The Terrible Gift

Terrible Gifts
Sometimes we may have even given them, either on purpose… or worse, by accident. We’ve also received them on purpose… or worse, by accident.

Several years ago, knowing my brother was very much an avid hiker and camper, I bought him a present which was both utilitarian and stylish. The gift was comfortable and when you put them on, you looked like you were ready to tackle Mount Everest without breaking a sweat. I knew he would love them. In fact, I was a bit reluctant to give them away.

Yet, when my brother opened his present on Christmas Eve, for the first time, I saw the gift through his eyes… he didn’t view them as the thrilling gateways to adventure and exploration. All he saw was socks. Wool socks. Green, with red stripe.

At that point, I could almost read his mind…. Is this a joke? What are you kidding? Thanks, brother. What’s next year’s gift, underwear?

The fact that he later wore the socks, liked the socks, loved the socks, did not (and to this day does not) stop him from reminding me that this was possibly the lamest Christmas gift he ever received.

Of course there are worse gifts (in the eye of the beholder), both accidentally and intentionally:

Taco Rob once got neon red Argyle socks. (So, brother Benson, I don’t feel so badly.)

Jeremy got a Tickle Me Gizmo (the Gremlin).

For a full year, for all occasions, people saw fit to give me unicorns. I got two more today.

My friend, Kip, received ladies underwear from his brother Danny.

Kip’s brother Danny once received a Star Trek t-shirt. Too small to wear.

My buddy, Doug, got a magenta (his word) hand-painted of Elvis.

Our embryologist, Shan, got a Heineken indoor grill from a cousin who got freebies through his work at a distributor.

Nicky, our andrologist, got Mariah Carey’s Rainbow.

My buddy Matt, laments receiving “The Audacity of Hope” – by Barack Obama (Knowing Matt, this was probably given intentionally).

Jeff Scotchie (Jessica’s husband) got stuck with “Don’t Hassle the Hoff” from Shan’s husband, Neal.

My buddy Ted received a used Chinese wok.

My friend Andrew got a $5 check from a great-great aunt with instructions to purchase a new “bonnet”.

So What’s the Point?

It was once said of James Michener, author of epic best-sellers like Hawaii, Alaska and Tales of the South Pacific, that it took him 50 pages just to say “hello”. If you’ve read my blogs before, you know I sometimes take a while before I get to the point.

Well, here we are again at the Christmas season, possibly the worst time of year for most patients suffering from infertility. They face this season knowing that they won’t have the opportunity to buy a toy for a child and to see the happy expression that toy brings or even the disappointment a bad gift brings. They fear they never will have that chance.

Last year, I wrote a blog about how to cope with the holidays. Rather than rooting around in the cumbersome blogspot, I’ve provided a link here, if you’re interested in reading it.

But this year, I want to focus on the terrible gift of infertility. It is terrible because it ushers so many opportunities for sadness and a sense of loss. It is the loss of a life that never was. It is terrible because the feelings it brings are often inescapable and frequently come without warning. It is terrible because it makes others frequently feel like they can’t speak to you about all the joys they experience with children and family – it can make friends censor themselves around you.

But I want to remind you of just one thing. Though terrible, infertility is still a gift. Only people who have been through war together know what kind of bond that can bring. While the war may have been terrible, the bond is the gift. Infertility may or may not be what is intended for you for the rest of your life. But it is a gift for now. It is a gift because it is an opportunity to build a bond with your spouse, and to help you understand those who are suffering with greater clarity.

I remember back when my wife and I had failed several IVF cycles. We could not get pregnant because of an issue with her fallopian tubes. I remember a time in my greatest sadness, thinking that if only, if only, if only…. If only I had married someone else, this curse would not have befallen me. I remember rolling that thought around in my mind, kneading it and shaping it until I finally realized that my love for my wife was so much greater than my need for a child. This terrible gift tested and strengthened my devotion to my wife.

Though terrible, it is also a chance of you to deepen your understanding that we live in a broken world. While there is great joy, within the world and our own community and even amongst our friends there is often great suffering and tribulation. We all know the world is not fair, but we don’t live like we understand that. Really the best we can do is to make the best of the gifts we receive, no matter how terrible they are.

Don't Let Me Be Misunderstood!

What do cheese-filled pizza crusts, The Mona Lisa, Valentine’s Day, being your high school’s most likely to succeed all have in common? They are all highly valued by some people and deemed overrated by others.

This is not much unlike our friend Progesterone, or P4, if you prefer a chemically accurate rap name.

P4, or Prog, as it is sometimes called, is one of the most measured and misunderstood, over and under estimated hormones that ever came into world of medicine.

While it is true that progesterone is important (indeed essential) to maintain a pregnancy, what is not commonly known is how little progesterone is actually required. In our experience, too much emphasis is placed on progesterone.

Part of this is our fault. By our fault, I mean the Reproductive Endocrinology Community (REI) as a whole. Years ago REI practitioners wrote papers and chapters in Ob/Gyn text books saying that a progesterone of 10 ng/ml was evidence of a high quality ovulation. This number was easy to remember and this factoid has been passed down through the ranks of Ob/Gyns in training and has essentially become “common knowledge.”

But this common knowledge has mutated over time. It’s like the childhood game of telephone where someone whispers something in ear of the person next to them, and the information is propagated down the line until the last person in line says what they heard. The first person says corn flakes, and it gets ultimately gets changed to something like, “Monkey Diaper.”

Well, that has happened with progesterone.

Today, if a progesterone is <10, some people think ovulation has not occurred at all! This is not always true. Far from it. In fact, long ago, it was known that any progesterone greater than 3 was consistent with ovulation. In fact, after ovulation, progesterone levels can vary every 90-120 minutes from 2 ng/ml all the way up to 40 ng/ml. If you measured near the bottom, you may be told you didn’t ovulate! So Why Do Dr. Murray and Dr. Scotchie Measure Progesterone? And why do they give progesterone to some women? Why to measure progesterone:

Reason Number One: Mainly we at TRM do it to confirm ovulation. Any level greater than 3 tells us that a woman did indeed ovulate. A low level (like 4) either means we caught it when it was just reaching a valley rather than a peak, or that the woman just ovulated, or that she’s just about to have a period. If she doesn’t have a period in 3-4 days, we can frequently check another level and often it’s at a high level.

Why to measure progesterone: Reason Number Two: Sometimes progesterone can tell you about the viability (survivability) of a pregnancy. Assuming a woman is not taking progesterone supplements, in pregnancy a progesterone less than 5 ng/ml is nearly always abnormal. Conversely, a progesterone >23 ng/ml is almost always viable and in the uterus (not ectopic, or tubal). Unfortunately, in most early pregnancies, progesterone levels will be between these two values.

When should progesterone be measured? Ideally progesterone should be measured at its peak. For most women, this occurs 7 after ovulation and around 7 days prior to menses. If a woman conceives, the hormone of pregnancy causes progesterone to rise throughout pregnancy. This is why high levels are frequently seen in pregnancy.

