You're listening to the fertility docs , uncensored podcast, featuring insight on all things, fertility from some of the top rated doctors around America, whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.
Speaker 2Hello, and welcome to another episode of fertility docs. Uncensored. This is Dr. Carrie Mediant from fertility center of Las Vegas. And I am joined by my two lovely charming evening companions here because we're, we're taking a change for a normal normally record. And usually mid-afternoon on like a weekend day. Um, and this isn't a weeknight evening. And so I feel like I am a robe child
Speaker 3Slipping away with your girlfriends.
Speaker 2Yeah, I kind of do so. I am joined by Dr. Susan Hudson of Texas fertility center. Hello and Dr. Abby , Evelyn of Nashville fertility center. Hello. How are you ladies doing on this lovely night?
Speaker 4Wonderful. It does feel weird to be recording kind of this time of night. Doesn't it I'll have to admit I'm a little bit sleepy, but I'm going to try and stay away. We were having a discussion earlier about some of our favorite drinks and Carrie brought up something really interesting.
Speaker 2So I, this is quite some time ago now, but I usually, when I have dinner with friends, I'm the one who brings dessert because have a massive sweet tooth. And so I make up , you know, whatever where we're dessert. I feel like I want to eat. And so I get there and I have this peanut butter and chocolate mousse cake that is very sinful and to die for. And somebody pulls out peanut butter whiskey. I, that's not nice to call people names, but
Speaker 3That's what it's called. It's called screwball . It's amazing. We have it all the time.
Speaker 4What kind of whiskey is it? Peanut
Speaker 2Butter whiskey,
Speaker 3Literally peanut butter whiskey.
Speaker 2It gets a dessert whiskey. I am not a whiskey kind of girl at all. How
Speaker 4Do you make peanut butter whiskey?
Speaker 3I don't know, but I will acquire a bottle for you. It is very interesting. You can like, we do it like over, like on the rocks and then just put a little cream. It are like half and half.
Speaker 4That sounds really good.
Speaker 3You can mix it with, I think maybe Madorie I'm not . No , no, no, no.
Speaker 2That sounds
Speaker 3Horrible. Not majority . That sounds terrible. Something that's like fruity. What's one of those fruity ones , uh, like a fruity low core shamed board. That's what I was thinking of. Sit with sham board and it makes a peanut butter and jelly.
Speaker 4That is crazy. Okay. So next week when next week we're all going to be together at our national meeting in Baltimore. So Susan, your job is to bring some spring ball . Okay.
Speaker 3Good stuff. We acquire frugal on a regular basis and my husband likes to give it to friends when they come over. It's like, here's your parting gift from our house? This bottle is ,
Speaker 2I remember, and this is years ago. I wasn't fellowship at the time. So this is like where it was several years ago now. But I went to this restaurant and they had, I like tequila typically is my, if I'm going to drink hard alcohol, I will get a nice bottle of tequila and we'll step, you know, sip on it. Um, but they had this drink that was like an espresso martini that was based in tequila as the drink. And it sounded questionable at best, but I ordered it and it's now, I don't know, seven, eight years later. And I am still thinking about this drink. And I have tried to go back and look at the cocktail menu of this restaurant and it's not on there anymore. And I'm like, well, how am I going to figure out how to do it? Cause I have no idea what they put in it, but , uh , it was really good.
Speaker 4Uh , well, you know, Kevin from Tennessee, you know, home of Jack Daniels , it's, you know, almost blasphemy to talk about these fruity whiskeys and stuff, but I'll have to admit I'm not a big Jack Daniels fan. So I think screw ball for me sounds a little bit better.
Speaker 3My husband is a bourbon fan and I'm like, I like the smell, but I don't like the taste and stuff. And he was like, oh, you got to try this. And I'm like, Ooh, this is like my , my gateway whiskey.
Speaker 2All right. So we have, we're going to do a bunch of questions today and go through things. And I almost asked if any of them involved alcohol, but I'm pretty sure that none of them do because all of our listeners are smart enough to know that our answer is going to be whatever related to alcohol is. Don't do it during the midst of, of a cycle. Now after negative pregnancy test, it's fair game for a couple of glasses of whatever your drink choices. Um, but in general, the, the answer to the alcohol questions is a unanimous. No, there's no non-safe amount and pregnancy. And so for us isn't
Speaker 3Okay. So our first one is, hello. I love your podcast. We had male factor infertility and my husband underwent [inaudible] ligation microsurgery . I have seen that the success of this is variable. People don't really know how it works with male factor. Could you talk about how America sale ligation helps with male factor infertility in the success rate?
