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I often role-play with nurse clients as I find it is an important teaching tool in exposing the nuances of patient care gaps that aren’t obvious by using traditional methods.

For example, I use this format when reviewing how to convey negative results, where I become the ‘patient’ on the receiving end of the phone call. Last week, during a client coaching session, my ‘nurse’ told me about my negative result, then quickly advised me about calling with my next Day 1 to start the process again.

When we later analyzed the conversation, I pointed out the haste in which she discussed next steps, arguably before I had a chance to process the bad news – a common complaint that I’ve heard from patients over the years. My ‘nurse’ admitted that she knew she was rushing, but was afraid that I would ask her something that she didn’t know, or would express an emotion that she couldn’t handle, one that would make her uncomfortable. But discomfort can be a potent tool, enhancing the patient experience, particularly during an emotionally-charged interaction.

Learning to embrace discomfort was a lesson that I learned 20 years ago in a yoga class, when my teacher told us that once we get deeply in the pose, that we are actually just getting started. The ‘work’ of the pose is what you do from there, when your legs are shaking and you are sweating and hoping that she remembers to count the seconds, and not forget while talking to another student.

You have a choice: do you stay, let up, or go deeper, curious to explore what happens after that? Never to the point of pain, but not skirting around the feeling of deep sensation, sensation that is uncomfortable. The times that I persevered, I discovered something new. Maybe that my legs were weaker than I thought, maybe that my right side was stronger than my left, and, after years of practice, maybe that I had feelings that were stuck, that needed permission to be released. I even found myself tearing up without any warning in class. This is not uncommon, according to my teacher, particularly during hip and shoulder opening poses since many of us hold onto stress in those spots.

This taught me something else about discomfort. It is the result of many factors, not the least of which is that it can be a sign you have triggered something unresolved in your own life. Had I not pushed, not crossed that threshold from content to discontent, I would have missed out on growth potential. I discovered an insight that, in retrospect, has proven to be important in my personal and professional life.

Ok, back to how this applies to being an infertility nurse.

I’ve learned to feel honored to be the go-to nurse in the offices I’ve worked in for relaying negative pregnancy test results to patients. Of course, I don’t enjoy the part of my job where I have to sever the hope of a patient that she achieved a pregnancy that month. I do, however, realize the weight of my contribution to this challenging conversation. Even though I can’t change the news, I can positively affect the experience of receiving it.  I find that applying this perspective gives my role the appropriate level of reverence and gravity that it deserves.

I invite you, as the nurse, to experience what it feels like to settle into the pause between giving bad news and advising of next steps. Allow the patient to express whatever she is feeling and just listen, as awkward or uncomfortable as this may make you. No empty words or platitudes, no story about your own life or other patients’ journeys unless she asks.

By pausing, you are creating an environment that gives her permission and space to mourn a loss. If she asks, “why,” you can answer honestly, and appropriately, that you don’t know. That she may never have an answer to this, but that she can rely on you, and you will be there to guide her through the next steps. If she asks what these are, then advise her to call with Day 1. If she’s not there yet, then maybe the ‘next step’ conversation takes place the next day on a subsequent phone call.

[amazon_link asins=’1592408419′ template=’ProductAd’ store=’fertileheal04-20′ marketplace=’US’ link_id=’019a1f78-2a2e-11e8-ab17-81713c8cc1db’]Realize that, at this time, the person who needs to feel heard is the patient, not you. At worst, she will be upset or angry and you won’t know how to respond, and maybe all you can do is express regret or apologize. Allowing yourself to be vulnerable also has its benefits by promoting human connection, just ask [amazon_textlink asin=’1592408419′ text=’Brene Brown’ template=’ProductLink’ store=’fertileheal04-20′ marketplace=’US’ link_id=’9075476b-2a2d-11e8-8580-6fccfb0ae5bf’].

As a disclaimer, I am just asking you to listen, not advocating that you absorb the patient’s pain. This can lead to compassion fatigue, a very real and damaging potential consequence of being a health-care provider.

Finally, whenever you have to impart bad news to a patient, you may be tempted to hasten the delivery of the news or end the phone call quickly. Consider this first: settling for being comfortable can lead to complacency and missed opportunities for both you and your patient.

You might notice that some people seem to be able to maintain a healthy weight effortlessly while others really struggle. Maybe you personally fall into one of these two groups and it’s difficult for you to relate to the other.

However, gaining an understanding of the reasons why people struggle to lose weight can help give you a better perspective when working with overweight or obese patients.

Traditionally, we are told that gaining or losing weight adheres to a mathematical formula: if caloric intake = caloric expenditure, you maintain weight. Following that same logic, caloric intake > expenditure = weight gain, and caloric intake < expenditure = weight loss.

But we are human beings, not math problems, so we have some nuances that are not addressed by a simple formula.

Satiety is the result of a cascade of events. It starts with the sensory perception of food, called the cephalic phase. Cephalic phase responses (CPRs) are physiologic responses that your body has when presented with the sensory aspects of food (such as sight, smell and taste) which communicate with the brain and advise it to start the process of digestion (Smeetz et al, 2010).

Your body starts the process of achieving fullness even before eating a bite of food. As you eat, there are receptors in the stomach that respond to the volume of food once it arrives there. As the stomach expands, due to the bulk of food or liquids ingested, signals are sent out to eventually stop eating.

