Ep 274: The Four Fertility Tests You Can't Skip

What are the must-have tests when trying to figure out infertility? In this episode of Fertility Docs Uncensored, we’re joined by Anate Brauer, MD, a physician at RMA New York, to break it all down with our trio of fertility gurus—Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. Together, they dive into the top 4 tests you shouldn’t skip when facing infertility. We’re talking AMH (antimullerian hormone) to evaluate egg quantity. They discuss egg quantity vs. quality (yes, there’s a difference!), why age really does matter (ugh, we know), and what tests like TSH, FSH, and estrogen levels can tell us. They get into the nitty-gritty of semen analysis—because guys, you’re half the equation—and the dynamic duo of uterine evaluations: HSG and saline sonogram to check for polyps, fibroids, and make sure your fallopian tubes are open. And just when you thought we were done, we throw in a little genetic twist with carrier screening, explaining why matching mutations isn’t as romantic as it sounds. Whether you’re just starting your fertility journey or deep in the diagnostic weeds, this episode is packed with laughs, knowledge, and more than a few “aha!” moments. Don’t miss it!

Transcript

Susan Hudson (00:01)

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.

Susan Hudson MD (00:22)

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Carrie Bedient MD (00:54)

Hello and welcome to another episode of Fertility Docs Uncensored. I am one of your co-hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas, joined by Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center. And this week we are joined by Dr. Anate Brauer, who is a partner physician at RMA New York, who's double board certified in obstetrics and gynecology and reproductive endocrinology and infertility. And we are very glad to have you with us this week.

Anate Brauer MD (01:21)

Thank you so much for having me.

Carrie Bedient MD (01:30)

So we were talking beforehand that you almost had an alternate career path. And as soon as you started talking, my heart did little jumps for joy because it sounds like you and I had very similar high school careers. And so tell us what you would have become if you didn't have parents who were extremely responsible.

Anate Brauer MD (01:36)

Yes, I still haven't given up on my dream, but my first love is really theater. And in high school, I was very involved with musical theater. My parents, who are both physicians, were adamantly against me pursuing it as a career, so much so that later on in life, they refused me applying to medical school in New York because they knew that it would be a cover for me to just get an agent and audition for things.

Carrie Bedient MD (02:13)

Wow

Anate Brauer MD (02:14)

By the time I made it to New York, I was a resident and clearly didn't have time for anything. So I basically parlay that into more of a debate and journalism way of still performing and ended up going to undergrad originally for broadcast journalism which evolved over time and I did a career change to medicine. So here I am.

Carrie Bedient MD (02:40)

So were you in the shows? Were you a techie? Were you a singer? Were you a dancer?

Anate Brauer MD (02:46)

I was in the shows. I loved to sing and dance and act. I did a lot of dance growing up, but I never took voice lessons. Actually, my first show that I auditioned for in high school was Funny Girl. ⁓ And my parents, the first time they ever saw me sing in anything, was me singing "My Man" up on the stage, which is part of Funny Girl, as you know.

Abby Eblen MD (03:09)

But they must have been really proud of you when you were singing on the stage. I mean, that's really cool.

Anate Brauer MD (03:14)

I mean, yeah, I thought it would convince them that maybe they'd let me do this in my life, but I was wrong. But my retirement plan is move into the city, get a little apartment, audition for every old lady off Broadway show that there is. Are you with me? Are you gonna come?

Susan Hudson MD (03:31)

Absolutely, we will be there opening night.

Carrie Bedient MD (03:33)

Sign me up.

Abby Eblen MD (03:33)

Yeah, let us know. We'll be there.

Anate Brauer MD (03:35)

Amazing. I want to hear your story.

Carrie Bedient MD (03:40)

Yes, we will definitely take every excuse. I did a ton of tech theater when I was in high school. I started when I was in sixth grade, because my mom was on the board for a local community theater. And so started building things and I did stage managing and I did a little bit in shows here and there, usually in the chorus or in the straight shows. But yeah, I really wanted to do tech theater and I thought I can be a professional stage manager. I can run all of these flaky actors and make sure that they're where they need to be.

