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Proov Podcast: Dr. Aimee Eyvazzadeh, MD, MPH

Dr. Amy Beckley:

All right. Welcome to another episode of the Proov Podcast. It is my honor and pleasure to have the amazing “Egg Whisperer”, Dr. Aimee Eyvazzadeh. She is a reproductive endocrinologist in the San Francisco area. She's one of our medical advisors at Proov and I just wanted to have a really honest, upfront conversation about progesterone, what it is, what it's not, all those awesome, cool things that you want to know about progesterone. So, Dr. Aimee, thank you for being here. Please tell us a little bit about yourself.

Dr. Aimee Eyvazzadeh:

I'm basically everything you just shared and a whole lot more. I sing, I dance for my patients, I’m just kidding, but I'm super passionate about educating people about their bodies and especially their fertility. And I want everyone to be fertility literate and knowing about your cycles and knowing about progesterone is all part of it. And I love what I do. I have IVF classes, I have a YouTube show, but at the end of the day, my goal is for people to hear this message so that they're not going back and saying, why didn't I know this before it was too late. So thank you for inviting me on today to talk about it.

Amy:

Thanks for being here. One of the things that we pride ourselves the most on is just education, it's just making sure that couples, women, they have the resources and the knowledge to ask better questions. The internet, Dr. Google, there's a lot of things flying around, a lot of fertility myths. What's true. What's not true. And so I really want to make sure that we provide scientifically sound information so they can actually advocate for themselves with their doctors. So let's say we've known each other for two years now?

Dr. Aimee:

It feels like forever. We’re soul sisters I think.

Amy:

I know, Amy and Aimee, although it's spelled a little bit differently. I remember you reached out to me on a Facebook page and you're like, “Oh my gosh, progesterone, everybody gets progesterone.” I'm like, “Oh my gosh, this is amazing.”

So the first thing I want to talk about is, I call them, “progesterone-friendly” doctors. So there are doctors that believe in progesterone and there are doctors that do not believe in progesterone. So what do I mean by “believe in progesterone?” So my fabulous uterus that I always have behind me, progesterone is what makes the uterus receptive to the embryo. You can not get pregnant without progesterone. You can not stay pregnant without progesterone. So it is a hundred percent absolutely essential for pregnancy.

But where the controversy comes in, there's this idea that if you're pregnant, your body will just produce enough progesterone. Like it's like this magic thing that your body is like, “Oh yeah, I'm pregnant. All right, cool. I'm going to make enough progesterone.” You're shaking your head no, so tell me why that's not true.

Dr. Aimee:

No, I'm saying you're totally right. No, that's totally true. I mean I'm right there with you, but it's like, sometimes the body doesn't do it. Like if you have PCOS you just don't make enough or if you are older, that egg is older. It's not going to potentially produce enough progesterone from that Corpus luteum after the egg comes out.

Amy:

Why do some doctors think that that is true?

Dr. Aimee:

Why do some doctors think that women with PCOS have lower progesterone levels?

Amy:

That your body will just magically make enough progesterone if you're pregnant.

Dr. Aimee:

I feel like there's people that have this philosophy that if the progesterone level’s low, it wasn't going to be a good pregnancy anyways. So why intervene? And we're really just treating something that's like, as women we're told, it's like in our heads, and that's so insulting. And we know from really good science that it's not in our heads, it's in our ovaries.

Treating low progesterone in a pregnancy with progesterone is sometimes too late. And that's why my goal for my patients, anyone who's trying to conceive, even if you don't do treatment with me, as I recommend, checking for ovulation, starting progesterone three days later until your pregnancy tests, about 14 days after your positive OPK or around one, and you'll get to know your body's signs. You don't necessarily have to do the OPKs, but if you want to track and trend things really closely, you can.

But taking progesterone after pregnancy, when it's low could be too late. And that's really frustrating for me as a doctor, because I would've felt like I would've wanted to do something better for that pregnancy, especially if it was genetically normal. And we know, especially in young women, a lot of pregnancies do stop growing that have normal chromosomes. They are not always genetically abnormal. So progesterone could be that little life vest that you can send out to that growing embryo, as it's carefully making its way down the fallopian tube into the uterus. And that's the utility of your tests is that people get to see if they need a little bit more help.