Hormones also influence eating patterns. A substance called leptin, known as the ‘satiety hormone,’ is produced by fat cells after someone eats. Leptin is part of a feedback system with the hypothalamus, a structure in the brain that controls, among other things, appetite.

When the system is working properly, increased leptin levels signal the brain to stop eating. Another hormone, dopamine (sometimes known as the feel-good hormone because it is secreted in response to activities that, well, make you feel good) is released when visualizing food or thinking about eating. This process is termed the ‘dopaminergic reward system’ as it activates reward centers in the brain so that people get a rush, so to speak, from eating. How much of a perceived reward is not the same for everyone, and this difference can also be an important contributor to over-nutrition (Val-Laillet, et al, 2015).

Ok, so with all of these mechanisms in place, how can anyone be overweight? Must be due to lack of self-control, right?

Actually no, and here’s why: Unfavorable genetics are largely to blame. Some people are born with glitches in the satiety system at any and all levels.

For example, human and animal research seems to indicate that certain types of gut bacteria make it harder to lose weight (Million et al, 2013). In one experiment, lean rats who had no endogenous stomach bacteria were injected with the bacteria of either rats who were obese or rats who were lean.

Guess what happened to the lean rats who were injected with the obese rat bacteria? They gained weight. So, it seems that people who have this gut bacteria are already prone to being overweight before they even put food in their mouth. Wouldn’t it be great if we could all be injected with lean-weight gut bacteria? I’m sure this is in our future but, unfortunately, we are not there yet.

Metabolic differences can make some more prone to overeating. Studies that compared dieters (people who diet frequently and, therefore, are likely overweight) with non-dieters found that dieters need to eat less than non-dieters just to maintain weight. Any extra calories, then, are converted and stored as fat in this group.

The cause of this could be that they are dieting and restricting their intake or that being overweight puts them at risk for this, but the outcome is the same: it’s easier for this group to gain weight while eating the same amount as some of their peers. Not fair, right?

Remember the dopaminergic reward system? There is emerging evidence that people who are obese have differences in their genes that affect dopamine signaling, such that their reward centers are hyper-responsive to food cues. They are susceptible to food cravings and overconsumption because they get a bigger ‘rush’ from seeing or eating food more than their lean counterparts do (Val-Laillet, et al, 2015).

This dysfunctional system can be so strong that it overrides the normal controls and feedback systems in the body that are in place to assure caloric and energy equilibrium. The reward centers for lean people may be less responsive to food, so it’s less of an effort for them to push the bread basket away or leave food on their plate. For them, eating isn’t the source of intense pleasure, so they are not as tempted by appetizing food, which may be misconstrued by others as self-control. If the above isn’t bad enough, there is something called, ‘leptin resistance.’ If you recall, leptin is the satiety hormone, the one made by fat cells that signals the brain to tell it to stop eating. Well, it has been found that obese people can have even higher levels of leptin than their lean counterparts (this makes sense since obese individuals have a more adipose or fatty tissue) but not be as sensitive to them (Myers, et al, 2012).

As a result, even with these high levels, obese people still have a desire to eat. This becomes a vicious cycle where the leptin resistance leads to overeating, which increases fatty tissue, which increases leptin (but the brain doesn’t respond to it) and the cycle perpetuates itself. As of now, there is no ‘cure’ for this.  Although some pharmaceutical approaches to increase leptin sensitivity appear promising, none are currently approved.

Don’t rush the soup. All of the above factors seem to make it easier for naturally lean people to succeed, and create very real challenges for people who are obese. These challenges aren’t insurmountable though. There are some strategies that might help. Taking extra time to smell and savor your meal before you eat it prolongs the cephalic phase of satiety and allows extra time for your body to recognize that it might be full. Eating soup or drinking water prior to eating can induce greater fullness by delaying gastric emptying, and stomach distention stimulates the gut receptors to tell the brain to stop eating. Also, there is some data to show that people can reset their leptin levels with long-term healthy lifestyle changes like eating whole foods that take longer to digest and exercising regularly.

Most importantly, for us in the health care industry, it’s important for us to not judge others who are overweight. Weight bias seems to be one of the few remaining acceptable biases left. Studies on weight bias report that overweight people have been labelled as ‘lazy, awkward and non-compliant’ as well as other hurtful and deleterious terms, even by the medical providers who take care of them (Foster, et al, 2003). As you can imagine, then, even a perceived weight bias by you or someone in your practice would negatively affect patient care and retention of overweight or obese individuals.

Related: How to talk to your fertility patients about their weight without seeming like a jerk

Since obesity is on the rise in the U.S., and an increasing number of our patients will be affected by this, it’s incumbent on nurses to understand what leads to over-eating.

We need to realize that eating behavior is multifactorial, the result of a complex interplay of many factors, only some of which are addressed here. Blaming over-nutrition on a lack of self-control is not only unkind, it’s untrue. Please realize that any discussion of weight should be done kindly, compassionately and with the knowledge that, for some, the decks are stacked against them.

References:

Foster, et al. Obesity Res 2003, 11: 1168-77.

Million, M. Et al. Clin Microbiol Infect 2013, 19(4): 305-313.

