Dear Infertility_Season 3_Episode_6_Starting to Try Checklist: Audio automatically transcribed by Sonix

Dear Infertility_Season 3_Episode_6_Starting to Try Checklist: 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 advocate, and co-founder of Rescripted.

Staci Tanouye:
And I'm Dr. Staci Tanouye, a board-certified OB-GYN striving to make reproductive and sexual health fun and empowering for all.

Kristyn Hodgdon:
Welcome to Dear Infertility. This season, we're going back to the basics. From menstrual cycle red flags to what you need to know before you start trying, we're giving you the tools you need to take control of your overall health and fertility.

Staci Tanouye:
Does birth control cause infertility? Do painful periods mean that I have endometriosis? We're here to answer all of your real-life questions and provide you with patient-centric advice and support so that you can be your own best health advocate.

Kristyn Hodgdon:
Now let's dive in and talk about everything sex ed failed to fill you in on.

Kristyn Hodgdon:
Hi everyone, and welcome back to Dear Infertility. I'm your host, Kristin, and I'm here with Dr. Staci Tanouye. Hi, Dr. Tanouye.

Staci Tanouye:
Hi, Kristyn. How are you?

Kristyn Hodgdon:
I'm doing well. I'm really excited to chat about today's topic, which is the starting to try checklist. So sort of everything you can possibly think of before you start trying to conceive, you know, so that patients can be proactive and be their own advocate.

Staci Tanouye:
It's kind of a long checklist, I'm not going to lie.

Kristyn Hodgdon:
It is. So it might be a long episode, but lots of necessary information, and, because I've, I've found on my own journey that like I didn't know enough prior to starting to try. And I think that's the case for a lot because as we talked about in our sex ed episode, sex ed doesn't really do us much good when it comes to when we actually want to have a baby. So I think this will all be really helpful.

Staci Tanouye:
Yeah. And I think to some extent, at the very beginning, it might be okay to not know every single detail because you don't, you don't need to get bogged down, you don't need to be overwhelmed. It is okay, like if this is too much at the time, we can kind of safely start to try even if we don't know this entire checklist like that can be perfectly healthy and okay too. But we all know that there's so many of us out there that are, you know, we want to be prepared, we want to know everything, we want to look it up, and if you're one of those people, this is the way to do it.

Kristyn Hodgdon:
Absolutely, that's a great point. And sometimes knowing too much can be.

Staci Tanouye:
It can be stressful.

Kristyn Hodgdon:
It can be stressful.

Staci Tanouye:
Yeah.

Kristyn Hodgdon:
That's where I'm at. But for, .... try, don't worry. This episode should tell you everything you need to know. So jumping right in when your patients come to you for a pre-conception appointment, how does that usually go?

Staci Tanouye:
There's a lot that we kind of go through and talk about, but the ultimate goal is that we want to completely optimize someone's health, so we're reducing any sort of risks for a future pregnancy. So that's going over their entire past medical history if they have any underlying medical issues, really optimizing each one of those to make sure we're fully treated, we're doing well, we're doing, we're stable. Going through a medication list, what medications are we taking and reviewing what we can and can't take if we're trying to conceive, and then during pregnancy, we want to go through other parts of the history, really talk about their menstrual history, their menstrual cycles and their periods. Are your periods regular? Are they predictable? Are they heavy? Not heavy? Are they super painful? How long do they last? And with that, we can kind of get an idea of, well, are we ovulating? Do we think we're ovulating? So we can just kind of try in on a normal route, or are we not ovulating? We have to change gears completely because if we're not ovulating and our periods aren't regular, then some of this isn't really going to apply right away. We've got to attack that problem from the get-go, and so that's really important. Surgical history, talking about your diet, what foods to eat and optimize, and what foods eventually we are going to avoid in pregnancy. Exercise. Exercise is a really great way to prepare your body so that you can continue an exercise plan during pregnancy. Because we all know pregnancy is very, it can be very stressful on the body physically. We review supplements, make sure we're not smoking, limiting alcohol or eliminating alcohol, depending on where we're at in that process. Reviewing travel history, reviewing a patient's goals, what they're looking for. We also have to talk about their partners, their partner's history. Does their partner have any underlying medical issues? Does their partner have any other children? Does their, has their partner ever had surgery on certain things? So there's lots of stuff that goes into there. I mean, there's just a ton of stuff I could go, I could go on.

