From Fertility to Menopause: Part II: HRT & The Change of Life

woman_fanDoes this sound familiar to you? It’s 2:00 a.m., and I am wide-awake. I’ve sweated right through my pajamas, and I need to change the sheets. I’m exhausted just thinking about planning tomorrow’s outfit – I’ll need at least four layers just to survive the flashes and make it through a day of work. My joints ache, and I live on Advil. And I can’t remember what was on my to do list.

This is a typical day for a menopausal woman. One year of no menses is the definition of menopause. The years leading up to menopause are called perimenopause, and frequently menopausal symptoms start to occur in those years prior to the last period. And then, many women suffer from menopause symptoms for several years after the last period. All in all, a woman will spend about a third of her life post-menopause.

So, what’s a woman to do, and what should she be concerned about during this time of life?

Vasomotor symptoms & hormone treatments: Hot flashes and night sweats can be very disabling, especially since sleep often gets disrupted. Hormone replacement with estrogen and with or without progesterone can really help a woman cope with these symptoms. There are many different formulations available, and every woman at this stage of her life should have a detailed discussion with her physician to review the pros and cons of using hormones. The main reason that hormones are often recommended is that relief is usually noticeable within two-to-four weeks. These medicines have been very well studied – in fact, they have been proven to be MUCH more effective than placebo at alleviating vasomotor symptoms – and continue to be scrutinized to better understand the risks and benefits.

Additional ways to cope with vasomotor symptoms: Other therapies have been touted to help alleviate symptoms related to menopause, but the data is less convincing. Clonidine is a medicine normally prescribed for high blood pressure that has been shown to improve hot flashes for some women. Effexor, which is an antidepressant, can help as well. Black cohosh is an herb that has been studied; in newer randomized control trials, however, it has not been proved to be better than placebo.

Additional symptoms of menopause: Most women focus on the disabling vasomotor symptoms and brain fog that accompany this time of life, but there are other significant physical changes that can occur from estrogen deprivation that markedly affect the body in negative ways, too. Estrogen deprivation is associated with bone loss and osteoporosis. Age, as well as menopause, contributes to the marked increase in bone fragility fractures. Cardiovascular illnesses and death markedly rises in women post-menopause. By the age of 70, the risk of cardiovascular death in women is equivalent to men, but prior to menopause, women are much less likely to have illness from such disease. Genital atrophy and vaginal dryness, as well as urogenital complaints (i.e., soreness, itching, decreased lubrication, discomfort during intercourse), also increase post-menopause. The central nervous system may also be adversely affected by a loss of ovarian hormones.

Hormone Replacement Therapy (HRT) – the basics: The beneficial action of estrogen is its ability to prevent changes in healthy tissue. It can have profound effects at slowing or halting tissue damage. Starting hormone replacement therapy (HRT) by age 60 or within ten years of the onset of menopause maximizes the risk-benefit profile. The dose of estrogen and progesterone is also important. Lower-dose HRT may be as effective at preventing bone loss and treating symptoms while also being associated with lower risks. Lower doses of estrogen are associated with decreased risk of heart disease and strokes, while higher doses are associated with a lower risk of heart disease, but an increased risk of stroke. The route of administration is also important. Oral estrogen first goes to the liver, thus increasing the risk of blood clots, but non-oral formulations of estrogen have been shown to have no increased risk of blood clots and/or embolism. Ask your doctor for more information on what would work best for you.

Benefits of HRT: If started soon after menopause, estrogen therapy has established benefits reported in multiple studies, including protection from bone loss and osteoporotic fractures and prevention of urogenital atrophy. Additionally, studies have reported lower rates of heart disease, decreased overall mortality, and less fat distribution and wrinkling due to protection against collagen loss. HRT may also be associated with less arthritis, decreased incidences colon cancer, and lower amounts of tooth loss. At the level of the brain, when started early, it has been associated with fewer incidences of Parkinson disease and dementia. Additionally, HRT may help prevent memory loss.

Risks of HRT: Use of estrogen and progesterone is not without risk. Increased rates of postmenopausal bleeding is noted with hormones, and a rise in endometrial cancer has been noted if progesterone in not added to estrogen therapy in a woman who still has her uterus. A history of breast cancer is a contraindication to the use of hormones, as breast cancer may have hormone receptors. The Women’s Health Initiative (WHI) study noted an increase in breast cancer when the combination of estrogen and progesterone was used, but not in women who only used estrogen (i.e., as seen in those with a prior hysterectomy). A large WHI study found an increase in heart attacks, strokes, and blood clots, but the initial results did not separate out the data by age of initiation or by years since menopause. Later analysis revealed that this markedly affected the reported risks of these events. Indeed, in the large WHI study, death rates were increased in the HRT group, advanced breast cancer was increased, and dying from lung cancer was increased, but again this data was not stratified by age. If HRT is started soon after menopause, many cardiovascular events may be prevented and this may affect the data.

