HSG: Killing Two Birds with One Stone

A fertility work-up is no walk in the park. It requires getting poked and prodded as well as scanned and surveyed. It’s an involved process. We are not doing this to torture you or to make the experience any more exhausting than it already is. We are doing it because there are a lot of aspects to investigate when trying to see where and why the fertility puzzle pieces are not fitting together. You have ovaries, tubes, and a uterus (in addition to many other non-fertility-specific organs). While they all don’t need to be batting a hundred for pregnancy to occur, they do have to know how to swing the bat and run the bases in order for you to get that coveted home run.

Any test that can do two things at one time is an obvious grand slam. The fertility testing and subsequent treatment takes A LOT of time out of your busy lives; anything we can do to streamline it gets two big thumbs up. The hysterosalpingogram (often referred to as the HSG or that “awful tube test”) can evaluate both the tubes and the uterus at the same time. It is an X-ray that uses radiopaque dye to evaluate these structures.

Not to sound like Google Maps (take a right at the light, and go 4.4 miles), but by infusing dye through the vagina, into the cervix, and hopefully into the uterus, it will find its way out of the tubes and into the pelvis. During the dye’s travels, we can learn a lot about what’s going on inside. So while the test may not be anyone’s idea of fun, it does kill two big birds in the infertility work-up with one stone (not sure where that saying came from…who really wants to kill two birds?).

Despite the information gleaned from the test, we have a breaking news update—the HSG is not perfect. It is limited in its ability to assess function. While it is pretty darn good at telling us if things (a.k.a. the tubes and the uterus) are open, open does NOT equal  functional. In other words, while the test may say the tubes are OPEN (liquid can travel through them) that doesn’t guarantee that a sperm and egg can find each other, and as a unit (aka an embryo) make their way back to the uterus. Therefore the results of the HSG should not be assessed in a vacuum–your medical and gynecologic history are important when deciding if the tubes are tunnels that can be easily traveled. 

The best time to undergo an HSG is in the early half of your cycle—think day 5 to day 11. This is done to make sure that you are not pregnant; dye and X-rays are not baby-friendly. It’s also important that your doctor KNOWS your medical history before you go; women with a history of pelvic infections or other serious abdominal surgery or disease are in need of some pre-HSG precautionary antibiotics. Additionally, if you have an allergy to iodine, make this well known to anyone and everyone; due to the dye used, an HSG is not right for you.

We all need a complete check-up every now and again; our hearts, our heads, our intestines, our kidneys, and our bones need to be checked out before they can be checked off (at least for that year). Same thing goes for all the structures/organs involved in the reproductive system. Things aren’t always as they seem. For instance, just because you don’t ovulate doesn’t mean you can’t also have a blocked tube. Simply stated, get your tubes checked out before you check the box for what’s causing your fertility problems. Things aren’t as “simple” as they seem. 

While some pathology can be what we like to call “incidentalomas” (medical way for saying we found it while looking for something else and are not sure how much meaning it has), if you see it, you should deal with it. You don’t want it to be your deal breaker once treatment starts to progress.

No one looks forward to a dental cleaning. No one looks forward to a colonoscopy, and no one looks forward to a Pap smear (we don’t either!). But they are necessary to get that clean bill of health. Think of the HSG for the tubes and the uterus in the same way; they are necessary to get your fertility clean bill of health. The good news is, if it’s normal, you can check two boxes off of your never-ending to do list. Isn’t that efficient?

Gone Shopping: What You Pick Up From a CVS Or an Amnio

When most of us hear CVS, we think of the store—shampoo, cotton swabs, bandages, vitamins. We rarely ever think of first-trimester genetic testing, unless you are an obstetrician! But CVS goes way further than your local drugstore and stands for more than Consumer Value Stores. In the land of OB, it means Chorionic Villus Sampling, and the information we get out of it is way more valuable than any Super Savings discount your local CVS has ever offered.

CVS and amniocentesis (a.k.a. amnio) comprise what we traditionally call invasive diagnostic genetic testing. They get answers that are highly accurate and therefore shed a lot of light about your little one’s chromosomes and genetics. Whereas in the past we only offered it to women based on their age (older than 35) or their risk factors, nowadays anyone who wants invasive diagnostic testing can have it. You just have to know about it and ask for it. And while prenatal genetic screening (what we can test for) has “come a long way, baby,” the options for diagnostic tests (a.k.a. how to get the cells to get the information) have remained the same. Let us give you the lowdown.

However, before we can delve deep into the depths of CVS and amnio, it’s important to clear up two key concepts:

  1. A screening vs. a diagnostic test
    Simply stated, a screening test is used to check for the possibility of a disease. Most of us get several of these a year (think Pap Smears, mammograms, colonoscopies) depending on our age. In most cases, the screening test is the end of the rope—see you next year! It is only when the screening test is positive and suggests that something is up that we need to move on to the bigger guns, otherwise known as the diagnostic test. A diagnostic test confirms if what was seen on the screening test is really there.Bringing this back to prenatal testing, screening tests include both blood tests (PAPP-A, hCG) and an ultrasound (nuchal translucency) that is usually done at about 11 to 13 weeks. When these look off, it’s a good idea to move on to more definitive and accurate tests. Cue the invasive tests.
  2. A non-invasive vs. an invasive test
    This one is probably a bit more straightforward but still needs some explanation. While a non-invasive test may require a blood draw or an ultrasound, the pregnancy itself (a.k.a. the amniotic sac, the chorion, or the placenta) is not being disturbed. An invasive test will break more than your skin. It will require that a needle be passed either through the vagina or the abdomen to obtain tissue. Given the more involved nature of the invasive test, it carries greater risk. However, it also carries greater reward; that is, it is accurate 99% of the time. Accuracy is key when couples and individuals are making difficult decisions

