Fertility Meds Made Clear

Trying to conceive can turn into a crash course in hormones overnight, and the medication list can feel like a different language. We slow it down and translate what fertility medications actually do in the body, why midwives still need to understand them even when we are not the prescribers, and how to support patients through the stress that often comes with IUI, IVF, and “why is this taking so long?” moments. 

We walk through the most common reason fertility care starts: ovulation problems. From anovulation and PCOS to the sometimes overlooked conversation about luteal phase length and early progesterone support, we talk about what might be happening on the HPO axis and what clinicians are trying to change with treatment. Then we break down the big names patients hear, including Clomid (clomiphene citrate) and letrozole (Femara), comparing how they work, what side effects to expect, and why practice has shifted toward letrozole for many people with PCOS and insulin-related hormonal patterns. 

We also dig into metformin and insulin resistance, because PCOS is not just “about weight” and fertility care should not be built on shame. Finally, we zoom out to the broader IVF medication lineup, including gonadotropin injections, GnRH agonist or antagonist protocols like Lupron, the hCG trigger shot, and progesterone support. We end with practical safety counseling, including multiples risk and ovarian hyperstimulation syndrome warning signs, plus clear guidance on when it is time to refer to reproductive endocrinology and infertility (REI). 

#FertilityMeds #PathToPregnancy #TTC #NavigatingFertility #PharmacologyForMidwives  #ConceptionSupport #ReproductiveEndocrinology #EvidenceBasedMidwifery #InfertilityCare

Transcript

Life Updates And Health Curveballs

SPEAKER_01 0:03

Welcome to the Engage Midwife podcast. This is Kara.

SPEAKER_00 0:07

And this is Missy. How are you? I'm good. How are you? Oh my gosh, life has gotten in the way, right? This last year. It has.

SPEAKER_01 0:15

And that's yeah, I mean, we're a little late getting this episode out. And it's because life is lifing.

SPEAKER_00 0:22

I we always look at each other in like March, April, May, and are like, what have we done to each other?

SPEAKER_01 0:29

With like commitments and busyness and well, into ourselves, into those real tests and everything. But this year is particularly nuts.

SPEAKER_00 0:40

Well, you have two kids graduating from call one from college, one from high school. Yes.

SPEAKER_01 0:47

My first set of graduating students with my new position in Arizona, which is exciting. Right. I started a new job and sold a house.

SPEAKER_00 0:57

I sold a house move. Survived junior theater season with my middle. Yeah. Uh and now we start like travel season.

SPEAKER_01 1:07

Well, and osteoporosis.

SPEAKER_00 1:08

Well, we already started travel season, right?

SPEAKER_01 1:10

Yeah. Survived um initial treatment for uh osteoporosis.

SPEAKER_00 1:16

Jesus help me.

SPEAKER_01 1:19

We're thankful for um a provider that quickly determines you failed a medication and can move on to something more tolerable.

SPEAKER_00 1:28

Right.

SPEAKER_01 1:29

Yeah. Right.

SPEAKER_00 1:30

Yeah, lots of things. I have I also have another podcast episode idea that we should um dig into and it's lymphatic things.

SPEAKER_01 1:39

Oh, that's a good idea. Write that down.

SPEAKER_00 1:41

Because now I have now I have learned this thing that all so much about lymphatics and um like what that looks like, and that there are actual people who just do that, which is also fascinating to me.

SPEAKER_01 1:52

So I also think I'm wondering. I'm wondering like cancer survivorship in general, right? Like that's a whole thing.

SPEAKER_00 2:02

Well, and what's crazy is like after my diagnosis, we all the people that we know that have come out of the woodwork that have had breast cancer that we didn't know about.

unknown 2:10

Yeah.

SPEAKER_00 2:11

Like lots of midwives.

SPEAKER_01 2:13

Yeah, I just have to mention, um, I lost a friend just in the last month. She was diagnosed and passed within the month of March with breast cancer. And it's really incredibly sad. And just another important part about really thinking about individual individualized care and early detection, and it's just crazy. So yeah. Yeah, this breast cancer.

SPEAKER_00 2:38

I still am in that place where I am like looking at things and like, what the fuck just happened to me?

SPEAKER_01 2:44

Sure. And I think that's gonna continue for a while.