Use of HRT is a personal decision that every woman should have with her doctor. The choice of estrogen and the dose should be individualized. Those with significant risk factors such as personal history of breast cancer or strong family history of significant cardiovascular disease or active liver disease may be discouraged from using HRT. For these women, alternatives need to be discussed (and we will do so in our next blog post!)

For more information on menopause and HRT, contact us.

From Fertility to Menopause: Phase I — Perimenopause

perimenopause_womanI just spent a long weekend with some college friends. We are all in perimenopause, which is as big of a mind shift as it is a physical transformation.

From the very beginning — in junior high and high school – the emphasis on how our bodies change was all about fertility. Our teachers and other educators made sure we understood how our bodies were maturing and evolving, and also how important birth control was. As we headed into college, we were inundated with information about contraception. All our focus was on preventing pregnancy.

And then, it was time to start a family, so we stopped using birth control. For some, pregnancy came quickly and easily.  For others, the information journey extended from the Internet to doctors and fertility clinics. Once pregnant, the education focus shifted again, and we were inundated with information on approaches from Lamaze to Bradley, and other childbirth techniques… soon followed by parenting classes.

But then… a drop off in information. The next life phase is perimenopause, and then menopause, and for many reasons – including that our culture glamorizes youth, but often ignores aging – there is a lack of education and understanding about these next phases of life.

It’s just as important to be informed about how your body will change, so here are some key facts:

Changing Menstrual Cycles: You are still cycling, and it may seem like it almost never stops; it is common to have shorter periods, more frequently. A menstrual cycle that is anywhere from 21 to 35 days is normal. Shorter cycles may mean early ovulation – it can be as early as cycle day seven, which may even be the last day of your period. Alternatively, you may be ovulating on time, but making less progesterone after ovulation, so your next period may come sooner than expected.

Considerations: Bleeding more frequently than 21 days from first day to first day of your period usually suggests no ovulation and estrogen withdrawal bleeding. This may puts you at increased risk of too much uterine tissue and abnormalities of the uterus including polyps and possibly precancerous and cancerous spots in the uterus. Be sure to let your doctor know if you experience frequent bleeding.

Contraception: During perimenopause, birth control is still essential. Over 53% of these pregnancies are lost as miscarriages, and if you conceive at the age of 45, there’s a 1-in-21 chance that the baby will have chromosomal abnormalities, such as Down’s Syndrome.  And those statistics continue to plummet as you age; at 48 years old, it’s 1-in-10. The bottom line is that you should continue to use contraception until menopause is over (no menses for one year).

So what contraception can you use?
1) The pill: Contraceptive pills can be taken if there are no contraindications. (Keep in mind that 5% of women on the pill have elevations in blood pressure while taking it; so keep an eye on your blood pressure.). The pill has many benefits during perimenopause:

  • It can control your cycle, stretching it to 28 days.
  • It can lessen the bleeding (which may help if you have developed anemia by bleeding frequently).
  • If you’d prefer to skip menses, certain birth control pills do that, too.
  • If you are experiencing hot flashes or night sweats, the pill should improve that as well.

For some, the regulated cycles that the pill provides also helps tame mood changes (PMS). Keep in mind, however, that for others the pill is associated with chronic PMS-like symptoms or mood disorders, so just like at any other phase of life, the pill may not be for you.

2) Intrauterine Device (IUD): The IUD is another great method of hormonal birth control. It won’t treat hot flashes or night sweats but the IUD will protect that uterus from extra bleeding. In fact, about 50% or more of women who have an implanted IUD don’t have periods, as there is no tissue developing in the uterus to bleed every month. Here are the top IUD options:

  • The Mirena IUD: This IUD should not exacerbate mood swings or negatively affects sex drive – you will still ovulate monthly. And it is even more effective than the pill – it’s 99.9% accurate! It also can help you through menopause, as it will protect the uterus from any estrogen that you may take to combat menopause symptoms.
  • The ParaGard IUD: This IUD is also very effective – 99% — and your periods will come monthly, but they may be heavier than if you used the Mirena IUD, and may also last a day or two longer and be associated with more cramps. If you are already having extra bleeding or irregular cycles, this may not be the best option for you as it may make it worse.

