When Everyone’s Positive Pregnancy Test Is Like A Punch In The Stomach

/in /by

Pregnant women are everywhere. They are on the street, on the subway, in the shopping mall, and in just about every store you step into. And when you are having trouble getting pregnant, their presence seems pervasive. Like ants on a hot summer day…no matter what you do, they just keep marching towards you!

Dealing with the “we are expecting” texts, the “coming in December 2016” Facebook posts, and the “join us as we shower our little one with love” emails is not easy when you continue to come up short each month. You start to wish that you lived in a bubble where no babies or women about to birth them were allowed. But unfortunately, no matter how much you wish them away, they will still be there when you open your eyes. Here are a few words of advice on dealing with the emotional aspects of infertility.

First things first, it is important to recognize that what you are going through stinks, big time. There is just no easy or fancy way to say it or scream it: it just stinks. In fact, infertility is one of the most distressing events that a couple or individual will ever face. It is such a devastating diagnosis that many in the mental health arena liken infertility’s impact to cancer’s.

Infertility can evoke feelings of loss, isolation, and a major lack of control. It can lead to anxiety, depression, and downright emotional mayhem. Relationships become strained, work performance can be compromised, and social interactions can become limited. If some or all of the above have happened to you, you are not alone.

And while we certainly know a lot about infertility and how to treat it, we are most certainly not the experts on how to treat the mental health issues caused by infertility. However, what we do know are friends in high places (a.k.a. mental health providers), and we can help point you in the right direction. We are big fans of our social workers, psychologists, and psychiatrists who specialize in the treatment of the psychological impact of infertility. They are major players on our infertility treatment team, and we frequently work together to provide couples with their help.

We are also serious supporters of support groups (both in person and online) as well as advocacy groups devoted to supporting women and couples who are struggling with infertility. Such groups can help you navigate the process, cope with physical and emotional changes due to fertility diagnosis and treatment, and deal with the fear surrounding the treatment and possible outcomes (unfortunately, things may not work the first time). Bottom line, they can do a lot.

We are going to say it again: infertility stinks. It’s okay to feel sad, it’s okay to feel frustrated, and it’s okay to want to scream (and maybe even throw something at the wall). However, getting down on yourself or your partner won’t change your situation. Withdrawing from friends, family, and your daily activities may limit the number of pregnant women you see, but it won’t change the way you are feeling. But asking for help, seeking out support groups, enrolling in counseling, and perhaps initiating medications will make a difference. And while you can’t totally avoid pregnant women or the “I am pregnant on the first try” text message, you can avoid the store Buy, Buy Baby on a Saturday afternoon. Trust us, it’s no fun there anyway!

Are We Doing Leftovers Tonight…What’s in the Freezer?

/in /by

Nothing tastes better the day after, the week after, or certainly after it’s been sitting in the freezer for a while (except maybe Haagen Dazs coffee ice cream!). With this being said (and true), it’s hard to believe that frozen embryos are as good as, if not better, than fresh embryos. Explaining this to patients can be incredibly confusing—and rightfully so. Who wouldn’t think that fresh chicken is better than the stuff you defrosted last night?

Given our perception of food and what happens after a stint in the fridge or freezer, it can take a while to convince patients to take a pass on the fresh embryo transfer and opt for a frozen one. However, embryo freezing has come “a long way, baby” since the first baby was born in Australia in 1984. Currently, nearly half of IVF transfers in this country are frozen embryo transfers. So why the shift? Changes in the freezing process and techniques have resulted in frozen embryo transfer success rates that in some cases top those of fresh cycles. Data from our OB friends have shown that babies born after frozen cycles do better in utero and as infants than babies born after fresh cycles! Large studies have shown lower rates of preterm delivery, low birth weight, growth restriction, and mortality after frozen embryo transfers—pretty impressive stuff.

Furthermore, the congenital anomalies/malformations that arise after frozen embryo transfers are no different than after fresh transfers. Your next question is likely…why? What could possibly be better about something that was frozen and then thawed rather than something that was hot (or fresh) off the press? Here’s the deal.

Researchers believe that it has something to do with the uterus and the endometrium’s ability to receive the embryo after a fresh vs. a frozen embryo transfer. The thought is that maybe the high estrogen levels seen in many fresh IVF cycles, while beneficial to the ovaries, may be detrimental to the uterus. An “unhappy uterus” means “unlikely to have implantation.” And if you take it one step further, maybe the high estrogen levels not only decrease the chance of implantation but also the ability of a good placenta to form.

