Playing the Lottery: Egg Count

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We’ve all been there before: lying in bed, listening to the local newscaster call out the Powerball numbers, hoping this may be your night! And while you may be a lottery regular, most of us hold out on playing until the pot is big. Really big. And if it gets super big, you might not only buy one ticket, but go in with your officemates for a bunch of them, because the more tickets you have, the better your chance of hitting the jackpot. The same can be said for egg number and good-quality embryos—the more eggs that are retrieved, the better your chance of having a baby!

Whether you’re an IVF newbie or have been through many retrievals, you know that numbers matter. Whether it’s from your fertility Facebook group or your fertility doctor, the numbers are a big deal in the land of fertility treatment. Not only does lower egg count reduce your chances, but also for many women, lower egg quantity is often linked to lower egg quality. For most women, both decline with age, and when low, make having a baby much harder.

Therefore, the more eggs that are produced during an IVF cycle (thank you, hormone shots!), the more embryos that can be created in the lab. The more embryos, the better the chance of having a baby. In many ways, it’s no more complicated than simple math. More leads to more leads to best leads to BABY!

And while the daily shots are no one’s idea of fun, they’re actually pretty essential to the process. The fertility medications serve as the “multiplier” in this mathematical equation—they take what’s already there and make them grow! Without this stimulus, it’s nearly impossible for the ovaries to produce multiple eggs.

So, although it’s fairly unlikely that any of us will even come close to winning the lottery, for many, it’s pretty likely that we’ll win the baby lottery. Because in the egg Powerball, even when you buy only a few tickets, with the right fertility clinic and fertility doctor, you have a serious chance of winning! And while we never encourage cheating, this is one place where a little help counting your cards (a.k.a. your doctor) is strongly recommended. Winning this game requires a strong and supportive team!

No Period, No Problem?

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For many of us, that time of the month is filled with moods, monster breakouts, and mounds of chocolate. We dread its arrival and plan our white pants-wearing days around it. However, if you ever or are now missing periods, this “period piece” is timely. Your period (while off hormonal contraception, remember that no period on the pill is a totally different non-alarming situation) is sort of like the sixth vital sign; it provides a lot of information about the health of your reproductive system.

The arrival of a girl’s first period is sort of a big deal. In many cultures, for many centuries, it has marked the transition from girlhood to womanhood. Historically, it indicated the promise of life, new beginnings, and the start of something. While today the pomp and circumstance around this event are much more hush hush, it is still a very intimate moment shared by mothers and daughters.

And despite the unpleasant cramps and cravings, menses does mark the culmination of puberty and the commencement of the reproductive years. So (playing off the graduation theme), when do you order your cap and gown? When will this process begin? The answer, while seemingly simple, is really somewhat complicated.

Your ethnicity, your family history, your genetics, your weight, your living environment (urban versus suburban), your fitness level, and your stress level all play a role regarding when you go through puberty. In fact, even the century that you live in plays a role in the timing of this event. (In the past 60 years, we have seen a decrease in the age at which girls get their periods.) While the arrival of a period is usually abrupt (wow, what is that?!?), the process that brought this to you actually took years. A period marks the end of the process of puberty.

Puberty encompasses many physical changes (breast development, pubic/underarm hair) as well as cognitive and psychosocial changes (sorry, Mom, for all those wild emotional tirades!). While all these things seem to occur at once, there is actually an orderly transition to this process; increases in a hormone called LH and FSH lead to the production of estrogen. Estrogen stimulates the development of breasts. Androgens from your adrenal glands stimulate the production of pubic and underarm hair (oh joy…get out the razor!). Somewhere in the midst of this, all you have a growth spurt, and then ultimately, your period arrives.

For most girls, puberty begins with the development of breasts at around 10 years (range 8–12). On average, from start to finish, the process takes between 1 and 4 years. African-American and Hispanic females, girls who live closer to the equator and in urban areas, girls who are overweight, and girls whose female family members went through puberty early are more likely to start the process at an earlier age. On the contrary, Asian and Caucasian girls, girls who are underweight, girls who are athletic, and girls whose female family members went through puberty late are more likely to start the process at a later age.

Although that first period marks the beginning of a brave new world, one period does not write the entire story. It suggests that the system has been primed but does not mean it is ready to run on autopilot. Now, while it is quite common for periods in the first two years to be irregular (many cycles during this time period occur without ovulation), after this point, they should start to follow some order. This pattern is not only good for wardrobe planning but also for demonstrating the system has matured.