SPEAKER_00 2:47

I and I look at I just I'm like, it's what April? I'm like the last five months, are you freaking kidding me? I know.

SPEAKER_01 2:56

So but maybe we'll set up the you know second half of the year to just coast coast and happiness. Joy.

SPEAKER_00 3:05

I don't know. I you're gonna end this era of kids like graduating, and I'm gonna be coasting into Brooks's senior year. I know, yeah.

SPEAKER_01 3:15

Well, and you have a kid that's like super involved and in all the things, which is awesome. Um, I would not necessarily stretch as far as saying that my children are apathetic, they're just not joiners. Um, and so uh I've probably had the easiest senior year ever for a mom, but um yeah, it's oh yeah.

SPEAKER_00 3:37

The tears, I think every every space of next year will be tearful for me. Not in a sad way, but just in a like overwhelmed, deeply empathetic, like yeah, feeling way.

SPEAKER_01 3:51

It's so being proud. Yeah.

Why Talk Fertility Medications

SPEAKER_00 3:54

So speaking of Brooks, because he is my IVF baby, it's such a good segue into what we're gonna talk about today.

SPEAKER_01 4:01

That's right. Let's talk about fertility and fertility medications.

SPEAKER_00 4:06

Yeah. So we've done a podcast episode on like assisted reproductive technology. We've talked some about IBF and like what that looks like. And then today's episode, we really want to talk about when our patients are trying to get pregnant and what that looks like.

SPEAKER_01 4:23

Yeah. And I think that, you know, as midwives, we do such a good job of supporting people through all kinds of life transitions and diagnoses and that sort of thing. And when it comes to fertility treatments and fertility medications, we may not be the ones that are necessarily doing all the prescribing and we may not be the ones that are, you know, developing the plans of care, but we are oftentimes supporting our patients through this. And this topic came to us because students requested it. So we're excited when we can talk about something that people want to learn more about.

SPEAKER_00 4:56

Yeah, and it's something that you don't get a lot of in school, right? I don't remember really talking about any of this when I was in midwifery school. Yeah. Um, maybe a little like Clomid here, Clomid there back in the day, but that was really like the extent of it.

SPEAKER_01 5:10

Well, and it, yes, I agree. I definitely had heard of Clomid and I knew people that had taken it, but I was not ever in a clinical practice where we as midwives managed any portion of infertility or Clomid management or that sort of thing. But certainly there are quite a few midwives that either work with reproductive endocrinology and infertility or they are prescribing it based on their clinical practice guidelines and that sort of thing. So I think it is worth spending some time, but then, you know, not even, but or just, but if you are supporting patients that are going through that journey, helping them anticipate um what might happen is really helpful.

When Ovulation Needs A Kickstart

SPEAKER_00 5:50

Yeah. I also, after I had my IVF journey, I really remember that my partners used to send me all the people who were pregnant with IVF or like or like IUI patients because they're like, you did this, so you're gonna be way more like you know, in tune with them being very worried. And like that's what comes with having an IVF or IUI pregnancy, right? Is like all of this like additional stress of am I gonna stay pregnant, like all of that. And I did, I took care of a lot of IVF and IUI patients as like a a special bond because you know, when you've done the thing, right? Yeah, absolutely. All right, so what should we start with? What don't we what do you think about like, you know, we we have a podcast on the HPO axis, right? Like what happens and what what can go awry, right, in terms of hormones and what's happening in the endocrine system that really controls fertility. But what let's maybe start with like ovulation, because that's the most important thing that has to do with fertility.

SPEAKER_01 6:52

Yeah, I think especially because we're focusing on the medications today. We've talked, like you said, about the evaluation, we've talked about assistive reproduction, but let's talk about ovulation induction to kick us off. Um, and because anovulation is one of the primary, you know, causes of infertility when we know what the cause is.

SPEAKER_00 7:13

Which, like 30 to 35% of the time, we have no idea why somebody is infertile, but we do know that like female infertility is generally caused by inovulation.

SPEAKER_01 7:24

Yeah, and a lot of times it's caused by PCOS, which we have another podcast episode on that is still timely. I know you'll look back at it, and it was like, I think in our first or second year of the podcast, but it is still relevant and timely. And so go listen to that about PCOS. But yeah, we're gonna talk about what we need to do when we need to kick start that hypothalamus pituitary ovarian axis because we're not getting ovulation from a normal cycle.

