Rescripted_Dear Infertility_S6_Ep2: Audio automatically transcribed by Sonix

Rescripted_Dear Infertility_S6_Ep2: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

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

Kristyn Hodgdon:
Hi, everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm back with Doctor Nicole Yoder, a fertility specialist and board-certified ob-gyn with Spring Fertility in New York City. Hi, Dr. Yoder.

Nicole Yoder:
Hello. I'm glad to be back with you.

Kristyn Hodgdon:
Great to be back. So in episode one, we talked about it's been a year of trying to conceive what now? What are your next steps? And today, we want to talk about that. After that, maybe initial medical history, trying to conceive history, initial blood work, and ultrasound. What are some diagnostic tests that you might recommend to your patients? I think the most common one that people know of is the am I going to say this right: Hysterosalpingogram they used to check if your tubes are open, genetic carrier screening, and all those sort of boxes that need to be checked before going down the road of IUI or IVF. So excited to dive in.

Nicole Yoder:
Yeah, it is a tricky word to say, but we fondly refer to it as HSG or commonly known as the A tube test. Now, depending on what you anticipate your route of approach being, sometimes we'll do this right away; we'll do it upfront. We'll say you need to do an HSG like soon. That's going to be part of our initial workup. Sometimes if you don't have risk factors or if there's a strong chance you're just moving straight to IVF. We may not do this at the front end of the evaluation, but it definitely is a very common test to have done when we're looking at trying to figure out why you might be having difficulty conceiving. And the primary goal of this test is just to assess if your fallopian tubes are open or not.

Kristyn Hodgdon:
Yeah.

Nicole Yoder:
And the reason I emphasize if they're open or not is because that's really all we can tell from this test. It's primarily I can't tell you. Guess I should back that up a little bit so we can tell her tubes are open or not open. And if they look like they are normal size, shape, and caliber, but you can have a test that is completely normal. We can do a tube test. We say, yep, tubes are open, but we can't really get information about how things move through the tube. So it can be that the tube is just an open pipe and thinks that at either end of the tube and Megan's sperm still don't meet. But regardless, having open tubes is a prerequisite for egg and sperm meeting. So we definitely want to know if your tubes are blocked.

Kristyn Hodgdon:
When we talked about last episode, like the semen analysis being low-hanging fruit, I feel like this is another low-hanging fruit where if you can rule that out.

Nicole Yoder:
Yes. Yeah. If your tubes are blocked, that is a very big determinant in what is going to be an appropriate treatment plan. Mostly if your tubes are blocked, there is a next to 0% chance you're going to conceive with an IUI or trying on your own. And we're going to tell you really, you have to do IVF to achieve a pregnancy.

Kristyn Hodgdon:
Yeah. And so, what can a patient expect during an HSG? The common question: is it painful?

Nicole Yoder:
So if you go on the internet, you will find the worst about an HSG. You will see people saying it was the most painful thing they've ever had done or it was worse than childbirth. Some things along those lines. I'm not saying that those people did not have that experience, but it does not have to be that way. And I'd say most people were doing this within the context of a fertility center. So, people who are doing this day in and day out, we do our best to make sure that it's not that type of experience. But yes, it can be painful, particularly if your tubes are blocked, mostly because then basically the premise of how it works is we put a little bit of dye into the uterus, and we see if it goes out the tubes. If your tubes are blocked, we're going to make those tubes a little bit angry and they might spasm and that can be painful. So that is primarily what contributes to the pain and spasms of the fallopian tube is something that you are not going to experience on a day-to-day basis. So it's a very unique pain, I think, is one of the things to know about it. People are like, whoa, I've never felt anything like that before. So that is something that can be a little can take you back a little bit.

Kristyn Hodgdon:
Yeah, for sure. I can attest to the fact that mine, mine were never painful, so.

Nicole Yoder:
That's good. I hope that gives people some solace.

Nicole Yoder:
And the good word is not painful. Some people do just fine, but we do tell people it is helpful if you can take some ibuprofen ahead of time if you do have some cramping with the procedure. The good news is it's usually pretty transient and is less than a minute. Ideally, 10 seconds of pain. And then we recognize, oh, you're not feeling so hot and we can back off with the procedure. But it is temporary and most people do okay with just some Tylenol, Advil, that type of thing up front.

Kristyn Hodgdon:
Awesome. So is that sort of the most standard across the board for all patients? Is there any other tests that you like to in addition to the blood work, ultrasound, and semen analysis? Is a saline sonogram or an SIS, is that sort of across the board, or is that more just in specific circumstances?

