When to Take the Plunge…Am I Getting Hot?

Arguably the most popular question we are asked, whether in our office or in the Women’s locker room, is when I should freeze my eggs (a.k.a. at what age). And while in our office we can give you a personalized opinion, it’s hard to tell you exactly what to do while waiting in the shower line (although we will try). But what we do tell everyone (friends, patients, and gym acquaintances) is that the reason to freeze and when is often very personal. And although there are better times to do it, there is really no best time. Here are three tips that should get you “hotter” to getting your eggs “colder.”

  1. How old are you?
    Although you may not look a day older than 25, no matter how much sunblock you use, how healthy you eat, or how many times you hit the gym your eggs don’t really care. Egg quantity declines from the moment you take your first breath (and actually even before that!). Nothing you do or don’t do (minus a bad tobacco habit) will halt egg decline, except egg freezing. Egg freezing offers you the chance to freeze a subset of eggs at a particular age, whatever that age is. And just as egg quantity decreases as you age, so does egg quality. Therefore, the younger you are when you freeze eggs, the better quality those eggs will be. So, while yes, it would make sense for us all to freeze our eggs in our twenties when our eggs are at their peak, most of us won’t need to freeze our eggs. Most of us will not experience infertility and will not need to use frozen eggs to achieve a pregnancy. With all of that being said, if you are looking for that magic age at which you are getting “hot” to the “cold,” we would suggest that you pencil egg freezing into your calendar on your 32nd birthday. For most women, 32 offers you a balance between good egg quality and adequate egg quantity at not too premature a point in your life. Happy birthday!

2. Where are you in your relationship?
While we are not asking you to check the single or married box, we are asking you to evaluate where you are in your relationship. Is it serious, are you on the same page about having children, what is your timeline (and do your timelines match up)? Although these are very rarely fun conversations to have, they are super important. Men will make sperm for nearly their entire lives. They can wait way longer than we can to pull the goalie. Make sure he (or she) knows what you want—and when. This should help you decide when and if you should freeze your eggs.

3. What happened in your past?
We are not here to judge; trust us (we went to college, too!). The past that we want to know about is your medical and GYN history (medications you have taken, surgeries you have had, the pain you feel with your period) as well as your mom’s, sister’s, aunt’s, and grandma’s fertility history. Did your mom have an early menopause? Did your sister have a hard time getting pregnant? We not only mirror our female relatives when it comes to our physical appearance but also how our ovaries function. Therefore, in many ways, before you can move forward, you need to look backwards!

By combining all three—age, relationship status, and your past—we can sum up when and if you should freeze your eggs. And if it adds up (a.k.a. you are getting “hot” to your eggs getting “cold”), the best way to kick the process off is to get real information (#trulyMD) on what the process is like. Not everything you hear or read is true. So, the best advice we can give you is to talk to your GYN, talk to a fertility doctor, or talk to us at Truly MD in the gym locker room about the process. We can help you decided when it’s time to take the plunge!

Can’t Stop, Won’t Stop: What to Do When Your First IVF Treatment Fails

Can’t stop, won’t stop; it’s not for nothing that this may be one of our favorite sayings. As overplayed as it might be and as trite as it might sound, it’s pretty much how we aim to live our lives, how we chose to tackle our challenges, and how we hope to make it to the end of a marathon. We push each other, we push ourselves, and we push ahead to get to OUR end.

But life is not a race, and there is no set finish line (except for the obvious one that we won’t harp on). How you end your day, how you end your career, and how you end any struggle in many ways is up to you. You set the start line, the halftime, and the finish line. Much can also be said for how many rounds of fertility treatment you decide to do and how long you continue to try for a baby.

Knowing when to call it quits can be nearly impossible. Whether professionally or personally, it’s hard to know when enough is enough. In terms of fertility treatment, specifically IVF cycles, how much is too much? How many is too many? When do you move on to something else?

A recent study from England published in a very prominent medical journal (JAMA) recently addressed this question. It got a whole lot of press and found its way into the New York Times, the Wall Street Journal, and all of the morning talk shows. It basically showed that women who hung in the game were more likely to get pregnant—quitting after a couple of failed IVF cycles was not the right move. Although they didn’t find a magic cutoff number after which patients should be told to exit stage left, they did find that nearly 70% of women under the age of 40 got pregnant after six IVF cycles. While about 30% of women got pregnant on the first cycle, many took longer to cross their finish line.

