Kind and Brave

To My Daughters,

I remember a car ride years ago when one of your brothers was upset that he got a bad grade and was worried that he wasn’t ‘smart’. I told all of you that the most important qualities in a person (to me) are being kind and brave. You all got the gist of being kind but had some trouble envisioning what being brave looked like at your age. Your then-5 y/o-brother asked if it meant that he should act like a superhero and save the world from villains, but we discussed that it’s actually simpler than that. You can be brave on a regular basis in small (but impactful) ways like standing up for a kid who is being made fun of, or staying firm in establishing boundaries, even when others don’t like them. Bravery is having integrity (often quietly but sometimes fiercely) in situations, even when it feels hard or when others don’t.

As you know, I am both heartbroken and infuriated by the decision of the Alabama Supreme Court in mid-February where it ruled that three couples who had frozen embryos destroyed in an accident at a storage facility could pursue wrongful death lawsuits for their “extrauterine children.” Although once Roe V Wade was overturned, we (in the infertility field) knew that this decision might negatively affect us and our patients, I naively believed that they would leave IVF alone for now, since (last I checked) trying to build your family is pro-life. To me, being ‘pro-life’ implies that you care about the life of the child at all stages, not just before he/she is born. Apparently, ‘extrauterine’ in Alabama extends to protecting embryos in an IVF lab but not the babies born from these embryos once they live in the real world. Alabama (along with many of the other restrictive states) has one of the highest rates of infant mortality and ranks as one of the lowest states in terms of the health of the children who live there. Making laws that only protect fertilized eggs (but not the babies generated from them) is not ‘pro-life’, it is pro-birth. What is even more alarming is that this decision is just the beginning of a dangerous trend nationally, as there are over a dozen states that consider ‘life’ starting at the time of fertilization.

The Supreme Court of Alabama consists of a chief justice and eight associate justices who, at the time of this writing, are all Republican. Their political affiliation shouldn’t matter as long as they remain unbiased and don’t use their positions to further their political agenda and/or personal philosophy. The issue with this decision is that it reads as theocratical. Consider the following language in the ruling: “The People of Alabama took what was spoken of the prophet Jeremiah and applied it to every unborn person in this state” and “[Alabamians] have required us to treat every human being in accordance with the fear of a holy God who made them in His image”. In fact, the lead justice not only often invokes scripture in making legal decisions, but he criticizes those who don’t and supports an organization of conservative Christians who believe that we should use fundamentalist beliefs to influence and run government.

The Bible is not (nor was it meant to be) a legal textbook, and it’s a judge’s job to be objective and rely on case law and legal precedent even if they are philosophically uncomfortable or opposed to it.

As you know, I grew up Catholic. I believe in God and I feel strongly about respecting other people’s religious and spiritual beliefs. As a Nurse Practitioner, I’ve seen many examples of patients or couples who chose to alter their suggested treatment course based on their religious beliefs. In the case of one couple who needed IVF, they asked that only a few eggs (out of the many that were produced) be fertilized as they were uncomfortable with freezing extra embryos. We counseled them that reducing the number of embryos created may reduce the odds of achieving a pregnancy that cycle (necessitating subsequent cycles at their financial and emotional expense) but then happily complied after we were confident that they understood. In one of my other jobs, we allowed rabbis to be present during IVF procedures whenever patients requested this.

In medicine, decisions and strategies are based on current, peer-reviewed, published scientific data that is analyzed and replicated so that it’s appropriate and applicable to most. We should not be basing medical care on the Old Testament.

The stimulation of multiple eggs during an IVF cycle is necessary to counter the natural attrition rate from mature egg to fertilized egg to blastocyst (the term for an embryo at implantation). Only approximately 30-50% of fertilized eggs progress to the blastocyst stage and 30-90% of blastocysts are aneuploid (an embryo that has an abnormal number of chromosomes, which is usually not consistent with life). This translates to the need to create many eggs just to be able to have 1-2 chromosomally normal blastocysts available to transfer back in the hope that one of them will implant and become a healthy pregnancy. Restricting the number of eggs that we can fertilize (and/or the ability to freeze extra embryos) based on theology forces medical professionals to abandon common sense and years of scientific data.

Ok, let’s circle back to you (and your brothers). Even though I am deeply concerned about the effects of this court decision (and others like it), there are still ways to be a superhero.

Maybe your sword is your voice or your pen which you can use to advocate for those who are disempowered to advocate for themselves.

Maybe your superpower is being respectful and considerate to all people, regardless of their appearance, politics, religion, circumstances, or how much money they make.

Maybe your cape is your suit or robe should you decide to pursue a role as a lawmaker or politician where you advocate for others and make fair and reasonable decisions based on common sense, defensible facts, case law, and empathy, not your personal religious beliefs or political views.

I know I sometimes embarrass you by being a firm (and sometimes loud) advocate for reproductive health but being kind and brave means doing the right thing. Even when it’s the hard thing.

But, to channel Glennon Doyle, “We can do hard things”.



A Letter to My Daughters Post-Dobbs

To My Girls,

I write this letter to you as I lie in bed, one of the many nights that I have had trouble falling asleep after the Supreme Court decided to reverse Roe V Wade. I alternate between being incredibly angry and profoundly fearful for what the aftermath will mean to both of you. We are already starting to see the repercussions of it, and they are not only deeply concerning but the antithesis of all that I’ve taught you.

We have talked about physical safety and how to protect yourself, but I know that you still have a one in four chance of being a victim of sexual assault. It is unimaginable to me to think that you may not only have to deal with the consequences of the assault, but you could be forced to live with the terrible consequences of a rape-related pregnancy including depression, unstable relationships, and self-destructive behavior. One-third of women who have rape-related pregnancies do not discover they are pregnant until the second trimester, which now drastically limits (or even eliminates) their reproductive options.

As a result, I’m sorry that we will need to think twice about allowing you to apply to college in a restricted state, even if it’s a great school.

We have talked about psychological safety, healthy relationships, and boundaries, but I realize that you still have a one in four chance of being the victim of intimate partner violence, and that this violence tends to escalate when the female partner is pregnant. In fact, women with unintended pregnancies have two to three times the risk of experiencing physical violence than women with intended pregnancies. Reproductive coercion (where the male partner may forbid or punish the female partner for using contraception) is prevalent in these toxic relationships because having a child together allows the male to solidify his hold on the female, mentally, physically, and financially. In keeping with this, women who are victims of intimate partner violence have a higher rate of unintended pregnancy. It breaks my heart a little to imagine this happening to you but infuriates me to think that if it does, you don’t have options in a restricted state.

Think about this when you decide where to apply for jobs and live after college.

Perhaps most importantly, we have talked about the components of self-esteem, how it includes having a sense of agency and self-efficacy, and that your body is your own.  This is no longer true if you live in a restricted state.

Don’t be fooled by the language in the concurrence which justifies taking away your right to bodily autonomy because you can travel to another state. Extremist politicians are trying to enact laws to ban travel or to receive medication for medical abortion from another state. Justice Kavanaugh’s insistence that “Federal and state laws now ban discrimination in pregnancy and offer parental leave and insurance coverage” is laughable. This concept is better suited to the fairy tales that I used to read to you at night than the real-world experience in many places. In Mississippi, for example, there is no guaranteed paid leave, no ban on pregnancy discrimination, and the highest infant mortality rate in the country.

As a women’s health nurse practitioner, I have dedicated my entire career to working with reproductive-age women. I can tell you that the consequences of this decision are profound and far-reaching.

*Since care after a miscarriage and after an abortion are similar, a clinician may delay caring for you as he/she fears legal consequences.

*If you need to take a medication to control a chronic condition and that medication happens to be teratogenic or an abortifacient, this medication may be withheld from you simply because you are of reproductive age and might get pregnant while on it.

