The Low Down on the Low-Dose Oral Contraceptive Pills

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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!

What Endo Can Do to Your Eggs, Your Tubes, and Everything in Between: Endometriosis and Infertility

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Endometriosis (a.k.a. endo) does not mess around when it comes to infertility. It can have some pretty serious consequences on almost every organ in your reproductive tract and beyond (ovaries, tubes, plus). That’s why it’s no stranger to any fertility MD or any fertility clinic. We are always on high alert looking for the “enemy” lurking in our midst. Many, if not most, cases of unexplained infertility are likely due to endometriosis, but it can play a pretty good game of hide and seek. Unless we go undercover in the operating room, we often won’t find that endometriosis, no matter how hard we look. While making endo’s official acquaintance may be difficult, we can speculate with pretty good certainty about its presence. Symptoms such as painful periods, chronic pelvic pain, pain with intercourse, and certain cysts serve as the “bread crumbs” (think Hansel and Gretel) for us fertility doctors who are looking for endometriosis.

Nearly quarter to a third of couples suffer from unexplained infertility (all points on the fertility list have been checked, but nothing seems to be wrong).  About 40% of these couples are battling the big bad E. Why and how endo causes infertility is about as controversial as the 2016 presidential election, and like it, we don’t recommend mentioning this topic at dinner with your future in-laws! Some think that the stage of disease (a.k.a. how aggressive it is) has an impact on how it does its dirty work.

For example, women with mild/minimal endo (stage I or II; after-surgery endometriosis can be “staged” or classified by an endometriosis grading system) may be battling infertility because there are a lot of negative vibes (say, prostaglandins, cytokines, and chemokines) lurking in the corners of the pelvis. These substances are hormones you hope to meet on only very few occasions: they are not kind to the body. They can cause pain, inflammation, and tissue damage. They are released by endometriotic tissue, and their presence in sacred places (ovaries, tubes) can throw things off. The ovaries, tubes, and even the endometrium are not happy with these guys around. Follicular development, fertilization, and implantation can be impacted (and not in a positive way!).

On the flip or the more severe side, when severe (stage III or IV) disease is present, it’s not only hormones that you have to worry about fighting. Picture a Sunday-night Game of Thrones episode—you have the Starks, the Lanisters, the Baratheons, and the Targaryens (not to mention the White Walkers and the Wildlings). In the “game of fertility,” severe endo not only causes inflammatory soup, which is thick and unappealing, but also adhesions and structural abnormalities. Scar tissue in the pelvis can impact the release of eggs, block a sperm’s ability to get from the uterus to the egg, and/or prevent the tube from picking the egg up if and when it is released. Furthermore, endo eats away at your egg count. Less eggs = less chance at a good embryo = less chance at having a baby.

In many ways, it is easier to get Congress to pass a bill on immigration then to get a group of fertility specialists to agree on how best to treat endometriosis. Bottom line, there will be a lot of filibustering on both the surgery and the medicine (clomid, letrozole, IUI, IVF) side. Back in the day, we did surgery (a diagnostic laparoscopy) on anyone who walked through our doors with infertility. It was a part of the evaluation just like a sperm check or tube check. Long gone are the days of diagnostic surgery. If you doctor suggests one, you should skedaddle your way out of that office! However, if the symptoms are there and enough red flags are flashing “endo,” you may consider going to the operating room to see what’s up. There are definitely medical data out there that show that, if endometriosis is removed, your fertility can get a boost, particularly when the disease is more mild/moderate AND in the approximately six-month window immediately following surgery. Watch for doctors who are having you double dip. You really want to avoid multiple trips to the operating room. This is where you are more likely to get complications, more likely to compromise your egg count, and less likely to get anything beneficial out of the surgery.

Think about when a congressman or woman is up there trying to sway voters. They will use a lot of reference and data points (some more accurate than others) to push the needle their way. The same can be said as to why your doctor thinks surgery gets a green or a red light. Some things that put you on the STOP or DO NOT ENTER THE OR list include previous surgery, advanced maternal age (greater than 35 years old), other fertility factors that would warrant IUI or IVF (low sperm count, blocked tubes), and a history of previous fertility treatment. Such factors usually warrant more aggressive fertility treatment (a.k.a. IVF) anyway, and therefore, going through surgery before would likely not be beneficial. Of course, there are always exceptions. We cannot stress how important it is to hash these points out before you take to the podium. You want all the information before you cast your vote.

If you do opt to give surgery a go, make sure it is with someone who specializes in endo surgery. Many doctors like to operate, but endo is not their area of expertise, even though they might say it is. Make sure they have been well vetted before you decide to go with them. If you do take the plunge and go to the operating room, depending on your level of disease, your age, and your other factors, you may be able to give the good ol’ old-fashioned “timed intercourse” a shot in the three to six-month window after surgery. There is some evidence to show that mild/minimal disease treated surgically in women less than 35 years old increases their fertility in the three to six months after surgery, but we cannot stress enough that the benefit of surgery does not last forever. The time window is limited!

While we would not recommend holding back on fertility treatment forever, a brief hiatus to give timed intercourse a go is acceptable. In women with more advanced endometriosis, fertility treatment is usually started right after surgery—there is not much time to waste. The additive effect of surgery plus fertility treatment can be just what the doctor ordered for pregnancy. While the fertility treatment can range from oral medications (think clomid or letrozole) + insemination, injectable medications (think Gonal F and Follistim and Menopur) + insemination or IVF, we usually want to optimize this endo-free or endo-reduced period to its greatest extent. It may take some time to reach a consensus on surgery vs. fertility medications/IVF, but there is one that is a total no brainer—medical therapy for those who are trying to get pregnant. Hormone therapy (oral contraceptive pills), Lupron, and anything that turns your system off is not going to allow you to get pregnant. Therefore, during these trying times, it’s a no go.