Why do we give progesterone to some patients?

IVF: We routinely give progesterone after in vitro fertilization (IVF). During IVF, we frequently give drugs which make it more difficult for the ovaries to make progesterone. Also, when we get the eggs out of a woman, we remove some of the cells that make progesterone. If we didn’t give progesterone to IVF patients, approximately 10% would lose a normal pregnancy.

IUI: We routinely give progesterone after intrauterine insemination (IUI). There is some evidence that progesterone a few days after IUI may promote pregnancy. There are lots of reasons this may be true, but we don’t really know why this is the case.

What about patients with recurrent pregnancy loss? Progesterone supplements have not been shown to decrease the chance of miscarriage, only to delay the diagnosis of miscarriage. In other words, a pregnancy can quit growing, but the progesterone we give can mask the miscarriage.

That being said, just because studies have not shown that progesterone prevents loss, this does not mean that there is a woman who would not benefit. It may take giving progesterone to several hundred women to prevent one loss. Since progesterone has no known negative effects on pregnancy, and since it’s relatively cheap, I educate patients about the studies, but do prescribe it for those who want it. This way, the patient never has to wonder what might have happened if they had taken progesterone.

In pregnancy, how long should my progesterone level be followed? In almost all cases, as soon as a heart-beat is seen, further progesterone measurements are not useful. The heartbeat can be seen as early as 5 weeks and 6 days. In natural pregnancies, at 7 weeks the placenta will make all the progesterone needed for a woman to stay pregnant. Even if you removed the ovaries and stopped all progesterone, the women won’t have an increased risk of miscarriage! How do we know this? A study was actually done that showed this!

We routinely give our IVF patients progesterone until around 8 weeks of pregnancy, one week beyond this critical week. If a patient wants to stay on longer, fine. No harm should come from it, but it’s not needed.

Measuring progesterone levels at this point are pointless. If the placenta can’t make enough at this point, then the placenta won’t be good enough to support the pregnancy and the patient would miscarry anyway.

We would argue that progesterone levels measured after 7 weeks, especially if a woman is taking progesterone as a medicine, these levels are providing no real useful information.

What if my doctor measures my progesterone and it is low… What should I do? This is a common situation patients face. The question is, what does “low” mean? If a woman is pregnant and progesterone is low… say 5 or less, giving progesterone supplements will not save the pregnancy. Progesterone is more likely a reflection of what’s going on and not a cause. It’s like looking at a car that has been in a wreck. You can see the dents in the body, but just by looking, you may not see that the engine has also been damaged.

If the engine is damanged…. Or in pregnancy, if the embryo is abnormal…. Fixing the exterior of the car may make it look pretty, but it won’t make it run better….. Same with an embryo….. If the progesterone is low, this means the embryo is not doing well…. And you can’t fix and embryo with a hormone.

As you can see….

There are many pitfalls to measuring progesterone and many ways to misinterpret the levels. Outside of IVF, there is no evidence that progesterone replacement is helpful.
In conclusion, Progesterone, P4, Prog is important. It is essential for pregnancy. We encourage any patient or doctor to contact us about questions regarding progesterone.

Does my thyroid matter? - By Dr. Jessica Scotchie

There are many causes of infertility and recurrent pregnancy loss. Often the tests performed by Tennessee Reprodictive Medicine are screening tests to guide further investigation or treatment. Thyroid dysfunction is one condition that may affect our patients.

The thyroid gland is a small gland located in the neck, responsible for making thyroid hormones which help regulate metabolism. Thyroid dysfunction is very common, affecting up to 10% of the population at any given time. In general there are two forms of dysfunction: decreased thyroid hormone production (hypothyroidism) and increased thyroid hormone production (hyperthyroidism). Underactive disease, or hypothyroidism, affects 2-10% of individuals, and occurs 5-8 times as often in women than men. Overactive disease, or hyperthyroidism, is less common, affecting 1-5% of individuals. With both forms of thyroid disease, women are affected far more commonly than men (5-8x more often).

The symptoms of thyroid disease are easily recognized, but are also commonly seen in other disease presentations and among healthy individuals. Hypothyroidism presents with weight gain, fatigue, cold intolerance, hair loss, constipation, muscle aches, and difficulty concentrating. Hyperthyroidism often presents with weight loss, tremors, hair loss, anxiety, irregular heart beat (palpitations), and sweating. Both underactive and overactive disease can result in menstrual irregularities in women.

Most thyroid diseases are caused by autoantibodies against components of the thyroid gland. Antibodies are molecules made by our immune system to fight infection; in the case of auto-antibodies, our immune systems mistakenly make molecules to fight a part of our body that the immune system should recognize as a normal part of the body. The end result is organ damage, which either causes decreased thyroid hormone production (hypothyroidism) or increased hormone production (hyperthyroidism).

How do we screen for thyroid disease? Physicians will generally start with a thyroid stimulating hormone level (TSH). The TSH hormone is made in the pituitary gland (in the brain) and is sent to the thyroid gland to tell it to make thyroid hormone (think of the accelerator in your car). The thyroid then makes thyroid hormones (T4 and T3) which circulate back to the pituitary gland; the pituitary gland then recognizes that there is sufficient circulating T4 and T3 and keeps the TSH in a normal range (think of a feedback loop). When there is too little thyroid hormone, the pituitary should respond by increasing the TSH level (as if stepping on the accelerator harder to make the car go faster), therefore underactive thyroid disease typically presents with an elevated TSH level. In contrast, if there is too much thyroid hormone, the TSH is usually suppressed, because the high levels of T4 and/or T3 have signaled back to the pituitary that there is no need for TSH to keep signaling for more T4 and T3 to be made (think of the accelerator being pushed as hard as possible, there would be no need for you to push harder to go faster). There are other conditions in which this relationship is not as straightforward as just described, and for this reason it is important to rely on your physician to correctly interpret hormone results.

How do we treat thyroid disease? For the two abnormalities described previously, the goal is to restore the thyroid hormone levels back to normal. For hypothyroid disease, we replete the patient with thyroid hormone. Usually after about 4 weeks of treatment the TSH level is rechecked and the dose adjusted until the TSH is in a normal range. For hyperthyroid disease, treatment options include medications to suppress thyroid production (propylthiouracil and methimazole), radioiodine ablation, and surgical removal of the thyroid. The optimal treatment can be decided with your physician. There are other causes of thyroid diseases (tumors, cancer, nodular goiter) that are treated differently and beyond the scope of this blog.

You may be asking yourself, why does a fertility specialist care about the thyroid? The answer is normal thyroid function is critical for normal menstrual function and for optimal pregnancy outcomes. Hypothyroidism has been associated with increased risks of miscarriage, pre-eclampsia (blood pressure disease in pregnancy), and low birth weight babies. Untreated hypothyroidism can also result in mental deficiencies in children, which in the most severe form is known as cretinism. Some women do not have overt hypothyroidism, but have mild lab abnormalities that we would call subclinical hypothyroidism (high TSH but normal thyroid hormone levels). Subclinical hypothyroidism has also been associated with higher rates of miscarriage.

