WEBVTT
00:00:00.000 --> 00:00:27.800
A lot of OB are not widely offering this test, and that because a lot of people don't go to their OB for what we call preconception counseling, right when someone decides they want to try to get pregnant, they kind of most of the time, just stop taking birth control, maybe stop using condoms, and to just start trying. At home, we rarely get to have a touch point of where we have a conversation about how to optimize pregnancy before you're actively trying.
00:00:30.800 --> 00:00:56.920
Welcome to perinatal and reproductive perspectives. This is a podcast where we empower birthing individuals, partners and health professionals with evidence based insights, holistic strategies and relatable stories. Hosted by a health care expert, this podcast fosters understanding equity and growth in perinatal and reproductive health. Here's your host, Becky Morrison gleed. You
00:01:00.000 --> 00:01:16.680
you. Welcome to another episode of perinatal and reproductive perspectives. I'm so excited because we are here with Dr Lucy Chen. She is a board certified Rei. So welcome to the show.
00:01:17.280 --> 00:01:19.260
Thank you. Thank you so much for having me
00:01:20.340 --> 00:01:23.420
tell folks what is an REI and what do they do?
00:01:24.439 --> 00:01:46.659
Yeah, so an REI stands for a reproductive endocrinologist and infertility specialist, which is obviously a mouthful, but essentially what we are, we're physicians who are trained and certified to assist in reproduction, whether that is in a form of natural conception or assisted reproductive technologies,
00:01:47.140 --> 00:01:57.040
walk us through some of the reasons that someone might seek your help. What are some of the common fertility challenges? Yeah, you
00:01:57.039 --> 00:03:16.859
know, the most common is obviously going to be couples struggling to achieve fertility, whether that's primary infertility, which is when they are having trouble just having their first child, or secondary infertility, they have been successful in the past, you know, they have a living child, but are now running into difficulties having a second pregnancy. So that is probably the majority. But then, of course, there are couples in same sex relationships who would like to have a child, whether that's using donor sperm for same sex female couples or those, you know, same sex male couples who would like to use a donor egg in a gestational carrier. So lots of different reasons, and I think more and more increasingly, I'm having patients who come for egg breathing, which is for fertility preservation, and that can be for, you know, elective or planned, you know, they're not at a part in their career where they're quite ready to start a family, or perhaps they just haven't met The right person, and they want to kind of preserve their fertility, or it could be for cancer reasons. You know, a woman just got diagnosed with breast cancer and she's about to undergo chemo, we know that that's going to impact our future fertility. So I do see a lot of onco fertility patients as well.
00:03:17.159 --> 00:03:38.360
And I initially asked, What are some of the challenges? But I think you bring up a good point of, there's not just challenges, but there's other reasons, such as preservation or, you know, curtailing oncology. Are there any other reasons that folks might seek fertility support that we haven't already pointed to?
00:03:39.259 --> 00:04:54.819
Yeah, something unique that I do, that maybe not all Reis offer is I do offer just kind of counseling and education. So, for example, a patient with PCOS, you know, they're just not getting, perhaps, the hormone control or a good understanding of what exactly like what kind of hormone imbalance is happening, you know, and they haven't gotten the answer from maybe their general OB, GYN, then I do have some patients who come who are not actively seeking fertility or pursuing fertility, but are struggling with some sort of underlying hormone imbalance. And we talk a lot about how to manage that, you know how to optimize their health, and not just PCOS, but, for example, premature ovarian insufficiency. These are young women in their 30s and 40s who are suddenly hit with ovarian failure. They're not quite menopausal. So it's not a that's not a patient population that often general OB GYN are used in managing so I do have a small group of those patients who I take care of. Again, they're not actively seeking for fertility, just to help maintain their hormone control, any hormone imbalances, and then just for overall healthcare.
00:04:55.120 --> 00:05:13.439
That sounds really helpful, even from a consultation piece. You don't have to know. Necessarily be okay, let's start fertility treatment, but let's just consult with Dr Chen to get you know, ready or prepared, or get additional information so you can be informed going into the process.
00:05:13.620 --> 00:05:29.060
Yeah. I mean Exactly. Our name, our title, is reproductive endocrinologist, and infertility, I think the infertility component of our field dominate, but there's definitely endocrine component.
00:05:24.980 --> 00:05:44.019
You know, we are in some ways. A lot of our fellowship training focuses on hormones and how that, you know, affects a woman's overall health. And so we're very much able to discuss that and kind of counsel patients. And I really enjoy doing that before
00:05:44.019 --> 00:05:56.920
we go into kind of the diagnostic assessment, what to expect with some of these presentations, or reasons why you would want Dr Chen's support. What inspired you to become an REI?
00:05:56.920 --> 00:06:37.639
I went to med school, and I really didn't know what I wanted to do for the first two years. From back then, my medical school was set up such that first two years, it's all academic, classroom learning, you know, taking tests you're not really clinical or seeing patients yet. And then during our women's health component, we had a local Rei come and give a talk as a guest lecturer, you know, because they're talking about oncology and they're talking about, you know, gynecologist and obstetrics and MSM and then so, because Rei is a sub specialty of OB GYN, they had a Rei come.
00:06:38.120 --> 00:07:40.100
And when I heard his lecture, I was just blown away, just seeing the fertilization the egg and the sperm coming together, and the embryo is growing, and there was still even back then, there was so much left to cover in the field, and I was just fascinated. So I wanted to be an REI, since I was second year medical student, and every decision I made for, you know, my career was based on my goal of, I want to be where I am today, which is to be a practicing Rei. And, you know, I love women's health, and I love delivering babies, and I do miss working on labor and delivery, but truly, this is what gets me out of bed. You know, there's not a day where I get up, even on the early days, the crack of dawn, where I dread coming to work. I'm literally so excited to come into work every day and that, you know, that's how I know, like, okay, all those years of training and schooling and fellowship, it was all worth it, because I'm literally living my dream.
00:07:40.279 --> 00:08:11.220
We share that in common. I love this work, which is why I was so excited to connect with you. From, you know, I'm more on the psych, emotional, relational side, and you're on the more medical. But I think both have some intersection, absolutely, yeah, tell us a little bit more about like, after you knew you had that moment of inspiration hearing that Rei, what were the components that continued your expertise in the field of endocrinology and reproductive health?
00:08:12.059 --> 00:08:30.259
Yeah, so the training pathway to be a board certified Rei is such that you have to complete four years of an OB GYN training. So you have to basically be able to function as an OB and as a gynecologist.
00:08:25.278 --> 00:10:20.099
And then after that, a typical Rei will complete an REI Fellowship, which is the sub specialty training, and that is generally about three years. I decided to do even one step further, and I actually did a combined fellowship in genetics and Rei. So I did a dual fellowship. And the reason why I did that was one of the things that stuck up to me when I was in clinical rotation and just had, like a brief exposure to be a part of the REI world, was there was all this talk about genetic testing. And I remember, even as a resident, we had such little teaching on genetic testing, right? Like, and anytime we talked about genetics, it was always kind of like this, like, scary, unknown thing, and I wanted to know more, because now they're talking about testing on the embryos, and there's pre Implantation Genetic testing, there's an employee, and then there's segmental aneuploidies, and now there's, you know, single gene testing. And so I was like, I want to know more, but everyone I had kind of gotten advice from had shared with me listen in a classic three year fellowship for a general Rei. There is not enough time to learn all that. There's just too much. So I thought, Okay, well, let me actually do it the right way. And so when I, you know, did my fellowship at Hopkins, I took some extra time and went deep into the genetics world. You know, I was doing metabolic genetics. I was doing working in the NICU, like learning from all sorts of genetic. Are who specialize in different fields, and learning about whole exome sequencing, and I think all that understanding and seeing what it's like to have an affected child, you know, with a genetic condition, and talking to those parents and seeing them at the bedside, it really gave me a really strong background and kind of like an understanding.
00:10:20.219 --> 00:10:40.239
So when I counsel my patient, I don't have to send them to a genetic counselor they've never met, right? We're having that conversation right then and there. And so I think it was a worthy investment of my time. It drove my husband nuts, but, but I think, yeah, it was a good investment. Yeah,
00:10:40.840 --> 00:10:58.659
help us understand a little bit more about the role that genetics play into, you know, patients undergoing infertility treatment, and what role does that play in kind of assessment and then treatment?
00:10:59.799 --> 00:13:15.840
Yeah, I mean genetics is, you know, kind of like underline so much of what we do. For example, I have a lot of patients who are in their late 30s and early 40s struggling with infertility. And commonly in that age group, it's recurrent pregnancy loss. You know, not only are they having difficulties, some of them are maybe even more frustratingly, getting pregnant by can't keep a pregnancy in the path. We could type the pregnancy tissue with a traditional type of genetic screening called karyotype. But the test was really hard to do because you had to culture cells. It had to be collected from a DNC. You couldn't pass that home. It was very susceptible to contamination, and then sometimes you wouldn't get any answers, and it was quite expensive. So I think some patients are kind of discouraged from testing their miscarriage tissue. Okay, then there. What happens is they're left with a lack of answer. Why am I having so many pregnancy losses? And of course, naturally, women tend to blame themselves. So then it becomes, there's something wrong with me. There's something wrong with my body. But in reality, if we actually tested the tissue, and there are so many ways to do that now that is affordable, and it gives us a breadth of information. If you actually tested that pregnancy tissue, oftentimes, what you'll find is that the pregnancy was an annual employee pregnancy, meaning that it did not have the right amount of genetic instruction manual right in order for a one cell embryo, when it first forms to progress and divide and replicate all the way into a baby, it has to have a complete genetic instruction manual to tell it to do that. This clump of cell becomes the brain, and that becomes the heart and so on and so forth. Right? If you have the wrong net material, that pregnancy will never make it to the end stage, or the end goal, which is a healthy baby. At some point, the cells might start growing and dividing, but then it hits a critical checkpoint where, if you don't have the instruction it needs, the pregnancy will stop growing.
00:13:16.080 --> 00:13:24.559
That is the most common reason for a first trimester pregnancy loss. If a woman knew that, then she had kind of closure, right?
00:13:24.799 --> 00:13:39.860
This had nothing to do with something you ate or drank. It didn't have anything to do with any activity you did, you know, it wasn't because you ran too much or you had intercourse or because, you know, you took a hot shower or anything, right?
00:13:39.860 --> 00:13:42.700
It had nothing to do with you.
00:13:39.860 --> 00:13:42.700
You could not have changed it.