Another no-go or not-necessarily-go is removing those unattractive blood-filled inflammatory-laden cysts (i.e., endometriomas) just because you want to have a baby or just because you are doing IVF. Their presence is only problematic if you have pain or we suspect an ovarian cancer might be lingering within, not because you want to have a baby. The exception to this rule in the land of fertility treatment is if the endometrioma’s position could impair your doctor’s ability to do an egg retrieval. Otherwise, while yes, you may want or need some antibiotics at the time of the egg extraction, (these cysts can become infected at the time of retrieval), they should not get in yours our way too much and can stay the course!

You can’t just flip the channel here and decide not to watch CNN until your trusted lawmakers finally make up their mind. With endo, you have to decide which route to go sooner rather than later. Otherwise, you could be waiting a very long time for a baby and dealing with a lot of pain—filibustering will not fly. Because endo has a real-deal impact on your fertility, we often need to pull the big guns out to get things going and to get endo out of your pelvis! Don’t get bullied into a treatment plan that you are not comfortable with; there are options. Stand your ground—your voice and your vote matter when it comes to endo and infertility. You need to like the view from your side of the aisle!

What’s Your Recipe? The Various Ways to “Bake” an Embryo

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Disclaimer: we are not cooks, chefs, bakers, or anyone who knows how to make much besides pasta, PB & J, and scrambled eggs. So while we don’t recommend seeking out our advice on the best ways to cook your Thanksgiving turkey or how to get your soufflé to rise, we are going to take a page out of our foodie friends’ recipe book to explain IVF protocols. We want you to think of the medications as the ingredients, the needles and syringes as the mixers and pans, and the eggs/embryos as the final project (a.k.a. the cake). And while you will likely never see either of us on the Food Network or competing on Top Chef, you will hear us use the cake baking reference frequently. It helps for visualization and in many ways is pretty spot on.

Think back to the last time you baked or, more likely, watched Paula Dean do it on TV! On almost all occasions, when setting out to bake a cake you need some core ingredients: sugar, flour, eggs, and butter. These basics are pretty standard. What varies is the amounts, the order in which they are added, and the “other” ingredients. Some recipes call for chocolate chips, some for oatmeal, and some for cinnamon and nutmeg. So pull out your rollers, put your apron on, and let’s get cooking.

Step 1: Think of the hormones and the needles as “your basics.” Every protocol requires injectable gonadotropins (FSH, LH) to stimulate the ovaries to produce multiple follicles/eggs. However, the dosages and the formulations can vary. If you have been through this process before or know a friend who has, you are probably pretty familiar with the likes of Follistim, Gonal-F, and Menopur (brand names of the hormonal medications). Just like Duncan Hines, Toll House and Betty Crocker, they are similar products produced by different companies. And although one may claim to be fluffier and the other moister, in many ways, just like the medications, those chocolate cakes taste pretty much the same!

Step 2: While some of us like to create our menu and set out our ingredients days before we get started, others of us get the ball rolling just moments before the party starts. Again, the same can be said for the medications. While some protocols call for “day 2 of your period’s start” others require you to begin the injections about a week before your period arrives. Some even have you take preparatory medications (patches or pills) for a full MONTH before you start.

Step 3: For most cakes, butter, eggs, sugar, and flour alone are not going to cut it. Yes, the batter will be tasty, but the cake will be somewhat bland. Similarly, you can’t just give FSH and LH (Gonal F, Follistim, Menopur) alone. While they will certainly provide needed motivation to make the follicles grow, they won’t prevent ovulation. High estrogen + big follicles = Impending ovulation. Therefore, to prevent this, we must add an extra ingredient to prevent ovulation from happening before it is time for the retrieval. It is with this “anti-ovulation” agent that we can spice our recipe up and give it some flair. By varying the “anti-ovulation” medication (examples include Lupron, “Micro-dose” Lupron, Ganirelix, Cetrotide), we tailor the recipe to your taste buds (a.k.a. ovaries!).

Step 4: It’s time to put your masterpiece in the oven, but how long do you set that timer and how high do you set that oven? Here, again, we see variability. While some chefs may like to turn that burner off when the browning process begins, some might prefer a more charred look. The same can be said for when the final trigger shot (a.k.a. ovidrel, hCG, or Lupron) is administered; while some doctors prefer a shorter stimulation course and smaller follicles, others like to let things go longer and push the size of the follicles.

The basics behind the various stimulation protocols are almost always the same—stimulate the ovaries to produce multiple high-quality mature eggs. And just like in the kitchen, we don’t always achieve perfection on the first attempt. We learn a lot from past trials and improve on future endeavors—add a little more cinnamon, add a little less sugar, cut down on the time in the oven…In the same vein, protocols change between cycles—add a little more FSH, add a little less LH, cut down on the length of stimulation. And although doctors and chefs make it look simple, neither baking nor achieving a perfect stimulation is just not “as easy as pie.”

Under Pressure! Pre-Eclampsia

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Pregnancy increases your pressure in a whole bunch of ways. For all of you ladies who have ever waddled through your home cities on hot days, you know that the pressure in your feet, your legs, your fingers, and your hands is way more than just some mild swelling. It can get so bad that some women can’t wear their shoes, their rings, and even their watches; it’s no joke. And don’t even get us started on the bladder situation. It’s hard to go anywhere without knowing where the nearest bathroom is. But the pressure that we are going to address in the next few paragraphs is that of your blood pressure and a condition unique to pregnancy called pre-eclampsia. For those of you who either didn’t have this problem, didn’t know anyone who suffered from this condition, or have never been pregnant, you might be thinking PRE what? Your eyes are glazing over, and you are considering closing your computer. Stop! Pre-eclampsia is a very serious condition, and although we don’t expect to make you into board-certified OB/GYNs in the next several minutes, you should know what it is, what symptoms to look for, and when you need to shake a leg to the labor floor.