Hyperthyroidism is also associated with adverse outcomes, including pre-term delivery, pre-eclampsia, maternal heart failure, low birth weight babies, and miscarriage. Fetal hyperthyroidism can also occur as a result of maternal autoantibodies passing through the placenta, and causing fetal goiter (enlarged thyroid) which in severe cases can affect the mode of delivery.

Clearly, avoiding these complications is critical and generally easy to do by closely monitoring a woman’s TSH level and adjusting thyroid medications to keep the TSH level in a low-normal range (ideally < 2.5 mIU/ml in pregnancy). Women with hypothyroidism typically require increased doses of levothyroxine in pregnancy due to the expanding plasma volume that occurs in pregnancy. Women with hyperthyroidism are usually treated with oral medications, as radioiodine cannot be used during pregnancy.

The big central controversy with thyroid disesae at the present time is whether or not to screen all women who are trying to conceive or newly pregnant. We clearly know that overt over- and underactive thyroid disease is bad. We don’t have solid evidence that subclinical disease poses the same risk, or that treating women with subclinical disease improves these possible risks. There are two main professional societies that regularly review available medical evidence and make recommendations on practice guidelines for physicians. The American College of OBGYN currently does not recommend universal screening, on the basis that there is insufficient data to suggest that treating subclinical hypothyroidism improves obstetric outcomes. The Endocrine Society tends to lean more towards liberal screening, however they also do not recommend universal screening. They instead recommend screening any women with the following characteristics:

1. Infertility.
2. History of miscarriage or preterm delivery.
3. History of any thyroid dysfunction, or a family history of thyroid dysfunction
4. Presence of a goiter (enlarged thyroid).
5. Known thyroid antibodies.
6. Symptoms suggestive of disease as outlined above.
7. Type I diabetes.
8. Presence of other autoimmune diseases.
9. Prior head or neck radiation.

Most of the patients we see are infertility and recurrent pregnancy loss patients. In our professional opinion, due to the fact that treatment for thyroid disease (especially hypothyroidism) is generally well tolerated and has few risks, we feel that the benefits of treatment outweight the risks of treatment, and therefore screen most of our patients trying to conceive with a TSH level.

Meet Shan

This is Shan Wilkinson, the embryologist at Tennessee Reproductive Medicine. I was picking on Dr. Murray the other day about how long it has been since his last blog post. He assured me he has done research about his next topic, but he’s still trying to wrap it all up in a nice little blog-package. He then suggested I write my own post to which I laughed, but then I thought I might have a few things to say.

While trying to figure out how to format what I wanted to say, I thought about the weekly Monday Morning Quarterback article by Sports Illustrated writer Peter King. I am a football fan, especially the NFL and specifically the New Orleans Saints (you might remember, they won the Super Bowl) and I like the way King finishes his article with his “Ten Things I Think I Think” section. So, here we go:

Ten Things I Think I Think

1. I think handling 10,000+ cow embryos prepared me for culturing human embryos. It allowed me to learn quickly and to evaluate morphology to help choose the best embryo(s) for transfer.

2. I think handling 10,000+ cow embryos did not prepare me for the emotional investment of “human IVF”. While I’ve been blessed to work in labs with above average pregnancy rates and while I celebrate each positive pregnancy, I think the negatives are difficult to overcome – you should see all my gray hairs! On my way to work one day I heard a verse on our local Christian radio station (J103) that sums up what we do. It is Romans 12:15 “Rejoice with those who rejoice; mourn with those who mourn.” There are many tears shed here for our patients, some of joy and some of sorrow.

3. I think I work for really good doctors. They are both smart and compassionate and hold each other to the highest standards. Our patients have different reasons for choosing the doctor they want to see (male/female, etc.) and some just want the first available appointment, but I believe all patients are in the hands of personable physicians with high morals.

4. I think it’s very difficult for me to make the leap from the ball of 8 to 150 cells in the dish to the baby that a patient brings in to visit after delivery. And if the embryo had been frozen it’s even harder for me to wrap my head around. I am blessed to do what I love to do in a place where I am appreciated. I hope to do it for a long time and I hope I will always make the right decisions to improve the laboratory to help our patients achieve their goals and realize their dreams.

5. I think TRM is a great place to work. I’ve worked in both small and large clinics before and morale can be a problem in any size practice. We have a great group of employees who honestly care for one another without any gossip or jealousy. As all of our job duties become more involved and our work schedules grow, we have to look to each other for support and encouragement.

a. Our office manager works many hours to ensure things are running smoothly and always is available to employees.

b. Our nurses see our patients more than they see their families and they always have a kind word and are ready to explain what this shot is for or what those initials mean. We use a LOT of initials around here!

c. Our front desk/billing ladies are some of the best at what they do. They give patients a face behind the voice on their initial visit and their behind the scenes work helps the office run more efficiently.

d. Our surgery scheduler is brave! After working for many years with the “elder” Dr. Murray, she now works a couple of days with his son, our Dr. Ringland Murray and his partner Dr. Jessica Scotchie. And despite the fact she spends most of her time talking to insurance companies (I think most people would rather have a root canal), she’s always smiling.

6. I think most people I meet have never heard of an embryologist. When asked what I do I say I’m an embryologist. When they say “A what?!” or ask what that is I explain that I put eggs and sperm together in a dish and grow embryos which the doctors transfer and which hopefully become babies. Most people are fascinated and some think it’s a little weird, but almost everyone knows someone who has needed help getting pregnant.

7. I think I cannot tell the difference between X and Y sperm. While I have been accused of choosing more Y sperm than X, there are no differences at the morphological level. If I could select X or Y sperm, we’d probably have a lot more patients and I’d probably make a lot more money.

8. I think almost every male partner is nervous and/or embarrassed by what they are asked to do. It’s normal to be nervous, especially when Dr. Murray is the only other male in our office, but it really is commonplace to us. Humor helps.

9. I think infertility sucks. I have friends and family members who have been affected by infertility and it is heart wrenching. And while some of them can get pregnant with the help of IVF (60 to 70% of women less than 35), it’s a fact that not everyone will get pregnant, including my friends and family members.