Poor placental development will ultimately translate into poor fetal growth (hence, the higher incidence of growth restriction and low birth weight after fresh embryo transfer cycles). Whatever it is, the data are fairly impressive. And while we are all rah-rah-go frozen embryo transfers for the above reasons, there are also two more important reasons to raise the pom-poms:

  1. When embryos are not transferred back into the uterus during the fresh cycle, it gives your body a chance to go back to baseline. Deep breath in, deep breath out! The pause allows your body and, in many ways, your mind to reset. Without a pregnancy in the uterus to provide the juice to keep the ovaries revved up and enlarged, you will get a period about 7–14 days after the retrieval. And this breather is more than just getting your pants to button again (although it does feel good!). It allows your body to return to baseline and prepare for pregnancy with a more normal hormonal environment.Additionally, for those of us who are exercise fanatics, once you get a period you can resume your normal activities (#run #spin #yoga). While we know that exercise is not the most important thing in the world, it and any activity you do to keep you sane are pretty important. If we can help you maintain some normalcy in the midst of shots, vaginal ultrasounds, and never-ending blood draws, we most certainly want to do that.
  2. Recently, embryo freezing has taken on a whole new meaning; it now is a major player in the genetic testing of embryos game. Call it what you want: PGS, CCS, TE biopsy. Embryo testing has become all the rage. It provides patients with important information, significantly increases success rates, and majorly reduces the twin rate. It’s the triple threat! However, in order to get an accurate read on all of your embryo’s genetic material it takes time. In a fresh embryo transfer cycle, time is of the essence. But if you freeze the embryos, time is also frozen. With the embryos on ice, you have time for chromosomes to be checked and your chances increased.

Bottom line, fertility treatment can be a cold place if you don’t have up-to-date information on what’s going on in the field of reproductive medicine. Be fluid; don’t be “frozen” in your thinking patterns or your plans. Medicine changes faster than ice melts in the summer. Ask your fertility doctor about what’s hot and what’s cold. You might be surprised at what’s hiding behind the frost!

Inflammatory Soup with a Side of Adhesion Bread: Endometriosis

/in /by

There are certain subjects in school (think calculus, physics, and for some of us, poetry) that just make you want to go, “Ugh.” Looking at formulas or sonnets makes you want to rip your hair out. No matter what you do, you just don’t get it. In many ways, the same can be said for endometriosis (a.k.a. endo). It is sort of like that black box in gynecology and infertility. We know it hurts. We know it can cause infertility, and we know it can cause problems. But we’re still a bit unclear on the hows and whys. How does it get there? Why does it get there? How does it cause pain? Why does it cause pain? While many of these questions have the start of an answer, they lack a conclusion. The unknown can make them hard to diagnose, to manage, and to treat.

Welcome to Endo 101. Here, we will give you the abridged version. Endometriosis is the implantation of endometrial tissue (that is, the tissue that is supposed to stay inside your uterus and only your uterus) in other places. How these cells break free from their uterine jail is as much of a mystery as how El Chapo escaped from jail. However, once the inmates (or cells) have been released, it’s tough to get them back in.

Many of us in the biz or in the know refer to endometriosis as “endo.” The shortened nickname does not mean the symptoms and the negative side effects that its presence brings are in any way short. In fact, this laundry list is quite lengthy. Women often report symptoms ranging from pain (including pain with periods, intercourse, defecation, and urination), infertility, diarrhea/constipation, and a no-joke impact on one’s quality of life. Symptoms can even be as vague as back pain, chronic fatigue, or abnormal bleeding.

The degree of pain and even infertility can be mild, or it can be severe. And the worst part of it all is that the extent of disease doesn’t equal the degree of symptoms (it’s sounding even more like calculus!). The trickiest part about endo is that, to diagnose it, you must operate on it. Symptoms and even visuals (ultrasound images) can’t make the call (although they can come pretty darn close). You must go to the operating room and have the tissue sent to the pathologist for a diagnosis. Although you can be nearly certain that the diagnosis is endometriosis, you can’t prove it without a reasonable doubt until the eyes of your pathologist friend sees the evidence. The judge and jury here are pretty small.

If you are suffering from endometriosis, you have probably thought on many a night, “Why me?” How did I win this unlucky lottery? Endo is no $200 million Powerball—it is actually fairly common. In women undergoing surgery for pelvic pain, up to 30% will have endometriosis. It’s nearly impossible to know how common endo is in the general population because many women will have it but won’t even know it. Bottom line, it is likely way more common than we know.

What makes someone more likely to hit the “un-lottery” lottery has not been fully worked out. While we know that there is definitely a genetic component, the endo gene(s) have not yet been identified. However, if your mom, grandma, and sister have it, there is fairly good chance you will, too. Other likely originators of endo include:

  • Changes in the immune system,
  • Retrograde menstruation (when the blood goes backwards through the fallopian tubes into the pelvis rather than out of the cervix into the vagina), and
  • The passing of endometrial cells through the lymphatic system (think lymph nodes, which are actually located not just in your throat but throughout your whole body!).

Who will win a game of Roulette is anyone’s guess, but our money is on a mixture of all three. Additionally, women are less likely to have endo if they have had multiple children, breastfed for a long time, or got their first period later.  On the flipside, women are more likely to have endo if they have not had children, got their periods early, went through menopause late, bleed for longer duration with their periods, have more frequent periods, and variations in their reproductive anatomy (called Mullerian anomalies). While you may have gotten it without any of the above, we as fertility MDs are definitely more likely to look for it in certain women.

The thing about endometriosis is that it only makes a peep when estrogen is around. If there is no estrogen (hence hormonal contraceptives, Lupron, or menopause), endo is quiet as a mouse! Because it can’t act without estrogen, it pretty much only impacts women during their reproductive years (late teens to 40s). For this reason, most of the treatments center on shutting down the production of estrogen. It’s like taking the logs out of the fire. Without fuel, nothing can burn! While this sounds all well and good, most of us can’t be without fuel for our whole life. At some point, you might want to get pregnant. This will require adding fuel back to the fire. For this reason, it’s not a bad idea to see a fertility specialist before you stir things up.