00:13:43.000 --> 00:14:45.399
No amount of progesterone support would have made a difference. At the core, the genetics of the pregnant speaking, you know, was was wrong. It just didn't have what it needed. I think that helped a lot of patients move forward, and it gives them a little bit of a direction on how to proceed with their next step, as opposed to kind of going down the path of like, oh, maybe it's because I'm not ovulating. Maybe it's my hormones. Maybe I need to drink this herbal tea, or do this or do that, because it gives such a clear cut answer. And so there's genetics in that perspective, and then there's understanding the genetic that our inherent genetics, why do we have this thing called the biological clock? Why does it affect women but not men? I have so many patients come to me and they're like, I feel so young, like, I know I'm 40, but I feel so young. I eat healthy, I eat organic, I take my antioxidant, I don't drink, I don't smoke.
00:14:41.379 --> 00:15:17.159
There should be nothing wrong with my genetic and it's like, okay, nobody explained to us how this works, that you're born with your eggs, that you can't control DNA aging the egg and the DNA are as old as you, whereas the. And firm men, they're testy, make firm roughly every 90 days. That means their DNA, in that sperm, is only as old as really 90 days, even if a male partner is 50 years old, 60 years old, you know, or you hear Robert De Niro, 80 years old.
00:15:17.460 --> 00:15:26.779
That's why there's such a discrepancy in the biological plot from men versus women, and a lot of it is not our blame.
00:15:26.899 --> 00:15:41.500
It's not our fault. We have no control over it. And so I think genetics helped. Part of understanding genetics is you start to understand like what is within your control, what is outside of your control, and just giving grace to yourself and your body.
00:15:41.799 --> 00:16:04.740
If anyone listener takes anything from today's episode, I love the message that it's you are not to blame, to externalize some of that, it must be me, and you know, take that out of you. Are there any other reasons that someone might want to consult with you from a genetic lens.
00:16:06.419 --> 00:17:01.679
I think if they have had an affected child, there's a different type of genetic testing called expanded carrier screening. And just stepping back a little bit, when people say genetic testing, it can mean so many different things, and it's really important to actually understand what you're being tested for and what is being discussed. Saying you had genetic testing is just like saying you had a blood work done, or what what did you test for? Right? So there is a type of genetic testing called expanded carrier screening. It's a risk calculation tool for two people individuals to see what their risk is of having a child with a major medical condition that's known to be affected by a single gene, cystic fibrosis is a perfect example of this.
00:16:56.740 --> 00:17:30.259
Cystic Fibrosis occurs when two parents are carriers for the cystic fibrosis gene. As a carrier, the parents are asymptomatic. They would never even know that they are carriers. However, each pregnancy they have, there's a 25% chance that they will have a child with cystic fibrosis, so a lot of OB are not widely offering this test, and that's because a lot of people don't go to their OB for what we call preconception counseling. Right?
00:17:30.500 --> 00:18:30.200
When someone decides they want to try to get pregnant, they kind of, most of the time, just stop taking birth control, maybe stop using condoms, and to just start trying. At home, we rarely get to have a touch point of where we have a conversation about how to optimize pregnancy before you're actively trying, though, there's not a good opportunity for you to get this testing done unless you've read about it. You've heard about it, you know, unless there's more awareness in a community. But once you know, I think there's a good proportion of couples who would rather know the information that they might be at risk of having a child, because there are a lot more reproductive decision options before you're pregnant than when you're already pregnant. So that's one type of, you know, very common testing, and it's not expensive. It is a standard of care per eight cog. Most intrinsic cover it. People just don't know to ask for it. They don't know about it, you know.
00:18:30.440 --> 00:19:09.779
And just because you do the testing and you and your partner are found to be mutual carriers, it does not mean that you cannot have a biological child together. There are ways that we can help to risk reduce so that you have an unaffected child that's still biologically yours, but it also doesn't mean you have to make any decisions. You could simply have that information, share it with your OB, share it with your pediatrician. It's more used to kind of, you know, optimize the pregnancy and optimize what happens after delivery so that there's no delay in medical treatment to your child for their specific medical condition. So that's an example.
00:19:09.779 --> 00:20:37.339
If a couple already have an affected child that's inherited in this known manner, and they want to risk reviews, and I have siblings, then they may seek out my care, even though they themselves do not actually have infertility or something that's more commonly done now is preventing cancer mutations from being passed down. So we know very well that there are certain cancer mutations that are passed down in families that predisposes a woman to getting early onset breast ovarian or uterine cancer or even colon cancer. So commonly turn common names are something like braca, BRCA mutation. There's something called Lynch mutation. If you know that you have this in your family and you yourself have been tested and you have it, you. Every single one of your offspring will have a 50% chance of also having them. Some couples would like to risk reduce. They would like to stop passing down the gene at their generation so we can help them out by doing IVF and helping to prevent or identify embryos that have the mutation and those that do not have the mutation, and if they have a decision that they can, rather, you know, they can transfer the embryo they would like to transfer. So that's another example. Some patients have a known neurological condition, such as Huntington.
00:20:38.059 --> 00:21:02.039
That's a really tough one, but if the mom or the dad know that they carry it, they know they have a 50% chance of passing it on, and if they have seen their mom pass away from it, or other grandparents pass away from it, and they don't want their offspring to be affected by it, that's another example of how genetics come into play, Even though the couple does not actually have infertility.
00:21:02.759 --> 00:21:19.440
This sounds so hopeful in terms of different avenues that couples can explore if there's a genetic component or concern. And can you tell folks one more time what that test is called that's accessible, often covered by insurance? Yeah,
00:21:19.439 --> 00:22:11.999
absolutely. It's called expanded carrier screening. In the past, it used to be ethnicity based. So for example, if you are African American, then you'll be screened for sickle cell and other conditions. If you were of Ashkenazi Jewish descent, then you would get screened for other conditions that are known to be more prevalent in that ethnic group. However, nowadays, everybody's a mixture of something, right? And we were missing so many people by not offering it to them purely based on their reported ethnicity. And so now what come out from the American Board of Medical Genetics is recommendation for Pan Ethnic screening. Everyone get the same large size panel.
00:22:06.538 --> 00:23:14.818
So on average, panel can testing. Panel can range between like maybe 170 and you you have panels that go up to about 700 even the smallest panels will have the most important genes, the major genes that are known to cause really severe medical issues. And so the panel size is really dependent on your physician's preference. But the type is called expanded carrier screening. There are multiple labs that offer it. For example, LabCorp offers wide and again, most insurances do cover and even if you were self paid, you know, we're not talking about 1000s here. We're talking about, like, maybe hundreds, you know, maybe 150, to 300 This is a huge change from what it was 10 years ago, where it wasn't a 1000s, and that was limiting access for a lot of people. And so I think, you know, the majority of the reproductive population probably do not know about this unless they have a very, you know, astute OB clinic who's offering it, or they've run into infertility and they're seeing a fertility specialist who's offering,
00:23:15.420 --> 00:23:31.220
yeah, I appreciate us shedding light on this today, because it opens it up for folks to know about it, and then just to ask their provider of hey, can we pursue this? Yeah, very accessible.
00:23:24.859 --> 00:23:36.920
Yeah, absolutely anything else you want to cover on genetics that would be helpful for a listener to know,
00:23:37.460 --> 00:23:40.460
I think the key is really just to ask questions.
00:23:40.460 --> 00:23:48.640
Don't be intimidated by the word genetics, and don't feel like it doesn't apply to you or you're too it's too overwhelming.
00:23:48.640 --> 00:24:04.079
There's a lot of really good resources. And honestly, ask your doctor you know whether that's your OB or that's your Rei fertility specialist, because they should be able to answer with confidence, right?
00:23:59.859 --> 00:24:42.460
Whatever genetic questions you have, whether that's about your in carrier testing for you and your partner, or whether that's about, you know, your pregnancy and the likelihood of miscarriage based on your age and etc. So don't be afraid to ask about options for testing number one. And then don't be afraid to ask about, you know, how it applies to your fertility goals and your fertility journey. And if they don't know, the next thing they should offer is counseling, please. Let me refer you to a genetic counselor who can better take a family history, a pedigree and give you a risk assessment. Yeah.
00:24:43.119 --> 00:25:09.299
Thank you so much. I think that will be really helpful for listeners, and you know, they'll share it with a friend or a sister or someone they know in their circle, if we move more into infertility, can you speak to some of those common reasons why some. One might come to your office. And then what does that assessment, diagnostic piece look like? And then what are some of the most common treatments?
00:25:09.599 --> 00:25:44.019
Yeah, I think you know, again, Infertility can be primary and it can also be secondary. It's shocking for a lot of couples when they do run into secondary infertility? I hear it all the time. You know, they didn't have any issues, you know, conceiving our son or daughter, and we just were just so puzzled and frustrated. And so it can happen even if you have had success before. I think the biggest I wish everybody knew when they came to me is understanding when to seek help.
00:25:44.859 --> 00:26:43.420
When is it time to see a fertility specialist, a fertility doctor? Because I see a lot of patients. Sometimes go years, you know, five years, six years, struggling with infertility, doing kind of things based on what a friend of a friend said, or a neighbor said, or what the internet said, and I wish I could have seen met them sooner. You know, if there's anything I want to share today, it's really just know when to seek help. Okay, so what does that entail? And this is going to go back to your question of, like, kind of, what do you see most often as the cause of infertility? So age plays a huge factor female age, and this goes back to the genetics of our eggs and things like that. But if you are 35 and older, I really encourage you to have a low threshold to come see a fertility specialist, right?
00:26:40.599 --> 00:26:52.000
Like generally, it's recommended six months of trying, and if you're not successful, it's time to have a comprehensive workup.
00:26:47.140 --> 00:28:14.880
If you're 35 or younger, you can give yourself up to about a year, 12 months before you seek a fertility specialist. However, if there's any concern whether you're ovulating, right? Maybe you have PCOS. Maybe you don't get a period every month, and instead, you're getting a period every three months. Or maybe your periods are actually shorter than 28 days. You know, maybe your periods are only 24 days. If you feel like there's anything kind of off or different about your body. You do not have to follow those guidelines. In fact, you can just come at any time. We would never turn a patient away from just consultation and talking through things. So I think that one of the biggest reason is just age, advanced maternal age, you know, and in the second is probably kind of not actually ovulating, whether that's because of PCOS or whether that's because you have other hormone issues going on. And then third is probably a structural there's a fallopian tube blockage, there's a fibroid that's inside a cavity, maybe there's a uterine polyp. And then don't forget, the male partners, right? 30% of infertility is due to male factor. And I cannot tell you how many times I've had a patient come and she's saying, I've done this, and I've done done and I've taken this pill and that pill, and I've done Clomid for six months, and then we did electrosol for six months, and I don't know what's going on, and we do a semen analysis and there's no sperm.
00:28:15.599 --> 00:28:34.579
And so getting a semen analysis done is so easy. I mean, in fact, at our clinic, we even allow home collection, so all you have to do is drop off a cup, and it can provide so much reassuring information, but can also provide a lot of diagnostic information. And so I think the fourth is probably male factor.