Fibroids & Polyps: If you notice that your bleeding frequency is more than expected, or if the cycle is regular but the flow is particularly heavy, you should speak to your doctor to see if your cycles are indeed ovulatory, or if there is a polyp or fibroid in the uterus that is causing the excess bleeding. Your physician can do an ultrasound to check the uterus, or a water ultrasound to better see the lining of the endometrial cavity (uterine lining). If there are growths, most can easily be removed in a simple, one-day outpatient surgical procedure.

It is very important to remember that too much bleeding during perimenopause may not be normal and should be discussed with your doctor.

Vaginal dryness: This is a common complaint – and I always say for vaginal dryness, a little bit of local estrogen cream can go a long way.  Another option is estrogen tablets, which are placed in the vagina twice a week and work really well.  Finally, using a lubricant during sexual relations is a great way to combat dryness.

Next time we’ll address what to do and discuss with your doctor when menopause truly sets in.

Why I Recommend Preconception Genetic Testing

choc boysRecently I saw a piece on NBC Nightly News about a pair of six-year-old boys, Dylan Siegel and Jonah Pournazarian, who’ve raised over $300,000 for to battle a rare disease that Jonah has called Glycogen Storage Disease (GSD 1b). It’s a beautiful story: best friends since preschool, Dylan wanted to help his friend by raising money to cure his disease, so he wrote a book called, “Chocolate Bar,” and that’s how they’ve raised such an impressive amount of money, with 100% going to research.

What caught my eye about the story, however, wasn’t just the fact that the kids are doing something wonderful and philanthropic – it was the cause itself. And while it inspired me to give to the foundation and encourage others to as well, it also has inspired me to blog about genetic testing.

GSD 1b is a rare genetic disease that occurs in one in a million children, and until very recently, it was always fatal. Luckily for Jonah, there have been great strides in treating the disease, including the discovery that a steady supply of glycogen in the form of a cornstarch solution, delivered through a feeding tube, can sustain him. Still, the regimen is grueling, and even a common cold can be a terrifying health hazard. And while the gene related to GSD 1b has been identified, there is no cure — yet.

We each inherit two sets of genes: one from our mother, and one from our father. There are many diseases that have been identified that are associated with mutations in our genes, including cystic fibrosis, sickle cell anemia, and Tay-Sachs, to name a few. Many of these diseases are inherited in an autosomal recessive fashion: this means a child will develop a genetic illness ONLY if they inherit two abnormal copies of the gene. But just because a parent is well, doesn’t mean that s/he doesn’t carry the mutated gene.

Since the human genome project, and the identification of the DNA sequence in humans, advances in genetic technology are moving at an exponential pace. When I was pregnant with my first child, Tay-Sachs testing was in its infancy. Now all pregnant women are encouraged to consider genetic testing. But what to test for and when?

For years, testing was done by sequencing the gene, and each test was run individually – a very expensive endeavor. For this reason, ethnic profiling was used to determine who should be screened by each test, as genetic diseases are often more prevalent in certain ethnic groups. Also, insurance companies only covered pregnancy; so genetic testing routinely happened AFTER conception. Of course this approach was inherently flawed, as if both of the parents screened positive for a recessive/mutated gene, then the only options available were to test the baby during pregnancy or at birth. If the baby was affected, the couple had two very difficult choices: either terminate the pregnancy or raise a child with a severe disease.

I believe preconception genetic testing and counseling should be the norm. If both parents carry the same mutated genes, then they can decide to take their chances and conceive and test the fetus OR they can choose to test embryos prior to conception. In Vitro Fertilization (IVF) can be performed and embryos screened for genetic diseases. The couple then can choose to transplant only non-affected or carrier embryos and avoid the transfer of a child destined to have this awful disease.  While this may sound like selective eugenics, if couples are offered amniocentesis and termination, then eugenics is already being practiced. And isn’t it easier for a couple to practice selectivity prior to a pregnancy?

As for ethnic profiling to choose who gets screened and for which tests, again technology is paving the way for improved options. Years ago, when the only tests were long intensive screening of each gene, the cost somewhat precluded offering all tests to all women and led to the rise of ethnic profiling in genetic counseling. Today, newer chip array technology has changed all that. Now we can do preconception genetic testing for ALL couples for a fraction of the cost FOR MORE diseases than was ever offered. Today approximately 100 genes can be screened for less money than one cystic fibrosis screening test.  Of course all of this brings up a host of ethical questions.