Anate Brauer MD (03:45)

Okay. 100%

Carrie Bedient MD (04:11)

Yeah, and my math professor father and my accountant mother were not real interested in that.

Anate Brauer MD (04:17)

We turned out okay and we still use it every day. I I really use, think speaking to patients, speaking on podcasts, I mean, all of that comes in handy. So I don't regret it.

Carrie Bedient MD (04:29)

Yeah.

Abby Eblen MD (04:30)

Yeah, I think that's just very useful.

I think when I grew up, I was just terrified of being in front of people. And it took me a while to evolve, evolve into myself and speak in front of people. I think that's good for any kid to get up on stage and perform and, just learn how to talk and be on a stage in front of people. That's very cool.

Anate Brauer MD (04:49)

Absolutely.

Susan Hudson MD (04:50)

RMA of New York is a global leader in state-of-the-art reproductive medicine, serving as

Division of Reproductive Endocrinology and Infertility at the Icahn School of Medicine at Mount Sinai. Led by an integrated team of physicians and scientists, RMA of New York is renowned for its pioneering research in the field and for delivering high IVF success rates. With locations across Manhattan, Brooklyn, Westchester, and Long Island, RMA of New York has helped thousands to build the families of their dreams for more than two decades and counting.

Carrie Bedient MD (05:20)

All right, so let's switch over to our question of the day. Susan, what do you have for us?

Susan Hudson MD (05:27)

Okay, so our question today is, hey, I love your podcast. I recently found it and it's helping us so much with my fertility journey. I listened to it from work and everywhere in between. I was hoping you could touch on male infertility. My husband and I found out in January, 2024 that he is infertile. We have done four failed IUIs using donor and now moving on to IVF. Looking forward, we have a constant battle with if slash should we tell baby he or she is not genetically my husband's. He worries baby will resent him. I worry if they find out they will resent both of us. Would love to hear more about what couples choose. This is a great question.

Carrie Bedient MD (06:07)

This is a fabulous question. I'm so glad that this couple is thinking about this now, well before they're into anything. So what do you guys think?

Anate Brauer MD (06:17)

I think, so this couple is definitely has to use donor sperm. Is that what I'm gathering?

Susan Hudson MD (06:22)

That's what it sounds like.

Carrie Bedient MD (06:22)

Yeah.

Anate Brauer MD (06:24)

I think the world of anonymity is no longer with all of the commercially available genetic tests out there. And this is why psychologists, I mean, we at our clinic, I don't know about your clinics, but do require a consult with a reproductive therapist to talk about how to disclose, when to disclose, anytime you're using donor gametes. And I think it's really important because if your child wants to find out, they will find out through commercially available tests, whether you want them to or not. And so it may as well be coming from you. That's my general feeling, which has evolved over the years.

Abby Eblen MD (07:04)

And I think our therapist says too, if you're not truthful with your child about this situation, then they worry, well, what else are you not truthful with me about? What else did you lie to me about? And I agree with you, I think it's much better coming from the parent at the appropriate time rather than the child doing a test and finding out when they're teenagers or something like that.

Susan Hudson MD (07:23)

Absolutely. And the thing is, is you're not alone in this. There are communities of people who have children who were donor conceived. There are communities of people who were themselves donor conceived. There's little books for kids. And I think it's one of those things that if a child grows up just as if they were adopted and they understand that this is part of their story. And as they age, you add information of that story.

But if it just is part of who they are and that mommy and daddy loved you so much that we wanted to bring you into the world and we needed to go down these options because of blank, blank, and blank, those are the things that are going to make your child feel secure. And I think the risk of having a child not be happy with your decision is much, much higher if you don't share than if you do share.

