Rescripted_Dear Infertility_S6_Ep1: Audio automatically transcribed by Sonix

Rescripted_Dear Infertility_S6_Ep1: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi, I'm Kristyn Hodgdon, an IVF mom, Proud fertility and women's health advocate, and co-founder of Rescripted. Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for all things fertility and women's health. This season, join me along with Dr. Nicole Yoder, a fertility specialist at Spring Fertility in New York City. As we explore what to do when you're trying to conceive and feel like nothing is working. From when to seek the help of a fertility specialist to what questions to ask. When IVF fails, we'll address all things fertility troubleshooting so you can become your own best reproductive health advocate. Now, let's dive in.

Kristyn Hodgdon:
Hi, everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm so excited to be here today and for this whole season, actually, with Dr. Nicole Yoder. Hi, Dr. Yoder.

Nicole Yoder:
Hello. It's great to be here with you for the season.

Kristyn Hodgdon:
Yeah, so happy to have you here. Dr. Nicole Yoder is a fertility specialist and board-certified OB-GYN with Spring Fertility in New York City. We love Spring Fertility, and we're just really excited to talk about all things fertility troubleshooting this season. Whether you've been trying to conceive for a few months or a year and are wondering what now to having multiple miscarriages or IVF failures. We're going to talk about what to do when it feels like nothing is working. There are always options, and knowledge is power. And we're here to give you the tools so that you can go back to your physician and healthcare providers and advocate for yourself. Really excited to dive in.

Nicole Yoder:
That sounds great. And I'm excited to delve into all sorts of topics that we'll cover. And as you said, we'll cover all the nuts and bolts things that might be useful tools, and happy to be here.

Kristyn Hodgdon:
Awesome. So I thought we could start with the first episode geared towards an individual or couple who they've been trying to conceive for a little while, maybe about a year. And they're, it's not, they're not having luck, and they're thinking, what's next? What are my options? And I see it all the time where, because of the sort of like lack of access to care and the cost, it's people automatically jump to IVF. It's so expensive. I don't know if I'll ever be able to afford that. And I really want to talk about there are options. You don't have to look at the whole mountain. There's it's one step at a time. And so, what would be, as a fertility specialist, the next step that you'd recommend?

Nicole Yoder:
So, I think you bring up a great point of taking it one step at a time. But if you have found that you've been trying for a year, which we define really as unprotected intercourse on a regular basis over the course of that year, it's really time to start thinking about the next steps. And maybe you need some sort of evaluation and a workup at that point. So, anyone who's been trying by a year, we say it's really time to take that next step and get an evaluation with a fertility specialist.

Kristyn Hodgdon:
Okay, So you would skip over the ob-gyn, or would that be a good first step or?

Nicole Yoder:
That is a very good point. And this comes back to another point that you mentioned with like resources and where you are, some places you're going to have readily available fertility specialists at your fingertips that might not be as feasible. And it's okay to start with your ob-gyn. It's okay to even maybe you don't have an ob-gyn yet. It's okay to first start with your PCP. But I think really what you need to be doing is just starting that first step of entry into some sort of evaluation and someone who can point you in the right direction. Now, maybe when they go through that history, they say, oh, this is a little out of my league, given what I'm seeing. You do need to go to a specialist. Hey, we can start the evaluation here. We'll do what we can. And if it feels like you're going to need a higher level of care, then we can get to that next juncture and maybe level it up at that point. But whatever your scenario is, it is time to take mental inventory of where you are, your overall health, and take that next step of getting some sort of evaluation so you can start to get some answers.

Kristyn Hodgdon:
Absolutely. That's great advice. You go to your healthcare provider, and you ask for a full fertility workup. What is that sort of include?