Endo plays a pretty bad game of hide and seek. (Basically, we can see it coming from a mile away!) When the decision is finally made to go into the operating room and take a look, the disease is often pretty easily spotted. While the most characteristic appearance consists of the blue/brown “powder burn” spots, the look of endo can be very Houdini-esque. Endometriosis can look like brown spots, red patches, yellow-brown discoloration, or white spots.

To know for sure what’s up, the tissue must be sent to the pathology lab for a thorough onceover. The most common places for endo to hang out are on the ovaries, on the tubes, in the pelvis, on the ligaments that hold up the uterus and the ovaries, in the colon, and on the appendix. Where it makes its home often translates into the symptoms that you have. Again, this is not always the case. Some women can have endo painting their ovaries, their tubes, their pelvis, and their colon and experience no symptoms.

While surgery is required to make a diagnosis, not everyone needs surgery. A good history, physical, and sometimes imaging can give us enough info to convict (a.k.a. start treatment). The treatments are plentiful (think Thanksgiving Day dinner) and will be passed around to see which “tastes” best for your body. Women who are trying to get pregnant ASAP will have to opt out of most of the dishes (although options still exist). The silver lining with endo is that, for almost all women, the symptoms disappear during pregnancy. While we don’t recommend getting pregnant simply for an endo time-out, it will make matters way better.

Unfortunately, endo is the gift that keeps on not gifting (or re-gifting things you don’t want!). And unlike a good gift giver, there is no receipt and no return policy. If it is yours, it’s yours for life. There are many ways to tailor that shirt or tighten those pants so that you can live with them. Same goes for endo. We can do a lot to make you pain free if we know what’s putting you out. It’s definitely a bumpy ride. You may need several fittings, but we know a pretty good tailor. Just make sure to be completely honest with your doctor, and do your research before committing to any treatment.

It’s All in the Sauce: Why the IVF Laboratory Matters So Much

/in /by

How many chefs do you know that will hand over the ingredients to their famous, to-die-for, take-seconds, -thirds, and even -fourths “sauce”? Not many. What makes their dish unique is usually kept under lock and key and shared with only their closest confidants. The same can be said for the conditions in an IVF laboratory. “Secret ingredients” (a.k.a. laboratory culture conditions, temperature settings, and embryologist technique) are in many ways what distinguishes one IVF center from the next.

When trying to figure out what doctor you should go to and where you should do your fertility treatment, it is important to have some stats about their lab. Think of a pitcher or a hitter. Would you draft a pitcher without knowing their ERA or a hitter without knowing their batting average? Probably not—especially not if you want to win! Think of pregnancy as the win. If the IVF laboratory the doctor works with has poor stats, no matter how much you like the player (a.k.a. the doctor), you should probably draft someone else.

Where you get these “player’s stats” can be tricky. Some sites and resources are not so reliable. We suggest you check out the CDC and SART websites. They are reputable and well researched. They give data to you straight and perform due diligence in getting accurate information from individual clinics before sharing it. Use their information to become informed. Checking them out before you draft your team might make you re-think your roster.

The old saying goes, “Behind every great man is a great woman.” Nowadays, you could say, “Behind every great woman is a great man” or “Behind every great woman is a great woman” or “Behind every great man is great man.” Whichever combination is specific to you and where you are standing, you can be sure whoever is standing behind you is the key to your success. The same goes for us fertility doctors and our IVF laboratory staff. Without the men and women who sit behind us, we are powerless. We can tell you what’s not working and figure out how to fix it, but only with the skill of our embryology colleagues.

In line with the overarching theme of Truly, MD (honesty and transparency), we are going to give it to you straight. The lab is where it’s really at. No matter how many accolades one physician receives, that person cannot do it alone. So while we can’t share the secret to each center’s sauce, we can recommend that you do some serious taste tasting before settling on your choice—it can make the difference between success and failure.

Epidurals, Episiotomies, and Elective C-Sections: What Are the Essentials for a Good Labor?

/in /by

From the moment you pee on the stick and see the two lines, the smiley face, or the word pregnant, your mind starts to run wild. Is this for real? Will it be good? Could this really be happening? After dropping about fifty more bucks at the drugstore by taking another three to four tests to confirm what the first showed (trust us, we’ve been there!), the idea of pregnancy and motherhood begins to settle in.

Through deep breaths and calming thoughts, you start to envision what the next nine months will look like. Cravings, nausea, fatigue (sometimes extreme), bloating, spider veins, acne, back pain, and maternity clothes…bring it on! And although you can handle almost any of pregnancy’s curve balls—and there are many—the unknown surrounding how that baby will actually make his or her entrance into this world is probably the most nerve racking. Will there be endless hours of pain where you spend every contraction cursing your labor team (gotta love the movies!), or will it be a peaceful few hours rocking back and forth to the iPod playlist you carefully selected? Whichever it winds up being, you can almost be sure it won’t be what you imagined. It will deviate from your birth plan or your non-birth plan, no matter how hard you will it not to.