Kristyn Hodgdon:
Well, this is really refreshing because I feel like, number one, you're very thorough. And I kind of had the experience where my OB-GYN just said, oh, just try and see what happens, which I think is the experience of a lot of people. It's like, don't worry until you have to. But at the same time, if there is a history of, you know, say you have an autoimmune disease or PCOS or anything like that that's underlying. And then number two, your partner, I mean, so many doctors I think don't even bring up the partner at that initial appointment. But there are some things that make you higher risk for male factor infertility, and so knowing that all that off the bat is really important.

Staci Tanouye:
Right. And I mean, I also we talk about like vaccination status, too, because there are certain vaccines that you can't give during pregnancy that it is preferable to have beforehand. So we often ask about like, well, do you have a history of chickenpox or have you been vaccinated against varicella? Same thing with the MMR vaccine because the rubella, the AR part of it is the more important thing. Everyone at a new OB appointment is going to get tested for the rubella status, but if we can test that ahead of time and kind of know because if someone's a non-responder or has has their immunity to that has worn off in some way, we can boost them before they even try to start to conceive, so it's not a nonissue during pregnancy. And then the last and probably, probably the most important thing is starting a prenatal vitamin.

Kristyn Hodgdon:
Yes.

Staci Tanouye:
And people stress out about what prenatal vitamin to, to pick and really simple is fine, simple as totally fine. Simple, cheap, over-the-counter is whatever, I tell people all the time, prenatal vitamins to some extent, I mean, vitamins in general are kind of gross, right? They leave that, they're big, they're chunky, they leave a weird aftertaste. And so it's basically whatever you will take is the best prenatal vitamin for you. Whatever one you tolerate that you can take every single day. Thinking into the future during pregnancy, if people are nauseous, like think about that, is this going to make that worse or are we okay with that? So that's the most important part of a prenatal vitamin. Number one, you're going to take it because you can and it's tolerable. And then most prenatal vitamins, if they have the label prenatal, they should have the standard amount of folic acid content because that's the other key factor to a prenatal vitamin.

Kristyn Hodgdon:
Okay. Yeah, that's interesting, that brand doesn't really matter. And I think relieving in some way because so much of, so many of us stress about what supplements we're taking, and.

Staci Tanouye:
Yes.

Kristyn Hodgdon:
Will this help egg quality and X, Y, and Z.

Staci Tanouye:
Yes. There's lots of little things that we can, everyone can get into at prenatal vitamins, but I think we don't need to stress out about it. There's no like one best prenatal vitamin for everyone. Like, that's going to be a little bit individualized because, again, it's what you're going to tolerate and what you can take. And then there's some little nitty gritty details that are in reality, less important in the grand scheme of things. But yeah, people get really hung up on prenatal vitamins.

Kristyn Hodgdon:
Yeah. And you mentioned exercise. I'm just curious, like, how much exercise is too much exercise? As someone who likes high intensity, you know, I would always beat myself up if I didn't get pregnant that cycle. Like, did I exercise too hard, you know?

Staci Tanouye:
Yeah. You know, if the general rule is if your body is used to what you're doing, you can go ahead and continue doing it. Because if your body, if, I tell people all the time, if you're a marathon runner, like go on and be your marathon runner yourself, like do your normal thing. Your body has adapted, your uterus is adapted, all of that is adapted to be able to provide your body fuel to do that, and so you will be totally fine. If you are not a marathon runner, trying, during the trying to conceive portion or during pregnancy is not the time to decide you're going to become a marathon runner, like that's not what's going to happen. But if your body is already trained to do something, it is completely fine to continue doing that throughout trying to conceive and mostly throughout during pregnancy with the caveat of no contact sports like no high-risk contact things. That's what we want to avoid.

Kristyn Hodgdon:
Got it. Perfect. So what tests, if any, do you typically run when you know your patient wants to be pregnant in the near future?

Staci Tanouye:
Yeah. And this could potentially depend on if they have a primary care doctor, if they have a primary care provider who's run a recent basic panel that most of us, if we're good about it, should be getting once a year anyway. Those are the basics, just the basic health stuff, a blood count to check your hemoglobin and iron levels to make sure you're not anemic right off the bat. Electrolyte levels, lipids, your cholesterol levels to make sure that's at a healthy level, a thyroid screen, vitamin D, most of us are vitamin D deficient, so most of us could use some extra vitamin D. Liver and kidney function are the very, very basics. Some people who have certain histories, like if you've had bariatric surgery, we're going to do some extended vitamin testing because you don't you may not absorb very well. People who are vegan, we need to check their B12 levels because vegans generally need a B12, extra B12 supplements because you can't get that from mostly plant-based things. And again, just kind of like we mentioned, if we're thinking about vaccination status, sometimes we'll check rubella status early or varicella status early, that sort of thing. And then besides that, it's just making sure everything else is up to date. The normal stuff your pap smears up to date. If you are high risk or of age, your mammogram's up to date, any STI screenings bring those up to date too.