00:28:35.660 --> 00:28:38.000
And what is the male factor for someone who may not know
00:28:38.900 --> 00:28:51.039
so there's any abnormality in the sperm production, whether that's count or motility or morphology. You know, these are the things that a semen analysis can provide.
00:28:51.640 --> 00:29:02.279
And having very low sperm or complete absence of detectable sperm, could be from a lot of different things, just like how female infertility can be broken down to different things, right?
00:29:02.700 --> 00:30:00.359
It could be because of structural issues, like anatomical issues. It could be because of stress, or maybe other endocrine disorders, like thyroid disorders in the male partner. I mean, a lot of times I'll ask the husbands or male partner, do you have any medical condition, not that I know of, and then I'll say, okay, when was the last time you went to get a checkup? And they'll say, like, right? Five years ago? He felt like, okay. And they end up having some underlying chronic medical condition like diabetes or hyperlipidemia, but they've just been ignoring it. Well, that's going to impact your sperm production, right? So checking for other things. And then, of course, you know, just like how women can have hormone imbalance, and so can men. Just like how women can have ovarian failure and men can have testicular failure too. And so it's really important to understand, you know, identify male factor and then try to figure out what's causing it, so that we can address. Process.
00:30:01.079 --> 00:30:04.440
Thank you. Those explanations are so helpful.
00:30:04.440 --> 00:30:13.380
And, you know, you simplify it so nicely. What are some of the treatments that kind of match that diagnostic piece?
00:30:13.859 --> 00:33:02.039
Yeah, and I kind of skipped over to diagnostic, but I'll, you know, I usually let the couples know we're going to do comprehensive testing, because by the time you've made it to me, you've done a few things on your own, you've bought the home urine hormone kits. You're checking those religiously. Most of them are tracking their mucus consistency, their body temperature. They're peeing on the ovulation stick. They're doing everything possible at home. And then some have also worked with their OB and got OB GYN. They've done some Clomid intercourse or lateral intercourse. So by the time they come to me, a lot of patients have already done some patchwork things. And I just like to say, listen, we're going to do it the right way. We're going to just do comprehensive workup and get an accurate assessment and accurate profile of your infertility. We're not going to do patchwork tapping and delay things even longer. So what does that entail? Well, there is a blood work component to it. The blood work looks at your hormone. It looks at your egg reserve. It checks for a hormone called A and H stands for anti malaria and hormone. We look at your you know, you know, if you have irregular periods, I check your thyroid, I check your prolactin, I check for other things that might impact your overall health that could either make pregnancy more challenging or it could impact your fertility treatment. So for example, checking for screening for diabetes when indicated, because we want to address all those things before you get pregnant. So there's the blood work component. This is also where we talk about genetic testing, like expanded carrier screening. And then there's an imaging component. The imaging component for the female partner typically involves the transvaginal ultrasound to get a baseline of their pelvic anatomy. So their uterus, are there fibroid, you know, are there other structural abnormalities in a uterus? And then we look at their ovaries, are there cysts? What does the egg count look like on the ultrasound when we look at the ovaries, and then the tubal testing. So we want to make sure that there's a nice, clear path for sperm to swim from the vagina, up the cervix, up the uterine cavity, in an out through the fallopian tube, because the egg is waiting for sperm in a fallopian tube. So if there is a blockage or a partial blockage, they're never going to meet, and we need to identify that. That concludes the female partner, the male partner, really just has to do a semen analysis. That's it. And so once we do the diagnostic testing component, then we sit back down and we go through everything and with that, okay, look, here's the cause of your infertility.
00:32:58.900 --> 00:33:09.359
Your tubes are blocked. Okay, let's talk about our options. Or we'll say, here's the cause of your infertility. You're not ovulating. Look for the PCLs.
00:33:09.359 --> 00:34:14.699
You know. This is going to explain all your other metabolic issues, your insulin resistance, the obesity, you know, the an ovulation, the Hershey doesn't, etc. So then we'll kind of tailor the conversation based on what we find and in the treatment can involve a couple things. Obviously, it depends on what the diagnostic testing shows. But we can go, you know, go from the lowest error vision up to the most. The lowest would be kind of, you know, ovulation induction, or super ovulation, with just little pill called kilometer lectures, all and helping patients time their intercourse. Some of that involves a little bit of kind of counseling and teaching about how does OB case work? You know, because it can be actually kind of quite confusing to use an ovulation predictor. Kid. You're like, Wait, is is this a positive? Is it not a positive, right? And sometimes they can be wrong. So teaching a little bit about that how to time your intercourse. There's a lot of patients who are not really, actually sure how to time their intercourse, and they're trying to have sex every single day for like, 10 days straight, and they're exhausting themselves.
00:34:15.000 --> 00:34:27.079
So we talk about optimizing the window of fertility, and then the next tier up is something called intrauterine insemination, and that's basically the next step to IVF.
00:34:27.079 --> 00:34:43.719
With intrauterine insemination, we're optimizing the fertilization window by kind of introducing washed sperm into the uterine cavity at the same time the woman is ovulating. And then the final step is IVF, which is a part of, you know, assisted reproductive technology.
00:34:44.380 --> 00:34:52.599
Can you tell folks a little bit more about IVF, of that process of the retrieval, the transfer, two weekly?
00:34:53.260 --> 00:36:18.239
Yeah, I talk to patients about IVF. They usually, you know, some patients will be shocked. That like when I when we actually sit down and look at the calendar and talk about the duration and what it takes, they're often shocked at how actually short the window is, because there's a lot of misunderstanding that IVF takes a long time. It takes forever, in a way it doesn't. When I talk about IVF, I like to split into two phases. My brain just works like that. I like things like, compartmentalize. Otherwise I'll kind of like, just go crazy worrying about everything. So I say, look, think about this in two phases. Phase one involves the egg retrieval. The goal of phase one is, breathe healthy embryos once we've completed that goal. Now we talk about phase two. Phase two is how do we transfer this embryo back into the uterus to achieve pregnancy? So transfer is phase two. Retrieval is phase one. The process of phase one really only takes about 12 days. On average, women are doing medication injections for anywhere between 10 to 12 Days of daily injections followed by the retrieval, and you're done okay.
00:36:11.699 --> 00:37:15.719
And for that time period, you are not bed bound. You do not have to take off time from work outlets. You just, you know, want to have low stress and all those things, because you're not coming to the clinic every single day. On average, in that 10 to 12 day period, you come roughly about three to four times for a morning monitoring, ultrasound, and then you have the egg retrieval, which most people will take that day off, and then the following day, you know, most people, I would say 50% take the next day off. 50% do not do just fine. So the time commitment is really about 12 days, and then you're done. And the rest happens in the embryology lab. The magic is happening back there, the fertilization, the embryo growth, of biopsy, there's a waiting period, though, in phase one, because for those who are doing genetic screening of their embryos, take about 10 to 14 days for results to come back.
00:37:12.599 --> 00:37:23.300
So there is a little bit of waiting period. And so that's why, you know, I think it feels like it's actually a lot longer.
00:37:19.440 --> 00:37:32.599
And then, of course, there's the prep phase, right? There's the, you know, some people will do, like, six months of lower intervention methods before they're ready to jump into IVF.
00:37:28.880 --> 00:38:18.780
Some people, you know, it takes a long time for them to get all the required lab work done and get their insurance organized and data that. So the prepping phase might take a couple weeks to a couple months, depending on the situation, so there's a lot of waiting period. But when it comes down to the actual treatment, it's only about 12 days. The transfer from the start of the transfer cycle to the actual pregnancy test is about four week. But the transfer typically you have less visits, a little bit more straightforward, and then after the embryo transfer, you know you have that 10 day waiting period until you find out. So yeah, the transfer is about three to four weeks, depending on which cycle you're doing
00:38:19.260 --> 00:38:21.199
and what happens after the transfer.
00:38:22.099 --> 00:38:32.239
So after the transfer, you know the transfer procedure, more or less each clinic is the same. You know, most of the time we do allow the partner to come into the room.
00:38:32.539 --> 00:38:48.940
We do the transfer. It's typically done awake. It takes about 20 minutes. And then after that, you'll continue your hormone medications, you know, us prescribed and you get to just live your life. No, we say, don't drink, don't smoke. You know, don't do anything you wouldn't do if you're pregnant.
00:38:50.019 --> 00:38:56.800
But if you run, you know, two miles every day, there's you can do that. You don't have to not run two miles every day, right?
00:38:57.039 --> 00:39:43.659
But if you never train for a marathon after transfer is not the best time to pick up a new like activity, and it's also not the time to break a PR so if you're someone who does do weight, you can continue doing those weights, but maybe don't try to push you know that during that 10 day period. But otherwise, you do not have to be bed bound. In fact, research has shown that being bed bound is not optimal, that you should be active and doing your normal daily activity. I have patients ask me about acupuncture, and I love acupuncture. You know, when paired with medical treatment, I think it can be really successful. Quite do encourage that if it's not cost prohibitive, but yeah, it's just a lot of, like, anxious waiting.
00:39:43.659 --> 00:39:52.539
And I usually say, like, it wasn't like, make sure you have some hobbies lined up. Make sure you have things to keep yourself busy. It's and you just got to wait.
00:39:53.440 --> 00:39:57.099
Yeah, that's one.
00:39:53.440 --> 00:40:01.199
One of my next questions was, what do you tell patients going.
00:39:57.340 --> 00:40:01.199
Through that two week wait?
00:40:01.440 --> 00:40:10.199
Well, it's not technically, you know, two weeks. You can that, but it can be psychologically distressing, very increditing.
00:40:10.619 --> 00:40:14.579
And what advice do you impart to them to get through that period?
00:40:15.059 --> 00:40:37.039
Yeah, I think kind of just practically, if they have a therapist, if I know if someone who's been through, you know, like pregnancy loss and recurrent implantation failure, we usually have a conversation beforehand. I encourage them to have a therapist, you know, to have a support group. Might tell them to find their happy thing, you know, things that bring you joy.
00:40:34.219 --> 00:40:43.840
Make sure you have those close to you. I think supportive things like, you know, acupuncture. Keep doing the activities that bring you joy.
00:40:43.840 --> 00:41:20.900
Don't withhold yourself from running. If that brings you joy, or playing tennis or whatnot, it's not going to impact that's not going to impact your success rate. You know, again, if you never play tennis, if you never run, if you never cycle like that's not the time. But you should do your normal daily activities. Don't just sit at home and kind of take off some some people take off work, and I think it's okay if you have a really stressful job, but you definitely don't need to be bed bound. I do. I really emphasize that it's actually been worse outcomes if you're just laying in bed all day.