Speaker 2Good question. So first things first, Abby, do you want to explain what a varicose seal is severe?
Speaker 4The seal is kind of like a varicose vein and enlarge bang , kind of like sometimes you see when women are pregnant or an older women in their legs, sometimes men can get them in their testicles. And so varicose seals generally increase the blood flow , um , near the testes can heat the testes up and at least traditionally I've always thought of it. More. It relates to decreased motility was from in talking to some of the urologists though. They tend to think it, you know, in repairing a varicose seal may fix other issues as well. Numbers , motility, morphology, et cetera. But really, I think generally, most people think it's best used if a man, low motility, what are your thoughts, Susan?
Speaker 3So what I've really gotten from my urology colleagues lately is Baraka seal repair is very helpful in a man that is having pain and in the absence of pain, the data really doesn't, it it's , it's essentially a wash. It helps sometimes it doesn't help. Sometimes, sometimes it might actually make things worse. So if the guy's having pain fix the varicose seal because we don't want the guy in pain, but if it has to do with fertility, probably not exceptionally worthwhile at this point in time, what do you think carry
Speaker 4Well? And I agree in my, in my own experience too . Sorry, Carrie , I cut you off there back in that experience. It just, it seems like when people have varicose seals repaired, we repeat the sperm count and it doesn't seem to ever be better. So in my own experience, I don't think it's a great idea either.
Speaker 2Yeah. I would agree with that. If you're doing it for pain, absolutely go for it. If you're doing it for fertility, it usually the tagline is always like, well maybe if we repair it, we can bump up from whatever type of treatment we needed to do to the less invasive treatment one step above it. So if you were going to have to do IVF, maybe we can do this and do IUI. If you're going to do IUI, maybe you can do this and conceive naturally. And I , I agree with your guys's experience and that it doesn't functionally make a huge amount of difference. And so save an incision and a bag of frozen peas on your parts. Um, and you know,
Speaker 4Nobody wants frozen peas on their parts.
Speaker 2Nobody wants to eat the frozen peas could have been on the party .
Speaker 3All right, we're going to go to our next one after that. No more talking frozen peas . All right . So our next question is, hello ladies background. I am a 26 year old female and I'm looking for a reproductive endocrinologist after finding out my husband has a reciprocal translocation. We have not started trying naturally, and I've no reason to believe there are any fertility concerns on my side. There are multiple providers in my network area. I just moved and do not know anyone locally that has gone through infertility questions. Um, how do I choose my reproductive endocrinologist? What kind of questions should I ask in the first consult session to decide if it's a good fit? I love your podcast. Thank you so much for all you do. That's a great question.
Speaker 2That is really fabulous. So let's talk about what what's a reciprocal translocation first. So we kind of know when she's looking for a doc , what needs to be considered Susan. You want to take that one.
Speaker 3So essentially a reciprocal translocation ha has to do with chromosomes, okay. Chromosomes, our genetic code. It's what we're built up of. And we all are supposed to have a certain number in there supposed to be in a certain place. And essentially a translocation is when something has been flipped over, you have the right numbers of everything, but not everything may be in the right place. And when we know have this type of thing, we know that that couple is going to be at an increased risk of potentially having trouble getting pregnant , um, and more commonly having multiple miscarriages because when things are flipped over when eggs and sperm come together and divisions are happening more mistakes than usual happen and things become unbalanced. And so when we hear this, we're thinking of somebody who's potentially going to have issues with recurrent pregnancy loss. And again, like I said, just not getting pregnant because most chromosomally abnormal embryos are never going to implant. And so it sounds like this person is really wanting to kind of bypass this potential level of heartache , um, without a better way of saying it and go to a treatment that's gonna help them ideally get a baby a little bit faster. And that's really going to be doing IVF or in vitro fertilization with pre-implantation genetic testing, looking for not only just are there the right number of chromosomes, which is PGT EA , but making sure that things are balanced and in the right places, which is going to be PGT Sr
Speaker 2Abbie , thinking about this young lady who knows that they're going to have to likely do IVF with a PGT. Sr, what things would you look for in a doc that are going to be kind of paramount for that situation?