Regular periods offer a visual that the following systems are a go:

1) About two weeks before the period, ovulation (egg release) has occurred (ovaries: check!)

2) A uterus with an open path for the blood to exist is present (uterus: check!)

3) The signal from the brain to the ovaries has been activated (hypothalamus / pituitary: check!)

Medically speaking, the lack of a period is called amenorrhea (for all you Latin buffs, a- in Latin means without, and menorrhea is menses). When a girl has not gotten her period by age 14 without evidence of breast development or by 16 with evidence of breast development, this is called primary amenorrhea (primary because there has never been a period). When a female has had a period(s) and then they stop for whatever reason, this is called secondary amenorrhea. While some processes can cause both, the causes of the two are usually different.

Primary amenorrhea cases require more detective work and are much less common. They are more likely to be genetic in origin, a sign of poor ovarian development, or a uterine-vaginal blockage (septum)…basically, the rarities of medicine.

Secondary amenorrhea is something that GYNs deal with almost on a daily basis. (Trivia question: what is the most common cause of secondary amenorrhea? Answer: pregnancy!) But aside from pregnancy, common causes are polycystic ovarian syndrome (PCOS), thyroid disease, over-exercise, and stress. Although a few months off from Ibuprofen and tampons feels good, you shouldn’t let this go on for very long without contacting your GYN.

Even though the arrival of Aunt Flo just in time for that weekend beach party is no one’s idea of pleasant, it isn’t all negative. Getting regular periods, while sometimes a pain, can be a plus. It shows us that the system is functioning. While there is absolutely no problem with going on some form of hormonal contraception (pill, patch, ring, IUD) and keeping your periods at bay for a vacation or big work deadline, this is VERY different than not getting period while off hormonal contraception.

Think of the reproductive system as an orchestra. The conductor is the brain, and the ovaries, the uterus, and the fallopian tubes are the instruments. So if the periods abruptly stop or never start, the conductor called off sick, or one of the instrument players have gone on strike, it is our job as GYNs to find out who is sleeping on the job and try to fix it! Although it might be easier to play over the group who’s gone, the music won’t sound or come out right. Periods mean something, and if they stop, someone needs to hear about it.

What Happens in the OR Stays in the OR!

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No matter how excited you are to get your eggs out (#retrievalday), the OR is no one’s idea of a good time. It’s cold, it’s sterile, and everyone is wearing a mask. To make matters worse, your backside is usually baring itself to a roomful of strangers (gotta love those hospital gowns)! And although you won’t remember a whole lot about what happens on that day (thank you, anesthesiologist!), here are the four things you can pretty much count on as you count yourself to sleep!

  1. Identification: We want to make sure you are who we think you are— repeatedly. When it comes to anything medical, particularly egg- or sperm-related, we’re super strict about identification. Plan on us asking you your name, your date of birth, your partner’s name, and their date of birth MANY, MANY times. This is one place that less is not more. Before you have any of the good stuff flowing through your veins, you want to make sure that you’ve been identified by the operating room team, the physician, and the embryologist. No shortcuts here! You want everyone to know who you are, why you’re there, and what you want done with your eggs.
  2. Recognition: You’ll see lots of familiar faces: The staff in the Operating Room generally includes a nurse, a surgical technician, an anesthesiologist, and a doctor (likely your doctor!). Given the amount of time you’ve spent getting your blood drawn and your ovaries checked, you’re probably on a first-name basis with almost everyone in the clinic. But if you’re not and these faces are somewhat foreign, they should introduce themselves. You should feel comfortable (although a bit cold) with the people around you!
  3. Reposition: While you’ll enjoy some Zzzs (again, thanks to your friend the anesthesiologist), we’ll ask you to do some exercise beforehand. And while we’re not talking about Soul Cycle, we do need to position your body so your bottom is aligned with the operating room table. Where you’re positioned on the operating room table will ensure that we can safely extract your eggs and that you can walk out of the office without any aches and pains.
  4. Relaxation: After the formalities have been exchanged (identification, recognition, and reposition) it’s time to go off to your “happy place” of choice. And whether you’re a beach or mountain girl, get ready to be there for the entire 15 minutes it takes your doctor to retrieve your eggs!