Amy:

I like that. It's a little life vest. I think some of the problems are, these big studies that they did, like the Promise study, is that they gave progesterone starting at the first positive pregnancy test. And so I really want to drive this point home that you just talked about, there's two times that are usually talked about on starting progesterone, there's right after ovulation, and then there's at the first positive pregnancy test.

And if you think about what progesterone's role is, it’s to prepare the uterus for that embryo to implant. And so if you're waiting for the positive pregnancy test, it could be too late. Like your uterus is just not receptive or it's not a good environment for the embryo to really sit down.

Dr. Aimee:

You would never give a marathon runner water at the end of the race. That's stupid. That little embryo needs that water, just like a marathon runner does.

Amy: 

It's these studies that the ACOG (American College of Obstetricians and Gynecologists) uses for their guidance. I believe, they said, okay, it's like a 5% higher chance of a live birth. If you start progesterone, but you have to wait for three consecutive losses in order to get that treatment — it is a hundred percent absurd.

Dr. Aimee:

I can't even imagine saying that to a man. I mean, a guy can just go online and get Viagra delivered to their door. And yet we have so many barriers for something that could be so helpful and potentially save a pregnancy. And I know I'm sounding quite dramatic, but this is dramatic when you go through a miscarriage and it's something that you see that stays with you for the rest of your life.

So whatever I can do to help my patients and give them progesterone. And I know I'm not a unicorn out there. A lot of my colleagues do the same thing that I do. And I was trained by doctors who did this, and they're the ones who taught me the importance of progesterone. So it's not like I'm making this up and I'm unusual. There are a lot of doctors and most fertility doctors do believe that progesterone can help in the same way that you described.

Amy:

That's the whole point of advocating for yourself and getting a second opinion if your first doctor isn't receptive to  your questions and doesn't want to kind of buy into the information that you're asking of them. Because there are doctors that believe in different things people believe in different things. There are Democrats and Republicans, right? That's just the way of life.

So a lot of people ask us, “Is there such a thing as too much progesterone, I'm worried I'm taking too much.” Can you comment on that?

Dr. Aimee:

There isn't such a thing. The only time it's a thing is if you're so dizzy, you can't stand straight, but if you're taking that much, you're going to just drop the dose, right? So sometimes, naturally your body is making so much, but adding a supplement can make you really symptomatic.

And there's several different ways of administering progesterone. And some people are really sensitive to it, no matter the dose. So you can place a capsule, for example, vaginally, you can swallow the same pill, it's actually approved for oral use, but we use it vaginally a lot. Like we do a lot of medications and fertility medicine, and you can also even do a shot. There are some patients who would try naturally or do inseminations and they still use a form that's a little bit more invasive, which would be an intramuscular shot because that's how they tolerate it the best.

So everyone's body is different, but it won't cause a birth defect. It won't harm a pregnancy if you take too much. I have a patient who's pregnant right now and her progesterone's 122 and she's on progesterone. She's totally fine. She's not feeling symptomatic at all. So I'm not going to change a thing.

And we know progesterone levels fluctuate from one second to the next. So just because it's super high right now, doesn't mean in five hours, it's also going to be super high. So that's the benefit of also taking it because of these fluctuations that we know occur in the body so that, you know, by taking it, you're going to keep it at a certain level or at a certain minimum level throughout the day.

Amy:

Awesome. I'm going to highlight what you just said, because this is like pure gold. Progesterone fluctuates, right? So it's produced in the ovary and the ovary gets a signal from the brain, which is in the form of LH that says, Oh, I'm low on progesterone and it pulses more progesterone. So it has to go low to go high, to go low, to go high. And that's just how it works.

So Proov measures the urine metabolite of progesterone. We don't measure progesterone directly, but we let it pass through the serum, get metabolized in the liver, into the bladder, and then secreted in your urine. And so it's more like an average of the day before. So when you get a single blood draw and it's low, does always necessarily mean it's low? And the other side is if you get a single blood draw and it's high, does it mean it's always high? So some people are like, well, my progesterone was 16. Why is my doctor wanting me to supplement? Because they know that it's not always going to be 16.

Dr. Aimee:

The other thing is, there's a lot of misdiagnosis too. I have patients that are told that their progesterone is low and they're actually quite normal and they feel like there's something wrong with them when there isn't. And then there's the other side of things where they're told it's normal and it isn't, so it's like ask your doctor, what do they feel comfortable with as far as the progesterone level, and then make sure it's timed at the right time of your cycle too.

