I Am Ready to Race Again; Is It Too Soon? Pregnancy Interval

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For any of you who have competed in a long-distance competition (be it a run, a swim, a hike, or a bike), you know what it feels like to cross that finish line. Total euphoria—combined with a fair amount of exhaustion, pain, and lots of blisters! The first thought that runs through your head, after the “I can’t believe I actually made it” moment is either “When can I do it again?” or “I am NEVER doing that again!”

The first group is already planning their next race, mapping out their training schedule, and thinking about how they could have done it better. While the “Okay, I can check that off my bucket list group” is looking for the nearest bar, a bath, and a bed. In many ways, pregnancy, labor, and having a newborn is very similar to the training and racing of a long-distance competition.

While the “Yes, let’s do it again” and the “No, I am so out” camps in pregnancy and parenthood are more fluid than the participants in long-distance competitions, (hard-core Group B members may move into Group A), people usually have a pretty set idea about how many times they want to be pregnant, how many times they want to give birth, and how many children they want.

Most of us even have a pretty good idea about how close together we want our kids to be (medically termed birth spacing). Whether you want them back-to-back or you prefer to space them apart is a personal decision. But how soon you can hop back on the baby machine is dependent on more than just your feeling ready. It also depends on factors out of your control such as if you had a C-Section or a vaginal delivery, if issues like high blood pressure or diabetes complicated your pregnancy, and if you required any additional procedures post-delivery. These all can hold you up even if your heart is ready to race again.

Regardless of what went down during your pregnancy, the time between delivery and a pregnancy should be AT LEAST 18 months. Any shorter inter-pregnancy interval can increase the chance of preterm delivery, premature placental separation (placental abruption), pre-eclampsia (high blood pressure in pregnancy), placenta previa (particularly after a C-Section), low birth-weight babies, and autism.

While the definitive reason behind why these events occur more frequently is debatable, fingers seem to point towards the “maternal depletion hypothesis.” Pregnancy and the stressors of a newborn takes a lot out of you, and your body needs time to re-fuel and re-energize before it starts the race again. Stressing the system before it is ready to function can interfere with its ability to do its job well.

Among the organs in the body that need a break, the uterus is at the top of that list, especially after a C-Section. The uterus is a muscle, and a muscle that is injured (particularly cut and sewn back together) needs to heal. Without adequate time to heal, there is a higher chance that it will open (a.k.a. rupture which is life threatening to  you and the baby) in the subsequent delivery. Furthermore, women who had a C-Section and want to try for a vaginal delivery in their next pregnancy (vaginal birth after cesarean section=VBAC) need extra-extra time to rest their uterus before it is pushed to push.

You don’t have to decide which group you are going to side with moments after crossing the pregnancy finish line (#delivery). Labor can be long and exhausting. Give it some time before you wave the “Yes, I want another baby” or “No way; I am done” flags. Even if you are raring to go moments after the race is over, give it time before you line up at the next start line. Hydrate, stretch, rest—do whatever it takes to get you ready to go again. The time off will do you good—and your next pregnancy.

How Old Is Too Old? The Age Limit for Pregnancy

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We have all heard the stories, seen the headlines, and talked about it over the water cooler on Monday morning: “66-year-old woman delivers twins,” “65-year-old woman delivers quadruplets,” and most recently, “72-year-old woman delivers baby” (that last one really made us stop in our tracks)! It gets us talking and gets us thinking: How old is too old for a woman to have a baby? Is pregnancy in your 60s really healthy? Is it fair for a child to be born to parents who are 60?

The questions are endless. And although we are not advocating for Congress to raise the age for Social Security or cut Medicare benefits, we do believe (as does the American Society of Reproductive Medicine) that at some point we all must throw in our reproductive towel. Here’s why.

Let’s start by shedding light on how we women in our 50s and beyond (as well as most women in their late 40s) conceive. In nearly all cases, the pregnancies have been achieved with donated eggs. By the time we hit our mid-40s, our egg supply has pretty much gone kaput. And the ones that are still hanging around often lack the ability to make a healthy embryo.