Should we screen everyone for VERY rare diseases?  Is it necessary to make patients anxious about their genetic mutations if the diseases are not fatal?  It is certainly a slippery slope of choosing genes for a child prior to conception or birth.  And it is my personal opinion that ethnic profiling in genetic counseling is wrong. When cost is no longer a significant factor, I feel it makes sense to screen everyone for all serious diseases.

As a physician, I took an oath to do no harm. If one of my patients were in an ethnic group that typically didn’t need screening for a diseases, such as cystic fibrosis or Tay-Sachs and yet they delivered an affected child, I would not feel comfortable telling her that I could’ve known the risk in advance, but it wasn’t worth testing her. This is not a hypothetical situation: according to the Tay-Sachs Society, more babies born with Tay-Sachs disease are not of Jewish, French Canadian, or Cajun descent, which are the groups traditionally offered testing. Of course a couple always should have the right to refuse testing or decline to act on the test results, but as a gynecologist, I am obligated to inform all of my patients of the available tests.

There are no easy answers in this brave new world of genetic testing. Jonah inherited a rare disease, but his twin brother and older sister did not. For some, genetic counseling can help inform decisions prior to conception; for others, the emphasis should shift to working for cures for these rare diseases. As a doctor, I am committed to staying on the cutting edge of research so my patients can make informed decisions about what is best for their families.

For more about Jonah’s story and to make a donation to help fight GSD 1b, visit

The Cons of Fertility Preservation

frozen eggsIn our last blog post we discussed the pros of fertility preservation. And there are many, as technology has finally caught up with women’s desire to have it all on their own terms and at their own pace. For many women, freezing their eggs when they are young can alleviate the anxiety and urgency related to everything from achieving education and career goals to finding the right match and settling down to start a family.

While all of this can be great, there are several pitfalls and considerations to keep in mind when making the decision to pursue fertility preservation:

1) Freezing eggs is expensive. The $5,000-$10,000 price tag is a hefty sum to come up with, particularly for a young person. And it requires more money and procedures later when it is time to thaw, fertilize, and implant the newly made embryos.  Natural conception is certainly more cost effective.

2) Statistically speaking, pregnancy rates per egg are low. Human biology, after statistical analysis, suggests it takes about 100 eggs to make one baby. That means for each egg there is only a 1% chance of pregnancy. Will women go through five to ten stimulated cycles to ensure 100 eggs are grown, recovered, and frozen? While this is the pessimistic way to view these statistics, it is relatively realistic, too. (Alternatively, if an egg survives the freeze and the thaw and is successfully fertilized via Intra-Cytoplascmic Sperm Injection (ICSI), then there is a 30% chance of pregnancy after an embryo transfer. Pregnancy rates per month in the population are 20% per month at age 25 and drop to 5% per month at age 40. So a positive way to look at the statistics is to recognize that if frozen egg cycles have a 20% success in any one cycle of thawed eggs, then older women do have a better chance at pregnancy using eggs frozen when they were younger.)

3) Eggs don’t always survive freezing. Delaying childbearing definitely impacts the natural ability to conceive. And if a woman waits into her 40s, it may be too late to stimulate the ovaries and use the eggs still available — thus the frozen eggs end up as a failed insurance policy.

4) Eggs and embryos may not be the same after they are frozen. There is data that supports the idea that women who conceive using IVF experience a slightly different pregnancy. There are more preterm births and low birth weight babies. Initial studies also suggest a 1% increase in birth defects in eggs, sperm, and embryos that are cultured in a lab. Other evidence suggests that with IVF and ICSI there may be an increase in “epigenetic defects” (i.e. Angelman and Beckwith-Wiedemann Syndromes), as well as sex chromosome anomalies. Autsim rates may even rise with Assisted Reproductive Technologies (ART).

When only a small percent of the population uses ART for infertility, the numbers of babies affected by this small increase in defects is infinitesimal. But if half the female population avails themselves of technology to delay childbearing, this may affect a much larger percent of the next generation. And these may be unnecessary risks that women are taking—if they had conceived at a younger age, they would not have needed ART.

5) Egg freezing may come at a price to the next generation—and that is an unknown risk. It is important to consider that children born to older parents may find themselves entering early adulthood without their parents’ help, as mom and dad may be dealing with their own failing health due to aging. And more and more young children may be forced to deal with their parents aging and mortality.