Checking it just randomly on day 21 is a way that has been described online, but every fertility scientist knows that you want to check progesterone when it's at its peak to really understand how well your body is making it. But at the same time, we can also use a random progesterone after ovulation to kind of confirm ovulation as well. And I also use it to guide my patients if they're, as far as when they might've actually ovulated, I can sometimes tell, if the progesterone is seven and she thinks she might've ovulated, but isn't sure. And it might've been in the last couple of days. And I can tell, “Yeah, your progesterone’s already 70, you probably ovulated about three days ago,” because I just know how it's going to trend from there.

Amy:

On the flip side if you, if you tested seven days after ovulation, when it's at its peak, does that mean that you have enough progesterone? And you're going to be fine. Like if you get pregnant, you're fine because they have that one really good result.

Dr. Aimee:

I mean the checking of post ovulation or the peak progesterone level, for me, it's more a didactic type of exercise, more of an exercise of like showing a patient what she does naturally, not necessarily a useful tool for me, because like I said, I'm checking everyone, I'm giving everyone progesterone. So why make them go in for progesterone? I'm already going to give it to them anyways.

And I know that when I give it to them, unless they're placing it rectally, just kidding. Just wanted to see if you were awake there, Amy, we know that the level's going to be good. So, I see a lot of OBGYNs sometimes checking progesterone to prove, no pun intended, to a patient that she actually does not need it, but I find that to be kind of helpful. So patients know that there isn't anything wrong with them, but at the same time, I wouldn't use that as a way to take the option of progesterone supplementation away from a woman.

Amy:

Proov is FDA cleared to confirm what we call successful ovulation. Successful ovulation is, you want your average progesterone levels that we measure in PdG sustained over this implantation window, this luteal window, which is when the fertilized embryo, if it is fertilized will get all the way down the fallopian tube, into the uterine cavity and implant. And if your Corpus luteum disintegrates or dies off too soon, then you'll get your next menstrual period before the embryo is actually implanted. It's like we have to confirm successful ovulation to make sure that progesterone is, we call high enough for long enough, to really be okay.

A question we get as well, “My Proov tests were positive, does that mean I'm out of the woods?” Like, no. I mean, at any point during your pregnancy, your progesterone can go down. Proov is one step in the journey to confirm, yes, you have the highest chance at a successful pregnancy, but it doesn't mean that you should stop talking to your doctor and stop seeking care.

And then, “Oh, I'm getting off the progesterone supplements. I'm 13 weeks. What do you think?” I'm like, “Whoa, I'm not your doctor. Talk to your doctor.” What's your advice on stopping progesterone?

Dr. Aimee:

So if it's in a frozen embryo transfer cycle where you've done IVF and your body's relying on the progesterone, nope, no sooner than like 10 weeks and lately I've been going longer to 12. If it's in a naturally conceived cycle, I would say 10 weeks is when I stopped the progesterone for my patients. And I can't really think of a reason why someone needs to go beyond 10. And the reason why we can stop at 10 is from studies showing that the placenta takes over progesterone production usually by seven weeks. And for the most part, you know, nine weeks for like almost everybody.

Amy:

I was one of those 16 weekers. I had so many losses and it was so traumatizing that it was like gold. And I'm like, I can't stop it. I just can't. It's like one of those addictions you're like, I can't stop.

Dr. Aimee:

I have a recurrent loss patient right now. She's 22 weeks. She still comes in for her progesterone blood draws because it helps with her anxiety and I'm happy it's a simple enough test. And her progesterone's 80, actually. I actually need to check with her. Cause I think she might be supplementing.

Amy:

Absolutely. Something that helps with anxiety and just gives you that peace of mind. I was also the one that had the little fetal doppler you get off Amazon and like every night I'd go in and hear the heartbeat. Okay. We're good.

Dr. Aimee:

Well now they have handheld ultrasounds. I think that's going to be next.

Amy:

Wow. That's pretty cool.

Dr. Aimee:

I'm thinking of buying them for my practice and then leasing them to my pregnant patients, especially patients who let's say have this story very similar to yours, especially with COVID and the decreased number of visits that patients are having. I think it could increase. I can't imagine that just looking really quickly at the baby on ultrasound would be that harmful and potentially could give people peace of mind.