Carrie Bedient MD (08:17)

Exactly. We actually did an episode and this is a while ago now, but we did an episode with Cascade Cryobank and it was focusing on all of this of how do you tell, should you tell, do you tell? And really the big upshot of all of it was anonymity is no more with the internet and some clever sleuthing. You can figure out just about anything.

Assume that this kid is going to find out in an information age and if you are the one to tell them you build trust and if you are not the one to tell them you lose trust and it's in some ways it's kind of a zero sum game. So you want to be the one who controls that narrative from the very beginning and you also have to consider the fact that if you have told anyone that this kid might find out from someone other than you and so you want to control that in the same way that you want to control any other piece of important information that they are getting.

All right, so today our topic is going to be the four big tests that you need as you're pursuing fertility treatment and the diagnostic testing that we really go into. Let's start out, what is one of the big tests that you get by default on pretty much everybody who walks through your doors?

Anate Brauer MD (09:37)

So anytime I have a consult of anyone trying to conceive or really if they're trying to do anything, freeze their eggs even, I like to start with a global picture of what do you need to make a baby? And you need sperm, you need open fallopian tubes and a normal uterus to implant, and you need normal ovaries with normal numbers of eggs and genetically competent eggs.

And I'm sure we'll get into all of these tests that test these things. I think one thing that is lacking is, and anyone coming to me, is kind of the real understanding of what happens to your ovaries over time. Everyone has this idea that if I'm healthy and I eat healthy and I exercise, then and I look young on the outside, it's going to be reflective focus on the inside. To me, everyone should, and it's a double-edged sword, and we'll talk about that, but everyone should know about the quantity and the quality of their eggs. You cannot test for quality. Quality is dependent on age, which we can talk about more. But quantity of eggs there are excellent markers for, one of which is a test called AMH, anti Mullerian hormone, which is a hormone that's made by the small resting eggs in the ovary, the more eggs you have, the more AMH you make, is directly reflective of how many eggs am I going to get if I stimulate your ovaries to grow eggs for an egg freezing cycle or an IVF cycle. And that's really reflective of where you are on your reproductive timeline, because we know women are born with all the eggs we'll ever have and lose them over time. And so to me, AMH is a really good baseline marker. There are other markers to corroborate that number, which we can talk about.

But that's whatever you're doing, freezing eggs, trying to conceive, you should know where you are so you know what you are and are not a candidate for and what your future might look like.

Abby Eblen MD (11:35)

So what are some of those other tests that you might want to do in addition to the AMH?

Anate Brauer MD (11:39)

So, we never just go on one number and it's also important to note that AMH isn't a perfect assay. There's a lot of inter and intra variability to the assay. If I send it on the same person on the same day to two different labs, it's going to be a little bit different. If I send it on to the same lab on two different days it's going to be a little bit different. So to corroborate that, we do an ultrasound and blood work on day two or three of a period. So you call on day one, we bring you in on day two or three.

Everyone thinks it's weird to have an ultrasound while you're on your period, but it's all we do all day long, so it's not weird. And we're basically looking at the ovaries. We can count how many little resting eggs are in them by seeing small sacs of fluid called follicles that house the eggs. And we also send a hormone called FSH, follicle-stimulating hormone. That's a hormone that your brain makes that tells the ovary to grow an egg. It's inversely proportional to how many eggs you have left. The harder your brain is working, the lower the reserve.

And so it's also a marker of where you are in that continuum of egg loss.

Susan Hudson MD (12:40)

I think of FSH also having some quality component to it. It's not only reflective of quantity as much as AMH is, but I do want to make a comment because I saw a question from one of our listeners recently and they were commenting about their fear of how quickly their AMH was dropping. And in this particular scenario, their AMH had been maybe 1.1 and it had dropped to like 0.8 or 0.9. What could you comment about drops in AMH like that? Are those a big deal or is that maybe some variability?

