I’m so excited to share the second installment of the Wine & Gyn series that covers women’s health, fertility, egg freezing, and more. This post covers questions focusing on fertility that were answered by Dr. Mary Rosser, Dr. Zev Williams, Dr. Brianna Ruddick, and Dr. Paula Brady from Sloane Hospital for Women at New York Presbyterian. Dr. Rosser’s specialty is Obstetrics and Gynecology and Dr. Williams specializes in Fertility, specifically recurrent loss. Dr. Ruddick is a Reproductive Endocrinologist within the area of third party reproduction and same-sex couples, and Dr. Brady specializes in egg-freezing. We were very lucky to have all four specialists in attendance to answer any and all of our questions to gain some clarity on sometimes confusing subject matter. To avoid a 30-page transcript of the conversation from the event, I divided the questions into three categories, like I did for the first installment of Wine & Gyn. You can find the first post about fertility here. Fertility is tricky subject because it is so specific to each person. From our lifestyle to our genetics, there is no silver bullet that will answer our personal questions without going in to see a doctor. I hope some of these questions and answers help you gain some clarity!
Dr. Ruddick: There are a number of options. Every aspect of this has been changing quite a bit over the past couple of years. There are very simple basic treatments, like artificial insemination, which we also call intrauterine insemination (IUI). There are more complex treatments like co-maternity where one partner can actually donate eggs to the other partner to carry. I'm not going to say that's the least expensive option and I'm not going to say that insurance companies have figured out a very easy way of covering really any of those services, which is challenging to say the least. I think at least on the political front there is a lot that still has to be done, but we are making strides in all the other areas and trying to make this more user friendly for same sex couples. We are trying to make the acquisition of sperm easier and trying to cater to patients wishes to keep it as natural as possible, or as aggressive as they want it to be. There are a lot of options.
20% of all couples are going to have infertility issues, including same sex couples. So, that particular transition when you have a same sex couple that's transitioning from I just needed sperm to maybe there is an issue, that's where it really helps to be getting care in a fertility clinic. We know how to handle that transition. We know what appropriate tests need to be done. That's really where it benefits people to be in a clinic. We also have more experience working with midwives in the community and trying to keep things as natural and simple as possible. It's just a matter of making sure that everything's still done in a safe way.
Dr. Rosser: Everyday I wish patients would ask me certain questions in our visits so I try to touch on them during their appointments with me. I love working with your age group (twenty-somethings) because you guys are very empowered and you advocate for yourselves and you have to continue to do that. I think lifestyle is really one of the biggest factors that we have in our health and definitely in our fertility and we have learned from studies that what you do in your teens, 20s, and 30s predicts how well you're going to live and feel in your 40s, 50s, 60s, and beyond. I think paying attention to your lifestyle is so crucial. That's including exercise, watching what you eat, your diet, maintaining a healthful weight, and watching the alcohol.
My cardiology friends tell me that women can have up to seven glasses of alcohol a week, preferably not all on the same night. In your 20s and 30s, people typically go out and they'll have a couple or three drinks, but you really have to think about that. Think about what is that going to do to my future health and maybe try to limit it to one or one and a half drinks. We have seen that as women get older when they have their second glass of wine their blood pressure starts to go up.
Also, it's really reassuring that everybody is stopping smoking and that the smoking rates have gone down. However, we still see a significant number of women in their teens and early 20s who smoke. If women smoke, they really do need to stop and there's no such thing as “Oh, I just have a couple of cigarettes when I drink socially”. They say even one cigarette can do quite a bit of damage so we have to be careful with that.
If you are sexually active, you need to be screened at least annually for sexually transmitted diseases. Obviously, which tests and how often depends on you as the individual and your history. People cannot forget that infections such as gonorrhea and chlamydia, which are cervical infections, can lead to pelvic inflammatory disease and damage the uterus and the fallopian tubes. Those are silent many times. Where everything in a man is mostly on the outside and discharge can be seen more readily in a woman, that may not be noticed so you really do need to be screened. The last thing I will say is that there is an increase in syphilis so you really need to be screened for that too.
Dr. Williams: I think those were great answers to your question for what lifestyle changes we recommend to give you the best chance of preserving fertility and maintaining fertility. The one thing I want to caution to everybody when you hear this is that what we're saying is different from our answer to individuals and couples who are having fertility problems, or when they're having miscarriages or difficulty conceiving. All these things might contribute to it, but the vast majority of cases of infertility are not due to something that the woman did wrong and I think that's an important message for those of you who are either going through this or have a friend, family member, or loved one going through this.