Amy:

Stress is a real thing. What are other myths we could talk about, fertility myths? We can talk about socks. I hear this all the time, warm uterus. It gives you the highest chance of conception. So wear socks at night, any truth to that besides, I wear socks because I’m cold all the time.

Dr. Aimee:

No, our body temperature is warm. Your uterus is coated with your intestines and the mentum and all of those organs that are over it to keep it nice and snuggly. So wearing socks on your feet, your uterus would never know. So wear socks if you want, but don't wear socks because you think it's going to somehow help.

Amy:

What about, I've seen this one recently, inserting a tampon or a menstrual cup after intercourse.

Dr. Aimee:

That's just silly. There's a reason why semen comes out, cause that stuff's disgusting. Sperm swim and they swim fast. So there's no reason to place a tampon after sex or a menstrual cup. If it will make you feel better and you want to do something like that, go for it. But it, especially the menstrual cup, can just get really, really messy. So I, from a technical standpoint, I can't see why placing a menstrual cup would be helpful. If anything, it just might give you an increased chance of having a bacterial vaginosis or some sort of infection by keeping something in there for a long time.

Amy:

That sounds lovely.

Dr. Aimee:

I've tried it all. I've talked to patients about every single possible thing you could possibly know, that you can think of. And and I would say, you know, having sex in the position, that's the most enjoyable for you is probably the best advice I can give somebody. And I'm placing a little pillow if you want under your butt for maybe 10 minutes and then washing with a peri bottle before and after to prevent infection, taking a probiotic if you're prone to infections around ovulation time, that could be good advice for some people. But for the most part, I would say, keep that stuff out of your vagina.

Amy:

Yeah. There's also this recent Tik Tok kind of craze going around about the Mucinex.

Dr. Aimee:

That's been a fad for the last 20 years. It was Sudafed before Mucinex was around and you know, sperm is viscous. It's really sticky and there's a reason why once it goes into the vagina, it actually liquefies from the heat. So what I'm saying is it's not necessarily something that we originally prescribed to women, it's really for men, but for women, this thought that somehow their cervical mucus needs to be thinned out and that can be something that Sudafed or Mucinex can do for you as a fertility treatment. It’s not proven to be true. So I would say just do it the old fashioned way, and cut out the cold meds, unless they have a cold.

Amy:

So maybe I misunderstood, but you're saying, originally thought to be given to the guy to help the semen be more liquidy?

Dr. Aimee:

That's right. So some guys have really, really viscous, thick semen and you can see it in a semen analysis report where they'll say highly viscous and they had to use like 10 CCs of HTF to, to be able to even do the semen analysis, because there was so much clumping, that guy might benefit from taking Mucinex starting like two weeks before the main event, which would be, you know, intercourse around ovulation time. So that is something that we have told guys to do. And maybe like one or two guys a year, I do suggest that as a possible remedy for super viscous sperm, if you're trying at home, if you're trying in the lab and when we can take care of that, it's not a big deal, but sometimes I even tell them to make it easier to potentially on the lab folks, I don't know how much it really helps, but Mucinex can help also potentially dry up.

So some women can have fluid collections inside their lining who are going through IVF, especially a frozen embryo transfer. And so adding Mucinex as a therapy, maybe like, a week before the lining check and someone who I know has made fluid in the past may help, who knows.

Amy:

So you're basically just wasting money and funding all of the Mucinex people.

Dr. Aimee:

Mucinex is not part of my fertility treatment. It's not a tool in my toolbox and it's not something that I would say, “Oh, you can take your fertility in your own hands by taking Mucinex and you'll get pregnant.”

Amy:

So now we're in this conversation with sperm. So I watched your video with the sperm where you get all the different lubricants, the sperm friendly lubricants and stuff. And it was shocking that Pre-Seed just like you have this modal sperm and then you add a Pre-Seed and it was like it just stunted their movement.

Dr. Aimee:

It was actually a professor of mine. I already knew that it was going to do that. One of my professors at the University of Michigan taught me that. And he was like, “Hey, this is all marketing. And it's all bologna.” These things are marketed as pro fertility, but they just kill sperm. And maybe not as much as KY but people go buy them and then they squeeze an entire bottle inside their vaginas. And they're basically using a spermicidal at the end of the day.