Pre-eclampsia is unique to pregnant women and newly post-partum women. It is a disorder that occurs in the last half of pregnancy and is characterized by new onset high blood pressure (a.k.a. hypertension) and protein in your urine (a.k.a. proteinuria). While it may be the first time you are looking at this word, it is actually not so uncommon. About 5% of pregnancies are affected by pre-eclampsia. Women who are having their first baby, are older, have a personal history or a family history of pre-eclampsia, have pre-existing medical problems (kidney disease, diabetes, obesity, a history of elevated blood pressure), or who have multiples are more likely to get pre-eclampsia. Why it happens is a bit unclear. While we know it involves both maternal, fetal, and placental factors, which ones, how much, and when they develop are still unclear. We do know that placental development early in pregnancy is probably a big contributing factor. The diagnosis is usually made in one of two ways—either you get picked up “coincidentally” when your doctor checks your blood pressure at a routine visit OR when you call with the scary symptoms.

The symptoms are pretty specific and usually cause your doctor, midwife, and/or nurse to quickly check your blood pressure and then check you into the hospital. Blood pressures are usually somewhere between the 140/90 to 160/110 mm Hg range—and trust us, this is not a place that you want to score high. The higher the blood pressure, the more severe the situation. (Same goes for the amount of protein in the urine; more is not better here!) To make the pre-eclampsia cut, your top BP number must be greater than 140 and the bottom greater than 90. In terms of the protein situation, you must have equal or greater than 0.3 grams in a 24-hour collection. (Yup, get out your bucket, and start peeing. We want all the urine you make for one whole day!) Other common symptoms include headache, blurry vision, flashing lights, abdominal pain (specifically in the center or the right upper abdomen), nausea and vomiting, shortness of breath, chest pain, and change in mental status (a.k.a. fuzzy thinking). If we feel pretty sure that you are headed for the pre-eclampsia party (elevated blood pressure, protein, and/or symptoms), we are likely going to send you an invitation to the labor floor. Regrets are not accepted. Here, you will find your place card with your room number on it. You will probably be sitting here all night! We will send some bloodwork on you to see how serious the situation is.

Just like most things, there are degrees of pre-eclampsia (mild to severe). We use your blood pressure, your urine, your symptoms, and your blood work to help us decide where you fall. Those that land at the severe table will not be leaving this party anytime soon. They will also likely not be leaving the hospital pregnant. Severe pre-eclampsia is often an indication for delivery. When a baby is delivered (at how many months/weeks pregnant) and how a baby is delivered (vaginal delivery vs. C-Section) are dependent on the severity of pre-eclampsia and the status of both Mom and Baby. When the baby comes out, the blood pressure usually comes down (or pretty shortly thereafter). Therefore, the best treatment for pre-eclampsia is delivery. However, while we are getting that baby to make its big debut, we have to protect you from seizures (no longer pre-eclampsia but now eclampsia) and other really unpleasant things. That’s why we give IV Magnesium. While the magnesium in many ways can be a miracle worker, it can make you feel many things other than good. You will feel hot; you will itch. You will be out of it; you will feel loopy. You will feel like you are having an out-of-body experience. It is not fun, but it is necessary. In most cases, we will also give you medications to lower your blood pressure. It will be a full-court press to protect you from the bad stuff associated with pre-eclampsia.

Most cases of pre-eclampsia occur after 34 weeks of gestation (about 8.5 months); however, some cases develop earlier. However early or late it comes, to be pre-eclampsia, it cannot come before 20 weeks (5 months) of gestation. And staying on the subject of timing, when you have had it once, you are more likely to have it again (and possibly) earlier than you got it last time. Unfortunately, there is no way to prevent the big P from making a return performance. Although newer scientific evidence shows that we can reduce the chances somewhat by giving aspirin, the data are not definitive. The data are even looser when it comes to things like extra calcium, anti-oxidants, vitamins C and E, and fish oil. Some say it can reduce the chances of having a repeat pressure performance, while others say it will do no more than a placebo pill.

We make a big deal out of pre-eclampsia because it is the real deal in terms of poor pregnancy outcomes. In fact, worldwide, about 10–15% of all pregnancy-related deaths are from pre-eclampsia and its nasty side effects (kidney failure, brain bleeds, strokes, heart muscle damage, liver failure/rupture, fluid overload in the lungs, seizures, and placental abruption). And in OB we have two patients (Mother and Baby), and pre-eclampsia does not spare either. It could cause serious problems for your plus one as well (growth restriction, low fluid, preterm delivery, and death). Pre-eclampsia can cause a precarious situation and therefore deserves our prompt attention.

Whenever we hear the word pressure, our brains automatically go to that Billy Joel song “Pressure.” You can hear those lyrics and that piano chord almost immediately. And with the opening vocals, up goes your blood pressure. You start thinking about all you have to accomplish in one day. It seems impossible! And the words of another musical great, David Bowie, remind us that we are always “Under Pressure”: pushing down on you/pushing down on me. But while normally these tunes pull you up a hill as you jog or are entertaining you on a car drive, when you are pregnant and your pressure rises, you can’t simply hum away the symptoms. Pre-eclampsia is not a song that can be changed or skipped; it’s here to stay. So make sure to share your symptoms and your medical history with your OB. We can rework this play list to make it something we can all listen to!

