone before we can comfortably call it. During this time, we may ask you to take it easy (no exercise, no intercourse), stay close to home (no major travel), and keep us on speed dial. We want to know what’s going on, as this may get us to make the diagnosis quicker.

     Bleeding in pregnancy not only brings women anxiety but also guilt and blame (almost all of which we point towards ourselves). However, whether bleeding happens for no identifiable reason or because of a miscarriage, in neither case is it a result of something you did, something you ate, or something you didn’t do. Bottom line, it is not your fault. Say that in your head ten times over until you truly believe it. Unfortunately, sh–t happens. And while that may not be eloquent, it is the truth.

     Although you probably found us through a Google search, an Instagram post, or a Tweet, the Internet can be a dangerous place (particularly in the middle of the night when it comes to bleeding and pregnancy). And while we too have our “Google MDs” (in everything non-OB/GYN related) and like to browse and self-diagnose, we caution you from putting a lot of stock into what you read and what you see. It may do nothing more than make you crazy and keep you from getting a good night’s sleep (which every expecting mother needs)!
     To put it bluntly, we have seen women soak their beds with bright-red blood who go on to deliver healthy babies and those who notice one spot of dark-brown blood who go on to miscarry. Nothing is predictive. So doctor’s orders (after you read this): close your computer. Pull out a good book, or put on a funny movie. Getting your mind off of what’s going on below is the best way to pass the time. Laughter certainly won’t make matters worse. Let your doctor focus on the detective work.

Let’s Dish on Dates: Last Menstrual Period (LMP)

When most of us hear the term dating, we think back to those days when we had butterflies in our stomach every time we imagined meeting our plus one for dinner and drinks. Questions from what should I wear to what should I say to when is it okay to stay flooded our minds. Fast-forward a few years, and now flings are out and fertility is in. Dates are now dictated by the arrival of our period and the most promising days to have sex.

The calendar is littered with red Xs and black circles rather than dinner reservations and drink locations. And while your chicken scratches can start to look like hieroglyphics, here’s why those “X marks the spot” notations really matter!

Pregnancies are dated (a.k.a. the due date of a pregnancy is calculated) based on the first day of a woman’s last menstrual period (LMP). Your chart will refer to this date as your EDC, a precise 40 weeks from your LMP.  This date is used to calculate when you ovulated and, therefore, when your egg met sperm. To confirm that you are spot on with when you saw that first “spot,” your OB/GYN will perform an early ultrasound measuring the length of the fetus (medically termed the crown rump length) to confirm that your date is consistent with the dates being picked up on the ultrasound. The two need to jive for the due date to be written in stone (or at least in your medical chart in black marker!).

In cases where there is a serious discrepancy, your OB will often re-date the pregnancy (that is, calculate a new due date based on the measurements noted on the ultrasound). Re-dating is dependent on how pregnant you are measuring at the time of the ultrasound and how discrepant the ultrasound findings are with respect to your LMP. Here’s when things need to change…
If you are 8 weeks pregnant based on your LMP but you are measuring 6 ½ weeks pregnant on the ultrasound, then your due date will need to be pushed back by 1 ½ weeks (you ovulated and conceived a little later than you thought!)  Additionally, if you are 10 weeks pregnant based on your LMP but your ultrasound measurement shows you to be 11 weeks and 3 days pregnant, then your due date will be pushed up by 10 days. While we don’t expect you to do this math alone we do want you to be comfortable with the numbers and the changes that might occur. Take a look below to see when things needs to be modified:

Pregnancy Weeks based on LMP Ultrasound measurement discrepancy
Less than 9 weeks If > 5 days off, change due date
9-14 weeks If >7 days off, change due date
14-16 weeks If > 7 days off, change due date
16-22 weeks If > 10 days off, change due date
22-28 weeks If > 14 days off, change due date
28+ weeks If > 21 days off, change due date

However, a change is only permanent if confirmed by a second ultrasound. In fact, every due date needs to be confirmed twice (sort of like sending a text and an email to say we will meet at 8PM!). Even in cases where you are for-sure positive about your last menstrual period (a.k.a. LMP), we will confirm it with an ultrasound.