Anate Brauer MD (13:19)

So to me, there's no clinical difference…they're pretty much the same and it's within that error margin of error of the assay as I mentioned. I'm also not a fan of repetitively checking AMHs. I think AMH is a double edged sword. We know that quantity does not predict your chance of conception. Chance of conception are predicted by egg quality, which is directly linked to age. And we know that as we age, our eggs age, they get more and more DNA mutations, that leads to an egg with the wrong number of chromosomes, which either won't fertilize or will fertilize and not implant or will fertilize and implant and lead to a miscarriage. And we know that between 30 and 34, around half your eggs are chromosomally abnormal. By the time you get to 40, it's about 90%. How many eggs you have doesn't really dictate your chances of natural conception. But it's important because it dictates how you perform in an IVF lab because IVF is a numbers game.

But we have to be careful on young patients who are checking their AMHs just to check it. I wouldn't check it just to check it. I would check it because you're going to do something about it. And this is a very personal thing for me because when I was 33 and a fellow and this new generation two of AMH came out, now I'm aging myself. I'm turning 47 this summer.

And my senior fellow said, hey, this new test came out. Let's check it. And mine was very, very low. And it threw me into this vortex of anxiety that eventually I had my first baby through treatment. And then my other two later in life, which when I'm sure my AMH was much lower, were spontaneous pregnancies. So we have to be careful with what we do. And there's more more startups and pop-ups of at home testing and just get your AMH done, but no one's counseling these patients and it creates a lot of fear and anxiety. So I would say understand the tests that you're sending and what it really means. And there is a lot of variability. So to me, there's no clinical difference between those three numbers really.

Abby Eblen MD (15:23)

That's a great point.

Susan Hudson MD (15:25)

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Carrie Bedient MD (15:39)

What do you think about the variability that we can sometimes see in the FSH and estradiol levels when we check those around day three? Because those, in general, in AMH, maybe it's 1.1 to 0.9, things like that, but your FSH has the potential to be wildly different from one month to the next. What do you tell patients who had perhaps serial levels checked a couple months over the course of a year, and they're wildly different?

Anate Brauer MD (16:06)

And that's why FSH isn't as reliable of a marker and what sent us on a hunt for a better marker, which is AMH. I don't put as much into the FSH. The way I use FSH is if someone has a low AMH, let's say someone has an AMH of, even an undetectable AMH, let's say it's an AMH of the lower end of the assay, 0.16 or whatever assay you're using. To me, there's a difference. Some people with a very low AMH will have a high-ish FSH.

Ideally, a high FSH is considered anything over 10 to 12, depending on what range you're looking at. So to me, there's a difference between someone with an AMH of, let's say, 0.3 and an FSH of 14 or 15, which I can work with, versus someone with an AMH of 0.3 and an FSH of 30 or 40, which, and I'm talking about patients who are considering IVF. Are you a candidate? So I use FSH, and I also use FSH to help me determine protocols for IVF. For example, if the FSH is totally normal, I'm more likely to be okay with a birth control pill protocol or a protocol that's just a straight start, meaning you don't have any pretreatment versus an FSH that's higher, which for me, usually I'll use over 10. I'm more likely to do an estrogen prime or estrogen patch protocol, which we can get into if you want, the purpose of it is to trick your brain into thinking you have an egg growing in the second half of your cycle so that your brain doesn't tell you're ovary to grow an egg when we're trying to take over and grow as many eggs as we can. And so I use FSH really as an adjunct to AMH, knowing that it fluctuates and to help me decide what the best protocol is, even for one specific month.

Susan Hudson MD (17:43)

What are your thoughts when a woman comes in, you do that FSH level and say it's 30 and she has a low estradiol, let's just say 28 or something. And she's like, well, can I check it next month to see if it's better?

