Hop on the Blame Train: Advanced Paternal Age Does Matter!

How many times have you read, been told, or watched someone lecture about what happens to us ladies as we age? Aside from the greying of our hair, the sagging of our bottoms, and the wrinkling of our skin, we can look forward to the withering of our ovaries. Sounds like fun! And while we women are used to shouldering all of the blame, men and advanced paternal age play a pretty sizable role in the fertility equation. Just because guys make sperm almost all of their life doesn’t mean that they should make a baby with this sperm. Here’s why.

Let’s start with a bit of basic biology…the process of sperm production in men is called spermatogenesis. Unlike oogenesis (the production of eggs), which occurs ONLY when you are a fetus inside of your mother’s womb (remember, a girl is born with ALL of the eggs she will ever make), spermatogenesis is like the Energizer Bunny—it keeps on ticking.

However, just like any device that is running on batteries that have seen their better days, over time, things start to go awry. Things stop moving, start sounding funny, and become unable to perform their duties. The situation is really not all that different with sperm. As guys age, their sperm-production battery (a.k.a. spermatogenesis) starts to become more error prone. We see more breaks in DNA (the genetic material that is passed down to your future lineage) and a higher frequency of mutations within the DNA. These mistakes translate into abnormal sperm, which translates into abnormal embryos and infertility. Additionally, as men age, their semen volume decreases, sperm motility decreases, and the percent of normal sperm decreases—D-Day is upon them.

The length of time it takes a couple when the male partner is older to conceive is longer than the time it takes a couple when the male partner is younger. The line in the “age” sand is debatable and usually set anywhere between 45 and 50. The same delay in conception appears to hold true even when doing IVF; older sperm will likely set you back (how much time is not clear).

And while the sperm may be slacking, there are also data to suggest that paternal age has a significant impact on how often a couple with an older partner not only has sex but also on sexual function. Studies show that older men have sex less often due to decreased sexual desire and diminished sexual function. Less sex is going to equal less chance of conceiving, no matter how good the sperm he still has.

Research has also shown us that advanced paternal age (again, think 45 or 50 years old) has an impact on specific genetic and medical conditions. These include autosomal dominant disorders (achondroplasia, Apert’s syndrome, Marfan syndrome, etc.) as well as schizophrenia, autism/autism spectrum disorder, and certain congenital anomalies. How or why these diseases or errors happen is not super clear. So far, scientists think the money is on a reduced amount of antioxidant enzymes hanging around in the semen. Think of these enzymes as the police; they are responsible for cleaning or stopping abnormalities. Just like a city without a good police department, the fewer enzymes, the more potential problems for the sperm and the resultant embryo.

Newer evidence also suggests that children born from older dads may have a SLIGHTLY higher chance of childhood cancers (specifically, leukemia and brain/nervous system tumors). Given these risks, most of us OB/GYNs will recommend chatting with a genetics counselor either before or in the very early stages of pregnancy. They can help break down even the most complex of issues and set the stage for what can happen when the curtain goes up.

Fertility is a two-way street. While we have let the guys off the hook when it comes to age in the past, we now know that paternal age does matter. It can most definitely play a role in infertility and abnormal pregnancies. Sperm, like their egg counterparts, seem also to be on the hunt for the fountain of youth. This is important to remember when looking for the cause of infertility.
And although we joked about it, this process is way stressful, and therefore, there is no need to blame, to point fingers, or to look for fault. While we want to find cause, we don’t want to ascribe blame. That train has left the station. It’s time to move together towards our destination.

5 Things Never to Do While You Have Your Period

There are not many things that you want to do when you have your period except lay in bed, watch re-runs of “Sex in the City,” and eat coffee Haagen Dazs ice cream! But between work, family, and an endless list of responsibilities, you have to get out of bed and get moving. And even though you may have to move through your day on a massive amount of Advil, there are a few things that you should not do while on your period.