*If you have an ectopic pregnancy that is not yet ‘life threatening’, your care may be delayed or denied as many doctors and hospitals fear the legal loopholes and subsequent repercussions embedded in the intentionally murky language of many state laws.  Waiting an hour or two can be disastrous, in the context of a ruptured ectopic pregnancy, as every minute counts.

*If your membranes rupture in the second trimester, but there is still a fetal heartbeat, you may have to continue to carry the pregnancy at risk of infection, which could affect your current health or future pregnancies, even though there is no chance that the fetus can survive.

The list goes on and on.

I’m sorry that your chance to have future children, your integrity, and your mental health can be sacrificed for potential life.

I worked in Labor and Delivery and was there to support families who had babies with catastrophic and/or lethal congenital anomalies. The families who delivered these babies (who died at birth or soon after, often with profound, visible abnormalities) were devastated. Many of the mothers, whom I kept in touch with afterwards, shared that they needed years of therapy and/or grief counseling as a result of that experience. One woman (whose baby had anencephaly) told me that the day she delivered felt like ‘a terrible movie that she couldn’t stop playing’ in her head. If a congenital anomaly like this is found during one of your pregnancies, and you choose to continue the pregnancy, I will be there with you to hold your hand and get you through the weeks, months, and years to come. If you decide to terminate, I will support your decision as I’ve seen first-hand the effects of this on families.

I just want you to have that choice.

Dad and I laugh at the story of how I became pregnant with your brother without realizing it for a few weeks as I was still breastfeeding. Dad’s joke is “How did you not know you were pregnant? Don’t you do this for a living?” We can laugh about it because we were in a loving relationship with the financial means and support needed to have kids so close together in age.

Many aren’t so lucky.

Close interpregnancy intervals (like mine) are a common reason for late recognition of pregnancy. Many women (like me) didn’t have a true menstrual cycle while nursing, and don’t realize they are pregnant until either symptomatic or showing. Had I been in an abusive relationship or not financially able to support so many kids at once, instead of a funny story, it would have become a cautionary tale. In a restricted state, it may have been too late for me to make a reproductive choice by the time I realized I was pregnant. I may not have been able to go back to work as my childcare costs would have exceeded my salary. I may have had postpartum depression after having had you, and the thought of another pregnancy would have made me feel mentally unfit to take care of you and your siblings. Although your brother is a treasure to me (and I can’t imagine our lives without him) I wasn’t a better person for having proceeded with the pregnancy, I was just lucky to have been in a situation where I was able to do so.

I will end with the fact that I also spoke to your brothers about the effect that this decision will have on all of us. One of them said to me “Well, mom, I hear you, but how are you going to change a bunch of middle-aged men’s minds?” My reply is, “I’m not starting with them, I’m starting with you.” If I can teach my sons empathy, to truly understand what it would feel like if their bodily autonomy and choices were taken away, then that is where I will start. If I can emphasize accountability, that it takes two people to generate a pregnancy then, maybe one day, one of my sons (or their friends) will grow up to shape laws that don’t marginalize women.

I could have never imagined that my children would have less reproductive choices than me and that my daughters would be treated like second-class citizens, but I promise you that my colleagues and I will relentlessly fight to restore your rights.

I hope and pray that, should you need it, you are in a state where your healthcare provider is permitted to prioritize you- the living, breathing person who is there in front of them, over any potential person, political agenda, or religious ideal.



When will we stop Blaming Women for their Infertility?

In 1997, when I first started working in the field of reproductive endocrinology and infertility (REI), there was a stigma attached to infertility, as if the women being treated for it were defective because pregnancy didn’t come easily or unassisted. Fortunately, over the last twenty-plus years, this perception has changed, and women are less embarrassed or ashamed to admit to being diagnosed with infertility. This shift is somewhat due to these women sharing their stories both publicly and privately, and increasing the awareness of the prevalence of infertility, its causes, and treatments.

Consequently, I was excited to see the publication of a recent article in the NY Times about female physicians relating their experiences with infertility. The authors represent a growing demographic within REI: women who delay family-building to pursue a career.  Unequivocally, the road to being a physician is rigorous (some would say arduous) and long: four years of college, four years of med school, and another few years of residency (and longer if you pursue fellowship). Half of all medical students are now women, and training to be a physician can occupy their peak reproductive years. (Most agree that fertility potential starts to decline when a woman is in her mid-30’s). This article underscored the importance that women who plan to become physicians (or lawyers or women who delay childbearing for any other reason) become aware of their fertility potential, options, and the procedures that are available to them.

The article was impactful, as evidenced by responses on social media.  Many were grateful that the authors gave a voice to the emotional impact of infertility. Some responded that they didn’t realize how quickly the clock ticks, in terms of fertility, and are now considering making an appointment with a specialist to review their options. Then, there was another subset of responders (largely men) whose derogatory and unenlightened comments illustrate a false, yet pervasive, narrative that women are to blame for their infertility.

“I suspect the stresses of being in that profession are much to be blamed.”-Marty G.

“Get married young and have support through graduate school.”-Nathan M.

“Older women are less fertile than younger. I’m really hoping they know this though?”-Stanley S.

“Can’t have everything, I guess.”-Tom H.

“Squanders most fertile years to pursue a career, then is surprised that their fertility went down.”-Jake W.

As if this wasn’t bad enough, faulting women who have infertility is not limited to strangers. Many of my patients have also been criticized by well-meaning relatives, friends, and co-workers who offer unhelpful advice such as:

“Just relax, you’re too stressed. Go on a vacation and it will happen. My friend’s daughter’s roommate did this and it worked” or “You are too fat to get pregnant. Lose some weight and see what happens” or “Maybe it’s a sign from God that you are too old to get pregnant.”

I don’t feel that it is worth anyone’s time debunking each of these comments, but I would like to stress the following:

Stress is never to blame for infertility. Full stop.

A woman is never to blame for her infertility. Full stop.

People make difficult decisions with the information that they have at the time. To criticize them for their choice is simply mean and short-sighted.

Finally, to the men whose responses I listed above, I would like to refer you to a quote by Brene Brown: “If you are not in the arena getting your ass kicked, I’m not interested in your feedback.”

Lessons I Learned on a Bus

Image courtesy of Adobe Stock

I am a nurse practitioner and a health coach who specializes in helping pregnant, or soon-to-be pregnant, women achieve their health goals. Many of my clients have bigger bodies and I, technically, am ‘standard’ weight, according to the very flawed BMI chart. As a result, I am frequently asked or emailed a version of the question below, as people wonder why, if I don’t have personal experience with obesity, am I so passionate about advocating for those who do. As is often the case, growth follows discomfort, and, for me, a painful event in childhood equipped me with the tools I needed to advocate for people of all shapes and sizes.

Dear Monica,

I love your blog posts and your “Ask Monica” series. You state that you’re an advocate for people in bigger bodies. Were you ever fat and, if so, how did you lose the weight? If not, why do you feel so strongly about this topic?



Dear Dana,

I started my career as an Infertility Nurse Practitioner but realized that I ideally wanted to spend more time talking to my patients about their physical, metabolic, and emotional health, and not just the medical aspects of fertility. So, I became a health coach and, as such, I have developed deep relationships with my clients (many of whom are women in bigger bodies) who share with me their personal narratives of shame and humiliation due to their weight.

Almost every single one of them has told me how important it is to have an advocate, someone to stand up to the fat-shaming that they often encounter.

Although I have not been mocked for my weight, I have been derided due to my appearance. It happened in seventh grade, when I was bullied on my school bus. The remarks and taunts were daily and relentless. My not-yet-diagnosed polycystic ovarian syndrome (PCOS) was raging, and every day it seemed I had a new pimple on my face or grew a dozen new body hairs. I am Italian-American, so there was no shortage of body hair anyway, but suddenly it seemed that my hair growth was supercharged and incredibly obvious.  