SPEAKER_00 7:54

So I just was saying this thing, like when we're thinking about ovulation, you're thinking about PCOS patients who are usually like an ovulatory, right? Right. So people who aren't ovulating at all. Um, and so we have to like give their axis a little like kickstart or a jump, if you will. Um then we also have patients who have oligo ovulation. So think about that. That's like infrequent ovulation. Like sometimes they might ovulate, other times they may not. Um, and so like we want to make sure that we can get them on a regular ovulation schedule in terms of timing. I just talked about the people who are unexplained in fertility, right? It appears as if they may be ovulating, right? But if we give them fertility meds for ovulation, potentially we can increase their chances, right, of ovulating. And then those this little, and I don't know what the percentage is, and Kara, maybe you do, of this little percentage of people who have luteal phase defects.

SPEAKER_01 8:56

No, and to be this is full transparency here. I've been a midwife for how long now? Uh 22 years almost. And I have heard discussion about luteal phase defect and never knew what it was. So I'm hoping that you can tell me a little bit more about it.

SPEAKER_00 9:12

Okay, so what I do know about it, and I have literally only seen this in one patient in 20 some odd years, is that we know that the luteal phase should be 14 days in everybody, like no matter what, the most constant how long the corpus luteum cyst will last, right? Yeah. And so what generally happens is like people in the normal population, I think it's about three or four percent. I actually, when I was saying that earlier, I was thinking it's probably less than 5%, right?

SPEAKER_01 9:42

Yeah.

SPEAKER_00 9:42

Um, and when you have luteal phase dysfunction, you have a higher incidence of recurrent pregnancy loss, right? Okay. Um, and so what ends up happening is it's a shorter luteal phase, less than 10 days. And what we know about the corpus luteum cyst is that it produces progesterone. And because the luteal phase is shorter by four days, then they have a low progesterone. Then they can't, their pregnancy isn't as well supported because there's not as much progesterone until the baby starts to implant and get a placenta.

SPEAKER_01 10:16

Well, and that makes sense when we think about the timeline of if ovulation is occurring and then we have fertilization out in that outer third of the oviduct or the fallopian tube, and then we know that it takes about eight to nine days post-ovulation before we have implantation, we're having it doesn't have a chance to get embedded or implanted before the cycle starts over again.

SPEAKER_00 10:40

Yep. And so luteal phase dysfunction is really a dysfunction of the corpus luteum cyst.

SPEAKER_01 10:45

That's silly, silly goose.

SPEAKER_00 10:47

Yeah, right. And so when people have recurrent pregnancy loss, I'm always thinking like, as soon as you have a positive pregnancy test, like day one that you've missed your period and your test is even the faintest bit light, I want to know what your progesterone level is. Because if your progesterone level isn't good, you could have luteal phase defect. And the only way we save a pregnancy like that is to immediately start progesterone supplementation. And um, and then we're able like, but what ends up happening is people just don't contact us. They're like, oh, I have a positive pregnancy test, but then I miscarry it five weeks, or I miscarry it five and a half weeks. And that's because they didn't have progesterone support to carry them through those first very early weeks.

SPEAKER_01 11:29

This makes sense to me now because I, you know, I've always said that progesterone supplementation was kind of controversial. Um, but in these few situations, it sounds like it would make sense, but we can't, I mean, we throw progesterone at a lot of people and we hope that it'll stick. But if they do have a corpus luteum defect, that makes sense.

Clomid And Letrozole Demystified

SPEAKER_00 11:50

Yeah. So that's the big reasons. Those are the big four about why we would need like help with ovulation induction. Now, what we're hoping in terms of the luteophase defect is that stronger ovulation or a higher probability of ovulation gives you a stronger corpus luteum cyst and better production of progesterone. But I don't know the research behind that exactly as to say whether or not that is actually like a super valid reason to use an ovulation inductor. But anyway.

