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Don’t Break My Heart: The Impact of Fertility Treatment on Heart Disease

Be still, my beating heart: Does fertility treatment increase your risk for heart disease? The latest results from a large Canadian study made everyone’s heart skip a beat with its recent findings. The data showed an increased risk in heart disease in women who required fertility treatment to get pregnant. And while this study got a lot of press, before you have a heart attack, here are five things that you should know:

  1. Even with the increased risk reported in the study, the absolute numbers are very low (a.k.a. the number of women who experienced cardiovascular events was pretty small). While we aren’t turning a blind eye or a deaf ear to the results, we are interpreting them with caution.
  2. IVF in the 1990s and IVF in 2017 are VERY different. The treatment protocols and techniques have changed more than the fashion trends (#bellbottoms). Therefore, it’s nearly impossible to study the aftereffects of treatments given then to the aftereffects of treatments given now. Our medications are different, our stimulation styles are different, and our dosages are different. In fact, it’s hard to find anything that’s the same!
  3. When analyzing any research study, it’s important to distinguish between correlation and causation. Although they may sound the same and start with the same letter, they are very different in what they suggest and what they mean for you. When you think of causation, think of cigarettes and lung cancer: We all know cigarettes cause lung cancer. When you think of correlation, think of cigarettes and infertility. Cigarettes do not specifically cause infertility, but they have been associated with infertility. In this study, fertility treatment has been correlated with heart disease (to a modest effect), but fertility treatment has not been demonstrated to cause heart disease. And although the distinction may seem insignificant, it’s actually pretty important!
  4. Anyone who is going to undergo fertility treatment should be in good shape. While you don’t need to join us for regular 5:30AM workouts, you do need to be in good health. Pregnancy is no walk in the park; you want your body to be prepared for those nine months and the many months that follow!
  5. The primary outcome studied was “adverse cardiovascular events.” The authors lumped stroke, TIA (think of it as a temporary stroke), MI (a.k.a. heart attack), and heart failure altogether. And while they all may affect your heart and your brain, they are not all the same. By opening up the floodgates (or adding more diseases to the primary endpoint), you will almost certainly capture more women who fall into the “I got that disease” category. So, while more women who took fertility medications may have gotten the primary outcome, the primary outcome was pretty expansive.

Your heart is as important as your ovaries, your uterus, and your fallopian tubes to us fertility doctors. While we may seem to have a one-track mind (#makingbabies), we are not only focused on your fertility but also your future health. Therefore, we will keep following the latest scientific breakthroughs and bring them to you hot off the press. We cross our hearts!

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.

Let’s Play Pill! Controlling the timing of your cycle.

For all of you blackjack and poker fans out there, you probably get the “Let’s play some cards” reference pretty quickly. And while you may have never put the words birth control pill and pack of cards together in the same sentence, there are some similarities. Think about it…both come in a pack, both have two colors, and both can be purchased at most local drugstores. And it doesn’t end there. In fact, the biggest similarity between these two “packs” is the way you can manipulate them to make things a little more interesting. If we lose, you don’t despair. We will lay all our cards on the table and talk you through this.

Although as GYNs we are pretty partial, in many ways, OCPs are science’s greatest gift to women. It gives us flexibility, it gives us choice, and it gives us control. It also takes away cramps, minimizes bleeding, and puts a stop to acne and unwanted hair growth. Not bad! And while it does require a daily thought (we recommend combining it with brushing your teeth!), most of us can handle that. On top of these pluses are some plus + pluses (a.k.a. contraception).

And if that wasn’t enough, the pill can now be used to adjust when and if you see red. By extending the active pill pack and skipping the placebo (sugar pills), you can avoid that un-fun time. The constant dose of estrogen and progesterone will keep the inside of the uterus (the lining) from shedding. And while it may sound like we have lost our minds, you can live in this steady state of estrogen and progesterone for many months, even years (truly, you can!). It won’t hurt your body or your future chances of having a baby.

Sometimes you just don’t like the hand you are dealt. Luckily, you are not in Vegas and can reshuffle your cards. In fact, counting cards is what we GYNs do best. By looking at your pill pack and your calendar, we can come up with a period schedule that not only works for your body but also for your life. Let’s face it,getting your period on your vacation, wedding day, or honeymoon is just not fun.