Myers, M.G. Et al. Cell Metab 2012, 15: 150-156.

Val-Laillet, et al. Neuroimage Clin 2015, 8: 1-31.

Sheets, et al. Nutr Rev 2010, 68(11), 643-55.

Dear Wonder Woman,

You are beautiful and you are not just a sum of your (sometimes seemingly faulty) parts. Because that doesn’t take into account your spirit and grit as you proceed on this path.

This journey, although tortuous at times, will make you stronger, even if you don’t see it right now. We will go through it together. I can’t possibly imagine how you feel, but I do know that you feel and that you feel deeply.

I care so much about you and your outcome, that I sometimes seem insincere. You might think I am flippant or not listening but I am actually protecting myself. It’s often that the thought of feeling helpless, incompetent, even futile, haunts me long after I hang up the phone or leave the room. Sometimes I lie in bed at night thinking if there is anything else I could have done, anything else I could have said….

If I could give you some advice, it would be that it’s so important to take care of yourself and allow others to take care of you. This is not being selfish, it’s practicing self-care. This is nourishing yourself at a time when you might feel that the outcome is out of your control.

And here is a secret: we experienced infertility nurses aren’t impervious to your discomfort during this process, even though you might not see us angry or sad or frustrated. Every time that we draw blood, we bleed for you. Every time we (inadvertently) hurt your feelings, we hurt too. Every time you feel pain, we ache too.

But every time you are ready to start again, we are right there with you, hopeful, excited and optimistic because we know that, for almost everyone who hopes to conceive, there will be a positive outcome.

So, my final thoughts are an echo of my first.

Please try not to let this process define you. Here is how I would define you: worthwhile, strong and amazing. Even when you don’t feel that way, you are. I should know, I’m the expert.

Finally, I want to thank you for teaching me to be a better nurse and person, just by knowing you and allowing me to care for you during this private and emotional time.

For this, I am grateful.

I was talking to my daughter the other day about why she shouldn’t post a picture on social media of a party that she attended because other kids who weren’t invited might feel sad and excluded seeing the post.
She persisted, but I was resolute. She finally agreed, but stomped away, mumbling how strict and uncool I was (both of which are true).
Why do I feel so strongly about this? Mostly due to working with infertility patients for the last 20 years who are often ‘left out of the party’.

Think about it.

Many women spend their 30’s either pregnant or breastfeeding. Most conversations revolve around topics related to challenges of these, i.e the number of dirty diapers in a day, breasts leaking at inappropriate times, what to do with young kids from 5- 7 pm when it was cold and dark outside and they were bored. Lunches and dinners consist of a discussion of the best products for babies or kids, I know this from personal experience. During this time period, I didn’t post much on social media, but if I did, it would be reflective of snapshots of this life: kids everyday, everywhere. Infertility patients are inundated with conversations and pictures of the family life that they hope to have at a time that they don’t have it yet. Sometimes I would complain about the struggles of having a young family and other times I would laugh about it, like when my daughter told everyone at my son’s baptism that she had lice. Either way, I developed a camaraderie with a group of my ‘mommy friends’ who were in the same life stage. We forged strong bonds as a result of learning how to be moms together. We were all attending the same party. How does a patient who is undergoing infertility treatments assimilate in this world?

In addition to social isolation, infertility patients also experience a lack of control. Consider when someone wants to lose weight. They go online, find exercises and diet tips, get a trainer, join a gym, maybe use some people’s own weight-loss journeys as motivation. Theoretically, if you create a calorie deficit, most likely you will lose some weight. Infertility patients can follow all of the rules, do everything that is asked of them, employ experts, and still may not conceive on a timeline acceptable to them. Consider the loss of control and frustration that ensues. It’s inescapable as reminders of other people’s fertility is present at all times of the day. Imagine being immersed in your own fertility journey and attending a baby shower during lunch at work. Considering going home and receiving an invitation to a baby shower in the mail or electronically. Reflect on relaxing at night while perusing social media and seeing picture after picture of women who seemingly conceive with ease.

My hope is that we are all aware that by living and celebrating our daily family life, we are tacitly, albeit unintentionally, creating an environment that isolates infertility patients and is a reminder of the lack of control they are having in their own lives. Of course, I’m not advocating that you don’t post pictures of your kids or your life, that would be unreasonable and hypocritical of me, as I, myself, do this often. But maybe we can use social media, in this case, as a reminder to be compassionate.

I was reading that a way to instill gratefulness into your life is to silently state something for which you are thankful every time you open a door. I’d love for you to consider that every time you post a picture, maybe you say a little prayer or put a kind thought out to the universe (if you’re not religious) for those who are struggling with infertility or pregnancy loss.

October is baby loss and miscarriage awareness month, so I thought I’d share a story with you about how I have been affected by this, both personally and professionally.

At 10 weeks, during my second pregnancy, I was told that my baby’s heartbeat stopped. Of course I was devastated, except that I did have a little nagging intuition that something ‘wasn’t quite right’ with this pregnancy which I had been hoping to disprove.

At the time, there was one sole physician at my practice, and I helped him with office procedures. He was away on a planned vacation, so it was up to me to cover the office. And, just to further add to my misery, my cat had escaped, my dad had received concerning test results and oh, it was my birthday.