SPEAKER_01 12:22

Okay. So let's talk about the two main players that we talk about when we talk about ovulation induction. And both of these are oral medications. But let's start out with kind of, you know, the classic, the old school clomid, which is clomethane citrate. It is a selective estrogen receptor modulator or a CERM, S E R M. Um, and it kind of tricks the blank the brain by blocking estrogen receptors in the hypothalamus. And so the brain thinks that estrogen is low, and so it releases more FSH and LH and stimulates the ovaries to grow follicles and release them. So again, it's a selective estrogen receptor modulator because it's tricking the brain into thinking there's low estrogen levels.

SPEAKER_00 13:12

That's pretty cool. I love it when drugs kind of like tell us what they do.

SPEAKER_01 13:17

Yeah, exactly. Exactly. So um the other medication, just so we name them both, and then we can talk more about each of them, but the other one is letrazole, which is also called FEMAR, and it is an aromatase inhibitor. And it stops the conversion of androgens into estrogens. So the systemic drop in estrogen triggers the same FSH and LH surge as clomyd, but it often results in a more natural, like single follicle growth, where with clomid, sometimes we get multiple follicles being developed and grown.

SPEAKER_00 13:54

Pretty cool. I would know a little thing about aromatase inhibitors. Yeah. Used in different for different reasons, different causes. Different reasons. So so back in the day, I think we used to use a lot of Clomid. If we were going to do something for patients, it was like a Clomid was the drug that we picked. But I think that we've seen a shift, especially in patients with PCOS, to more a different approach in terms of using which drug to use. And now we're starting to use more letrozole.

SPEAKER_01 14:26

Yeah, it has better outcomes overall, meaning more live births, but we also avoid some of the complications that Clomid had by doing that super ovulation or multiple follicles. Um, so just a little bit better outcomes with letrozole. And I think it's easier tolerated by patients as well.

SPEAKER_00 14:44

Yeah, I like I said a little bit ago, like Clomid is like the old standby, like the old guard, right? But it can sometimes cause some symptoms that are unpleasant. Crankiness. I love the word crankiness because it's like, I'm generally cranky. I don't need drugs to tell me that I need them cranky. But cranky, it can cause hot flashes that all should track, right? With um how the drug works in terms of like what kinds of symptoms that it causes. Where letrasolts tends to be a little bit more precise and has fewer side effects. So fewer of those like gross, maybe feeling perimenopausal side effects.

SPEAKER_01 15:28

Yeah, yeah. Um, I always, you know, we talk about visual learners and different types of auditory and all of those sorts of things, but I think sometimes trying to imagine how this is all playing together is kind of helpful. So if you think of the brain like a control center and your ovaries are the garden, right? The to get a flower to grow or an egg to grow, the control center has to send out growth signals to the ovary. And usually that control center, the brain, looks at how much estrogen there is in the body to decide when to send that signal. But clomid um kind of is a blindfold and letrozol kind of is kind of the kitchen that shuts things down. So you talked about these side effects. Let's talk a little bit more about how clomid could cause overgrowth. We could have lots of flowers in the garden.

SPEAKER_00 16:31

Um resulting in what? What does that what happens when we have too many flowers in the garden?

SPEAKER_01 16:37

Well, sometimes we get um a bouquet rather than a single roast. How's that?

SPEAKER_00 16:44

Yeah.

SPEAKER_01 16:45

But we can also make the garden just kind of feel like a mess. How you said cranky. Cranky is a cranky. Um so if you think of the control center and it's looking for estrogen, right? We said it's always wanting to know how much estrogen it is. Um, and when the eyes, you know, when it's looking and it sees enough, it stops sending growth signals. Clomid basically acts as a blindfold on, you know, looking. So then the brain, the control center can't see that there is any estrogen. And so it just pumps out. Grow, grow, grow, grow, grow with follicle stimulating hormone and LH. And that makes big, healthy ovaries gardens full of eggs. Um, and you're hoping that at least one of them will pop out, but sometimes you have a chance that maybe more than one will. So that's kind of how the control center in the garden works with Clomid, where letrozole, instead of wearing a blindfold, the letrozole goes like to the kitchen of the body and cooks up estrogen and then tells the chef to take a break for a few days. So it stops the body from making estrogen for a little bit because it's like, hey, I got it. I'll take over. Chef, get out of here. We don't need any more. And the body then the control center says, okay, we're out of estrogen, and it sends that gross signal to the ovaries to get things moving again. But it's a little bit more precise than completely blindfolding the brain or the control center. So I like how you talked about the old reliable and the new favorite. Those are great ways to describe Clomid and Letrazole.