Now that we cleared that issue up, we can get down to the nitty gritty of CVS and amnio: when they are done, how they are done, and what you can expect. So if your screening test came back abnormal, e.g., an elevated risk for chromosomal abnormalities or if you chose to skip screening and go right to diagnostic—which some women do, it’s your choice!—you have two options…

  1. CVS
    • The cells (a.k.a. information on the genetics) are obtained from the placenta.
    • We can get these cells in one of two ways: either by passing a needle through the abdomen or the vagina. The approach varies based on physician preference and skill.
    • The test is usually performed between 10 and 13 weeks.
    • The results are not only super speedy (the cells are processed quicker after a CVS than an amnio) but also the test is performed early in the pregnancy.
    • There are risks. And just like any procedure, the risks must be weighed against the benefits. In terms of CVS, our no. 1 concern (and yours truly, too) is fetal loss. Good news is that the numbers are reassuring, and the risk of loss following the procedure is very low (1 in 455).
  2. Amniocentesis
    • The cells are obtained from the amniotic sac (the fluid that surrounds the fetus).
    • We can get these cells one way and one way only—by passing a needle through the abdomen.
    • The test is usually performed between 15 and 20 weeks but can also be done later in certain situations.
    • The results are more like snail mail than email. It takes the lab about 7 to 14 days to come up with a final answer (CVS takes about 5 to 7 days). Additionally, it is done later in the pregnancy.
    • There are risks here, too. But here the risk of fetal loss is somewhat lower at about 1 in 800.

Admittedly, we just barely scratched the surface of prenatal genetic testing (#weLOVEtheTRUTH). The specifics of what can be tested for, in what lab, and what it really means goes way, way deeper. However, in most cases you don’t even need to walk past the shallow end to get what’s going on. But before you take the plunge into the CVS or amnio pool, make sure you have lifeguards on deck (a.k.a. a genetics counselor and your OB). Even the “best swimmers” can get lost, confused, and overwhelmed without someone watching over them.

Just as you wouldn’t swim in rough waters alone, don’t venture into invasive diagnostic testing without a guide. This stuff can get complicated quickly. No matter where you swim, safety always comes first!

When Babies Are Not on the Brain: Post-Partum Contraception

Babies out. Bleeding is on. Boobs are big. Belly is still large. Sounds awesome. With all of these bothersome symptoms, “bonking” is completely out of the question. Let’s face it: when you look and feel like you have been through the wringer, intimacy is probably the last thing on your mind. But before you know it, all systems will be healed, and sex will be a go. And while those days seem further away than your first full night of sleep, it will happen. We promise! And when it does, even if you are breastfeeding, you can get pregnant without contraception. To avoid that major oops, here’s how best to prevent pregnancy postpartum.

Let’s do a quick Obstetrics 101 review. In most cases, it takes at least three weeks before ovulation resumes. Prior to this, elevations in your hormones (think hCG, progesterone, and estrogen) will keep ovulation in a holding pattern. After about one month, these levels will drop, and ovulation will resume. However, in women who are breastfeeding, prolactin (the hormone that helps you produce milk) will arrive and stay on the scene until you are ready to move on to formula or milk. In high levels, prolactin can function similar to hCG and prevent ovulation for some time.

No ovulation = no egg = no embryo = no pregnancy

The sticking point is that “some time” can be anytime; how long you can use breastfeeding as contraception depends on how frequently you are feeding/pumping, how many other “things” (a.k.a. formula or food) your baby is taking in, and your own body. Women with the exact same routines can start ovulating at very different times. Bottom line: breastfeeding is not a completely reliable source of contraception. You need a back-up mechanism.

So, what are your options? While there aren’t as many choices as for non-breastfeeding women, you do still have choices. Think about the contraceptive choices for breastfeeding women as a three-choice exam. Option A = oral contraceptive pills (a.k.a. OCPs), Option B = IUD, and Option C = barrier devices (condoms or a diaphragm).

You can go with any of the three and achieve pretty good results—if they are taken correctly! Which you select really depends on what is best for you, your medical history, and your personal needs. The first few months after bringing a baby home can be exhausting and hectic, to say the least. Remembering to take a pill daily at the same time may be harder than it sounds. The OCP prescribed to breastfeeding women, a.k.a. the “mini-pill,” only includes progesterone and must be taken at the same time daily to remain effective. While the toothbrush or shower trick may help, believe it or not, some days you might not make it into the shower (or even brush your teeth)! If you go with an Option B (IUD), you won’t have to think at all. Combined with its good contraceptive benefits, this may B the right choice for you!

If you have decided to go right to the bottle (aka formula)—and trust us, there is no judgment in that statement—you need post-partum contraception ASAP. This convo will usually commence at your six-week postpartum visit. Remember: sex before six weeks is off limits anyway! The options for women who are not breastfeeding are no different than for women who are breastfeeding. Where things diverge is in the type of oral contraceptive pills (a.k.a. hormones) that one can take.