10. I think these are my non-embryology thoughts of the blog:

a. My husband is a saint for following me around the country for the last 15 years. I hope the next 15 years (and the 15 after that) we stay a little more rooted.

b. I love living in Chattanooga. We were walking downtown the other day after enjoying some popcorn and ice cream at a Lookouts game and I just really had a sense of feeling at home.

c. I could eat ice cream every day if I had less willpower and more money. I crave ice cream at least once a day.

d. I love my church. In a city with so many transplants, it’s nice to establish a church home where there are people you can count on to do life with you. www.christwaychurch.org

e. I’m so glad Chattanooga finally got a Red Robin! We used to go to one after our trips to Hershey Park when we lived in Pennsylvania.

f. Coffeenerdness: I don’t drink coffee. Although the Mocha Frappe’ at McDonald’s is really good, I don’t think it really counts as coffee more like dessert. I do, however, love a good hot chocolate. If I’m at home I’ll heat up milk on the stove and add either Christopher Elbow’s Cocoa Noir (www.elbowchocolates.com) or Valor Chocolate a la taza. If I’m at work, I make due to with hot water, Swiss Miss Dark Chocolate Sensation, and a couple of squares of Dove Dark chocolate melted in the cup.

g. I’m from Slidell, Louisiana, and yes, my parents’ house did flood during Hurricane Katrina. I know a lot of people are tired of hearing about the storm and now that the 5 year anniversary is approaching they’re going to hear more about it. However, if you or anyone you know was affected by it, you know that time along the Gulf Coast has been divided between before Katrina and after Katrina.

h. I spend a lot of time searching for the perfect dark chocolate truffle. One of my favorites is the Velvet Sin from Chocolate Fetish in Asheville, NC. Well, now Chattanooga is home to a very good chocolatier named Wendy Buckner, owner of The Hot Chocolatier. Her Oatmeal Stout truffle (made with Oatmeal Stout from the Terminal in downtown Chattanooga) rivals the Velvet Sin. She is awesome, her shop is great, and wait until you see her chocolate sculptures! www.thehotchocolatier.com

An REI’s Bad Language - The T Words, The Q Word

There are a lot of extreme words out there. Some words, or in some instances, are so extreme that they’re referred to only by their first letter. For example: the L word, is an example of a nice word (Love), as is the M word (Marriage). The D word (Divorce) is usually not so nice. Please don’t ask me to elaborate further on examples of the bad extreme words.

In the world of REI, we have our own examples of this. The T word is one. (Really, we could have two T words.) We also have two Q words. Who knew we’d have an O word? Together, we can refer to them as the M words, or multiples.

My first experience with a Q word was in residency. I had the great pleasure of taking care of a courageous and committed young lady who was about 26 weeks pregnant (full term is 40 weeks). She was hospitalized, on bed rest, with quadruplets - the lesser Q word.

She was in the hospital in an effort to prevent preterm delivery at home. She had a short cervix and frequently had contractions. Her physicians had placed a cerclage (sewn her cervix shut) to help prevent preterm delivery. She had received steroid injections. Her day consisted of daily heparin injections (blood thinners), twice daily ultrasounds to look for heartbeats, and a laborious trip to the chair next to her bed maybe once or twice a day. She had to sit in the shower and spent most of her time on her computer, watching movies, reading books, but generally feeling miserable.

She had worked so hard to get pregnant and had failed several attempts in the past leading her physicians to get progressively more aggressive with her treatment until she made up for lost time and cycles grouping 4 pregnancies into one. I don’t know who was more worried about her, me or her. I did not help her get pregnant, but felt very obligated to try to keep her pregnant as long as possible. I was usually the first person she saw in the morning and the last doctor to see her at night.

I can’t tell you how many false alarms we had over the next few weeks. We were frequently rushing to her room to check on her or bringing her to labor and delivery to try to stop the contractions. She finally went into labor for real around 32 weeks. It was the fastest Cesarean section I think I ever did. Four babies in under two minutes. Each baby was taken to a different corner of the room and tended to by expert neonatal intensivists and nurses. We filled the nursery quickly that day.

She would be in the hospital for 3 days after her delivery, but her children would remain for up to 8 weeks later, in the intensive care unit.

She had a good outcome. Her babies were born healthy and progressed through infancy without many significant setbacks. The last time I saw her was about 6 months after delivery. She was pushing a ridiculously long stroller that was about 5 feet long and contained four seats, for four babies.

At that point, she was not yet out of the woods. There was still time for lifelong problems to arise, even if she had escaped the immediate complications of preterm delivery.

My next encounter with one of the M words was when I took my first job out of fellowship, in Memphis.

On a hot summer day in 2006, I pulled up to the Memphis Children’s Museum with my wife and child in tow. We were parking when I first saw the sign at a parking spot near the entrance. At first I thought it was just a joke, then I saw the next sign and thought maybe it was an indictment.

The first sign said, Triplet Parking.

The second, Quadruplets Parking.

Since I had just taken the job at Memphis’ only fertility clinic, I worried exactly what in the heck was going on in that city that would prompt a children’s museum to even need such signs.

Did a lot of out-of-towners with triplets and quadruplets travel to Memphis to go to the children’s museum?

Did the clinic where I had just taken a job have so many triplets and quads that it was actually altering parking practices at local businesses?

Or was there a rogue doctor, shooting up fertile women with fertility drugs so that there would be an abundance of children?

I was quickly reassured to learn that triplet pregnancies were very rare at the practice in Memphis and that there weren’t other doctors prescribing fertility shots to women…. So I settled on the idea that the museum was trying to be cute and serve a relatively rare need.

In truth, the triplets and quads parking are sort of like handicapped, expectant mother, or senior citizen parking seen at some businesses and churches. They give assistance to people who might need a little more time, or find it a little more onerous to get from the car to the front door.
So where am I going with this? I’m not sure…. I had the pictures and wanted to print them, but I really should talk about the perils of multiple gestation.

I know, I know, most people reading this would never set out to try to have triplets, quadruplets, or octuplets. But the truth is, a high number of fertility patients actually want twins. Most people appreciate a bargain, and when they have to pay out of pocket for fertility treatments, two for the price of one sounds like a good deal.

I have to remind my patients and myself that twins are a high risk pregnancy. With twins, the average duration of a pregnancy is only 36 weeks (four weeks short of term). This means a considerable number will deliver much earlier. The earlier the delivery, the more likely a child will experience life-long complications such as cerebral palsy or chronic lung, eye, or gastrointestinal problems.

The rate of cerebral palsy is 0.1-0.2% in singleton pregnancies, but rises to 1.2-1.3% in twins and up to 4.5% in triplets.

With triplets, average delivery occurs at 32 weeks with approximately 90% being preterm. And preterm delivery is not always the result of preterm labor. Many other complications can arise which might cause a doctor to have to deliver a baby before the baby is ready to be born. Due to competing space within the uterus, some babies may not get the blood flow required for growth and they can be small. If one of the babies becomes ill or if they stop growing in the womb, a woman has to decide if she needs to deliver all the babies to save the sick one.

The higher rates of diabetes (high sugar), preeclampsia (high blood pressure), premature rupture of membranes (water breaks), placental abruption (separation of placenta from uterus) can all lead to the need to deliver these babies early.