My appearance did not go unnoticed by a girl on my bus (whom we will call) Tricia. She called me names like Fuzzy Muzzi (Muzzi is my maiden name) and gleefully and mercilessly taunted me on the way to and from school.  She warned me that I would never have a boyfriend ‘looking like I do’ and that the girls I thought were my friends were just pretending because they felt sorry for me.

It seemed that she spent her time and energy finding new words for ‘ugly’, and I spent mine trying not to cry.

Of course, I told my parents, whose advice was to ignore her (although my mom used this inopportune time to give me an eyebrow-plucking tutorial). I begged them to drive me to school, but neither of them had jobs that allowed this.

I begged the driver to let me change my seat, but all seventh graders sat in the same section.

So, I had to deal with Tricia, her taunts, and the interminable bus ridesfor the remainder of the school year. I don’t even remember how long it lasted or how it ended (I think she found someone else to harass) but here is what I do remember: hot shame, embarrassment, and the confirmation of what I already knew: I was unattractive, gross, and unacceptable.  

I had friends who rode that bus, but they didn’t defend me for fear that they would become her next target. Some of them didn’t even want to sit with me for the same reason. Although I now understand this, I felt isolated and alone. The situation seemed unbearable.

I remember feeling helpless and anxious as I walked up the stairs of that bus day after day, like I was entering a firing squad without armor. It took me a long time (and hours of laser hair removal) to believe in my self-worth again, and I am still triggered by certain situations that remind me of being the target of a bully. Even as I write this, thirty-plus years later, I recognize the tight knot of anxiety and shame in my chest and feel my eyes burning as I visualize myself at that age.

I wish I could go back and hug the seventh-grade me and assure her everything will work out.

So, to answer Dana’s question, no I was never *fat but I was a target, due to my looks. I felt angry, sad, and helpless at being ridiculed for something beyond my control, which I can imagine is not dissimilar to my clients’ personal experiences with being the victim of weight bias.

The science behind bodyweight (and weight loss) is clear. Our bodies have an evolutionary adaptation to avoid (what is perceived as) famine. Once weight is gained, the body employs many metabolic adaptations to keep it there, and the higher weight becomes the body’s new set point. Gaining excess weight is easy. Many who fall in the ‘obesity’ categories on the BMI chart have a strong genetic tendency to gain excess weight, quite possibly as strong as a tall person’s predisposition to being tall. This genetic disposition combined with an environment where ultra-processed food is plentiful and cheap, and the common habit of emotional eating, create the perfect cocktail for excess weight. Diets don’t work and exercise is great for mental benefits, but as recent data shows that when someone in bigger body exercises, their brain conserves energy in other ways to maintain their current weight.  

Consequently, I always stress that people with obesity have bigger bodies not because of what they do, but despite what they do.

Women in bigger bodies live in a world that is full of people like Tricia. The fat-shaming that they experience is constant and relentless and certainly doesn’t help them lose weight. It has the opposite effect. Studies show that being the recipient of weight bias contributes to weight gain and weight cycling, two factors that contribute to obesity.

I now see Tricia as my teacher and the situation on the bus as my classroom. The author Glennon Doyle writes: “Pain is not a hot potato to pass on to the next person or generation. Pain is not a mistake to fix. Pain is just a sign that a lesson is coming. Discomfort is purposeful: it is there to teach you what you need to know so you can become who you were meant to be. Pain is just a traveling professor.”

I use the helplessness that I felt then as motivation to be the person that I wished I had in seventh grade. I empower and advocate for my coaching clients by providing information and support and, in doing so, help them reclaim any dignity that they may have lost by being the recipient of discrimination and cruelty. Most importantly I try to make a dent in a deeply-flawed health care system where we are trained to manage the consequences of excess weight, but not informed about the factors that lead to it.

Those of us who care for people with obesity need to understand the complexities and nuances of excess weight and our body’s determination to hold onto it. Most health care providers are well-meaning but, like me and all the nurses and doctors that I know, not formally trained on the science or behavioral aspects of excess weight and how to combat it.

As a health coach, my job isn’t to help women to become thin. My job is to help women become the best version of themselves, whatever that looks like.

By the way, I did find Tricia on social media recently and sent her a message thanking her for making me who I am today. I didn’t receive a response but then, none is needed.

*Author’s Note: I am following Dana’s lead and using the word ‘fat’ as a neutral, descriptive word, not as a pejorative term.

Dear Fertility Nurse: Scrabbled

“I am really having trouble being happy for my friends and family who seem to be getting pregnant easily. I’ve cut off communication with some of them, stopped going to baby showers, and I feel like a jerk. How do I manage this?”-Heidi R.

Dear Heidi,

Growing up, I played a lot of boardgames, one of my favorites was Scrabble. Scrabble is a game where everyone gets tiles that are letters and you compete against 1 to 3 other people to use your letters to form words on the board. You are trying to get the most points and get rid of your tiles.

Playing hundreds of rounds of Scrabble taught me two things about myself that still hold true today: I love words and I hate to lose.

Most of the time, I would play with my immediate family or my sister’s friends and we would look for ‘tells’: signs that someone was about to unleash a word that would generate a bunch of points. If you are not familiar with Scrabble, the rarer the letter, the more points you could get, so an Z or a Q were each worth 10 points due to the degree of difficulty finding a word in which you can use them.

One time, I was riding high on an amazing (I thought) word that really pushed me past most players and tied me with my sister who was not only 7 years older, but a walking dictionary. As we were going around the table for one of the final laps, I see a change in my sister, a tell. Hers is an almost imperceptible smile, a look that I interpreted as smug and self-satisfied, and I knew it could only mean one thing: She is using her J. You see the J is the holy grail of Scrabble, in my opinion. It’s worth a whopping 8 points but you can actually use it in a decent number of words (unlike Z) and you don’t need to also have a U (unlike Q). The J is a game-changer and I knew then and there that my sister had won. I felt angry and resentful.

It felt like an unfair fight.

My sister and her friends knew more words anyway and were very clever. I needed a plan to level the playing field.

So, next time I offered to set up the game. I made sure that no one was around, then I pocketed two of the J’s. Not all of them, because that would be obvious, just two that I later could imperceptibly add to my stash of letters until I used mine or someone else’s letters to build the perfect J word. This worked for a while. I was often the winner if my sister wasn’t playing, and pretty even with her if she was, and it felt great. I felt redeemed.

Until one day, I was putting the game away and heard someone crying. I took a quick peek and saw that it was my closest friend. She had come in last that day. In fact, since she was the youngest she often came in last, but today she was burdened by a bunch of Q’s with no U’s and just shitty luck and I guess it felt like too much. My feeling of elation quickly soured and I realized that I had to confess. I told her about the J’s. She was both horrified and impressed. Then she said to me “Why are we even playing this game, Moni? It’s making us both so sad and frustrated.”

I strongly believe that it is a worthwhile skill to accept your feelings (even so-called negative ones) as valid and necessary in order to live a vibrant life.

You see, Heidi, your pregnant friends were lucky enough to have all of the good tiles. And it sucks because you try your best and persevere through your treatments and deep down you’re happy for them, but it feels like every time you turn over a tile, it’s another Q (without the U) or Z. Now you’re in a quandary because this bad luck is starting to really get to you and making you avoid events and conversations with people that you love which makes you feel disconnected from the person that you want to be in life.

