Rescripted_S2_E1_What To Expect At Your First Fertility Appointment: Audio automatically transcribed by Sonix

Rescripted_S2_E1_What To Expect At Your First Fertility Appointment: 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, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi everyone, and welcome to episode one of Season two of the Dear Infertility Podcast. I'm your host Kristyn Hodgdon, and I'm so excited to introduce you all to my co-host, Dr. Lucky Sekhon. Hi, Lucky!

Lucky Sekhon:
Hi. Thank you for having me on!

Kristyn Hodgdon:
Absolutely! So excited to sort of take a medical approach to this next season of the podcast because I know our community has so many questions about what to expect during each stage of the fertility journey, from the first appointment to what to do if IVF fails, we're kind of going to go through it all.

Lucky Sekhon:
Yeah, I'm really excited to be doing this. I loved season one of this podcast, and I really think it can be so helpful to have a doctor on to help kind of break down seemingly complex topics in an easy-to-digest way.

Kristyn Hodgdon:
Absolutely. And do you want to tell everyone a little bit about yourself before we jump in?

Lucky Sekhon:
Yeah, I'd love to! So I am a practicing double board-certified OB-GYN and reproductive endocrinologist, and fertility expert. I'm based at RMA of New York, which is a large program, a large fertility clinic in New York City. I see patients that our Soho and Midtown East locations, so that's my day job. By night, after my clinical work is over, you can find me on channels like Instagram. I'm pretty active on social media as a doctor, trying to advocate for women, for patients, to help them better understand how their bodies work, to understand fertility, and to dispel common myths and misconceptions. I'm also a mom of two girls, and I have gone through IVF as a patient myself for the purpose of fertility preservation when I was 34, 35. So I think I have a unique perspective both on the professional and personal side.

Kristyn Hodgdon:
Absolutely. And speaking of being your own advocate, this season really is all about empowering patients to be their own advocate at the doctor's office when trying becomes trying, because you can never be equipped with enough knowledge and questions to ask and test to run in order to get to the bottom of why you're not getting pregnant.

Lucky Sekhon:
Yeah, I completely agree.

Kristyn Hodgdon:
So to kind of go back to the basics, this first episode is what to expect at your first fertility appointment. So really wanted to start at the very beginning, which is when should you seek the help of a fertility specialist versus working with an OB-GYN?

Lucky Sekhon:
So I think the broad question of when to seek help is traditionally based on how old you are, because so much of our fertility can be influenced by age, on the female side. So in general, a rough guide would be under the age of 35. If you've been trying for at least a year, it's time to go speak to a professional and get some help. If you're over the age of 35, then less than or up to six months. And if you're over 40, it's a good idea to check in even sooner, maybe even at the three-month mark. In terms of whether to seek the help of a fertility specialist or work directly with your OB-GYN to start, I think that depends a lot on a lot of different factors. You know, I think in New York City, we're spoiled. You can't really walk more than a block without hitting a fertility clinic. But there are parts of the country where there is not as much availability, and it might be smarter to start the conversation or at least the testing with your OB-GYN. So I really think it just depends on where you are, but I also think it depends on the comfort level and the expertise of your OB-GYN. Obviously we get that basic training, and we learn about what goes into reproductive health and fertility. But not every general OB-GYN is going to be so focused on the workup and even the management of simple fertility related issues. So I think you have to have a really honest conversation with your GYN to figure out if they're comfortable managing it or if you're better suited to speak with a fertility specialist right off the bat.

Kristyn Hodgdon:
That's a great point. And quick question for you, do you normally need a referral to go to a fertility clinic or can you just kind of make an appointment and go right in?

Lucky Sekhon:
So it depends on where you're at in the US. That's not how the healthcare system works. So you could actually just call up a fertility clinic and establish care. I'm Canadian, and I know in Canada you have to have a referral. So in socialized healthcare systems, usually it's a referral-based type system.

Kristyn Hodgdon:
Okay. So we source a bunch of questions from our community, and we got some great ones that I think everyone will be able to benefit from. The first one was I have two months to prepare for my initial consultation, is there anything I should start doing now?

