Knocked Up Podcast - We answer your questions: part 2
Such great questions! Thank you listeners :)
Questions answered in this episode:
What are the options for getting pregnant with cystic adeno?
Treatment options for short luteal phase
What pre-conception supplements do you have to take?
How to work on mindset before procedure?
How would someone know when it’s time to stop?
What do I do if I feel my specialist doesn’t have the same sense of urgency that I feel
What is the average drop in AMH from late 20’s to early 30’s? What would be DOR?
Does vaping effect fertility?
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
Find us on Instagram - @knockeduppodcast
Have a question about women's health? Is there a specific topic you'd like us to cover? Email podcast@womenshealthmelbourne.com.au. We keep all requests anonymous.
TRANSCRIPT
Intro
Women's Health Melbourne is an innovative, holistic fertility and women's health practice.
We are world leaders in IVF and egg freezing and provide our patients with every opportunity to achieve their goals.
Jordi Morrison:
Our handpicked expert team provides the ultimate care experience for our patients.
Reach us at womenshealthmelbourne.com.au and follow us at Women's Health Melbourne and @drraelialew.
Hello, and welcome to Knocked Up, the podcast about fertility and women's health.
You are joined as always by me, Jordi Morrison:, and Dr Raelia Lew, CREI fertility specialists.
Today's episode is part two of your questions.
So if you didn't hear part one, that's the episode before this—and this episode, completely different type of questions.
Thank you so much, everyone. We loved answering these.
What do people mean when they say they've done seven rounds of IVF? Do they mean stim cycles or transfers? And a follow-up from me on—really quickly—what's a stim cycle?
Dr. Raelia Lew:
A stimulated IVF cycle is when you do an egg collection to create embryos, and you stimulate the ovary to collect multiple eggs.
An embryo transfer cycle is when you place an embryo in the womb with the ambition of creating a pregnancy.
And I guess you'd have to ask an individual what they mean by that.
It's not the way the doctors describe IVF.
How I would interpret that is that somebody may have done seven full stimulated cycles and transfer of every embryo created, or they may have had one simulated cycle and seven embryo transfers.
So it's ambiguous.
I think it is really important as an audience though to realize that IVF is something that we use to try and help people with really significant problems and barriers to conception have a baby—be that very advanced age and a high number of embryos with serious problems, be that multifactorial male and female anatomical, physiological disease process-related barriers.
And it is a journey as opposed to a treatment, and most people who have a baby through IVF will require serial treatments, and that is normal.
Jordi Morrison:
Next question.
What are the options for getting pregnant when you have cystic adeno?
And to start, what is cystic adeno?
Dr. Raelia Lew:
Again, not a medical term.
What I think the person who asked this question is referencing is adenomyosis, potentially with cystic change.
Adenomyosis is a disease process where glands of the endometrium or uterine lining grow in and diffusely infiltrate the muscle of the womb, and they can cause cystic space formation because that's what glands do.
They can create an inner liquid within the tissue.
It can make the uterus very boggy and enlarged.
The way it tends to be described on ultrasound is globular, like in reference to the shape of an old-fashioned light globe.
Bigger on top, narrower on the bottom.
Often, the walls of the uterus are thickened asymmetrically.
Often, the posterior wall is thickened more than the anterior wall.
And there are different characteristic ultrasound findings like subendometrial cysts and Venetian blind shadowing is a typical way that adenomyosis is described on ultrasound because the sound beam is disturbed as they travel through the uterus, a bit like light can be disturbed into rays coming through a Venetian blind.
Adenomyosis is a condition that is not able to be treated surgically.
It is diffuse and affects the whole uterine muscle.
It can be mild or it can be severe.
One of the ways that we sometimes treat adenomyosis is to do a long down regulation.
So sometimes depriving the uterus of hormonal exposure for a while can help the adenomyosis settle down.
It won't get rid of it, but it can help it settle down and become a little bit less problematic.
And that would be something that you could discuss with your own specialist in a very severe case of adenomyosis.
Mild adenomyosis does not warrant such measures and is a very frequent finding on ultrasound.
So it is important to treat the patient in front of you as opposed to treating the patient's concerns from what they've read online.
Very mild adenomyosis doesn't need any treatment at all.
Jordi Morrison:
What are the treatment options for short luteal phase?
Dr. Raelia Lew:
It's a one-word answer, and that word is progesterone.
So if somebody truly has an isolated short luteal phase, which means that they've ovulated at the right time, but their own ovary is not making enough progesterone, we give progesterone.
Jordi Morrison:
Love a quick answer.
What preconception supplements do you have to take?
Dr. Raelia Lew:
Again, you don't have to take any.
Your grandmother took none.
Your great-grandmother took none.
What we can do is learn from science and experience and try and optimize our chance of having a healthy pregnancy by making sure that we're nutritionally replete in substances that, when we're not replete, we know are associated with problems.
An example is folic acid.