Babies born very prematurely frequently are hospitalized for weeks to months in an intensive care unit and face too many perils to be listed here. The earlier the birth, the more likely they are to suffer lifelong consequences. The immediate and long-term medical costs and time required for follow up can put a strain on relationships. Once in a grand rounds lecture, an authority gave the staggering statistic on triplets, saying that more than 80% of parents of triplets ultimately get divorced. I have not been able to find a credible reference with that high a number. Not all data shows that high of a rate, as reported here. While no study to date has looked at this adequately to say with complete authority what affect multiples have marriage, patients should realize that there can be considerable strain on a relationship.

So how do we prevent multiples?

Avoidance is the key.

Many people think IVF (in vitro fertilization) poses the greatest risk for multiples. This is not true. While there are many things which influence the risk of multiples, using injectable gonadotropins can cause a woman to release multiple eggs. The physician may have little control of how many of these eggs fertilize and result in pregnancy.

Very rarely do we get more than twins with IVF. In IVF we can control how many embryos are placed in the uterus. ASRM has published guidelines on the number of embryos to transfer in IVF. Adherence to these guidelines will help practitioners avoid high order multiples (triplets or more) and minimize the risk of twins. To see ASRM guidelines, click here.

One strategy employed to decrease the risk of multiples is to grow embryos out to the blastocyst stage. In the past, physicians routinely transferred embryos at the cleavage stage (three days after fertilization) when embryos are generally made up of around 8 cells. Top quality day 3 embryos have about a 30% chance of resulting in a pregnancy. Some day three embryos will stop growing after day 3. So if we wait two more days, frequently we can see which of the embryos has the greatest potential to make a baby. By waiting until day 5, we can place fewer embryos back into the uterus and theoretically reduce the risk of twins, triplets and more.

At TRM, we encourage women with good quality blastocysts (day 5 embryos) to transfer a single embryo to maximize the chance of a singleton. The down side to blastocyst transfer is that it seems something in the culture system may increase the risk of identical twins! This is a slight increased risk, but not insignificant.

If you want further proof that even elective single embryo (eSET) transfer can’t prevent multiples from occurring, consider the case of an Iowa woman who did IVF, had an eSET and was discovered to have 7 babies implant. Presumably, she conceived 1 through the embryo transfer, but due to the fertility medications and the fact that she had intercourse, she conceived multiple others on her own at the same time. The lessons learned from this case were: 1) don’t have intercourse during IVF if your tubes are open, 2) this lady probably didn’t need IVF in the first place.

The bottom line is that it is very difficult to maximize the pregnancy rate and minimize the multiples rate at the same time. This can be especially true if we rush people into IVF.
Selective reduction, or elimination of embryos within the womb has been used by some patients to decrease the risks associated with high order multiples. Such a procedure requires placing a needle into the uterus and either stopping the fetal heart with potassium, or cutting the umbilical cord.

Many patients would never consider selective reduction under any circumstances. Others thought they would be able to reduce, but after seeing a baby’s heartbeat, the reality of what they are doing sinks in and it is too much for them to do.

It is my opinion, a patient’s stated willingness to undertake selective reduction should never influence the medical decision of how many embryos to place in the uterus or how to proceed with therapy. Because some patients are so desperate to achieve pregnancy, because some just don’t believe it can actually happen, some patients will want more embryos than recommended. If a physician decided to be more aggressive because a woman said she would consider selective reduction, then the patient may wind up in a situation that places her and her babies at risk.

Finally, the nature of health insurance is to blame for some patients wanting to be aggressive and increasing their risks of multiples. Because of the expense of treatments, many patients cannot afford more than 1-2 treatment cycles of any kind. This causes them to want to maximize their chances of pregnancy with each treatment, especially in what they deem as their last treatment. These kinds of pressures can lead to bad decisions and pressures to be more aggressive than recommended.

Concluding Thoughts
Will we ever eliminate the increased risk of multiples in fertility treatment? It’s not likely.

Until insurance pays for fertility care, economic forces will drive couples to aggressively pursue a positive pregnancy test and accept the risk of multiples. In fact, insurance companies should probably pay for IVF (where the number of embryos transferred can be controlled) more readily than they pay for injection-IUI (where the number of eggs released is not always controlled).

Doctors have a fairly equal incentive to maximize their clinics pregnancy rates. Therefore they may risk pushing patients to IVF who don’t need it. They may also have incentives to place more embryos into the uterus to keep those rates high.
Singletons could be maximized by mandating single embryo transfers on day 3 (at the cleavage stage), but we must be willing to accept lower pregnancy rates.

Alternatively, if we are able to improve blastocyst culture to reduce the risk of identical twins, an elective single embryo transfer on that day would increase pregnancy rate without increasing multiples. Embryo biopsy may in the near future maximize the chance of a viable singleton, but this procedure is not quite ready for prime time.

The bottom line is: things need to change. And I think things can and will. Technology needs to change. Patients need to change and doctors need to change. I will do my best to educate patients on the risks and benefits of their choices, and I will still grant patients autonomy in the choices they make. Together, I believe we can minimize the extremes and get the Q words out of our vocabulary, and most of the T words, too.

(Now that I've written this, hopefully, we don't have a patient turn up with high order multiples. I fear writing about this would be similar to working in the Emergency room and saying "everything is so slow tonight" and then the avalanche of patients hits.)

There Is Always Something To Worry About - Part 3

How to Get Pregnant and Have a Healthy Pregnancy

Step 3 – Getting Pregnant

When I meet an infertility couple, the first things I want to know are the age of the woman, her past reproductive history and how long this couple has been having intercourse without contraception. I’m generally not as interested in how long they’ve been “trying” to get pregnant. The reason I say this is because if couple has been “trying” to get pregnant for 6 months but have not used any form of birth control in six years, then they have 6.5 years of infertility. Their prognosis is frequently much worse than another couple who quit birth control 12 months ago and is not pregnant.

If you have not used birth control in 1-2 years and are not pregnant, call and make an appointment today to be seen by your provider or by us at 423-876-2229. If you are still truly in the early stages of trying to get pregnant, please continue to read.

Areas of Concern
When we give talks about getting pregnant, we frequently discuss 6 areas of concern: duration of infertility, adequate intercourse, adequate ovulation, adequate sperm, anatomy and ovarian reserve.

Of the six areas of concern, three are essential to conception and these are: a woman must produce an egg (ovulation), the man must have sperm, and the sperm and the egg must be able to meet (adequate anatomy.

Adequate Intercourse
Many couples who are trying to conceive fixate on exact timing of intercourse, when in truth exact timing is not particularly important. What is essential is that a couple has intercourse on, or prior to, the day of ovulation. Sex on a single day of the month has virtually the same chance of pregnancy if the sex occurs on the day of ovulation, the day before ovulation or even the day before that. Sperm can live up to 5 or 6 days and still fertilize. This means, for most couples, intercourse every 2-3 days is adequate.

Intercourse 24 hours after ovulation has a very low chance of pregnancy. After ovulation, the egg lives only about 12-24 hours. So make sure you have sex prior to ovulation if you want to conceive.