In cases where you don’t have a clue in the world about when you conceived, we will use two ultrasounds to create and then confirm your due date. This is particularly true for women with irregular cycles. Additionally, in pregnancies conceived after fertility treatments, we will use dates such as the day of ovulation, the day of the IUI, and the day of the ET to help us decide when the infamous D-Day (a.k.a. due date) is.

So even when you find yourself seeing a plus sign or a smiley face, don’t throw that calendar out. What you have written down, even if illegible to anyone but you, matters. It will help your OB pick your due date and know when measurements are off (say, the baby looks too small or too big). Dating is the real deal for us OBs—so make sure to keep us in the loop about those Xs and Os, no matter how hectic your schedule!

Doctor’s Note: Truly, MD

While this note won’t get you out of work or off from school, it will give you information on who we are and why we built Truly, MD. It will tell you why we are lending our voices to everything female and why we, a couple of girls in the know, are sharing our medical knowledge and personal experiences with anyone who will listen.

We are doctors, moms, and athletes, and we are on a mission. Our goal is to empower and educate women on all things reproductive. We are honest, we are direct, and we don’t sugarcoat the truth. From your first period to your last, Truly, MD, offers answers, insight, and awareness of all things female-related. Is birth control bad? Am I fertile? When do I need to see a fertility doctor? Are these pregnancy symptoms normal? Can I exercise in pregnancy? Do I have to breastfeed? Can I take hormone replacement therapy? You name it, and we will talk about it. From the complex to the basic, we are going to give you answers, real answers.

At Truly, MD, no conversation is off limits. No question is dumb, and nothing is too controversial. Truly, MD, was born (no pun intended) out of our desire to change the dialogue, shake up the conversation, and revamp the answers women were being given about their reproductive health. It is our quest to help women conquer their future with accessible, digestible, and honest medical advice.

We, Jaime and Sheeva, are fertility specialists who work and live in New York City. For a full run-down of education and articles written, click here. Our practice is devoted to helping women achieve their goal of parenthood. Using a team approach (two minds are always better than one) rooted in honesty and transparency, we are redefining the doctor-patient relationship. We give it to you straight, like your best girlfriends would, but with years of medical training and experience to back it up.

However, there are only so many patients we can see in a day, only so many women we will meet in our day-to-day activities, on the spin bike, in the line at Starbucks, and at our kids’ school. Time and geography will limit which women we cross paths with. We wanted to take our message nationally, possibly even globally, educating and empowering more women to become their own advocates through our medical advice. And that’s why we launched Truly, MD.

At Truly, MD, we care about you as a whole. The body and the mind, the fitness and the food, Western and Eastern medicine. You are a sum of a lot of parts, just like we are a sum of all members on our team. It takes more than one doctor to treat you and more than just a pill or a shot to heal you. We get how complex things can be. We want to help you find what you need to make you healthier, stronger, cognizant, and empowered. Our words are simple, and our message is clear, true, and honest. Take our medical advice, and use it to change your reproductive future. Take our personal experiences, and use them to change your overall future. Take what we, a couple of girls, know, and shape your now.

Truly Yours,

Jaime and Sheeva

About Doctors Jaime and Sheeva

Our Details

Friends for almost twenty years and colleagues for about 10, Dr Knopman and Talebian will be practicing together at CCRM NY in the Fall 2016.  Areas of medical specialty include:  treatment of menstrual irregularities, assisted reproductive technologies, in vitro fertilization, oocyte cryopreservation, oncofertility, same sex reproduction, and third party reproduction.