Speaker 4Well, really kind of the key thing is make sure that the practice that you talked through , the physician that you talk to, you make sure they have the capability of doing IVF. So not all reproductive endocrinologists have the capability to do Nivea, but more importantly, if they do IVF to make sure that they do genetic testing can do genetic testing on embryos. And there's kind of different practices, do different types of testing, but you know , you want to make sure that your doctor, that you have can look like Susan said at all the chromosomes. So when we take the embryo biopsy to sales , make sure that they look at all 23 pairs of chromosomes and then make sure that they can get the data back in time for you to have a transfer and to kind of know what the results are. And so you also want other way to kind of know who might be a good fit or at least a place to start would be well ASR in website. You can actually go on there and you can put in where you live and it will let you know who the reproductive endocrinologist are in that area because sometimes OB GYN are interested in fertility. And so they have a focus on infertility, but an OB GYN who has a focus on fertility is very different than a reproductive endocrinologist who has the capability of having you go through IVF and being able to genetically test your embryos.
Speaker 2So board certified REI is a huge thing here. Somebody who has good success rates is a huge
Speaker 4Thing. Yeah, that's a good point too .
Speaker 2Success rates is a tough
Speaker 3Nut to crack.
Speaker 2That's a tough nut to crack because the SART and the CDC data tells some of the story, but not all of the story. That's something where we could probably spend 65 episodes on just that issue and , and where the holes are in that reporting because the data is good, but it really doesn't tell you a whole lot about the,
Speaker 3Especially if you're new in the area. I mean, there's a lot of times that we as physicians really dislike social media, but this is one time where, you know, you might want to get on Facebook or whatever your social media have choices. Look at local groups of women and ask, Hey, who's seen a reproductive endocrinologist or infertility specialist in this area. What did you like? What did you not like? Because that way you're gonna , you're gonna get people to dish. And I can tell from this question that they're wishing they had somebody local to ask and go, there's plenty of stuff. I mean, I know like I'm on the moms of new Braunfels, Facebook group, and there's always people asking about OB-GYNs or asking about fertility doctors or, you know, all kinds of things like that. And those things are going to be in all areas. So what I would do is find a local women's group that you can join on a social media site and ask there to get that kind of gestalt of , you know, is this a place that, you know, has great success rates, but may treat you like cattle? I can say I went to , uh , IVF place. Like that means to an end, I gotta be beautiful baby out of it, not how I like to treat my patients. And , um , that type of thing. Is it a place that holds your hand? Is it a place where, you know, your more anonymous, some people want to be more anonymous. Some people really want to have a more deeper relationship with their fertility team. Those are things that you can kind of figure out what's going to fit your personality and potentially your partner's personality by asking those types of questions to local women,
Speaker 2Looking at some of their social media can sometimes be helpful. Cause you can kind of get an idea of what their personalities are. Like. We know a lot of us have videos up or, or things like that where you can kind of get an idea of how do they explain things? Is it to your liking? Like you can kind of pick up who's cut and dried. Who's going to hold your hand. Who's a really good teacher, those types of things and finding that fit that's best for you. I mean, ultimately it's going to come down to who can get you the embryos to get tested, to make your family, and you may need to go through multiple IVF cycles to get there. And so being comfortable wherever you are, is going to be key because there's going to be some bumps in this road and that's okay, but it's helpful to be at a place where they're going to get you that information, get you through that in a way that is good for you as a patient
Speaker 4Too . I know you're new to town, but if you have an OB GYN, you know, that's a great place to start too, because they can kind of compare and contrast the different practices in town and maybe kind of figure out which practice is a better fit for you. Um, you know, since I, they know the lay of the land a little bit better.