Probably like, “Oh, it can help the sperm swim faster,” but it's the opposite. So I just tell people, use it if you want to use it, Pre-Seed fine. Use it on the outside sparingly, but don't be squirting that stuff inside the vagina and trying to get as much in there as possible.

Amy:

I watched a video, I think it's going on like a year ago. Whenever I see these comments about pre-seed I always mention the video and kind of tag you or put the video link on there and somebody tagged me about it. It wasn’t me that said it. But you should watch this video.

Dr. Aimee:

And people get pretty fired up about it. And they want to defend Pre-Seed and I'm like, that's great that it worked for you, but I know so many people who stop using it and then they get pregnant the next cycle. And they're like, “I wish someone had told me that I was basically killing this sperm the whole time,” but it could work for some people, maybe the pH of their sperms, is a little bit different than the pH of the sperm of the donor that I used, the willing participant that I use for the video. No one was harmed filming that video. That's what I should say. Anyways, I promised him that I would never reveal who he is. My husband, shh.

Amy:

I had the guys over at YO Sperm kit. They have that cool little microscope thing that you take a semen sample and you look at it underneath the microscope. And he wanted to have me test it out, well, my husband's had a vasectomy like three years ago, but I'm happy to test it out for you. So we did, we went through the whole process and it was very much no sperm. It was pretty cool to see the sperm swimming or not swimming, or just to kind of see the video.

Dr. Aimee:

That's my version of porn. I've been like, I don't watch porn and this isn't TMI because I just don't. But I can tell you I love sperm videos. I mean, that's hot. I'm just like, holy. That is amazing sperm. And that excites me because when it's good, you know that my patient has a really good chance of pregnancy. And when it's not good, I'm like, thank God I know now. And I can help my patient get pregnant.

Amy:

Women come to us with their Proov results and they're like, everything looks beautiful. We timed intercourse at the right time, PdG levels look great, all this and I'm like, did you get a sperm test? No, we're not going to do that yet. Why not come on? Just do it.

Dr. Aimee:

Or my favorite is, “My husband doesn't want to, or he doesn't think it's him.” And I'm just like, “Okay, you're not allowed to be my patients then.”

Amy:

So this is actually why I love YO. And this is why we recommend YO, because it makes it kind of cool to do it because you're like, this is your sperm on a video. How cool is that?

Dr. Aimee:

Yeah, totally. And then I get to, I tell my patients to send the videos to me. I think they're adding on some new things. So I think they're changing the report soon as well as from what I can tell.

Amy:

It takes two, right. I mean the biggest causes of infertility that we see are, you don't have an egg, you don't have sperm and you didn't get them to meet. So if you're checking those three bases, that's like what? 87% of the issues.

Couples will do a lot to try to conceive. I mean, I was in that boat too. I was taking my temperature, peeing on all kinds of sticks, doing all kinds of crazy things. I never did the menstrual cup thing and I never did the Pre-Seed thing. But there's just so many products out there now that are just giving more data and more information.

Typically we have women that are like, I'm using these five apps and these two different types of thermometer and these five different ovulation tests and like all this, like just gobs and gobs information, but then they're missing something so easy as a sperm test. Don't take all that burden on yourself.

Dr. Aimee:

Well then unfortunately they're told that they have unexplained infertility and they're told the sperm is low, but it's still good enough. And then that aspect is just forgotten. And then after way too long, they learned that it was from the whole time because someone finally tells them the real deal. So that's why I always use the method of getting your sperm checked. And I think it should be done at the beginning of the journey. So your journey is not a long one. You don't learn after a year of trying that there's no sperm or the sperm is really low. Cause that would just drive anyone mad.

Amy:

Then the thing with sperm. So with an egg and a sperm, right? Sperm is produced minute by minute. It's just constantly being produced and ovulation is a monthly thing. So you're constantly ovulating every single month. So you go in and then you get your sperm checked once and you check your ovulation once doesn't necessarily mean that it's always bad or always going to be good, that is something that you kind of have to continually monitor.

We like to tell women that if you have an ovulatory problem, say you're just not producing enough progesterone or it's kind of dropping too soon. That's actually in our minds as not a good thing, but a positive thing because that's one of the easiest things to fix. I mean, endometriosis is so hard, it's a surgery. Blocked tubes that can be really difficult, no sperm, that's really difficult. So not to be depressed that you found something wrong, but that you found something wrong that you can fix and it's relatively easy.