 

Jaime M Knopman, MD FACOG

Education:

University of Pennsylvania, B.A. 2000

Mount Sinai School of Medicine, M.D.  2005

Residency in Obstetrics and Gynecology NYU School of Medicine 2009

Fellowship in Reproductive Endocrinology and Infertility NYU School of Medicine  2012

Certifications:

Board Certified Obstetrician/Gynecologist

Board Certified Reproductive Endocrinologist & Infertility

Awards:

Summa Cum Laude, University of Pennsylvania

Phi Beta Kappa, University of Pennsylvania

Alpha Omega Alpha, Mt. Sinai School of Medicine

Personal

Born and raised on Long Island, New York Jaime now lives on the Upper East Side of Manhattan with her husband and two daughters. Jaime starts every day with a workout (running, cycling, pilates) and ends it writing for Truly, MD.  In addition to her love of medicine, Jaime has a true passion for writing!

 

Sheeva Talebian, MD FACOG

Education

Columbia University, B.A. 1997

Mount Sinai School of Medicine, M.D. 2001

Residency in Obstetrics and Gynecology NYU School of Medicine 2005

Fellowship in Reproductive Endocrinology and Infertility NYU School of Medicine 2008

Certifications:

Board Certified Obstetrician/Gynecologist

Board Certified Reproductive Endocrinologist & Infertility

Awards

Magna Cum Laude, Columbia University

Phi Beta Kappa, Columbia University

Personal

Born and raised on Long Island, New York Sheeva now lives on the Upper West Side of Manhattan with her husband and two children.  When not wearing her mommy or doctor hat, Sheeva can be found sweating in a cycling studio or running in Central Park (most often before 7am!).

 

Peer-Reviewed Manuscripts

Murashov AK, Talebian S, and Wolgemuth DJ.  Role of heat shock protein Hsp25 in the response of the orofacial nuclei motor system to physiologic stress.  Mol Brain Res 1998. 63:14-24.

Knopman JM, Talebian S, Keegan D, Grifo JA.  Heterotopic abdominal pregnancy following two-blastocyst embryo transfer.  Fertil Steril. 2007. 88(5):1437.e13-5.

Knopman JM, Copperman AB.  Value of 3D Ultrasound in the management of suspected Asherman’s syndrome. J Reprod Med, 2007. 52 (11): 1016-22.

Grifo JA, Talebian S, Keegan DA, Krey LC, Adler A, Berkeley AS.  Ten-year experience with Preimplantation Genetic Diagnosis (PGD) at The NYU Fertility Center (New York University School of Medicine).  Fertil Steril 2007. 88:978-81.

Knopman JM, Copperman AB. Endometrial thickness measured by ultrasound scan in women with uterine outlet obstruction due to intra-uterine or upper cervical adhesions. Hum Reprod, 2008. 23 (5): E14.

Knopman JM, Noyes N, Talebian S, Krey LC, Grifo JA, Licciardi F. Women with cancer undergoing ART for fertility preservation: a cohort study of their response to exogenous gonadotropins. Fertil Steril, 2009. 91(4): 1476-78.

Knopman JM, Krey LC, Lee J, Fino ME, Novestsky AP, Noyes N. Monozygotic twinning: an eight-year experience at a large IVF center. Fertil Steril, 2010. 94 (2): 502-10.

Knopman JM, Talebian S, Berkeley AS, Grifo JA, Noyes N, Licciardi F. Fate of Cryopreserved Donor Embryos. Fertil Steril, 2010. 94 (5): 1689-92.

Knopman JM, Papadopoulos E, Fino ME, Grifo JA, Noyes N. Surviving childhood and reproductive age malignancy: Effects of treatment on fertility, gametes and future parenthood. Lancet Oncol, 2010. 11(5): 490-8.

Knopman JM, Noyes N, Grifo JA. Cryopreserved oocytes can serve as the treatment for secondary infertility: a novel model for egg donation. Fertil Steril, 2010. 93 (7): 2413.e7-9.

Noyes N, Knopman JM, Labella P, McCaffrey C, Clark-Williams M, Grifo JA. Oocyte Cryopreservation Outcomes Including Pre-Cryo and Post-Thaw Meiotic Spindle Evaluation Following Slow Cooling and Vitrification of Human Oocytes. Fertil Steril, 2010. 94 (6): 2078-82.