My first question to you is do you want to ‘play the game?’ That is, do you even like going to baby showers or is this something that you feel that you need to do? I didn’t like going to baby showers. I had so many cousins and went to so many baby showers by the time that I was old enough to have a baby that I was ‘baby-showered-out’. So I reserved my right to say no to some people and only attend the baby showers of my closest friends and family members. This is one option for you. You may decide to conserve your mental energy to only attend the baby showers of your super-close friends, ones for whom the risk of missing their shower feels worse than going to it and possibly feeling sad for a while after. You can expect that you will probably feel sad or some other yucky emotion afterwards, but I strongly believe that it is a worthwhile skill to accept your feelings (even so-called negative ones) as valid and necessary in order to live a vibrant life, and allow yourself to feel them (I will be writing about how to do this on a future post).  

During your fertility journey, maybe if you can’t find fair, you can find meaning.

Remember when I said that playing Scrabble against older kids didn’t feel like a fair fight? During your fertility journey, maybe if you can’t find fair, you can find meaning. For many of my clients, it is the perfect time to cultivate an important life skill: setting and maintaining boundaries.

A boundary is for your benefit and defines what you will and will not do. For example, for many, scrolling your social media feed may feel like a land mine. You want to catch up on other people’s lives, but you have to carefully sidestep the endless parade of hot button issues for you. These can include your cousin who posts strong political views or a high school classmate posting pictures of maimed animals or your friend who keeps complaining that she “just looks at her husband and gets pregnant”. May I suggest that you “Marie Kondo” your social feed and pause, mute or unfollow those feeds that don’t bring you joy. Even if you like the people posting them. Getting bombarded by pictures of injured wildlife or pregnant bellies when you are struggling can make anyone feel like crap. They have the right to post them and you have the right to shield yourself from them.

“…those who are mad that you enforced a boundary probably benefited from you having none.

You may have to tell your close friends and relatives that you don’t want to talk about your family planning every phone call or family event. This should be done in advance via phone call or conversation and can sound something like: “Aunt Cathy, I’m excited to get together for Thanksgiving, but I no longer want to discuss when I’m going to have a baby.” Be both firm and fair and if someone doesn’t respect your boundary, then be prepared to enforce a consequence (i.e. you won’t go to Aunt Cathy’s for the holidays). I read once that “those who are mad that you enforced a boundary probably benefited from you having none.”

Setting boundaries can be difficult, but they are a huge component of self-care and one of the most important actions that you can take during your fertility journey to protect your mental health. There are many resources about how to set boundaries (one of my favorite is @the.holistic.psychologist on Instagram and and one of the best ways to practice these is to role-play with a trusted friend or family member. I’m not kidding. I do this with all of my clients and actually give them scripts before we practice (we call it ‘striking while the iron is cool’) so that when the time comes to actually enforce one, it feels intuitive.

Finally, Heidi, I hope you use my story as a cautionary tale. Consider and decide (on a case-by-case basis) if you want to engage in a situation or setting that tests your resilience.  If you do, don’t steal the J’s, like I did. Proceed with caution, but integrity, and expect to have an emotional hangover after. If you decide to pass, realize that this was the best decision for you at the time.

You don’t need to play the game.

Scrappy not scrabbled,


Letting your hair down

Hello Readers. I decided to start an (irreverent) advice column to answer the many questions that I get on a regular basis. Here is my first attempt.

“What do I do with the negative emotions that I’m experiencing during my infertility journey? I feel like I lose it all of the time, spending my days getting upset, reactive or angry.” —Claire G.

Dear Claire,

I have curly hair. This is both a blessing and the bane of my existence, depending on the day and my mood. If you have curly hair, you know that it can get very big and unruly and hard to hide. I have spent the decade of my 20’s trying various methods of taming it: braids, hiding it under hats, blowing it dry section by section. I have paid inordinate amounts of money on hairstyles that supposedly emphasize my natural curls and have come out of the salon thinking I looked pretty good. That is, until I notice a very similar-looking style on a dog leaving the pet grooming salon. I still spend a silly amount of time brushing it into the perfect ponytail that I see well-groomed, not-sweaty people wear on Instagram, only to go outside in the humidity and realize that the short hairs on my forehead have curled up in less than 5 minutes.

I have a drawer full of products to tame my hair or make it look like someone else’s. These work, sometimes for 5 minutes (if the weather is particularly bad that day) or for a whole day (this is bliss, but only happens one month out of the year or if I stay inside a climate-controlled room where only a few people get to see my hair masterpiece anyway).

So, I gave up trying to manage or tame my hair. Some days, when I really can’t deal with it, using a product or shoving it under a hat is best for me. Most days, though, I allow it to be in its natural state while I continue with my day. In time, I realized that having curly hair is part of me, but it doesn’t capture the essence of me, it’s just something sitting on my head. I can’t let it distract or deter me from going toward my personal or professional goals. My job often involves people seeing me, either via Zoom or giving presentations or teaching in front of a group. Showing up looking like a freshly-groomed poodle is distracting to all of us, at first, but in time we all just ignore my hair and listen to what I have to say.

Why am I telling you this? Because my curly hair represents your big emotions: fear, shame, anger, sadness. Like my curls, these emotions don’t capture the essence of you, they are just words and thoughts that are sitting in your head. Maybe your ‘braid’ consists of tightly-woven emotions, thoughts and feelings that you want to suppress, but then the tightness starts to cause headaches, so you unravel the braid and now you have messy hair and a headache. Maybe your ‘hat’ is the mask that you wear when you want to pretend that you are ok with the helplessness and frustration that often is generated by an infertility cycle.

You probably have a drawer of ‘products’ too because, well, some days you just want a quick way to feel good. Your drawer might contain junk food or wine or Netflix or mindlessly scrolling social media. These ‘products’ make you feel good for 5 minutes or a full day. But they don’t change the fact that you have curly hair.

You need to let your hair down while going through your journey. By this, I mean that you need to realize that you are a deeply-feeling person in a messy and challenging situation. Your feelings aren’t ‘good’ or ‘bad’. They are just part of you. Trying to suppress them is both futile and exhausting, so let them be and use your time and energy on what you need to do to be your best self that day or to accomplish your goals. Like the curly tendrils that escape from my ponytail, you might notice a particularly annoying or persistent emotion, at times, that is trying to get your attention. Notice it. Acknowledge it. Slap some hair gel on it or bobby-pin it if you need to in order to get through your day and realize that that was the best action or strategy for you at the time. Similarly, don’t base your day or self-worth on the fact that you felt angry and acted on it.   

Most of us think that our big emotions can hurt, harm or kill us unless we do something about them, but this isn’t true. In fact, our brain processes emotions very quickly (in about 90 seconds) when we don’t attach or tether them to a story or allow them to play on an endless loop in our heads. It might seem counterintuitive, but let them be. If particularly painful, sit with them, notice what they feel like in your body and how it feels to let them go. Allow them to co-exist with the behaviors and actions that help you feel productive or powerful. It might surprise you to know that there is room for everyone.

So now you know my secret: every time you see me with straight, beautiful hair, just know that the curls are lurking, just waiting to come out. If you see me with crazy, curly hair, then that day I clearly didn’t care to spend the time taming it. But guess what? I can be the best damn me regardless of hair or humidity and you can too.  

Warmly and Wildly,


Hundreds of Tiny Jabs

Photo by Arisa Chattasa on Unsplash

Image credit: Arisa Chattasa on Unsplash

“What can I do to relieve the stress of Infertility?”

It is the question that I am asked most often and my answer has evolved over the years based on my personal and professional experience.

My answer is that Infertility is like a boxing match. It consists of mostly hundreds of tiny jabs that leave you unbalanced and hyper-alert until sometimes a big punch comes along that knocks you on your butt. These jabs consist of stressors and disappointments during diagnosis and treatment that can wear you down, decrease your resistance and have a cumulative effect on your mental health.

Your insurance won’t pay for a test or treatment. Jab.  Your medication order is delayed. Jab. You have to tell your boss that you will be late for work (yet again) due to an office visit. Jab.  You didn’t make enough eggs to go to an IVF retrieval and my cycle is cancelled. Jab…Jab.