Kristyn Hodgdon:
Absolutely. So I think a lot of people think that, after they stop birth control, they have to wait a certain amount of time before starting to try. Is that true?

Staci Tanouye:
No. None. No. No. Birth control, you don't have to wait, ever. So if your IUD gets pulled, you can, you can start trying right away. Once you stop your pill, you can start trying right away. People often have this misconception that birth control, especially a birth control pill, if we've been on it for a long time, that is going to take us like 3 to 4 months to return to ovulation. And for most people, that's simply not true. And so the average time that it takes for people to return to normal period, their normal periods after stopping a birth control pill is 32 days. So on average, about a month to return to normal cycles. 97% of people will return to their normal cycles within three months. And so the vast majority of people by that three-month mark should be cycling like they were before, like their body wants to cycle. Now, if at baseline, if you weren't cycling normally before whatever birth control, hormonal birth control you were taking, you may still not cycle normally when you stop it. So that's a totally different concern. So people who are not ovulating to begin with, we need to address that issue first. But back to the basic question in general, no, you don't have to wait any amount of time after you stop any sort of birth control method. You will ovulate once, approximately two weeks before that first period comes back. So if you don't get your period within like 5 to 6-ish weeks or so, make sure you take a home pregnancy test just to make sure you didn't, you may have caught that first ovulation and not even gotten your period back. I've seen that many times. And so that can happen. And if that's negative, then just track how long, because if you, it gets out to an extended period of time, if you're getting close to 2 to 3 months of no period after you've stopped, we need to see you because we got to work on what, what is going on and why you're not returning to normal ovulation.

Kristyn Hodgdon:
Exactly. And just a reminder, if you're interested in learning more about birth control or the menstrual cycle, we do have whole episodes dedicated to both of those topics, so go back and listen. So do you find that your patients are educated about their reproductive health at the time of when they're starting to try? Or have you found the need to educate them about simple topics like ovulation and cycle tracking?

Staci Tanouye:
I think it depends, right? Because I think as a whole right now, with the advent of social media and the Internet and so many people being vocal about these topics and proactive people are coming in a lot more informed than they probably have in the past. If you're thinking about trying to conceive, I always recommend to patients to make us completely separate appointment for what we call a pre-conceptual consult where this is all we talk about and honestly, the patients and the people who are making those appointments are probably pretty well informed because they're already thinking about it, they're already planning and they've come in and taken the time to make that appointment, so they've probably already done some of the legwork. And so I do think people are more well informed than we have been in the past. But like we've talked about before, like sex ed in general is just really, really poor, if existent at all in this country. There's a lot of stigma surrounding these topics. And with that there there still is a big group that are not well informed or, and it's not their fault, right? It's just how we were kind of brought up. And so some of that, sometimes we do have to go back to the basics and educate on this is what the, this is the menstrual cycle, this is the timing of it, this is what happens and this is how you ovulate, this is when you ovulate, and so we can optimize when we want to time sex to that ovulation and that sort of thing. And so it varies quite a bit, but at baseline, I think there's so much information out there these days that it's people are kind of more on top of things than they have been in the past.

Kristyn Hodgdon:
And that's a great tip to book a separate pre-conception appointment, because if I'm remembering correctly, I think I just did it at my annual. I was like, oh, by the way, you know, and and you're right, doctors will have a lot more time to sit with you and talk about all of these various points if, if you ... Specifically for that reason.

Staci Tanouye:
Exactly. And if even at any annual visit, like the annual visit, we want to hear what's going on. But don't be surprised if we say, okay, that's a big topic. We really need a lot more time to dive into that. Let's make another appointment so we can dedicate the entire appointment to that topic. And full pre conceptual counseling is one of those topics, like I talk for a full like 15 to 20 minutes just on all of that question and answer and everything and I can't do that on top of an annual visit. So, so yes, always try to make a separate appointment so you can really get the full picture of, of and cover everything you want to.

Kristyn Hodgdon:
Absolutely. So for patients older than 35, do you typically let them know right off the bat that it might take them a little longer than they think to conceive due to their age?