Lucky Sekhon:
Yeah, for sure. I think it's always good to be able to go into your appointment with a clear mind and a focus. So I think if you're doing this on your own and you're planning to use a sperm donor, etc., that's fine. If you're doing this with a partner, I think it's important to have conversations with them ahead of time and to really think about the big picture. What are your family-building goals? What are your concerns? Going in with data, starting to track your cycle, and even keeping a log. For example, if you have irregular bleeding throughout your cycle, it would be really helpful to know when that spotting is occurring, is it happening post ovulation? On which days, and what symptoms are associated with different parts of your menstrual cycle? So I think collecting data, that's where a lot of apps can be very helpful because when we are interviewing a patient and taking their history, we're going to ask you a lot of those types of questions. I think going into a visit, having talked to your insurance company and understanding what's covered and if there's different medical criteria for getting fertility coverage or even talking to HR at your job to try to optimize your benefits going into that appointment so that the decision making, obviously, this is in an ideal world, but it would be great if the decisions we make are more driven by the medicine and what we think is right for you versus what's feasible or what your insurance dictates.

Kristyn Hodgdon:
Absolutely. So kind of to that point, what should you be, what should patients be looking for when it comes to a clinic and a fertility doctor? And what are some giant red flags that tell people to run away?

Lucky Sekhon:
Yeah, I think when you think about where you want to go, if you have the luxury of having options depending on where you're geographically located, I think word of mouth is always a great place to start. If you have friends or family members who have gone through the fertility journey and they are raving about their doctor and they had a great experience at a particular clinic, that's always going to give you a lot of confidence going into the situation that you feel that this has been vetted by someone you know and trust, who understands what your needs are. So I think that that's great if you have that ability to get recommendations from firsthand experience. I think, personally for me, just putting on my fertility patient hat and thinking about the things that were important to me, I think if you can't, if you feel like it's not a setup where you can get directly in touch with your doctor or team to talk about your concerns or to have your questions answered, that is a major red flag to me because the doctor-patient relationship or the care team-patient relationship is so important when it comes to an area like fertility care. This is not a sprint, oftentimes it's a marathon and there might be bumps along the way. And troubleshooting and clear, consistent communication, I think is very important, and you need to have that trust because there's so much that happens behind the curtain. Most patients don't understand the intricacies of what's happening in the lab. And so there has to be a lot of trust and you have to be able to communicate clearly with your care team. I think any time you go into a doctor's office and you feel like your doctor or the team looking after you is spending more time talking and dictating rather than listening to your experience and your concerns, that's another huge red flag. I think if there's a lack of transparency when it comes to pricing or what your insurance will cover, that's a huge issue, especially when you're dealing with treatments like IVF that can be very expensive out of pocket. The clinic where I work, what I love about it is that we work with a team, a large team of finance coordinators, and their only purpose is to help patients and hold their hand through navigating the murky world of IVF coverage and all the things that go into it. So I think having that support staff and having clear communication again is so important. I think there's certain key triggers that would make me run the other way as well. Like if someone tells me that, well, you have the eggs of a 29 year old and you're not 29, that doesn't make sense. So there's really clear things that we all know and understand that our blind spots in our field, we don't have direct ways of testing someone's egg quality. So if someone tries to interpret an AMH level or a blood test or even an ultrasound to tell you about your egg quality, then what else are they not informed about, right? Because we know that there's no way to really test directly for someone's egg quality. You know, a more recent thing that came up in the pandemic, over the past year and a half, was the issue of vaccines and fertility. And of course, in the early stages we didn't have a lot of information and we were gathering data. But at this point in the game, I would say any fertility doctor, OB-GYN that says that you should wait and not get vaccinated in pregnancy or while you're doing fertility treatments, I would also run the other way because that's a clear deviation from what's being recommended by major societies like the American Society of Reproductive Medicine. So I guess my point is these are examples of deviations from the standard of care, and that's always a red flag in my mind.

Kristyn Hodgdon:
Yeah, no, absolutely. Those are all really important points. And I like how you mentioned too that your doctor should talk about your family-building goals with you, because I was devastated to realize after many failed IUIs that I had to do IVF. But I also knew I wanted a large family and I sort of felt like that conversation should have been had a year prior, you know, about how many kids I wanted to have and maybe IVF would have been a sooner. brought up sooner to me as an option, because once I did get pregnant with IVF, like having those embryos remaining frozen was a really nice feeling, knowing that I didn't have to kind of go through all that trial and error again because like you said, it is a marathon, not a sprint for sure.