When Having Sex Is More of a Chore Than a Choice: Sexual Dysfunction

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Talking about sex is not always easy. Although it is plastered on magazine covers and frequently a hot topic on “The View,” opening up to others about your sex life (or lack thereof) can be difficult. In fact, dishing about how much you are “doing it,” whether you’re talking with your friends, your sister, or even your GYN, can make even the most open amongst us close up. Bottom line, it’s not an easy conversation to have. And the topic can become particularly taboo when we aren’t having it or aren’t even wanting to have it. Your lack of desire and/or pleasure from what is supposed to be one of the most pleasurable acts can make you feel alone. But we are here to tell you that you are most certainly not alone. Millions of women, particularly during the post-partum period plus, shudder at the thought of sex. So, in the words of our favorite ‘90s hip-hop artists Salt-N-Pepa, “Let’s talk about sex…”

Starting with the basics: sexual dysfunction actually comes in a few different flavors. And while most suffer from a lack of sexual desire, there are actually three other types that may be forcing you to choose sleep, shopping, and even sorting laundry over sex: impaired arousal, inability to achieve an orgasm, and sexual pain.

We learned a lot about sex and sexual response from the Kinsey, Masters, and Johnson sex studies. In fact, the sexual response is pretty intense (no pun intended). There are four phases (excitement, plateau, orgasm, and resolution), and in sexual dysfunction, any or all can be off. It goes something like this:

  1. Sexual Desire Disorders
    Those who fall into this category are basically suffering from “hypoactive sexual desire disorder” or “sexual aversion disorder.” The former is the most common in women of all ages. And while it seems to get us all equally (no matter how old or young we are), it gets us in different age groups for different reasons. For our seasoned women, it usually has to do with things like atrophic vaginitis (a.k.a. dry vagina from hormonal shifts), chronic disease, medication use, and even mental health issues. In our mommying group, we are more commonly looking at situational circumstances. Think of things such as newborn babies, terrible twos, crazy fatigue, and even dysfunctional relationships. The treatment for sexual desire disorders usually consists of counseling plus or minus medications (including creams/lubricants/ moisturizers that can help with vaginal dryness).
  2. Sexual Arousal Disorder
    Women in this category are generally unable to go the distance (a.k.a. complete sexual activity) due to inadequate lubrication. It is usually linked to a chronic medical condition or medication use. It usually exits stage left once the condition is treated or the medication is stopped. Additionally, lubricants and/or moisturizers can also be particularly helpful.
  3. Orgasmic Disorder
    When all seems to be going just right (normal excitement phase) but you can’t get to that place (achieve an orgasm), you have female orgasmic disorder. In most cases, orgasmic disorder does not stand alone. It is generally linked to hypoactive sexual desire, and therefore, the treatment is fairly the same. The one exception are women who have never achieved an orgasm (medically termed, primary orgasmic disorder). We usually prescribe masturbation, education, communication exercises, and body awareness.
  4. Sexual Pain Disorders
    Dyspareunia and vaginismus are the two culprits when it comes to sexual pain. While dyspareunia is pain with sex not caused by a lack of lubrication and vaginismus is an involuntary spasm of the outer vaginal muscles that make sex and any vaginal penetration nearly impossible, they are both a pretty big pain (no pun intended). They are frequently linked to some of the above diagnoses. In most cases, CBT as well as physical therapy and some at- home dilator use are key to quelling this problem.

Finding a doctor who not only gets you but also gets the difference between the various types of sexual dysfunction is key. The only way to get to the bottom of what’s bothering you is to lay it all out there. If the person across the table doesn’t evoke that vibe, then you need to evict yourself from their office, ASAP. Everything you take (particularly medications like anti-depressants and anti-hypertensives), everything you feel, and everything you don’t feel should be shared. No judgment here.

If you feel more like lying on the couch than lying in bed with your partner, you are not weird, you are not atypical, and you are certainly not alone. Many of us have also gone through this (especially when you have little ones at home). Major life events can take a major toll on your body and your psyche. And while we certainly don’t expect you to post hypoactive sexual disorder on your Facebook page, we do suggest you share it with you GYN. They will have ways to help you work through this time and get you back to your home base. If we don’t know the answers, we have colleagues (a.k.a. sex therapists) who have seen it all, heard it all, and have all the tricks to treating this issue. So, as our girls Salt-N-Pepa liked to say… “Let’s talk about sex.”

Are the Tubes More Than a Tunnel? Their “Connection” to Ovarian Cancer

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For decades, we thought of the fallopian tubes as no more than a plus one. Whether they were the sidekick to the ovaries or to the uterus, they were sort of like the accomplice that everyone overlooked. We did make some noise about damaged or blocked tubes in women who were trying to get pregnant because damaged tubes meant the sperm and egg would need to find another way to meet up. But for women who had let the fertility ship set sail, the tubes seemed like no more than an afterthought. However, times have changed: the tubes have taken center stage. Here’s why.

In order to understand the tube story, you must first hear the ovary story, specifically the part that addresses ovarian cancer and ovarian cancer screening. Unfortunately, when it comes to ovarian cancer screening tests, the ending is not a happy one. The tests either fail to detect ovarian cancers until they are advanced, or they over call benign processes (think simple cysts, dermoids, and endometriosis) as cancers. And while you certainly don’t want to miss an ovarian cancer, you also don’t want to put women through additional testing and surgery that they may not need. Hence, every GYN faces a conundrum when trying to screen for ovarian cancer. How do you avoid missing an ovarian cancer without miscalling something as ovarian cancer? Cue the tubes…

When the news broke that the tubes might play a big role in ovarian cancer (basically, that ovarian cancers might start in the tubes and the endometrium and then spread to the ovary) and that tubal removals (medically termed salpingectomies) could be the answer to early screening and detection, the OB/GYN community erupted in cheers. Could we have found a clue to cracking the ovarian cancer code? For decades, the theory had been that cancer spread from the ovary to the tube. Could it really be the opposite? Evidence suggested that for select types of ovarian cancer this could very well be the case. A breakthrough that could have big-time benefits: if you took out the tube, then you could take out or at least take down the chance of ovarian cancer later.