The results were less promising for women older than 40; while they also got pregnant at a higher rate after more IVF cycles, the total number did not exceed 30%. Bottom line, even though this study got as much press as a Kardashian wedding, it’s important not to misanalyze the data.

This study is NOT giving the green light to endless IVF and fertility treatments. This study is NOT saying that multiple IVF cycles are always the way to go. This study is NOT saying everyone who does multiple IVF cycles will get pregnant. This study is simply saying that, if you can emotionally, physically, and financially (unfortunately, finances come into play big time) swallow the treatment AND your doctor believes you are a good candidate, it’s okay to keep on keeping on.

Knowing when to bow out is nearly impossible. Unfortunately, there is no magic number. But here’s the CliffsNotes version from girls in the know… For starters, we use age, pregnancy history, and ovarian reserve testing to decide when enough is enough; these initial parameters can shed a lot of light about what’s to come.

Additionally, we use IVF response as a gauge of how much gas you have left in the tank—are you responding to medications, are you producing follicles, is your estrogen level rising?

Last, we use embryo development and, if available, embryo genetic testing results (PGS/CCS/TE biopsy, which tests for aneuploidy) to help patients decide whether further treatment is a go. For example, if patients have done several IVF cycles without any viable or normal embryos, we are hard pressed to recommend continued fertility treatments with your own eggs. And while no, history doesn’t always repeat itself, in these cases, it comes pretty close.

We are not dictators, czars, fortune tellers, or goddesses (although we wish we were)—and we are not afraid to admit that. We can’t tell you that more will be better; it may just cost more money, cause more physical discomfort, and evoke more emotional anguish. But quitting too early can be a real shame.

Just like in sports (from two women that love to pound the pavement!), there should always be a day for rest, always a moment to breathe, and always a time to stop. Without a break, you get injured. Without a day to sleep in, you get fatigued, and without days off from work, you get frustrated. In cases where there is no definable finish line for you or your partner, you may need your doctor to help you set it. When you collectively find that line in the sand, be careful not to step over it. Things will start to sink quickly on the other side.

The Art and Science of IVF

As first-year medical students sitting in the back of the Mount Sinai School of Medicine lecture hall, we had no idea what to expect from the Art and Science of Medicine course. We all thought of ourselves as scientists (I mean, this was medical school!). Art was far from most of our minds. Questions like “What will this class be like?,” “Will it be lecture-based or textbook-based?,” and “Will the exams be graded or simply marked Pass or Fail?” flooded our minds. In typical Jaime and Sheeva fashion, poised with pens in our hands (we were both ferocious note takers!), we were ready to transcribe every word uttered by the lecturer to soak up and eventually memorize every piece of data shared. However, what followed surprised us: we would not be note taking, we would not be studying, and we would not be test taking.

We would learn about the art of medicine.

Art and medicine may strike some of you as odd. It did us! Medicine is a practice rooted in science and data, not color or design. The people you knew who became doctors did it because they liked facts, not pictures. However, in reality, how we diagnose a disease, how we treat a problem, and how we formulate a plan are really an art. The many available imaging modalities, medications, and surgical procedures are our colors. How we blend them to get the best outcome for you, the patient, is our art.

For fertility doctors, ovarian stimulation in particular (a.k.a. how you get the ovaries to produce multiple eggs) is our art. What protocol we select for a patient, when we increase and decrease medications, and how to obtain the highest percentage of mature, good-quality eggs is our art (not to be confused with ART= assisted reproductive technology!). Sure, we have scientific data to guide us in our decisions, but what can make one IVF cycle more successful than the other has a lot to do with the art of ovarian stimulation. And we bring you back day after day for blood draw after blood draw and ultrasound after ultrasound not because we like to torture you but because it helps us customize your design, your art.

Don’t get us wrong. There is a lot of science in what we do. The laboratory is our science. The embryologists, the culture system, and the genetic testing are science. And without the science, our art is just some strokes on a blank canvas. It takes both, the art and the science, to treat a patient and to achieve success in all areas of medicine.

So, if you ever wonder why we do what do and how we decide on treatment protocols, they are our art. And when they are combined with science, it can make a beautiful picture!

