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Trying to conceive

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My friend’s very real reasons why she – and others – are hesitant about seeking help from a fertility specialist.

I recently had a very candid discussion with a close friend about her two-year struggle with fertility. Before this conversation, I had no idea how long she’d been trying or what she’d been going through. She’s a tough, smart, independent woman who is great at tackling problems in her professional and personal life, and I was surprised to hear that she hadn’t seen a fertility specialist, or even spoken to her OB/GYN about her concerns.

For me, as a fertility specialist, I’m used to seeing women and couples who can’t wait to talk to someone like me and are open to using medical treatment to build their families. It was incredibly eye-opening for me to hear the very real reasons why someone would be hesitant to seek help from a fertility doctor.

After our talk, I kept thinking about everything that she had said and wondered how many people with similar feelings might be too afraid to take the first step toward learning more about their fertility and their options.

My hope is that this can provide some information to others who may feel the same way.

Seven reservations that hold patients back from seeing a fertility doctor

“I don’t want to do IVF.”

Who does? I know we are nobody’s Plan A. But seriously, there are many other treatment options besides in vitro fertilization (IVF). Fertility doctors can help you maximize your efforts at home with tips and techniques for “unassisted conception.” There are medications that can help optimize your cycle, as well as other lower-tech fertility treatments like intrauterine insemination  (IUI).

Coming to a fertility clinic does not equal signing up for IVF. It may be one option presented to you, but it’s unlikely to be your only option. And it is just that, an option. Starting a conversation with a fertility specialist in no way commits you to doing something you’re not comfortable with.

I also find that many people have heard things that do not really represent the experience most women have with IVF. There is a lot of misinformation and many misassumptions about IVF that make it seem a lot scarier than it has to be. So, it’s worth talking to an expert to get the real story. It’s likely not half as bad as you are expecting.

“I don’t want twins.”

Me neither! I want you to have the safest, healthiest pregnancy possible. And that often means a single baby at a time. It’s true, that many of our treatments increase the chances of a multiple pregnancy (twins or more), but fertility doctors are getting better all the time at reducing and controlling this risk.

With IVF, we actually have a lot of control over this. With a single embryo transfer, the risk of twins is less than 2 percent. Talk openly with your doctor to really understand what the chances of multiples are with each treatment option you have, and know that our goal is the same as yours: a healthy, happy, and low-risk pregnancy.

“They’re just going to tell me I’m too fat, too thin, and need to stop drinking coffee, and alcohol, eating gluten, dairy, etc.”

It’s true that your fertility doctor will likely review lifestyle factors that may be impacting your ability to conceive, but know that many people who are not at an ideal weight or who consume alcohol/caffeine in reasonable amounts don’t have any trouble conceiving. So those factors are unlikely to be the only thing affecting your fertility. You still deserve to know if there is something else going on that we can help with.

Healthy looks different for a lot of people, and there is no one perfect weight, diet, or lifestyle for fertility. Many studies indicate that light alcohol intake is okay until you know you’re pregnant. Caffeine has also been studied extensively and there is no evidence that the equivalent of 1-2 cups of coffee per day is a problem. While many studies have been done looking at nutrition and fertility, there is no one best fertility diet and most people are fine continuing to eat reasonably without dramatic restrictions.

I personally do not ask my patients to make lifestyle changes that I don’t see good evidence for. I don’t want to deprive you of anything that we have reason to believe won’t really make a difference. But I promise, I will tell you, as any doctor should if I think there is something in your lifestyle that can make a difference in your success.

“If it was meant to be, it would have happened already.”

This is a tough one for me to accept, hence my career choice. There are many things that are possible with modern medicine that would be impossible without it. We fight infections with antibiotics and prevent others with vaccines; we operate on broken bones and sick organs. None of this would just happen on its own. So why do we view fertility challenges differently? Often there is a real, tangible medical issue with a concrete solution. If that solution exists for your problem, you deserve to know about it and choose if you want it.

“I’m afraid of what they’ll find. What if it doesn’t work?”

I get this. I really do. It’s scary to ask a question knowing that the answer could be hard to hear. And it’s super scary to try what you think is the last option and face the possibility that it might not work. But please know that we are able to help a huge number of the people who walk into our offices conceive. There are new advances in this field all the time, and we are able to help solve many fertility challenges – some of them, with really simple solutions.

Even if we do find something that we can’t fix, that information can be very valuable in letting go of the unknown, and the guilt that many people feel when getting pregnant isn’t easy. Knowing that the problem is beyond your control and it’s nothing that you’ve done or not done properly can be very freeing.

“I’m too old or it’s too late.”

Maybe, but likely not. There is at least one option out there for almost everyone. If not, your fertility doctor can explain why and point you toward other options for building your family. Ask. Don’t you want to know?

“I don’t know where to start. How do I find a good doctor?”