Anate Brauer MD (18:09)

So you can check it next month to see if it's better. But in general, it probably will still be high. And once you're getting into these much higher FSHs, like the 20s, 30s, 40s, you're really most likely entering into a perimenopausal phase, which no one can predict for you the exact natural history of that. No one can tell you, even based on AMH, when am going to stop getting periods? Because you can have an undetectable AMH for a long, long time and FSHs that are highish for a long, long time before you officially go into menopause. But I use that in conjunction with what are your cycles doing? So if your FSH is consistently high like that, obviously your brain is working on overtime to grow an egg and it shrinks the follicular phase, the first half of the cycle when an egg is growing, thereby shrinking the whole cycle. Whereas you used to have 28 day cycles, now you have 25 and 24 and 21. Everyone thinks all of a sudden you're just gonna stop having periods, but you don't. It just shrinks first and then they start to drop out. So to me, I never go just on one lab. I would of course want her to check it again and see if she's a candidate for treatment, but an FSH of 30 is not a good prognostic indicator.

Carrie Bedient MD (19:19)

So how do ultrasounds fit into egg testing when we're looking at those four big things that you need in order to get pregnant, the uterus, tubes, ovaries, sperm? How do ultrasounds fit into this?

Anate Brauer MD (19:30)

So that day two or three ultrasound where we look at the ovaries, we can count how many little resting eggs are housed in the follicles. That's also, by the way, a very subjective marker. It really depends on who's doing the ultrasound, how closely they're looking. Sometimes you think it's a follicle, but it's a blood vessel caught in a cross section. So follicles, follicle counts are yet another data point, but we have to be careful because I feel that patients really hang their hats on the follicle numbers, and I don't know if you've experienced this, but sometimes I'll have patients come in. They're getting ready to start IVF. We already have all their protocols in place. And then they come in and someone scans them. Whereas last month, the person that scanned them saw eight follicles, now the person that scans them only saw five follicles. And they say, wait a minute, I don't know if I want to do it this month because last month I had eight. I never counsel people to start or not start based on follicles. How about by you guys?

Abby Eblen MD (20:28)

Yeah, same. And sometimes patients will also go, well, when I started out, I had eight eggs. And now why did I only get three that we were treating? It's like, well, because those are all really tiny micro follicles and they just didn't grow, unfortunately. Yeah, I agree. Micro follicles. I like AMHs because it's a little bit more cut and dried. I usually tell my patients an antral follicle count is a bit subjective. It's like if you check a urine pregnancy test, it gives you a sense that it's good or it's not good.

Susan Hudson MD (20:29)

Yeah.

Carrie Bedient MD (20:54)

So once you get past all of the egg testing, what is the next big thing that you want to check in your patients to get a gestalt of what might be going on with their fertility as a whole?

Anate Brauer MD (21:06)

So first, I like to do everything concomitantly. So I'm in New York. We like for everything to be done yesterday. So most people have like, So when a patient comes in, that day they're getting their AMH, they're getting their ultrasound. It'd be great if they're on day two or three of their cycle.

Susan Hudson MD (21:14)

That doesn't matter whether you're in New York, Texas, Nashville, or Vegas.

Anate Brauer MD (21:26)

Women come in and they think, oh, everything's my fault. Just check me and check my partner later. No. Men are 50 % of the game. The sperm, I should say, are 50 % of the game and a semen analysis should be done up front. I won't give medication if someone's trying to have a baby with their partner, I will not give them medications without seeing the semen analysis first. Just a touch on the semen analysis. It's basically a test of the sperm.

We look at three things. We look at multiple things, but there's three that we care about. Count, so how many sperm there are, and that's always listed as a concentration of millions sperm per milliliter. Motility, which is how the tails are moving, and morphology, which is how the heads are shaped, and the heads have to be shaped a certain way, and the tails are moving a certain way in order to penetrate an egg. And so I always do that concomitantly with all the female testing. Also, we want to do pre-conceptual genetic testing. So this is testing for recessive disorders. There's hundreds of them and 80 % of us are carriers for something, but some examples are cystic fibrosis, fragile X, SMA. If I'm a carrier of CF, of cystic fibrosis, that doesn't impact me or the baby in any way. But if my partner's also a carrier, the baby has a one in four chance of having that disease.