MDs love the operating room. It’s part of why we do what we do. But we get that, to most folks, it’s a scary place. And while we’re not likely to convert you into a surgery fan, we can help alleviate some of your anxiety surrounding the procedure by sharing some of our tips. So, take a deep breath, and know that most likely your doctor has done this MANY, MANY times. He or she has this covered. And don’t worry; whatever secrets you share are safe with us. What happens in the operating room stays in the operating room!

A Fishy Situation: Safe Seafood for Expecting Moms

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Eating when you are pregnant can be a tricky situation. What you want and what you can have don’t always jive. Menu choices can become a bit complicated, particularly when it comes to fish and seafood. While we want you to get the good stuff fish has (think Omega-3s, protein, and vitamins), we don’t want you to take in too much mercury. For those of us who are sushi addicts or fish fanatics, you may have to modify what you eat and how often you eat it to make it ok during pregnancy. Here’s how to modify the menu to make fish, sushi, and seafood acceptable during pregnancy.

Simply stated, mercury is not a mother-to-be’s best friend. While you may be close to it after or before pregnancy, during pregnancy (and while breastfeeding), you need to put your relationship on hold. The reason for this temporary breakup is the potential negative impact high levels of mercury can have on your growing baby. Mercury turns into methylmercury, which is a toxin to the developing brain/neurologic system of a fetus as well as the future vision and hearing of a child.

While you can be exposed to mercury in many ways, it is most frequently found in fish, particularly large fish. For this reason, swordfish, shark, king mackerel, and tilefish are totally off limits during pregnancy and while breastfeeding. Fish that is low in mercury (think shrimp, wild salmon, trout, catfish, cod, tilapia, canned light tuna) should be on your table at least once a week. In general, about 8 to 12 ounces (2–3 servings) of low mercury fish/week is recommended. White albacore tuna can be added to the list above, but consumption should be limited to 6 ounces a week.

Fish caught in local waters are a slippery situation. You can check with your state or local health and environmental agencies to find out what the mercury content is, but if there is no answer, you should probably limit your intake to 6 ounces/week.

A discussion about seafood would not be complete without the temperature situation (a.k.a. raw vs. cooked). And while the CDC and the FDA say no to raw fish, this is one area in which we have set sail in a slightly different direction. Although undercooked, seared, or raw fish has a higher chance of harboring a parasite, a bacteria, or a virus, women from other parts of the world have been consuming raw fish for centuries without a problem (think Japan).

Additionally, because most of the fish used in sushi in the United States has been flash frozen before it makes its way to your local jaunt, the majority of parasites and bacteria have already been eliminated. However, while we may let raw fish slide (or swim!), what we don’t deviate on is where you consume this raw or undercooked food AND the type of raw fish you choose to eat.

Make sure you are getting your food from a reputable establishment that not only handles and stores food properly but also serves it soon after purchasing it. Last, choose the low mercury menu choices (a.k.a. fresh or wild salmon) rather than the high mercury options (farmed salmon and the like).

Your taste buds will change faster than your body. One week, you will be obsessed with shrimp, and the next, just the sight of it will make you want to vomit. It’s totally normal. The tides of eating and cravings move fast in pregnancy. Make sure to chat with your captain (a.k.a. your OB/GYN) before you embark on a new food journey. Safety is first no matter where you choose to set sail.

Milk Maid: Are the Benefits of Breastfeeding Bogus or a True Bonus for Your Baby?

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Ah, breastfeeding. What can we say? Just the word, the thought, and the image can engender emotions as variable as night and day, north and south, love and hate. People are very passionate (on both sides of the aisle) about this topic. Remember how much flak that lady took who was breastfeeding her 3-year-old son on the cover of Time magazine? She almost got as much press as Caitlyn Jenner!

For those who have danced the dance before, some recall the experience with fondness and affection, while others remember it with frustration and fury. For those who have not yet even tried, the thought can create both anxiety and excitement, nervousness, and anticipation. Wherever you fall on the breastfeeding spectrum, it is worth a discussion. Why is there so much buzz around this subject, including if you do it, where you do it (who knew a woman breastfeeding her baby would make its way to the floor of Congress!), and how long you do it?

The tides on breastfeeding have changed more than the Atlantic Ocean in hurricane season. In the 1950s, women were given medications that put them in a twilight state for delivery (no memory of the pain, the pushing, and the other glories of childbirth) and given formula to feed their babies when they woke up.