Ideally, adequate intercourse would mean satisfactory intercourse for both partners. Unfortunately, for the purpose of getting pregnant, it really only has to be satisfactory for the male – as he must deposit sperm into his partner. Female orgasm has no significant role in fertility. I know, it’s not fair.


Adequate Ovulation
Ovulation (producing an egg) is essential to getting pregnant. Most women who have regular predictable menses are ovulating. Ovulation is even more likely in regularly cycling women who reliably predict their menses because of breast tenderness or bloating or mood changes that precede the menses by a few days. Ovulation can be confirmed various ways, with basal body temperatures, ovulation predictor kits, or even a blood test. Ovulation is generally deemed adequate when the luteal phase is 11 days or longer based on basal body temperature charts or 12 days or longer based on ovulation predictor kits. For more details, click Ovulation.

Normal menstrual cycles are between 24-35 days. Shorter cycles frequently mean a woman’s ovarian reserve is declining and should be evaluated. Longer cycles can mean a woman is not ovulating and also should be evaluated.

Adequate Sperm
If a man has any sperm, it is possible to get pregnant; however, once sperm counts go below 15 million per ml, the chances of pregnancy can plummet significantly. Of course, we don’t recommend home sperm testing, because there are many facets of sperm which may affect fertility. Because it is a painless test, this should be the first test sought by a couple.

If there is a history of frequent sauna or hot tubbing, significant testicular trauma, testicular surgery, undescended testicle, prior radiation or chemotherapy, low libido, erectile dysfunction or low volume ejaculations then a more immediate evaluation should be pursued.

Adequate Anatomy
The fallopian tubes serve as a transit system for sperm and eggs. When a woman ovulates, the tube picks up the egg and holds it there for sperm to fertilize. For their part, the sperm are deposited in the vagina and have to swim through the cervical mucus, up through the uterus and out to the tube. Only 1 in a million sperm will eventually make it to the egg with intercourse.

□ If the cervical opening is small or scarred due to prior surgery it may not produce the needed cervical mucus which assists in the transport of sperm.
□ If the tubes are blocked, the egg and the sperm cannot meet.
□ If sheets of adhesions (scar tissue) separate the ovary from the tubes, getting pregnant can be a real challenge.
□ If benign tumors such as fibroids are growing in the uterus, this may prevent a pregnancy from taking hold.

Women with infertility for more than 1 year should have an x-ray called a hysterosalpingogram performed. For more details, click on HSG.

Endometriosis, a condition in which uterine lining grows outside the uterus, can sometimes distort the anatomy. Even when it doesn’t distort the anatomy, endometriosis can make getting pregnant more difficult. If you are just starting to get pregnant and you have a history of endometriosis, ask your physician if yours is so severe that you should do something about it. We’ll talk more about endometriosis and fertility in a future post. For more information now, click Endometriosis.

Ovarian Reserve
This is the biologic clock. The best predictor of the biologic clock is a woman’s age. By age 35, nearly 30% of women will be sterile. By age 40, nearly 70% will be sterile. In a study of women who never used any birth control and stayed married their entire lives, the last average pregnancy occurred at age 42. Many of these pregnancies ended in miscarriage because the embryos have a higher rate of being abnormal the older women get.

The biologic clock, or ovarian reserve, is determined by several factors: how many eggs a woman had at birth, how much damage has occurred to her ovary or eggs throughout her life, and how quickly she has lost her eggs.

Smoking, ovarian surgery, radiation and chemotherapy can all lead to premature depletion of eggs. Genetics can also cause early loss of eggs. We find that many women with unexplained infertility and with endometriosis have findings consistent with diminished ovarian reserve.

A sign that ovarian reserve is decreasing is a shortening of the menstrual cycle. Women who were regularly menstruating every 28 days, may find themselves having cycles every 24 days. This can be evidence of diminished ovarian reserve. The same goes for women who had PCOS and who never or rarely ovulated on their own who suddenly find themselves having normal menses.

If you have any of the risk factors above, strongly consider having your physician, or us, evaluate your ovarian reserve.

For more information click on diminished ovarian reserve.

If you have questions on any of the topics listed above, call us and make an appointment, visit our website: http://www.trmbaby.com/.

There Is Always Something To Worry About - Part 2

How to Get Pregnant and Have a Healthy Pregnancy

Step 2: Preconception Counseling

Informing your obstetrician of your intention to get pregnant is advised. He or she can tell you what the risks of pregnancy are for you, given your past medical history. Prior to pregnancy, your pap smear and breast examination should be up to date.

Vaccines: Chicken pox can be devastating to a baby and fatal to a pregnant woman. If you have no history of chicken pox and never received the vaccine, your doctor should test you to see if you are immune. Prior to pregnancy, the chicken pox vaccine can be administered and very effectively reduce the chances of infection during pregnancy.

Rubella (which causes German Measles) can also harm a pregnancy. Just because you had a vaccine once (or twice) does not mean you are immune. Rubella testing can tell you if you are at increased risk for German Measles. If you are not immune, you may receive a two dose booster to induce immunity.

Neither the chicken pox or Rubella vaccine should be given during pregnancy, therefore, testing and vaccination prior to conception are advised.

Genetic testing: Your doctor should determine if your ethnicity or family history places you at increased risk for having a baby with a genetic disorder. If a known genetic disorder runs in your family, you may be at increased risk for having a baby with that disorder. Frequently, testing can be done to screen for that disorder in an individual patient.

Groups at high risk for genetic disorders include:
Women who are 35 years old when they deliver: While the risk of having a baby with Down Syndrome or other chromosomal abnormality is never zero, the risk does increase with age. At age 35, the risk of having a baby with a chromosomal abnormality is greater than the risk of losing a baby from amniocentesis (test for the abnormality), so counseling is advised.

African Americans: approximately 1 in 12 carry the trait for sickle cell disease.

Caucasians: approximately 1 in 25 carry the trait for Cystic Fibrosis.

Ashkenazi Jewish: are at increased risk for multiple diseases including Tay Sachs, Canavan, Neimann-Pick, Blood Syndrome, Fanconi’s Anemia, Familial Dystautononemia, BRCA mutations and many other diseases and syndromes.

Families with a history of Autism or mental retardation should consider testing for Fragile X Premutation.

For more information preconception testing, see: http://www.trmbaby.com/fertility/preconception_counseling.shtml

If you have questions on any of the topics listed above, call us and make an appointment, or visit our Facebook Page.



Coming next: How to Get Pregnant

There Is Always Something To Worry About - Part 1

How to Get Pregnant and Have a Healthy Pregnancy

For many people, how to NOT get pregnant is the most important question relating to fertility. Yet when the time comes to start a family, the anxiety can shift to the opposite camp and people begin to worry if they CAN get pregnant.

If you are in the early stages of trying to get pregnant or are thinking about getting pregnant in the near future, there are some things that you can do to optimize your chances of getting pregnant and of having a healthy pregnancy.