6) Egg freezing may be the beginning of eugenics, which opens up a number of moral questions. The science of theoretically improving the human population by controlling breeding is evolving, and as we use technology to conceive and “order up a baby,” our perspectives on reproduction choices are also changing. As Christine Rosen so aptly put it in her recent Wall Street Journal editorial, “The Ethics of Egg Freezing, “A society in which young women routinely freeze their eggs could develop very different attitudes about children and the arc of a human life. The more control we have, the more we expect the end result — the child — to turn out the way we want it to, and the greater the disappointment when he does not.”

The bottom line is we are entering into a new world, and we don’t have all the answers. But there is enough early information that begs equal consideration from each angle: both the pros and the cons.

For more information and to discuss your personal fertility preservation pros and cons, CONTACT US.

The Pros of Fertility Preservation

biological_clockEgg freezing is a boon for women, giving them the option to preserve their fertility until they are truly ready to have a child. The label “experimental” was recently lifted by the American Society for Reproductive Medicine (ASRM) from the title of the procedure; however, it is still debatable how women will and should incorporate the option into their reproductive lifespan.

The following are some of the ways egg freezing can make a positive impact and present a great option for childbearing:

  • For women facing cancer treatments or surgery to remove damaged or abnormal ovaries, egg freezing is an amazing gift to save their reproductive potential.
  • For women who need egg donors to conceive, this procedure may lead to the creation of more egg banks, which will be similar to sperm banks in terms of helping to make using egg donors a less costly and more widely accessible fertility treatment. (Egg banks exist now, but they’re not as abundant, affordable, or widespread as sperm banks.)
  • For women not able to conceive in the traditional sense or not ready to conceive at a young age, egg freezing can be an amazing insurance policy. It allows women to proceed with their educational and career goals without anxiety about their future ability to bear children.
  • Having eggs in the freezer can certainly take the pressure off dating, particularly when a woman is in her 30s, and her biological clock begins loudly ticking. It allows women to enjoy dates without hurrying to find mates.
  • The new technology – flash freezing eggs in a technique called “vitrification” – boasts IVF success rates that are almost identical to using fresh eggs.

In an articulate and insightful Wall Street Journal article by Sarah Elizabeth Richards, Why I Froze My Eggs (and You Should, Too), the author makes a compelling argument for delaying childbirth until she is fully ready, and also reveals how empowering it can be to “truly own your desire to be a mom,” by investing time, money, and physical preparation in harvesting and freezing her eggs. With the pressure off of her “ticking biological clock,” Richards was able to do it all at her own pace. Today, at 42 years old, she is in love with a man who shares her desire for a family, and she is currently trying to get pregnant naturally. And if that doesn’t work by the time she is 44 years old, she is prepared to conceive via IVF with the eggs she froze when she was 36 years old.

While I believe in the benefits of egg freezing, as a fertility expert and doctor, I have some concerns that a generation of women will be sold a bill of goods and perhaps will be disappointed in their 40s when their carefully laid plans don’t necessarily pan out as hoped. The technology is still new, and the implications – both scientific and ethical – have yet to be fully explored.

In my next post, I’ll explore the cons and pitfalls of fertility preservation.

Infertility Factors: Understanding is the 1st Step to Beat the Odds

infertility signInfertility is increasingly a problem in our country. Yet the public isn’t aware of how widespread fertility issues truly are. An estimated 7-15% of the population suffers from sub-fertility. As more and more couples delay childbearing, that number may continue to rise. Well over five million children worldwide have been conceived with the help of medical interventions, and the number of babies born from parents who utilize assisted reproductive technologies is steadily growing. Up to four percent of all children born in the developed world were conceived by In Vitro Fertilization (IVF).

Several factors help explain the rise of couples who suffer from infertility or subfertility:

Social: This includes the increasing age of mothers who delay childbearing for various reasons, including pursuing higher educational degrees and/or advancing careers prior to motherhood. People are also marrying later,  delaying settling down until they have had more life experiences.

Environmental: The planet is changing and there is more pollution and toxins, such as mercury in fish and lead in the environment, that are be poisonous to the gametes (reproductive cells) and growing embryo.

Dietary Changes: The food we consume may affect fertility outcomes.  Processed and prepackaged foods that include few “real” ingredients and instead have filler chemicals, which may deprive the body of the necessary vitamins, minerals, and nutrients that are essential to maximize the quality of gametes and antioxidants.

Medical Illnesses: As the population grows statistically more obese, there are more instances of  metabolic derangements, which occur when medical disorders happen together and cause cardiovascular diseases and diabetes. Health issues including increasing insulin resistance and higher  insulin levels lead women to present with higher testosterone levels, diabetes, hypertension, and ovulation malfunction. This means that fertility rates may also decline. Additionally, obesity may also be associated with a rise in inflammatory markers and these may affect the uterus and its ability to nourish the embryo. Finally, studies have suggested that obesity is associated with a rise in reactive oxygen species, which are linked to a change in hormone levels and a decrease in sperm quality.