  1. Bikini Wax: As if a bikini wax wasn’t torture enough, try doing it while you have your period. Double trouble! Your pain receptors are extra heightened and your skin extra sensitive when you have your period. Add to that a pretty messy situation, and waxing while on your period is something you should not do. Period!
  2. Pro-Inflammatory Foods: Your period is a period of heightened inflammatory mediators—hence, menstrual cramps. While foods filled with inflammatory mediators (sugars, saturated fats, fried foods, artificial additives) are all you really want to eat, they are best avoided during your period.
  3. Breast Exams: The breasts are incredibly sensitive to changes in hormonal production. Fluctuations in estrogen and progesterone can make both breast exams and mammograms more uncomfortable. Additionally, cystic breast changes are more likely to be palpated on an exam, which can unnecessarily raise a red flag. While monthly breast exams are a very good idea, don’t set your alarm to the first few days of heavy flow.
  4. Unprotected Sex: While unprotected sex is never a good idea, it is a particularly bad idea when you have your period. Blood is a good medium for viruses and other bugs. Therefore, the transmission of things like HIV can be higher during this time period. Furthermore, the cervix is slightly dilated (a.k.a. open) when you have your period. This makes it easier for bugs to get from the vagina to the cervix and into the pelvis.
  5. White Pants and Bathing Suit Shopping: This likely goes without saying, but wearing white when you have your period is not the best idea you have ever had. While you may be super fashionable, now is not the time to showcase your new white jeans! On that same note, Aunt Flo is not who you want to go bikini shopping with. Aside from the technical difficulties (trying on bikini bottoms with a pad and/or a tampon), you are going to be extra bloated. This will make any bikini look blah at best!

We all have our “go tos” during that time of the month. Heating pads, teas, soups, and stretches…whatever helps you relieve the pain, the discomfort, and the all-around blahs is okay in our book. However, when the pain is unbearable, the discomfort distressing, or the blahs are making you more than blue, you should think about talking to your GYN. They will likely have a “go to” that can make you good to go during everyone’s favorite time of the month.

The Lingo

We talk fast, sometimes too fast…way too fast! We also move fast and think fast—we can’t help it; we’re New Yorkers! But sometimes we need to slow down, not only how we talk but also how we move, both through our days and through our lives. And while it’s going to take work (#meditation) to slow things down, we can help those whom we frequently talk to (a.k.a. our patients) better understand the shorthand or lingo that we are using for medical terms. Think of the following as the Truly, MD, fertility language translator. We offer you the top 15 most frequently heard acronyms in the halls of a fertility clinic, in alphabetical order.

ART: Who doesn’t like to paint and color? And although we, too, like an adult coloring book (they’re now all over the place!), the ART we are referring to stands for Assisted Reproductive Technologies. Anything where fertilization occurs outside of the body (think IVF, egg donation, or surrogacy) is under the paintbrush of ART.

Azo: Despite the way it’s written, you’re not about to visit the zoo. Azo comes from the Greek word azoos, which means lifeless. In fertility medicine, azoo– is a prefix that, when placed before -spermia describes the lack of sperm found in the ejaculate. It can occur either when sperm is not being produced OR when sperm is being produced but its exit out of the testicles is blocked. In both cases, it requires an evaluation by a urologist.

CCS: Think of a girl named Elizabeth. Elizabeths can be Lizs, Beths, Lizzies, and even Elizas. Sometimes they drop the nickname thing completely and go by Elizabeth. Simply stated, there are many ways to refer to your friend named Elizabeth. Same goes for the names we use to describe the genetic testing of embryos. CCS, or comprehensive chromosomal screening, is a term used to describe the genetic testing procedure that checks to see how many chromosomes an embryo has (remember, 46 is the magic number!).

DOR: Women with low egg count and low egg quality are frequently diagnosed with diminished ovarian reserve. Simply stated, the “fuel tank” in the ovaries is running low. The ovaries have a finite number of eggs. Once we exhaust that supply, there is unfortunately no way to “refuel the tank.” To maximize what is remaining in the ovaries, fertility doctors will often recommend IVF.

hCG: Everyone’s favorite hormone. hCG is the hormone that is secreted by a pregnancy, so when it is positive or present in your blood or urine, it indicates that you’re pregnant. And while it can’t tell us if the pregnancy will be good, it tells us if something is there. On the flip side, it is also a shot we administer to achieve ovulation and egg maturation.