Metformin PCOS And Insulin Resistance

SPEAKER_00 18:21

So I think like maybe the other piece of this is outside of like the Clomid and Letrazol, which seem like the big obvious things, right? The things that we would do that are very like hit you in the face. Like, of course, you would do those things. It's important to really like talk about the metabolism. And one of the things I can talk to, and you can talk to too, because of Julia's experience, is um that metabolic connection with PCOS that has to do with like insulin resistance too.

SPEAKER_01 18:48

Yeah.

SPEAKER_00 18:48

So another drug that we might not think of as necessarily as a fertility drug is metformin. Yeah. Yeah. And um with PCOS patients in particular, they have a really high insulin level. And that tells the ovaries to make extra testosterone. That should make sense to you when you think about PCOS and all of the symptoms that go along with PCOS, right? Abdominal obesity, hercytism, all of that is from that extra testosterone. But that can also like make the ovaries sleepy and make them not want to ovulate. And so metformin can actually be something that we use for patients. It's for a lot of things. It can be for like decreasing their insulin resistance, like stabilizing their blood sugars, losing weight, right? Yes. Um, and all of those things in combination then can also allow people to get spontaneously pregnant.

SPEAKER_01 19:43

Yeah. Yeah. Well, and I think I think both of us have taken metformin in our lives as well. And, you know, what is the big thing that we have to remember about metformin?

SPEAKER_00 19:54

Oh, the GI upset.

SPEAKER_01 19:57

Yeah. So it's interesting. It doesn't really necessarily like have such a direct impact on your blood sugar in the moment. It just makes your insulin work better, right? Like insulin resistance, taking metformin makes the insulin work better, less resistant. Um, but it, oh gosh, it can do a number on your belly. So a lot of times we're dosing it kind of like slowly working our way up to the dosages that are effective. Sometimes we have to back back down as people have GI upset. Um, and then obviously, as with most medications, if we have extended release available, that is usually more well tolerated than having to take just, you know, the regular dosing more frequently through the day.

SPEAKER_00 20:41

I mean the GI thing, right? Yeah.

SPEAKER_01 20:45

Or belly girls too. Like, I mean, yeah. Give somebody something that's gonna upset their belly and it's going to.

SPEAKER_00 20:53

Yeah, it's going to for sure. So I think that there are other like ways to talk about like how our hormones get sort of wonky or sideways. So we just talked about insulin resistance, right? Yep. And um, like the analogy is that with insulin resistance, like imagine that your cells are like little tiny houses, right? And the houses need fuel, so they need sugar. I always say to people when they're on like low sugar diets or no sugar diets, I'm like, your brain cannot function without sugar.

SPEAKER_01 21:24

No, my brain needs a fair amount, it's working hard.

SPEAKER_00 21:27

Like you have to have sugar because your brain needs it. So if your cells need sugar, right? Your cells need that to like keep the lights on and keep everything running, right? So our bodies make insulin and insulin as a key to these doors, right? It you its only job is to open the front door of the house, unlock them, and let the glucose inside. Yeah. Right. So, but just like with all old houses. The locks on these doors are sometimes sticky, right? So that's insulin resistance. If that lock is rusty or sticky and the insulin can't get in, that's when you are insulin resistant. And when the body is like, oh my gosh, I can't get the fuel I need because it can't get in, right? It just like sits in your bloodstream, right? And that's what causes your blood sugar to be high.

SPEAKER_01 22:24

Yeah.

SPEAKER_00 22:25

So it's like this whole idea of like insulin unlocks the door so that glucose can come in. But if glucose can't come in, it's just gonna sit on the outside. And so that's the just the idea of why how like insulin resistant works, resistance works in the body, so that um you can kind of get a better idea of like how some of these drugs facilitate, you know, those physiologic processes.

SPEAKER_01 22:52

Yeah.

SPEAKER_00 22:52

But like testosterone as well. Do you want to talk some about testosterone?