Stress: Modern life is so busy. Gone are the lazy days of summer when friends sit around drinking lemonade in rocking chairs and enjoying the afternoon sunshine. Americans don’t take siestas. We race from home to work to gym to “de-stress,” then gobble down a meal, often at a drive through in a fast food restaurant, and then possibly off to a second job or night school for career advancement. We don’t unplug the cell phone, and that allows us to stay connected, 24-7. All of this often leads to fewer up close and personal interactions. Having a baby becomes a job in itself. Aspiring moms must check their temperatures, pee on ovulation sticks nightly and Google, Google, Google about infertility to stay up to date on the newest treatments. Altogether, stress can have major negative impacts on fertility.

If any of these factors describe your world and you are trying to get pregnant, then it may be time to consider making shifts in your lifestyle. Contact us today for guidance and help in increasing your chances in beating the infertility odds.

In Honor of National Infertility Week: Lifting the Taboo from Infertility

infertility_week_post_picAs a young doctor, I quickly learned that some medical conditions were considered taboo. Infertility is a one of those conditions, and couples often suffer in silence. Even though there are many online communities for chatting with others who share their diagnosis, this is often done from the privacy of their living room and under pseudonyms.

When infertility is a secret from close friends and family, walls go up and what the couple needs most – support and true connections – are blocked out. Loved ones may unknowingly and unwittingly inflict more emotional pain as they ask seemingly “normal” questions or make statements that are meant to be kind, but have the opposite effect, such as “all I want for Christmas is a grandchild,” or “stop working so hard and have kids already!”

Slowly, infertility is coming out of the closet, and it’s my opinion that it can’t be soon enough. Like any other affliction, emotional support from friends and loved ones may help with infertility treatments. Hugs and love cannot fix the problem, but they can help with disappointment when a treatment is not successful. Supportive friends can assist with managing medications or appointments. Being honest with your boss allows you to easily visit your doctor, rather than sneaking away or calling in sick on the day of a procedure. Co-workers can pitch in and help decrease the stress of a full workload when you are undergoing intensive treatments.

Nowadays, we recognize how important it is for a woman’s health to have friends rally around to support her in times of medical hardship. Having a meal train, someone to drive you to doctor appointments, and generally surrounding yourself with people who encourage you to take breaks and go easy on yourself is an important part of wellness. I often encourage my patients to get a massage, take a bath, relax, and live in the moment. Worry is a wasted emotion; instead it is important to be mindful of all that you have. A positive emotional state is key.

As a diagnosis, infertility can be as stressful as a serious illness. It can crush self-esteem and may affect feelings of self worth. Infertility is life changing and sometimes it is for the worst, affecting marriages and other relationships. It is important to remember that it is not your fault. Fertility treatments are medical treatments for a diagnosed condition and are not merely elective procedures. And infertility can cause real emotional, physical, and psychological pain. Its by-products can affect your home life, work life, and important personal relationships. And it should not be suffered in silence.

While medical treatments are important, being open and honest with friends and loved ones about infertility is essential. And the opposite is true, too – be aware that your closest friend, coworker or cousin may be suffering in silence, too. Everyone should be mindful of what they say to childless couples, as the cause of them not having children may not be a choice they’ve made, but a medical reality.

And finally, the advice I tell my infertility patients is to embrace the diagnosis and see it as a challenge to overcome and conquer. Consider it a wake-up call to treat yourself more lovingly. Get educated about biology. We can modify our destiny, but we may not always have complete control over it. Still, it’s just an obstacle, and have faith you will find a path to the other side – what is right for you and your family.

Education, honesty, and awareness are the first steps to banishing the taboo forever.

Please share this sentiment with friends and family so they can learn to be more mindful of your condition.

The Ovulation Situation, Part II: The DuoFertility Monitor – As Effective as IVF!

duofertility-monitorYou’ve been trying to get pregnant for while, but despite the fact that all of your tests for fertility are normal, nothing’s happening. You’ve tried to assess your ovulation situation using an app, a kit, and even a watch, with no luck yet.

Before you throw the towel in and pursue aggressive treatments, there is hope: the DuoFertility Monitor. This new apparatus that precisely monitors your body’s temperature has been clinically shown to improve pregnancy rates.

HOW IT WORKS: You wear a sensor under your arm like a patch, and it takes numerous temperature readings each day. The information is then sent wirelessly to a reader, which uploads the data to your computer.