But while the ovaries have waved goodbye to most things fertility, the uterus is still hanging on. It is like that friend you had growing up who could be dared to do anything (you know the kind we’re talking about… “Dare you to eat a worm…”). The uterus is sort of a pushover for anything with estrogen and progesterone. However, like your middle school friend, just because it will do it doesn’t mean it should do it.

There are guidelines released by the American Society of Reproductive Medicine (they’re sort of like the fertility FBI) suggesting at what age people should and should not be pregnant (no matter how willing their uterus is!). This is what they have to say:

“Physicians should obtain a complete medical evaluation before deciding to attempt transfer of embryos to any woman over age 50. Embryo transfer should be strongly discouraged or denied to any woman over age 50 with underlying issues that could increase or further obstetrical risks and discouraged in women over age 55 without any issues.” (ASRM Ethics Committee)

Let us translate. What they are really saying is that it’s okay to attempt pregnancy in women over the age of 50 as long as they have really, really clean bills of health. It is not okay to transfer embryos, no matter how clean their bill of health, if they are over the age of 55. And while they don’t have your phones wired and your Internet tapped, even if you as the doctor or the patient don’t get “caught” doing this, if you violate the rules, you could get hurt.

Pregnancy complications increase markedly as women age. It can be a pretty dangerous nine months for both mother and baby. In medicine, when the risks start to approach the benefits, you have to seriously stop and consider what you are doing. Donor egg pregnancies in women who are above the age of 55 are one of those times. There is an increased risk of pre-eclampsia (pregnancy-induced high blood pressure), gestational diabetes, low fetal birth weight and, in some studies, fetal mortality. Additionally, nearly three quarters of the babies born to woman above the age of 50 are delivered via C-Section—and while we all think of a C-Section as nothing, it is a major surgical procedure.

Pregnancy is somewhat of a conundrum for us doctors. It is the first time and the only time that you have two patients AT ONCE (in the same body!). It is not only difficult medically but also ethically. Donor egg pregnancies in women who are older than 50 bring up the “fair-to-child” debate. This topic is more controversial than who you voted for this election season.

Let’s just say it’s a good thing there are curtains at the polling places and in doctor’s offices—privacy is key! And while medical ethicists could debate this topic for hours (similar to MSNBC and Fox re: presidential candidates) citing studies and data points on both ends, the bottom line is that no one really knows the answer.

There are those who say that it is not uncommon for grandparents to raise grandchildren, to provide economic support to the family/children, and to serve as the parents in a family unit, so what’s the big deal with women getting pregnant in their 50s? Is it sexist to limit a woman’s ability to have a child while allowing older men to keep on keeping on, no matter how old they are? Shouldn’t women be given the same opportunity as men?

On the flip side, there are those who argue that older parents can’t meet the physical and emotional demands of raising a child. And furthermore, there is a fairly good chance that the child will lose one or both parents at a young age—how can losing a parent or parent (s) before adulthood be fair to a child?

It’s a pretty intense debate. And while all the speaking points may get muddled in your head and you don’t really know whose side you are on, what is important to remember is the following: our jobs as MDs is to keep you informed and healthy. If we think something could hurt you, no matter how badly you want a baby, we must hold up a big flashing STOP sign. While we want to make you a parent and help you build a family, our primary duty is to keep you healthy.

When we say no, it is not because we are being ageists, it’s because we are being “aware-ists.” We are aware of what could go wrong and don’t want to see this happen to you. We won’t play truth or dare with your health. Trust us, no dare is worth it.

How Does Food Affect Your Vagina?

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While your diet and vagina may seem unrelated, what you ingest can make a difference in your vagina’s health. Vaginal odor, vaginal secretions, and overall vaginal health can be impacted by what you eat and what you drink. Here’s why….

You were probably unaware that your vagina is home to lots of good bacteria. And while you may never see them or even feel them, these bacteria are far from lazy houseguests. They are working around the clock to keep the vagina healthy, balanced, and acidic. Believe it or not, your vagina (just like your Secret deodorant!) is pH balanced. A normal, healthy vagina, in large part due to good bacteria, is acidic. This acidic environment helps to keep infection and the resultant nagging symptoms at bay. Therefore, when this balance is interrupted, your vagina can go a bit haywire. Here are some tips on what you can eat to keep your vagina in “tip-top” shape!