On the Road to Delivery…GBS

While the title may have you doing a double take (and maybe even looking for some directions on how to decode GBS), rest assured, you are not lost out there on the road. You are in your home, your apartment, your office, or maybe even in the car (although hopefully not driving and reading!) hanging with your girlfriends at Truly, MD. But if you are nearing the end of pregnancy, you are probably getting pretty good at navigating the streets between home base and the hospital. And although we may not know the quickest way to get you to the labor floor, we definitely know how to get you up to speed on all things third trimester. First stop: Group Beta Streptococcus (a.k.a. GBS).

GBS is a type of bacteria. And although it may not be on your daily bacteria radar (think strep throat or staph skin infection), it is pretty important to us OBs. GBS took center stage in the OB world of the 1970s when it was identified as a culprit in the land of perinatal morbidity and mortality—that is, newborn illness and death. The newborns of pregnant women with GBS in their vaginal canal who were not given antibiotics during labor were at risk for some pretty heavy hitters. Think sepsis, meningitis, and death. Pregnant women were not immune to the negative effects of GBS. They, too, were at risk for things like UTIs and uterine infections.

Despite its bad-guy tendencies during pregnancy, GBS lives fairly peacefully within the vaginas and the rectums of non-pregnant women. Don’t bother me, and I won’t bother you. Given its Jekyll and Hyde persona, we only start to look for the presence of GBS in a woman during the latter half of pregnancy, when it can really turn into Hyde. To uncover whose vagina/rectum is “covered” in GBS and whose is not, your OB will perform a screening test on you between 35 and 37 weeks. And although it may sound scary, it’s no more than a cotton swab test of the vagina and the rectum. Those that test positive are given antibiotics during labor. Those that test negative are not. Pretty simple.

The ACOG has made it their business to get in the business of all pregnant women when it comes to GBS because, like the old adage says, when GBS is bad, it is very, very bad. Anything that can be done to decrease the bad is a major bonus…cue screening for GBS. The universal screening of all pregnant women has done a very, very good job at stopping most widespread GBS infections in newborns, particularly in the first six days of a baby’s life. In fact, since national guidelines for screening and treating pregnant women who test GBS positive were implemented, there has been nearly an 80% reduction in early onset (the first six days of life) neonatal sepsis due to GBS. Pretty impressive stuff.

Women who go into labor before their GBS test was performed (a.k.a. preterm labor), women who have previously given birth to a GBS-infected newborn, or women who test positive for a GBS UTI during pregnancy are automatically treated with antibiotics for GBS during labor. Basically, in these cases where the risks are high, it’s better to be extra safe and add an extra layer of protection. It’s sort of like extra insurance for a driver with lots of points on his license. While he may never speed or get ticketed again, given that his chances are higher, you want extra protection—we’re not saying we know anyone like this!

For most women, the GBS test comes and goes without a bump in the road. It’s sort of like passing a yield sign on the road. You know it’s there. You slow down somewhat, but you don’t really pay it much mind (we didn’t say that we offered good advice on driving!). Don’t fear the results. Positive or negative, we are pretty good at directing you to the right path. No one gets lost out here on this road; think of us as your GPS for your GBS!

Even Moms Need a Day Off!

As moms, we often think we can do things one-handed, backwards, and in the dark. You know how it is. You use any extremity (even teeth) to hold bags, babies, and BIG cups of coffee. Your day starts with the roosters and ends with the owls. The responsibilities are endless, the needs of others limitless, and the workload large. Motherhood is the most rewarding job—but it’s also the most exhausting. On a daily (more like hourly) basis, you want to quit. You wonder how can things get any harder or any more harried, and then your toddler empties your jewelry box into the toilet bowl—and you think, I guess it can get worse!

The only way to survive the disaster days is to allow yourself time to recharge. Even the fanciest cars need to refuel (nobody can run on empty forever). You are not a horrible person for thinking that time with your kids can be terrific and terrible all at the same time. They can push your buttons, make you want to pull all your hair out, and force you to ask yourself, Why did I ever do this? Let us remind you that you did this because even on the temper-tantrum, drama-filled, never-ending-tears days when they are finally sleeping and you stand at the door watching them breathe, you think, I never knew a love like this existed.

That’s why.