But don’t count your cards before the game is over. While altering the pill schedule usually works to avoid bleeding on big days, sometimes your body has a mind of its own. Breakthrough bleeding can occur despite continuous OCP use—and although it’s a big bummer, it’s not a big deal (medically speaking).

So if you play your cards right, you might just be able to avoid taking tampons on your next trip. It requires some planning, but with your ace up your sleeve (a.k.a. your OB/GYN), you can plot out your next move. While most card players are taught to keep their cards close to their chest, in this game, to win you have to let a couple of people in. Don’t worry; we won’t tell the dealer!

Monday Morning Quarterbacking… I Knew I Shouldn’t have Thrown that Pass!

How many times have you sat and replayed your day, week, or even the last few years in your head? You say to yourself things like, “I shouldn’t have said that,” “I shouldn’t have done that,” and “I definitely shouldn’t have gone there.” Trust us, we get it (because we do it too!) But unfortunately, no matter how hard you try, you can’t turn back the clock. This includes your reproductive clock (as well as your reproductive treatment to date). You can’t recreate eggs, IVF cycles, or treatment outcomes. However, what you can do is change your future—and we are here to get you started and tell you how.

Second opinions are essential in medicine. No matter whether we are talking about a major operation or the blood pressure medication your primary care doc recommended, you have to be certain that you are comfortable, both with the physician providing the care AND the care that they are providing. And while you may be on board with the former, you may not agree with the latter. Don’t settle for second best just because the office is near your house, you don’t want to go through the trouble of retrieving your medical records, or all of your friends said “this doc is the best.” You owe it to yourself to hear what another professional who specializes in the field has to say. While support groups (both in person and online) are excellent resources (many experienced patients could almost be doctors themselves!), you should give major thought to seeking out an official second opinion.

We are going to let you in on a little secret… patients are not the only people who seek out other opinions and question their care. We do too! While this may come as a surprise to many of you, doctors don’t always have all the answers. We talk—A LOT! Many of us engage in weekly educational seminars, including conferences, journal clubs, and treatment planning meetings, to discuss our patients and how to provide them with the best care. We go through the literature and review the most recent studies to determine the optimum methods of treatment. Most of us are not afraid to ask for help or advice from our colleagues. Most of us recognize our limitations and welcome the perspectives and knowledge of our peers. Take it from me, we understand that we are human and only as good as the other players on the field.

Your health and care is your business. Don’t be afraid of offending your doctor or the friend who sent you there by switching practices. What works for one person may not work for another. Don’t hesitate to ask questions and seek out other opinions (no, this will not annoy anyone!). Always be sure to transfer your medical records (they are your holy grail) and don’t be afraid of what someone thinks of you when you go elsewhere for another opinion. You don’t have to please anyone but yourself. Do what you need to do to feel like you gave it your best shot—you don’t know how many chances you will have and you want to feel like you gave it your all!

No Y, No Way? How to Achieve a Pregnancy in a Same-Sex Relationship

Long gone are the days of June Cleaver, her dress and pearls, and her white picket fence. Nowadays, the face of families has had a major facelift. Two mothers, two fathers, working mom with a stay-at-home dad…it has all changed. Kudos to choice and change! But while you can mold your family to take whatever shape you want without an egg and sperm source, you will need some outside help manipulating the “clay.” Cue your friend, the fertility doctor.

While all pregnancies require an egg, a sperm, and a uterus, how these three sources meet and where they come from can be quite variable. It is our job (a.k.a. that of the fertility specialist) to help make these necessary introductions and ensure that, from this meeting, comes a baby!

The first order of business when we meet with a same-sex female couple is to figure out preferences and timing. Simply stated, do both partners want to give an egg, do both partners want to give a uterus (a.k.a. carry), and if so, when? And taking it one step further, do both partners want to carry their own genetic child or their partner’s genetic child? (Don’t worry if this sounds confusing; we will explain!) We then use this information to formulate your fertility plan. Here’s how.

Timing is not only everything in relationships but also in family planning. Which partner should go first (#getPREGNANT) is not only based on personal preference but also on medical factors (egg quality, egg quantity, and uterine receptivity). Therefore, before any final decisions are made, it’s a good idea for both partners to visit a fertility specialist and get checked out.

