Family get-togethers: How to manage in an uncomfortable situation

November 28, 2018

Hi! Dr. Jungheim here! The holidays are coming up.  So much fun, but also a painful reminder for some of us that another year has gone by and we’re still trying.  I watched a movie on Netflix the other day called Private Life and it reminded me of some of the dynamics that go on when we’re struggling to have a child.  The movie follows a couple who has been trying to have a child for a number of years.  They are in their forties and they’ve decided to move on to using donor oocytes.  They’ve asked a younger relative if she would consider being an oocyte donor.  She is excited to help them.  What an amazing thing in my book, but at Thanksgiving dinner when she announces to the family she is doing this (after a few glasses of wine), her mother pulls her aside and is upset.  The daughter counters that if a family member needed a kidney, her mother would volunteer to be a donor.  The mother counters back and refers to the woman struggling with infertility by saying, “it’s not like she’s dying”.  The daughter yells back, “HOW DO YOU KNOW”!?!

WOW!  The movie hit the feeling spot on… sometimes it can feel like you are dying…

Sorry to get so serious, but seriously, recognize your family loves you.  The don’t want to be insensitive.  They may just not understand.

How do we navigate these situations and stay strong?  Cocktails?

Maybe one or two, BUT, advice from some of you who’ve found things that work would be wonderful!

My advice?  Stay close to your partner during the holiday celebrations…whether its physically standing/sitting near them, or having a pep talk before entering one, or regrouping afterwards.

Looking forward to what others have found helpful…
Please share your advice in the comments of this post on our facebook page!

Pregnancy and Infant Loss Awareness Month

October 23, 2018
This is pregnancy and infant loss awareness month…so glad this issue is getting attention.  While I regularly work with individuals and couples who are struggling with pregnancy loss or who have lost children, it is difficult to talk about.  It is difficult to write about.  I think, and I think most who have gone through it will agree, it is one of the most difficult things we can endure.  Why?  Because having a child is love.  Being a parent is love.  The emotions we experience in these relationships are at the core of what it means to be human.  So, despite the fact that it is difficult to talk about pregnancy and infant loss, I love my job, and I am grateful to have the opportunity to work with individuals and couples through their grief as they continue to build and raise their families.  These are the families that make up the communities we live in and enrich our lives.

I am also grateful to have the opportunity to work with the March of Dimes (MOD) Prematurity Research Center at Washington University.   The MOD has a long history of supporting families with premature babies, but they are branching out.  More recently, the March of Dimes has broadened their attention to supporting healthy mothers and healthy communities.  They recognize that these elements are essential to having and raising healthy children. The work I’ve been doing with the MOD focuses on things that we can modify prior to pregnancy to lead to reduced risks of miscarriage and improved chances of a healthy baby.  Our most recent findings from this work were presented at this year’s annual meeting of the American Society for Reproductive Medicine in Denver, Colorado.  Here’s a summary from one reporter about our findings:

I’ve learned a lot working with the MOD, and I’m proud to be a part of it.  In addition to supporting the Prematurity Research Center at Washington University, the MOD also supports research centers at 4 other centers in the U.S. including the Ohio CollaborativeUniversity of Pennsylvania, Stanford University, University of Chicago-Northwestern-Duke along with one international center at London Imperial College.  We work cooperatively with these centers to learn more about the causes of adverse pregnancy outcomes and to understand how we can improve pregnancy outcomes in the future.

Kelle Moley, MD recently joined the MOD as their Chief Scientific Officer.  Kelle was part of our team at Wash U for years, and she was my fellowship director when I came to Wash U in 2005.  I trained in her lab during my fellowship and that’s where my interest in preconception modifiable risk factors was sparked.  As a fellow in Kelle’s lab I studied the impact of obesity and diet/nutrition on pregnancy outcomes.  I’ve learned a lot from Kelle.  She is an incredible scientist and physician (she’s a member of the National Academy of Sciences), and it will be exciting to see how she impacts the MOD and their research mission in the future as we strive for improved maternal-child health here and across the globe.

Post by: Emily Jungheim, MD, MSCI

Yoga + Fertility

The diagnosis of infertility and the decision to pursue treatment can present significant emotional, financial and physical challenges for individuals and couples that ultimately contribute to increased anxiety and depression.  Behavioral interventions such as meditation and yoga, that focus on increasing mindfulness and self-compassion, have been successfully implemented in couples undergoing fertility treatment and have been shown to improve psychological distress and coping strategies.1,2

The success of assisted reproductive technology therapy relies on numerous factors that are outside the control of any one individual.  Developing a mindfulness practice that facilitates finding peace within the chaos, periods of waiting and unknown is critical to maintaining overall quality of life throughout the process.