Nicole Yoder:
So that one is another one that can be in a little bit more specific circumstances. Certainly, if you know you're going to do IVF and we ideally are going to do an embryo transfer, we're going to do a saline sonogram beforehand, because if you're going through all the energy and effort to make that beautiful embryo, we want to make sure it has the most perfect home to place that embryo in. So we'll do that saline sonogram just to make sure that there aren't any subtle findings that we're not catching on that 2D ultrasound. The 2D ultrasound really doesn't find like small polyps, maybe subtle fibroids, maybe some subtle scar tissue. Not the best for seeing that, but a saline can really help us get a better view of the inside of the uterus.

Kristyn Hodgdon:
And what does that process entail?

Nicole Yoder:
Similar to the HSG, the tube test, it starts with putting a little catheter through the cervix into the uterus. And then, as the name implies, we infuse saline into the uterus just to open up those walls. And this is a test that, this is generally not as painful as the HSG or tube test, but you can have a little cramping with it. Some people's uterus is a little more resistant to opening up for us than others. So some people can have some cramping but tends to be more well tolerated than the HSG.

Kristyn Hodgdon:
Okay, good. Yeah. Again, didn't have any pain with that one either.

Nicole Yoder:
Is the common thread on that. The internet is less full of horror stories and.

Kristyn Hodgdon:
I remember my first saline sonogram was, or maybe not my first, but they said that they were checking if there was any scar tissue following my C-section. So for anyone who's dealing with secondary infertility too, that's important.

Nicole Yoder:
Yeah, anyone who's had procedures on their uterus before or miscarriages, we want to know if there's any abnormal shape. So maybe a septum that we can't really see on the 2D as well. Or if you've had infections in your uterus, any of those types of things will probably do it sooner rather than later. And sometimes with the secondary infertility, like what you were alluding to, if you had a baby and then afterwards maybe you had retained placenta, maybe your periods were super light after you had that baby. Maybe there's scar tissue there and it's the most we're able just to see the cavity better with that saline when we suspect there might be something like that going on.

Kristyn Hodgdon:
Yeah. And I'm glad you brought up miscarriage as well, because obviously that can, that affects the uterus, and yeah, as far as like recurrent just talking about testing, if you've had multiple miscarriages, what are the next steps there?

Nicole Yoder:
Yeah. So if you had multiple miscarriages, we're starting to think of other things in our mind besides garden variety like tubal factor, male factor. Then we're starting to wonder about the uterus itself? Is it something about the structure of the uterus? Is it something about the genetic makeup? Is there may be an abnormal karyotype going on? Is there something about your overall health that is not normal? So maybe pre-diabetic, or maybe the thyroid is way off. So there's definitely going to be a further evaluation. If you've had recurrent miscarriages already coming into this. And sometimes, we don't find a good explanation and maybe we just chalk it up to it wasn't the right month or it's maybe age-related. We know miscarriages are more frequent with older age, but certainly, we'd want to make sure it isn't because there is something abnormal structurally, genetically overall in your blood work, and just make sure that all of those things are looking okay. That might point us in one certain direction.

Kristyn Hodgdon:
And is it typically two miscarriages where you would recommend seeking further evaluation?

Nicole Yoder:
That is a sort of hotly debated topic. What we define as recurrent pregnancy loss or recurrent miscarriages. We don't have a great consensus in our governing bodies, which is a little frustrating. I think a lot of people will definitely, at three miscarriages, think universally we would say yes, time to get the work up for RPL. Two, I think a lot of people would do it at that point. But then you get the category as a biochemical. Do we count that? Do we not count that? How old are you when you had these miscarriages? If you have a miscarriage in a biochemical pregnancy at 42, that's different than someone who's had three miscarriages in a row at 26.

Kristyn Hodgdon:
Yeah.

Nicole Yoder:
It came into consideration as well. But I think once you have more than one, you can definitely start asking your provider, hey, does this seem concerning for my overall background and age, or are you not too concerned yet to do the extra tests?

Kristyn Hodgdon:
Yeah, yeah. You always have to be your own advocate, for sure.

Nicole Yoder:
Yeah.

Kristyn Hodgdon:
And so you mentioned briefly. The karyotype screening. So let's talk a little bit about genetic testing. I think genetic carrier screening is like a blanket like everyone gets that done, correct?