Software on your computer then shows your detailed fertility information on a cycle calendar. You can also sign in and add information about your health or sexual activity to this calendar. All of this rich information is then transferred to the company’s Fertility Center, where experts review it all and make suggestions.

WHAT IT DOES: While using temperature as a predictor of ovulation has been a common practice for decades, the DuoFertility Monitor takes measuring body basal temperature to an entirely new level. It relieves you of the stress of having to wake up every day and immediately record your temperature. And thanks to its ability to gather exponentially more data, its predictive power is much more precise. Best of all, you can let the monitor do all the work – the only time you have to lift a finger is to log into the website to see your profile.

HOW EFFECTIVE IS IT? In Great Britain, where the DuoFertility Monitor was initially introduced, it was offered to couples that had been trying for one year but were not eligible in the UK National Health Service to do IVF yet. (In Great Britain, IVF is done after 2-3 years of trying.) For those couples with unexplained infertility that used the DuoFertility Monitor, pregnancy rates after one year of trying “naturally” were almost as high as IVF success rates: about 30% of couples conceived.

IS DUOFERTILITY FOR YOU? While we don’t recommend that you delay a full fertility evaluation, using the DuoFertility Monitor may be synergistic during the early stages of this work-up. If you have been trying for six months, have unexplained infertility, and all of your tests are normal, talk to us about trying DuoFertility. In this case, you may start using it as your begin your evaluation with us or as you are waiting to visit a specialist, such as a reproductive endocrinologist if you are over 35. In fact, DuoFertility may help us learn more about your cycle and potential interventions that may be used to improve it. And you might just get pregnant before resorting to more invasive methods of conception assistance!

CONSIDERATIONS:  Remember, if your fallopian tubes are truly blocked or if there are no sperm or eggs, natural conception may not be feasible and aggressive treatments may be necessary.

For more information, visit DuoFertility’s website,

The Ovulation Situation, Part I: Cheap & Effective Fertility Tests

fetility_calendar17854217_sThe first time you heard the word “ovulation” was most likely in middle school health class when you learned that once a month a mature egg is released from the ovary, pushed down the fallopian tube, and is ready to be fertilized. That simple textbook explanation made getting pregnant sound so easy that you’ve been a diligent user of contraception your entire adult life.

Until now.

You’re ready to get pregnant, and you realize that you need help figuring out when you’re most fertile. While we’re always here to help advise you, there are also several free or low-cost options on the market that can help you figure out the optimal time for you and your partner to try to conceive.

Here’s a roundup of what’s out there, including how they work and considerations, to help you choose the best option(s) for your needs:

1) Online/App Ovulation Calendars and Calculators: A friend tells you about an app she downloaded on her cell phone that tells her when to expect her period and when she is fertile. And guess what? Your lucky friend conceived within two months! You’re encouraged, but will it work for you?

Cost: Free to approximately $4.99.

How it works: This works great for women with VERY REGULAR cycles, as ovulation calculators are based solely on the calendar and the average of cycle lengths. It does not take into consideration bodily functions or chemistry.

Considerations: If you have variation in your cycles, this is not the best predictor for you. But if you do decide to follow the calendar, remember that usually the steady part of the cycle is the 14 days from ovulation to period (the second half of the cycle). If, for example, you have long 35-day cycles, your ovulation may be as late as Day 21. This means it’s best for you to try to conceive between Day 14 and 21. If your cycles are short, you may be ovulating very early and you should be trying to conceive just when your period ends.

2) Ovulation Detection Kits: If you find the calendar option confusing, consider an ovulation detection kit.

Cost: Approximately $25- $30 per kit. Digital monitors are also available for approximately $150.

How it works: There are many different brands of ovulation predictors; most use urine to detect the luteinizing hormone that stimulates ovulation and the development of the corpus luteum – the so-called “LH surge” – and the sex hormone (estradiol) levels. When the brain/pituitary tells the ovary to release the egg, these hormones rise, and the kits detect a peak level. This predicts the egg will be released in 1-2 days. Some kits are semi- quantitative, so the test line goes from pale to dark. When that test line is darker than the control line, then you know the surge is occurring and you are in prime fertility time. Other kits wait until both the estradiol and LH hormones both peak and tell you with a happy face symbol that it is your optimal time to try.

Considerations: Some people find comparing lines somewhat difficult, and the happy face is an easier alternative. As a fertility specialist, I prefer the kits where you compare the lines, as that lets you know before you peak that fertility levels are rising. Some months, if the happy face symbol doesn’t show up and you wait too long to check out why there wasn’t a happy face, the opportunity to force ovulation is missed or the critical window is never detected.