Noyes N, Labella P, Grifo JA, Knopman JM. Oocyte cryopreservation: a feasible fertility preservation option for reproductive age cancer survivors. JARG, 2010. 27 (8): 495-9.

Mullin CM, Fino ME, Talebian S, Krey LC, Licciardi F, Grifo JA.  Comparison of pregnancy outcomes in elective single blastocyst transfer versus double blastocyst transfer stratified by age.  Fertil Steril 2010. 93: 574-578.

Noyes N, Knopman JM, Long K, Coletta JM, Abu-Rustum NR. Fertility considerations in the management of gynecologic malignancies. Gynecol Oncol, 2011. 120 (3): 326-33.

Noyes N, Knopman JM, Melzer K, Fino ME, Friedman B, Westphal L. Oocyte cryopreservation as a fertility preservation measure for cancer patients. RBM Online, 2011 (Epub).

 

Feeling More Than Blue: The Reality of Postpartum Depression

There is no easy way to say this…the postpartum period can suck. It can be awesome and awful, exhilarating and exhausting, and precious and painful all at the same time. You will find strength you never knew you had to get through those long days and even longer nights. But while nearly 40 to 80% of women feel postpartum blues, about 10 to 15% actually suffer from postpartum depression. It is a serious illness that requires serious attention. We want to address it with all the gravity that it deserves.

The emotions following the birth of a baby are as labile as the weather in the tropics. In minutes, you can go from elated to dejected. While it is quite common for women to experience what is called postpartum blues (a.k.a. the baby blues), the symptoms of depression are usually mild and short lived. Why it happens is not clear; most of the research points towards those crazy hormones that are flooding your system post-delivery. Women report sadness, tearfulness, irritability, anxiety, insomnia, and decreased concentration.

In the first two to three days following delivery, about 40 to 80% of women report feeling blue. In most cases, the symptoms of being “blah” (medical term = dysphoria) will peak over the next few days and then resolve within two weeks, basically, like a blip on the radar. So while some moments—and days—will be harder than others, all in all your mood and emotions should be stable.

Postpartum depression is in many ways the baby blues magnified by 100. Unfortunately, because the symptoms often overlap with the typical postpartum pleasantries, many women are misdiagnosed or undiagnosed and suffer in silence. Fatigue, difficulty sleeping, change in appetite/weight, and low libido (to name a few) are often seen in both processes. Again, what fuels postpartum depression is largely unknown; however, much like the blues, hormonal changes are thought to be the culprit (although here genetics is also thought to play a role).

While we are all at risk, there are specific risk factors that make us more likely to develop this disease: a history of depression, history of abuse, stressful life events, lack of a partner or social/financial support, family history of psychiatric illness, and childcare stressors (inconsolable infant crying). If postpartum depression is left untreated, it can often develop into chronic depression. It can also have a major impact on our ability to bond with the baby and can impact the development and mental health of infants and children.

To minimize the negative domino effect for both mother and baby, we as OBs need to ask the right questions and encourage you as moms to share your emotions. While we can’t definitively prevent who develops postpartum depression and how it affects them, we can identify women who are at significant risk and start treatment early. For example, if you have a history of major depression and were successfully treated with antidepressants in the past, you may be a candidate for immediate medical treatment postpartum. Bottom line, don’t be afraid to share your past history (physical and mental) with your doctor; this sort of information may make a big difference on how you weather the postpartum storm.

The “fourth trimester” (aka the postpartum period) is largely dominated by breastfeeding. Therefore, taking medications for both depression and anxiety while breastfeeding has become a hot topic. As moms we don’t want to take anything or do anything that could affect the health or development of our baby. We martyr ourselves to the umpteenth degree for our children; what we ingest, be it food or medicine, while breastfeeding is no different. But the reality is an unhappy mom makes for an unhappy baby. While medications may not be the first or only step (cognitive behavioral therapy is recommended initially) they are a close second. And in cases of severe major depression or mild/moderate depression that is not treated with psychotherapy alone, medication should be initiated. In general, for women who are breastfeeding SSRIs (selective serotonin-norepinephrine reuptake inhibitor) are the preferred class of medications as they present the lowest risk to your baby.

