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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.

The Seesaw of Hormonal Production: Why Your Periods Are Wilder Than the Old- School Wild, Wild West!

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When the arrival of your period becomes more erratic than airplanes during the holiday travel season, you know something is up, especially if before they were like clockwork. Why this is happening and what this all means can be confusing. It can also make deciding if you should wear white jeans very difficult! Most fingers point towards the ovaries and their dwindling supply of eggs and specific hormones: think inhibin, estrogen, and AMH.

As the ovaries start to run on empty, they shoot mixed messages to the brain. The brain, which is used to orderly and steady hormone levels from the ovaries, is thrown into a tailspin. Without adequate ovarian hormone production, the brain overproduces certain hormones. Think FSH and LH. There goes the regularity of your menses. In medicine, we refer to this period of confusion and “crazy” period timing as perimenopause. And to put it bluntly, this period (no pun intended) can be a big pain.

In terms of the brain-ovary relationship, think of a seesaw. As the ovaries (egg production and select hormones) go down, the brain’s hormone production goes up—and in some cases, way up. FSH levels can reach the high double digits. Ovarian hormones and hormones in the brain, specifically the pituitary gland, work in a negative feedback loop—high ovarian hormones keep the brain’s reproductive hormones low. So when you are nearing menopause and the ovarian production lays low, lower, and then lowest, the seesaw will remain lopsided. And while on this seesaw, the person left high won’t get hurt, it will have a major impact on how frequently you see your periods—as well as other things like your internal temperature gauge.

For most of our reproductive lives, the ovaries and the brain work as a team to prepare an egg, ovulate an egg, and maintain the corpus luteum (a.k.a. the structure that makes progesterone and helps maintain a pregnancy). There are some conditions where this system doesn’t run so smoothly—cue PCOS, thyroid disease, or hypothalamic amenorrhea. But for most of us, it is pretty well-oiled machine, that is, until we hit our mid-40s or so. Then the pendulum starts to swing erratically. Periods come closer together (about 20 days) and then farther apart and then close together AND farther apart. Not a pleasant combo.

Consistency becomes a thing of the past. While your mind may view pregnancy as a thing of the past, your ovaries haven’t quite given up. They are still working to prepare and ovulate an egg each month. Because of the diminished supply, they start to prepare the egg in the second half of the menstrual cycle the month BEFORE that egg will be ovulated. Simply stated, they are letting the horse out of the gate (a.k.a. the egg) long before the race goes off (a.k.a. the next menstrual cycle starts). As a result, the menstrual cycles will get shorter and shorter.

Although irregular menstrual cycles are quite common when we hit our 40s and beyond, when bleeding becomes excessive or all of the time, you need to speak to your OB/GYN. While it likely means nothing more than the ovarian reserve fuel tank is running on empty, you want to make sure there is nothing structural (a polyp, a fibroid, or even a cancer) that needs to come out. Don’t brush it off as another joy of aging!

Just like any relationship, when one member of the team goes haywire, things can fall apart pretty quickly. If you are not in sync with your partner, the partnership falls apart. The brain and ovary alliance is no different. When one stops working, the other one tries to overwork or make up for the deficiencies, which leads to irregular and often frequent periods. Although there may be nothing you can do to mend or tame this wild relationship (once ovarian production goes down, it generally will remain down), just acknowledging it can bring you some peace.

And with that, you can go out and face the wild, wild west!

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!

It’s Not You, It’s Me: When Is It Time to Break Up with Your Pill?

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As much as it hurts to remember, we have all been the victims of a painful breakup at some point. Whether it was your high school sweetheart, your first kiss, or the guy whose professions of love sounded convincing after numerous tequila shots, we have all been there.

While some are more painful and memorable than others, breaking up with your pill (or thinking about breaking up with your pill) can be pretty frightening. For many of us, it keeps us pain free, it keeps us headache free, it keeps us acne free, and most importantly, it keeps us baby free. However, when you start to think about having a baby, you start to wonder: could all those years on the pill be doing something bad to me?

Although voices don’t carry over the Internet or through the written word, picture us shouting NOOOOOOO as loud as possible! The pill did not harm your fertility, and the pill is not causing your infertility. The pill did not harm your ovaries or your eggs or your uterus or your tubes. Whether you spent one, five, ten, or twenty years on the pill, it does not matter. Fertility issues arise totally irrespective of the length of time you were on the pill. In many ways, the pill protected you from some of the fertility monsters (think fibroids and endometriosis) as well as some of the other monsters in GYN (ovarian and endometrial cancer).

One of the most common complaints we hear is “I spent so much time on the pill I don’t know what my period is like.” And while this is true, it doesn’t matter so much. Yes, it might have tipped you off to menstrual irregularity before you started to try and led you to stop the pill a couple of months sooner, but in the grand scheme of things, it won’t make a huge difference in your fertility or your future pregnancies.

While you may not know you had something going on, the delay is unlikely to change the outcome. The only time it may have blinded you to important information is for women who undergo an early (a.k.a. premature) menopause. In these rare and select cases, had a woman not been on the pill, she might have seen her cycles becoming shorter and more irregular and therefore sought treatment earlier. However, premature menopause is very, very rare (affecting an infinitesimally small subset of the population). Bottom line, breaking up with your pill to rule this diagnosis out is completely unnecessary.

There have been many amazing developments along the way for women and women’s reproductive rights. Oral contraceptive pills are definitely at the top of this list. And while your friends, your mom, or any stranger willing to give you advice on anything and everything, we want you to stop worrying about how many years of your life you have devoted to this daily ritual; you did NOTHING wrong by engaging in chronic pill use. In fact, you did just the opposite—you were proactive in thinking about your reproductive health. This wise and thoughtful decision definitely gets a double thumbs up.