While the excitement in the OB/GYN community is palpable, neither the American Congress of Obstetricians and Gynecologists nor we are recommending salpingectomies for everyone. Rather, we are suggesting that you view the tubes as more than just an afterthought, that you treat them as more than a plus one. If you are planning to extract your uterus or you are planning a tubal sterilization procedure (a.k.a. tie your tubes), you should have a serious conversation about simply removing the tubes at the same time. Think of it this way: if you aren’t planning future fertility, those tubes will not be missed. And their departure might help you duck out of the way of ovarian cancer.

Ovarian cancer is like the enemy that lurks in the dark. You often can’t see it until it’s too late. And while many have attempted to find some good night-vision goggles (a.k.a. good screening tests), they have repeatedly come up short. Tubal awareness/removal may be the first light in the dark. And although there is still a lot of black and grey in the area of ovarian cancer prevention and early detection, the data on salpingectomies have certainly brightened the situation.

Maybe soon, we will be able to see it all.

Keep on Climbing: The Clomid Stair Step Protocol

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When you have gone through about 40 of those ovulation predictor kits without ever seeing a smiley face, a dark line, or even a hint of a peak reading, you are likely experiencing ovulatory dysfunction. And when you don’t ovulate, you don’t release an egg. If you don’t release an egg, you can’t get pregnant. No matter how wide open your tubes are, no matter how fast your partner’s sperm can swim, and no matter how welcoming your uterus is, no egg = no embryo. However, the good news is that, in most cases of ovulatory dysfunction, if you can achieve ovulation, you have a pretty good chance of getting pregnant. The only trick is finding something to trick your ovaries into ovulating. Don’t worry; we have a lot of tricks up our sleeves!

It’s pretty unlikely that if you are a female between the ages of 20 and 50 that you have not heard of Clomid. The “C” word is often batted around in ladies’ locker rooms, girls’ dinners, or women’s outings. You have almost certainly have had a friend, a coworker, or even a sister who have taken it.  It is one of the most commonly prescribed oral fertility medications and therefore is no stranger to anyone experiencing fertility problems. In fact, Clomid is most commonly used to induce ovulation in women who don’t ovulate (or ovulate as frequently as airplanes land on time at LaGuardia airport!). It can also be used to achieve “super” ovulation (a.k.a. ovulating more than one egg) in women who ovulate regularly but are not getting pregnant. Although Clomid is “super,” it isn’t a slam-dunk. Some women don’t ovulate in response to Clomid and ultimately may require multiple rounds (a.k.a. dosing cycles) of Clomid before an egg is ovulated.

Clomid belongs to a family of medications called SERMs (selective estrogen receptor modulators). And like most families, they don’t agree on everything (or anything)! In some areas of the body, they bind to receptors and exert a pro-estrogen response, while in other areas of the body, they bind to receptors and exert an anti-estrogen response. In women who don’t ovulate, Clomid will bind to estrogen receptors in the brain and alter the release of the hormones responsible for sounding the alarm clock to the ovaries—wake up, it’s time to ovulate! Here are some important bullet points to remember when considering the big C:

Clomid is typically given for five days (five days = 1 round of Clomid); in most cases, it is started on day 2 to day 5 of the menstrual cycle. We can practically hear your next question: nope, it does not matter which day you start! The goal is to start when the ovaries are at their baseline (a.k.a. bottom of the stairs) so that we are most effective in getting a follicle to respond.

Clomid comes in 50 mg tablets. So, simple math: when your doctor prescribes 100mg, you need to take two pills a day; 150mg, you need to take three pills a day; and so on and so forth…. However, like most medications, our goal is to find the lowest effective dose. Although the line in the sand with Clomid can vary based on the physician, most fertility doctors won’t give more than 200mg per day. The reason for the red light at this dose is that, above this dose, you will pretty much only get side effects without much success.

Clomid doesn’t always work (achieve ovulation) on the first attempt (or the first dose). And here are the stats to prove it!

  • 52% of women will ovulate on 50mg.
  • An additional 22% of women will ovulate on 100mg.
  • An additional 12% of women will ovulate on 150mg.
  • An additional 7% will ovulate on 200mg.
  • An additional 5% will ovulate on 250mg.

Those who ovulate at lower doses are much more likely to get pregnant than those who require higher doses to achieve ovulation. When one dose doesn’t work (that is, you come back to your doctor with no signs of a follicle growing or ovulation), don’t despair. You can simply “stair-step” up to the higher dose without missing a step. In these cases, a period brought on by Provera is like a pause. Sometimes, you need them, but oftentimes, you don’t (who doesn’t like a good run-on sentence; let’s face it, punctuation and deep breaths can be way overrated)! While there are certainly clear indications for Provera, it is no longer required between Clomid and/or Letrozole (another oral ovulation induction medication) cycles.

When a specific dosage of either oral ovulation induction agent is not doing the trick (a.k.a. inducing ovulation), you can simply step up the dose. For example, if your doctor prescribes 50 mg (one tablet of Clomid/day for five days), and your ovaries are hanging out in the pelvis saying, “That’s all you got?” you can immediately start a five-day course of Clomid 100mg. And if that doesn’t do the trick, you can proceed directly to Clomid 150mg without passing go. Clomid can be affected by obesity. Simply stated, women who have a higher BMI are more likely to fall into the group of women who either do not ovulate or do not ovulate but don’t get pregnant. Bottom line, Clomid works better in concordance with a good diet and exercise plan.  

Clomid can make you feel like crap. Although most women tolerate the medication without so much of a peep to their doctor, side effects are fairly common. The most frequently reported include mood swings, hot flashes, and bloating. While more serious side effects do exist (visual changes), they are pretty rare. Clomid cannot be given indefinitely. If you are going to see the double line on the EPT stick after taking Clomid, it is most likely to come in the first 3–6 cycles. If it doesn’t happen during this time, it’s probably best to move on to a different type of treatment. Clomid can cause you to have twins. As much as double strollers, double diaper duty, and double feedings seem fun, our goal is one healthy baby at a time. Although the likelihood is fairly low (about 8% of Clomid cycles result in multiple gestations, with the majority being twins), it is important to discuss this with your doctor and vocalize your concerns about multiples early.