Start with the people whom you trust, such as friends or family who’ve gone through fertility treatment themselves. Talk to your gynecologist or family physician. How about your acupuncturist, nutritionist, personal trainer, counselor, etc.? These people know you and probably know the fertility providers in your area and can let you know who might be a good fit for you.

If you don’t feel comfortable with the first physician you see, seek a second opinion or a third. Most cities have multiple good options for fertility care and it’s important that you find the clinic or physician that feels like the right fit for you and your goals.

The bottom line is, you deserve to know what may be causing your fertility challenges and if there is a solution that might work for you. Please don’t be afraid to ask for help.

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An article published on The List outlines nine things women should know about getting pregnant as they age.

trying to conceive | The List | Dr. Evan Rosenbluth
The List

It’s no secret that one of the biggest factors that influences a woman’s ability to conceive is her age. A recent article published on The List enlists the expertise of a number of fertility doctors to compile some important things to know about trying to conceive as you get older. Among those interviewed is RSC’s Dr. Evan Rosenbluth.

“At 35 years old, approximately 35 percent of our eggs are abnormal,” Dr. Rosenbluth explains. “At 38 years old, 50 percent, and at 41 years, old 70 percent of our eggs are abnormal!” If a woman of advanced maternal age chooses to pursue fertility treatment, these abnormalities can be detected using preimplantation genetic screening.

In another section of the article, Dr. Rosenbluth discusses the emotional and psychological factors that play into trying to conceive at a later age.

Related Fertility Edge Podcast: Male Age & Fertility

Read the Full Article

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A Woman’s diet during pregnancy is very important, especially when it comes to cholesterol.

It’s always wonderful when our infertility patients become pregnant. Like all mothers to be, they want to know what they should do to take care of their precious pregnancy, and diet is often a first concern. Many women ask me if they have to watch what they eat, now that their diet is a factor in two lives.

The answer is yes, as a general principle in a healthy pregnancy. However, women with high cholesterol levels should be particularly careful about what they eat during pregnancy. At Reproductive Science Center we check cholesterol panels on all women over 40 years old and in women with polycystic ovary syndrome (PCOS) and obesity, as cholesterol levels are usually higher among these groups of women. High cholesterol can run in families and can be elevated even in otherwise healthy women.

We know that lipid (fat) levels increase during pregnancy, so if you have high levels of lipids (cholesterol is a type of lipid) before you conceive, be very careful when you become pregnant. Doctors are just beginning to understand the associations between lipid levels and pregnancy outcomes.

High levels of triglycerides, which are another type of lipid found in the blood, appear to double the risk of gestational diabetes and preeclampsia in pregnant women. These conditions are dangerous for both mother and child. This appears to be independent of body mass index, meaning this increased risk is not due to obesity.

Presently, medications to combat high triglyceride levels are usually not used during pregnancy, so diet and exercise are the mainstay of treatment. Reducing your triglycerides before pregnancy seems to be the best medicine.

How can you reduce triglyceride levels?

  • Reduce the amount of trans fats and saturated fats you consume (butter, oil, etc.)
  • Eat foods with less sugar
  • Choose whole-grain foods
  • Exercise at least 30 minutes daily
  • Limit alcoholic beverages

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The Bump

Do a 90-day detox

Bet you didn’t know it takes somewhere between 75 and 90 days for sperm to form and mature before shooting out into the world. That means your guy needs to start taking care of his body at least three months before he starts thinking about making babies.

“Have him look at his lifestyle habits,” says RSCBA’s renowned reproductive endocrinologist Carmelo Sgarlata, MD. “You want him to be free of anything that could hinder sperm production. The goal is to have a healthy environment from the start.” Translation: If he only cuts back on drinking, smoking or junk food when you’re ovulating it won’t make much difference, but having him embrace an anti-inflammatory diet and an exercise routine on a daily basis leading up to when you plan to get pregnant will.

Go nuts—seriously

It turns out consuming healthy nuts leads to, well, healthy nuts! UCLA researchers studied more than 100 men to investigate the effect of eating walnuts. Three months later, the men’s semen quality was analyzed and showed that those who consumed 2.5 ounces each day had significantly increased levels of omega-3 fatty acids.

That translated into better sperm vitality, mobility and fewer chromosomal abnormalities. “Eating any type of nut could reduce oxidative stress in your body,” adds Sgarlata. “And, in turn, potentially improve sperm production.”

Make like a Mediterranean

Maintaining a healthy weight ups his chances to fertilize your egg. And while there are many ways to go about dropping pounds, his best bet is to follow the Mediterranean diet, which emphasizes plant-based foods including whole grains, greens and nuts as well as fish and poultry. “Consume five to six servings of fruits and veggies every day,” adds Sgarlata.

“Make sure you eat across the color spectrum—from eggplants to strawberries—to get the most antioxidants.” Just check that your produce is low in pesticide residue, which can negatively affect sperm quality. You’ll also want to cut back on processed meats, like bacon. One study showed that men who ate one to three servings per day had worse sperm quality. On the other hand, those who ate fish, especially fatty fish such as salmon, had 34 percent higher sperm count.