I scheduled a D & C on a Friday because I couldn’t miss too many office days. I dropped my daughter off at my friend’s house then headed to the hospital with my husband, who didn’t know what to say, so he kept making jokes until I told him that I would punch him in the face if he didn’t stop. He stopped.

My sweet OB/GYNs (Drs Gennaro and Cahill) were there to do the procedure and, as always, were so kind and awesome. I tried to seem ok with it all, because oddly I didn’t want them to worry about me, and the procedure was uneventful. Once released from the hospital, I picked up my daughter (who was 14 months at the time) and we all headed home where my hubby asked if he could take a quick nap as this was “very stressful” for him (he actually is a great guy, but seriously?)

I returned to work that following Monday and my schedule was ironically crammed with pregnancy scans. I was wholeheartedly happy for all of the patients, as I knew most of them well and was part of their journeys so far, but there was an undercurrent of sadness for my own situation. I bottled up these feelings as they felt too self-indulgent and selfish.

Somehow, I got through that week, with my bottled-up feelings and conflicting emotions until that Friday. That day I did a pregnancy ultrasound on a patient and didn’t see a heartbeat.

We sat in silence for a bit while I searched, and she desperately wanted to hear what I desperately wanted to say. That all was ok. But I couldn’t. Because it wasn’t.

I felt my face get hot, my throat closed up and my eyes welled with tears at the same time that hers did. The words “I’m sorry” got caught in my throat, but they felt so inadequate that I didn’t say them. Her husband wasn’t there and she looked at me and asked if she lost the baby. I said that she had, and she just nodded. Then, eloquently, I said, “This sucks, this just *bleeping* sucks.” To my horror and amazement, she laughed and I cried at the same time. And not girl crying, by the way, but big, runny nose, unattractive, sobbing crying. Eventually, we both did.

They chose to have a D & C the following week, and I visited her in the recovery room and we chatted. She told me that I was so kind and caring, and I revealed what had just happened, as I felt like a fraud. I had used her experience to release my own feelings of loss, and for this I felt both empathetic and pathetic.

Ultimately, she conceived again, and delivered a healthy baby (as did I), and sent me a card thanking me for all that I did. How about that for grace. I’m not sure if I would have done the same if I was in her shoes.

I hear, from my patients and friends, that some clinicians are, well, not so great at delivering bad news and I can tell you, it’s not because they don’t care. It’s because they care too much. I am now actually grateful that I had this negative experience, as it has given me perspective that I tap into every single time I do a pregnancy scan. Now I don’t run from this discomfort, I lean into it. I allow myself to feel and absorb what this patient or couple is experiencing, and try to give them what they need, whether that is talking it through, not saying much, or sitting quietly while she (or they) cry and process the news.

I have also learned that people handle grief differently and no way is the wrong way. My husband tried to diffuse the situation with humor, then gave up and realized that caring for me and feeling what he felt was exhausting. I tried to make myself feel better by trying to make everyone around me feel better until it didn’t work anymore. My patient laughed until she cried.

If you have had this experience, you might have your own way of dealing with loss. And that’s ok. Just please realize that we, as your clinicians, may not say or do the ‘right’ thing, because we feel deeply for you and we handle this emotion in a variety of ways. Witnessing the naked emotion that is expressed when anticipation and cautious optimism becomes grief can be heartbreaking and can make us feel intrusive.

My fervent wish is that, as clinicians, we can learn to see our interaction at this time as a privilege and an opportunity to be the person that you need us to be.

Warmly,

Monica

I’ve had the opportunity over the years to work in a few different fertility clinics, all sizes and in many regions. I’ve also, as a consultant, have been privy the inner-workings of many others and have come to the conclusion that the following factors are important for staff and patient satisfaction at a Reproductive Endocrinology and Infertility (REI) center.

Of course, pregnancy rates are important (and can be researched on the CDC SART website) but that only reflects the outcome of your cycle. Since you will most likely have multiple visits to an infertility center, spread out over weeks or months, and have many points of contact with all of the staff, the quality of your experience while there is also pivotal.

Look out for these five elements when looking for a quality fertility clinic:

• 1) The staff genuinely seems like they like each other.

The importance of staff cohesiveness can’t be emphasized enough, in my opinion. We have all had bad days at work (or a bad day in life and had to go to work) and the camaraderie of your colleagues can go a long way in helping to elevate a bad mood.

How this translates in a fertility center is that a staff that works together at all levels can enhance the patient’s cycle, from start to finish. A fertility cycle requires input from multiple departments (finance, nursing, embryology) at many different points in the cycle(s).

For example, insurance verification is a time-consuming, necessary evil and having a nursing department that is in close contact with a finance department can help facilitate the process of cycle authorization and assure that the patient is capitalizing on what their insurance offers.

Medical assistants who talk to nursing to see if a blood test is necessary in someone who is self-pay or who has a particularly bad needle-phobia are the best kind of patient advocates. Also, staff that are happy to be there are also happy to help and will often go above and beyond their job to optimize their patient’s experience.

• 2) You get a good feeling when you walk into the office.

This is hard to describe, but you know when you feel it (and particularly when you don’t).

Just like your introductory meeting with a person, the first impression that you have in an office is important and often sets the tone for the rest of your visits.