Non-breastfeeding women can take good old-fashioned estrogen + progesterone pills as well as progesterone-only pills. Usually, the former is preferred due to slightly more flexibility in how perfect your timing when it’s taken needs to be. Because milk production is not an issue, the suppressive effect of estrogen on milk production is no big deal. If OCPs are not your speed (or medically a no go), you can also go with the patch, the ring, implantable devices, Depo-Provera, the IUD, condoms, or diaphragms.

Basically, barring any underlying medical issues, the sky is the limit. Pick what’s best for you and your busy lifestyle. Just remember: fatigue will be an issue, so the less you have to think, the better. Whatever you choose, be sure to commit; otherwise you may find yourself expecting way before you were expecting!

Fibroid: What to Do When Fertility Is No Longer on Your Mind

If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some case) big uterine friend (s). They can be a big pain in the rear. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun.

Unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Simply stated, you are not the only person who RSVPed yes to the fibroid gala. While there are many ways to treat them, not everything works for everyone at every point in their life. Women at different stages of their lives (a.k.a. reproductive “stages”) and symptomology warrant different procedures. For those of you whose fertility ship has long since sailed and you are done and done, here’s what we recommend.

When babies are no longer on the brain, your options with regard to fibroid management (as well as where to go to dinner) are way more expansive. It no longer matters if they have crayons and serve you fast. You can do a lot with or to your uterus, if you don’t care if it functions for fertility purposes ever again. While you still have both medical and surgical options if you are totally fed up, going down the surgery path is a way to be totally done.

You still have medical options, and those include: oral contraceptive pills (a.k.a. “the pill”), the intra-uterine device (a.k.a. “the IUD”), Lupron (a.k.a. “I feel like I am in menopause with these hot flashes and vaginal dryness”), progesterone receptor modulators (mifepristone or ulipristal acetate), SERMs (raloxifene), aromatase inhibitors (letrozole), and anti-fibrinolytics. While some of the medical options are better at improving some of the symptoms (for example, OCPs will improve heavy bleeding but not the pressure symptoms), they very rarely fix it all.

Just like when selecting the OCP you want to “marry,” you may have to shop around the medical options before you land at your symptom-free spot. While Lupron (GnRH agonist) will do it all, it will cost you in the side effect department. Hot flashes, sleep problems, vaginal dryness, muscle and bone pains, and even changes in mood/thinking often come in conjunction with the reduction in fibroid bleeding, pain, and pressure. It’s because of the side effect profile that we don’t go with Lupron as our first medical treatment (and very rarely for women who are ready to wave goodbye to their fertility). It’s reserved for the fibroids that we don’t like in women who still want to give fertility a chance!

If having kids is no longer a consideration, surgically, you are no longer boxed into the myomectomy corner. While you can certainly elect to retain your uterus and just remove the fibroids (a.k.a. myomectomy), you can also go for broke and remove the whole uterus. By undergoing hysterectomy, you ensure that the symptoms are sayonara (even if you are not yet in menopause).

The approach for both a hysterectomy and a myomectomy can vary; the procedure can be performed abdominally through a bikini cut incision, laparoscopically through a camera, robotically through a robot (and small incisions), or vaginally (no explanation needed!). The approach depends on the size of the uterus and fibroid (s). If you are going for a myomectomy, the location and number of the fibroids also play a role. Lastly, your surgeon may have a bias and a preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

Just as there are minor and major life decisions (dating vs. marriage, contraception vs. babies), there are minor and major surgeries. The majors, we described above; they require the big guns: anesthesia, intubation, hospital admission, and everything in between.

Minor procedures are still procedures but are much less involved. They can often be done in an office and under less paralyzing anesthesia, that is, no breathing tube. When it comes to fibroids, the minors we talk about in a major way include uterine-artery embolization (UAE) and endometrial ablation.

Our radiology friends perform UAE; they use some fancy catheters and particles (threaded from the groin to the uterus) to block off the uterine arteries (the blood supply to the uterus). By starving the uterus, they starve the fibroids. The fibroids shrink, and symptoms in most cases will resolve. While the uterus is not removed, we don’t recommend performing UAE in women who want to keep using their uterus. It can impact ovarian function and egg quantity. Endometrial ablation is also an option, particularly for women whose biggest gripe is bleeding. There are various devices and mechanisms to ablate the uterus (burn, freeze, microwaves, radio frequency), but essentially in all cases, the endometrium (uterine lining) is destroyed.

As with most things, there are pros and cons to all options. If you like lists (we love them!), here are the important points to note…For most women who have closed the kid chapter, the options are endless. You are not thinking with your fertility hat anymore! You can do whatever necessary to halt all symptoms. Based on your symptoms, the size of your fibroids/uterus, and your medical/surgical history, your OB/GYN will decide which route is the best to go.

Give their opinion a lot of thought, and seek out another one if you are on the fence so that you feel more than fine with your decision. News flash. If menopause is in the very near future, you may not need to do anything. Without postmenopausal hormone replacement therapy, fibroids will shrink, and symptoms will subside. Just make sure that your reproductive timeline matches up with your treatment timeline; in some cases, time will be on your side!

Fibroids are pretty pesky for most of us, but some women are completely unaware of their presence. They find out totally by accident during an ultrasound, a pelvic exam, or pregnancy. And just like if it isn’t broken don’t fix it, fibroids that are causing no symptoms are really no big deal. They can hang with you for as long as you both shall live. No divorce in sight. If they don’t bother you, don’t do anything with them until you have to. Prophylactic or preventative therapy to avoid future problems is not recommended (no pre-nup here!). Fibroids need to be fixed only if you can’t take them anymore. Otherwise, do your best to forget they even exist!