Although the stair “master” was designed with Clomid in mind, the same applies to Letrozole (common alternative to Clomid). You can stair step from Letrozole 2.5 to 5 to 7.5 in the same way you do Clomid 50 to 100 to 150. In fact, recent data suggest that Letrozole may in fact be more efficacious than Clomid in getting women to ovulate. Additionally, the side effects with Letrozole are a bit more tolerable, and the risk of twins is lower. So if Clomid doesn’t work for you or your ovaries, there is another staircase that should get you to the same destination!

Who doesn’t love to skip a few stairs on the way up to the top? However, in this “flight,” it’s better to take each step at a time. While the top is ovulation, how far you have to climb to reach it will vary—some may peak with a mere 50mg of Clomid, while others will take it to the top with 150. If you “jump,” you may over respond to the higher dose (#twins). And although it may seem that two is better than one (it would be nice to only have to be pregnant once!), multiples introduce much more risk. Just make sure you are holding on to the banister, walking in a single-file line, and keeping your head up. If you follow these instructions, we can get you to the summit safely!  

Oops, Shoot, Sh-t: What to Do When You Have a Medication Error

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No matter how you choose to say it, either PG or double-X rated, medication errors can make you nuts. Depending on when and where they happen in your cycle, they can cause major anxiety. The fear of knowing if you tanked your IVF cycle can be overwhelming, to say the least! And while some errors can be cycle ending, most are no more than a minor blip (and one that we can fix pretty easily). The best advice we can give you is to take a deep breath, gather your thoughts, WRITE down what you took and when you took it, and contact your doctor’s office. Going on the Internet to see how serious of a snafu it was or panicking is not going to solve any problems. Letting us know and letting us help you fix it will.

As fertility doctors, we give A LOT of medications—both oral and injectable. While the orals are pretty straightforward (most of us have been swallowing pills for the entirety of our adult lives), the injectable ones can get a bit dicey. Sure, you can miss a pill, and that can set you into a panic. But most of the time, we tell you to double up or simply skip what you missed. No harm; no foul. With the injectable ones, there is a little bit more to it. First, you have to learn how to not only inject but also mix medications. Problems on both ends can result in a medication error. Most fertility centers will have you sit through a class or take an online course to review the process. And while there are no grades and no pop quizzes, we recommend that you don’t snooze through this class. It will be important down the road. Often, when something seems to go awry or you are having a memory lapse, going to an online source, be it the fertility clinic site, YouTube, or a Facebook group, can be helpful. It can get you back on course. But again, take it from girls in the know…call your doctor!

Although we don’t want to raise your blood pressure, we don’t want to give you a preview into what might go wrong. Here are the six most common mistakes we have seen:

  1. I gave myself the wrong dose (too much or too little).
  2. I gave myself the wrong medication.
  3. I left my medication out on the counter overnight.
  4. I didn’t mix the medication correctly.
  5. I injected, but a lot of the water leaked out.
  6. I took my medication at the wrong time.

Again, we are not sharing them to stress you out (if you on the verge of doing IVF) but to bring you solace. You are not alone if you mess up—you are certainly not the first to have done it and definitely won’t be the last.

Although we likely won’t be the ones to pick up the phone when you do make that mistake, here is what we would say (in the order we wrote them above):

  1. Most over- or under-dosing (if caught quickly) can be remedied without so much as a hiccup. And while no one wants to be running at half-mast, the ones that make us cringe are the dangerous-, you-can-get-seriously-sick ones—women who have ovaries with tons of follicles are generally put on a low dose of hormones to prevent ovarian hyperstimulation syndrome (OHSS). If they accidentally triple their dose, they are seriously increasing their risk for OHSS.We can usually remedy the problem by reducing the dose, but it’s VERY important to call once you identify the mistake. Most of the times dosage errors happen when you didn’t get the right instructions or dialed up the pen incorrectly (for those formulations using a “pen” to administer). The best way to solve this is to write your instructions down in a SAFE place (not on your crumpled napkin from lunch) and to carefully set that dial. If you are getting an “I dunno type of feeling” when you are about to dial in the dose, phone a friend (a.k.a. your doctor) before you inject.
  2. Many of the medication names read like foreign languages. Most of us have never heard of Follistim or Gonal-F, let alone human chorionic gonadotropin (hCG). Swapping Follistim for Menopur or Gonal-F for Follistim is NO big deal (it’s like drinking Coke instead of Pepsi). However, giving yourself hCG instead of Ganarelix can be a big no-no. Our suggestion to ensure that this doesn’t happen is the following: become acquainted with all of your medications BEFORE the cycle starts. Open up those many boxes, and lay all of the contents out on your kitchen counter. While it may sound overwhelming, it will let you know what you have (and what you don’t have). Check it like you would a packing list with the list of instructions you got at the outset of the cycle. If something is missing, let your doctor know ASAP. Knowing what you have and what you are missing will not only let you prepare for the cycle in its entirety, but it will also make interpreting the daily medicine instructions a bit easier. It will be like hearing a foreign language a couple of times before traveling to that country!
  3. There are a lot of medications that come with an IVF cycle. They can turn your fridge into a pharmacy! Some medications need to be kept in a cold place. Make sure you are aware of which prefer the hotter climates and which like colder ones before you run out and leave all of the drugs on the counter. In reality, unless you are in the Deep South in the dead of summer, even if you left the “cold-blooded” ones out of the fridge for a night or two, you would be totally fine. However, prepping for what goes where will make the organizational aspect of things a whole lot simpler.
  4. Mixing can get people all mixed up! IMs, ccs, syringes, and needles; it’s like a baking experiment gone wrong. And unfortunately, more than one of the medications we use needs to be mixed. Our solution to this is practice—a test run before the big day. It will alleviate a lot of anxiety and clear up some of the confusion. If you are confused by what to mix with what and how much to pour where, make sure to ask before the oven timer goes off!
  5. The leakage effect is all in effect when it comes to shots. There will be water going in and going out after you administer a shot. The out part is usually what gets people freaked out and thinking that they must have done something wrong. Let the leaking go! It is highly unlikely that you lost a substantial amount of the medication in that trickle. Focus on what you did get in and how fierce you are to take shots two, sometimes three times, a day!
  6. Set an alarm clock. Set two alarm clocks. Set three if you need to! Timing for fertility medications is important, particularly for the last shot (a.k.a. the trigger shot). That final injection is timed to precede the retrieval by about 34–36 hours. While being off in the grand finale by minutes is nothing to lose sleep over, being off by hours can be pretty dramatic. Although we can usually match your time to ours, it’s best to be as in sync with our show time as possible.