However, when you are worked to the bone, appreciating even the most precious moments of motherhood can be difficult. If you’re feeling like you can’t take another minute of the crying, you’re not alone. You are not a bad person or a bad mother. It is because of the enormity of it all, the all-consuming, all-in and all-on, that we beg you to take a break. We ask you to give yourself a rest—even if only for a few hours. Ask your partner, your parents, your friends, or a sitter to come over and relieve you for a few minutes, a few hours, or even a few days. It’s okay to need time off; we all do! You shouldn’t feel guilty because you want a day to sleep past 5 a.m., not change a dirty diaper, or not have an argument about why you can’t eat dessert before dinner.

We get that guilty feeling too when we clock out, but you gotta do it. Time away from any job is needed, especially one that’s all day and all night. Don’t beat yourself up because you can’t be on ALL the time. Nobody can (and anyone that says they can is lying to you). We moms can sort of do it all, carry a kid, a bag, a stroller, and pay for groceries all at one time. You do whatever you have to do to keep them safe, smiling, and healthy, in body and spirit.

Just because you can do it all doesn’t mean you don’t need some time to just do nothing. You’re not a machine; you’re just an awesome mom.

SPF: Don’t Let Your Bones Get Burned

Whether you opt for 15, 30, or 50, it’s rare to find someone amongst us that doesn’t lather up before laying out (or even being out on a summer day!). The sun and its rays are no joke. They can leave their mark in the form of burns, peels, sunspots, and even wrinkles—ugh! And if that wasn’t enough to scare you into some good water-resistant SPF, think skin disease and skin cancer. But while sunscreen fills the shelves at nearly every drugstore, reminding you to lather up or pay the price, what lies under your skin is much quieter. Your bones don’t tell you when they are about to burn (a.k.a. break), and the reminders to protect them are much subtler. However, if they are ignored, the burn can be just as severe as the strongest rays.

In the same way that you would protect your skin during the summer, you should protect what lies under your skin #yourbones all year round. Adequate calcium and vitamin D intake, coupled with a healthy diet, weight-bearing exercises, and estrogen during the reproductive years are the SPF that your bones need. In fact, this is the formula that makes up the SPF 70 sunscreen for your bones!

But while most of us know that milk (a.k.a. calcium and vitamin D) is “what does a body good,” you might be surprised to know that estrogen is equally as important. News flash: estrogen is not just a hormone made by your ovaries to keep your eggs developing. It is also necessary for bone buildup and bone strength. In fact, how much you take in during your adolescent and young adult years can dictate what happens in your later years. No estrogen in your younger years can cause some major breakage in your later years (think osteoporosis and osteopenia).

Bones reach their peak mass by about age 30. However, to reach the “summit,” they need estrogen during your teens and twenties. Therefore, women who are not on hormonal contraception and don’t get regular periods (a lack of periods because of continuous pill usage does not count!), is sort of standing out in the sun without sunscreen. When your bones don’t reach peak bone mass, there is nowhere for them to go but down later.

And as most of us know, the estrogen story does not end at age 30. Your bones continue to rely on their fountain of youth for years and years to come. Estrogen production is essential deep into our 40s and even 50s. Therefore, for women whose periods bid them adieu early it’s important to make sure that you speak to your GYN about hormonal replacement therapy.

While postmenopausal hormone therapy has gotten more bad press than both Democrats and Republicans making a decision combined, it’s actually not bad for most women. In fact, estrogen supplementation, started at the right time in the right woman, can be the key to reducing your chances for heart disease, bone disease, memory loss, and serious vaginal dryness. So, don’t listen to everything you hear on TV; this is one decision for which you should hear what your doctor has to say.

It’s really no different than sun damage. Burns sustained in your younger years make your skin way more susceptible in the later years. And while freckles and sun spots may be cute at age 15, they’re not so much at age 55. Additionally, they pose a risk for skin cancer at age 50. The same goes for how you treat your bones then and now. So, don’t forget to lather them in milk, vitamin D, calcium, and exercise: this SPF will save you big-time breakage in the future.

Don’t Worry, It’ll Be Fine: The Power of Peers

Hearing those five (or five and a half, depending on how you look at it) words brings a feeling of “Ahh” and a sense of calmness over most of us. With reassurance, our shoulders drop, our jaws loosen, and our minds are put at ease. This is not CBS’s “Survivor”; no one wants to be left on the island alone. In real reality, we want to be surrounded by others who are also fighting the elements, trekking through the same terrain, and battling the same villains. Fellow soldiers on the field make the foxhole a lot less scary.