  1. Sugar: Sugar in many ways is public enemy #1 when it comes to your vagina. It increases your vaginal pH (a.k.a. makes things more basic), making you more prone to yeast infections. And while yeast infections are known for that annoying itchy sensation, they are not only uncomfortable but can also change the vagina’s odor.
  1. Salt: Although we, too, love a bag of potato chips, popping one open before you hop into bed may not be the best idea. Salty foods can decrease blood flow to the vagina—decreased blood flow can lead to decreased sex drive and the decreased ability to orgasm.
  1. Probiotics: There may be no better friend of the vagina than yogurt and probiotics. These items are super important to maintaining the healthy vaginal flora (a.k.a. bacteria) and that acidic pH. Yogurt, kimchi, and probiotics are chockfull of good bacteria. They serve as reinforcements to your own fleet of good bacteria and are essential to maintaining vaginal health.
  1. Vitamin C: Hello, sunshine state! Foods high in vitamin C (think oranges, lemons, and grapefruits!) help reduce inflammation and infection throughout the body (your vagina included). By increasing your vitamin C intake, you will not only ward off that cold circulating around your office, but you will also help protect your vagina from unwelcome guests.
  1. Phytoestrogens: Phytoestrogens are structurally very similar to estrogens. Therefore, they can cause very similar effects throughout bodies. Take that one step further, and eating foods high in phytoestrogens (flax seeds, tofu) can increase vaginal lubrication.
  1. Omega 3 Fatty Acids: Start making your way over to the seafood shop because foods like salmon and tuna, which are teeming with omega-3 fatty acids, are super important for circulation. And increased blood flow is not only good for the heart and the brain but also the vagina. It can help improve sex drive. They also come with the bonus of decreased inflammation, which can translate into decreased menstrual cramps!
  1. Magnesium: And if fish isn’t your speed, make a sharp left for your veggie aisle. Foods high in magnesium, spinach, avocado, and leafy green vegetables also improve circulation and blood flow.  
  1. Oysters: Oysters are no strangers to the vaginal health list. The high zinc content in oysters has been demonstrated to increase sex drive.
  1. Green Tea: While we all know that cranberry juice can help fight urinary tract infections, it is also loaded with sugar (public enemy #1 for the vagina). So if you are looking to ward of those pesky UTIs but not overload on sugar, try green tea. Data shows that green tea may possess the properties needed to fight off UTIs.

   10. Water: Last, we all know that water does a body good, but it also can do your vagina good.        Staying well-hydrated improves vaginal lubrication and maintains proper vaginal pH balance. So keep on chugging that water. Your entire body will thank you!

 

The Retrieval: The “Eggs” Are Cooked!

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After multiple days and nights of shots, several early morning ultrasounds, and endless blood draws, D Day has arrived: it’s time for the retrieval! Your doctor has used the information from these early AM get-togethers to time the procedure perfectly. While the goal is to obtain the highest number of mature eggs (remember, only mature eggs can be fertilized!), we don’t want to risk quality. Therefore, while the shots could go on and on (don’t look so excited!), we stop them when we feel we have hit the sweet spot—the highest number of mature high-quality eggs.

The retrieval (a.k.a. the egg extraction) will occur approximately 35 hours after the trigger/final shot (hCG, ovidrel). The finale of shots and the retrieval are timed so that the eggs have reached their “finale” in maturation when they make their curtain call in the embryology lab!

In nearly all cases, the egg retrieval will take place in an operating room adjacent to the embryology lab. And while it may be cold in there (brrrr, blankets please!), there will be many people ready to make the experience less frigid and less frightening. In addition to the physician, the nursing staff, and the operating room staff, there will most likely be an anesthesiologist present who will administer pain medication to you during the procedure. This will alleviate almost all of the discomfort and erase most of your memory of the procedure. However, because anesthesia will be given, we ask you not to eat or drink anything after midnight on the night of the procedure (a small price to pay for a pain-free experience!).

The egg retrieval is a vaginal procedure; with the help of a vaginal ultrasound, physicians watch themselves as they pass a needle through the vagina into the ovary and ultimately into the follicle. The needle is attached to a suction system which, when activated via a foot pedal, allows the follicular fluid and egg to drain into a tube.