We know that when women have adequate folic acid supplementation, the risk of having a baby with a neural tube defect such as spina bifida goes down.
Now that doesn't mean that women who don't take folic acid are definitely gonna have a baby with that problem.
It's something that we've noticed.
Likewise, having enough iodine in the diet so that your thyroid functions normally can reduce the chance of having a baby with congenital hypothyroidism.
There are many different examples where being nutritionally replete in trace elements has been associated with better chances of healthy pregnancies.
What I would say to any individual—and our needs are very different—is that it does not hurt to have a holistic assessment personalized, and consider a nutritional assessment with a clinical nutritionist if you feel that that would be a benefit for you.
And you'll get personal advice on any additional supplements that might be useful for you.
If you have low iron, taking an iron supplement, for example, might be very advisable.
However, if you have normal iron levels, taking an iron supplement is not necessarily helpful.
So I would say there's no one-size-fits-all.
There are many prenatal vitamins on the market which are essentially a multivitamin with folate.
And there are different individual concerns that people face where things need to be added or subtracted from their diet, and individualized advice is always best.
Jordi Morrison:
I remember a while ago, we recorded an episode with Women's Health Melbourne dietitian, Wendy Fedele, specifically about supplements for pregnancy, pre-pregnancy.
So we'll link to that and also to Wendy's page who can give you individualized advice.
How to work on your mindset before a procedure?
Dr. Raelia Lew:
I guess the most important thing from a medical perspective is that, you know, when we discuss procedures with patients, we have multiple hats on, and there's a very big emphasis on informed consent.
So we find that even risks of rare conditions that are unlikely to occur, rare complications, we must discuss them with patients.
And often that can result in patients being frightened of what is ahead.
Firstly, every procedure should be necessary.
If a procedure doesn't have a purpose, it shouldn't occur.
So when a procedure is necessary, what we do is we calculate risk versus benefit.
And if the benefit outweighs the risk, the procedure proceeds.
We tell you everything that can possibly go wrong as medical professionals.
It doesn't mean that that will happen in your case, but it is a duty of care.
So it is quite normal for patients to feel quite worried, concerned, anxious prior to a procedure.
It's also really important to recognize that while for a doctor, going into hospital is a daily occurrence and not particularly stress-provoking, for a patient, it can be something that happens very rarely in their lifetime, and it's an unusual and sometimes anxiety-provoking occurrence.
What I'd say is have confidence in your team.
Choose a team in which you can have confidence.
At Women's Health Melbourne and at Life Fertility, we pride ourselves in our team.
We have consciously and carefully chosen the professionals with whom we collaborate, both in terms of specialists with the highest qualifications in fertility, but also every member of our team—our scientists, our nursing team, our allied health colleagues, and medical colleagues within the practice.
And having a team of such caliber, I hope, gives patients confidence that while not every procedure in IVF such as embryo transfer will result in the end goal that is our shared end goal, which is a pregnancy, patients can have confidence that their team are doing their very best for them and will take very good care of them.
It's important to me in IVF practice, even with the youngest patients and the best prognosis, when we transfer an embryo under the most favorable circumstances, only one in two patients will get pregnant from that procedure.
So it's very important to me that we provide care and a positive experience for patients who are successful and also for patients who don't achieve their goal in that cycle.
And that, I feel, is actually a very important point in assisting patients to ultimately achieve their goals, because IVF sometimes does take time and quite often requires serial efforts in order to achieve our goal ultimately.
And caring for patients beautifully and supportively helps them to retain the stamina they require to ultimately achieve their goals and stay in treatment until they have their baby.
Jordi Morrison:
How would someone know when it's time to stop?
Dr. Raelia Lew:
Usually, if a patient has a very poor prognosis, that's something that would have been discussed multiple times along their journey, often even from a first appointment.
And there will be some patients who I support who do have a poor prognosis from the outset, and some of them will have a baby.
And it's always a struggle.
It's actually a struggle as a medical director, because there is temptation, especially when we look at IVF success rate reporting, to deny patients treatment if their prognosis is poor, because it ruins your statistics to treat someone with a poor prognosis.
I've never been of that mindset personally, and it's something that I grapple with epically.
I tend to try and empower patients and give them their chance, even if it's a low chance.
And I understand that sometimes that's part of the process of a patient being successful, and for others, it's part of the process of having tried and achieving some closure if they're not going to be successful.
It's something that needs to be discussed at every time point—at every clinical time point—with patients, and something that needs to be discussed very honestly and very empathically.
Some patients need to consider other roads, and donor egg conception is an example.
And that's acceptable to some, ultimately.
It's nobody's first choice.
Acceptable to some, unacceptable to others.
So I would say the time to stop treatment is personal, and it depends on what are your deal breakers.
Because for some, if they're not successful, ultimately they come to terms with that and decide that their journey is over and they're gonna open another life chapter.
And for others in the exact same position, they may pivot to a different strategy, and it is very personal.