Over time, even the most well-balanced people can feel anxious and like they are ‘up against the ropes’.

Mentally, infertility is not so much a disease as a state of dis-ease, and I don’t think anyone emerges from an infertility journey the same way they entered it. One can’t go around infertility, you have to go through the diagnosis and treatment(s) anyway, so I would reframe the above question as: Can the infertility journey itself be an opportunity for personal growth? Is there a gift in this crisis, such as a chance to develop and cultivate inner strength that can help us deal with other challenges in life and be the person we want to be most often?

Not only is the diagnosis of infertility upsetting, but the process itself often generates complex and difficult feelings in us, some of which we may not have experienced at this level before. As humans, we rely on the principle of having agency, that is the knowledge that our choices can lead to a certain outcome, that what we do matters. So, if we study hard, we do well on a test. If we work out regularly, we experience gains in muscle and cardiovascular fitness.  Infertility doesn’t behave and adhere to this concept. A woman can follow her treatment plan perfectly and not achieve a pregnancy that cycle. Over time, one can imagine that this causes feelings of hopelessness, helplessness, and a lack of control, and many of us are ill-equipped to handle these difficult emotions. So we feel stressed and anxious and our self-confidence can suffer.

I think it’s important to remember that the brain and body’s default response to a perceived threat is to activate the stress response (fight, flight or freeze), and this response is appropriate and necessary, as the brain must constantly scan for perceived danger in order to protect us from it. It is when we stay in this activated state, either because we don’t realize there are other options or because we don’t have the skills or tools to manage it, that we can suffer emotionally.

So, what can we do? Here are some of my thoughts:

  1. Words matter. Precisely identify and label what you are feeling. To say that you are feeling ‘stressed’ or ‘anxious’ is not only too broad but how do we ‘fix’ stress or anxiety? If we knew how to do this, we would have already. Saying that you feel ‘lonely’ or ‘overwhelmed’, though, is helpful and actionable because we can identify strategies that help us connect or find calm, respectively, and employ those when needed (see below). If you find yourself in fight, flight or freeze, and can’t precisely identify a specific emotion, then just say to yourself that you are “activated” and thank your brain (I’m serious) for its help. Think of your brain as a highly-trained watchdog, on high-alert for perceived threats that can put you in danger. By acknowledging that you are in this state and thanking the brain for this coping mechanism, you are effectively telling your brain that you are safe; patting the watchdog on the head (so to speak) and giving it permission to engage the part of the nervous system that’s responsible for relaxation and recovery.
  2. Make a Nourishment Menu. This is an activity that I do with all of my health coaching clients very early on in our sessions. It involves writing down activities, thoughts, or behaviors that help you feel a certain way, and sorting them into columns under the feeling that they are trying to create. For example, if they want to feel calm, they can: listen to music, go outside in nature, go for a walk or talk to a trusted friend. If they want to feel empowered (this is a big one for women TTC) they can: work on setting and maintaining personal boundaries, complete a small task like cleaning or organizing an area, listen to a certain playlist, or lift weights/do a powerful yoga pose.
  3. Realize that even though you can’t control your environment or outcome, you still have choices. In response to a challenge or stressor, you can make a choice to avoid feeling a certain difficult emotion (anger, shame, resentment) or you can chose a behavior that leads you toward your (previously-identified) core values. This is the premise of ACT (Acceptance and Commitment Theory) and making a personal ACT Matrix has been incredibly helpful for many of my clients. Although I can’t describe it fully here (it will be the topic of a future blog post) it’s important to note that as long as you are mindful and intentional, your choice (whatever it is) is the appropriate one at the time. For example, you might feel fragile or the stressor feels acute and you need immediate relief from pain, so you cry or get angry (away behaviors), and that’s ok. You might, in a certain circumstance, want to work on your boundaries, assertiveness, or diffuse a situation with humor (toward behaviors) and that is perfect for you at that time. The important point is acknowledging that in every situation, you still have choices. Since a lack of agency is a core component of many of the negative emotions associated with infertility and its treatments, then restoring it in this way can increase self-esteem and a sense of empowerment. We don’t try to suppress these uncomfortable feelings (such as pain or anger) because that never works, so this exercise helps us realize that we are ok and can co-exist with them. This is a weird concept for most of us but, with practice, can really help. For many, it can be the difference between helplessness and hope. For more information on the ACT Matrix, go to

I’d like to end by talking about pain. None of these strategies are meant to downplay the pain that many feel when experiencing infertility. It is both chronic and acute and can feel unrelenting. But as painful as it can feel, it can’t harm us and can actually be a powerful tool. In my own life, I found that a difficult situation provided the push I needed to guide me in the pursuit of my best self.

I think the best description of this concept of pain is by author Glennon Doyle in her book Untamed. She writes: “I can feel everything and survive. Every time I thought I couldn’t take any more, I was wrong. I can also use pain to become a more beautiful version of myself again and again.”  

Back to our original metaphor. Infertility can throw you lots of obstacles, many of which can feel incredibly painful, but these ‘jabs’ need not trap you in a reactive position. By realizing that not only can you handle pain and uncertainty, but you can actually grow in their presence, can generate feelings of power and preparedness during a journey that is often short on both.

Nurses Week 2020

A letter written by my friend and colleague, Lisa Rinehart, RN, BSN, JD

Nurses Week 2020– A Perspective in a Unique Time

As Nurses’ Week is celebrated this year, I have no doubt that we will continue to hear about the wonderful accolades and sincere gratitude that we have seen attributed to all nurses during the pandemic that has settled over our world. They are all well-deserved and so appreciated. Each vision of a nurse (or any health care provider) working with a patient in gowns, masks, gloves and all types of PPE, can’t help but stir our emotions and remind us why nurses are so integral to all of our health and well-being. But particularly, in such scary times, these scenes may also raise the question: ‘WHY do they do it?” Well, I’ll tell you my version…

I am a nurse. I started nursing over thirty years ago. Who knew that my chosen career would be both a noun and verb at the same time! Perhaps, this exemplifies the often ‘schizophrenic’ nature of my professional days – the mixed bag of easy and hard, happy and sad, win and lose. Each day is a new surprise, and a new challenge to which I can bring what I learned yesterday. But as I reflect on my experiences, I must admit that the overriding emotion is JOY. Being a nurse gives me the ever-amazing ability to be on the “inside” of so many life events. Watching a newborn as he takes his first breath, holding the hand of a cancer patient as she says good-bye to her children, and doing the “baby dance” with a fertility patient who is finally pregnant – and it’s a good one! These shared moments are precious. Not everyone gets accepted into a patient’s “inner circle” as readily as their nurse. And not everyone gets the honor of participating in a patient’s life events – to help them cope, heal, decide, accept or just be. So, while there is a certain amount of excitement at getting that IV stick on the first try (seriously, it can be fun!), the real kick for me is knowing that my presence – by providing a skill, an ear, or information – helped someone. Making a patient feel that they matter, makes me feel like I matter.

More recently, my joy in nursing embraces my colleagues and community. Many of my special nursing moments now include mentoring and encouraging others to enter the nursing profession. What a thrill to have a great med tech get her nursing degree or have a niece graduate with her BSN and “love” ER nursing (even during a pandemic!) or a nephew text you that he “got in” to the nursing program of his choice. I cannot help but let my pride in my chosen career spill over to others. Why wouldn’t I want to share this rewarding, crazy, hard, but joyful career.

So, as I add my good wishes, love and encouragement to all nurses during Nurses’ Week 2020, I ask that we continue to thank the nurses and nurse extenders who give so much of themselves in so many areas of patients’ lives. I also hope that we will take the time to encourage others to join the nursing profession. I won’t sugar-coat it: the road can be really hard, but the pay-off of being let into a patient’s life is so worth it!