Amidst all the unattractive parts of pregnancy, there will be the most attractive things you have ever experienced. You will feel your baby kick. You will listen to your baby’s heartbeat, and you will watch your baby grow. You will think a lot about your future, both immediate and distant, and try to imagine what your days, nights, and years will look like. (Spoiler: the nights will be long, and the sleep, short!) While you can’t know when or how everything will happen during labor, you can take those sleepless nights preparing for a variety of possibilities. By educating yourself (through reputable sources—shout out to Truly, MD!) and talking to your doctor or midwife, you can prepare yourself for what might come. There is a lot to learn and a lot to consider, so we will give you the abridged version.

Epidurals are not your enemy; in fact, they are sort of your fair-weather best friend. (Labor isn’t so long!) Despite all the pros, unfortunately, for some reason there is a lot of negative hype around epidurals, such as:

  • They will cause a C-section.
  • They will hurt your baby.
  • They will cause permanent back pain.

These are simply not true. While epidurals have been demonstrated to increase the second stage of labor (a.k.a. how long it takes you to push that kid out) and increase a woman’s need for labor augmentation (Pitocin), they have not clearly been linked to increased C-sections.

Data show that timing may be the issue, and getting your epidural too early (defined as < 4cm) may be what increases the risk of a C-section. So while we will do our best to coach you through those early contractions sans an epidural, in our opinion, next to the pill, epidurals may be medicine’s best gift to women. Think of any other medical situation where it would be okay for a woman to have intense pain and no pain control. We can’t think of one! So don’t try to be a hero. If the pain is too much, it’s okay to cry mercy. We promise this doesn’t make you a failure. While pain-free labor seems pretty amazing, we would be remiss not to mention that there are some negative side effects with epidurals (headache, temporary weakness/numbness, fever, low blood pressure, rash). However, in general epidurals are incredibly safe and in our opinion a total lifesaver!

Hot topic #2 on the L&D floor. Put your scissors away, because episiotomies (a cut along the perineum to increase space) are no longer standard practice. The routine use of episiotomies is sort of an old-school practice (reference to it can be found in the medical literature for over 300 years!). Historically, it was done to help expedite the pushing process, more space presumably equaling more speed. It was also thought to decrease the incidence of bad tears and future leakage (a.k.a. your dependence on Depends!). But the studies demonstrated that the proof was missing from the pudding. Most evidence showed that the benefits of routine episiotomies were sparse and in more of doctors’ anecdotal experiences (let me tell you about what I’ve seen!) more than evidence-based. Medicine moves faster than a NASCAR racer in the final lap of the Daytona 500; research is the fuel driving the process. Routine episiotomies are out of gas; restricted use is preferred and is the current practice.

Zodiac signs, numbers, days of the week, and months are all important. I mean, if you deliver a Taurus as opposed to an Aries you could be up against a bull versus a ram. But despite your love of certain signs, elective anything when it comes to labor should be carefully considered. Scheduling C-sections and deliveries to fit between scheduled appointments, commitments, and important events has become a popular trend. The “Cesarean delivery on maternal request” (the PC way to say “no medical reason to go under the knife”) encompasses about 2.5% of all births in this country (about 1.3 million births per year). Simply stated, if this is what you want you are clearly not alone. But before you go under the knife, we ask you to consider the potential downsides of this seemingly benign procedure.

While the most common surgical procedure performed on women in the US is a C-section, they are most certainly not risk-free. A C-section is still surgery. You will be in the hospital longer; your baby has a higher chance of respiratory problems. Squeezing through the birth canal squeezes the fluid out of the lungs, while taking the “easy way out” does not allow the fluid to come out, and you are at higher risk of problems in your next pregnancy. Think of it this way: when you fall and cut your knee, you usually get a scab. The area heals, but often a scar remains. As long as it isn’t on your face, you can pretty much deal! Well, when a C-section is performed and the uterus is cut, it (just like your knee) will scab and eventually will heal. But even in the hands of the best OB, it is not uncommon for scar tissue to form on the uterus. Scar tissue on the uterus may be hard to see, but trust us, it is not a pretty sight. While cosmetically, you won’t have a problem (only your OB sees your uterus!), scar tissue can negatively affect your future pregnancies in a pretty big way. Placental implantation problems, uterine rupture, and even the need for a hysterectomy can all occur the next time around.

And in this case, the motto “The more, the better” does not apply. The more kids you have, the more C-sections you will likely need and the worse the situation can become. A planned “C” will decrease your urinary leakage (cough, sneeze, laugh, oops!) in the first year after delivery, but after that, the playing fields between elective C-section and vaginal delivery are pretty much equal. (Basically, we all will be peeing on ourselves at the same rate.) So while it seems simpler, cleaner, and easier, we again remind you that it is surgery, and surgery has risks. Think before you sign up. Read, ask, consider, and investigate.

Flashing alert…we are talking about the elective-not-in-labor C-section, NOT the “I’ve-been-in-labor-for-24-hours-and-pushing-for-four,-and-this-kid-won’t-come-out C-section!” Or this baby is breech and won’t turn C-section.  Trust us, we are not knocking C-sections or those who have them; being awake while somebody is operating on your belly is more than admirable. If you wind up needing a C-section, don’t sweat it. You are no less of a woman, a mom, or a tough chick because you couldn’t push your baby out from below. It’s your voice, your body, and your baby. And as long as you are at least 39 weeks pregnant (one week before your due date or more), you can request an elective-not-in-labor-just-because-I-want-it C-section!