Should Pregnancy Put a Pause on Your Gym Membership?

Run, work, eat, sleep, repeat: this pattern plus/minus a few other key activities is the daily routine of many women we know…including ourselves. While fitting it all in can be a challenge, remaining fit is at the top of many of our lists (which for most of us tends to be very long!) Although the physical benefits are a plus, for many, the primary reason to pound the pavement while everyone else is still sleeping is the mental release these 30 minutes offer. Tuning out from the daily grind, forgetting about the constant to-do list, and the stress of trying to balance it all are key.

For us, a commitment to exercise started in college. In many ways, although it took fuel to power through a workout, the workout itself provided us with the mental clarity and physical strength to get through the 15 years of education to become a fertility specialist. The juice your brain gets from a run, a swim, or a bike ride can be as invigorating as a Starbuck venti (and cheaper!).

For all these reasons, plus many others, we maintained our exercise regimens during pregnancy. While there were definitely some double takes as our bellies bounced in and out of the saddle at cycling class, we both continued to go strong until the very end. So, as both moms who have done it and doctors who have spent a lot of time researching it, we are here to say pregnancy is not a reason to pass up peddling, paddling, or pushing on.

Let’s share some facts. The American College of Obstetrics and Gynecology (ACOG) makes it clear that, in the absence of either medical or obstetrical complications, moderate exercise for at least 30 minutes or more is recommended on most, if not all days of the week. So if the gurus of all things pregnancy give it the green light, why does exercise during pregnancy still conjure up so many negative emotions? Why do we rarely see a picture of a pregnant athlete? And why does a model that is fit and posts pictures of herself while pregnant cause so much negative buzz? Whatever the reason for the dirty looks, there is a widespread misconception that pregnancy is a handicap and women who continue to live their normal lives and engage in their normal routines are doing harm to their unborn child. They will cause themselves and their babies problems and should just relax. This is so NOT true. Yes, there will always be certain situations (see below) when an OB advises a patient to sit on the sidelines, but that is more the abnormal than the norm:

  • History of preterm delivery
  • History of short cervix/incompetent cervix
  • Significant maternal heart disease
  • Restrictive lung disease
  • Persistent bleeding in your second and third trimesters
  • Placenta previa after 26 weeks
  • Premature labor
  • Premature rupture of membranes
  • Pre-eclampsia
  • Growth-restricted fetus (IUGR)

As avid athletes, OB/GYNs, and women who have worked out with a plus one in the womb, we are constantly asked by friends, patients, and even strangers at the gym, “What can and can I not do during pregnancy?” as it relates to exercise.

So here are the most frequently asked questions and our well-rehearsed answers….

I am a fitness fanatic…is there a time when I should stop exercising?

While you may have been given the green light to continue exercising during your pregnancy, you should consider stopping in the following scenarios:

  • You start to experience vaginal bleeding.
  • You are having difficulty breathing with exercise or feel dizzy, or
  • You experience chest pain, muscle weakness, or headaches with exercise. You should also stop exercising ASAP if you note uterine cramping or leakage of any vaginal fluid, and consult your OB if these symptoms develop.

I like to hang glide, sky dive, and rock climb…are there any exercises that are dangerous?

Most exercise regimens are a go in pregnancy. However, any sport that can lead to abdominal trauma should be avoided after the first trimester. This includes extreme sports as well as contact sports like basketball and soccer. Additionally, while many skiers chose to continue swooshing down the slopes throughout their pregnancy, it is generally not recommended due to the risk of falling or collision, which can result in significant abdominal trauma. Furthermore, the higher altitudes associated with skiing can be more difficult to tolerate when pregnant. Don’t hold your breath: scuba diving is also not recommended during pregnancy. The risk of decompression syndrome (related to pressure changes) is real and therefore not a wise choice. Lastly, don’t forget that your center of gravity shifts while pregnant; this places pregnant women at slightly higher risk for falls. So put the tightrope down. Pregnancy is not the time to take that walk!

I want to achieve my personal record during pregnancy…Do I need to modify my workout during pregnancy?

Probably yes. But the best advice we can give you is to listen to your body. It will tell you when it’s had enough. Pregnancy is not the time to push your pace or take your athletic endeavor to the next level. Your heart, lungs, and circulation are working for two, and you will feel changes as early as that missed period. The physiologic changes that occur in the first trimester will make you feel more winded and short of breath. Hear what your body is saying, and take some time to cool down.

I never eat before I work out…should I start to snack before?

Talk about changes in metabolism and energy storage! During pregnancy, while your body feels heavy and full, it is less equipped to handle dehydration and drops in your blood sugar. Therefore, you need to pull out those water bottles and hydrate up. In addition, make sure to chomp on something before and after your workout. In general, pregnant women need to consume 200 more calories a day. If you are going to exercise while pregnant, just be aware that you need to fuel and then refuel your tank more frequently than when not pregnant.

I used to dream about my Sunday long runs, now I dread them…is something wrong?

Nope, your change of heart is normal. As pregnancy continues, what feels right and good will change (not to mention what tastes good!). As avid runners, we found running much less comfortable in the late second and third trimesters, causing muscle strain in the lower abdomen and groin. The hormones of pregnancy cause laxity (loosening) of your ligaments and muscles that can lead to discomfort and possibly injury. Be smart. If it’s a really hot and humid day, you may want to second guess that long run in the park during prime sun hours. Likewise, if it is very cold and icy, it’s probably not the right time to check out a trail run. Again, listen to your body…it knows what it wants and does not want to do!