3) The Ovulation Watch: This is another device designed to help detect ovulation, and it is easy to wear and easy to use – no urine testing necessary!

Cost: $125, which includes one month; $40 per month after that.

Considerations: Since it is easy to wear and you don’t have to test your urine daily, it may be less stressful than the urinary kits.

4) Basal Body Temperature: For years gynecologists have suggested patients take their “basal body temperature” – the first temperature of each day – to chart their cycles.

Cost: Approximately $11 for a basal body thermometer

How it works: You take your temperature the minute you first wake up EVERY morning — even before you brush your teeth or shower! It can provide information about ovulation, as the day you ovulate your temperature drops a degree or half a degree, and after ovulation, your temperature rises a degree.

Considerations: Unfortunately basal body temperature can’t predict when you will ovulate, and it’s often hard to detect the temperature drop on the day of ovulation. Moreover, it can be stressful, as your first thought of the day is a reminder that you are not yet pregnant. For this reason, I recommend that temperature charts not be used for more than 3 months MAXIMUM, as stress and worry may exacerbate infertility.

There are other options to help you track your ovulation (including the Duofertility Monitor, which I’ll tell you about in the next blog post, “The Ovulation Situation, Part II”), but these are the least expensive and a good place to start.

And remember, we’re always here to answer questions and help you access your ovulation situation!

Everything You Ever Wanted to Know About Your Annual GYN Visit (But Were Afraid to Ask)

dr_koop_patientIt’s that time of year again – time to get what you most likely call your annual Pap smear. But there’s more to this important annual visit than just a screening test for cervical cancer (which is what a Pap test is). It’s now considered a preventative visit and is called a well woman exam.

What you may not know is that this important check-up is covered under the new Obama Health Care Plan — with no co-pay and no deductible!

To prepare for this visit, which includes screening tests and an exam of your thyroid, breasts, abdomen, and pelvis, there are several things you can do to help ensure accurate results:

  • Schedule your appointment for when you DON’T have your period.
  • If you think you might be pregnant, let us know in advance.
  • If you’ve had a recent abnormal Pap smear, also let us know.
  • 24 hours before the test, please avoid anything that might affect the state of your cervix, including having intercourse, douching, using a tampon, or even taking a bath.
  • Be sure to empty your bladder before the exam, but do your best to use our restroom, as we may want a urine sample.

During your visit, we do several preventative-screening tests. These frequently include:

  • A Pap smear, beginning at age 21. If you have no history of treatment for HPV in the past and if you are over 30 years old, we may only do a Pap smear every 3-5 years.
  • For patients over 30 years old, a screening to detect the HPV virus.
  • Younger women and women who have more than one sexual partner may be checked for sexually transmitted infections.
  • Additional screening blood tests may be ordered to test for anemia, kidney and liver function, diabetes, cholesterol, and thyroid function.

We also recommend additional tests outside of our office:

  •  For patients over 40 years old, we order a screening mammogram (done at a radiology lab).
  • For patients over 50 years old, we recommend that a gastroenterologist perform a screening colonoscopy.

Your well woman exam is the perfect time to discuss what’s on your mind, including contraception options, or conversely, if you are considering getting pregnant. We may also offer general counseling about how you can lead a healthier lifestyle, with recommendations including diet and exercise.

During your well woman exam, some issues that fall outside the parameters of this annual check-up may arise. While we are happy to briefly address conditions such as vaginal and bladder infections, issues with periods (frequent, too infrequent, or nonexistent), and other potential health issues (thyroid, diabetes, high cholesterol, etc.), we may have to schedule a return visit for additional testing (i.e., ultrasounds, cultures, biopsies, etc.), more extensive examination, and/or a more in depth discussion. If you suspect that you have issues that fall outside of screening and prevention, let our staff know in advance so that we can schedule a separate session to address your concerns. And FYI, there may be co-pays and other charges associated with the diagnosis and treatment of any conditions or illnesses.

After your annual visit, there are a few final things to keep in mind. While a Pap test is an important preventative measure, it is not always 100% accurate. If your results indicate a potential issue, we will explain it to you and bring you back in for a follow-up visit. Also, we strongly encourage all of our patients to familiarize themselves with the new Obama Health Care Plan. With the new laws, insurance companies are changing their coverage. This is a learning process for us, as it is for you. So be sure to double check your bill and let us know if you have any questions as the new health care laws go into effect.