~~ Lisa A. Rinehart, RN, BSN, JD

Ovarian Reserve Testing and Diagnosing Diminished Ovarian Reserve

Ovarian Reserve Testing and Diagnosing Diminished Ovarian Reserve

Dayna Browning, BSN, Jennifer Dwyer, BSN and Monica Moore, MSN, RNC

Edited by Paul Bergh, MD

A woman’s ovarian reserve refers to both the quantity and quality of her eggs, and diminished ovarian reserve means either or both of these factors are declining. 

Ovarian reserve testing specific for the quantity of available oocytes consists of biochemical and ultrasonographic tests that represent a snapshot of where a woman falls along this continuum. 

Surprisingly, women have the most eggs (oocytes) when they can least use them, prior to birth as a 20 week fetus! After birth, this oocyte pool dwindles until very few remain at the time of menopause. Ovarian reserve testing specific for the quantity of available oocytes consists of biochemical and ultrasonographic tests that represent a snapshot of where a woman falls along this continuum.  It’s critical to have an accurate assessment of reproductive potential when planning for pregnancy, whether utilizing advanced reproductive technologies (ART) or not. When proceeding with ART, ovarian reserve testing dictates stimulation protocols to avoid unwanted outcomes, like cycle cancellation or ovarian hyperstimulation.  Nurses are often the ones who interpret and review these results with patients, so in this article, we will explore the available tests, their applicability and pitfalls, and how best to discuss with the outcome with patients.  

Egg Supply Chart
Egg Supply Diminishes with Age

Regarding the quality of oocytes, the millions of eggs that represent a woman’s oocyte pool are dormant for years, arrested in meiosis (cell division for sex cells). The next time these oocytes are re-activated and meiosis resumes is after selection within the dominant follicle, at the time of ovulation with the luteinizing hormone (LH) surge. So, at the time the oocytes are expected to resume cell division, they may have been paused in the middle of cell division from 13 years to as many as 40+ years. Cell division is a process that requires a significant amount of energy.  As eggs age, so do does the cell machinery that is crucial for efficient cell division. Accordingly, aging oocytes may not respond as well as younger eggs once recruited from the original supply. These older oocytes are less effective at correctly completing meiotic cell division and thus are at an increased risk for aneuploidy (an abnormal number of chromosomes in the embryo, which is often lethal).This is often the cause for the exponential decline in fertility and increase in miscarriage rates seen in women who attempt to conceive in their later reproductive years. This decline in the oocyte’s ability to complete meiosis error-free is a reflection of oocyte “quality” and, other than a women’s age, there is no way to evaluate the chance of oocyte meiotic error.  

Regarding quantity, the rate of follicular depletion varies considerably among women. Chronological age is an important factor when counseling infertility patients, but it’s important to note that two age-matched women can have very different levels of ovarian reserve. Although some lifestyle choices, such as smoking, trauma from surgery, or radiation/chemotherapy can be detrimental to oocytes, exercise and a healthy diet are important, but not necessarily protective. The fact that a fit, active woman in her 40’s can still have diminished ovarian reserve demonstrates the inescapable reality of ovarian aging.  

The fact that a fit, active woman in her 40’s can still have diminished ovarian reserve demonstrates the inescapable reality of ovarian aging.

Diminished ovarian reserve (DOR) is a term used to denote that the decrease in the oocyte pool has reached a level in which it impairs fertility. DOR occurs even in women with regular menstrual cycles. Those who are diagnosed with DOR can be counseled that they will have a lower response to stimulating medications, a higher cancellation rate, and a lower chance of pregnancy after an IVF cycle than an age-matched woman whose ovarian reserve testing is normal. 

Although it would be helpful if ovarian reserve testing reflected both the quality and quantity of the oocytes that remain (and are available for that particular patient), there is a stronger association between the outcome of the tests and the quantity of oocytes available, not their quality or competence. Research on the predictive value of the existing tests is mostly undertaken in the setting of a high-risk population, i.e. those who present to infertility centers, and caution should be taken when extrapolating these results to a low-risk group, such as women who have not been diagnosed as subfertile. The applicability of the results, then, should mostly guide clinicians about expected outcomes during ART cycles, for example, response to stimulating medications, possible cycle cancellation, and the chance for pregnancy after a treatment cycle. They are less reliable when used to predict the probability of a natural pregnancy or when menopause will occur. Also, no single test is predictive of reproductive potential and the patient’s medical history and clinical picture should always be considered when interpreting results.  

Historically, a follicle stimulating hormone (FSH) level on cycle day 2-4 was used as the ‘gold standard’ of ovarian reserve testing. FSH is produced by the pituitary gland and is an important hormone necessary for follicle growth, particularly small follicles. As a follicle grows, it produces estradiol (E2) and inhibin B, and the increase in these hormones decreases the release of FSH from the pituitary. So adequate early follicular levels of E2 and inhibin B maintain FSH at normal levels. E2 and FSH levels are inversely proportional, so lower E2 levels would signal the pituitary to increase the production of FSH. As a result, it is important to also draw an E2 level when an FSH is drawn to assure that E2 is not elevated (>60-80 pg/ml) which would falsely lower FSH. As women age, the quantity and quality of the follicles that they produce declines.  A poor-quality follicle (or a reduction in the number of follicles) results in an E2/inhibin B levels not high enough to provide negative feedback to the pituitary to reduce the production of FSH, so it is over-secreted. Consequently, elevated FSH levels on day 2-4 can be an indicator of diminished ovarian reserve. An FSH level >10 mIU/ml, according to the World Health Organization (WHO) 2nd international standards, is considered a sign of decreased ovarian reserve. FSH alone, though, seems to be a limited measure of ovarian response. It’s specificity and sensitivity vary in the literature, and it’s a poor predictor for pregnancy and live birth, particularly for young (<35 y/o) patients. As a result, most clinicians do not rely on this level alone when counseling patients.  

A dynamic measure of ovarian reserve, that has been used in the past but is no longer widely used, is a clomiphene citrate challenge test (CCCT).  Women undergoing this test have an E2 and FSH level drawn on day 2-4 of their menstrual cycle. Then, 100 mg of clomiphene citrate is taken orally on days 5-9, and an FSH level drawn on day 10. This has been termed a ‘stress test’ for the ovaries as it might show how ovaries respond to stimulation and reveal more subtle DOR that may be concealed by using a static test/single level. This test is in effect a bioassay of the inhibin B response of the follicle.  Clomiphene citrate blocks estrogen’s negative feedback to the pituitary and the hypothalamus, however inhibin B produced by the follicles is not blocked by clomiphene citrate and is still recognized by the brain. In a normal CCCT test, with a sufficient inhibin B response, the FSH with the day 10 blood work should still be suppressed to the normal levels expected on day 3. Recently, though, other methods are increasingly used over this test as some feel that there is only a minimal to moderate benefit over testing FSH levels alone (if any) and is not necessarily cost-effective. As a result, some centers opt to use this test for patients in whom they suspect a poor response to stimulation (over the age of 35, I.e.) whereas others do not use this test at all.  

Anti-Mullerian Hormone (AMH) is starting to emerge as the preferred measure of the quantity component of ovarian reserve. AMH is a hormone secreted by the granulosa cells that surround the early, small (up to 4 mm) follicles in the ovary. Normal levels are lab-specific, but many use >1.0 ng/ml as the cut-off. AMH expression is not gonadotropic-dependent, so can be drawn at any time during the menstrual cycle.  Levels peak at 25 years of age and decrease with age (the opposite of FSH), with a level <1.0 mg/ml indicating diminished ovarian reserve and very low levels can be seen about 5 years prior to menopause. Elevated AMH levels also have clinical utility, as they would suggest a robust ovarian response, and have been shown to correlate with an increased risk of ovarian hyperstimulation syndrome (OHSS). AMH can be helpful in predicting the response to gonadotropin stimulation, and possibly pregnancy rates. The data is mixed regarding the predictive value of AMH levels and live birth, although there is some evidence that it might be better than FSH levels in this regard.  Also, in women without a history of infertility, a prospective, randomized study found that low AMH levels do not predict a decrease in fecundity as compared to those with normal levels. AMH might also be useful in assessing the need for fertility preservation strategies. The data on AMH as being a reliable predictor of natural fertility is mixed, though, larger studies are needed to elucidate this.  