I bought a heart rate monitor…Does my heart rate have to stay below 140 while I work out?

Old school ACOG guidelines (pre-1992) recommended that pregnant women keep their heart rate under 140 beats per minute. News flash…this dictum was removed over two decades ago, as there was NO scientific basis to support it. All women enter pregnancy in different cardiovascular shape. If we start differently, we will likely be able to achieve differently; some can go above 140, some below, and some way below. We like to recommend what we call the Talk Test. If you can talk or sing (sorry for all of those who have to listen to us belt it out off key) as you go about your workout, you are all good.

I just entered my third trimester…do I have to stop exercising?

Not really. Keep going unless you don’t feel right or if your obstetrician or midwife advises you that it is no longer safe due to a pregnancy complication. Otherwise, many women will exercise up until the day they give birth (we both did!).

Other than fitting into my skinny jeans sooner after delivery, are there other benefits to exercise in pregnancy?

Short answer is: yes. Fit moms who maintain their exercise regimen during pregnancy are less likely to develop gestational diabetes (diabetes during pregnancy), preeclampsia (high blood pressure), excessive weight gain, needing a C-Section, and low back pain. It also seems that women who peddle paddle and things in between push for a shorter amount of time and have a higher likelihood of a vaginal delivery. It should come as no surprise that if you are fit enough to make it through a cycling class, you are more likely to be fit enough to make it through labor.

Are there any risks to my fetus if I exercise during my pregnancy?

Despite the negative buzz and the whispering that goes on, no, not if you follow the advice of your doctor and exercise safely. In fact, you can tell those finger pointers to point somewhere else. There is a good deal of data to the contrary suggesting stronger cardiovascular systems in newborns of mothers who exercised during pregnancy. Additionally, the babies born from moms who move seem to have a lower incidence of obesity and diabetes.

When can I work out after I give birth?

Here are the “deets” on when you can get down and dirty again. While the general recommendation has always been six weeks, it’s not a mandatory sentence. If you had an uncomplicated vaginal delivery (no major tear), you can probably start back much sooner. Let’s face it, the first couple weeks post-delivery, you and your body are in survival mode. Your priorities are feeding your newborn and yourself and getting as much rest as possible. Exercising even for the most hard core is not at the top of your list. Ease back into it when you feel your body is ready; whether that is two weeks or six weeks, it’s up to you.

The bottom line is that exercise during pregnancy will not only keep your bottom line a bit trimmer but also have big-time benefits for you, your pregnancy, and your baby. While no one is expecting you to PR in a race, you can continue to move. Moms on the move are everywhere. Join the movement!

Key words: Exercise, pregnancy, heart rate, cycling, dehydration, nutrition, fitness, fit pregnancy, preeclampsia, gestational diabetes, postpartum

Let’s Not Make a Stressful Situation Worse

Our lives are filled with stress. Busting at the seams, boiling over the top, big-time stress. Will I get there on time? How can I pay the bills? And what can I do to improve my health? It never seems to end. From the moment we open our eyes to the second our heads hit the pillow, we have found hundreds of things to stress over. We even stress over the weather!

How we deal with that stress and remain positive and productive can be difficult. Succumbing to the anxiety and negative emotions can be tempting; in many ways, it is easier than powering through, becoming stronger, and seeing the positive. Difficulty conceiving can rock the core of even the toughest individuals. Getting a negative result month after month can bring anyone to her knees. And the more negatives you get, the more stressful the situation becomes…stress on top of stress on top of stress. It would drive anyone crazy. Finding ways to relieve this stress, quell your anxiety, and cope with the situation at hand is key.

It seems pretty clear that stress plays some role in infertility. How big or how small is hard to define, as it is difficult to study the impact of stress on infertility. But there is definitive evidence that stress levels influence the outcome of fertility treatment and contribute to a patient’s decision to remain in treatment. Trying to get pregnant can be stressful; when something that you thought would just happen doesn’t, it can be incredibly difficult to deal with. And as you get deeper into the world of infertility, from Clomid to IVF to egg donation, studies show that the level of stress rises.

In a large study, more than 50% of women reported that infertility was the most upsetting experience of their lives. It was likened to a cancer diagnosis. After a failed cycle, most women reported feelings of depression, anxiety, anger, and isolation. Bottom line, it sucks. And it often sucks so bad, patients quit. They stop the race and pull off to the side of the road before hitting the finish line.

While it has always been assumed that the brake was a financial or medical reason, data shows that it is actually the emotional stress of the situation. In countries where IVF and fertility treatment are paid for by the government, patients still veer off the road (and not for a pit stop, but for a total stop) before using up all of their free cycles.

What is even more of a bummer is that, for most women, the longer you stay in the game, the better your chances are of scoring; the chance of success (having a baby) increases over time (more treatment cycles). This is not the place to quit while you are ahead. Rather, don’t quit until you have succeeded. The exception is when your doctor has deemed it medically unadvisable, given a poor prognosis.

One of the most common questions we are asked is “Is my stress causing my infertility?” The answer is flat out, without a doubt, no. Your stress, your eating habits, and your activity level are not causing your infertility (extreme situations aside!). You are not the culprit. You did not cause this. You did not make this happen, so stop blaming yourself. Don’t forget about self-compassion. You have compassion for your partner, your friends, and your co-workers, but not enough compassion for yourself. You beat yourself up for every failure, every loss, every bad event; doing this won’t change the situation.