Lucky Sekhon:
Yes, I think the big picture approach is essential and I can always read the look on a new patient's face when I'm running through, here are your different options, because a lot of times I think patients will walk in having an idea, a lot of patients have done research or they've talked to people, and maybe you have this preconceived notion, I'm going to be doing, you know, medication to make my ovulation regular and I'm going to do IUI. And when I'm running through, yes, we can do that. And here are the pros and cons, but let's also talk about this other treatment option, I'm not saying that you have to do IVF or that I think you need it, but it's important to understand that there are really two major treatment approaches if you put them in categories and there are things that IVF can offer, like being able to freeze embryos for future use if you want to have a big family that IUI can't. And so I always run through all of the different treatment options and the pros and cons of each. And it's not to overwhelm a patient or give them unnecessary information. It's rather to give them the big picture so that they can really form a strategy that makes sense and will help them achieve their goals.

Kristyn Hodgdon:
Absolutely. So another question we received is, is there testing that can be done prior to the first appointment to help move things along?

Lucky Sekhon:
Definitely! A lot of my patients will come to me and their OB-GYN has already started ordering things like a semen analysis for their partner. That's a relatively cheap and easy test and it can give you a lot of information about the male side of fertility. So it's usually done by appointment, we can do it at our fertility clinic, but there's also outside centers that will run it and it's helpful to just have that information off the bat. I think getting an ultrasound with your GYN can be helpful, but I'm still going to want to repeat it myself because there's ways that we look at ultrasounds that are different and more specialized than just a general transvaginal ultrasound. But I think getting one can be helpful to identify really preliminary look at whether you have things like fibroids or other fertility related concerns. You can always have a hysterosalpingogram done before or in the lead up to your fertility consultation, that's to check to see if your fallopian tubes are open or if there's any scarring or structural issues with the inner lining of your uterine cavity. And genetic testing is a big one. A lot of people don't think about this, but if you are in a situation where you're with the person that you want to combine your DNA with to create a baby, it makes so much sense to do pre-conception genetic testing, not to diagnose any sort of medical problem in yourself, but to rather see if you carry any mutations. We all carry mutations, that's part of being a human and there's a lot of redundancy as long as you have at least one functional copy of a gene. If one copy is mutated, it doesn't matter. But if you and your partner both happen to carry the same mutation, which happens like 2 to 4% of the time, among the couples that I treat, then there is a one in four chance that you could have a child with two copies. So I think it makes sense to figure that out in advance. You find out that you're in that situation, there are many different options to consider and conversations that would come up as a result of that. So I think it makes sense to do that testing. There are panels that will look for like 500 different conditions now and it can help you avoid problems before they can start if you choose to take on certain strategies, I think doing simple blood work to look at things like your AMH that tells us about your egg count, doesn't tell us anything but your egg quality, to look at markers, hormone markers like thyroid stimulating hormone to make sure your thyroid is functional, looking at other hormones like your estrogen and progesterone levels and your pituitary hormones. And those usually are tested when you're off the pill and on day two or day three of your period, but it doesn't always have to be like that. I think another major thing people don't think about is just looking at their overall health and making sure that they're up to date on their health surveillance. Things like pap smear, if you're over 40, mammogram, if you have chronic health conditions, checking in with your specialist, like if you have inflammatory bowel disease, check in with your GI specialist and make sure that they're on board and they feel like your condition is stable and they're giving you the go ahead that it's safe to embark on fertility treatment if you need it and getting pregnant, and that you don't need to potentially change your medications to more pregnancy-safe medications. So these are all things that you can be thinking of and preparing for in advance of your consultation.

Kristyn Hodgdon:
I love that you brought up TSH-2. About a year ago, I was feeling really fatigued and just not myself and no really big red flags but just off and I had a physical and my TSH levels were through the roof, got diagnosed with hypothyroidism and Hashimoto's and really have had to spend a lot of time getting those levels under control before I could start trying to conceive again. So you know your body better than anyone else and if anything feels off, see your doctor and take care of that before, before you head to the fertility clinic. I think so much of it can be wanting to feel proactive and these are all great suggestions for kind of taking it, taking things into your own hands before that first appointment. So thank you. So someone asked, will I have a plan walking out the door? I think, I think everyone wants to leave that first appointment with, with the plan, it always feels better having a plan. So what would you say to that?