We’ve seen women who swore off epidurals like the devil begging for them and women who signed up for elective C-sections walk onto the labor floor 10cm and pushing. You just never know how it will go. Have an idea what you want—midwife or OB, doula or partner, C-section or vaginal delivery—but be ready to accept the exact opposite. You can print it 100 times, in color and in bold, but it likely won’t change what happens on that fateful morning, afternoon, or evening. In the words of our girl Elsa, “Let it go.” More important than the perfect story or the kickass photo ops is safety (yours and your baby’s).

Hours of painful contractions can blur your ability to reason. That’s what your trusty OB/midwife is there for. Sure, we’ve probably been up with you, but sleepless nights are par for the course for an obstetrician (coffee is our best friend!). Even the best of stories and plans often needs editing. And while chapters 1–10 may not be a New York Times bestseller, it’s the last page that matters most: a healthy mom and a healthy baby. The rest are just words on a page!

Fitting It All In: Maximizing Your Day

/in /by

How do you get to work, work out, and work on your kid’s homework, all in one day? Trust us, it’s nearly impossible. We fight the same battle every day. Trying to figure out how to fit it all in is a daily struggle. And trying to fit it all in with a smile on your face and some positivity is even harder! While we don’t really have any magic bullet and, unfortunately, have not found a way to add extra hours to the clock (we’ve tried), we have figured out a way to be as efficient as possible—walking and talking, running and listening, watching and writing. Here are a few tips from two busy moms to get as much done as possible in those waking hours.

Start the day early. As much as a five AM wakeup call seems ungodly, it is a great way to get things going (that and a shot of espresso!). The early-morning wakeup call offers you some quiet time before your brood beckons you to their bedside (say that five times fast!). The “Mom” calls come early, but if you can beat them to the punch, you might be able to squeeze some you time in. While we use this time to sweat and burn some calories, it is also a way to let loose and set the cadence for the rest of our day. Exercise does way more than just burn calories; the release of endorphins improves your mental state and focuses you for the rest of the day.

Whether it’s a cycling class, a run, or a Pilates session, whatever gets your blood going will likely get your brain going as well. While we get it’s hard to get out of bed when it’s dark and cold, it may just provide you with more motivation than a Starbucks trenti (did you know they had something bigger than a venti?)! On the days that your kids are up early and you can’t go before they cock-a-doodle-doo, take them with you. Maybe invest in a jogging stroller. The car is a great place to nap, so why wouldn’t the jogging stroller do the same trick? Even if you can’t fit it in but you need your fix, play tag, lift them in the air, and clean up their toys. Although unconventional, if your kids are anything like ours you will be sweating in no time! And don’t underplay getting to and from work. Walk or run (did we really say run?) to and from the office. This is a great way to save money (and the environment) and get your blood going. Keep a mini shoe collection under your desk, an extra pair of underwear/bras, some deodorant, and even a dress (trust us, it will get some good use). You may even consider splurging on a hair dryer. It will “dry” away all the evidence!

Listen to music as much as possible—you don’t need to jam out for hours, but some good tunes on your way to and from work will reset your head and help focus you. We have found this is also a good trick when writing, studying, and even completing tasks. We all need a zone-out/Zen-out session from time to time. It gives you time to decompress and recollect your thoughts. Music has a way of doing this that is unlike any other medium. While we too love a good Bravo reality TV show, it can be a bit more distracting. Definitely get your fix of Real Housewives, but maybe not every day. Reading is also an excellent way to let your mind go; a good novel can literally transport you to another century. Book clubs with friends and even your kids are a great way to get conversations going.

Set aside email/work time. Whether you work in or out of the house, the emails are constant. They are literally non-stop. Trying to stay on top of them can be exhausting. It can also detract from your time at home, time with your kids, and time with your partner. Pick two to three times a day where you return emails, respond to text messages, and return phone calls. The worst thing we can do is be a slave to our phones (and we are culprits of this in the highest order)—it distracts us from our family, detracts from the flow of our day, and can be downright depressing. We all have to work, and we all have to take care of business. But if we are more efficient with our time, we can accomplish a whole lot more.

Make meals matter. Whether it be with your family, your friends, or with your co-workers, put your phone down, and turn the TV off. Meals can be a great time to communicate. You don’t have to make the food (we get it), but you do have to eat. Use your mealtime to make the most of your day. Go on a date with your partner. While it doesn’t have to be a big to do, it can do big things for your relationship. Kids bring with them a whole new world. The nonstop “Mommy, I need you” can wear you down. Remember that time alone with your partner is important. And while you may not make it to Bali or the Bahamas for a week’s kid-free vacation, you can make it to your local bar for a beer! Put time aside for you and your partner. It may be the necessary ingredient for a long and healthy relationship.

Write as much down as possible. As much as you think, “Yeah, I’ll remember that,” you will forget it. So become tight with your calendar. It will make sure you don’t miss a beat (or an important event)! Be it Google, Microsoft Outlook, or an old-school refrigerator door with a magnet, write things down. Whether it be your kids’ school activities, your shopping list, or when your bills are due, this will help you remember who needs to be where when and what needs to be done when. Being aware of what’s coming up will alleviate anxiety because it will allow you to plan. It will also allow you to see when you need extra help.