Dr. Aimee:

And it doesn't involve needles or shots or anything more than maybe just a pill in your vagina.

Amy:

Or rectally, right?

Dr. Aimee:

Well, I had a patient that was like, I read online that you can place it rectally. And she was right. I literally Googled it. I was like, that is a troll who's writing that who hates all of you who is just trying to trick you guys into seeing like how gullible everybody is on this message board. But no, you should not ever place progesterone, rectally, but she was right, it actually was there and I thought it was a joke and it totally wasn't, she's like, I'm getting irritated, my vagina. And I was told I can place it rectally. I'm like, huh? I'm like, no.

Amy:

So, this is another question back on the progesterone. So say a woman is getting irritated vaginally. She's getting yeast infections because of all the extra fluid. What would you say to her?

Dr. Aimee:

Just take that same capsule and swallow it. People look at me like I have three eyes, this is a vaginal pill. You want me to swallow it? Actually it's an oral pill and we tell people to place it vaginally. So you're good, I promise you. Okay. I actually have a bottle somewhere still. It's so funny.

I had a patient; she took it literally and the pharmacist did this and it was really funny. It said place vaginally by mouth literally. And so her husband was like, okay, so I have to put it in my mouth and then put it in her vagina. And I was like, yes, you have to do that. And I want to hear about how that goes, please let me know. So I took a picture of the bottle, still laugh about it to this day. I know her very well, it was literally that funny. She got pregnant, had a beautiful baby, but we still laugh about it to this day.

And I remember the bottle and it was so funny because they took it seriously because this is serious stuff and you want to follow instructions and make sure you don't screw it up. So when I saw those instructions, like, “Oh my God, like I can be laughing for days about it,” but you can take it orally or vaginally. Right. If not vaginally by now.

Amy:

There's so many different ways to do this. You could do vaginally at night and then orally in the morning, or vaginal three times, that's what I did three times a day because I could not handle the shots. I literally could not walk. But there's all this kind of research about orally versus vaginally versus intramuscularly. And now they have a sub Q version of progesterone, I guess, somewhere in Europe.

Dr. Aimee:

There's all sorts of stuff outside this country we won't ever have access to because of the FDA and how expensive it is to get things approved. There are pestaries out there in other countries as well, just randomly placed in your vagina, just place it, forget it. And for us, like we don't have it, it's sad. I wish we had that stuff because it would be so much easier for us.

Amy:

The one thing I would say is follow whatever your doctor says, take an orally or vaginally. If one way is not working for you, take another, some people get side effects taking it orally and then vaginally is fine or vice versa.

But I will say if you take it orally, it will pass through your system and your urine. And it will show up on the Proov tests. If you're taking it, vaginally usually it does not. So it doesn't go through the blood urine kind of flow. So just something I like to tell people that once you've actually started to take progesterone, you don't need to use Proov anymore. It's not really as useful information anymore.

All right. I feel like I'm missing some of these things that as soon as I hang up and be like, Oh man, I should have asked her. I can't think of them right now. Top three pieces of advice that you would give couples trying to conceive, sorry, put you on the spot.

Dr. Aimee:

I think the top three are to talk to your partner about your family size goals. I'm so surprised when I sometimes meet people and they're like, Oh, we never talked about how many kids we want. I'm like, what? Because I think in order to create your fertility roadmap, you need to know how many kids you want. How old are you at the time?

And then how are you going to reach those goals, is kind of part of that whole thing. Because if you're like 37, I want three kids. And you're like, how are you going to do that without using a donor egg? You can't. So if you're going to have your next kid at 43, the likelihood of being able to do that without freezing your eggs or embryos is probably about 2%. But if you talk about that stuff up front, you can literally create some sort of plan for yourself. And that's what I'm all about. I'm like your Google maps for fertility care.

Amy:

I remember before my husband and I got married, I sat him down and I'm like, look, I know we're just dating. But my life plan is to have children. That's just my life plan, for two children. If that's not cool with you, that's the door. And that was before we even got married. Could you imagine a situation where you're married and you're like, Oh, I want to have kids. And then you find out your husband doesn't want kids or only wants one or wants six. And you only want two, you know what I mean?