IC: Simply stated, IC = intercourse. Intercourse = sex. We, as fertility doctors, “prescribe” IC frequently. By using tools like your menstrual cycle, your ultrasound, and your blood work, we can predict when you will ovulate and when “having IC” will give you the best chance of “having a baby.”

ICSI: Staying with the egg-meets-sperm concept when ICSI is performed, this meeting takes place in a whole different spot in a whole different way. There is no swimming or mingling, but there is a whole lot of selection. During ICSI (intra-cytoplasmic sperm injection), an embryologist will select individual sperm and physically inject them into the egg to achiever fertilization. In most cases, the highest rates of fertilization are achieved following ICSI.

IUI: In the body, sperm has to swim—from the vagina, to the cervix, to the uterus, and to the tube to finally meet the egg. And while this journey is fairly short and fairly quick (most sperm reach the tube in less than two minutes), it can be taxing. IUI (also known as intrauterine insemination) is sort of like a way to bypass step A and step B, allowing them to get to step C much faster!

IVF: Fertility medicine has come a long way, baby! And while we have seen a lot on both the diagnostic and treatment side, the biggest leaps and bounds have come with in vitro fertilization (#IVF). In the most basic terms, when an egg meets a sperm outside of the body and fertilization occurs in the laboratory, that’s called IVF. The resultant embryo is either transferred back into the uterus three to five days later or frozen for future use.

Oligo: Going back to our Greek roots is where we will find the definition for the frequently used prefix in fertility medicine, oligo-. Simply stated, oligo means few, little, or scanty. We often put it in front of medical terms such as -spermia (a.k.a. sperm) or -menorrhea (a.k.a. period) to describe how many or how frequently something occurs.

OPK: OPKs have become a part of a reproductive age woman’s vernacular! They are so commonplace that we often forget they are somewhat new to the fertility scene. OPK stands for ovulation prediction kits, and they are an OTC (a.k.a. over the counter) means to know if you’re ovulating. While it does require urine, some diligence (you frequently need to take the test several days in a row), and anywhere between $20 and $100, it can provide helpful information regarding when and if you’re releasing an egg.

PGD: Although PGD and PGS are used interchangeably, they are not identical. PGD describes the genetic testing of embryos for single-gene disorders. PGS is looking to make sure that the embryo has the accurate number of chromosomes. To do PGD, you have to be looking for the presence or absence of a specific genetic condition, not for overall chromosome number. Picture this…if you and your partner are both carriers for Cystic Fibrosis, you would do PGD on the embryo to make sure that embryo will not inherit the disease. We can test for hundreds of genetic conditions as long as we know what the specific mutation is.

PGS: In many ways, PGS is the umbrella term for everything that “rains” genetics. Pre-genetic screening involves screening the embryos through a variety of techniques for chromosome number. It is probably the most frequently used term, by both physicians and patients, to describe embryo genetic testing.

TE Biopsy: We are taking you back to “Elizabeth” one last time…just with a bit of a twist. TE biopsy (a.k.a. trophectoderm biopsy) finds itself in the same family of terms used to describe genetic testing. However, TE biopsy actually describes the technique that we use to obtain the cells needed for the genetic testing. The trophectoderm is the part of the embryo that will become the placenta, months down the road. We take cells (biopsy) from the trophectoderm and send it to the genetics lab for analysis.

Although it’s fairly likely that we missed a few frequently used ph-rases (that’s what happens when you move fast!) this list captures most of the big ones. Use it as your cheat sheet when trying to decode the language you hear at a fertility clinic. And while you may never totally speak the same language as your fertility doctor, at least you will come pretty close to being fluent.

Don’t Be So Negative….What Your Rh Status Means for You and Your Baby

There are “blood type” diets, “blood type” personalities, and even “blood types” that are tastier to mosquitos (apparently if you are type O, you should go out and buy some more bug spray!). And while most of us have no idea what A, B, AB, or O mean until we visit our first American Red Cross blood drive, your blood type is actually pretty important in the land of obstetrics. Although most of us don’t think past those three letters (and four groups), the plus or minus that comes after the A, B, AB, and O is equally as important as the letter. The negative or positive denotes the Rh factor. If there is a mismatch between the negative and positives in a pregnant woman, just like those AA batteries you are always in need of, this system won’t work the way it is supposed to.