Don’t be a martyr. Ask for help, and let others help you. While you are almost superwoman, you still can’t fly! As women, we hate asking others for anything. We take one more, add another thing to our plate, and say yes to another task. Know your limits, and don’t be afraid to set them. Spreading yourself thin will lead to exhaustion, exasperation, and a less than ideal outcome.

Try to plan for what’s to come (and not necessarily the next five and ten years; that’s just not possible). Plan for the immediate foreseeable events. For example, lay out your clothes for both you and your kids the night before. Mornings can be stressful, and this can alleviate the “oh no, where are those shoes?” moments. Keep a good weather app on your phone; it can save you from wearing your favorite suede boots in the pouring rain! While you won’t be able to plan away every problem, conquering a few things will help alleviate some of the stress and anxieties that we all feel.

While we certainly don’t have all of the answers and most definitely lay awake at night thinking of all the things we didn’t do that day rather than all that we did do, we try to use the hours we are awake in the best way possible. Plan, plot, proceed, and prepare. But don’t forget to play; unfortunately, once we are out of school, the last “p” is often forgotten. Put it back in your day; it makes a difference in your mood and can often make you more productive. And remember that, no matter how much you accomplish, it will never feel like enough. We all feel this way. It’s a part of being a mom. Welcome to the club!

Post-Menopausal Bleeding: A Drop in the Bucket?

/in /by

Month after month, year after year, we are running for the bathroom searching for the tampon or pad that we keep buried in our purse for an emergency. After realizing that we used the emergency supply last month and never restocked, we seek out help from one of our bathroom mates who smiles and says, “Don’t worry; I’ve been there.” The truth is, we all have at some point; the monthly mess is just a part of a woman’s life. It can be so unpleasant—the cramps, the moods, the pimples, and of course, the endless bleeding—that it’s hard to imagine ever missing this. I mean, if your 20-year-old self could talk to your 50-year-old self, what a conversation that would be! When you are in the thick of those reproductive years, a little irregular bleeding here or there often goes unnoticed: what’s a little more bleeding? You probably don’t make much of it and maybe even forget to mention it to your doctor. It is, so to speak, just a drop in that much larger bucket. However, when bleeding arises post-menopause, it can be serious and should never be shrugged off, ignored, or go unnoticed.

Menopause is the end of a very, very, very long race; “miles” of menses ultimately come to an end. While this race is long, its end is gradual and is preceded by a major “spacing” out of rest stops. All regularity and predictability are lost, and irregularity and the unknown take the lead. Medically, this time of irregular periods is known as perimenopause; perimenopause and the haphazardness that it brings (both physical and often emotionally) can (oh joy) last for years.

It isn’t until a full year from the last period that you receive your official medal (a.k.a. menopause). From this point on, the flood gates are closed. No more bleeding should occur. Without the ebbs and flows of estrogen and progesterone made by the ovaries, the stimulus for a uterine lining to be produced and shed monthly is lost. The uterine lining becomes thin (no diet required!) and in most instances remains that way indefinitely. If it starts to receive mixed messages (um, no way, that’s not what she told me!), it can thicken and bleed. But let’s cut the game of telephone ASAP. This is not evidence that you are once again fertile. It can hint at a seriously serious situation, such as endometrial cancer, which requires immediate attention. Endometrial cancer is the most commonly diagnosed gynecologic cancer; about 55,000 women will be diagnosed in the US each year. Luckily, most endometrial cancers give you a heads up: a “get out of the way; the bus is about to hit you”-type of thing. For most women, bleeding, long after the days when there was bleeding, will happen.

Bleeding is an obvious and often early sign that something is off. Because it is so visible, endometrial (uterine) abnormalities are often picked up early in the game. In fact, in many cases, they are not even fully cancerous but rather precancerous (about 70% of endometrial cancers are stage I when diagnosed). The precancerous condition is called endometrial hyperplasia. Basically, the cells are becoming a little hyperactive and if untreated could be on their way to some serious Ritalin-requiring behavior. There are four types of endometrial hyperplasia, with some being more in line with cancer and others just slightly out of line with normal. As a common precursor to endometrial cancer, endometrial hyperplasia in a post-menopausal woman often leads to a hysterectomy.

Not all postmenopausal bleeding is bad. Some is just a reflection of a thin uterine lining or thin vaginal wall (medically termed atrophic). Think of dry hands or lips in the winter…they get dry, chapped, and cracked. This can lead to bleeding. There is no medical problem that caused the bleeding (it’s your lack of lotion and chapstick!). And while it can be unsightly, it usually doesn’t require medical treatment. The same goes for what we call endometrial atrophy. With years of low estrogen, things can sort of thin and shrivel. One such thing is your uterine lining. It can become so thin that it bleeds. Last, in certain cases the answer is C: neither of the above. Often, a benign structure like an endometrial polyp (an overgrowth of glandular tissue) can cause postmenopausal bleeding.

Our job is to sort out which type of bleeding you are having—the “I need some chapstick bleeding” or the “I need some surgery bleeding.” We don’t have eyes in the back of our head (even though our kids think we do), and we can’t diagnose endometrial pathology just by looking at your abdomen. In order to make a diagnosis, be it a cancer, hyperplasia, a polyp, or just a really thin lining, we need to perform an ultrasound and possibly even an in-office biopsy.