Oprah made the “Aha” moment famous; we want to make the Ahh moment famous. While we certainly want you to have your Eureka moments (they’re great!), our primary goal is to help you find that moment of peace—that moment when you realize you are not alone, you’re amongst millions of other women facing similar struggles, and you realize their strength can help you achieve your goal. No matter what we look like, what clothes we wear, or where we live, we ladies are all trying to make it as far as we can in those horrible high heels (Why do we do that to ourselves? They hurt so badly!). And while we can’t help you find ones that are cute and comfortable (trust us, we’ve searched everywhere), we can help you find and build a community of fierce women.

We talk a lot, not only to our patients but also to each other (you would be amazed at how many text messages we send to each other a day!). We are very open about our own experiences,  struggles, and failures. Our personal and professional goals have not only centered on helping couples make families but also creating a community of openness, honesty, and empowerment. Admitting our weaknesses and advertising our fallibilities is never fun; it takes a ton of courage. But it makes us human. And when you take it back to the basics, we are all people trying to survive, find joy, and make our footprint on the world.

While we recommend you letting stuff out and finding your Ahh moment, we don’t recommend turning your life into a Bravo reality TV show (although we do love those Bravo-lebrities!). Sharing your experiences will not only help you but also your fellow femme fatales. Believe it or not, even the most soft spoken amongst us can scream—our voices can empower someone else to make a change, seek support and conquer her fears. We are stronger together than alone. Collectively, we can make a difference.

We are often asked about the obsession with group fitness studios like Soul Cycle and Flywheel. Why do they hit it out of the park repeatedly? In many ways, their popularity is a direct result of the community, camaraderie, and unity their classes create. I mean, why else would you sit in a dark and sweaty room at all hours of the day spinning your legs? It’s because riding next to you are a group of kickass women (and some men) who struggle with the same problems. Their energy and strength will help elevate you to another level. They will inspire you to not be scared about what’s over the next hill. They will motivate you to not hold back because you think you can’t do it. They will encourage you to not limit yourself to only try what you know you can achieve. The fact is that we push harder together, we push longer together, and we break barriers together. Next time you see someone struggling, tell them, “Don’t worry; it’ll be fine.” And then add our three favorite words:  “I got you.”

Double Duty…Why Two Is Not Always Better Than One

It would be nearly impossible to count the number of times patients tell us the following regarding how many embryos to put back into the uterus: “I want two…it’s like two for the price of one!” “I want to be one and done!” “It’s like getting a twofer!”

And while we understand the desire for two (trust us, the thought of minimizing the number of times one is pregnant does sound appealing), twins are not just double strollers, matching onesies, and names that start with the same first letter. Twins and triplets-plus can be complicated, not only for the babies but also for the mother. Therefore, serious thought needs to be put into how many embryos are put back into the uterus.

Old-school fertility doctors routinely transferred several embryos into the uterus at one time; twins, triplets, and even quadruplets were sort of the “cost of doing business.” Back in the day, our IVF techniques weren’t so great. The procedures were new, and there were a lot of unknowns. To increase a patient’s chance of getting pregnant, multiple embryos were put in. Although even then, “the more the merrier” wasn’t our motto, (women are not meant to carry litters!), we were limited in our ability to identify which embryos had the best chance of making a healthy baby.

Fast-forward 20-plus years, and we are actually really, really good at this stuff. Not only do we know exactly what a three-day-old embryo needs to grow in versus a five-day-old embryo (can you believe it they are already picky eaters at this age!) but we also actually have the ability to check them and make sure they have the right number of chromosomes!

Now, while we can’t tell if they will look like you or your partner or go to Harvard or Yale, we can take a few cells and check to make sure they have the correct number of chromosomes. (The magic number is 46!) When this technique is done and a healthy embryo is found, we almost routinely only put one back in because even this guy or gal more than half the time makes a baby.

If you are considering an IVF cycle or are maybe even in the midst of one, make sure to have a long and serious discussion with your doctor about the number of embryos to transfer back in. Nowadays, not every IVF center is the same; many have the ability to grow embryos in the laboratory to day 5, rather than the traditional day 3. Although two days may seem inconsequential when it comes to most things in life, for an embryo, it’s a big deal. Just these 48 hours gives the embryo time to develop and the embryologist who is watching the embryo develop more information to pick the one that has the best chance of making a baby!