Speaker 3Yep . That was a great one. Um, my husband and I have a 19 month old son who we conceive naturally on our first child until five months ago, I was nursing him and I was on the mini pill until six weeks ago. So I didn't think anything of the fact that I had not gotten a period since my son was born. I just started trying to conceive a second and used ovulation test strips, which were positive a hundred percent of the time leading me to get blood work done. The blood work revealed a high LH 27.5, a high FSH, 76 low estrodial , less than 24 and normal hormone in pituitary function. I have had no symptoms of menopause. And my doctor said, this seems very sudden for ovarian failure. Is there anything else that could be
Speaker 2So when in doubt, repeat the test . Yeah , definitely because you, you want to make sure this is real now keep in mind. Sometimes you can have ovarian insufficiency. That's not full-blown failure, but it's heading there. And so sometimes you end up with these crazy high levels that , that then go down because you pop out an egg on an ovulatory cycle. Seeing an FSH going from 76 down to a normal level is not super likely. But the other thing that you have to keep in mind is that you haven't, your system has not been tested in if your kiddos, 19 months old, then your system really hasn't been tested in 28 months. That's over two years. And so this may not be a sudden as it appears because you haven't had any reason to check it because hot flashes and hormonal screenings happen all the time in pregnancy, your estrogen level goes high in pregnancy as a result of what your placenta is doing. So that's going to mask it when you're a new mom, your , your brain is not on anything other than how do I keep this small human being alive and how do I keep myself functional? And then when you're breastfeeding, of course, you're not going to notice that your periods not there because so many women have lactational amenorrhea where they're breastfeeding all the time. And so their periods don't come back and that's, that's used as birth control in many forms in many parts of the world. And so this may not actually be quite as sudden as it appears.
Speaker 3Yeah. It feels sudden to you because it's not something you were expecting, you got pregnant very quickly and that type of thing. But we do see this happen. And , and also realize that a couple of things to think about is when women normally go through menopause, they're not technically out of eggs. They still have about a thousand eggs left. And even with women who have established premature ovarian insufficiency, which it sounds like there's a reasonable chance. This may be that there's a 7% lifetime chance of conception of, of getting pregnant and having a baby. And so it's possible, especially if you had maybe, you know , been on birth control pills for a number of years, y'all all like, okay, we're going to try for a baby stop birth control pills. You obviated. We had an egg, there was sperm, you know, baby happened. And this may have actually been something that was brewing and you didn't even know it because you were , you were taking birth control pills, which a lot of people even use to help control hormonal swings and fluctuations and symptoms and women with premature ovarian insufficiency.
Speaker 4I'd be interested to know the age of the patient. Did she mention hell to us?
Speaker 3No, we don't have that because it
Speaker 4Would be unlikely in a 20 something. But you know, if you were 40 and got pregnant with baby number one, and now you're 42, you know, again, that's not as much of a surprise, but you know, regardless of whether it's a surprise or not, it's still really bad news. I think overall, you know, because your , your estrogen levels low and your FSH is really high. And that generally indicates that your ovaries are not doing what they're supposed to. And your brain is kind of talking to him , kind of yelling at your over . If you need to get going, you need to make estrogen, you need to make eggs. So I wish we could kind of candy coat this a little bit better, but it kind of looks like you're going in that direction. Unfortunately, that it looks like it's, you know, at least peri-menopause , if not menopause at this point,
Speaker 2And it was about it is that you can still carry a baby. There's no reason you can't carry as long as, I mean, assuming they're your first pregnancy went just fine. Um, but it may be that using your own egg is going to be really more challenging. So,
Speaker 3All right , so let's get to our next one. Let's see. So delivered healthy baby boy in 2017, took five to six months to conceive, started trying again in 2018, have since had two miscarriages by workups shed it MTHFR gene mutation. I have been taking baby aspirin . Methylfolate my GYN recommended, and we still haven't gotten pregnant. I didn't know I had this and took OTC prenatal vitamins when I was pregnant with my son. I'm wondering if this gene mutation is making as big of a difference as my OB gen suggests since delivering in 2017, I have developed Hashimoto's my TSH days less than two in preparation of conceiving. I am 25 pounds heavier now than when I conceived . Initially I never lost the baby weight. Honestly, I think this is likely my issue. I'm 32 and my husband is 38. We had workups at preg and everything was normal. Just wondering about the MTHFR gene mutation.