As stated above, the follicles which become dominant and ovulate are just the ‘tip of the iceberg’ and demonstrate the immense attrition rate seen with normal human aging. Only 0.1% of oocytes present at birth make it to ovulation. Every month, a small portion of follicles (containing oocytes) are drawn from a woman’s egg supply in the hopes of being selected to become a dominant follicle.  Around day 5-7 of a 28 day cycle, the follicle which has the most FSH receptors becomes dominant and the remaining follicles get reabsorbed by the body. Measuring the number of small (2-10 mm), antral follicles that are present by ultrasound on day 2-4, then, before dominant follicle formation, termed the Antral Follicle Count (AFC) is a helpful measure of ovarian reserve as it can be appreciated that the lower the overall egg supply, the lower the number of follicles available to be recruited. These are the follicles that contribute to the AMH level so it is no surprise that the AFC is highly correlated with AMH levels. This is supported in the literature as women with a lower AFC are more likely to have cancellation for poor response in IVF cycles. The literature is mixed regarding with the lower limits for AFC are, there is some agreement that less than a BAFC of <3-6 is concerning.

Poor AFC

Poor AFC
Poor AFC

Normal/Good AFC

Good AFC
Good AFC

Although not well-established until the last decade, AMH and AFC seem to be emerging as the best approaches to procreative testing, as they are the most accurate in predicting poor response to IVF (better than FSH). They are also better at predicting hyper-response and elevated levels of either should alert the clinician to the possibility of OHSS. Although AMH seems to be superior to FSH in predicting live birth, data is conflicting regarding its ability to predict miscarriage rates.  

Treatment of DOR 

Very few treatment options are available when a woman has been diagnosed with diminished ovarian reserve. One reasonable, and affordable, strategy is advising the patient to begin supplements such as DHEA (Dehydroepiandrosterone) and Coenzyme Q10. DHEA is in a class of steroid hormones known as androgens which are at peak levels in humans in their mid-20s. Coenzyme Q10 (CoQ10) is an antioxidant that your body produces naturally to use for growth and maintenance and plays a key role in mitochondrial function. There has been recent data that suggests DHEA improves ovarian function, increases pregnancy chances and, by reducing aneuploidy, lowers miscarriage rates. Similarly there is also data that Coenzyme Q10 can not only help preserve the ovarian follicle pool, but also facilitates ovulation of gametes able to support normal development. Other suggestions include maintaining a healthy lifestyle and avoiding factors that can impair fertility such as an elevated BMI and smoking.  

 Historically, it was thought that superovulating patients with diminished ovarian reserve gave them the best chance of pregnancy during a treatment cycle, but a growing body of research suggests that ‘mini’ or ‘mild IVF’ might offer outcomes similar to conventional IVF cycles. Conventional IVF consists of the administration of high-dose external hormonal injections with the goal of developing a large quantity of oocytes. These oocytes are retrieved during a surgical procedure and later fertilized with sperm in a controlled laboratory setting. In mild ovarian stimulation, or mini IVF, an oral ovulation induction agent such as clomiphene citrate or letrozole is initially used, followed by the administration of low-dose injections to stimulate follicular growth. Because this approach leads to less oocytes retrieved, it can be done with local anesthesia as opposed to general anesthesia. The cost is also less because less injections are used. When comparing conventional IVF and mini IVF, a study found that there is fair to good evidence that clinical pregnancy rates are not substantially different between two types of stimulation in women predicted to be poor responders.  

Counseling the Patient 

When couples begin their fertility journey they are seeking answers as to why they are unable to conceive or have been experiencing recurrent pregnancy losses.  A comprehensive diagnostic workup is the first step to treatment and, for many women, it is found that they have diminished ovarian reserve.  Receiving and accepting this message, and its ramifications, is incredibly difficult for patients. As REI nurses it is our responsibility to assist in counseling the patient on appropriate care measures based on their results.  Although it is more common to see a decline in ovarian reserve in women over the age of 35, this unfortunately can affect women of all reproductive ages.  If a woman’s ovarian reserve testing (hormone levels, follicle count) falls within a normal range, a less invasive option such as IUI (Intrauterine Insemination) may be recommended as first line treatment.  However, if a woman is shown to have signs of diminished ovarian reserve (low AMH, high FSH, low AFC) she would need to be counseled on the importance of aggressive fertility treatment such as IVF to optimize her chance of success for a current and potential future pregnancy, the higher chance of cycle cancellation, and the lower chance of pregnancy when compared to women her age with normal ovarian reserve.  It is important to share with the patient that as she gets older her reserve and egg quality/quantity will continue to decline.  This is especially pertinent for women who want to have multiple children, so ovarian reserve testing results should be taken into context with the couple’s family-planning goals, such as how many children would they ideally like to have.   

One of the most difficult and emotionally-charged treatment options to discuss with a patient is the potential need for OD or ED (Oocyte or Embryo donation), as it requires that she accepts the inability to use her own eggs and agree to use someone else’s, a huge shift in her family-building perspective and the loss of a life-long dream.

One of the most difficult and emotionally-charged treatment options to discuss with a patient is the potential need for OD or ED (Oocyte or Embryo donation), as it requires that she accepts the inability to use her own eggs and agree to use someone else’s, a huge shift in her family-building perspective and the loss of a life-long dream. When delivering this sensitive news to the patient or couple it is important to be forthcoming , but empathetic and sensitive as well (Review How to Deliver Bad News here).  Realize that the patient needs to essentially grieve the loss of her fertility.  When making this phone call, make sure there is adequate time to discuss results and answer any follow-up questions the she (or her partner) may have. So be prepared that this call might take more time and allow for that when planning your day.  Setting realistic expectations for the patient in terms of recommendations for treatment and the potential for success is crucial.  Keep in the mind that the patient may not readily accept your news and may have an understandably defensive or aggressive reaction.  Reminding the patient that you are available as a form of support will allow them to express their feelings and concerns once they are ready.  Offering additional support resources for the patient such as speaking with a social worker, or scheduling a follow up appointment with their physician can be offered as well.   

Ovarian reserve testing provides important information regarding likely reproductive outcomes in infertility populations. AMH and AFC are emerging as the more widely used tests to evaluate the quantity of oocytes remaining. Evaluating the quality of the remaining oocyte pool remains elusive though is often correlated with age. Currently there is no real treatment for women with DOR, but supplements and personalized stimulation protocols are options. When ovarian reserve testing results are abnormal, nurses need to realize that this news can be devastating to a patient. As a result, time and care should be taken when making the phone call to deliver these results, considering the patient’s clinical situation and desire for family-building.

Endometrial Receptivity and the ERA biopsy

Endometrial Receptivity and the ERA biopsy

Everyone would agree that functionality of the uterine lining is incredibly important for implantation of the blastocyst to take place. The question of how to measure this, termed ‘uterine receptivity’, has been studied extensively in the literature. The methods that have been used in the past were indirect, assumptive and not reproducible. Researchers in Spain have created a new tool which has been shown to be promising for identifying molecular markers for uterine receptivity.