The tube filled with follicular fluid and hopefully an egg is walked from the operating room into the IVF laboratory; an embryologist will be anxiously awaiting its arrival (let the egg hunt begin!). In most cases, the retrieval is pretty short and straightforward and takes no longer than 20 minutes (timing can vary based on how many follicles you have to drain). You will wake up in the recovery room with little memory of the event, asking us when it is going to start!

In many ways, although the egg retrieval feels like the finish line, your journey is only just beginning. And while the stomach/thigh shots will come to a halt as well as the early AM rendezvous, the waiting game has just begun. Much of the real information about egg, sperm, and embryo quality will come over the next several days.

Although the waiting game is the worst, a lot of information will be gleaned during this time period. One word of advice: be aware of the dropoff that will inevitably occur over the course of the next few days. Follicle number does not equal egg number, egg number does not equal embryo number, and embryo number does not equal baby. (LINK: 5 + 5 = 2? The Difference between Follicle Count and Embryo Number) If you are prepared for this dropoff, the loss will be easier. Remember—don’t count your chickens before they hatch!

“I’m Ready for My Close Up” – Preparing for Baby’s First “Screen” Test

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Pregnancy brings with it a battery of tests – not just those that your doctor requests. Sleep disturbances, food cravings, and fatigue may make some of us want to put a “pause” on pregnancy!

One of the many tests your doctor will recommend is baby’s first “up close and personal” – a screening test to make sure baby’s chromosomes (translation – what holds genetic material) and anatomy is a-ok. #babysfirstselfie.

We talked a bit about screening versus diagnostic testing and invasive versus non-invasive tests in our “Gone Shopping” post (LINK). As a refresher, the goal of this screening test is to identify moms with babies who may be at higher risk than normal for certain abnormalities. But, remember, like using an Instagram filter, a screening test doesn’t give us the clearest picture. If your screening test indicates you may be at higher risk for something fishy, your doctor will recommend a definitive test to make the picture crystal clear. Screening tests are “non-invasive” in doctor-speak, meaning a simple blood draw or ultrasound is usually all you need!

As if there aren’t enough decisions to make in pregnancy, there is a laundry list of different methods to screen for chromosomal abnormalities. Your doctor will talk to you about the pros and cons of each and what he or she usually does or recommends.

To prep for that visit, we’ll break it down for you. Let’s start at the very beginning – a very good place to start!

DOES THE EARLY BIRD GET THE WORM? FIRST TRIMESTER SCREENING:

If you want to start the screening early (think 10–13 weeks), you may get a special ultrasound, called a nuchal translucency, and a blood test to look at two markers.

The pros of the method are that you get risk assessment early. The cons are that sonographers must be certified in nuchal translucency scans, and this isn’t the best test to assess the risk of certain structural anomalies, like spina bifida.

GIMME SOME LEG POWER – THE QUAD SCREEN:

The quadruple (a.k.a. “quad”) screen is a blood test done in the second trimester. The combination of these four blood markers assesses the possibility of both chromosomal and certain structural problems.

To be clear, by “structural,” we mean things like spina bifida or other abnormalities affecting the spine. This is assessed with one of the blood tests available (called AFP), but will also be checked for during your anatomy scan, which happens around 20 weeks.

 

STEP BY STEP – USING THE BEST OF BOTH WORLDS:

By using a combination of blood tests in the first and second trimester along with an ultrasound (in some cases), you can get an assessment of your risk for both chromosomal abnormalities and structural problems. This approach is a bit better at detecting problems, but you have to wait until a little bit later in pregnancy to know.

There are a few ways of using this step-by-step approach – integrated, stepwise, and sequential. Your doctor will help guide you on this decision if you choose this method.

THE NEW KID ON THE BLOCK – CELL-FREE DNA:

Cell-free DNA is the most accurate “cell-fi” available (see what we did there?).

This test looks for DNA from the baby’s placenta (the organ your body grows to feed the baby!). Since it will be different (hey – 50% of baby’s DNA comes from someone else!), the test looks for the baby’s DNA and makes sure the chromosome numbers are correct.