Staci Tanouye:
Yes, for patients who are mid-thirties to late thirties, that's one of the first things we start talking about, is what age means with your fertility, what that could mean with egg quality and getting pregnant, the genetics of that, risk of miscarriage, all of that sort of stuff. We talk about the timing of things and how we don't want to wait as long of just trying naturally to conceive before we address it and start doing evaluation and workup because time is of the essence. You know, six months matters when it comes to fertility and age, tne year definitely matters when it comes to fertility and age. Those are big deals, and so if anyone is kind of in the mid to late thirties range, definitely schedule a separate appointment and start talking about these things.

Kristyn Hodgdon:
Absolutely. And so at what point do you typically refer your patients to a fertility specialist versus running tests at your office?

Staci Tanouye:
Yeah, and that can vary a little bit, person to person too, again, just depending on their goals, what they would want to do, their comfort level with where they're at. Because I have some patients who really don't want any sort of major intervention, but they would like a basic workup. And so we might do a little more with me and I might hold back on their referrals. And I have some people that really want to be efficient about it and I won't even do a work, I will just send them to the fertility specialists. So it is very patient dependent and what you want to do as well, so you have a big voice in how we go about this. But the general rule of thumb is, you know, an infertility diagnosis comes after 12 months of trying to conceive with regular periods, with what we think is regular ovulation and not being successful at that. If you've gotten to that point and you have regular periods, we should definitely start a basic workup in your general OB-GYN's office. Again, if you prefer to be more efficient with it and go to a reproductive endocrinologist and infertility specialists, that is also a good option too, so you could do it either way. If you are 35 or older, that timeframe for diagnosis of infertility gets shortened to six months because again, time is of the essence. So if you're 35 or older, you've been trying for six months or more with regular periods and unable to conceive, I need to see you and for 35 and older, personally, this is my personal practice, I don't even do the workup, I recommend that they go straight to the REI, because again, with time of being of the essence, I don't want to double up on anything, I don't want to waste anyone's time, I want them to get answers and tests as quickly as possible. So 35 and older, if they're getting worried, I send you straight to the REI.

Kristyn Hodgdon:
Yeah, yeah. I think a question that a lot of people don't often get asked is like, how many kids do you want to have? Because like, if you're, if you're 39 and you want three kids, like it's probably pertinent to go straight to the fertility clinic. But if you're 35 and don't want intervention and, or if you're trying on your own for a little bit, that's kind of a different story, so it really is so individualized.

Staci Tanouye:
Yeah. And I kind of ask patients, I say, okay, where is your headspace at right now? Like, what are you feeling that you want right now? Are you in the mindset that like, I want to get pregnant yesterday and I need that to happen now, then I'm going to talk to them about an earlier referral, right? And be more efficient and more aggressive with that process. If you're in the headspace of, oh, I'm okay with just trying, I really don't, I want minimal intervention, I don't want to go down that route just yet, then you might not be the right person to go to the, the specialist right away and you're going to stick with me and we're going to start doing some of this stuff. So it's also how efficient and how aggressive you want to be with it too, and that varies person to person, so there's a lot of personal preference that goes into how we should be approaching these topics.

Kristyn Hodgdon:
Definitely. So are there any lifestyle tips or supplements? We touched on prenatal oils a little bit, but anything that, you know, trying to conceive from out of our control. So anything that you recommend that could give someone a greater sense of control during this process?

Staci Tanouye:
Yeah,I think we've talked about it a lot in some past episodes too, but I can't emphasize enough like the all around overall health of everything, right? So it's not just, it's not just what supplements you're taking, it's everything that you're doing to your body and putting into your body. So you want to look at your diet, and in general, everyone should just eat more plants and whole foods. Whatever you're doing with your diet currently is probably fine, but add in more plants and more whole foods because that's going to have a good, well rounded nutrition base. Exercise plan, you know, if you're not exercising, start light and get some movement to your body to build strength and to build stamina, because that can help keep your body healthy, too. And then we we cannot emphasize enough sleep and stress control. Sleep habits need to be on point and regular. You need to be getting enough sleep, and I'm saying this as I was like up with my baby all night last night, I didn't sleep at all. So my sleep habits kind of suck right now, but sleep is so important and sleep and stress kind of tie in together. So stress control, whatever you need to do for stress control, whether that's exercise, meditation, seeing a therapist or having your self-care time with friends or doing whatever you need to do. Stress control and sleep control is super, super important. So just that overall basic health is going to be really important, probably more important than any supplement anyone can ever talk to you about. Besides that, the second most important thing is, again, a prenatal vitamin. Just, I usually tell people every person with a uterus should be on a prenatal vitamin if they are reproductive age. It doesn't matter if you're on birth control, not trying to conceive, trying to conceive, whatever it may be. If you take a prenatal vitamin as your basic multivitamin every single day, you're going to be set for whatever happens.