The vast majority of times, the woman did not do something wrong and still often has a sense of self blame. People think back to the things they did and that's rarely the true cause of their fertility issue. Sometimes the causes aren’t known, it could be genetic or something they were born with, and obviously there was nothing they could do about that. There is also unexplained infertility. I think it's so important that when we talk about these causes that are preventable, they are not necessarily what's causing those problems later.
Dr. Rosser: I apologize if I was misleading before, what I was talking about was being healthful now and what you can do to protect yourself in general to remain healthy. Stress and fertility are definitely connected though.
Dr. Williams: We did a study across the U.S. looking at public perceptions of miscarriage and what was interesting was first of all, people grossly underestimated how common it is. It can happen in 1 out of every 4 or 5 pregnancies that result in a pregnancy loss and most people thought it was less than 5%. The other thing is when you look at what people think cause the pregnancy loss, probably the number one factor after genetics is stress. What we know from pretty well designed studies is that stress does not cause pregnancy loss. I think this is important because for a lot of people it's something you hear a lot of. Friends will go through it and well-intentioned people will say to them, “Oh, you just need to relax don't worry”. The implicit message of that is, because you are worried this is what happened. It is very natural for essentially every woman and her partner that I've seen to think back about the week, the month before the loss happened to ask themselves, “was it because I had a deadline at work” or “did I lift something heavy” or “did I get into an argument with someone?”. The answer is no, that's not what it is. We have to do a careful evaluation of what it was, but we know it wasn't that.
In terms of actually getting pregnant, it's a little bit different. There, stress can play a role. If you think about it from an evolutionary standpoint, if someone is under stress, it used to be there wasn't enough food, you were in starvation mode, it was not a good time to be pregnant, so the body said let's protect the woman at this time and wait until it's a safer time to conceive. So, stress can play a role in terms of the ability to conceive. Now, the challenge is what do you do with that information. If I told someone just relax, they’ll respond, “Ok! Thanks, I wanted to be stressed, but I want to follow your advice so I won’t be stressed anymore”. It really is genuinely a very stressful period to go through. It's tough on the couple too. Very often people ask, “is it me or is it him?”, and while it might be some factor in your body, it’s not you that is doing this. It’s a question of working together to find out what is happening.
What helps relieve stress is different for everyone. Something like acupuncture can be helpful, but for others, scheduling and going to that acupuncture appointment is the most stressful part of their day. Mindfulness, meditation, yoga, exercise, going for a long walk in the park. There’s not one particular thing that works but I think anything that you can do that puts you a little bit more at ease is a good thing. That's part of the reason why centers like ours exist, so you can come in and put all the worry, as much of the stress, as possible on us. You’ll feel like there's somebody looking after you and all these different aspects while doing everything they can to make sure nothing is being missed.
Dr. Williams: So it is definitely a real thing and you can go to the CDC’s website and they'll show you which areas to avoid traveling in. What's interesting about the virus, it’s really kind of a tragic situation, but it likes to go to the baby. That's the kind of tissue the virus likes so pregnant women should avoid these areas. What is not as well known though is that if a man acquires Zika, it can be sexually transmitted to his partner because it can survive in this testes for six months afterwards. So even if the woman never went to the place where Zika was present, it can still be transmitted. If you are planning travel, look at the CDC map, to avoid those places and the map is updated frequently.
Dr. Ruddick: Sperm banks are responsible for examining risk factors based on a questionnaire. They do ask you where have you traveled in the past 6 months. Then, they will actually do a test before and after a 6-month quarantine to avoid disease transmission. The FDA doesn’t have great Zika testing yet so we don’t have testing that can give us good enough results yet.
Dr. Williams: What you experienced in terms of having an ovarian reserve test done and then it got better after going off birth control is to be expected, that’s not unusual. And the reason is there are a lot of different variables that we look at. One of them is looking at the eggs at a certain stage in their development. When someone is on birth control pills, it suppresses the eggs from getting to that ovulation stage so it can look like it is actually falsely depressed. In fact, the last issue of OBGYN Management, which is one of the big journals that obstetricians read, the cover article last month was on ovarian reserve testing and it was authored by Dr. Brady. So what you went through is actually very predictable.