Step 1: Optimizing your health before you get pregnant

Fitness: Women with a normal body weight prior to pregnancy have lower rates of pregnancy complications including diabetes, pre-term delivery and preeclampsia. Women who are physically fit also have lower rates of cesarean section. Three hours of aerobic exercise per week should be the minimum goal of any woman trying to get pregnant.

If you are morbidly obese (BMI 40), you are at increased risk of many pregnancy complications including birth defects such as heart malformations and spina bifida. Alternatively, if you have been underweight and not ovulating or if you have been taking steroidal medications for a long time, you may be at increased risk of osteoporosis and of experiencing bone fractures during pregnancy.

Nutrition: Women who are deficient in folic acid or other B vitamins have an increased risk of neural tube defects (or spina bifida). At a minimum, a woman should supplement her diet with 400 mcg, ideally 800 mcg daily.

It is also becoming apparent that Vitamin D is important in many aspects of health and pregnancy. Vitamin D is also important for bone health. Fish and sunlight are good sources of Vitamin D. The daily recommended intake of Vit D is 600 IU daily, which means many people need to take a supplement.

In general, a healthy diet will contain the RDA recommended nutrients and consist of 1200-1500 calories per day (depending on the weight of a woman).
> See more regarding weight and fertility

Smoking: Smokers and women married to smokers have lower monthly pregnancy rates. Smokers more frequently have small for gestational age babies.

Alcohol: Even modest alcohol consumption has been shown to decrease pregnancy rates and increase miscarriage. In the IVF setting, 1 drink per day has been associated with both lower pregnancy rates and higher miscarriage rates. In natural populations heavy alcocohol consumption is associated with high estrogen levels in women and this can impair egg growth and has been shown to cause a woman to stop ovulating.


Caffeine: More than 300 mg of caffeine per day has been associated with miscarriage. Next time you're at Starbucks check out the caffeine dose in a Grande coffee - 330 mg.

Summary:

A bad lifestyle is not birth control. So if you don't want to get pregnant, I wouldn't count on drugs, alcohol and cigarettes to save you. On the otherhand, if you are young and fit, a non-smoker, who doesn’t drink or have any medical problems then you’re off to a good start, but this does not mean you will be fertile. It doesn't even mean you are nutritionally ready to conceive. In our next post we will discuss preconception counseling and the labs that are advised prior to conception.

If you have questions on any of the topics listed above, call us and make an appointment, or visit Tennessee Reproductive Medicine's Facebook Page.

Coming Next: Preconception Counseling, then How to Get Pregnant

Fertility Testing At Home - Ovarian Reserve Tests

Ovarian reserve is basically another phrase for the biologic clock.

Younger women generally have more eggs and more of those eggs are normal, compared to older women. Women who have gone through menopause generally have no normal eggs remaining and they cease to ovulate. Between normal ovarian function and menopause, there is a state called diminished ovarian reserve.

Women are born with 1 – 2 million eggs and every day of a woman’s life she is losing eggs. Some women are born with fewer eggs, some women lose them more quickly, and some women accumulate damage in their eggs more rapidly than others and they develop diminished ovarian reserve.

Women with diminished ovarian reserve frequently have a more difficult time getting pregnant.

Genetic predisposition is one cause of diminished ovarian reserve, so premature menopause in a relative should alert women to the possibility that this can occur in them. Other causes include smoking, ovarian surgery (such as the removal of a cyst).

A sign that ovarian reserve can be decreasing is if a woman's menstrual cycle begins to shorten betweeen periods. If a woman has always menstruated every 28-30 days and starts to menstruate every 24-26 days, this can be a sign of diminished ovarian reserve and should be evaluated.

Now women have the choice of testing ovarian reserve through their physician, or in the privacy of their own home through urine test kits that are used much like a home pregnancy test.

The kits range in price from under $4 to nearly $100, and they test for a hormone called follicle stimulating hormone (FSH) on or around menstrual cycle day 3. FSH is what makes eggs grow. It’s like the gas pedal to the ovary. Like a well tuned car does not require someone to mash hard on the gas pedal to get up to speed, the normal ovary only requires a little FSH to ovulate. If the FSH is high, then the ovary is not working well and the woman has diminished ovarian reserve.

The inexpensive kit costs around $4 per test and is available at http://www.early-pregnancy-tests.com/fsh-tests.html . This kit detects the equivalent of an FSH of 25 mIU/ml, which is consistent with infertility and possible menopause. A normal test is when the FSH is below 25 mIU/ml. The problem is, women are generally infertile when FSH exceeds 17 mIU/ml.

A more sensitive kit by Genosis Ltd, called Fertell, can detect FSH levels of 10 mIU/ml, which is consistent with diminished ovarian reserve. Fertell has recently become unavailable in the United States, but may be purchased on line. A normal test is when the FSH is below 10 mIU/ml

The problem with both tests is that they only measure 1 hormone, FSH, which by itself can be meaningless. To know if the FSH is valid, an estrogen level must accompany it.

If a woman has a normal test it can be falsely normal (because estrogen is elevated prematurely – as can be seen in women with diminished ovarian reserve. See Pitfalls of Day 3 FSH Testing at: http://www.trmbaby.com/welcome/WebPearlsDec08FSH.pdf .

So a normal test does not mean the woman has normal ovarian reserve.

An abnormal test can be falsely abnormal, too. During the midcycle, many women will bleed due to a temporary drop in estrogen associated with ovulation. If the woman thinks this is her period, she might measure FSH at an inappropriate time. If a woman measures her FSH during the midcycle, the FSH is normally high and might trigger a positive test.

So either way, these tests need to be confirmed by a doctor. This is the best way to avoid false alarms and false reassurances.

Fertility Testing At Home: Home Sperm Testing

Over the past few years more and more fertility tests have become available for home use. This month one of the leading journals in the fertility world, Fertility and Sterility, published a very nice review of many of these home tests. Coincidentally, I just gave a talk about many of these tests and thought I would share my thoughts about them.

For the sake of time and space, I’ll tackle these one at a time. Today, we’ll talk about home sperm testing.

Before we get there, let me give some background.

The idea of home testing fits a definite need among consumers. It’s nice to be able to learn that you’re pregnant without making a doctor’s appointment. It’s also nice to identify problems early, if that leads to evaluation and effective treatment.

The problem with a lot of tests on the market is that they can be falsely reassuring and may cause some people to delay proper evaluation. There is no good evidence that performing such tests actually improve a couple’s chance of conception. A patient without a history of infertility is most likely wasting their money. On the other hand, if a couple has not conceived within 1-2 years of unprotected intercourse, I’m not sure that any home test is particularly reassuring. A falsely reassured patient may delay treatment and therefore is at risk for not meeting their reproductive dreams.

Several years ago after hearing a story about home fertility testing on NPR’s All Things Considered, http://www.npr.org/templates/story/story.php?storyId=10712488 I wrote a letter describing some of the pitfalls to such testing. http://www.npr.org/templates/story/story.php?storyId=10819112

The two tests described where a semen test and a test to measure a woman’s FSH, marketed under the name Fertell (Genosis Ltd).