00:41:22.340 --> 00:41:57.639
Yeah, it's I'm hearing, keep those coping tools that you already know work and you know, keep the people close by that will bring you joy and positive distractions can go along too and get therapists, you know, from my seat as a fertility counselor and Perinatal reproductive mental health professional, you know, this comes with a lot of layers emotionally. Yeah, do you have any other besides the two week wait, things that you see from the psych emotional perspective that would be helpful to highlight?
00:41:59.199 --> 00:42:03.900
I think it's just that. Why us? And it's so hard.
00:42:03.960 --> 00:43:34.099
It's really hard because there is a about 30% of the time we don't have an answer, and that's called unexplained. In fact, unexplained infertility couples have a worse prognosis than if you do have an explanation. You know, if you know that you have a male factor, or you know that you have PCLs, your treatment outcomes are so much better than if you are labeled unexplained couples, they've done all the tests, diagnostic testing, they did all the imaging to semen analysis, and nothing can be found. And often, those couples will find success in IVF, however, even IVF can be challenging, and I think when they do everything, when the female partner, they do everything, you know, they take the supplement that they eat clean, and they eat healthy, and they're exercising, and they're still not seeing the outcome they want. It's really hard, and I internalize some of their pain and struggles, and I it's hard for me because as a physician, our intuition, our instinct, is to fix things, to kind of take the pain away, help heal the injury, you know? But there are things that are even outside of my hand, outside of their hand outside of all our control, right? There's, you know, if the egg quality is not good, or we keep getting aneuploid embryos.
00:43:27.380 --> 00:44:46.840
Unfortunately, besides turning back time, there's not much we can do, and that's a really hard place. I still struggle with how to best counsel patients, you know, and how to best offer support, because I can't give them what they really want, which is success and pregnancy, but I try to be there to help them navigate through the journey. And sometimes that involves, maybe it's time to talk about other ways to achieve motherhood. Sometimes that involves, you know, maybe we try something else one more time, and sometimes it, you know, let's see if you can get a second or third opinion. Loving me, I will do I'm open to doing anything to kind of support that patient through that journey, but it's hard, you know, I depth. There are days where I have to make some really hard phone calls, sure, and when they are in that kind of depth of darkness, I think any human would share that with them. You know my clinic staff, you know the IVF nurses. They cry tears, whether it's happy tears or sad tears. They cry with the patients you know, anybody in the business, I don't think you could not connect with what they're struggling
00:44:46.840 --> 00:44:50.619
through.
00:44:46.840 --> 00:44:50.619
Absolutely, yeah, there's
00:44:50.619 --> 00:45:38.239
a famous study that said, you know, the psychological impact of infertility is like that of getting a cancer diagnosis right. And I think. If you didn't struggle with it, and if you don't know the field, you may think, you know, this is like nothing, right? Like, you would think, Oh, infertility is optional. Like, I think people don't take it seriously, and I think that's why there's a lack of insurance coverage, because it's not taken to be like cancer, but it had sheltered much trauma, and it induces just much stress and as something of a diagnosis cancer. So it's really hard. I still I'm still learning on ways to kind of best support my patient as they go through the ups and downs of this journey.
00:45:38.840 --> 00:46:20.960
I am so glad that we are shedding light on this today and also underscoring the humanness of all of the providers and professionals in this field. And I know that I will echo that, not just for you, but I know I'm speaking for other professionals, the humanness, the empathy that we all feel. It's not just as simple as not being able to get pregnant, there's grief and loss and role confusion and expectations. There's so much that go to this. And I love that you know your patients are so lucky to have such a compassionate provider. And maybe that's a segue into like for Dr Chen, what does a typical day look like for you?
00:46:21.500 --> 00:46:51.639
Well, our clinic starts at 730 and we usually will have some egg retrievals and some surgeries in our outpatient surgery center, and then that most of the morning and around midday, I'm catching up on patient messages and labs and reviewing them and dosing them, checking in with my nurse practitioner to see if she has any, you know, had any heart cases or have any questions for me. And then the afternoon is usually consult.
00:46:52.360 --> 00:47:19.739
How about any ethical dilemmas that you run into that you'd be willing to share? Maybe you run into where you're feel like a gatekeeper when you know that's a really tricky place to be, or, I know there's a lot of talk, talk about, you know, whether you discard embryos or you keep them, or surrogacy. You know, as a physician, as you know, there's some type of gatekeeping role like to run into any ethical dilemmas.
00:47:21.000 --> 00:47:40.159
I think, you know, there are, I don't see it so much as gatekeeping. I think it's more there are certain parts of our field where we do have kind of strict guidelines set forth by the national organization ASRM, and I think they're there for a good reason.
00:47:36.260 --> 00:48:39.380
There's very few things that's a hard no, there's a lot of conversation, there's a lot of like, compromise, there's a lot of, you know, let me bring this up to the board and see, and so on and so forth. But I think those guidelines are there too for us to just kind of pause and say, Wait a minute. Let's look at the pros and cons. Let's look at the potential risk and other situations are just more practical, you know, like STD screening. Now, if someone is using donor sperm or donor eggs or donor embryo, we really want to make sure that they're not going to get some sort of, you know, infection, right? So there's a lot of screening guidelines in place. But, you know, I really, I try to be as honest as possible with my patients about what I'm thinking. And sometimes it can be challenging, because patients come in and they have kind of, like, their own already preset goal and how they envision this process to be. And sometimes we can work together and make that happen, and sometimes we have to bend a little bit. But, you know, ultimately, it's a partnership.
00:48:40.219 --> 00:49:04.019
I love this idea of collaboration, following the ASRM guidelines, honesty, having creative solution, focused conversations. That sounds really nice. Yeah, yeah. And as a couple final questions, do you have any fun, interesting facts about yourself that you could share with the audience, and then what do you hope for the field in the next five to 10 years?
00:49:05.099 --> 00:52:23.059
Yeah, so I have two kids. I had my son when I was an intern, and in OB GYN residency, and I went to a pretty busy residency program, and in fact, it's the largest OB GYN residency program in the entire country. It's the, it's called parkland in a hospital, you know, I just don't remember the first, like, four years of his life, because I was working like 90 hours plus a week, you know. And I knew I wanted to get into Rei fellowship. And Rei is one of the more competitive programs. They're like, I was, like, just trying to, like, stay alive. And I kind, I mean, I think he raised himself, because I honestly just don't remember, you know, I took four weeks off after delivering him, and I went right back to work, and I didn't deliver until 40 weeks. Plus change, and he was like, a huge baby, and I it's just a blur, you know. And my husband always jokes like he was a single dad for four years. And I say that more so because it took me, like, a really long time before I could, like, even think about having a second, sure, and by the time I was ready to actually have a second I had infertility, you know, and that was, like, interesting, because here I am, I got pregnant with my son while I was birth control, because I wasn't taking it correctly, because I was young, and, you know, didn't really understand how hormones were. And, you know, fast forward, like, five years. I'm an REI fellow trying to learn to specialize in infertility, and I'm running into infertility myself. So, you know, eventually I had my daughter, but just to say, I really whatever extra free time I have that's not given completely to my patients, you know, it's to my kids. Because I think my experience with my son, I just have so much regret, you know, all those shifts where I stayed late so I could wrap everything up so I didn't look like I was letting the team down. And you know, all those extra things that I prioritize over him, or just have a lot of regrets, and I wish I could turn back time, because I don't even remember him as like a toddler, and so I really try to dedicate my time now to the kids and helping them through school and trying to be there for the extracurriculars, making an effort and kind of drawing boundaries between my clinical work and my dedication to my Patients and when it's family time, because I am really, really bad about obsessively checking my patient like my EMR inbox, and because I want to make sure that the patients know that I am aware of whatever difficulty, challenge, question they have, and I want to get back to them. But I've also learned like there are things that could wait, and I do need to separate that kind of professional commitment to my family, because ultimately that makes me a better physician, and that makes me actually be more available to my patients, if I know that my family is taken care of. So not really an interesting fact, other than I'm just, I'm a mom for two kids,
00:52:24.380 --> 00:52:35.960
and then interesting and I you sharing, that was probably why you're so empathetic and compassionate this work life balance as a mom, working mom is is no joke.
00:52:36.199 --> 00:53:03.480
Yeah, yeah. I know you, of course, would know that very well, but, and it's hard, I'm still learning, and now that my son is older, and then he had some sharp comeback, like, like, oh, you know you're not gonna be at my whatever performance at school. And I'm like, Why do they always make it at like, 10am on a Thursday, like, often supposed to make it to these like performances, but
00:53:03.840 --> 00:53:07.559
yeah, try to schools to better support working parents. Absolutely.
00:53:07.559 --> 00:53:15.840
Yeah, yeah. So anyways, yeah, I think I'm hoping to find some hobbies, and I'm starting to work out more.
00:53:15.840 --> 00:53:22.460
So my nurse practitioner is a huge health nut. She loves working out and eating healthy, and so she's been inspiring me.
00:53:22.940 --> 00:53:28.940
I ran a race this weekend with my son school, so I'm getting there. Amazing.
00:53:29.059 --> 00:53:32.599
Yeah, and what do you hope for the field in the next five to 10 years?
00:53:32.599 --> 00:53:49.719
Just better access. We really need to work on getting patient access to this to this field. There's a lot of barriers. The biggest is probably financial, and I need the insurance companies to kind of provide more accessibility.
00:53:50.079 --> 00:54:22.820
It's just so it's been, it's gotten better, but it's just really frustrating. And if I could give away free cycles, oh my gosh, like I would, you know, and I do whatever I can to make it work for my patient. But this is, it's a huge investment, and I think it's hard when it's not a guarantee to work. You know, we put what we can into it, and we, you know, obviously optimize everything as possible, but the fact that it is quite an investment makes it prohibitive.
00:54:17.519 --> 00:54:58.960
And I feel like I would love to see this field become more accessible to a larger population of patients, regardless of their social economic status. And that treatment, yes, but also education, right? Like learning about some of these things that you know. How are you supposed to track ovulation? All these like little home kits, they're expensive too. There are cheaper options, like to strip, but maybe some people don't know how to use that. And so I think increasing awareness, increasing education, increasing accessibility to care, that's what I would like to see in the field.
00:54:59.800 --> 00:55:33.860
Yeah. Yeah, and I sat here nodding almost this entire episode, because I just echo so much of what you're sharing. And part of the mission of this podcast is to bring that education and awareness. And I am very confident that so many people listening will be sharing this and so appreciative of education and awareness you've you've shared and imparted today. So thank you for coming on. Oh, absolutely, yeah. This is Dr Lucy Chen. She's an REI, and we are so grateful that you were able to share your wisdom today. Thank you for having me.
00:55:37.039 --> 00:56:02.579
If you would like to learn more about how we can help, visit our website at perinatal reproductive wellness.com, and while you are there, check out the latest edition of our book, employed motherhood. We also invite you to follow us on social media at employed motherhood. Finally, if you enjoyed listening to the show, please subscribe and rate it. Thank you. You.