Let’s start with the simple stuff…

1. There are four basic blood groups; A, B, AB, and O. What distinguishes A from B or AB from O are the antigens (a.k.a. the proteins) on the surface of red blood cells.

2. The symbol, plus or minus, which follows the letter is referring to the presence (+) or absence (-) of the Rh factor. Rh stands for rhesus, and Rh or Rhesus factor is another antigen that is found on red blood cells. Rh antigen is present or + in Rh (+) individuals and absent or – in Rh (-) individuals.

Moving on to a couple of fun facts that will make you look smart at a cocktail party…

3. The most common blood type is O+.

4. The universal blood donor (you can give to anyone) is blood type O-.

5. The universal blood recipient (a.k.a. you can take from anyone) is AB+.

6. You inherit your blood type from your parents, and you will pass your blood type on to your children.

Last, the essential stuff for anyone who has been or will be PREGNANT….

7. Rh-negative women need special attention. If untreated AND pregnant with an Rh-positive baby, they have the potential of forming antibodies against the Rh factor that is covering their baby’s red blood cells. And while this may not be a big deal in their current pregnancy (antibodies are like Rome; they were not built in a day), it will be a major deal in future pregnancies. Therefore, all Rh-negative women should receive a medication called RhoGAM (a.k.a. RhoD or Rh immune globin) during their pregnancy to prevent the formation of these antibodies.

8. RhoGAM is an injectable medication that contains a small amount of antibodies pooled from blood donors…it works to kill off any Rh-positive blood cells lingering in the immune systems of Rh-negative women. Think of RhoGAM as a stun gun to the immune system of an Rh-negative pregnant woman. Basically, it will “daze and confuse” her immune system so that she doesn’t have a chance to make antibodies to the Rh factor her body is seeing during pregnancy. Problem solved. And in the past, this was a big problem that not only cost a lot of perinatal morbidity but also mortality. So kudos to those who racked their brains and “birthed” RhoGAM.

9. When it comes to most things pregnancy, it takes two to tango. Therefore, just because you are Rh-negative doesn’t mean that your baby will be. If your partner is Rh-positive, there is a good chance your little one will be too (and that’s when you have a problem on your hands)! To be safe, all Rh-negative women will be given RhoGAM during pregnancy (remember, we won’t know your little one’s Rh factor until birth). The good news is that the majority of pregnant women will only need to roll up their sleeves and stick out their arms twice, once at 28 weeks and once following delivery. This is because in most cases maternal and fetal blood don’t say, “It’s nice to meet you” until delivery. However, because this introduction may speed up to the third trimester in about 2% of pregnant women, we give a precautionary dose at 28 weeks.

10. Unfortunately, two times may not be the “RhoGAM charm.” If bleeding should occur during the pregnancy or if you undergo an invasive procedure such as a CVS or an amniocentesis, your blood and your baby’s blood might get mixed up. Therefore, to be extra careful, we recommend you get another shot within 72 hours of the bleeding or the procedure.

11. Rh-negative women that are NOT given RhoGAM are at serious risk during their NEXT pregnancy. So while many of us have the “I will deal with that tomorrow” attitude when it comes to things that don’t impact us immediately but can hurt us in the future (think not paying your bills and dealing with your credit score later), you really shouldn’t mess around with RhoGAM. Antibodies to Rh take some time to form. Therefore, while your current passenger might pass through without a problem, the next baby on board could be at serious risk if a woman is NOT given RhoGAM during the current pregnancy. Don’t push this one to the side; this sort of credit your next child can’t afford!

