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Looks Can Be Deceiving…We Recommend a Double Take!

At least once a day we get a call from a friend, a friend of a friend, or a friend of a friend of a friend (say that three times over) asking us to review their results and give them our advice. Inevitably, they are overwhelmed, frightened and often confused. “FS something, I’m not sure” and “mobility of sperm okay but appearance abnormal.” After we sort out some of the details, we are ready to break it down for them in the most basic of terms. Here are some of our tidbits from girls in the know.

  1. FSH means NOTHING without Estradiol. FSH and Estradiol are like Bert and Ernie or Bonnie and Clyde. You can’t test one without the other; they don’t make sense when analyzed alone. FSH is a hormone made in the brain (pituitary gland) that signals the ovaries to ovulate (and make estrogen measured as estradiol in your blood).  When FSH is measured early in your cycle, if elevated, it may indicate a decline in ovarian function (meaning your egg quality is declining, making pregnancy more difficult).
  2. FSH is falsely lowered by a high estradiol. A normal FSH level with a high estradiol level means that the FSH is NOT normal. Estrogen from the ovaries sends a signal back to the brain to make less FSH in the brain. When estrogen levels in the body are high, the brain makes less FSH. While abnormal levels don’t mean you’re down for the count in terms of baby making, it does make us question whether your ovaries are the cause of your fertility struggles.
  3. FSH and Estradiol MUST be sent to the lab on days 2-4 of your cycle. They are not accurate (in all cases except for women with very long, irregular cycles) if sent at other times. Don’t have the blood work done on the wrong day just to check it off your list; you will be re-writing it on your To Do list for the next month.
  4. The ranges on the lab report are not always right. Yes, we know that this may sound confusing and totally contradictory but levels need to be interpreted by a physician. Make sure that if you get your levels you speak to a licensed professional before shedding too many tears.  Don’t go straight to Dr. Google with your FSH level until you understand what it means for you specifically!
  5. The “dye test” (or the HSG, as we call it) must be done in the early part of your cycle. It cannot be done after you ovulate (you could be pregnant!)
  6. An HSG is not meant to be torture. While it can hurt, in most cases it’s pretty tolerable. Take some Ibuprofen before…You should be fine!
  7. A “luteal progesterone” test is not equivalent to a day 21 progesterone test. Luteal means “post-ovulation.”  Physicians often test a progesterone (blood test) on “day 21” to confirm an elevation, indicating ovulation.  A day 21 progesterone test is only appropriate for women who have (approximately) 28 day menstrual cycles. If your periods are 35 days, your progesterone on day 21 may be negative (low indicating no ovulation), but that doesn’t mean you won’t ovulate or didn’t JUST ovulate. It just means that it is  (approximately) 7 days too early to check the levels. Make sure to share how long your cycles are with your doctor before diving into the blood work.  If you have longer cycles, then going in after day 21 may be better to confirm whether or not you are ovulating.
  8. Not all fibroids are created equal. Fibroids can be a big deal. They can cause pretty bad bleeding, pretty significant pain and pretty real infertility. However, the caveat to the infertility issue is location, location, location. Whether or not a fibroid causes infertility depends on the location of the fibroid. Fibroids located within the uterine cavity are WAY more likely to cause infertility than those in the muscle. Make sure you have a road map of where your fibroid is before you undergo surgery.
  9. Motility (a.k.a. mobility in the words of many patients!) is how sperm swim. It is reported as a percentage (% of sperm moving in the sample). Old school normal was 50%. Now that number has been knocked down to 40% (and only 32% need to be moving forward). While no one wants to fail at anything, take it easy on your guy if his “mobility” is off—chances are if you use the newer guidelines things won’t be too bad.
  10. Sperm shape has really taken center stage recently. It has become one of the most debatable, doubtable and don’t-know-what-to-do-about-it issues. While it is still unclear as to what abnormal morphology means (impaired fertilization potential currently tops the list), the level of normal to abnormal has been reduced significantly. The new normal is 4% or above. Make sure that you are aware of the new numbers and are aware of what the information means before you start any treatment (some centers are still using the old reference values and therefore are calling anything <14% abnormal rather than <4%). Additionally, while low morphology does mean your partner needs more testing, it does not mean that he needs IVF (in vitro fertilization)!

There are a lot of myths circulating out there. Make sure to ask a reliable source before counting yourself out. While we may not be a friend of a friend of a friend, we are certainly your professional pals!

The Low Down on the Low-Dose Oral Contraceptive Pills

Loestrin, Mircette, Yasmin, Yaz, Ortho-Tricyclin, Ortho-Novum, and Alesse—the list goes on and on. Many of us have sampled more pills than flavors at our local ice cream shop (even when the sign says one per customer). And no, it is not all in your head; different pills make you feel differently! Who is the culprit, or the Oz, making your body and maybe even mind feel different on Ortho-Tricyclen vs. Yasmin? Drum roll, please: it’s the progesterone!