Nicole Yoder:
Let's say you're starting with your ob-gyn. The first thing that they're going to do is probably take a pretty detailed history. We really start by just having a conversation. We always want to know what is the last year been like for you? What have you been trying? Have you had any biochemical pregnancies? Absolutely no pregnancies. Have you had any pregnancies in the past? So we're really going to dig into that history, your medical history, your GYN history, and then just how you've been trying. That might sound like a silly thing to say, like how you've been trying, but you'd be surprised. Some people, they're like, We've had sex, and nothing has happened. But maybe they haven't timed things. Whereas other people are already using the apps. They're already looking at like fertility trackers, maybe using OPKs. So there are definitely different levels of where people are coming from, and it's good for us to understand what you have and have not done. How often are you having intercourse? Does your partner travel half the year, Maybe six months? Are those attempts weren't actual, quote-unquote real tries if they weren't really there. That helps us get a little context of the bigger picture. But we're going to start literally just by having a conversation.

Kristyn Hodgdon:
Yup. And right then and there, in my case, it was like, oh, I wasn't even getting a period. So I wasn't. That is a big red flag that I wasn't ovulating and still somehow is a 27 year old college-educated woman.

Nicole Yoder:
Yeah. Yeah.

Kristyn Hodgdon:
Realized that meant I couldn't get pregnant. Fast forward six years and or seven years, and knowing what I know now. But hindsight is 2020. But yeah.

Nicole Yoder:
You bring a good point. All of our reproductive education is mostly how to not become pregnant. So there are things that you might have happening that you think nothing of. Oh, I missed a period here or there. Like no big deal. That doesn't matter. But it matters. It actually matters, and it matters to us when we're looking for what could be going on. So sometimes you don't know what you don't know. And it's good to just start that conversation of getting into those more details and maybe things that you didn't think were important that actually are. Happens to everyone. The most educated people don't get good reproductive education or specifically infertility education.

Kristyn Hodgdon:
Yeah, we just did a major survey of a thousand of our community members on the state of sex ed in America. And the results were pretty staggering.

Nicole Yoder:
I'm sure. I'm sure. Just shocking.

Kristyn Hodgdon:
Yeah, Just. And it's not our fault. It's like we were taught how not to get pregnant. Yeah, Yeah. And less about fertility awareness and our bodies.

Nicole Yoder:
Exactly. And even in more higher level reproductive specific education even then. So, OB-GYNs and training do not get a lot of information or background on infertility. It's a very small slice of our educational pie. So, it really is something that even well-educated medical people are not going to have a lot of solid information about.

Kristyn Hodgdon:
Awesome. So, actually, I wasn't planning on asking this, but now that we're here and it's just so important, what do you typically advise patients who may not be doing it?

Nicole Yoder:
My biggest thing is are you ovulating regularly, and does the timing seem to be at least somewhat accurate? Do you feel when you're fertile window is? And are you having sex during those times? Those are that's like kind of the basic, and you would be surprised that some people, it takes energy and effort to track these things, and we're all busy people, and sometimes people don't realize until maybe six months a year has gone by, and then they retrospectively look back and try to figure out when their periods happened. They're like, oh, shoot, That was all over the map.

Kristyn Hodgdon:
So that's even ovulation test strips. I was I'm embarrassed to say how not long ago it was. That's when I learned that you get the peak prior to ovulation. It doesn't mean that you're necessarily ovulating that day.

Nicole Yoder:
Yes. Yes, exactly. Even little details like that. And some of them work differently. Yeah. That no one teaches you these things. You have to read it like on the back of the box and interpret it yourself. And it's not as straightforward as one would think.

Kristyn Hodgdon:
That's why Rescripted is here.

Nicole Yoder:
Exactly.

Kristyn Hodgdon:
So say your patient has been doing everything right, all the right things, using the apps tracking her cycle but she's been trying for a year with no luck. She gets the fertility evaluation. What are some of the markers that you would be looking at in the evaluation to determine what your next steps would be?