*This was my question because I took a Modern Fertility test while on birth control, which they claim is fine to do, but my results were quite low. Then, I went off birth control and got another fertility test done by a doctor and my results were higher. This is why I don’t believe that taking a fertility test while on hormonal birth control is a good idea. It is not going to show you an accurate picture of where your fertility stands. But, the doctors did say that if you have a Copper IUD, the numbers in the Ovarian reserve test will not come out skewed like other birth controls.
Dr. Williams: It is different in men. There's two challenges that are different in terms of the way the sperm are produced compared to the eggs. As Dr. Brady mentioned, a woman is born with all the eggs she will have which declines over time. The consequences to that are as a woman ages, the egg are more likely to have chromosomal issues meaning having an extra or missing chromosome. That's why things like Down's Syndrome becomes more common as women age, particularly after age 38.
With the male, sperm is constantly being regenerated. The decline isn't so much in terms of having chromosomal problems. It's more an issue of having mutations within the sperm that can develop. So things like the risk of schizophrenia and autism that can go up with increasing paternal age. However, the Canadian prime minister has fathered a child in his 70s, so the decline that happens is real but it's much less than what women experience. Lifestyle plays a role as well.
Dr. Rosser: To go back to the alcohol question. First of all, men have more of an enzyme called alcohol dehydrogenase (ADH) and that brings down the alcohol when you take it into your system and because men usually have bigger muscle mass they can drink a little bit more, like up to two glasses a day, or 10 to 14 per week, which is what the cardiologist recommend.
Dr. Rosser: I don't think that we have a lot of data on looking out that far. The recommendation is for women to abstain for three months after they come back and men six months. Now, I don't think that you would have to worry if you're not getting ready to get pregnant within that time frame or even within a year.
Dr. Williams: The good thing is that in this country there are safe options for women to have procedures or take medication to end a pregnancy. There are risks but the reality is the risk of actually continuing the pregnancy and going on to deliver are even higher. With safe, medically supervised management of elective eliminations it is a very, very safe procedure, but with everything there are risks. Most of the cases, there’s not going to be long term consequences for the woman. One of the things that can happen is to develop scarring inside of the uterus and infection. So are those things possible? Yes, but thankfully they are quite rare.
Dr. Rosser: And if I could add, you don't want to use abortion as a birth control method. The higher number of abortions, a pregnancy later can be challenging along with the labor and delivery. It can increase your risk of having a postpartum hemorrhage after you deliver. I do agree with Dr. Williams that there generally are no long term effects but after practicing for a while, I've noticed that women will think about this over the years so, psychologically it can be impactful. I think it's wonderful that we have the freedom for choice, but it is an emotional issue too.
Dr. Williams: So PCOS, is Polycystic Ovarian Syndrome, as with most things in medicine when we call it a syndrome that means we're not really sure what it's all about so we just sort of group all the symptoms together. It's a constellation of symptoms where there can be elevated levels of some of the male hormones, which is why acne and hair on the face are symptoms of PCOS. They don't ovulate regularly so you'll see often women with PCOS not getting regular periods and on ultrasound the ovaries have tons and tons of those little follicles and Dr. Brady mentioned as little black circles where the eggs are. Instead of every month one follicle and one egg starting to develop, they're all sort of competing with each other and staying in this resting phase. The good thing about it is there are very effective methods to treat a lot of the symptoms of PCOS, such as hirsutism and acne. PCOS is one of those examples where it could be something as simple as a pill that sort of triggers the body to allow one follicle or two to grow that could solve the problem. It's really a question of tailoring the treatment to what the patient's individual needs are at that moment. If it is symptom management, like not having regular periods, controlling hair growth, and trying to conceive- for all of them there are effective treatments.
Dr. Rosser: And don't forget that people have been having sex for years and people have been getting pregnant for years, so it is also possible for people to conceive without having any intervention, but it's so wonderful that we have these options available.
Dr. Williams: This ties in very nicely with the whole idea of trying to understand what you're getting from people who are not trying to conceive or not having any problems with fertility, just say look my body is doing this I want to understand what's going on. Ava, for full disclosure we are actually partnered with them and are in the midst of doing a clinical trial, but it's a bracelet that you wear and it measures 3 million datapoint points while you sleep. It measures things like the beat to beat variability in the heartbeat, movement, temperature, etc. The purpose for it is to try to figure out when ovulation is happening. I think these are great tools that will help you and it's also interesting to learn more about your body. You can also use simple things like apps that use trackers that are available on your phone. It's a great way to learn more about what's going on as well as.