While almost all oral contraceptive pills share the same type of synthetic estrogen component (ethinyl estradiol, a.k.a. EE) the progesterone content can vary significantly. Some may make you feel good, even great, while others can make you feel down right crummy. In order to understand the difference in progestins, we want you to picture your family tree. Hone in on four consecutive branches, or generations: from great grandma right down to you. And as with most families, generational changes are huge—think landline to the iPhone, black and white TVs to flat-screen monstrosities, a quarter to ride the subway to a whopping $2.50 per ride.

Similar changes can be seen in the generational changes of synthetic progesterone. The first-generation crew was not so specific in whom they “mated and connected with.” Therefore, they would bind to both progesterone and androgen receptors alike. Their affinity for the androgen receptors resulted in some unwanted side effects: think hair, acne, and bloating. Oh, what a joy! Such side effects made them somewhat unattractive and unpopular.

However, over the next several years, scientists found ways to alter the synthetic progesterone component and reduce the androgenic properties; this translated into way less negative side effects and even some positive ones! Such alterations made pills way more appealing and widespread in their use. Bottom line, if one type of pill (a.k.a. progesterone) doesn’t agree with you, try another. There are many “branches” to climb!

Now, while the progestin component varies, the synthetic estrogen component is pretty much always the same—think of the menu at Applebee’s. It’s just not going to change! However, while the estrogen content is always the same, the dose will differ. And what makes the modern-day pills low dose or, even better, low, low dose is the very low dose of estrogen that each pill contains.

Today, most pills have between 20–35 mcg of EE. This is in contrast to traditional pills (circa 1960), which contained about 50 micrograms of estrogen in each pill. The past 50 years have shown us how low we can go on the estrogen—minimizing clots, strokes, and a slew of negative side effects—while maintaining the efficacy. So although lower dose EE = lower negative side effects, lower dose ≠an increased chance of pregnancy. Currently, we are, taking it back to the limbo reference, as low as you can go without giving up on efficacy.

While intuitively, it seems that the lowest would be the best, this is not the case for everyone. Sometimes the low-low versions cause lots-lots of breakthrough bleeding; this can often be fixed by raising the estrogen dose. So just because low-low seems to be the “in thing” to do, it may not be right for your uterus. A slight bump up in the estrogen dose won’t take you back to the doses seen in the 1960s, but it will give your body just enough estrogen to maintain the lining and maintain your sanity.

You might be wondering what is up with the Tri and even Bi part in the name of some pills (e.g., OrthoTri-Cyclen vs. Ortho-Cyclen). For all of you number fans who can’t wait to travel back in time to middle school math class, tri means three, bi means two, and mono means one. The number part of the name describes the number of phases or changes in hormones that will occur throughout the cycle (a.k.a. the pill pack). Monophasic pills (Loestrin, Ortho-Cyclen, Yaz, Yasmin, Seasonale) contain the same amount of estrogen and progestin in all of the active pills. Biphasic pills (two-phase pills; e.g., Mircette, Ortho-Novum) alter the level of estrogen and progestin twice during the active pack. Last, triphasic pills (three-phase pills; e.g., Ortho Tri-Cyclen, Enpresse) have three different doses of estrogen and progestin in the active pills; the dose changes every seven days during the first three weeks of the pack. These triphasics were the original pills. Scientists were doing their best to mimic the natural cycle. However, research soon showed us that we didn’t need to vary the dose each week. Slow and steady could also win the race! In fact, monophasic pills are equally as effective and in many ways more tolerable. The consistency of the dose translates into less side effects and less breakthrough bleeding.

We have covered doses, phases, and progestins. Last but certainly not least is the number of active pills contained within the pill pack. Traditionally, pill packs contained 21 active pills and seven inactive (a.k.a. placebo or sugar pills). This, like the triphasic pills, was designed to mimic the natural cycle. However, newer formulations have increased the number of active pills to 24 and reduced the number of inactive pills to four. By altering the balance and pushing the pendulum a bit further to the right, there are fewer days off the active pills. Fewer days off the active pills means fewer days of bleeding. In fact, some women skip the placebo pills all together every month and only take the active pills. This does no harm to them or their fertility. It merely removes the need to buy tampons or pads.

Believe it or not, the pill has benefits beyond contraception. It can reduce the risk of ovarian and endometrial cancer, improve acne and unwanted hair growth, regulate the menstrual cycle, decrease heavy menses, reduce the size of fibroids and painful periods, treat PMS symptoms and menstrual migraines, and offer symptomatic relief to women with endometriosis. The list is long, and the benefits variable. Simply stated, the pill can do a lot more than prevent pregnancy!