When you walk in, does the front desk address you in a timely, pleasant way? Or are they looking anywhere but at you? Does the medical assistant or nurse who takes your vital signs introduce herself? Do you see lots of smiles and eye contact? Or does it feel like you walked into a rival sorority house when you walk in, i.e. an undercurrent of hostility, unpleasantness, frenetic busyness. Do you feel like you are bothering or interrupting the staff every time you ask a question?

You want to be in a place that exudes positive energy, whenever possible, particularly when you will be undergoing a process that can generate varying levels of stress.

• 3) The office emphasizes general health and wellness.

You are not just a walking uterus and ovaries (let’s not even mention how one could envision the men). You are a whole person. As a whole person, what you eat, do and think can, arguably, affect your fertility.

It would be remiss of any physician’s office not to ask you about your nutrition and lifestyle, and then emphasize non-pharmacological ways to assist you in your attempt to conceive. Kudos to an office that emphasizes the importance of nutrition and extra fist bump for those who have close contact with a nutritionist or, the holy grail, one that employs a nutritionist in the office.

Ask yourself: what do you see first when you walk into the office? Are there seminars and opportunities for small group meetings? What magazines are in the waiting room? Old issues that the staff wasn’t interested in taking home, or magazines that emphasize health and wellness? The waiting room can be a microcosm of the components of care that the REI center finds important, so what you find there is often reflective of what you will experience during your visits.

• 4) The website is robust and has patient education opportunities.

A fertility center’s website is another way to make a first impression, and it can help you decide what the staff thinks is important for you to know.

I have seen websites for big centers that are just a few pages and emphasize only the surgeries the doctors do. They have no real introduction to the rest of the staff or services offered.

In contrast, I’ve seen websites that offer educational articles and videos, links to helpful patient advocacy groups, and offer live-feed Q and A’s with clinicians. Think about the website in the same way you would look for a mate. Don’t make a youthful dating mistake and go for style over substance.

• 5) The physicians rely on current, relevant scientific research in their everyday practice.

The good news about working in the infertility field is that there are so many advances and new techniques. The bad news is that there are consistent advances, and it’s vital to keep abreast of them, researching which ones will have longevity and which ones start as good ideas but don’t work once put into practice.

For example, we weren’t sure that ICSI would be safe for oocytes when it was first utilized, but now we can’t imagine IVF treatments without it. One of the hardest diagnoses to manage and overcome in infertility is that of a diminished ovarian reserve, when the quality (and quantity) of the women’s eggs is low or lessened. Since many of our patients face this diagnosis, much REI research is done to find ways to combat it, since it can’t be “cured” at this point.

Whenever I go into another center, I ask the physicians what they do differently for this subset of patients, and I often am told a variety of methods. Not all may work, but hopefully the physician has researched them, asked colleagues about them, and has gone to an academic conference where it was discussed.

This generates another important point. Good fertility centers promote professional development opportunities for their staff. They are willing to have either an in-house nurse educator or employ an outside consultant to educate and enrich their nursing staff. They are always striving to refine current protocols and standing orders. They send their staff to conferences, both local and national. They support the staff’s efforts at obtaining continuing education units or advancing their degrees. In return, the staff feels valued, which leads to higher morale and better patient care.

Currently the CDC database lists 450+ REI centers in the US that report to SART and offer infertility treatments. The choice of which fertility clinic to use (or in which to work) is a big one and ultimately, like any big decision, one that you will probably make with a combination of information gathering, logic and your gut instinct.

Hopefully, these tips will help you refine your search for the REI center that meets your needs.

As a fertility nurse, I know that we often receive emails from the front desk asking us to call a patient about a particular question or problem.

Although fertility treatments, and the challenges inherent in them, can be incredibly stressful (and this is not meant to minimize that) you might get a laugh from some of these. Whether you are a nurse or patient, I’m sure you can identify with many of these scenarios.

The following is a list of some recent (and real) email subject headings as well as a description of the situation and outcome.

• 1) “Patient’s husband can’t leave a sample because there was a bat in the house and he’s very stressed out.”

We often joke about the male partner’s role in fertility treatments. The female has to do the bulk of the ‘work’: mix and administer injections, undergo blood draws and vaginal ultrasounds…etc.

All the man has to do is to provide the sperm sample. Well, we need to remember that the ‘act of providing’ the sample is somewhat dependent on the male being relaxed and in the mindset to ‘produce.’  Having any kind of added stress can be deleterious to the production process, to say the least. So in this particular situation, after chasing a bat around the house in the early morning hours, the last thing this poor guy wants to think about is producing into a cup. This can happen in even less eventful situations, like having an important work meeting or just feeling the stress of a positive ovulation predictor kit month after month.

If you think this might be an issue for your partner or your patient, have a back-up plan. Consider a frozen sample, or renting a local hotel room (seriously, sometimes the proximity to the office or escaping an office-like atmosphere can help). Although we often focus most of our care and attention on our female patients, this serves as a reminder not to forget about the men.

• 2) “Please call patient, she has a meeting and can’t have her egg retrieval today.”

There are many variations of this: husband unable to bring in his sample due to traffic, unable to come in for a blood test or ultrasound due to bad weather … etc. Yes, there are many components of a fertility treatment cycle that are precisely timed, but there are some that can be modified.