If you are lucky enough to have several A-plus embryos and your doctor only recommends putting one back in, the others can be frozen. Yup, we said frozen. Don’t worry; frozen embryos are not like frozen chicken! Embryo freezing has come a long way, and now in many centers, frozen embryo transfers have a better chance at making a baby than a fresh one. Simply stated, you won’t lose anything from freezing the extra embryos and putting only one embryo back in at a time. Sticking with the “one and done concept,” many couples get all the embryos they will ever need in one fresh cycle, thanks to good freezing techniques!

It’s sometimes hard to imagine that anything can go wrong in twin pregnancies. Nowadays, our schools and parks are teeming with twins; it really has become all the rage! But take it from us, not every twin pregnancy ends in a cute Anne Geddes photo. Twins have a higher chance of almost all risky pregnancy complications. On the fetal side, these include stillbirth, preterm delivery, and the serious problems that can come along with having a preterm baby: neurologic, cardiac, pulmonary, gastrointestinal, and serious developmental issues. Additionally, a high percentage of twins will experience some delay (motor and verbal skills) in the first two years of their life that requires treatment.

On the maternal side, women carrying twins or more have a much higher chance of serious medical complications. These include diabetes, high blood pressure (preeclampsia), heavy bleeding, hyperemesis (significant nausea and vomiting), Cesarean Section, and post-partum depression. Although most twins and most moms of twins will be running (actually, probably sprinting) and laughing in no time, there are a number of twins that will suffer permanent consequences from prematurity. The risks are real and should not be ignored.

And partners of those who have twins don’t get off easily, either. Sure, they don’t have to endure the insane stretch marks, the prominent varicose veins, and crazy swelling that multiple babies in one uterus at one time can bring, but let’s face it, double the work comes with added stress on the relationship. Studies have shown that divorce/separation rates are higher in families of multiples. Having a baby is not easy, sleepless nights and long days can be beyond difficult; imagine multiplying that by two!

We live in America too, and trust us, we get it. Other than pounds, for most of us, more or bigger always seems to be better. Why have one of something when you can have two? While we are not going all one-child-policy on you, we are advocating having one child at a time. It will be healthier for you and healthier for your unborn children. While twins are adorable and the bond they share is unlike any other sibling relationship, we are big fans of taking it one step at a time if possible.

When building a family, slow and steady is the best and safest way to get to the finish line.

Metformin Madness…Will It Make Me a Momma?

Any medication that promises to make you pregnant (or at least markedly increase your chances) and make you lose weight seems too good to be true. Wait, so I can eat ice cream and French fries while losing weight and getting pregnant? Count me in! But like most things that sound too good to be true, so is the hype surrounding metformin.

Metformin is a medication that is traditionally used to treat diabetes. It lowers sugar and insulin levels: hence, why it is used for diabetes. For women with PCOS, in whom insulin levels are high, metformin can not only improve the abnormal glucose/insulin situation but also improve ovulation rates. When metformin was released as an ovulatory agent, it became all the rage for women with ovulatory dysfunction. It was handed out like candy to anyone who had even the slightest ovulatory issues. However, while it was in the medicine cabinets of thousands of women, it didn’t stand up to all the hype. It didn’t turn ovaries of stone into sand—many ovaries still stood their ground.

Turns out, metformin is not a magic potion. A large randomized control trial (randomized control trials are the gold standards of medical research) did not show that metformin was even in the same ballpark as Clomid. Women who took Clomid ovulated and got pregnant at a much higher rate (about three-fold higher) than women who took metformin. Additionally, the metformin-Clomid combination was no better than Clomid alone. The only group of women in whom metformin was semi-magical was overweight/obese women with metabolic disturbances (elevated sugar and triglyceride levels, abnormal liver function, and high cholesterol). In these women, metformin combined with diet and exercise could be quite helpful in kicking the ovaries into gear. Additionally, this dynamic duo can significantly improve your overall health, wellness, and longevity.

With the pluses come the minuses. Metformin can make your stomach feel a little funky; be sure to talk to your doctor if you experience GI side effects (bloating, diarrhea, etc.). It is also important to have your kidney and liver functions measured while taking metformin, as it can do some not-fun things to your kidneys and your liver. While there are certainly occasions and cases where metformin is the magic ingredient, it’s not the “butter” in the ovulation concoction. It may help with the flavor, but it isn’t the force behind what gets the ovaries going.
Don’t fool yourself into thinking that metformin is magic. You still need to eat right, exercise, and maybe even take some Clomid. We will find some cocktail that makes your ovaries shake!