As September is National Yoga Awareness month, we want to give a nod to the practice of yoga, as it has been shown to be an incredibly effective tool when implemented prior to and throughout initiating fertility treatment. In addition to the physical benefits such as increased strength and flexibility, the mental benefits from an increasing inner calm, stress reduction and overall relaxation can positively impact many areas of life.3The additional beauty of yoga is that it can be done in the comfort of your own home without any equipment (you don’t even need a mat!) and you can practice anytime you want. So what’s stopping you?

What kind of yoga should I do?
Much of the research that has focused on yoga as an intervention in individuals undergoing fertility treatment has used hatha yoga, which is a type of yoga that combines movement with breath, but you can choose whatever practice suits you best. Other common styles include vinyasa, deep stretch and power yoga. Regardless of the style of your practice. the focus should be on the breath, because that’s where the yoga truly is. Once you learn to breathe and center yourself effectively within the movement, you can translate that practice into everyday life… when you’re stressed about a deadline… while stuck in traffic driving to work or driving to your next appointment… when you find all the ultrasound appointments and injections overwhelming… while waiting in the waiting room… you can find a sense of calm and centeredness within the chaos and keep breathing.

What evidence is there for yoga with fertility treatment?
One study of women undergoing IVF treatment demonstrated that as little as one 55-minute yoga practice once a week for six weeks leading up to IVF treatment resulted in significantly improved overall quality of life, emotional and mind-body scores in addition to a significant reduction in mean anxiety and depression scores.4Another study used a combined approach emphasizing mindfulness of thoughts and feelings through breath, guided body scans and hatha yoga which resulted in improved self-compassion, coping strategies and improved scores in all domains of a quality of life assessment.2

How do I get started?
Make a commitment to dedicate one hour a week to yourself to get started, and see what happens. You could do three 20 minute sessions, two 30 minute sessions, or one hour straight through. Whatever suits your schedule and mind best. Choose a positive mantra to begin your practice with and when you notice your mind wandering, repeat it throughout your practice:
“I am strong… I am capable… I am beautiful… I am resilient… I am a survivor… I am grateful…” Choose a mantra that speaks to you.

There are numerous free yoga videos on YouTube to get you started. Check out our Yoga quick links to view some of our favorites! Once you have the basics down you can simply turn on your favorite music, set a timer for 20 minutes to an hour, go with the flow and breathe. If you prefer a group exercise setting, multiple studios offer very reasonable walk-in rates for anywhere from $5-$10 class.

Commit to taking care of yourself, one breath at a time.

If you have any questions, give us a call! We’re happy to chat!

Namaste,
Ashley Eskew, MD
Wash U Fertility Team

  1. Galhardo A, Cunha M, Pinto-Gouveia J. Mindfulness-Based Program for Infertility: efficacy study. Fertil Steril2013;100:1059-67.
  2. Li J, Long L, Liu Y, He W, Li M. Effects of a mindfulness-based intervention on fertility quality of life and pregnancy rates among women subjected to first in vitro fertilization treatment. Behav Res Ther2016;77:96-104.
  3. Valoriani V, Lotti F, Vanni C, Noci MC, Fontanarosa N, Ferrari G, et al. Hatha-yoga as a psychological adjuvant for women undergoing IVF: a pilot study. Eur J Obstet Gynecol Reprod Biol2014;176:158-62.
  4. Oron G, Allnutt E, Lackman T, Sokal-Arnon T, Holzer H, Takefman J. A prospective study using Hatha Yoga for stress reduction among women waiting for IVF treatment. Reprod Biomed Online2015;30:542-8.

 

Thoughts on PCOS

September 21, 2018

In honor of PCOS awareness month, let’s open up a conversation…

Polycystic ovary syndrome? What is it? 
The first people to describe PCOS were Stein and Leventhal.  They described it in 1935 in an article published in the American Journal of Obstetrics and Gynecology.  They described a handful of women with irregular menstrual cycles, a sign of irregular and unpredictable ovulation, and excess hair growth.  Ultrasound wasn’t available at the time, but Stein and Leventhal took these women to the operating room, and they did laparotomies (abdominal incisions) and took a look at these women’s ovaries.  They found them to be “polycystic” in appearance. Stein and Leventhal took wedges out of these women’s ovaries and post-operatively most of the women started to ovulate regularly and got pregnant.