Usually, the most flexibility occurs earlier on in a treatment cycle, so if you have to miss or reschedule an appointment, it can often be done then. If you have ‘blackout dates,’ or those days that you are unable to come into the office due to vacations or work conflicts, we can often plan around them, if we know in advance. There are some procedures, though, that are specifically timed and can’t be rescheduled, such as having an insemination or retrieval after your trigger shot. It’s still worth calling the office if you have a change in your schedule to see what can be rearranged and what can’t, but just know that some timing is beyond our control and rescheduling might be detrimental to your cycle. Regarding the semen sample timing, most centers are comfortable with the sample arriving within 45 -60 minutes of production (check with yours to see their policy). The sample should be kept close to body temperature, not frozen, for example, we had one male partner put his in a cooler with frozen veggies as he thought he would run errands on his way home from the grocery store.

• 3) “Patient sneezed and her embryo fell out. She saved it, though, and can bring it in.”

So…this one, or some version of this, has come up almost every year since I’ve working in REI. Even though a blastocyst (an embryo at its implantation stage) is only the size of a period on a keyboard, infertility patients will obviously do anything to protect it and facilitate implantation.

We can only be so proactive to help implantation take place. Even when we do IVF, where we transfer the embryo directly in the uterus, it still floats around and finds a comfortable spot on its own, which can take a day or so. No amount of pressure (such as sneezing and going to the bathroom) will expel the embryo. Likely, what is being seen or felt is residue from vaginal medications, mucus or (yup) urine. So don’t worry if you sneeze or cough or yell. Your blastocyst is safely ensconced and is looking for (or found) its cozy spot.

• 4) “Patient sent a picture of her butt and wants to know if she gave injection in the correct spot.”

Well, I have seen many butts, stomachs, and thighs over the years, and even seen some remotely (and abruptly) over FaceTime or Skype. Patients are taught how important it is to give the proper amount of medications, in the proper spot, and avoid big veins and the sciatic nerve. It’s no wonder they are so careful about where to give the injection. Even though we are happy to draw circles on their butts, when it is time to actually give the injection, it is still scary and nerve-wracking to give yourself or your partner an injection.

One of my patients asked her grandmother to help, because she is diabetic and used to giving injections. However, she didn’t take into account her grandmother’s poor eyesight issue, which generated an interesting injection site and caused some pain for the next few days. Also, sometimes, no matter how careful someone can be, there will be a little bleeding at the injection site, even moderate bleeding, because there are superficial blood vessels that can’t be avoided. Hitting these is ok, it just might cause a little bruise. We know that you’re nervous, so we are happy to draw circles, help with injections or look at your butt whenever necessary.

• 5) “Patient’s dog ate her estrogen and she is wondering what to do.”

Fertility patients are very protective of their medications and with good reason. They are expensive, not easily obtained, very time-consuming and dose-specific. It can be overwhelming to receive the big box that is shipped and wonder, “what goes in the fridge?” or, “what needle do I use with what medication?” …etc.

I usually suggest separating and batching the medications and syringes, that is, putting stuff next to each other (or rubber banding it) that goes together. So, progesterone with progesterone needles, leuprolide with leuprolide needles…etc. As for the pills, many of them are not used until later, so they can be put away until you’re told to use them, in an effort to avoid any confusion and stay organized. It is helpful to keep the medications in a safe, climate-controlled area (unless they need to be refrigerated) away from kids, pets and nosy mother-in-laws who might snoop. Maybe in the master bathroom or in your bedroom, but out of reach. We have had cats knocking over and playing with medication vials, birds flying off with syringes, and dogs eating pills. By the way, the dog was ok, just a little breast tenderness.

Many of my colleagues and I really enjoy our roles as fertility nurses. We love taking care of our patients and helping them through the process, and absolutely understand that questions arise along the way. Hope that this answers a few of them and in the future, we will pick on the men a little more.

Ok, so you are starting fertility treatment. Overall, it’s exciting to have a plan to be able to achieve the family you have envisioned. At your appointment, your health care provider reviews the basics with you, discusses medications, next steps, treatment strategies, percentages. You hear most of it, and will probably ask a few questions.

Then, he or she sneaks in, “Oh, and by the way, no drinking, no recreational drugs, no high-impact activities and either schedule or abstain from sex depending on where you are in your cycle.”

Umm… what? Immediately, you’re probably thinking, “Let’s be clear. You guys are going to, arguably, create stress for me in my life and take away my methods of stress release?” What are we supposed to do now to keep from going crazy? Most likely, you either are embarrassed to ask, or you may not get a solid answer.

As a nurse with over 20 years of experience in reproductive medicine, I can tell you that yes, it feels unfair. I can also tell you that we are not really taught or advised what we can offer you as a substitute for your usual methods. We understand that we are asking a lot of you, and because of this lack of training, often we’re just hoping you don’t realize that at the time, or you are so excited to get started that you’ll think, “Well, ok, I can give up anything if it means that I’ll have a good outcome.”

Most people will have a good outcome – at some point. However, it won’t necessarily be on the first cycle. So, you might get a call with a negative result, and not be able to have wine to relieve that stress. Or in the midst of a cycle, you might want to go for a long run and realize that you aren’t supposed to be doing this.