The Fertell sperm test can determine if a man has 10 million total motile sperm and is sold for close to $100. The advantage of this test is that many men are embarrassed to have a formal semen analysis performed. Also, the test determines the motile concentration, which is fairly predictive of normal fertility. Recently, the World Health Organization (WHO) published findings showing that 95% of fertile men had a sperm concentration of 15 million sperm/ml and 32% were progressively motile and 5% or more had a normal shape. A reassuring Fertell tests should correlate well with 2 of those 3 parameters. If abnormal, the test should lead a man to have further testing performed.

The drawback to the Fertell sperm test is that it does not test morphology, which can be very important. The cost is also a drawback. For an additional $50, a patient can have a full semen analysis at our clinic and have it interpreted by a physician who can interpret the results in the context of the couple.

Other home semen tests are also available. Embryotech has marketed several tests FertilMARQ, Start Male Infertility Test and PreConceive: A Male Fertility Sperm Test, all of which purport to evaluate sperm concentration. Because it tests only a single parameter (concentration), it tells nothing about motility or morphology. A man with few or no moving sperm may be falsely reassured. (As with the Fertell test, an abnormal result should be followed up with a visit to a physician’s office.)

There are also small microscopes available: http://www.amazon.com/Micra-Sperm-Test-Count-Motility/dp/B000SLM504. The disadvantage of this test is that interpretation is left up to the patient. As with all home testing, the disadvantage to the home microscope is that there is no one with clinical experience to interpret the test in the context of the couple.

One of the tenants of good medical practice is to treat the patient, not just the test.

As I said above, a normal test does not mean that all is well. A person without infertility may find this test reassuring; however, this person probably doesn’t need the test in the first place. A full semen analysis gives significantly more information than any of these tests. A couple with infertility is probably better off having a medical evaluation by a knowledgeable physician. However, if the only way to get a man to get tested is with at an at home test, I would pick Fertell since it gives the most information with the easiest interpretation.

It’s a Mother of a Day

This week some of our patients have had some good news about their pregnancies and this Mother’s Day may be like no other. For them, this will be a joyful occasion, a day many of them never expected to have.

However, some of our patients and friends have had crushing news and are not yet pregnant, or are grappling with the possibility of never having a child. I know of others who have recently lost a child or a parent. I can’t imagine the sorrow a day like Mother’s Day may bring for them.

I can count my blessings for now, as both my wife and I still have our parents and we have our children. We can still celebrate this day with all the people who have been a part of our lives.

It is my hope and my prayer for all of those who are suffering a loss…either loss of what never or has not come to pass, or the loss of a parent or a child…can find a path to peace.

I well remember those Mother’s Days, waking next to my wife, when we were childless. It is a certainty that I felt sadness and fear. But I can tell you this: the sadness I felt was shared. It seems strange to say, but sharing a burrowing sadness was somehow comforting to me. The fact that I shared it with the person whom I loved more than any other person on the planet somehow made the sorrow not only bearable, but good.

My wife and I shared a sorrow. It was a sorrow wrapped, enveloped in a deep love…which in the end felt like a form of gratitude.

So this weekend, this is my wish for all of us, in case anyone has forgotten…. May you all have peace in your hearts and be grateful for your shared sorrow, cherish the ones you love, whether they are here or not. Cherish the Mother you were, the Father you were, or the one you could have been.

If you have lost a child or a parent, honor them by living a life which pays tribute to them.

It’s the rarest elements in nature that are valued so dearly. The time we have together here on earth is so small, so fragile and so very precious. We never know exactly what we will be given, or how long we will have it. I think we should all be thankful for what we have been given, no matter how briefly. If we have been given less, or have suffered loss…it is my hope that we can all appreciate even the small gifts as what they are….precious and rare.

This world contains enough sorrow that no one will ever go wanting for it. May we all recognize joy, too, and let it overflow from us and into others around us. If you know someone who is in the depth of sorrow and can’t find a way out, may you help to bring them peace.

True Love May Last Forever, But Fertility Does Not

When it comes to fertility, we frequently find that our patients take their lead from celebrities. Too often, this has a negative impact on our patients. We see Hollywood starlets, senators’ wives, and TV personalities having children in their mid-to-late 40s or even early 50s, and we are left with the impression that fertility is lasts longer than it actually does. Sadly, as we have said before, many of these pregnancies are achieved through egg donation (using a younger woman’s egg to get pregnant), but the general public is not really aware of this.

Lately, we’ve had a new couple to watch, a couple to remind us about the choices that face all of us who are lucky to find our true love. The couple is Prince William and his bride, Kate Middleton. The choice is: when to start a family.

I came across a nice little article by Dr. Manny Alvarez, who had some advice for this couple. And by extension, it applies to many couples.

(See the article here: http://www.foxnews.com/health/2011/04/27/kate-middletons-pregnancy-plan/ )

Dr. Alvarez correctly points out that Kate’s fertility will be on the decline from this point on. He advises her to try to conceive soon, rather than wait. Of course, from a medical perspective, he’s correct.

But life is about balance and, for many of us, the trick is to know what decisions to make to maximize our chances of future happiness.

Most of us dream about finding true love. We dream of all that comes with it. We will be secure. We will be complete. We will have children and we will watch them grow. We will be happy.

But most newly married couples do not want to have children right away. They want to have time on their own to consolidate their married life together, to grow accustomed to the changes this brings. Adding a child immediately into the mix can place a couple under financial strain, time constraints and emotional fatigue that can interfere with the initial bonding between the couple.

In the case of Prince William and Kate Middleton, I’m not sure we could concoct a more story-book modern day romance. Kate, the commoner (a term we don’t use in the US), marries a prince and becomes a princess. The presumption is that she will also become a mother and chances are good that she will reach this goal without any assistance from me or any other infertility specialist.

I hope they do have a story book life.

But if I were in Kate and William’s shoes, would I follow Dr. Alvarez’s advice and try to have children right away?

That would depend on my goals, I guess. I frequently ask patients to project themselves into their early to mid 40s and picture themselves childless. From that vantage point I ask them to look back on their lives and reflect, to the best of their ability, what choices do they wish they had made when they were younger.

If the life they spent growing together fuels their happiness, perhaps that is more important. If not having children is a devastating thought, perhaps they should begin just as soon as they are ready.

Either way, this decision is to be considered carefully. Think about the pitfalls of each choice, about each direction. Think about how you will deal with those pitfalls ahead of time. Talk about them as a couple. Have a plan for what you will do if things don’t work out as planned. Agree with each other about how you will treat the other person if things don’t work out as planned. Agree to remain flexible as, sometimes, we can all change our minds.

As for Will and Kate? It’s the same as I have for any couple. I wish them a storybook ending no matter whether it was the ending they planned, or not.