There are medication errors that matter and those that don’t mean all that much. You won’t know what’s yours is unless you ask. Take copious notes when you get your instructions, and if something is unclear, press pause and ask the person on the other end to repeat. It may save you a major error and some major anxiety. And even if you do make the error of all errors, it was an accident. We all make mistakes—how we handle them is what determines the outcome. Think of it this way: you certainly won’t make that same mistake again!

Pap Smears, Pelvics, and Plenty of Good Advice

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Most of us associate Pap smears with the OB/GYN. A light goes off in our head, usually around the same time every year, that says, “You need a Pap.” After you make sure to get a bikini wax and shave your legs (we do it too, but we promise your GYN does not care!), you book your appointment, and off you go. When you get there, you might be surprised when your OB/GYN, or GYN-O, as we know many of you like to call us, conducts nothing more than a pelvic exam, a physical exam, and a good old-fashioned chat. You may be thinking, has she/he developed a case of memory loss and forgotten that I need a Pap? And although we may be super tired from that delivery the night before (yes, we work a lot of nights!), no, we have not lost our minds. Pap smear guidelines have changed a lot over the past 10 years, and most women no longer require yearly Pap smears. Pap smear recommendations change faster than Kim K changes husbands. It’s sort of hard to keep up. And we don’t expect you to. But what we can tell you is that things have loosened up a lot (unlike Kim K’s clothes!). We are less aggressive with what we biopsy and what we remove. We Pap less frequently, and we watch and monitor a lot more. And while we want to see you and hear what’s up in your life, we want to see your cervix a bit less.

For starters, we no longer perform Pap smears on anyone under the age of 21 (regardless of when they started to have sex). While it is a good idea to visit a GYN at about 15 years of age, Pap smears are no longer part of this visit. Data demonstrated that testing such young women did more harm than good (meaning invasive procedures due to abnormal results that would have gone away on their own). Furthermore, after the first Pap smear (if all looks good), we won’t invite your cervix back for another three years. Pap smears can be performed every three years in women between the ages of 21–30 if they are totally negative. And get this: if you are between the ages of 30–65, your Paps are normal, and your HPV (human papillomavirus) test is negative (called co-testing), then we don’t need to see that cervix for five years! If you opt for just the Pap smear, then we need to see you every three years. While we still want to see you and dish on what happened last year, we don’t need to do a Pap smear if the above guidelines are met. Once you start to collect Social Security (age 65), if you have never had any high-grade cervical abnormalities (HGSIL), you can say adios to another Pap smear. The only time the above rules don’t apply (at all) are women who are HIV+ or have severely weakened immune systems. Furthermore, if your Pap smear has been abnormal and your biopsies have come back abnormal, you will be on a totally different plan.

The screening intervals have been spaced out, not because insurance companies are trying to save money (although that is usually the right answer) but because, in reality, most cases of cervical cancer occur in women who were never screened or who were not screened well—not women who were screened by guidelines. If you follow the rules, it’s very rare that you will get burned. Cervical cancer development is slower than the slowest tortoise in a tortoise-and-hare race. It usually takes years and years and years (about 10) for an HPV infection (the most common precursor) to develop into cancer. In many ways, HPV and cervical abnormalities/dysplasia/cancer are the opposite of the chicken and the egg. While both are always seen together, in this case, we know who came first! HPV, specifically subtypes 16 and 18, cause the majority of cervical issues, including cancer. Interestingly, while most of us will contract HPV in our teens/early 20s (about 70% of sexually active college-age women have or have had HPV), most of us will clear it by the time we hit our middle to late 20s and 30s. Most women younger than 21 will clear the HPV infection in eight months. In fact, the majority of HPV infections have said hasta luego two years after they landed on your cervix.

It is when we hit the big 3-0 that things start to change and the HPV infections that are there are more likely to stay there. It is for this reason that HPV co-testing is only done in women older than 30; by this point, if it is still present, we are way more concerned. HPV testing can also be used to sort out if a mildly abnormal (medical term “ASCUS” on the Pap smear report) needs to be investigated further. If the HPV is positive, the situation is way more serious than if the HPV is negative.

Many of us are grade obsessed, number fanatics, and goal oriented. We are not much different when it comes to our health. So here is what those grades mean. Generally speaking, Pap smear reports can be thought of as negative (a.k.a. normal) or abnormal. This may be the one time you want to be negative! The abnormals are like college kids living in New York City after they graduate. That one-bedroom apartment is subdivided in a million different ways to house many and cut costs. Pap smear reports will report on a bunch of things. However, what you are most likely to hear about are the squamous cell abnormalities (these are the main cells that make up the cervix and can become cancerous!). Squamous cell abnormalities can fall into one of the following categories:

  • Atypical squamous cells (ASCs of undetermined significance = ASCUS or ASC. We cannot rule out more serious abnormalities)
  • Low-grade intra-epithelial lesions (LGIL or CIN 1)
  • High-grade intra-epithelial lesions (HGSIL or CIN 2 or CIN 3).