Even though it is asking a lot, there are reasons why we impose these restrictions, mostly because you are attempting pregnancy and need to limit any alcohol, drugs, and smoking, plus taking fertility medications will enlarge your ovaries, which means that there is a limit on your exercise as well. So, what can you do?

The following are some suggestions that I recommend to my patients for self-care that you can use during your fertility cycle:

• 1) Surround yourself with people who “fill your tank.” This means limit toxic people, or those who are time-consuming, negative or just annoying. You can do this. It is absolutely ok.

Right now, while you are somewhat stressed and focused on a certain outcome, it’s important to interact with people who are helpful or make you happy. You know who these people are – every time you see them or get off the phone with them you seem lighter somehow. Maybe you are smiling more or just feel like you have more energy. Then there are those who require maintenance and hard work. Be kind to yourself at this point and trim the address book. Limit your interaction with people who take more than they give. You have enough to think about without worrying about your mother’s bunions.

• 2) Research “hygge” and incorporate it into your life. Hygge is a Norwegian word that means doing something that generates a feeling of contentment/happiness/well-being (Wikipedia.com). Just do yourself a favor and don’t try to say it, because it is not pronounced the way it is spelled and you might feel like an idiot saying it incorrectly at a dinner party – definitely not the kind of stress you need.

In the summertime, incorporating hygge into your life can mean growing herbs or flowers, or going for a walk and noticing beautiful scenery or smells. In the cooler months, maybe covering yourself with a cozy throw or taking a warm (not scorching hot) bath. There are several books on the topic, as well as examples on Pinterest and other sites.

• 3) Employ all of your senses. I sometimes recommend essential oils to those who are interested. They have many uses and certain ones can help with relaxation when added to a carrier oil and applied or diffused. Many are safe to use in pregnancy.

Aside from that, take your dog for a walk, or enjoy curling up with a purring cat. Listen to your favorite songs, maybe make a few new playlists, one that is happy and one more contemplative. Have a cup of coffee (yes you can have some caffeine during your cycle) or better yet a great herbal tea. Sometimes just the scent of it is calming.

• 4) Reading or journaling. I know that these are two separate interests, but most people like one or the other. Journaling is great because you can get your thoughts on paper, and out of your mind for the moment, even the ones that don’t seem ok, that you might not admit that you are having to anyone but yourself.

Some experts recommend keeping a gratitude journal to remind yourself of all of the positive things in your life (preferably do this at night or in the morning) when the other, less positive thoughts feel overwhelming. If you don’t like to write, I have advised people to keep an online album of photos that make them happy that they can refer to when they don’t feel so happy, a good memory such as a picture of a concert that you loved. A picture of your walk on the beach or along a tree-lined path. A picture of the great dinner that you made and enjoyed with friends. For me, I love to read, so a good book is my ‘go-to’ for stress relief. Sometimes fiction, but recently I’ve found myself drawn to inspirational books, those that have a message that resonates with me. I just recently finished an excellent book, “The Universe has your Back” by Gabrielle Bernstein. It was so good, that I originally purchased the Kindle edition, but found that I wanted to bookmark so many pages and underline so many phrases that I also bought the paper copy.

Pinterest is also a great resource to find suggestions for books, either by the year (I.e. the best books of 2017) or by the subject. There is also a Facebook site, The Modern Mrs. Darcy, that is great if you need a few book recommendations.

• 5) Don’t give up on movement and exercise. Just because we limit the high-impact activities, doesn’t mean that you can’t still move. Physical activity produces endorphins (feel-good hormones) and even short bouts of it can be helpful and have lingering, positive effects.

Instead of running, you can walk with water bottles, so you can stay well-hydrated, but the weight of the water also provides resistance and requires extra effort. Yoga is great, both for its physical activity but also mental benefits. Some centers, like RMA of CT, even offer yoga in-house. Low-impact group exercise is great, if being in a group is more motivating for you, as is swimming. How do you monitor if you are pushing yourself too hard? You should be able to speak in a sentence at a time. If you are huffing and puffing, and can only string together two-three words at once, you need to bring it down a notch.

• 6) Get a massage or, even better, schedule acupuncture. I put this one last, not because it’s the least important but because it can be expensive to go to multiple sessions. Yes, regularly scheduled appointments are better but, like exercise, even a few sessions can help.

You know how your spouse/partner/friend/family member is always asking you what they can do to help? Ask them for a gift card to a massage place (make sure that you tell the therapist that you are hoping to get pregnant or could be pregnant) or to pay for an acupuncture session (also tell the acupuncturist about attempting pregnancy). Acupuncture has the added benefit, in some studies, of increasing blood flow to the uterus, relaxing smooth muscle (which the uterus is) and promoting relaxation.

Congratulations on taking the next step in building your family. I forgot to mention a very important resource during the process – your nurse! We are here for you, and nothing you say or do will shock us (we have heard everything, which is the topic of another blog post that will be coming out later in the month), and we might even have some suggestions other than the ones listed above. Please feel free to ask us or let us know that you need some advice. It’s ok to say that you are not feeling ok.

And we apologize in advance for the demise of your wine during your cycle. You can always write about us in your journal. We’ll never know.