Developing the skills to accept the situation, to stop fighting the outcome, and to move forward can often be the difference between success and failure. How this is accomplished can be different for different people. While we all have the image of the therapist on a couch, there are many different forms of counseling and types of psychological interventions. Use whatever works for you because if it works in not getting you worked up, it will likely have a positive effect on your treatment outcome and even improve your chance of pregnancy.

Do what relaxes you. Whether that be running, reading, or riding, if it relaxes you, it is good for you. Don’t sit around stressing about your stress…if you stress about stress, then you will just have more stress! We all find our inner peace and meditate in different ways. Not all of us do this on a couch. For some, it’s out on the track; for others, it’s in a house of worship. For many of us, it’s toasting with good friends. But what makes you Zen is what makes you stronger, calmer, and more skilled to cope with what lies ahead.

The road may be long and filled with lots of ups and downs. Developing the tools to navigate this unpaved path will not only allow you to stay on the road but also may make for a more positive outcome. Finding the right tools can be challenging, but the options are limitless. Explore meditation, yoga, exercise, acupuncture, support groups, cognitive behavioral therapy, and in some cases medications. Something is bound to fit.

Unfortunately, there will always be things to worry about, from the banal (Will I make the next train?) to the critical (Will my loved one survive this deadly disease?). Some will turn out good, and some will turn out bad. Learning to accept the unknown and recognizing that you have done all that you can will help alleviate a great deal of stress. Remember, you can’t live life in reverse. If you knew what was going to happen tomorrow, you would probably live your life differently today.

We are certainly not here to echo the words of your friends and family who say “If you just relax, it will happen,” because in all honesty, it might not. And your stress is likely not the reason you haven’t gotten pregnant. But it will make the situation worse and possibly have a negative impact on your fertility treatment. Take a deep breath, let it out, and do it again. You can get through this, and you will get through this. Turn your stress into something positive, and kick infertility’s behind!

The Buzzz on Zika

It’s hard to remember a day in recent months that the word Zika hasn’t come out of our mouths, come off our desks (a.k.a. a letter to an airline or hotel explaining why a woman can’t make her trip to the Dominican Republic), or caused a whole lot of fear for anyone who is pregnant or thinking about having a baby.

Like that insect buzzing in your ear, no matter how much you swat it away (no pun intended), it just keeps coming back. And while Zika might become “blood sisters” with everyone it lays its lips on, this virus has not made many friends. From reproductive-age women to OB/GYNs to pediatricians, Zika has become Public Enemy Number One. And while much of Zika is changing faster than Larry King changes wives, here’s what we know and don’t know today.

Here’s what we know about Zika:

  1. Zika said “Hello, world” in 1947. It made its first marks in monkeys who “swung out” in the Zika forest (hence how it got its name) in Uganda.
  2. Although Zika may have made its mark on the world in early 2016, it’s been a pesky pain since 1952. The first human infections were reported at this time, and since then, outbreaks have been identified in Southeast Asia, the Pacific Islands, and tropical Africa.
  3. Fast forward nearly 65 years, and Brazil reported the first Zika virus infection. Shortly after this, the WHO (World Health Organization) went all WHOAH over Zika, declaring it a public health emergency (a.k.a. this is some serious stuff). And while the current epidemic started in Brazil, other countries and territories have reported active Zika virus transmission.  As of September 2016, local transmission of Zika has been confirmed in Miami-Dade County, Florida marking the spread to the continental US.  
  4. Although most of us know little more about a mosquito than when it bites, it itches, these blood suckers are not all created equal. Different species carry different viruses. When it comes to Zika, it’s the Aedes species that is making all of the noise. And these guys like to hang out and breed in water-holding containers.
  5. Aedes has an appetite—a big appetite. They are fairly aggressive eaters and will feed both indoors and outdoors.
  6. Humans and primates are prime meat when it comes to Zika. They serve as the reservoirs (i.e., holders) of the virus. And while the virus moves mosquito to man or woman, it can also go mosquito A to person A to mosquito B to person B. So even if mosquito B was buzzing around blissfully without Zika, if person A had Zika and was bitten by mosquito B, mosquito B would now have Zika. Therefore, whoever is mosquito B’s next meal will be infected with Zika. We know…pretty crazy…
  7. Most people who are bitten by Aedes and infected with Zika are none the wiser;  they are completely asymptomatic. Those that do feel it feel the following: a fever, a rash, joint pain, muscle aches, headaches, and conjunctivitis. In most cases, the symptoms are mild and gone within a week.
  8. While most people feel little pain from their Zika infection, pregnant women, not so much. Medical evidence indicates that Zika is very likely to be a cause for microcephaly.
  9. Zika gets around—and not just via a mosquito. Zika can be transmitted to people through sexual contact, through a blood transfusion, or from mom-to-baby at birth.
  10. As of today, there is no vaccine or medication to treat Zika. Like most viruses, it just takes time to work its way out of your system.

Here’s what we don’t know about Zika:

  1. Where it will go next? (That is, what will that Zika map look like in a few months?)
  2. How long does the Zika virus persist in the semen of infected men? Although we are recommending men to abstain or use condoms for six months, is this too long?
  3. Can infected men who are asymptomatic spread Zika to their sexual partners?
  4. Do infected women have the ability to transmit Zika to their sexual partners just like men do?
  5. Once people are infected with Zika, are they protected for life (like chicken pox), or can you get Zika twice?
  6. Are pregnant women at higher risk for being infected with Zika than non-pregnant women?
  7. If a pregnant woman is infected with Zika, what is the chance that her baby will develop microcephaly?
  8. When will we discover a vaccine, AND who should get it?