Given that 85% of individuals are Rh+, this incompatibility issue does not come up every day. Simply stated, most moms and their babies are in sync when it comes to Rh status. However, given the serious impact an untreated Rh mismatch can have on a woman and her future children, it is something that we OBs get pretty pesky about. We have to be doubly POSITIVE so that nothing NEGATIVE happens. And while we can’t validate the stuff out there which suggests that As may be “more responsible and patient” while Bs are more “passionate and creative,” we can tell you that your blood type means a lot for your baby (and the babies that you may have to come). That much, we are triply super positive about!

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.

Mother’s Day: Enjoying the Moment

In honor of Mother’s Day, we, two mothers who often find ourselves running (literally!) from work to home, from kids’ schools to kids’ soccer practices, and from our offices to our errands, wanted to press “pause” and share with you our most precious mommying moments. These make us stop and forget about the dirty dishes, the unfolded laundry, and the to-do list that’s a mile long. These remind us of why we endured endless hours of labor, weeks of sleep deprivation, and years of dirty diapers (and in some cases, hundreds of shots, blood draws, and ultrasounds to achieve motherhood). So, while our words may never make it into a Hallmark card, here are our Mother’s Day thoughts.

Sheeva:

Work out, take care of patients, family time, sleep. Repeat. This pretty much sums up my day-to-day routine. It can get pretty repetitive. And although routines are soothing (it’s nice to know what’s coming next!), they can also get monotonous. You can lose sight of the little things. However, the little things amidst the regularity of my days have come to be my most special mom moments.

It’s funny. As a mom, these cherished daily moments sprinkled throughout your day of “regular” activities change as your children age. From rocking your baby to sleep to watching your toddler tackle that art of talking to pushing your kids on the swing after dinner, the precious moments change. They transform as your family transforms. And while you will never forget the firsts, sometimes the lasts become just as important. As the mother of an almost seven-year-old boy and 11-year-old girl, now my most precious moments are bedtime.

And although for many years this was probably my most dreaded time of the day (putting a toddler to sleep can be terrible!), now bedtime is our time to lay together, share stories about our day, and talk about what we hope for tomorrow. My favorite moment of late was one night, when my kids were lying side by side (they have their own rooms and own beds but most nights like to share the same room!). I laid next to them and asked what was so funny. They made me pinky promise and then proceeded to tell me their crushes (P.S. my daughter has one, and my son has four)! Their giggling voices still make me smile. As a mother, I hope they always feel safe enough in my presence to share their most intimate moments. I hope our nights are always free from judgment, shame, or holding secrets back.

 

Jaime:

Life moves fast—especially in New York City. We are always running, doing, going. Standing still is rarely an option (or safe; someone is likely to push past you!). And for as long as I can remember, moving forward at a fast pace was who I was and how I functioned. However, despite the efficiency of this pace, this notion of constant movement can breed anxiety and stress—not just for you, but for your little ones.

It wasn’t until a forced time out from work this past summer that I realized just how toxic my “need for speed life” was for my daughters. My constant telling them “let’s go,” “you’re on the clock,” and “move it” did not fall on deaf years. They were listening. I heard this when my older daughter began to use an impatient tone with her younger sister and her friends. She exhibited anxiety, a need to keep on task, and a fear of being late. She seemed, like me, to always be stressed about the next event. Even at the young age of five, she was anxious about fitting it all in. I felt awful. I thought long and hard about how to slow her down, make her less conscious of the clock, and relish relaxation. I soon realized that, to change her, I had to change me. Her actions were not innate but learned—from me. To help her, I had to slow down and take a deep breath.

This summer, I did just that. I stopped, and I tried to take it all in. And although I was not perfect, I took time to watch the sunset, play tag, and color silly pictures. I didn’t rush dinner, and I didn’t stress over how long they took to brush their teeth. I simply enjoyed them and our time together.

We have chosen to share the good and not the bad not because we don’t have endless trying mom moments; trust us, we have many! We by no means want people to think that we’re perfect. We simply want to encourage others to hold on to the good and to let go of the bad, to remember the special and let go of the sordid. The bad doesn’t mean you’re a bad mother; it means you’re normal! Holding on to the bad will put you in a bad place. Try and take a moment to remember the good, the special, and your most precious Mom moments.

Happy Mother’s Day!

Truly,

Jaime and Sheeva