What your MD finds might have a major impact on what fertility options are available and in what order. For example, if you are 35 and your partner is 38 but your ovarian reserve is approaching that cliff (a.k.a. about to take a sharp decline), we may recommend that you go first in the pregnancy process. On the flip side, if your partner is 40 and you are 30 and you were hoping to have your little one before 31, we will probably recommend that you put your baby button on pause and let your partner go first. Nuances like this are not apparent unless you get down to the nitty gritty (blood work, ultrasounds, and a full exam) with a fertility doctor.

After you have been checked out, there are a few options for you to check out. Unbeknownst to most, there are a couple of ways (other than the obvious) to get egg and sperm to meet. These include inseminations (IUI) or IVF.

And the variety doesn’t stop there. When it comes to IUI, you can do it as bare bones as possible (a.k.a. time the inseminations to when you are ovulating) or add medications to boost your fertility (e.g., Clomid, letrozole, gonadotropins). Which route you choose to take is often made after recommendations from your doctor. If IUI isn’t working out, we might recommend that you amp it up a bit (#IVF). If other medical issues exist (low egg reserve, advanced maternal age), we may suggest skipping IUI altogether and going right to IVF.

In many ways, same-sex female couples have the most options on how to make and carry children. Let’s face it: although you may be at a loss for sperm, you have double the eggs and double the uterus. This doubling will come in very handy when mapping out how you want to enter motherhood. The reason is that, if you want, you can switch things up. You can carry the embryo created with your partner’s egg and donor sperm, and she can carry the embryo created with your egg and donor sperm. It’s a unique way to build a family, though it requires IVF, creativity, and cash. (We too believe the lattermost is unfair. We have added our voices to the fight against insurance inequities!).

Think about a cake. While the core ingredients are always the same (think flour, sugar, and butter), there is more than one way to mix it up (add cinnamon, nutmeg, or chocolate chips). The same goes for building a family—although you need those core ingredients (an egg, a sperm, and a uterus), how you combine these three can vary. Today’s family should have the flavor and flair of you and your partner—rigid guidelines are “rotten.” Anyone who tells you otherwise has way passed his or her expiration date.

Am I Ready to Be a Parent? Single Parenthood

Of all the questions we ask ourselves, “Am I ready to be a parent?” is probably the biggest one (followed by “What should I wear on that first date?” and “Should we go for dinner or drinks?”). But all kidding aside, knowing when the time is right to become a parent can be downright difficult. Even us non-lawyer types can convincingly argue both sides and sway even the toughest of juries (ourselves, our besties, and our family) to see it our way. Add to that deciding to go at this on your own, and the decision can be even more difficult. When embarking on single parenthood, you need to think about things like sperm source, fertility medications, inseminations, and ultrasounds. Sorting this stuff out can make even the most level-headed among us a little loopy.

But just like any legal battle, evidence is needed before a decision can be made. And to get to that decision, it takes time, research, and a whole lot of effort! Deciding if, when, and even how to have a baby without a partner is no different. It takes a lot of thought and evidence before you can reach your decision. And although it is unlikely that we will be sitting with you when your personal verdict is delivered, we can offer some advice on how to craft your argument about if single parenthood is right for you (#PROSandCONS).

PROS

  • You are ready to be a mother. You don’t want to freeze your eggs and think about becoming a parent in the future but are ready to become a parent (without a plus one) today.
  • You no longer want to wait for someone else to do this with—you are pretty sure that you can do this on your own.
  • You spoke with a fertility specialist, reviewed all options, and are cleared for pregnancy (a.k.a. you are in good health, your reproductive organs ready, and you have selected a sperm source).
  • You have thought about your decision for a while; it was not made in haste.

CONS

  • You are not physically your best you. While most of us can tolerate pregnancy (aside from the back pain, the constant urge to pee, and the swollen hands and feet), there are some medical conditions that preclude us from getting pregnant. Although most of them can be fixed (blood pressure can be controlled, diabetes can be regulated, and seizure medications, changed), it is super important that you deal with all of this before you get pregnant.
  • You are not financially stable. Kids cost money! And while you certainly don’t need to be a billionaire before you bring a baby into this world, you do want to make sure that your financials are in order before you start a family.
  • You are not emotionally ready. Children require A LOT of attention and time. They are pretty much all-consuming all of the time. Make sure you are ready to give of yourself to someone else before you go all in.
  • While you want to be a parent, you don’t want to be a single parent by choice.