While this NKOB is pretty cool, here are a few caveats to consider:

  • The strong suit of this test is picking out those at high risk for three of the most common chromosomal abnormalities – Trisomy 21 (a.k.a. Down Syndrome), Trisomy 18, and Trisomy 13.
  • This test has been most studied in women at high risk of abnormalities, like moms over the age of 35. So, if you’re not one of those high-risk individuals, you may have a higher chance at a false positive, meaning the test might detect a problem when there is none.
  • This test will not assess risks for certain structural defects, like spina bifida.

GREY’S ANATOMY [SCAN]:

Last but not least, your doctor will likely recommend a detailed ultrasound to look at the baby’s anatomy somewhere around 20 weeks. This is considered a part of your prenatal care checklist that is separate from the above blood tests, but we felt it was worth a brief mention!

This bird’s eye view (we just scratched the surface of each test!) of general screening for the baby should hopefully give you a primer for when it’s time to decide what is #truly best for you and baby. And, remember, you’ll have your best supporting actor or actress (your doctor!) guiding you through this process.

The Ultimate Snow Day: What It Really Feels Like to Have a Newborn

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A couple of weeks ago, we were chatting with a friend who recently had a baby. After the routine pleasantries—“He is so adorable,” “You look amazing,” and “How magical is motherhood?”—the conversation got real. We started to dish on the unbelievable fatigue, the shower drain-clogging hair loss, and the daily outfit dilemma (nothing fits my top or my bottom!).

Let’s face it: those first few weeks can be pretty blustery. To quote a fellow member of the new mom club: “That first month is like one long snow day. You hang out in your PJs, you eat lots of comfort food, and you lay around on the couch.” Your days snowball into nights and avalanche into the next day. It’s one big mental blizzard.

And although many of you will bring your little ones home during a heat wave in August, when snow days are far from your mind, you get the concept. It’s that never-ending feeling of being in a daze. Not only are you utterly exhausted, but you are also completely confused: nipple pads, Diaper Genies, and breast pumps. It’s like speaking a foreign language. It makes you want to bury your head in your pillow, pull up the covers, and take a long nap. But you can’t. Motherhood calls.

At some point, you will have to put on regular clothes, you will have to cook yourself a meal, and you will have to leave your apartment. You will have to go back to normal. And finding out how to adapt to that new normal can be tough—it’s hard for even the most seasoned mothers. It’s important to remember that things will be “chilly” when getting your cadence down, but with time, help, and patience, things will get easier.

Take it from us, former members of the new mom “snow day club.” Motherhood, particularly those first few months, will throw you lots of snowballs. Some will land softly, and some will hit you smack in the face. But wherever they hit, you can brush them off and get back up.
The sun is on its way out!

Should They Stay, or Should They Go? The “Ovary Debate”

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The ovaries are many women’s unsung heroes. They not only make the estrogen that keeps your body and brain going, but they also house the eggs that form your baby’s “better half.” Month after month and year after year, they do their job without even a pat on the back or a nod of appreciation. Unless a problem arises (a cyst forms, they stop releasing an egg, or they prematurely run out of their supply), no one pays them much mind.

Therefore, when a woman is having her uterus removed (medically termed a hysterectomy) and the question “Do you want to take or keep your ovaries?” is posed, many of us are not sure what to do. Unlike the “milk and sugar?” question, this isn’t something you’re asked on a daily basis. If you do find yourself straddling the in or out line, here are some pointers to help you make the “ovary in” or “ovary out” decision when you are planning to undergo a hysterectomy.

Think of the ovaries as a professional athlete. They peak in their 20s. After that, things start to go downhill. However, most don’t really hit retirement age until their late 40s. The ovaries hang on for even a bit longer and are producing estrogen and eggs until menopause. After this, things start to change. The estrogen production drops significantly (#helloHOTflashes), and ovulation ends.

The ovaries enter retirement; they are ready to sit back with a good book and watch the sunset. They seemingly aren’t doing a whole lot. But what their presence perpetuates is the possibility of ovarian cancer. If they stay in, there you are, at risk. And while the risk of ovarian cancer in the general population is about 1 in 70, most ovarian cancers are pretty good at hide and seek. They are often not detected until they have reached an advanced stage. This makes them a formidable foe and nobody we women want to mess with.