Nicole Yoder:
So anyone who is actively trying to conceive, whether that's on your own, if you go to your Ob-gyn, say, hey, we're going to try next year, or if you're in my office and you've been trying, we would recommend that you get genetic carrier screening done.

Kristyn Hodgdon:
Yeah, and they test for so many more things now because I had to get my medical records recently. And I think when I did it six years ago, there were like 273 diseases, and now there are over 500.

Nicole Yoder:
Yeah.

Kristyn Hodgdon:
So it's.

Nicole Yoder:
The number of things they can test for is it feels like it's exponentially increasing. So you're right, some people have they're like, oh, we did that. I'm like, okay, when did you do it? And it's ten years ago. I'm like, oh, that's going to be a baby panel now.

Kristyn Hodgdon:
Yeah, exactly. Science is always advancing.

Nicole Yoder:
Yes. Yes. But basically, what's the genetic carrier screening is looking for is to see if you are a carrier of any abnormal gene. We should have two copies of every gene, and most people will carry 1 or 2 abnormal genes here and there. But you would never know it because if you're a carrier, the other one is normal, and you walk around healthy, fine, no problems. The only reason it's an issue when we screened for this is because if your partner is also a carrier of that same thing, then your offspring, your babies, have a 25% chance of getting the affected copy from both you and your partner. And that's how you end up with these babies that can have really severe health conditions. Examples would be like Tay-Sachs, cystic fibrosis, Gaucher disease. They're not common in the population, but they're out there and they can be really devastating and they're preventable. Or at least you can have screening to know if you are at risk of those things happening.

Kristyn Hodgdon:
Yes. No, that's so helpful. I remember I came back with a few things that I couldn't even pronounce, but my husband didn't have any of the same ones. So we were. Yeah, but.

Nicole Yoder:
Yes, as you said, most of them are like, what is this, this thing? But yes, as long as you don't carry the same thing, you're not concordant carriers, then you're good to go.

Kristyn Hodgdon:
Yeah, exactly. So what about the karyotype screening? How is that different?

Nicole Yoder:
The karyotype that is looking to see if there are anything, just not specific genes. So the carrier screening is looking at specific genes like the examples I gave. Maple syrup, urine disease, or something like that. The karyotype is making sure that you have 46 chromosomes that are structurally normal. So sometimes, if you have recurrent miscarriages, it may be there's something abnormal about the structure of your karyotype. And maybe it's like you had a balanced translocation, or there's an inversion. So you have all of the genetic makeup that you should have as an adult and you're healthy. But when your eggs and sperm are, when you're making eggs and sperm, the complement of the eggs and sperm get might not be balanced. And then when your body tries to make embryos from the unbalanced egg or unbalanced sperm if that's the case, then you have these embryos that are made that don't have the correct genetic makeup, and they just continually fail to implant or fail to progress as a pregnancy. And that might manifest as recurrent pregnancy failure.

Kristyn Hodgdon:
Okay. And so that would be a part of the RPL workout.

Nicole Yoder:
Yes. We just want to make sure that maybe you're like a Turner Mosaic or have some inversion translocation that certainly will be part of the workup if you've had multiple miscarriages.

Kristyn Hodgdon:
And is that a blood test?

Nicole Yoder:
It is.

Kristyn Hodgdon:
And the genetic carrier screening is a blood test, too, right?

Nicole Yoder:
Yes. Both are blood tests. We tend not to do that off the bat because the incidence of it is pretty low and the screening is actually quite expensive. So we don't just do it on everyone who walks in the front door, but in the appropriate people who have the history. That is an important component of the workup.

Kristyn Hodgdon:
Awesome. Also wanted to talk a little bit about Hysteroscopy. We actually post we wrote an article on Rescripted about the Hysteroscopy procedure yesterday actually, and posted about it on Instagram. And the comments were like on fire with people saying what they're Hysteroscopy experience was like like a lot of again, it was really painful. Meanwhile, like I was knocked out for mine. So I don't know if what you guys do at Spring, but I was under anesthesia, so I got a nice little nap and that was it. But I couldn't believe some people said that they were. I think it depends whether you're a week or under, but so what even is a hysteroscopy and when in what cases do you recommend it?