00:00:00.000 --> 00:00:27.800
A lot of OB are not widely offering this test, and that because a lot of people don't go to their OB for what we call preconception counseling, right when someone decides they want to try to get pregnant, they kind of most of the time, just stop taking birth control, maybe stop using condoms, and to just start trying. At home, we rarely get to have a touch point of where we have a conversation about how to optimize pregnancy before you're actively trying.
00:00:30.800 --> 00:00:56.920
Welcome to perinatal and reproductive perspectives. This is a podcast where we empower birthing individuals, partners and health professionals with evidence based insights, holistic strategies and relatable stories. Hosted by a health care expert, this podcast fosters understanding equity and growth in perinatal and reproductive health. Here's your host, Becky Morrison gleed. You
00:01:00.000 --> 00:01:16.680
you. Welcome to another episode of perinatal and reproductive perspectives. I'm so excited because we are here with Dr Lucy Chen. She is a board certified Rei. So welcome to the show.
00:01:17.280 --> 00:01:19.260
Thank you. Thank you so much for having me
00:01:20.340 --> 00:01:23.420
tell folks what is an REI and what do they do?
00:01:24.439 --> 00:01:46.659
Yeah, so an REI stands for a reproductive endocrinologist and infertility specialist, which is obviously a mouthful, but essentially what we are, we're physicians who are trained and certified to assist in reproduction, whether that is in a form of natural conception or assisted reproductive technologies,
00:01:47.140 --> 00:01:57.040
walk us through some of the reasons that someone might seek your help. What are some of the common fertility challenges? Yeah, you
00:01:57.039 --> 00:03:16.859
know, the most common is obviously going to be couples struggling to achieve fertility, whether that's primary infertility, which is when they are having trouble just having their first child, or secondary infertility, they have been successful in the past, you know, they have a living child, but are now running into difficulties having a second pregnancy. So that is probably the majority. But then, of course, there are couples in same sex relationships who would like to have a child, whether that's using donor sperm for same sex female couples or those, you know, same sex male couples who would like to use a donor egg in a gestational carrier. So lots of different reasons, and I think more and more increasingly, I'm having patients who come for egg breathing, which is for fertility preservation, and that can be for, you know, elective or planned, you know, they're not at a part in their career where they're quite ready to start a family, or perhaps they just haven't met The right person, and they want to kind of preserve their fertility, or it could be for cancer reasons. You know, a woman just got diagnosed with breast cancer and she's about to undergo chemo, we know that that's going to impact our future fertility. So I do see a lot of onco fertility patients as well.
00:03:17.159 --> 00:03:38.360
And I initially asked, What are some of the challenges? But I think you bring up a good point of, there's not just challenges, but there's other reasons, such as preservation or, you know, curtailing oncology. Are there any other reasons that folks might seek fertility support that we haven't already pointed to?
00:03:39.259 --> 00:04:54.819
Yeah, something unique that I do, that maybe not all Reis offer is I do offer just kind of counseling and education. So, for example, a patient with PCOS, you know, they're just not getting, perhaps, the hormone control or a good understanding of what exactly like what kind of hormone imbalance is happening, you know, and they haven't gotten the answer from maybe their general OB, GYN, then I do have some patients who come who are not actively seeking fertility or pursuing fertility, but are struggling with some sort of underlying hormone imbalance. And we talk a lot about how to manage that, you know how to optimize their health, and not just PCOS, but, for example, premature ovarian insufficiency. These are young women in their 30s and 40s who are suddenly hit with ovarian failure. They're not quite menopausal. So it's not a that's not a patient population that often general OB GYN are used in managing so I do have a small group of those patients who I take care of. Again, they're not actively seeking for fertility, just to help maintain their hormone control, any hormone imbalances, and then just for overall healthcare.
00:04:55.120 --> 00:05:13.439
That sounds really helpful, even from a consultation piece. You don't have to know. Necessarily be okay, let's start fertility treatment, but let's just consult with Dr Chen to get you know, ready or prepared, or get additional information so you can be informed going into the process.
00:05:13.620 --> 00:05:29.060
Yeah. I mean Exactly. Our name, our title, is reproductive endocrinologist, and infertility, I think the infertility component of our field dominate, but there's definitely endocrine component.
00:05:24.980 --> 00:05:44.019
You know, we are in some ways. A lot of our fellowship training focuses on hormones and how that, you know, affects a woman's overall health. And so we're very much able to discuss that and kind of counsel patients. And I really enjoy doing that before
00:05:44.019 --> 00:05:56.920
we go into kind of the diagnostic assessment, what to expect with some of these presentations, or reasons why you would want Dr Chen's support. What inspired you to become an REI?
00:05:56.920 --> 00:06:37.639
I went to med school, and I really didn't know what I wanted to do for the first two years. From back then, my medical school was set up such that first two years, it's all academic, classroom learning, you know, taking tests you're not really clinical or seeing patients yet. And then during our women's health component, we had a local Rei come and give a talk as a guest lecturer, you know, because they're talking about oncology and they're talking about, you know, gynecologist and obstetrics and MSM and then so, because Rei is a sub specialty of OB GYN, they had a Rei come.
00:06:38.120 --> 00:07:40.100
And when I heard his lecture, I was just blown away, just seeing the fertilization the egg and the sperm coming together, and the embryo is growing, and there was still even back then, there was so much left to cover in the field, and I was just fascinated. So I wanted to be an REI, since I was second year medical student, and every decision I made for, you know, my career was based on my goal of, I want to be where I am today, which is to be a practicing Rei. And, you know, I love women's health, and I love delivering babies, and I do miss working on labor and delivery, but truly, this is what gets me out of bed. You know, there's not a day where I get up, even on the early days, the crack of dawn, where I dread coming to work. I'm literally so excited to come into work every day and that, you know, that's how I know, like, okay, all those years of training and schooling and fellowship, it was all worth it, because I'm literally living my dream.
00:07:40.279 --> 00:08:11.220
We share that in common. I love this work, which is why I was so excited to connect with you. From, you know, I'm more on the psych, emotional, relational side, and you're on the more medical. But I think both have some intersection, absolutely, yeah, tell us a little bit more about like, after you knew you had that moment of inspiration hearing that Rei, what were the components that continued your expertise in the field of endocrinology and reproductive health?
00:08:12.059 --> 00:08:30.259
Yeah, so the training pathway to be a board certified Rei is such that you have to complete four years of an OB GYN training. So you have to basically be able to function as an OB and as a gynecologist.
00:08:25.278 --> 00:10:20.099
And then after that, a typical Rei will complete an REI Fellowship, which is the sub specialty training, and that is generally about three years. I decided to do even one step further, and I actually did a combined fellowship in genetics and Rei. So I did a dual fellowship. And the reason why I did that was one of the things that stuck up to me when I was in clinical rotation and just had, like a brief exposure to be a part of the REI world, was there was all this talk about genetic testing. And I remember, even as a resident, we had such little teaching on genetic testing, right? Like, and anytime we talked about genetics, it was always kind of like this, like, scary, unknown thing, and I wanted to know more, because now they're talking about testing on the embryos, and there's pre Implantation Genetic testing, there's an employee, and then there's segmental aneuploidies, and now there's, you know, single gene testing. And so I was like, I want to know more, but everyone I had kind of gotten advice from had shared with me listen in a classic three year fellowship for a general Rei. There is not enough time to learn all that. There's just too much. So I thought, Okay, well, let me actually do it the right way. And so when I, you know, did my fellowship at Hopkins, I took some extra time and went deep into the genetics world. You know, I was doing metabolic genetics. I was doing working in the NICU, like learning from all sorts of genetic. Are who specialize in different fields, and learning about whole exome sequencing, and I think all that understanding and seeing what it's like to have an affected child, you know, with a genetic condition, and talking to those parents and seeing them at the bedside, it really gave me a really strong background and kind of like an understanding.
00:10:20.219 --> 00:10:40.239
So when I counsel my patient, I don't have to send them to a genetic counselor they've never met, right? We're having that conversation right then and there. And so I think it was a worthy investment of my time. It drove my husband nuts, but, but I think, yeah, it was a good investment. Yeah,
00:10:40.840 --> 00:10:58.659
help us understand a little bit more about the role that genetics play into, you know, patients undergoing infertility treatment, and what role does that play in kind of assessment and then treatment?
00:10:59.799 --> 00:13:15.840
Yeah, I mean genetics is, you know, kind of like underline so much of what we do. For example, I have a lot of patients who are in their late 30s and early 40s struggling with infertility. And commonly in that age group, it's recurrent pregnancy loss. You know, not only are they having difficulties, some of them are maybe even more frustratingly, getting pregnant by can't keep a pregnancy in the path. We could type the pregnancy tissue with a traditional type of genetic screening called karyotype. But the test was really hard to do because you had to culture cells. It had to be collected from a DNC. You couldn't pass that home. It was very susceptible to contamination, and then sometimes you wouldn't get any answers, and it was quite expensive. So I think some patients are kind of discouraged from testing their miscarriage tissue. Okay, then there. What happens is they're left with a lack of answer. Why am I having so many pregnancy losses? And of course, naturally, women tend to blame themselves. So then it becomes, there's something wrong with me. There's something wrong with my body. But in reality, if we actually tested the tissue, and there are so many ways to do that now that is affordable, and it gives us a breadth of information. If you actually tested that pregnancy tissue, oftentimes, what you'll find is that the pregnancy was an annual employee pregnancy, meaning that it did not have the right amount of genetic instruction manual right in order for a one cell embryo, when it first forms to progress and divide and replicate all the way into a baby, it has to have a complete genetic instruction manual to tell it to do that. This clump of cell becomes the brain, and that becomes the heart and so on and so forth. Right? If you have the wrong net material, that pregnancy will never make it to the end stage, or the end goal, which is a healthy baby. At some point, the cells might start growing and dividing, but then it hits a critical checkpoint where, if you don't have the instruction it needs, the pregnancy will stop growing.
00:13:16.080 --> 00:13:24.559
That is the most common reason for a first trimester pregnancy loss. If a woman knew that, then she had kind of closure, right?
00:13:24.799 --> 00:13:39.860
This had nothing to do with something you ate or drank. It didn't have anything to do with any activity you did, you know, it wasn't because you ran too much or you had intercourse or because, you know, you took a hot shower or anything, right?
00:13:39.860 --> 00:13:42.700
It had nothing to do with you.
00:13:39.860 --> 00:13:42.700
You could not have changed it.