Nicole Yoder:
Yeah. So a basic evaluation is going to start with, as we said, going through your medical history, do you have any medical conditions that may make your success rates less than somebody else your age or that are uncontrolled? So medical history, your GYN history, we alluded to this already with looking at your period pattern, are you presumably, if you're having regular periods, that is our best marker for ovulating regularly. We're going to ask you a lot of questions about the details of those things. What are your periods like? Are they super painful? Is the average 28 days, but maybe some months are 24 and some are 34. That's a little bit of a different picture. So we're going to get more details about the period and any history that's relevant. Do you have any history of sexually transmitted infections? Have you had any procedures on your uterus? Those types of things, full history, GYN history. And then we're going to do, most likely, that first visit an ultrasound, really just to take a look at the uterus and the ovaries and get a sense of is there anything structural with the uterus that sticks out to us. Polyps, fibroids, step down, those types of things that are really obvious, and your ovaries, just to see what type of ovarian reserve do we see. Which we can, I'm sure we will talk a lot more about that over the course of the season. But ovarian reserve is something that we, not necessarily use as a marker of your natural fertility, but it's definitely helpful when we're thinking about how to move forward and what makes the most sense.

Kristyn Hodgdon:
Would that be the antral follicle count?

Nicole Yoder:
Yes. Yeah. Part of that is the antral follicle count, and part of that is the AMH or anti-mullerian hormone. And that those two things combined give us a pretty good sense of what your ovarian reserve is. But that's a good transition into other bloodwork that we also do. So we'll check other bloodwork like thyroid prolactin, depending on your history, some basic blood work like your blood counts, infectious disease screening, and then genetic carrier screening is another bloodwork that you'll probably get at that first visit if you haven't done it already.

Kristyn Hodgdon:
Love that you mentioned the thyroid. I feel like that's like the one that not everyone knows to ask for. But I was having a chronic fatigue and it turned out that I had a full-blown thyroid condition, an autoimmune condition. So it's yeah, it's just a couple years ago. But I always say make sure you ask, the thyroid.

Nicole Yoder:
Yeah. And thyroid. You can be fine one year and you're totally out of whack the next. So it's something if you have changes in symptoms and the one you mentioned is a really good example of something that thyroid issues can cause fatigue, but so can 10,000 other things like life or anything else can also cause fatigue. So it's not always top of mind. Oh, maybe my thyroid is off. So that's another reason why we like to just talk first and go through what are you feeling like. Any symptoms that you're having? Because it can clue us in certain directions in terms of what may be going on, but just to round out sort of the overall initial workup. So we talked about your history, your blood work, your ultrasound genetics, and a semen analysis. Those are going to be the initial screening and the nuts and bolts of the very basic fertility assessment that's going to start to give us some clues as to what may or may not be going on.

Kristyn Hodgdon:
I also love that you mentioned the semen analysis because fertility takes two to tango.

Nicole Yoder:
Absolutely. And I can't tell you how many times we have a single woman who comes in, not a single woman, a woman who walks in the office, who has a partner, and they're like, oh, this is you go do the workup. I'm like, Oh, no, this is a two-party situation. So they are not exempt from that initial workup either.

Kristyn Hodgdon:
And it's actually probably one of the most affordable fertility tests out there. And it's literally 50% of the equation. So for nothing else, like just marking that off the list and like process of elimination.

Nicole Yoder:
Yeah. Yeah. Like in terms of evaluation, it's a pretty low-hanging fruit. So.

Kristyn Hodgdon:
Yeah. Exactly.

Nicole Yoder:
For the most part, pretty easy to do. Pretty accessible, pretty affordable. And it is definitely, as you mentioned, it's 50% of the equation. And so, you know, there's 100% part of the initial work of.

Kristyn Hodgdon:
Absolutely. So when should someone go see a fertility specialist, whether they've gotten a fertility workup with their ob-gyn or maybe their age is obviously a big factor here, too.

Nicole Yoder:
Yeah. So we talk about age. Anyone who is under 35, we're going to draw that line in the sand at a year of trying. That's when it's really start time to start going and getting a fertility evaluation. Now, if you're over 30, 35, or over, we shorten that duration to six months. So anyone who is of 35 or older, if you've been trying for six months, then would say also time to go get that evaluation, mostly because these outcomes are all age-related, unfortunately, and there's just a higher chance that you're getting some sort of intervention. So we don't say to wait for a year. If you're if you're 42, don't wait a year. Come on in. There are other reasons why you don't need to wait that amount of time. So if you know that you do not ovulate or you do not get periods, come on in earlier where you can. That's an issue. If you have a history of pelvic inflammatory disease or history of sexually transmitted infections, I'd say that's a good reason to come on in earlier. If you think that you have super painful, heavy periods, it just don't seem normal to you. Another reason why you don't need to wait that full amount of time to get an evaluation. A year and those six months are for traditional teaching. But there are definitely reasons why it would be acceptable and preferred to come in for an evaluation sooner.