While the ovaries occasionally play the bad guy role, most of the time they are doing a lot of good, particularly for women who are peri-menopausal. Therefore, taking them out (medically termed an oophorectomy) may cause problems before natural menopause occurs. Issues like heart disease, osteoporosis, and cognitive impairment occur more frequently in women who experience premature surgical menopause (a.k.a. the ovaries come out before they have stopped functioning).

Even after the ovaries have taken their last bow (no more eggs and no more estrogen), they continue to produce hormones (specifically, testosterone) that are important to the postmenopausal body. Therefore, while we used to lump an oophorectomy in with a hysterectomy (sort of like peanut butter and jelly), that’s no longer the case. While removing the ovaries can eliminate your risk of ovarian cancer, it can also add to your risk of other diseases.

Bottom line, before you sign on the dotted line, you should know what you’re taking out—and why. We love widely televised debates as much as the next gal, but the ovarian preservation conversation should be between you and your GYN surgeon. He or she knows your medical history, your family history, and your risk factors for developing cancer better than anyone else. Together, you can create a pretty comprehensive pros and cons list for keeping or taking the ovaries out. Make sure to hash this one out with your doctor before you take anything out. While your vote is important, this is one decision that shouldn’t be made alone.

I Am in the Mood for a Chocolate Chip Cookie…Follicles and Ovarian Reserve.

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Who doesn’t like a good gooey, moist, chocolate-filled chocolate chip cookie? The more chips the better, says every part of your body but your tush! The same can be said for the follicles (and eggs) in your ovaries. The more, the better—at least most of the time!

A big part of the fertility assessment is ovarian reserve. You probably hear your fertility doctor throw this term around like it’s candy (or cookies! ): “Your ovarian reserve looks good!” “Your ovarian reserve is not so good.” You may be nodding and thinking, “What in the world are they talking about?”

Ovarian reserve is the medical way of saying how many eggs you have and what their quality is. While most of our assessment comes from hormones and blood work (cue FSH and AMH), a big “bite of the cookie” comes from our ultrasound. This ingredient is as basic as sugar and flour to making a finger-licking calorie worth its cookie.

An ultrasound performed in the early part of your menstrual cycle (a.k.a. the follicular phase) can tell us a lot about what your ovaries have left to give. Is your bag of chips half full, or are you running dangerously low on supply? By measuring the follicles (a.k.a. “chocolate chips”), we can get a good idea about the egg quantity (a.k.a. ovarian reserve). We call this measurement of follicles your antral follicle count (nicknamed AFC).

An AFC is ideally done on day 2–5 of the menstrual cycle. By doing it early, we can catch you at what we like to call baseline. “Home base” is when we can get the best idea about what is going on in those ovaries because no follicles have yet to start running the bases.

Eggs are invisible (to the naked human eye). It doesn’t matter how high we crank the ultrasound waves, we will never be able to see those eggs unless we bust out our microscopes and speed-dial our embryologist friends. Eggs live in follicles. (Picture a dozen eggs that you would buy in a grocery store—the shells cover the eggs. Unless you crack them, you won’t see them.) We need to count follicles to find out about egg number. Although it is an indirect measure of ovarian reserve, it is pretty on point.

We do a lot of ultrasounds. We can look at the screen and pretty quickly size up those ovaries. But a little baker’s secret for all of you laypeople—the little black circles in the ovaries are the follicles. (Anything fluid filled on an ultrasound will be black). The ovaries are usually grayish/white. So put that together, and what do you get? Bibbidi bobbidi CHEW! You probably get the visual at this point…the more follicles (number of chocolate chips) in the ovaries, the chewier they look. The chewier they are, the more eggs you have!

On the flip side (or the less tasty side), the fewer the follicles and the more white/gray ovary, the lower the antral follicle count. The lower the antral follicle counts, the fewer the eggs. It’s a simple as your most basic recipe!

Surprisingly there are some times when cookies can be just too sweet. You know when you take that first bite, and you think, hmm, I can’t go much further? Well, the same goes for ovaries. There are some with too many chips. Polycystic ovaries can have too many follicles or structures that look like follicles. There is a plethora (think many, many bags) of these small follicles/cysts that can impact the regularity with which you ovulate and your ability to make a baby on your own. It can also lead to elevated testosterone levels and cause all of those unfavorable side effects (think hair and pimples).