00:13:43.000 --> 00:14:45.399
No amount of progesterone support would have made a difference. At the core, the genetics of the pregnant speaking, you know, was was wrong. It just didn't have what it needed. I think that helped a lot of patients move forward, and it gives them a little bit of a direction on how to proceed with their next step, as opposed to kind of going down the path of like, oh, maybe it's because I'm not ovulating. Maybe it's my hormones. Maybe I need to drink this herbal tea, or do this or do that, because it gives such a clear cut answer. And so there's genetics in that perspective, and then there's understanding the genetic that our inherent genetics, why do we have this thing called the biological clock? Why does it affect women but not men? I have so many patients come to me and they're like, I feel so young, like, I know I'm 40, but I feel so young. I eat healthy, I eat organic, I take my antioxidant, I don't drink, I don't smoke.
00:14:41.379 --> 00:15:17.159
There should be nothing wrong with my genetic and it's like, okay, nobody explained to us how this works, that you're born with your eggs, that you can't control DNA aging the egg and the DNA are as old as you, whereas the. And firm men, they're testy, make firm roughly every 90 days. That means their DNA, in that sperm, is only as old as really 90 days, even if a male partner is 50 years old, 60 years old, you know, or you hear Robert De Niro, 80 years old.
00:15:17.460 --> 00:15:26.779
That's why there's such a discrepancy in the biological plot from men versus women, and a lot of it is not our blame.
00:15:26.899 --> 00:15:41.500
It's not our fault. We have no control over it. And so I think genetics helped. Part of understanding genetics is you start to understand like what is within your control, what is outside of your control, and just giving grace to yourself and your body.
00:15:41.799 --> 00:16:04.740
If anyone listener takes anything from today's episode, I love the message that it's you are not to blame, to externalize some of that, it must be me, and you know, take that out of you. Are there any other reasons that someone might want to consult with you from a genetic lens.
00:16:06.419 --> 00:17:01.679
I think if they have had an affected child, there's a different type of genetic testing called expanded carrier screening. And just stepping back a little bit, when people say genetic testing, it can mean so many different things, and it's really important to actually understand what you're being tested for and what is being discussed. Saying you had genetic testing is just like saying you had a blood work done, or what what did you test for? Right? So there is a type of genetic testing called expanded carrier screening. It's a risk calculation tool for two people individuals to see what their risk is of having a child with a major medical condition that's known to be affected by a single gene, cystic fibrosis is a perfect example of this.
00:16:56.740 --> 00:17:30.259
Cystic Fibrosis occurs when two parents are carriers for the cystic fibrosis gene. As a carrier, the parents are asymptomatic. They would never even know that they are carriers. However, each pregnancy they have, there's a 25% chance that they will have a child with cystic fibrosis, so a lot of OB are not widely offering this test, and that's because a lot of people don't go to their OB for what we call preconception counseling. Right?
00:17:30.500 --> 00:18:30.200
When someone decides they want to try to get pregnant, they kind of, most of the time, just stop taking birth control, maybe stop using condoms, and to just start trying. At home, we rarely get to have a touch point of where we have a conversation about how to optimize pregnancy before you're actively trying, though, there's not a good opportunity for you to get this testing done unless you've read about it. You've heard about it, you know, unless there's more awareness in a community. But once you know, I think there's a good proportion of couples who would rather know the information that they might be at risk of having a child, because there are a lot more reproductive decision options before you're pregnant than when you're already pregnant. So that's one type of, you know, very common testing, and it's not expensive. It is a standard of care per eight cog. Most intrinsic cover it. People just don't know to ask for it. They don't know about it, you know.
00:18:30.440 --> 00:19:09.779
And just because you do the testing and you and your partner are found to be mutual carriers, it does not mean that you cannot have a biological child together. There are ways that we can help to risk reduce so that you have an unaffected child that's still biologically yours, but it also doesn't mean you have to make any decisions. You could simply have that information, share it with your OB, share it with your pediatrician. It's more used to kind of, you know, optimize the pregnancy and optimize what happens after delivery so that there's no delay in medical treatment to your child for their specific medical condition. So that's an example.
00:19:09.779 --> 00:20:37.339
If a couple already have an affected child that's inherited in this known manner, and they want to risk reviews, and I have siblings, then they may seek out my care, even though they themselves do not actually have infertility or something that's more commonly done now is preventing cancer mutations from being passed down. So we know very well that there are certain cancer mutations that are passed down in families that predisposes a woman to getting early onset breast ovarian or uterine cancer or even colon cancer. So commonly turn common names are something like braca, BRCA mutation. There's something called Lynch mutation. If you know that you have this in your family and you yourself have been tested and you have it, you. Every single one of your offspring will have a 50% chance of also having them. Some couples would like to risk reduce. They would like to stop passing down the gene at their generation so we can help them out by doing IVF and helping to prevent or identify embryos that have the mutation and those that do not have the mutation, and if they have a decision that they can, rather, you know, they can transfer the embryo they would like to transfer. So that's another example. Some patients have a known neurological condition, such as Huntington.
00:20:38.059 --> 00:21:02.039
That's a really tough one, but if the mom or the dad know that they carry it, they know they have a 50% chance of passing it on, and if they have seen their mom pass away from it, or other grandparents pass away from it, and they don't want their offspring to be affected by it, that's another example of how genetics come into play, Even though the couple does not actually have infertility.
00:21:02.759 --> 00:21:19.440
This sounds so hopeful in terms of different avenues that couples can explore if there's a genetic component or concern. And can you tell folks one more time what that test is called that's accessible, often covered by insurance? Yeah,
00:21:19.439 --> 00:22:11.999
absolutely. It's called expanded carrier screening. In the past, it used to be ethnicity based. So for example, if you are African American, then you'll be screened for sickle cell and other conditions. If you were of Ashkenazi Jewish descent, then you would get screened for other conditions that are known to be more prevalent in that ethnic group. However, nowadays, everybody's a mixture of something, right? And we were missing so many people by not offering it to them purely based on their reported ethnicity. And so now what come out from the American Board of Medical Genetics is recommendation for Pan Ethnic screening. Everyone get the same large size panel.
00:22:06.538 --> 00:23:14.818
So on average, panel can testing. Panel can range between like maybe 170 and you you have panels that go up to about 700 even the smallest panels will have the most important genes, the major genes that are known to cause really severe medical issues. And so the panel size is really dependent on your physician's preference. But the type is called expanded carrier screening. There are multiple labs that offer it. For example, LabCorp offers wide and again, most insurances do cover and even if you were self paid, you know, we're not talking about 1000s here. We're talking about, like, maybe hundreds, you know, maybe 150, to 300 This is a huge change from what it was 10 years ago, where it wasn't a 1000s, and that was limiting access for a lot of people. And so I think, you know, the majority of the reproductive population probably do not know about this unless they have a very, you know, astute OB clinic who's offering it, or they've run into infertility and they're seeing a fertility specialist who's offering,
00:23:15.420 --> 00:23:31.220
yeah, I appreciate us shedding light on this today, because it opens it up for folks to know about it, and then just to ask their provider of hey, can we pursue this? Yeah, very accessible.
00:23:24.859 --> 00:23:36.920
Yeah, absolutely anything else you want to cover on genetics that would be helpful for a listener to know,
00:23:37.460 --> 00:23:40.460
I think the key is really just to ask questions.
00:23:40.460 --> 00:23:48.640
Don't be intimidated by the word genetics, and don't feel like it doesn't apply to you or you're too it's too overwhelming.
00:23:48.640 --> 00:24:04.079
There's a lot of really good resources. And honestly, ask your doctor you know whether that's your OB or that's your Rei fertility specialist, because they should be able to answer with confidence, right?
00:23:59.859 --> 00:24:42.460
Whatever genetic questions you have, whether that's about your in carrier testing for you and your partner, or whether that's about, you know, your pregnancy and the likelihood of miscarriage based on your age and etc. So don't be afraid to ask about options for testing number one. And then don't be afraid to ask about, you know, how it applies to your fertility goals and your fertility journey. And if they don't know, the next thing they should offer is counseling, please. Let me refer you to a genetic counselor who can better take a family history, a pedigree and give you a risk assessment. Yeah.
00:24:43.119 --> 00:25:09.299
Thank you so much. I think that will be really helpful for listeners, and you know, they'll share it with a friend or a sister or someone they know in their circle, if we move more into infertility, can you speak to some of those common reasons why some. One might come to your office. And then what does that assessment, diagnostic piece look like? And then what are some of the most common treatments?
00:25:09.599 --> 00:25:44.019
Yeah, I think you know, again, Infertility can be primary and it can also be secondary. It's shocking for a lot of couples when they do run into secondary infertility? I hear it all the time. You know, they didn't have any issues, you know, conceiving our son or daughter, and we just were just so puzzled and frustrated. And so it can happen even if you have had success before. I think the biggest I wish everybody knew when they came to me is understanding when to seek help.
00:25:44.859 --> 00:26:43.420
When is it time to see a fertility specialist, a fertility doctor? Because I see a lot of patients. Sometimes go years, you know, five years, six years, struggling with infertility, doing kind of things based on what a friend of a friend said, or a neighbor said, or what the internet said, and I wish I could have seen met them sooner. You know, if there's anything I want to share today, it's really just know when to seek help. Okay, so what does that entail? And this is going to go back to your question of, like, kind of, what do you see most often as the cause of infertility? So age plays a huge factor female age, and this goes back to the genetics of our eggs and things like that. But if you are 35 and older, I really encourage you to have a low threshold to come see a fertility specialist, right?
00:26:40.599 --> 00:26:52.000
Like generally, it's recommended six months of trying, and if you're not successful, it's time to have a comprehensive workup.
00:26:47.140 --> 00:28:14.880
If you're 35 or younger, you can give yourself up to about a year, 12 months before you seek a fertility specialist. However, if there's any concern whether you're ovulating, right? Maybe you have PCOS. Maybe you don't get a period every month, and instead, you're getting a period every three months. Or maybe your periods are actually shorter than 28 days. You know, maybe your periods are only 24 days. If you feel like there's anything kind of off or different about your body. You do not have to follow those guidelines. In fact, you can just come at any time. We would never turn a patient away from just consultation and talking through things. So I think that one of the biggest reason is just age, advanced maternal age, you know, and in the second is probably kind of not actually ovulating, whether that's because of PCOS or whether that's because you have other hormone issues going on. And then third is probably a structural there's a fallopian tube blockage, there's a fibroid that's inside a cavity, maybe there's a uterine polyp. And then don't forget, the male partners, right? 30% of infertility is due to male factor. And I cannot tell you how many times I've had a patient come and she's saying, I've done this, and I've done done and I've taken this pill and that pill, and I've done Clomid for six months, and then we did electrosol for six months, and I don't know what's going on, and we do a semen analysis and there's no sperm.
00:28:15.599 --> 00:28:34.579
And so getting a semen analysis done is so easy. I mean, in fact, at our clinic, we even allow home collection, so all you have to do is drop off a cup, and it can provide so much reassuring information, but can also provide a lot of diagnostic information. And so I think the fourth is probably male factor.