SPEAKER_01 22:55

Yeah. I mean, you talked about how the brain likes sugar, right? The really interesting thing is that the ovaries love them some insulin. So crazy. This is why insulin resistance has such an impact on what's going on in the ovaries. But these ovaries love those insulin keys. But when there's too much, then they can see all those extra keys and they get excited because they're like, oh my God, here comes all this insulin, and they're so pumped about it. And instead of pumping out the normal hormones, the ovaries start pumping out testosterone instead. They get a little confused. They're in their excited state, they get confused and they start pumping out testosterone instead. And that is, it can be okay, but in people that have PCOS, and this is what we often see with people that are having these high testosterone levels, they can have the hirsitism, they can have acne. It impacts obviously their ovulation. And that's why they can have a lot of really pesky side effects, but also it can certainly impact their um fertility. Really interesting.

SPEAKER_00 24:00

So, like going back to that idea of metformin, it's working on both of these things, right? It is working on letting letting the insulin in so that glucose can get into the cells and not staying out, right? Yeah. And it's fixing the idea that the ovaries are like feeding, right, on that extra insulin when they can't get in. So it's working kind of on both sides of that um analogy.

unknown 24:30

Yeah.

SPEAKER_01 24:30

And you know, I think why this is really important to understand this physiology and pathophysiology is that it can remove some of the blame from patients. Because how many people that have PCOS are just told to lose weight? And if they just had a better diet and if they just took better care of themselves, then they would ovulate and they wouldn't have all these, you know, pesky side effects. And I think the really great thing is understanding that this is a metabolic condition. It does have a lot of familial um characteristics. There are some behavioral characteristics to it too. But let's take away some of the blame and help these people understand the physiology and why treatment is so helpful and why treatment is necessary. People, I hate the word compliance, but they're much more likely to take the medication, tolerate the medication when they know why it's working.

SPEAKER_00 25:20

Yeah. I the blame thing is so interesting too, because women are almost always when they're overweight, getting not so much shamed, but like ignored when they have health complaints because they're obese, right? Or if you just lost weight, you could have a baby. Or if you just lost weight, your blood sugar wouldn't be what it is. Like none of that is true. Um, I mean, you know as well as I do, like I have two diabetic parents. I am not overweight, and my blood sugar and my insulin level and my A1C suck because I have this genetic predisposition to the idea that like insulin doesn't like work like it's supposed to in my body. It's probably never going to. Both my parents are on insulin, right?

SPEAKER_01 26:07

Yeah, yeah.

SPEAKER_00 26:09

So even like if I was overweight, it'd be like, oh, well, if he just lost weight, right? That's not it. That's just not it. And so I when we're talking to patients about their insulin resistance, I think it's better now to leave weight out of the conversation and talk about physiology and why things may not be working, because then it opens up a different conversation about treatment that is not weight-based.

SPEAKER_01 26:42

Yeah.

SPEAKER_00 26:42

Yeah. And you know, there's tons of literature about weight bias and what happens in healthcare with weight bias and especially with women, right? But I do think that if you can really talk to patients about physiology and about what how these medications work and like take the blame off of their weight and put it more onto that metabolic process, um, I think it's helpful.

IVF Meds Beyond The Basics

SPEAKER_01 27:03

Yeah, absolutely. Absolutely. So we've talked a lot about when we need ovulation induction, but there's other types of medications that can go along with IVF and assisted reproductive technologies. There's different medications that may be offered to our patients at different points in their cycle or trying to encourage a healthy pregnancy. And so I think it's worth talking about what some of those other medications are. We're not going to go in depth, but at least we can talk a little bit about um why they might be used and what they are. Does that sound good? Yeah.

SPEAKER_00 27:40

Yeah, absolutely.

SPEAKER_01 27:42

Okay. So I think the first one is our gonadotropins. And if we remember, those are FSH and LH. And we can have these in injections. And so things like um, I think it's called gonal or gonal F, bolastem. I've definitely heard that name before, or Mini Pure. Um, and they are direct hormones that tell the ovaries to grow many follicles at once. Makes sense. FSH is our follicle stimulating hormone, right? And LH is our lutinizing hormone. Okay, what's our next one?

SPEAKER_00 28:16

The next one is the G and RH agonists or antagonists, right? So this is lupron. Um, these things are the ones that put on the brakes. Yep. And when I say when I saw people we're gonna give them like lupron, lupron is generally something that we give people who have like abnormal or dysfunctional uterine bleeding because it like literally tells your HPO access to just like shut down. It is like forced menopause. It is forced menopause, yeah. Um, and we use it for all kinds of things. We use it um in people who have breast cancer to shut down their access if they have estrogen-positive breast cancer. We use it for AUB and DUB because it will stop their periods. But the un the side effects of that then are like menopausal symptoms, right? Yeah, but lupron is definitely like part of that parking break um where it just tells the body like, don't do a thing yet.