Speaker 4So MTHFR, I would say probably six or eight or maybe even 10 years ago. That was kind of a big thing that a lot of us checked and, you know, sometimes we checked it for the recurrent pregnancy loss workup, and, you know, we were really concerned about it. And now I think most physicians, most fertility physicians, most hematologists, most, most general OB GYN, kind of think that it probably, we, it was kind of overblown in terms of how much problem it really caused probably in reality. It really didn't cause that much issue with fertility and pregnancy. And , um , it was really a more of an issue that if you had this abnormality in some women, homocysteine could be elevated and it would increase the risk of miscarriage. But now the American college of OB GYN and ASR, M doesn't even really recommend that you test that as part of a workup for recurrent pregnancy loss. So, you know, I wish I could point to that and say that that's the problem, but I , I doubt that that's the problem. You mentioned your weight and for many women, if they gain weight with pregnancy, sometimes it makes their cycles irregular and they don't ovulate regularly. And you didn't really mention, or at least I didn't hear about your menstrual cycles, but certainly gaining 10 pounds even can make a big difference in terms of your hormone levels. And some women can go from having regular ovulatory cycles every month with the addition of 10 pounds of weight, they can go to where their cycles are very irregular and they're not making an egg every month. So, you know of the things that you mentioned at your Hashi motives seems to be under good control. You know, the weight could be an issue, but I don't really think the MTHFR is really having a significant impact on your ability to get pregnant
Speaker 2With MTHFR. About 40% of the population carries at least one mutation for it. And 40% of the population is not having recurrent miscarriages. And so, you know, you can, on the one hand you can take heart and that that's probably not it. On the other hand, one of the most frustrating thing about recurrent losses is that the better part of them , 50% of them, we don't ever get a diagnosis for it. We don't ever have a reason why that happens. And more than anything, people want to know why, because most people would accept that you have a mutation that is going to, you know, give every child three heads and 65 arms because you can accept that it's much harder to accept. We don't know what it is. So I don't, I don't know that I go blaming the MTHFR. Um , I don't think the methyl folate or the aspirin is really going to do any harm, but I don't know that they're gonna help much either. Um, oftentimes for my patients anyway, I'll tell them to take the aspirin as soon as they get pregnant, rather than before. Cause I was worried if you've got high levels of EnSite , you're going to block ovulation. I don't know that you're going to really block anything with an 81 milligram dose of aspirin. Like it's tiny. So that's a wash. You can go either way. But
Speaker 3Yeah, I think if you had significantly high homocysteine levels or you had maybe second or third trimester losses, but I'm assuming that's not the case because most of the time people are very specific about that, that it's, you know, it's a test kind of, of the past. Um, you know, we've done an episode on it , things like that before, you know, I , I do see quite a few people in my practice who have been, had an evaluation by their, you know , primary OB who've had, you know, lengthy coagulation workup . And I'm like, yeah , you know, the data just doesn't, it , it really doesn't support all that. And, and you know, I don't think you're a candidate for like blood thinners, like Lovenox or heparin or anything like that. We know that most miscarriages are due to chromosomal abnormalities of the embryo. Um, you know, mistakes that happen as , um, those little cell divisions are happening after egg and sperm come together. And so that is, that is most likely the case. You know, if you've gone potentially six months and haven't conceived, you may want to consider going to a reproductive endocrinologist just to get a second set of eyes on things, you know, maybe have a salient ultrasound, make sure kind of I's are dotted and T's are crossed for a full recurrent pregnancy loss evaluation.
Speaker 2Right? So it looks like we've got time for maybe you one , either two quick ones, one longer one,
Speaker 3All right, let's do this one. I am 37, my husband's 44. We have been trying to conceive for 18 months. We just finished fertility testing. And besides my AMH being on the low end, everything was normal. My OB-GYN said my uterus looks great and she thinks I would have no problem carrying to term because of my age and AMH. She doesn't recommend that I try Clomid or Letrozole, but instead goes straight to a fertility clinic for IUI or IVF. I'm kind of let down that we can't try Clomid or Letrozole. We are not in a place where a fertility clinic is an option. Should we get a second opinion? Are we stuck trying the old fashioned way? And again, she's 37 husbands 40 .