I've got many patients in my practice over the years who I've supported with egg donation IVF, having tried autologous or own egg IVF, and who have ultimately had beautiful families and been very happy.
So usually, when there's a will, there's a way.
It's not true one hundred percent of the time.
There are some people who have sterility as opposed to infertility or subfertility, and that can be very tragic for that very small minority of patients.
But for most patients, when they're open to all possibilities, we can find a solution.
Jordi Morrison:
What do I do if I feel my specialist doesn't have the same sense of urgency that I feel?
Dr. Raelia Lew:
So I really thank the person who asked this question for this question.
It really relates to what I call a patient's appetite for intervention.
It's a question of a misaligned sense of communication with the doctor–patient relationship.
It's something I actually reflect on in the way that I speak to patients, and it can go both ways.
I certainly don't want to talk patients into treatments if it's not what they want to do or within their philosophy, before they've exhausted their kind of comfort zone of options.
And I also don't want to deprive patients of treatment if they feel that they'd like to be more proactive.
I think my answer to the question is be honest with your doctor and voice your concerns.
Your doctor may not be able to read your mind and they may not completely or accurately read your mood.
So verbalize your concerns to your doctor.
And they'll either explain their thinking and rationale, but most likely they'll be open—if you want to be more proactive—to move forward faster.
I always feel that way.
And, you know, there are advantages and disadvantages to every potential treatment and approach.
And sometimes there's more than one reasonable option.
So I would say to the person who asked this question, if you feel anxiety that you've not been heard and that your level of concern has not been, I guess, acknowledged—or if you want to be more proactive—you can go back and speak to your specialist about that, and they'll give you a bit more of an explanation as to what their position had been and why, and what the options are for you moving forward.
And you may always seek a second opinion if you don't feel comfortable with having open conversations with your specialist.
Not to say that their advice was necessarily incorrect.
Sometimes it's also powerful to hear things twice from two different perspectives because that also can be very valid and affirming.
At the end of the day, in our practice at Women's Health Melbourne—and I can speak for my colleagues—I feel our approach is personalized.
And one of the things we take into account is the patient's feelings and concerns about the pace of escalation of treatment.
Jordi Morrison:
What is the average drop in AMH from late twenties to early thirties?
What would be DOR?
I don't know what DOR is. Can we—
Dr. Raelia Lew:
Start there?
DOR is diminished ovarian reserve.
So it's kind of one of the many acronyms we have in reproductive medicine.
In terms of AMH, I think the first thing I'm going to do is just challenge the premise of the question.
Average means nothing.
It means nothing to a person. It doesn't matter what the average AMH is. It doesn't matter what the average ovarian reserve is.
It matters what your circumstances are. It matters what your goals and ambitions for family planning are.
Everyone's egg count is as high personally as it will ever be when they are born, and it will diminish over time.
And what the AMH tells us is how a person might respond to a stimulation cycle in assisted reproduction.
And it can be used as a bit of a surrogate marker.
Does someone have polycystic ovaries?
Or is someone at risk of premature ovarian insufficiency or early menopause, as to where they are on the spectrum?
But, you know, we've had previous episodes, which we can link to, about AMH, and I use the analogy of bra size quite commonly because some people are an A cup and some are a double D, and the average is what—a 12C?
So does it matter if you're a double D that the average is a 12C?
You're never going to fit into a 12C.
So I would say don't worry about averages.
Worry about yourself.
And if you need advice, seek an individualized opinion.
And what a doctor will take into account as to whether they recommend an intervention like egg freezing or an earlier escalation to a higher-end technology if you're struggling to get pregnant—
It'll be about your context.
It'll be about the number of babies you want to have in your life.
It'll be about where you are in life in terms of planning your first, second, or third child.
If I see a patient and they've got a low AMH that they've discovered on incidental testing, but they've conceived naturally and readily and are thinking about a second baby, the right advice might be: have a second baby and don't worry about it.
Whereas if someone has a low AMH and they're nowhere near planning a family, and they're worried that by the time they do think about it or are in a position to do so, they may have missed the boat, then being proactive is very relevant.
And in neither of those circumstances does average have anything to do with it.
Dr. Raelia Lew:
Does vaping affect fertility?
It's interesting.
Obviously, we're learning because it's a relatively new phenomenon.
We think it does.
I mean, all the chemicals that we have in cigarettes come in vapes, and they're not good for you.
So, unfortunately, I can't give any reassuring advice to the vapers out there.
I've seen sperm get better when people stop vaping.
I've seen that personally on many occasions.
There haven't been big studies on it yet because it's relatively new, but we know smoking's bad.
We know ingesting chemicals into your body that are unnecessary can be detrimental.
Jordi Morrison:
If you're—
Dr. Raelia Lew:
Trying to have a baby, don't do it.
Jordi Morrison:
Thank you, Raelia.
Jordi Morrison:
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Join us on Instagram at @knockeduppodcast, and join Raelia at@drraelialew, and email us your questions to podcast@womenshealthmelbourne.com.au.