Lucky Sekhon:
I think it depends on who you're speaking with. My style tends to be to give as much information upfront as possible. Others may say, you know what, let's do all the testing, these are the things we should be looking for and then let's schedule a follow up. But I think you should always have some sort of action point to walk away with. I personally like to talk about tentative treatment options, and I'll say these are the tests we're going to run if everything comes back normal. This is a good question, actually, you could ask someone if you're seeing them in a consultation. If all my test results come back normal, what's next? Right? And then obviously you can build off of that plan and be flexible and know that it's subject to change if any of the test results end up coming back and swaying us in a different direction. But I think that common example is patients who have been trying for a year or however long and they haven't done any workup, they have no information coming in. And I'll run through all of the basic fertility workup and say, look, if everything comes back normal, you could start with Medicated IUI, or we could go straight to IVF. I think that based on your age, might make sense to do X, Y and Z first, here are the pros and cons of either option. So I kind of leave it very open ended and say there might be things that come back, and I give them very definitive examples. Like, for example, if your HSG shows your tubes are blocked, well then that's going to point us in the direction of IVF being the first step. So I think just kind of charting out a tentative plan, but knowing that it might change depending on what information we find out.

Kristyn Hodgdon:
That was a question we got a lot, too. So what, what other questions should patients be asking their fertility specialist at the first appointment?

Lucky Sekhon:
So I think it's always helpful to say after they've gone through your whole history and they've done an ultrasound, ask if they, off the bat, suspect anything diagnosis wise just because that will help your anxiety and it will just give you a little bit more clarity because sometimes we can tell from the get go from doing an ultrasound, I might see endometriosis in the ovaries. You can't always see endometriosis on an ultrasound, but when it's in the ovaries it's very obvious. So I think it's just helpful to ask what they're thinking in that moment based on that preliminary evaluation. I think really understanding what tests they want to run, why and what the timeline will be to get the results back so that you have a clear expectation of when you can hear back about certain things. Genetics, for example, might take up to three weeks to result. So I think it's just helpful to ease your mind and know, okay, I'm not going to hear from them for another three weeks because that's the expected timeline. Like I said, going through tentative treatment options and getting an overall balanced view of what's out there. I think oftentimes because of everything that you can read online and you can fall down a Google rabbit hole, it's very easy to think there's a million different options. But I think getting a simplified overview and understanding the pros and cons of each category of treatment will help put your mind at ease. Side Effects, what to expect with each type of medication or procedure, whether it be IUI or egg retrieval, in terms of recovery, and what your day-to-day would look like, how is your medical history and any medications you're taking going to impact the plan or should any of these things be adjusted? And I think overall tentative timelines. Some of my patients will say like, okay, maybe we'll start with IUI, if the tests say that that makes sense to do that, and how many rounds do you think that we should do before we sit down and have a conversation about ways to make treatment more aggressive? And I think really important to have a clear expectation setting of how to best get in touch with your doctor and communicate with them. Some doctors will be really great over email, some would prefer that you make an appointment for a follow up. And if that's the case, I would make the appointment for the follow up to follow that first appointment, maybe in three weeks or so, whenever you think that all the results will be back so that you're not wasting time and that you always have ways to touch base.

Kristyn Hodgdon:
Mmhmm. I think it's so important to ask about the sort of time commitment, because I went into my IUIs having zero idea of how much I had to be in the office for monitoring.

Lucky Sekhon:
Yes.

Kristyn Hodgdon:
And that might have changed my mind about when to start or, you know, you really have to be sort of like mentally prepared going into it. As much as I would never want to scare anyone out of it, it's just, you kind of have to be in the right mindset for added, added responsibilities in your week, in your schedule.

Lucky Sekhon:
Yes, exactly. I think it's really just important to get as much information upfront as possible. And you should view that initial consultation and meeting with your doctor and their team, whether they work with nurses or coordinators as an opportunity to get as many questions answered as possible. So I think coming in even with notes is always helpful, but having a way to contact them after because I'm sure there will be questions that come up that you didn't think of in the moment. So it's nice to be able to have an avenue to ask them later on.

Kristyn Hodgdon:
Absolutely. Well, this is so helpful, Dr. Sekhon, thank you so much and we'll see you next time.

Lucky Sekhon:
Awesome. Thanks for having me!

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe. To find this episode, show notes, resources, and more, head to Rescripted.com and be sure to join our free fertility support community while you're there.

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