00:28:35.660 --> 00:28:38.000
And what is the male factor for someone who may not know
00:28:38.900 --> 00:28:51.039
so there's any abnormality in the sperm production, whether that's count or motility or morphology. You know, these are the things that a semen analysis can provide.
00:28:51.640 --> 00:29:02.279
And having very low sperm or complete absence of detectable sperm, could be from a lot of different things, just like how female infertility can be broken down to different things, right?
00:29:02.700 --> 00:30:00.359
It could be because of structural issues, like anatomical issues. It could be because of stress, or maybe other endocrine disorders, like thyroid disorders in the male partner. I mean, a lot of times I'll ask the husbands or male partner, do you have any medical condition, not that I know of, and then I'll say, okay, when was the last time you went to get a checkup? And they'll say, like, right? Five years ago? He felt like, okay. And they end up having some underlying chronic medical condition like diabetes or hyperlipidemia, but they've just been ignoring it. Well, that's going to impact your sperm production, right? So checking for other things. And then, of course, you know, just like how women can have hormone imbalance, and so can men. Just like how women can have ovarian failure and men can have testicular failure too. And so it's really important to understand, you know, identify male factor and then try to figure out what's causing it, so that we can address. Process.
00:30:01.079 --> 00:30:04.440
Thank you. Those explanations are so helpful.
00:30:04.440 --> 00:30:13.380
And, you know, you simplify it so nicely. What are some of the treatments that kind of match that diagnostic piece?
00:30:13.859 --> 00:33:02.039
Yeah, and I kind of skipped over to diagnostic, but I'll, you know, I usually let the couples know we're going to do comprehensive testing, because by the time you've made it to me, you've done a few things on your own, you've bought the home urine hormone kits. You're checking those religiously. Most of them are tracking their mucus consistency, their body temperature. They're peeing on the ovulation stick. They're doing everything possible at home. And then some have also worked with their OB and got OB GYN. They've done some Clomid intercourse or lateral intercourse. So by the time they come to me, a lot of patients have already done some patchwork things. And I just like to say, listen, we're going to do it the right way. We're going to just do comprehensive workup and get an accurate assessment and accurate profile of your infertility. We're not going to do patchwork tapping and delay things even longer. So what does that entail? Well, there is a blood work component to it. The blood work looks at your hormone. It looks at your egg reserve. It checks for a hormone called A and H stands for anti malaria and hormone. We look at your you know, you know, if you have irregular periods, I check your thyroid, I check your prolactin, I check for other things that might impact your overall health that could either make pregnancy more challenging or it could impact your fertility treatment. So for example, checking for screening for diabetes when indicated, because we want to address all those things before you get pregnant. So there's the blood work component. This is also where we talk about genetic testing, like expanded carrier screening. And then there's an imaging component. The imaging component for the female partner typically involves the transvaginal ultrasound to get a baseline of their pelvic anatomy. So their uterus, are there fibroid, you know, are there other structural abnormalities in a uterus? And then we look at their ovaries, are there cysts? What does the egg count look like on the ultrasound when we look at the ovaries, and then the tubal testing. So we want to make sure that there's a nice, clear path for sperm to swim from the vagina, up the cervix, up the uterine cavity, in an out through the fallopian tube, because the egg is waiting for sperm in a fallopian tube. So if there is a blockage or a partial blockage, they're never going to meet, and we need to identify that. That concludes the female partner, the male partner, really just has to do a semen analysis. That's it. And so once we do the diagnostic testing component, then we sit back down and we go through everything and with that, okay, look, here's the cause of your infertility.
00:32:58.900 --> 00:33:09.359
Your tubes are blocked. Okay, let's talk about our options. Or we'll say, here's the cause of your infertility. You're not ovulating. Look for the PCLs.
00:33:09.359 --> 00:34:14.699
You know. This is going to explain all your other metabolic issues, your insulin resistance, the obesity, you know, the an ovulation, the Hershey doesn't, etc. So then we'll kind of tailor the conversation based on what we find and in the treatment can involve a couple things. Obviously, it depends on what the diagnostic testing shows. But we can go, you know, go from the lowest error vision up to the most. The lowest would be kind of, you know, ovulation induction, or super ovulation, with just little pill called kilometer lectures, all and helping patients time their intercourse. Some of that involves a little bit of kind of counseling and teaching about how does OB case work? You know, because it can be actually kind of quite confusing to use an ovulation predictor. Kid. You're like, Wait, is is this a positive? Is it not a positive, right? And sometimes they can be wrong. So teaching a little bit about that how to time your intercourse. There's a lot of patients who are not really, actually sure how to time their intercourse, and they're trying to have sex every single day for like, 10 days straight, and they're exhausting themselves.
00:34:15.000 --> 00:34:27.079
So we talk about optimizing the window of fertility, and then the next tier up is something called intrauterine insemination, and that's basically the next step to IVF.
00:34:27.079 --> 00:34:43.719
With intrauterine insemination, we're optimizing the fertilization window by kind of introducing washed sperm into the uterine cavity at the same time the woman is ovulating. And then the final step is IVF, which is a part of, you know, assisted reproductive technology.
00:34:44.380 --> 00:34:52.599
Can you tell folks a little bit more about IVF, of that process of the retrieval, the transfer, two weekly?
00:34:53.260 --> 00:36:18.239
Yeah, I talk to patients about IVF. They usually, you know, some patients will be shocked. That like when I when we actually sit down and look at the calendar and talk about the duration and what it takes, they're often shocked at how actually short the window is, because there's a lot of misunderstanding that IVF takes a long time. It takes forever, in a way it doesn't. When I talk about IVF, I like to split into two phases. My brain just works like that. I like things like, compartmentalize. Otherwise I'll kind of like, just go crazy worrying about everything. So I say, look, think about this in two phases. Phase one involves the egg retrieval. The goal of phase one is, breathe healthy embryos once we've completed that goal. Now we talk about phase two. Phase two is how do we transfer this embryo back into the uterus to achieve pregnancy? So transfer is phase two. Retrieval is phase one. The process of phase one really only takes about 12 days. On average, women are doing medication injections for anywhere between 10 to 12 Days of daily injections followed by the retrieval, and you're done okay.
00:36:11.699 --> 00:37:15.719
And for that time period, you are not bed bound. You do not have to take off time from work outlets. You just, you know, want to have low stress and all those things, because you're not coming to the clinic every single day. On average, in that 10 to 12 day period, you come roughly about three to four times for a morning monitoring, ultrasound, and then you have the egg retrieval, which most people will take that day off, and then the following day, you know, most people, I would say 50% take the next day off. 50% do not do just fine. So the time commitment is really about 12 days, and then you're done. And the rest happens in the embryology lab. The magic is happening back there, the fertilization, the embryo growth, of biopsy, there's a waiting period, though, in phase one, because for those who are doing genetic screening of their embryos, take about 10 to 14 days for results to come back.
00:37:12.599 --> 00:37:23.300
So there is a little bit of waiting period. And so that's why, you know, I think it feels like it's actually a lot longer.
00:37:19.440 --> 00:37:32.599
And then, of course, there's the prep phase, right? There's the, you know, some people will do, like, six months of lower intervention methods before they're ready to jump into IVF.
00:37:28.880 --> 00:38:18.780
Some people, you know, it takes a long time for them to get all the required lab work done and get their insurance organized and data that. So the prepping phase might take a couple weeks to a couple months, depending on the situation, so there's a lot of waiting period. But when it comes down to the actual treatment, it's only about 12 days. The transfer from the start of the transfer cycle to the actual pregnancy test is about four week. But the transfer typically you have less visits, a little bit more straightforward, and then after the embryo transfer, you know you have that 10 day waiting period until you find out. So yeah, the transfer is about three to four weeks, depending on which cycle you're doing
00:38:19.260 --> 00:38:21.199
and what happens after the transfer.
00:38:22.099 --> 00:38:32.239
So after the transfer, you know the transfer procedure, more or less each clinic is the same. You know, most of the time we do allow the partner to come into the room.
00:38:32.539 --> 00:38:48.940
We do the transfer. It's typically done awake. It takes about 20 minutes. And then after that, you'll continue your hormone medications, you know, us prescribed and you get to just live your life. No, we say, don't drink, don't smoke. You know, don't do anything you wouldn't do if you're pregnant.
00:38:50.019 --> 00:38:56.800
But if you run, you know, two miles every day, there's you can do that. You don't have to not run two miles every day, right?
00:38:57.039 --> 00:39:43.659
But if you never train for a marathon after transfer is not the best time to pick up a new like activity, and it's also not the time to break a PR so if you're someone who does do weight, you can continue doing those weights, but maybe don't try to push you know that during that 10 day period. But otherwise, you do not have to be bed bound. In fact, research has shown that being bed bound is not optimal, that you should be active and doing your normal daily activity. I have patients ask me about acupuncture, and I love acupuncture. You know, when paired with medical treatment, I think it can be really successful. Quite do encourage that if it's not cost prohibitive, but yeah, it's just a lot of, like, anxious waiting.
00:39:43.659 --> 00:39:52.539
And I usually say, like, it wasn't like, make sure you have some hobbies lined up. Make sure you have things to keep yourself busy. It's and you just got to wait.
00:39:53.440 --> 00:39:57.099
Yeah, that's one.
00:39:53.440 --> 00:40:01.199
One of my next questions was, what do you tell patients going.
00:39:57.340 --> 00:40:01.199
Through that two week wait?
00:40:01.440 --> 00:40:10.199
Well, it's not technically, you know, two weeks. You can that, but it can be psychologically distressing, very increditing.
00:40:10.619 --> 00:40:14.579
And what advice do you impart to them to get through that period?
00:40:15.059 --> 00:40:37.039
Yeah, I think kind of just practically, if they have a therapist, if I know if someone who's been through, you know, like pregnancy loss and recurrent implantation failure, we usually have a conversation beforehand. I encourage them to have a therapist, you know, to have a support group. Might tell them to find their happy thing, you know, things that bring you joy.
00:40:34.219 --> 00:40:43.840
Make sure you have those close to you. I think supportive things like, you know, acupuncture. Keep doing the activities that bring you joy.
00:40:43.840 --> 00:41:20.900
Don't withhold yourself from running. If that brings you joy, or playing tennis or whatnot, it's not going to impact that's not going to impact your success rate. You know, again, if you never play tennis, if you never run, if you never cycle like that's not the time. But you should do your normal daily activities. Don't just sit at home and kind of take off some some people take off work, and I think it's okay if you have a really stressful job, but you definitely don't need to be bed bound. I do. I really emphasize that it's actually been worse outcomes if you're just laying in bed all day.
00:41:22.340 --> 00:41:57.639
Yeah, it's I'm hearing, keep those coping tools that you already know work and you know, keep the people close by that will bring you joy and positive distractions can go along too and get therapists, you know, from my seat as a fertility counselor and Perinatal reproductive mental health professional, you know, this comes with a lot of layers emotionally. Yeah, do you have any other besides the two week wait, things that you see from the psych emotional perspective that would be helpful to highlight?