SPEAKER_01 29:09

Interesting.

SPEAKER_00 29:10

Yeah. Yeah. Yeah.

SPEAKER_01 29:11

The next one is the trigger shot or HCG, our human chorionic ganadotropin. We know that's our pregnancy hormone, right? And this mimics that LH surge and it tells the eggs to go through their final stage of maturation so that they could be retrieved, or so that we could do like an intrauterine insemination. It's just getting things primed up and ready for that.

SPEAKER_00 29:35

Yeah. And then we talked some about progesterone support, right? When we use progesterone, it can either be progesterone and oil. I also did that. I did progesterone and oil for a very long time with Brooks. It's I am. You give yourself a shot. It is the worst. It has to go in a big muscle, and they tell you not to put it in anything but your glute because I was gonna say a PIO is a PIA, right? Yeah. And I tried one day to put it in my quad because I'm like, certainly my quad's a huge muscle. It's gonna feel better than my butt. And then nope, my leg was so sore for like a week, I was like, I'll never do that again. But yes, um, estrogen support can be injection or it can be vaginal inserts. And I think depending on who like the physician or the REI is as to what they prefer. But I I absolutely did those injections.

SPEAKER_01 30:26

Yeah. Some other things you mentioned the letrozole um and how we can use it in fertility, but I certainly have heard it used in endometriosis. You mentioned AUB, D U B. Um, it really is to kind of completely take over that HPOA, right? And just shut it down. Yep. So shut it down. Good to know.

SPEAKER_00 30:48

So when do we think we need to like hand off the patient, right? Like, first off, I tell midwifery students all the time, I want you to know the first thing to do or the first workup. And then if the first medication or the first thing you try works, great. But if not, you that's when you should think cons should consider sending them to your physician or referring them out.

SPEAKER_01 31:10

Yeah. So I I have some strong feelings around this. Um, you know, we were always told kind of, you know, before H35, it's like after 12 months of unprotected intercourse and they haven't achieved pregnancy, or um, you know, after 35, it's six months. I don't know. I just would have always tended to go on the more aggressive side of getting people to the help that they need sooner because also knowing that referrals take time, knowing that people getting appointments takes time, but I can start some of the work up and get them on their way much sooner. I also think it's so weird how so many like general OB offices feel like they somehow got the patient pregnant because they like to dabble in a little bit of infertility. And, you know, I like an expert. I like someone that that is their job. So I have feelings about this, but certainly I will get someone to the referral center sooner rather than later. Um, but we certainly know fertility starts to decline. I think they say our peak is what, isn't it? I remember Oprah doing an episode at like age 27, and everything's downhill from there. But certainly as we age, um, not only does the number of available follicles decrease, but um the quality may also decrease.

SPEAKER_00 32:30

And I think too, when you're thinking about how quickly you can get to somebody somewhere else, also has a lot to do with insurance coverage and those kinds of things. I mean, some patients are really trapped in the box of having to stay with their OB and they don't have coverage to go to REI or to do any of those kinds of things. So when I see people get trapped, it's um it's hard because you know, we are limited in what we're able to do. And somebody else might do a way better job, but Kim, it's you know, IBF is not inexpensive.

SPEAKER_01 33:02

Well, and I'm curious because I feel like things are so much better than they were 20 years ago when you and I started practicing. But, you know, I was always told do not ever write infertility in someone's chart because insurance would so often deny anything that was related to fertility treatments. But I feel like insurance is a little bit better. I still would err on the side of using symptom kind of diagnoses. Um, and you know, labeling someone with a certain diagnosis can be not only troublesome for insurance coverage, but just psychologically as well, right? Yeah. And so, but there's certainly things that we know we should send for. So if someone has a very long history of irregular cycles, it is unlikely that we're gonna fix something with one simple little minor change in medication or something. If they have a history of PID or endometriosis, we're really concerned about the patency of their tubes at that point, right?