Read the full article

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At least once or twice a month, I see a patient who comes in for fertility treatment frustrated by the presence of an ovarian cyst.

Women may have a simple benign ovarian cyst which comes and goes without detection. However, a patient undergoing fertility treatment is more likely to have this cyst noticed because she is having frequent pelvic ultrasounds as part of her fertility treatment.

IVF treatment and cysts

When a cyst is seen, the patient must hold off on fertility medications for at least 1 to 2 months (which is frustrating when you are so anxious to get pregnant) These cysts can often be painful or annoying physically.

Clomid, Femara (letrozole), and even gonadotropin shots may make cysts appear more often. For some women, moving directly to IVF may help them conceive in a more efficient manner, not only by increasing their pregnancy rate per month but also by avoiding the necessary rest periods between treatment cycles.

But for the physician, these ovarian cysts must be evaluated as there is always a chance they are not just simple benign cysts but instead are precancerous or cancerous.

Ovarian cysts and cancer

In the United States, women have a 5-10% chance of undergoing surgery to evaluate an ovarian “mass” (cyst) but only approximately 15% of these patients are diagnosed with cancer.

Cancer is much more often seen in the postmenopausal age group, however, younger patients must also be evaluated as some could have cancer or precancerous cysts. Luckily, the majority of cysts in younger women are not Cancer. Non-cancerous cysts include endometriomas or ruptured hemorrhagic cysts. Tubal ovarian abscesses or ovarian torsion can also present with an ovarian mass or cyst appearance.

After a detailed history by a physician, an ultrasound should be performed. Worrisome features on ultrasounds include solid components, septations thicker than 2 to 3 mm, nodules, and vascular flow or ascites.

CT scan or MRI may also be used if ultrasound is equivocal.

Biomarkers in the blood may be helpful to decide whether to involve a gynecologic oncologist in the surgery, but should not be used alone to decide to undergo surgery.

CA-125 is the most well-studied biomarker but is very non-specific. HE4 may also be used to calculate the risk of malignancy in conjunction with CA-125.

A new test, OVA-1 may also be helpful in knowing whether to involve an oncologist in the surgery. For young women, germ cell markers (in the blood) may be more helpful including LDH, HCG, AFP, DHEA, AMH, INH B, estrogen, and testosterone.

Since the word “cyst” just means a fluid-filled sack, these are most often benign and will disappear on their own in time (or while a woman’s body “rests” on birth control pills). However, following up with your fertility doctor is necessary to keep you in optimal health.

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Many times patients ask why we as Fertility specialists can’t find a reason for their lack of success. Genetic factors, lifestyle and age are just a few influences for successful pregnancy.

Consider what has to work properly:

  • The hormones that stimulate egg and sperm development must be made in the brain and released properly
  • The egg and sperm must be present in sufficient numbers and be chromosomally normal
  • The egg and sperm must be able to develop to maturity
  • The uterine lining (endometrium) must be receptive to estrogen and progesterone
  • The uterus must be normally shaped and free of disease
  • The Fallopian tubes must be free of disease and open
  • The cervix must produce receptive mucous at the time of ovulation
  • In the woman, the brain must release a sufficient surge of the LH hormone to stimulate the final maturation of the egg
  • The follicle (eggs develop in structures called follicles in the ovaries) must rupture and release the egg (ovulation)
  • Intercourse needs to occur near the time of ovulation
  • Sperm must be deposited into the vagina, survive their brief visit to the vagina, enter the cervical mucous, swim to the Fallopian tubes, and “find” the egg
  • The Fallopian tube must “pick up” the egg and support the egg, sperm and embryo
  • The sperm must be able to get through the cells that surround the egg (cumulus cells) and bind to the shell (zona pellucida) of the egg
  • The sperm must undergo biochemical reactions and release their DNA package (23 chromosomes) into the egg
  • The sperm and egg must each contain only 1 copy of the needed 23 chromosomes
  • The fertilized egg must be able to divide
  • The early embryo must continue to divide and develop normally
  • Proper gene expression and imprinting must occur
  • After 3 days, the tube should have transported the embryo into the uterus
  • The follicle(s) that release the egg(s) must convert to the corpus luteum cyst(s) and continue to produce the hormones necessary to support and nourish the endometrial lining
  • The endometrial lining of the uterus must be properly developed and receptive
  • The embryo must develop into a Blastocyst
  • The Blastocyst must hatch from its shell (zona pellucida)
  • The hatched Blastocyst must attach to the endometrial lining and “implant”
  • Early embryonic and fetal development must then follow….

Wow, that’s a lot. There is so much more we do not currently understand. Much of what must happen is still beyond our ability to observe and understand. Even with the amazing treatments we now have, there are factors well beyond our control.

A healthy child is truly a miracle. The good news is that miracles happen all the time!

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