Dr. Aimee:

I see that struggle. It's real. It can feel pretty good for things like that. So it's like, what do you want? And then what is it going to take? Because to know what it's going to take to get what you want, you have to do some testing. So I tell people to get your fertility levels checked, do a uterine ultrasound, make sure there isn't a fibroid smack-dab in the middle of your uterus. And people say to me; I have my pap smear every year. Can't they tell? And I'm like, no, isn't that a complete waste of time that you go in for your pap smear and they don't do a basic ultrasound just to look at the most important organ related to your pregnancy?

Amy:

Ultrasound things that you're talking about, will they be able to do that too?

Dr. Aimee:

Yes. It’s pretty cool. And then making sure that you're willing to do what it takes, right? So what is it going to take?

And then the third thing to make sure, are you willing to do it? So both you and your partner have to be on the same page about that and be willing to put in the work. And then if it looks like you want two kids and you're not willing at 30, let's say you're 42 and you want two kids and you're not willing to, let's say you do four to six IVF cycles and use a donor egg. You need to reframe what you want and be very specific about that. So that you're spending your energy and time on something. That's going to be productive like adoption and putting your energy in that right away.

People who show up at the fertility clinic are ready for babies. I want to have two kids and I'm 44. And I'm like, well, it's not going to work out the way that you want with your own eggs. Obviously I want it to work out for everybody. But you know, 44 year olds have about a 2-4% chance at best of having a healthy pregnancy. And people are just shocked when they hear. And they think that's me being really mean and me being really negative, but this is the real deal. And you got to know it upfront because if you expect it a hundred percent you're going to be really disappointed.

Amy:

That's what I love about you. You're honest, you're truthful, like 44, probably not going to happen naturally, but here's your other options. I love it. Okay. So open communication on family size, again, open communication about what you need to do with a sperm test.

Dr. Aimee:

Getting diagnostic tests done and then being willing to do the work.

Amy:

All right. Tip number two.

Dr. Aimee:

So being on the same page, tip number two is doing the diagnostic tests, right. So be sure to get your tests done would be tip number two.

And then I think right now, with COVID, tip number three, this sounds really weird. And I can't believe I'm saying this but be super annoying. That's kind of what it's going to take right now with what's going on for you to be able to advocate for yourself. So a lot of times people are asking questions and they're not getting a reply or they're calling into the clinic and no one's calling them back and they don't know what questions to even ask because no one's giving them the information about what their levels are, what they mean.

And that's why I've come up with these little tools for IVF patients, the sparkle checklist, that's your checklist for knowing what size your follicles are and what the plan is until the next appointment. Are you happy? When's the retrieval going to be? Are we going to keep going? What does the lining look like? What are my estrogen levels? And then the embryo diamonds were the eight things you need to know about your embryos, right?

So always just asking questions and advocating for yourself and listening to your gut. Or I should say listening to your ovaries and your uterus is probably the best bit of advice. So if something doesn't feel right, if you're pregnant right now and you're like, baby's not moving as well. That's a huge myth that babies shouldn't move as well in the third trimester, that is not true. If your baby is not moving well, and you're in the third trimester, get in and get seen. Don't pick up the phone and allow someone to tell you, “Oh, that's normal. Just the amount of room is going down so the baby's not moving as much.” No, that is not correct at all. There's so many heartbreaking stories I've heard where people have tried to advocate for themselves and they were told, “Oh honey, you're fine.” And the patient was like, “But something's just not right.” Listen to your thoughts. You listen to yourself and just be annoying.

Amy:

Preach it. Seriously. The one thing that I hate the most is; I'm five weeks pregnant and I'm spotting and you're calling the doctor and you're telling them I'm cramping, I'm spotting, I’m five weeks and nine times out of 10 that doctor's going to say, “You know what? There's nothing I can do for you. I'm sorry.” Because most women don't want to go see a doctor until they're eight weeks pregnant. So it's like, Oh, you know, 25% of pregnancies end in loss. So this could be it.

Dr. Aimee:

Oh my God. And you and I both know it could be an ectopic, it could be a miscarriage, but who would want to wait another three weeks to find out or even worse? People are told to go to the emergency room. I'm like, that is the last place someone who's early pregnant and bleeding should go because the emergency room is just going to waste your time, giving you no information

They might just check a quantitative HCG, no ultrasound. Or they might do an ultrasound, not see anything. And just tell you something's wrong when it really isn't because they just don't know what to look for. I do very careful early pregnancy tracking for my patients and provide care with the minute I see a positive pregnancy test. It's like level check, level check, two days apart, depending on the second level, another global check, two days apart, and then another global check a week later. And then the first ultrasound a week and a half later, and then another ultrasound two weeks after that. And then I do the NIPT at nine weeks. And then we do a celebration at 10 as they go to their OBGYN.