Kristyn Hodgdon:
Oh, wow. I like that tip.

Staci Tanouye:
Yeah, people people will kind of question that sometimes they're like, well, I'm not trying to conceive. I was like, well, birth control fails, right?

Kristyn Hodgdon:
Yeah.

Staci Tanouye:
So if you're thinking about taking a multivitamin of any sort, just take a prenatal every single day, no matter if you're thinking about pregnancy or not. And that, that will give you that basic folic acid level that can be helpful because that folic acid level is important and it's important to take it 2 to 3 months before conceiving, because that's where we see the benefit of your prenatal vitamin. So if you just take it as your daily multivitamin, no matter where you are in your reproductive health journey, that will be you'll be totally fine there. Yeah, most people could use some extra vitamin D because like 70% of us are deficient in that. Again, vegans need B12 because they can't really get that from a plant based diet. And there's, there's lots of other supplements that the fertility doctors will touch on a little bit. People will mention things like CoQ10, Inositol, those sorts of things, and those things could be a little more individualized. There's mixed information out there on some of those things, but those things can be a benefit to some people, but not necessarily a necessity for anyone.

Kristyn Hodgdon:
Right, exactly. So definitely talk to your doctor about your needs. I wanted to just circle back quickly on the mental health topic really quick because we touched on it, but I wanted to get your take on because we don't have enough, so we probably could have a whole episode dedicated to this. But I want to get your take on like SSRIs and medication, like medication for anxiety and depression, because so many people struggle with mental health and a lot of those people are trying to conceive. And, you know, a lot of people think that they can't be on anything when they're trying to conceive or pregnant. And I just kind of wanted to demystify that really quick because it's something that I'm passionate about and because you're, the most, your mental health is the most important to. And so in addition to meditation or exercise or whatever makes you feel good, self care wise, like, is that something that's okay when you're trying to conceive?

Staci Tanouye:
I cannot stress enough that people, if you are on an SSRI for your mental health and it is a benefit to you and you're stable on it and doing well, you must continue that SSRI through trying to conceive and through your entire pregnancy and postpartum. It's so, so important. There are a select few SSRIs that we might switch people on, but it's like just a tiny few that aren't really used as often anymore. All the more kind of modern, more recent SSRIs, you can continue, can continue through trying to conceive and through pregnancy and postpartum, because, like you said, mental health is so damn important. Like it's more important than we ever, ever thought in the past. And this is kind of a 180, because old school docs used to like rip people off of their antidepressants and anti-anxiety depressions like quick. Yeah and that that is wrong. We know, we now know that that is not what we want to do. Now getting into some of the mild risks involved with that is a little bit beyond our scope. But what I often emphasize to patients is that we actually have data that supports that if you are someone who has depression and anxiety that is untreated during pregnancy, that has a worse effect on your pregnancy and infant outcome, your future infants health than being on the SSRI, that the untreated depression-anxiety is far more detrimental to all around maternal and, and neonatal health than the SSRI itself. So don't think that just being, because I'm not taking the medication, I'm healthy and that's better for me. It may not be. If you're someone who needs to be treated and needs that stability, that SSRI is most likely going to be more beneficial for you than being off of it and being untreated. So don't neglect your mental health, stay on your SSRI, of course, talk to your doctor and make that in an individualized decision for yourself. But like I, like you said, we could have a whole episode on this, and if, if you have a doctor that is suggesting that you have to come off your SSRI or and I'll throw in there too ADHD medication, because kind of the same goes with that too, you might want to find a new doctor because you need someone who's up to date on mental health and pregnancy.

Kristyn Hodgdon:
Mic drop, I love it. Well, thank you, Dr. Tanouye, that was a great episode. And ending on the mental health note I think is really important. So until next time.

Staci Tanouye:
Hey, what are we talking about next?

Kristyn Hodgdon:
Vulvovaginal health.

Staci Tanouye:
Oh, that'll be a good one. That's my favorite.

Kristyn Hodgdon:
Okay. Talk to you soon. Thank you.

Staci Tanouye:
Okay.

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it left you feeling more educated and empowered about your reproductive and sexual health. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe, and to join Rescripted Free Fertility Support Community, head to Rescripted.com.

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