And you have the opportunity to go straight to IVF then and choose embryos without the disease. So I always like to do that testing upfront along with all the other preconceptual testing that could impact fertility like thyroid, prolactin if you have irregular cycles, making sure you're immune to things like rubella and varicella, et cetera. And then the last component, is making sure you have open fallopian tubes, because that's where egg and sperm meet, and a normal uterus to implant. And for that, we usually do an X-ray. The gold standard is still an X-ray called an HSG, or hysterosalpingogram, where we basically put a speculum in, we put a little catheter in the cervix, and we infuse the uterus with liquid that lights up on an X-ray. So you can actually see the liquid filling the uterus and coming out of the tubes to make sure the tubes are nice and open and the uterus has a normal contour.

So those are really the major tests, making sure the sperm is okay, the tubes are open, the uterus is fine, and egg count.

Carrie Bedient MD (23:44)

So what are some of the nuances with the tube test that you can find? Like with an HSG, it may say, yes, the tube is open. But what are some other things that we might see on that report that give us pause and say, we need to think about this?

Anate Brauer MD (23:58)

Yeah, so HSG's, first of all, they're not very comfortable. So if you're getting one, I definitely recommend taking two or three Motrin 45 minutes before. And what happens when you're uncomfortable is remember the tubes, opening to the tubes are really smooth muscle that can spasm. And so what we see sometimes on these results is when I see a proximal block, especially if both of them are proximally blocked, which means it's blocked at the beginning where it connects. Then I'm more concerned about spasm. And I usually have patients either repeat it or go to a place that you can repeat it with a cannulization, which means they adjust the catheter to be a little bit closer to the entrance of the tube and they can directly inject the fluid. But when you see a blockage that's more distal, meaning away towards the end of the tube or you see a dilated tube, that's when I tend to really believe the test that the tube is actually blocked. We also see things like polyps. You can see things in the uterine cavity itself, polyps or scar tissue. But sometimes these little filling defects, as they call them, can actually be air bubbles. And so my patients who come back with a filling defect on HSG always follow it up with a saline sonogram, a 3D saline, which I do in the office. It's the same idea of infusing fluid into the uterus, but instead you're taking 3D pictures with an ultrasound to make sure it's actually a real polyp and not an air bubble or something else that could be lighting up on the x-ray.

Susan Hudson MD (25:27)

A question regarding something you mentioned as one of the minor tests but I actually think it's one of a really important one for safety is you mentioned checking to see if somebody's immune for varicella or chickenpox as well as for rubella. Why why are those important nowadays?

Anate Brauer MD (25:48)

So, yes, so we know that both rubella and varicella, so chickenpox, if you acquire them in pregnancy can result in danger to the fetus with various syndromes associated with either. And unfortunately, because over time there is a waning, most of us got these when we were little, but unfortunately that wanes over time and now we see some in the population who don't vaccinate their children anymore. And so you're seeing these outbreaks of measles and chickenpox. And so you really want to make sure you protect yourself and any of our patients who are nonimmune. And some patients, by the way, will never mount an immunity. They have repetitive vaccines for both varicella and rubella and they don't mount immunity. And that's okay. In those cases, you just have to protect yourself as much as you can. But if you haven't had one of those in a while and you're not immune, we always recommend getting the series of vaccines. And for varicella, it's a series of two vaccines. And so you get a shot, you wait 30 days, you get another shot. And because these are live vaccines, you have to wait another 30 days after the last shot before you even try to conceive. For rubella, it's one, it's one MMR. And then 30 days later, you can start to try. But now it's really important to protect yourself really for that reason. And so all of our patients who are not immune, we really encourage them to get it. So I definitely recommend that.

Abby Eblen MD (27:15)

So what would you say to patients who say the female partner wants to do the expanded carrier screening test to look for genetic abnormalities, but the male partner's like, no, I'm good. I don't really want to be tested for this. What does your practice do in that situation?