The story of Stein and Leventhal’s success in helping these women conceive is terrific.  Especially given the fact that there was so little we could do in 1935 to treat infertility.  BUT, our understanding of this condition has changed dramatically over the years, and our options for treating PCOS medically has also improved.

So, here we are over 80 years later…
How do we diagnose PCOS today?  Well, there are a number of different expert opinions on this.  For this I like to turn to the American College of Obstetricians and Gynecologists.  They just published a new Practice Bulletin for OB-Gyns to look to for guidance in helping patients.  To summarize their advice, here goes:

  • PCOS is characterized by hyperandrogenism (high androgens measured by blood test like testosterone, excess hair growth, and/or acne), irregular menstrual cycles (<8 per year or >35 days between menstrual cycles), and/or polycystic appearing ovaries on ultrasound.
  • PCOS can only be diagnosed once other causes of these symptoms have been excluded. These potential causes include thyroid disease, pituitary adenoma, testosterone secreting tumors, and non-classic congenital adrenal hyperplasia.

Overall, how we diagnose PCOS is a lot more nuanced than it used to be, and how we treat it should really be based on what a woman’s symptoms are and what her treatment goals are.

We have a PCOS clinic at Wash U where we work with women to address their goals.

For women who may want to get pregnant in the future, I recommend checking an antimüllerian hormone (AMH) level.  AMH is made by follicles in the ovary—follicles contain eggs and AMH tells us how many eggs are sitting, resting in the ovaries that could potentially be recruited if someone were to undergo fertility treatments.  Easy, repeatable tests to measure AMH only became clinically available recently.   How we counsel women on improving fertility today is largely based on what their AMH value is.  So we may counsel someone with a low AMH value differently than how we might counsel a woman with a high AMH despite the fact that both women might technically meet diagnostic criteria for PCOS.

PCOS & Insulin Resistance
For women with PCOS who are insulin resistant, we may add medications or counsel on specific dietary plans that may help improve insulin sensitivity.  Insulin is the hormone we make that helps us metabolize carbs.  If we have insulin resistance, our ability to metabolize carbs (or glucose/sugar) is impaired.  Sometimes a low-carb diet may be helpful.  This doesn’t necessarily mean NO-carb…NO-carb can be difficult to sustain (oh, how I love pasta, bread, and ice cream).  It means eating good carbs, and being sensible.  We can eat ice cream once in a while, but if we have insulin resistance we should limit it and keep it in check being aware of all of the other carbs we are eating.

So how do we know if we have insulin resistance?  There are lots of way to screen for it, but the easiest way is probably to measure a hemoglobin A1c.  If your level is 5.7 or higher you may be insulin-resistant.  You may also be pre-disposed to developing diabetes down the road. The good news about this though is if you know you are insulin resistant, you can do something about it! You can modify your lifestyle (diet—food choices, exercise habits, sleep habits), consider medications, and improve your long-term health outcomes.  You can do it!

In regards to pregnancy, the main reason PCOS can impede our chances of conception is that it is associated with infrequent ovulation.  So we can’t predict when we are going to ovulate making it difficult to time intercourse.  There are a number of simple oral medications we can use to help improve ovulation. Letrozole is a common one to start with. Clomid used to be our first choice, but a study published in the New England Journal of Medicine in 2014 showed that letrozole may lead to pregnancy faster.  The side effect profile of letrozole is a lot better than Clomid too. So letrozole is often where we start.

Aside from ovulation, there are other things that can impact our chance of pregnancy including our partner’s sperm counts and the uterus and fallopian tubes.  I often discuss this with my patients.  I ask my patients to consider having imaging of their uterine cavity and fallopian tubes with some non-invasive imaging and that their partners to consider having a semen analysis performed.

Overall if ovulation is the only issue we are dealing with pregnancy comes quickly and somewhat simply with the right treatments!

Education is key in managing PCOS.  There is a lot of good information out there, and we have a lot of experience in helping our patients achieve their goals.  If you have questions we can help you!  Give us a call and let us know! 314-286-2400


Post by: Emily Jungheim, MD, MSCI