Nicole Yoder:
Yeah. So a hysteroscopy is a procedure where we take a little camera and look inside the uterus. You can do this awake or asleep. There are certain cases depending on what we're expecting to see, where you would not want to be awake, where you can't do this awake. So doing a hysteroscopy because there is a very large fibroid or you're expecting a lot of adhesions, it's going to take a long time to to tidy up, you're not going to want to be awake for that. If we're just doing a little peep, we just want to see. Maybe we're not actually expecting to see much, but just want to lay our eyes on the inside of the uterus. That person could be a good candidate for one where we're not using your traditional asleep anesthesia or if it's a very tiny polyp that we see, we think it's going to be very quick procedure. Then sometimes you'll have an in-office hysteroscopy which doesn't, maybe you are not fully asleep. Hear in Spring, we do use anesthesia in general for our hysteroscopy so that you would be in the napping category here. It's generally more comfortable for everybody. But for like people who maybe want to avoid anesthesia or it definitely saves on costs. If you're not using anesthesia, it can be an appropriate choice to do it without, like full on being asleep.

Kristyn Hodgdon:
Yeah. And is it just a little bit of a more close up view versus the saline sonogram?

Nicole Yoder:
Yeah. So the saline sonogram really were working with a reflection of your uterus, but there's nothing quite like seeing it with your own eyes because sometimes, when we do that saline sonogram, we think we get a good idea of what the cavity looks like. But ultimately, we're looking at a screen that is a 2D image. And sometimes, there are subtle things that we can't appreciate with just that saline sonogram. And then when you go in and you look with an actual camera, it may actually look quite different than you thought. I think the biggest, the example that comes to my mind is sometimes you think, oh, I see a polyp, I see one, you see polyp on the saline should be straightforward. And then you go in with the hysteroscopy and you're like, oh my gosh, there are way more polyps than I appreciated on the other imaging.

Kristyn Hodgdon:
Yeah.

Nicole Yoder:
Or with a septum. Sometimes you think something about the angle of the top of the uterus looks like quite right. Like maybe it's a small septum and then you get in and you're like, oh, my gosh, this is a huge step-down. So sometimes, the saline can actually compress the abnormalities and diminish them. And then when you get in and you see it with your own eyes, you're like, wow, that was definitely more pronounced than I appreciated.

Kristyn Hodgdon:
Interesting. So is this sort of is a hysteroscopy sort of standard practice for you before embryo transfer, or is it only if you suspect something?

Nicole Yoder:
Right. Only if we suspect something. Even so, we will do the saline sonogram upfront for anyone doing an embryo transfer and make sure that looks good. If that looks good, we'll proceed. Now, if you fail, depending on how many embryos you've banked overall picture. But if you fail embryo transfers that we think had a decent prognosis, even if we don't see anything on the saline, we may say, I don't see anything on the saline, but I just want to look with the hysteroscopy just to get the better gold standard imaging to really get all of the information that we can get. And the other benefit of the hysteroscopy is that we can do a biopsy at the same time, so we can get a tissue sample and send that for testing as well. So sometimes maybe the whole uterus looks like it has little petechiae or like maybe it looks inflamed, so we can send a biopsy sample and test it for stuff like chronic endometritis or any abnormal cells that are coming back. So that's the other benefit of actually going in with the camera, getting the sample.

Kristyn Hodgdon:
Yeah, a little bit more peace of mind.

Nicole Yoder:
Yeah.

Kristyn Hodgdon:
So wanted to talk a little bit about just general health tests, and obviously, there are certain boxes you have to check for or you'll want to check before you're trying to conceive and getting pregnant. And I was just telling you how I just came from my annual ob-gyn appointment. So this is your reminder to go get your.

Nicole Yoder:
Yeah.

Kristyn Hodgdon:
Go get your Pap smear, go get your annual appointment. But do you recommend everyone be up to date on their Pap smears? And then what about mammograms?

Nicole Yoder:
Absolutely. So. You come for treatment. And most fertility centers, they will require that you are up to date, or they will emphasize the importance of you need to be up to date on your Paps and on your mammos. And the mammogram, we would usually say we go by the age-related recommendations for 30. No, you don't need a mammogram yet unless you have a suspicious lump. But if you're 40 and you're going to be hopefully pregnant while you're 40, you're going to want to get that mammogram beforehand. Mammograms in pregnancy are just really hard to decipher. They're not as accurate. So if there is a concern that develops, you're going to wish you had gotten that screening done beforehand just to get the best imaging and the best care.

Kristyn Hodgdon:
Awesome. So are there any that I missed?

Nicole Yoder:
So the other thing that I would mention are making sure you're up to date on vaccines.

Kristyn Hodgdon:
Oh, love it.