Everything in medicine (and in life) has a risk-benefit ratio. It’s like a seesaw; sometimes you are up, and sometimes you are down. Our goal when prescribing treatment is to find a balance. For example, while breastfeeding on an antidepressant may pose a small risk to your baby, the benefits of breastfeeding appear to outweigh the small risk of the antidepressant on the baby. All medications will make their way into your breast milk, but the amount can vary.

Here are some pointers to reduce the exposure:

  • Select medications that are in your system for a shorter amount of time.
  • Take medications immediately after you nurse (so that the levels in your milk are the lowest).
  • Work with your OB, your mental health provider, and your pediatrician and see what is best for you and your baby. You wouldn’t stop taking medicine for your blood pressure if it was high. Your brain is no different!

The problem with post-partum blues, depression, and the feelings of being down and out is that we are afraid to admit things are not perfect and that maybe motherhood is not all that we imagined. We feel guilty for wanting to scream when the baby won’t stop screaming or drink a bottle of wine when the baby won’t take the bottle. We feel guilty about not loving every second of what is supposed to be the most precious moments of our lives.

But the reality is, we all feel like this. For some of us, they are transient, and we quickly return to our baseline. But for others, the feelings remain and can worsen. Don’t be afraid to share your feelings; help is available. You are not a bad mother for feeling this way. In fact, admitting there is a problem and getting help makes you bold, courageous, and actually a pretty badass mom!

Done and Done! Permanent Contraception

Most mothers could probably recall the day they found out they were pregnant like it was yesterday: where you were standing (or sitting if it involved peeing on a stick), what you were doing, maybe even what you were wearing. There truly is no other feeling like that of becoming a parent. But when you decide that you are done, there may be no other fear like finding out you are going to be a parent again. How can we afford another child? Where will we live? Can I take those sleepless nights again? And while we definitely don’t have the answers to these questions (trust us, we live in New York City and get the space thing!), we do have suggestions on how to avoid having such things happen. Simply stated, we offer: permanent contraception.

It’s funny, women ask each other the question “Are you done?” all the time. And without more than those three little words, we know exactly what the question means. Are you having more kids? Cutting, tying, blocking, or clogging are common ways to permanently turn the system off. Both women and men can undergo procedures that will make getting pregnant without any fertility assistance nearly impossible (nothing is impossible because all methods, even the forms discussed below, have a failure rate).

The options available to women all center on blocking an egg from meeting a sperm, a.k.a. tying, cutting, or blocking the fallopian tubes. Tubal sterilizations can be done immediately after a woman has a baby, a few weeks after a baby, or years after a baby. When the former is done, a small incision is made below the belly button, and the tubes are found and subsequently cut/tied. When done weeks or years later, the procedure is most commonly performed through a camera (medically termed a laparoscope). The laparoscope is inserted through the belly button, and the surgery is performed through three tiny holes (one in the belly button and two above the hipbone). When done this way, the tubes are most frequently burned and cut (although a clip can also be placed).

Last, GYNs now have the ability to place a spring-like device (think a Slinky) into the fallopian tubes through the vagina. Again, a camera is inserted, but rather than placing it into the belly button, it travels through the vagina, past the cervix, and into the uterus. Under direct visualization, these springs are deployed into the tube; in the months following their insertion, the body forms scar tissue around them. Together, a serious roadblock is formed and it becomes nearly impossible for anything (including those swimmers) to get through. The caveat here is that you need to make sure all systems are a no go before having unprotected intercourse. Therefore, a hysterosalpingogram (a.k.a. HSG or dye test) must be performed approximately three months after the device is placed to confirm that the tubes have become a steel trap. Once the red light is seen, you get the green light for unprotected intercourse.