Back in the day, women with “PCO ovaries” were routinely taken to the operating room to remove a piece of their ovary to cut down on these small follicles/cysts and all the negative things that they bring.

Just like chocolate chip cookies, we all have brands we prefer. Some of us swear by Duncan Hines, while others of us go for the Nestle Tollhouse. And there are those that are out there and like to make them themselves (go, girl, go!). Whatever your sweet tooth desires, there is something to get it going. Ovaries are the same way. Some of us may have chocolate chips galore while others of us are more like a sugar cookie.

While antral follicle count tells us a lot about what your egg number may be, it does not mean that just because your bag needs to be refilled, you won’t have a baby. It just helps us pick the right ingredients (fertility meds) in the right amount to make your cookie!

Putting Out the Fire: Endometriosis Treatment

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Living in New York City, we don’t usually see those forest fires some of you ladies see out West. While we watch it on TV and read about it on the Internet, those days and days of blazes are something of a foreign concept to us. However, what we have taken away from those images are the hoses upon hoses and the buckets upon buckets that those firefighters must use to quell those flames.

Endometriosis (a.k.a. endo) is to your pelvis as a big forest fire is to California. If it is not put out quickly, it can be devastating. The good news is that, just as the firefighters have many tools in their truck, we too have several potential treatment options.

For women who do not have babies on the brain, there are many “hoses” that can help put out your fire. You have both medical and surgical options. When fertility is not in the near future, shutting your own system off medically with hormonal therapy is no big deal. Most GYNs will recommend that you start basic (non-steroidal anti-inflammatory agents/NSAIDs plus hormonal contraceptives).

Go big only when the fire continues to rage. NSAIDs combined with continuous hormonal contraceptives (continuous birth control pills) are usually pretty good at putting out “smaller fires” (mild/moderate endometriosis). It doesn’t matter if you prefer the oral, vaginal, or skin (a.k.a. patch) route for hormonal treatment. They all work the same, and here, it is more a matter of preference than potency. If estrogen is out because of a medical contraindication (clots, smoking etc.), then progesterone can be given in isolation with NSAIDs.

If this concoction is not keeping your symptoms quiet, we start climbing the treatment ladder. Our next step is usually a GnRH agonist (cue Lupron) combo’d with add-back hormonal therapy (estrogen and progesterone). If this doesn’t bring things to a halt, we usually give aromatase inhibitors (think Femara) a try. The aromatase inhibitors work by decreasing circulating estrogens in the body.  Estrogen is like gasoline to the endo fire. It doesn’t take a firefighter to tell you that it’s probably not a good idea to throw gasoline on a fire!

One treatment is not necessarily better than another. Some just work better in certain people. What is different is how they are administered (oral, injection), how frequently they must be taken (daily, weekly, monthly), and how much they cost (a little vs. a lot!). You have to see what works best for you and your symptoms.

When medical treatment isn’t cutting it, surgery is an option—no pun intended. We try to reserve the bigger guns for the bigger flames; starting with surgery is usually not a good idea. In general, the basic tenant of endo is to max out on medical treatment and avoid repeat surgeries—repeat trips to the operating room do not earn you frequent flier miles. It just earns you a lot of scar tissue, a lot of risk, and a lot of anesthesia. It’s not something you want to do.

If you do find yourself needing to make that trip down the runway, make sure your pilot has been around the block several times—no first-timers here. Endo surgery is no walk in the park; you want your surgeon to be experienced.

Gynecology has gained a couple of new subdivisions in the past few years. There are now GYNs who spend years after their residency learning how to do endo surgery. Their second home is in the operating room. Let’s just say that, when you need a tour, they should be the ones to do it! There are a variety of surgical procedures that can relieve your symptoms. The specifics are above the scope of our conversation, but what you do need to know is the following. Know your surgeon, know why they are doing what they are doing, and know how many times they have done what they are suggesting you do. Trust us; it’s super important.