Today, hospitals are jockeying to receive the prestigious “Baby Friendly” recognition where Baby and Mom are never separated (the newborn nursery no longer exists). Lactation consultants occupy the hallway. Breastfeeding classes happen twice daily, and formula is hardly even mentioned. In 1971 only, about 25% of mothers left the hospital breastfeeding. In 2005, this number had risen to 72%. The change has come on the heels of extensive research, which has demonstrated the numerous benefits of breastfeeding for both Mom and Baby.

So what is so magical about that milk? Why is it liquid gold? Breast milk offers numerous benefits for both babies and mothers. The list is long, and at the top is the protection it offers against infection. Buried within the milk are antibodies that strengthen your baby’s immune system. While women are breastfeeding, their babies have a lower chance of infections, including stomach bugs, respiratory illnesses (colds and coughs), ear infections, and urinary tract infections. Additionally, breast milk has been shown to help stimulate the growth and motility of a baby’s GI tract.

And as if the carats of this gold were not high enough, breastfeeding does not just offer short-term gains but also major long-term benefits for your child. The pluses seem to persist for years after the last drop is released; a mother’s milk provides protection against illnesses for the first several years of a child’s life. Fast-forward into your child’s adolescent and adult years, and there is evidence that suggests breastfed babies have a lower incidence of chronic diseases, including obesity, cancers, allergies, diabetes, and even adult cardiovascular disease.

And if you think that’s it, think again. Select studies have shown that breastfed babies may have better vision, hearing, cognitive development, childhood behavior, and stress reduction. But while the list is long, some points deserve more press than others. While the early benefits are clear, the later ones are controversial. Don’t let the fear of what might happen to your child ten years into their life if you put the pump away after six months keep you going. Whatever you have done or will do is better than nothing! And remember, many of us have gotten to the top of the professional ladder and never consumed even one ounce of breast milk. Your child’s success is not solely based on their first diet.

Breastmilk doesn’t just do a baby’s body good; it also does your body good! Breastfeeding hastens your recovery post-delivery (the hormone that produces milk also helps the uterus to shrink back down to its normal size). It helps the weight come off faster (a magic diet pill—we’ll take that!), and it can serve as a form of birth control (at least in the first few months after your delivery).

Some data suggest that women who breastfed have a lower incidence of breast and ovarian cancer as well as a lower risk of heart disease. Lastly, it’s basically free! Formula is not cheap, and babies drink a lot of it! Take the money you saved, and buy yourself something special. You deserve it. Breastfeeding is hard work!

But while breastfeeding may not be right for every woman, it is medically not advised for some women. These include women who are HIV+, HTLV type I or type II, have active untreated tuberculosis or varicella (chicken pox), or have active herpes with breast lesions. Women who are advised to take certain chronic medications that they briefly stop during the pregnancy may also be advised to resume postpartum and not breastfeed. Additionally, women who use illicit drugs or consume excessive alcohol should not breastfeed. Lastly, babies with a condition called galactosemia (inability to break down a milk byproduct) should not be breastfed.

Let’s face it, even the best milk producers amongst us need a break every now and again. An afternoon to pamper yourself or an evening out with friends is important for your mental state and can actually help with your milk production. Making milk is hard work. You need to eat well, drink lots of fluid, take your vitamins, and try your best to get some rest (we understand how hard this is!) Continue to watch your fish intake (like you did during pregnancy), as some are loaded with mercury  (Link: A Fishy Situation). Bottom line: in order to keep the milk flowing, you need to maintain your health.

You’re not a machine, but even machines don’t work without maintenance! In fact, it is estimated that you need an extra 500kcal per day when breastfeeding. And although infant demand (how much your baby wants and needs) is the major factor determining how much milk you produce (some women breastfeed twins, triplets, plus!), maternal stress, anxiety, fatigue, illness, and smoking can all lead to a tapping out of your supply. A little pumping and dumping now and again never hurt anyone or left any baby hungry.

While we are not here to tell you not to try or to stop prematurely, we are here to say, cut yourself some slack. You are not a failure if you didn’t make milk, if you couldn’t get your baby to latch, or if you simply could not do it. Breastfeeding does offer many benefits, but it’s not right, easy, or appropriate for every mother. And that’s ok. No baby was rejected from Harvard because his or her mother did not breastfeed, quit after a few months, or didn’t make the recommended six-month mark.

In an ideal world, we would have an extended paid maternity leave—this time together would be more conducive to continued breastfeeding. But most women don’t get this; shortly after delivery, they must return to work. So we recommend you use all the resources available to you: lactation consultants, breast feeding organizations/stores, websites, and your friends. Many of them will have walked in your footsteps only months before and can be your cheering squad pushing you forward. Their knowledge can benefit you and offer you solutions to a problem that, despite the loneliness you feel, millions of women before you have faced.