Zika has made quite the buzz over the past several months. Its bite is big. From the news to the media to the medical journals, it’s all over the place. And while we know a lot more today than we did yesterday, we will almost certainly know more tomorrow than we did today.

Bottom line: the Zika recommendations are constantly changing. In the words of the NYPD, if we see something, we will say something. So keep checking the CDC, ACOG, ASRM and the Truly, MD, websites for updates. Until then, buy a lot of bug spray, stay away from Zika-infected areas, and stay in constant communication with your OB/GYN. This is one mosquito you don’t want to mess with.

Let’s Get the Screening Started

If your little ones have finally started to sleep through the night, eat real food, and maybe even venture onto the potty, you are probably feeling pretty good. Major milestones for your kids mean a lot to you not only as a mom (#ProudMom) but also as an individual (#HiWorldIamBack). While your schedule still somewhat revolves around your little ones’ naptime (which, let’s face it, none of us really likes to give up), the bonds of babyhood are slowly being released. (See you later, diapers and bottles!) As things settle, you are ready to get not only your house back into order but also your health. This includes sleeping, eating, exercising, and screening. While screening may conjure up an image of TSA and airport security, what we are referring to may include an X-ray machine and takes a whole lot more than 3 seconds.

The screening we are talking about includes visiting your MD for a good, old-fashioned chat, a physical exam, and probably some tests. Although most of us can barely find time to get a haircut, a checkup is kind of essential. While this meeting may include nothing more than a quick conversation along with a height, weight, and blood pressure check and focused physical (think heart, lungs, breasts, abdomen, and pelvis), if something looks or sounds off, we recommend a more detailed follow-up exam with blood tests and imaging studies (X-ray, MRI, or CT scan).

Depending on where you are in life (a.k.a., your age) and what your family’s history is like, you are probably getting teed up for a mammogram and maybe a colonoscopy. Although you should already be doing breast self-exams and clinical breast exams (by a healthcare specialist), most of us welcome the big 4-0 with our first mammograms. While there is a lot of fear and anxiety over entering the world of mammograms, for most of us (no matter what your breast size is), it’s nothing more than a few minutes of discomfort. You have endured endless sleepless nights, changed innumerable dirty diapers, and sat with a breast pump on for hours—you can tolerate a mammogram!

Although admitting this is hard (it is for us too), as our kids age, so do we. With age comes not only maturity and perspective but also disease and illness. As a result, your body needs to be “looked at” more frequently than it was in your 20s. Prevention is the key to your body’s prosperity and longevity. So, while we don’t doubt that you are a woman with a loud roar, even the strongest among us can get sick. Having a good doctor who knows you and your body is crucial. Get checked up and checked out on a regular basis (not just when you are sick). Screening may not be as “sexy” as getting your hair colored or your skin cleansed, but it will likely help you keep looking and feeling sexy.

The bottom line is that you should get a mammogram, get a Pap smear (or at the least have your OB/GYN review your cervical cancer screening history), and share your past and your family’s past with your doctor. While your kids may no longer be babies, there will be several bumps in the road for which they will need you by their side. Screening will help you stay strong!

The Big O: Cysts, Solutions, and All the Steps in Between

Your mind probably went somewhere we don’t want to know about after reading that title, and you are likely thinking, So this is where they are going to tackle the sex thing. And although, yes, we will, no, it is not here. In this debriefing or girl talk, we will begin an extended conversation on ovarian cysts. We want to demystify their presence and debunk many of the myths. So let’s get gabbing!

The second you hear the word cyst your mind starts racing—and not to the same places the “big O” takes you. You think surgery, cancer, and possibly even death. It’s beyond overwhelming.

The good news is that, in the large majority of women who are diagnosed with an ovarian cyst, the pathology will be benign. In fact, a good proportion won’t ever even need surgery—the cyst will resolve on its own, like magic (take that, David Blaine!). Ovarian or adnexal (as we doctor types like to say) masses are very common. In many ways, they are the bread and butter of gynecology. Luckily, only about 15% will be cancer. The overwhelming majority are benign. The odds of it being something bad are pretty low. A woman’s lifetime risk of developing ovarian cancer is 1 in 70 compared to breast cancer, which is 1 in 8. Nevertheless, you never want to ignore something that could be serious.

What determines what sort of pathology cards you are dealt is usually age. Think of age as the worst Vegas blackjack dealer; when it comes to ovarian masses, he is not your friend. After that, the others who are lining up to take your chips include those with a family history of breast or ovarian cancer and BRCA carriers (a genetic mutation that increases your chance for breast and ovarian cancer). How we determine who has what is through a good medical history, a thorough physical exam, comprehensive imaging studies, and a couple of tubes of blood (e.g., CA-125).

If it looks like a duck, swims like a duck, and quacks like a duck, then it probably is a duck. When it comes to ovarian cysts, you want to make sure all of your ducks are in a row, that is, you have confirmed that the “ovarian” mass is not a something else (diverticular disease, appendicitis, pelvic kidney, etc.). This is where a really complete and comprehensive check-up comes in—every stone should be unturned before you step foot into an operating room. If all fingers point to the ovary, then you are in the right place. How we determine who needs treatment and who needs time is based on age, size, and cystic features (blood flow, septations, and fluid).