While women often find themselves in the driver’s seat for permanent contraception, the number of men electing to undergo a vasectomy is rising. Similar to what happens to a woman’s tube, a man’s vas deferens is “interrupted.” The vas deferens (like the fallopian tube) also serves as a tunnel, transporting sperm from the testes to the urethra. So while the path out may be closed after a vasectomy, men who have had a vasectomy are still producing sperm. The testicles go on as usual, producing both sperm and testosterone, ignorant that their hard work is for naught!

The procedure has no impact on a man’s ability to achieve an erection or to ejaculate. The prostate, the ejaculatory duct, the seminal vesicles, and the glands are all functioning as is, and while the ejaculate is devoid of sperm, it is chock full of other products. While post-operatively there is some pain, in most cases a little Advil and Tylenol should do the trick. It’s quick (usually no more than 15 minutes) and can be performed in the office. The biggest point to stress is that, similar to female sterilization, in which spring-like devices are placed into the tubes, a three-month wait period is required before it’s safe to use this as reliable contraception.

If you should have a major change of heart, there are ways to undo the undoable. Fertility treatment has found a way around tubes that have been tied or sperm that has been stopped. Although it requires in-vitro fertilization, IVF allows women a second (or third or fourth) chance if they should want it. In reality, both men and women who have undergone a tubal sterilization or a vasectomy are still producing both eggs and sperm. They are just no longer able to meet up with each other (think being grounded and stuck in your room).

Fertility doctors have the ability to go right to the source (ovary or testes) and get the goods (egg or sperm). So while we recommend you be certain about your decision before taking the leap, remember there is always a back-up plan should you change your mind.

 

Does My Positive Pregnancy Test = Baby?

When the stick starts to smile, reads pregnant, or gives you a double line, most of us have to do a double take. After we double check (in the form of another test; trust us, we all do it!), we usually pick up the phone and call our plus one, our best pal, or our partner in crime. Whether you were waiting for this for years or just started trying a month ago, finding out that you are preggers can be pretty overwhelming. The emotions can be as volatile as the weather in the tropics. Even if you have a child (or children), adding to your clan can make you clamor.

For most of us, those first few minutes/hours after that positive test are dominated by questions—and the majority are about the very distant future (a.k.a. nine months away). When is my due date? Will this baby be a girl or a boy? Do we have enough space in our home? When should we tell our family and friends? And while we, too, love a good future plan, unfortunately, there is not all that much that we can make of or plan for after one positive pregnancy test. The reality is that, from the pregnancy test to the postpartum unit, there are A LOT of hurdles. In fact, a good chunk of positive pregnancy tests don’t even make it past the first week or so.

Although many of us blame that box we lifted or that bike ride we took, in most cases, early pregnancy losses have nothing to do with our actions. It has everything to do with the embryo that implanted. The majority of early pregnancy losses are the result of abnormal embryos (an extra or missing chromosome). In the land of embryos, fetuses, and human genetics, 46 is the sweet spot. We get 23 chromosomes from our mom and 23 from our dad. Anything more or less than 46 is considered abnormal.

While not all pregnancies with abnormal chromosomes miscarry or don’t make a baby, the majority does not make it very far. Very few abnormal derivations of 46 chromosomes are even compatible with life. And luckily for us, the body knows this and puts up a big red STOP sign to the pregnancy.

We in no way mean to rain on your pregnancy parade. A positive test definitely means something, and for many, it is the beginning of a long and fruitful journey. And while we, too, get super excited at the pregnancy texts and emails our patients and friends send us, we want to remain cautiously optimistic.

Tempering your emotions can soften the blow when things don’t go right. Remaining realistic in the beginning of a pregnancy is key. While we certainly don’t recommend you walk around with your head and heart low, we do suggest that you hold off posting your pregnancy test on Facebook. Give it some time; see how things progress. Let your doctor confirm that he or she sees fetal development and a heartbeat before you let your heart go crazy. It can prepare you for those potential skipped beats.