I spoke to my female patient about her weight the other day. Wait, you say. Isn’t that against “Girl Code”? Tantamount to replying “yes” to the “Do I look fat in this” question?

Actually, I would counter that discussing excess (or not enough) weight, as a nurse to your fertility patient, is not only appropriate, it’s necessary. Here’s why.

There are many studies that show that being obese has detrimental effects on getting pregnant, staying pregnant, and on the baby. One study showed that natural fertility rates declined comparable to a year in age for every BMI (body mass index) unit over 30. That means that your ovaries act ‘older’ the higher your BMI category, and everyone knows that age and fertility are natural foes.

While we are not sure of the exact mechanism of how weight affects fertility, we know that ovarian, uterine and sperm function are all affected (yes, regardless of your weight, an overweight male partner also puts you at a disadvantage). We know that as BMI increases, so does time to conception, the amount of fertility medications needed, and the chance the cycle will be cancelled due to poor response.

Once you are pregnant, elevated BMI increases the chance of stillbirth, or pregnancy complications, such as gestational diabetes, and labor complications. Finally, a suboptimal uterine environment, such as that caused by gestational diabetes or obesity, can cause gene mutations in the fetus that follow him or her into adulthood, such as Type 2 diabetes, obesity, and cardiovascular disease.

One of the most common questions I get as a fertility nurse practitioner, and I’m sure that you do too, is, “what can I do to improve my chances/outcome?”

We would then discuss any necessary lifestyle changes (such as stopping alcohol, smoking, etc), so why exclude a discussion about weight with someone whose BMI puts them in the very overweight/obese/morbidly obese category, giving them less of a chance to conceive than other age-matched patients?

Armed with the information above, I think we can now all agree that excess weight is not helpful when trying to conceive, but how do we discuss it with our patients? In my opinion, it can be done honestly, appropriately, kindly and in context.

Let’s start with how to appropriately introduce the topic when speaking to your patient. I was speaking to a patient the other day whose BMI was 46 and she asked me if there was anything that she can do while waiting to proceed with IVF (in vitro fertilization). In my mind, that number, 46, was like a flashing neon light in her record that I couldn’t ignore. Just as I would honestly and openly discuss elevated blood pressure or an abnormal lab value, that is how I treat BMI.

Someone’s weight doesn’t define them, but it can be an obstacle.  

So, I say something like, “Your BMI category is ‘x’ (underweight, overweight, obese, etc) and I fear that this is hindering your ability to conceive.” Realize that most people underestimate their BMI category, so obese patients think the they are “just overweight” and very obese patients think that they are “mildly obese,” etc.

The BMI category matters, because, as stated above, as BMI category increases so, potentially, do the adverse effects of it on a patient’s fertility potential.  I feel comfortable discussing the topic of weight mostly because I am passionate about it, but also, importantly, because I have the support of the clinicians in my practice, www.rmact.com, and we have an in-house nutritionist. This is important, because I don’t have to introduce a challenge without offering a solution.

You should develop your own “script,” or wording that you feel comfortable using, that you can refine with time and experience, while starting to impress upon the rest of the clinicians and staff at your practice the importance of support for patients of all sizes.

Once you have that script, when is it appropriate to broach the topic? I prefer to discuss a patient’s weight after I have established a relationship or rapport with her, maybe during her diagnostic cycle as that generates many phone calls and interactions.

I hope, that after having spoken with me, she realizes that I have an emotional investment in her and her child’s outcome, and discussing her weight is just another aspect of this. But sometimes, a patient’s BMI needs to be discussed during the initial consult, as perhaps your practice has a BMI cut-off for services that your patient exceeds. How, you may ask, can you initiate this conversation when you first meet a patient, before you have developed a relationship?

One way is to embed questions about weight in your new patient questionnaire, such as “Have you had a significant weight gain or loss in the last year,” or, “On a scale of 1-10, how motivated are you to make a change in your weight.”

Then, as you review the questionnaire with the patient, you can not only use the questions as a segue into a discussion about their BMI, but also assess their motivation to make a change at this point. Another way is to assure that you have a “healthy office.” This means an office that is equipped with the equipment (large blood pressure cuffs, cloth gowns and stools without wheels, etc) needed to properly care for overweight or obese patients. It is also one that has a staff who has been prepared to sensitively care for overweight and obese clients, keeping in mind the influence of weight bias, a form of discrimination that, arguably, most of our overweight or obese patients have experienced at some point by people who take care of them, including health care providers.

It is an office that has healthy magazines and maybe cookbooks in the waiting room to give clients a first impression that health is important to those who work there, which helps to facilitate a conversation about weight in the context of the general health of your patients. The clinical suggestions above and more are available from the UConn Rudd Center  (www.uconnruddcenter.org) which offers a great online course on this topic.

I don’t enjoy the potential embarrassment that can be generated by a discussion about weight, but I don’t use discomfort as an excuse to avoid it.  In my opinion, this conversation must occur in order to provide comprehensive, individualized care to overweight or obese patients. In fact, I would argue that all staff in fertility settings should, at the very least, be sensitive to this patient population, be knowledgeable about the effects of weight on fertility and pregnancy, and strive to find ways in their office setting to incorporate discussions about weight.

If you are interested in this topic, please contact me at monica@fertilehealthexpert.com or surf this website to view services that your practice might find helpful.