Amy:

So to get away from this disaster of your doctor, not listening to you when you're interviewing doctors and you're going through this, maybe have honest conversations, like how do you treat early pregnancy? What is the protocol? Because you're not going to know what they're going to do until you get to that particular point.

Dr. Aimee:

You have to say what you want. You have to say, I've been through so much. I want to make sure if I come see you that as soon as I'm pregnant, that you will check my HCG and progesterone and monitor it. And then as soon as possible, see me for an ultrasound.

And if they say no, a lot of times it has to do with insurance, right? So insurance won't pay for the visit because you only get so many ultrasounds in a pregnancy. So if they say no, then you might want to say, “Well, I'd be happy to pay the out-of-pocket price for this ultrasound.” It might be a hundred dollars. It might be $150, but you might want to find out why they aren't able to do it because sometimes, unfortunately it has to do with billing and insurance.

Amy:

So I'm going to go back to number two because we skipped over this, the testing, the diagnostic, right? So that's the TUSHY method. We love the TUSHY method. Tell us a little about each letter and what it is.

Dr. Aimee:

Super easy. They're the five tests that you do to get your fertility health checked. You can do it in one menstrual cycle.

Here we go. Period starts. Cycle day three, you're going to get your hormones checked. That's FSH, estradiol, AMH. I also do a complete preconception panel as well. Vitamin D, prolactin, blood count, TSH, making sure you're immune to German measles, chicken pox. So that's all part of my age.

Then at that visit, I also do the genetic screens, which are your genetics. So it's a carrier screen and chromosome analysis.

Then I also schedule in the hysterosalpingogram. So the hysterosalpingogram is the tube test. So that's an x-ray dye test that allows me to see the fallopian tubes and make sure that they are either open or close and sometimes one can be open and one can be closed. So it's really important for me to know, cause ovulation is the flip of a coin. It doesn't happen alternating moms on one side or the other. And then typically, depends on the patient's comfort level, I'll have her also do that ultrasound on cycle day number three or, and the reason why I say her comfort level is some people just don't like to meet me for the first time on their period to have an ultrasound done, but help bring them back in for an office to take a look at their uterus and their ovaries.

I typically like to do the ultrasound before the HSG. And the reason is if there's something obviously abnormal with the tube that I can see on ultrasound, which is not typical, I wouldn't want them to necessarily go right into an HSG at the same visit and coordinate the semen analysis, which is the S of the tissue method.

So that by the end of that menstrual cycle, guess what, I'm going to know about the tubes. I'm going to know the uterus. I'm going to have the sperm count. I'm going to all the hormones and your genetics. And then it's like, what's up, bam, we got a fertility roadmap. We can talk about the results, your goals, and create a plan that seems really reasonable and acceptable to you honoring what your priorities are, understanding that when you're dealing with human biology, sometimes other things happen that are out of our control. Not just sometimes, all the time, but at least we know that we were as prepared as possible. And we always talk about taking supplements like cocuten, vitamin D, fish oil, your prenatal and all that good stuff along the way.

Amy:

Awesome. I thank you for your time. I know you're super busy and to get you in on a Sunday afternoon, so I will give you the rest of your weekend back, go home, hang out with family. I appreciate it.

Dr. Aimee:

A patient of mine got me this little gift basket right here. It's a bottle of wine and some adorable slippers. So I'm just going to go crack this baby open and put on my adorable slippers. And there's also a beautiful candle in here. We'll just be hanging out at home.

Amy:

Cool. So one last thing before we go, where can everybody find you?

Dr. Aimee:

I'm really easy to find. So my website, like my shirt says, is D-R-A-I-M-E-E.org or Dr.Aimee.org. And you can seam my blog article, sign up for my IVF class, get to my YouTube page, and get to my podcast. It's all right there.

Amy:

Yeah. Great YouTube content, all those great educational content. So thank you very much.

Dr. Aimee:

Great, see you next time.