Anate Brauer MD (27:27)

So we do them in tandem and actually we use BeaconFulgent. I mean, there's a million different companies out there. They actually won't run the female test until they get the male test. So they hold.

Abby Eblen MD (27:38)

interesting.

We have started doing that more recently too, because we have a lot of people who the female partner will get a test and then, you know, maybe a year later the the partner will say, okay, let me go ahead and get it done. Well, then by that time, it's like, okay, you got a different test sheet. just, so we've, I've started doing that too, where I say either you both do it or neither of you do it, you know, because it's just too complicated. Yeah.

Anate Brauer MD (27:53)

Yes, and then they sign a waiver. We usually, if the partner is there on the initial visit, we do both right then and there. If the partner's not there, I know I'm bringing them in for a semen analysis. So when they come in for the semen analysis, we go ahead and get their blood. So otherwise, it's impossible to get.

Susan Hudson MD (28:20)

What do you say when somebody comes in and they're like, I don't really wanna do testing, I just want you to have me take medicine or something like that? How do you respond to those types of inquiries? They just really don't want a fertility evaluation, they just want treatment.

Anate Brauer MD (28:31)

I won't give them treatment because the workup is what dictates the treatment. So if your tubes are blocked, you need to go straight to IVF. If your sperm count is very low, you need to go straight to IVF or see a urologist at least. If you have a very low AMH, you really want to talk about is IUI the best option? If I want three kids and I'm 38 and my AMH is low, maybe I should be going straight to IVF because I really want to complete my family or have the chance to complete my family. So it really behooves you to do the work up because it will dictate the treatment. And even for my patients who say, I want medication like letrozole or clomid with with timed intercourse. And my partner hasn't had a semen analysis. I won't prescribe it because I feel like it's a liability. General OBs are prescribing it all the time. I see it. I see patients coming in who've been on clomid for six to eight months.

Partner's never had a semen analysis. Yeah. Yeah, It's not only a waste of time, but it gets dangerous. You don't want to take medication like it's candy. It can have an impact, so I won't treat. Hard line. Yeah.

Carrie Bedient MD (29:49)

What happens if you have patient who comes in who has had testing done with their OBGYN, but it was done a year and a half ago and now they're finally getting to the point where like, okay, I'm going to go see the infertility specialist and you tell them, oh, I want this and this and this. And they're like, oh, I already had that done two years ago. What do you repeat? What do you not repeat?

Anate Brauer MD (30:11)

Yeah. So depending on the genetic panel, if it was an expanded screen, although most of these screens expand every year. So if that's up to date, I don't have them repeat or if they had a pretty comprehensive screen, I have them sign a waiver and say that's good enough for me. The semen analysis always repeat once a year. The AMH always repeat once a year. The varicella and rubella immunities, I'm OK taking two years.

CBC, think our cutoff is six months actually, like a blood count. And so everything has a timeline on it, but most of the actual fertility testing is within a year. The HSG, if you haven't had any interim abdominal surgeries or C-section or anything like that, I don't repeat it. Because if nothing's happened, then it should be the same as it was two years ago.

But I pretty much repeat, like most of the blood tests we repeat annually.

Susan Hudson MD (31:06)

The things that can change with time.

Anate Brauer MD (31:09)

Correct.

Abby Eblen MD (31:10)

So on a different note, what would you tell a patient who said, well, my older sister had fertility problems and she found out she had endometriosis. Have you checked me for endometriosis?

Anate Brauer MD (31:20)

Yeah, I hear that. I heard that three times today.

Abby Eblen MD (31:23)

And what did say to them? What did you tell them?

Anate Brauer MD (31:26)

Okay, so here's the problem with endo is endometriosis is very common. The only way to really definitely diagnose endo is through a laparoscopy, meaning we put a scope in your belly button and we take a little piece of what we think is endo and we send it to pathology, or at least we see what's very clearly endometriosis.