Why Am I Making Milk…I Have Never Even Been Pregnant! Prolactinomas

Looking down at your shirt and seeing two stains over the nipples can be disconcerting, to say the least. Yes, if you are breastfeeding it’s par for the course (words from girls in the know…never leave home without nipple pads postpartum!), but if you are eons away from pregnancy it can be beyond confusing. However, there are certain instances, which are not super uncommon, where this can happen. In most cases, it comes from the overproduction of a hormone produced in the brain called prolactin. Here’s a preview of what this prolactin can do.

Think Ps…prolactin is made in a part of the brain called the pituitary. While you can’t see it and probably have never even heard of it, the pituitary is a pretty powerful hormone in the world of OB/GYN reproductive hormones. The pituitary is not only known for its good looks and funny personality but also for the production of hormones that initiate periods, help with pregnancy, and promote overall health and wellness. While post-pregnancy you want that pituitary to be making prolactin in overdrive, pre-pregnancy, you don’t want to hear more than a peep from it.

Normally, prolactin production is kept in check by other hormones. They control the production and release of prolactin into the bloodstream. However, when these hormones are not functioning properly or there is a tumor that is producing prolactin, that’s when things can get milky.

Although classically we talk about women and breast discharge, in reality most women who have elevated prolactin levels may never know it. Contrary to popular belief, the levels actually need to be fairly elevated for milky breast discharge to occur (FYI: the medical term for this discharge is galactorrhea). Most women come to the doctor complaining of irregular or lack of periods and/or infertility. In the evaluation for these conditions, the elevated prolactin is identified. In many ways, it’s a good problem to have. It is most often easily fixed and causes no significant medical problems.

Prolactin tumors, prolactinomas, are some of the most common benign brain tumors. They can be small (micro) or large (macro) and are often the culprits for elevated prolactin and milky discharge from the nipples. While the word tumor can send everyone into a tizzy, they are most often treated with oral medications. The medications, bromocriptine and cabergoline, work to decrease the prolactin levels and therefore decrease the symptoms. For most women, taking them can be a no brainer—they can reduce your prolactin levels, reset the system, and ultimately turn your periods and your fertility back on.

While prolactinomas are definitely at the top of the list for causing elevated prolactin, there are other problems that could cause this problem. Culprit No. 1 is pregnancy. Even if you don’t think you could be pregnant, we are always going to ask. Other potential causes include medications (particularly antidepressants), chest wall stimulation (massage) or a lesion (think herpes zoster), hypothyroidism, or other tumors in the brain.

When trying to determine what, where, how, and why (it sounds like a game of Clue!) the prolactin is elevated, we usually start with a repeat blood test. Yes, you read that correctly. We have you come in and repeat the levels to confirm that they are actually elevated! However, this time we ask you not to eat and to come in first thing in the morning. Food and late-night fun can throw off the accuracy of the prolactin hormone test.

If the repeat levels are high, then it’s the real deal. Our next move is to send you for an MRI of the brain. This will tell us if it is coming from a benign tumor in the brain, and if so, how big it is. The bigger, the more bothersome and the better chance that you will need surgery. Luckily, most prolactinomas are “micro” (less than 1 cm), requiring only medical treatment. If the MRI is negative, we start the hunt for Professor Plum in the kitchen with the candlestick (a.k.a. we look for other potential problems).

Why do we care? Well, it’s not just that milky discharge is driving up your dry cleaning bill! It may also be preventing you from getting regular periods and getting pregnant. Additionally, no period means low estrogen, which means a risk for bone breakage. For women who are nowhere near being ready for a baby, the easiest thing to do is to put them on the birth control pill. This will control their periods and make sure they are getting the appropriate amount of estrogen. For women who are ready for a plus one, we initiate medical treatment (cabergoline or bromocriptine) to drive down the prolactin levels and allow ovulation to occur.

For many, prolactin is a word as foreign as incinta (that means pregnant in Italian!). You may never say it, hear it, or think of it. However, it doesn’t mean you won’t find yourself in Italy pregnant and need to know how to say pregnancy! In the same vein, you or one of your girlfriends may experience milky breast discharge and start to freak out.

Don’t freak out. You are not a cow. You are not alone. This is not uncommon. Go speak to your GYN—they will get to the bottom of this, get treatment going, and stop the milk from flowing.