Kristyn Hodgdon:
Awesome. Yeah, I think some people automatically think it's a year no matter what. Oh, it's great advice because we know that female fertility declines as we age. Unfortunately.

Nicole Yoder:
Yeah, exactly.

Kristyn Hodgdon:
What if you're in a same-sex female relationship? What would your sort of next steps be there?

Nicole Yoder:
That is definitely a situation where people are usually coming as soon as they're starting to try oftentimes. Just because, you know, without male partner or a sperm source, as we sometimes call it, readily available, you're probably going to need some sort of assistance to achieve it, right?

Kristyn Hodgdon:
Yep.

Nicole Yoder:
And really, what the best route is going to depend partially on those same things we're going to talk about, like your medical history, your overall goals. But a lot of times you can start with things like an IUI before you need to necessarily move on to IVF. I think a common misconception is if you walk in the door of a fertility office that we're going to tell you to go straight to IVF. That's the only way to achieve a pregnancy. Or that's like what you have to do if you walk in here. And this is a really good example of why that's not the case. And for some people that is actually completely inappropriate to start there. But things like insemination are a great step for people who are using their donor sperm because their single parent by choice or same-sex female couple. And we can start the pertinent work up for that situation instead.

Kristyn Hodgdon:
Who else might be a good candidate for IUI?

Nicole Yoder:
People who are good candidates for IUI tend to be people who don't ovulate regularly, whereas when we're doing IUIs we're improving that parameter. People who may be the sperm quality is not quite what we want it to be and we can improve that a little bit by doing like a sperm wash or something like that. Or maybe just the motility is a little low. Those people tend to benefit from doing an IUI and they tend to have higher success with IUI than they are trying on their own. So donor sperm, you don't ovulate or a semen analysis is not quite up to snuff, but not severely low. All of those are great candidates for IUI, or maybe it's somebody who only wants one kid and they really don't want to do IVF and they don't want to do the time money like all the shots, and they just want to try to optimize the system as best they can. A lot of those types of people will start with IUI as well. So really depends on your overall goals and also what we think is the reason for the infertility.

Kristyn Hodgdon:
Yeah, I love hearing that. A lot of our listeners know that I've been on a long fertility journey and I only want one more baby. And IVF didn't work, or at least the embryos we had and the thought of going back and doing another retrieval just scares me.

Nicole Yoder:
Yeah, no, that's a lot. If you are just in a really intense IVF situation and it didn't work like going back to it.

Kristyn Hodgdon:
Yeah.

Nicole Yoder:
And right for you right now.

Kristyn Hodgdon:
And so sometimes it does make sense to just go back to the basics. If ovulation is the issue or do you ever recommend because at the very beginning of my journey, this was years ago before my twins, but I think I did one cycle with just Clomid and timed intercourse. Do you ever recommend that in a fertility care setting or do you always just say, I will give you the better chance?

Nicole Yoder:
Now, if the issue is really that you just don't ovulate? It's not that if that's really the core issue. Ovulation induction with timed intercourse can be a great way to start because you're addressing the main problem, which is ovulation. It's not that there's not sperm exposure, it's not the goal factor or something like that. We just need to get you to ovulate, Presumably if we have no other major concerns, that can be a really great way to a great starting point.

Kristyn Hodgdon:
Yeah. And when is it, IVF is definitely the way to go?