However, with every peak there is always a valley, and with every pro, there is also a con. Even with the best medications, you must read the fine print. Although the pill has a lot of benefits, there are some of us for whom the glass slipper just doesn’t fit. Certain medical problems preclude women from even trying to shove their foot in! Such conditions include women with a history of blood clots (or a family member who harbors an inherited clotting disorder), impaired liver function, smokers older than 35 years, elevated blood pressure, migraines with visual aura (think flashing lights), and markedly elevated cholesterol/triglycerides. Before starting you on the pill your doctor will likely take a thorough medical and family history to make sure you are a good candidate.

You will likely not marry the first person you date or say yes to the first dress you try on. Don’t quit after one bad month on OCPs; just because one didn’t agree with you it doesn’t mean the dozen others will too. OCPs are a great form of birth control and come with a lot of other benefits. As long as you can remember to take it daily (put it by your toothbrush or face wash!), it’s worth giving it a go. You’ll find something that fits!

Time after Time: Recurrent Preterm Birth

Trying to figure out when your little one will make his/her first appearance is a game many of us have played. And while family and even office pools are often centered on birth stats (I’ll take a girl on Tuesday, May 18, weighing 7 lbs., 2 oz.), when the grand finale will actually take place is really nothing more than a guessing game, minus those who have scheduled a C-Section or an induction! No matter how much you like fours or sevens, evens or odds, babies come when babies come. Bottom line, don’t take this bet to Vegas. The odds are not likely to be in your favor, and you probably need to save your money. Diapers aren’t cheap! Just like those who go to Vegas and count cards, we OBs have some ways to “cheat” and figure out who is likely to deliver early, sometimes even weeks before their due date. And although we wish it was because we were all-knowing, it’s really because women who have a history of a spontaneous preterm birth (delivery at less than 37 weeks because of preterm labor or preterm rupture of membranes) are significantly more likely, about 1.5–2X, to be exact, to deliver early in their next pregnancy. In fact, one of the strongest risk factors for preterm birth is a prior preterm birth. Add to that the number of times you delivered early (one vs. two vs. three, etc.) and how many weeks you were at delivery (24 vs. 26 vs. 28, etc.), and you have an even better idea about whose baby will make their debut before the curtain officially rises.

The more times you delivered early and the earlier you were (24 vs. 28 weeks), the more likely you are to be early again. There are other risk factors for preterm delivery, like a history of cervical surgery, UTIs and genital tract infections during pregnancy, smoking, substance abuse, low maternal pre-pregnancy weight, and short inter-pregnancy interval. But none is nearly as strong as a previous history of a preterm birth. Simply stated, a history of preterm birth is the odds-on favorite for a preterm birth in your next pregnancy. So why do we care about when and if a preterm delivery occurs? Sure, we love to win a good family/office pool as much as the next gal, but you can be sure that whether we take home the pot is not what’s perturbing us. What keeps us on our toes is the following: babies who are born premature (a.k.a. early) have a much higher risk of serious morbidity and even mortality, particularly in the first year of life.

Nothing good comes out of an early delivery, except maybe a few less pounds gained and stretch marks formed. Pregnancy was meant to go the distance, that is, 39 weeks, and when it is cut short, bad things can happen to your baby. To prevent a recurrent preterm birth, your OB will be on your speed dial—and you on theirs! We want to know how and what you are feeling. We also like to see your cervix via vaginal ultrasounds every couple of weeks. These checkpoints can clue us into what might be coming (a.k.a. another preterm birth). If things start to change, say, the length of the cervix gets shorter or the cervical opening begins to dilate, we will call “Freeze” and often admit you to the hospital for medication and monitoring. Additionally, women who went early before will usually be prescribed weekly IM shots, which are progesterone injections starting between 16–24 weeks. And while the shots may be a big pain in the butt  —we’re not going to lie; that needle is long!—they are a big player in the prevention of recurrent preterm birth.

Although we can never be sure whose baby is likely to break out of the womb before his/her time is up, we can narrow down the lineup to a few of the most likely candidates. And because we don’t like to make any wrongful convictions, we use the evidence (a.k.a. what happened in your previous pregnancy) to hone in on those who have planned a successful escape in the past. While we may put you on high surveillance (frequent office visits, ultrasounds, weekly injections, and possibly even reduced activity) to encourage this pregnancy to go the distance, it’s a small price to pay for your baby’s safety. While we may not be spot on with the weight and date of your little one, we will be on the money with how best to prevent a recurrent preterm birth. Here, we are not willing to gamble!