No two fires are exactly alike. Similarly, no two cases of endo are exactly alike. While for some, pain is the biggest problem, for others, it is GI symptoms. Because of the variability in symptoms, in severity, and in life plans (fertility vs. no fertility), the treatment plan that “puts out your fire” will likely vary. What gets you going or stops your endo from growing may be different than what helped your sister or what helps your BFF.

Although we probably won’t ever treat you, we can recommend that you treat yourself with the utmost respect. Be aware of your symptoms and what makes them better or worse. Have your GYN on speed dial—don’t tell them we told you that!—and tell them when things are not going so well. And while we don’t recommend you ringing them on weekends and in the nighttime unless urgent, you should feel comfortable calling them. If their answers are not cutting it, don’t be afraid to remove them from your contacts and find a different doctor.

Unfortunately, endo is a chronic condition. Once the treatment hoses are turned off, the fire will likely return. After your baby days are done, you may elect to undergo definitive surgical treatment (a.k.a. a hysterectomy and bilateral salpingo-oophrectomy: simply stated, ovaries, tubes, and uterus out) to ensure that you never face another forest fire. Until then, let us help you temporize the flames so that you can fight whatever fires, be it professionally or personally, that you choose to extinguish. There is nothing you can’t put out if you put your mind to it!

Why We Say that IVF (In Vitro Fertilization) Is Therapeutic and Diagnostic…

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What on earth are those ladies talking about? Have they lost their minds? How can treatment tell you more about what the problem is than the diagnostic tests themselves? Isn’t the treatment supposed to treat the problem, not tell you what’s wrong? Yes and no and everything in between. Hold your questions for a moment, because we have answers.

A good chunk of couples today suffer from unexplained infertility. While much of that infertility is thought to be related to egg quality, often times unexplained infertility dodges our current diagnostic capabilities (the tests in our arsenal). No matter what tests we perform on you and your partner, we find nothing. Blood work, physical exams, ultrasounds, sperm checks, and the tube test: they all come back normal. This can be beyond frustrating, for both you and us! We want to give you answers just as much as you want answers. Unfortunately, despite our endless years of schooling, training, and post-training, we can’t.

In many cases, we can’t tell you about your reason for infertility until you go through treatment (a.k.a. IVF) and we take a magnifying glass to your gametes  and embryos.

Yes, ovarian reserve testing (FSH, AMH, AFC) tells us a whole lot. While these tests often help us diagnose the problem (diminished ovarian reserve-low egg quantity) and give us a good idea about how to treat the problem (and how much medication to treat it with), they don’t always tell the whole story. There are many women who have tons of follicles/eggs but have very poor egg quality. However, when their eggs come out and the resultant embryos don’t divide well, degenerate, and don’t make babies, we by the transitive property (woo-hoo, algebra) know a lot about the embryo quality. Furthermore, if such embryos make it to PGS (pre-implantation genetic screening = genetic testing for abnormal chromosome number), the abnormal-to-normal ratio can surprise us and provide even more answers to a previously unanswerable problem.

One of the most interesting parts of our job is to spend time in the IVF laboratory. Watching our skilled colleagues (embryologists) as they manipulate eggs, sperms, and embryos is fascinating. Through our time in their presence, we have learned a lot about infertility, fertility, and the grey in between. Eggs that degenerate, sperm that is abnormally shaped, and embryos that arrest, fragment, and break down provide us with a lot of answers (#diagnosis). If you get pregnant, then it is also treatment.

In many ways, we find answers in the smallest or tiniest members of our crew. It is for this reason that we say, nearly three times a day, that “IVF is both diagnostic and therapeutic.”

IVF is certainly not always the answer, for either diagnosis or treatment. It doesn’t always work and doesn’t always succeed in getting women pregnant. Even when the embryo quality is an A++++ in embryology labs that are not giving triple-A ratings just to get in good standings, IVF can fail over and over again.

We do not have tunnel vision, and we are not afraid to change directions or ask for directions. We want to do what’s best, and if that does not mean IVF or Western medicine or traditional treatments, we are open to trying new things. But just remember, when you hear “IVF” and think, “I will never do that,” and your doctor says, “IVF is not only diagnostic but also therapeutic,” that person has not lost his or her mind! The lab lets us in on a whole lot and in many cases leaves you pregnant!