Nicole Yoder:
Time is going to tell you proceed directly to IVF. If we do an analysis and we see that your tubes are blocked, both tubes are blocked. There is a, I never say zero because that's a very strong number, but a almost 0% chance that natural intercourse or inseminations, any of that is going to be successful. So we say go directly to IVF. If you do a semen analysis and we see no sperm or very low amounts of sperm, severe male factor, we're going to say go straight to IVF. In cases where the age of the female partner is older, is that a hard and fast must go straight to IVF. But the IUI success rates can be so low that we're going to tell you this might not be worth your time, and money, and energy, and effort. And if you want a decent success rate, you're really going to want to go straight to IVF. And then the other scenario is if there are any genetic concerns or specifically if there are genes that we are trying to screen out for. And we need to make a probe for those genes. Then we're going to say you have to do IVF to test for specific genes, which is known as PGT-M. But if you are a PGT-M candidate, you have to go straight to IVF as well.

Kristyn Hodgdon:
Oh. I love that. That's an option, too.

Nicole Yoder:
I know, it's an amazing thing that has evolved through all of this, like reproductive technology, and really a really great benefit.

Kristyn Hodgdon:
I love it. And I love what you said earlier about depending on how many kids you want to have because that was a question that my original fertility doctor never asked me. And I did a lot of IUIs without having ever communicated that I knew I wanted like at least three kids. And so.

Nicole Yoder:
Yeah,

Kristyn Hodgdon:
I wished at that point that I had gone to IVF sooner because then you have the potential to get more embryos. But I think that's such an important factor for people to consider.

Nicole Yoder:
Yeah, and that's one of the things that we should be asking you at your initial visit. And if they don't ask you to tell them because your overall family planning goals really play into the whole picture. If you tell me you want four kids and you're starting at 38, I'm going to tell you, go straight to IVF because you're gonna want to take some embryos. But if you're in my office and you're 28 and you want 1 or 2 kids, maybe you don't have to jump to that route quite as quickly.

Kristyn Hodgdon:
Yeah

Nicole Yoder:
I always tell people it's a good idea to keep in the back of your mind when you could foreseeably be having your last baby. So the pregnancy spacing is important as well, and obviously, no one knows what life will hold and no one knows like how things will play out ultimately. But if in your ideal world, you have a kid at 35 and that a kid at 40, you're having a kid at 40, and then the chances are going to be a lot lower and you're going to wish you did IVF sooner. So number of kids, pregnancy spacing, and when you could foreseeably be having your last child or all things that you should be talking about in that first visit.

Kristyn Hodgdon:
That's great advice. What about someone hoping to freeze eggs or become an independent parent? What do you recommend their route be as far as how many eggs they want to freeze or just overall considerations?

Nicole Yoder:
This is another situation where it's really important to understand that patients overall. So some people will come in and say, I don't know if I want kids, and if I did, it would only be one. And if it didn't work out, I would live my life peacefully. But I want to keep the option open so I'm going to freeze some eggs. Other people come in and they say. I know. I want to be a mom. I know I want to have a family. I don't foresee this starting until I'm like maybe closer to 40 and I want five kids. And it's really important to me that I would be devastated if this didn't happen. So that's a very different scenario in terms of, you know, what their goals are. So you always have to know what their overall goals are in like numbers, size of family in order to have that conversation about what's a good number of eggs to freeze. The other big component is age. So the age at which you're freezing the eggs so people who are younger do not need as many as people who are older to get the same outcome.

Kristyn Hodgdon:
Yeah, awesome. I think this was such a great sort of overview of what to do if you've been having trouble trying to conceive at home and what your next step should be. I would like to ask, since.

Nicole Yoder:
The one thing that I would say to rescript is you never know what you don't know about fertility. And we really do a poor job of educating people about it. So there's no shame in asking. There is no shame in getting that information, and there's no shame in educating yourself about fertility.

Kristyn Hodgdon:
I love it. You're speaking my language. Thank you so much, Dr. Yoder. Next time we're going to be talking about some of the diagnostic tests that are typically done before patients move forward with fertility treatments. So I'll talk to you then. Until next time.

Nicole Yoder:
All right. Looking forward to it.

Kristyn Hodgdon:
If this podcast means something to you, be sure to hit, follow, or subscribe. This helps you because you'll never miss an episode and it helps us because you'll never miss an episode. For everything you need to know about fertility and women's health, head to rescripted.com or follow us on social @HelloRescripted.

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