Sometimes, if more information is needed to make the appropriate diagnosis a D&C is required. The thickness of the uterine lining on ultrasound serves as sort of the gatekeeper for what should be done next. In this case, the line in the sand is 4mm. When the lining is less than or equal to 4mm, you pretty much have the all clear. No further testing is required unless the bleeding continues to occur because the risk of uterine cancer is so low. When the uterine lining is greater than 4mm, you have entered the no-fly zone, and further evaluation is required.

Luckily, the warning signs are fairly bright, so most endometrial cancers are diagnosed and treated early (making survival rates quite high). While most women with endometrial hyperplasia and cancer will require a surgical procedure (hysterectomy), it is a small price to pay to be cancer free. While seeing red again can be alarming, it is not always bad. However, you do need to sound the sirens (a.k.a. call your OB/GYN) and police the situation. Even the smallest drops in the bucket matter. When you are postmenopausal, every spot matters.

The Five Best Ways to Prepare for the Embryo Transfer

/in /by

The big day is finally here! After days and likely months of planning, you are ready to walk down that aisle—with your embryo. You are probably anxious, excited, scared, nervous, and overwhelmed all at the same time. This ball of emotions can become a snowball of negative energy if you don’t know how best to prepare for the main event. Here are five tips to prepare for the embryo transfer.

  1. Hydrate.
    The bladder and the uterus are very tight. They run in the same circles at all times. We ask you to fill your bladder because it not only allows us to see the uterus with more clarity but also can change the angle of the cervix and uterus (# make the transfer easier!). And while we, too, are type A perfectionists who err on the side of doing more rather than less, we recommend underfilling rather than overfilling your bladder. Overfilled bladders can be uncomfortable and cause your muscles to contract, making the transfer more difficult. And one last word of bladder advice: if you do lose it and let some urine out on the table, don’t worry. You aren’t the first and certainly won’t be the last!
  2. Hear, but don’t listen to the doctor doing the transfer.
    No, we did not write that backwards. We want you to hear the information we give you about the embryo quality, but limit how much you take in. Patients often want to know every detail about embryo grade, embryo quality, embryo survival, and everything else in between. While you should be educated and you should know what’s up, obsessing over your grades in this classroom won’t help. You couldn’t have studied anymore. At this point, it is what it is. There will always be time with the “teacher” in the future to break down the cycle if it doesn’t work!
  3. Valium is a very good thing.
    Valium is not a villain. If you are a ball of nerves or the speculum is Public Enemy #1, taking something to calm you down before the transfer is a good idea. It won’t hurt your chances and might even help.
  4. Keep your eyes on the prize.
    You will be asked to identify your name, your partner’s name, and even your embryo before the transfer is performed. Make sure that the doctor, the nursing staff, and the embryologist identify you. While the endless checkpoints will feel like O’Hare on a bad day, they are not set up to be annoying but to be extra cautious.
  5. Make sure your plus one is one with positive energy.
    There is no rule as to whom you have to bring with you on transfer day. In fact, given that you don’t get anesthesia, you don’t need an escort home. Most women like to bring someone along with them. Whoever you pick, whether it is your plus one, your parent, or your pal you want to make sure they are exuding lots of positive energy. You don’t need any Nelly Negatives around on this day.

No matter how hard you try, you can’t control what happens over the next 48 hours; after a transfer, embryo (s) will bounce around for about 48 hours before it/they implant. Those guys and/or gals are either going to find some good real estate and set up shop or not. If they don’t, try to remember that it was nothing that you did or didn’t do, nothing that you said or didn’t say, and nothing that you ate or didn’t eat. You covered all of your bases. If you don’t hit it out of the park this time, you can take another swing soon.

8 Symptoms That Suggest You May Have Endometriosis

/in /by

Most of us have never even heard of endometriosis (a.k.a. endo) before our GYN throws it out there as a possible reason for those wildly unpleasant symptoms that wake you up every 30 or so days. When getting your period feels like getting hit by a sledgehammer, you very well may be suffering from endo (the implantation of uterine tissue on other organs in the pelvis/body). Here are some other red lights that should flash “endo” in your head.