Remarkably, as the blastocyst floats within the uterine cavity looking for a place to land, a dialog takes place between the blastocyst and the endometrium. In order for a successful implantation to take place, the blastocyst needs to be at the appropriate stage, and it needs to signal the uterine lining to ‘accept’ it. Within the uterine cavity, once ready for implantation, the microvilli present on the trophoblast cells of the blastocyst act as one side of ‘velcro’ to adhere it to the uterine lining. The embryo is in search of a receptive endometrium (the other half of the velcro) which will ‘fasten it’ to the uterine wall. The hormonal preparation of the uterus plays a critical role each month in creating this environment in which the blastocyst can adhere to the endometrium in the hope that implantation will take place.

The uterine lining undergoes changes during the two phases of the menstrual cycle that prepare it for blastocyst implantation. During the proliferative phase, it grows due to the increasing production of estrogen by the ovaries. The second phase is called the secretory phase where the production of progesterone, produced by the corpus luteum, converts the endometrial lining to a secretory one, changing the cells to prepare for implantation (a process called decidualization). Should implantation not take place, the hormone levels will fall, resulting in a shedding of the lining, which results in menses. Studying the mid-secretory phase is of great importance since the window of implantation (WOI) takes place then. The sweet spot of WOI is approximately a 2-day period when the uterus is prepared to accept the implantation of a blastocyst. Conventionally, it was assumed that every woman had the same WIO, (approximately 8-10 days after ovulation) so embryo transfers would be scheduled to take place during this time. This theory has recently been challenged, with researchers proposing that the WOI can vary among women.

Research has been done extensively to detect and determine criteria necessary in order to call an endometrium ‘receptive’. In the past, this was done using histological criteria, i.e. the microscope appearance of the endometrium (termed the Noyes Criteria). Certain days of the menstrual cycle have typical microscopic characteristics and a pathologist would determine if the sample looked like day 16 or 17..etc (dates were reported with ovulation normalized to day 14-so an endometrium that was day 17 by Noyes Criteria should be 2 days post ovulation). As one can imagine, there is much variability and subjectivity in this interpretation between pathologists, plus womens’ cycles can show considerable variability. Also, just because the cells have the appearance of a typical cycle day 16, for example, doesn’t mean that the lining is actually receptive. That would just be implied. As a result of these limitations, and some recent studies that found this morphological dating method to have poor predictive value, this method of assessing uterine receptivity is no longer widely used.

One can also look at the appearance of the lining by ultrasound in the late proliferative phase. Many studies have focused on the endometrial thickness and type (triple-line vs homogenous appearance). Although the lower limit of an acceptable lining has not been agreed-upon by researchers or practitioners (most would arguably be satisfied with a lining of 7 mm or above) that information is a reflection of the adequacy of the proliferative phase, which tells us that the lining was properly primed by estrogen, but doesn’t give us any information other than that. Ultrasound in the secretary phase is not helpful, as it shows a thick, homogenous lining that doesn’t usually affect clinical decision-making, so is not routinely performed.

Over the last decade, different ways of studying the endometrial lining more directly have been investigated, first by attempting to identify the substances that were generated at the time of implantation, the cytokines, adhesion molecules and other proteins. To date, this line of investigation has been unsuccessful, so the focus has shifted to the stage that leads to the production of these substances, the stage of RNA transcription. Transcriptomics allows the study of gene expression by looking at the mRNA produced. It can provide a molecular profile of the status of the endometrium by telling us what genes are actually “turned on”. Gene expression profiling is now widely used for other disciplines, such as tumor classification.

With the relatively recent advent of DNA microarray analysis we can measure the expression of thousands of genes simultaneously, allowing us to explore which ones are expressed in the mid-secretory phase, when implantation takes place. The discovery of this technology was a major turning-point in the study of endometrial receptivity and several studies were undertaken to determine which of these genes were important during the WOI. Researchers agree that there is a specific and unique action that takes place during the process of transcription, when RNA creates the ‘script’ for a protein, in order for the endometrium to become receptive, but the identification of the specific genes involved was elusive until recently. A group in Spain identified 238 genes related to endometrial receptivity and collected the data to create a tool, named the endometrial receptivity array or ERA (Diaz-Gimeno, et al 2011). This test purports to identify if an endometrium is receptive or not based on the mRNA profile or the endometrial gene expression. It further differentiates the non-receptive category into pre- or post-receptive) in natural or hormone-replacement (HRT) cycles, regardless of it’s appearance by ultrasound or under the microscope (histological). This group then applied their tool by testing it on patients with recurrent implantation failure (RIF) by performing a multi-center, prospective study. What they found is that the WOI was ‘displaced’ in 26% of the women with RIF, so in 1 out of 4 patients with RIF, dysynchrony between the blastocyst and the endometrium might be to blame (Ruiz-Alonso, et al, 2013). They then did a second ERA test on the patients who had the displaced WOI to confirm that by adjusting the progesterone start or transfer day (see more on this below) increased implantation rates. They performed a subsequent adjusted embryo transfer (termed a personal embryo transfer or pET) and demonstrated a 50% pregnancy rate and a 38% implantation rate in this group of patients (which is the rate similar to the control group who did not fail a treatment cycle). This data supports the concept that the conventional window of implantation differs among women (at least a fourth of us) maybe only slightly in some cases, but enough to preclude implantation.

The test is performed in the secretory phase of either a natural cycle or a hormone replacement (HRT) cycle. If during a natural cycle, then the biopsy is done on LH surge + 7 . If during an HRT cycle, then the biopsy is performed on exogenous progesterone start + 5 (120 hours post start of progesterone). The biopsy sample is sent to the lab and analyzed (this takes approximately 2 weeks) and results are termed either ‘receptive’ or ‘non-receptive’. If non-receptive, it further analyzes the sample as pre-receptive or post-receptive. If pre-receptive, then the patient needs more time (hours or days) of progesterone, so the progesterone is started earlier or the transfer is moved later. If post-receptive, then the WOI has already passed, so the recommendation would be to start the progesterone later or move the transfer earlier. The recommendation is to repeat the cycle after modifying it according to the suggested intervention (more or less days of P) and the biopsy is redone to confirm that the endometrial tissues sent now receptive. This step is center-specific with some practices often performing a repeat mock cycle with biopsy and others only occasionally repeating it, but still using the recommended progesterone modifications for the frozen embryo transfer cycle, thereby creating the patient’s personalized embryo transfer(called pET). For more information on the specifics of the results and testing criteria, see the video here.

Although the data collected so far is promising, there are some limitations in the study design that should be considered when interpreting results. One is that all of the studies performed so far have relatively small sample sizes. Another is that there was no effort (in most studies) to separate out the embryo quality so that this important variable could be controlled. (There is a recent, retrospective study, in Japan where the researchers only transferred back euploid embryos with optimistic results, but it was retrospective and had a small sample size.) Furthermore, in the initial ERA studies, the non-receptive group was not further stratified to include a segment who did not have pET prior to their next transfer, so it is not known if they would have been pregnant just due to trying again, without further intervention. Finally, keep in mind that if 25% of RIF patients had a displaced WOI, 75% did not, implying that there are other factors (embryo quality among them) that could be the cause of implantation failure.

The importance of determining the timing of endometrial receptivity has always been emphasized in reproductive endocrinology. Now, instead of just relying on the way the endometrium appears, either by ultrasound or microscopically, some researchers suggest that we have the added benefit of being able to study the molecular changes that happen within the endometrium and act on these results to form a personalized prescription for subsequent transfers. Although exciting, further studies are needed to confirm this small subset of studies and also to determine if this test will be useful for an expanded group of women (Currently it has been suggested that it should be offered to those who have failed >2 IVF cycles or >1 donor oocytes cycle.) Methods of non-invasive testing are also being explored and might be a viable option within the next decade. The idea that every woman has their own personalized window of implantation (and that we can determine and take advantage of this) is a new and exciting concept in REI.

Special thanks to Paul Bergh, MD, FACOG For his assistance with editing this article.