Dr. Williams: I specialize in recurrent pregnancy loss, so the question I get a lot of times refers to that. I think the biggest take away when people are going through it or someone you know who is going through it, is the misconception that it's rare. Pregnancy loss is actually very, very common. That isn’t due to something they did wrong, so I try to let them know that's not the case. It's almost never due to something the person actually did wrong. Also, the emotional impact of a pregnancy loss can feel like the equivalent of losing a child. Understanding that and being sensitive to the grieving that they might be going through.
Dr. Rosser: And this is really changing the topic. But I wish people understood that just because you've had the HPV vaccine, you can still be positive for HPV and you can still have an abnormal pap smear you will need to be treated for. The other point for this I know it's opening up a different can of worms but while men cannot be tested for it, they can be vaccinated for it just like women. And we start vaccinating people in their early teens and it's a series of three vaccines and we like to vaccinate both boys and girls.
It's become such an epidemic so we like to do that before you are even thinking about becoming sexually active. We used to finish vaccinating around 26 years of age, when your immune system is very, very strong through your late 20s. Now, the age has been extended to 45 and that’s for both men and women. Remember, men do not get tested for HPV so they unknowingly may give it to a woman. It's very important you take care of yourself and get tested to make sure that your partner and other men you know become vaccinated, We really need to try to eradicate this. HPV has been implicated not just in cervical cancer for women but vaginal and vulvar cancers, rectal and anal cancers, and now head and neck cancers from oral sex. People are getting head and neck cancers in their 50s and 60s, so this is vitally important that you spread the word that people need to be vaccinated and practice safe sex.
Dr. Williams: The terms and even the language that we use is interesting. We say the word miscarriage, which is a commonly used term and it implies that the pregnancy wasn't being carried out properly. We really want emphasize to people that while that is a common use of it, it sort of implies we've been thinking she miscarried it and something wasn't done right. Most pregnancy loss is actually very, very, very early before women might even know she was pregnant. The likelihood of pregnancy loss goes down as a pregnancy advances and the reason for that is simply that you know it really is an incredible number of steps that have to go absolutely right for any pregnancy to succeed. The farther along a pregnancy is able to progress, that many more hurdles have been overcome. Most pregnancy losses occur very early around four or five weeks or even before the embryos planted. People often think once they get to seven weeks, there's something magical that chances. There's nothing really different from the day before versus the day after, just a continuous process of the pregnancy developing and therefore a lot of these hurdles that need to be overcome, are being done so successfully.
Dr. Williams: Pregnancy losses occur for one of two reasons. Either there's something chromosomal that goes wrong with the embryo, meaning it has an extra chromosome or a missing chromosome or multiple missing and/or extra chromosomes. That's one category. Then there is everything else. The category of having extra or missing chromosomes is what causes sporadic miscarriages. If someone had a child, a miscarriage, and then a successful pregnancy, it is usually because of that chromosomal tissue that is very much age dependent. So much so that if you test the embryos, as a woman goes through IVF, and we have the embryos in the lab, we take a couple all the cells from the outside of them and test them. We look to see if they have the right number of chromosomes or not. We only put back an embryo that has a right number of chromosomes to decrease her miscarriage risk a little more.
Dr. Williams: What's amazing is you know we're talking about how pregnancy requires a lot of different things to be functioning absolutely right. One of those are the hormones that are important in regulating functions that are going on the body. Hashimoto's is a condition where there's antibodies acting against the thyroid and that could impact the thyroid function. That does directly relate to causing pregnancy loss, but the good thing about it is it's also very controllable.
So one of the key things to make sure of is that the thyroid hormone levels are properly regulated. We know that when they're very outside of the normal ranges it can impact pregnancy so the thyroid level has to be carefully monitored and controlled. There are some trials going on in terms of other supplements that can be used to try and reverse the antibodies that are causing the thyroid problem in the first place, but I think the big picture for everyone is that when there is a lot of recurrent pregnancy loss happening or infertility it's important to take a broad view to try and make sure that all the little steps that have to be going right are going right. If you see a problem, we try to correct that problem without trying to introducing anything else.