Nicole Yoder:
Yes, we will. Typically in our first visit, run some blood tests that look at immunities. These days most people did not have to go to chickenpox parties like I did as a child and had a vaccine against it. And we checked your immunity for that. Rubella as well. Make sure our immune against rubella. And if you are not and you do not recall if you've had a vaccine, we would encourage you to do that before pursuing pregnancy. So some of these vaccines you can't get while you're pregnant because they're live vaccines, and there is a small risk that it could turn into an actual infection. So you're going to want to be up to date on all routine vaccination, routine screenings. That's usually pap, mammo, depending on your family history, maybe a colonoscopy, and have all your other health conditions tidied up. So if you are pre-diabetic, get that under best control as you can. If you have hypertension, get that really well controlled. If your thyroid issues optimize those things, always good to be like as well as up to date with your appointments, with your PCP appointments.

Kristyn Hodgdon:
And this has just been top of mind for me recently. But what about I don't know, there's just so much like medical misinformation, nutrition advice, hormone advice on the Internet. Are there anything that you advise against, anything that you advise against, or like the lifestyle things that you recommend?

Nicole Yoder:
I would advise against or things that seem like extreme measures that make your life unlivable. Sometimes we have people who come in and doing all the things that the Internet says, I'm gluten-free, I don't eat dairy. I'm like eating a plate worth of supplements a day. All of those things. There's not a lot of evidence that they're going to make things better. And certainly, if you are super stressed out doing all of them, I believe that there is probably some detriment to that stress you're adding of trying to do it. This is coming from someone who eats like only gluten and cheese. So I'm a little biased, but.

Kristyn Hodgdon:
No, but it's so you.

Nicole Yoder:
Have to live your life.

Kristyn Hodgdon:
Ever since I got diagnosed with Hashimoto's, which is the autoimmune thyroid condition, for those of you who don't know, I like, I see all the time that like, gluten is the enemy. And I'm like, but I don't have any sort of like negative reaction to it. So I like bread. I'm Italian.

Nicole Yoder:
Yeah, exactly. It's like integral part of your life. We don't want to take that away from you. We don't have a good darn good reason to do it.

Kristyn Hodgdon:
We're all though, the research, right? Like we if there's no really real research behind it, then or if it's been debunked, then we just always want to make sure who your sources are.

Nicole Yoder:
And if it makes you feel better doing it, great, fine. But if you're going to extreme measures and you're really unhappy, it's not worth it. Maybe you can let it go.

Kristyn Hodgdon:
So what do you typically recommend? The prenatal vitamin and.

Nicole Yoder:
Yeah, so prenatals, I would say, for anyone trying to conceive. Obviously prenatal. I don't, you just want to make sure it has the appropriate amount of folic acid in it. But most of them are pretty well-rounded in terms of all of the other vitamins that you need to get. CoQ10 that is another supplement that I think most reproductive endocrinologists will get behind and say it has pretty good biologic plausibility. Just as a general antioxidant good for your overall health, cardiovascular health, and certainly may improve some vascular flow to the ovaries. Those are the main things. And then really assess your lifestyle. If you're a smoker, don't do that. That's the one. That's the number one thing that I can say. Quit smoking. So smoking. You have to look at your overall diet. Now, is there any one diet that is going to be the silver bullet? No, but limit things like heavily processed foods, limit red meat to probably three servings or less per week. Make sure you're heavy on fruits and vegetables, but at the same time, wash your fruits and vegetables, get all the pesticides off of them that you can. But those are the basics. If you're doing all of those things, you're probably in a pretty good spot.

Kristyn Hodgdon:
I love that. Let's end on. There's no need to add to your mental load any more than already.

Nicole Yoder:
Yes, it's already.

Kristyn Hodgdon:
More than you already are.

Nicole Yoder:
Yes, it's already hard enough. So you got to give yourself a little grace.

Kristyn Hodgdon:
Exactly. This is awesome. Thank you, Dr. Yoder. And next week, we are going to be talking about, all about IUI. So digging in a little bit more there. So, yeah, thank you again. And till next time.

Nicole Yoder:
I would be looking forward to it.

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

Sonix is the world’s most advanced automated transcription, translation, and subtitling platform. Fast, accurate, and affordable.

Automatically convert your mp3 files to text (txt file), Microsoft Word (docx file), and SubRip Subtitle (srt file) in minutes.

Sonix has many features that you'd love including automated subtitles, secure transcription and file storage, automated translation, generate automated summaries powered by AI, and easily transcribe your Zoom meetings. Try Sonix for free today.