00:41:59.199 --> 00:42:03.900
I think it's just that. Why us? And it's so hard.
00:42:03.960 --> 00:43:34.099
It's really hard because there is a about 30% of the time we don't have an answer, and that's called unexplained. In fact, unexplained infertility couples have a worse prognosis than if you do have an explanation. You know, if you know that you have a male factor, or you know that you have PCLs, your treatment outcomes are so much better than if you are labeled unexplained couples, they've done all the tests, diagnostic testing, they did all the imaging to semen analysis, and nothing can be found. And often, those couples will find success in IVF, however, even IVF can be challenging, and I think when they do everything, when the female partner, they do everything, you know, they take the supplement that they eat clean, and they eat healthy, and they're exercising, and they're still not seeing the outcome they want. It's really hard, and I internalize some of their pain and struggles, and I it's hard for me because as a physician, our intuition, our instinct, is to fix things, to kind of take the pain away, help heal the injury, you know? But there are things that are even outside of my hand, outside of their hand outside of all our control, right? There's, you know, if the egg quality is not good, or we keep getting aneuploid embryos.
00:43:27.380 --> 00:44:46.840
Unfortunately, besides turning back time, there's not much we can do, and that's a really hard place. I still struggle with how to best counsel patients, you know, and how to best offer support, because I can't give them what they really want, which is success and pregnancy, but I try to be there to help them navigate through the journey. And sometimes that involves, maybe it's time to talk about other ways to achieve motherhood. Sometimes that involves, you know, maybe we try something else one more time, and sometimes it, you know, let's see if you can get a second or third opinion. Loving me, I will do I'm open to doing anything to kind of support that patient through that journey, but it's hard, you know, I depth. There are days where I have to make some really hard phone calls, sure, and when they are in that kind of depth of darkness, I think any human would share that with them. You know my clinic staff, you know the IVF nurses. They cry tears, whether it's happy tears or sad tears. They cry with the patients you know, anybody in the business, I don't think you could not connect with what they're struggling
00:44:46.840 --> 00:44:50.619
through.
00:44:46.840 --> 00:44:50.619
Absolutely, yeah, there's
00:44:50.619 --> 00:45:38.239
a famous study that said, you know, the psychological impact of infertility is like that of getting a cancer diagnosis right. And I think. If you didn't struggle with it, and if you don't know the field, you may think, you know, this is like nothing, right? Like, you would think, Oh, infertility is optional. Like, I think people don't take it seriously, and I think that's why there's a lack of insurance coverage, because it's not taken to be like cancer, but it had sheltered much trauma, and it induces just much stress and as something of a diagnosis cancer. So it's really hard. I still I'm still learning on ways to kind of best support my patient as they go through the ups and downs of this journey.
00:45:38.840 --> 00:46:20.960
I am so glad that we are shedding light on this today and also underscoring the humanness of all of the providers and professionals in this field. And I know that I will echo that, not just for you, but I know I'm speaking for other professionals, the humanness, the empathy that we all feel. It's not just as simple as not being able to get pregnant, there's grief and loss and role confusion and expectations. There's so much that go to this. And I love that you know your patients are so lucky to have such a compassionate provider. And maybe that's a segue into like for Dr Chen, what does a typical day look like for you?
00:46:21.500 --> 00:46:51.639
Well, our clinic starts at 730 and we usually will have some egg retrievals and some surgeries in our outpatient surgery center, and then that most of the morning and around midday, I'm catching up on patient messages and labs and reviewing them and dosing them, checking in with my nurse practitioner to see if she has any, you know, had any heart cases or have any questions for me. And then the afternoon is usually consult.
00:46:52.360 --> 00:47:19.739
How about any ethical dilemmas that you run into that you'd be willing to share? Maybe you run into where you're feel like a gatekeeper when you know that's a really tricky place to be, or, I know there's a lot of talk, talk about, you know, whether you discard embryos or you keep them, or surrogacy. You know, as a physician, as you know, there's some type of gatekeeping role like to run into any ethical dilemmas.
00:47:21.000 --> 00:47:40.159
I think, you know, there are, I don't see it so much as gatekeeping. I think it's more there are certain parts of our field where we do have kind of strict guidelines set forth by the national organization ASRM, and I think they're there for a good reason.
00:47:36.260 --> 00:48:39.380
There's very few things that's a hard no, there's a lot of conversation, there's a lot of like, compromise, there's a lot of, you know, let me bring this up to the board and see, and so on and so forth. But I think those guidelines are there too for us to just kind of pause and say, Wait a minute. Let's look at the pros and cons. Let's look at the potential risk and other situations are just more practical, you know, like STD screening. Now, if someone is using donor sperm or donor eggs or donor embryo, we really want to make sure that they're not going to get some sort of, you know, infection, right? So there's a lot of screening guidelines in place. But, you know, I really, I try to be as honest as possible with my patients about what I'm thinking. And sometimes it can be challenging, because patients come in and they have kind of, like, their own already preset goal and how they envision this process to be. And sometimes we can work together and make that happen, and sometimes we have to bend a little bit. But, you know, ultimately, it's a partnership.
00:48:40.219 --> 00:49:04.019
I love this idea of collaboration, following the ASRM guidelines, honesty, having creative solution, focused conversations. That sounds really nice. Yeah, yeah. And as a couple final questions, do you have any fun, interesting facts about yourself that you could share with the audience, and then what do you hope for the field in the next five to 10 years?
00:49:05.099 --> 00:52:23.059
Yeah, so I have two kids. I had my son when I was an intern, and in OB GYN residency, and I went to a pretty busy residency program, and in fact, it's the largest OB GYN residency program in the entire country. It's the, it's called parkland in a hospital, you know, I just don't remember the first, like, four years of his life, because I was working like 90 hours plus a week, you know. And I knew I wanted to get into Rei fellowship. And Rei is one of the more competitive programs. They're like, I was, like, just trying to, like, stay alive. And I kind, I mean, I think he raised himself, because I honestly just don't remember, you know, I took four weeks off after delivering him, and I went right back to work, and I didn't deliver until 40 weeks. Plus change, and he was like, a huge baby, and I it's just a blur, you know. And my husband always jokes like he was a single dad for four years. And I say that more so because it took me, like, a really long time before I could, like, even think about having a second, sure, and by the time I was ready to actually have a second I had infertility, you know, and that was, like, interesting, because here I am, I got pregnant with my son while I was birth control, because I wasn't taking it correctly, because I was young, and, you know, didn't really understand how hormones were. And, you know, fast forward, like, five years. I'm an REI fellow trying to learn to specialize in infertility, and I'm running into infertility myself. So, you know, eventually I had my daughter, but just to say, I really whatever extra free time I have that's not given completely to my patients, you know, it's to my kids. Because I think my experience with my son, I just have so much regret, you know, all those shifts where I stayed late so I could wrap everything up so I didn't look like I was letting the team down. And you know, all those extra things that I prioritize over him, or just have a lot of regrets, and I wish I could turn back time, because I don't even remember him as like a toddler, and so I really try to dedicate my time now to the kids and helping them through school and trying to be there for the extracurriculars, making an effort and kind of drawing boundaries between my clinical work and my dedication to my Patients and when it's family time, because I am really, really bad about obsessively checking my patient like my EMR inbox, and because I want to make sure that the patients know that I am aware of whatever difficulty, challenge, question they have, and I want to get back to them. But I've also learned like there are things that could wait, and I do need to separate that kind of professional commitment to my family, because ultimately that makes me a better physician, and that makes me actually be more available to my patients, if I know that my family is taken care of. So not really an interesting fact, other than I'm just, I'm a mom for two kids,
00:52:24.380 --> 00:52:35.960
and then interesting and I you sharing, that was probably why you're so empathetic and compassionate this work life balance as a mom, working mom is is no joke.
00:52:36.199 --> 00:53:03.480
Yeah, yeah. I know you, of course, would know that very well, but, and it's hard, I'm still learning, and now that my son is older, and then he had some sharp comeback, like, like, oh, you know you're not gonna be at my whatever performance at school. And I'm like, Why do they always make it at like, 10am on a Thursday, like, often supposed to make it to these like performances, but
00:53:03.840 --> 00:53:07.559
yeah, try to schools to better support working parents. Absolutely.
00:53:07.559 --> 00:53:15.840
Yeah, yeah. So anyways, yeah, I think I'm hoping to find some hobbies, and I'm starting to work out more.
00:53:15.840 --> 00:53:22.460
So my nurse practitioner is a huge health nut. She loves working out and eating healthy, and so she's been inspiring me.
00:53:22.940 --> 00:53:28.940
I ran a race this weekend with my son school, so I'm getting there. Amazing.
00:53:29.059 --> 00:53:32.599
Yeah, and what do you hope for the field in the next five to 10 years?
00:53:32.599 --> 00:53:49.719
Just better access. We really need to work on getting patient access to this to this field. There's a lot of barriers. The biggest is probably financial, and I need the insurance companies to kind of provide more accessibility.
00:53:50.079 --> 00:54:22.820
It's just so it's been, it's gotten better, but it's just really frustrating. And if I could give away free cycles, oh my gosh, like I would, you know, and I do whatever I can to make it work for my patient. But this is, it's a huge investment, and I think it's hard when it's not a guarantee to work. You know, we put what we can into it, and we, you know, obviously optimize everything as possible, but the fact that it is quite an investment makes it prohibitive.
00:54:17.519 --> 00:54:58.960
And I feel like I would love to see this field become more accessible to a larger population of patients, regardless of their social economic status. And that treatment, yes, but also education, right? Like learning about some of these things that you know. How are you supposed to track ovulation? All these like little home kits, they're expensive too. There are cheaper options, like to strip, but maybe some people don't know how to use that. And so I think increasing awareness, increasing education, increasing accessibility to care, that's what I would like to see in the field.
00:54:59.800 --> 00:55:33.860
Yeah. Yeah, and I sat here nodding almost this entire episode, because I just echo so much of what you're sharing. And part of the mission of this podcast is to bring that education and awareness. And I am very confident that so many people listening will be sharing this and so appreciative of education and awareness you've you've shared and imparted today. So thank you for coming on. Oh, absolutely, yeah. This is Dr Lucy Chen. She's an REI, and we are so grateful that you were able to share your wisdom today. Thank you for having me.
00:55:37.039 --> 00:56:02.579
If you would like to learn more about how we can help, visit our website at perinatal reproductive wellness.com, and while you are there, check out the latest edition of our book, employed motherhood. We also invite you to follow us on social media at employed motherhood. Finally, if you enjoyed listening to the show, please subscribe and rate it. Thank you. You.