Speaker 4Yeah. I think everything kind of hinges on, or at least for me, I would like to know what your AMH is because a low AMH can be a lot of different things that an AMH of like one versus an AMH of 0.9 versus an AMH of 0.1 is really is different in terms of the prognosis. And so, you know, most fertility physicians would say, or actually the , the American society for reproductive medicine says if you've tried for more than six months and you're beyond the age of 35, you probably should seek a fertility doctor. And, you know, I tell my patients, it's not that you can't do Clomid or Femara Letrozole , but it's just, it's probably not a good decision because your reproductive life span is limited. Particularly if you have a low AMH. And so I think most fertility physicians would say, you know, ideally, we want you to do something more aggressive to speed up the time it takes you to get pregnant. And frankly, many fertility doctors would be even encouraging you toward IVF because it's the quickest route to pregnancy and the most successful route to pregnancy. And you know, it's not that we wouldn't let you do those other things. I usually tell my patients, my job is to let you know what your options are, your job is to make the final decision. But I think most fertility physicians would recommend more aggressive therapy because of your age and because of your AMH.
Speaker 2And it's important to know that when you come to see us, you're not coming to us for fertility treatment, you're coming to us to get help. You get a baby. And so when we're making recommendations, that's what we have in mind, because it's really easy to get caught up in. Oh , I want to do Letrozole . I wanted to clone that I want to do. And that I , I want to do that for six cycles. And then I wanted to do an IUI for six cycles. And then I'll try VF. Our goal is to get you a baby in , in the fastest, most efficient way possible. And if, if you just flat out, can't do IVF, you can do IVF, but when we're making these recommendations and it sounds like your OB GYN is on this page, they're thinking of what do you want out of this? At the end of the day, you want a small human being that you can cuddle, who can keep you awake at night and going to see a fertility doc and being more aggressive from the outset is more likely to keep you awake and destroy your sleep for the next several years.
Speaker 3So a couple of things that I'm thinking of is, you know, when I talked to patients, one of my kind of philosophies is I want to do the least invasive, but the most appropriate. And that's going to vary from couple to couple, it's a very individualized type of thing, but sometimes the least invasive, but the most appropriate is Clomid or Letrozole or, or something like that. But sometimes it is the whole shebang and going straight to IVF, it just kind of varies. And it's also, you know, what's the best thing for the two of you. If you sit there and say, we absolutely cannot do anything except for blank, because of whatever reason, whether it's financial geographic, ethical, moral, religious, whatever it is, that's fine. What we want to do is make sure you understand the different risks and benefits of those different treatments. The other thing is this being 20 21, 1 of the beauties of COVID because there have been actually a few beauties of COVID is that telemedicine among fertility clinics is , is not an unheard of thing, which two years ago it was okay. Nobody in fertility did telemedicine except for people like Carrie who were doing telemedicine across the world. Okay.
Speaker 2I'm sticking my tongue out at Susan right now.
Speaker 3Most of us did not do telemedicine. And it was very much an exception than a rule. Whereas now, I mean, a lot of us are doing a lot more telemedicine. And so, you know, we're, we are all very much aware that there are very few reproductive endocrinologists in the United States. And there are some states that have very few like literally handful. I have patients who come to see me all the time from three hours away. And I have colleagues who, you know, it's not unheard of for people to drive 3, 5, 6, sometimes eight hours to go see a fertility doctor, but realize that we do have resources like telemedicine at our fingertips. We also have resources like remote monitoring, different things like that. So it sounds like you probably live kind of in the middle of nowhere, which can be absolutely beautiful, but don't count yourself out from actually getting medical guidance and expertise of a board certified reproductive endocrinologist, because you really do have access to these people now more than ever because of the availability of these different aspects. All
Speaker 2Right. Well that's
Speaker 4Yeah . Yeah.
Speaker 2I like these question episodes. It's kind of fun to think about, think about all these things and to hear the other opinions that,
Speaker 4Yeah , it's kind of fun that the three of us are all kind of given our perspective and it's fun how we kind of take different points from the questions and focus on them. We don't even practice these daily
Speaker 3Now . It's good.
Speaker 2That's good. All right. So to our audience, thank you so much for listening. Be sure to tune in next week for more, be sure to subscribe, leave a review in iTunes. If you appreciate those an awful lot. And we would love to hear
Speaker 3From you . You can also visit fertility to accent , censored.com to submit specific questions you have about infertility or ideas that you have four episodes. All of your questions will be answered on the podcast anonymously for the ask to doc segment. So don't hold back. We love to hear your ideas in questions
Speaker 4Is this podcast is intended for entertainment and it's not a substitute for medical advice from your own physician. All right , we'll talk to you soon.