First up in the lineup for what matters is age; unfortunately, yet again, time does not heal all wounds. When comparing premenopausal women to postmenopausal women, cancer is way more frequently encountered in postmenopausal women. In fact, nearly all pelvic masses in pre-menopausal women are benign. What matters most for the “young-uns” is what brings you into the office. Those who come in with pain, fever, and lots of symptoms usually need immediate treatment. Whether this is surgery or antibiotics or a little bit of both, it always warrants something ASAP. The “this” we are talking about are things like tubo-ovarian abscesses, ovarian torsions (ovaries that twist), and ruptured benign cysts. Never say never, but it is almost never that a woman with acute symptoms has cancer—that’s just not how cancer comes on.

Premenopausal women are also affected with the chronic stuff. Think endometrioma, dermoid, hemorrhagic corpus luteum, and serous and mucinous cyst adenomas (two types of benign cysts). While you may not know every name we just rattled off, you likely have heard of one or two.

Bottom line is that there are a lot of different things that can call your ovary home. Some are more welcome visitors than others. Although at some point we would like all of these houseguests to leave, the urgency with which we kick them out is varied.

Women who are postmenopausal are way less likely to present with acute symptoms and are way more likely to present with those “nagging, persistent” sort of symptoms. To differentiate the bad stuff from the benign, we take a lot of pictures, get a couple of tubes of blood, and start our workup.

In most cases (except for the simplest of simple), postmenopausal women will require surgery to figure out what’s up with their ovary (s). The ovary is also a common site for cancer metastases. Therefore, it’s important to look at the breasts, the uterus, and the GI tract of postmenopausal women with cysts before calling it a wrap.

How a cyst looks on ultrasound is a big deal for how anxious we get about its pathology. If the cyst has a thin wall, has smooth, regular borders, and appears empty (think of a black hole) then there is a very, very good chance (no matter how old you are) that it is benign. In fact, it’s okay to play the waiting game with (repeat exam/ultrasound in six months) even those that are big (up to 10 cm) but appear super simple in patients that are post-menopausal. In fact, about two out of three of these cysts will resolve on their own without us doing anything! So in most cases our answer to these is patience, time, and lots of deep breaths. They will go away!

Next comes size, and guess what? It does matter, at least when it comes to cysts. How big they are has a big impact on how likely they are to be something bad. The bigger the cyst, the more likely you are to need it out and need it evaluated. Additionally, the bigger it is, the less likely it is to resolve on its own. Last, those that are big may cause the ovary to twist (ovarian torsion) and require immediate evaluation.

When we think things don’t look good (a.k.a. concern for cancer), most of the time we general OB/GYNs turn things over to our oncology colleagues. They are trained in surgery and cancer and are the ideal people to treat any cysts that appear worrisome. Studies show that women who start with a GYN ONC (as we have affectionately nicknamed them) do better overall, with longer survival rates. Never be afraid to ask your doctor to consider asking for help.

While there are innumerable things to stress about, most ovarian cysts, even in postmenopausal women, are not it. You can usually stick to a good follow-up schedule and cross the bad stuff off your list. And just like if you see something, say something, if your symptoms change or you don’t feel right, tell your doctor. Although we usually have some tricks up our sleeves, we are not magicians and need to hear from you if something seems different. Together, we can usually make things disappear!


Let’s play a game (and we promise it doesn’t involve balls, bats, or scorecards)! Try to think back to the last time that you sat in silence and were aware of your body, your presence, and your surroundings—a moment where you turned off your computer, forgot about that ever-growing to-do list, and ignored the incoming slew of text messages. For most of us, this is “game over” before the first pitch is thrown.

When it comes to taking time to be aware of ourselves and our needs, we are fighting a losing battle. From work to home, friends to family, and bills to babies, our lives are busier than the NYC streets during UN week. Awareness of anything (except the ticking clock) is nearly impossible to achieve. But in reality, awareness of yourself and your body is the battery that makes your clock tick. Without a reboot or an occasional repair (aka a day off and a check-up with your doctor), the system won’t run.

While most of us view awareness on a personal level (my leg hurts, my car won’t start, or my sink is leaking), awareness has many “faces.” It can be public or private, professional or personal, physical or mental. You can focus on being aware of your partner’s needs as well as the stranger seated next to you on the train all in the same minute.

For us as physicians, awareness denotes prevention, particularly screening for a disease process. And when it comes to screening, there may be nothing more near and dear to our hearts as OB/GYNS and as women than breast cancer screening. In our world, October means a whole lot more than costumes and candy; it’s the month we dedicate to breast cancer awareness and highlight the important of breast screening. We don our pink, and we push women to be aware of their bodies, especially their breasts.

Although awareness may not equal A+ health (unfortunately bad things happen to the healthiest of us) and eternal happiness, being cognizant of yourself, both your body and your mind, will move you much closer to that better place. Try to take time every day (even if just while brushing your teeth!) to be aware of yourself and of your body (#mindfulness). Be aware of what brings you up and who brings you down, what makes you feel good, and who makes you feel badly.

And while we may assign months to awareness of different body parts (#October=BreastCancer), we at Truly, MD, urge you to assign minutes of each day to awareness of yourself. Whatever it takes to take the tick out of the tock—do it. And while you may never actually stop to “smell the roses,” or appreciate the sun as it rises and sets, you might see something in a new light. And who knows, it might even look better that way.