It’s likely not a day will go by that you don’t blame yourself for something, feel guilty about something, or think that someone else would have done it better. It’s par for the course. Parenting is a big responsibility. We get it; the thought is overwhelming. But on this journey of motherhood, you will bogey, you will eagle, and sometimes you will even par. We all do. Breastfeeding is only the first putt on the course. Do your best, and the rest will likely take care of itself.

Done and Done! Permanent Contraception

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Most mothers could probably recall the day they found out they were pregnant like it was yesterday: where you were standing (or sitting if it involved peeing on a stick), what you were doing, maybe even what you were wearing. There truly is no other feeling like that of becoming a parent. But when you decide that you are done, there may be no other fear like finding out you are going to be a parent again. How can we afford another child? Where will we live? Can I take those sleepless nights again? And while we definitely don’t have the answers to these questions (trust us, we live in New York City and get the space thing!), we do have suggestions on how to avoid having such things happen. Simply stated, we offer: permanent contraception.

It’s funny, women ask each other the question “Are you done?” all the time. And without more than those three little words, we know exactly what the question means. Are you having more kids? Cutting, tying, blocking, or clogging are common ways to permanently turn the system off. Both women and men can undergo procedures that will make getting pregnant without any fertility assistance nearly impossible (nothing is impossible because all methods, even the forms discussed below, have a failure rate).

The options available to women all center on blocking an egg from meeting a sperm, a.k.a. tying, cutting, or blocking the fallopian tubes. Tubal sterilizations can be done immediately after a woman has a baby, a few weeks after a baby, or years after a baby. When the former is done, a small incision is made below the belly button, and the tubes are found and subsequently cut/tied. When done weeks or years later, the procedure is most commonly performed through a camera (medically termed a laparoscope). The laparoscope is inserted through the belly button, and the surgery is performed through three tiny holes (one in the belly button and two above the hipbone). When done this way, the tubes are most frequently burned and cut (although a clip can also be placed).

Last, GYNs now have the ability to place a spring-like device (think a Slinky) into the fallopian tubes through the vagina. Again, a camera is inserted, but rather than placing it into the belly button, it travels through the vagina, past the cervix, and into the uterus. Under direct visualization, these springs are deployed into the tube; in the months following their insertion, the body forms scar tissue around them. Together, a serious roadblock is formed and it becomes nearly impossible for anything (including those swimmers) to get through. The caveat here is that you need to make sure all systems are a no go before having unprotected intercourse. Therefore, a hysterosalpingogram (a.k.a. HSG or dye test) must be performed approximately three months after the device is placed to confirm that the tubes have become a steel trap. Once the red light is seen, you get the green light for unprotected intercourse.

While women often find themselves in the driver’s seat for permanent contraception, the number of men electing to undergo a vasectomy is rising. Similar to what happens to a woman’s tube, a man’s vas deferens is “interrupted.” The vas deferens (like the fallopian tube) also serves as a tunnel, transporting sperm from the testes to the urethra. So while the path out may be closed after a vasectomy, men who have had a vasectomy are still producing sperm. The testicles go on as usual, producing both sperm and testosterone, ignorant that their hard work is for naught!

The procedure has no impact on a man’s ability to achieve an erection or to ejaculate. The prostate, the ejaculatory duct, the seminal vesicles, and the glands are all functioning as is, and while the ejaculate is devoid of sperm, it is chock full of other products. While post-operatively there is some pain, in most cases a little Advil and Tylenol should do the trick. It’s quick (usually no more than 15 minutes) and can be performed in the office. The biggest point to stress is that, similar to female sterilization, in which spring-like devices are placed into the tubes, a three-month wait period is required before it’s safe to use this as reliable contraception.

If you should have a major change of heart, there are ways to undo the undoable. Fertility treatment has found a way around tubes that have been tied or sperm that has been stopped. Although it requires in-vitro fertilization, IVF allows women a second (or third or fourth) chance if they should want it. In reality, both men and women who have undergone a tubal sterilization or a vasectomy are still producing both eggs and sperm. They are just no longer able to meet up with each other (think being grounded and stuck in your room).

Fertility doctors have the ability to go right to the source (ovary or testes) and get the goods (egg or sperm). So while we recommend you be certain about your decision before taking the leap, remember there is always a back-up plan should you change your mind.