  1. Painful Painful Painful Periods
    For most of us, no period is a fun period. Those three to five to seven days are never anyone’s idea of a good time. However, for women with endometriosis, these days can be debilitating (and they can start about 1–2 days before your period even begins)! The pain that comes with your periods can put you on the sidelines from work, from exercise, from socializing, and from life. Lying in your bed doubled over in pain is nobody’s idea of a good time. Medically painful periods are called dysmenorrhea. We GYNs ask about it all the time because it gives us a better idea about what you are going through when you get your period. It is the most common symptom associated with endometriosis (nearly 80% of women with endo report it). Therefore, if you are one of the unlucky ladies who languishes on the couch during your time of the month, it’s time to share this info with your doctor.
  2. Chronic Pelvic Pain (a.k.a. Pain All the Time)
    When you are singing the “pain, pain go away, come again another day” song, without any relief in symptoms, no matter where you are in your cycle, there is a pretty good chance that you have endometriosis. The pain can be sharp or dull, focal or diffuse—bottom line, it can be pretty variable. Chronic pelvic pain is seen in about 70% of all women with endo. It can cause a serious roadblock in one’s ability to function both at home and in the office and therefore needs to be cleared ASAP.
  3. Pain with Intercourse
    Women who have endo complain of pain with intercourse (medically termed dyspareunia) fairly frequently (about 45% of women with endometriosis report this symptom). The pain reported is generally a sensation of pain in the pelvis with intercourse (not pain with insertion or vaginal pain). As expected, it can have a serious impact on a woman’s quality of life, and while many women hold back in talking to their GYNs about sex, this is something you should definitely share.
  4. GI Distress
    Endometriosis is not picky in whom she decides to annoy. Lesions are not only limited to the reproductive system but also set up shop on the bowel (intestines). Where they lay their roots dictates what symptoms are felt. GI symptoms include diarrhea, constipation, bowel cramping, and difficulties going to the bathroom. Bleeding from the rectum can also occur. For some women, the GI symptoms can be worse than the GYN ones; it can be pretty intense.
  5. Infertility
    One of the biggest criminals in the infertility battle is endo. Endo can have a seriously negative effect on a woman’s ability to conceive—it can be a pretty formidable challenge for us in the Land of Fertility. The good news is that our treatments can also throw a pretty strong punch, and they can usually knock it out. Pregnancy is most certainly not impossible in women who have endo.
  6. Ovarian Cysts
    The most common site for endo to set up shop is in your ovaries. While the implants can be superficial and select, they usually form a cyst(s). The cyst (medically termed endometrioma) can cause some serious pain. It can also eat away at your eggs and reduce your egg quantity; this translates into what we call diminished ovarian reserve (low egg quantity). While surgery can help with cyst size, it can further hamper your egg reserve. Make sure that you consult with a surgeon who is skilled in endometriosis surgery before you make a date for the operating room. There is no frequent flyer program for surgery. Therefore, you want to limit the number of times you go to the operating room.
  7. Pain with Urination
    Although this may come as a shock, endometriosis can hang out in your urinary tract system. When it pitches a tent, it can cause urinary frequency, urinary urgency, urinary pain, and even retention. Not fun. These symptoms can be scary and confusing, especially when you are totally in the dark about the connection between the urinary system and the GYN system. The two are pretty close, and as a result, one can rub off on the other pretty easily. Definitely let your GYN know what your urinary system is up to.
  8. The Odd Ones
    Endo could be a US spy—it can slide and slink its way into almost every corner of the body. It has been reported in the lungs, the arm, the thigh, the diaphragm, and even surgical scars! So while it is unlikely to hide out in these spots, any atypical symptoms should be reported to your doctor, as it might break the code as to what’s going on in other parts of your body.

Put them all together, and what do you get? No, not bibidi bobidi boo, but rather a pretty bad case of the blues. The symptoms of endometriosis can take quite a toll on your quality of life. They can cause you to withdraw from friends, family, and all sorts of fun. Don’t suffer in silence. There are not only thousands of women who are in a similar situation but also several physicians who are well equipped to treat your pain. We just need to know what’s bothering you, how bad it is, and how best to fix it. Together, we can knock this out!

5 Pointers for a Peaceful, Productive, and Plentiful Egg Retrieval

/in /by
  1. It’s go time!
    The big day is here. You are filled with anticipation, angst, and probably some fear. To minimize some of the negative thoughts running through your hormone-infused head, we have a suggestion. Before you walk into the operating room, make sure you have spoken with your doctor and have an idea about what to expect. What will the procedure be like, how many eggs do they think you will get, and how many embryos will you ultimately have? Managing expectations (particularly when it comes to the number side of things) will make both walking in to and out of the operating room a whole lot easier.
  2. Pain is not a part of the process.
    No pain, no gain does not apply to the retrieval. We want to minimize the physical (and mental) discomfort you feel in every way possible. There will be an anesthesiologist present during your retrieval whose job is to focus on you, your comfort, and your overall well-being. Their cocktail will ensure that you neither feel pain nor remember a thing (without the calories or the hangover!).
  3. Don’t be tardy for this party.
    We are pretty punctual when it comes to retrieval time (no airport delays here!). The time of the trigger medication and the retrieval are more coordinated than the worst bridezilla’s bridal party’s attire; while clinics vary in how many hours separate the trigger medication and the retrieval (some do 34, some 35, and some 36), what doesn’t vary is their commitment to staying on time. When things run behind schedule, what’s at stake is not your connecting flight but our ability to retrieve those eggs (ovulation can occur). So give yourself plenty of time to face the morning rush hour and the inevitable street closures—you don’t need another thing to stress about.
  4. All in all, the process is pretty quick.
    Retrieving eggs is a fairly simple and fast procedure. In fact, most egg retrievals are no longer than a power nap and take no more than 15–20 minutes. Before you know it, you will be recovering in the recovery room, drinking apple juice, and eating graham crackers!
  5. Relax—we’ve got you covered!
    Most fertility doctors are more comfortable doing retrievals than tying their shoes. As medical procedures go, this is our “bread and butter.” Think of something that you do every day (with ease and with grace): that is how we feel about extracting eggs. So while fear and anxiety are totally normal emotions, take solace in our experience. Close your eyes, enjoy the relaxing medications, and dream of something good. We will see you on the other side.