SPEAKER_00 34:03

I also would like to add somebody who's had recurrent pregnancy loss because is there a reason, like that luteal phase defect we were talking about in the beginning.

SPEAKER_01 34:11

Yeah. Those people, I'm not necessarily waiting as long for referrals. Um, and I'm wanting to get them help and more, maybe they need a histosopingogram, maybe they need a histosonogram. I mean, there's all kinds of different things that they could potentially need as part of their evaluation that's outside of our scope as certified nurse midwives and certified midwives.

Multiples Risk And OHSS Red Flags

SPEAKER_00 34:31

Yep. Yep. So I think we've talked some about what the side effects of all these drugs are. So I don't think we need to belabor that. A lot of them have these, you know, we talked about metformin and GI upset. We talked about clomid and the cranky, you know, hot flash, perimenopause kinds of things. And then letrozol, all of the aromatase inhibitors, not just letrazol, will cause joint pain and fatigue, sometimes brain fog too. So um I think whenever we talk about pharmacology, it never goes without um there being side effects that you have to consider before you prescribe things to patients. But um I there is also think that we would be remiss to not say that like there's also other risks that go along with some of these fertility medications, like the risk for multiples.

SPEAKER_01 35:19

Yes, yes, that is certainly true. Um, it's less with letrozole and more with Clomid, but certainly there is a risk there. What I wanted to make sure, and I'm sorry I started to interrupt you, is that we do definitely need to make sure people understand that there can be ovarian hyperstimulation syndrome. And it is a medical emergency at times, but that can happen with our fertility meds, and it's much more common with Clomid than it is with letrazol. But um, the ovaries get really swollen and they leak fluid into the abdomen, and so they could have bloating and nausea and fullness in the pelvis. But the big red flags are rapid weight gain. Um, it would be more than two pounds in 24 hours, severe abdominal pain and swelling, decreased urination or shortness of breath. And I have seen a patient when I was in practice that was in the ICU with ovarian hyperstimulation, and it is a real thing. So you need to be careful and make sure patients really know what the emergency signs are and when to seek help.

Full Circle IVF Moment Closing

SPEAKER_00 36:24

Yeah, absolutely. Well, this has been a really good conversation. I hope that in like just in like midwifery world, we understand like how the HPO access works, what kinds of things may cause infertility, what the tools are in our toolbox that we can use, and why we would use them. Like, why would you use progesterone versus why would you use something like Clomit or Letrozole? And then just really understanding kind of like what the steps are. And if you want to listen to us talk about PCOS or you want to listen, listen to us talk about IVF, you certainly can go back and listen to that. It'd be a really nice refresher.

SPEAKER_01 37:03

Yeah, absolutely. Well, I so appreciate this conversation. I really appreciate you sharing your personal perspectives as a patient that has used some of these medications as well and gone through the process. Um, and you know, I certainly am not a believer that we all have to go through these things to be good midwives, but I think your perspective helps all of us in thinking about patients being empathetic and providing them the support that they need.

SPEAKER_00 37:30

Well, on a side note, I took my 17-year-old IVF baby to meet the doctor, the REI that helped us get pregnant all those years ago, because he is now my new boss. So it was that total full circle moment where I was like, Dr. Thomas, I'd like for you to meet Brooks. Brooks, I would like you to meet the man who is responsible for your being here. It was very sweet. Um, that's awesome. And I tell Brooks all the time that it's probably a good thing that all three of those embryos didn't take because I can't imagine three of them.

SPEAKER_01 38:00

Yeah, no kidding. Um, also, I just want to take this opportunity, since you mentioned it, of um saying congrats on your new job and going back home. UC was your home for so long, and it's great to see you back there.

SPEAKER_00 38:14

Yeah, it's a whole um adventure. Yeah. It's um it, you know, being the first of something is also a growing pain, but we will talk more about that. I'm sure there'll be an upcoming podcast where this will come up.

SPEAKER_01 38:28

So that sounds good.

SPEAKER_00 38:30

Yay for being back in Cincinnati. So all right.

SPEAKER_01 38:35

Well, I can't wait to see you at the beach soon.

SPEAKER_00 38:37

And um podcasting from the beach.

SPEAKER_01 38:40

That's right.

SPEAKER_00 38:42

Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again.

SPEAKER_01 38:47

Take care.