Odds are that, although our list may not match your list, there is probably a good amount of overlap. Minus the few additions or subtractions, at the heart of it lies the big question: “Are you ready to do this on your own?” And while we as physicians can’t tell you which way your “jury” will go (a.k.a. are you ready to do this?) we can tell you if your uterus, your ovaries, and your body are ready do this.

Furthermore, no matter how long that list is, we can assure you that while you may be thinking of this as single parenthood or as “having a baby on your own,” you are really never alone. You have friends, you have family, you have your fertility team, and you have an entire community of individuals who have also become single parents (many who are eager to share their experiences and offer advice). Go and speak to your OB/GYN and/or a fertility doctor—they can not only provide you with the information about the process but also help you make this baby thing happen.

We will make this closing argument brief. If you want to be a parent, you can become a parent. The modern family has many different faces. Find out what you want yours to be, and shape it. In this courtroom, you write your own verdict. While the process of becoming a parent may take a slightly circuitous path, with a knowledgeable physician and a good support system, you can certainly do this—case closed!  

My Vote Doesn’t Matter, Anyway: Why Not Caring About Your Reproductive Health Is The Worst Thing You Can Do!

Apathy stinks. No matter what you are apathetic about: your job, your partner, your country’s politics, or your body, it is a major bummer. And while it may seem a long way away, you should not only care about things that affect your world but also things that affect your womb. Unprotected sex can lead to some pretty unpleasant things (a.k.a. sexually transmitted infections—think gonorrhea, chlamydia, syphilis, HIV, and herpes), which can cause some pretty serious damage to your fertility (specifically, your fallopian tubes) down the road.

So, here’s why your vote matters.

Sexually transmitted infections are no fun. But unfortunately, they are sort of frequent. Approximately one in four women will be diagnosed with an STD during their lifetime—and given that many who contract an STD never seek treatment, this number is likely a lot larger. In fact, there are about 19 million new cases reported every year in the United States.

The problem with STDs is not only the possible itching, burning, and oh-so unpleasant discharge but also the long-term effects like chronic pelvic pain, scar tissue, and infertility. Infections like gonorrhea and chlamydia can leave a mark that even the best of treatments can’t erase. However, the earlier you seek treatment, the less the negative impact will be. Therefore, don’t be shy about sharing your secrets with your doctor. We never judge!

While prevention is the key (think condoms), sometimes the door has already been opened—think sex without condoms. In this case, curtailing what could potentially happen next is the goal.

Lesson 1, share everything with your doctor. Make sure we know what you are doing and whom you are doing it with.

Lesson 2, if it is a new partner or one that you are not in a monogamous relationship with, you should undergo STD testing.

Lesson 3, while many sexually transmitted infections don’t announce themselves: “Hello, my name is Chlamydia, and I am here to annoy you,” if you are experiencing atypical symptoms (abnormal vaginal discharge, abdominal/pelvic pain, vaginal itching, or burning and fever), you need to go and get things checked out.

Lesson 4, use your voice to effect change. If you test positive for an STD, make sure to share this with your partner(s). They too will need treatment; you don’t want go into the ballot box on this decision alone. Be vocal about what’s going on with anyone who too is at risk.

Lesson 5, don’t take shortcuts when it comes to your course of treatment. Some antibiotic regimens can be lengthy and can require commitment in the form of a couple of weeks. Finishing what you started in terms of medication is mandatory to make sure you have rid yourself of these unwanted guests.

Lesson 6, while STDs come and go, even those that are treated can leave their mark in the form of scar tissue and tubal damage. Therefore, while we don’t recommend you wake up each day remembering the STD you contracted five years ago, when you start thinking about starting a family, you should consider seeking fertility assistance early in your fertility journey. Making the acquaintance of a fertility doctor early can make the path from potential parent to parent much shorter and smoother.

Not caring about what happens is a bad thing. Your voice and your vagina matter (spoken like true gynecologists!). The decision you make today can affect your health and your fertility in the future. While you may not walk out of the GYN’s office with a sticker that says, “I got tested for STDs,” you will get a clean bill of health.

And although this does not ensure that when you are ready to have a baby it’s smooth sailing, it does increase the chances that things get off to a good start. Giving up on yourself, particularly your health, is not an option. So, get out, and vote for your future. In this election, it’s a victory either way!