I still think path is required for actual diagnosis. But if I were to scope 100 women walking around on the street, I would probably see endometriosis in greater than 50 percent of them. And and the trick with endo is that disease burden does not totally go along with symptoms. There can be patients with severe symptoms who have very little endo or patients with very little endo and have very severe symptoms.

And while there is a genetic component, I would not treat that patient any differently. I'm not gonna automatically go and scope them because I don't even know if that endo is impacting them. A lot of patients, it doesn't impact their outcomes. And so I would treat them as I would really any other patient. And we know that the most efficient route to pregnancy with endometriosis with significantly impactful endometriosis is IVF.

And the reality is at the end of the day, you will eventually get there if you need to get there. But if your tubes are open and the sperm is fine and the AMH is fine and everything looks great, I don't think there's a need to be more aggressive just because you have a family history of endometriosis personally. I don't know what you guys feel about that, but those are my thoughts tonight.

Abby Eblen MD (32:56)

I would agree. Think if somebody's having a lot of pain or something like that, or it's really affecting their activities of daily living, that's the reason to scope them. Or if you see a huge endometrioma, not a small one, things like that.

Anate Brauer MD (32:59)

Yes. Of course. ⁓

Carrie Bedient MD (33:08)

All right, any other general tests that you guys can think of that we order on a reasonably routine basis? I think we've hit really all of the big ones that are defaults in our offices of everybody who comes in, can't go home without egg testing, uterine testing, sperm testing, and tube testing. Sometimes we will go for a little bit more detail on the uterus by doing a saline ultrasound, a 3D, a hysteroscopy, something where we can go in and maybe get a more specific result, especially if you've got the the HSG that looks suspicious at all, because HSG's are great at looking at tubes. They're a little questionable about looking at the inside of the uterus. And so oftentimes we'll get get a separate test there. But anything else you guys can think to add about testing that we know? We didn't really talk about thyroid. We talked about in fact, we talked about immunology.

Susan Hudson MD (33:56)

Did we talk about thyroid?

Anate Brauer MD (33:58)

Thyroid is very controversial right now, ladies. What are you doing? 

Susan Hudson MD (34:07)

I test everybody's thyroid. I mean, if it's clearly abnormal, start them on meds. If it's between 2.5 and 4.1, I order antibodies. And if antibodies are positive, then I start meds. And if it's less than that, then I'm like, we'll recheck it when you're pregnant.

Anate Brauer MD (34:27)

Great, that's exactly what I do and we didn't talk about it before, so I'm glad to hear that. But everyone gets a TSH and exactly what you just said that I used to treat everyone to 2.5 until a few months ago, until the guidelines changed. And now I do exactly that. Between the 2.5 and the 4.1, I send antibodies. If they're positive, I treat. Otherwise, watch it.

Susan Hudson MD (34:31)

Hahaha!

Yeah.

I find it's a happy medium between what I think the OB-GYNs want us to do and what the endocrinologists want to do. And since we wear both of those hats, we're the happy medium.

Anate Brauer MD (34:59)

Yeah, agreed.

Carrie Bedient MD (35:01)

We talked about AMH varying from month to month. I feel like thyroid, if you sneeze, you will get a different response.

Anate Brauer MD (35:04)

Yes.

Abby Eblen MD (35:09)

I agree, yeah. I've seen some wildly different numbers in patients before.

Carrie Bedient MD (35:13)

Wonderful. Well, thank you so much for joining us in that. We are very appreciative of your expertise and the time that you're spending with us today.

Anate Brauer MD (35:23)

Thank you so much for having me. I love being surrounded by power ladies and fellow reproductive endocrinologists. This is awesome. Thank you.

Carrie Bedient MD (35:33)

All right, so to our audience, thank you so much for listening. Subscribe to Apple Podcasts to have the next Tuesday's episode pop up automatically for you. Be sure to subscribe to YouTube as well. That really helps us to spread reliable information and help as many people as possible.

Abby Eblen MD (35:47)

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Susan Hudson MD (35:54)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye!

Carrie Bedient  MD (36:03)

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