As you walk up the stairs, the abnormalities become more significant. You are climbing closer and closer to cancer. It is for this reason that the interventions become more and more serious; you may go from an office-based biopsy (medically termed colposcopy) to a procedure where we cut out a portion of the cervix (LEEP or cold knife cone). While Pap smears have the ability to tell you even more than we listed above (such as cellular changes suggestive of an infection, the presence of endometrial cells and glandular cells), these are much less likely. We have backed off big time with the screening, not because we want to see more badness, but because we want to prevent badness. Excisional cervical procedures increase the risk of preterm labor/preterm delivery. The cervix is there, at the end of the uterus, to keep things closed until it’s go time. If there is only a sliver of cervix left, it is going to have a hard time doing its job. By avoiding unnecessary procedures in young women who will most likely clear the HPV infection and the cervical cell abnormalities, we avoid future fertility issues.

Breaking news: if you are young enough (we are not!) to have received the HPV vaccine, that does not mean you don’t need Pap smears or cervical screening. HPV vaccine is like a really good insurance policy. However, it doesn’t mean that you can’t be caught in a bad flood or have a house fire. You still need cervical screening and should follow the same age-appropriate guidelines.

The yearly trip to the OB/GYN is usually met with the same feeling we have when going to the dentist. Yes, you have to do it but are always a little afraid to hear what they have to say. Most of the time, it’s good. You get the all clear and don’t need to worry until the next year. Even if you don’t need that Pap smear, you do need to go to the doctor. While we don’t clean teeth, we don’t check your vision, and we don’t check your hearing, we do make sure that your female organs are A-ok. Make sure when you do get a Pap smear you write down the results and keep it with your most treasured items (Grandma’s earrings, Mom’s ring, your first lock of hair). That way you will not only know what’s up, but also if you move or move away from your OB/GYN, you will know what happened in the past. You don’t need to understand the grades or know when Kim gets divorced and remarried (that is, the Pap smear guidelines change), but you should be the master of your own medical records. It will cut down on a lot of unnecessary testing.

Lighting up Will Make You Lose Your Eggs!

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There are not many things in this world you can be sure of. In the words of Ben Franklin (shout out to all our fellow Penn alums), “In this world, nothing can be said to be certain except death and taxes.” And while we love you, Mr. American, we would like to add a third: cigarettes are bad for you! Despite the Marlboro Man’s best efforts, we all know nothing good can come out of lighting up. The litany of negatives when it comes to tobacco is so long, it couldn’t even fit on one page! Brain, lungs, heart, blood vessels, esophagus, stomach, hands, and feet are all victimized by the tar and tobacco filling that little white stick. While this may have been obvious to you, you may not have known how bad smoking is for your reproductive system.

Simply stated, smoking sucks for your reproductive system. Years of data have shown that smoking can lead to infertility and early menopause. In fact, women who smoke will go through menopause one to four years earlier than nonsmoking women. (Who wants hot flashes, headaches, and vaginal dryness before you need them?) And it seems that, the more you smoke, the more damage you do; with every puff you take, you are not only burning out your lungs but also your egg supply. Additionally, women who smoke are more likely to miscarry once pregnant. The chemicals in cigarettes can damage the DNA (genetic information) inside your egg and lead to a miscarriage. But it’s not only eggs that fizzle in the face of cigarettes; the fallopian tubes also sustain damage. Think of the tubes as tunnels. Their job (most of us have two!) is to transport the sperm to the egg and the fertilized embryo to the uterus. If blocked or damaged, the sperm or egg either never get together, or if they do, the embryo is more likely to get stuck on its way to the uterus. That’s called an ectopic pregnancy (pregnancy located outside of the uterus). Ectopics can be life threatening if not treated appropriately. How and why does this happen? Well, there are little hairs called cilia (we have them in our nose as well) that line the inside of our tubes. Imagine a car wash; think of the wipers that come beating down on the car when the wash first starts. That’s sort of like what the cilia look like, but rather than beating the dirt off your car, they are propelling the sperm to the egg and the embryo to the uterus. If they don’t work, you have a problem.

But get this. Even if you don’t smoke but your partner does, you are also in trouble. There are significant effects on a woman’s fertility from passive smoking (a.k.a. second-hand smoke). The effects of smoking on male infertility are less clear. Sperm function tests are poorer in smokers. There is not clear, conclusive evidence that men who smoke are more likely to be infertile, but given the impact it has on your female partner, guys, we urge you to put it out!

So let’s say you can’t quit and you find yourself pregnant and smoking. Then what? What impact is your habit having on your unborn child? If you have ever taken biology, you probably guessed it: not a very positive one! Babies born to women who smoked are at risk for growth restriction (stunted growth) inside the uterus, small birth weight, early/preterm delivery, stillbirth, and problems with the placenta.

But we get it. Despite all that, going cold turkey can be hard. Habits, no matter how bad, are hard to break. And because of all the “yuck” that is inhaled, it is actually not only okay but preferable to start nicotine replacement therapies (the patch, the gum, etc.) during pregnancy and when trying to conceive rather than continuing to smoke. Yes, they have their effects and are no prenatal vitamins, but they are way better than the tar and tobacco that you are inhaling. There are no ifs, ands, or buts about it, butts are bad for your lungs, bad for your heart, bad for your brain, bad for your skin, bad for your ovaries, and unbelievably bad for your unborn baby. You will burn through your wallet, your lungs, and your eggs. So take it from us. Put out that cigarette, and never pick one up again!